Bisher AKIL, MD

Archive for the ‘Heart’ Category

Saved by the Watch?

In Heart on November 14, 2019 at 5:29 pm

The Apple Watch has an optical sensor that can detect heart rates, thus introducing the possibility of detecting atrial fibrillation (AF) [Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. At least 2.7 million Americans are living with AFib] . The industry-sponsored, prospective [forward] , open-label, siteless, pragmatic Apple Heart Study tested an algorithm to identify AF (NCT03335800). The 419,297 adult U.S. participants enrolled via an app, owned Apple Watches and iPhones, and had no prior AF.

During the study, 2161 people were notified of an irregular pulse, of whom 79% were excluded for various reasons, including 1216 who failed to attend a telemedicine visit. The researchers urgently contacted 20 people: 18 with AF and a rate >200 beats/minute, 1 with a pause >6 seconds, and 1 with non-sustained ventricular tachycardia >6 seconds.

For confirmation, electrocardiographic patches were mailed to 658 participants with nonurgent symptoms. Participants began wearing the patches about 13 days after the notification, for about 6 days. Of 450 people who returned the patches, AF was confirmed in 153 (34%); 20% had continuous AF. The yield was higher in older than younger people. Of 293,015 participants who never received a notification and who returned an end-of-study survey, 3070 reported new AF diagnoses.

As appeared in NEJM – Journal Watch – Edited.

Citations: Perez MV et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med 2019 Nov 14; 381:1909. (

Campion EW and Jarcho JA. Watched by Apple. N Engl J Med 2019 Nov 14; 381:1964. (


Comments: this is a large study and first of its kind; this maybe what we will see with future studies using wearable health monsters; despite its limitations (no follow up information is a big one), this remains a beginning of a potentially useful mix. Not there yet, though – BA

Six teaspoon of added sugar, no more!

In General Health, Heart, Kids & teens on August 23, 2016 at 8:00 pm

The American Heart Association now recommends that children limit their added sugar intake to 25 g daily or less, the equivalent of 6 teaspoons of sugar, or 100 calories. On average, children currently consume about 80 g daily.

Some definitions are needed here:

Sugar: Although commonly used more broadly, the US Federal Drug Administration defines the term sugar as a sweet ,crystalline substance, obtained chiefly from the juice of the sugarcane and the sugar beet.

Total Sugars: The term total sugars is used conventionally to describe the monosaccharides: glucose, galactose, and fructose, as well as the disaccharides sucrose, lactose, maltose, and trehalose (sunflower seeds, shiitake/mushroom, oyster). Total sugars include all sugars in a food or beverage from any source, including those naturally occurring (such as fructose in fruit and lactose in milk) and those added to foods.

Naturally occurring Sugars include those that are an innate component of foods (eg, fructose in fruits and vegetables and lactose in milk and other dairy products).

Extrinsic and Intrinsic Sugars terms originated from the UK Department of Health.  Intrinsic sugars are defined as sugars that are present within the cell walls of plants (eg, naturally occurring sugars)  and are always accompanied by other nutrients. Extrinsic sugars are those not located within the cellular structure of a food and are found in fruit juice, honey, and syrups and added to processed foods. The term non- milk extrinsic sugars is used to differentiate lactose- containing extrinsic sugars from all  others  because the metabolic response for the 2 types of sugars differs  substantially.

Free Sugars a term used by the World Health Organization that refers to all monosaccharides and disaccharides added to foods by the manufacturer, cook, and consumer (eg, added sugars) plus sugars naturally present in honey, syrups, and fruit juices (eg, non-milk extrinsic sugars).

The Risk:

  1. Excess weight gain and obesity
  2. Elevated blood pressure and uric acid levels
  3. Dyslipidemia
  4. Nonalcoholic fatty liver disease and
  5. Insulin resistance and diabetes mellitus.

Data source: They  used publicly available data from the most recent cycles of the National health and Nutrition Examination Survey ( NHANES)  (2009–2012) to estimate current levels of added sugars intake. These estimates may be conservatively low because it is well established that self-reported dietary assessments under report. Their analysis demonstrates that US children 2 to 19 years of age consume an average of 80 g added sugar daily . Absolute intake is higher among boys than girls (87 versus 73 g), but there were no differences when intake was assessed in relation to total energy intake (16.1% for both). Added sugars intake increases with age . Intake of free sugars, the combination of added sugars and sugars that occur naturally in honey, syrups, and juices, is 91 g and 18.5% total energy. Foods and beverages each contribute half of the added sugars in children’s diets, 40 g each. The top contributors to added sugars intake include soda, fruit- flavored and sports drinks, and cakes and cookies. Previous research has suggested that most added sugars are consumed at home rather than away from home.

Sobering findings: 

  1. Children consuming 3.5% to 6.8% of calories as sucrose (the lowest consumption group) had lower triglycerides and higher High density lipoprotein(HDL) than higher consumers.
  2. Children consuming no sugar-sweetened- beverages (SSBs) such as sodas,  compared with those consuming an average of 8 oz/d had lower C-reactive protein, smaller waist circumference, and higher HDL cholesterol.
  3. Each additional Sugar- sweetened beverages (SSB) equivalent (≈1 cup or 8 oz) consumed by children daily was associated with a 5% increase in Homeostatic model assessment and insulin resistance (HOMA-IR – , a method used to quantify insulin resistance and beta-cell function) 16-mm increase in systolic blood pressure, a 0.47-cm increase in waist circumference, a 0.90-percentile increase in BMI for age, and a 0.48-mg/dL decrease in HDL concentrations. The low consumers in this analysis consumed a mean of 0.1 oz of SSBs per day.
  4. Adolescents who consumed >10% of their total energy as added sugars had lower HDL levels, higher triglycerides, and higher low-density lipoprotein cholesterol levels than those who consumed less. Overweight or obese adolescents had higher insulin resistance (as assessed with HOMA-IR).

They concluded,  the available evidence found that associations with increased cardio-vascular disease (CVD) risk factors are present at levels far below US children’s current added sugars consumption levels. Current evidence supports the associations of added sugars with increased energy intake, increased adiposity (severe or morbid overweight), increased central adiposity, and increased dyslipidemia (elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein level that contributes to the development of atherosclerosis, all of which are demonstrated CVD risk factors. Importantly, the introduction of added sugars during infancy appears to be particularly harmful and should be avoided. Although added sugars can mostly likely be safely consumed in low amounts as part of a healthy diet, little research has been done to establish a threshold between adverse effects an health, making this an important future research topic.

Summary appeared in JWatch, August 23 2016

Citation: published ahead of print

Comments: This is my review of the paper. The conclusions are: Children and adolescents should limit their intake of sugar-sweetened beverages (like sodas) to one 8-oz serving per week, or less, and for those under 2 years of age, added sugars should be avoided entirely_BA


Not all statins are equal

In General Health, Heart on September 13, 2013 at 7:57 pm

Because statins lower the incidence of adverse cardiovascular and cerebrovascular events — even in low-risk patients — they are used broadly. Statins’ reported adverse effects include myalgias (muscle pain) , myopathy(muscle disease), rhabdomyolysis (muscle damage / breakdown), transaminitis (elevated liver enzymes) , and diabetes mellitus. In a meta-analysis of 135 randomized trials (247,000 participants) that involved seven statins (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin [Crestor], simvastatin, and pitavastatin [Livalo]), investigators evaluated adverse effects associated with statins overall and individually. The overall rate of statin discontinuation owing to adverse effects was low (6%) for all statins combined. Statins as a class caused no more medication discontinuations, myalgias, creatinine kinase elevations, myopathy, rhabdomyolysis, or cancer than placebo. However, statins significantly increased relative risk for transaminase elevations (by 50%; baseline incidence, 1%) and diabetes (by 9%) compared with placebo. Simvastatin( Zocor)  and pravastatin(Pravachol)  were associated with best overall tolerability and lowest discontinuation rates. Compared with controls, atorvastatin( Lipitor) and rosuvastatin (Crestor)  were associated with the highest discontinuation rate because of adverse events; whereas atorvastatin (lipitor) and fluvastatin( LesCol)  were associated with higher risks for transaminase elevations (odds ratios, 2.6 and 5.2, respectively). Higher doses of all statins were associated with higher risk for transaminase elevations. Although low doses of simvastatin (Zocor) appeared to be safest, daily doses >40 mg significantly raised risk for creatinine kinase elevation (OR, 4.1) and transaminase elevation (OR, 2.8).

Appeared in NEJM Journal Watch

Source: Naci H et al. Comparative tolerability and harms of individual statins: A study-level network meta-analysis of 246 955 participants from 135 randomized, controlled trials. Circ Cardiovasc Qual Outcomes 2013 Jul; 6:390. –

Comments: Useful analysis; choosing the safest statin is exceedingly important, particularly when we have significant side effects such as diabetes and elevated liver enzymes, and muscle problems. Unfortunately, we are often obligated to use other than the safest statins to achieve the desired effect on lipids, leading to the choice of the lesser of the two evils; this is certainly a discussion to have with the PCP _BA

Mediterranean Diet Lowers Rates of Adverse Cardiovascular Events

In General Health, Heart on June 14, 2013 at 1:01 am

The so-called Mediterranean diet is thought, mostly on the basis of observational studies, to confer cardiovascular benefit. Now, Spanish researchers have put this diet to the ultimate test — a large, randomized, primary-prevention trial. About 7500 people (age range, 55–80) without known cardiovascular disease but with either diabetes or 3 non-diabetes cardiac risk factors were randomized to one of three diets:

  • Mediterranean diet supplemented with extra-virgin olive oil (at least 4 tablespoons daily)
  • Mediterranean diet supplemented with a daily 30-g serving of walnuts, almonds, and hazelnuts
  • Low-fat control diet

During average follow-up of 5 years, the primary composite outcome (myocardial infarction, stroke, or cardiovascular-related death) occurred significantly less often in the two Mediterranean-diet groups than in the control group (8 per 1000 person-years in each Mediterranean group vs. 11 per 1000 person-years in the control group). Among the three components of the primary endpoint, only stroke was significantly lower in the intervention groups. The two Mediterranean diets did not lower all-cause mortality significantly.

Summary appeared in Journal Watch General Medicine.

Comment: Few clarifications: 

1. Depending on group allocation, either a 15-liter (1 liter per week for 15 weeks) supply of extra-virgin olive oil (®Hojiblanca and ®Fundación Patrimonio Comunal Olivarero, both from Spain) or 3-month allowances of nuts consisting of 2 Kg (15 g per day) sachets of walnuts (®California Walnut Commission, Sacramento, CA), 1 Kg (7.5 g per day) sachets of almonds (®Borges SA, Reus, Spain), and 1 Kg (7.5 g per day) sachets of hazelnuts (®La Morella Nuts, Reus, Spain) were delivered to participants in the corresponding Mediterranean diet groups during each quarterly group session.

2.  In the Mediterranean diet with nuts group researchers offered participants three types of tree nuts, walnuts, hazelnuts and almonds. As stronger evidence supports that alpha-linolenic acid-rich walnuts might offer special advantages in cardiovascular prevention, researchers supplied a higher amount of walnuts than of almonds and hazelnuts.

3. The general guidelines to follow the Mediterranean diet that dietitians provided to participants included the following positive recommendations:

  1.  abundant use of olive oil for cooking and dressing dishes;
  2. consumption of ≥ 2 daily servings of vegetables (at least one of them as fresh vegetables in a salad), discounting side dishes;
  3. ≥ 2-3 daily servings of fresh fruits (including natural juices);
  4. ≥ 3 weekly servings of legumes;
  5. ≥ 3 weekly servings of fish or seafood (at least one serving of fatty fish);
  6. ≥ 1 weekly serving of nuts or seeds;
  7. select white meats (poultry without skin or rabbit) instead of red meats or processed meats (burgers, sausages);
  8. cook regularly (at least twice a week) with tomato, garlic and onion adding or not other aromatic herbs, and dress vegetables, pasta, rice and other dishes with tomato, garlic and onion adding or not aromatic herbs. This sauce is made by slowly simmering the minced ingredients with abundant olive oil.
  9. Negative recommendations are also given to eliminate or limit the consumption of cream, butter, margarine, cold meat, pate, duck, carbonated and/or sugared beverages, pastries, industrial bakery products (such as cakes, donuts, or cookies), industrial desserts (puddings, custard), French fries or potato chips, and out-of-home pre-cooked cakes and sweets.

4. The dietitians insisted that two main meals per day should be eaten (seated at a table, lasting more than 20 minutes).

5. For usual drinkers, the dietitian’s advice was to use wine as the main source of alcohol (maximum 300 ml, 1-3 glasses of wine per day). If wine intake was customary, a recommendation to drink a glass of wine per day (bigger for men, 150 ml, than for women, 100 ml) during meals was given.

6. Ad libitum consumption was allowed for the following food items: nuts (raw and unsalted), eggs, fish (recommended for daily intake), seafood, low-fat cheese, chocolate (only black chocolate, with more than 50% cocoa), and whole-grain cereals.

7. Limited consumption (1 serving per week) was advised for cured ham, red meat (after removing all visible fat), and cured or fatty cheeses.


CITATION:  Estruch R et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013 Feb 25.

Eggs and CVD

In General Health, Heart on February 25, 2013 at 12:04 am

The American Heart Association (AHA) recommends consuming <300 mg of cholesterol daily (Circulation 2006; 114:82), to lower blood cholesterol and cardiovascular disease risk(CVD), and because chicken eggs are high in cholesterol (about 200 mg each), clinicians commonly advise patients with elevated blood cholesterol to avoid eating them. However, the association between egg consumption and cardiovascular disease is unclear. In a meta-analysis of 17 prospective cohort studies in which egg consumption was measured with food-frequency questionnaires, investigators assessed this association.The analysis included nine reports on coronary heart disease (CHD) and eight reports on stroke, with 10 to 20 years of follow-up in most studies. No associations between egg consumption and risk for CHD or stroke were observed. However, subgroup analyses of diabetic patients in which highest and lowest egg consumption were compared showed excess risk for CHD (relative risk, 1.5) and less risk for hemorrhagic stroke (RR, 0.8).

Comments: Another myth is challenged. This meta-analysis shows little association between egg consumption and coronary heart disease or stroke, and consumption was not associated with coronary heart disease or stroke except for excess CHD risk in diabetic patients, suggesting that most patients don’t need to avoid eggs. The findings are consistent with metabolic research showing that, in most people, dietary saturated and trans fatty acids influence serum LDL cholesterol more than dietary cholesterol does. As the authors note, chicken eggs are inexpensive and rich in protein and other nutrients.

CITATION: Rong Y et al. Egg consumption and risk of coronary heart disease and stroke: Dose-response meta-analysis of prospective cohort studies. BMJ 2013 Jan 7; 346:e8539. Appeared in Journal Watch General Medicine.

Elevated Serum Uric Acid Predicts Metabolic Syndrome in Adolescents

In General Health, Heart on June 20, 2012 at 8:59 pm

Elevated uric acid (UA) is one of a number of clinical abnormalities associated with the metabolic syndrome in adults and children. To examine this association in adolescents, researchers followed 613 randomly selected male adolescents (age range, 10–15 years) from a health screening center in Taiwan for a mean of 2.7 years. Baseline UA, waist circumference, blood pressure (BP), body-mass index (BMI), fasting plasma glucose, and cholesterol levels were measured at baseline and follow-up. Adolescents with metabolic syndrome, type 1 diabetes, hypertension, or hyperlipidemia at baseline were excluded. Adolescents were divided into quartiles according to UA levels, ranging from lowest (mean, 5.2 mg/dL) to highest (mean, 8.9 mg/dL). Nineteen adolescents (3.1%) developed metabolic syndrome as defined by the International Diabetes Federation consensus criteria (>3 of the following: abdominal obesity, triglycerides 150 mg/dL, high-density lipoprotein cholesterol <40 mg/dL, hypertension, and fasting plasma glucose 100 mg/dL). Age, waist circumference, BMI, BP, high-density lipoprotein cholesterol, and triglycerides were significantly associated with baseline UA. Risk for developing metabolic syndrome was significantly greater in adolescents in the highest UA quartile than in those in the lowest quartile (odds ratio, 6.39). The positive predictive value of a baseline UA value of 7.6 mg/dL for developing metabolic syndrome was 79% and the negative predictive value was 94%. Higher UA, waste circumference, and BP were independently predictive of metabolic syndrome at follow-up. Conclusion: Male adolescents with the highest uric acid levels at baseline were 6 times more likely to develop metabolic syndrome after 3 years

 Comments: small but interesting data. The positive predictive value is somewhat low but was strong. This is another marker in this disease _ BA


  1. Wang J-Y et al. Predictive value of serum uric acid levels for the diagnosis of metabolic syndrome in adolescents. J Pediatr 2012 May 11
  2. Journal Watch

Metabolic Syndrome: Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes.

For more info:

low dose aspirin and risk of bleeding

In General Health, Heart on June 20, 2012 at 5:09 pm

Low-dose aspirin use lowers risk for recurrent adverse cardiovascular (CV) events in patients with known CV disease. Its benefit for primary prevention of CV events, especially in low-risk patients (those with 10-year risk <10%), is less clear given the risk for complications, particularly major bleeding. In this Italian study, researchers used a population-based database to identify 186,425 patients (mean age, 69) who took low-dose aspirin (81-83 mg) daily for at least 75 days and matched them to the same number of control patients who had the same bleeding propensity and did not use aspirin. During median follow-up of 5.7 years, 6907 episodes of major bleeding requiring hospitalization in aspirin and control patients occurred; about two thirds of bleeds were gastrointestinal, and one third were intracranial. The incidence rate was 5.58 events per 1000 person-years in aspirin users and 3.60 for nonusers, an excess of 2 per 1000 person-years.

Editorial: This is an observational study, and other factors could not be accounted for, these factors could change the outcome / conclusion of this study. Nevertheless, these are important data. An editorial that accompanied this study in JAMA,  puts these risks into perspective with the calculation that, for 10,000 patients without known cardiovascular (CV) disease followed for 1 year, aspirin would prevent about seven (7) major CV events and would cause four (4) major bleeding events. Not a big benefit! Other data have shown different results, , in 10,000 patients with known CV disease, aspirin use would prevent about 250 major CV events and would cause about 40 major bleeding events.

CITATION(S): 1. De Berardis G et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA 2012 Jun 6; 307:2286.

2. Siller-Matula JM. Hemorrhagic complications associated with aspirin: An underestimated hazard in clinical practice? JAMA2012 Jun 6; 307:2318.

3. Journal Watch & Thomas L. Schwenk, MD


HIV infection, inflammation and heart disease

In Heart, HIV on May 20, 2009 at 5:22 pm

Growing evidence suggests that the risk for atherosclerosis is higher among HIV-infected individuals than among HIV-negative persons; potential explanations include deleterious effects of antiretroviral therapy (ART), virus-induced endothelial injury, and chronic inflammation. To examine the role of these factors, investigators studied carotid intima-media thickness (IMT; a measure of atherosclerosis) and C-reactive protein (CRP; a marker for systemic inflammation) levels in HIV elite controllers (infected patients who maintain undetectable viral loads without taking ART), untreated HIV-infected patients, HIV-infected patients on ART, and HIV-negative controls (total, 494 participants). The median carotid IMT was significantly higher in HIV-infected patients than in HIV-negative individuals, even after adjustment for cardiovascular risk factors. The median carotid IMT in elite controllers was significantly higher than that in HIV-negative individuals and was similar to that in untreated HIV-infected patients. The median CRP level was significantly higher in HIV-infected patients, including controllers, than in HIV-negative patients. Published in Journal Watch. Hsue PY et al. Role of viral replication, antiretroviral therapy, and immunodeficiency in HIV-associated atherosclerosis. AIDS 2009 Apr 22. Comments: these data and others seems to suggest that HIV infection by itself , not medications, cause inflammation maybe due to viral replication (with and without treatment for HIV); this inflammation can lead to atherosclerosis and heart disease. People with HIV infection should be screened for heart disease early and aggressively _BA

C-Reactive Protein (CRP) and Heart Disease in HIV

In Heart, HIV on May 14, 2009 at 7:26 pm

Inflammation is suspected to contribute to increased risk for both AIDS- and non–AIDS-related outcomes in HIV-positive patients. To evaluate how HIV infection and elevated C-reactive protein (CRP) levels each influence risk for acute myocardial infarction (MI), investigators reviewed data from a large patient registry in Massachusetts. Analysis included 487 HIV-infected patients and 69,870 HIV-uninfected patients, all of whom had CRP data available from between 1997 and 2006. Patients who had an MI were eligible for analysis only if their most recent CRP level was obtained 3 years to 1 week before the MI. In a univariate analysis, HIV infection and elevated CRP levels were each significantly associated with increased risk for acute MI (odds ratios, 2.1 and 2.5, respectively). In a model adjusted for age, sex, race, hypertension, diabetes, and dyslipidemia, both of these associations remained significant (ORs, 1.9 and 2.1, respectively). HIV-infected patients with elevated CRP levels were four times more likely to have an acute MI than HIV-uninfected patients with normal CRP levels. Overall, these findings suggest that CRP levels might help predict MI risk in HIV-positive patients. Published in Journal Watch and original paper: Triant VA et al. Association of C-reactive protein and HIV infection with acute myocardial infarction. J Acquir Immune Defic Syndr2009 Apr 21. Comments: There is a bias in this trial, since only patients with CRP levels were included. To better evaluate the role of CRP and other inflammatory markers, a study of all comers is more useful. In the meantime, this is something to watch _ BA

Aspirin and Heart Disease

In Heart on April 1, 2009 at 12:38 am

The U.S. Preventive Services Task Force now recommends that aspirin be used in men to prevent MIs (Myocardial Infarction) — and in women to prevent ischemic strokes — when these benefits outweigh the risks for gastrointestinal bleeding.

The task force considers older age and male sex as the major risk factors for gastrointestinal bleeding, followed by upper GI pain, ulcers, and NSAID use.

The recommendations, published in Annals of Internal Medicine, update the USPSTF’s previous statement, released in 2002. The current statement factors in evidence from the Women’s Health Study that “aspirin may have differential benefits and harms in men and women.” The task force also concludes that evidence is “insufficient” to weigh the benefits and harms of aspirin prophylaxis among people over age 79 — and that use among men under 45 or women under 55 should not be encouraged. An editorialist writes: “Aspirin continues to be underused, and the routine incorporation of the USPSTF’s recommendations … [will] prevent many thousands of cardiovascular events every year.”
Here is a summary of the recommendations to physicians:
1. Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions (heart attack) outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation)
2. Encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation)
3. Evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (I statement)
4. Do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years. (D recommendation).