Do coronary artery stents work?

Stenting the coronary arteries for angina is one of the most commonly performed procedures performed today.
There is no debate that in patients with unstable angina (chest pain at rest or about to have a heart attack,) stenting is lifesaving. There is however some discussion on whether cardiologists are stenting more patients than they should. For example there is no evidence that it increases mortality or recurrent heart attacks, but until recently we have always believed that it reduced pain.

In the last few days a recent trial called OBITA has suggested that stenting for single coronary artery disease may be no better than a dummy procedure. In this study, 200 patients in the United Kingdom with only one narrowed coronary artery, were either stented, or had an angiogram but no stent, and then were followed up. At 6 weeks there was no difference in the patient's assessment of angina. (There was however improved exercise time, evidence of ischaemia (poor function) on stress echocardiogram, and the patients who had the dummy procedure were on more medications.

Nevertheless this has ruffled many feathers in the cardiac community.
While waiting for more evidence, what can we say?
1. Angioplasty and stenting is effective and lifesaving in patients with unstable angina.
2. The study was only for single coronary artery disease, and cannot be applied to patients requiring multiple stents.
3. It does mean that we shouldn't be so eager to step in and stent everything, if the patient is not getting a lot of angina (in the study this was the case), just because we show a narrowing in one coronary artery does not mean it should be stented.
4. Stenting is still the treatment of choice if the patient is getting a lot of angina, despite optimal medical treatment.

I believe this study simply confirms that we are stenting to many patients, but there is a real role for using this procedure as part of good cardiology management.

Another benefit of aspirin – cancer prevention.

There is much debate on the value of the humble aspirin, and decade ago it was suggested that everybody over the age of 40 should be taking an aspirin tablet, it does seem to reduce the risk of heart disease and strokes but slightly increases the risk of bleeding, and currently most people believe that only those with definite heart disease or stroke should be taking it.
But a recent presentation from China suggests that aspirin might reduce the risk of cancer.
They followed over 600,000 people for 7 years, and those taking aspirin long-term had a 47% lower risk of liver and oesophageal cancer, 30%  of gastric cancer, 34% pancreatic cancer and 24% less leukaemia and colon cancer. (click here)
These are fairly spectacular numbers, I think the study needs to be repeated and analysed more before we recommend people take aspirin to prevent cancer, but certainly it gives another potential benefit from taking this drug.   Perhaps those with a family history of these forms of cancer could consider taking a small dose (100mg) daily with food.   Its only real risk is to increase the risk of bleeding, and that risk is very small.

Cholesterol – good or bad?

Cholesterol is a crucial compound in our body, making up a lot of our cell wall, many hormones and most of our brain. High levels of cholesterol (even mildly raised cholesterol) have been blamed for causing heart disease and stroke, and the pharmaceutical industry has been creating more and more powerful drugs to lower cholesterol. Is this good, or is it in fact doing us harm?

Cholesterol is a very hot topic in medicine, unfortunately vested interests and misinformation has given us a very confusing picture. If you would like to understand the background to this and the reasons for my recommendations then read the next few paragraphs (in italics) , if you want my recommendations, skip this and go down to "my thoughts on the topic."

The theory that dietary saturated fat was the principal cause of elevated serum cholesterol and heart disease comes from some research in the 1950s by an American scientist Ancel Keys. This theory was embraced by the American Heart Association.
At the same time however another scientist Johnny Yudkin argued that sugar intake was more closely related to heart disease and mortality.
Both of these were observational studies of populations, and both results were possible because most people who ate saturated fats also ate a lot of sugar. (Humans have always been carnivorous, carbohydrates became a major component of their diet 10,000 years ago, and sugar a pure carbohydrate with all the fibre and nutrition trimmed out has been part of the diet for just 300 years). The Ancel Keys 7 country study showing that those countries who ate most saturated fat have the highest levels of heart disease convinced the cardiac community and has done so ever since, even though one of his co-authors (Alessandro Menotti) later reanalysed the data and showed that the food people ate in the study that was most closely related to deaths from heart disease was not saturated fat but sugar. However the horse had bolted from the stable, and saturated fat has been targeted as the main cause ever since!

The reason for this rather confusing introduction is to show that medicine really has not made up its mind on the status of saturated fat, cholesterol and heart disease. In fact in early 2017 there was a paper written by Malhotra stating "saturated fat does not clog the arteries, coronary artery disease is a chronic inflammatory condition which can be effectively reduced by healthy lifestyle interventions", and in response to this has been a flood of papers defending the saturated fat theory.
Unfortunately big business, butter and sugar manufacturers and most importantly companies making cholesterol-lowering drugs have all stirred the pot, and it is almost impossible for doctors and laypeople to make sense of it. (Unfortunately for the sugar hypothesis, there are no companies making sugar lowering drugs, people simply have to eat less sugar, and thus the cholesterol lowering drug manufacturers have a clear advertising field.)

My thoughts on the topic –

I don't think there is any doubt that coronary artery disease is due to inflammation causing cholesterol to build up the artery walls. If you have a very high cholesterol it is easier to build up, but not so for mildly high and normal levels. The major cause of inflammation is oxidation and free radicals, and this is made worse by a diet high in sugar, and obesity.
What is the best diet? – The Mediterranean diet which is high in monounsaturated fats, moderate intake of saturated fat, low in sugars is probably the healthiest. There is no doubt that trans-fats found in processed foods and high sugar are undesirable and should be avoided. Natural foods containing saturated fats such as butter cheese are much healthier and better than artificially created margarines etc.

• Should I eat saturated fat? My answer to this is yes, but not in huge amounts.
• What about sugar? I personally feel, along with many others that this is the major problem in the world today, and we should remove as much sugar from our diet as we possibly can, particularly in our children. Obesity leading to diabetes is going to be the Grim Reaper of our children unless we do something about it, and that is our role as parents to change. Children must be brought up to enjoy drinking pure water, not soft drinks, energy drinks and flavoured milk.
• What about cholesterol-lowering drugs? There have been numerous studies over the years trying to reduce heart disease with diet, bile acids sequestrants (which trap the cholesterol in our gut) and many drugs. None have showed any reduction in heart disease with the single exception of the statin drugs. This does suggest that it is not cholesterol that is the major problem, and lowering it is not the way to go.
• Statin drugs – these have become the most profitable drugs of all time, and at one stage it was suggested that everybody over the age of 50 should be taking a statin. I have written a page on statin as well, but in brief statin drugs do appear to reduce the incidence of heart disease by between 15 and 25% depending on the study. Almost certainly they do this through some mechanism other than lowering cholesterol, probably as an antiinflammatory. However if you have a high risk of heart disease (previous heart attack, angina, angioplasty or bypass surgery, have demonstrated coronary disease on angiograms or CT scan, or have a very high cholesterol and/or family history of heart disease), then taking statin drugs will reduce your risk of having a heart attack or death by between 15 and 25%. These drugs do have side-effects but most can be detected, and if you are at high risk my recommendation would be to take the drugs but stopped them if significant side-effects occur.

So there we are, you're probably more confused than when you started reading this page, but welcome to the crowd.
In my opinion concerning heart disease – sugar is the major problem followed closely by trans fats, obesity, lack of exercise, refined food and not eating enough fruit and vegetables.
For primary prevention I believe reversing these is the best approach. If you have definite heart disease, I would avoid all of these and probably take a low dose of a statin drug provided it does not cause significant side-effects.

These headlines are NOT TRUE - 

Always read the small print in supplement trials!

The results of 2 recent trials have caused international headlines – claiming multivitamins do not work nor does vitamin D.
This information actually comes from 2 studies which are far from conclusive.

Multivitamins and heart disease – this is a huge study (in part funded by Pfizer) looking at doctors in the United States aged 50 years and over. 13,316 doctors were either given multivitamins (Centrum Silver) or dummy tablets and followed for 13 years. Their conclusions was slightly strange – "there was no consistent evidence of various foods, nutrients, dietary patterns or multivitamins on cardiovascular disease in points. However there were statistically significant interactions between multivitamins and B6 and heart attacks, multivitamins and vitamin D on cardiovascular mortality, and multivitamins and B12 on cardiovascular and total mortality." Then commented however that these patterns were inconsistent, and thus ignore them. They also concluded that future studies are needed.
This is not the message that the public have received.

Questions that could be asked:
1. Doctors on the whole eat well if not perfectly, and are probably the least likely populations needing multivitamins.
2. Is Centrum the best multivitamin to recommend?
3. They did show benefits on heart attacks, heart and total deaths, why did they chose to ignore them?

The 2nd study is equally puzzling, it comes from a New Zealand group studied the benefits of vitamin D and heart disease. Just over 5000 people were in this general practice study, half received monthly vitamin D 100,000iu and the other half dummy tablets for 3 years. This appeared to have no effect on cardiovascular disease. They concluded "this result does not support the use of monthly vitamin D supplements, the effects of daily or weekly supplementation requires further study."
Again this is not the message that has been publicised.
Questions that could be asked:
1. Is 3 years ready long enough to have an effect?
2. The quality of general practitioner studies is often patchy.
3. Were we ever designed to receive 100,000 international units of vitamin D monthly? This equates to 71 tablespoons of cod liver oil or 19 L of milk drunk on the 1st of the month, and then none for 30 days!

Once again the publicity against supplements shows very biased reporting.

To Pee or not to Pee?

How to make bladder catheterisation less painful.

A strange title for a web page, but many or most of us will be catheterised or have friends undergoing what is often a very painful procedure. This little gem which I read in a recent medical Journal is something I thought I should share.
We have two muscuar valves leading out of the bladder stopping the urine from leaking, and usually these are closed. They open when we go to the toilet. They are not designed to allow a structure like a small snake to pass backwards up into the bladder, and tend to slam shut. Pushing past these closed valves causes most of the pain during urinary catheterisation.
Doctors, nurses, house surgeons, medical students have been instructed to tell patients to cough or breathe slowly and deeply when the catheter cannot get past the valves - none of these work. Why should they? Why not ask the patient to open the valves by peeing?
Nobody has ever suggested this before, how can we have been so obtuse? In a recent paper in the Journal Urology (April 2017) in just under 100 patients having a catheter inserted, half were asked to lie back and grin and bear it, and half were asked to try to pee while the catheter was being inserted. The pain in the Peeing group was less than half that of the others (41%).

Almost certainly none of the people trying to catheterise us with have read this article, so just share this information if you know that one of your friends or yourself will be having this procedure. While the doctors/nurses/medical students struggle down one end, you just lie there and gently try to pee, they will never know.

To continue Shakespeare's soliloquy – "whether tis nobler in the mind to suffer" – the answer is NO!

Phytochemicals

Phytochemicals 

These are chemicals from plants (phyto is Greek for plant)  Polyphenols, phytochemicals, flavanols, bioflavonoids etc are names which cause a lot of confusion.

Polyphenols:
The most studied class of phytochemicals are polyphenols because of their potential health benefits. There are numerous polyphenols (poly means many, phenols means benzene rings) which come from different plants and have different actions. 

• Phenolic acids – blueberries, tea, cereal grains.

• Stilbenes – the best known of these as resveratrol found in red wine, it is quite poorly absorbed.

• Lignans are found in flaxseed which may have some oestrogenic properties.

• Flavonoids (also called bioflavonoids) are named for the yellow colour and are found in flowering plants and fruit and vegetables. Flavonoids cause the colour and taste of foods, and have an antioxidant effect on fat, vitamins and enzymes.
  Flavonoids are divided into 6 subclasses many of which have confusingly similar names:
• Flavonols – found in onions, curly kale, leeks, broccoli blueberries, red wine and tea. Its production stimulated by sunlight and so its highest concentration is in the outer parts of the plants.
• Flavones - are found in parsley and celery
• Flavanones - are found in citrus fruits, tomatoes, and plants such as mint.
• Isoflavones - these have a structure similar to oestrogen, and are often called phytoestrogens. Most are made from soy and soy products.
• Flavanols - these are found in green tea, chocolate, red wine, apricots and other fruit. Also in fruits such as grapes, peaches and berries, and also cause the bitterness of chocolate.
• Anthocyanins - . These are pigments creating the blue purple red and pink colours of 4 hours fruits and vegetables.

Many variables affect the amount of polyphenols found in food, including the degree or ripeness at harvest, the rainfall, the sun exposure, how they are stored and how they are cooked.The polyphenols are designed to protect plants from oxidation, toxins and damage, and by consuming them, we can achieve some of these benefits.
The still is quite a lot of scepticism in conventional medicine on their value when taken the supplements, although there is no debate that we should all be eating plenty of fresh fruit and vegetables on a regular basis. The difficulty is to obtain polyphenols that have been growing correctly, picked at the right time, not over processed or over cooked and are available all year round. For this reason a quality supplement which is well absorbed containing these products should also be beneficial, but does not replace the need for fresh fruit and vegetables as well.

STATIN DRUGS

One of the most frequent questions I am asked as a Cardiologist and physician is – do I really need to take Statin drugs?  On one side doctors are suggesting they be incorporated in a polypill which everyone should take, to other more ‘naturally based’ experts saying they do not work and people should not take them (click here)

This article is my assessment from the current medical literature, and the advice I give to my patients.  Because the article is quite long, I will put my conclusion first as well as at the end, but I would recommend that you read the reasons for my conclusions as well.

My Conclusion – sifting through all of the data below, my recommendations are relatively simple:

1. If you have proven cardiovascular disease (heart attack, angina, stroke, angioplasty, high levels of calcium in cardiac CT scan) then you should take a statin drug preferably at a low dose. This would reduce your risk of a heart attack, stroke or death by about 20%.

2. If you get any side-effects – muscle pain, abnormal liver function tests, or you feel that your mental function has deteriorated, stop the drug for a couple of months, and then restart. Possibly consider restarting with a water-soluble statin such as pravastatin. If the symptoms recur then don't take the statins anymore.If you feel fine, then continue the statin. There is little evidence showing that any other cholesterol-lowering agent provides any benefit.

3. If you don't have cardiovascular disease (primary prevention) unless you have a very high cholesterol, diabetes or an extremely strong family history then I would not recommend that you take a statin drug. My advice would be to have a CT scan for calcium**  which will show early coronary artery disease, if this is strongly positive then maybe you should consider taking a statin drug. If it is negative or normal for age, then I would not take a statin.

4. For elderly people the benefits of statins do continue, but if there is any suggestion of impaired mental function, then stop taking the statin.

5. If you are taking a statin, you must be taking the supplement coenzyme Q 10, at least 100 mg daily.