More Feathers in the Cap of Icosapent Ethyl

I am reminded of my late mentor, Dr. Peter O. Kwiterovich, Jr. who used to say when we published new research findings that “this is another feather in your cap”! Well, this expression could not be truer than what we have been witnessing with icosapent ethyl (IPE), the highly purified omega-3 fatty acid, EPA. First there was the landmark study, REDUCE-IT where IPE reduced the risk of cardiovascular death, heart attack, stroke, bypass/stent placement and rehospitalization for unstable by an astounding 25% in statin treated men and women with high triglycerides and cardiovascular risk. To date, IPE remains the best treatment for patients at similar underlying risk.

Last week, 2 new feathers were added to the IPE cap during presentations at the European Society of Cardiology (ESC), one of medicine’s premier international meetings. The first paper presented by my colleague, Dr. Deepak Bhatt found IPE to reduce the risk of the 2 types of heart attacks (ST and non-ST elevation) by 40% and 27%, respectively. The second feather was the result of another analysis showing that IPE eradicated the excess risk of cardiovascular events attributable to cigarette smoking; the manuscript is published in the European Heart Journal Cardiovascular Pharmacotherapy. For a comprehensive review of other IPE “feathers”, check out the excellent new review by Dr. Prakriti Gaba published in JCL.

During an ESC presentation, the prominent Danish Professor and Lipid Expert, Dr. Borge Nordestgaard, commented to me that every analysis performed for IPE has shown strikingly positive results. Could the reason for IPEs success be that the compound has unique characteristics that other fatty acids don’t? In fact, my colleague Dr. Preston Mason has performed a number of elegant studies demonstrating that to be the case. Specifically, IPE reduces inflammation and oxidative stress while improving endothelial function.

You certainly don’t have to convince me that IPE acts different fatty acids. Decades ago, we examined the role of purified EPA in human cells and found favorable effects that were not observed with other fatty acids- perhaps a presage of good things to come for IPE.

Michael Miller, MD is a cardiologist and Chief of Medicine at the Corporal Michael J Crescenz VA Medical Center and Vice Chair of Medicine at the Hospital of the University of Pennsylvania. Prior to his arrival in Philadelphia, he was Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine. He is the author of numerous scientific publications and several books, including Heal Your Heart published by Penguin Random House. Check him out on twitter: @mmillermd1

Increasing Awareness of Disparities in Cardiovascular Health Care

It is well established that cardiovascular disease is disproportionately higher in blacks than in whites, Asians and Hispanics.  In fact, death from heart disease is 1.7 to 2-fold higher in black men compared to white men 45 years and older.  Similarly in women, cardiovascular events are also elevated in blacks compared to whites with an approximate 2.5-fold risk beginning in middle-age (45+ years).

According to the American Heart Association, 7 core health behaviors/risk factors shape the likelihood of developing a heart attack or stroke. They include: blood pressure (BP), body mass index (BMI), cholesterol level, dietary habits, glucose control, physical activity and smoking history.  In an otherwise healthy individual, “ideal” cardiovascular health would be defined as optimal core health behaviors/risk factors such as 1) BP less than 120/70; 2) BMI between 18-24.9 kg/m², 3) LDL cholesterol levels less than 100 mg/dL, 4) a diet low in animal based saturated and trans fats, 5) fasting blood glucose less than 100 mg/dL, 6) being physically active (at least 150 minutes of mild-moderate activity [such as brisk walking at 3-5 mph] per week) and 7) not smoking cigarettes.  Unfortunately, less than 1 in 3 adult men/women exhibit ideal cardiovascular health led by Asians (29%) and Whites (19%) while Hispanics and Blacks (14% and 10%) lag well. behind this milestone.   For a more comprehensive review on this topic, check out our recent paper led by my colleague, Dr. Penny-Kris Etherton.

Listed below are further insights into the barriers, challenges and opportunities for implementing change to reduce disparities in diet-related heart disease based upon the publication in the Journal of the American Heart Association.

1. Food deserts are areas that lack access to affordable foods that comprise a healthy diet (e.g., fruits, vegetables, low‐fat milk, whole grains). In Baltimore, high availability of healthy foods was only present in 19% of predominately black neighborhoods compared to 68% of white neighborhoods.
2. A study conducted in Atlanta found that individuals in food deserts were more likely to be black, less likely to be college graduates, and had lower income compared with individuals in nonfood deserts.
3. Access to supermarkets stocking affordable healthy foods is associated with greater likelihood of fulfilling healthy dietary recommendations. For each supermarket present in a census tract, the intake of fruits and vegetables rose by 32%.
4. Large disparities exist in supermarket access in predominately black communities. There are 5 times more supermarkets in census tracts where whites live compared to where blacks reside.
5. Approximately 3.5% of the US population live in a food swamp, defined by the ratio of fast-food outlets and convenience stores to supermarkets and grocery stores in a given area.
6. Financial incentives to encourage purchasing of healthy foods and/or disincentives or restrictions on purchasing of unhealthy foods improves diet quality, especially in low‐income groups. A 10% reduction in the price of healthy foods increased consumption by 12%.
7. An increase in the cost (tax) of unhealthy foods decreased consumption by 6%. This approach reduced intake of sugar‐sweetened beverages (9%), fast food (3%), and other unhealthy beverages (5%).

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

Top Nutrition Controversies in 2021

In our 3rd installment on “Trending Nutrition Controversies” by the American College of Cardiology’s Nutrition Workgroup and led by Dr. Monica Aggarwal, we describe some of the popular dietary-related controversies in 2021.  For a link to this publication, press here.

Below are highlights of this review and the evidence for or against the use of these products and development/progression of cardiovascular disease.

1. Artificial and Non-Nutritive Sweeteners: Whether they contain aspartame (Equal), saccharin (Sweet & Low), sucralose (Splenda) or stevia (Truvia), the artificial sweetener franchise has been stirred into a frenzy as several large studies have linked the frequency of these sweeteners to weight gain, increased risk of Type 2 diabetes and cardiovascular disease. Consequently and until new studies suggest otherwise, we recommend limiting the use of artificial sweeteners.  Instead, consider adding unsweetened vanilla/ cocoa extract and/or a cinnamon stick to your morning Java.
2. Cocoa/Cacao:  As a rich source of antioxidants, studies have shown that 1-2 tablespoons of cocoa/cacao daily is associated with 10-15% lower risk of heart disease compared to non-consumers.  Minimize use of  chocolate-containing products that are highly processed (e.g., sugar and corn syrup) to maintain the benefits.
3. Soy:  Isoflavones (e.g., genistein, daidzein) present in soy are powerful antioxidant and anti-inflammatory mediators.  Substitution of soy in place of animal based protein has been associated with reductions in LDL cholesterol (3-5%), systolic blood pressure (5-7 mmHg) and overall improved survival from heart disease and cancer.
4. Plant-based Meats and Substitutes:  Despite the recent hoopla surrounding the alternative meat craze for the plant-based Beyond Burger (mung bean/pea) and Impossible Burger (soy), both products also add saturated fat (coconut oil) and sodium to enhance flavor and texture. While these substitutes may be viewed as “healthier” compared with animal sources of protein, they are viewed as less healthy choices  when compared to minimally processed proteins, such as lentils, peas and beans.
5. Dietary Nitrates: Foods such as beet root, celery and dark green vegetables are high in dietary nitrates. Plant based nitrates promote the production of nitric oxide that in turn improves vascular health, reduces insulin resistance and improves exercise capacity. Supplementation with beetroot juice (high in dietary nitrates) was shown to reduce systolic blood pressure by 8 mmHg (the near equivalence to a single BP medication). After nitrates are converted to nitrites, the antioxidants contained within plant but not animal based products also protect against the formation of carcinogenic nitrite (N-nitroso) compounds.
6. Grass-Fed versus Grain-Fed Meats:  Grass-fed beef has a lower fat content with a more favorable saturated fat profile than consumption of grain-fed meat.  However, both grass-fed and grain-fed meats contain trans-fats that promote heart disease and studies to date have not shown differences between the two in cholesterol levels, triglycerides, blood pressure or insulin sensitivity.                                                                                                                                                                                                                                   In case you missed highlights of our 2nd Nutrition Controversy paper press here and see below:
7. Added Sugars: Individuals should limit added sugar to less than 10% of calories and preferably less than 100 calories daily for women and less than 150 calories daily for men.
8. Legumes: Consuming 3.5 ounces of legumes (such as beans, chickpeas, lentils and peas) at least 4 times each week is associated with ~15% reduction in the risk of heart disease.
9. Tea consumption: Daily consumption of any tea is associated with an 8-10% reduced risk of heart attack or stroke.
10. Kimchi: In a 2-week study in overweight/obese men and women consumed 3 servings (3.5 ounces) of kimchi daily, significant decreases in weight (3.3 lbs), fasting glucose (100to 94 mg/dl), and systolic BP (126 to 121 mm Hg) were observed.
11. Folic Acid & Vitamin B12: Although folic acid and vitamin B12 supplements lower homocysteine levels, results from large clinical trials studies have failed to demonstrate reduction in cardiovascular events.
12. Probiotic yogurt: Diabetic patients randomized to probiotic yogurt containing Lactobacillus acidophilus (300 g daily) for 8 weeks experienced a 23% reduction in LDL-C and 15% increase in HDL-C compared with baseline.                                                                                                                                                                                                                                                                                                                                             And for some of the highlights of our 1st Nutrition Controversy paper press here and see below:
13. Green Leafy Vegetables: For each oz of green leafy vegetables consumed daily, there is a 13% lower risk of developing T2DM.
14. Southern Foods: A Southern pattern of eating consisting of fried foods, egg dishes, processed meats, and sugar-sweetened drinks is associated with a 50-60% increase in cardiac events over a 6-year period compared to a primarily plant-based pattern.
15. Cholesterol: For each 300-mg increment in dietary cholesterol (~2 egg yolks), blood cholesterol levels rise 6-7 mg/dL
16. Blueberries: Consuming ~1 cup of blueberries per day is associated with blood pressure reduction of 7 mm Hg systolic and 5 mm Hg diastolic.
17. Anthocyanins: A 32% lower risk of a heart attack was observed in those with the highest compared to the lowest quintile of anthocyanin intake (e.g., blueberries and strawberries).
18. Mixed Nuts: A Mediterranean diet supplemented with  a 1 ounce serving of mixed nuts daily for 5 yrs was associated with a 30% lower risk of cardiac events compared with a lower-fat control diet.
19. Plant-based diet: A study conducted in Tarahumara Indians consuming a plant-based diet (e.g. corn and beans) did not identify a single overweight or hypertensive man during the 4-yr follow-up period.
20. Vegetable Oils:  A study conducted in Costa Rica found that the saturated fat, palm oil used for cooking was associated with 25-30% higher risk of heart disease compared to use of less saturated vegetable oils (soybean and sunflower).

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

Does a High Fat Diet Promote Memory Loss and Cognitive Decline?

A new study out this week and published in iScience found that fat cells play a major role in advancing brain aging and cognitive decline through Na,K+ATPase signaling.  Recent studies have suggested that this pathway is also responsible for conditions that accelerate cardiovascular disease risk including, metabolic syndrome and fatty liver (nonalcoholic steatohepatitis).

The new study was conducted in mice that were genetically modified to release the peptide, NaKtide, in fat cells.  NaKtide is a direct inhibitor of Na,K+ATPase signaling.  The authors found that compared to a control diet, a Western diet (greater than 40% of calories derived from fat) resulted in Na,K+ATPase -mediated cellular inflammation and altered levels of brain biomarkers that affect memory and cognition. These proinflammatory effects were abolished when NaKtide was activated, thereby resulting in improved function of regions that include the brain’s memory center (hippocampus).

The bottom line is that in a mouse model, Na,K+ATPase signaling in fat cells promotes memory loss and neurodegenerative changes.  They raise the possibility that a similarly operative signaling -pathway in humans might lead to adverse long-term neurologic consequences under certain conditions (such as repeated exposure to a high fat diet).  Finally, they suggest that effective therapies directed against this proinflammatory signaling pathway could offset cognitive decline.

Of course, the most effective and currently available approach to reduce cognitive decline as related to this pathway would consist of reducing daily intake of highly saturated, processed and deep-fried foods!

Listed below are additional features related to diet, physical activity, obesity and brain health.

1. Obesity promotes inflammation within the brain leading to cognitive decline and progression of neurodegenerative disorders.
2. Significant and rapid weight loss as a consequence of bariatric surgery has been associated with improvements in cognitive function including memory and executive function.
3. Adherence to the Mediterranean diet – high in vegetables, whole grains, fish, and olive oil – correlates with higher cognitive function.
4. Compared to a high fat, Atkins Diet, a low fat Ornish Diet is associated with low levels of TMAO, a gut metabolite predictive of increased cardiovascular disease risk and reduced cognitive function.
5. Replacement of saturated fat by polyunsaturated or monounsaturated fat is associated with lower rates of neurodegenerative disease.
6. Higher levels of physical activity are associated with a 35% reduced risk of cognitive decline and 14% reduced risk of dementia.
7. A diet containing at least one serving of green leafy vegetables each day is associated with slower age-related cognitive decline by approximately 10 years.
8. Metabolic Syndrome is associated with increased risk of developing cognitive impairment and premature dementia.
9. Chronic exposure to stress confers a higher risk of developing neurodegenerative disorders including Alzheimer’s disease.
10. Chronic insomnia is associated with a 30-35% increased risk of progressive dementia.
11. Musicians are 64% less likely to develop mild cognitive impairment or dementia, even after adjusting for physical activity and education.
12. Drinking 3-5 cups of coffee per day at midlife was associated with a decreased risk of dementia and Alzheimer’s Disease by about 65% at late-life.
13. Speaking at least 2 languages has been shown to delay the onset of dementia by 4-5 years.

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

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

 

Nutrition & Dietary Approaches to Prevent/Treat Cardiovascular Disease

This past week, I was delighted to receive my copy of “Prevention and Treatment of Cardiovascular Disease: Nutritional and Dietary Approaches” an important new book edited by my colleagues Drs. Michael Wilkinson, Michael Garshick and Pam Taub that focuses on lifestyle strategies for optimizing cardiovascular health.

There are numerous excellent contributions encompassing plant-based, Mediterranean and other popular diets, intermittent fasting/restrictive feeding, dietary recommendations for diabetes, metabolic syndrome, heart failure, atrial fibrillation and many other cardiovascular/inflammatory disorders.

Our contribution entitled, “Lifestyle Approaches to Lowering Triglycerides” was led by Dr. Stephen Hankinson (former University of Maryland medicine resident, currently affiliated with Brigham & Women’s Hospital).

Listed below are some of the numerous “pearls” throughout the book. It is a superb resource for anyone interested in evidence-based medicine as it relates to nutrition and cardiovascular risk reduction.

1. Overwhelmingly, consumption of whole foods enriched in dietary macronutrients have a more pronounced benefit on heart disease risk factors (such as high blood pressure/ cholesterol) than dietary supplements, for whom minimal if any such evidence exists.
2. Inadequate intake of selenium is associated with adverse effects on the cardiovascular system including oxidative stress and inflammation. Excellent sources of selenium include Brazil nuts, oysters and yellowfin tuna.
3. Low levels of magnesium may increase aortic valve calcification (due to buildup of calcium within cardiac and smooth muscle cells). Make sure to include green leafy vegetables, legumes, seeds and whole grains in your diet to maintain healthy magnesium levels.
4. A review of 50 studies evaluating more than 500,000 men and women found that adherence to a Mediterranean diet correlated with a 31% reduced risk of developing the Metabolic Syndrome over a 6-year period.
5. The DASH (Dietary Approaches to Stop Hypertension) is among the most effective non-pharmacologic treatment for high blood pressure with average reductions in systolic pressure (~11 mmHg) and similar to that observed with a single blood pressure medicine.
6. When controlled for total caloric intake, a ketogenic diet does not result in greater weight loss than other diets.
7. In the REGARDS (REasons for Geographic And Racial Differences in Stroke) study, a primary plant based diet (vegetables, fruits, beans, fish) was associated with a 41% lower likelihood of developing heart failure over an approximate 9 year follow-up period.
8. In contrast to popular belief, corn oil has a more profound effect on lowering LDL levels than olive oil (11% vs 4%).
9. A mildly caloric restrictive diet (12% reduction in daily calories) was associated with significant weight loss (average, 16.5 lbs) as well as improvement in cholesterol, blood pressure, insulin sensitivity and inflammation over a 2-year period.
10. Time restrictive eating (6-10 hour window of eating followed by a 14-18 hour fast) reduces risk of cardiometabolic diseases by promoting weight loss and improving sleep.
11. In women with early-stage breast cancer, overnight fasting of 13 (or more) hours was associated with an improved cancer prognosis, longer sleep duration and better glycemic control.
12. In men and women with Metabolic Syndrome, 12-weeks of time restrictive eating (10 hour feeding window) resulted in significant reductions in waist circumference, blood pressure and LDL cholesterol.
13. In more than 1100 men and women with psoriasis, dietary intervention that included a structured exercise program to promote weight loss resulted in a 75% improvement in psoriatic skin lesion severity.
14. In obese men and women with a history of atrial fibrillation, 10% weight loss resulted in a 46% likelihood of sustained normal (sinus) rhythm without medication over ~5 years of follow-up.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland and author of multiple books and book chapters related to heart disease prevention and treatment.

Got High Triglycerides? Check out our New Decision Pathway from the American College of Cardiology

For decades, triglycerides (TGs) took the proverbial back seat in the lipid/lipoprotein hierarchy.  In recent years, however, TGs have gained increasing traction as a bonafide and independent biomarker of cardiovascular risk based on a series of well conducted epidemiologic and genetic (Mendelian randomization) studies.

Earlier this month, the American College of Cardiology released a new document that systematically outlines a series of decision trees that clinicians and health care professionals might consider when treating patients with elevated TG levels.  It was a great privilege to work with colleagues and “lipid luminaries” in an highly engaging effort spearheaded by Drs. Salim Virani and Pam Morris.

Listed below are some of the highlights of the document that can be accessed by clicking here.

1. Lifestyle interventions should be initiated in adults with fasting triglyceride levels of 150 mg/dL or non-fasting triglycerides of 175 mg/dL or higher.
2. Among lifestyle recommendations for treating high triglycerides, weight loss is among the most robust (10-20% reductions on average) with up to 70% reductions potentially achievable.
3. Dietary recommendations to lower elevated triglyceride levels include switching from a low-fat, high carbohydrate diet to a higher-fat (predominantly mono/polyunsaturated) and low-carb diet (30-40% of calories).
4. In men and women with the metabolic syndrome, a high protein/weight loss diet (greater than 25% of energy intake/500 calorie per day deficit) is associated with ~35% reduction in triglycerides.
5. Physical activity and exercise may contribute up to a 30% reduction in triglyceride with both resistance training and aerobic activity contributing to these effects.
6. Excess alcohol consumption, especially with pre-existing high triglyceride levels can precipitate pancreatitis.

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

Billy Joel was Right…Just Ask Anthony

In his classic/catchy tune, “Movin’ Out” (AKA, “Anthony’s Song”), Billy Joel once lamented to Howard Stern that the song reflected friends taking jobs to fulfill others rather than themselves.  Beyond the colorful characters, Mama Leone, Sergeant O’Leary and Mr. Cacciatore, it’s poor Anthony (among others) for whom it’s suggested that “working too hard can give you a heart attack…”

We’ve known for some time that working too many hours is associated with increased risk of cardiovascular disease.  For example, a study of more than 600,000 men and women published in the Lancet found that those who worked at least 55 hours each week experienced a 13% higher risk of a heart attack over a 5-year period, and 33% greater likelihood of a stroke, compared with those who worked 35-40 hours.

Let’s suppose that Anthony experienced his first heart attack after working more than 55 hours a week in the grocery store.  A new study now shows that if Anthony continues to work more than 55 hours a week he is 67% more likely to have another heart attack (or more than a 2.5 fold increased risk if there is associated job strain), compared to other heart attack survivors who dropped their workload down to 40 hours or less per week.

Bottom Line:  Working 55 hours or more per week may be hazardous to your health, unless of course, you thoroughly enjoy what you do.  After all, as my late father-in-law, Paul Miller (who taught math for 80 years) used to say “if you love what you do, you’ll never work a day in your life!”  

Below are additional tips related to workplace stress and the heart

1. Jobs that are of high-demand, low-control are associated with increased risk of heart disease. They include factory workers, firefighters and postal workers.
2. Jobs that are of low-demand, high-control are associated with reduced risk of heart disease. They include architects, dentists and sales representatives.
3. A study conducted in Germany found that job stress was associated with increased inflammation and 2-fold increased risk of a heart attack over an 11-year follow-up period.
4. Stressful working conditions are associated with reduced life expectancy of 2 and 1.5 years in men and women, respectively.

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

“Go with your Gut”: Unlocking Secrets of Centenarians

Despite the ravages bestowed by COVID-19, more than 500,000 men and women worldwide have attained centenarian status (living to 100 years and beyond), including nearly 100,000 residing in the U.S.  Among this special group was my beloved father-in-law, Paul Miller, who taught math for 80 years and lived to the ripe young age of 104!

Many of us both inside/outside the medical profession find these individuals to be awe inspiring especially when they are still in relatively good physical and mental health upon reaching this major milestone. While we appreciate that exceptional longevity may be more heavily concentrated in a “Blue Zone“, the overwhelming majority of centenarians do not live in these regions.  In fact, there are nearly 2,000 centenarians living in the great (though non-Blue Zone U.S.) state of Maryland!

Now a new study published in the prestigious journal, Nature, is assisting scientific efforts toward unlocking secrets for healthy aging and longevity.  The study conducted in Japan, found that centenarians had high levels of protective gut byproducts.  Also known as isoalloLCA, these secondary bile acids, contribute to gut health by inhibiting gut bacteria that promote inflammation and disease (such as C. difficile). While a cause-effect relationship between protective gut byproducts and longevity has yet to be established, this study is an important step in furthering our understanding of the relationship between gut and overall health.

Listed below are other secrets to enhance the likelihood of healthy longevity.

1. Keep Saturated Animal Fats at Bay:  A study that we conducted with Dr. Stan Hazen and colleagues at the Cleveland Clinic found that a low fat Ornish diet was associated with reduced levels of the gut byproduct TMAO compared to a high saturated fat Atkins diet.  High levels of TMAO are associated with an increased risk of heart disease.
2. Think Positively about Aging: A study from the Yale School of Public Health found that older men and women who were genetic carriers of a gene that promotes dementia (APOE4 variant) were 50% less likely to develop dementia if they felt positively about the aging process.
3. Be Resilient: In a study of centenarians from Georgia and Japan, personality traits included a high degree of resiliency as characterized by high levels of openness and extraversion and low levels of hostility and neuroticism.
4. Have a Sense of Humor:Jeanne Louise Calment, the world’s oldest woman who died at age 122, credited her sense of humor for successful aging. In fact, a 15-year study from Norway found that women with a strong sense of humor experienced a nearly 50% higher survival rate compared to those lacking a sense of humor even with pre-existing heart disease or other chronic ailments.
5. Engage in Mentally Stimulating Activities: A Mayo clinic study found that participating in 3 mentally stimulating activities such as reading books, craft activities (e.g., quilting, or sewing) or playing card games/doing crossword puzzles ~age 70 was associated with a 45% reduction in cognitive decline over the subsequent 5 years.
6. Volunteer: Volunteering, especially over age 60 is associated with meaningfully positive effects on health and overall well-being.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.  Check out his updated author page on Amazon.

 

 

 

EPA versus EPA/DHA: What Have Clinical Trials Taught Us?

Our new review paper out this week entitled “A Fishy Topic: VITAL, REDUCE-IT, STRENGTH and Beyond; Putting Omega-3 Fatty Acids into Practice in 2021” was designed to reduce the confusion surrounding the use of the marine derived omega 3 fatty acids, EPA (eiscosapentanoic acid) and DHA (docosahexanoic acid).  Coincidentally, this paper compliments last week’s publication in the Lancet journal, EClinical Medicine entitled, “Effect of omega-3 fatty acids on cardiovascular outcomes: A systematic review and meta-analysis” led by my colleagues,  Drs. Safi Khan and Deepak Bhatt and showing that EPA but not the combination of EPA+DHA was associated with reduced risk of cardiovascular events such as heart attacks, strokes and heart related death (see Figure).

As both EPA and DHA are extracted from oily fish including salmon, sardines, anchovies and herring and both lower triglycerides to a similar degree, why have clinical trials using EPA compared to EPA+DHA shown contrasting results?   Elegant work from Dr. Preston Mason and his co-workers have provided important insights at the cellular level demonstrating that EPA possesses cardioprotective anti-inflammatory, anti-oxidant, endothelial normalizing and membrane stabilizing properties that become suppressed in the presence of DHA.  Thus while DHA plays a pivotal role in brain growth and development, clinical trials to date have not borne out similar benefits with respect to cardioprotection.

I’ve been intrigued with EPA for more that a quarter century after we first observed dramatic differences in the way EPA was processed into cellular lipids when compared to prototypic saturated and monounsaturated fatty acids.   As differences between EPA, DHA and other fatty acids continue to emerge, listed below are a series of highlights related to the intake of these fats whether as a supplement or in medicinal form.

1. Dietary supplements such as “fish oil” capsules are NOT regulated by the FDA and should not be viewed in the same context as OTC products (such as Advil) that are regulated.
2. Fish oil capsules, a dietary supplement not regulated by the FDA, has been shown to contain a number of impurities such as saturated fat and oxidized lipids that impair its effectiveness.
3. EPA but not DHA exhibits heart protective antioxidant, anti-inflammatory and membrane/plaque stabilizing properties that help to reduce the risk of cardiovascular disease.
4. In the MESA study, higher blood levels of OM3 (inclusive of EPA) were associated with reduced risk of hospitalization for bleeding events.
5. In the REDUCE-IT USA study, 4 grams of Icosapent ethyl, the prescription form of highly purified EPA, was associated with a 30% reduction of death from all causes.
6. In the REDUCE-IT trial, total primary events (cardiovascular death, heart attack stroke, stent placement, bypass surgery or hospitalization for unstable angina) were reduced by 30%.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore,MD.  He is a Scientific Advisor for Amarin, Corp. and Steering Committee Member of the REDUCE-IT trial.  Dr. Miller is also the author of several books; including his most recent,  “Heal Your Heart…“