CARDIOVASCULAR

Fluoxetine May Help Older Depressed Patients With Severe Heart Ailments

WASHINGTON, MD -- May 1, 1998

The results of the second in a series of studies, published today in the American Journal of Psychiatry, confirms that the newer selective serotonin-reuptake inhibitor (SSRI) antidepressants such as Prozac (fluoxetine) are safer than the older, commonly used tricyclics for treating patients with coexisting depression and heart disease. An estimated 20 percent of people with heart ailments develop major depression and the two diseases frequently coexist in older patients. "Heart disease is complicated and rehabilitation is often hindered in patients who have depression which goes undiagnosed and untreated," said Steven Roose, M.D., lead researcher on the study and a member of the American Association for Geriatric Psychiatry (AAGP). "It is possible that patients who are successfully treated for depression will be more active participants in their own rehabilitation from heart disease." Approximately six million older adults suffer from major depression and approximately one million older adults with depression are undiagnosed or untreated. Citing the high incidence of untreated depression among older adults, AAGP has called for depression screening as a routine part of elder medical care. "The findings are positive news for depressed patients who also suffer from heart ailments," said Dr. Roose, also a professor of clinical psychiatry at Columbia University and AAGP's lead researcher on heart disease and depression in late life. "The older tricyclic antidepressants have always been effective for the treatment of depression, but their cardiovascular toxicity has been a concern. Our latest study showed that fluoxetine appears to be a safer choice of medications for patients with heart disease." Older antidepressants, known as tricyclics, previously have been linked to troubling adverse events such as increased heart rate and orthostatic hypotension, which can lead to further heart complications and cardiac death. Although the SSRI class of antidepressants have been available in the United States for more than 10 years, until now little data have been available for patients and physicians regarding the impact of these medications on the heart. The most recent study examined 87 patients with severe depression and severe heart disease, including congestive heart failure, conduction disease and/or ventricular arrhythmia. Nearly three-quarters of the patients were men and the average age was 73. There were 27 patients given up to 60 milligrams of fluoxetine for up to seven weeks. Sixty patients in a comparison group were given nortriptyline, a tricyclic antidepressant. Researchers determined that fluoxetine -- the first SSRI antidepressant introduced more than 10 years ago -- was not associated with the cardiovascular effects that often are linked with tricyclic antidepressants. In fact, researchers determined that fluoxetine appeared to be a benign treatment in depressed patients with cardiac disease. Nortriptyline had a 20 percent rate of cardiac adverse events (12 of 60 patients) while just one of 27 fluoxetine patients (four percent) showed adverse cardiac events. "There still is not a tremendous amount of data on this issue but the data we do have is encouraging," Dr. Roose said.

Large waists a sign of health at risk

LONDON, March 20, 1998

Slender waists and flat abs may be more than attractive - they may be a sign of good health. In a study of 5,887 men and 7,018 women, researchers say Friday that people with spreading middles had an ''excess burden of ill health,'' with higher risks of high cholesterol, high blood pressure, stroke and diabetes. Apple shaped people were also more likely to sweat excessively, get winded and had a harder time with everyday activities, like bathing, dressing, shopping and walking up a flight of stairs. Researchers from Scotland's University of Glasgow, and the National Institute of Public Health and Environment in the Netherlands report their study in Friday's issue of the journal The Lancet. Dr. Michael Lean, the study's lead author, says doctors have focused on obesity as a major risk factor for heart disease, but ''the biggest impact on health is a lot of the other symptoms.'' These include diminished work capacity, excessive sweating, back pain and incontinence, which lead to depression. He says doctors will first reach for drugs to treat many of these conditons, but this approach overlooks the root cause of the problem _ excess pounds. He says doctors do not take into account the ''huge range of impact on daily life and the distress of obesity.'' Lean says that the ''danger level'' for men is about a 40-inch (102- centimeter) waistline, and for women about 35 inches (88 centimeters). That's when they should ''be seeking professional health,'' in bringing their weight down, he says. But even men with slightly smaller waistlines, of about 37 inches (94 centimeters), and women with about a 32-inch (81-centimeter) waistline, should start taking some steps steps on their own to cut fat and get more exercise. And, he says, that doesn't necessarily mean gut-busting sit-up workouts. For many people a half-hour of brisk walking may do the trick, he says. The scientists say that even a slight-belt tightening, about 2 to 4 inches (5 to 10 centimeters), can lead to better health, they say. Lean decided to measure waistlines because some of the other ways of determining whether a person is overweight _ such as the Body Mass Index _ required calculations ''too complicated for the man in the street.''

Moderate drinking tied to arterial disease

NEW YORK -- May 7, 1998

Firing another round in a continuing controversy, European researchers report that moderate to heavy drinking increases the risk of atherosclerosis, the build-up of fatty deposits inside arteries that can cause heart attacks or strokes. Regular consumption of more than 50 grams/day of alcohol -- roughly equivalent to two bottles of beer or two glasses of wine -- is "a prominent risk factor for early atherogenesis, surpassing even the effect of heavy smoking," according to a report by Dr. Stefan Kiechl, of Innsbruck University Hospital, Austria, and others in the May issue of the journal Stroke. Kiechl and his colleagues asked 826 men and women, aged 40 to 79 years, to report their drinking behavior on a standardized questionnaire. They sent the same questionnaire 5 years later, then conducted face-to-face interviews with the 780 participants whose drinking patterns had not changed substantially. The research team also found that light drinkers, those who consumed 50 grams of alcohol per day or less, faced a lower risk of atherosclerosis than heavier drinkers or abstainers. In particular, light drinkers had 50% less risk of developing blockages in the carotid arteries, which supply most of the blood to the brain. Occasional drinking, defined as alcohol intake less than once per week, did not affect the risk of atherosclerosis either way. Even after the investigators took into account the effects of high blood pressure, smoking and high cholesterol levels, their statistical analysis showed that alcohol consumption was an independently significant risk factor for atherosclerosis. There were no significant differences between the results for men and women. Low levels of alcohol seem to "lessen the vessel injuries brought about by high levels of low-density lipoprotein (LDL), the 'bad' cholesterol," Kiechl said in a statement released by the American Heart Association. But he and his colleagues note that further studies are needed to confirm this theory. SOURCE: Stroke (1998;29:900-907)

Natural protein contributes to heart problems: study

WASHINGTON -- April 13

US researchers have found that in laboratory animals a protein naturally produced in the heart can cause heart problems, according to an article in Tuesday's issue of Circulation. The study was done by researchers at the University of Texas in Dallas and at the Baylor College of Medicine in Houston. Circulation is the magazine of the American Heart Association. The researchers said the protein, which they have called tumor necrosis factor alpha (TNF), can cause an "inflammatory cascade reaction" which can weaken the heart. While the protein helps repair damaged heart tissue it can also increase the risk of congestive heart failure, the researchers found. Their hypothesis was demonstrated in laboratory mice that were genetically altered to produce large amount of TNF. "Production of TNF by cardiac myocytes is sufficient to cause myocarditis, myocardial dysfunction, cardiac failure and premature death and therefore supports a causal role for TNF in the development of diverse cardiac diseases," wrote Deborah Bryant of University of Texas Southwestern Medical Center in Dallas. Her colleagues in Houston said the newly discovered role of the protein could help lead to new heart treatments. They found that some treatment could erase the effects of TNF in the heart. Almost five million Americans suffer heart trouble, which the American Heart Association said is the main cause of hospitalizations for Americans over the age of 65. Hopkins Q&A: Personality and Heart Attacks March 30, 1998, Baltimore Not so long ago, high-power types were taking inventory to determine if they were a "Type A" personality and, therefore, prone to heart attacks. Now, it may be time to check yourself for a Type D personality, which researchers at the University of Antwerp in Belgium suggest may increase your likelihood of experiencing recurrent heart attacks. Their study, based on 87 men who had suffered at least one severe heart attack, and reported in a recent issue of Circulation: Journal of the American Heart Association, found that Type D individuals who harbor constant feelings of negativity, distress, inhibition and inadequacy, are three times more likely to suffer recurrent heart attacks than their "non-D" counterparts. The group was monitored for up to 10 years. The rate of repeat heart attacks was 52 percent for "Type D" personalities and 12 percent for "non-D" types. While further research has demonstrated that certain psychological factors like stress and depression also come into play, this was the first study to pinpoint personality as a possible cause. In this interview, Roger Scott Blumenthal, M.D., assistant professor of medicine and cardiology at the Johns Hopkins Medical Institutions and director of its Ciccarone Center for the Prevention of Heart Disease, says that personality type may certainly be something to consider when evaluating heart attack risk factors.

Interviewer: First, a bit of background. What exactly happens during a heart attack?

Dr. Blumenthal: A heart attack occurs when the heart muscle is damaged due to an occlusion or blockage of a heart artery. If part of the heart muscle is deprived of blood flow for 20 minutes or more, that part of the muscle will become damaged and die. Therefore, a heart attack refers to permanent damage to a small area of heart muscle.

Interviewer: What are some well known risk factors for heart attacks?

Dr. Blumenthal: Some of the better known risk factors include a family history of early heart disease; high total cholesterol or a low level of High Density Lipoprotein (HDL), commonly known as the "good " cholesterol; high blood pressure; diabetes or high blood sugar; cigarette smoking and a sedentary lifestyle (lack of exercise). Post menopausal women also may be at risk as they experience low levels of estrogen. Age also comes into play, as well, for both men, 45 and older, and women, 55 and older.

Interviewer: What are some common characteristics of "Type D" personalities?

Dr. Blumenthal: People with "Type D" personalities typically exhibit ongoing feelings of negativity, anxiety, insecurity and distress. They are socially isolated, lack self-esteem, are non-assertive and worry incessantly.

Interviewer: What do you think of this new finding linking personality to heart attack risk?

Dr. Blumenthal: Although the study is a very interesting and provocative one, it is limited by the fact that only a relatively small group of people were followed. Hopefully, this theory will be tested on a larger number of the population to see if the data holds up. It does seem to make sense, however, that people who are consistently distressed, insecure and negative - all "Type D" personality traits - could be at higher risk for developing further heart disease. Having an abnormal mental outlook or personality can certainly translate into a high risk of heart disease later on. What's particularly interesting about this study is that it is one of the first to suggest that psychological factors can influence the clinical course of patients who have already suffered a heart attack. Psychological intervention may play as important a role in treating heart disease as other types of medical therapy.

Interviewer: Does this theory hold as much weight as more common heart attack risk factors such as obesity, high blood pressure, diabetes and the like?

Dr. Blumenthal: At this point, we have to reserve judgment, since this is just one small study that looked at patients who had already suffered a heart attack, and as a result, have a weakened heart muscle. So while we've always suspected that personality and stress may play a key role in heart disease, it's been difficult to design studies to measure these risks. It may very well be that personality and stress have a comparable importance to other traditional risk factors, such as high blood pressure and high cholesterol, but more research needs to be done.

Interviewer: Why are those with "Type D" personalities more likely to suffer recurrent heart attacks than "non-D" types?

Dr. Blumenthal: Because Type D personalities are more prone to anxiety, depression and repressed anger, they may be more likely to develop abnormal heart rhythms which can lead to heart attacks or sudden death. Stress has long been thought to increase the tendency for blood vessels to abnormally constrict, thereby reducing the blood flow to the heart - the root cause of heart attacks.

Interviewer: What can you do to prevent repeat heart attacks if you've been classified as a "Type D" personality?

Dr. Blumenthal: The best thing to do is seek psychological counseling. Talk to your family physician, cardiologist or primary care provider who may in turn refer you to a psychologist or psychiatrist. Sometimes, psychological therapy can be as beneficial and as important as some of the medications commonly prescribed for heart disease. Also, if you notice that a family member or friend who has suffered a heart attack is depressed, withdrawn or isolated, encourage him or her to seek counseling as well.

Interviewer: Why do social inhibition, insecurity, unassertiveness - all characteristics of "Type D" personalities - affect high risk heart patients?

Dr. Blumenthal: Different types of stressors may tend to cause arteries to abnormally constrict, leading to further decreases in heart flow and subsequent heart attacks. But we don't have any solid proof of this. Our group at Hopkins has done some work showing that cold exposure and mental stress can cause arteries to abnormally constrict. Other researchers have had similar results. Thus, individuals with "Type D" personalities may be predisposed to having recurrent heart attacks.

Interviewer: All of us exhibit feelings of negativity, insecurity and anxiety at one time or another. At what point are you classified as a true "Type D" personality?

Dr. Blumenthal: It's hard to know. This study just looked at patients who had already had a heart attack and didn't look at typical, asymptomatic people. But all these behavioral or personality traits could be detrimental. If an individual exhibits these feelings on an ongoing basis, he or she would be wise to talk to his/her health care provider.

Interviewer: The study suggests that those with "Type D" personalities are at increased risk for a second heart attack. Does the same hold true for a first heart attack?

Dr. Blumenthal: Personality type could very well be an important factor in causing the initial heart attack. But it's just one factor. Traditionally, hardening of the arteries and heart attacks can usually be tied to abnormalities in cholesterol, blood pressure, diabetes, smoking and lack of exercise. But one's psychological state can also play a role.

Interviewer: People characterized as "Type A" personalities are known to be aggressive, high strung, workaholics and such like. Are they at high risk for heart attacks as well?

Dr. Blumenthal: While previous studies have shown that people with "Type A" personalities are at increased risk for heart disease, as well, it appears that the subset of people who don't express their anger ("Type D" personalities) are at higher risk for recurrent attacks. While there have been inconsistent findings regarding "Type A" personalities, the hostility factor is probably the behavioral trait that puts them at increased risk for heart attacks.

Interviewer: What is the psychological profile of individuals with "Type B" personalities? Are they less likely to suffer heart attacks?

Dr. Blumenthal: In contrast to "Type A" personalities, people with "Type B" personalities are more laid back, not as easily upset, and more even-tempered. So perhaps their risk for developing coronary disease is reduced. Of course, all of these classifications are artificial. Some people are more apt to be labeled "Type A" at various stages of their life or under certain conditions, whereas others will be classified as "Type B" at some points.

Interviewer: Has any other research been conducted linking personality to heart attack risk?

Dr. Blumenthal: Yes, our group at Hopkins recently published an article which tested the effects of mental stress on blood pressure and heart rate. After conducting a series of mental stress tests on those individuals with a family history of heart disease, we found that those who had shot up their blood pressure or pulse in response to various types of mental stress tests had a much higher incidence of decreased blood flow to the heart muscle as determined by stress testing.

Interviewer: Do you think this theory warrants further investigation or should researchers concentrate their efforts on more concrete risks?

Dr. Blumenthal: This is a very reasonable theory for people with this personality type and definitely warrants further testing on a larger population. The bottom line is that individuals classified as "Type D" personalities should talk to their primary care physician or cardiologist and consider counseling.

Sticky Blood May Underlie Early Atherosclerosis In Men

DALLAS, TX -- April 20, 1998

The stickier, or more viscous, a man's blood is, the greater his risk of developing the kind of blood vessel damage that can eventually lead to a heart attack or stroke, a study published in tomorrow's issue of Circulation. The increased risk does not hold true for women -- which may shed light on why males tend to develop heart disease and suffer strokes at a younger age than females, said lead author Amanda Lee, Ph.D., research statistician at the University of Edinburgh Medical School, Scotland. The study is the first to link blood stickiness to the early development of atherosclerosis, which results from the build-up of cholesterol, fats and biological debris in the tissue lining the inside of blood vessels. This build-up can obstruct blood flow to the heart and brain and thereby cause a heart attack or stroke. The researchers cannot explain the lack of correlation between blood viscosity and blood vessel-wall thickening in women. They do, however, have several hypotheses. A number of risk factors contribute to the development of atherosclerosis and an interaction may be required among these risk factors to cause the blood vessel damage that occurs in men. One interaction may involve cigarette smoking, which is greater in men than women. A more likely explanation, however, is that blood viscosity has a different effect in men than women, which accounts for its role in early blood vessel damage, Lee said. Blood viscosity may act differently in the two sexes because of differences in speed of the blood as it courses through vessels and subtle differences between the two sexes in the geometry, or shape, of blood vessels, she said. A higher blood velocity in men, coupled with greater viscosity, cigarette smoking and blood pressure, may create greater sheer stress that does more damage in men than in women to the one-cell-thick inner lining of blood vessel walls. This may preferentially predispose men to the build-up of deposits in the blood vessel walls that can eventually lead to heart attacks and strokes, Lee explained. "Therefore, it may be that viscosity may explain why men have higher heart attack and strokes rates than women." Previous studies identified blood viscosity and elevated levels of certain blood substances, including the protein fibrinogen, as increasing the risk of a heart attack or stroke caused by atherosclerotic disease. Other studies have shown that an increased thickness of the intima and the media, the two layers within the blood vessel wall where deposits form, can indicate early atherosclerosis. "But nobody before us looked at the stickiness of blood and its various determinants to see whether they may have an effect on intima-media," she said. Moreover, when the researchers statistically adjusted their findings to account for the role of cholesterol, age, blood pressure and cigarette smoking in blood vessel thickening, they found that sticky blood still increased the intima-media thickening risk in males. "We've shown that these effects are independent of the known common risk factors, and so basically, we can say that viscosity has an effect on early atherosclerosis in men," Lee said. She and her colleagues used data from the Edinburgh Artery Study, a prospective study of 1,592 men and women 55 to 74 years old when they were enrolled in the late 1980s. At the time of entry, each answered a risk-assessment questionnaire and gave blood. Five years later, as part of their follow-up, the volunteers were given a B-mode ultrasound scan, which can provide a image of the thickness of the intima and media layers in the blood vessels to the brain. This ultrasound technique yields a black-and-white longitudinal image of a vessel from which thickness measurements can be made. "We're talking very small thicknesses-millimetres or parts of millimetres thick," Lee said. The researchers compared the intima-media thickness measurements of 1,106 study participants with their blood-flow status and the levels of various substances in their blood. These included blood and plasma viscosity; packed red cell volume (hematocrit); fibrinogen, a protein involved in clotting; von Willebrand factor, which can indicate damage to cells lining the vessel; tissue plasminogen activator, an anticlotting factor; and fibrin D-dimer, an indicator of fibrinogen activity. The study noted significant correlations in men, but not in women, between intima-media thickness and elevated blood viscosity and three major elements that determine blood stickiness: plasma viscosity, fibrinogen and the red-blood-cell count.

Fat may not always be unhealthy, experts say

WASHINGTON -- May 28, 1998

Fat may not always be an automaticindicator that someone is unhealthy, researchers said Thursday. They said more careful measurements can show someone'sprecise health risks and might be a better way of measuringobesity. The most common measurement of obesity right now is bodymass index, or BMI. This is calculated by dividing someone'sweight in kilograms by their height in meters squared. So for example someone who is five feet, five inches tall,or 1.65 meters, and weighs 132 pounds or 60 kg, has a BMI of 22.A BMI of 25 or above is considered overweight and one of 30 orabove is obese. The measurement is supposed to allow for different bodybuilds, but it does not account for the risk factors that goalong with being fat, such as high blood pressure, heart diseaseor diabetes. Arthur Campfield, Francoise Smith and Paul Burn at drugmaker Hoffman-La Roche said some obese people may not be unhealthy atall. Writing in the journal Science, they said a new measure,called metabolic fitness, looks at the specific health riskfactors such as cholesterol, triglyceride, glucose and insulinlevels in the blood, blood pressure and the way the body handles glucose. Weight loss is not always necessary to improve health, theysaid. ``For example, insulin sensitivity and cholesterol levelscan be improved by physical activity in the absence of weightloss,'' they wrote. ``The hope is that by using metabolic fitness as a measureof success, health professionals can shift the patient's focusfrom unrealistic, culturally imposed goals (for example, dresssize or belt size) to the more appropriate and achievable goalof better health.''

*MUCH MORE TO COME