Protect your kidneys

It isn’t easy to be a heart patient, there are so many medication and lifestyle consideration to prevent further injury or illness.

Common heart medication interact with our foods and other medications.  NSAIDS increase heart problems, Coumadin requires watching vitamin K, Grapefruit interacts with many heart medications, some diabetes medications increase heart risks, some heart medications increase risk for diabetes. Now we have a another  to be concerned about. Here is a new advisory the combination of NSAIDS and hypertensive drugs. This is challenging as we encourage patients to exercise and often there are side effects of sore muscles and joints. Based on this the recommendation for sore muscles and joints should be to use  ice and stretch…avoid the Motrin, Advil, Ibuprofin, Moabic, etc. The other challenge is to get the orthopedic physician and the cardiologist to work together to prescribe the safest medication regiment for you. Most importantly do not stop your anti-hypertensive medications without first consulting your physician, sudden withdrawal can be very problematic.

side effects and contraindications: antihypertensives

Adding a non-steroidal anti-inflammatory drug (NSAID) to dual antihypert ensive therapy (a diuretic plus either an ACE inhibitor or an angiotensin receptor blocker) is associated with an increase in risk for kidney injury, according to a large new retrospective study published inBMJ.

Adding a non-steroidal anti-inflammatory drug (NSAID) to dual antihypertensive therapy (a diuretic plus either an ACE inhibitor or an angiotensin receptor blocker) is associated with an increase in risk for kidney injury, according to a large new retrospective study published in BMJ.

Analyzing data from nearly half a million people taking antihypertensive drugs, researchers found 2,215 cases of acute kidney injury after a mean followup of 5.9 years. People on dual therapy were not at increased risk for acute kidney injury. However, when NSAID use was added to dual therapy, there was a modest but significant increase in risk (rate ratio 1.31, CI 1.12- 1.53). The increase in risk was highest in the first month of treatment.

The authors concluded that “increased vigilance may be warranted when” NSAIDs are used with dual antihypertensive therapy, especially in the early treatment period.

In an accompanying editorial, Dorothea Nitsch and Laurie A Tomlinson write that the safety of dual therapy still remains to be demonstrated and that the study likely “underestimates the true burden of drug associated acute kidney injury” in patients taking antihypertensive therapy and NSAIDs. Physicians should inform patients taking antihypertensive therapy about the possible risks of NSAID use and should ”be vigilant for signs of drug associated acute kidney injury in all patients.”

Here is the BMJ press release:

Triple mix of blood pressure drugs and painkillers linked to kidney problems

Absolute risk still low, but doctors and patients should be vigilant

Research: Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study

Editorial: Safety of co-prescribing NSAIDs with multiple antihypertensive agents

Patients who take a triple combination of blood pressure drugs and common painkillers are at an increased risk of serious kidney problems, especially at the start of treatment, finds a study published on bmj.com today.

Although the absolute risk for individuals is low, it is still something doctors and patients should be aware of, say the researchers.

Acute kidney injury (also known as kidney failure) is a major public health concern. It occurs in more than 20% of hospital inpatients and is associated with around half of all potentially preventable deaths in hospital. It is often triggered by adverse reactions to drugs, but little is known about the safety of different drug combinations.

So a team of researchers from the Jewish General Hospital and McGill University in Montreal, Canada, set out to assess whether certain combinations of drugs to lower blood pressure (antihypertensive drugs) and non-steroidal anti-inflammatory drugs (NSAIDs) are linked to an increased risk of kidney injury.

These drugs are commonly prescribed together, particularly in elderly people with several long term conditions.

Using the world’s largest computerised database of primary care records (CPRD), they identified 487,372 people who received antihypertensive drugs between 1997 and 2008. Drugs included angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and diuretics, with NSAIDs.

Patients were tracked for nearly six years, during which time 2,215 were diagnosed with acute kidney injury that prompted admission to hospital or dialysis (7 in 10,000 person years).

The results show that patients taking a double therapy combination of either a diuretic or an ACE inhibitors or ARB with an NSAID were at no increased risk of kidney injury. However, a triple therapy combination of a diuretic with an ACE inhibitor or ARB and an NSAID was associated with a 31% higher rate of kidney injury, particularly elevated in the first 30 days of treatment during which it was 82% higher.

These results remained consistent after adjusting for confounding factors and controlling for other potential sources of bias.

The authors conclude that, “although antihypertensive drugs have cardiovascular benefits, vigilance may be warranted when they are used concurrently with NSAIDs.” They add: “In particular, major attention should be paid early in the course of treatment, and a more appropriate choice among the available anti-inflammatory or analgesic drugs could therefore be applied in clinical practice.”

In an accompanying editorial, researchers at the London School of Hygiene and Tropical Medicine say this study “is an important step in the right direction” but “probably underestimates the true burden of drug associated acute kidney injury.”

They suggest that clinicians advise patients of the risks and be vigilant for drug associated acute kidney injury, and say “the jury is still out on whether double drug combinations are indeed safe.”

http://cardiobrief.org/2013/01/10/acute-kidney-injury-associated-with-dual-antihypertensive-therapy-and-nsaids/

Heart Patients must Prepare for Emergencies

Researchers have noticed that number of heart attacks increases during earthquakes and other natural disasters.

One reason may be that during a stressful episode, your heart’s need for oxygen increases but the body is unable to increase the blood flow through the diseased heart (ischemia). Stress hormones also make arteries narrow, which may cause a break in the fatty material built up in the blood vessel.

Do you have enough Heart Medications  in the event of an emergency?

Do you have accessibility to all your medications? What medications are critical to not run out of? Having a supply of prescription medications on hand in the event of a disaster or weather emergency could mean the difference between survival or being another number added to the death toll. Most prescriptions are dispensed as 30-day units through retail pharmacies with refills available after 75% of use, leaving a monthly medication reserve of 7 days. For patients to acquire 14- to 30-day disaster medication reserves, health professionals understand there are many barriers including restrictive insurance benefits, patients’ resistance to mail order, and higher co payments. Physicians, pharmacists, and insurers also vary widely in their preparedness planning. It can be difficult to get a physician or a pharmacist in the event of disasters.

Getting more than a 30 day supply, in the U.S., can be difficult if not impossible.Even if you have a sympathetic doctor that you can talk into writing an extended prescription, getting around the insurance company’s “three month limit” policy can be an insurmountable roadblock. So how do you stock up on prescription medical supplies? How do you get enough on hand to see you through an extended emergency, one that could last for days or weeks?

Be prepared to pay for the extra medications entirely out of your own pocket. This could get expensive rather quickly, so consider what medications you absolutely cannot be without such as pressure medications, diuretics, insulin, blood thinners. You can ask your physician for samples to prepare for emergencies.

Diabetes Medications Emergency Preparedness

Everyone needs to be prepared for emergencies–but a person with diabetes has additional issues to consider. When establishing your disaster preparation kit, include a seven-day supply of some diabetic foods and a seven-day supply of medications and testing equipment. Blood sugar levels should be carefully monitored during an emergency because the added stress may cause blood sugar levels to fluctuate more than normal.

People with diabetes should tell rescue workers and/or shelter staff that they have diabetes. They should also drink plenty of clean water, watch what they eat, and stick with the regular testing and medication schedule.

For more information, visit http://www.ready.gov/seniors

Living with an LVAD emergency preparedness 

Battery life becomes an issue without electricity. Does your local EMS know that you have a LVAD and will need electricity to stay alive? If you do not have a generator to keep your batteries charged in the event of a power outage, call your local Emergency Medicine Station and let them know you may be in need of help.

You can safely plug your battery charger into a generator to charge batteries, and you can safely plug in your power base unit to maintain the internal battery to a generator. DO NOT hook up to the power base unit that is being powered by a generator. Generators experience power surges, and you cannot be hooked up to the pbu. STAY ON BATTERY POWER throughout the power outage. If you do not have a means to charge batteries, contact your local EMS, explain your medical need for power, and take your battery charger to the EMS to charge batteries. If you cannot drive, ask them to send transportation for you or to supply you with a generator. If you have any questions or problems, please call your LVAD Coordinator on call at your hospital center.

  Another thing to do in the event of power outage…If you cannot keep your power base unit plugged into a generator, please remove the battery from the bottom of the PBU. There are instructions for doing this in your HeartMate II manual. If you do not remove the internal battery, the low battery alarm will continue to squeal at you! Also, this may damage the battery. Again, if you have questions, call your LVAD Coordinator on call.

Nutrition in emergencies

If you are sensitive to sodium and have to cope with no electricity do you have access to foods that won’t put you in congestive heart failure. Many pre packaged ready to eat meals are very high in sodium. This can add additional stress to your cardiovascular system, which may be already stressed due to the emergency. Will others know if you have special nutritional needs?

Hydration:     Liquids are important to your health do you have access to clean water?

Winter effects on your heart

If you are a heart patient you might be concerned about how the cold weather affects your heart.  The body constricts blood flow to the skin to conserve heat, which also raises blood pressure. Many experience angina when active in cold weather.

Advice for how to manage angina related to cold includes:

  • Do a warm up indoors to dilate the blood vessels and get heart rate slightly elevated before outdoor exertion
  • Create a zone of warmer air to breath by using a scarf, mask or parka
  • Discuss using nitroglycerine before activity with your healthcare practitioner. Using the nitro to dilate the vessels prior to cold air exposure is a method used by some.
  • Avoid large meals and alcohol before exerting outdoors. Blood flow gets diverted and doesn’t go to the heart or exercising muscles instead it works to digest the food.

Snow Shoveling for Heart Patients

  • Warm up, do some light exertion to dilate the blood vessels and get the heart rate slightly elevated before really “digging out”
  • Dress appropriately in layers, when you feel warm take layers off. Preventing overheating from being overdressed is as  important as dressing for the cold. Your heart  works harder to cool your body down. Sweating excessively will lead to being cold later.
  • Do not eat a large meal or smoke prior to shoveling, these divert the blood flow away from the heart and exercising muscles.
  • Push the snow don’t lift if  you can.
  • Exhale on Exertion.  Breath out when pushing or lifting, don’t hold your breath!!!! Holding breath increases blood pressure even further than the cold and exercise already has.
  • Switch sides keep alternating the shovel in left and right hand. The constant twist to one side produces muscle injury and can be hard to distinguish between muscles and heart. Muscle pain can reproduced with touch or movement, where as heart pain cannot be set of by touch.
  • Take breaks, listen to your body don’t over do it. The body constricts blood flow to the skin to conserve heat, which also raises blood pressure.
  • Stay fit enough to shovel snow. If you don’t exercise regularly you are not strong enough to shovel wet heavy snow. The cardiovascular demands are even more due to excessive cold temperatures. Train for snow shoveling by performing aerobic exercise and resistance training.
  • If you have symptoms STOP

Dealing with Raynauds in the cold weather

Raynaud’s occurs when the fingers and/or toes come into contact with cold. Beta blockers medications actually can aggravate Raynaud’s by leading to increased blood vessel spasmThis class of drugs, used to treat high blood pressure and heart disease, includes metoprolol (Lopressor, Toprol XL), nadolol (Corgard) and propranolol (Inderal, Innopran XL). It is important to cover your feet and hands before they get cold with warm gloves and socks. Make sure they are not too tight allow for circulation. Prevent the symptoms by creating a barrier between your skin and the cold. Even if you are only going out for a short while keep your fingers covered and wear warm foot protection. Frostbite occurs much quicker in persons with Raynaud’s.

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Atrial Fibrillation is more common in Winter

The likelihood of being admitted to hospital or dying with atrial fibrillation, a life-threatening chaotic heartbeat common among the elderly, increases dramatically during winter months. Atrial Fibrillation is common in persons with heart disease. Be alert for symptoms of irregular heart rhythm, increased shortness of breath, increased fatigue. Additional factors contributing to the winter connection to atrial fibrillation  may include drinking too much alcohol which leads to high blood pressure, heart failure, and possibly even stroke due to the  atrial fibrillation.

http://www.hearthealthywomen.org/am-i-at-risk/am-i-at-risk/hfother2.html

http://www.nhlbi.nih.gov/health/health-topics/topics/raynaud/

Choices in the care of your heart

Heart disease is challenging and frightful. Sometimes decisions are made very quickly regarding managing the disease process. Heart disease is a chronic condition that rears its ugly head over and over for many. As a heart patient  your best off having a good knowledge of the disease process and the choices of interventions.  Methods of intervention include:

  • Angioplasty (balloon opening of artery)
  • Cutting balloons and roto ruters
  • Stent
  • Drug eluting (coated) stent
  • Open heart surgery – Bypass Surgery
  • Treat medically with medicine and lifestyle
  • Enhanced Eternal Counter pulsation therapy
  • Left Ventricular Assistive Devices
  • Heart Transplant

Many of these decisions are based on the amount of heart tissue that is involved. If there is a large region with insufficient blood flow caused by numerous blocked vessels you most likely will be recommended to have bypass surgery. The general rule is if three vessels are involved you will most likely require surgery. You do have choices though, as the main blockage can be intervened on through stents and the other vessels can be addressed at a later time. We call this staged stents. The  cardiologist do not  recommend placing stents to both the right and the left side of the heart during the same intervention. They will treat the culprit, and then come back later for the others.  The decision tree also takes into account what other issues (co morbidities) a patient has. If  a patient has end stage renal disease or their kidneys were severely affected by the heart problem then the physician my want to avoid treatments that place a heavy burden on the kidneys such as angioplasty or stents. They may opt to treat medically until the kidneys have recovered if they can.

A single vessel blocked will more likely be treated with a stent. However the location of blockage can be very challenging. If the blockage is  where the artery separates to another branch – called an anastamosis  these are very difficult to deal with because a stent would block the flow to the other artery. Sometimes they require surgery, new technology in stents is coming and these may be able to be stented in the future.  Some vessels are too torturous – meaning twisty and turny to allow a stent to be placed. Again surgery, treat medically  or EECP therapy would be considered.

Small vessels are less likely to be treated with stents and more likely to be treated with medications.  Medication includes nitro, long acting nitro, calcium channel blocker, ace inhibitors, beta blockers and occasionally EECP.

Intervention is determined by how viable the heart muscle is. If the heart muscle was severely damaged due to a heart attack  and now scarred over – or remodeled, further intervention to that region is not likely to be of any help.

EECP – it is enhanced external counterpulsation therapy. The therapy consists of cuffs wrapped around legs, calves and buttocks. When the heart finishes pushing the blood flow out, the cuffs sequentially inflate to push the blood back up the heart. By doing this the heart is somewhat engorged with blood and forms collateral vessels. The treatment consists of one hour treatments 5 days a week for 7-9 weeks.  Most patients find their frequency and intensity of angina is greatly diminished. Many patients hold the benefits for 2-5 years, but others will require more frequent return treatments to hold the gains. It is usually covered by insurance such as Medicare if the angina is considered functionally limited or disabling.  For some people with very serious heart damage this improves the pumping ability of the remainder of the heart muscle, as it becomes stronger due to increased blood flow from collateral arteries. The EECP alone will not maintain the benefits, you must still keep physically active through exercise to maintain the benefits.  The treatment is non invasive.

LVAD is a left ventricular assistive device.  These are used when the heart cannot meet the demands any longer to adequately circulate the blood. For many this is now considered a destination therapy. This means they will not be a candidate for a heart transplant but will forever rely on the mechanical pump to circulate their blood. These are becoming more frequently used, and the mortality rates are decreasing with these pumps. If your health care provider is contemplating this route for you, I would strongly suggest you contact support groups of patients who already have LVADS here is a Facebook link to such a support group.  https://www.facebook.com/pages/LVAD-Recipients/207915222572308

Heart transplants are necessary when the damage is such that the heart cannot meet the needs. Often the patient is repeatedly hospitalized in congestive heart failure. They are disabled due to the heart condition.

The take home is know the procedures, research the pro’s and con’s of each. Don’t walk in to the physician’s office and simply take the first suggestion. Question the efficacy, ask the probability of success and what are the limitations, what can you expect in the future. Be active in your healthcare. Most inpatient nurses will tell you they witness too many incidents where the health care provider tells the patient and family if you don’t do this you will die. Thus the patient feels compelled to have the intervention performed. You have choices.

Choices involve the above discussion, but also include risk factor modification every single day. Choose to exercise, choose to eat healthy, choose how to respond to stress, choose to take your medications,  choose to not smoke, choose to monitor blood sugar.

Bypass

Stent

Left Ventricular Assistive Device

 Enhanced External Counterpulsation Therapy

Blood Pressure Measurement – things you might not know

How is your blood pressure measured? 

The blood flow to the arm is cut off, as the cuff slowly decreases the pressure the systolic – the top number is the pressure of the blood flowing through the arteries when the heart squeezes.

The bottom number  the diastolic is the pressure that remains in the vessel when the heart is relaxed.

Automatic cuff or manual cuff.

This was always an issue in cardiac rehabilitation. In my opinion automatic cuffs tended to read considerably higher than listening with our own ears. They might be fine while lying in a bed in the hospital, but in a busy outpatient facility I question their accuracy.  There are factors that can contribute including is the cuff over clothing, sitting still, not talking, feet square on floor. Even though these factors could be corrected often the readings were high.  Biomedical engineering would calibrate the machines regularly but the readings remained higher with automatic compared to manual. Patients were trained to instruct staff if the automatic cuff reading was unusual to compare it to a manual reading.

How about your home automatic cuff – how accurate is it?  Bring your cuff in to your next doctors appointment, and compare the two readings. There is always some variability but it shouldn’t be extreme. A common cause reading  may be off can be due to the size of the cuff.  There is a reference line on most cuffs as to where the end of the cuff should be. If the cuff is too small the readings will be high, if the cuff is too large the readings will be too low. For severely obese patients it isn’t uncommon to take a small cuff and read the pressure at the wrist instead of the arm. Many  frail thin people require a pediatric size cuff.

True Resting Blood Pressure – A true resting blood pressure is one where you have rested quietly for 5 minutes, feet flat on floor, shoulders square on chair, no caffeine or tobacco prior to measurement.  Activity will influence the blood pressure greatly. If you just rushed in to the office, had a long walk through the parking lot or up stairs your readings will be higher. Remember with blood pressure if it is taken 10 times in 10 minutes you will get 10 different results. What is being assessed is the average number your pressures are readings. If taken in the arm or the wrist the arm should be resting at the heart level.

Does the Time of Day Matter?  – Blood pressure is characteristically highest first thing in the morning, however with medication effects some people will peak later in the day as medications may be wearing down. Vary the times you measure it, get an understanding of the patterns that you run. Keep a log of your blood pressure, make sure to bring your log when you see your health care practitioner.

Should my pressure be taken in my Left arm or Right Arm?  Trick question. Use the arm the reads the highest. Not the lowest! Blockages that occur in the heart don’t just occur there, they can occur anywhere in the body. It isn’t unusual to have blockages in the arteries of the arms. Have your health care provider check both arms. Make sure they chart what arm they should measure your pressures in. I’ll bet at your next appointment they only check one arm, and never ask.  This can be a big problem for some people.

Is there a difference if taken in the wrist or the arm?  – It  doesn’t ‘matter the pressures should be similar. 

What about Leg Pressures? – As noted above, the pressure should be similar from legs to arms. However people with Peripheral Artery Disease – which is blockages in the arteries going to the legs will have a lower blood pressure in the legs. There is a measurement called an Ankle Brachial Index which measures the legs compared to the arms. If there is a big difference there should be additional testing done as these blockages often lead to poorly healing wounds, amputations, severe leg pain with walking.

How Frequent should I  Measure my Blood Pressure? – In cardiac rehabilitation we measure blood pressure at rest – it isn’t safe to exercise if your blood pressure is greater than 170/100 at rest, as we know exercise elevates blood pressure and we don’t want blood pressure to exceed 220/110 as this is dangerous to the heart, brain and organs and can cause stroke or heart attacks to occur. If the blood pressure is too low 80/40 the pressure is usually considered too low to exercise. Exercise dilates the arteries and after exercise the pressure will be lower than entry. If lower than 80/40 most people will feel like they might pass out.

Blood pressure is measured during exercise. Large drops can indicate the heart isn’t tolerating the blood pressure, or excessively elevated blood pressure with exercise can signal poorly controlled and additional intervention might be needed. We compare weight-bearing exercise to non weight-bearing. Bearing one’s body weight with activity is generally harder on the heart.

Blood pressure is also measured after exercise. Exercise dilates the arteries and they stay dilated for a period of time afterwards, the heart rate slows down, and sometimes this causes the blood pressure to fall severely causing one to feel light-headed or possibly to pass out. For this reason it is recommended for all heart patients to perform a nice long cooldown, gradually slow the exercise, do some stretches, drink some water, slowly stroll around. This helps to keep the blood from pooling in the muscles that were being used and keep it circulating. If it does drop severely, lie down get your feet elevated, drink some water. If this happens frequently see your healthcare provider as your medications may require tweaking.

So how often should you check it at home? If it has been fairly stable measure it about once a week. If you are not feeling well, or had recent changes to your medication check once or twice a day. Every person will have occasional spikes or random variations in their blood pressure. Try not to be overly concerned if the number is elevated one day compared to another. So if you normally run 140/80 and today is  160/90 don’t worry.  Note that it is running higher and watch over next few days. Make sure you have taken your medications, review your diet to see if you had more sodium than recommended 1500 mg/day, as increased fluid volume from sodium is a frequent culprit. Did you eat out the day before? If it stays elevated for several days, contact your healthcare provider.   If the Blood Pressure readings are reading 220/110 see your healthcare provider immediately. 

There are several Blood Pressure Apps for iPhones, android devices. These are great. I think they are the future of health care. Some cuffs will download right to your app, others  require you to enter the data. Coming along with the urgent development of wireless technology, wireless devices have invaded the medical area with a wide range of capability. Not only improving the quality of life of patients and doctor-patient efficiency, wireless technology enables clinicians to monitor patients remotely and give them timely health information, reminders, and support – potentially extending the reach of health care by making it available anywhere, anytime.

Below are a few helpful links and resources:

An overview to measuring blood pressure at home. This is an overview of the benefits and resources. Lots of good information.

http://www.michigan.gov/documents/mdch/home_bp_328345_7.pdf

Public Information on  High Blood Pressure and Sodium. A website link and material from the National Institutes of Health with information in several languages on high blood pressure. Topics include, diet, sodium reduction, and risk factor advice to lower high blood pressure

http://ww.nhlbi.nih.gov/hbp/prevent/h_eating/h_eating.htm

“Salt matters. We must act, and act now.” A video featuring the CDC Director, Thomas R. Frieden, MD, MPH that discusses the importance of reducing salt and strategies for consumers to use in their effort to reduce it.  A Public Service Announcement – about 2 minutes

http://www.youtube.com/watch?v=k-YIO5lg9-w&feature=related%20v=k-YIO5lg9-w&feature=related&noredirect=1

Know the Facts About High Blood Pressure.  This  full-color, easy-to-read handout describes the risk factors,     prevention, diagnosis, and treatment of high blood pressure.

http://www.michigan.gov/documents/mdch/Know_the_Facts_About_High_Blood_Pressure_320302_7.pdf