When Natalie Hollabaugh tested positive for Covid-19 in March 2020, her recovery felt extremely slow. Eighteen months later, she was still suffering from a litany of symptoms, including fatigue, shortness of breath, headaches and joint pain. She saw a cardiologist and a pulmonologist, who both ruled out other health problems, she said. And they advised her to start exercising, suggesting that some of her symptoms may have been a result of being out of shape. So Ms. Hollabaugh dutifully began using an exercise bike, speed walking on a treadmill and walking her dogs several miles a day.

Worldwide, heart disease and strokes are the leading causes of death. They’re also the leading killers of Americans, accounting for one out of every three deaths in the United States. But there’s good news, too. About 80 percent of all cases of cardiovascular disease are preventable. You can lower your risk markedly by making some changes to your lifestyle including doing some things that are easy, simple and even enjoyable. (Two of our favorites? Drink red wine and get a dog.) Here's what you need to know about heart health, along with some of the best ways to improve and protect yours.

Abstract

We share with you today the AVATAR trial.

Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated.

Methods: The Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trial is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm² with aortic jet velocity >4 m/s or a mean trans-aortic gradient ≥40 mm Hg), and with normal LV function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite endpoint of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure, as compared to a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries.

Results: Between June 2015 and September 2020, 157 patients (mean age 67 years, 57 % men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in conservative treatment group. In the early surgery group, 72 patients (92.3 %) underwent SAVR with operative mortality of 1.4 %. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite endpoint than those in the conservative arm (HR 0.46, 95 % CI 0.23-0.90, p=0.02). There was no statistical difference in secondary endpoints, including all-cause mortality, first heart failure hospitalizations, major bleeding or thromboembolic complications, but trends were consistent with the primary outcome.

Conclusions: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. 

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At CCC Mount Sinai, our team of skilled and seasoned cardiac professionals can evaluate, diagnose and recommend treatments as they pertain to this and other heart conditions.  Make an appointment today and know you have the best care. Call 201-499-7361 or go online to learn more.

Original article published 11/13/21 in American Heart Association Journal by authors: Marko Banovic, Svetozar Putnik, Martin Penicka, Gheorghe Doros, Marek A. Deja, Radka Kockova, Martin Kotrc, Sigita Glaveckaite, Hrvoje Gasparovic, Nikola Pavlovic, Lazar Velicki, Stefano Salizzoni, Wojtek Wokakowski, Guy Van Camp, Serge D. Nikolic, Bernard Iung and Jozef Bartunek on behalf of the AVATAR-trial investigators

A new study highlights an independent association between obstructive sleep apnea and coronary plaque presence and burden, suggesting it may be a risk factor for coronary events.

LDL, or “bad” cholesterol, is a major risk factor for coronary heart disease. Now a new study suggests that, like smoking, it has a cumulative effect over a lifetime: The longer a person has high LDL, the greater their risk of suffering a heart attack or cardiac arrest.

Coronary heart disease, also known as “hardening of the arteries,” is the leading cause of death in the United States. It is caused by a buildup of plaque in the arteries that narrows the vessels and blocks the flow of oxygenated blood to the heart. Often, people have no symptoms and remain unaware they have the disease for years until they develop chest pain or suffer a catastrophic event like a heart attack.

Using data from four large prospective health studies, researchers calculated LDL levels over time in 18,288 people who had multiple LDL tests taken at different ages. They calculated their cumulative exposure to LDL and followed their health for an average of 16 years. The study is in JAMA Cardiology.

The researchers found that the longer a person had high levels of LDL — no matter what their LDL level is in young adulthood or middle age — the greater the risk for coronary heart disease. Compared with those in the lowest quarter for cumulative exposure, those in the highest had a 57 percent increased risk.

They found no increased risk for stroke or heart failure associated with cumulative LDL exposure. The researchers suggest that many factors can contribute to heart failure, and their study had too few cases of stroke to achieve statistical significance.

The study controlled for race and ethnicity, sex, year of birth, body mass index, smoking, high-density lipoprotein (HDL, or “good” cholesterol), blood pressure, Type 2 diabetes and the use of lipid-lowering and blood pressure medicines.

In people under 40, current guidelines recommend treatment with cholesterol-lowering statin drugs only with LDL readings higher than 190, but the researchers found that the increased risk for coronary heart disease may start at a much lower level. (LDL levels below 100 are generally considered normal.)

“Our figures suggest that the risk starts at LDL levels as low as 100,” said the lead author, YiYi Zhang, an assistant professor of medical sciences at Columbia. “That doesn’t necessarily mean that a person under 40 with an LDL of 100 should immediately start treatment. We need more evidence to determine the optimal combination of age and LDL level.”

Dr. Tamara Horwich, a cardiologist and professor of medicine at the University of California, Los Angeles, who was not involved in the study, noted that medical guidelines on choosing who needs statin therapy are heavily weighted toward older people, since advancing age is a major risk factor for complications from heart disease.

Still, she said, “From autopsy studies, we have known for some time that atherosclerosis begins to develop in the arteries of young individuals, as early as the teens and 20s. I think this study may entice physicians to move the needle back on the age of starting, or at least thinking about starting, statin therapy.”

Young people have a low short-term risk, Dr. Zhang said, but a high long-term risk. “The main message is to try to maintain low LDL through middle age. That will reduce your heart disease risk.”

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This study showcases how important it is to get your cholesterol checked, even from a very young age.  We know this to be the case at CCC-Mount Sinai all too well.  Just ask Dr. Rick Pumill to discuss his son Christopher's journey.  He's been prescribing him Statin since age 19 and he still has high LDL, despite regular exercise and a very good diet.  Moreover, Christopher Pumill is a cardiologist too, so he knows all too well about the risks and benefits of a sustaining a good level of LDL. 

We asked Dr. Christopher Pumill to add his perspective to this article:

"In all truthfulness, if you are obese, your cholesterol will change dramatically with diet and weightloss. However, if your cholesterol is elevated at a young age, it is very likely genetic. And therefore modification of diet will have a much smaller impact. For patients who are younger with high cholesterol, we often need medications (as in my case) and consideration of genetic testing and consultation, as it can be hereditary." 

His dad, Dr. Rick Pumill adds:

"I truly believe, having a personal connection with patients improves compliance and I also believe that making them understand that there are times that their abnormal studies are not their fault, makes a difference as well."

At CCC-Mount Sinai, your health and family are important to us.  Call us today at 201-499-7361 or go to our website to schedule an appointment for a cholesterol check on you or your children.  We can evaluate the whole family and help to treat (if necessary).

Authored by Maria Hergueta and published 10/18/21 on the NYtimes.com.

Katherine Leon was 38 and living in Alexandria, Va., when she gave birth to her second son in 2003. She was discharged from the hospital, but instead of getting better, she recalls, she kept feeling “worse and worse and worse.”

Five weeks after she had her child, Ms. Leon’s husband came back early from work and found her barely able to breathe. “I hate to use the word panic, because so many people say if it’s a woman she is just having a panic attack, but I was terrified,” she said.

Her husband called 911, and she was taken to the emergency room where, after a few tests, the physicians told her there was nothing wrong with her. She went home but continued to have bouts of chest pain and kept laboring to breathe.

Things came to a head several days later, she said, when she developed “that impending doom feeling.” Reluctantly, she called 911 again. Things went differently in the emergency room this time.

“There was a young woman doctor who took care of me,” said Ms. Leon. “Her reaction was totally different. She knew that there was something definitely wrong.”

A few days later, she underwent an explorative cardiac catheterization procedure and received a devastating diagnosis: She had a critical blockage in the main artery supplying her heart. She would need emergency heart bypass surgery.

She remembers thinking at the time: “Are you kidding me? I have two babies and I was going to do the whole mom thing, with playgroups and a jog stroller, and take classes. I may have tried one cigarette in my life. I didn’t have cholesterol issues. I didn’t have blood pressure issues.”

She received what at the time was considered one of the rarest possible diagnoses: spontaneous coronary artery dissection, or SCAD. The condition occurs when one of the arteries supplying the heart with oxygen spontaneously tears open, leading to a heart attack that can sometimes be fatal. It occurs most often in women, and can be exacerbated by pregnancy.

But at the time, few doctors knew that SCAD even existed, or knew much about it. “You are never going to meet anyone else who has this,” Ms. Leon remembers one doctor telling her. Another told her, “You need to move on and enjoy your children.”

Her doctors also told her that the only thing she could do to avoid SCAD in the future was to never get pregnant again. But seeking to learn more about the disease that had almost taken her life, she went online and started to find other women with similar symptoms around the world.

In 2009, Ms. Leon went to the WomenHeart Science and Leadership Symposium at the Mayo Clinic, where she met Dr. Sharonne N. Hayes, a professor of cardiovascular medicine at Mayo. At that time, the largest study on SCAD included 43 patients. “I walked up to Dr. Hayes and told her we had 70 people, and we wanted research,” Ms. Leon recalled. “She was like, ‘Wow.’”

“Everything I learned about SCAD in my medical training was wrong,” Dr. Hayes said.

By 2010, with the help of Dr. Hayes, and subsequently SCAD Research Inc., an organization founded by Bob Alico, who lost his wife to SCAD, Dr. Hayes devised an innovative way to do research, using online networks of far-flung patients and analyzing genetic and clinical data. “We never imagined there would be 1,000 female patients in our virtual registry,” Dr. Hayes said.

That fortuitous meeting between Ms. Leon and Dr. Hayes has helped transform SCAD from being an unknown, unrecognized condition to something all physicians are taught about during medical school and in later training. SCAD is now recognized as the most common cause of heart attacks in women under 40.

Why did it take so long for physicians and researchers to recognize SCAD? The most important reason might have been that the condition predominantly affects women. “We listen less well to women,” said Dr. Hayes. “We are much more likely to associate their symptoms with psychological causes.” A heart attack is more likely to be fatal in a young woman than a young man, perhaps because women’s cardiac symptoms are more often misattributed to anxiety or depression than men’s.

The bias that many women feel they face in the clinic or the emergency room has led some, like Ms. Leon, to take action and advocate for themselves and others. “People are activated by injustice, by unanswered questions,” said Dr. Hayes

She offers this advice: “Don’t walk out of a doctor’s office without answers. Find a doctor who is committed to listening to you and does not think they know everything about anything.”

The story of SCAD underscores how much we doctors still don’t understand, including about heart disease in women. Too often those in the medical profession downplay women’s complaints, telling them nothing is wrong. Women are often expected to take care of others but too often neglect themselves. Indeed, women take much longer to seek medical care for a heart attack than men. As we embrace new technologies to peer ever deeper inside the human body to find answers, perhaps the better route might be simply to attend to the patient in front of us. Often what we need to do is listen.

At Cross County Cardiology - Mount Sinai, we are leading experts in cardiovascular care, with the best resources to help you or someone you love with your heart health.  So if you think you maybe suffering from SCAD, please give us a call at 201-499-7361.  Timing is so key!

Original article published on nytimes.com on Feb 1, 2019 by Haider Warraich, M.D.