Ask Dr.  Grossman
Dr. William Grossman, Director, UCSF Center for Prevention of Heart and Vascular Disease, answers some frequently asked questions.

A PATIENT ASKS: “What alternative therapies with regard to vascular/heart disease appear worth considering? Also, please comment on mineral and trace element deficiencies in relation to heart function, specifically potassium and magnesium.”

ANSWER: As many of you know, Bernard Osher established the Osher Center for Integrative Medicine (initially for Alternative Therapies) at UCSF nearly 15 years ago. They provide acupuncture and traditional Chinese medicine, Ayurveda, biofeedback, guided imagery, manual medicine and spinal manipulation, massage therapy, and several other forms of treatment.
My reading of the literature is that these treatments are not yet convincingly proven, at least regarding heart disease. I have no objection to patients utilizing massage therapy. Whether they will live longer or be less likely to have a stroke or heart attack, I don’t know. I don’t want to discourage physicians from exploring these avenues, since many conditions (e.g., refractory atrial fibrillation, stroke, advanced heart failure) require better therapies. My approach generally is to try things that have been shown to work, and to use alternative medicine in addition, if that is the patient’s preference. Stress is a very important risk factor for many conditions, and I work with patients to reduce stress. Unfortunately, I don’t have a one-size-fits-all solution.
Regarding your question about minerals and trace element supplementation:
  • Potassium is extremely important, and inadequate potassium intake can be a major cause of heart rhythm disturbance, very high blood pressure, etc. Eat more fruit!
  • Magnesium is rarely deficient, except in people taking diuretics (such as Lasix), and does not need to be taken as a supplement by most people.
  • Selenium, zinc and chromium are often marketed as supplements, but there is little evidence supporting their use.
  • Finally, vitamins! Most of us are eating a reasonably balanced diet, and the evidence that taking a daily multivitamin has a positive influence on virtually any defined outcome (e.g., incidence of cancer, stroke, heart attack) is close to zero. I don’t take a daily multivitamin. Specific vitamin D deficiency is fairly common, in this era of avoiding sunshine to protect against skin cancer; for those patients who need it, I recommend that they take a vitamin D supplement. Best to have your blood vitamin D level measured first, to see if it is necessary, and what dose you need. My vitamin D level was quite low, and I am now taking 2000 units of vitamin D3 daily.
  • Vitamin B12 likewise may be deficient, and both vitamin D and vitamin B12 deficiencies can have cardiac implications. I am now routinely measuring vitamin D and B12 in my Prevention Practice.
  • Other vitamins (vitamins C, B6 and B1 and folic acid) are still controversial; some studies show benefit, and others show no benefit. I don’t take any of them myself, but I don’t object if my patients choose to take them.
  • Finally, vitamin A is also controversial. Some ophthalmologists recommend it for retinal health, but there are several large studies showing that very high levels of beta carotene (which is the natural precursor of Vitamin A) cause cancer and hemorrhagic stroke. Chronic, high doses of synthetic beta carotene supplements have been associated with increased rates of lung cancer among those who smoke. Also, supplemental beta carotene may increase the risk of prostate cancer, intracerebral hemorrhage, and cardiovascular and total mortality in some populations.

    Bottom Line: The jury is still out on most forms of alternative therapies, but many are safe and worth a try if traditional medicine is not working for you. Some mineral and vitamin supplements are safe and definitely beneficial for SOME individuals, but not for all. Work with a physician you trust on the merits of these supplements for your particular case.
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    A PATIENT ASKS: “A few years ago I had an attack of atrial fibrillation, and I was miserable. My local cardiologist tried several medications, but was unable to find a solution. However, I then came under the care of a UCSF cardiologist, and in short order, he was able to bring my heart back into rhythm with amiodarone (initially), and I have been in sync ever since. My questions: First, how long can the average patient expect to stay “in rhythm” with medications, and secondly, if catheter ablation is the next step, how successful have ablation procedures become?”

    ANSWER: My thanks to this patient for his kind comments about UCSF Cardiology. One of the advantages of being a consultant is that when a patient is referred to you, you usually know what treatments have NOT worked for him (i.e., the drugs or other treatments that his previous doctors have tried). This usually narrows down the field of remaining choices considerably. For example, if there are seven drugs which can be used to potentially prevent recurrent atrial fibrillation, and the patient has been tried unsuccessfully on six of them by his previous doctors, my choice is easy: try the seventh. If it works, we are great heroes, and the patient asks, “Why didn’t my other doctors try this drug?”

    Now, in answer to your questions, there is no simple answer. I have had some patients who stop having atrial fibrillation on a particular drug and never have another attack, now 10 to 15 years out. However, other patients develop delayed side effects to the most effective drugs (this is especially true for amiodarone) and may have to stop the drug. Then, atrial fibrillation often comes back and we have to try another drug. Eventually, none of the drugs may work, and then ablation is a reasonable approach. In answer to your second question, ablation therapy is getting better and better, and we now have a success rate of 80% after a first ablation, and if there is recurrence and a second ablation is performed, about 90% overall. This all depends a little on the type of atrial fibrillation, and for some types the success rate is even higher. However, any invasive procedure has certain risks, and I do not recommend ablation as first-line therapy for newly developed atrial fibrillation. Current national guidelines, with which I agree, recommend ablation only for patients with symptomatic atrial fibrillation (such as you were when I first saw you) who have failed medical therapy. We may be at a point someday where everyone with atrial fibrillation goes straight to the Electrophysiology Laboratory for a curative ablation, but we are not there yet!

     


    A PATIENT ASKS: “What is the latest spin on Pradaxa (dabigatran)? All of the press has sure been controversial. I for one am staying on Coumadin, which seems to work for me without any known complications.”

    ANSWER: Pradaxa is one of the new anticoagulants that does not require any regular monitoring by blood tests, and whose efficacy is not affected by foods or multiple other drugs. It is as good, or even slightly better, than Coumadin (warfarin) in preventing blood clots and strokes in patients with atrial fibrillation. It is a twice-daily drug, and if you need to go off it for a surgical procedure, it wears off very quickly so that you can stop it 24 to 36 hours before the procedure, and start it up again right after the procedure. In contrast, Coumadin has a very prolonged action, and has to be stopped five days or more before a surgical procedure, and sometimes needs to be “bridged” with 3 to 5 days of an injectable blood thinner such as heparin or Lovenox. A more recent entry into this field is Xarelto (rivaroxaban), which was recently approved by the FDA in November 2011. It is a once-daily drug, and so far appears to be excellent compared to Coumadin. Xarelto has also been shown to be effective in preventing deep venous thrombosis and pulmonary emboli, and more recently it has proven effective in patients with unstable angina or heart attack in preventing death, stroke or recurrent heart attack. This drug is also very promising as an alternative to Coumadin for patients with atrial fibrillation.

     

    Having said this, I agree with you and many of my other patients that if they are stable on Coumadin, with very little fluctuation in the INR (that test should be between 2.0 and 3.5 for proper blood thinning), and don’t mind having their regular blood tests, stick with Coumadin. As you might expect, these newer drugs are much more expensive for the patient (but probably not for the overall medical system, once you factor in the cost of INR blood tests and monitoring), although the cost to the patient varies depending on their insurance.

     

    Bottom Line: I am increasingly impressed with these new anticoagulants, and all things being equal (especially cost) I would probably use them exclusively in place of Coumadin. However, for the patient stable on and happy with Coumadin, there is no need to change at this time.

     

    A PATIENT ASKS: “What will be the impact of the recent advances in UCSF heart stem cell research, and how soon will it be useful in everyday practice?”

    ANSWER: For the answer to this question, I turned to Dr. Yerem Yeghiazarians, holder of the Patricia and Douglas Leone Endowed Chair in Cardiology, who heads our Cardiac Stem Cell Translational Research program here at UCSF. Dr. YY writes:

     

    “The UCSF Translational Cardiac Stem Cell Program was established in 2003. The overall goal of this program is to address whether stem cell-based therapies can improve the heart’s function after a heart attack. There are many different types of stem cells. These can be broadly categorized as adult stem cells (derived from the patient) vs. embryonic stem cells.

    “As the first goal of the Program, UCSF researchers undertook experiments to determine which stem cells would have the ability to improve heart function after a heart attack was induced in a mouse heart-attack model. Three different types of stem cells were examined: 1) adult bone-marrow-derived cells; 2) native cardiac progenitor stem cells (these are stem cells that were isolated from adult hearts using special techniques); and 3) human embryonic-derived stem cells.

    “Interestingly, it was shown that all three types of stem cells have the ability to improve the heart function after a heart attack, decrease scar size and increase the number of blood vessels in the heart as compared to control treatments which were injected with no stem cells. To further characterize how these improvements were occurring, our UCSF team conducted experiments using an extract of the proteins and other chemical factors that the bone marrow cells were releasing and found that the extract alone, in the absence of live stem cells, was also able to improve heart function after a heart attack and led to all the beneficial effects observed when live cells were used as therapy.

    “Our team has subsequently identified novel factors from the extract that appear to have the ability to rescue heart muscle cells from dying when under stress (for example, stress resulting from low oxygen levels). This is of great significance, since a heart attack causes a decrease in the oxygen level which results in the death of heart muscle cells, whereas administration of this novel factor appears to rescue the cells from dying when oxygen supply is low. This factor has never before been studied in the cardiac field, and our team has recently obtained a patent for their discovery. The team is currently conducting experiments using this factor in heart attack models. If the results are positive, the goal is to then conduct experiments in heart attack patients. In addition, experiments are ongoing in isolating a specific type of human cardiac stem cell for therapeutic purposes. I am proud to report that our team recently published these results, and our findings were widely reported in the press and covered by NBC and CBS News.

    “There is a great deal more work to be done, but there continues to be great hope that cell-based therapies can lead to new discoveries in the treatment of patients with heart disease. Our UCSF team has received numerous grants and philanthropic support over the years for their work, and has published over 30 peer-reviewed manuscripts and become recognized as a leading center for cardiac stem cell therapies.”

     

    I am excited about the new findings and directions discussed by Dr. YY above. It has been frustrating that the promise of stem cell therapy, so widely touted in the news media six or seven years ago, has been slow to become new therapies for neurologic and cardiac diseases. Nevertheless, I am still very hopeful. STAY TUNED!



 
   
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