The Cleveland Clinic Heart Advisor

Volume 12
Number 1
January 2009

Many of the charts & tables found on this site are PDFs.

January 2009

Statin Therapy May Do Much More Than Lower Cholesterol
The cholesterol-lowering drugs known as statins have been in the news again in recent months, following the landmark JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) trial, in which the medications were found to cut the risk of heart attacks and strokes in half, even among people with low levels of low-density lipoproteins (LDL or "bad" cholesterol). But Leslie Cho, MD, director of Preventive Cardiology and Rehabilitation at Cleveland Clinic, says it’s important that the study results not be interpreted as evidence that everyone needs to begin statin therapy, regardless of their cholesterol levels. Dr. Cho points out that the study participants were specifically selected because they had some risk factors—particularly elevated levels of C-reactive protein (CRP), a sign of inflammation in the body. She adds that the average age of the study participants was 66 and that 41 percent of the people in the study had metabolic syndrome, a collection of risk factors such as obesity, high blood pressure and elevated CRP.

Diabetics Need Blood Pressure and Kidney Function Control
If you have diabetes, your risk of death increases by a factor of seven if you also have hypertension—and it’s estimated that more than 75 percent of diabetics have high blood pressure or are taking blood pressure medication. Given those statistics, it’s not surprising that new guidelines for treating hypertension in patients with diabetes have recently been issued by the American Society of Hypertension (Journal of Clinical Hypertension, October 2008). The guidelines urge a more aggressive treatment approach as well as more frequent medication monitoring. They also note that early identification and management of proteinuria—an elevated level of protein in the urine that signals the possibility of kidney disease—is an essential part of lowering heart risks for diabetics. "It is a vicious cycle—once you start developing kidney disease, your blood pressure goes up further. It’s a feed-forward kind of thing," says Leann Olansky, MD, an endocrinologist at Cleveland Clinic.

Even Mild Sleep Apnea Increases Heart Risk
According a study published in the Nov. 1 issue of the American Journal of Respiratory and Critical Care Medicine, even people with minimally symptomatic obstructive sleep apnea (OSA) may be at greater cardiovascular risk because of increased arterial stiffness. Traditionally, more severe forms of OSA have been linked to heart disease, but this recent research suggests that people with mild forms of the condition should take steps to protect their hearts as well. "Obstructive sleep apnea is a growing public health problem in the United States and other developed countries," says Michael D. Faulx, MD, FACC, a staff cardiologist at Cleveland Clinic. "Increasing research supports a causal role for OSA in diurnal (daytime) hypertension, and the importance of this relationship is illustrated by the inclusion of sleep apnea as an identifiable cause of hypertension in current management guidelines. Additionally, individuals with OSA are more likely to suffer from heart failure, ischemic heart disease, stroke, and recurrent atrial fibrillation than are subjects without OSA."

Age Alone Not a Barrier to ICD Therapy
Elderly heart patients are seldom included in formal clinical trials of devices such as implantable cardioverter defibrillators (ICDs), yet doctors insist that older and younger people can reap similar rewards from the technology that helps hearts beat in normal rhythms. "ICDs can be just as effective in both types of patients," says cardiologist Bruce Wilkoff, MD, director of Cardiac Pacing and Tachyarrhythmia Devices at Cleveland Clinic. "There’s no evidence to suggest that elderly patients shouldn’t have the device. You just want to know what are the co-morbidities and what are the risks of therapy." And research from earlier this year suggests that elderly patients with ICDs live longer after heart failure than those who don’t receive the devices and that quality of life doesn’t suffer if you’re on ICD therapy.

Do You Need a Stress Test Before Stenting?
A recent study suggests that many patients may not get the stress test the American Heart Association (AHA) recommends prior to percutaneous coronary interventions (PCI), such as stenting and angioplasty. A stress test can weed out patients with minimal symptoms who may not need risky invasive procedures, but Stephen Ellis, MD, Section Head of Invasive/Interventional Cardiology at Cleveland Clinic’s Heart and Vascular Institute, says the study findings may reflect the fact that the test isn’t always accurate: "I think the main reason stress tests aren’t more often used is that they’re generally considered quite unreliable."

What You Need to Know About Warfarin
Warfarin (Coumadin) is an anticoagulant medication commonly used by heart patients to help prevent blood clots that can result in a heart attack or stroke. It works by inhibiting the action of vitamin K, which is vital to the blood-clotting process, but it’s a notoriously difficult drug to manage, particularly in those who’ve just started using it. Too high a dose raises the risk of hemorrhage, while too low a dose can mean clots still form.