The American College of Cardiology and the American Heart Association has given us a new tool and to assess an individual's risk of having a heart attack and new guidelines on treatment. It is somewhat different than the old Framingham risk assessment and if followed will result in more patients taking "statin" drugs to lower cholesterol. There remains much disagreement, including among cardiologists, about which tool should be used. An individualized patient approach is still preferred among many physicians. Your cardiovascular risk, scored as your risk of a heart attack in the next 10 years, can be done in a regular office visit.
The CDC recommends that anyone born in the US between 1945 and 1965 be tested for the Hepatitis C virus. This infection can sometimes lead to chronic liver disease, cirrhosis, and liver cancer. A simple blood test sent from the office can screen for Hepatitis C.
Is hormone replacement in postmenopausal women good or bad? It was thought that the benefits far outweighed the risks until the Womens Health Initiative (WHI) study was stopped early because of an apparent increase in cardiovascular disease However, there are some caveats. The hormones used in the study were oral forms of synthetic hormones, which may pose more risk than natural forms of these hormones or hormones given by a different route, such as via a patch. Also, the WHI included older postmenopausal women, who would naturally be at higher risk of cardiovascular disease based on age or other risk factors and who would be less likely to suffer from some postmenopausal symptoms, such as hot flashes. Women less than 10 years into menopause had a slightly reduced risk of heart disease, although a slightly increased risk of some cancers when on both synthetic hormones. The upshot is that for otherwise healthy women without a family history of gynecologic cancer who have menopausal symptoms (hot flashes, night sweats, depression, fatigue, insomnia, etc.) and who are less than 10 years into menopause, certain forms of hormone replacement for a limited time probably confer more benefits than risk. Smaller studies on such women are ongoing. Cynthia Gorney's article "The Estrogen Dilemma" in the N.Y. Times magazine of April 18, 2010 provides a fairly good overview of some of these issues.
Shingrix, a new vaccine against Shingles, has been FDA-approved. It is given as 2 injections 2 to 6 months apart and is recommended for adults 50 years of age or older. It is more effective than Zostavax, the prior Shingles vaccine. Shingles is a reactivation of the Chicken Pox virus.
The herbal preparation Coenzyme Q-10, 100 mg./day, may alleviate the muscle aches associated with "statin" drugs, such as Lipitor and Zocor. The number of patients in the study was small. Nevertheless, Coenzyme Q-10 has long been thought to have minor cardiovascular benefits and may be useful in such cases.
A small amount of dark chocolate each day may provide some health benefits. As with alcohol and caffeine, moderation is the key.
Try Kyolik liquid garlic extract, 1/4 teaspoon every other day, for prevention of common colds. It's available in health food stores and some pharmacies and mixes easily in juice, with no odor or aftertaste.
Recent reports have questioned the usage of the cholesterol-lowering drugs Zetia and Vytorin (a combination of Zetia and simvastatin), indicating that they actually might cause a slight increase in atherosclerotic plaque in the coronary arteries and that there may not necessarily be a reduction in cardiac problems. For now, I believe that these these drugs should be used as I and many other doctors have been using them. Statins, such as Lipitor, simvastatin, and Crestor should be used initially, with the addition of or substitution with Zetia if the statins cannot be tolerated by the patient or if there is insufficient cholesterol reduction with the statin.
On a related note, patients on certain calcium channel blocker drugs such as amlodipine (Norvasc) who are also on simvastatin may need to have their simvastatin dose reduced or the drug changed.
Should I take an aspirin a day? There is moderately good evidence that a small dose of aspirin each day may prevent some heart attacks in men over 45 and some strokes in women over 55. The optimal dose is unknown but I recommend 81 mg./day (equivalent to a baby aspirin). Of course, for some patient, the risks of aspirin may outway the benefits so this decision should be individualized. For otherwise healthy people taking cholesterol-lowering drugs, which also have some additional vascular benefits, there may be no compelling reason to take aspirin.
A recent report found that people with normal cholesterol but elevated levels of blood C-reactive protein (CRP) had improved cardiovascular outcomes if treated with Crestor, a statin drug. CRP is a crude indicator of excessive inflammation in the body, which may indicate a tendency towards coronary artery inflammation and therefore coronary atherosclerosis and narrowing. It is unclear whether this practice should now be followed. I believe most physicians will individualize treatment and perform and utilize CRP more in patients with mildly elevated cholesterol and no other cardiac risk factors (smoking, diabetes, strong family history, hypertension) or with normal cholesterol and an additional risk factor. Statins may be more beneficial in such patients.
Patients , women in particular, often ask whether they should take calcium supplements. Most people who have an adequate dietary intake of calcium and Vitamin D do not need supplements, although adequate Vitamin D intake may be difficult with diet alone. Good sources of dietary calcium include most dairy products, tofu, and dark greens, especially spinach. We frequently test patients' blood for Vitamin D levels, particularly older men and women. Daily dietary intake should be 1000-1200 mg/day for calcium and 600-800 u/day for Vitamin D. Good sources of Vitamin D include milk and fish, especially salmon, tuna and sardines. Some studies have found a lower risk of spinal and hip fractures in postmenopausal women who took extra calcium and Vitamin D. The benefit is most marked in women older than 65, and those in institutions such as nursing homes. Many supplements combine the calcium and the vitamin. Popular brands include Oscal, Citracal, Caltrate, and Viactiv. Calcium citrate (such as Citracal) may be taken on an empty stomach. The daily dose should be split between lunch and dinner if taken with food. Another group of patients who need additional calcium are those taking long-term PPI drugs, such as Prilosec and Prevacid, as these can sometimes cause mild bone loss over time.
Another related topic: Most men over 60 should now be screened for osteoporosis with a bone density test done by a radiologist, similar to what we do in postmenopausal women.
Medicare now covers a preventive "Welcome to Medicare" exam during the first year of enrollment, as well as an "Annual Wellness Visit" once per calendar year. This is paid for in full by Medicare with no copayment.