Heart Attacks in Women

From Heartwire

Young Women With MI Most Likely to Have No Chest Pain

Sue Hughes

Authors and Disclosures

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February 21, 2012 (Lakeland, Florida) — Women under 55 having an MI are more likely to present without chest pain than older women or men, and they also have the highest risk of death from MI of any group, new data from the US National Registry of Myocardial Infarction (NRMI) suggest [1].

Lead author Dr John Canto (Lakeland Regional Medical Center, FL) commented: "While chest pain is still the hallmark symptom of MI in women, more women than men present without chest pain, and this is particularly applicable to younger women. We need to be more aware that younger women with atypical symptoms could be having a MI."

Canto's study, published in the February 22/29, 2012 issue of the Journal of the American Medical Association, used the NRMI database to examine the factors associated with MI without chest pain and the relationship between age, sex, and hospital mortality.

Canto told heartwire : "While it has been widely reported that women often have a different MI presentation from that of men, we also know that women are an average of 10 to 15 years older than men when they have an MI. Many papers that have examined the gender differences in MI presentation have failed to adequately account for this age difference. We had an opportunity to look at this more thoroughly in the NRMI database, which includes around one million MI patients."

They found that women are more likely to present without chest pain than men (42% vs 30%), but that this difference is more pronounced in younger women (under 55). The difference in symptoms at presentation between men and women declined with age, and in the older patients (over 75) there was little difference between the genders.

Adjusted Odds Ratios for Lack of Chest Pain for Women vs Men

Age	OR
<45	1.30
45–54	1.26
55–64	1.24
65–74	1.13
>75	1.03

The second major finding of the study was that younger women having an MI have a higher mortality rate. "Younger women are not supposed to have an MI, but when do, they are at higher risk of death than the rest of the population," Canto commented.

In the registry, the in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age.

Adjusted Odds Ratio for Death After an MI in Women Without Chest Pain vs Men Without Chest Pain

Age	OR
<45	1.18
45–54	1.13
55–64	1.02
65–74	0.91
>75	0.81

The researchers also found that young women without chest pain were up to two to three times more likely to die than similarly aged men with classic presentation.

They write: "Women in whom coronary atherosclerosis develops before age 75 years may be predisposed to a particularly aggressive disease or may have more risk factors for coronary heart disease, which might override the protective effect of estrogen." They add that young women who die after an MI are often smokers with plaque erosions and relatively little coronary narrowing, whereas older women who die tend to have a pathology more similar to men, with high cholesterol levels and subsequent plaque rupture and relatively severe coronary narrowing.

Canto also suggested that the higher likelihood of atypical symptoms in younger women could contribute toward their high death rate. "If a young women presents without chest pain, it is easy not to realize that she is having an MI. Triage staff are less likely to think about MI in a younger woman, especially one without chest pain, so there is a higher probability of not receiving timely treatment. This could easily explain some of the increased mortality in this group."

He added: "Our results challenge the wisdom that one size fits all in terms of men and women and presenting MI symptoms. I would argue that we need to tailor the MI message and that young women are particularly at risk for an atypical presentation." Canto noted that the atypical symptoms of MI include pain in the jaw, neck, shoulder, arm, back, or stomach and unexplained shortness of breath.

References

Vit D & Allergic Rhinitis

From Current Opinion in Allergy and Clinical Immunology

Vitamin D and Chronic Rhinitis

Waleed M. Abuzeid; Nadeem A. Akbar; Mark A. Zacharek

Posted: 02/05/2012; Curr Opin Allergy Clin Immunol. 2012;12(1):13-17. © 2012 Lippincott Williams & Wilkins

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• Abstract and Introduction
• Chronic Rhinitis and Chronic Rhinosinusitis Pathophysiology
• Vitamin D and Immunomodulation
• Vitamin D and Cathelicidin
• Vitamin D and Chronic Rhinosinusitis
• Conclusion

• References
• Sidebar

Abstract and Introduction

Abstract

Purpose of review To discuss the role of vitamin D in chronic rhinitis and chronic rhinosinusitis (CRS).
Recent findings Vitamin D has been shown to have an immunomodulatory effect with a significant impact on immune function. Specifically, vitamin D regulates the mechanisms which suppress the inflammatory response and direct the differentiation fate of immune cells. Vitamin D has been shown to play an important role in asthma, and the concept of the unified airway model allows the extrapolation of vitamin D as a critical player in chronic rhinitis and rhinosinusitis.
Summary Recent findings on the function of vitamin D may explain aspects of the pathophysiology of chronic rhinitis and CRS, and may help direct future treatment of these diseases.

Introduction

The importance of vitamin D as an essential nutrient is well known, given its role in calcium and phosphate homeostasis. Over the past two decades, the influence of vitamin D on the immune system has become increasingly clear.^[1] Recent work has elucidated that vitamin D harbors actions more akin to hormones and pro-hormones. The discovery of the vitamin D receptor (VDR) has stimulated more research into the nature of this vitamin which has, subsequently, been shown to be a steroid hormone. This steroid constitutes a component of a complex endocrine pathway termed the 'Vitamin D endocrine system'.^[2] Investigators have found that vitamin D plays an integral role in the induction of cell differentiation, inhibition of cell growth, immunomodulation, and regulation of other hormonal systems.^[3] This review seeks to highlight the recent research with respect to vitamin D and its role in chronic rhinitis and chronic rhinosinusitis (CRS).

Smokers at risk for Psoriasis

From Reuters Health Information

Smoking Tied to Higher Psoriasis Risk

By Amy Norton

NEW YORK (Reuters Health) Feb 03 2012 - A large study suggests that smokers have an increased risk of developing psoriasis.

People who were current smokers at the study's start were almost twice as likely as lifelong non-smokers to develop psoriasis. And past smokers had a 39% higher risk than non-smokers, the researchers reported January 12 in the American Journal of Epidemiology.

It is clear that the smoking came before the psoriasis, said senior researcher Dr. Abrar A. Qureshi, of Harvard Medical School and Brigham and Women's Hospital in Boston.

Past studies have found links between psoriasis and both obesity and heavy drinking. But after accounting for those factors, the smoking-psoriasis link remained, Dr. Qureshi told Reuters Health.

"I think if there's one message, it's that for now, smoking seems to be a risk factor for new-onset psoriasis," Dr. Qureshi said.

Other studies have pointed to some reasons that smoking could contribute to psoriasis -- mainly its effects on immune system activity and inflammation. Smokers, for instance, tend to have higher levels of autoantibodies.

Using data from three large, long-running studies of U.S. health professionals - including nearly 186,000 men and women followed for 12 to 20 years - researchers found that 2,410 developed psoriasis. And the risk was greater among both current smokers and former smokers.

As for smokers who already have psoriasis, the current findings don't speak directly to whether quitting will help their skin disease, according to Dr. Qureshi.

SOURCE: http://bit.ly/yUGYiX

Am J Epidemiol 2012.

Antinuclear Antibodies

From Reuters Health Information

Antinuclear Antibodies Common in the US

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By David Douglas

NEW YORK (Reuters Health) Feb 07 - Roughly one in seven U.S. adults has antinuclear antibodies (ANA), researchers report.

"These findings emphasize how common ANA positive tests are in the general population and who is most likely to have them," senior author Dr. Frederick W. Miller told Reuters Health by email.

Dr. Miller, of the National Institutes of Health in Bethesda, Maryland and colleagues note that ANA prevalence estimates have ranged from as little as 1.1% to as high as 20%. They note that estimates often come from selected populations, or are developed using different methods. Some reports suggest a higher prevalence in women and the elderly, but firm data are lacking.

For a study published online January 5th in Arthritis & Rheumatism, the researchers analyzed serum samples from 4,754 participants in the US National Health and Nutrition Examination Survey (NHANES) from 1999-2004.

The overall ANA prevalence in adolescents and adults together (everyone at least 12 years old) was 13.8%. The prevalence was significantly higher in women than men (17.8% vs 9.6%); the disparity peaked in the fifth decade.

The adjusted prevalence odds ratio was slightly greater in blacks than whites (1.30). It was lower in people who were overweight or obese compared to those of normal weight (0.74). Broadly, the prevalence increased with age.

Although some individuals had more than one ANA staining pattern, the most common patterns were nuclear (84.6%). Cytoplasmic patterns were seen in 21.8% and nucleolar patterns in 6.1%.

The most common specific autoantibodies were anti-Ro autoantibodies (3.9%), followed by anti-Su autoantibodies (2.4%).

These findings show "a high prevalence of ANA in the U.S., especially in females and older individuals," the authors say. They estimate that 32 million people are affected, and they say the number is likely to increase.

Dr. Miller stressed, however, that "there are many possible causes for a positive ANA, and these causes should be considered when ordering and interpreting ANA tests in individual patients."

SOURCE: http://bit.ly/yXXc8J

Arthritis Rheum 2012.

Fluoride in Drinking water

From Medscape Pediatrics

Fluoride Supplementation: The Ongoing Debate

Diane L. Markowitz, DMD, PhD

 

• Fluoride: Striking a Balance
• Supplemental Fluoride: Benefits and Harms
• Fluorosis
• How Much Fluoride Does This Child Need?
• Conclusion

• References

Fluoride: Striking a Balance

Along with vaccination, control of infectious diseases, and motor vehicle safety, adding fluoride to US drinking water is considered one of the greatest public health achievements of the 20th century.^[1] Fluoride was first added to water in 1945, a measure that was followed by a dramatic 50%-70% decline in the incidence of decayed, missing, or filled teeth (DMFT) in the United States.^[2]Fluoridation was considered a safe and inexpensive way to prevent tooth decay, regardless of socioeconomic status or access to dental care.

The success of supplemental fluoride in reducing tooth decay and loss led to a search for additional modalities for delivery of fluoride, such as toothpastes, gels, mouth rinses, tablets, drops, and professionally applied fluoride treatments.^[2] More than 65 years after fluoride was first added to community water supplies, the outcome of the "more is better" approach is an inability to accurately quantify the population's exposure to fluoride. Is it enough? Is it too much?

One year ago, after extensive review of the available evidence, the US Department of Health and Human Services (HHS) and the US Environmental Protection Agency (EPA) recommended that the maximum level of fluoride in drinking water be lowered to 0.7 mg/L (currently the minimum of the optimal range, 0.7-1.2 mg/L).^[3]This step was taken to balance the benefits of supporting dental health in all children by preventing dental caries while limiting the risk for inducing fluorosis because of the unknown, and possibly excessive, exposure to fluoride from multiple combined sources.^[4] Still, the practice of adding any fluoride at all to municipal water supplies has vocal opponents.

What Is Fluoride?

Fluoride is the reduced form of fluorine. It can occur as fluoroacetate, which is a fluorinated calcium phosphate that is common in silicates found in bedrock. Depending on the bedrock's mineral content and climate factors, rainwater filtration through these geologic formations can result in unsafe levels of naturally occurring fluoride in aquifers used for municipal drinking supplies.^[5] Naturally occurring fluoride in ground water is not found in significant amounts in the overwhelming majority (96%) of US communities.^[6]

Fluoride is incorporated into the mineral portion of tooth enamel, hydroxyapatite, as it develops. Hydroxyapatite becomes fluorapatite, which is more resistant to demineralization caused by bacterial acidification in oral plaque. Dietary fluoride incorporated in plaque has an antibacterial effect, slowing the growth of Streptococcus mutans, the primary cause of dental caries.^[7]

Statins and Muscle pain

Reuters Health Information CME

Benefits of Statins Outweigh Musculoskeletal Effects, Say ExpertsCME

Clinical Context

Statins are usually well tolerated, but the most common adverse effects are musculoskeletal, including muscle aches and pain, weakness, cramps, or increases in creatine kinase levels. In the general population, little is known about the prevalence of musculoskeletal pain and statin use.

Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2002 had suggested an association between statin use and musculoskeletal pain among individuals without arthritis, but the relatively small sample size precluded determination of whether statins increased musculoskeletal pain in those with arthritis.

The objective of this study by Buettner and colleagues was to evaluate the association between statin use and musculoskeletal pain in the general population, including those with and without arthritis, using 6 years of NHANES data.

Study Synopsis and Perspective

In a cohort of people without arthritis, musculoskeletal pain, most often in the legs and lower back, was reported 33% more often by those using statins.

"Although the majority of people who use statins do not experience statin-associated musculoskeletal side effects, about 6% (or one out of every 17 people) without arthritis have pain associated with statin use," Dr. Catherine Buettner, who led the study, told Reuters Health.

In people who do have arthritis, statins didn't seem to add to the pain burden — although the pain of arthritis could mask statin-associated pain, she and her colleagues say.

Dr. Buettner, from Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, added, "Our study did not allow us to discern why those with arthritis do not report higher pain when using statins. Statins are known to have some anti-inflammatory effects so, theoretically, it is possible statins may decrease arthritis pain by decreasing inflammatory processes."

"On the other hand," she said, "most arthritis is due to osteoarthritis (rather than inflammatory arthritis), so we need to consider other reasons; it could simply be that pain from arthritis is more severe and masks mild-moderate pain related to statin use; it may be that patients with arthritis are more reluctant to start a statin, or discontinue them more frequently, due to concerns that using a statin is adding to their pain; or it may be that doctors are less likely to prescribe a statin to patients with painful musculoskeletal conditions, such as arthritis."

Statin drugs are one of the most widely prescribed classes of medications. In 2003-2004, an estimated 24 million adults in the United States received a prescription for one. Although generally well tolerated, musculoskeletal side effects, including muscle aches, pain, weakness, cramps or creatine kinase elevations are the most common adverse effects of statins.

Asked for his thoughts on the new findings, Dr. Harlan Krumholz of Yale School of Medicine in New Haven, Connecticut, who was not involved in the study, said: "It's an observational study and has some limitations. Nevertheless, we know that statins can cause some muscular discomfort — and this article is consistent with that knowledge."

"The bottom line," he told Reuters Health, is that the "33% relative increase in risk translates to a few additional patients feeling discomfort for every 100 treated. This study should not deter patients from taking their medication — or shake their faith in the powerful risk reduction effect of statins — but people with these complaints should talk with their doctors."

Using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004, Dr. Buettner and colleagues estimated the prevalence of self- reported musculoskeletal pain according to statin use.

The analysis, reported in the February issue of the American Journal of Medicine, included 8,228 adults (representing 113 million US adults) aged 40 and older; 1,306 of them (representing 17 million US adults) reported using a statin in the past month.

Statin use increased significantly over the study period, with prevalence of use in the last 30 days estimated at 13% in 1999-2000, 15% in 2001-2002, and 18% in 2003-2004.

Musculoskeletal pain was assessed by asking participants: During the past month, have you had a problem with pain that lasted more than 24 hours? Those who answered "yes" were asked where the pain was.

In the overall sample, the unadjusted prevalence of musculoskeletal pain was significantly higher among statin users reporting pain in any area than nonusers (30% vs 26%; p=0.007); in the lower extremities (18% vs 14%; p=0.008); and in the lower back (14% vs 11%; p=0.02).

After controlling for confounding factors, among the 5,170 subjects without arthritis (about 63% of the complete cohort), statin use was associated with a significantly higher prevalence of musculoskeletal pain in any region, the lower back and the lower extremities. The adjusted prevalence ratios were 1.33, 1.47 and 1.59, respectively.

Conversely, there was no association between musculoskeletal pain and statin use among the 3,058 adults with arthritis.

"Being aware that statins may cause musculoskeletal pain is important and should be considered when new symptoms start in a patient who has recently started a statin, had an increase in statin dose, or started a medication that interacts with a statin," Dr. Buettner said.

"However, it is also important to recognize that the background prevalence of musculoskeletal pain is high among adults (more than 20% in non-statin users in this study). Therefore the majority of people using statins who have muscle symptoms are more likely to have symptoms due to another cause rather than due to use of a statin," she commented.

Dr. Krumholz agrees. "Many people have musculoskeletal pain, and for those on a statin the pain could be unrelated." However, the use of statins "is associated with an increased risk of muscle discomfort and that adverse side effect can be evaluated by discontinuing the statin and seeing if it goes away."

It should also be recognized, he said, that the musculoskeletal side effect "is not consistent across statins and people should try another one if they do have this side effect, in collaboration with their doctor."

The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Am J Med. 2012;125:176-182.

Fitness and Fat effect on Cardiovascular health

From Heartwire

Fitness and Fatness Independently Linked With CVD Risk Factors

Michael O'Riordan

Authors and Disclosures

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February 6, 2012 (Columbia, South Carolina) — Maintaining or improving current fitness levels, as well as not packing on the fat pounds, are both independently associated with a lower risk of developing hypertension, metabolic syndrome, and hypercholesterolemia in healthy adults, research shows [1].

"We know that people who exercise will lose weight and improve their fitness, but in the real world, some people don't lose weight even though they might gain some fitness," Dr Duck-chul Lee (University of South Carolina, Columbia) toldheartwire . "Some of these people might stop exercising because they expected to lose weight and haven't, but this study shows that they should also be aware about their changes in fitness. Even though they don't lose weight, if they increase their fitness, they can offset some of the negative effects of being overweight."

The results of the study, an analysis of the Aerobics Center Longitudinal Study (ACLS), a prospective study of individuals who received preventive medical examinations, are published online February 6, 2012 in theJournal of the American College of Cardiology.

Fitness and Fatness Both Important

To heartwire , Lee noted that fitness and fatness are two variables that consistently change over time in individuals and that there are many diverse combinations of fitness and fatness in US adults. In fact, the "fit-fat" paradox has been demonstrated in some studies, showing that improvements in fitness can eliminate the harmful effects of fatness and suggesting that fit but fat individuals might not develop health problems.

In the ACLS analysis, 3148 healthy subjects underwent three medical examinations, with fitness levels assessed using maximal treadmill testing and fatness documented with body-mass index (BMI) and skinfold measurements of percentage of body fat. During a six-year follow-up after the second medical examination, 752 subjects developed high blood pressure, 426 developed metabolic syndrome, and 597 developed hypercholesterolemia.

Individuals who maintained or improved their fitness levels had a 26% and 28% lower risk of developing hypertension, a 42% and 52% lower risk of developing metabolic syndrome, and a 26% and 30% lower risk of developing elevated levels of LDL cholesterol, respectively. These reductions were observed after adjustment for potential confounders and baseline fitness levels.

For those subjects who got fatter in follow-up, as measured by percentage of body fat, they had a 26%, 71%, and 48% higher risk of developing hypertension, metabolic syndrome, and hypercholesterolemia, respectively, when compared with individuals who lost weight. Similar results were observed when BMI was used as the criterion for fatness levels.

Every 1-MET improvement in fitness was associated with a 7%, 22%, and 12% lower risk of developing hypertension, metabolic syndrome, and hypercholesterolemia, respectively, while every unit increase in percentage of body fat was associated with a 4%, 10%, and 5% increased risk of developing the cardiovascular risk factors.

"In the real world, people change their fitness levels or fatness over time," said Lee. "Fitness and fatness, not the baseline levels, but the changes over time, are both independently important to reduce cardiovascular disease risk factors."

Attenuating the Adverse Effects of Weight Gain

In joint analyses, the researchers found that patients who had stable or increasing amounts of fatness in combination with loss of fitness had significantly higher rates of cardiovascular risk factors when compared with the reference group, that being individuals who gained fitness over time and lost fat. They did observe that losing fitness regardless of fat changes and getting fatter irrespective of the change in fitness levels were associated with a higher risk of developing metabolic syndrome. The adverse effects of getting fatter were attenuated slightly if fitness was maintained or improved, while declines in fitness could be offset by reductions in body-fat percentage.

"Maintaining or improving fitness levels and preventing fat gain are both important, independent of the changes of each other," said Lee. "Second, we found that the ideal combination is to improve fitness and prevent fat gain, but as long as individuals maintain fitness and fatness, they are not likely to be at higher risk of cardiovascular disease risk factors. Losing weight and gaining fitness is very challenging to the general population, but maintaining fitness and fatness are less so and more doable."

References