Finding the Heart Healthy “Sweet Spots” as you Age

This article was adapted from my piece in yesterday’s Baltimore Times.

Overall death rates from heart and blood vessel disease are down, thanks to improved prevention and treatment, but the rates of cardiovascular disease are expected to double over the next 20-30 years among people 65 years and older. Three out of every four men and women in this age group have at least one major risk factor: a history of smoking, diabetes mellitus (sugar diabetes), high blood pressure, and high cholesterol. You can’t stop aging, but the good news is that even if you have several of these risk factors, it’s never too late to boost your cardiovascular health by focusing on what I like to call the “sweet spots.”

Cigarette Smoking: Smoking makes your heart work harder and raises blood pressure. A history of cigarette smoking can shave 10 years off your life, but your risk drops by 50 percent after quitting for one year, and drops more as time goes on.

Sweet Spot: To eliminate the risk, you eventually have to get down to zero cigarettes (without switching to vaping). Non-drug options include hypnotherapy, acupuncture and behavioral counseling. Another option that has worked well for my patients is a prescription nicotine inhalation system that simulates the act of cigarette smoking, while gradually reducing the urge to smoke.

Diabetes Mellitus: High levels of blood glucose (sugar) from diabetes can damage your blood vessels and the nerves that control your heart and blood vessels. Normal glucose is 100 mg/dL, while diabetes is defined as a fasting glucose greater than 125 mg/dL. Between those extremes is a pre-diabetes range,100-125, which often responds well to lifestyle changes: diet, exercise and weight loss.

Sweet Spot: I ask my patients in their 60s or 70s how much they weighed when they were in good shape, in their 20s or 30s. That helps us to develop diet and exercise goals to either halt full-fledged diabetes if they are in the pre-diabetes stage, or role back the metabolic clock if they have early-stage diabetes. The magical amount of weight loss that can often reduce the risk of diabetes or cardiovascular disease is about 5-10 percent of body weight.

High Blood Pressure: Hypertension is quite common, often has no symptoms, yet can lead to stroke and sometimes death. It’s defined as a systolic blood pressure (top number) of 140 mmHg and diastolic blood pressure (lower number) of 90 mmHg and above; the ideal blood pressure is less than 120/80. The goal is to gradually lower blood pressure in older men and women, since a drastic or quick reduction may compromise blood flow to the brain.

Sweet Spot: Too much salt in the diet is one cause of high blood pressure. Limiting salt to no more than half a teaspoon per day can help lower the pressure, as can the use of medication that is gradually adjusted over weeks to months.

High LDL Cholesterol: High LDL (bad cholesterol) can damage your arteries over time and increase the cardiovascular risk. Studies have found that driving down LDL in patients in their 70s and even 80s continued to benefit those patients. A healthy LDL level is less than 100 mg/dL but if you have cardiovascular disease, your LDL target goal should be less than 70 mg/dL.

Sweet Spot: High fiber foods such as oats, beans and psyllium can lower LDL, as can safe and effective cholesterol-lowering medications, which have been proven to reduce the risk of a heart attack and stroke.

Michael Miller, MD, is a Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine and Director, Center for Preventive Cardiology, University of Maryland Medical Center. He is author of the book, “Heal Your Heart: The Positive Emotions Prescription to Prevent and Reverse Heart Disease.” 

Taking the Road Less Traveled… to Help Others

Last week, My daughter started medical school in her quest to help others. But the road she took was less traveled compared to many of us, including yours truly, who took the more traditional/direct route of entry. As an undergraduate at the institution that Benjamin Franklin founded, she was drawn to architecture and after receiving a Masters degree from the home of the Trojans, she settled in Los Angeles. She began work at a firm whose mission was a bit different than hers. To put the word “green” in perspective, Avery’s vision was to construct environmentally-friendly buildings that could serve as community hubs. While the firm worked on large commercial projects, she discovered that the sustainability of the buildings was driven by the developer, not the firm. And so, she moved on.

I was delighted when she was hired to work at one of the premier architecture firms for designing health care related facilities, including medical schools. During this time, the American Heart Association was interested in collaborating with architectural groups to create “healthy spaces” in medical facilities. My colleague Dr. Francine Welty and I, volunteers for the AHA, arranged with Avery to set up a meeting between her CEO and AHA to initiate discussions toward this goal. One idea, for example would be to create more attractive stairwells, that might include piping in lively music (NOT “muzac”) to encourage and energize us to use the stairs daily. Heck, wouldn’t it be cool to have an internal Spotify player (or “Jukebox” to us older folks) inside the stairwell, where you can choose the song you would love to hear as you climb up to your designated floor?

Needless to say, I was caught off guard several years ago when upon visiting Avery and her fiancé, Andrés, she said “Dad, I’m thinking of applying to Medical School”. It wasn’t so much that she didn’t enjoy her job. Rather, she had a deeper passion to help others and a career in medicine certainly provided the perfect vehicle to accomplish this long-term goal. Over the years, Avery has certainly walked the talk. Not only did she donate peripheral blood stem cells (PBSC) for a stranger requiring a life-saving bone marrow transplant, but she has also been a strong advocate for the homeless (often giving away her lunch/buying a sandwich for someone in need) and spent countless hours after work as a volunteer tutor for disadvantaged youth.

As Avery embarks in this new and exciting phase in her life, I have no doubt that she will be an extremely empathetic and devoted physician. I recall that my classmates who took time off between college and medical school were at the top of the class. This stemmed in large part because of their deep appreciation and passion for medicine that grew after college. While Avery may be the only accredited architect in her class, there are undoubtedly other classmates who took time off to have successful ventures prior to committing to medicine. This is supremely encouraging because with medical school applications rising to new heights in the middle of the COVID pandemic, we need the best and brightest to drive the future of healthcare and medicine.

While I may have been a bit squeamish at the prospect of her desire to become a physician in 2017, based upon the many years of study/training that lie ahead, my viewpoint in 2020 is: “Avery, I couldn’t be prouder!”

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.

Where Has All the COMMON SENSE Gone?

 

Two of the many things I vividly remember about my grandfather, a product of the Greatest Generation and a 25 year veteran of the U.S. postal service, was to 1) constantly correct me when I said “you know, you know” (his retort: “…you know, you know…I DON’T KNOW”) and to teach me about common sense when I would do something stupid (not a rare occurrence) using his favorite expression…”why don’t you use a little common sense?”. There is no doubt that the Greatest Generation had a great deal of common sense to continue to build and lead this country.

I was reminded about “common sense” recently following a conversation I had with one of Baltimore’s most beloved pastors, Bishop Marcus Johnson, Sr. As we discussed the continued spike of COVID-19 in many states across the country, I asked “Isn’t it just simple common sense to wear a facemask and keep social distance?” His tongue in cheek response was “maybe common sense isn’t so common anymore!”

What has happened to common sense in our society? My grandfather was a great storyteller and had a lot of common sense. If he and many others of the Greatest Generation were alive today, they would have taught us the importance of using common sense to combat this pandemic. Since they are not, I will at least try to represent how I believe my grandfather would have responded to some ludicrous comments and continued disregard by some to use proper precautions in order to slow the spread of this potentially lethal virus.

First, the Greatest Generation would have had no problems wearing a face mask and socially distance, especially after many had experienced the 1917-1918 Influenza pandemic, a time when common sense prevailed. Yet, a Sheriff of Marion County, Florida recently ordered his Deputies NOT TO WEAR MASKS! His reasoning was: “it would be better if officers’ voices were not muffled behind masks and that citizens’ faces were not obscured.” I can hear my grandfather state the obvious: “Sheriff, if you are so worried about watching the words come out of the mouth of the Deputy or citizen, why don’t you provide them with clear face masks?”

But how would my grandfather have responded to large gatherings that disregard social distancing or face coverings, including “COVID parties“? Well, he loved to sell his stories through pictures, and it would not have been surprising if he had asked my brothers and me to think of COVID as “leprosy inside our body”. When many of us think of leprosy, we think of skin disfigurement, loss of digits, etc. But if we now visualize COVID as “leprosy inside our body” this virus would be viewed through a very different lens….after all, would anyone ever consider attending a party where they might catch leprosy? I could also envision his pinball analogy for why the virus loves to invade humans the closer we are to each other; just like more points are obtained as pinballs bounce off bumpers, the virus can more easily “bounce off” and invade people who are close to each other. The farther away (greater than 6 feet) the less likely that the virus sustain its reach and energy level.

My grandfather also taught me that listening to and heeding the advice of experts is common sense. In fact, my colleague, Dr. Robert Redfield, whom I had the pleasure of interacting with when he was Professor at the University of Maryland School of Medicine prior to becoming Director of the CDC, has repeatedly emphasized the importance of social distancing and face protection. Why would you not listen to experts such as Redfield, Fauci, and Birx who have made significant contributions and have devoted their careers to this field?

To continue not to take this virus seriously is hard to understand as we continue to lose friends, colleagues, loved ones and heroes on the front line. This was the case of Jeff S., a paramedic who was passionate about helping others. Several weeks ago, Jeff was called in to resuscitate a Police Office who was suffering from COVID. Jeff knew that the officer had COVID and despite wearing protective gear, contracted the virus and passed away earlier this week. Even first responder heroes need to ensure that their protective equipment, including N95 masks remain tightly sealed at all times, including active resuscitation efforts.

Perhaps, Pete Seeger’s classic song “Where Have All the Flowers Gone” says it best in its final lines…”when will they ever learn, when will they ever learn“?

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.  He is the author of more than 200 original scientific publications and 3 books. His most recent book is  “Heal Your Heart“ published by Penguin Random House.

Cannabis and Your Heart: Unresolved Issues

This past week, the American Heart Association released its long awaited scientific statement on the effects of cannabis on cardiovascular health. This document provides an excellent summary of available evidence to date, but it is important to note that data are limited. This limitation is largely due to the fact that cannabis is still classified in the U.S. as a Schedule 1 controlled substance, meaning that it has no currently accepted medical use and has a high potential for abuse. Consequently, research funding for well-designed studies aimed at understanding the effects of cannabis on the cardiovascular system have been non-existent. Instead, we’ve relied upon weaker evidence derived from observational studies to help define the problem. It is exceedingly hard to believe that in 2020, cannabis remains in the same category as two other Schedule 1 controlled substances, heroin and LSD (neither of which of course are legal for purchase, either medically or recreationally). Consequently and as aptly pointed out in the AHA document, the first (and second) order of business is: 1) removal of cannabis from Schedule 1 of the U.S. Controlled Substances and 2) removal of all legal barriers in order to permit research funding and well-designed clinical trials. Current evidence suggests that cannabis has opposing heart-related effects depending upon its formulation. That is, cannabis products containing pure THC can have adverse effects on the heart while those containing pure CBD may have beneficial effects.

1. THC Potency and Administration: The potency of THC containing cannabis changed significantly in 1996 when California became the first state to approve marijuana for medicinal purposes. A marijuana induced “high” occurs following inhalation of a joint with an average THC content of 7.5 mg (onset: seconds-minutes/duration: up to 3 hours) or after consumption of an edible at a THC dose of 10 mg (onset: 30 minutes-2 hours/duration: up to 8 hours). High doses (e.g., 30 mg THC or greater) are more likely to produce adverse effects as was the case in a 70-year old man who suffered a heart attack after sucking a marijuana lollipop in a single sitting; the THC content of that lollipop was 90 mg! Users of marijuana prior to 1996 who are now considering its medicinal or recreational use would be surprised to learn that the content of THC is now ~3-fold higher. Consequently, a higher likelihood of adverse effects is more likely to be encountered especially when other risk factors co-exist (e.g., cigarette smoking/vaping) or when certain medications are prescribed (refer to AHA document for details). Side effects include acute rise in blood pressure, rapid heart rate and/or abnormal heart rhythm, most notably atrial fibrillation. In American states where cannabis is legal, hospitalization for heart attacks have increased and the risk of stroke has been reported to be 3-fold higher in frequent users (at least once a week) compared to less frequent or non-users. As with other therapies, benefit versus risk should always be assessed with the lowest amounts recommended to achieve the desired effect.
2. CBD Potency and Administration: In contrast to marijuana/THC cannabis, CBD cannabis is derived from the hemp plant that was excluded from the Control Substances Act and legalized in the 2018 Farm Bill. Like THC products, CBD can be inhaled (onset: 3-5 minutes/ duration: up to 3 hours), consumed (onset: hours/ duration 12-24 hours) or applied as an oil. CBD containing products may not only help to reduce anxiety and emotional stress but also exhibit anti-inflammatory properties which may help to reduce the risk of heart disease. In one small study of healthy volunteers, a single dose of 600 mg CBD lowered systolic blood pressure by 5 mmHg in response to stress (about 1/2 the amount observed with a blood pressure medication). In another small scaled study of volunteers with heightened anxiety, oral administration of 400 mg CBD was associated with reduced levels of anxiety. Despite encouraging preliminary data, large clinical trials are required to determine whether regular use of CBD reduces the risk of heart disease. In addition, the optimal CBD dose for specific conditions have yet to be determined. Finally, regulation of CBD products will also help to protect consumers against product impurities. The new AHA statement will hopefully set the stage for addressing these unresolved issues and advancing this growing field.

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His latest book is  “Heal Your Heart“ published by Penguin Random House.

 

 

 

 

 

The COVID HEART: More Mysterious/Unpredictable Effects

The more we learn about COVID-19, the more we’ve come to appreciate that it’s a virus like no-other due to its unpredictable nature and mysterious effects (see “From Head to Toe“). For example, we initially thought that like other corona (or common-cold like) viruses, once the infection ran its course, then all would return to normal, in otherwise healthy people. While this is true for the majority who are infected, provided that they are not immunocompromised, do not have pre-existing conditions (cancer, diabetes, hypertension, obesity) or have unhealthy habits (cigarette smoking/vaping), a significant caseload has emerged demonstrating the potential for adverse long-term consequences after the acute phase of the infection has resolved.

This was initially demonstrated in children who developed severe inflammation of blood vessels known as multisystem inflammatory syndrome in children (MIS-C) that developed weeks after the initial infection; ironically, many of these children never experienced COVID symptoms! The second has been the persistence of symptoms well after recovery, with fatigue, shortness of breath, joint pain and chest pain as the most common complaints. Now a new study (see #3 below) adds to the growing complexity of COVID-19 and to the list of potential heart related complications that have arisen as a result of the ongoing pandemic.

1. Broken Heart Syndrome: Also known as Takotsubo or stress cardiomyopathy, prior cases of “Broken Heart Syndrome” have traditionally occurred during times of extreme stress, such as the unexpected death of a loved one. In addition to the first case of stress cardiomyopathy reported with COVID-19, other cases have now surfaced. The basis for the increased number of cases during this pandemic is believed to reflect the inordinate amount of stress, both psychologically and economically, experienced rather than the direct complication of COVID-19, especially since most of the affected cases have tested negative for the virus.
2. Heart Muscle Injury: Heart muscle injury occurs in severe cases of COVID-19 and is most likely to occur in those with pre-existing heart disease. The virus increases the risk of blood clot formation and vascular inflammation with a number of cases reported among survivors as well as those who have died of COVID.
3. Lingering Heart-Related Effects: A recent study from Germany found that 60% patients who had “recovered” from lung infections due to COVID-19, exhibited active inflammation in their heart muscle weeks later with associated reduction in heart function. This suggests that a COVID-19 infection may have a lingering effect on the heart- this in turn may produce symptoms such as palpitations, fatigue and shortness of breath. Consequently, COVID-19 survivors who experience such symptoms after their infection has seemingly resolved, should be evaluated by their physician to rule out the possibility of new-onset heart failure.

 

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His latest book is  “Heal Your Heart“ published by Penguin Random House.