2022 AHA/ACC/HFSA Guideline for the Management of Heart ...
Exposure To Heavy Metals Increases Your Heart Disease Risk
Numerous studies show the risk factors for cardiovascular disease, which include high blood pressure, high cholesterol, and smoking. However, there is limited research on the impact of toxic metals on heart health.
According to a scientific statement published in the Journal of the American Heart Association, chronic exposure to contaminant metals found in household products, air, water, soil and food is linked to a greater risk of cardiovascular disease.
The metals found were lead, cadmium and arsenic.
Even low-level exposure to these metals is considered dangerous. Researchers found a connection between lead, cadmium and arsenic exposure and coronary artery disease, stroke and peripheral artery disease.
"These metals interfere with essential biological functions and affect most populations on a global scale," Ana Navas-Acien, M.D., Ph.D., vice chair of the statement writing group and a professor of environmental health sciences at Columbia University's Mailman School of Public Health and the director of the Columbia University Northern Plains Superfund Research Program in New York City, said in a statement. "After exposure, lead and cadmium accumulate in the body and remain in bones and organs for decades. In the U.S. Alone, one large study suggested that more than 450,000 deaths annually could be attributed to lead exposure."
Interestingly, even though there has been evidence of these harmful effects, many health professionals are only now beginning to understand the severity of this issue.
"The most surprising finding to me is the multi-decade disconnect between public health scientists, who proved over and over again that toxic metals were related to cardiovascular disease, and cardiologists, who only now accept the connection and the validity of environmental cardiology," Gervasio A. Lamas, M.D., FAHA, chairman of medicine and chief of the Columbia University Division of Cardiology at Mount Sinai Medical Center, told Healthline.
The next phase of research is to determine if a drug called EDTA, which increases lead and cadmium excretion from the body, reduces or prevents cardiac events, Lamas added. In 2012 in JAMA we showed this to be true, in the TACT trial. The confirmatory study will show results within the year.
Experts are still learning about the science behind this connection.
"This is complex, and the scientific community may not fully understand the science behind the mechanism," said Dr. Garry Winkler, MD, an Emergency Medicine physician and Medical Toxicologist at UTHealth Houston. "Heavy metals such as lead, cadmium, and arsenic can mimic normal metals that our body uses, thus leading to enzymes not working correctly, and some heavy metals also interfere with DNA/RNA function."
The science and pathophysiology behind how cancer or cardiovascular disease occurs is still being studied. For example, one mechanism is that arsenic itself inhibits nitric oxide synthase in the lining of blood vessels, Winkler explained. This leads to a reduction of the generation and bioavailability of nitric oxide limiting the dilation of blood vessels. Ultimately, this leads to high blood pressure or hypertension and coronary artery disease.
"These non-essential metals trigger a number of harmful processes in our bodies, including inflammation, that can ultimately cause diseases such as high blood pressure, high cholesterol, and atherosclerosis (plaque buildup in the arteries)," said Herb Aronow, M.D., Medical Director of Heart & Vascular Services at Henry Ford Health. "As a result, exposure to these metals may lead to heart attack, stroke, heart failure, and limb loss."
The main way people are exposed is due to contaminated air, water, and soil.
"While it sounds simple, avoiding exposure can be difficult for patients and may involve moving. It is typically difficult to decontaminate the environment," Winkler stated. "If someone is concerned for toxicity from these metals, then they should have their environment tested for heavy metals. Human testing should be performed with urine testing and not hair samples."
Worldwide, the biggest cause of elevated arsenic levels is due to water from wells; exposure from foods tends to be minimal. Lead exposure is most frequently caused by contaminated soil around homes due to contamination from lead paint, Winkler explained.
Lead can also be found in herbal supplements from foreign countries (eg Ayurvedic and Traditional Chinese Medications), and some occupations are also at increased exposure risk. Environmental exposure to cadmium generally occurs through the consumption of foods grown in cadmium-contaminated areas, Winkler added. Welders, solderers, and jewelry workers who use cadmium-containing alloys are at risk for cadmium toxicity as well.
"The most impactful interventions should be enacted by governmental agencies as the result of legislation," Aronow stated. "Such interventions could limit allowable amounts of metal contamination in air, water food and soil, and monitor for these metals to protect our communities. People are encouraged to let their respective congresspersons know how important this issue is to them and their communities."
The study authors also stated that addressing metal exposure in these populations may provide a strategy to reduce cardiovascular disease disparities and advance environmental justice.
"I agree with this statement," said Winkler. "Cardiovascular disease prevalence, incidence, and disparities are more pronounced in low socioeconomic areas. The reason for this is complex, but areas of environmental contamination are also typically higher in low socioeconomic areas. Addressing environmental contamination and exposure is a strategy to reduce cardiovascular disease disparities and advance environmental justice/equity."
The most polluted areas tend to be the poorest or more disadvantaged areas, Lamas explained. Making an effort to "clean up" these metal-polluted areas will, or should, reduce the differences in vascular disease between rich and poor.
According to a new scientific statement released by the American Heart Association, chronic exposure to contaminant metals found in household products, air, water, soil and food is linked to a greater risk of cardiovascular disease.
If you're concerned about metal toxicity in your area, you can have your environment tested.
Experts agree that to reduce cardiovascular disease disparities and advance environmental justice, it's important to address metal exposure in low socioeconomic areas.
Study: Bempedoic Acid, A Statin Alternative, Reduces Heart Attack Risk By 39%
Those who took bempedoic acid once a day had on average a 30.2 mg/dL or 21.3% reduction in ... [+] low-density lipoprotein (LDL) cholesterol levels over about a three-year period. Elevated LDL levels can lead to cholesterol plaque formation that can narrow blood vessels, as seen in this 3D rendering. (Photo: Getty)
gettyIf you have elevated levels of "bad cholesterol" and are at greater risk for having a heart attack or stroke, it's common for doctors to start you on a statin. But what if you are on a statin island, so to speak, and among the 15% or so of people who can't tolerate being on such an anti-cholesterol medications? Well, you may want to take to heart what a clinical trial just revealed about bempedoic acid, a potential alternative to statins. In this "acid test" of a trial, those who took bempedoic acid once a day had on average a 30.2 mg/dL or 21.3% reduction in low-density lipoprotein (LDL) cholesterol levels over about a three-year period, as described by a June 24 publication in JAMA.
Plus, compared to those who took placebo, those taking bempedoic acid were also 39% less likely to suffer heart attacks, 39% less likely to die from heart disease, and 36% less likely to die of either a heart attack or a stroke. That's encouraging news for those with statin intolerance. But take all of these results with a grain of salt—figuratively, of course, and not literally because too much salt isn't good for your cardiovascular system. It is only one study. And one study is, you know, just one study.
Now, statin intolerance is not when you insult and bully statins. Rather, it's when you can't continue taking statins like atorvastatin (which is the generic name for Lipitor), rosuvastatin (Crestor) or simvastatin (Zocor) due to significant side effects from the medication. Most commonly, what may happen with muscles is what will pull the use statins. Some people may develop muscle aches, pains, weakness, or cramps that become intolerable or an elevation in the blood levels of creatine kinase, which is a marker for muscle injury. Another reason for stopping a statin is when blood tests show elevations in liver enzymes that suggest that some kind of liver injury may be occurring.
Statin intolerance can be a real barrier to lowering elevated LDL levels. LDL is not an LOL type of cholesterol. It's the bad kind of cholesterol that can clog up arteries that are supposed to supply blood to your heart and brain, arguably two of your three most important body parts, depending on where you happen to rank your genitals. When your LDL is elevated, doctors will usually first suggest lifestyle changes such as reducing the amount of saturated fat that you consume, eating foods rich in omega-3 fatty acids, increasing your fiber intake, adding whey protein to your diet, cutting down your 19-hot-dogs-a-day diet, increasing your physical activity, trying to lose weight, quitting smoking and reducing your alcohol intake.
Lifestyle modifications are typically the first line of therapy for elevated cholesterol. (Photo: ... [+] Getty)
gettyWhen you've made "whey" too many unsuccessful lifestyle modification attempts, doctors often will prescribe statins to help "de liver" lower cholesterol. Statins work by inhibiting HMG-CoA reductase, an enzyme that the liver uses to manufacture cholesterol. Statins can also help your liver remove cholesterol from the blood and reduce inflammation in your artery walls. Studies have shown that for each 1.0-mmol/L (39-mg/dL) reduction in LDL achieved by statin use, the risk of major cardiovascular problems can drop by 20% to 25%, as determined by a meta-analysis published in The Lancet.
Bempedoic acid is an intriguing alternative for those with statin intolerance. In early 2020, the U.S. Food and Drug Administration (FDA) granted approval to Esperion Therapeutics, Inc, to market their version of bempedoic acid called Nexletor. That made oral history, so to speak, as it was the first oral, non-statin, LDL-lowering medication to earn such approval since 2002. This medication can reduce the amount of cholesterol made by your liver via a somewhat different mechanism. It inhibits a different enzyme, adenosine triphosphate-citrate lyase (ACL), that works earlier in your liver's cholesterol making process. Bempedoic acid can lead to increased expression of LDL receptors as well, leading to more removal of LDL from the blood.
This alternative possibility is why a research team from the Cleveland Clinic (Steven E. Nissen, MD, Venu Menon, MD, Danielle Brennan, MS, Luke Laffin, MD, Denise Mason, BSN, Leslie Cho, MD, and A. Michael Lincoff, MD), Monash University (Stephen J. Nicholls, MBBS, PhD), Brigham and Women's Hospital (Paul Ridker, MD, and Peter Libby, MD), Imperial College London (Kausik K. Ray, MD, MPhil), the University of Amsterdam Academic Medical Center (John J. P. Kastelein, MD), and Esperion Therapeutics, Inc, (Na Li, PhD, JoAnne Foody, MD, and Michael J. Louie, MD, MPH, MSc) embarked on a study of 4,206 people who were considered statin-intolerant. These 4,206 were actually a subset of 13,970 statin-intolerant patients who were enrolled in a clinical trial from December 2016 through August 2019 run at 1250 different centers across 32 different countries. In this subset, 2,100 were randomly assigned to receive 180 mg of bempedoic acid by mouth once a day and 2,106 were randomized to receive a placebo.
Study participants began with an average LDL level of 142.5 mg/dL. That's in the borderline high range of 130 to 159 mg/dL. In a perfect world, your LDL should be below 100 mg/dL. Participants also started the study with an average high-density lipoprotein (HDL) cholesterol level of 51.0 mg/dL and a median triglyceride level of 161.8 mg/dL. A little over half (59%) of the participants were female. Close to two-thirds (66%) had diabetes. The average age of participants was 68 years. The research team followed participants for a median of 39.9 months.
Muscle pain can be a side effect of statin use. (Photo: Getty)
gettyAs mnetioned earlier, the study suggested that bempedoic acid "bempe-did" have help lower LDL levels and the risk of bad cardiovascular events. Ultimately, 112 study participants or 5.3% of those in the bempedoic group ended up suffering death from cardiovascular causes, a heart attack, stroke, coronary revascularization, or hospitalization for unstable angina. That was 31% less than the 164 patients (7.8%) in the placebo group. In addition to the aforementioned results, those on bempedoic acid experienced an average decrease of high-sensitivity C-reactive protein levels of 0.56 mg/L (21.5%), down from an initial median level of 2.4 mg/L. Those in the bempedoic acid group were also 27% less likely to have died for any reason.
Of course, taking a medication every day ain't exactly like eating avocado toast each day. You've always gotta wonder what the side effects may be. While there were no adverse events serious enough to prompt the discontinuation of the bempedoic acid, the research team did notice some other differences between those in the bempedoic acid group and those in the placebo group. A higher percentage of those taking bempedoic acid did develop gout (2.6% vs 2.0%), gallstones (2.5% vs 1.1%), and increases in serum creatinine, uric acid, and hepatic enzyme levels than those on placebo.
Again, keep in mind that this just one study. And one is usually not enough when it comes to sheets of toilet paper and scientific studies. Moreover, this wasn't the biggest of clinical studies. The number 4,206 may seem large when it comes to tea party and the number of ferrets in your pants. But such a number is actually not large enough to represent the full diversity that exists in the general population. More studies are needed to determine whether bempedoic acid can truly serve as alternative to statins.
Nevertheless, the results from this study are encouraging that bempedoic acid could help fill an important need. After all, you may want the statin. But what if you can't handle the statin? Until now, there have been few good medication alternatives to statins. Things like fibrates, bile-acid binding resins like cholestyramine, and niacin all have their limitations. So, bempedoic could bump itself to the top of alernatives to statins. Now, bempedoic acid shouldn't necessarily be the first cholesterol-lowering medication to try, especially if you have the muscle to tolerate statins. But bempedoic acid could provide doctors with some extra muscle to lower patients' LDLs and cardiovascular risks when statin intolerance is intolerable.
Congestive Heart Failure: Stages And Types
Systolic congestive heart failure occurs when the heart does not pump blood effectively. There are 4 stages of congestive heart failure.
Congestive heart failure may happen when the heart muscle is too weak or when another health problem prevents it from circulating blood efficiently. Over time, systolic congestive heart failure, or heart failure (HF), can lead to dysfunction of other organs due to inefficient pumping.
This article discusses how HF progresses over time and explains the outlook for people with this condition. It also examine the causes, symptoms, treatment options, and stages.
There are four different stages of systolic heart failure: A, B, C, and D.
When the condition progresses to the next stage, a person's chance of surviving decreases.
People with stage A HF do not yet have dysfunction of the pumping activity of the heart but have a high risk of developing HF due to related conditions, such as chronic high blood pressure, diabetes, and coronary artery disease.
SymptomsA person usually has no symptoms of HF at this stage but may experience symptoms of their chronic conditions, including:
People with this stage HF have no problems with the structure of the heart or how their heart works. Treatment should focus on managing risk factors.
Structural heart disease develops at this stage, such as reduced pumping function of the heart, which can lead to an enlarged left ventricle. It can also result from a previous heart attack.
SymptomsMost people at stage B still do not show symptoms of HF.
OutlookA doctor may prescribe medication at this stage for the management and prevention of future problems. It is common for a doctor to prescribe ACE inhibitors/ARB or ARNI and beta blockers at this stage.
People at this stage will show symptoms of HF linked to underlying structural heart disease, including fatigue or breathlessness. These symptoms usually occur due to problems with the squeezing function of the left ventricle, or the pumping chamber of the heart.
Stage C HF also includes people who no longer show symptoms but are currently undergoing treatment for previous symptoms, such as those who spent time in the hospital with heart failure exacerbation.
SymptomsCommon symptoms include:
A doctor will definitely prescribe medication at this stage for the management and prevention of future problems. It is common for a doctor to prescribe diuretics, ACE inhibitors/ARB/ARNI and beta blockers, mineralocorticoid receptor blockers, or SGLT2 inhibitors at this stage.
A doctor also may consider implantable cardioverter-defibrillators and cardiac resynchronization therapy at this stage.
At stage D, people will have advanced structural heart disease and display significant symptoms, even when they are at rest.
SymptomsSymptoms may include:
This stage is severe and may require advanced specialized treatment. Such as mechanical circulatory support, continuous inotropic infusion to make the heart squeeze harder, cardiac transplant, or hospice care.
The most common type of HF is left-sided HF. The left side of the heart must work harder to move the same volume of blood around the body. This may cause a fluid buildup in the lungs and make breathing difficult as it progresses.
These fluids give congestive heart failure its name.
There are two kinds of left-sided HF.
With systolic heart failure, the left ventricle cannot contract normally, limiting the heart's pumping ability. The stages of HF only refer to systolic heart failure and not the other types.
With diastolic heart failure, the muscle in the left ventricle stiffens. If the muscle cannot relax, the pressure in the ventricle increases, causing symptoms.
Right-sided HF is less common. It occurs when the right ventricle cannot pump blood to the lungs. This can lead to blood backing up in the blood vessels, which may cause fluid retention in the lower legs and arms, abdomen, and other organs.
A person can have left-sided and right-sided HF at the same time. However, HF usually begins on the left side and can affect the right side if a person does not receive effective treatment.
Symptoms of HF range from mild to severe but may get worse over time if not managed medically.
Lifestyle strategies can reduce the risk of developing HF and can also slow its progress.
To prevent or slow the progression of HF, people should take the following steps:
People who already have HF should take the following steps to prevent further progression:
Without treatment, HF can be fatal. Even with adequate treatment, HF may get worse over time, triggering dysfunction of other organs throughout the body.
HF is more likely to occur in people with other conditions or lifestyle factors that weaken the heart.
Risk factors for HF include:
A doctor or cardiologist will perform a physical exam. This involves listening to the heart, checking for fluid retention, and looking at the veins in the neck to see if there is extra fluid present in the heart. They may order other diagnostic tests, including:
Systolic congestive heart failure occurs when the heart does not pump blood effectively. It may happen for a variety of reasons such as a weak heart muscle or underlining health problems.
There are several stages of systolic congestive heart failure and each stage requires a different treatment. Lifestyle changes, medication, and surgery are typical methods of treatment.
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