Common Painkillers May Be Risky After Heart Attack

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By Salynn Boyles
WebMD Health News

Reviewed by Louise Chang, MD

Sept. 10, 2012 -- Heart attack survivors who take commonly used pain relievers have a higher risk of dying or having another heart attack, new research shows.

The Danish study adds to the evidence linking non-steroidal anti-inflammatory drugs (NSAIDs) such as celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Advil, Motrin), and naproxen (Aleve) to poorer outcomes in heart patients.

Using the painkillers after a first heart attack was linked to a higher risk for a second heart attack or death from any cause. And the risk persisted over at least five years.

Like previous studies, the new research does not prove that NSAIDs are directly responsible for these events.

But the evidence as a whole strongly suggests that the pain relievers should be used cautiously, if at all, by heart attack survivors, says Anne-Marie Schjerning Olsen, MD, who led the Danish study.

"Our results indicate that use of NSAIDs is associated with persistently increased coronary risk, regardless of the time elapsed after a [heart attack]," she says. "Thus, long-term caution is advised in all patients."

The study included data on nearly 100,000 survivors of first heart attacks, taken from Danish hospital and pharmacy registries.

Just under half of the people (44%) filled at least one prescription for an NSAID at some point after their heart attack.

Compared to those who presumably did not take NSAIDs, people who did had a 59% increased risk of death from any cause within one year of having the heart attack and a 63% increased risk over five years.

The risk of having another heart attack or dying from heart disease was 30% higher after one year in NSAID users and 41% after five years.

American Heart Association (AHA) immediate past president Gordon Tomaselli, MD, says the study is one of the first to suggest that NSAID use may be risky for many years after a first heart attack.

Tomaselli directs the division of cardiology at the Johns Hopkins University School of Medicine in Baltimore.

In 2007, the AHA issued a statement on NSAID use in heart patients, urging doctors to carefully weigh the risks vs. benefits before recommending the drugs or prescribing them.

Tomaselli says this means carefully assessing a person's risk, which is influenced by conditions like heart failure or diabetes.

He says for many heart patients, non-NSAID painkillers like acetaminophen (Tylenol) or even short-term prescription-narcotic use may be safer pain-relief options.

"Patients who do take NSAIDs should always use the lowest dose possible to control pain for the shortest duration," Tomaselli says. Heart attack survivors should talk to their doctor before regularly using any NSAID, even those available without prescription like ibuprofen or naproxen, he says.

Even though there have been concerns about the safety of NSAID use in heart attack survivors for many years, Schjerning Olsen says most people, and many doctors, are unaware of the potential risk.

"It is important to get the message out to clinicians taking care of patients with cardiovascular disease that NSAIDs are harmful, even several years after a heart attack," she says.

The study appears today in the journal Circulation.

SOURCES: Schjerning Olsen, A.M. Circulation, Sept. 10, 2012. Anne-Marie Schjerning Olsen, MD, research fellow, Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark. Gordon Tomaselli, MD, director, division of cardiology, Johns Hopkins School of Medicine, Baltimore, MD; immediate past president, American Heart Association. News release, American Heart Association.

©2012 WebMD, LLC. All Rights Reserved.

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Many Heart Attacks May Go Unrecognized in Seniors

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By Steven Reinberg
HealthDay Reporter

TUESDAY, Sept. 4 (HealthDay News) -- Far more older people than thought may suffer heart attacks that are never diagnosed, a new study suggests.

These so-called "silent heart attacks" can increase the risk of dying as much as any confirmed heart attack does, the researchers added.

To reach their conclusion, the study authors used sophisticated MRI scans to spot heart trouble among more than 900 older Icelanders between the ages of 67 and 93.

"MRI scanners are really a spectacular tool for finding heart disease," explained lead researcher Dr. Andrew Arai, chief of the cardiovascular and pulmonary branch at the U.S. National Heart, Lung, and Blood Institute.

However, people shouldn't be running out to get scanned, he stressed: "I wouldn't recommend that. Most guidelines don't recommend having these expensive tests unless you are having symptoms."

Right now, it isn't clear when such scans are called for and who would benefit from them, Arai noted, although this latest finding is a first step toward determining that.

The report was published in the Sept. 5 issue of the Journal of the American Medical Association.

Among the more than 900 Icelanders studied, 91 had heart attacks that had been diagnosed, while 157 had heart attacks that had not been recognized before, the researchers found. Cardiac MRI detected more cases of unrecognized heart attack in people with diabetes (21 percent) than in those without diabetes (14 percent), the researchers added.

Over more than six years of follow-up, 33 percent of those who had recognized heart attacks died, as did 28 percent of those with unrecognized heart attacks, which was significantly more than the 17 percent who died among those who had never had a heart attack, the researchers noted.

Not surprisingly, significantly more people who had a recognized heart attack were taking beta blockers to lower blood pressure and statins to lower cholesterol than people who had an unrecognized heart attack.

In fact, about half of those with an unrecognized heart attack were taking aspirin, but less than half were taking beta blockers or statins. This may well have added to their risk of having a heart attack, the researchers suggested.

The greater number of unrecognized heart attacks may be due to several factors, including diabetes, which raises the risk of a heart attack, milder symptoms and a less severe attack, the study authors noted.

Although the study was done in Iceland, Arai said he believes the results would be similar in the United States.

Commenting on the study, Dr. Gregg Fonarow, a spokesman with the American Heart Association and a professor of cardiology at the University of California, Los Angeles, said: "Prior studies have demonstrated that a portion of myocardial infarctions [heart attacks] are not detected clinically, or are so-called 'silent myocardial infarctions.'"

Cardiac MRI is a very sensitive approach for detecting heart attacks, he added.

"This study found a higher prevalence of previously unrecognized heart attacks than described in prior studies," Fonarow said. "Silent heart attacks have a similar adverse long-term prognosis as clinically recognized heart attacks."

Fonarow, however, doesn't think cardiac imagining is useful yet as a screening tool to find people at risk for a heart attack or to diagnose an unrecognized heart attack.

"At this point in time, there is not sufficient evidence on which to recommend cardiac imaging as a screening test. Further studies are necessary," he said.

Copyright © 2012 HealthDay. All rights reserved. SOURCES: Andrew Arai, M.D., chief, cardiovascular and pulmonary branch, U.S. National Heart, Lung, and Blood Institute, Bethesda, Md.; Gregg Fonarow, M.D., spokesman, American Heart Association, and professor, cardiology, University of California, Los Angeles; Sept. 5, 2012, Journal of the American Medical Association

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Fish Oil Fizzles for Fighting Heart Attack, Stroke

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By Salynn Boyles
WebMD Health News

Reviewed by Louise Chang, MD

Sept. 11, 2012 -- Millions of people take omega-3 supplements to improve their heart health, but new evidence questions their benefit.

Researchers looked at 20 studies involving nearly 70,000 people, many of whom were heart patients. Adding omega-3 to their diet did not appear to lower the chance of having a heart attack or stroke or lower the risk of death from these and other causes.

Many people take fish oil capsules to get omega-3. But, as in this study, not all omega-3 came from fish oil. It also came from other sources.

The study appears in the Sept. 12 issue of the Journal of the American Medical Association.

A study published last spring failed to show a benefit for omega-3 supplements in people with existing heart disease.

The American Heart Association recommends that all adults eat at least two 3.5-ounce servings of fish a week, and that people with heart disease take about 1 gram total of two types of omega-3 fatty acids (EPA and DHA) per day, preferably from fatty fish.

Capsules containing DHA and EPA are an option, but talk to your doctor before using them.

The AHA also recommends that people with high levels of blood fats known as triglycerides take 2 to 4 grams of EPA+DHA per day under a doctor's care.

Higher doses should only be taken under the supervision of a doctor, as they can cause dangerous bleeding.

In the new analysis, when people who took omega-3 were compared to people who took placebo capsules, no major difference was seen in the risk for heart attacks, strokes, sudden cardiac death, and death between the two groups.

The findings do not justify the use of omega-3 supplements regularly as a treatment or prevention, researcher Evangelos C. Rizos, MD, and colleagues from Greece's University Hospital of Ioannina write in the Journal of the American Medical Association.

Heart doctor David A. Friedman, MD, calls the new analysis, pun intended, "disheartening."

He is the chief of heart failure services for North Shore-LIJ Plainview Hospital in Plainview, N.Y.

Friedman prescribes high-dose omega-3 to many of his patients, and he says the supplements clearly lower blood triglyceride levels.

But he says this may not translate into the heart benefits that had been expected.

"It may be that food sources of omega-3, rather than supplements, are a better choice," he says.

But Dariush Mozaffarian, MD, of Harvard's School of Public Health, says there may still be a role for omega-3 in the treatment and prevention of heart disease.

Mozaffarian studies fish oil and heart health but did not take part in either review.

"The good news is that the combined evidence from controlled trials confirms that fish oil reduces death from heart disease," he says. "The bad news is that effect appears smaller than we had thought -- about a 10% lowering of risk."

He says that many studies may have failed to show a benefit because participants did not take high enough doses of the supplements or because most were also taking other drugs to lower their heart attack and stroke risk.

SOURCES: Rizos, E.C. Journal of the American Medical Association, Sept. 12, 2012. Dariush Mozaffarian, MD, co-director, Program in Cardiovascular Epidemiology, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School; department of epidemiology, Harvard School of Public Health, Boston. David A. Friedman, MD, chief, Heart Failure Services, North Shore-LIJ Plainview Hospital, Plainview, N.Y. News release, JAMA. AHA: "Fish and Omega 3 Fatty Acids." Kwak, S.M. Archives of Internal Medicine, 2012.

©2012 WebMD, LLC. All Rights Reserved.

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More Patients With Irregular Heartbeat Recognize Stroke Risk: Survey

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FRIDAY, Sept. 7 (HealthDay News) -- Patients with atrial fibrillation -- a heart rhythm disorder -- are increasingly aware of the link between their condition and the increased risk of stroke, according to a recent survey.

Atrial fibrillation is a quivering or irregular heartbeat that affects about 2.7 million people in the United States.

A 2011 survey of more than 500 people with atrial fibrillation found that half of them were unaware they had a fivefold increased risk of suffering a stroke. But the more recent American Heart Association/American Stroke Association 2012 poll of 500 people with atrial fibrillation found that 64 percent knew about this level of increased stroke risk.

The improved awareness "is a great step in the right direction," association spokesperson Dr. Patrick Ellinor, associate professor at Harvard Medical School and a cardiologist at Massachusetts General Hospital in Boston, said in an AHA/ASA news release.

"The American Heart Association/American Stroke Association works to provide health care providers, patients and caregivers the educational tools and resources they need on this very important topic," Ellinor added. "We hope to report a higher percentage annually until we reach 100 percent."

The 2012 survey also found that 82 percent of respondents believe having atrial fibrillation increases their stroke risk, compared with 75 percent in the 2011 survey.

Many atrial fibrillation patients rely on their health care providers for information about their condition and education about its health risks, the release noted. The recent survey found that two-thirds of patients have discussed their risk for stroke with their health care provider, but only about one-third were told they are at high risk for stroke.

-- Robert Preidt Copyright © 2012 HealthDay. All rights reserved. SOURCE: American Heart Association, news release, Sept. 5, 2012

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Longer Resuscitation After Cardiac Arrest May Be Warranted, Study Suggests

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TUESDAY, Sept. 4 (HealthDay News) -- Longer resuscitation efforts improve the chances of survival in patients who suffer cardiac arrest in a hospital, new research contends.

The finding, published Sept. 4 in The Lancet, may be controversial, since it challenges the common belief that it's futile to extend resuscitation in patients who do not respond immediately, the study authors said.

However, study lead author Zachary Goldberger of the University of Washington said the new findings "suggest that prolonging resuscitation efforts by 10 or 15 minutes might improve outcomes."

Speaking in a Lancet news release, he added that extending resuscitation would not use up much more medical resources and have only "modest" effects on the patient's neurological health, should he or she survive.

In the study, Goldberger's team analyzed data from more than 64,000 patients at 435 U.S. hospitals who underwent resuscitation after suffering a cardiac arrest between 2000 and 2008. There was wide variation in the average duration of resuscitation attempts at the hospitals.

However, patients at hospitals where resuscitation efforts lasted the longest were more likely to be successfully revived (restoration of heart beat for at least 20 minutes) and to survive to be discharged from the hospital than patients at hospitals where resuscitation attempts were shortest.

The percentage of patients who survived to hospital discharge and had little or no brain damage was similar regardless of the length of resuscitation, the study found.

The researchers said their findings can't be used to define the ideal duration for resuscitation attempts, but do suggest that establishing minimum lengths of time for resuscitation may help improve outcomes in patients who suffer cardiac arrest in a hospital.

Currently, survival for these patients is low. Between one and five of every 1,000 hospitalized patients in developed countries suffer a cardiac arrest, and fewer than 20 percent of those patients survive to be discharged, according to journal background information.

Two specialists were cautious about the findings.

"It is difficult to draw definitive conclusions from this study," said Dr. Kenneth Ong, acting chair of the department of medicine and cardiology at The Brooklyn Hospital Center, in New York City.

"There are many variables that affect a person's survival after cardiac arrest," he said. "As the authors correctly point out, few guidelines exist to assist the resuscitation team, including the duration of the attempt. It is possible that those who survive and undergo the longest resuscitative efforts may have clinical features pointing toward success compared with those who may be judged medically futile by the caretakers and thus have a shorter period of resuscitation."

Another expert said the finding may not apply to most cardiac arrest patients.

"From clinical experience, overall survival after in-hospital cardiac arrest is quite poor when there is no clear reversible cause for the arrest," noted Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital, in New York City. "However, when there is a potentially reversible cause for the arrest, successful resuscitation efforts may potentially improve. This suggests that in these limited clinical situations, there may be a window of opportunity to improve care by increasing duration of resuscitation time prior to termination of efforts."

Glatter added, however, that the study "did not demonstrate that longer resuscitation efforts resulted in a higher percentage of patients who were neurologically intact upon discharge." He believes that there is no specific, ideal duration for resuscitation and decisions must be made on a case-by-case basis.

Also, Glatter noted, "this study was purely observational, and therefore cannot directly demonstrate a causal relationship between length of resuscitation and improvements in survival."

-- Robert Preidt Copyright © 2012 HealthDay. All rights reserved. SOURCES: Kenneth Ong, M.D., acting chair, Department of Medicine and Cardiology, The Brooklyn Hospital Center, New York City; Robert Glatter, M.D., emergency physician, Lenox Hill Hospital, New York City; The Lancet, news release, Sept. 4, 2012

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Some Minor Strokes Lead to Disability

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By Denise Mann
WebMD Health News

Reviewed by Louise Chang, MD

Sept 13, 2012 -- Minor strokes and transient ischemic attacks (TIAs) are red flags for full-blown strokes in the future. But new research suggests that they can lead to disability in their own right.

A TIA, sometimes called a "mini stroke," causes stroke-like symptoms, but they last for less than 24 hours.

Fully 15% of 499 people who had a minor stroke or TIA had some disability 90 days later. The type of disability seen in the study included being unable to perform previous activities, but still being capable of handling personal affairs on one's own.

Minor stroke or TIA symptoms may include:

Inability to move one side of your bodyNumbness on one side of the bodyDizzinessSevere sudden headacheDifficulty speaking

In the study, people who had blocked brain arteries and/or ongoing or worsening symptoms were more than twice as likely to have some disability at 90 days. Others who were at higher risk for disability included people with type 2 diabetes and women. More than 50% of people who had recurring strokes were disabled at 90 days, compared to 12% of those who did not have a recurrent stroke.

As a result, the study authors suggest that some high-risk people may benefit from the same clot-busting medication given to people who've had major strokes. These medications can help stave off lasting disability after a stroke, but must be given within a specific time frame.

Most people who've had a minor stroke do not get these drugs because the condition was thought to be too mild.

The new findings appear in Stroke.

"Patients with symptoms initially perceived as minor have a high risk of disability. This is especially true in patients with blocked or narrowed arteries," says researcher Shelagh Coutts, MD. She is a neurologist at Foothills Hospital in Calgary, Alberta, Canada.

"Time is an issue, and even when patients [show] 'mild' deficits they need to be assessed very quickly, and ideally get urgent brain and blood vessel imaging," she says. "In many centers, these patients are not seen urgently and this needs to change."

Coutts and colleagues are now conducting a study to see if clot-busting drugs are effective in minor stroke patients with blocked blood vessels in the brain.

"There has been accumulating evidence regarding the not-so-great 90-day outcomes seen after mini or minor strokes," says Ralph Sacco, MD. He is chair of neurology at the University of Miami Miller School of Medicine and a past president of the American Heart Association.

The message is clear: If you or someone you love has stroke symptoms, seek evaluation ASAP. "Even if the symptoms vanish or get better, it is still urgent to get medical attention," he says. "You may not be out of the woods. Symptoms could come back or get worse and cause lasting damage."

Andrew Slivka, MD, agrees. He is a neurologist at Ohio State Wexner Medical Center in Columbus. "We have moved toward getting these people evaluated sooner so we can treat them and/or prevent a recurrent stroke," he says.

Treating with clot-busting drugs may prove challenging because of the time constraints, he says. Some people may benefit from preventive measures aimed at getting better control over risk factors for stroke, including smoking, high blood pressure, and diabetes.

Many doctors don't think about rehab for people after minor strokes, but the new findings suggest this may be an option for some people as well.

SOURCES: Shelagh Coutts, M.D, neurologist, Foothills Hospital in Calgary, Alberta, Canada. Coutts, S.B. Stroke, 2012, study received ahead of print. Ralph Sacco, MD, chair of neurology, University of Miami Miller School of Medicine, Florida. Andrew Slivka, MD, neurologiost, Ohio State Wexner Medical Center, Columbus, Ohio.

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