MARCH 19, 2012
Lisa Nainggolan 

London, UK - A 23-year-old British soccer player remains in critical condition in the hospital today after suffering a cardiac arrest during a game on Saturday evening. Fabrice Muamba, who plays midfield for the club Bolton Wanderers, collapsed in the 41st minute of the match at Tottenham in London and was quickly attended by doctors for both clubs, as well as a consultant cardiologist who happened to be in the crowd, Dr Andrew Deaner(London Chest Hospital), who reportedly insisted that the player be taken to his specialist unit.

Muamba received prolonged resuscitation on the ground and en route to the hospital, where his heart eventually started working. The quick treatment he received has been praised. He is still under sedation in intensive care at the London Chest Hospital.

The case has received unprecedented media attention and led to calls for universal national screening of soccer players and other athletes in the UK, as is done in Italy. However, as it's likely that Muamba—as an elite soccer player—would have been screened, one cardiologist told heartwire she believes he may have a very rare condition.

Dr Sarah Clarke (Papworth Hospital, Cambridge, UK), vice president of education and research at the British Cardiovascular Society, says: "[Muamba] would have been deemed fit and healthy from what we can gather; his heart is to all intents and purposes normal, so this has to be more of an electrical or electrolyte imbalance or an ion-channel abnormality, one of those rare genetic problems that can present in this way." It's important to note that "less than 1% of cardiac arrests that occur out in the community will be this healthy-heart/ion-channel electrical-abnormality group, of which we are surmising—from what we know—that he is likely to fall into," she says.

Dr Stephen Cox (Cardiac Risk in the Young [CRY], Tadworth, UK) told heartwire that, in the UK, 12 people under the age of 35 die every week, or 600 per year, from sudden cardiac death.

More widespread screening would help identify more affected individuals and save lives, he says. But he too believes Muamba would "have been screened because he was a [Football AssociationAcademy player, and they have a strong screening program, and it's not just ECG, he would have had ECG and echo as a routine. They are one of the few sports [in the UK] to have instigated it to that level."

But "there are certain conditions that will not be detected through screening," Cox added. CRY's consultant cardiologist, Dr Sanjay Sharma (St George's Hospital, London), who runs Britain's only cardiac unit for sportspeople and who is official cardiologist to the London 2012 Olympic Games, told the Independentnewspaper that 80% of conditions causing sudden death will be picked up by screening. "I am surprised the heart problem was not picked up. The medical screening these players get is extremely comprehensive".

Muamba was born in Kinshasa, Democratic Republic of the Congo, and came to the UK at the age of 11 after his father was granted political asylum here. Asked whether Muamba's background might hold any clues as to what happened on Saturday, Cox said that any heart damage, such as myocarditis from rheumatic heart disease, would have been seen on echo: "Something like that would have been identified on screening."

Cox added that one of the areas of research at his organization involves looking at ethnicity and how this affects the interpretation of ECG and other screening.

In 2005, the European Society of Cardiology recommended screening of young people taking part in competitive sport, a move that was then endorsed by the International Olympic Committee (IOC), says Cox.

Obtained from heartwire...
http://www.theheart.org/article/1371249.do 

 
MARCH 12, 2012
Lisa Nainggolan

Boston, MA - Sugary drinks are associated with an increased risk of coronary heart disease (CHD) as well as some adverse changes in lipids, inflammatory factors, and leptin, according to a new analysis of men participating in the Health Professionals Follow-up Study, reported by Dr Lawrence de Koning (Children's Hospital Boston, MA) and colleagues online March 12, 2012 in Circulation [1].

"Even a moderate amount of sugary beverage consumption—we are talking about one can of soda every day—is associated with a significant 20% increased risk of heart disease even after adjusting for a wide range of cardiovascular risk factors," senior author Dr Frank B Hu (Harvard School of Public Health, Boston, MA) toldheartwire. "The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda, not only in the US but also increasing very rapidly in developing countries."

The researchers did not find an increased risk of CHD with artificially sweetened beverages in this analysis, however. "Diet soda has been shown to be associated with weight gain and metabolic diseases in previous studies, even though this hasn't been substantiated in our study," says Hu. "The problem with diet soda is its high-intensity sweet taste, which may condition people's taste. It's still an open question whether diet soda is an optimal alternative to regular soda; we need more data on this. "

Hu says water is the best thing to drink, or coffee or tea. Fruit juice is "not a very good alternative, because of the high amount of sugar," he adds, although if diluted with water, "it's much better than a can of soda," he notes.

And Hu says although the current results apply only to men, prior data from his group in women in the Nurses' Health Study [from 2009] were comparable, "which really boosts the credibility of the findings."

Inflammation could be a pathway for impact of soda upon CHD risk
Hu and colleagues explain that while much research has shown a link between the consumption of sugar-sweetened beverages and type 2 diabetes, few studies have looked at the association of these drinks with CHD.

Hence, they analyzed the associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (MI) in 42 883 men in the Health Professionals Follow-up study. Beginning in 1986 and every two years until December 2008, participants answered questionnaires about diet and other health habits. A blood sample was provided midway through the study.

There were 3683 CHD cases over 22 years of follow-up. Those in the top quartile of sugar-sweetened-beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (RR 1.20; p for trend <0.001) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body-mass index, preenrollment weight change, and dieting.

Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes only slightly attenuated these associations, which suggests that drinking soda "may impact on CHD risk above and beyond traditional risk factors," say the researchers.

Consumption of artificially sweetened drinks was not significantly associated with CHD (multivariate RR 1.02; p for trend=0.28).

Intake of sugar-sweetened drinks, but not artificially sweetened ones, was also significantly associated with increased triglycerides and several circulating inflammatory factors—including C-reactive protein, interleukin 6 (IL-6), and tumor-necrosis-factor receptor 1 (TNFr1)—as well as decreased HDL cholesterol, lipoprotein (a) (Lp[a]), and leptin (p<0.02).

"Inflammation is a key factor in the pathogenesis of cardiovascular disease and cardiometabolic disease and could represent an additional pathway by which sugar-sweetened beverages influence risk," say Hu et al.

Cutting consumption of soda is one of easiest behaviors to change
Hu says that one of the major constituents of soda, high-fructose corn syrup, is subsidized in the US, making such drinks "ridiculously cheap" and helping explain why consumption is so high, particularly in lower socioeconomic groups.

"Doctors should set an example for their patients first," he stresses. "Then, for people who already have heart disease or who are at high risk, physicians should be advising them to cut back on sugary beverages; it's almost a no-brainer, like recommending that they stop smoking and do more exercise. The consumption of sugary beverages is a relatively easy behavior to change."

And although this particular study included mostly white subjects and there are few data on the risk of cardiovascular disease associated with the consumption of soda in people of other ethnicities, there are data on its effect on type 2 diabetes in these groups, he says.

"It has been shown for minority groups—such as African Americans and Asians—that they are more susceptible to the detrimental effects" of sugary drinks on diabetes incidence, he notes.

Obtained from heartwire...
http://www.theheart.org/article/1368375.do 

 
Howard S. Weintraub, MD
Posted: 03/06/2012

Video:  http://www.medscape.com/viewarticle/759735?src=emailthis 

I am Dr. Howard Weintraub, a cardiologist at the New York University Langone Medical Center, where I am Clinical Director for the Center for Prevention of Cardiovascular Disease. I want to thank Medscape for asking me to comment on what is probably a very important recent US Food and Drug Administration (FDA) decision. They called it a "crucial decision" that offers a reworking of the product insert for a very important class of drugs: statins.

The use of statins has expanded to phenomenal proportions in this country and around the world. This class of drugs has been very influential in allowing for reductions in the development of cardiovascular disease -- stroke and myocardial infarction (MI) -- by slowing the progression of atherosclerotic plaque and preventing mortality from stroke and MI.

Use of statins is no longer confined to older individuals or patients whom you would think of as "older." Statins are used more widely in individuals in their 20s, 30s, and certainly in their 40s and 50s. Individuals are now being treated with statins in adolescence. The safety of this class of drugs has very important implications when it is being prescribed to patients who haven't reached their 20th birthday.

The concerns voiced by the FDA were fourfold. One concern was that we should abandon compulsory performance of liver function tests. Many of us in the cardiology community have known about this for years. When you look at the mortality from liver disease in patients with previously normal livers who then start taking statins, this number is infinitesimally small. In their infinite wisdom, the FDA recognized this and chose to remove this obligation. They do request that a blood test looking at liver functions be performed before the drug is started.

The FDA also calls attention to data that show that statins may raise blood glucose and hemoglobin A1c levels. The latter are more long-term blood sugars that provide a better idea of the 24-hour balance of blood sugars over the course of days, weeks, and months. This is very important because when a single blood test is performed in the fasting state, patients can prepare for this blood test and eat the right way in the hours before the test and perhaps have an inappropriately low blood sugar that does not reflect their true glycemic risk.

Nonetheless, the possibility of raising blood glucose is concerning, certainly for younger individuals, but particularly for those who are at risk of developing diabetes, and this has raised many questions. However, the unambiguous data show that in patients with and without diabetes, as well as in those whom we can call "diabetics in training" (those with metabolic syndrome), evidence for the benefits of statin drugs has been unambiguous and very forceful. Ultimately, despite a mild change in certain laboratory parameters, where the rubber meets the road, we want to prevent heart attacks and strokes, prevent the development of atherosclerosis or slow its progression, and reduce mortality.

The third concern, something that also affects younger individuals, is cognitive impairment. I find that people who are particularly worried about taking medicines in general are focusing on this with even greater intensity because they want to use any excuse they can to avoid taking a drug. I can understand this fully; however, at the same time, we have to hark back to the benefits of statins and hope that the physician has put the patient on the statin drug for a good reason.

Nonetheless, isolated reports (not based on mechanism of action because this has not been established) maintain that in some people on statins, cognition slows, and they may develop some changes in short-term memory. This can occur as early as 1 day after starting the statin, according to some reports; but more commonly it takes longer -- up to 1 year -- after the drug is initiated.

The good news is that these changes are generally mild and tend to disappear within 2-3 weeks of stopping the drug in patients in whom the statin is not a hugely important issue. However, you don't want patients who just received a stent or had an MI or a stroke to go on and off statin drugs without a very good reason. Most people who are taking statins for the prevention of disease can safely come off the statin for a couple of weeks to see if the symptoms that have been troubling them abate. If not, it may simply be that the patient is living in a very stressful environment, and their cognition may be impaired as a consequence of their stress levels or other issues.

Finally, the FDA made what I feel to be a very well-deserved change in the product insert for lovastatin. You may recall that lovastatin's "stable-mate," simvastatin, received a similar going-over (appropriately, I think), and use of the drug in its very highest dose (80 mg) was limited on the basis of 2 studies (SEARCH and A TO Z). Lovastatin, which is very similar to simvastatin, should not be used in combination with many of the antiretrovirals, antifungals, and certain macrolide antibiotics and their derivatives.

Also important for internists and cardiologists are the restrictions on other antihypertensive drugs, particularly calcium channel blockers like verapamil, amlodipine, and diltiazem. In my opinion, with the other drugs that are generically available in the statin class, this should steer us to other safer and probably more potent statin drugs, the same way that we have begun to steer away from simvastatin in individuals who require 40 or 80 mg and are on confounding medications.

I want to encourage physicians to not become spooked by this change in the product insert. I want to even more strongly encourage patients to not even think about coming off medications without discussing it with their healthcare practitioner. You should have a good relationship and a bond with this individual so you can talk with him or her about what is best for long-term and short-term prognosis. It is very important to not change these medications because, in many individuals, the degree of lowering of low-density lipoprotein cholesterol and triglyceride, and small elevation of high-density lipoprotein cholesterol, can't be duplicated with lifestyle modifications (diet and exercise).

These drugs have been shown to be phenomenally safe. If you look at the history of these drugs, there was concern early on that lovastatin might cause cataracts. This, too, was dispelled. We rely on this class of drugs. In the setting of rampant obesity, and with type 2 diabetes ascending, these drugs have managed to keep mortality and the development of cardiovascular disease at the levels that we have now.

It is important that we listen to these recommendations and to calm, sensible knowledge, and understand that statins are very good drugs that should be continued in appropriate patients.
Obtained From MedScape...
http://www.medscape.com/viewarticle/759735?src=emailthis