Diuretics

There are three types of diuretic: thiazides, loop diuretics, and potassium-sparing diuretics. “All three promote the excretion of excess water and salt from the body,” says Judith Beizer, PharmD, clinical professor at St. John’s University College of Pharmacy and Health Sciences. “This reduces the amount of fluid flowing through the blood vessels, decreasing pressure on the walls of the arteries and enabling the heart to pump more easily.”

Thiazides are the first-line choice (loop and potassium-sparing diuretics are more likely to be used if you have heart failure), but may not be suitable for people with impaired kidney function. They also may increase blood sugar levels in people who have diabetes and raise the risk of gout.

Angiotensin Inhibition

Two drugs inhibit a naturally occurring chemical called angiotensin. There are four different forms of angiotensin—angiotensin II plays an active role in blood pressure because it causes the muscles surrounding blood vessels to contract, narrowing the arteries and raising blood pressure.

• ACE inhibitors stop the body from manufacturing angiotensin-converting enzyme (ACE), which converts angiotensin I into angiotensin II. ACE inhibitors may cause hyperkalemia (elevated potassium levels), which can raise the risk of abnormal heart rhythms, so you’ll need to avoid using potassium-based salt substitutes if taking these drugs. You also may be advised to limit your consumption of potassium-rich foods like such as bananas, oranges, dried peas and beans, and potatoes, and avoid vitamin supplements that contain potassium.

• Angiotensin receptor blockers Known as ARBs, these drugs work by blocking the action of angiotensin II and may be prescribed if ACE inhibitor side effects are intolerable. Like ACE inhibitors, ARBs generally are well tolerated. ARBs can cause elevated potassium levels, so the same dietary precautions apply as for ACE inhibitors.

Calcium Channel Blockers

These may be used to treat high blood pressure in people with angina (a painful squeezing sensation caused by narrowed or blocked arteries in the heart) and those who are at increased risk of stroke. “Calcium channel blockers slow the rate at which calcium— which helps power the heart and maintain its rhythm—passes into the heart muscle and blood vessel walls,” Beizer explains. “This increases the diameter of the arteries and blood pressure falls.”

Very rarely, calcium channel blockers can cause chest pain, a very rapid or very slow heartbeat, and breathlessness. If you should experience any of these reactions, contact your doctor immediately. “Grapefruit juice interferes with the metabolism of some calcium channel blockers,” Beizer adds, “so check with your pharmacist to see if this applies to your medication.”

The post Blood Pressure Drugs: Your Primer appeared first on University Health News.

Diagnosing Kidney Disease

Diabetes is the top cause of kidney failure, causing nearly half of new cases. High blood pressure is the second most common cause of kidney failure, causing 28 percent of new cases; one in five adults with high blood pressure may have kidney disease.

Kidney disease is not reversible, but it is treatable. It’s important for your annual physical exam to include a blood test to evaluate kidney function, especially if you are older than age 60 and have high blood pressure, diabetes, a family history of kidney disease, an autoimmune disease, or a history of pre-eclampsia, which are all risk factors for kidney disease.

“Early detection is the key to effective long-term management,” says Line Malha, MD, Assistant Professor of Medicine, Division of Nephrology & Hypertension, Weill Cornell Medicine. Blood tests check how well kidneys are working by analyzing the glomerular filtration rate (GFR). Current guidelines say that a GFR below 60 for three months indicates chronic kidney disease (CKD). “We all lose kidney function as part of natural aging, but in people with kidney disease, the kidney function decline is faster,” says Dr. Malha.

Keeping Your Kidneys Healthy

Kidneys have several important jobs: They clean your blood, help control your blood pressure, help make red blood cells, and keep your bones healthy.

Focusing on these things can help keep your kidneys in tip-top shape:

Check your blood pressure. If it’s too high, that can put stress on your kidneys.

Watch your A1C. Keep your blood sugar levels in check. If they’re not under control, that can cause problems for your kidneys over time.

Drink water. Drinking water is a great way to keep your kidneys healthy. A word of caution, however: Drinking too much water can lead to low blood sodium levels, which can cause confusion, disorientation, nausea, and vomiting. If your urine is pale yellow or clear, it’s fine. If it’s dark yellow, you probably need more water.

Don’t Overdo NSAIDs. Prolonged use of NSAIDs can potentially damage the kidneys. NSAIDs, which include common medications like ibuprofen and naproxen, can reduce blood flow to the kidneys and may cause changes in fluid and electrolyte balance, leading to kidney dysfunction or damage over time.

Drug Treatment Options

Several types of medications are used to treat kidney disease. Since diabetes and hypertension are the two top causes of kidney disease, many medications used to treat kidney disease also treat these conditions. For example, hypertension drugs also used for kidney disease include:

• ACE inhibitors, such as lisinopril (Prinivil, Zestril), benazepril (Lotensin), and enalapril (Vasotec)
• Angiotensin II receptor blockers (ARBs), such as telmisartan (Micardia) and losartan (Cozaar).

Medications originally formulated for diabetes, called SGLT2 inhibitors, including dapagliflozin (Farxiga) and empagliflozin (Jardiance), have also been approved by the FDA to help delay the worsening of CKD, and these drugs have the added benefit of lowering blood pressure. One of the newest medications approved for CKD is finerenone (Kerendia). This drug is used for treating CKD associated with type 2 diabetes. “These medications have all been shown to halt the progression of declining kidney function over time,” says Dr. Malha.

Maintaining Kidney Function

Kidney disease can often be prevented, and the progression to kidney failure can often be slowed or stopped. To maintain kidney health, follow up with your doctor and control your blood pressure and blood sugar levels,” says Dr. Malha.

The post To Maintain Kidney Health, Keep BP and Blood Sugar in Check appeared first on University Health News.

A person whose blood pressure is usually normal has an appointment at a clinic or medical center. There is a bit of anxiety about the visit. Anxiety elevates blood pressure, and having it checked is a routine procedure.

Blood pressure is taken by a physician or other provider who often wears a white coat that symbolizes medical professionalism. The reading is higher than it normally would be when not in a clinical setting. The presumed result: white coat syndrome.

Until recently, white coat syndrome had been considered a temporary spike—no harm, no foul. But not anymore.

Real—Dangerous for Some

White coat syndrome/hypertension was first described more than 40 years ago. Since then, multiple studies have confirmed that it’s a real thing. The original scenario is the same—anxiety can elevate blood pressure in a clinical setting. But current research suggests that white coat syndrome may also be a symptom of something more concerning.

In February 2022, a review of studies in the journal Hypertension became the first to provide evidence that white coat syndrome in patients (with no previous organ damage) had an increased risk of mortality, new hypertension, and new organ damage. This study and others have resulted in a decidedly different approach to white coat syndrome diagnosis and treatment. (https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.121.18792)

Blood Pressure—How High is Too High?

To be clear, white coat hypertension for most people is still a one-time event that needs attention only in combination with other cardiovascular conditions. According to Cleveland Clinic and other medical centers, the syndrome affects 15-30 percent of people who already have high blood pressure. Patients who don’t normally have high blood pressure can also have the syndrome. (https://my.clevelandclinic.org/health/diseases/23989-white-coat-syndrome)

The definition of high blood pressure has been a moving target and remains a number that your physician determines is right for you. The American Heart Association defines “normal” as less than 120 for the upper (systolic) number; less than 80 for the bottom (diastolic) number. “Elevated” is 120-129 over 79 or less. For numbers defining three advanced stages of hypertension, go to https://www.heart.org/en/health-topics/high-blood-pressure.

The definition of normal can change, depending on a person’s age and health conditions. The AHA’s guideline for those 65 and older is lower than 130/80.  Normal for patients over the age of 80 may be higher.

Diagnosis— Multiple Readings

Diagnosis of white coat syndrome requires at least three separate blood pressure readings at a clinic, as well as elevated numbers when checked at home. Home blood pressure kits and regular checks are a good idea, regardless of the white coat issue.

When you take your blood pressure (BP) at home, follow these CDC guidelines: 1) nothing to eat or drink 30 minutes before taking BP; 2) empty bladder; 3) feet flat on the floor, legs uncrossed; 4) arm resting on a surface, chest high; 5) cuff snugly against bare skin, not over clothing; 6) no talking; 7) same time every day; 8) at least two readings, 1-2 minutes apart. (https://universityhealthnews.com/daily/heart-health/how-to-get-an-accurate-blood-pressure-reading/)

Treatment—Lifestyle Changes, Medications

If blood pressure is found to be slightly elevated—your doctor makes that call—you may be asked to consider lifestyle changes. You’ve heard them; all easier said than done. Here’s a review:

• Lose weight.
• Sit less, exercise more.
• Eat more fruits and vegetables, less red meat and processed foods.
• Limit daily salt intake to 2300 mg.
• Don’t smoke.
• Work on managing stress. (https://universityhealthnews.com/daily/stress-anxiety/how-to-deal-with-stress/)

If your blood pressure is more than slightly elevated, your doctor may prescribe medications to lower it. Examples are diuretics, alpha- and beta-blockers, ACE inhibitors, and calcium blockers. The Hypertension study mentioned earlier also found that patients with white coat syndrome who take medications to control blood pressure don’t have elevated risks of cardiovascular disease.

Antihypertensive drugs carry risks, mostly mild, for some patients. Ask your doctor about medications that might lower your blood pressure too much. Hypotension, as it’s called, could cause dizziness, lightheadedness, passing out, weakness, nausea, and other symptoms.

How low is too low? The National Library of Medicine says that while there is no universally-accepted standard, blood pressure readings under 90/60 indicate hypotension.

White Coat Syndrome—Answers and Actions

It’s real—well documented. It can be dangerous for some, leading to a variety of conditions that require medical intervention. High blood pressure, whether conventional or white coat, is treatable. It starts with lifestyle changes, and for more serious cases, advances to effective and safe antihypertensive medications.

Don’t dismiss white coat hypertension if it shows up at your next doctor’s appointment. Have it checked or regularly check it yourself.

Other Helpful Links from University Health News

https://universityhealthnews.com/daily/heart-health/uhn-blog-whats-the-right-blood-pressure-for-you-it-depends/

https://universityhealthnews.com/daily/heart-health/is-the-blood-pressure-reading-from-your-doctors-visit-accurate/

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“Chronic kidney disease (CKD) is a very common disease with a high mortality risk, but not many people know about it,” says Line Malha, MD, a nephrologist at Weill Cornell Medicine. “We need to increase awareness of kidney disease.”

What Your Kidneys Do

Your kidneys function as a filtration system for your blood. The kidneys contain structures called nephrons, which are composed of clusters of tiny blood vessels, tubules, and collecting ducts; each kidney contains more than a million nephrons.

The kidneys remove toxins, excess fluid, and other waste products. They also help regulate amounts of substances that play an important role in bone health, red blood cell production, and regulating blood pressure.

Assessing Kidney Function

Dr. Malha says it’s very important to have annual physical exams and blood tests that include an evaluation of your kidney function. One substance measured on a standard blood test is creatinine. “Creatinine is a waste product filtered out by the kidneys,” explains Dr. Malha.

“Creatinine is used to interpret the glomerular filtration rate, or GFR, which tells us how well the kidneys are filtering the blood.”

Another indicator of kidney function is a substance called albumin, which consists of protein fragments that are too large to pass through the filtration system into the urine if the kidneys are working properly. The albumin level is checked with a urine sample.

“When urine albumin is high, it indicates the possibility that the filter is more ‘leaky’ than it should be,” explains Dr. Malha. “An albumin level above 30 milligrams per gram (mg/g) is called microalbuminuria, and a level above 300 mg/g is macroalbuminuria.”

If test results suggest kidney function is impaired, further screening tests may include laboratory testing (blood and urine), a kidney ultrasound, and sometimes a biopsy, in which a tissue sample is taken and then examined.

Risk Factors for Kidney Disease

“Diabetes and hypertension (HT) are the top risk factors for kidney disease in U.S. adults. This is why earlier detection and better management of diabetes and HT are key for protecting kidney health,” emphasizes Dr. Malha. “Over time, diabetes and HT damage blood vessels. The filtering apparatus in the kidneys is made up of clusters of tiny blood vessels, so vascular damage can make them less functional. On biopsy, you can see the damage.” Other risk factors include:

• Autoimmune diseases, such as lupus, which are more common in women than in men
• A history of preeclampsia (new onset of hypertension) during pregnancy
• Being treated with chemotherapy
• Taking medications that can be toxic to the kidneys, such as nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen)
• A family history of CKD or kidney failure. Dr. Malha adds that some types of kidney disease have genetic or congenital causes.

Treatment Options

Several types of medications may be used to treat kidney disease. Since diabetes and hypertension are the two top causes of kidney disease, many medications used to treat kidney disease also treat these conditions. For example, HT drugs also used for kidney disease include:

• ACE inhibitors, such as lisinopril (Prinivil, Zestril), benazepril (Lotensin), and enalapril (Vasotec)
• Angiotension II receptor blockers (ARBs), such as telmisartan (Micardia), losartan (Cozaar), and valsartan (Diovan)
• Aliskiren (Tekturna), a renin inhibitor

“Medications originally formulated for diabetes, called SGLT2 inhibitors, including dapagliflozin (Farxiga) and empagliflozin (Jardiance), have also been approved by the U.S. Food and Drug Administration to help delay the worsening of CKD,” notes Dr. Malha. “An added benefit of these drugs is that they also help lower blood pressure.”

One of the newest medications approved for CKD is finerenone (Kerendia). This drug is used for treating CKD associated with type 2 diabetes.

Dr. Mahla stresses that, if a person with CKD also has diabetes or high blood pressure, good management of these conditions is essential.

If the progression of CKD cannot be halted, kidney failure results. If that occurs, the options remaining are a kidney transplant or dialysis.

This may sound grim, but the upside is that, if kidney disease is identified and treated in the early stages, there’s a much lower risk of ending up with kidney failure.

The post Raising Awareness About Kidney Disease appeared first on University Health News.

Heart failure is a serious condition that can result in frequent hospitalizations and declining quality of life, and, if it’s untreated, it can be fatal.

“If you have heart failure, eating right, exercising regularly, and being compliant with your medications and your doctor appointments are keys to feeling good, reducing exacerbations of the condition, and living a longer, higher-quality life,” says Joy Gelbman, MD, a cardiologist at Weill Cornell Medicine.

What Is Heart Failure?

Heart failure is not a disease itself but a condition resulting from injury to the heart muscle. The term “heart failure” can be frightening, since it suggests that the heart is no longer working, but the term actually means that the heart is no longer able to effectively pump enough blood to meet your body’s needs. This results in less oxygenated blood reaching the brain, organs and muscles, fluid build-up, and an increased risk of blood clots forming in the heart.

Symptoms and Diagnosis

The most common symptom of heart failure is shortness of breath, which may be sudden and severe or may occur when you are lying flat or exercising. Other symptoms include swelling in the legs, feet, and/or abdomen, fatigue and leg weakness that occur when you are physically active, heart palpitations, coughing up pink phlegm or mucus, and lightheadedness or dizziness. Since these are symptoms that may be caused by a number of conditions, a medical evaluation is necessary to determine what is causing them.

An evaluation for heart failure will include a review of your medical history and symptoms and a physical examination. Blood and urine tests and other noninvasive tests, such as a stress test, echocardiogram, magnetic resonance imaging (MRI) test, or coronary computed tomography (CT) angiogram, also may be ordered.

Risk Factors and Causes

Heart failure is most common in people who have had a heart attack and suffered damage to part of the heart. Heart failure also can result from hypertension, diabetes, a malfunctioning heart valve, cardiomyopathy (a disease that causes the heart muscle to enlarge), myocarditis (inflammation of the heart) or heart defects that are present at birth (congenital heart disease).

Other conditions that raise the risk of heart failure include kidney disease, obesity, thyroid disorders, emphysema, and lupus. Some medications can raise the risk of heart failure, and severe infections and viruses that affect the heart may cause acute episodes of heart failure.

Treatment Options

A heart-healthy diet and regular exercise are key elements for treating heart failure. Your eating plan should consist mainly of fruits and vegetables, whole grains, lean proteins, and healthy fats. Limit red and processed meats and highly processed foods, especially those that are high in sodium.

Exercise is also important, although the shortness of breath that’s a common symptom will probably make physical activity challenging. For guidance on exercise, ask your cardiologist for a referral to a cardiac exercise program, where the staff can create an exercise regimen that is both safe and effective. In addition to benefiting your entire circulatory system, exercise can help you lose weight—an important treatment target since a majority of patients with heart failure are obese.

Some of the medications that may relieve your symptoms and help your heart pump more effectively include beta blockers (Lopressor, Inderal) and ACE inhibitors (Lotensin, Vasotec), angiotensin II receptor blockers (Cozaar, Diovan), and aldosterone antagonists (Aldactone, Inspra). Many patients need to take more than one medication to manage their heart disease.

Advanced heart failure therapies include intravenous medications, implantable cardioverter-defibrillators, pacemakers, and ventricular assist devices that help the heart pump more blood. If all other treatments fail and heart failure is severe, a heart transplant may be the final option.

It is also important to adhere to your doctor’s instructions for managing other conditions that contribute to heart disease, such as high blood pressure, high cholesterol, and high blood glucose levels. And, be sure to tell your doctor about any other over-the-counter or prescription medications you take, as well as any nutrition or herbal supplements, since some can slow your heart rate, worsen high blood pressure, or interact with heart failure medications.

While lifestyle strategies and medications cannot cure heart failure, they can reduce symptoms and prevent the heart from becoming weaker, giving you a longer, more enjoyable life.

The post Take Shortness of Breath Seriously; It May Be a Symptom of Heart Failure appeared first on University Health News.

Hard on Your Heart

In hot weather, your core temperature rises. Your body responds to this rise by attempting to transfer heat to the environment. Two methods it uses are vasodilation (dilation of the blood vessels) and sweating.

• Vasodilation enables more blood to flow through the skin so that heat can be lost. But to increase blood flow to the skin, blood has to be redirected from elsewhere in the body. This may lower your blood pressure—and low blood pressure places extra demand on the heart. Mount Sinai cardiologist Bruce Darrow, MD, PhD, adds that heart medications may make the problem worse. “For example, beta-blockers and calcium channel blockers, which are used to treat high blood pressure and abnormal heart rhythms, can slow the heart rate,” he says. “This means that your heart rate may not increase appropriately to compensate for the change in blood pressure.”

• Sweating helps cool the body as it evaporates—but it also removes water and vital minerals, such as sodium and potassium, from the body. Dehydration is a risk, and this forces the heart to work harder and raises the risk of blood clots. “Fluid loss may be exacerbated if you take diuretics to treat high blood pressure or heart failure, since these drugs increase urine output,” Dr. Darrow notes. “ACE inhibitors—also used to treat high blood pressure— can increase sweating in some people, thereby raising the risk of dehydration.” Other drugs you may take alongside heart medications also may alter the way the body responds to heat—for example, anticholinergic drugs, pain medications such as opioids, and some antidepressants.

Dr. Darrow recommends these strategies to keep your heart safe in the heat.

1. Stay Indoors When the Sun is Strongest If you like exercising outdoors, schedule it for the early morning. “Aim to stay inside between 10 a.m. and about 4 p.m., when the sun is strongest,” says Dr. Darrow. “It’s also a good idea to engage in activities that keep you cooler— for example, swimming or a water aerobics class, instead of jogging or tennis—or join a gym so that you can exercise indoors in an air-conditioned environment.”

2. Dress Light Lightweight, light-colored clothing in breathable fabrics like cotton reflects the sun’s rays and allows heat to escape from your skin.

3. Stay Hydrated Water is best—avoid caffeinated or alcoholic beverages, since these contribute to dehydration. “If you have heart failure, drinking large amounts of water may contribute to swelling or sodium imbalance,” Dr. Darrow says. “Clarify with your doctor how much you can safely drink.” Keep in mind that older age, as well as medical conditions like stroke, Parkinson’s disease, and Alzheimer’s disease can dull your sense of thirst—people with these conditions need to be particularly careful about rehydrating throughout the day.

4. Keep Your Home Cool If you don’t have air conditioning, purchase some freestanding fans. Applying cool, damp cloths to your skin and standing or sitting next to a fan is a great way to cool down.

5. Take Your Medications Even though some of the drugs that are used to manage cardiovascular disease can contribute to dehydration, you shouldn’t stop taking them—their benefits far outweigh their risks. “If you are at all concerned that a medication you take may be causing heat intolerance, discuss your worries with your health-care provider,” advises Dr. Darrow.

6. Know the Signs of Heat Exhaustion They include headaches; chills; dizziness; fainting; a rapid heart rate; muscle cramps; and nausea. If you experience these symptoms, take steps to cool down.

7. Treat Heatstroke as a Medical Emergency Signs of heatstroke include warm skin with no sweating; a rapid, strong heart rate; confusion; fever (103 degrees Fahrenheit or higher); headaches; nausea; vomiting; and loss of consciousness. “Seek immediate medical help if you or a loved one experience these symptoms,” says Dr. Darrow.

The post Protect Your Heart in the Heat appeared first on University Health News.

Understanding Heart Failure Heart failure can develop over time when the heart is unable to pump sufficient blood out to the body. As the heart struggles to keep up with the body’s demands for oxygen- and nutrient-rich blood, its main pumping chamber—the left ventricle— may enlarge, in a phenomenon called remodeling. “Remodeling represents the heart muscle gaining mass, as all muscles do when their workload increases,” Dr. Darrow explains. “Initially, remodeling helps the heart pump out a normal volume of blood with each beat. But in the long term, remodeling stretches the walls of the heart, impacting its ability to contract.” The heart grows weaker, leading to the characteristic symptoms of heart failure. These may include fatigue; breathlessness; edema (swelling) of the feet, ankles, legs, and abdomen due to fluid retention; weight gain due to fluid buildup in the body; dizziness; chronic cough; and an increased heart rate. “Heart failure also can be the result of heart attacks or other chronic heart conditions, such as irregular rhythms or valve dysfunction,” Dr. Darrow adds.

Missed Diagnoses Improvements in medication and device therapies have helped make heart failure a more manageable condition. There also is much you can do in the way of lifestyle interventions that mitigate the health issues that are known to underpin heart failure. “Many people with heart failure can do most normal activities with optimal medical therapy,” Dr. Darrow observes. “Many more are able to improve their strength and quality of life through a combination of medications and lifestyle changes.” But if your condition is not detected, you won’t get referred to specialists who can prescribe specific treatments and you also may not feel sufficiently motivated to follow a heart-healthy lifestyle.

The study we reference (Heart Failure: Circulation, August 2021) indicates that women and African Americans may be especially vulnerable to underdiagnosis. Researchers looked at health-care claims from nearly 1 million adults with a firsttime heart failure diagnosis. The analysis showed that a significant proportion of new heart failure diagnoses (38 percent) occurred in the emergency room or during hospitalization. Diagnosis in an acute-care setting was more likely for women and African Americans. Among those diagnosed in an acute-care setting, 46 percent had reported potential heart failure symptoms—including edema, shortness of breath, and chest pain— during primary care clinic visits in the previous six months.

Possible Reasons Dr. Darrow says that further research is needed to understand the disparities seen in these data, but adds that limited access to outpatient care, poor communication between doctors and patients, and lack of knowledge of heart failure signs and symptoms may factor in. “It also may be that acute-care settings are more likely than smaller primary- care clinics to have diagnostic equipment, such as echocardiograms, which use ultrasound to measure heart function,” he says.

While heart failure in the setting of reduced heart function is easier to diagnose with an echocardiogram, Dr. Darrow notes that women are more likely than men to develop a type of heart failure called heart failure with preserved ejection fraction (HFpEF). “Most of the tests doctors use to diagnose heart failure may show normal results in people with HFpEF,” he says. “This means doctors often have to rely on the presence of symptoms like breathlessness. However, breathlessness is common in older adults and is known to reflect age-related declines in exercise capacity and/or noncardiac problems.” Previous research also has suggested that women are less likely than men to be prescribed certain recommended heart medications, including ACE inhibitors (which treat high blood pressure), and that both women and African-American people are less likely to be referred to a cardiologist or receive advanced heart failure treatment early in the course of the condition.

Be Proactive These facts underline how important it is to get informed about common heart failure risk factors— which include high blood pressure, a sedentary lifestyle, poor diet, and obesity— and take steps to address them if necessary. Getting plenty of exercise and eating a healthful diet can help you manage all of these health issues, and you also should follow your doctor’s advice when it comes to taking medications to manage them. Keep in mind that this approach also can help your heart if you’ve already been diagnosed with heart failure. “And be proactive about discussing any potential heart failure symptoms with your primary care physician and getting referred to a cardiologist if you feel your concerns warrant further investigation,” Dr. Darrow concludes.

The post Do You Have Undiagnosed Heart Failure? appeared first on University Health News.

Metabolic Syndrome Explained

Metabolic syndrome is a cluster of risk factors linked to poor cardiovascular health. The risk factors include excess abdominal fat, high blood pressure, low levels of high-density lipoprotein (HDL, also known as “good” cholesterol), elevated blood sugar, and high levels of triglycerides (a type of fat that stores excess energy from the food you eat and circulates in the blood). Metabolic syndrome is diagnosed if you have any three of the five. Previous research has associated metabolic syndrome with a greater risk of heart disease, heart attack, a first stroke, blood clots, and diabetes—it also increases the risk of severe disease from viral infections such as COVID-19.

Subsequent Stroke and Metabolic Syndrome

Jonathan L. Halperin, MD, professor of medicine at Mount Sinai, says doctors have long suspected that metabolic syndrome and its components are predictive of recurrent stroke. However, studies looking at the link have shown conflicting results.

Researchers writing in Neurology, Aug. 17, 2021, set out to clarify the risk by combining the results from six studies that included 11,000 participants ages 60 and older, who were followed for up to five years. During that time, 1,250 people had a second stroke. The analysis showed that people with metabolic syndrome were 46 percent more likely to have a second stroke than people who did not have metabolic syndrome. Specifically, having a low HDL level along with two or more other components of metabolic syndrome was associated independently with an increased risk of a second stroke. Excess belly fat, high blood sugar, high triglycerides, and high blood pressure did not increase the risk of stroke recurrence on their own, but it is possible that drugs taken by the participants to manage these risk factors confounded the results.

For the risk of death from any cause, the researchers combined results from eight studies with 51,613 people ages 60 and older who also were followed for up to five years. During that time, 4,210 people died. People with metabolic syndrome were 27 percent more likely to die during the study than people without the syndrome. “However, the analysis did not prove an association of the components of metabolic syndrome with all-cause mortality, and we are left wondering whether that might be found if more people had been followed for longer periods of time,” Dr. Halperin observes. “The study also doesn’t tell us which interventions targeting which components of metabolic syndrome most effectively reduce the risk of recurrent stroke or death. That information can only come from long-term prospective trials of large populations.”

Medications Can Help

Dr. Halperin emphasizes that controlling high blood pressure and cholesterol are key to preventing a first or subsequent stroke. “Managing these risk factors may require you to take ACE inhibitors and statins,” he says. “The drug regimen used for stroke survivors depends on the type of stroke you had and whether you have any associated cardiovascular conditions.” If you had an ischemic stroke (the type caused by a blood clot), you likely will need to take an antiplatelet agent. Aspirin is the first-line option, but some people also may need to take a second antiplatelet drug—such as clopidogrel (Plavix®)—for a limited period of time. Others may need to take a low-dose anticoagulant, such as warfarin (Coumadin®), dabigatran (Pradaxa®), edoxaban (Savaysa®), rivaroxaban (Xarelto®), or apixaban (Eliquis®). “For strokes that are primarily hemorrhagic—that is, due to bleeding—no antithrombotic therapy is appropriate, and the focus is on controlling blood pressure,” Dr. Halperin adds.

Lifestyle Modifications Vital

Dr. Halperin adds that lifestyle modifications also are important for controlling metabolic syndrome and protecting against stroke. “A healthy diet and regular exercise will help curb weight gain as well as lower blood pressure and cholesterol,” he says.

Where your diet is concerned, boost your intake of fruits and vegetables, whole grains, low-fat dairy, fish, and healthy fats. Cut back on saturated fats (red meat, full-fat dairy), sodium, added sugar, and alcohol. For exercise, try to get at least two hours and 30 minutes of moderate-intensity aerobic activity, such as brisk walking, per week. You can best meet this goal by setting aside 30 minutes per day and lacing up your sneakers. A recent study (Neurology, Aug. 11, 2021) may incentivize you to aim higher—the results showed that the more exercise done each week the greater the decrease in mortality over a period of 4.5 years. Among study participants who had previously suffered a stroke, exercising at least the equivalent of three to four hours of walking each week was most beneficial.

Also schedule muscle-strengthening activities two or more days per week (these should work all of your major muscle groups). If you’re not used to exercising, or have a chronic health conditon, discuss with your doctor the amount and intenstity of exercise you should aim for.

The post You Can Prevent a Second Stroke appeared first on University Health News.

Better Memory Recall

The review (Hypertension, September 2021) gathered information from 14 studies that included nearly 12,900 cognitively normal people ages 50 years and older. All of the participants were taking either angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). Rather than sort the drugs by type, the researchers categorized them by whether they crossed the blood-brain barrier. Compared with participants who did not take blood pressure drugs that cross the blood-brain barrier, those who did take these drugs had better memory recall for up to three years of follow-up even though they had a higher level of vascular risk.

Angiotensin II In the Spotlight

It makes sense that blood-pressure lowering drugs might confer protection against memory decline. Your brain uses about 20 percent of your body’s oxygen, which is carried in the blood. If blood flow to your brain is reduced by high blood pressure it won’t get sufficient oxygen, and this will impact your brain function. But why should drugs that cross the blood-brain barrier confer most benefit? Mount Sinai neurologist Sam Gandy, MD, PhD, points to the effects of angiotensin II, a protein that contributes to high blood pressure by causing vasoconstriction (the narrowing of blood vessels). Dr. Gandy notes that in the brain, angiotensin II doesn’t just cause narrowed arteries and reduced blood flow. “It also is associated with chronic inflammation and the depletion of cholinergic neurons, brain cells that release acetylcholine, a chemical believed to be important for memory,” he explains. “ACE inhibitors and ARBs that cross the blood-brain barrier may attenuate these cognitive harms as well as lowering blood pressure.”

ARBs More Protective?

Delving deeper, Dr. Gandy posits that ARBs may be more protective of cognition than ACE inhibitors because of their mechanism of action. Angiotensin II achieves its constricting effect by activating specific receptors (essentially docking areas on the surface of cells). ACE inhibitors prevent the activation of these receptors by blocking the body’s production of angiotensin II. ARBs don’t interfere with angiotension II production—instead, they block one specific angiotensin II receptor. “They leave another type of angiotensin II receptor active,” Dr. Gandy notes. “Animal studies have associated the activation of this second receptor with brain cell repair and decreased inflammation in the brain.”

Some Caveats

Dr. Gandy points out that the participants in this study were cognitively normal—further research is needed to definitely show whether blood pressure drugs help people who already are cognitively impaired. He also notes that the participants’ memory recall was assessed by asking them to remember words from a list, and emphasizes that this type of test does not measure executive function. “Executive function is the ability to plan, organize and regulate thought processes, and it’s vital for independence as you age because it aids you with multitasking and decision-making,” Dr. Gandy says. “As an example, preparing a meal requires executive function—it enables you to cook two things on the stove at once and ensures you don’t forget that you also have something roasting in the oven. Most importantly, impairments in executive function are highly correlated with future dementia.”

Something to Go On

Overall, Dr. Gandy says we don’t yet know enough to repurpose blood pressure medications to prevent cognitive impairment. But he adds that these studies do provide us with something to go on. “If you are diagnosed with high blood pressure and medication is recommended, or you already take blood pressure meds, it may be worth checking with your doctor whether the medication crosses the blood-brain barrier,” he says. “If it doesn’t, you may be able to switch to one that does. But don’t rely just on medication—also follow lifestyle interventions that can help you maintain a normal blood pressure.” Self-help strategies include eating a healthful diet, getting plenty of physical activity, quitting smoking, and limiting your alcohol consumption.

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Longer Track Record

ACE inhibitors have been around longer than ARBs and are less expensive; hence, they are more widely used than ARBs as initial therapy for controlling high blood pressure. But the drugs have been associated with bothersome side effects in some people, including a persistent dry cough, dizziness, headaches, weakness, rash, and a reduced appetite. Rarely they may cause swelling of the lips, tongue, and face that may obstruct breathing. In light of these side effects, a study published in Hypertension, July 26, suggests that doctors should consider bypassing the drugs in favor of ARBs for people who are just beginning treatment.

The study—the largest to compare the safety and efficacy of ACE inhibitors and ARBs—included 2.3 million people who were initially treated for high blood pressure with ACE inhibitors and 674,000 people initially treated with ARBs. The analysis found no significant differences among the two groups when it came to the occurrence of heart attack, stroke, hospitalization for heart failure, or any cardiac event. However, differences were found in the occurrence of medication side effects. Compared with people taking ARBs, those taking ACE inhibitors were three times more likely to develop swelling, and 32 percent more likely to develop a persistent dry cough.

Helpful Guidance

There are some caveats to the data. For example, the most commonly prescribed ACE inhibitor in the study was lisinopril (Prinivil®, Zestril®), while the most common ARB was losartan (Cozaar®), so the results may not be fully generalizable to other medications in these classes. “It also is important to note that many people with blood pressure try more than one medication, or multiple medications at the same time, and the data may not reflect that level of detail,” Dr. Darrow says. “Even so, given that professional guidelines equally recommend several classes of medications as first-line therapies for high blood pressure, the data may provide helpful guidance to doctors and patients when it comes to selecting between ACE inhibitors and ARBs.”

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