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Monthly Archives: March 2017

Idiopathic Hypertrophic Subaortic Stenosis (IHSS): Hypertrophic Cardiomyopathy

  • What is it?
      • Disease characterized by marked hypertrophy of the left ventricle
      • Involves interventricular septum & left ventricular outflow tract
      • Usually asymmetric
      • Obstructive vs nonobstructive
      • More common in males
      • Most common cause of sudden cardiac arrest (SCA) in young athletes
  • Etiology
      • Most commonly a mutation of MYH7, beta-myosin heavy chain gene in heart muscle protein
  • What is happening?
      • Muscle fibers are thickened & shorter
      • Muscle bundles in left ventricle arranged in a bizarre fashion
      • Possibly LVOT abnormality → creates turbulence in blood flow → progressive LVOT thickening, fibrosis, and scarring
      • During systole, the hypertrophied muscle in the outflow tract bulges into right ventricular outflow tract and often the left → narrows this region → produce obstruction to left ventricular ejection
  • Common consequences?
      • Damage heart muscle → arrhythmias
      • Increase blood pressure
      • Marked enlargement of the papillary muscles and trabeculae carneae
      • Deformation of the mitral valve by the thickened ventricular septum
      • Thickening of the anterior mitral leaflet / mitral regurgitation
  • Signs and symptoms
      • Ejection type systolic heart murmur with thrill – mid left sternal border *often first sign*
        • Valsalva: increases murmur
        • Leg lifting: decreases murmur
      • Dyspnea
      • Angina
      • Dizziness
      • Syncope
      • Enlarged heart with double apical impulse
      • Apex cardiograms: abnormally tall presystolic expansion wave (a wave)
  • Diagnosis
  • Definitive: Echocardiogram
      • Continuous wave Doppler: to determine gradient and degree of obstruction  
      • EKG: shows LVH
      • CXR: normal or cardiomegaly
      • Cardiac catheterization: gradient across valve, measurement of cardiac output, & degree of aortic regurgitation
  • Treatment and management
      • Patients are told to avoid strenuous activity, stay hydrated, and have close follow up
      • Meds: Beta blockers or Ca2+ channel blockers
      • ICD placement
      • Definitive: Surgical correction of obstruction
        • Surgical resection of the subvalvar membrane or fibrous crescent, with myectomy
        • High rate of reoccurrence
        • “Prevention” of aortic regurgitation alone is not a criterion for surgery
        • We defer surgery in the first decade of life if obstruction is moderate or less (maximum instantaneous Doppler gradient ≤50 mmHg or mean LVOT gradient <30 mmHg) and regurgitation is no more than trivial
        • Patients with more severe obstruction or with progressive aortic regurgitation are surgically corrected
        • Children with a LVOT gradient <30 mmHg and no significant LVH are followed closely
  • Pearls
    • No antibiotic prophylaxis (for endocarditis) is recommended anymore
    • Second most common form of AS
    • Patients are not born with it, develops later
    • Mortality after surgery is very low

Overview Video

https://youtu.be/KodyU7tUVO8

 

Arugula Quinoa Salad (2 Servings)

Ingredients:

4C Arugula

1C Cooked quinoa, cooled

1 Tomato, chopped

1C Cucumber, chopped Juice & zest from

1 lemon

1/4C Olive oil⇒ 2 teaspoon raspberry vinegar/red wine vinegar/apple cider vinegar + ¼ cup vegetable broth + 1 teaspoon honey/pomegranate molasses  

1/2C Slivered almonds or walnuts

1-2T pomegranate seeds

 

Directions:

  1. In a large bowl, mix arugula, quinoa, tomato and cucumber. Dress with lemon juice, lemon zest and olive oil
  2. Top with pomegranate seeds and almonds or walnuts and enjoy!

 

Zucchini Ribbon Salad (2 Servings)

Ingredients:

4 cups spinach or arugula

1 small zucchini 2/3 cup pecan halves

1/3 cup unsalted salted, roasted sunflower seeds

Juice from 1 lemon 2 Tbsp

freshly grated orange zest

¼ cup extra virgin olive oil ⇒ Remove

Directions:

  1. To make zucchini ribbons, shave zucchini using a vegetable peeler.
  2. Add spinach to a large bowl and top with ribbons.
  3. Sprinkle with pecans and sunflower seeds.
  4. Squeeze lemon over salad. Sprinkle with zest and drizzle with olive oil.
  5. Add ingredients and lightly mix.

 

Asian Tofu Lettuce Wraps (2-4 Servings)

Ingredients:

2t olive oil ⇒ remove

1 Medium onion, chopped

1T fresh ginger, minced

1T lemongrass, minced

2 Cloves garlic, minced

1 Package Non-GMO extra-firm tofu, drained and crumbled

2 Tbs. Bragg liquid aminos

2 Tbs. hoisin sauce

1-2t low sodium chile sauce

4 Butter lettuce or iceberg lettuce leaves

 

Toppings: 1 large carrot, grated

1/2 C bean sprouts 1/2C edamame

1 Green onion, chopped ½ cup fresh mint, chopped

½ cup peanuts, finely chopped Sprinkle of red pepper flakes

 

Directions:

  1. Heat oil in large skillet over medium heat.  Use a cast iron skillet to cook. Heat the skillet for a few minutes until hot and then add onion. Sautee on low heat until golden brown. Stir onions to keep from burning and sticking to the pan since no oil is being used. Then add ginger, lemongrass, and garlic, and cook until flavors from ingredients blend.
  2. Add tofu and cook 5 minutes, or until heated through. Stir in soy sauce, hoisin sauce, and chile sauce.
  3. Add a scoop of the tofu mixture to each lettuce leaf. Top with carrots, sprouts, edamame, green onions, peanuts, mint and red pepper flakes. Enjoy

 

Black Bean & Kale Haystacks (3 Servings)

Ingredients:

1 Can low sodium black beans, rinsed and drained

1C Cooked quinoa 2C Kale, chopped 1T Olive oil 1/2 Onion, diced 2 Cloves garlic, minced

1 Tomato, chopped

1 Avocado sliced

2 Green onions, chopped

3T Non dairy, unsweetened plain yogurt

3T low sodium salsa

1 Head of romaine lettuce, shredded

Juice from 1 lime

 

Directions: Use a cast iron skillet to cook. Heat the skillet for a few minutes until hot and then add onion. Sautee on low heat until golden brown. Stir onions to keep from burning and sticking to the pan since no oil is being used. Add garlic when onions are cooked. Add black beans and kale and stir until heated through. Remove from heat. On the bottom of the plate add a scoop of quinoa. Top with black bean and kale mixture. Stack on a big handful of lettuce. Top with tomatoes, green onions, avocado, salsa and yogurt. Squeeze a wedge of lime over your haystack and enjoy

 

The Quick & Easy Salad Ingredients:

1 Head of romaine lettuce, chopped

1 Tomato, chopped 1/2C Cucumber, chopped

1/4 Red onion, sliced thin 1 Carrot, peeled and grated

1/2C Low sodium chickpeas, rinsed and drained

Juice & zest from 1/2 lemon Drizzle of olive oil (1-2t)

Directions: 1. Combine ingredients in a big bowl. Top with lemon juice, zest, and a drizzle of olive oil. Enjoy

Dinner (frank)

 

  • Power Bowl

 

-spread out  the chopped sweet potato on one sheet and drizzle with ½ T olive oil  and toss on black pepper. (just remove oilive oil).

     

    

  1. Tempeh Quinoa Salad

replace 1T olive oil -> with 1T water

While the quinoa cooks, prepare the tempeh: heat olive oil vegetable broth in a skillet on medium heat and add onions. Cook until soft (about 5 minutes) 2. Add the bell pepper, tempeh, lime juice and seasonings and cook the mixture for about 15 minutes (stirring occasionally) 3. Pour the cooked quinoa and tempeh mixture into a bowl and add the black beans, cilantro and tomatoes 4. Serve with sliced avocado, a dollop of nondairy yogurt or hummus

  1.  Cauliflower Rice Stir Fry
  2. Place cauliflower in food processor and pulse until finely chopped 2. Heat 1 T olive oil  water in a large pan on medium heat. Add ½ of the onions and garlic to the pan and sauté for 5 minutes. 3. Add cauliflower to the pan along with 1/4 cup of water. Steam the mixture for about 6 minutes, or until the water has evaporated and cauliflower is tender. Transfer to a bowl and cover to keep warm. 4. Sauté the remaining garlic and onions until tender. Add the ginger and chili and cook another minute. 5. Add the broccoli, carrot, bell pepper to the pan and cook 5 minutes or until tender. Turn off the heat and add the spinach and lemon juice, stirring to combine. For each serving, top cauliflower with vegetables and garnish with edamame, pumpkin seeds and cilantro
  3. Spiced Lentil Stew over Quinoa (6 servings)
  4. Heat olive oil  vegetable broth in a pan and sauté onions and garlic for 5 minutes. Then add the tomatoes, lentils, celery, carrots, vegetable broth and spices. Cover and cook on medium heat for 1 hour or until the lentils are soft. 2. While the lentils cook, make the quinoa. Add dry quinoa and 2 cups of water to a pot and heat on high. Once it comes to a boil lower heat to a simmer and cook. After 10 minutes, add beans and carrots and cook for another 10-15 minutes or until the quinoa is cooked. 3. To serve: place quinoa mixture in the bottom of the bowl and top with lentil stew. Enjoy!
  5. Lemon Dill Tofu Steaks
  6. Rinse the tofu and wrap in a few paper towels. Place a heavy object (like a saucepan) on top of the tofu for 25 minutes to remove the moisture. 2. While the tofu is straining, make the lemon dill sauce. Add all dressing ingredients to a food processor and pulse until well incorporated. 3. When the tofu is ready, slice into four large steaks. Heat a skillet over high heat and add non-stick spray to the pan and add the tofu. Let brown on one side for 6 minutes and then flip. Reduce heat if necessary to avoid burning. 4. When tofu is golden on each side, transfer to a bowl and pour on the dressing, stirring to coat. 5. Serve immediately with steamed vegetables and/or quinoa.

 

Healthy Snacks

Nuts/Seeds/Trail Mix: The best trail mixes are free from sugary yogurt bites and chocolate. Beware of the high calorie content and to not overdo consumption. Try to mix your own.

Assess:

  •    How do you know what your risk of having a heart attack will be? Should you be on therapy to lower your risks? What are the best ways to check your cardiovascular risks?
  •    To calculate your Heart Attack Risk, click here and have your recent Cholesterol and blood pressure numbers ready.

This calculator will give you your risk percentage of having a heart attack over the next 10 years

  •     How do you know what your cancer risk is? What are factors that increase my risk? What can I change in my life to lower that risk?

To evaluate your risk of cancer please click here.

Education

  •         Educating yourself on risk factors for having a heart attack is a crucial first step.
  •         Unsure what HDL Cholesterol or Total Cholesterol are?

o   Total Cholesterol:

  •  This is simply a total of all your cholesterol you have in your blood which includes the bad cholesterol  (VLDL and LDL) as well as the good cholesterol (HDL).
  •  What kind of numbers do you want?
  •         Anything over 240 mg/dL is considered high and puts you at twice as much of a risk of developing a heart attack
  •         At the Cardiovascular Institute we like to have our patients aim to keep their total cholesterol levels below 200 mg/dL

o   HDL Cholesterol:

  •  This is considered the good cholesterol. It is good because it carries cholesterol in your blood and brings it to the liver to remove it from your body. In doing so, HDL helps fight the “bad” cholesterol from building up in your arteries, thereby preventing strokes, heart attacks and high blood pressure.
  •  What kind of numbers do you want?
  •         Anything below 40 mg/dL puts you at risk for a heart attack
  •         At the cardiovascular Institute we like to aim to have our patient’s have levels above 60 mg/dL for optimal heart protection.

What can I do to increase my HDL cholesterol?

One of the best ways proven to increase your HDL or “good” cholesterol is exercise! Regular walking, jogging, or activity each day has been shown to increase HDL cholesterol.

  •         Unsure about blood pressure?

o   How exactly does high blood pressure affect my chances of having a heart attack?

  •  A heart attack is the result of a blocked blood supply to the heart muscle tissue. This can happen when the arteries to the heart become thicker and harder from a buildup of plaque. High blood pressure causes scarred arteries that fill up with plaque and become more prone to blood clots. Sometimes plaque or a blood clot can completely close an artery, blocking the blood flow to tissue on the other side.

High blood pressure, over time, also puts a strain on the heart and makes it work harder to pump blood out to the body. With this extra effort to pump, the heart grows in size and may compromise its ability to pump blood as well.

 

  •  What kind of numbers do you want?
  •         
Total cholesterol
Desirable Below                       Below 200
Borderline high                        200-239
High                                           240 or above
LDL (bad) cholesterol
Optimal                                 Below 70
Near/above optimal 100-129
Borderline high 130-159
High 160-189
Very High 190 or above
HDL (good) cholesterol
High 60 or above
Low Below 40
Triglycerides
Normal Below 150
Borderline high 150-199
High 200-499
Very high 500 or above

 

Up to 35% of cases of cancer have a dietary component, with some cancers being tied directly to diet. Research shows patients who follow a plant based diet that is low in fat and high in antioxidants and nutrients is associated with a lower risk of developing cancers such as colon, breast, pancreatic, and prostate cancer.

Implement:

Two of the biggest things you can do to lower your risk of both cancer and heart disease is to eat a healthy diet and exercise daily.

 

Exercise

  • Daily exercise is highly encouraged. We recommend 30 minutes to 1 hour of aerobic exercise. This can include jogging, walking, swimming, or biking. The benefits of daily exercise will not only make you feel better, more confident and happier but it will ultimately prevent disease and unnecessary trips to the doctor.

Diet

  • The old saying of “we are what we eat” has truth to it. We get out of our bodies what we put into them and how we care for them. New research points to a plant based diet reducing the risk of heart disease and many cancers. We also highly encourage a diet low in salt and carbohydrates. For numerous tips on what to eat , tasty recipes, and exercise please take a look at our book online, From Our Heart To Yours,

 

Meat doesn’t only affect your heart – it can lead to many other problems as well. On October 26, 2015, the World Health Organization (W.H.O) officially concluded that processed meats are linked to cancer. These include salted, cured, smoked, or fermented meat like hot dogs, sausages, corned beef, and jerky. The W.H.O based their conclusion on the results of over 800 scientific studies. Most of the studies showed a link between meat and colorectal cancer, but many others found that meat may cause other types of cancer as well, including prostate, pancreatic, and stomach cancer. Based on sufficient evidence regarding the association between consumption of processed meat and colorectal cancer, processed meat was classified as a Group 1 carcinogen. This group of carcinogens include, but are not limited to X-rays, radiation, and even radioactive elements such as Radium. So, perhaps think twice about that weekend barbecue.

the International Agency for Research on Cancer (IARC), which is the cancer agency of World Health Organization, released a report regarding the consumption of red and processed meat, and their role in the development of cancer. A Working Group of 22 experts from 10 countries convened by the IARC Monographs Programme to thoroughly review the accumulated scientific literature regarding the consumption of red meat and processed meat from over 800 different studies on cancer in humans. The report refers to red meat as unprocessed mammalian muscle meat, and most notably includes beef, pork, and lamb. Processed meat refers to meat that has been salted, cured, smoked, or fermented. Such meats include hot dogs, sausages, corned beef, and beef jerky to name a few. The process of cooking meat at high temperatures, in addition to the actually processing meats, have been shown to result in known or suspected cancer causing chemicals. These agents include things called N-nitroso-compounds (NOC), polycyclic aromatic hydrocarbons (PAH), and heterocyclic aromatic amines (HAA), which are all known to damage DNA. Popular ways of preparing meats such as barbecuing and curing or smoking meats may not be so great after all.

 

This report assessed over 800 epidemiological studies that were performed all over the world, thus taking into account a diverse array of diets. These studies all sought to find a link between eating red or processed meat and the development of cancer. Colorectal cancer was the most studied type of cancer, and half of the studies performed showed a positive association with the consumption of red and processed meats. One such study, a meta-analysis of colorectal cancer in ten cohort studies reported a statistically significant dose–response relationship, with a 17% increased risk (95% CI 1·05–1·31) per 100 g per day of red meat and an 18% increase (95% CI 1·10–1·28) per 50 g per day of processed meat (Chan DS, Lau R, Aune D, et al). This study showed that a diet including either 3.5 ounces of red meat or 1.75 ounces of processed meat daily were associated with increased risks of colorectal cancer. More than 15 other cancers were also shown to have a positive association, including prostate, pancreatic, and stomach cancer.

 

Based on sufficient evidence regarding the association between consumption of processed meat and colorectal cancer, the Working Group has classified it as a Group 1 carcinogen, which means it is known to cause cancer in humans. This group of carcinogens include, but are not limited to X-rays, radiation, and even radioactive element such as Radium.


Based on limited evidence regarding the association between consumption of red meat and cancer, the Working Group has classified it as a Group 2A carcinogen, meaning it probably causes cancer in humans. However, the report states that strong mechanistic evidence exists for red meat as a cancer causing agent because of the fact that cooking red meat at high temperatures creates chemicals that cause DNA damage. Group 2A carcinogens include, but are not limited to UV radiation, as well as many chemicals.

 

Red Meat:

A Working Group of 22 experts from 10 countries convened by the IARC Monographs Programme to thoroughly review the accumulated scientific literature regarding the consumption of red meat and processed meat from over 800 different studies on cancer in humans. Red meat refers to unprocessed mammalian muscle meat. Processed meat refers to meat that has been transformed by salting, curing, fermenting, and smoking. While cooking allows for red meat to be easily digested by the body, it “can result in the formation of carcinogenic chemicals, including heterocyclic aromatic amines (HAA) and PAH.” ½ Some people may question the consumption of raw meats to decrease the chance of cancer, but it usually also comes with the risk of getting an infection.

 

1 Alaejos MS, Afonso AM. Factors that affect the content of heterocyclic aromatic amines in foods. Comp Rev Food Sci Food Safe 2011; 10: 52–108.  

2 Alomirah H, Al-Zenki S, Al-Hooti S, et al. Concentrations and dietary exposure to polycyclic aromatic hydrocarbons (PAHs) from grilled and smoked foods. Food Control 2011; 22: 2028–35.

3 Chan DS, Lau R, Aune D, et al. Red and processed meat and colorectal cancer incidence: meta-analysis of prospective studies. PLoS One 2011; 6: e20456.

 

“This recommendation was based on epidemiological studies suggesting that small increases in the risk of several cancers may be associated with high consumption of red meat or processed meat.”

World Health Organization – Meat is linked to higher cancer risk

https://www.iarc.fr/en/media-centre/pr/2015/pdfs/pr240_E.pdf

 

http://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(15)00444-1.pdf

  • journal summary

 

Screening for Colorectal Cancer

https://youtu.be/ilXPgpJAdb8

Resources from Vegan Video

http://www.ncbi.nlm.nih.gov/pubmed/21135028

Risk factors for mortality in the nurses’ health study: a competing risks analysis.

look for note about 1 egg a day is like smoking 5 cigarette a day

http://www.ncbi.nlm.nih.gov/pubmed/22210577

High fat intake leads to acute postprandial exposure to circulating endotoxin in type 2 diabetic subjects.

the endotoxins in the animal products is the real issue

http://www.ncbi.nlm.nih.gov/pubmed/19279082

Cancer incidence in vegetarians: results from the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford).

blood of vegan fights cancer more

http://www.ncbi.nlm.nih.gov/pubmed/21558046

Red meat and colon cancer: should we become vegetarians, or can we make meat safer?

looking into meats

http://www.ncbi.nlm.nih.gov/pubmed/16094059

Intensive lifestyle changes may affect the progression of prostate cancer.

http://www.ncbi.nlm.nih.gov/pubmed/16965238

Effects of a low-fat, high-fiber diet and exercise program on breast cancer risk factors in vivo and tumor cell growth and apoptosis in vitro.

Top Ten Excuses People Give to Not Go Vegan

  1. I enjoy cheese and meat too much to give it up
  2. How am I getting enough vitamins and minerals?
  3. Will my protein intake be enough
  4. I feel too tired when I try and eat all vegan
  5. I am always hungry
  6. It take too much time to try and get everything ready
  7. The food is too bland (Fact about taste buds changing in 2 weeks…salt will then taste bad)
  8. Will the diet provide my kids with everything they need to grow

changing old habits- ppl will ask if you have cancer

make small changes every day

where is the research

possibly give patients a short handout that has snack/ quick and easy meals to have. along with things to avoid!

 

local cooking classes? sometime it helps to do it all together and then it is easier to do on your own

Preheat oven to 400°F.   In a food processor, process cauliflower until finely chopped.    In a microwave-safe bowl, cook cauliflower for five minutes or until tender. Place cauliflower in a towel, and squeeze out excess water so it is completely dry.    In a bowl, mix egg and cauliflower until well-combined.   On a parchment-lined baking sheet, spread cauliflower dough out until it resembles a pizza round. Bake for 40 minutes.    Top however you want and bake in a 450°F oven for 7 minutes or until cheese and toppings have baked. – See more at: http://www.rachaelrayshow.com/recipe/17239_Cauliflower_Pizza_Dough/#sthash.xOOuW5Ev.dpuf

 

Flax seed: Mix 1 tablespoon of ground flax seeds with 3 tablespoons hot water, set aside for 3 minutes to thicken. Add 1/4 teaspoon baking powder for leavening. This recipe can also be used without the baking powder for recipes needing binding and moisture, according to Angela’s Kitchen.

 

Electrophysiology Study and Radiofrequency Ablation

 

What is an Electrophysiology Study with Radiofrequency Ablation?

An electrophysiology study is a procedure used to evaluate abnormal heartbeats. During the procedure Dr. Ben-Zur uses a special type of cardiac catheter to inspect the electrical activity of the heart and assess heart rhythm, rate and type of heart beat. Radiofrequency ablation is performed for many different types of heart arrhythmias such as atrioventricular reentrant tachycardia (AVRT) or AV nodal reentrant tachycardia (AVNRT), atrial flutter, atrial fibrillation, and Wolff-Parkinson-White syndrome. The radiofrequency ablation procedure blocks the electrical signals traveling through your heart to stop the abnormal rhythm and allow signals to travel over a normal pathway instead.

 

When does a patient need this procedure?

Electrophysiology study and radiofrequency ablation will be considered if you have a persistent symptomatic arrhythmia that is refractory to medications and direct current cardioversion.

Dr. Ben-Zur will determine the need for this procedure based on your symptoms, results of diagnostics and current medical condition.

 

How are electrophysiology study and radiofrequency ablation procedures done?1

Before your procedure begins a specialist will insert an intravenous line into your forearm or hand, and you will be given a sedative to help you relax. After your sedative takes effect, Dr. Ben-Zur will numb a small area near a vein on your groin. A needle will be inserted into the vein with a tube (sheath) placed through the needle. Catheters will be threaded through the sheath and to the heart. Dye may be injected through the catheter to visualize blood vessels and heart via x-ray imaging. The catheters have electrodes at the tips that will be used during the procedure. Once in place, the electrodes will send electrical impulses to your heart and record your heart’s electrical activity. This will help detect the abnormal heart tissue that is causing the arrhythmia in your heart. Once the abnormal heart tissue causing the arrhythmia is identified, heat energy is applied at the catheter tip that alters the tissue triggering your arrhythmia.

 

Cardiac ablation usually takes 2-4 hours to complete, but complicated procedures may take longer. During the procedure, it’s possible you’ll feel some minor discomfort when energy is run through the catheter tips. If you experience any type of severe pain or shortness of breath, you should alert the medical team.

 

What to expect before the procedure:

Before the procedure you will have a pre-procedure appointment. This will include obtaining labs and any necessary imaging as well as any medication adjustments that need to be made for the procedure. This is an additional opportunity to ask any questions that you may have.

 

How long will the procedures take?

An electrophysiology study and ablation usually take 2-4 hours.

 

On the day of the procedure:

  • Do not eat or drink anything after midnight the night before the exam.
  • Do not ingest any stimulants for 24 hours BEFORE the test. This includes coffee, tea, and cola drinks.
  • Wear loose fitting, comfortable clothing.
  • Do not wear necklaces or clothing with metal on it (metal buttons, sequins, brooches, etc.).
  • If you have asthma presently or previously, bring your inhaler(s) with you.
  • Bring a list of your medications with you.
  • Take your usual morning medications with sips of water on the day of your test unless directed by Dr. Ben-Zur.
  • Notify Dr. Ben-Zur if you take insulin or diabetic medication as these medications may need to be discontinued or decreased the morning of the procedure.

 

What are possible complications?

With any procedure there is always a risk of complications. Electrophysiology studies and radiofrequency ablations are common medical procedures. Serious complications are uncommon but may occur. If Dr. Ben-Zur determines that you are a candidate for electrophysiology study and radiofrequency ablation, he will have a long discussion with you regarding the risks, benefits, and alternatives of the procedure, including but not limited to: infection, bleeding, heart attack, stroke, death, neurologic deficit, nerve injury, lymphatic injury, venous thrombosis, pericardial effusion (blood around the heart), pleural effusion (blood around the lungs), pulmonary embolism, hematoma, pain, need for an emergent operation such as emergency coronary artery bypass grafting, possible blood transfusion and its complications, complications associated with anesthesia, drug allergies, vascular perforation, dissection, rupture, thrombosis, distal embolization, arrhythmia (irregular heartbeat) that may require a pacemaker to correct, renal insufficiency/failure, dialysis dependence, limb loss, dye allergy, discomfort and bleeding at the catheter insertion site, and radiation exposure. Your risk of having these complications may increase if you have diabetes or kidney disease.

 

Wound site care:

  • No stitches are needed.
  • You will have a small sterile dressing on your wound. It may be removed the next day.
  • Keep the area clean and dry.

 

Need more information?

We encourage you to ask Dr. Ben-Zur any questions and discuss concerns you have at anytime. Visit our website at www.DrBenZur.com, give us a call at (818) 986-0911, or email us at [email protected]. You may also call Dr. Ben-Zur after hours if you have any additional questions that you did not have a chance to ask during your visit.

Cardiac Catheterization and Percutaneous Coronary Intervention (PCI)

 

What is cardiac catheterization?

Cardiac catheterization is a medical procedure that visualizes the blood vessels of the heart to detect narrowing or obstruction in blood vessels that can reduce blood flow. A small hollow tube called a catheter is inserted into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Once the catheter is in the heart, a special type of dye is injected and allowed to flow through the bloodstream in your heart. Dr. Ben-Zur proceeds to take x-ray pictures of you heart. The dye will make the heart arteries visible on the pictures. This test is called coronary angiography and allows Dr. Ben-Zur to determine the location and degree of blood vessel narrowing or obstruction. If narrowing or obstruction is detected, he will continue with a percutaneous coronary intervention (PCI) procedure to open up the narrowing or obstruction.

 

What is Percutaneous Coronary Intervention (PCI)?

Percutaneous coronary intervention (PCI) or coronary angioplasty is a procedure that uses a catheter to place a small device, either a balloon or a stent, to open up a blood vessel that has been blocked by plaque. Plaque is a buildup of cholesterol and other inflammatory particles. Imagine placing a deflated balloon in the hole of a donut and slowly inflating it. In blood vessels, the balloon is placed at the site of narrowing and carefully inflated against the blood vessel wall, which gradually expands the wall. This procedure reestablishes blood flow in your vessels so that you can get more oxygen to all areas of your heart.

 

What types of stents are used in PCI?

A stent may be placed in your blood vessel during a PCI procedure. There are two main stents used: a traditional, bare-metal stent and a drug-eluting stent.

 

When does a patient need this procedure?

Catheterization and PCI procedures will be considered if there is suspicion that you have a blocked vessel in the heart. Dr. Ben-Zur will determine the need for this procedure based on your symptoms, results of diagnostic tests and current medical condition.

 

What to expect during the procedure:

Access to your arteries will be obtained through the femoral artery located in your leg. This is often called percutaneous access. Once access is obtained a sheath will be used to hold the artery open while also inhibiting blood loss. A long, thin hollow tube, known as the “guiding catheter”, is inserted into the artery and travels up to your heart. This cather has a reservoir of radio-opaque dyes, which allows you to see the dye on x-ray. Once the catheter reaches the target location dye is injected throughout your heart’s blood vessels so that Dr. Ben-Zur can detect which blood vessels are blocked. Once the blood vessels are visualized with the x-ray, he can estimate the size of the balloon or balloon/stent catheter and guidewire needed to break up the plaque. From here the guidewire creates a hole in the plaque and the balloon is inflated to push the plaque up against the wall. If a stent is needed it will be implanted at this time. The balloon and guidewire are retracted out of the blood vessel and the sheath is removed from the femoral artery.

What to expect before the procedure:

Before the procedure you will have a pre-procedure appointment. This will include obtaining labs and any necessary imaging as well as any medication adjustments that need to be made for the procedure. This is an additional opportunity to ask any questions that you may have.

 

On the day of the procedure:

  • Do not eat or drink anything after midnight the night before the exam.
  • Do not ingest any stimulants for 24 hours BEFORE the test. This includes coffee, tea, and cola drinks.
  • Wear loose fitting, comfortable clothing.
  • Do not wear necklaces or clothing with metal on it (metal buttons, sequins, brooches, etc.).
  • If you have asthma presently or previously, bring your inhaler(s) with you.
  • Bring a list of your medications with you.
  • Take your usual morning medications with sips of water on the day of your test unless directed by Dr. Ben-Zur.
  • Notify Dr. Ben-Zur if you take insulin or diabetic medication as these medications may need to be discontinued or decreased the morning of the procedure.

 

What are possible complications?

With any procedure there is always a risk of complications. Cardiac catheterization and PCI are common medical procedures. Serious complications are uncommon but may occur. There are risks, benefits, and alternatives of the procedure. Risks include but are not limited to: infection, bleeding, heart attack, stroke, death, neurologic deficit, nerve injury, lymphatic injury, venous thrombosis, pericardial effusion (blood around the heart), pleural effusion (blood around the lungs), pulmonary embolism, hematoma, pain, need for an emergent operation such as emergency coronary artery bypass grafting, possible blood transfusion and its complications, complications associated with anesthesia, drug allergies, vascular perforation, dissection, rupture, thrombosis, distal embolization, arrhythmia (irregular heartbeat), renal insufficiency/failure, dialysis dependence, limb loss, dye allergy, discomfort and bleeding at the catheter insertion site, and radiation exposure. Sometimes chest pain can occur during PCI because the balloon briefly blocks blood supply to the heart.

 

The risk of complications is higher in patients:

  • aged 65 and older
  • who have chronic kidney disease
  • who are in shock
  • who have extensive heart disease and blockages in their coronary (heart) arteries

 

There are also possible complications after stent placement. Stent restenosis is a problem that can occur after PCI.This results from too much tissue growth within the treated portion of the artery. This can cause the artery to become narrow or blocked again, often within 6 months.

 

Stents coated with medicine (drug-eluting stents) reduce the growth of scar tissue around the stent. These stents further reduce the risk of restenosis. There are risks and benefits of each type of stent. Please ask us for more information.

 

Need more information?

We encourage you to ask Dr. Ben-Zur any questions and discuss concerns you have at anytime. Visit our website at www.DrBenZur.com, give us a call at (818) 986-0911, or email us at [email protected]. You may also call Dr. Ben-Zur after hours if you have any additional questions that you did not have a chance to ask.

DMD Nephrology Case 1 – Acute Renal Failure

 

You are requested to see an 80-year-old man on the surgical service because of an elevated BUN and creatinine. He had just undergone a splenectomy for thrombocytopenia secondary to splenomegaly from underlying chronic lymphocytic leukemia.  Immediately before surgery his BUN was 22 mg/dl, creatinine was 1.3 mg/dl, urinalysis was normal.  When checked two days post operatively, his BUN had increased to 40mg/dl, and creatinine was 3/0 mg/dl.  Urine output for each of the last two days was approximately 250 ml/day.

 

Discussion points:

  • Given the above information, how would you characterize this patient’s kidney problem? (Go through the differential of prerenal, renal and post renal causes of azotemia)
  • What further information do you need to get historically, through the hospital record, and on physical exam on assessing this patient’s problems?

 

The patient denies symptoms of congestive heart failure.  He has not been extremely thirsty over the last several days.  He has had difficulty urinating over the past several years with a weak urinary stream and nocturia 3-4 times per night. His doctor told him that he had BPH but no therapy was given. The patient denies leg pain or flank pain.  The hospital chart is reviewed which showed the patient had significant bleeding in the operative period with several episodes of hypotension with systolic blood pressure in the 80 range.  These episodes lasted for short periods of time less than 5 minutes and returned to normal blood pressure after that period.  His urine output was 700 ml/day immediately after surgery and dropped to 200-300 ml/day over the past two days.  For the three days after surgery his total fluid balance is positive 3 liters.  His only medication postoperatively was analgesia with Dilaudid.  He did receive one dose of Cephalothin preoperatively and none since that time.

 

Discussion point:

  • How does this historical information affect your differential? (Include possibilities of post-obstructive renal failure secondary to prostatism, and acute tubular injury secondary to hypotensive episodes.)

 

The patient’s physical exam showed his T-37 C, RR-14, BP-130/90, P-82 with no orthostatic changes.  His mucous membranes were moist.  Neck pains were 1cm above the sternal angle.  The patient’s lung exam was clear to auscultation and percussion without rales.  Cardiac exam has a normal S1, S2 without S3 or murmurs appreciated.  The patient’s abdomen was soft with slight tenderness over the surgical scar.  No ecchymosis were noted.  The patient had no CVA tenderness or ecchymosis present in the back.  A foley catheter was placed in the patient at that time which showed approximately 50 cc of urine in the patient’s bladder.

 

Discussion points:

  • How does his physical examination help you in determining the cause of this patient’s acute renal failure? (No signs or symptoms of prerenal azotemia, or post renal obstruction.  The patient could conceivably have ureteral obstructions or trauma to his ureters during surgery though both seem unlikely?
  • What laboratory tests would you order at this time?

 

A fresh specimen of the patient’s urine is examined under the microscope and showed numerous epithelial cells and brown degenerating cellular casts.  No crystals or WBC’s were noted, and only rare RBC’s were present.  The urine sodium was 40 meq/l.  Urine specific gravity was 1.01.  Repeat BUN and creatinine on the 4th day after surgery are BUN-52 mg/dl, creatinine-3.5mg/dl. Uric acid was 9.2 mg/dl.  A renal ultrasound is done, kidneys are normal in size, and no signs of obstruction are present.

 

Discussion points:

  • What is your diagnosis at this time? (ATN seems most likely secondary to the patient’s episode of  hypotension during surgery. Both physical examination and renal ultrasound confirm no signs of bladder obstruction or ureteral obstruction)
  • How would you treat the patient at this time?

 

On day 6 after surgery, the patient’s BUN is 68 mg/dl, creatinine is 4.1 mg/d.  His urinary volumes are between 300-500 ml/day.  Serum electrolytes are NA – 142 mg/dl, K-4.2 mg/dl, Cl-98 mg/dl, HCO3-23 mg/dl.  The patient is started on fluid and salt restriction but he remains oliguric. By day 8 the patient’s BUN is 85 mg/dl, creatinine is 6.3 mg/dl.

 

Discussion points:

  • Is there anything else you would do to manage the patient at this point? (When do you start dialysis on a patient? What are the signs of uremia?)
  • What is the expected course of patients with acute tubular necrosis?

On day 9, postoperatively the patient’s urine output begins to rise to one liter per day, and by day 11 it is up to 3 ½ liters per day.  The patient’s BUN is up to 92 mg/dl, creatinine is 6.9 mg/dl on day 11.

 

Discussion points:

  • Given the patient is now in the polyuric phase of ATN, how would you change his fluid and electrolyte management?

 

On day 12 the patient’s urine output begins to decrease to 1/5 liters per day.  His BUN and creatinine begin to fall.  Fluid and salt restrictions are discontinued.  The patient is discharged from the hospital on day 14 and followed up as an outpatient. His BUN and creatinine returned to normal three weeks after surgery.

Triglycerides and Cholesterol

– Two primary forms of lipids in the blood
– Triglycerides function as energy source and are stored in adipose tissue.
– Cholesterol is primarily used to make steroids hormones, cell membranes.and bile acids.
– Water-insoluble fats that must be bound to apolipoproteins, specialized lipid-carrying proteins
– Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein

Lipoproteins

Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein

– Lipoproteins transport lipids via the blood.

Different types:
– Very-low-density lipoprotein (VLDL)
Produced by the liver
Transports endogenous lipids to the cells

– Low-density lipoprotein (LDL)

– High-density lipoprotein (HDL)
Responsible for “recycling” of cholesterol
Also known as “good cholesterol”

Cholesterol levels and risk for CHD ( coronary heart disease)

The risk of CHD in patients with cholesterol levels of 300 mg/dL is three to four times greater than that in patients with levels less than 200 mg/dL

Coronary Heart Disease
Positive Risk Factors

-Age
Male 45 years or older
Female 55 years or older
Family history of premature CHD
– Current cigarette smoker

– Hypertension
BP 140/90 or higher, or on antihypertensive medication
– Low HDL levels: less than 40 mg/dL
-Diabetes mellitus

Coronary Heart Disease
Negative (Beneficial) Risk Factor

High HDL (“good” cholesterol): 60 mg/dL or higher

 

Secondary causes of dyslipidemia

 

  • In patients with type 2 diabetes mellitus (DM), hyperlipidemia occurs in association with insulin resistance and frequently involves increased triglycerides and low serum high density lipoprotein (HDL) cholesterol.

 

  • Excessive alcohol consumption can raise triglyceride levels.

 

  • Primary biliary cholangitis and similar disorders may be accompanied by marked hypercholesterolemia that results from an accumulation of lipoprotein-X.

 

  • Marked hyperlipidemia can occur in the nephrotic syndrome due primarily to high serum total and low density lipoprotein (LDL) cholesterol concentrations.

 

  • Dyslipidemia is less prominent in chronic kidney disease (CKD), but CKD is associated with elevations in LDL cholesterol and triglycerides, and low levels of HDL cholesterol; hypertriglyceridemia (type IV hyperlipoproteinemia) occurs in 30 to 50 percent of cases of CKD.

 

  • Hypothyroidism is a common cause of hyperlipidemia, most typically raising LDL cholesterol, but hypertriglyceridemia can also be seen. We suggest screening for hypothyroidism in all patients with dyslipidemia.

 

  • Smoking modestly lowers the serum HDL cholesterol concentrations and HDL atheroprotective properties. (See ‘Cigarette smoking’ above.)

 

  • Obesity is associated with a number of deleterious changes in lipid metabolism, including high serum concentrations of total cholesterol, LDL cholesterol, VLDL cholesterol, and triglycerides, and a reduction in serum HDL cholesterol concentration.

 

  • A number of medications can affect serum lipid concentrations, either directly or through effects on weight or glucose metabolism: thiazide diuretics, beta blockers, and oral estrogens, atypical antipsychotic agents.

 

Treatment Guidelines

-Antilipemic drugs
Drugs used to lower lipid levels
Used as an adjunct to diet therapy
-Drug choice based on the specific lipid profile of the patient
– All reasonable non-drug means of controlling blood cholesterol levels (e.g., diet, exercise) should be tried for at least 6 months and found to fail before drug therapy is considered

The different types of antilipemic drugs

-HMG-CoA reductase inhibitors (HMGs, or statins)
-Bile acid sequestrants
-Niacin (nicotinic acid)
-Fibric acid derivatives (fibrates)
-Cholesterol absorption inhibitor (Zetia)
Combination drugs (Vytorin)

HMG-CoA Reductase Inhibitors (HMGs, or statins)

Most potent LDL reducers

HMG-CoA Reductase Inhibitors:
Mechanism of Action

-Inhibit HMG-CoA reductase, which is used by the liver to produce cholesterol
-LOWER RATE OF CHOLESTEROL PRODUCTION

HMG-CoA Reductase Inhibitors:
Indications

-First-line drug therapy for hypercholesterolemia
– Treatment of types IIa and IIb hyperlipidemias
Reduces LDL levels by 30% to 40%
Increases HDL levels by 2% to 15%
Reduces triglycerides by 10% to 30%
– Atorvastatin appears to be more effective in lowering triglyceride levels than other HMG-CoA reductase inhibitors.

HMG-CoA Reductase Inhibitors:
Adverse Effects & contraindications

Contraindications: allergy, pregnancy, liver disease or elevation in liver enzymes

Adverse Effects:
– Mild, transient GI disturbances, Rash and Headache. ( most common problems)
– Myopathy (muscle pain), possibly leading to the serious condition rhabdomyolysis
– Elevations in liver enzymes or liver disease

rhabdomyolysis

breakdown of muscle protein accompanied by myoglobinuria
– abnormal urinary excretion of protein can place a severe strain on the kidneys, possibly leading to acute renal failure and even death.

Atorvastatin (Lipitor)

Pregnancy X

-statin drug
most commonly used drug in this class of cholesterol-lowering drugs.
– to lower total and LDL cholesterol levels as well as levels of triglycerides.
– raise levels of “good” cholesterol, the HDL component
– can be dosed at any time of day. However, bedtime dosing provides peak drug levels in a time frame that correlates better with the natural diurnal (daytime) rhythm of cholesterol production in the body.

Bile Acid Sequestrants

These drugs are now considered second-line drugs in most cases, less preferred than the more potent statins

– However, they are still a suitable alternative in patients intolerant of the statins.
-Generally these drugs lower the plasma concentrations of LDL cholesterol by 15% to 30%.
– They also increase the HDL cholesterol level by 3% to 8%
– increase hepatic triglyceride and VLDL production, which may result in a 10% to 50% increase in the triglyceride level.

Bile Acid Sequestrants:
Mechanism of action

– Prevent resorption of bile acids from small intestine
-Bile acids are necessary for the absorption of cholesterol from the small intestine and are also synthesized from cholesterol by the liver. This is one natural way that the liver excretes cholesterol from the body.
-The more that bile acids are excreted in the feces, the more the liver converts cholesterol to bile acids. This reduces the level of cholesterol in the liver and thus in the circulation as well.
-The liver then attempts to compensate for the loss of cholesterol by increasing the number of LDL receptors on its surface. Circulating LDL molecules bind to these receptors to be taken up into the liver, which also has the benefit of reducing circulating LDL in the bloodstream.

Bile Acid Sequestrants:
Indications

-Type II hyperlipoproteinemia
-Relief of pruritus associated with partial biliary obstruction (cholestyramine)
-May be used along with statins

Bile Acid Sequestrants:
Adverse Effects & contraindications

contraindications:
drug allergy, biliary or bowel obstruction, and phenylketonuria (PKU)

Adverse effects:
-Constipation
-Heartburn, nausea, belching, bloating
These adverse effects tend to disappear over
time- Increasing fiber and fluid intake may relieve constipation and bloating.

Cholestyramine (Questran)

Bile Acid Sequestrants drug
-contraindicated in patients with a known hypersensitivity to it and in those who have complete biliary obstruction or PKU.
-It may interfere with distribution of the proper amounts of fat-soluble vitamins to the fetus or nursing infant of a pregnant or nursing woman taking the drug. -Cholestyramine is now being used for its constipating effect, often given as needed for loose bowel movements.

Niacin (Nicotinic Acid) ) Nicobid

-Vitamin B3
-Lipid-lowering properties require much higher doses than when used as a vitamin
-Effective, inexpensive, often used in combination with other lipid-lowering drugs

Niacin: Mechanism of Action

-Thought to increase activity of lipase, which breaks down lipids
-Reduces the metabolism or catabolism of cholesterol and triglycerides
– In large doses, it may produce vasodilatation that is limited to the cutaneous vessels. This effect seems to be induced by prostaglandins.
– Niacin also causes the release of histamine, which results in an increase in gastric motility and acid secretion.

Niacin: Indications

-Effective in lowering triglyceride, total serum cholesterol, and LDL levels
-Increases HDL levels
-Effective in the treatment of types IIa, IIb, III, IV, and V hyperlipidemias

Niacin: Adverse Effects & contraindications

Contraindications: liver disease, hypertension, peptic ulcer and active hemorrhagic procress

adverse effects:
-Flushing (caused by histamine release)
-Pruritus
-GI distress
– small doses of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) may be taken 30 minutes before the niacin dose to minimize the cutaneous flushing. These undesirable effects can also be minimized by starting patients on a low initial dosage and increasing it gradually, and by having patients take the drug with meals.

niacin
drug profile

very effective, inexpensive medication that, as previously mentioned, has beneficial effects on LDL cholesterol, triglyceride, and HDL cholesterol levels.

– Drug therapy with niacin is usually initiated at a small daily dose taken with or after meals to minimize the adverse effects previously discussed.

– Liver dysfunction has been observed in individuals taking sustained-release forms of niacin, but not immediate-release forms. However, newer extended-release dosage forms, which dissolve more slowly than the immediate-release forms but faster than the sustained-release forms, appear to have even better adverse effect profiles, including less hepatotoxicity and flushing of the skin.

– Niacin is contraindicated in patients who have shown a hypersensitivity to it; in those with peptic ulcer, hepatic disease, hemorrhage, or severe hypotension; and in lactating women.
– It is also not recommended for patients with gout.

Fibric Acid Derivatives (also known as fibrates): Mechanism of Action

-Believed to work by activating lipase, which breaks down cholesterol
-Also suppress the release of free fatty acid from adipose tissue, inhibit synthesis of triglycerides in the liver, and increase secretion of cholesterol in the bile

Fibric Acid Derivatives: Indications

all decrease the triglyceride level and increase the HDL cholesterol level by as much as 25%.

– Treatment of types III, IV, and V hyperlipidemias

Fibric Acid Derivatives:
Adverse Effects and contraindications

Contraindications:
– rug allergy and may include severe liver or kidney disease, cirrhosis, and gallbladder disease.

Adverse Effects:
-Abdominal discomfort, diarrhea, nausea
-Blurred vision, headache
-Increased risk of gallstones
-Prolonged prothrombin time
-Liver studies may show increased function

Gemfibrozil (Lopid)

Fibrate

-decreases the synthesis of apolipoprotein B and lowers the VLDL level. It can also increase the HDL level. In addition, it is highly effective for lowering plasma triglyceride levels.

Cholesterol Absorption Inhibitor:
EZETIMIBE — Ezetimibe is a cholesterol absorption inhibitor that impairs dietary and biliary cholesterol absorption at the brush border of the intestine without affecting the absorption of triglycerides or fat soluble vitamins. Its mechanism appears to involve inhibition of Niemann-Pick C1 like 1 (NPC1L1) protein, which is expressed both in the intestine and the liver, with this inhibition resulting in a net decrease in cholesterol absorption from the intestine

In two randomized, double-blind, placebo-controlled trials, ezetimibe at a dose of 10 mg/day reduced LDL-C by approximately 17 percent. Ezetimibe is also effective as adjunctive therapy to a statin

IMPROVE-IT, the first large trial to directly assess clinical outcomes with ezetimibe plus a statin compared with a statin alone, found that after a median follow-up of six years, patients with an acute coronary syndrome randomized to ezetimibe/simvastatin had a lower rate of the primary composite CV outcome (CV death; MI; hospital admission for unstable angina; coronary revascularization 30 or more days after randomization; or stroke) than those randomized to simvastatin alone (hazard ratio [HR] 0.94, 95% CI 0.89-0.99; seven-year event rates 32.7 versus 34.7 percent)

 

The precise role of ezetimibe relative to other lipid lowering drugs is unclear. Similar reductions in LDL-C can often be achieved simply by maximizing the dose of statins.

 

Ezetimibe may be helpful for avoiding high doses of statins (and potentially increased susceptibility to muscle injury) in patients who do not meet cholesterol goals on low dose statin therapy alone.

Ezetimibe has been well tolerated in clinical trials. When administered alone, the incidence of either myopathy or serum transaminase elevations was similar to that of placebo; when coadministered with a statin, the incidence of serum transaminase elevation has been slightly higher than with statin therapy alone. The manufacturer suggests measurement of liver function tests prior to initiating treatment with ezetimibe plus a statin.

 

Gemfibrozil and fenofibrate have been noted to increase ezetimibe levels although the clinical significance of this is uncertain. Ezetimibe and fenofibrate have been safely used in combination. It is ok use this combination clinically.

 

PCSK9 INHIBITORS — Proprotein convertase subtilisin kexin 9 (PCSK9) is a serine protease produced predominantly in the liver that leads to the degradation of hepatocyte LDL receptors and increased low-density lipoprotein cholesterol (LDL-C) levels.

Therapies that lower circulating PCSK9 levels significantly lower LDL-C levels. This category of lipid lowering therapy appears promising in a range of clinical situations.

Monoclonal antibodies that inhibit PCSK9 (PCSK9 abs) reduce LDL-C in a dose-dependent manner, by as much as 70 percent, and by as much as 60 percent in patients on statin therapy. In contrast with many of the other agents that have been used for lipid lowering, these agents also appear to produce substantial clinical benefits; this may reflect the much greater reductions in LDL-C seen with anti-PCSK9 abs than with most other agents.

 

In particular, treatment with PCSK9-abs appears to result in additional reductions in CV risk even in patients already on intensive or maximal statin therapy:

 

  • In two open-label trials of the monoclonal antibody evolocumab that were combined for analysis, 4465 patients who had completed one of twelve phase 2 or phase 3 trials of evolocumab were randomly assigned to evolocumab (140 mg injected subcutaneously every two weeks or 420 mg monthly) plus standard therapy, or standard therapy alone The patients in the underlying trials included those on statin therapy (approximately 70 percent), including high-intensity statin therapy (approximately 27 percent), as well as patients who were statin intolerant or who were on no other lipid lowering therapy, and the median duration of follow-up was 11.1 months. Adverse events were similar in both groups (69 versus 64 percent), as were serious adverse events (7.5 percent in each group); neurocognitive events, although uncommon, were more frequent with evolocumab (0.9 versus 0.3 percent). Patients treated with evolocumab had a lower rate of cardiovascular (CV) events (1.0 versus 2.2 percent, hazard ratio [HR] 0.47, 95% CI 0.28-0.78).

 

Herbal Product: Garlic

-Used as an antispasmodic, antihypertensive, antiplatelet, lipid reducer
-Adverse effects: dermatitis, vomiting, diarrhea, flatulence, antiplatelet activity
-Possible interactions with warfarin, diazepam
-May enhance bleeding when taken with NSAIDs

Herbal Product: Flax

-Both the seed and oil of the plant are used
-Uses: atherosclerosis, hypercholesterolemia, GI distress, menopausal symptoms
-May cause diarrhea and allergic reactions
-Possible interactions: antidiabetic drugs, anticoagulant drugs

Herbal Product: Omega-3
Fatty Acids

-Fish oil products
-Used to reduce cholesterol
-May cause rash, belching, allergic reactions
-Potential interactions with anticoagulant drugs

 

Nursing Implications

-Assess dietary patterns, exercise level, weight, height, VS, tobacco and alcohol use, family history
– Contraindications include biliary obstruction, liver dysfunction, active liver disease
– Obtain baseline liver function studies
-Patients on long-term therapy may need supplemental fat-soluble vitamins (A, D, K)
-Take with meals to decrease GI upset
– Counsel patient concerning diet and nutrition on an ongoing basis
-Instruct patient on proper procedure for taking the medications
-Powder forms must be taken with a liquid, mixed thoroughly but not stirred, and NEVER taken dry
– Other medications should be taken 1 hour before or 4 to 6 hours after meals to avoid interference with absorption
– To minimize adverse effects of niacin, start on low initial dose and gradually increase it, and take with meals
– Small doses of aspirin or NSAIDs may be taken 30 minutes before niacin to minimize cutaneous flushing
– Inform patients that these drugs may take several weeks to show effectiveness

 

Treatment of patients with a history of any of the following is considered “secondary prevention”
Coronary heart disease
Myocardial infarction
Angina
Coronary revascularization
Cerebrovascular disease
Stroke
Transient ischemic attack
Peripheral arterial disease
Multiple risk factors that confer a 10-year risk of CVD >20%
Chronic kidney disease with estimated GFR <45 mL/min per 1.73 m2*

 


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