Early Onset Hypertension= Early Onset Dementia

 

 

A new study out this week has found that being diagnosed with elevated blood pressure at a young age, is associated with risk of early dementia.

The study published in the American Heart Association journal, Hypertension analyzed 11,399 Chinese adults who were diagnosed with hypertension at 3 age groups: 1)when they were younger than age 35; 2) between ages 35 to 44 and 3) aged 45 to 54 years. Another 11,399 men and women without a history of high blood pressure served as the control group.  Brain MRI scans were performed in all participants. The results of the study indicated that in all 3 comparator age groups, those with hypertension exhibited smaller brain (volume) sizes with the largest difference observed in the group under age 35.

Among the subjects who developed any type of dementia during the study period, the risk was 61% higher in men and women 35-44 years of age who had been diagnosed with hypertension compared to similar aged normotensive controls. In addition, vascular dementia was increased 45-69% when hypertension was diagnosed between ages 35-54 years. To review this paper, click here.

The study supports early identification and treatment of high blood pressure – it stands to reason that control of hypertension at a young age would reduce development of dementia.

High blood pressure can occur under a variety of circumstances and may be associated with the following:

1. Exercise induced hypertension (systolic pressure greater than 210 mmHg in men and 190 mmHg in women with exercise) is associated with a 35-40% increased risk of cardiovascular events and mortality.
2. Hypertension of the eyes (ocular hypertension) raises the risk of glaucoma.  Risk factors for ocular hypertension include diabetes, hypertension, extreme nearsightedness and chronic steroid use.
3. Black licorice can raise blood pressure and cause palpitations when 2 or more ounces are consumed per day.
4. Herbal supplements that may raise blood pressure include ginseng, guarana, ma-huang and St. John’s Wort.
5. Examples of commonly used drugs that may raise blood pressure include NSAIDs (ibuprofen), steroids (prednisone), decongestants (pseudoephedrine), antidepressants (fluoxetine) and anti-infectives (ketoconazole).
6. The 4 “classic H signs” of Pheochromocytoma, Hyperhydrosis (excessive sweating), Hypertension, Heart palpitations and Headache are only observed in 40% of cases.
7. Hypertension with disproportionate pulses (reduced in lower compared to upper extremities) could be due to narrowing of the aorta (coarctation). Coarctation is associated with exercise induced hypertension.
8. Recent onset of high blood pressure associated with kidney stones, bone pain and abdominal pain (also known as “stones, bones and groans”) may be the result of high calcium levels due to an overactive parathyroid gland.
9. Hypertension is observed in up to 70% of those affected with obstructive sleep apnea. Treatment of sleep apnea and its underlying causes, may effectively reduce blood pressure.
10. Up to 30% of patients with hypertension do not respond effectively to 3 blood pressure medications. The most common condition associated with “resistant hypertension” is obstructive sleep apnea.
11. A recently diagnosed elevation in blood pressure that exceeds 150/100 mmHg on 3 different days should be screened for the rare medical condition, primary aldosteronism (Conn’s Syndrome).
12. A young woman with recent onset hypertension in association with tinnitus (ringing in the ears), dizziness, neck pain and poor kidney function may be due to another rare medical condition, fibromuscular dysplasia, recently been linked to spontaneous coronary artery dissection (SCAD).
13. Consider a workup for acromegaly in someone who has recently developed hypertension along with an increase in shoe (and glove) size. Complications of acromegaly include resistant hypertension, diabetes, and an enlarged heart, thereby raising  the risk of arrhythmia (abnormal heart rhythm) and sudden death.

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 Statin Use Reduce Psychiatric Hospitalizations and Emergency Room Visits?

 

A new paper out this week led by my colleague, Dr. Teo Postolache raises the intriguing question as to whether patients prescribed statins have lower rates of psychiatric based hospital admissions as compared to non-statin users.  The rationale for this study was based on prior work suggesting that statins not only slow cognitive decline and reduce the risk dementia but also decrease hospitalization rates as much as 25% in men and women with a history of major depression.  Additional support for statin use includes inherent beneficial effects on oxidative stress, neuroinflammation and immune function, all of which that are commonly aggravated in psychiatric illnesses.

In the current study of ~680,000 Veterans with a history of schizophrenia or bipolar disorder studied, statin use was associated with a 15-30% lower likelihood of psychiatrically based hospitalization and emergency room visits.  While this study cannot prove cause-effect (that is, statin use being directly implicated in lowering hospitalization rates) it does support further investigation testing various statins -including those that dissolve in fat (lipophilic) or do not (hydrophilic) – and monitoring hospitalization rates between randomization of assigned statin and the prespecified follow-up period.

Listed below are additional considerations related to psychiatric illness and cardiovascular disease.

1. Adults with major depressive illness experience a 15-25% increased risk of heart attacks, cardiovascular death and all-cause mortality compared to those without depression.
2. Optimism is associated with a 35% lower risk of future heart attack, stroke or death from heart disease.
3. Serious mental illness (schizophrenia, bipolar disorder, major depression) is associated with a 78% increased risk of future cardiovascular events (heart attack/stroke) than those without mental illness.
4. Serious mental illness is also associated with a 2-fold increased risk of cardiovascular death. A comprehensive risk reduction program (IDEAL trial) is underway to assess whether innovative interventions can reduce risk.
5. A Japanese study found that rarely or never laughing was associated with a 20% higher risk of heart disease and 60% higher risk of stroke compared to those who laughed daily.
6. A new study finds robust evidence that statins are unlikely to lead to depressive symptoms in the general population.
7. A recent analysis of more than 500,000 men and women found no association between statin use and ALS (amyotrophic lateral sclerosis) or Lou Gehrig’s disease.
8. Statins have no significant adverse effect on sleep duration and efficiency.  In fact, statins significantly reduce wake time and number of awakenings.
9. Statin treatment is not related to cataract development or progression.
10. There is no good evidence to suggest that statins increase the risk of tendonitis or tendon rupture.
11. There is no need to avoid statin therapy in patients with stable chronic liver disease and normal or modestly elevated transaminases (up to 3 times the ULN).
12. At the present time, however, there is no conclusive evidence for a causal relationship between statin treatment and peripheral neuropathy.

 

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. 

Did You Hear That? If Not, Blame it on Your Heart

As we age, the loss of high frequency sounds becomes a common sign of hearing impairment due to degenerative changes in the inner ear.  High frequency hearing loss is common in the U.S. (~1 in 5 adult men and women are affected) and the classic sign is a decreased ability to hear high pitched sounds (voices of children/women) as well as to decipher conversations in a crowded room.  Loss of low frequency sounds (voices of men, thunder, bass) is less common but is also an important cause of hearing loss.

A study from the Yale School of Medicine suggests that having a history of cardiovascular disease or at least 1 cardiovascular risk factor (diabetes, high blood pressure, history of smoking) also raises the risk of both high and low frequency hearing loss.

Bottom Line: While heart related risk factors may promote hearing loss, it still remains to be determined whether intensive management of these risk factors delays progression of this process.

Listed below are some tips related to hearing and cardiovascular health

1. High frequency hearing loss is common in patients with diabetes (Type 1 and Type 2) due to disease of small blood vessels of the (cochlear) inner ear.
2. Treatment of high cholesterol with statins has been shown to improve tinnitus (ringing of the ears).
3. In a study of 274 men and women aged 45-64 years, hearing loss was 2-fold greater among those with hypertension (140/90 or higher) than with normal blood pressure.
4. A study conducted in Korea found that obese men and women with elevated cholesterol and triglyceride levels were at increased risk of high frequency hearing loss.
5. Data from the Nurses’ Health Study found that women who consumed 2-4 fish meals per week experienced a 20% lower likelihood of hearing loss compared to women who consumed less than 1 fish meal per month over the 18-year followup period.
6. Cigarette smoking cessation eliminates the excess risk of hearing loss within 5-years of quitting.

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.

 

 

 

A Memorable Discovery for Dementia?

Having recently celebrated my 30^th anniversary at the University of Maryland School of Medicine and upon hearing the Beatle’s tune, “In My Life”, I was struck by the verse “and these memories lose their meaning”.  Though highly unlikely that John (Lennon) wrote this verse with “dementia” in mind, the words can certainly be consistent with memory loss.

Yet while tremendous strides have unfolded in treating cardiovascular disease (heart attacks, strokes, etc) in recent decades, the pace of progress has been slower when it comes to prevention/treatment of Alzheimer’s disease and other forms of dementia.  The initial exhuberance following FDA’s approval of Biogen’s Alzheimer’s disease drug, (aducanumab or  “Aduhelm”) last month, despite mixed study results, was met with immediate skepticism and calls for a federal investigation as to whether there was sufficient justification to warrant approval.   Undoubtedly, stakes are high with an estimated 6.2 million Americans (~1 in 9) aged 65 and older having some form of dementia.

However, hope may be on the horizon as a new study out this week sheds important insights into how memory loss may be reversed.  The study conducted in the United Kingdom examined PNNs (perineuronal nets), highly specialized structures involved in regulating neuroplasticity (the way the adaptive brain learns and develops new memories).  In early childhood, there is increased neuroplasticity but as the brain ages, PNNs decrease and neuroplasticity wanes. An important compound in PNNs that promotes neuroplasticity is chondroitin-6-sulfate (C6S).  The new study found that administration of C6S to aged mice restored their ability to quickly recognize objects at levels similarly observed in younger mice.

Bottom Line: while more animal studies are required to confirm the effects of C6S on memory before progressing to human trials, the new study may turn out to be a memorable discovery for dementia.

In the meantime, listed below are lifestyle related tools that may help sharpen your memory:

1. Reduce Sugary Beverages: Drinking more than 1 sugared beverage (soda, juice) daily was associated with reduced memory and lower brain volume compared to minimal or no sugary beverage intake.
2. Add Blueberries: 1 cup of fresh blueberries daily is associated with fewer learning errors and improved cognition in men and women aged 60 years and older.
3. Practice Mind–Body Exercises: Participating in mind-body exercises such as Tai Chi, yoga and dancing mindfulness movements improve learning, memory and adaptable brain responses (neuroplasticity). 
4. Aerobic Activity: Moderate aerobic activity (walking at a pace of 3-5 mph) was shown to improve cerebral blood flow and cognitive function in men and women with mild cognitive impairment over a 12-month period.
5. Sneak in an Afternoon Nap: Power napping for as little as 30 minutes in the afternoon is associated with improved memory and cognitive function.
6. Stay Hydrated: Dehydration is associated with impaired cognitive function. Drinking  6 ounces of water each hour over a 10 hour period will help keep your mind sharp.

Dr. Michael Miller is Professor of Medicine at the University of Maryland School of Medicine.

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…“