The Vioxx

If the world’s death toll from chronic diseases eased just a little bit, 36 million lives could be saved by 2015, health experts report.

All it would take is an additional 2% yearly drop in deaths from chronic diseases, the researchers estimate. Chronic diseases include heart disease, stroke, diabetes, and cancer.

Easier said than done? Several research teams offer their suggestions in The Lancet.

Global Health Quiz

First, test your knowledge of the world’s health:Which country has the largest number of people with diabetes in the world? How many men in China smoke cigarettes: 5 million, 50 million, or more than 300 million? True or false: Most people who die of chronic diseases in low- or middle-income countries are middle-aged. How many people will die of chronic diseases worldwide in 2005: 10 million, 25 million, or 35 million? What percentage of those deaths is expected in low- and middle-income countries? 25%, 65%, or 80%?

The answers may surprise you:India has the largest number of people in the world with diabetes. More than 300 million men in China smoke cigarettes. True. Most people who die of chronic disease in low- or middle-income countries are middle-aged, not elderly. 35 million people worldwide are expected to die of chronic diseases in 2005. That’s out of 58 million global deaths of all causes. Eighty percent of deaths from chronic diseases are expected in low- and middle-income countries.

Those facts are based on data from the World Health Organization, as noted in The Lancet.

If smoking, obesity, and diabetes rise in low- and middle-income countries, chronic disease might take even more lives in those countries, write the researchers. They included the World Health Organization’s Kathleen Strong, PhD.

Success Stories

Countries have made dramatic health improvements before.

“The experience of high-income countries clearly shows what can be achieved with sustained interventions,” write Strong and colleagues.

“Death rates from heart disease have fallen by up to 70% in the past three decades in Australia, Canada, Japan, the U.K., and the U.S.,” they continue. “Between 1970 and 2000, 14 million deaths due to [heart] disease were averted in the U.S. alone.”

The trick is extending that trend to countries that are less wealthy and have fewer medical resources.

Strategies for Saving Lives

Curbing global deaths from chronic diseases will take a lot of work on many fronts, write Strong and colleagues.

Each person can make a difference. Health experts generally recommend being physically active, eating healthfully, staying (or getting) in shape, avoiding harmful substances (like tobacco smoke), and getting recommended medical care.

Efforts are also needed on a bigger scale. Any single person or group probably can’t single-handedly reach the goal; new coalitions must be built, write the researchers.

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C-reactive protein in your blood. It is not, except when your body is recovering from infection or injury.

But “traditional” risk factors tell most of us when it’s time to do more for our hearts, find Michael Miller, MD, director of preventive cardiology at the University of Maryland School of Medicine, and colleagues.

“We can explain the overwhelming majority of coronary heart disease. It is pretty much under our noses,” Miller tells WebMD. “We don’t need to look for new avenues.”

Traditional Risks Tell (Nearly) All

Only last January, a New York Times editorial warned that high CRP levels mean high heart risk even for people whose low cholesterol levels make them feel safe.

many of us like that? Miller’s team tried to find out. Using data from 15,341 men and women enrolled in the National Health and Nutrition Examination Survey (NHANES III), they looked for people with high CRP levels.

They did, indeed, find people whose CRP levels suggested high risk of heart disease. But the vast majority of these people also had other, “traditional” risk factors. Those risk factors:Obesity/overweight High blood pressureHigh levels of bad LDL cholesterol High blood-sugar levels, or diabetes High blood-fat (triglyceride) levels Low levels of good HDL cholesterolSmoking

Only 4.4% of men and 10.3% of women had high CRP levels without having at least one of these traditional risks. Although male gender is more often associated with heart disease, women were more likely to have high CRP values.

“If all other risk factors are normal, and you exercise moderately, your risk of having high CRP is one in 2000,” Miller says. “A person who is a little overweight, with blood fats and cholesterol a little elevated, maybe with a little bit of high blood pressure we didn’t used to think that having several of these little risk factors were a big deal. But it is. These little risk factors add up in a way that is worse for you than one big risk factor.”

Why CRP Is Important

Miller doesn’t think routine screening for CRP is a good idea. But he stresses that what CRP measures is immensely important. In fact, it’s the essence of heart disease.

CRP is a marker for inflammation the body’s first line of defense against infection and injury. When fats build up in the arteries, the body fights them by mounting an immune response. It’s a good idea that leads to disaster, says Russell P. Tracy, PhD, Russell P. Tracy, PhD, professor of pathology and biochemistry at the University of Vermont College of Medicine, Burlington. Tracy was part of the team that developed the first test for CRP.

Practice may not make perfect, but it may be a plus for doctors who implant heart devices called ICDs.

ICDs are implantable cardioverter defibrillators. They’re tiny devices placed under the skin, with electrodes leading to the heart. If the heart starts beating at a dangerous rhythm, the ICD can shock it back to a normal rhythm.

ICD placement may be recommended by a cardiologist for people with a history of certain abnormal heart rhythms and other heart conditions that have high risk for a dangerous heart rhythm. These may include some cases of cardiomyopathy and heart failure.

Are doctors with more experience in placing the ICDs better for patients? That’s what Sana Al-Khatib, MD, MHS, FACC, and colleagues asked.

In Al-Khatib’s study, patients were less likely to have mechanical problems with their ICDs or infections if their doctors did a lot of ICD implantations.

The study appears in the Journal of the American College of Cardiology.

Impact on Patients

The study tracked more than 9,800 Medicare patients for three months after getting an ICD between 1999 and 2001. Patients’ doctors implanted on average 1 to 87 ICDs per year.

Patient survival was similar among all patients. But the results differed for mechanical problems and infections.

Patients of doctors who did the fewest ICD implantations per year were more likely to have infections or ICD mechanical problems within three months, the study shows.

Doctors’ Experience Counted

“This association suggests that ICD implantation should not be performed by physicians without regard to their procedural volume,” write the researchers.

In other words, it might be a good idea to check how often your doctor implants ICDs before getting the procedure.

The study noted how many ICD implantations doctors did each year not how many ICDs they’d implanted during their entire career.

The study only included Medicare patients. Medicare patients are “older and are more prone to complications,” so the results might not apply to non-Medicare patients, write the researchers.

“However, there is little reason to believe that volume would be less important in younger patients,” they add.

Al-Khatib works at the Duke Clinical Research Institute in Durham, N.C. She receives research funding from ICD makers Medtronic and Guidant, states the journal.

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Alcohol may lower the risk of heart disease by acting as a
blood thinner, a new study shows.

But the news isn’t totally rosy. Blood thinning could raise the risk of
bleeding-type strokes, the researchers note.

So should you drink or not? The study doesn’t issue a verdict. It focused on
the science of how moderate drinking may affect the heart.

“The findings” should not be used by people as any reason to begin
drinking,” researcher Kenneth Mukamal, MD, MPH, MA, says in a news
release.

Mukamal works at Boston’s Beth Israel Deaconess Medical Center. His study
appears in the October issue of Alcoholism: Clinical & Experimental
Research.

Sticky Situation

The researchers concentrated on blood platelets. Those are small cell
fragments in your blood. They’re made in the bone marrow, and their job is to
help blood clot.

That’s a great thing when you have a skin cut. But you don’t want a blood
clot in an artery because that could block blood flow and cause a heart
attack.

Platelets aren’t lone rangers. They cluster together to do their work.
Platelet “stickiness” and activation were topics for Mukamal’s
team.

Alcohol Study

Mukamal’s study included about 3,000 adults who didn’t have heart disease.
They were the children of participants from the Framingham Heart Study.

Participants gave blood samples in 1991 and 1994 as part of the Framingham
Offspring Study, which began in the early 1970s. They were also surveyed about
their drinking habits, smoking status, physical activity, and other health
problems (such as high blood pressure and diabetes).

Participants were asked how often and how much they drank of wine, beer, and
liquor. Beer was the most common drink for men; wine was women’s most common
drink.

Study’s Findings

“We found that among both men and women, an intake of three to six
drinks per week or more was linked to lower levels of stickiness by
aggregability,” says Mukamal in the news release.

“Aggregability” means the ability to cluster together. It measures
platelet stickiness.

“Among the men, we also found that alcohol intake was linked to lower
levels of platelet activation,” Mukamal continues.

“Together, these findings … identify moderate drinking as a potential
blood thinner,” he says.

The type of alcohol didn’t appear to change the results. The study didn’t
specify whether wine was red or white.

Possible Impact

Moderate drinkers have been shown to have lower rates of heart attacks than
nondrinkers, the researchers note.

But “at the same time, moderate drinking has been linked to a higher
risk of hemorrhagic [bleeding] stroke, even [after] accounting for its effects
on blood pressure,” they write.

“Our findings add to a large body of evidence showing that moderate
drinking has effects on blood coagulation, which may have both good and bad
effects, but now identify a new avenue by which this effect may occur,”
says Mukamal.

Blacks are more than twice as likely as whites to have clogged leg arteries, and no one knows why, researchers report.

The condition is called peripheral arterial disease (PAD). It affects arteries that bring oxygen-rich blood from the heart to the arms, legs, abdomen, and neck. These blood vessels develop buildup of plaque on the inside that results in gradual narrowing of the vessels. This narrowing impedes the circulation of blood flow, which deprives oxygenated blood to areas that need it.

“For reasons that are still unclear, something related to African American ethnicity raises the risk of PAD,” says researcher Michael Criqui, MD, MPH, in a news release.

Criqui is a professor of medicine and a professor of family and preventive medicine at the University of California, San Diego (UCSD).

Warning Signs

Doctors should keep the findings in mind, Criqui notes.

“Physicians decide which patients to check carefully for PAD based on their age and other risk factors,” he says.

“This research says that physicians need to be particularly alert to the possibility of PAD in their African American patients,” Criqui says.

Patients can also watch for symptoms. The earliest and most common symptom may be tightness or a squeezing pain in the calf, thigh, or buttock during exertion (such as walking). This pain is called claudication and is usually relieved with rest. When your muscles are being used, the demand for oxygen to these areas rises. If there are circulation issues, then your muscles will be deprived of oxygen and you will feel pain.

As PAD progresses, it can occur at times of inactivity, such as at bedtime, and is referred to as “rest claudication” or “rest pain.”

Other PAD symptoms can include decreased leg strength and function, poor balance while standing, cold and numb feet or toes, slow-to-heal sores, foot pain at rest, and erectile dysfunction.

PAD Study

Criqui’s study appears in Circulation. It included 2,343 current or retired UCSD employees. They all had health care coverage through the university.

Participants were white, black, Hispanic, or Asian. Their average age was 60 for the men and 59 for the women.

Participants were screened for clogged leg arteries. They were also checked for other heart hazards diabetes, smoking, high blood pressure, cholesterol problems, body mass index (BMI), and personal or parental history of heart disease.

Does your boss treat you fairly? There may be more at stake than your next promotion. A large, long-term study of British office workers links a sense of justice on the job to a lower risk of heart disease.

The study appears in the Oct. 24 issue of Archives of Internal Medicine.

“This is the first study, to our knowledge, that demonstrates that justice at work may protect against [coronary heart disease],” the researchers write. To measure justice at work, they asked more than 6,000 male civil servants to answer questions such as:Do you ever get criticized unfairly? Do you get sufficient information from your supervisors? Do you ever get praised for your work?

The researchers measured the participants’ sense of justice between 1985 and 1990 and recorded the incidence of heart disease from 1990 to 1999. Employees who reported a high level of justice at work were 30% less likely to develop heart disease than those who perceived a low or intermediate level of justice.

The results were not related to baseline differences in age, weight, employment grade, or other risk factors for heart disease such as cholesterol level, blood pressure, smoking and alcohol use, or physical activity.

Fairness May Reduce Stress

The authors suggest that employees who perceive a high level of justice at work may have less chronic stress, and less stress is associated with a reduced risk of heart disease. But the link between justice at work and heart health was independent of other measures of stress, including job strain.

Because the findings were based on self-reported perceptions of justice, the researchers caution that “it is unclear whether actual managerial treatment or the characteristics of the respondent determined it.”

They also say further research is needed to determine whether the results apply to women and employees outside of civil service. “Our findings on [coronary heart disease], the leading cause of death in all Western societies, suggest that organizational justice is also a topic worthy of consideration in health research.”

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Growth patterns during infancy and childhood are strongly linked to heart disease risk later in life, new research suggests.

Being very thin until the age of 2 was found to be an independent risk factor for heart disease, as was rapid weight gain between ages 2 and 11. The study followed subjects from birth into their 60s.

The study was conducted by the research team that first reported a link between lower-than-average birth weight and future heart disease more than a decade ago.

Their latest research is published in the Oct. 27 issue of The New England Journal of Medicine.

Three Times the Risk

Researcher David Barker, MD, PhD, tells WebMD that the message is clear: Nutrition and growth in the womb and in the first years of life are strongly associated with chronic diseases such as heart disease and diabetes later on.

He points out that children in the study who weighed less than their peers at age 2 and more than their peers by age 11 had three times the risk of heart disease later in life as children who weighed more than their peers at age 2 and less later on.

“We now know that nutrition and growth before birth and early in life plays a critical role in adult disease risk,” he says.

Growth and Heart Risk

Barker and colleagues reviewed detailed growth histories of 8,760 people born in Helsinki, Finland, between 1934 and 1944. Weight and height were recorded once a month for the first two years of life, and then once a year until age 11.

A total of 357 men and 87 women had either been hospitalized for heart disease or had died of heart disease between 1971 and 1998. Roughly 2,000 of the surviving participants were randomly selected to undergo testing for heart disease risk factors.

The researchers found that the participants that had associated heart disease risk were those with lower body mass index (BMI) at birth and at ages 1 and 2, lower ponderal index (measurement of thinness), and those that had both a low BMI at 2 and then high BMI at 11. However, BMI at 11 alone did not show increased risk.

Biggest Threat

Barker tells WebMD that together the three early-life influences represent a greater threat than any other recognized cardiovascular risk factor, including obesity during adulthood.

Matthew W. Gillman, MD, is not so certain. Gillman also studies early-life influences on chronic disease.

“I think it is going a little far to say that early growth is the strongest risk factor for adult heart disease,” the Harvard Medical School researcher tells WebMD.

“Everything in chronic disease depends on a combination of factors. What we are showing in this field is that prenatal and early postnatal factors are very important. But that doesn’t mean that adult risk factors are not.”

Gillman points out that other studies have linked rapid weight gain in the first few weeks and months of life to adult obesity and related diseases in adulthood.

“The relationship between early growth and later health is still an open question, but it is an important one to answer,” he says. “Every mother wants to know how to best feed her child early on.”

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New research shows that the drug Plavix may help people survive heart attacks.

Plavix should be considered for almost all patients hospitalized for suspected heart attacks, the researchers report in The Lancet.

Plavix is used to prevent heart attacks and strokes in people with heart disease.

Plavix is an antiplatelet drug. That is, it blocks platelets which are a component of blood from sticking together in clots. Blood clots can prompt a heart attack or stroke.

The researchers included Zhengming Chen, MBBS, DPhil, of England’s University of Oxford. The study was partially funded by drug companies Sanofi-Aventis and Bristol-Myers Squibb, the makers of Plavix. Sanofi-Aventis is a WebMD sponsor.

Treatment Started Quickly

The study included more than 45,000 people throughout China. Each had been hospitalized within 24 hours of the onset of a suspected heart attack.

All patients got standard medical care and aspirin. Half were also given Plavix; the rest got a fake pill (placebo). No one knew which patients got Plavix.

Patients took the drugs until they went home or for 28 days, whichever came first, starting within hours of hospital admission. They took the pills for an average of 15 days.

The Plavix group had 7% fewer deaths of any cause than the placebo group during the study.

The researchers also bundled together the risk of three other problems: stroke, repeat heart attack, and death from heart attack. The Plavix group had a 9% edge in that category.

Although antiplatelet medications can cause increased bleeding, no significant rise in fatal bleeding was seen in this study, the researchers note. There was an increased risk for minor bleeding such as from the gums or easy skin bruising.

Saving Thousands?

Every year, about 10 million people worldwide have heart attacks, write the researchers.

If a million of those heart attack patients got Plavix as part of early hospital care, it would save 5,000 lives and prevent an equal number of heart attacks and strokes, “probably with no great increase in major bleeding,” write Chen and colleagues.

Second Opinion

Chen’s study gets support in an editorial in The Lancet.

The finding “represents a major advance in the care of patients with acute [heart attack],” writes editorialist Marc Sabatine, MD, MPH.

Sabatine notes that the study showed “clear benefit” for a broad range of patients and patterns of practice.

Sabatine works in the cardiovascular division of Harvard Medical School and Boston’s Brigham and Women’s Hospital. He wasn’t involved in Chen’s study.

Sabatine he has received grants from Bristol-Myers Squibb and served on scientific advisory boards for Bristol-Myers Squibb and Sanofi-Aventis.

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The FDA has approved the drug Oracea to help treat rosacearosacea in adults.

Rosacea is a skin disorder known for patchy flushing (redness) and inflammation, particularly on the cheeks, nose, forehead, and around the mouth. Rosacea may also include small, red, solid bumps called papules and pus-filled pimples called pustules on the skin.

The FDA approved Oracea to treat inflammatory lesions (papules and pustules) in adults with rosacea.

Oracea comes in 40-milligram capsules taken once daily and will be available by prescription in July, according to a news release from the drug’s maker, CollaGenex Pharmaceuticals, Inc. About the Drug

CollaGenex states that Oracea is a “unique capsule formulation of doxycycline” taken once daily. Doxycycline is an antibiotic.

Oracea’s doxycycline dose differs from the usual dose used to treat infections. Oracea’s formulation has not been evaluated as an antibacterial treatment for infections, states the drug’s label.

According to CollaGenex, Oracea was approved based on two studies that included 537 patients in 28 centers across the U.S. Patients either received Oracea or an empty drug (placebo), without knowing which was which.

“In the two studies, patients receiving Oracea experienced a 61% and 46% mean (average) reduction in inflammatory lesions compared to 29% and 20% mean (average) reduction, respectively, in patients receiving placebo,” states the CollaGenex news release.

Side Effects

In Oracea’s clinical trials, “side effects of the drug were similar to placebo,” states the CollaGenex news release.

Oracea’s label also warns that Oracea shouldn’t be used during pregnancypregnancy. Doxycycline is in the family of drugs that includes tetracycline.

“Doxycycline, like other tetracycline-class antibiotics, can cause fetal harm when administered to a pregnant woman,” states the drug’s label.

Tetracycline drugs may cause permanent discoloration of teeth if taken during tooth development, which happens in a fetus during the last half of pregnancy and in infants and kids up to 8 years old. For that reason, those drugs shouldn’t be used while teeth are developing unless other drugs aren’t likely to be effective or can’t be taken for other reasons, states Oracea’s label.

The FDA’s approval letter for Oracea states that CollaGenex has committed to do postmarketing studies related to Oracea’s effects on human sperm in male patients with rosacea and on cancercancer. The sperm study is due for submission in two years; the cancer study is due in early 2010, according to the FDA.

Nov. 7, 2005 – The drug made famous for its treatment of erectile dysfunction appears to have another therapeutic use.

A study in the journal Circulation suggests Viagra could help treat a circulatory disorder called Raynaud’s phenomenon, which affects about 5% of the population. Raynaud’s phenomenon can be associated with other diseases such as lupus.

Raynaud’s phenomenon causes episodes of numbness, tingling, and pain in the fingers and toes, as well as skin sores or gangrene in severe cases. The attacks are spawned by spasms in small blood vessels in response to cold temperatures or emotional stress.

These spasms cause blood vessels to constrict and compromise blood flow to distal areas such as toes and fingers. The disorder is sometimes treated with medications to relax the blood vessels, but this is not always successful.

The Viagra study involved 18 patients (mostly women) whose Raynaud’s symptoms were not responsive to conventional therapies. While taking Viagra twice a day for four weeks, the patients experienced improved blood flow in the capillaries and fewer Raynaud’s attacks. Symptoms improved and the duration of attacks was also shorter. In those who had skin sores, the ulcers began to heal visibly.

These effects did not occur while patients were taking a placebo. At the end of the study, 16 of the participants asked to continue taking Viagra off-label (that is, for a purpose other than its FDA-approved use).

Viagra causes blood vessels to dilate in a different way from other vasodilating drugs, which may explain why it helped Raynaud’s patients who didn’t respond to standard treatments. The researchers conclude that drugs like Viagra could offer “a promising new approach in patients with microcirculatory disorders.”

Although Viagra has risk for serious side effects such as heart attack, stroke, and vision loss, none of the study participants reported any such adverse effect. The side effects reported by study participants included headache, muscle pain, flushing, mild nausea, dizziness, and nasal congestion.

One of the researchers has served as a consultant and speaker for Viagra’s manufacturer, Pfizer. Pfizer is a WebMD sponsor.

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