should we trust and follow evidence based guidelines?

Guidelines authored by Medical bodies like American Heart Association are strongly followed in our cardiology practise in India as there is lack of trial data conducted in India. I as a practising cardiologist strongly advocate Guideline based therapy. 

However, lately I have been surprised by the recommendations of the new guidelines on various topics. This is because of the change in recommendations which are totally contrary to the previous version of the guidelines. 

Let me cite some examples:

  1. The ATP-3 guidelines strongly advocated Goal based therapy for LDL-cholesterol management. They suggested that LDL cholesterol should be maintained below 100 mg/dl in patients with diabetes  or coronary artery disease. These recommendations were followed by Cardiologists all over the world for the last 12-13 years. However, the new guidelines on Lipid management released by the ACC 2014 mentions that there is no trial to suggest that the target-based therapy of LDL cholesterol works. Instead they advocate high dose statin to be given in patients with high risks and to bring down the LDL cholesterol levels by 50%. This is a drastic change which then calls into question the data on which the earlier ATP guidelines were based.

2.  Beta-blockers were advocated in earlier version of guidelines for treatment of Vasovagal syncope. Even, in my personal experience I have number of patients who felt better with beta-blockers and had remission in their symptoms. However, the new guidelines mentions beta-blockers as Class III (harmful).

3. Amiodarone was advocated earlier for acute treatment of  recurrent ventricular tachycardia (VT). However the new European guidelines on Arrhythmias in ACS mentions that it should be avoided and instead Cardioversion should be preferred.

 

The drastic change in the new recommendations/ guidelines  for treatment of the various disorders (as mentioned above in examples) is unexpected and surprising. The reasons for these may be availability of new trial data or not a thorough evaluation of the trials by earlier committees.

Whatever the reasons, for us as practising Clinicians, patient safety is paramount. Thus, Strict adherence to the new guidelines is advisable and to be followed (till the time we have data available from trials conducted in India on Indian patients). However the therapy should be discussed with and individualised for each patient.

 

 

Warning Symptoms Precede Sudden Cardiac Arrest in most cases.

Warning symptoms, notably chest pain and dyspnea, occur during the 4 weeks preceding sudden cardiac arrest (SCA) in at least half of cases involving middle-aged adults, suggests a new study. The warnings are usually ignored, observe researchers, with few patients phoning 911 in response to what is almost always a fatal event.

The analysis is based on the Oregon Sudden Unexpected Death (SUD) cohort which was published online December 22, 2015 in the Annals of Internal Medicine.

It suggests that sudden death may not be as sudden as we have been thinking till now. There were people who had their symptoms not only in the 24 hours that preceded the arrest, but also in the 4 weeks that preceded their event.

 

The Oregon SUD study is a large, prospective, community-based study of deceased and surviving patients who had an SCA in the Portland, Oregon metropolitan area. The analysis included 839 patients between 35 and 65 years of age with SCA whose prodromal symptoms could be comprehensively assessed.

Of the 839 patients, 430 patients or 51% of the cohort experienced at least one symptom within the 4 weeks preceding their arrest. Men and women experienced prodromal symptoms with equal frequency at 50% vs 53%, respectively.

Symptoms also started more than an hour before SCA onset in 80% of patients; but in 147 of these patients, symptom onset occurred more than 24 hours before their arrest. Among this subgroup of patients, 93% had recurrent new episodes of symptoms during the 24 hours preceding their arrest.

The main symptom was chest pain, documented in 199 patients,” or 46%, Marijon observed. Of those, 76% had “intermittent typical angina,” he said.

Another 18% of patients had dyspnea as their apparent prodromal symptom; about one-third of this group had established congestive heart failure or a pulmonary condition.

 

What Can Be Done

An early call to 911 was associated with better survival odds in the current study suggesting that there is a potential to enhance short-term prevention of SCA by targeting public awareness of SCA.

Source: Warning Symptoms Can Often Precede Sudden Cardiac Arrest

Meditate, Pray and do Yoga to remain healthy!

A recent study by a MGH affiliate shows that RELAXATION STRATEGIES like Praying, Meditation, Deep Breathing and Yoga can keep us healthy and could cut health care costs by 43%.

We all know that there a strong indisputable Mind-Body connect which exists and Stress over long periods can cause illnesses like anxiety, depression, blood pressure, obesity and coronary heart disease.

Individuals in this study participated in programs that train patients to elicit Relaxation response.

“The relaxation response is elicited by practices including meditation, deep breathing, and prayer”. 

4400 patients were enrolled and compared with 13150 controls over a 2 year period. The control group had an overall, but not statistically significant, increase in clinical service utilization in the second year. Patients who used Relaxation strategies had a reduction of around 25 percent across all clinical services. Clinical areas in which there was greatest reduction in service utilization were neurologic, cardiovascular, musculoskeletal, and gastrointestinal. The researchers estimate that this could cut down health care costs by 43%!

 

So, Pray, Meditate and Do Yoga!!!

 

Mind-Body Medicine: New Science and Best Practices to Meet Public Health Challenges”

Source: Relaxation response proves positive | Harvard Gazette

Leisure Jogging Associated With Lowest Mortality Risk!

 

The optimal frequency of jogging in terms of mortality risk was shown to be two to three times a week and at a leisurely pace, according to a study published Feb. 2 in the Journal of the American College of Cardiology (JACC). Jogging three times or more a week was not shown to be statistically different from remaining sedentary.

 

Using data from the Copenhagen City Heart Study, researchers observed the pace, quality and frequency of jogging in 1,098 healthy joggers and 3,950 healthy non-joggers to evaluate the association between jogging and long-term, all-cause mortality. Participants were excluded for a history of coronary heart disease (CHD), stroke and cancer. Participants rated their physical activity on a graded scale of one to four: one, almost entirely sedentary; two: light physical activity 2-4 hours per week; three: vigorous activity for 2-4 hours per week, or light physical activity for more than four hours per week; four: high vigorous physical activity for more than four hours. Joggers were further divided into three subgroups based on dose of jogging: slow (5 mph, 7 mph, >4 hours per week, >3 times per week).

Follow-up of all participants occurred from their first examination in 2001 until 2013, or death (a 12 year followup!).

The results of the study showed that jogging from 1 to 2.4 hours per week was associated with the lowest mortality, while greater quantities of jogging were not significantly different from remaining sedentary in terms of mortality risk. Further, researchers found a U-shaped association between jogging and mortality. Researchers reported 28 deaths among joggers and 128 among sedentary non-joggers, though no causes were recorded.

The authors conclude that “the U-shaped association suggests the existence of an upper limit for exercise dosing that is optimal for health benefits…If the goal is to decrease the risk of death and improve life expectancy, going for a leisurely job a few times per week at a moderate pace is a good strategy.”

In an accompanying editorial comment, Duck-chul Lee, PhD, Department of Kinesiology, College of Human Sciences, Iowa State University, adds that the study “adds to the current body of evidence on the dose-response relationship between running and mortality. However, further exploration is clearly warranted regarding whether there is an optimal amount of running for mortality benefits, especially for cardiovascular and CHD mortality. In addition, because self-reported doses of running may induce measurement error and bias, it would be preferable to use an objective assessment of doses of running in future studies.”

Valentin Fuster, MD, PhD, MACC, editor-in-chief of JACC, remarks that “this study attempts to answer the question about whether increased intensity among better trained individuals results in improved outcomes. What is most interesting in this paper is the U-shaped curve of the findings, indicating that moderate exercise, with regard to total duration, frequency and intensity, results in the best benefit. Thus, it was fascinating to see that both the sedentary population and the aggressive exercisers (with regard to frequency, duration and speed) have higher mortality rates than the moderate exercisers.”

 

So, slow down a little if you are jogging too fast and too much! Soak in the surrounding and enjoy the jog at a leisurely pace!

 

 

via Study Shows Leisure Jogging Associated With Lowest Mortality Risk | ACC News Story – American College of Cardiology.

Cooking oils? Which ones are good for heart?

Cooking oil is plant, animal, or synthetic fat used in frying, baking, and other types of cooking. It is also used in food preparation and flavouring that doesn’t involve heat, such as salad dressings and bread dips, and in this sense might be more accurately termed edible oil.

Cooking oil is typically a liquid at room temperature, although some oils that contain saturated fat, such as coconut oil, palm oil and palm kernel oil are solid.

The FDA recommends that 30% or fewer of calories consumed daily should be from fat.

Oils containing higher percentage of saturated fats are associated with higher cholesterol and triglyceride levels. This can be bad for the heart.

Oils containing higher percentage of Unsaturated fats (monounsaturated or polyunsaturated fats) are generally healthier.

Mayo Clinic has highlighted oils that are high in saturated fats, including coconut, palm oil and palm kernel oil. Those of lower amounts of saturated fats, and higher levels of unsaturated (preferably monounsaturated) fats like olive oil, peanut oil, canola oil, avocado, safflower, corn, sunflower, soy, mustard and cottonseed oils are generally healthier.

The National Heart, Lung and Blood Institute and World Heart Federation have urged saturated fats be replaced with polyunsaturated and monounsaturated fats. The health body lists olive and canola oils as sources of monounsaturated oils while soybean and sunflower oils are rich with polyunsaturated fat.

Here is the List of Cooking oils arranged in increasing amount of saturated fats!

Type of oil or fat Saturated (%) Monounsaturated (%) Polyunsaturated (%)
Canola oil 6 62 32
Almond oil 8 66 26
Pumpkin seed oil 8 36 57
Sunflower oil (high oleic) 9 82 9
Walnut oil 9 23 63
Hemp oil 9 12 79
Safflower oil 10 13 77
Flaxseed oil 11 21 68
Sunflower oil (linoleic) 11 20 69
Avocado oil 12 74 14
Grapeseed oil 12 17 71
Macadamia oil 12.5 84 3.5
Mustard oil 13 60 21
Corn oil 13 25 62
Olive oil 14 73 11
Seame oil 14 43 43
Soybean oil 15 24 61
Groundnut/peanut oil 18 49 33
Rice bran oil 20 47 33
Margarine (soft) 20 47 33
Tea seed oil 22 60 18
Cottonseed oil 24 26 50
Lard 41 47 2
Palm oil 52 38 10
Ghee 65 32 3
Butter 66 30 4
Margarine (hard) 80 14 6
Coconut oil 92 6 2

oils

Its better to choose oil which are low in Saturated fats and high in monounsaturated fats as they are found to be healthier. However, the total amount of oil consumed still needs to be less than 30% of your calorie intake!