Category Archives: coronary heart disease

Premature Death and Cardiovascular Disease Linked to High Glycemic Index Eating

Naan, a type of flat bread with a high glycemic index

Haven’t we know this for years? From New England Journal of Medicine:

Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population.

METHODS

This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used country-specific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause.

RESULTS

In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease.

CONCLUSIONS

In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death.

Source: Glycemic Index, Glycemic Load, and Cardiovascular Disease and Mortality | NEJM

The Advanced Mediterranean Diet (2nd edition) is low glycemic index.

Steve Parker, M.D.

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Prevent Second Heart Attack With the Mediterranean Diet

Heart attacks and chest pains are linked to blocked arteries in the heart

Most patients with a heart attack have underlying atherosclerosis (“hardening of the arteries”) in the heart, called coronary artery disease. Around the time of a heart attack (if not before), doctors and patients should focus on mitigating risk factors for future heart attacks and other cardiac events. This is called “secondary prevention.” Risk factor modification might include smoking cessation, regular exercise, stress reduction, and diet modification. For years, I’ve been recommending the Mediterranean diet. Many others recommend a low-fat diet instead. A recent study supports my diet recommendation.

One way to assess risk of progressive atherosclerosis is to measure the thickness of the the carotid artery wall by ultrasound. Increasing thickness of the artery wall is linked to higher risk of atherosclerotic complications like heart attack and stroke. To drill down deeper, it’s the thickness of the innermost two layers of the artery wall, called the intima-media, that matters. The study at hand showed a reduction in carotid artery intima-media thickness over five years on a Mediterranean diet compared to a low-fat diet. Here’s the abstract:

Background and Purpose:

Lifestyle and diet affect cardiovascular risk, although there is currently no consensus about the best dietary model for the secondary prevention of cardiovascular disease. The CORDIOPREV study (Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention) is an ongoing prospective, randomized, single-blind, controlled trial in 1002 coronary heart disease patients, whose primary objective is to compare the effect of 2 healthy dietary patterns (low-fat rich in complex carbohydrates versus Mediterranean diet rich in extra virgin olive oil) on the incidence of cardiovascular events. Here, we report the results of one secondary outcome of the CORDIOPREV study. Thus, to evaluate the efficacy of these diets in reducing cardiovascular disease risk. Intima-media thickness of both common carotid arteries (IMT-CC) was ultrasonically assessed bilaterally. IMT-CC is a validated surrogate for the status and future cardiovascular disease risk.

Methods:

From the total participants, 939 completed IMT-CC evaluation at baseline and were randomized to follow a Mediterranean diet (35% fat, 22% monounsaturated fatty acids, <50% carbohydrates) or a low-fat diet (28% fat, 12% monounsaturated fatty acids, >55% carbohydrates) with IMT-CC measurements at 5 and 7 years. We also analyzed the carotid plaque number and height.

Results:

The Mediterranean diet decreased IMT-CC at 5 years (−0.027±0.008 mm; P<0.001), maintained at 7 years (−0.031±0.008 mm; P<0.001), compared to baseline. The low-fat diet did not modify IMT-CC. IMT-CC and carotid plaquemax height were higher decreased after the Mediterranean diet, compared to the low-fat diet, throughout follow-up. Baseline IMT-CC had the strongest association with the changes in IMT-CC after the dietary intervention.

Conclusions:

Long-term consumption of a Mediterranean diet rich in extra virgin olive oil, if compared to a low-fat diet, was associated with decreased atherosclerosis progression, as shown by reduced IMT-CC and carotid plaque height. These findings reinforce the clinical benefits of the Mediterranean diet in the context of secondary cardiovascular prevention.

Reference

Parker here again. Undoubtedly, it would be more helpful if the investigators reported the actual rates of heart attack, stroke, and death in the two diet groups over five years. I suspect that will be in a future report.

An article in Clinical Cardiology states the serious nature of coronary artery disease (CAD) in those with diabetes (DM): “CAD is the main cause of death in both type 1 and type 2 DM, and DM is associated with a 2 to 4-fold increased mortality risk from heart disease. Over 70% of people >65 years of age with DM will die from some form of heart disease or stroke. Furthermore, in patients with DM there is an increased mortality after MI [myocardial infarction], and worse overall long-term prognosis with CAD.”

Steve Parker, M.D.

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Filed under coronary heart disease, Health Benefits, Heart Disease, Mediterranean Diet

Should You Reduce Your Aspirin Dose from 325 to 81 mg/day?

Photo by Anna Shvets on Pexels.com

For patients with established cardiovascular disease, a recent study found that aspirin 81 mg/day was just as effective as 325 mg/day in preventing combined risk of death and hospitalization for heart attack or stroke. Rates of major bleeding were the same regardless of dose.

Click for details at NEJM.

Don’t make changes in your medication regimen without consulting your personal physician.

Steve Parker, M.D.

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High Glycemic Index Eating Linked to Higher Risk of Cardiovascular Disease and Death

Haven’t we known this for years? Click for definition and discussion of glycemic index and glycemic load.

“One little piece won’t hurt . . .”

From New England Journal of Medicine:

Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population.

METHODS

This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used country-specific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause.

RESULTS

In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease.

CONCLUSIONS

In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death.

Source: Glycemic Index, Glycemic Load, and Cardiovascular Disease and Mortality | NEJM

The low-carb Mediterranean diet is low glycemic index.

Steve Parker, M.D.

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Olive Oil Linked to Reduced Cardiovascular Disease Risk

Steve Parker MD, low-carb diet, diabetic diet

Olives, olive oil, and vinegar: classic Mediterranean foods

A new analysis of the Nurses Health Study confirms the headline above. Olive oil, of course, is a primary component of the healthy Mediterranean diet. From the American College of Cardiology:

Higher olive oil intake was associated with a lower risk of CHD [coronary heart disease] and total CVD [cardiovascular disease] in two large prospective cohorts of US men and women. The substitution of margarine, butter, mayonnaise, and dairy fat with olive oil could lead to lower risk of CHD.

***

This study of well-educated health professionals is the first in the United States to show the relative value of higher intake of olive oil for preventing CHD and CVD. It was conducted in the era that margarine was primarily trans fatty acids and would not apply to the present soft and liquid margarines. The benefit attributed to olive oil is not simply the substitution for saturated fatty acid. The modest benefit of olive oil in the United States occurred at relatively low olive oil intake (average 12 g/day). In contrast, the Mediterranean diet generally has over 25 g/day. In European studies, a healthy cohort had a 7% reduction in CHD risk for each 10 g/d increase in olive oil; extra virgin olive oil reduced cerebrovascular events by 31% in a high-risk group, and regular olive oil was associated with a 44% lower risk of CHD after about 7.8 years in Italian women survivors of an MI. Amongst the benefits of olive oil include positive effects on inflammation, endothelial function, hypertension, insulin sensitivity, and diabetes.

Source: Olive Oil Consumption and Cardiovascular Risk – American College of Cardiology

Steve Parker, M.D.

low-carb mediterranean diet

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Think Twice Before Heart Artery Stenting or Bypass

Heart attacks and chest pains are linked to blocked arteries in the heart

Doctors are often criticised for over-using coronary artery angioplasty/stenting and coronary artery bypass grafting.

From Stanford Medicine:

Patients with severe but stable heart disease who are treated with medications and lifestyle advice alone are no more at risk of a heart attack or death than those who undergo invasive surgical procedures, according to a large, federally-funded clinical trial led by researchers at the Stanford School of Medicine and New York University’s medical school.

The trial did show, however, that among patients with coronary artery disease who also had symptoms of angina — chest pain caused by restricted blood flow to the heart — treatment with invasive procedures, such as stents or bypass surgery, was more effective at relieving symptoms and improving quality of life. “For patients with severe but stable heart disease who don’t want to undergo these invasive procedures, these results are very reassuring,” said David Maron, MD, clinical professor of medicine and director of preventive cardiology at the Stanford School of Medicine, and co-chair of the trial, called ISCHEMIA, for International Study of Comparative Health Effectiveness with Medical and Invasive Approaches.

***

“Based on our results, we recommend that all patients take medications proven to reduce risk of heart attack, be physically active, eat a healthy diet and quit smoking,” Maron said. “Patients without angina will not see an improvement, but those with angina of any severity will tend to have a greater, lasting improvement in quality of life if they have an invasive heart procedure. They should talk with their physicians to decide whether to undergo revascularization.”

Source: Stents, bypass surgery show no benefit in heart disease mortality rates among stable patients | News Center | Stanford Medicine

Steve Parker, M.D.

PS: The Mediterranean diet is a healthy diet, reduces the risk of heart disease, and you can even lose weight with it!

low-carb mediterranean diet

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Takine BP Meds at Bedtime Prevents Cardiovascular Events

High blood pressure is linked to heart attacks

Very recently I have noticed hypertension patients taking their medications at bedtime. Now I know why.

From Medscape:

Taking antihypertensive medication at bedtime led to an almost halving of cardiovascular events in a new study.

The Hygia Chronotherapy Trial is the largest ever study to investigate the effect of the time of day when people take their antihypertensive medication on the risk of cardiovascular events.

The trial randomly assigned 19,084 patients to take their medication on waking or at bedtime and followed them for an average of 6 years.Results showed that patients who took their pills at bedtime had a 45% reduction in overall cardiovascular events. This included a 56% reduction in cardiovascular death, a 34% reduction in myocardial infarction (MI), a 40% reduction in coronary revascularization [bypass surgery and angioplasty/stenting], a 42% reduction in heart failure, and a 49% reduction in stroke, all of which were statistically significant.

***

“We showed that if blood pressure is elevated during sleep then patients have increased cardiovascular risk regardless of daytime pressure, and if blood pressure during sleep is normal then cardiovascular risk is low even if the [doctor’s] office pressure is elevated,” Hermida said.

***

Results showed that during the 6.3-year median patient follow-up, 1752 participants experienced the primary cardiovascular disease (CVD) outcome (a composite of CVD death, MI, coronary revascularization, heart failure, or stroke).

Drug classes at physicians’ disposal were ARBs (angiotensin receptor blockers), calcium channel blockers, ACE inhibitors, and diuretics. Preventative effects were most pronounced for ARBs and ACE inhibitors.

Don’t change your BP medication dosing until you check with your personal physician.

Source: Bedtime Dosing of Hypertension Meds Reduces CV Events

Did you know most heart attacks occur in the morning, and those tend to be the most serious?

Steve Parker, M.D.

PS: Exercise and loss of excess weight help control blood pressure and prevent cardiovascular disease. I can help you with those…

low-carb mediterranean diet

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Do Certain Diabetes Drugs Protect the Heart and Kidneys?

 

Blood pressure control is also extremely important for protection of heart and kidneys

I’ve been reticent to tout the putative heart-protective effects of diabetes drugs in the classes called SGLT2 inhibitors and GLP-1 receptor agonists. Frankly, their supposed kidney-protective effects haven’t even been on my radar. My hesitation to report on these matters stems from:

Maybe if Big Pharma sent me a nice check….

The GLP-1 receptor agonists seem to have beneficial effects on both heart and kidney. With SGLT2 inhibitors, renal benefits may be more prominent than cardiac. Also note that any beneficial heart or renal effects may be attributable only to certain drug within the class, and not a class effect.

For what it’s worth, the American Diabetes Association recently hosted a conference on these issues. I assume the ADA endorses the report written by three experts, two of whom have received some sort of compensation from pharmaceutical companies. This doesn’t necessarily mean they are biased. Some excerpts:

Since patients with diabetes are at increased risk for CV [cardiovascular] and renal events, reducing the risk of these events is of primary interest to improve outcomes in the long-term. [Cardiovascular events usually refers to heart attacks, strokes, and death from those. Renal events would be high loss of protein through the kidneys, impaired kidney function or chronic kidney disease, or the need for dialysis.]

SGLT2 inhibitors and GLP-1 RAs have dramatically changed the treatment landscape of type 2 diabetes due to their established CV benefits, and the observed improvements in renal function seen with these classes of agents are currently undergoing intense investigation.

***

It is now apparent that both SGLT2 inhibitors and GLP-1 RAs show consistent reductions in major adverse cardiovascular events for patients with established cardiovascular (CV) disease, and both appear to have renal benefits as well.

***

The nephron is the microscopic structural and functional unit of the kidney.

Renal effects of GLP-1 receptor agonists

These drugs may exert their beneficial actions on the kidneys through their effects on lowering blood glucose and blood pressure and by reducing the levels of insulin.

For GLP-1RAs, these [studies] include ELIXA with lixisenatide, LEADER with liraglutide, SUSTAIN-6 with semaglutide, EXCSEL with exenatide once-weekly, HARMONY with albiglutide, and REWIND with dulaglutide.

All these studies indicate that albuminuria [protein loss through urine] is reduced during treatment with GLP-1 RAs, and eGFR [estimated glomerular filtration rate, a measure of kidney function] appears to be stabilized.

These benefits are seen independently of HbA1c, weight, and blood pressure variations.

***

Heart attack is only one type of cardiovascular event

Cardiovascular effects of GLP-1 receptor agonists

Large CV outcomes trials with GLP-1 RAs have shown that these agents can reduce the risk of major adverse CV events, CV mortality, and all-cause mortality.

These CV benefits appear to be related to four distinct mechanisms:

    • Improve myocardial [heart muscle] performance in ischemic heart failure [caused by poor blood flow to heart]
    • Improve myocardial survival in ischemic heart disease
    • Ameliorate endothelial dysfunction [endothelium is the lining of arteries]
    • Decrease markers of CV risk.

***

Renal effects of SGLT2 inhibitors

  • However, many potential mechanisms have been linked to the renoprotective effects of SGLT2 inhibitors.
  • These include reduction of blood pressure, improved metabolic parameters, reduced volume overload, reduction in albuminuria, and glomerular pressure.
  • For the latter, SGLT2 inhibition appears to reduce hyperfiltration via a tubuloglomerular feedback mechanism.
  • Clinical data from CV outcomes trials have shown consistent variations in eGFR and reduction in death from renal causes with empagliflozin, canagliflozin, and dapagliflozin.
  • However, to gain more information about the renal effects of these agents, dedicated renal outcomes trials are needed to study reductions in albuminuria, changes in eGFR, number of patients reaching end-stage renal disease, need for dialysis, and deaths due to kidney failure.

***

Key Messages from the authors

Large CV outcomes trials have shown that both SGLT2 inhibitors and GLP-1 RAs are associated with significant reductions in CV events in patients with elevated CV risk.

From CV outcomes trials both classes of agents also appear to have renal benefits, although large dedicated studies are needed to establish the magnitude of this potential benefit

The mechanism of action at the basis of CV and renal benefits of SGLT2 inhibitors and GLP-1 RAs is complex, multifactorial, and still not completely understood.

 

I’m still skeptical but will keep an open mind.

Steve Parker, M.D.

PS: Bold emphasis above is mine.

low-carb mediterranean diet

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Does Diet Quality Affect Cardiovascular Disease Risk in Post-Menopausal Diabetic Women?

I’m increasingly skeptical of studies like this: observational, relatively low numbers of participants, and dubious premises. regarding premises, the article at hand mentions the American Diabetes Association diet. But there is no ADA diet. You won’t hurt my feelings if you jump straight to the “conclusions” section.

Abstract

Background

Dietary patterns are associated with cardiovascular disease (CVD) risk in the general population, but diet-CVD association in populations with diabetes mellitus is limited. Our objective was to examine the association between diet quality and CVD risk in a population with type 2 diabetes mellitus.

Methods and Results

We analyzed prospective data from 5809 women with prevalent type 2 diabetes mellitus at baseline from the Women’s Health Initiative. Diet quality was defined using alternate Mediterranean, Dietary Approach to Stop Hypertension, Paleolithic, and American Diabetes Association dietary pattern scores calculated from a validated food frequency questionnaire. Multivariable Cox’s proportional hazard regression was used to analyze the risk of incident CVD. During mean 12.4 years of follow-up, 1454 (25%) incident CVD cases were documented. Women with higher alternate Mediterranean, Dietary Approach to Stop Hypertension, and American Diabetes Association dietary pattern scores had a lower risk of CVD compared with women with lower scores (Q5 v Q1) (hazard ratio [HR]aMed 0.77, 95% CI 0.65-0.93; HRDASH 0.69, 95% CI 0.58-0.83; HRADA 0.71, 95% CI 0.59-0.86). No association was observed between the Paleolithic score and CVD risk.

Conclusions

Dietary patterns that emphasize higher intake of fruits, vegetables, whole grains, nuts/seeds, legumes, a high unsaturated:saturated fat ratio, and lower intake of red and processed meats, added sugars, and sodium are associated with lower CVD [cardiovascular disease] risk in postmenopausal women with type 2 diabetes mellitus.

Source: Diet Quality and Cardiovascular Disease Risk in Postmenopausal Women With Type 2 Diabetes Mellitus: The Women’s Health Initiative. – PubMed – NCBI

Steve Parker, M.D.

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

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LCHF Diet Improves Metabolic Syndrome Even Without Weight Loss

Use the search box to find the recipe for this LCHF avocado chicken soup

“Metabolic syndrome” may be a new term for you. It’s a collection of clinical features that are associated with increased future risk of type 2 diabetes and atherosclerotic complications such as heart attack and stroke. One in six Americans has metabolic syndrome. Diagnosis requires at least three of the following five conditions:

  • high blood pressure (130/85 or higher, or using a high blood pressure medication)
  • low HDL cholesterol:  under 40 mg/dl (1.03 mmol/l) in a man, under 50 mg/dl (1.28 mmol/l) in a women (or either sex taking a cholesterol-lowering drug)
  • triglycerides over 150 mg/dl (1.70 mmol/l) (or taking a cholesterol-lowering drug)
  • abdominal fat:  waist circumference 40 inches (102 cm) or greater in a man, 35 inches (89 cm) or greater in a woman
  • fasting blood glucose over 100 mg/dl (5.55 mmol/l)

One approach to improving the numbers is a low-carb, high-fat (LCHF) diet. Here’s a journal article abstract from JCI Insight:

BACKGROUND. Metabolic syndrome (MetS) is highly correlated with obesity and cardiovascular risk, but the importance of dietary carbohydrate independent of weight loss in MetS treatment remains controversial. Here, we test the theory that dietary carbohydrate intolerance (i.e., the inability to process carbohydrate in a healthy manner) rather than obesity per se is a fundamental feature of MetS.

METHODS. Individuals who were obese with a diagnosis of MetS were fed three 4-week weight-maintenance diets that were low, moderate, and high in carbohydrate. Protein was constant and fat was exchanged isocalorically for carbohydrate across all diets.

RESULTS. Despite maintaining body mass, low-carbohydrate (LC) intake enhanced fat oxidation and was more effective in reversing MetS, especially high triglycerides, low HDL-C, and the small LDL subclass phenotype. Carbohydrate restriction also improved abnormal fatty acid composition, an emerging MetS feature. Despite containing 2.5 times more saturated fat than the high-carbohydrate diet, an LC diet decreased plasma total saturated fat and palmitoleate and increased arachidonate.

CONCLUSION. Consistent with the perspective that MetS is a pathologic state that manifests as dietary carbohydrate intolerance, these results show that compared with eucaloric high-carbohydrate intake, LC/high-fat diets benefit MetS independent of whole-body or fat mass.

TRIAL REGISTRATION. ClinicalTrials.gov Identifier: NCT02918422.

FUNDING. Dairy Management Inc. and the Dutch Dairy Association.

Source: JCI Insight – Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss

Steve Parker, M.D.

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