Is there a scope of Polypill in CMAAO countries in people with poor adherence to medicines?

Is there a scope of polypill in CMAAO countries in people with poor adherence to medicines?

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

A study in the New England Journal of Medicine reported positive results for people taking a polypill to lower blood pressure and cholesterol.

The study enrolled 303 people with estimated 10-year risk of CVD at 13%.

Half of the study subjects were randomly assigned to receive a polypill containing low-dose atorvastatin (to lower cholesterol) and three medications to lower blood pressure (amlodipine, losartan, and hydrochlorothiazide). The other half were randomly assigned to “usual care” (as recommended by their personal physicians) and compared to the polypill group after one year.

Those assigned to the polypill group had larger reductions in blood pressure, larger drops in LDL (“bad”) cholesterol and excellent medication adherence.

There were no serious medication-related side effects reported in either group.

Authors estimated that based on the observed reductions in blood pressure and cholesterol levels, treatment with the polypill could reduce cardiovascular events by 25%.

Also another study published in The Lancet, found a reduction in major cardiovascular events with a different polypill (which included aspirin)

Untreated white-coat hypertension increases risk of cardiac events and mortality

(ACP Internist excerpts): Untreated white-coat hypertension, but not treated white-coat effect, was associated with an increased risk for cardiovascular events and all-cause mortality, according to a systematic review and meta-analysis published in June 11 by Annals of Internal Medicine.

Twenty-seven observational studies with at least three years of follow-up were included. They evaluated 25,786 participants with untreated white-coat hypertension or treated white coat effect and 38,487 participants with normal blood pressure followed for a mean of 3 to 19 years.

Compared with normotension, untreated white-coat hypertension was associated with an increased risk for cardiovascular events, all-cause mortality, and cardiovascular mortality. The risk of white-coat hypertension was attenuated in studies that included stroke in the definition of cardiovascular events.  No significant association was found between treated white-coat effect and cardiovascular events, all-cause mortality or cardiovascular mortality.

The elevated risk associated with white-coat hypertension was particularly evident in studies that used ambulatory blood pressure monitoring (not home self-monitoring) and studies with at least five years of follow-up time. These findings suggest that individuals with isolated office hypertension who are not receiving antihypertensive treatment should be closely monitored, while individuals who are receiving antihypertensive treatment could be harmed by overly aggressive management. They added that out-of-office blood pressure monitoring is critical in the diagnosis and management of hypertension.

White coat effect is not associated with increased risk, and out-of-office monitoring seems warranted to prevent intensification of antihypertensive treatment. For adults not taking antihypertensive medication, the risk for CVD [cardiovascular disease] events and all-cause mortality is only moderately increased, and this risk is substantially lower than that associated with sustained hypertension. Therefore, out-of-office BP monitoring is useful for distinguishing between white coat hypertension and sustained hypertension among persons with high office BP. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Long-term antibiotic use tied to higher CVD risk

Women in middle or late life who use antibiotics on a long-term basis have a higher risk for cardiovascular disease events. In a new research investigators followed close to 36,500 female participants in the Nurses' Health Study (NSH) who were free of CVD at baseline over an 8-year period.

After adjustment for demographic, lifestyle, medical, and medication-related covariates, they found that women 60 years or older who took antibiotics for 2 months or more had the greatest risk for CVD, but long-term use of antibiotics was also associated with increased cardiovascular risk if taken by women at midlife (40–59 years).

Lu Qi, MD, PhD, MS, director of the Tulane University Obesity Research Center, Tulane University, New Orleans said that longer duration of antibiotic use may be linked to higher risk of CVD among women. The study was published online April 24 in the European Heart Journal.

Comments: The reason may be killing of the natural microbiome. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

The four keys to prevent cardiovascular disease

An estimated 80% of all CVD cases — heart disease, heart attack, heart failure, and stroke — can be prevented. The key is to control high blood pressure and high cholesterol and to maintain healthy habits, such as exercising regularly, eating a plant-based diet, getting enough sleep, and not smoking.

Exercise: Guidelines recommend 30 minutes of moderate-intensity exercise five times a week. "Doing more is better.

·         Walk for 5 minutes every 2 hours. Do a set or two of push-ups either on the floor or against the kitchen counter.

·         Perform up to 10 repetitions of stand-and-sit exercises, where you rise from a chair not using your arms and then sit down again.

·         Find opportunities to do extra movements. For example, park farther away from the grocery store, take the stairs, and do simple yard work like weeding, planting, and raking. Every bit of everyday movement can count toward your overall exercise requirements.

Diet: Focus on plant foods; minimize intake of red meat, especially processed meat.

Sleep: Guidelines from the American Academy of Sleep Medicine and the Sleep Research Society recommend adults get at least 7 hours of sleep per night on a regular basis. Studies have found that getting less than this amount is associated with heart disease risk factors like higher stress, increased inflammation, high blood pressure, and weight gain. Sleep apnea can also increase the risk. According to a study published online Feb. 12, 2018 in the Journal of Sleep Disorders & Therapy, people with sleep apnea are more likely to also have heart failure, an irregular heartbeat and diabetes

Numbers: Keep the lower BP, LDL cholesterol, abdominal circumference and fasting sugar < 80

(Source: Harvard Health Watch)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Should air pollution be named as one of the causes of sudden death?

Nine out of ten people now breathe polluted air, which kills 7 million people every year, says the World Health Organization (WHO).

Air pollution has now emerged as a major environmental risk factor for health. “The health effects of air pollution are serious – one third of deaths from stroke, lung cancer and heart disease are due to air pollution. This is having an equivalent effect to that of smoking tobacco, and much higher than, say, the effects of eating too much salt” (WHO).

In 2016, as per WHO, ambient or outdoor air pollution caused an estimated 4.2 million premature deaths worldwide in both cities and rural areas; 58% of outdoor air pollution-related premature deaths were due to ischemic heart disease and strokes, while 18% of deaths were due to chronic obstructive pulmonary disease (COPD) and acute lower respiratory infections respectively, and 6% of deaths were due to lung cancer. More than 90% of these deaths occurred in low- and middle-income countries.

And it’s just not outdoor air pollution; household (indoor) air pollution also causes 4 million deaths annually.

Pollutants with the strongest evidence for public health concern include particulate matter (PM), ozone (O3), nitrogen dioxide (NO2) and sulfur dioxide (SO2).

Air pollution has been identified as a trigger of acute cardiovascular events (myocardial infarction and stroke). A recent study presented at Heart Rhythm 2018, the Heart Rhythm Society's 39th Annual Scientific Sessions, which evaluated 112,700 women in the ongoing Nurses' Health Study showed that lower-risk women exposed to particular matter (PM) for even a short amount of time are at an increased risk of sudden cardiac death. This association was significant on cold days - at low temperatures below 13°C.

In a report published by the ICMR in The Lancet Planetary Health in December 2017, ICMR clearly stated that 1.24 million deaths in 2017 were caused by exposure to air pollution; one in eight deaths was due to the constantly deteriorating air quality.  ICMR also observed that life expectancy in India is reduced by 1.7 years on an average due to bad air quality.

This report was considered devoid of merit by the Environment ministry.

But, prior to the ICMR report, in 2015, the health ministry had released a report saying that air pollution causes impacts similar to that of tobacco smoking. The report also said that there was evidence of adverse pregnancy outcomes, tuberculosis, asthma exacerbation, cancer and thus, air pollution needs to be addressed during public health programs.

The environment ministry maintains that since no death certificates have pollution listed as the reason of death there is no correlation between air quality and deaths due to the same.

Doctors do not mention pollution as a cause of death, because pollution is not recognized as a cause of death and has no insurance cover. Natural disasters are generally not covered in routine insurance.

However, these statistics only serve to emphasize that perhaps the time has come to declare pollution as one of the causes of all sudden deaths, particularly when the pollution levels in the city are high.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Central obesity is very prevalent in persons at high risk of heart disease and stroke

Results of the European Society of Cardiology (ESC) EUROASPIRE V survey presented yesterday at the World Congress of Cardiology & Cardiovascular Health in Dubai, UAE show that almost two-thirds of people at high risk of heart disease and stroke have excess belly fat or central obesity. EUROASPIRE is a series of cross sectional surveys on the prevention of heart disease in ESC member countries.

The survey found that almost two-thirds (64%) were centrally obese, with waist circumference ≥88 cm for women and ≥102 cm for men). Some 37% were overweight (body mass index [BMI] 25-29.9 kg/m2) and 44% were obese (BMI ≥30kg/m2 ).

Less than half (47%) of those on antihypertensive medication achieved the target BP of less than 140/90 mmHg (less than 140/85 mmHg in patients with self-reported diabetes). And, only 43% of the participants on lipid-lowering drugs attained the LDL cholesterol target of less than 2.5 mmol/L, while 65% of those being treated for type 2 diabetes achieved the A1c target of less than <7.0%.

About 18% were smokers and just 36% achieved the recommended physical activity level of at least 30 minutes, five times per week.

The EUROASPIRE V was conducted in 2017 to 2018 in 78 general practices in 16 primarily European countries and involved 2,759 participants. Each general practice enrolled consecutive individuals under the age of 80 years with no history of coronary artery disease or other atherosclerotic disease, but who were at high risk of developing CVD. High risk was defined as having high BP, high cholesterol, and/or diabetes; the study therefore recruited individuals who had been prescribed antihypertensive, lipid-lowering, and/or anti-diabetes treatments (diet and/or oral hypoglycemics and/or insulin).

BMI is generally used as a measure of obesity. It takes into consideration height and body weight, but not body fat.

A correct measure of obesity therefore is via measurement of body fat, especially the fat around the abdomen. A high waist-to-hip ratio indicates high amounts of abdominal fat. A person can be obese even if the body weight is within the normal range. This is called normal weight obesity, where the BMI is normal as per the age and height, but the body fat percentage is high. Typically, such individuals have a potbelly but otherwise appear normal. Abdominal obesity is more dangerous than generalized obesity.

Any weight gain after puberty is invariably due to fat as most organs also stop growing, once the height stops increasing. One should not gain weight of more than 5 kg after the age of 20 years in males and 18 years in females. And, after the age of 50, the weight should reduce and not increase.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Guidelines may underestimate the harms of statins: Follow person-centric approach

A new modelling study involving persons aged 40 to 75 years with no history of cardiovascular disease (CVD) suggests that 10-year risk thresholds used in current guidelines to prescribe statins for primary prevention of CVD are probably substantially too low.

A new study published online Dec 3, 2018 in the Annals of Internal Medicine has suggested that instead of 7.5% to 10% 10-year risks one should use 14% risk thresholds where the benefits of statins exceed the harms.

Using an approach originally developed by the National Cancer Institute to look at tamoxifen for breast cancer prevention, the investigators show that statins provide net benefits at higher 10-year risks for CVD than are reflected in most current guidelines; 14% for men aged 40 to 44 years. The risk threshold, however, increased to 21% for aged 70 to 75. For women, the risk thresholds were higher at 17% and 22%, respectively. Individuals, who were at high risk for CVD (>21%) were likely to benefit from statins, regardless of sex or age.

Among the four commonly used statins, atorvastatin was found to have the most favorable benefit–harm balance, followed by rosuvastatin, especially for younger adults with low or medium CVD risk.

New research and/or guidelines are suggestions and recommendations, which are definitely evidence-based. While they do standardize treatment for any given condition, they are not without their limitations. They cannot be generalized as each patient is different and hence treatment has to be individualized.

Also, western data cannot be extrapolated to our Indian settings.

Do not follow guidelines blindly and give statins to every case with 10-year risk of heart disease of more than 10%.

Instead every case should be individualized based on age  and other factors.

The individual risk for CVD events should be calculated before prescribing statins. This will result in individual patient harm reduction in CVD risk.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

#AskDrKK: What is post prandial hyperglycemia?

#DrKKAnswers: Post prandial state is a contributing factor to the development of atherosclerosis. It is a direct and independent risk factor for cardiovascular disease. The mechanisms through which acute hyperglycemia exerts its effects may be identified in the production of free radicals. Correcting the postprandial hyperglycemia may form part of the strategy for the prevention and management of CVDs in diabetes.

Dr KK Answers : Can we allow low dose aspirin holidays?

Those at risk of heart attack or other cardiovascular events taking a low dose aspirin holiday can increase their risk of acute heart attack as per a large case-controlled study of 39513 patients aged 50-84 by Dr Luis Garcia Rodriguez, of the Spanish Centre for Pharmacoepidemiologic Research in Madrid and published in British Medical journal.

Compared with those taking aspirin, individuals prescribed aspirin for secondary prevention who had recently discontinued the drug had a significantly increased risk of nonfatal heart attacks or death from coronary heart disease combined and nonfatal heart attacks

Aspirin holiday can cause four more cases of nonfatal heart attacks for every 1,000 patients over a period of one year.

The current American Heart Association/American College of Cardiology practice guidelines recommend 75 mg to 162 mg of aspirin as low dose aspirin per day.