ACOG/AHA calls for including a ‘Heart-talk’ during the annual well-woman visit

A joint advisory issued by American College of Obstetrician and Gynecologists (ACOG) and American Heart Association(AHA) calls for all gynecologist to screen women for signs of cardiovascular disease and risk factors during their annual ‘well-woman’ visit.

The presidential advisory published 10 May in Journal Circulation calls for a collaboration between cardiologists and Ob/Gyn physicians to use these visits as an opportunity to screen, counsel and educate women about lifestyle factors that influence the risk of heart diseases.

This is important because, for more than 50% of women, their Ob/Gyn physician is the only primary care doctor they visit every year.

“OB/GYNs are primary care providers for many women, and the annual ‘well woman’ visit provides a powerful opportunity to counsel patients about achieving and maintaining a heart-healthy lifestyle, which is a cornerstone of maintaining heart health” said John Warner, M.D. president of the American Heart Association, executive vice president for Health System Affairs at University of Texas Southwestern Medical Center in Dallas, Texas.

Dr. Stacey Rosen, MD, a cardiologist, co-author of the advisory and vice president of The Katz Institute for Women's Health at Northwell Health said, "We know that 90 percent of women have at least one risk factor for heart disease and that 80 percent of heart disease is preventable through a heart-healthy lifestyle.”

A post-partum visit is an ideal opportunity to identify women with pregnancy complications like pre-eclampsia, eclampsia, chronic hypertension, gestational diabetes, gestational hypertension, pre-term delivery, and low-for-estimated-gestational-age birth weight which all indicate a subsequent increase in the mother’s cardiovascular risk.

Preeclampsia and gestational hypertension impart a three- to six-fold excess risk of subsequent hypertension and a two-fold risk for subsequent heart disease.

In 2001, the Institute of Medicine now the National Academy of Sciences, issued a monograph" Exploring the Biological Contributions to Human Health: Does Sex Matter?" This initiated research on gender-specific risk factors for chronic diseases and development of guidelines that are distinct for men and women based on their unique health risks.

This has considerably helped in bringing down the morbidity and mortality associated with cardiac disease in women in last two decades.

Despite this progress, gender-specific inequalities continue when it comes to managing risk factors for cardiac disease. For example, women who have diabetes are at increased risk of CVD as compared to men (19% vs 10%) but they are far less likely to receive preventive treatment as compared to men.

Similarly, only 29% of older women have a well-controlled blood pressure as compared to 41% of older men.

In women, the CVD risk factors are often related to hormonal or pregnancy influences, such as pregnancy complications and polycystic ovary syndrome, menopausal status and hormone use, but these are seldom considered when calculating the risk of CVD.

Some of the common recommendations in the advisory include:

• All women should be weighed at every visit and diet assessment should be performed through a predetermined questionnaire.
• Women are advised to perform 150 minutes per week of moderate-intensity physical activity, 75 minutes per week of vigorous-intensity aerobic physical activity or a combination of both levels. Women should also walk 10,000 steps per day.
• Presence of behavioral risk factors like smoking and alcohol should be assessed.
• Screening for Glucose intolerance should be done in women 40 to 70 years with obesity or overweight, a history of gestational diabetes, a family history of diabetes or established CVD.
• All women above 20 years of age with a family history of CVD, should undergo lipid screening. Lifestyle modification followed by statins is advised in those with elevated lipids.
• Women with family history of CVD should also be screened for blood pressure every 2 years and annually after 40 years of age.
• Medical therapy would be considered for women without CVD or elevated risk for the disease and with BP measurements greater than 140 mm Hg/90 mm Hg.
• Ob/Gyn and cardiologist should make sure that patients Electronic Health Record (EHR) is complete during each visit and is something does not look good, patients should be referred to a specialist.

The clinicians and patients can visit the following websites to get patient education material.

AHA Life's Simple 7 

AHA's Go Red for Women

ACOG's patient page

Full Text

Ob/Gyn Updated Facebook page

Here is one video from  AHA series ' Life's Simple 7'

Now, know your cellular age and manage it too: measuring telomere length by Teloyears

Flickr.com

How well we are aging? That question is often pondered upon but, till now there was no readily available tests to measure our cellular age and compare it with the chronological age. Telomere Diagnostics(TDx), a molecular testing company based in Silicon Valley, California has launched Teloyears. It is home based, easy to use test that requires just a drop of blood sent to the lab, where the telomers in White Blood Cells (WBC) are analyzed and the results are mailed back in 6 weeks. The results show that how well or bad you are aging as compared to others of your age and gender, along with insights into improving it. 

One of the TDx founder, Dr. Elizabeth Blackburn, was recipient of 2009 Nobel Prize in Medicine and a trailblazer in molecular biology. It’s been more than two decades that numerous research papers have well established the importance of measuring Average Telomere Length (ATL) as a predictor of overall health.

The New York Times bestselling book is coauthored by the Dr. Elizabeth Blackburn who discovered telomerase and telomeres' role in the aging process and the health psychologist who has done original research into how specific lifestyle and psychological habits can protect telomeres, slowing disease and improving life. Get the bestseller by Dr Elizabeth Blackburn

Teloyears 

Unlike other genetic test which just tells you about traits or risk for a particular disease, knowing telomere length is much more dynamic because personal lifestyle interventions can slow down or even reverse the aging. In fact, it is known that stress, serious illness or infection can accelerate the telomere shortening and during period of good health the shortening is slowed down.  Along with your results, you also receive expert guidance from ‘Telocoach’ to establish your own custom lifestyle improvement plan based on telomere science. It’s way beyond the routine cholesterol test or tracking ordinary vital signs.

Studies have shown that it’s possible to slow down aging by managing diet, exercise, stress and sleep.

Telomeres are protective caps at the end of our DNA stands. If we imagine that the DNA strand is a big ladder with millions of rungs, telomeres are few thousand rungs at the end of each strand that keep it from ‘unzipping’ and protect the genes which are in the middle of the ladder. Remember the stopper like thing at the end of ordinary zipper, telomeres are just like that.

https://beautyblackbook.com

As we age, the telomere shorten because of repeated division and a stage comes when they can no longer replicate and become “senescent” which is the cellular equivalent of aging. There is growing evidence (nearly 20,000 peer reviewed publications) that shortened telomeres are related to many chronic diseases, particularly cardiovascular diseases. Average telomere length is associated with risk of cardiovascular disease independent of other vascular risk factors.

The company wants to increase awareness among consumers and physician about the Teloyears test, so that it is integrated in annual physical exams, as the information it provides can help change the life style.

It will also help physician in managing individual patients as the Telomere blueprint is different for each one of us.

It is worth noting that Teloyears test does not replace age appropriate medical tests recommended by physicians based on your risk profile or age, nor does the results should be used in making any treatment decisions for existing  medical conditions.

Telomere Diagnostics has successfully resolved the lawsuit it brought to prevent Titanovo from using the patented technology behind the TeloYears™ genetic test for cellular age. In response to the lawsuit, Titanovo has taken down its website and ceased all sales and distribution of all of its products and services.

Teloyears has not been cleared or approved by the U.S. Food and Drug Administration.

Here is a video about Telomere length by Teloyears.

Teloyears.

Related link:  23 and Me receives FDA clearance for at home risk testing for 10 genetic diseases 

North American Menopause Society (NAMS) video series about important midlife health topics: hormone therapy for women 65+

HRT if used properly and under expert care have the potential to offer multisystem benefits at relatively low cost. But, sadly the acceptance of HRT is quite low in society because of risk of breast cancer and is frequently discontinued because of breakthrough bleeding.

The acceptance further dropped after the results of Women's Health Initiative study (WHI) in 2002 found that it actually increased a woman's risk of heart disease, stroke, dementia and breast cancer.

Within months a 50% drop was noticed in women using HRT.

But a final comprehensive report published in JAMA and took a deeper look at the WHI study and the results were broken down according to age and number of years elapsed since menopause.

The key findings were HRT is appropriate for younger women who are in early menopause because the Quality of life benefit derived will be much more as compared to the adverse effects. In older women who are 60+ the risks are entirely different and outweigh the harm.

The dilemma has since continued about initializing or extending HRT in women who are 60+ years. Some women still want to continue using hormones because of the ‘feel good factor’ or because the menopausal symptoms of hot flashes and urogenital syndrome of menopause still continue bothering her.  

The North American Menopause Society (NAMS) thinks that women should be evaluated according to circumstances and risk/benefit ratio. They should use the lowest possible dose under strict monitoring.

This latest video, Extended Hormone Therapy Use, Dr. Shapiro interviews Dr. Cynthia Stuenkel, Past President of NAMS, an internist, endocrinologist, and reproductive endocrinologist at the University of California, San Diego. Dr. Stuenkel discusses the safety and risk for hormone therapy use in women 65 years of age and older.  

                 Dr Stuenkel discusses risk and benefits of hormone therapy for women 65+

News from ACOG 2017: Despite being equated to failed stress test, primary care physicians seldom screen for history of preeclampsia.

Several studies have demonstrated that women with a history of preeclampsia have 2-4-fold increased risk of cardiovascular diseases(CVD) later in life, yet internist and family physicians seldom ask the women about this during a well women examination, reports a small study presented at American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting (ACOG)2017 in San Diego, California.   

This is a very small observational study conducted by Dr. Lewnard and her colleagues at the Medical College of Wisconsin, Milwaukee. They retrospectively reviewed the charts over a period of 2.5 years to see whether internal medicine physicians ask for history of preeclampsia during annual well woman examination visits.

The study included 89 women, who had at least one prior delivery. The researchers also scanned the charts to see whether they were asked about history of other CVD risk factors like diabetes, hypertension and smoking. 

All 89 women were asked about hypertension, 88 were asked about diabetes or smoking but just 21 were asked about history of preeclampsia. (P = .0002)

The study was conducted between January 1, 2013 to May 31, 2016 after ACOG and AmericanHeart Association had issued guidelines that recognized the elevated CVD risk for women with a history of preeclampsia.

AHA says “Healthcare professionals who meet women for the first time later in their lives should take a careful and detailed history of pregnancy complications with focused questions about a history of gestational diabetes mellitus, preeclampsia, preterm birth, or birth of an infant small for gestational age.”

The AHA also asked Ob/Gyns to refer these patients to a primary care physician for to control and modify the risk factors.

ACOG also recommends that those women who have history of preeclampsia and preterm delivery should have yearly assessment for total lipids, BMI, blood pressure and blood glucose.

Of the 89 patients in the study, 6 patients had confirmed history of preeclampsia and their demographics were similar to other patients. So, it was very important to ask the patients about prior obstetrics history in detail.

When Dr Lewnard asked the internists about missing the history of preelampsia, many replied that there are no clear-cut guidelines for assessing this risk factor. “There is a screening gap leading to missed opportunities to identify women at risk for cardiovascular disease,” opined Dr. Irene Lewnard.

“Preeclampsia meets or exceeds traditional risk factors for cardiovascular disease,” She further added.

Dr. Lewnard and her colleagues are looking at efficacy of adding prompts to electronic health record so that more women can be screened in the future by the primary care physician.

More on Preeclampsia and future risk of CVD:

Preeclampsia doubles the risk of future major fatal and nonfatal coronary event.

Pre-clinicalatherosclerosis persists up to 10 years after preeclamptic pregnancy.

History of preeclampsia linked to coronary artery calcification 30 years later.

‘Weekend warriors’ workout tied to longevity with low risk for CVD, cancer and all-cause mortality.

Courtesy: Pixabay

The standard recommendation by CDC[1] and American Heart Association[2] is 150 minutes of moderate or 75 minutes of vigorous physical activity per week for achieving health benefits for those aged 18 to 64 years. But, very few people can keep up with this routine and most of us just cram the workout of entire week into 1- 2 weekend sessions, 2-3 long runs or participating in our favorite sports like hiking, basketball or Zumba.

Courtesy: Pixabay

Well, although not ideal but, it reduces your risk of dying from cardiovascular, all cause and cancer by 30% according to a new study published in JAMA Internal Medicine online on January 9, 2017.[3] The study was conducted by researchers from the National Centre for Sport and Exercise Medicine–East Midlands at Loughborough University in the United Kingdom.

This study examined whether ‘weekend warriors’ also derive the same benefits as their more active, regularly hitting the gym counterparts.

Gary O’Donovan did a pooled analysis of 63 591 adult respondents (>40 years old) who answered a household based survey in England and Scotland. The survey was conducted between 1994 to 2012 and analyzed in 2016. The survey was prospectively linked to British National Health Service Central Registry which identified participants who died, including the cause of death.

For the purpose of analysis, the respondents very divided into 4 groups depending on their exercise pattern:  Those who  were inactive (reporting no moderate- or vigorous-intensity activities), insufficiently active (reporting <150 min/wk in moderate-intensity and <75 min/wk in vigorous-intensity activities), weekend warrior (reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from 1 or 2 sessions), and regularly active (reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from ≥3 sessions). 

The mean age of the study participants was 58.6 years with nearly equal gender ratio. About 40,000 people did not exercise at all, 14000 were insufficiently active, 2500 were weekend warriors and 7000 people were regularly active.

During the follow up period of 9 years, 8,800 people died, CVD being responsible for 2780 and cancer for 2500 deaths.

A detailed analysis of ‘weekend warriors’ group showed that, men were more likely to work vigorously on weekends, mostly engaging in some sort of sports. Walking briskly was also very popular and reported by 30% of weekend warriors. Weekend warriors spent a total of 300 minutes exercising as compared to 450 minutes spent by those who are regular.

After adjustment for all confounders, as compared to inactive participants risk of all cause death for weekend warriors was 30% less (hazard ratio [HR], 0.70), risk of CVD was 40%( HR=0.60) less and cancer death was 18% less (HR= 0.82).

Similar pattern of risk reduction was found in insufficiently active people too, indicating any exercise is better than being totally inactive.

When analysis was run between inactive group and regular exercise group, the regularly active persons have a 35% decrease in all-cause mortality (HR=0.65),  41% lower CVD death(HR=0.59), and 21% lower cancer death(HR=0.79).

During the follow up period of 9 years, 8,800 people died, CVD being responsible for 2780 and cancer for 2500 deaths.

"These findings suggest that some physical activity in an isolated session, or low activity, is certainly better than no activity for reducing mortality risk," Hannah Arem and Loretta DiPietro, of George Washington University, wrote in a commentary accompanying the new study in the journal.

The study has its own limitations that it is dependent on self-reporting and assessed the activity level only once at the start of the study. The study also did not assess the risk of injury in the weekend warriors.

But, the encouraging new conclusion emerging from the study is for those who exercise less frequently is even 1-2 vigorous activity session per week have health benefits and can lower the mortality.

The recommendations by CDC for regular physical activity can be found here.

The recommendations by American Heart Association ( AHA)  for regular physical activity can be found here.

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[1] https://www.cdc.gov/physicalactivity/basics/adults/

[2] http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-Heart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.jsp#.WIPgqBsrK00

[3] http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2596007

Managing Menopause: Is it time to take a second look at the Women's Health Initiative (WHI) study results?

Menopause is an important life event for a woman that signifies the end of her reproductive era and transitioning into a period of increasing health risk from cardiovascular disease, osteoporosis, and other chronic diseases.

According to a census in 1998, there were more than 477 million postmenopausal women in the world, and the number is going to rise to approximately 1.1 billion by 2015. Life expectancy for women worldwide was 65 years in 1998 which has currently increased to 73.2 years (81 years in developed countries).  With increasing life expectancy women spend one third of life in this phase of life.  

In the year 2000, there were an estimated 45.6 million postmenopausal women in the United States, out of which about 40 million were older than age 51, the average age of natural menopause in the Western world.                                    

According to a book chapter by Dr.  JoAnn E. Manson, MD, DrPH professor of medicine at Harvard Medical School and Brigham and Women's Hospital “Aging of the female reproductive system begins at 20 weeks gestation with regard to follicle atresia and proceeds as a continuum. It consists of a steady loss of oocytes from atresia or ovulation, and does not necessarily occur at a constant rate. Because of the relatively wide age range (40-58 y) for natural menopause, chronologic age is a poor indicator of the beginning or the end of the menopause transition.

This article is based on a perspective by JoAnn E. Manson, M.D., Dr.P.H., and Andrew M. Kaunitz, M.D. in March 03, 2016 edition of  The New England Journal of Medicine( NEJM).

Menopausal symptoms are well tolerated by some women, but may be very troublesome to other women. Often there is underreporting of menopausal symptoms due to cultural taboos. The attitude towards menopause varies according to culture and ethnicity, with 80% African women reporting symptoms versus very few Asian women reporting symptoms.

There has been an ongoing confusion regarding the findings of WHI study and prescription of hormonal therapy to relieve the symptoms of menopause.

The Women's Health Initiative (WHI) was launched in 1991 and consisted of a set of clinical trials and an observational study, which together involved 161,808 generally healthy postmenopausal women.

The clinical trials were designed to test the effects of postmenopausal hormone therapy, diet modification, and calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer. The trials were specifically designed to address questions about effect of initiating menopausal hormone therapy for the prevention of chronic disease in postmenopausal women across a broad range of ages, including many women in their 60s and 70s?

In 2002, the study results ripped the widely held belief that hormone replacement therapy protected women from heart disease and other chronic illnesses.  Instead, the Women's Health Initiative study found concluded that taking estrogen plus progestin hormone replacement therapy — HRT — actually increased a woman's risk of heart disease and breast cancer.

Within months of the results, number of women using HRT dropped by half. 

The results of the study were extrapolated to women in 40s and 50s who had severe vasomotor symptoms disrupting quality of life. In-fact, these women had trouble finding clinician who could prescribe them with HRT.  

But, studies conducted during Extended Poststopping Phases of the Women’s Health Initiative Randomized Trials when broken down according to age groups showed entirely different outcomes. Subgroup analysis stratified according to age and time since menopause onset modified the effect of HRT on some of the outcomes. The study concluded that HRT is a reasonable option for the management of moderate to severe menopausal symptoms among generally healthy women during early menopause.

In-fact, the USPSTF in its recommendation made a specific mention that “This recommendation applies only to postmenopausal women who are considering hormone therapy for the primary prevention of chronic medical conditions. This is not a recommendation about the use of hormone therapy to treat menopausal symptoms, such as hot flashes or vaginal dryness; the USPSTF did not review the evidence related to this possible indication because it falls outside of the mission and scope of the USPSTF. This recommendation also does not apply to women younger than 50 years who have had surgical menopause”.

The North American Menopause Society (NAMS), the Endocrine Society, the American College of Obstetricians and Gynecologists (ACOG) endorse the use of HRT in younger women for treating postmenopausal symptoms, who do not have specific contraindication for the therapy.

This will definitely improve the quality of life and it is quite likely that the benefit would outweigh the risks.

These organizations have many resources that help clinicians in decision making, the NAMS have a MenoPro Mobile App, which helps in personalization of treatment to individual patient and help patient in shared decision making.

The MenoPro app has several unique features, including the ability to calculate your 10-year risk of heart disease and stroke, which is important in deciding whether a treatment option is safe for you. It also has links to online tools that assess your risk of breast cancer and osteoporosis and fracture.

Photo courtesy: NAMS

Finally Dr. JoAnn E. Manson emphasized the need of training young healthcare providers to keep up with the variety of options in treating postmenopausal women. This will certainly help in improving the quality of life of a growing population.

References:

Manson JE, Kaunitz A. Menopause management: getting clinical care back on track. N Engl J Med. 2016;374:803-806.

https://www.google.com/?gws_rd=ssl#q=current+life+expectancy++in+world+

http://www.menopause.org/docs/2012/cg_a.pdf?sfvrsn=2

http://www.npr.org/sections/health-shots/2013/10/04/229171477/the-last-word-on-hormone-therapy-from-the-womens-health-initiative

http://jama.jamanetwork.com/article.aspx?articleid=1745676

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