Coronary Heart Disease

Sodium and fluid retention

How Sodium causes fluid retention

The job of the kidneys is to filter the excess sodium into the urine so that the body can get rid of it. Many with heart disease and diabetes kidneys cannot handle all the extra work. The kidneys become less efficient at filtering the blood stream. This causes excess sodium to enter the bloodstream. Sodium attracts water to it and effect known as being osmotic. Water follows the sodium  and is drawn into the bloodstream. Excessive salt keeps the circulatory volume higher than it should be, creating and increased pressure in the blood stream and pressing on the blood vessel walls. The stress of the pressure on the walls creates thickening and narrowing of the vessel, leaving less space for the fluid in the blood vessels and raising resistance.  The body then requires higher pressure to move blood to the organs. The heart has to pump against this high pressure system.

I equate it to trying to blow up one of those kids balloons that is turned into animal shapes. They are really tough to blow air into, your cheeks get really sore – this is the resistance of air, similar to the resistance pressure of blood in the arteries. If you stretch the balloon (relax the arteries) then there is less resistance in blowing up the balloon (filling the artery with blood). Twenty percent  of the blood pumped from the heart goes  first to the kidneys.  High blood pressure within the kidneys cause  damage to the heart and to the vascular system in the kidneys. Salt makes you thirsty so limit salty foods, especially if on a fluid restriction.

I once had a patient who lost 45 lbs simply from adhering to low sodium diet. He had a very weak heart with only 10% ejection fraction meaning very limited pumping ability. So a weak heart and sodium in the diet made him retain fluid more than most. He began to measure and count sodium with every meal for a few months and was shocked by how much sodium he consumed even though he thought he ate pretty healthy. By reading labels, doing the math every day and making changes such as eating out less, ordering special, reviewing his medication he lost the fluid and added years to his life, not to mention the improved quality of life with less shortness of breath and fatigue by easing the workload of the heart.

                      

According to the American Heart Association, eating more than the recommended 1500 milligrams a day puts you at direct risk of high blood pressure. Yet in America we consume an average of 3400 milligrams a day; more than twice what we should. While people with hypertension, heart and kidney disease are always advised by doctors to eat less salt, the AHA wants all of us to do this, whether or not our blood pressure is currently in the normal range. So if you are cooking or know the cook for pass this info on!

 

When holiday meal are  upon us  remind heart patients of being acutely aware of the sodium content in foods. The holiday meal contributes to many heart patients having increased symptoms of  high blood pressure, congestive heart failure, fluid retention, shortness of breath. The holiday meals  can be the culprit. Traditional foods like the turkey are often injected with  approximately 8% solution sodium to enhance moistness and flavor. If you read the ingredients you will often note: turkey broth, salt, sodium phosphates, sugar & flavoring. Then many a cook will soak the already salt injected turkey in a brine solution or salt it well, prior to cooking. The turkey alone gets many into trouble, then you add pre-packaged stuffing, broth, or use canned mushroom soups in casseroles. Did I mention the relish tray with pickled foods?

                                                        

A little extra salt in or on your holiday foods makes a difference.

1 teaspoon salt = 2131 mg sodium                                          1/2 teaspoon salt = 1066 mg sodium

1/4 teaspoon salt = 533 mg sodium                                        1/8 teaspoon salt = 266 mg sodium

75 mg—the average sodium content of 3 ounces fresh, unsalted beef, turkey, chicken, pork

240 mg sodium in 3 ounces self-basting frozen turkey, cooked (that’s without the gravy!)

580 mg sodium in 3 ounces frozen fully cooked baked turkey

820 mg sodium in 3 ounces honey baked ham

Bread is a major sodium contributor if you eat more than a couple of pieces a day unless you buy special low sodium bread. A slice (1 ounce) of loaf bread has 150 to 200 mg sodium—not including salted butter or other spreads or toppings. Consider using a bread maker to make a low sodium recipe.

Skip the gravy! But if you must go for low or reduced sodium gravy instead of regular salted gravy which has more than 300 mg sodium for 1/4 cup.                                                                                                                                                              

Measurements and labels of sodium

•  1/4 teaspoon salt= 600 mg sodium
• 1/2 teaspoon salt= 1,200 mg sodium
• 3/4 teaspoon salt=1,800 mg sodium
• 1 teaspoon salt= 2,300 mg sodium
• 1 teaspoon baking soda =1,000 mg sodium

• Sodium-free: Less than 5 milligrams of sodium per serving
• Very low-sodium: 35 milligrams or less per serving
• Low-sodium: Less than 140 milligrams per serving
• Reduced sodium: Sodium level reduced by 25%
• Unsalted, no salt added, or without added salt: Made without the salt that’s normally used, but still contains the sodium that’s a natural part of the food itself.

Names for salt

• sodium alginate
• sodium ascorbate
• sodium bicarbonate (baking soda)
• sodium benzoate
• sodium caseinate
• sodium chloride
• sodium citrate
• sodium hydroxide
• sodium saccharin
• sodium stearoyl lactylate
• sodium sulfite
• disodium phosphate
• monosodium glutamate (MSG)
• trisodium phosphate
• Na

Some drugs contain high amounts of sodium.

Need an antacid after that holiday meal?  Watch out there is excess sodium there too. Carefully read the labels on all over-the-counter drugs. Look at the ingredient list and warning statement to see if the product has sodium. A statement of sodium content must be on labels of antacids that have 5 mg or more per dosage unit (tablet, teaspoon, etc.). Some companies are now producing low-sodium over-the-counter products. If in doubt, ask your healthcare practitioner or pharmacist if the drug is OK for you.

 

Exercise precautions diabetic heart patients

Many with type I diabetes have a very difficult time controlling their blood sugars. For most diabetics, most of the time, the “rules” work. ” The rules being “If I do this, or do not do that, I can expect this result.” But there are many individuals for whom the rules do not appear to apply to them. Control may be elusive and they simply react to blood sugars swinging from highs to lows. When these diabetics attempt to practicing tight control they find their blood glucose level “over-reacts” to minute changes in diet, exercise, and/or insulin. They can  experience unpredictable rises and drops in blood glucose, within very short periods, as the result of very small changes. Small changes “break” their control, and they are thus said to be “brittle.”

The medical community stresses  the importance of exercise for all and especially for diabetics as they have a stronger likelihood of developing heart disease. Exercise is thought to reduce the risk of heart disease by keeping the arteries flexible, and diabetes has a tendency to harden the arteries. Yet for diabetics exercise carries risk.

I have frequently  had patients develop severely low blood sugars with exercise even though  when tested it was adequate prior to activity and they had eaten a decent meal. Some patients have been severely low – as in blood sugars 28-32 range. To an untrained eye it might have gone unnoticed. Often the sign in which I would pick up the emergent low sugar was the patient had more perspiration than usual or a vacant look in their eye.  Angina can occur if the blood sugar is low. If you are a heart patient and experiencing angina when exercising, stop and check you blood sugar.

An additional  challenge for many insulin dependant diabetics who are trying to lose weight through exercise  and nutrition is they have to eat a certain amount to maintain their blood sugar for exercise, and end up consuming more calories than the exercise session burns. When this occurs the advice is see a diabetic educator or health care practitioner to adjust medications.

I have also argued with many a patient who has blood sugars in the 400’s and wants to exercise, as they know the exercise will lower their sugars. However it is dangerous to the body to exercise strenuously when the blood sugar is elevated above 240’s or if there are ketones present. Ketones in diabetes usually indicate that you don’t have enough insulin. As a result, your body can’t use glucose for fuel, so it starts to burn fat, and that forms ketones. The presence of ketones in someone with type 1 diabetes shows a dangerous lack of insulin and the immediate need for more insulin. Exercise, at this time, will only burn more fat and produce more ketones. If ketones build up in the blood, it can lead to a serious condition called diabetic ketoacidosis (DKA), which requires immediate medical treatment. Exercising when you have ketones may make the situation worse and also put you at risk for DKA.  Ketoacidosis then increases the likelihood of heart attack, and arrhythmia. If you want to exercise, check your blood glucose. If your glucose is above 240 mg/dl, check for ketones. If ketones are present do not exercise until blood sugar is down, try again later in the day.

To begin an exercise program when one has poor control of blood sugar there are several safety issues to consider.

Guidelines for exercise for type 1 diabetes include:

• If blood sugar is low (less than 100), it is necessary to eat  a minimum of 15 grams of carbohydrates and  preferably a protein which helps to hold blood sugar up for longer periods of time. Consider a snack such as a granola bar or cheese and crackers, a glass of milk. Plan on needing an additional 15 grams of carbohydrate for every 30-60 minutes of planned activity. Very active exercise may require more carbs. Many diabetics who work out strenuously will have to have a small snack midway through the activity to maintain the blood sugar in a safe range.
• If blood sugar is over 240, test for ketones. If ketones are negative, exercise is permissible and encouraged.
• Test blood sugar every 30-60 minutes during exercise.
•  If blood sugar is between 100-200, take an extra 15 grams of carbohydrate for every 30-60 minutes of planned activity. Very active exercise may require more carbs.
• If blood sugar is over 200, it is not necessary to have a snack unless exercising for 1 hour or more.

Testing  blood sugar after exercise will give varied results.

Often, a higher than normal blood sugar is seen right after exercise. Generally, exercise will lower your blood sugar. If the post- exercise blood sugar reading is unexpectedly high, you may need to consider if your blood sugar dropped so low during the activity that your body re-regulated itself by releasing counter-regulatory hormones. These can cause a  rebound and thus a high blood sugar reading.

Other considerations might be overestimating the impact of the exercise, engaging in a stressful kind of exercise (such as weight lifting) and eating too much carbohydrate beforehand. The blood sugar may drop in 30-60 minutes after the activity. This is a normal pattern due to hormonal changes and other factors. If taking an insulin dose shortly after intense exercise, less insulin may be needed. If correcting a blood sugar after intense exercise, correct blood sugar to a 200 target.

Often 6-12 hours after prolonged activity, the blood sugar may decrease. When starting a new exercise plan, or more activity is done, insulin doses may need to be lowered. It is advised to check blood sugar values  frequently and consider checking in the middle of the night if you have found very low levels in the early mornings.

 Do not take insulin to cover exercise-related snacks or snacks used to prevent or treat a low blood sugar!

Here are some points to keep in mind:

• People who work out or are physically active on a daily basis may need to lower the total daily dose of their insulin.
• For people who exercise more sporadically, the acute effect of exercise on insulin sensitivity may last hours to half-a-day and may require the insulin dose to be lowered just around the time of the exercise.
• Unusually prolonged or vigorous activity may result in a decrease in insulin dose requirements, overnight and even into the next day.

If you have concerns or struggle with exercise consider joining a medically supervised exercise program run by exercise physiologists. Many hospitals have these within their cardiac rehabilitation programs. Benefits include – increased safety, use of their blood sugar monitoring equipment, reporting results and communicating with healthcare practitioners and better control of your blood sugars.

 

Diabetics Weight Loss and Heart Health

Misleading

This report is somewhat misleading. I get concerned when reading negative sounding reports involving exercise and health. I have several thoughts on this report. One is that the study is too short. Heart disease doesn’t just disappear, once it is active in aggressive disease form it can continue to be problematic for quite some time. 1-4 years is a pretty short period of time to expect change. How long does it take the development of diabetes to display physiologic changes. The inflammatory response of diabetes irritates the arteries making heart disease more prevalent. It may take a decade of maintaining these lifestyle changes before the pay off of less cardiovascular issues shows in the statistics.

To say there was no benefit discounts all the good lifestyle adherence of  nutrition and physical activity did for the patient. It initially  focused on weight loss only, I do look forward to seeing the further analysis. Benefits go well beyond the heart. Weight loss through lifestyle changes caused the hemoglobin A1c levels  to decrease, thus decreasing the likelihood of progression of diabetes such as if unchecked increases the need for insulin or other pharmacological agents. These pharmacological agents as with any drug have good and bad components to health. One could extrapolate and assume if the patients maintained this lifestyle they would have less diabetes complications, such as non healing wounds, chronic renal disease, peripheral artery disease etc., as well as less needs for medications to control the disease. Blood pressure improvement was probably noted as well.   Ah but it is stopped because of futility, the study’s data and safety monitoring board recommended the trial be stopped.

The lifestyle modifications arm of this study showed improved Hemoglobin A1c levels. If the study looks at  keeping the HgbA1c lower rather than simply weight loss, over a period of 10-20 years I bet one would note a decrease in the incidence of heart attack, stroke, angina, re hospitalizations for cardiovascular issues.  Mentally the patients were happier, if you work in healthcare….that means alot!!!

I would still push hard for any and all with diabetes to adopt a healthy lifestyle of good nutrition and exercise, and not just for those who need weight loss. I hope the final research will address these issues and not just focus on a negative. I can just hear patients thinking well I don’t need to worry about weight loss through activity as that won’t help my heart, lets just see what medication I can take to improve my glucose control.   Nutrition and exercise are crucial and should be the front line of treatment for heart disease and not just limited to weight loss.

Weight Loss No Help for Diabetic Heart

By Chris Kaiser, Cardiology Editor, MedPage Today

Published: October 19, 2012

Losing weight — an average of 5% of total body weight — `and keeping it off for 4 years didn’t reduce the number of heart attacks or strokes in persons with diabetes.

That result prompted the National Heart, Lung, and Blood Institute to pull the plug on its massive Look AHEAD (Action for Health in Diabetes) study.

The study enrolled 5,145 people with type 2 diabetes and a BMI greater than 25, randomizing half to a lifestyle intervention and half to a general program of diabetes support and education.

Although those in the intervention group kept off 5% of their initial body weight at 4 years, there was no difference between them and the standard care group in the rate of myocardial infarction, stroke, hospitalizations for angina, and cardiovascular death — the primary outcome.

Essentially, there was no harm from the intervention, but there was no benefit either, according to a statement from the NIH.

Because of the finding of futility, the study’s data and safety monitoring board recommended the trial be stopped.

Mary Evans, MD, director of special projects in nutrition, obesity, and digestive diseases at the National Institute of Diabetes and Digestive and Kidney Diseases, told MedPage Today that people who “volunteer for a weight-loss intervention study involving reductions in calorie intake and increased physical activity may be healthier than the general population with type 2 diabetes.”

She said that participants had to pass a treadmill test to assure it was safe for them to exercise. They also received annual feedback about their risk factors, including HbA1c, blood pressure, and cholesterol levels.

After the first year, Look AHEAD participants in the lifestyle intervention arm had lost 10% of their initial body weight, but as time went on, they gained some of it back. The standard care group lost about 1% of its initial body weight at both 1 and 4 years.

Despite no reduction in cardiovascular events in those in the intense intervention arm, they did experience other health benefits. Patients in this group saw improvements in sleep apnea and mobility, as well as quality of life. In addition, their diabetes medications were reduced.

In addition, at 1 and 4 years, both diabetes control (glucose, HbA1c) and most cardiovascular disease risk factors (blood pressure, HDL cholesterol, triglycerides) were more favorable in the lifestyle intervention than in the control group with the exception of LDL cholesterol, which was not different between groups at year 1, Evans shared.

At year 4, those in the intensive lifestyle intervention group continued to have more favorable diabetes control and CVD risk factor reduction, with the exception of LDL-C in which there were slightly greater reductions in the standard care group. Participants in the lifestyle intervention group maintained greater improvements in fitness at both years 1 and 4, Evans said.

To be enrolled, patients had to have their blood pressure under at least moderate control (160/100 mmHg), HbA1c levels ≤11%, and fasting triglycerides concentration less than 600 mg/dL. The trial included those with and without a history of cardiovascular disease.

“Cardiovascular event rates in diabetic individuals with heart disease are expected to be approximately twice those of diabetic individuals without a history of heart disease,” according to the study protocol.

The ages of participants ranged from 45 to 76, and 60% were women.

“Data from the end of the study are currently being analyzed to better understand the relationship between changes in fitness, weight, diabetes control, cardiovascular disease risk factor control, and outcomes in the Look AHEAD study,” Evans said.

Researchers also are exploring differences in subgroups, such as minorities (about 37% of the total population) and those with a history of cardiovascular disease.

Diabetes blood sugar and A1c elevation tied to heart disease

There  is a strong link  in people with diabetes who also have high cholesterol  Cardiovascular disease  is much more prevalent if their  Hemoglobin A1c is chronically elevated. This significant contribution by elevated HbA1c to increased CVD is independent of statin therapy, and thus requires appropriate HbA1c management in addition to lipids reduction. It is vitally important that any individual with known heart disease and diabetes gets their hemoglobin A1c measured approximately 4 times per year by their primary health care provider. Once a year is not enough. Tight control is imperative. If the blood sugars are constantly running high the vessels that deliver blood to the heart are constantly inflamed setting the stage for further heart issues.

There are many hemoglobin A1c calculators can be found on the internet. here is Medscapes version

http://reference.medscape.com/calculator/hemoglobin-a1c-est-plasma-glucose

Peripheral Artery Disease

Heart patients often have Peripheral Artery Disease

Peripheral Artery Disease also known as PAD is when the arteries in the legs become narrowed or clogged with fatty deposits, or plaque. The buildup of plaque causes the arteries to harden and narrow, which is called atherosclerosis. It is the same process that causes heart disease. It doesn’t just happen in the heart it can occur elsewhere in the body and this is known as PAD.  When leg arteries are hardened and clogged, blood flow to the legs and feet is reduced. Lower-extremity PAD is a serious disease that affects about 8 million Americans. The hardened arteries found in people with PAD also put them at risk for hardening and narrowing of the arteries to the kidneys and the brain. That is why people with  heart disease are at risk for PAD, kidney disease and stroke.

How do I know if I have PAD?

Working in cardiac rehabilitation I would often encounter patients who ended up having peripheral artery disease and were unaware of it.  Some of the tell tale signs would be pain with walking, or complaining of wooden feeling in the legs when walking. Fatigue, tiredness or pain in your legs, thighs or buttocks that always happens when you walk but that goes away when you rest.  This discomfort often goes away within two to five minutes of rest. This is a  very classic symptom.  Another classic symptom is night pain in legs, calves, feet or toes that wakes you up. Many patients describe having to sit at the edge of the bed and dangle their feet or get up and walk to relieve the discomfort. Be alert as well for slow to heal wounds in the legs or feet, as the poor blood supply limits wound healing is another clue to peripheral artery disease. Changes in the color of your legs, or the temperature – often the limb feels cold, looks whitish or bluish.

Smoking and PAD

If  you are a heart patient and a smoker  you are very likely to have PAD.  Smoking is  the number one cause of PAD.  Studies show that smoking even half a pack of cigarettes per day may increase the risk of having PAD by 30 to 50 percent. If you do smoke it is imperative that you quit as soon as possible. A cardiologist I worked with would tell his patients if you are diabetic and smoke you will lose a limb to PAD it is a matter of when not if.

Diabetes and PAD

The other big risk factor is diabetes. Diabetes makes the arteries narrow and hard thus restricting blood flow. People with diabetes are at higher risk for having PAD.  Some studies have found that one out of three people with diabetes over age 50 has PAD, and PAD is even more common in African Americans and Hispanics who have diabetes.  The challenge of course with this is that if blood flow is reduced wounds do not heal properly, and limbs can become necrotic and require amputations. A challenge with diabetes is that often the patients with PAD will not get the classic leg pain symptoms. For this reason any diabetic with risk factors for PAD should have his/her legs checked regularly.

Testing for PAD

Testing for PAD includes palpating for pulses in the foot and ankle region. If pulses are not easily felt then the next step is a Doppler ABI – Ankle Brachial Index measurement. This is a painless test in which the blood pressure of the arms is compared to the blood pressures in the lower leg. If there is a large difference this suggests PAD.  Other imaging including CT scans may be done. The next step is a segmental MRA -magnetic resonance angiography,- like a heart catheterization  but looking at the vasculature below the heart. 

Treatment of PAD

Treatment is similar to the heart. If the disease is in the small vessels it is better to intervene with risk factor modification and exercise. Yes it hurts to walk but paradoxically walking is the best activity to help re route the blocked blood supply. The more a person walks the more likely they will develop what is known as collateral arteries around the blockage. Other risk factor modification issues include stopping smoking, lowering cholesterol, being physically active, and keeping blood pressure in control.

If the blockage is in primary arteries of the legs or kidneys then interventions include angioplasty, stenting and/or bypassing the blockages. These are all very similar to the interventions done for atherosclerosis of the heart. Once an intervention is done  it is important to understand the issue is not fixed. Like a car it will need continual maintenance. There is high probability that is will continue to develop further blockages even if you modify all the risk factors and walk regularly.

Exercise and PAD

Many Cardiac Rehabilitation programs will also offer a PAD walking program as well. This usually involves walking on a treadmill or riding a bike 5 days per week and working your way up to a one hour walk. Most patients who experience pain while walking think that sound impossible to walk one hour. The walking program is a graduated program in which one works their way up to one hour, and usually it isn’t a fast walk, but may include walking a grade. Most patients find it quite do able once started. Many find the support given through the rehabilitation programs makes all the difference, as they wouldn’t do it on their own, and the education received while attending gives them the understanding needed to cope with this chronic condition.

 From the Vascular Disease Foundation WHY WALK?

Walking can make a real difference for people with peripheral artery disease (PAD). Recent studies show that for many people with PAD, a structured walking program is one of the best treatments for reducing leg pain or cramps (claudication) when walking. In fact, studies show that over time a structured walking program is often more effective and can work better than medicine or surgery in helping people with PAD walk longer and further without having to stop due to pain.

A regular walking program will:

• Let you do more and stay active.
• Reduce stress and help you relax.
• Help you control your blood glucose, blood pressure, cholesterol, and body weight.
• Improve muscle tone.
• Lower your chances of having a heart attack or stroke.
• Give you peace of mind that you are taking care of your health.

For more information visit

http://vasculardisease.org/