Published : Friday, 9 November, 2018 at 12:00 AM Count : 1040
Raihana Sayeeda Kamal
What is heart failure?Heart failure is a condition when heart does not pump blood efficiently. As a result, the body’s vital organs such as the brain, kidneys or liver do not receive adequate nutrients and oxygen. Common causes include coronary artery disease (blocked heart arteries), heart rhythm problems, heart valve problems or holes in heart can result in heart failure.
What are common signs and symptoms of heart failure?
What are the types of heart failure?
Can a patient have heart failure without being aware of it?
What are risk factors for heart failure?
Is smoking related to heart disease?
What are the treatment options?
Medications can help stabilize the condition. It helps control heart failure symptoms, reduce the need to be hospitalised and improve survival rates.
What is the advanced treatment for heart failure?
At what age should people begin paying attention to heart health?
Do heart diseases have any link to gender?
There has been a perceptible rise in cardiovascular disease in South-east Asia. The obvious culprits here are unhealthy eating habits and lifestyle. What is your opinion on this topic? Are we oversimplifying a complex problem? What role does stress play here?
I think what the physicians have said are true. They say “We are what we eat”, and our poor diet has led to a rise in conditions like high blood pressure, high cholesterol and diabetes. These are the biggest risk factors for cardiovascular diseases and are often the consequence of an unhealthy lifestyle and diet. Another risk factor is smoking. A smoker has twice the chances of getting a heart attack when compared with a non-smoker. People are also leading a more sedentary lifestyle, which also increases the risk of them developing heart disease.
Most people think that stress plays a major role here since stress can lead to higher blood pressure, higher heart rate. Most physicians believe that stress does contribute to cardiovascular diseases, although it may be hard to prove this. This is simply because it is difficult to quantify stress and thus determine its impact on our body.
What patients are the most susceptible to heart disease? Does genetics play a major role in determining the health of our heart?
The patients with the risk factors of diabetes, high blood pressure, high cholesterol as well as the ones who smoke, are the most susceptible to heart disease. Genetics unfortunately also plays a role in determining your cardiovascular health. Having a first-degree relative suffering coronary heart disease at a young age predisposes you to also developing it. In Asia, studies have shown that individuals of Indian/South Asian ethnicity are at five times increased risk of heart disease when compared to their Chinese counterparts.
If you had one piece of health-related advice as a cardiologist, what would it be?
Prevention is always better than cure. Heart disease, while not 100% preventable, is certainly treatable. We need to start early by being mindful of our lifestyle choices and exercising regularly from a young age. Engaging in moderate forms of exercise for 30 minutes at least 5 days a week will be enough. We should also go for regular check-ups, to keep track of our blood pressure, cholesterol and sugar levels.
One of your sub-specialty is heart transplant. The process can be grueling on the patients. What would you like to say to patients who are waiting for a heart transplant?Heart transplant is a high- risk surgery and is reserved for very sick patients with advanced heart failure. However, a heart transplant can offer a significantly better quality of life for a heart failure patient. I would encourage all potential heart transplant patients to look to the past thousands of patients who have successfully gone through the surgery for motivation and inspiration.
The rate of heart transplants in the world has reached a plateau in the past 20 years. This is simply due to the limited supply of healthy donor organs. Due to an aging population, greater number of people getting cardiovascular diseases and better survival rates due to medical and technological advancements.
One of the most established treatment methods for end-stage heart failure these days is the Ventricular Assist Devices (VAD), otherwise commonly known as an artificial heart pump. The VAD is implanted into the heart and its key function is to pump blood out of the heart to the rest of the body. With a VAD patients have an 80% chance of surviving beyond 2 years, based on statistics from worldwide data. In Singapore, patients who use VAD have an 80% chance of surviving for more than 4 years.
What has been the most challenging aspect of working as a cardiologist?
I have witnessed many patients who were on the brink of death. It is heart-wrenching when we cannot manage to save a patient despite our best efforts. On the other hand, it is extremely rewarding when a patient survives and recovers fully. I think the most challenging part of working as a cardiologist is going through these critical situations with the patients, keeping my emotions in check and not let them affect my objectivity.
By Dr Paul Chiam
Published on Ezyhealth on April 2015
Work stress can do a real job on your ticker
It is commonly accepted that work stress can affect our cardiovascular health. You’re probably familiar with the phrase “worked to death”!
Various kinds of jobs create different types of stress, and whether the stress becomes harmful depends on the individual – some people cope much better than others.
Some individuals even thrive as the stress drives them to work harder and improve work performance! So is job stress actually bad for your heart?
What is a stressful job?
Most studies concur that jobs become stressful in situations where the worker feels that he or she has little or no control. Let’s say you have a highly demanding job. If you have minimal power to make decisions about your daily tasks, that makes it a lot more stressful than if you have some control. If you love your job and enjoy what you’re doing, then putting in long hours is not going to have too much impact.
How stressful a job is also depends on the personality of the individual and his co-workers. Persons with hostile personalities face more job stress and are at higher risk of a cardiovascular event. Jobs that require sudden intense bursts such as firefighters may also place more stress on the workers.
The Stats on Job Stress and Your Heart
- A large British study of over 10000 white collar workers over a 12-year period found that people who felt stressed at work were 68% more likely to die of heart disease, suffer a non-fatal heart attack or have exertional chest pain (angina).
- Another British study of over 6000 civil servants found that overtime work of three to four hours a day was associated with a 1.5 times increased risk of heart disease, independent of other risk factors.
- Researchers in South Korea found that increasing numbers of hours worked per week correlated with increased heart disease. Compared to those who worked 31 to 40 hours a week, workers putting in 61 to 70 hours a week had a 42% increased likelihood of developing coronary heart disease; those working 71 to 80 hours a week had a 63% increased likelihood; while those working more than 80 hours a week had a 94% increased likelihood.
Although these statistics look alarming, they must be considered in the context of other risk factors that can contribute to heart disease. In an analysis of 13 studies pooled together, job strain was found to contribute to 3.4% of heart attacks; conversely, smoking alone accounted for 36% and physical inactivity for 12% of heart attacks! So though job stress can indeed increase heart disease, the overall burden on heart disease is small.
How does one’s job affect the heart?
Job stress can affect the heart arteries directly by causing mild vasoconstriction (artery narrowing). Stress causes blood pressure to rise, and blood platelets (a group of cells that promote blood clotting) to become stickier. These changes have been associated with increased risk of heart attacks.
Job stress and long work hours can also result in poor sleep, a lack of physical exercise, increased smoking (to cope with the stress!) and in some people, heavy alcohol intake and binge eating, resulting in weight gain (which predisposes them to diabetes and heart disease).
Working at odd hours and shift work can also result in sleep deprivation. This can lead to high blood pressure, weight gain and increased levels of a stress hormone called cortisol (this hormone increases blood pressure and blood sugar), raising the risk of heart disease.
What can one do to reduce job stress?
It may not always be possible to reduce job stress in a fast-paced competitive society like ours, and it certainly is not an easy thing to do in any case. However, there are some things we can do to help mitigate job stress.
- Regular exercise – Take short breaks where possible and move around. Even walking around is better than sitting at the desk all day. Schedule regular exercise on a weekly basis, ideally at least three times a week for 20 to 30 minutes each time. Exercise helps take our minds off work.
- Relax – Learning how to relax can be beneficial to one’s overall health. Picking up a new hobby takes the mind off work and helps relaxation.
In many situations, we cannot reduce the job stress that we face. We can help ourselves, however, by getting regular exercise, not smoking, adhering to a sensible diet, and screening for and controlling cardiovascular risk factors for heart disease such as diabetes, high blood pressure and high cholesterol.
Screening for cardiovascular diseases
By Dr Paul Chiam
Published on Medical Grapevine on October 2015
The aims of cardiovascular screening are to identify cardiac or vascular disease and detect cardiovascular risk factors in asymptomatic or “well” patients.
Screening starts with a thorough history and physical examination, and simple laboratory investigations. Other tests may also be performed when necessary according to the patient’s risk profile.
The tests that we choose should be cost effective, reproducible and accurate, and that the diseases being screened should be serious with early detection leading to a better outcome.
However as no test is 100% sensitive nor specific, false positive results may paradoxically increase costs due to the need for further tests and create unnecessary anxiety, whereas false negative results may confer a false sense of security to the patient.
Thus screening should be evidence based and should result in a change in lifestyle leading to improved outcomes.
Screening for cardiovascular risk factors and cardiovascular disease
The screening usually starts with a detailed history and physical examination. They are part of the initial consultation, and do not involve additional cost or risk to the patient. A cardiovascular risk profile (eg 10-year risk of cardiovascular event – high, moderate, low risk) can be estimated using the Framingham risk score calculator (cvdrisk.nhlbi.nih.gov) or the HeartScore risk calculator (escol.escardio.org/Heartscore/calc.aspx?model=europelow). These have been shown to predict likelihood of future events and can serve as an impetus for behavioural change.
Subsequent tests such as the electrocardiogram (ECG) and chest x-ray (CXR) can help further stratify the risk profile of the patient. Apart from the ECG and CXR, the fasting glucose and fasting lipid profile are amongst the most useful screening tests. These tests, together with the office blood pressure, will detect the 3 common risk factors for cardiovascular disease as a significant proportion of the population may have silent diabetes mellitus, hypertension or dyslipidemia. Early detection and treatment (lifestyle or drugs) are likely to have an impact on future event rates as demonstrated in the primary prevention trials (eg. West of Scotland Coronary Prevention Study (WOSCOPS), Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) and STOP-NIDDM trial). WOSCOPs showed that primary prevention with pravastatin reduced myocardial infarction (MI) and death from cardiovascular causes in men with hypercholesterolemia compared to placebo. ASCOT showed that treatment of hypertension with amlodipine and perindopril significantly reduced all-cause and cardiovascular mortality and strokes. STOP-NIDDM demonstrated that arcarbose could reduce progression of impaired glucose tolerance to overt Type 2 diabetes as compared with placebo. More recently, a lifestyle-intervention program or metformin have been shown in a major study performed by the Diabetes Prevention Program Research Group to reduce the progression of glucose intolerance to overt diabetes.
The NCEP guidelines which are endorsed by the American Heart Association, recommends a fasting lipid profile in all adults aged 20 years or older, and if optimal, every 5 years subsequently. If the results are sub-optimal, the fasting lipid profile should be repeated at earlier intervals. At the same time, the fasting glucose level can also be performed. The Ministry of Health, Singapore strongly recommends a fasting lipid profile at age 40 years (or younger in those with comorbidities or family history).
Silent peripheral vascular disease has been shown to confer a poorer long term outcome as these patients usually have multiple risk factors and/or heart disease. Asking for a history of claudication and palpation of the foot pulses are simple and effective methods of screening for peripheral artery disease.
Use of stress testing and imaging in cardiovascular screening
The treadmill ECG stress test (TMX) is a test that can be easily performed and is most useful for patients in the moderate risk category with atypical chest pain or patients who have a high cardiovascular risk profile. With a sensitivity and specificity of 70% at best, the TMX is not useful in low risk patients as it does not alter the low pre-test probability of heart disease. However, most patients presenting for cardiovascular health screening would want a TMX performed. The main utility is that it has been shown that patients with a normal result and good exercise capacity (Bruce protocol stage 3 or more) have a good long term prognosis and a low yearly cardiovascular event rate.
More recently, the CT heart scan derived coronary calcium score has been shown to be a predictor of future cardiovascular events since the calcium score is a reflection of the coronary plaque burden. The calcium score has become recommended by certain scientific societies for use in cardiovascular screening, and when combined with the TMX, gives added prognostic value.
In contradistinction, the CT coronary angiography is not recommended for use in screening as it entails a higher radiation dose, a need for intravenous contrast administration and the possibility of false negative and false positive results due to the limitations in the technology.
In patients whom silent peripheral vascular (artery) disease is suspected, an ultrasound Doppler of the lower extremity arterial system is a test that is safe and easy to perform and is fairly accurate.
Screening in the endurance or competitive athlete
This group of patients often present for screening. One knows too well of the rare incidences when a seemingly fit and healthy athlete suddenly collapses and dies. Though it is a rare occurrence, it is shocking and devastating. Common causes of sudden death in young athletes would include cardiomyopathies (in particular, hypertrophic cardiomyopathy), long QT syndromes and other arrhythmic/ conduction disorders, congenital anomalous course of the coronary arteries and silent ischaemic heart disease.
In general, competitive and endurance athletes should have at least an ECG performed before embarking on such activities. In selected patients, a TMX and echocardiogram may also be considered.
Regular cardiovascular screening may identify risk factors and preventive measures such as adopting healthy lifestyle habits can be carried out to minimise subsequent disease. With early detection and proper medical treatment, cardiovascular disease can be treated or even prevented.
Skinny people can have high cholesterol too
By Judith Tan
Featuring Dr Paul Chiam
Published on The New Paper on 24 May 2015
What is cholesterol?
The fat that we eat gets changed by the liver into cholesterol, a waxy substance that is important for our bodies to function but (it) could also cause problems if there is too much in our blood.
Why is too much dangerous?
High cholesterol levels have been shown to be a cause for heart disease, when arteries of the heart are blocked; and stroke, when arteries to the brain are clogged. Cholesterol can also cause blockages in the blood vessels to the legs or arms, causing pain.
How is “good” and “bad” cholesterol detected?
After you fast, a blood test would be able to differentiate “good” cholesterol (high-density lipoprotein or HDL which pick up excess cholesterol in your blood and take it back to your liver where it is broken down) from “bad” cholesterol (low-density lipoprotein or LDL which can enter your blood vessel wall and start to build up under the vessel lining, narrowing blood vessels).
What if you have high levels of both good and bad cholesterol?
The primary target would still be the bad cholesterol or LDL.
If the patient already has vascular disease (heart disease, stroke, etc), then lowering of the LDL with a statin (a cholesterol-lowering drug), for example Lipitor, is required.
Similarly, for patients with diabtes or other risk factors that increase the risk of a cardiovascular event, statin therapy should be strongly considered.
In some patients without any risk factors but with a very high LDL level, therapy with a statin should also be considered.
Are only overweight people at risk of having high cholesterol?
The cholesterol level in a person is due to many factors but genetics plays an important role. So skinny people can have a high cholesterol level too.
Of course, if the person is overweight and has an unhealthy diet, the cholesterol level would be even higher.
When should I worry and see a specialist?
If you have high cholesterol levels, particularly if you also have diabetes or there are other risk factors like high blood pressure, smoking, family fistory of heart disease or stroke.
Or, if you had a previous cardiovascular disease (heart artery blockage, stroke, narrowing of the arteries supplying the limbs, etc).
Is it an occupational hazard that you notice what people eat?
Not really. I think eating in moderation is the key, and the occasional sinful treat is unlikely to significantly change one’s risk. Of course, this does not apply if one eats char kway teow every day.
How would you describe your job?
I get to manage patients with cardiovascular disease, control their risk factors, that is, their cholesterol levels with both drug therapy and lifestyle changes. I also get to perform angioplasty (ballooning and stent placement) of my patients’ arteries, if they require it.
Best moment ever?
I did a heart angiogram for a patient.
He had no real blockages in his heart arteries, but he told me he had severe pain in his legs whenever he walked a few metres. He couldn’t even go out of his house very often.
Tests showed that the arteries to his legs were completely blocked. Due to the very complicated blockages, it took several angioplasty proceures to successfully open them up.
He improved tremendously, and could even go on a holiday to China and walked a few kilometres.
Medication for High Cholesterol – What are your options?
By Dr Paul Chiam
Published on Ezyhealth on December 2014
There are several medications used in the treatment of high cholesterol (otherwise known as dyslipidemia). As the low density lipoprotein (LDL) or “bad cholesterol” is the main target of treatment, most of these drugs act primarily to reduce the LDL. Other drugs act mainly to reduce triglycerides (TG) or to raise the high density lipoprotein (HDL) or “good cholesterol”.
The various medications belong to different drug classes:
- Bile acid sequestrants
- Cholesterol absorption inhibitors
- Nicotinic acid (a derivative of the vitamin niacin)
- Omega oils
How They Work
Statins block an enzyme that is required in the production of LDL, thereby lowering the “bad cholesterol” level in the blood. They are the commonest cholesterol lowering drugs used in the treatment of elevated LDL levels, as this class of drugs has been shown in many large studies to reduce the risk of heart artery blockages, heart attacks and strokes, and also reduce risk of death from any cause. In addition, these drugs are considered quite safe to use and are well tolerated.
What is Available
The available statins are:
Although there are some differences between the various statins, the effects are mostly similar. The major difference is the potency of the individual drug. For example, 10mg of rosuvastatin is equivalent to 20mg of atorvastatin, which is equivalent to 40mg of simvastatin.
Side effects of statins are generally mild and well tolerated. They include:
- Mild muscle aches
- Abdominal discomfort
- Mild increase in liver enzymes
These symptoms usually resolve spontaneously or may improve when the statin dose is reduced.
More severe side effects are rare and require use of the statin to be stopped. These include:
- Significant elevation of liver enzymes
- Severe muscle aches
- Severe muscle breakdown
Patients who experience these symptoms generally require some other class of cholesterol lowering drug.
2) Bile Acid Sequestrants
How They Work
Bile acid sequestrants bind to bile acids in the intestine and prevent them from being reabsorbed into the blood. The liver then produces more bile to replace the bile that has been lost. Because the body needs cholesterol to make bile, the liver uses up the cholesterol in the blood, which reduces the amount of LDL cholesterol circulating in the blood.
They are now considered a “third line” drug to reduce LDL, and are usually used in combination with a statin or with ezetimibe. The LDL lowering effect of bile acid sequestrants is moderate at best and there is no convincing evidence that bile acid sequestrants reduce cardiovascular events or death.
What is Available
Currently available bile acid sequestrants are:
Major side effects are rare, but the usage of bile acid sequestrants is limited by these common side effects:
- Abdominal bloating
They also should not be taken by patients who have high triglyceride levels as they may worsen the high triglycerides.
3) Cholesterol Absorption Inhibitors
What is Available
There is only one drug in this class – ezetimibe (Ezetrol).
How It Works
Ezetimibe binds to cholesterol in the gut and inhibits the absorption, thus lowering blood cholesterol (LDL) levels. It is most often used together with a statin to produce additional LDL lowering, although it has not been shown to further reduce narrowing of the heart arteries or reduce cardiovascular events. In patients who cannot tolerate a statin, ezetimibe is usually used as the second line agent. The drug is well tolerated and is usually safe to use.
Side effects are uncommon and usually minor, and include:
- Abdominal discomfort
How They Work
This group of drugs activate an enzyme called lipoprotein lipase, reducing triglycerides and raising HDL (good cholesterol), but have little effect on LDL (bad cholesterol). They are currently mainly used to treat patients with very high triglycerides. This is to reduce the risk of pancreatitis, a serious inflammation of the pancreas which is potentially life threatening, resulting from the very high triglyceride levels. These drugs were previously commonly used in patients with heart disease to raise the HDL (good cholesterol) and although they did reduce the risk of cardiovascular events, they did not reduce cardiovascular or all causes of death, and thus are now not used commonly in patients with heart disease unless these patients have a very elevated triglyceride level.
What is Available
The two fibrates available are fenofibrate (Lipanthyl) and gemfibrozil (Lopid).
Minor side effects include:
- Mild muscle ache
- Abdominal discomfort
- Mild elevation of liver enzymes
Serious side effects are:
- Severe liver enzyme elevations
- Severe muscle aches
- Severe muscle breakdown
The serious side effects can occur especially if fibrates are combined with statin, which is a fairly common treatment strategy. In such cases, only fenofibrate (and not gemfibrozil) should be used in combination with a statin at the lowest possible dose.
5) Nicotinic Acid
How It Works
This is a drug derived from the vitamin niacin (vitamin B3). The actual mechanism whereby nicotinic acid works is not known. It raises HDL (good cholesterol) and lowers LDL (bad cholesterol) and triglycerides.
Despite being the seemingly ideal agent, large studies using nicotinic acid have shown disappointing results. Although blood cholesterol profiles were improved, there were no reductions in cardiovascular events or death. Furthermore, the side effects of the high dose nicotinic acid required limits its use.
Flushing is a common and troublesome side effect and is a major reason the drug is discontinued.
Other side effects include:
- Muscles aches
- Abdominal discomfort
- Liver enzyme elevation
- May predispose to development or worsening of diabetes.
Thus, this drug is now rarely used.
6) Omega-3 Oils
How They Work
These are considered more as a dietary supplement and are derived from fish oils. They are mainly used to lower triglyceride levels. Although generally safe and well tolerated, there is a lack of evidence that omega-3 oils reduce cardiovascular events.
Side effects are usually mild and include:
- A fishy taste in the mouth
- A fishy breath
- Abdominal discomfort
- Loose stools
Overall, statins are the first line drugs used in the treatment of patients with high cholesterol. They are effective and have been shown to reduce cardiovascular events and death in large studies, and are generally well tolerated and safe. Other agents are usually added on to a statin as directed by the physician. In rare patients who cannot tolerate a statin, an alternative drug may be considered.
Cholesterol Control – How can you keep cholesterol in check?
By Dr Paul Chiam
Published on Ezyhealth on March 2015
Cholesterol is important for our body functions but could also cause problems if there are high levels in our blood. The fat that we eat gets changed by the liver into cholesterol and triglycerides. Since cholesterol is made in the liver, it is only found in animal products and not in vegetables.
The Good and the Bad
The cholesterol and triglycerides are packaged into lipoproteins for transport through the bloodstream.
The two types of lipoproteins we are concerned about are:
- Low density lipoprotein (LDL)
- High density lipoprotein (HDL)
LDL is also known as the “bad” cholesterol because it gets deposited in the blood vessel walls. This is called atherosclerosis and leads to blood vessel narrowing and can result in heart attacks and strokes. HDL is also known as the “good” cholesterol as it brings the bad cholesterol back to the liver.
The High and the Low
To measure your cholesterol levels, you can take a fasting blood sample for lipid profile. You will need to fast for at least eight hours before the test. The numbers usually measured are:
- Total cholesterol
- Triglycerides (TG)
Of these, LDL is considered the most important parameter.
- Patients with established heart disease, previous stroke, peripheral artery disease or diabetes should aim for an LDL level lower than 2.6mmol/L (100mg/dL) or even less than 1.8mmol/L (70mg/dL).
- For people with no cardiac risk factors, an LDL level less than 3.4mmol/L (130mg/dL) would be the target.
- An LDL level above 4.0mmol/L (160mg/dL) is considered high.
- HDL should be at least 1.0mmol/L (40mg/dL) and ideally above 1.5mmol/L (60mg/dL). Simply put, the lower the LDL, the better; and the higher the HDL, the better.
- The target for TG is less than 1.8mmol/L (150mg/dL) and a level of over 2.3mmol/L (200mg/dL) is considered high.
Why are these numbers important?
Reducing LDL decreases cardiovascular adverse events (heart attacks, strokes) and overall cause of death. The lower the LDL, the greater the risk reduction.
Similarly, people with high HDL levels seem to be at lower risk of cardiovascular events.
Although high TG levels are associated with increased cardiovascular events, the main concern with very elevated TG levels (> 5.0mmol/L or 450mg/dL) is the risk of pancreatitis, an inflammation of the pancreas that can be potentially fatal. Reducing TG levels can reduce the risk of cardiovascular events.
Causes of High Cholesterol
The commonest reason for elevated cholesterol levels is dietary (eating food with high saturated fat and cholesterol content). Animal fat is saturated fat and is solid at room temperature, whereas fats that are liquid at room temperature (such as olive oil, canola oil, safflower oil, soybean oil, corn oil) are unsaturated (polyunsaturated or monounsaturated) fats. Eating saturated fat increases LDL and eating unsaturated fat actually lowers LDL and raises HDL.
Trans fats (found in cookies, crackers, potato chips, margarine etc) are particularly bad as they raise LDL and lower HDL. Thus, consuming foods with trans fats is even worse than consuming foods with the same amount of saturated fat.
High cholesterol tends to run in families. Other conditions that can lead to high cholesterol levels are diabetes (lowers HDL and raises LDL), a lack of thyroid hormone, obesity and rare genetic diseases.
Treatments for High Cholesterol
The first step is to get one’s cholesterol levels checked. You should perform a cholesterol profile as early as at age 20, and get re-tested every five years. More frequent testing (every one to two years) may be required if your levels are not desirable.
Diet and Exercise
Patients with high cholesterol should first try dietary modification and exercise for three to six months.
Cut down on foods high in saturated fat and cholesterol. No more than 30% of your total daily calories should be from fat, no more than 8% to 10% from saturated fat, and total cholesterol intake should be less than 300mg per day.
Incorporate greater proportions of green leafy vegetables and fruits (high fibre diet), fish and white meat (instead of red meat) in your diet. Choose whole-grain breads, whole- wheat pasta, brown rice, oatmeal and oat bran.
Moderate amounts of alcohol may increase the level of HDL. However, be careful not to over-indulge. Alcohol also increases caloric intake.
Moderate intensity aerobic exercises reduce LDL and raise HDL levels and can help lower blood pressure.
Diet and exercise can achieve about 10% to 15% LDL reduction and 5% to 10% HDL increase in most patients. For most people with high cholesterol levels, drug therapy would also be required.
As LDL is the main target of treatment, most treatment drugs primarily reduce LDL. Other drugs mainly reduce TG or raise HDL.
Statins (e.g. Zocor, Lipitor, Crestor) lower LDL levels by decreasing liver production of LDL. They are generally well tolerated and safe. Other classes of drugs (e.g. Ezetimibe, a cholesterol absorption inhibitor) may be added on if the LDL level is still high despite high doses of the statin.
Alternative drugs may be considered for rare patients who cannot tolerate statins. A repeat fasting cholesterol level test is usually performed after six to 12 weeks and the liver function is also checked (as the drug can cause liver enzyme levels to be raised). In rare cases where the liver enzyme is very elevated, the drug has to be stopped.
Fibrates are used for patients with very high TG levels. Fibrates reduce liver production of very low density lipoprotein (VLDL) which contains mainly TGs, and increase removal of TGs from the blood. A repeat cholesterol level and liver function test should be done after six to 12 weeks.
A combination of a statin and fibrate may be combined cautiously as there is a higher risk of severe side effects. One rare but serious side effect of statins or fibrates is muscle breakdown. Patients who experience severe muscle ache/ pain while on cholesterol medications should inform their physician promptly.
Omega-3 fatty acid supplement lowers TGs. Omega-3 oils do not have significant effects on LDL or HDL levels.
High cholesterol levels (especially LDL) can cause blood vessels to narrow and lead to heart attacks or strokes. Regular cholesterol tests are recommended and a high cholesterol level can be treated with a combination of dietary modification, exercise and drug therapy.
Updates on the management of hypertension
By Dr Paul Chiam
Published on Medical Grapevine on August 2015
Hypertension is a common condition whose incidence rises with age. With with an aging population, it is increasingly common. Hypertension is usually diagnosed when the patient has 2 separate readings of blood pressure (BP) > 140/90 mmHg.
Some of our patients have “white coat” hypertension; though this condition usually does not require treatment, there is some evidence that it is not as benign as previously thought, and close monitoring of the patient’s BP would be required. However, for the purpose of this article, white coat hypertension would not be further discussed.
Why bother detecting hypertension
Hypertension is asymptomatic in the vast majority of patients. In rare cases, very high blood pressure can result in headaches (although most headaches are unrelated to the patient’s BP), blurred vision (due to papilloedema) and shortness of breath (left ventricular failure). In most people, it is however, a “silent” killer. Long standing poorly controlled hypertension increases arterial stiffness and causes end organ damage leading to an increased risk of stroke, myocardial infarction, heart failure, renal failure and aortic aneurysm.
This makes it important to detect and treat patients, especially younger patients, to reduce the risk of such events. It has been shown however, that even very elderly patients (> 80 years) derive benefit in the treatment of hypertension as they experience less stroke and less cardiac adverse events. Thus regardless of age, treatment of hypertension would be beneficial in virtually all patients.
Causes of hypertension
In the vast majority of patients with hypertension, no specific cause can be found (“essential” hypertension). Usually many factors contribute to hypertension in such patients including genetics (family history), lifestyle (sedentary lifestyle), stress (high stress environment), high salt diet etc.
In few patients (usually the very young patients < 35 years), an underlying disease may be the cause of hypertension. In this age group, investigations (including an ultrasound of the renal arteries, blood and urine tests) are performed to rule out an underlying disease. In older patients, particularly those > 65 years, the commonest underlying cause (if any) is renal artery stenosis. In these rare cases, treatment of the underlying disease may “cure” the patient of hypertension.
Treatment of hypertension
Most patients with hypertension can achieve satisfactory BP control with lifestyle modifications and drug therapy. A low salt diet, regular exercise, weight loss and reduced stress can lead to a lower BP. These may help patients with mild hypertension; however, as it is unlikely that the BP would be reduced by more than 10 mmHg on average even with these measures, most patients will still require some drug therapy.
The new JNC 8 guidelines (issued in 2014) from the American Joint National Committee on Hypertension have recommended a slight relaxation of blood pressure targets as compared to the previous JNC 7 guidelines. For elderly (>60 years) with hypertension, the guidelines recommend initiating therapy when the BP is ≥ 150/90 mmHg and to treat to a target BP of ≤ 150/90 mmHg (previously the target was ≤ 140/90 mmHg). For younger patients (< 60 years), the recommendation is to initiate therapy when the BP is ≥ 140/90 mmHg and to treat to a target BP of < 140/90 mmHg (previous target unchanged).
The other significant recommendations are for patients ≥ 18 years with diabetes mellitus or chronic kidney disease, the guidelines now recommend initiating therapy when the BP is ≥ 140/90 mmHg and to treat to a target BP of < 140/90 mmHg (previous targets were 130/80 mmHg for both patients with diabetes or chronic kidney disease [CKD]).
These new targets have come about from a comprehensive review of only randomized trial data compared to JNC 7 where non-randomized trial data and expert opinion were also used in generating the guidelines. Thus these new targets were derived from larger trials showing clinical benefit in treating the various groups of patients to the respective targets.
The new guidelines also recommend only 4 classes of drugs as the first line in treating (non-black) patients with hypertension: thiazide-type diuretics, calcium channel blockers (CCB), angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB). However, note that ACEI and ARB should not be used together in the same patient.
This is different from the JNC 7 guidelines where a thiazide-type diuretic was recommended as the initial therapy for most patients. Significantly, beta-blockers are no longer recommended for initial BP treatment because of a higher rate of composite cardiovascular events in some studies (driven largely by an increase in stroke).
In patients with CKD between age 18 – 75 years, anti-hypertensive treatment should include an ACEI or an ARB, as these drugs have been shown to improve renal outcomes.
A few different dosing strategies are also suggested by the JNC 8 guidelines to try to reach BP goals. The conventional method has been to maximise the first drug before adding a second. Another option would be to use an initial drug, and to add a second drug before reaching the maximum dose of the first drug. A third option would be to start 2 drugs at the same time especially if the systolic BP is ≥ 160mmHg and /or the diastolic BP is ≥ 100mmHg, OR if the SBP is ≥ 20mmHg and/or the DBP is ≥ 10mmHg. Whichever the method employed, titrate drugs doses or add a third drug to achieve BP targets. If BP goals still cannot be achieved after maximizing doses of all 3 classes of drugs, then antihypertensive drugs from other classes can be used (eg. hydralazine etc.). In patients with refractory hypertension or in complicated patients with hypertension, a referral to a cardiologist or a hypertension specialist may be indicated.
The new guidelines represent a simplification and “relaxation” of BP targets with a goal of < 150/90mmHg for elderly patients above age 60 years, and < 140/90mmHg for all other patients (younger patients, or patients of any age with diabetes or chronic kidney disease). However, for pre-existing hypertensive patients with BP control below the new targets, there is no necessity to amend or adjust their therapeutic regimen.
Hypertension in Seniors – When your health comes under pressure
By Dr Paul Chiam
Published on Ezyhealth on September 2014
Hypertension, or simple high blood pressure, is a common condition that afflicts many people. The incidence rises with age and is increasingly common with an ageing population. Hypertension is diagnosed when a patient has two separate readings of blood pressure (BP) >140/90 mmHg.
Some patients experience high BP when in the doctor’s office whereas their BP is ‘normal’ at home. This condition is termed ‘white coat’ hypertension and can be picked up with a 24-hour ambulatory blood pressure monitoring (a small portable device easily available in a cardiologist’s office). Although this condition usually does not require treatment, there is some evidence that is it not as benign as previously thought, and close monitoring of the patient’s BP would be required.
Importance of Detection
Hypertension has no symptoms in the vast majority of patients. In rare cases, very high blood pressure can result in headaches (although most headaches are unrelated to the patient’s BP), shortness of breath and blurred vision. In most people, however, it is a ‘silent killer’. Long standing poorly controlled hypertension increases the stiffness of the blood vessels and causes damage to many organs. The heart has to pump harder against the higher presuure, placing greater stress on the heart muscles. Patients with hypertension are at increased risk of stroke, heart attack, heart failure, kidney damage and aortic aneurysm (enlargement of the aorta) that can lead to fatal rupture.
This makes it important to detect and treat patients, especially younger patients, to reduce the risk of such events. Even very elderly patients (>80 years old) benefit from treatment of hypertension as they experience less stroke and adverse cardiac events. Thus, treatment of hypertension would be beneficial in virtually all patients, regardless of age.
In the vast majority of patients with hypertension, no specific cause can be found (this is medically termed ‘essential’ hypertension). Usually many factors contribute to hypertension in such patients, including genetics (family history), lifestyle (sedentary lifestyle), stress (high stress environment), high salt diet etc.
In a few patients (usually the very young patients <35 years), an underlying disease may be the cause of hypertension. In this age group, investigations, including blood and urine tests, are performed to rule out an underlying disease. In older patients, particularly those >65 years, the commonest underlying cause, if any, is the narrowing of the blood vessel supplying the kidneys. In these rare cases, treatment of the underlying disease may ‘cure’ the patient of hypertension.
Most patients with hypertension can satisfactorily control their BP with lifestyle modifications and drug therapy. A low salt diet, regular exercise, weight loss and reduced stress can lead to a lower BP. These may help patients with mild hypertension. However, as it is unlikely that BP would be reduced by more than 10mmHg on average even with these measures, most patients will still require some drug therapy.
There are four major classes of drugs available to treat hypertension and a variety of combinations could be used. In elderly patients, a thiazide diuretic (salt and water loss promoting drug) and a calcium channel blocker seem to be particularly effective in treating hypertension and also help reduce the risk of stroke. The ideal combination of drugs is best left to your primary physician as he/she will take into account other risk factors or presence of other diseases.
Recent guidelines from the American Joint National Committee on hypertension have recommended treating the elderly (>60 years old) to target BP of <150/90mmHg. In the younger patient, the goal is <140/90mmHg.
Screening and Prevention
The easiest way to detect hypertension is to go for regular screening with your physician. A simple office BP measurement is useful. In borderline cases, a more specialised 24-hour BP monitoring with a portable non-invasive device can be performed. Early detection and treatment can help to prevent many of the complications associated with hypertension. A healthy lifestyle (exercise, low salt fiet, maintaining an ideal weight, avoidance of prolonged stress, not smoking etc.) may reduce the likelihood of developing hypertension. If in doubt, see a doctor for a simple screen. This screen may ultimately save you from a more severe complication down the road.
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