Heart News and Notes

High blood pressure is a risk factor for heart disease, and consuming too much salt - at least in some people - raises blood pressure to dangerous heights.

Dr. Thomas R. Frieden, the commissioner of New York City’s Department of Health and Mental Hygiene, has won battles against smoking, trans fats and calories. Now he’s taking up arms against salt - not the salt in your salt shaker, but the salt in processed foods and restaurant meals, which accounts for about 80 percent of the sodium in the average diet. He hopes to save 150,000 lives a year by reducing that salt by half, and he wants to persuade the U.S. food industry to meet that goal in ten years.

Readers of The New York Times asked him some hard questions. They pointed out that most people don’t have high blood pressure and aren’t sensitive to salt, and that people need salt, some more than others. They also argued that educating the consumers would be better than compelling the suppliers.

Dr. Frieden answered them. Educating consumers won’t help because they have no choice. People consume far more salt than they need because it’s already in the food they buy. It could be cut in half without harming anybody. If you need more salt, you can add it from your salt shaker, but you can’t take it out of the can or off the plate that’s put before you.

Light to moderate consumption of alcohol lowered the risk of physical disability in older adults, but only if they were healthy to begin with, in an analysis of survey data at the University of California, Los Angeles, in which over 4,200 people age 50 or over were followed for five years. Those who rated their health as fair or poor got no benefit. Lead researcher Dr. Arun Karlamangla suggests (among other reasons) that alcohol might interact with their medications.

But when the effect of moderate drinking on the risk of heart disease was examined in an observational study at University College, London (UK), in which over 9,600 middle-aged civil servants without heart disease were followed for a median of 17 years, only the people who did not follow a healthy lifestyle gained any benefit, reportedly echoing a similar result in a U.S. study.

Observational studies are often misled by unrecorded factors. But supposing that both studies are correct, one might conclude that moderate use of alcholic beverages gives the most benefit to healthy people with unhealthy habits. The numbers in the London study even suggest that moderate drinking is a good substitute for healthy habits.

Plavix (clopidogrel) is prescribed for heart patients, often after stent implantation, to prevent blood clots that could block an artery and cause a heart attack. Preventing blood clots, of course, can lead to excessive bleeding.

Usually only severe bleeding is reported as a side effect. But as many as 85 percent of patients experience “nuisance bleeding”: easy bruising, prolonged bleeding from small cuts, and minor hemorrhages, according to a study of 2360 stent patients in Washington, DC.

Patients have to live with this nuisance day after day, and more than one-tenth of the patients stopped taking Plavix because of it. Doctors want to prolong their lives, but the patients also want quality of life. (Your editor quit Plavix after two years in spite of his cardiologist’s objections).

COGENT 1 was to be a trial of a combination of clopidogrel (Plavix, an antiplatelet drug) and omeprazole (a proton pump inhibitor marketed as Prilosec). Plavix is used to prevent heart attacks due to blood clots, but it can cause gastrointestinal bleeding, which the omeprazole was expected to prevent.

The study was planned as a 4000-subject randomized, double-blind, phase 3 trial - a highly reliable test of effectiveness. But while the trial was still listed as in the “recruiting” phase, the sponsor, Congentus Pharmaceuticals, announced that it was filing for bankruptcy and could no longer continue to pay for the study.

Researchers were told to return the combination drug, and some may not even be paid for work they have already done or will do to close down the study. Subjects already enrolled will continue on Plavix alone.

Many treatments are available for cardiovascular disease, broadly grouped as lifestyle, medication, and revascularization, with many choices in each category (e.g., revascularization could be angioplasty, stenting or bypass). A new guide to treatment, titled “Appropriate Use Criteria for Coronary Revascularization,” was published online last month and in the February 10 Journal of the American College of Cardiology.

The guide was developed by a panel of physicians for application to real patients, who can differ from subjects selected for trials. The choice of treatment depends on symptoms, plaque in the arteries, how much heart muscle is starved for blood, and the patient’s medications, and was selected to offer the best chance for survival and quality of life. Revascularization is not often recommended, but when it is, bypass is often preferred to stenting.

Let’s hope that not only your physician, but also your health insurer, learns to use the new criteria as quickly as possible.