My Trainer, My Desk

Everybody get on your feet,
You make me nervous
When you're in your seat
-----Jerry Jeff Walker


    
     What on earth would our Ice Age ancestors think?  Genetically identical to our 21st century selves, they were perfectly suited to a life of obligatory physical exercise, periodic famine, and unrelenting cold.  We, on the other hand, no longer running from predators or chasing our dinner, pass our days on the job and at leisure slouched in our chairs, inert, well-fed, and warm.
     My Fitbit, a pedometer-plus, tallies steps, stairs, and calories. Gizmos within know when I am active and know when I am not.  After a day at home or at work, add housework or laundry plus a walk and a trip to the store, I might manage to reach the 10,000 step goal. Syncing with Fitbit on-line turns daily data into a pie chart of motion, gray for sedentary with blue, yellow, and pink for light, moderate and heavy action.  Alas, my so-called busy day is awash in inert--big yawning gray, a thin slice of sky, a sliver of sun, and one slash of pink.
     Perhaps it's time for on beyond Fitbit. A smart--and very pricey!--desk might be the next best thing to a personal trainer.  For several thousand dollars, you can buy a work station at stirworks.com that greets you by name, gently nags you to move, keeps a log of your day, week, and month, and advises you how long until you're next scheduled to fidget.  When you've been too still for too long, the thing takes a 'whisperbreath', heaving beneath your laptop like an impatient dog past due for a walk.
     Sit-stand workstations are today’s medical news; studies prove they decrease on-the-job sedentary behavior (SB), may or may not affect productivity, and mostly don’t cause workplace injuries.  Ingenius, creepy, or just a sign of our times? 

Bystolic testimonial

I wrote some time ago about a medication called Bystolic, a beta-blocker used for hypertension and irregularities in heart rhythm. Beta-blockers also have been used for years to calm the body manifestations of anxiety such as a racing heart, and they are, therefore, useful for stage fright. I have several lawyer/patients who use beta-blockers when they must speak in court. Another patient was having panic attacks that were difficult to diagnose as they manifested with symptoms quite similar to TIAs. After completing a detailed cardiac work-up, I put her on a small dose of Bystolic (2.5 mg. or 1/2 of the smallest available tablet) which controlled both her attacks and her blood pressure.

Here is an e-mail I received from Cheryl on her experience:

I have been using Bystolic for over a month. I love it. Not only is it controlling my anxiety and fast heart rate, my blood pressure is down and I have a generalized good feeling. Things don’t get me worked up like before. And, I’m breaking the 5mg in half. I did have to stop taking it in the evening because my sleep was restless. But, I start my day with a cup of coffee and half a Bystolic and it’s a good thing. I was reluctant after trying samples of Diovan that almost killed me. (Yuk on that one….Poison*).

If I had known how great I would feel on Bystolic, I would have taken it a long time ago. I’m not a pill-popper and dodge it, but this works! I am a health freak and have fought taking meds, but my doctor prescribed it for my racing heart. The benefits make my life happier and healthier.

*This is Cheryl's reaction to Diovan. It often works well for others, and is a good drug for hypertension.

Heart attacks and low cholesterol

Can you have bragging rights cholesterol and still suffer a heart attack? You bet, read on:

My patient sat relaxed and smiling in the exam room. He was here, per my schedule, for 'follow-up."

"So, what's going on?" I asked.

"Well, haven't you heard?" he asked. "I just had a heart attack a week ago Sunday."

There he sat, tan, comfortable, the only visible sign of less than perfect health in his 61 year old self was a little bit more belly than ideal bulging out at his midriff.

"You're kidding, right?"

"Nope," he replied, "to make a long story short, I had a heart attack while reading the morning paper and drinking my coffee. I started having severe chest pain, told my wife that this was the real deal, and within 78 minutes I was on the table getting a stent placed in my heart"

Gad, this guy has perfect blood pressure (110/72) on a low dose of heart-healthy lisinopril, 'walks some' for exercise which is not enough but more than many people, and has an LDL cholesterol of 80 on no meds. His dad had diabetes and died of coronary artery disease at 73.

The cardiologist found a complete blockage of his left anterior descending artery--the so-called 'widow maker-- on catheterization, which means no blood whatsoever was getting to the front wall of his left ventricle prior to stent placement. An echocardiogram after the procedure showed that only a small part of the apex of his heart was damaged.

When I was in med school, this fellow would've gone straight to bypass surgery followed by a prolonged post-op stay in the CCU. Yet here he was, scarcely a week later, already starting a cardiac rehab exercise program.

Two lessons here: prompt access to modern medicine is grand, and none of us can rest assured in our low cholesterol numbers.

LDL particle size

LDL stands for low density lipoprotein, a worthy protein that picks up cholesterol particles that have either been absorbed from your diet or manufactured by your liver and totes them out to the cells. And it's a good thing that we have LDL-C; our cellular membranes are made out of cholesterol as are our steroid hormones. But as you know, while a little LDL-cholesterol (LDL-C) is a good thing, a lot is not. In susceptible persons, excess LDL-C enters the arterial wall where it may become oxidized and set off a world of inflammation and cholesterol schmutz known as atherosclerosis.

Turns out, there's bad LDL-C and then there's really bad LDL-C, and the difference lies in the particle size. There's no improving on the metaphors of noted lipidologist Dr. Thomas Dayspring, so here's the scoop in his own words:

Large-sized LDL is a beach ball. It bounces off the artery and goes back to the liver. Small LDL is a bullet. It lacks vitamin E, is very prone to oxidation, and crashes right through the artery.

So how do you know if your cholesterol is bouncing or crashing? LDL particle size is measured in the pricey VAP test which stands for vertical auto profile, but the information is actually right there on your standardized lipid profile. If you've got triglyceride levels over 200 and HDL-cholesterol (that's high density lipoprotein or the good stuff) levels below 45 (35 for the guys) we're probably talking bullets in your bloodstream.

Any hope of changing bullets to beach balls? Well surprise surprise, it's the same old song as always--weight loss and exercise. But wait, there's drugs that help as well, including Tricor, gemfibrozil, niacin, and the diabetic medication metformin, Actos, and Avandia.

You can change your wicked ways...

but at the heart of your matter, your poor choices live on.

The Coronary Artery Risk Development in Young Adults (CARDIA) study followed twenty years of health outcomes in over 3500 young adults. The researchers studied modifiable risk factors such as cigarette use, prehypertension (BP's 120-139/80-89), LDL-cholesterol, and fasting blood sugars.

Many of the subjects with less than sterling health habits didn't smoke that much nor did they have huge elevations in the other parameters studied. Many of them turned their acts around and improved their lifestyle choices over the course of the trial. Despite improvements made, their early adult profiles were more predictive of the presence of coronary artery calcification (CAC) after age 35 than their most current situation. CAC has been shown to correlate with the presence of atherosclerotic changes in coronary arteries.

Red Yeast Rice

I was very grateful that i didn't have to be put on Lipitor. I just took one every evening after dinner, that was it, That easy!
--A happy Red Rice Yeast consumer on Amazon.com

Interesting stuff, this red yeast rice (RYR).* Used for over 1,000 years in Chinese medicine to promote circulation, this medicinal food is made by fermenting rice with red yeast or monascus purpureus. One of its active constituents --monacolin K-- is also known as lovastatin. Monacolins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase) which is an enzyme essential to the body's production of cholesterol. In fact, lovastatin was the first statin drug marketed in the U.S. years ago under the trade name Mevacor.

So is RYR an effective, natural, and SAFE way to lower your cholesterol? Even though the Chinese have a century+ of casual, everyday, human trials, the first formal study of the substance was conducted there in 2002. The results confirmed its efficacy: total cholesterol, LDL cholesterol, and triglycerides dropped by 23, 31, and 34 percent, respectively and HDL levels increased by 20 percent. In other words, RYR did all the good things that statins do because RYR is basically a statin or rather a statin is basically RYR. Other studies, one of which was conducted by the American Heart Association, confirmed the general findings although the benefits weren't quite as robust.

The doses used in these studies were 1.2-2.4 gms/day; some Asian diets include up to 55 gms of RYR per day. Because agents such as RYR and statins decrease the production of coenzyme Q10 which is important to energy production in muscles, supplementation of CoQ10 is recommended with either the nutraceutical or the pharmaceutical approach. The standard dose of lovastatin, however, is 20-40 mg/day whereas the daily amount present in most RYR preparations varies between 5-15 mg.

ConsumerLab.com is an independent testing laboratory that evaluates the quality and contents of nutritional supplements. In a recent investigation, they looked at different RYR products both for the amount of active ingredient (lovastatin) and for the presence of citrinin, a renal toxin that may be produced by yeast grown on cereal grains such as rice. Nature's Plus® Herbal Actives Red Yeast Rice contained very high levels of lovastatin whereas Walgreen's brand contained very little of the active monacolin. Four products had citrinin contamination.

What's in it for your brain? Recent Taiwanese studies of RYR compared its protective effects on cells under ambush from beta-amyloid (the sticky protein that gums up the brain in Alzheimer's disease) with those of lovastatin. The RYR won hands down in not only protecting against cell death from beta-amyloid but also in decreasing inflammation and oxidative stress. This same research group found that rats infused with beta-amyloid learned more, had better memories, and accumulated less beta-amyloid when they signed up for RYR supplements with their kibble.
____
*Red mold rice (RMR) if you're a Taiwanese biotech sort, and red mould rice if you're British.

Blood vessels love grape juice

They're not just passive pipes anymore. Blood vessels, or rather the single layer of cells known as the endothelium that line these passages, actively regulate blood pressure, blood flow, clotting, inflammation, and the immune response. And endothelial cells love purple grape juice whether it's fermented or not.

Persons with arterial disease such as hypertension or atherosclerosis are known to have endothelial dysfunction. In other words, their blood vessels are unable to expand normally in response to such things as exercise and cannot, therefore, efficiently increase blood flow and oxygen delivery when needed. Researchers are able to measure the health of the endothelium and its ability to increase blood flow by a simple test called flow-mediated dilation (FMD).

This test uses ultrasound technology to measure the diameter of the brachial artery at the elbow. A blood pressure cuff is then inflated on the forearm to the point where blood flow through the area is stopped. When the cuff is released, blood surges back into the forearm. Ultrasound is again used to the brachial artery, and the state of blood vessel health can be judged by the post-test expansion of this artery.

Fifteen patients with proven coronary artery disease were hooked up with daily grape juice over the course of 2 weeks(1). Prior to being juiced, these patients, as expected, demonstrated impaired FMD. After 14 days of Welches (and this must be concord grape juice), their FMD tripled. No such changes were observed in other studies conducted with OJ or grapefruit juice.

Grape juice kind of makes my skin crawl, but I drink it anyway. Pair it up with dark chocolate and oatmeal, and your endothelium will be relaxed, your arteries surging with blood.
_____
(1)Stein, JH et al. Purple grape juice improves endothelial function and reduces the susceptibility of LDL cholesterol to oxidation in patients with coronary artery disease. Circulation. 1999 Sep 7;100(10):1050-5.

Lotrel

Twofers --pills that include more than one blood-pressure lowering medication-- are a good choice for the treatment of hypertension even when the patient's blood pressure is not that hyper. Not only does the combo form eliminate one prescription co-pay and improve patient compliance, attacking hypertension with two different therapeutic approaches often achieves better control.

A popular and effective twofer pill called Lotrel has now become one of those 'stop the study' pills--therapy so effective that they stopped the study as it was no longer ethical to withhold the drug from the control group. This medication, now available in some strengths as a generic, combines an ACE inhibitor called benazepril (Lotensin) with a calcium channel blocker called amlodipine (Norvasc). Each of these drugs works in a different way to cause relaxation of the blood vessel walls. As a result, the same fluid volume (that would be the circulating blood) moves through a larger space causing a drop in pressure.

Here's what the Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial accomplished. Over 11,000 hypertensive subjects, all of whom were over 55, obese, and many were diabetic were put on one of two different twofer drugs: Lotrel or lotensin plus a diuretic. Those patients who took Lotrel were 20% less likely to end up with a stroke, heart attack, unstable angina, or a need for procedures to open their coronary arteries over the first 3 years of the study. These results were highly significant in this high risk group, and may well change our standard protocols for treating hypertension which has, until now, started with a diuretic then added on an ACE inhibitor.

Per ACCOMPLISH investigator Dr. Michael Weber: Right now, there is a recommendation that when you're putting together combination treatment for hypertension you need to normally include a diuretic as one of the two agents. I'm sure that recommendation will change.

My medical partner and I have long been impressed with the efficacy of Lotrel in hypertension control.

On the dangers of not drinking

This from Dr Jane Østergaard Pedersen National Institute of Public Health, Copenhagen:

Another important finding is that physical activity can reverse some of the adverse health effects associated with alcohol abstention. People who did not drink but whose physical activity was moderate or high had a lower risk of IHD [ischemic heart disease] than the inactive nondrinkers.

I just told a group of nurses yesterday that while moderate alcohol intake (from 1-14 drinks/week) decreased risk of heart disease and raised levels of HDL-cholesterol, we were not yet recommending that non-drinkers consider drinking. These Danish researchers analyzed 20 years of data from nearly 20,000 persons enrolled in the Copenhagen City Heart Study. They found that mortality from ischemic heart disease and all cause mortality dropped with physical activity or moderate drinking, but dropped most with those Danes who celebrated their post-exercise glow with a beer or two.

Pedersen concludes: "The lowest risk of death from all causes was observed among the physically active moderate drinkers and the highest risk as seen among the physically inactive non- and heavy drinkers."

So drink a little, move a lot. And if you don't drink, you gotta' move!
_____
1. Østergaard Pedersen J, et al. The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality. Eur Heart J. 2008; DOI:10.1093/eurheartj/ehm574.

Bystolic and stress

All stressed out and nowhere to run, no one to punch out. I was at a meeting yesterday, one of the most stressful meetings I've ever attended. My heart was pounding, I'm sure my face was red, and I had no recourse but to listen politely to the proceedings. If ever there was a stress test for my aging heart, that hour-long ordeal was it.

My forty-something year old patient lives a perpetual stress test. Caught in a years long legal battle with a former business colleague, he lives his life in a never-ending nervous fit. His heart pounds along at a resting heart rate above 110, his blood pressure is high, but the worst symptom, the one that brought him in 2 weeks ago, is how very, very hot he feels. He can scarcely stand indoor heating; his secretary suffers the open office windows while his wife piles on the covers in their breezy bedroom.

I have seriously entertained the notion that this poor fellow has an adrenal tumor, so intense are his symptoms. While waiting for his first round of tests to come back, I wondered if we might give him, his secretary, and his wife a break with beta blockers.

Originally developed for blood pressure troubles, beta blockers have since been tapped to control abnormal heart rhythms, protect heart muscle after a heart attack, and to combat performance anxiety. They work by competitively blocking cellular receptors for beta-sympathetic adrenal hormones such as norepinephrine which set off the 'fight or flight' response. As such, they can slow down the pulse and blood pressure response to stress. The problem with earlier versions of beta-blockers is that they blocked both beta-1 receptors responsible for cardiovascular changes and beta-2 receptors which, among other things, relax smooth muscle and dilate the airways (so you can get more oxygen to run away from lions, tigers, and meetings, oh my).

As my patient also has asthma in addition to more stress than any human should have, I needed a beta-1 selective agent that would not contribute to an asthmatic constriction of his airways. Lucky for us, the sales rep from Forest Pharmaceuticals had just left a big supply of Bystolic (generic name nebivolol) in our drug closet. I gave him a bottle and hoped that there would be no unexpected beta-2 blockade.

Here's the phone message I received 2 days later:

Said the pill you gave him works wonders. His heart rate went from 160 to 78, no more body heat, has not been using his inhaler, and his BP has gone down. He also has been working all day.

Now that is a wonder drug! I wonder why I didn't take one before the meeting from hell.

Flow-mediated vasodilation

They're not just passive pipes anymore. No longer do scientists view our blood vessels as mere conduits that carry blood from heart to bod and back again. The worthy endothelial cells that line our arteries and veins not only respond to signals from the kidneys and adrenal glands to dilate and constrict, they actively produce substances themselves that affect their functioning.

One way that researchers test the health of blood vessels is through an indirect method called flow-mediated vasodilation (FMV). This test, an indirect measure of the ability of the arterial system to respond to increased demand, is performed by pumping up a blood pressure cuff on the subject's arm to some intolerable level for a few minutes, releasing it, and then calculating the subsequent surge of blood flow through the brachial artery at the elbow with ultrasound technology.

A small study from Italy looked at the effects of a high-fat meal on blood vessel reactivity in ten postmenopausal women. The ladies were invited down to the lab for an 'oral fat load,' doubtless a large piece of tiramisu. At two hourly intervals thereafter, their FMV was measured. At baseline, the ladies sent nearly 8% more blood coursing through their fingertips after the cuff was removed. Two hours after the high-fat treat, this number fell by two-thirds, meaning that their blood vessels' capacity to dilate in response to increased blood flow fell by over 60%.

Theoretically, then, a high fat meal, whether consumed in a fast food joint or as part of an Atkins diet, can wreak havoc in an individual with unsuspected coronary artery disease. A burst of activity after the feast, say a sprint up the block to catch a bus, calls on diseased arteries to provide extra blood flow at a time when they are clamped down from a load of Nacho Belle Grande. When blood supply can't keep up with demand, the oxygen-starved portion of the heart can be damaged.

Air pollution, cigarette smoke, and early morning hours all can muck up your FMV. Vitamin E, oatmeal, dark chocolate, green tea, JuicePlus, and ACE inhibitors (a class of blood pressure meds that includes lisinopril and enalopril) all support your endothelial cells to expand on demand.

Beyond Zetia

This Zetia business seems to be rocking the cardiology world just like the Women's Health Initiative blew up conventional wisdom on hormone replacement therapy.

Cholesterol in the body comes from two sources: one pool manufactured in the body, and the other from the diet. Zetia is a drug that lowers LDL-cholesterol levels by partially blocking the absorption of cholesterol from the small intestine. Statins such as Zocor and Lipitor, on the other hand, decrease some of the activity of an enzyme that is important in the body's own cholesterol production. Zetia has been heavily marketed as a good drug for persons with high cholesterol who either can't tolerate statins or who don't reach their goal LDL-cholesterol levels on statins alone.

The ENHANCE trial found that persons taking the Zetia-Zocor combination for 2 years (aka Vytorin) did no better than those on Zocor alone with respect to unwanted thickening of their carotid arteries. As a result, not only are cardiologists taking sides in the Zetia/no-Zetia debate, now they're wondering if lowering LDL-cholesterol is even an important goal in the war against heart disease. Consider these varied opinions from the nation's top heart specialists:

The idea that you're just going to lower LDL and people are going to get better, that's too simplistic, much too simplistic.
Dr. Eric Topol, Scripps Institute

The message for me is not that lowering LDL cholesterol doesn't work to prevent disease progression or to prevent clinical events. The important thing to remember is how the cholesterol levels are lowered...There are many advocates out there who espouse lowering LDL cholesterol by any means possible. But let's be clear: 95% of the studies that form the basis for the cholesterol hypothesis are based on studies of statins
Dr. Steven Nissen, Cleveland Clinic

Anytime you can lower LDL-cholesterol levels safely, you are going to see reductions in the risk of clinical events.
Dr. Patrick McBride, University of Wisconsin

Per Dr. Nissen, the bottom line here is that statins not only lower LDL-cholesterol, but they also can raise HDL-cholesterol (a weensy bit), decrease triglycerides, and lower c-reactive protein or CRP. CRP is a pro-inflammatory molecule in the body; when present in elevated amounts, CRP not only is a marker for risk of coronary artery disease, the substance actually causes trouble in arteries whose walls are streaked with fat.

The Premarin drug rep started sneaking through our door after the 2002 WHI results were released, sheepishly bearing samples and M&M's. The Avandia reps don't even come around anymore. Come to think of it, haven't seen the smiling face of the Vytorin rep in the last week either.

Fretting to my grave

Here I sit at the computer obsessively checking the conditions at Denver International Airport and the latest predictions from Frontier about the outlook for flight 448 to Philadelphia. Fret, fret, fret. Will my daughter even get over the river and through the woods to DIA? Once there, how is the line at security? Did they properly deice the plane? Will they take off on time? Will her driver, my husband, successfully navigate the icy round-trip on I-70 without mishap?

Took a break from flight checks to check the latest from Psychosomatic Medicine. Scottish docs did some checking of their own on middle-aged Brits with respect to anxious neurotic behavior and their tendency to pitch over dead. Those who fretted endlessly in their own neurotic way were 12% more likely to keel over from cardiovascular disease than those devil-may-care devils who flitted through life without worry.

Those who were extroverted, however, were less likely to die of respiratory disease. Perhaps the socially ept are less likely to smoke? What about those of us who are extroverted AND neurotic? No comment from the researchers on that.

It pays to be a little hippie

Well, I used to be a little hippie, and life was good if not lucrative. These days, however, research suggests that those who wear dessert upon their hips have less risk of heart disease compared to those who waist their fat.

This 'apple' vs. 'pear' thing has been known for some time. Abdominal obesity--that fat which is packed under your abdominal muscles and around your organs--is metabolically active, producing inflammatory molecules such as c-reactive protein and interleukin-6 which hasten the formation of cholesterol plaque in the arteries. How do you know where your fat resides? Lie on your back. If your fat puddles off to the side, gotta love it as it's stowed beneath your skin. Does it sit firmly above your body in the supine position like a late-term pregnancy? That's the bad visceral stuff.

This study from the UK was published in the latest edition of Circulation. The Cambridge docs showed that waist-to-hip ratio was a more important predictor of heart disease risk than BMI*. In other words, given similar degrees of overweight, the bigger the hips relative to the waistline, the less the risk of keeling over with a heart attack.

The researchers took it one step further. Even considering various cardiovascular risk factors like smoking and age, their analysis indicated that for every increase of 2.5 inches in hip circumference for men and for roughly 3.5 inches in women, risk of developing CHD was reduced by 20%.

If you're thinking what I was thinking, Dr. Dexter Cannoy has a final note of caution for both of us: We're not saying people should develop a big hip circumference to protect themselves from risk, but for any body size, those with bigger hips tended to be associated with lower risk...
_____
*BMI combines height and weight in a single number and, on average, the higher the BMI, the higher the body fat except in the well-muscled young.

Pulse pressure

If you're a little stiff from aging--in an arterial sense--new data from the Baltimore Longitudinal Aging Study suggests that you are at increased risk of memory troubles.

Here's one more vital sign to add to your life list: pulse pressure. This is the difference between the top and bottom numbers of your blood pressure. The top number or systolic blood pressure is that pressure generated by your heart as it squeezes blood from the left ventricle into the aorta and from there to the rest of your body. The diastolic pressure on the bottom represents the residual pressure in your vascular system as the heart relaxes and refills with blood in preparation for the next beat. Whether the top or the bottom value is more relevant to your health and length of life has been a matter of some debate through the years, but the systolic one is now generally accepted as most important. That said, not only is diastolic hypertension also of interest, but the gap between systolic pressure is increasingly noted as relevant to future stroke risk.

So, ideal blood pressure is less than or equal to 115/75. The difference, 115-75 or 40, is the pulse pressure. As people age and get all sorts of fat-laden schmutz in the walls of their arteries, this difference widens. Interestingly, while 170/110 (pulse pressure 60) would make your doctor pale, 170/70 (pulse pressure 100) is even worse yet.

Maryland docs studying Maryland old folks as part of the Baltimore Longitudinal Aging Study looked for a correlation between memories lost and pulse pressure. Sure enough, increasing pulse pressures and higher pulse wave velocity* were directly correlated with decreasing memory and concentration functions in aging individuals.

No more of those "at least your bottom number's okay" sort of reassurances of yore. The current goal is to keep the arteries pliable from the get-go by jumping all over cardiovascular risk factors such as blood pressure and cholesterol values. Those strategies that keep the arteries elastic--such as exercise and eating oatmeal--and those meds that directly promote endothelial cell health (those are the little hummers that line your blood vessels) such as ACE inhibitors are top of our A-list.

_____
*The mountainous curve which can be traced graphically from the pulse in your wrist as a wave of pressure goes by with each beat of the heart; the steeper the mountain, the bigger the difference between systolic and diastolic.

Quality of sleep

This is one of those QoL inquiries that I ask early on in my annual physicals. Along with 'how's your energy' and 'are you having any fun?', I feel like these quality of life questions give me a good starting place for assessing my patients' general health. N-QoL (nocturnal quality of life) is one of those fancy catch phrases that medical researchers love. Embedded in your N-QoL is your QoS (quality of sleep of course) and your HUS (hours of uninterrupted sleep).

The urological investigators particularly seek information on HUS as a measure of bladder capacity in men with enlarged prostates. A bulgy prostate partially squashes the urethra. A full bladder generates a certain amount of pressure as it contracts to send urine out the urethra. Pressure falls as the bladder empties, and at a certain point, the pressure is too low in the partially emptied bladder to shoot urine through the narrowed urethra. As a result, men with benign prostatic hypertrophy--an enlarged prostate-- incompletely empty their bladders. They have less bladder capacity for newly-manufactured urine heading down from the kidneys and, therefore, a need to void more frequently. This obviously impacts their N-QoL.

Drugs also impact our N-QoL. I love my improved QoS from melatonin and natural progesterone both of which improve QoD (dreaming). Nexium gives me nightmares. Recent evidence suggests that simvastatin (aka Zocor) can also produce nightmares and reduce QoS. Simvastatin is a lipophilic (fat loving) drug as opposed to pravastatin which loves water. We are all fat-heads insofar as our brain is largely made up of fat, so simvastatin crosses into brain tissue where it may adversely affect sleep in some. As sleep gets a little dicey with aging, simvastatin may not be a good choice of drugs for those with QoS issues.

Exhausted arteries

My mom lives in a condominium complex with a beautifully landscaped central area, complete with pond. As you walk the grounds, a background roar suggests the wind or sea but is, in fact, the traffic noise of I-25 just behind the high wall surrounding the complex. Out of sight may be out of mind, but the arteries within may never forget that highway nearby.

German researchers studied nearly 5,000 subjects living in the industrialized Ruhr area(1). The participants underwent electron-beam computed tomography or heart CT scans to determine their degree of coronary artery calcification (CAC) which indicates the level of cholesterol build-up in arteries. The investigators found a significant correlation between CAC scores and the proximity of the nearest highway to the subjects' homes.

Immunologists at UCLA determined the underlying mechanism of this relationship between urban air pollution and risk of heart disease(2). In both human artery tissue samples and in mice, these California docs determined that diesel particles plus LDL-cholesterol leads to more severe atherosclerosis than either soot or cholesterol alone. Both arterial irritants cause the release of 'free radicals' or reactive oxygen molecules known to be highly damaging to human tissue.

My guess is that the summer air here in Denver that hangs visibly through the trees on a hot summer day is the equivalent of living next to I-25 with respect to our heart's health.
_____
1. Hoffmann B et al. Residential Exposure to Traffic Is Associated With Coronary Atherosclerosis Circulation. 2007;0: CIRCULATIONAHA.107.693622
2. Nel a et al. The cellular impacts of diesel exhaust particles: beyond inflammation and death. Eur Respir J. 2006 Apr;27(4):667-8.

Chlorthalidone for blood pressure

I'm not joking about this issue. It is easier for doctors to write HCTZ than to write chlorthalidone, even though study after study has shown that chlorthalidone is a better drug...if you want to prescribe chlorthalidone, you have to write out all 14 letters.
---William Elliott, MD Rush Presbyterian St. Luke's Medical Center in Chicago

So are we docs really that lazy that 10 letters come between us and better care for hypertension? Sort of, that and habit--always have written for the water pill HCTZ (hydrochlorothiazide) and always will. Also the lack of recent literature on the superiority of chlorthalidone (man I don't even like typing that sucker) AND the fact that all the standard twofer drugs for hypertension as in two drugs in one tablet are HCTZ plus whatever. Except for Tenoretic which is now known as atenolol/chlorthalidone which is even a bigger drag to write out.

At least three large studies have shown that patients on CTD (there, see, it can be abbreviated) have better outcomes than those on HCTZ with respect to blood pressure control and, more importantly, 58 percent less coronary heart disease and 41 percent fewer deaths.

Am I going to start writing for CTD? Not only does that mean all those extra letters all day long, it means pulling out the other med (lisinopril, Diovan, Cozaar to name a few) and writing out all those letters in a separate script along with the one for CTD plus asking patients to cough up an extra co-pay as the twofer becomes two.

Where's the Acomplia?

This drug, generically known as rimonabant, is an endocannabinoid receptor blocker. Do you recognize that word in there--cannabis as in marijuana?

All that is pleasurable in an illegal sort of way mimics some function in the body that causes good vibrations through the central nervous system. As some of you who once inhaled your way through your youth may remember, marijuana not only feels good but causes enormous craving for and pleasure in eating. Block those cellular receptors that hook up with marijuana, and research suggests you can mash the munchies and lose the weight.

Acomplia looked like just what the doctor ordered for those expanding midlife waistlines resulting from years of overeating. Studies suggest that not only can weight be lost, but the metabolic syndrome, a dangerous body state contributing to diabetes and heart disease, can be reversed as well through use of this drug.

Unfortunately, we've got endocannabinoid receptors for more reasons than just enjoying the occasional funny cigarette. Data now suggests that blocking those feel-good receptors increases risk of depression and suicide. The FDA continues to investigate these unwanted outcomes of the drug, and Acomplia's approval is not expected in this country any time soon.

I recently had a slim and fit sixty-something year old lady come in for a discussion on her elevated cholesterol. While her total and LDL-cholesterol were notably high, her protective HDL-cholesterol levels were elevated as well in a satisfying sort of way.

The first step in determining whether or not she should be on cholesterol-lowering meds involved totaling up her risk factors for coronary artery disease according to guidelines issued by the National Cholesterol Education Program(1):
__________

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

* Cigarette smoking
* Hypertension (BP greater than or equal to140/90 mmHg or antihypertensive medication
* Low HDL cholesterol (<40 mg/dl)*
* Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years)
* Age (men greater than or equal to45 years; women greater than or equal to55 years)

* HDL cholesterol greater than or equal to60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.
__________

According to our calculations in her situation, she had zero risk factors as her HDL-cholesterol of 87 canceled out her age of 62. Her goal LDL-cholesterol was less than 60, and the recommended level at which to use medication was greater than 190.

Her LDL-cholesterol was 197. She, as so many people are, was reluctant to start drug therapy. Off she went, instead, to Colorado Heart & Body Imaging for a $395 CT scan of her heart. The news was not good--she had a fair amount of calcifications in her coronary arteries, correlating with more plaque in those vessels than 90% of women her age.

She started treatment with Lipitor yesterday.

_____
1. See NHLBI, ATP III At-A-Glance for the complete algorithm.