Dr John M

cardiac electrophysiologist, cyclist, learner

CW: Omega-3 Fatty Acids–Part 2

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The Biology of Omega-3 fatty acids: (Just a little science:)

When fish, flax-seeds or Brussels sprouts pass through the intestine, pancreatic enzymes transform the fat to free fatty acids. These acids are quickly taken up by the cells. Once in the cell, these fatty acids enter the mitochondria, endoplasmic reticulum and cytosol–places that you might recall because your mom helped you make a Cell sponge cake in 7th grade Biology.

In the cells, the Omega-3 fatty acids (ALA, DHA and EPA) exert their healthy influence in three major ways:

  • in the control of chemical messengers;
  • in the flux of ions—cell electricity;
  • in the smoothness and health of the cell membrane.

That’s enough about cells.

How do these (good) fats help our bodies?

Omega-3 fatty acids reduce Inflammation:

–Omega-3s get in the cellular (not phone) mix and end up competing with chemicals that cause inflammation—medical people say they antagonize bioactive mediators of inflammation.

–Newly-discovered by-products of Omega-3s are important in the resolution phase of inflammation. Biochem people call these chemicals, resolvins. All you have to remember here is this: to resolve (inflammation) is heart-healthy.

–When omega-3s are incorporated into the membranes of cells they do a lot of good: things like making the membrane more fluid and less sticky. For some reason, they even block genes that induce hardening of the arteries. (Genomic effects.)

Omega-3s benefit the heart: They…

–Reduce high triglyceride levels: In high doses (3-4 grams per day) one might expect a 20-30% reduction of triglycerides levels.

–Lower blood pressure and resting heart rate:

–Enhance heart rate variability: a more variable heart rate is a good thing.

–Mild inhibition of platelets: Less sticky blood reduces the risk of clots.

–Enhance insulin-sensitivity: This is a huge positive because greater insulin sensitivity means lower levels of insulin. Since insulin promotes hardening of the arteries, the lower the level of insulin, the better.

Do the seemingly beneficial biologic actions of omega-3s translate to a real benefit? What do clinical trials with omega-3s show?

Before I tell you about the Omega-3 trials, let me introduce the basics of how medical people judge whether the science shows that a treatment works.

Medical people call studies that look at hard endpoints, like heart attack, stroke and death, outcomes trials. Consider the example of a drug like Torcetrapib, a pill that reliably increased HDL levels. Since elevated HDL levels are associated with a lower risk of heart disease, it was assumed that the drug would be beneficial. But when outcomes studies were done on patients taking Torcetrapib, the higher HDL levels did not translate into benefit. In fact, the drug made people worse.

Ultimately then, the question with omega-3s, as it is with any medical treatment, is not whether bio-markers change, but whether people live longer, with fewer heart attacks and strokes.

With hard endcpoints in mind, let me tell you about a few of the major studies on Omega-3s and heart disease.

The DART trial (1989-Lancet) looked at 2100 patients after heart attack that were given only dietary advice. Amazingly, there was a 29% reduction in the death rate of those patients told to eat more fish.

A decade later, the GISSI-Prevenzione (1999-Lancet) investigators looked at 11,324 patients after heart attack who were given either Omega-3 supplements, Vitamin E, both, or neither. Subjects that took fish oil enjoyed a 20% reduction in overall death rate, and a 45% lower rate of sudden death. (Vitamin E had no benefit.)

The JELIS trial (2007-Lancet) looked at 18,645 Japanese patients with high cholesterol that were randomized to EPA supplements (1.8 grams/day) plus statins or just statins. Though the LDL level decreased equally in both groups, the EPA-treated patients had 19% fewer coronary events.

So far, all these studies considered high-risk patients or those with documented heart disease. When one looked at a group of lower risk patients, say 3000 men from South Wales with chest pain (angina), it turned out that those who received advice about eating more fish were more likely to die from a heart-related event. Contradictory studies like this one highlight the vagaries of looking at add-on treatments like Omega-3 supplements.

Another confounding problem with the Omega-3s are questions about what is the best dosage. The Alpha-Omega investigators (2010-NEM) randomized 4800 post-heart attack patients to low dosages of Omega-3-containing margarines. Cardiac events were not lowered by any of the beneficial margarine combinations; but was the inefficacy of Omega-3s in this trial the result of inadequate dosing?

Do Omega-3s prevent heart rhythm problems, like sudden cardiac death, ICD shocks and atrial fibrillation?

They surely should. I have already told you that omega-3s decrease inflammation, lower resting heart rate, and enhance heart rate variability. Combine these actions with their known ion-channel blocking properties, and it’s easy to assume the evidence will point to a benefit. (And If I made money selling supplements to you, this is where I would stop.) But…

At least in high risk ICD patients, Omega-3s do not have a beneficial effect on the heart rhythm. To date, most reports on the heart rhythm effects of Omega-3s are non-controlled small observational studies which are inconclusive.

What are the downsides of taking omega-3 supplements?

Through their beneficial effects on lower platelet activity, the Omega-3s slightly increase the bleeding time. However, there are no reported cases of abnormal bleeding because of fish oil. Medical people say the bleeding risk of Omega-3s is clinically insignificant.

Mercury contamination of large predatory fish is a controversial health topic that is beyond the scope of this post. It seems fair to say, however, that no amount of mercury is healthy. Most high-quality fish-oil supplements do not contain mercury.

Omega-3s may also cause nuisance side-effects like, a fishy after-taste, bloating, and belching. Ick, that sounds worse than quinoa.

Summary/Bottom Line:

The American Heart Association (AHA) recommends that we eat more fish—at least two servings per week, along with plant-derived omega-3 fatty acids. (Note: Fried fish sandwiches on white bread with French fries does not count as your fish and vegetable!)

The AHA also says that high-risk patients with documented coronary artery disease, or very high triglycerides may benefit from Omega-3 supplements.

Here’s my Omega-3 synthesis:

The overwhelming majority of people could improve their heart health without swallowing fishy pills. Most could exercise more, eat better foods (more plants and fish), and go to bed a little earlier.

And for those still looking for extra credit in heart health, there are still these bonuses:

Heart-Healthy Grins

More friends;

More optimism;

More satisfaction;

and the healthiest bonus of them all…

More Grins!

JMM

Not funny…anymore

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As most know, a good laugh is indeed good for the heart.  I get this.

However, in the case of using a donut bacon cheeseburger as a vehicle for making fun of the abysmal nutrition of KY state fair goers, the blurry line separating funny from not funny is clear, at least for me.

What is responsible journalism?

I am no expert, but am fairly sure that this report in our hometown newspaper is not an example of such.   Both the article and accompanying video make light of this nutritional cluster bomb.  No mention in the article that this 1000 calorie disaster is a pictorial metaphor for our state’s obesity epidemic.  No link to this Washington Post expose on obesity in Kentucky.

Here is an excerpt from this fine piece of journalism…

I finished without having a coronary or chest pains, but I did take two Tums tablets as a pre-emptive strike against acid reflux.

So two thumbs up from this cheeseburger guinea pig. Just think twice before a second and third after you get hooked — there’s a funnel cake stand nearby.

To one who witnesses the disasters of obesity nearly every day, making light of a donut cheeseburger seems akin to making fun of cancer or heart disease–which surely wouldn’t be tolerated.

Until the paradigm changes, a sea change in a nation’s view of obesity and sedentarism, there will be little movement in overcoming one of our country’s most pressing (and most expensive) diseases.

Some things used to be funny, but times change.

JMM

h/t: A very conscientious cardiac cath lab nurse, who would not touch a donut.

Have a heart America…

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As an American, I was proud when I heard the news.  I grinned to myself.

It was on my way to work, through a beautiful city park, with the sun rising over the hillside.  The morning radio program reported the news that a California judge overturned their state’s ban on gay marriage.

I know what you are thinking; a medical blog is running amok right into a political hornet’s nest.  
But…

Isn’t it true that a nation’s kindness is a defining characteristic?

America and Americans do much that is good and right.  Examples of such goodness are too numerous to list.  If you are a victim of a calamity, you can be sure that America will help.  Ask Haiti.  And it’s not just foreign countries, we help each other.  There is a flood and then there are volunteers.  A power outage and there are cords across the streets.  It is not controversial to say we are a kind nation.

But it would also be naive to suggest that this decision doesn’t have major political ramifications.  I get that.  Nonetheless, I like the judge’s decision on two grounds.  One is that I find solace in common sense.  The other reason is more pragmatic: kindness to others reduces inflammation.  And as a nation we could really use smoother arteries and less sticky platelets.

So here goes…

First the common sense part.

It has been many years since I spent my Sunday mornings sitting in hardwood pews at Saint Mary’s on Spring St in Windsor Locks.  And the details from Thursday’s after-school catechism sessions are even cloudier.  It was forever ago.  However, I do remember the basic theorems of my childhood religion experience.

Things like we should love our neighbor (heck, I think that is engraved in stone tablets and displayed all over Kentucky), and we should be kind, tolerant and generous.  It seems that I remember these were the characteristics of certain tall, tan, bearded gentleman who ended up dying on a cross.

Another lesson I learned in that same small town in Connecticut came from middle-school American history class.  Being a forest–rather than a tree–type person, I seem to remember the notion that our country was formed on the basis of freedom. And there was something about all men are created equal.

So, enough with politics.  Let’s get to some scientific reasoning about inflammation and heart disease.

Heart disease is serious.  It is our nation’s leading cause of death.  And all agree that heart disease is incredibly expensive to treat.   But what is cheaper therapy than medicine, stents and surgery–even less expensive than diet and exercise?

Nothing costs less than kindness to others.  There are no more cost effective strategies for treating heart disease than kindness.  The inner peace that comes from tolerance, generosity and down-home goodness to others soothes the arteries and platelets. It is anti-inflammatory.   (Come to think of it, I have practiced Cardiology for 17 years and never seen a heart attack in a nun.)

What ever the legal means were, the end result of the judge’s decision exudes rightness and kindness.

Our country’s heart is better for it.

JMM

Alcohol and atrial fibrillation: questions, conflicts and choices…

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Have you ever had a cold beer after a mountain bike ride?

Oh my!

But does such indulgence put one at risk for an arrhythmia?

Does alcohol exacerbate an existing arrhythmia?

How much, if any, alcohol is acceptable?

These are questions I am asked frequently.  And for those asking, they are very important questions.

I wish the answer was straightforward.  But it is not.

Undoubtedly, excessive alcohol can precipitate an abnormal rhythm.  Look no farther than the well known “holiday heart” syndrome.  It is a not uncommon that a seemingly normal individual can develop atrial fibrillation after partaking in excessive alcohol consumption.

Although it is clear that binge drinking can precipitate AF, it is also known that individuals vary in their susceptibility to alcohol.  Some patients develop arrhythmia after only one drink. We do not understand why this is, just that it is.  

As said concisely by DrRich,

Patients who have episodes of paroxysmal atrial fibrillation should carefully examine whether the episodes seem in any way to be related to alcohol consumption. And doctors who treat patients with this condition should be careful to ask about even minor exposure to alcohol. Making the proper diagnosis may spare the patient from inappropriate treatments.

Conflicts:

Patients who ask about alcohol intake are most often conflicted.  They hate the idea that their heart is under duress, but forever giving up a beer, a glass of wine, or a cocktail is equally troublesome.

Also, most patients have read conflicting stories on alcohol and heart disease.  We have all heard the notion that the French have less heart disease because of red wine consumption. However, just because two facts are true does not mean they are related. For instance, maybe the French have less heart disease because as a whole they are thinner and they walk much more than the average American.

Doctors are conflicted as well.  The data are not entirely clear.  We know life is short, and since it is generally agreed that alcohol used in moderation is not detrimental, it is hard for us to tell a patient, “yes, that’s it, no more beer or wine for you, forever.”  On the other hand, we are keenly aware of the devastating effects of alcohol overuse.

Living in a state with “dry” counties highlights the moral conflicts of alcohol.  Even though alcohol use is legal, telling patients to stop drinking is not like telling them to quit donuts. A patient has to judge whether a doctor is telling me to stop drinking for moral or medical reasons?

How may alcohol cause AF?

In most new cases of AF, or AF associated with normal hearts, there are specific sites in the atrium which act as triggers–call them initiators.  These sites are often within muscle bundles of the pulmonary veins. (Hence the success of pulmonary vein isolation.)

These nests of irritable cells begin firing for a reason.  In normal hearts particularly, such triggering begins “out of the blue,” often with no easily identifiable reasons.   For some, even small amounts of alcohol can induce firing of these trigger sites.

How alcohol affects the heart is highly varied and the exact mechanisms remain obscure. Along with alcohol’s propensity to induce AF trigger sites, it also induces both an “on alert” state of high adrenaline, as well as impaired sleep.  All these effects create a vulnerable state that favors AF.  An encyclopedic article on alcohol and the heart is here.


What do I tell patients?

Drinking alcohol is not likely to enhance health.  Used in moderation, it may be neutral, but barely.  The ninety-year old that you know is not likely ninety because of her nightly bourbon habit.

Alcohol is clearly associated with AF.  The threshold amount of alcohol is not known.  A recent study in women suggests that more than two drinks daily is associated with an increased risk of AF.  This is but one study; clearly individuals vary in their susceptibility to alcohol.

Before embarking on potentially toxic AF drugs or an invasive ablation procedure, a trial of abstinence from alcohol seems to be a good idea. (As well as other important lifestyle modifications, like improved sleep and stress reduction.)   If cessation of alcohol intake eliminates or reduces AF episodes, then the answer is obvious.  A delicate choice awaits: alcohol or AF.  I know, it stinks to have to choose.

Here’s a tough question–for thought provoking reasons only…

Is it reasonable to do a 50,000 dollar ablation on a patient with AF whose disease could be controlled with lifestyle modifications?  For example, what if alcohol cessation (along with improved sleep and stress reduction) quiets the pulmonary vein triggers, but the patient chooses to persist in consuming alcohol?  Let’s say for the sake of argument, not an excessive amount.  Should a complex, expensive and risky ablation be performed?

To answer this question, we may look to other parallel scenarios for help.  Like the patient with vascular disease who continues to smoke.  In American healthcare, this patient is not denied stents, or bypass surgeries.  Or the obese patient who chooses to keep consuming excessive calories.  We offer them laproscopic banding surgery.  The list goes on and on.

Since I live in the same glass house as my patients, I will not heave the stone too far.  I understand the dilemma.  That pesky gastro-esophageal reflux of mine would surely improve with less coffee.  But this has proven a difficult choice thus far.

Choices.

Facts.

That’s the point.

JMM

Success in heart health stems from the simple…

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The solution is so easy.  It sits right before our eyes.  The methodology is known.

Small Steps to Heart Health was big headlines in today’s WSJ.  As if the secret was revealed.

The report succinctly argues that simple lifestyle choices, like daily exercise and better nutrition are surprisingly successful. Shocking! As an illustration of a model patient, they used the example of an overweight interventional cardiologist (a squisher) who caught the health bug.  By making better food choices and exercising on a daily basis, he was able to glean huge gains in objectively measured parameters of heart health.

The review cited three studies from this Spring’s ACC meeting.  All three studies revealed that more aggressive pharmacologic management of medical conditions was not always better.  There exist many examples of this phenomenon, but the specifics here were:

In diabetes, more medicine to aggressively control blood pressure made little difference.  In high cholesterol, adding a fibrate to statin therapy did not lower heart attack risk.  In permanent AF, the strategy of using lower dosages of medicine for heart-rate control was equivalent to present day recommendations for strict heart rate modulation.   

Translation:

More medicine cannot substitute for life’s simple choices. Although pills have undoubtedly enhanced the lives of many, they will never replace the importance of the big three components of health: good food, good sleep and good movement.  Really, it is that simple.

Our challenge as doctors is not just in telling our patients of the fruits of healthy living.  Most already know. The real challenge is infecting our patients with the “healthy-living” virus.  So many in America–and especially Kentucky–remain immune.

In the implementation of healthy living, doctors might need help.  Thus far, we are not doing so well.

Even with my motivational pitch at full throttle, successful infection of the healthy-living virus is a rarity.  I will continue to try, though the futility of the effort creeps closer and closer with each successive failure.

Frown.

JMM