Let’s Shake on It: Surprising Clues to Heart Disease & Overall Health

Observant physicians can identify important clues about the heart (and overall) health of their patients simply by being attentive to physical appearance and interactions.   While telemedicine has provided an invaluable service during the COVID19 pandemic, many, if not most of us have missed the informative “personal touch”  we have with our patients.

Perhaps the first clue we receive when patients walk through the door is through a simple handshake.  While some of my patients continue to feel more comfortable with a fist/elbow bump greeting since COVID-19, a sizeable proportion have returned to handshakes following vaccination.

As it turns out, grip strength is a strong predictor of cardiovascular and all-cause mortality.

Grip strength can be measured using a hand dynamometer that is relatively inexpensive and readily commercially available. One study found that for each 11% decrease in grip strength, there was a 17% increased risk of death from heart disease. Another study showed that in men and women aged 60 and over, reduced grip strength was also associated with reduced mobility, functional status and cognitive function.

A third study of 500,000 men and women conducted in the United Kingdom also found reduced grip strength to be associated with a 15-30% higher risk of lung and heart disease as well as certain cancers (breast, colon, lung) over the 7 year follow-up period.  Finally, a more recent UK study in 68,000 middle aged men and women (average age, 63.8 years) found greater grip strength to be associated with a diet enriched in omega-3 fats (oily fish such as salmon and sardines) and magnesium (greens, nuts, seeds, whole grains, dark chocolate).

Listed below are several other physical signs that provide important clues when it comes to increased risk of cardiovascular disease.

1. Progressive skin tanning: In the absence of sun exposure, progressive skin tanning may be indicative of acquired hemochromatosis, a condition of iron overload due to excessive intake of iron or multiple blood transfusions.  In this condition tanning may be seen throughout the body, including the face and upper eyelids. Affected individuals should avoid Vitamin C supplementation because of increased iron availability that in turn, may promote disease progression.
2. Bilateral carpel tunnel syndrome:  While carpel tunnel syndrome can occur with repetitive motion/ overuse of a wrist such as from continuous typing/surfing the internet, the development of carpel tunnel syndrome in both hands especially in the absence of repetitive motion/overuse may be due to transthyretin cardiac (hATTR) amyloidosis. This disorder results from the accumulation of abnormal (amyloid) proteins that deposit in various organs and tissues.  Fortunately, treatment is now available for this condition.
3. Blueish Tint of Eye Whites (sclera): In adults, the appearance of blue sclera may be indicative of Ehlers Danlos Syndrome, a connective tissue disorder characterized by joint hypermobility (“double jointed”), skin that is easily stretchable (and susceptible to bruising) and heart involvement (e.g., aortic dilation).
4. Brown discoloration on Neck and Armpits: Also known as Acanthosis Nigricans, dark velvety patches occur in the back of the neck, below the breasts, armpits and groin regions that occur in association with insulin resistance, metabolic syndrome and diabetes.
5. Premature Graying and Baldness: A study of nearly 1400 young men (under age 40) from South Asia found that premature thinning or graying of hair was also associated with a 5-6 fold increased likelihood of premature heart disease.
6. Poor Dentition: A recent study found that spending less than 2 minutes tooth brushing twice daily was associated with a greater than 2-fold increased risk of poor vascular health (as measured by endothelial function).
7. Painful Mouth Sores: Consider Behcet’s disease in someone with a history of recurrent (painful) mouth sores and new onset heart failure.
8. Large Tongue: In addition to amyloid, a large tongue (macroglossia) may be observed with an underactive thyroid (hypothyroidism) especially when accompanied by high levels of (LDL) cholesterol.
9. Split Uvula: A split or bifid uvula is seen in the Loeys-Dietz Syndrome, a disorder affecting connective tissue and associated with aortic enlargement/dissection. The disorder is named after Dr. Bart Loeys and my colleague, Dr. Hal Dietz.
10. Yellowish-Orange Tonsils: Yellowish-orange tonsils is a classic feature of Tangier Disease, a disorder characterized by extremely low levels (e.g., less than 10 mg/dL) of HDL (the good cholesterol).
11. Nodules on the legs: Clues to the diagnosis of sarcoidosis are tender raised reddish bumps (nodules) on the front of the lower legs (Erythema nodosum) combined with heart-related symptoms such as palpitations, dizziness or progressive shortness of breath.
12. Itchy Rash on Chest, Back & Arms:  Very high levels of triglycerides (e.g., greater than 1000 mg/dL) may be associated with a yellowish-red (papular) rash on the chest, back and arms and is often due to poorly controlled diabetes.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.  Check him out on twitter: @mmillermd1

 

Are the Benefits of Omega 3’s Outweighed by Potential Side Effects?

In last week’s post, I highlighted differences between two omega 3 preparations, 1) purified EPA (Icosapent ethyl) and 2) combination of EPA/DHA as it relates to the risk of heart disease.

This past week we published a new study that examines the association between blood levels of omega 3 -fatty acids and the risk of major side effects (bleeding and atrial fibrillation).   Led by my colleagues Drs. Karan Kapoor and Michael Blaha, the study was designed to determine the extent to which these side effects might occur in participants of MESA (Multi-Ethnic Study of Atherosclerosis), a national study of men and women being monitored for the development of heart related events over a multi-year period.

Decades earlier, Danish physicians Jørn Dyerberg and Hans O. Bang reported that heart disease was rare but bleeding risk increased among Greenlandic Eskimos that they proposed was due to their high consumption of EPA from whale blubber, herring and other omega-3 enriched fish. These studies gained worldwide attention and laid the foundation for the hypothesis that omega-3 supplementation intake might reduce the risk of heart disease.

As an aside, I had the opportunity to meet Dr. Dyerberg when I presented some of our earlier work on triglycerides and heart disease at the International Society for the Study of Fatty Acids and Lipids in Lyon, France in 1998.

And although an increased risk of abnormal heart rhythms was not reported in Greenlandic Eskimos, two recent clinical trials that used high doses of purified EPA (REDUCE IT) or the combination of EPA/DHA (STRENGTH) identified an increased risk of atrial fibrillation.

Back to our study, not only was there a significantly lower (rather than higher) risk of major bleeding in men and women participants from MESA, but also the risk of atrial fibrillation was not increased.

Bottom Line: Adding omega 3 containing fish to your diet in place of saturated animal fat, is heart healthy- based on our current study it is also safe from major bleeding complications and atrial fibrillation. Purified EPA (Icosapent ethyl) as used in the REDUCE-IT study lowered the risk of cardiovascular events. Even though atrial fibrillation was slightly increased in REDUCE-IT, stroke rates-a primary complication of afib- were decreased.

Below are additional reasons why adding omega-3’s to your diet may improve overall health.

1. We recently found supplementation with Icosapent ethyl to maintain bone mineral health in men and women with the Metabolic Syndrome.
2. For each 1 serving per week increase in fish consumption, there is an approximate 7% lower risk of Alzheimer’s disease.
3. Eating salmon 3x weekly may lower blood pressure by 3-5 mmHg.
4. Consumption of fatty fish improves tear production and symptoms related to dry eyes.
5. Adding 1.5 grams of omega-3 fatty acids daily is associated with reduced mental stress and anxiety.
6. High blood levels of omega-3 fatty acids is associated with a trend towards reduced death from COVID-19.
7. In men and women with heart failure, the addition of 1 gram of omega-3 fatty acids may reduce the risk of re-hospitalization for heart failure.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland and author of  “Heal Your Heart….”: published by Penguin Random House.  He served on the International Steering Committee for the REDUCE-IT trial.

4 Reasons to be Optimistic about COVID in 2021

With the COVID-19 pandemic serving as the most physically and emotionally distressing health event of 2020, there are a number of reasons for optimism that new treatments for COVID will improve overall health and mental wellness in 2021.  Because optimism in general may improve heart-health through better nutrition and sense of well-being, it stands to reason that starting the season with an optimistic disposition especially as it relates to conquering COVID is likely to pay off healthy dividends for your heart and overall health.  Here are 4 reasons to get excited that COVID will soon be behind us.

1. COVID Vaccines are here.  Yes, I know that vaccinations got off to a slower start last month than projected, but now with nearly 6 million in the U.S. receiving the first dose of the Pfizer or Moderna vaccine, these numbers are expected to increase rapidly after President-Elect Biden assumes office later this month.   Later this quarter, we anticipate emergency approval of additional vaccines that include the single dose vaccine from Johnson & Johnson.
2. COVID antibodies last longer than previously thought.  For those who have recovered from the virus, a new study suggests immune protection for at least 8 months!  This is particularly encouraging if you are not among the priority groups for vaccination and may have to wait until later this spring/summer.
3. Antibody infusion therapy reduces the need for hospitalization.  If you have recently been diagnosed with COVID, this therapy may be useful for you.  It received emergency approval from the FDA in late November for mild-moderate COVID symptoms but you would not qualify if you require oxygen treatment or hospitalization.  The procedure takes a couple of hours and has been shown to reduce hospitalization rates by 70% as well as shorten the overall duration of illness (see my previous blog, “My Bout with COVID”).  There have been reports of significant improvement in fatigue, muscle aches and even restoration of taste and smell soon after receiving this therapy.
4. Plasma Exchange may reduce lung-related complications if given early.   Another new study found that in men and women aged 65 and older, convalescent plasma (plasma donated after COVID recovery) was associated with a near 50% reduction of severe lung disease that would have otherwise required oxygen therapy.  The key finding here was that plasma exchange had to be undertaken within 3 days of symptoms.  In addition, those receiving plasma with the highest antibody titers also had the greatest likelihood of success.   Use of plasma exchange and antibody infusion therapy is only effective during the early stages of the disease as other studies have shown that hospitalized patients do not reap these benefits.

I don’t know about you, but I am optimistic that we will not be talking about COVID in 2022!

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  To improve your heart health, check out his latest book:  “Heal Your Heart: The Positive Emotions Prescription to Prevent and Reverse Heart Disease“ published by Penguin Random House.

My Bout with COVID

After writing numerous blogs throughout 2020 on ways to protect yourself from COVID-19, the cruel irony was being diagnosed with COVID last month.   But in my case, COVID was not transmitted in the hospital setting. Even though I was treating COVID patients, all precautions were taken and I was well protected.  Nor was COVID transmitted through travel or attending social engagements during the Thanksgiving holiday weekend as we were non-participants.  So how did COVID reach our household?  We are still mystified.  One day, my wife experienced a rare headache, fatigue and chills and was diagnosed with the virus.  As the only other occupants in our home, my son and I tested negative and we both self-quarantined.  It was suggested that we retest 5 days later (the amount of time it generally takes for the virus to replicate in the body and become infective). My retest came back positive, although I had minimal symptoms initially (my son remained COVID negative). 

What makes COVID-19 so tricky (and elusive) is that if you lack or have very mild symptoms, it is very easy to spread the virus to others. For example, I never experienced a cough or shortness of breath; my only early symptom was mild fatigue that could have easily been explained by not having a good night’s sleep.  That is why it is critically important to self-isolate if you have been exposed to someone who is COVID positive until you are cleared (7-14 days) by your local health department.

While my wife fortunately recovered within a week of her symptoms, I began to experience severe body aches, fevers and fatigue.  To neutralize the virus, I qualified for and received the monoclonal antibody treatment. This is the treatment that  President Trump, Dr. Ben Carson and others have received. Immediately after treatment, my body aches resolved and I was well on my way to recovery.

Monoclonal antibody therapies from Regeneron and Eli Lilly have been shown to reduce COVID symptoms (depending upon viral load), speed of recovery and most importantly, lower hospitalization rates by up to 70%.   I have referred my patients with significant COVID symptoms who qualify for this therapy to our Johns Hopkins/University of Maryland infusion center in Baltimore.  Infusion centers are located throughout the U.S. with infusion taking 1 hour for the Lilly therapy that I received followed by another hour of monitoring.  Unfortunately, those who require hospitalization (low oxygen saturation levels, for example) do not qualify for this outpatient procedure. 

Until a high proportion of the population is vaccinated, we now have at least 1 proven therapy that reduces hospitalization rates for COVID.  However, while the U.S. government through Operation Warp Speed has funded this therapy at no cost to those who qualify, it remains vastly underused.  Should you have COVID and symptoms within 10 days of the diagnosis, be sure to contact your physician to determine whether you may be a candidate for antibody therapy.  It can make a big difference in your recovery from COVID.

Wishing you a Happy New Year and COVID free 2021!

Michael Miller, M.D., is Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine in Baltimore, Maryland, USA.

 

COVID-19: Thinking About Ben Franklin

When Benjamin Franklin said “An ounce of prevention is worth a pound of cure” he was referring to creating a fire department to protect the people of Philadelphia rather than having to rebuild a city in the event of a catastrophic fire.  Nearly 3 centuries later, this prophetic statement has been viewed as blasphemous amidst the worst global pandemic since 1918. Instead of the U.S. making every effort to prevent/control the spread of the virus by adopting the proven methods used in 5 other countries, (limiting social gatherings, wearing masks, socially distancing), we have failed. As a result, numerous lives have been lost and continue to be placed at risk.

Whereas Ben Franklin and our Founding Fathers would have worked tirelessly to prevent/control spread of COVID-19, current pandemic messaging contains reverse logic: ‘We’re not going to control the pandemic…what we have to do is make sure that we fight it with therapeutics and vaccines“. In other words, “let the pandemic spread like wildfire and then we will try to put out the fire”. With nearly 250,000 beautiful souls lost (greater than the combined number of U.S. lives lost in WWI, Korea, Vietnam and the American Revolution), the pandemic’s fire continues its reckless and devastating path throughout our great country. Unfortunately, it is not “rounding the final turn” and its embers will continue to inflict pain on affected families years after it has been vanquished.

Even 300 years ago at a time when there were many magical thinkers, Benjamin Franklin was scientifically grounded- he was a thoughtfully lucid and logical, critical thinker. Have we reverted back to the age of magical thinking? For the sake of science and our world renowned experts, I hope not.

Michael Miller, M.D., is Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine in Baltimore, Maryland, USA.

Love in the time of COVID-19

25 years ago today, my wife Lisa and I had our first date.  Months earlier, we met each other the old fashioned way, at one of Baltimore’s landmark watering holes…the “Cat’s Eye Pub”.  But as they say, life got in the way.  It wasn’t until the Saturday evening in late October, as I was heading into my elevator for a night on the town. Sparks flew as I came face-to-face with the same strikingly good-looking woman (shown above) that I had met earlier that winter.  As it turns out, she was exiting the elevator to attend a party for two of her friends who just happened to live on my floor!  Several days later, we met for sushi.  Minutes of easy conversation flowed seamlessly into hours; the rest is history.   Over the years, I’ve learned more than a few lessons that has enhanced our relationship in good times and in times of stress.   That said, here are five simple things that guys can do to enrich their love in the time of COVID-19 (and beyond).

1. Start the day on the right foot:  Whether it is unloading the dishwasher, feeding the dog, making coffee, etc.-whatever eases her burden will go a long way toward contentment.   
2. Touch base midday:  Check in each day with a simple text to see how her day is progressing.  
3. Do something together each day: The after-dinner walk is always a great activity weather permitting, but even doing puzzles/word games together are fun. Our favorite these days is NYTs “Spelling Bee”.  
4. Express gratitude: This might seem obvious, but expressing gratitude for the time you spend and things you enjoy doing together, never grows old…even as we all do. 
5. Laugh together: Take the 4 things mentioned above, add up their significance and you arrive here.  Laughing together helps to sustain and nourish relationships. While it might be more difficult to easily engage in laughter during this time of crisis, it is also a powerful de-stressor that may improve your overall health and spirits (more to come).   

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His latest book is  “Heal Your Heart: The Positive Emotions Prescription...” published by Penguin Random House.

COVID-19: Response from the Medical /Scientific Community

In recent weeks, two prestigious scientific journals took the unprecedented step of denouncing President Trump’s handling of COVID-19. In the most recent edition of the New England Journal of Medicine, the Editors wrote that “Our current leaders have undercut trust in science…instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth…” And in this month’s issue of Scientific American, the storied publication that began 16 years before “Honest” Abe served in the White House, an inaugural presidential endorsement was made (against Mr. Trump) due to continued rejection of “evidence and science“.

My colleagues are not wrong. To become a scientist, physician and expert in a specialized medical field takes years of intensive training. Experts in public health (such as Drs. Fauci and Birx) have become trusted voices that the public has relied upon during the current pandemic. Other highly talented researchers at Regeneron (and Eli Lilly) have developed innovative treatments for COVID-19, as recently bestowed to Mr. Trump. Unfortunately, widespread availability of experimental therapies and vaccines is not likely to happen anytime soon. Until herd immunity develops (70% or more of the population develops immunity), we need to remain diligent to protect ourselves and others (masking/socially distancing/handwashing).

Bottom Line: Listen to the scientific experts who have spent their careers in advancing science, medicine and public health. They have no bone in this (dog) fight!

Michael Miller, M.D., is Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine in Baltimore, Maryland, USA.

 

 

COVID-19: Do Masks Really Work?

Now that the President, First Lady and others have contracted COVID-19, presumably linked to last week’s Rose Garden Event where COVID restrictions were neither practiced nor enforced, is there scientific evidence to back up safe practices recommended by CDC and others since the pandemic arose many months ago?

My friend and colleague, Dr. Deepak Bhatt recently spearheaded a study at Harvard’s Mass General & Brigham & Women’s Hospital that found that universal mask wearing by health care workers was associated with a significantly lower COVID-19 positivity rate than when masks were not worn. Another study showed that face masks worn by 2 hair stylists who tested positive for COVID did not transmit the virus to any of their clients, all of whom had also worn face masks. And in another case, an international traveler with a dry cough that was subsequently confirmed to be due to COVID-19, did not infect any of his fellow travelers during a 15-hour flight from China to Canada.

Bottom Line: Wearing a mask really does work to protect against the spread of COVID-19. Protective masks include N-95 (for health care professionals) and level 3 surgical masks, the latter of which are now readily available and inexpensive. As long as these masks don’t get wet, they can be reworn; otherwise they need to be replaced. We absolutely do not recommend masks with valves because the virus can be transmitted through the valve outlet area. In other words, wearing such a mask is not protective to others. In addition to the mask, maintaining social distance (at least 6 feet), and keeping your hands well sanitized reduces your risk of the virus to very low and to negligible levels when interacting with others who are also wearing a (non-valve) mask. It is fair to say that had such COVID restrictions been practiced at last week’s Rose Garden (and/or possibly another recent event), neither the President nor those he was in close contact with, would have become infected. While we wish the President, First Lady and all those affected with COVID-19 a speedy recovery, why not apply common sense methods to protect each other until we can eradicate this deadly virus?

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  His latest book is  “Heal Your Heart: The Positive Emotions Prescription...” published by Penguin Random House.

 

 

The COVID-19 Heart: Scientific Sense

This past week, I had the pleasure of being a guest on Gill Eapen’s Podcast, “Scientific Sense” where we discussed the latest evidence related to COVID-19 and the heart (and other issues). Click here for the full podcast.

Below are a few highlights of the program.

1. COVID-19 is like no other virus we’ve ever experienced in our lifetime; the virus is highly unpredictable with many different signs/symptoms/presentations and the potential for long-term consequences on the heart.
2. Compared to seasonal flu where the death rate is ~1 per 1000, the death rate for COVID-19 is ~3-5 per hundred; In other words, fatality rates for COVID-19 are 30-50x fold higher than seasonal influenza.
3. The amount of virus (viral load) exposure predicts how sick you may become. Wearing a surgical quality mask and social distancing can reduce the potential viral load to minimal levels.
4. Level 3 masks (surgical quality) are recommended, especially when indoors and interacting with strangers.
5. Vitamin D supplementation may be protective, especially if levels are low (less than 20 ng/ml)

Michael Miller, MD is Professor of Cardiovascular 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.

Back To College in the COVID-19 Era

With one of my daughters returning to college over the weekend, I reminded her that she needs to remain diligent both on and off campus, to wear a mask, to socially distance and to not attend parties or social gatherings of more than a handful of people who are also diligent. I know…good luck with that one!

Before she left, I impressed upon her to make every attempt to avoid COVID-19 if at all possible and was delighted to see that she was very well prepared for a safe flight! Even though the vast majority of healthy young men and women stricken with COVID-19 make complete recoveries, some develop longer-term heart related complications. They include myocarditis that was first reported in China and more recently identified in college athletes. Another newly reported heart related complication that may occur weeks to months after being infected with COVID-19 infection is postural orthostatic tachycardia syndrome (POTS). This condition is characterized by inability of the body to respond properly with changes in position, especially when standing, due to pooling of blood in the lower part of the body rather than throughout the body and brain. As a result, the longer you stand, the more likely you are to experience lightheadedness, fatigue and poor concentration. Pulse rate increases 30-40 beats per minute when standing for more than 10 minutes and you can experience premature (skipped) beats and chest discomfort. Expect to hear more about this association in the coming months.

The Bottom Line: COVID-19 is not going away anytime soon, so best to listen to and heed the advice of qualified health care experts, like Dr. Anthony Fauci. I met Tony when I was a medical student and researcher at the National Institutes of Health during the early stages of the AIDS epidemic and have the highest regard for him. I also had the opportunity to work with Dr. Phil Pizzo, who was also at NIH during that time. Like Dr. Fauci, Dr. Pizzo is of the highest integrity and aims for the promotion of honesty and truth in science.

Michael Miller, MD, is a Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore. Check out his twitter handle: @mmillermd1