R.I.P. James "Tony" Gandolfini - What Can We Learn?

When I was living in Chicago, missing the brash Jersey attitudes and Italian delicatessens of my youth, The Sopranos provided me with a sixty minute journey back home every week. Whoever watched with us, as we hung on every word, would also be forced to endure my vocal alerts for every North Jersey sighting embedded in a TV drama that seemed so real. The Lincoln Tunnel exit, Route 3, Bloomfield Avenue, lots of cured meats and wet muzz - things that were unique to my home - Jersey.

The viewing of The Sopranos began to take on an event-like atmosphere, preceded by numerous pots on the stove, sausages and meat balls, gravy simmering, wine pouring, friends talking and congregating - until, that is, the intro began with its heavy baseline and Tony, arm out the window, cigar in hand, making all of us feel lucky to know him, and to not be on his bad side. The good bad guy.

The controversial fade-to-black finale without closure now takes on such a more profound tone - since we know what happens in real life. James Gandolfini's passing is sad for so many reasons - the term "untimely" hardly does it justice. The death of any young person - particularly from potentially preventable causes - is a tragedy. And events like this, because of their notoriety and widespread media coverage, have the opportunity to spur change.

 Gandolfini was such a young man at 51, leaving 2 young children and a wife behind; aborting a proud and accomplished acting career; and for those of us who hale from his home state of New Jersey, the former Rutgers grad's death cements his image in our minds as a small screen icon. Jersey has had so many famous residents (don't make me name them, 'cause I can) but none as "Jersey" as Gandolfini.

The fact that he was so famous/beloved and so young and didn't die of what so many young, famous people die of (addiction), makes the story so acutely interesting - not just in a Page 6 way, but more from a "what can I do to prevent that?" way.  The death of any young person is tragic and often engenders questions of how and why - yet the answers sometimes leaves us unsatisfied.

Objectively, Gandolfini was not the picture of health. He was likely technically obese and had a well-documented penchant for food and cigars - to the point that his last meal has been chronicled in every newspaper that reported his death - as if it had a direct relation to his sudden cardiac death. Which it very likely, did not. Would they have done that for a thinner man?

The fact is that out-of-hospital cardiac arrest occurs more than 380,000 every year in the United States alone - with the vast majority occurring inside the home. Many of those happen in people with no known heart disease. This is an incredibly strong argument for why ALL people should learn hands-only CPR - an unbelievably  simple skill that can literally make the difference between saving a life or watching someone die. This link will teach you all you need to know: http://www.heart.org/HEARTORG/CPRAndECC/HandsOnlyCPR/DemosandVideos/Demos-and-Videos_UCM_440561_Article.jsp.

 Less than one third of all cardiac arrest victims actually receive CPR - a shame when you can literally triple the likelihood of saving someone's life just by pushing on their chest to the tune of Staying Alive.

That said, how can you prevent a tragedy like this from happening to you or a family member? Knowing the obvious warning signs is  a good start: so, if you have chest discomfort that lasts more than a few minutes, or that goes away and recurs (particularly with exertional activity) - that's concerning and needs to be worked up by a doctor. Alternatively, some people may also develop left arm pain, jaw pain, nausea and/or diaphoresis (sweating) - equally concerning signs that merit a visit to your doc. Women and diabetics tend to present with somewhat atypical signs e.g. abdominal pain, back pain, shortness of breath. The take home message: if you are concerned with symptoms in or around your chest area and you have one or more of the risk factors described below: GO TO YOUR DOCTOR.

Once the event has occurred, damage has been done - so the real question is: who is at highest risk for having a cardiac arrest or heart attack at a young age? Contrary to popular opinion, early onset coronary disease has never been conclusively linked to a stressful job or life. In fact, it is more likely people's coping mechanisms (smoking, drinking, drugging, eating), triggered by their stress, that cause their cardiac events. Actual statistically proven risk factors for coronary artery disease include:

• Smoking
• High blood pressure
• Elevated cholesterol and/or triglycerides
• Family history in 1st degree relatives (father, mother, bro, sis) of CAD before 55 in males and 65 in females.
• Diabetes 
• Obesity

The above risk factors are vetted by numerous studies, but I will add one more that I feel likely contributes to a vast number of these cardiac embarrassments: lack of medical attention. Younger men in particular often veer away from medical attention despite the proverbial writing on the wall. They also tend to ignore symptoms that may herald an impending disaster. The fear of discovering something trumping the much less realistic seeming fear - that one may die from doing nothing. So, if you are one of these men (or women) - or live with one of them -  do not ignore your symptoms. Go see a doctor.

Cases like Gandolfini's and Tim Russert's death not too long ago, remind us that coronary disease and its sequelae can be devastating and without obvious preceding symptoms. In the interventional cardiology community we see these events fairly frequently, and most of them do not receive much fanfare. With the advent of so many new technologies and vastly improved treatment of heart attacks, we still are unable to save everyone. The key to better outcomes is better prevention.

The Truth About Shoveling Snow

With the snowiest weeks ahead, we thought it would be good to uncover the truth about shoveling snow. Slips and falls, not cardiac catastrophes, are the most commonly seen winter-related injuries - but heart problems account for almost every recorded death in reported studies.

It is quite possible that you have heard about the risks of shoveling snow on the news, or possibly from your doctor, and most likely from your spouse. However, it is very unlikely that anyonw has shown you the proof that it can be deleterious to your cardiac health.

 "It's a dangerous activity. People who are middle aged or older with a history of heart problems simply should not shovel snow," said Barry Franklin, director of Cardiac Rehabilitation and Exercise Laboratories at William Beaumont Hospital in Royal Oak, Mich.

But why? In an ABC News report, Franklin lays it out fairly well explaining that many people may not realize that a shovel full of wet snow can weigh as much as 15 to 16 pounds. So he said that if someone is shoveling snow at a rate of 12 shovelfuls per minute, they will have moved nearly a ton of snow if shoveling their driveway in just 10 minutes.

"So the physical demands are really, really substantial," said Franklin. When you couple that with the cold air that they are breathing, which causes the coronary arteries to constrict, in many respects you've got a perfect storm for heart trouble," said Franklin.

"Being out in the cold, some of the warning signs may be camouflaged," he added.

Cold weather and hard work can mask those symptoms, delaying people's responses and sometimes leading them into more trouble.

"We really encourage people beyond the age of 50 to try to hire a neighborhood kid to do it," he added.

Not everyone is at risk for a heart attack while shoveling, of course and people in cold climates often have "conditioning," according to Dr. Randal Thomas, director of the Mayo Cardiovascular Health Clinic in Rochester, Minn.

Studies published in the Lancet and the American Journal of Cardiology show that the incidence of heart failure goes up in the week after a blizzard. The Lancet study, based on death certificates in eastern Massachusetts after six blizzards from 1974-78, demonstrated that coronary artery disease-related deaths rose by 22 percent during the blizzard week and stayed elevated for the subsequent eight days, suggesting that the effect was related to storm-related activities, like shoveling, rather than the storm itself.

Similarly, the AJC article, based on medical examiner records from three Michigan counties, found that there were more exertion-related sudden cardiac deaths in the weeks during and after blizzards, and that 36 of the 43 total exertion-related deaths occurred during or shortly after snow removal.

Here are some tips from Brigham and Women's Hospital cardiologist, Daniel Forman M.D.,director of Exercise Testing Laboratory and Cardiac Rehabilitation.

Certain individuals should consult their doctor before shoveling snow:

• People who have previously had a heart attack or other cardiovascular disease.
• People with a history of chest pain or angina.
• People with medical histories of high blood pressure, diabetes or high cholesterol levels.
• People who smoke or who have other cardiovascular risk factors.
• People who do not exercise regularly.

For those who wish to shovel snow, follow these general tips to help stay healthy:

• Dress warmly and be sure to protect extremities such as your nose, ears, hands and feet. This is important because cold weather can reduce circulation, aggravating heart disease.
• Stretch your arm and leg muscles as you would before any exercise; this minimizes musculoskeletal injury and strain.
• Also warm up your cardiovascular system with a light activity such as marching in place or walking before shoveling. Warming up is an important means of modifying cardiovascular strain.
• Don’t eat a heavy meal or drink alcohol prior to shoveling (this is not a good way to work off a big meal!). Avoid stimulants such as caffeine or nicotine, which increase heart rate and cause blood vessels to constrict.
• Use a shovel with a small blade. It is safer for your heart as well as your back and joints to lift smaller and more frequent amounts of snow than to haul a few huge shovelfuls. Likewise, it is important to have a shovel that is suited for your height.
• Pace yourself. Start out shoveling slowly, and don’t try to clear the entire area at once.
• Take frequent breaks to give your heart a rest. Use the time off to drink plenty of water and stay hydrated. Also make sure you are eating normally and taking your routine medications. Push the snow rather than lifting and throwing it.
• If you must lift, do it properly. Spread your hands along the handle for more leverage, stand with your feet hip-width apart, and bend at the knees (not at the back).
• Do not twist or throw snow over your shoulder. Scoop in a forward motion and step in the direction you throw the snow to avoid lower back pain the day after shoveling.
• Know the warning signs of a heart attack. Stop immediately and seek emergency medical help if you experience heart attack symptoms such as chest pain, shoulder, neck or arm pain, shortness of breath, dizziness, fainting, sweating or nausea.

Don’t Be a Holiday Heart Attack

Don’t Be a Holiday Heart Attack
We don't want to be too much of a downer but it's hard to argue with cold hard facts and unfortunately, the data shows that you are more likely to die of a myocardial infarction on Chritsmas or New Year's than on other days.

This does not mean you are more likely to have an MI, though. So why would people perish more often on these days? Are the docs and RNs frolicking in the ER? Unlikely. The most reasonable explanation is that people are relucttant to ruin their own good time (and embarassed to ruin other people's good time) by admitting that something may be seriously wrong. 

Waiting the additional 30 minutes to present to the ER may ruin the Holidays for years to come as delay in presentation is one of the leading causes of death, associated with a heart attack. The quicker you call 911, the sooner an ECG can be done and the sooner a diagnosis can be made. As we say in the cardiac cath lab, time is muscle.

Medication Compliance: Not A Money Issue?

It's no secret that adherence to medications is not great in America - or the rest of the world, for that matter. But you would think that if the medications were shown in numerous studies to actually save lives people would take them, right? And, if these patients had just had a heart attack then you would think that they would really take them, right? And if you offered these life-saving prescription medications to these heart attack patients for FREE then they would absolutely positively take them, right?

Wrong.

In fact, barely half of the patients who received prescriptions for standard, post-heart attack medications, free of cost, were filling them after one year. The other group, the ones who had to pay about $50 per month (the average copay) fared only slightly worse. 

Dr. Niteesh Choudhry of Brigham and Women's presented his study's findings Monday at an American Heart Association conference in Florida. They also were published online by The New England Journal of Medicine.

The study did not examine why people didn't take their medications, but was funded by Aetna (yes, that Aetna) in an effort to see if providing free medications would impart clinical benefit to their patients, and decrease long term costs as a potential aide effect.  But it appears money is not the major issue limiting medical compliance in this country.

As a physician, and a patient, I can attest to the fact that compliance with doctors' instructions is affected by so many things, money often playing a minor role.

Why is it so hard to take the medications doctors precribe? Is it because it makes us actually feel the opposite of healthy to take a medication? Is it that we're too busy? Too forgetful? Maybe it's because we can't actually feel the positive effects that it has on our bodies - there's no tangible reward like there are with dangerous drugs that we can't stop people from taking, e.g. weight loss pills and anabolic steroids.

Perhaps doctors have to do a better job explaining what it is that patients are ingesting and why these medications will help them down the line - even if they can't feel it.

Instead of subsidizing co-pays, perhaps insurance companies could spend that money on patient education or programs that reward compliance, encourage physical activity and emphasize healthy milestones.

Are you compliant with your medications? If not, why? Tell us what makes it so hard to follow instructions that should ostensibly improve your health.

Dr. Safirstein Featured on News 12

Our own Dr. Jordan Safirstein will be featured this weekend on News 12's health segment 12 To Your Health. It will appear on Saturday and Sunday, August 6th and 7th, at 6:30am, 9:30am and 1:30pm.

The host, Dr. Derrick DeSilva will be briefly discussing the benefits of the transradial approach to cardiac catheterization. Cardiac catheterization is a procedure that allows cardiologists to assess and fix blocked coronary arteries. The radial approach uses a small artery in the wrist, and allows patient to sit up immediately after the procedure, as opposed to the standard groin access where patients lie flat up to 6 hours after the procedure.

Numerous studies have shown improved patient comfort as well as a significant decrease in bleeding complications when the radial approach is used.

Cholesterol-Lowering Foods: They Do Exist

So, we've talked about the No-brainer bad foods, and the High-cholesterol surprises,  but there are rumors out there that all foods are not created equal and that you can actually improve your LDL by eating more of certain food items. It's true! Some of them decrease your LDL (should be <100 mg/dL), some increase your HDL (should be >35 mg/dL), and some do both.

"These foods may not be magic, but they're close to it," says Ruth Frechman, RD, a spokeswoman for the American Dietetic Association.

1. Nuts - Let's not get crazy here, only some nuts and in their healthiest form are good for you. Summarily discount anything that is honey-roasted, salted, or candied. The raw versions, and to a lesser extent, the dry roasted are your best bets. Believe it or not, the esteemed cardiac journal Circulation published a study
demonstrating that people who had two handfuls of almonds, lowered their LDL by more than 9%!
Along with almonds and walnuts, the FDA gave its qualified health claim to peanuts, hazelnuts, pecans, some pine nuts, and pistachios. Another study, published in the Journal of Nutrition, examined a standard low fat/low cholesterol diet with a diet that replaced one-fifth of the calories with pecans. When compared to the standard diet, the pecan diet lowered bad LDL cholesterol by 10.4% and decreased triglycerides by 11.1%. It also raised the levels of good HDL cholesterol by 5.6%.

2. Oatmeal - Yes, those annoying breakfast commercials are partially true. Oatmeal actually decreases the bad cholesterol (LDL) without affecting HDL. It is also a recipient of the illustrious FDA's "health claim" status, granted in 1997. Most adults should get at least 25 grams of fiber a day.There are 3 grams of soluble fiber in 1.5 cups of oatmeal -- enough to lower your cholesterol, according to the American Dietetic Association. It may be a bit much for breakfast, so just add in oatmeal or bran to dishes at other times of the day.

3. Plant sterols - "Eating sterol and stanol-containing foods is an easy way to lower your LDL cholesterol, which helps reduce the risk of heart disease," says Ruth Frechman, RD, a spokeswoman for the American Dietetic Association (ADA). A more recent study from the University of California Davis Medical Center looked at the effects of sterol-fortified orange juice. Of 72 adults, half received regular orange juice and half the fortified OJ. After just two weeks, the people who drank the stanol-fortified juice had a 12.4% drop in their LDL levels. The results were published in the journal Arteriosclerosis, Thrombosis, and Vascular Biology. Ok, that's easy enough, but what are they? And where do I find them? Many of the butter, or better even, margarines that you smear on bread have sterols added - check the labels! Sterols and stanols are also found in some cooking oils, salad dressings, milk, yogurt, and juices.

4. Fish - Because of the high levels of the oft praised Omega-3 fatty acids, which have been shown to reduce the risk of heart disease and stroke while helping to reduce symptoms of hypertension, the American Heart Association recommends eating a variety of types of fatty fish (such as salmon, tuna, and mackerel) at least twice a week. You should be grilling or baking that fish though and not eating out of a can, covered in oil, or frying it!

5. Olive Oil - The cholesterol-lowering effects of this Mediterranean Diet staple is most effective when it is the extra virgin variety, meaning the oil is less processed, thereby leaving many of the beneficial nutrients. Careful though, the caloric content is high so only use the recommended amount.

High Cholsterol Surprises

Not all of the high cholesterol foods are as obvious as milk, ice cream and egg yolks. Staying heart healthy is all about being aware of the not-so-obvious things that put you at elevated risk for coronary artery disease. So here's a few more clandestine cholesterol-containing food items:

1. Lobster - If you listen to most of my patients, they will tell you that anything that tastes good, is probably not good for you. And sure enough, this most prized crustacean packs a walloping 61 mg of cholesterol in every 3 oz bite! Add the melted butter and you might as well schedule your stress test for the following week. If you're going to splurge, avoid the butter (or most any "dipping" sauce for that matter), steam that sucker and watch your portions! By the way, processed shrimp, crab cakes and anything fried also have super high levels of cholesterol as well.

2. Chicken - But you were told it's so healthy, right? Well, it all depends on how it's prepared. With the skin on, a drumstick has more cholesterol than a cup of ice cream or a burger. Also, the dark meat, which tends to contain more fat, is higher on cholesterol. When the chicken is breaded, egg-dipped, fried, sauteed in butter/oil it becomes no more healthy than any of the other offenders above. Bake or broil it, stick to the white, skinless meat and surround it with vegetables - not batter.

3. Liver - While most of the younger readers will cringe at the thought of eating liver there are still many out there who gladly smother it in onions, spread it on a cracker or choose it in a fine dining establishment where it gains the much prettier title of foie gras. But no matter what name it is give, this organ meat is like the motherload of cholesterol, amassing more than a single day's daily allowance in one 3 oz chunk. Yikes! If you need further discouragement, just picture it when it's raw and that should do the trick.

4. Mashed potatoes - Surprise! They're not really much healthier than fries. The majority of recipes for this classic American side dish involve whole milk, lots of butter, and sour cream - the perfect storm. Throw some liver on top and you might break some kind of record.

5. Movie theatre popcorn - There seems to be a popular myth that popcorn is a healthy snack. This is very untrue unless you're popping those kernels in a pan by yourself, without oil. WebMD reports that Regal Cinema's medium-sized popcorn has a whopping 60 grams of saturated fat and 1,200 calories. Not healthy! Definitely do not add any of the liquid coronary-clogging butter and go for the small - we want you to have some enjoyment!

Stay tuned for the next installment where we discuss foods that may actually improve your cholesterol profile.

Stents and How They Help

The Society of Cardiac Angiography and Intervention (SCAI) recently realeased a video showing how interventional cardiologists use cardiac catheterization and stents to improve your quality of life and save lives. At Cardiology Consultants of North Morris, we offer every interventional cardiac modality. All 3 of our intervntionalists are board certified and fellows of the Society of Cardiac Angiography and Intervention. We also offer the transradial approach to cathaterization, using the wrist instead of the groin to make your recovery easier.

Enjoy....