Echocardiography – Part 1 – What is an echocardiogram

By Julian Booker, MD

An echocardiogram or echo for short, is a powerful tool used primarily by cardiologists to evaluate the heart’s structure and function. An echocardiogram is a type of sonogram which means that it uses sound waves to take pictures of your heart and related structures. The system is very similar to sonar on a submarine. The echo machine sends out sound waves in short bursts through a special wand called a transducer. The transducer transmits the sound waves through a conductive gel placed on your chest. The echo machine waits for the sound waves bounce off structures and return to the transducer. The timing and pattern of the returning sound waves is converted to electricity and transmitted to the computer housed within the echo machine. Through a combination of equal parts science and magic the information is converted into a 2-dimensional moving picture.

There are several things that your doctor will be looking for when they review your echocardiogram. The first thing will be the ejection fraction. The ejection fraction (EF) represents the percentage of blood that the heart ejects with each heartbeat. Although this method does not actually measure the strength of the heart muscle, it does an amazing job at giving us an estimate of how effective the heart is supplying blood to the remainder of the body. As a general rule, the higher the ejection fraction the more effectively your heart is working. As with everything in life there are exceptions. Another neat trick is the identification of portions of the heart muscle that are not as active as they should be. This can be suggestive of other problems like coronary artery disease or myocarditis, a type of infection. We can also look for aortic aneurysms, mitral valve prolapse, congenital heart disease, tumors, etc.

The echocardiogram is also equipped with a Doppler function. The Doppler effect is the change in the frequency of a periodic event by an observer moving relative to its source. What does this mean in plain speak? If there is a sound emanating from a source, an ambulance for instance, the frequency (pitch) of the siren will change depending upon whether the ambulance is driving towards you or away from you. We have all experienced this phenomenon. The echocardiogram uses this physical principle to its advantage. We can tell which direction blood is traveling throughout the heart and how fast that blood is traveling. This helps us determine whether you are having specific valve abnormalities such as regurgitation (leaking) or stenosis (blockage). We are able to determine if you have an inappropriate hole in your heart such as a ventricular septal defect (VSD) or atrial septal defect (ASD).

For more complicated cases 3-dimensinoal imaging may be helpful. The same echocardiographic principles can be used to construct a 3D image to allow your physician to more completely evaluate your heart structures. Three dimensional imaging is not always necessary but sometimes it can be invaluable.  Not everyone has pretty echo pictures for various reasons but when it happens, it becomes nearly impossible for your doctor to get you the answers that you need. The decision may be made to give you contrast. Echo contrast is like turning on the lights in a dark room. This contrast does not have iodine so you do not have to worry about allergies.

Later we will discuss other forms of echo tests like transesophageal echocardiography and stress echocardiography.

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The Fish Oil Diaries – Part 2 – Supplements and a Western diet

By Julian Booker

What is the Western diet pattern or Western diet? The western diet is a common dietary pattern found in a number of developed countries and is growing in popularity in developing countries. There are two common characteristics found in the Western diet:

  1. The food tastes awesome
  2. The food is generally really bad for you.

A western diet is filled with fatty foods, fried food, red meat, sugary and/or processed foods. It is associated with a higher incidence of obesity, diabetes, coronary artery disease and colon cancer. If you are unsure whether your diet qualifies as a Western diet pattern, follow this simple rule…

If all the food on your plate are differing shades of brown then you probably adhere to a Western-type diet.

What can we do to bring greater cardiovascular health to our diet? The prudent thing to do will be to evolve your diet to a more cardiac friendly diet such as the Mediterranean diet, DASH diet, paleo diet, etc. Those that adhere to the western diet have a hard time foregoing all that greasy goodness. How can we continue to enjoy all of our golden brown fried foods while improving heart healthiness? In the previous post, we reviewed some of the history behind the cardiovascular benefits obtained from certain high fat diets. We learned that there are some health benefits extended to omega-3 fatty acids found in certain plant fats and fish oils. Can we have the best of both worlds? Can we enjoy all of our brown food and still have a healthy heart? Can we harness the power of these omega-3 fatty acids? Although these omega-3s come in many shapes and flavors we will focus specifically on fish oil supplementation as it has received the most publicity and market share.

It had become clear that there was some cardiovascular benefit to diets based around substances high in omega-3 fatty acids. The next logical step was to see if we could purify these omega-3s to be used as an additional weapon in the war against cardiovascular disease. We thus entered the fish oil revolution. Year after year research directed towards determining the benefits of fish oil was published and year after year the evidence mounted supporting fish oil use.  The range of benefits was broad. It seemed to do almost everything. It could decrease the risk of dangerous heart rhythms, decrease the risk of a second heart attack, decrease the risk of first heart attacks, improve blood pressure, improve triglycerides and decrease mortality associated with cardiovascular disease. I believe there may have been a small study that suggested fish oil could improve your credit score. It was so promising that it became fashionable to prescribe. For patients it became fashionable to take.

As time went forward something strange started to happen. The studies were no longer all supportive of fish oil. It seemed like every study that said it was a good thing was followed by a study that showed no benefit. Still the potential was so great that we moved forward. On some level, I think as physicians needed it to be beneficial. In 2006, a meta-analysis, a study which combines several smaller studies to create more powerful data showed no clear benefit to fish oil. This really got people going. Scientist argued about why the research was incorrect…”The used olive oil as a placebo and it may have skewed the results,”…”The fish oil dose was too small”… The medical community needed could no longer walk in darkness.., we needed answers. A number of large randomized trials, the pinnacle of medical research, were specifically designed to look at fish oil. Again there has been too much conflict for us to make a conclusive answer but the balance now seemed to be tipping in the opposite direction against fish oil.

The GISSI group is an Italian consortium responsible for some of the largest most well recognized clinical trials in the past 20 years. Their landmark trials have been creatively entitled GISSI-1, GISSI-2 , GISSI-3 and GISSI-Prevention. GISSI-prevention was a cornerstone of the pro-fish oil argument. When the benefits of fish oil came into question, the Italians decided to find the answer. In 2013, a study was published in the New England Journal of Medicine from a group that was essentially the GISSI research group. The trial did not carry the GISSI title but was a powerhouse study nonetheless. It may have put the nail in the proverbial coffin of the fish oil supplementation argument. This study followed over 12,000 people for 3 years using doses of fish oil that have been proven to be effective in prior studies. All the patients were at high for having cardiac events. If anyone was going to show improvement it would be these patients. Unexpectedly, there was no difference in major cardiac events between the group receiving fish oil and the group undergoing standard therapy.  Similar findings were seen in patients with a previous heart attack in the Alpha Omega trial.

Despite the evidence for fish oil being shaky at best, the American Heart Association still recommends eating a diet with at least two servings of fish per week. It cannot hurt you to substitute fish, which is generally healthier than beef or pork, for less healthy sources of protein (like beef or pork). Regarding fish oil dietary supplements, there is no clear evidence of benefit but thankfully it won’t hurt your heart either.

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Secret to the Ultimate Six Pack – Revealed

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The six-pack.  The holy grail for many health enthusiasts, amateurs, and members of the general public alike.  Every health magazine cover boasts a model with washboard abs and those who cast eyes upon them dream that one day they too may possess a rippling midriff.  To most people first getting involved in exercise, this is seen as one of the most desirable things to achieve, and for good reason.  There is little doubt that a six-pack is ‘sexy‘ and those who possess it often ooze confidence and attract awe.

However, the reality is that most of those onlookers feel that such a thing is unattainable for them, and as a result will never achieve it.  Despite following the numerous different programs in each issue of the popular magazines, or paying a personal trainer hundreds of dollars to guide them, many people just can’t seem to reach the top of the proverbial mountain.  The look they so crave continues to elude them despite all their efforts and hard work.  After continually trying and failing, despite following the plans laid before them, disappointment and frustration often gets the better of people and they give up and go on having never attained something they so desired.

To me this is a real shame, as in all honesty I see the six-pack as something quite attainable by most if they are dedicated and willing to put in the effort.  The fact is that many people are willing to put in the effort and simply get let down by the advice and programs fed to them by amateurs or non-qualified professionals.  Fraudulent claims such as “10 minute abs” and articles such as “six-exercises to a six-pack” dominate the TV, magazines, and internet, misleading trusting people and often taking their money in the process.

I myself must admit that there was a time when I fell victim to inadequate advice and phony programs.  During my early days of training, I followed many different plans but could not attain the look I desired in my mid-section.  After years of trial and error, studying anatomy and exercise physiology, I discovered how simple it was to get what I wanted, and this is what I want to share with others.

The fact of the matter is that there is no one trick or secret to developing the perfect look.  It is a combination of techniques and discipline, each a different but vital building block needed to complete the structure.  Put them all together and voila! Miss one out and the result is a weak physique which will impress no-one.  Below, I will explain all of the fundamentals so that you to can go on to achieve the look you dream of.

Anatomy of the Abdomen

The most important, and often most overlooked, aspect of achieving your ideal mid-section is understanding the anatomy of what you are trying to develop.  Think about it, there is no way you would try to build a car without understanding all the parts that make it up and how they work, so why should your body be any different.  To me there is nothing worse when it comes to exercise than an article or program that tells people what to do without explaining WHY!!! Once you understand the make up of the mid section and functions of each of the muscles, you understand the importance of full development and how to achieve complete development of each aspect.

Many people think the abdomen is mainly made up of the strip of muscles down the middle (the six to eight muscles that give the ‘six-pack’ appearance).  In reality, this couldn’t be further from the truth.  This strip, known as the rectus abdominus, forms only a small part of the mid-section, and is certainly not solely responsible for the strength or overall look of the abdomen.  Concentrate on developing this muscle alone and you will end up with a less than desirable result (although very common when you look around the gym).

The main muscles that you should be aware of are the rectus abdominus, transverse abdominus, internal obliques, and external obliques.  The rectus abdominus runs down the middle, from the chest to the pelvis, and is made up of three or four (responsible for the eight-pack) pairs of muscles separated by a midline band of connective tissue known as the linea alba.  The other three muscles can be found to the side of (or lateral to) the rectus abdominus.  The deepest of the muscles is the transverse abdominus, which runs horizontally, and superficial to this are the internal and then external oblique muscles, which, as their names suggest, run in an oblique manner perpendicular to each other.

When all the muscles are working in tandem, the end result is a tightening of the mid section and compression of the chest towards the hip.  When contracting, the main direction of action of the rectus abdominus is up-down.  It has no real role in rotation.  An interesting point to note here is that when contracting, the rectus abdominus acts as a whole.  It is not possible to contract the top muscles in preference to the lower ones, they instead just activate in a graded manner.  So anyone who tells you that certain exercises are for the top abs and other exercises are for the lower abs quite frankly hasn’t a clue what they are talking about (so stop listening).

The transverse abdominus is a deep muscle and, as mentioned, runs in a horizontal direction.  It cannot be seen externally and is an important stabilization muscle.  The obliques form the bulk of what you see to the side of the rectus abdominus and have an important role in rotation of the abdomen.  As the fibers run perpendicular to each other, the external oblique on one side has the opposite effect to the internal oblique on the same side.  So if you were to use your internal oblique to rotate in a particular direction, the external oblique on the opposite side would also activate to aid in this movement.  When obliques on both sides activate, the net result is cancellation of the rotation effect and compression of the chest directly towards the abdomen.

There are also other muscles to consider such as the serratus anterior (scapula protractors) which are responsible for the finger-like projections seen on top of the ribs under the chest, but the muscles above are the main ones to be aware of.  It is vital that any exercise program directed at developing the abdomen consists of exercises that challenge each of these muscles, otherwise the result will be a poorly-balanced physique.

Skinny Pack’ vs Six-Pack

The importance of developing a full abdominal section is seen most in those who possess what is commonly referred to as a ‘skinny-pack.’  Some people are naturally thin and as such possess a low body fat percentage despite doing no exercise.  The result is that there is no fat over their rectus abdominus and you can visualize each individual member of the six-pack.  This look is often seen in endurance athletes also.  These individuals are often very happy with their appearance and take pride in showing their six-pack.  However, to the trained eye, it appears as nothing but a disappointment.  The six-pack formation is very narrow, the muscle bellies are small and underdeveloped, and the obliques are non-existent.  This hourglass appearance has been dubbed the ‘skinny-pack’ and is absolutely nothing to be proud of.  As I mentioned, there are several aspects to attaining the perfect six-pack.  Yes, low body fat is one of them, but alone it is far from impressive.

Complete body development

Just as complete development of the abdomen is necessary to gain an impressive mid-section, complete development of the body is necessary to adequately house the abdomen.  When I look around any gym, 90% of the people I see are shockingly dis-proportioned.  It seems to be fashionable to build a big chest, arms, and abdomen but totally neglect the back and even more so the legs.  This results in a horribly proportioned body that is not pleasing to look at.  Please, please, please do not fall into this trap.  If you are guilty of this, or are just starting out, it is vitally important that you build a strong back, legs and chest before putting any special concentration into the abdomen.  Ignore this advice and you will never gain any true respect or admiration from your contemporaries.  Follow this advice and you will find that, without even trying, you have built an impressive mid-section.

Compound Exercises

This is where almost all abdominal exercise programs go wrong.  The fundamental exercises in any abdominal development program should be compound movements.  I often wish people would understand the importance and power of these exercises in building a strong desirable abdomen.  The basis of most peoples abdominal exercise regimes are variations on the abdominal crunch.  Why?  I do not know–but I can guess.  The crunch is an incredibly easy exercise that requires little effort.  As a result, people can do 30, 40, 50, or even 100 at a time.  This results in a build up of lactic acid in the muscles resulting in a burning sensation.  People mistake this sensation as meaning they have worked the muscle hard, and as a result continue to repeat it week after week.

The fact is that we don’t do more and more press ups to develop our chest, but instead when it gets too easy we use the bench press to allow us to add more weight and drop the reps back down.  When pull ups become too easy we strap on weight to make it harder.  So why should abdominals be treated any differently?

Although the abdominals act to compress the chest towards the pelvis, one of their primary functions is stability of the core.  Along with the back, they are integral to holding the body together.  One of the best ways to develop the abdominals, whilst at the same time making them functionally strong, is to challenge their core function.  Deadlifts, squats, and cleans are amongst the best exercises you can do in the gym, and when done regularly are capable of building an incredibly strong midsection.  They allow you to stress the abdominals with large amounts of weight and provide them with continuous stimulation.  Just feel someone’s abdomen during a heavy deadlift and you will understand exactly what I mean.  If these were the only exercises you did in the gym, you would have an incredibly impressive abdomen.

If you are not carrying out these compound exercises on a regular basis, you certainly shouldn’t be concentrating on isolating the abdominals yet.  First build up your strength and overall physique (along with solid abs) through squats, deadlifts, military presses, cleans, etc. then concentrate on the finer points.

Isolation Exercises

Although compound movements should form the base of any regime, isolation movements can be added in once you are ready to develop different aspects of the abdomen more specifically, or if you want to train the abdomen on ‘rest days’ when you aren’t doing compound exercises.  You probably see people doing all manner of crunches, sit-ups, leg raises, etc. when you look around the gym.  It may look complicated but it is in fact extremely simple and should be treated as such.  There are two main movements you need to target, and as long as you follow this, the choice of exercise is personal.

To target the rectus abdominus, you just need to pick an exercise that brings the pelvis towards the chest.  This can be sit-ups, crunches, leg raises off an incline bench, hanging leg raises (a great all round developer!) or anything else you have tried that accomplishes this movement.  As I mentioned earlier, exercises don’t isolate the top or bottom of the six-pack, they all work it as a whole, so just pick whatever you like.

An important area that a lot of people neglect is the obliques.  They do all manner of crunches, but end up with a severely underdeveloped outer abdomen.  It is fairly obvious when you see it.  Don’t fall into this trap, or you will forever be playing catch-up.  I would actually go as far as saying that for the first few months you should concentrate primarily on oblique isolation exercises instead or straightforward transverse abdominus exercises.  Remember that anything that works the obliques is also stressing the whole abdomen, so this way you will end up developing everything concurrently.  A good way to achieve this co-development is to add a twisting motion to your normal abdominal exercises.  When doing leg raises, bring your right knee towards your left shoulder and vice versa, or during crunches bring your elbow towards the opposite knee.  The important thing to note here that most people get wrong is that the twisting motion originates from the torso, not the shoulders or hips.

With all isolation exercises, concentrate on slow controlled movements.  Remember that the abdomen is primarily a stabilizer, so by moving in a slow and controlled manner, you achieve optimal development.  Don’t bounce up and down trying to get lots of reps out as it is pointless.  Fifteen quality leg raises are far more beneficial (and harder) than thirty achieved in an uncontrolled, swinging manner.


You will often hear that a ‘six-pack is built in the kitchen not the gym,’ and whilst there is some truth to this, it is not the whole story.  As I have stressed, there is nothing more unimpressive when it comes to a mid-section than the ‘skinny pack.’  If you just dieted your way to a six-pack, you are setting yourself up for failure.  The best way is to work on both aspects concurrently.

That being said, body composition is incredibly important for bringing out your six-pack.  The average male body fat percentage may be about 15-18% (higher in females), but to really bring out the abdominal section, you need to be heading towards the 10% range.  The fact is that doing this can take a real toll on the body.  To get below 10% body fat is not that hard, but staying there can prove difficult.  Once we get this low, the body feels it is being starved and will take measures to try to get us to increase our fat levels again.  This means that you can spend your whole time constantly fighting to stay thin.

The fact is that few people are able to keep a perfect six-pack all year round.  Even body-builders only spend part of the year in this shape, as it is simply too hard!  Personally, I fluctuate between 8-12% body fat.  This allows me to easily attain the six-pack look at the times of the year when I want to, whilst not having to struggle to maintain it all year round. This is why I disagree with a six pack being made solely in the kitchen.  If you spend the whole year ensuring you have a solid base, you can easily bring it out whenever you feel like it (it only takes a few weeks).  It’s also important to remember that a well-developed mid-section will be visible at higher body fat percentages, and looks impressive even at 12-15% body fat, which is even more reason to pay attention to it.

How to reduce body fat percentage is a whole science in itself, and you can read about how to achieve it in a safe and reproducible manner in my other articles  (where to start, what’s in my food?energy balance, weight loss tips, paleo diet).  Once you understand the science behind it, your weight is truly in your control and dropping weight when you feel like it is not a challenge, but simply a decision.

In a nutshell

Attaining a six-pack is the goal of many a fitness enthusiast and regular gym-goer, but often eludes those who go in search of it.  Far too often, this is the result of people falling into the trap of following ‘quick-fixes’ or programs devised by people who have no real place doing so.  Of those who do attain some definition, many have poorly developed musculature, and even worse may have bodies that are in no way proportionate.

In reality the secret to a six-pack is not that complicated and the result is attainable by almost anyone.  Follow these simple principles and you will gain not only an extremely impressive abdomen, but also a well-developed, strong body that will leave others in awe.

  • Understand the anatomy – know what you are trying to build before starting construction.
  • Concentrate on the whole body and not just the mid-section – train your legs, back, and chest.  The abs will appear.
  • Compound, compound, compound.  Squat, clean, and deadlift your way to a rock solid abdomen.  Everything else is only supplementary.
  • Isolation exercises are great once you have your base, but don’t become obsessed by them.  When you do decide to do them, concentrate on the whole abdomen and you will reap the rewards.
  • Learn the art of safe, reproducible weight management (a very powerful weapon), and you will never be more than 4 weeks away from a six-pack.
  • Be patient – allow yourself several months to develop your base.  Do it properly and it will always be with you.
  • KEEP IT SIMPLE – because it is.
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The Fish Oil diaries – Part 1- high fat diets and heart protection

By Julian Booker, MD

The fish oil diaries may be controversial and upset some people. Fish oil therapy has become a staple of many American’s fight against heart disease. Some take prescription fish oil, over the counter fish oil, cod liver oil, and McDonald’s Fillet-o-fish sandwich, anything to protect our hearts from having a heart attack. Is fish oil in isolation really good for you? I don’t know if anyone really knows the answer. We will delve into the facts and touch on some of the controversy. You can make own decision.

The belief in the benefits of fish oil has been to prevent significant cardiovascular events can largely be traced back to a study in from the 1970s. That study followed a group of Eskimos and found that their risk of cardiovascular events was surprisingly lower than comparable groups of people despite their uncharacteristically high fat diet. How could this be? We all know that fat is bad for you. At one point we knew the Earth was at the center of the universe and we knew the world was flat. Upon further review, the Eskimos diets were found to have an unusually high content of omega-3 fatty acids. Could this be the key?

Omega-3 fatty acids are a group of essential polyunsaturated fatty acids that generally cannot be synthesized by the human body. Mammals are unequipped to make these fatty acids in sufficient quantities so it is essential that they be included in your diet. Two of the three primary types of omega-3 fatty acids are found in high quantities in fish.

High fish diet has presented with some conflicting data on the overall benefits to one’s heart health. In general, fish is considered a healthier option than meat such as pork and beef. Decades of data has been accumulated showing that high fish diets result in improved outcomes with coronary artery disease, heart failure and clinical improvements in regards to dangerous heart rhythms originating from the ventricles. Of late, there has been some contradictory research that suggests that the benefits of fish may not be as powerful as we once hoped. However, the American Heart Association feels that the benefits of incorporating more fish in our diets at least twice weekly is still a worthwhile endeavor. Even if a high fish diet does not have the magical effects that we once hoped, common sense tells us that replacing meat with a healthier alternative cannot be a bad thing*.

Sometimes the medical field can be slow to action, particularly if the message is contrary to conventional thought. It may take 20-30 years for a novel ideal to be tested and retested before being accepted as fact, hence the seemingly recent discovery that a diet heavily based in oily fish has heart protective effects. If only we had known before 1970s that a high fat diet may actually be good for you. If only someone had done research perhaps 30 years earlier that showed that certain fats might actually be healthy…

Enter the Mediterranean diet. The power of the Mediterranean-type diet first came to light to the worldwide community during the “Seven Countries Study” in the 1940s. The researchers found that the people that were included from the Mediterranean countries inexplicably had fewer heart attacks and strokes than people from outside the region (does this sound familiar, if not please see the earlier paragraph on the Greenland Eskimos). The benefit could not be explained by the typical risk factors for heart disease such as age, gender, blood pressure, cholesterol, smoking, weight or history of smoking. This flew in the face of classical understanding of what increases cardiovascular risk. Moreover, once a person from that region changed his diet and lifestyle, their risk for cardiovascular disease increased.

Although this information has been available for public consumption (the pun was probably intended) for decades, the Mediterranean diet did not reach the mainstream until the Harvard School of Public Health aggressively pushed the diet into the public consciousness in the 1990s. But why would it take nearly 50 years for the medical community to fully recognize this goldmine? Well, as with the Greenland Eskimos, as much a third of the calories in this dietary philosophy are from fat. Again, we know that fat is bad for you.

Along came PREDIMED. The PREDIMED study was recently published in the New England Journal of Medicine, perhaps the world’s premier medical journal. This large randomized trial shows that making simple dietary changes with the Mediterranean diet does indeed have a profound effect on our heath and is probably the most definitive study to date. The evidence doesn’t stop there. There have been major publications in the Journal of the American College of Cardiology, Neurology, Journal of the American Medical Association, etc. Study after study reaffirms the benefits of the Mediterranean diet on ones health.

People living along the northern shore of the Mediterranean and Morocco have become legendary for their resistance to cardiovascular disease.  Their diet is primarily based fruits, vegetables, nuts, legumes, and whole grain. What is somewhat unique about their diet is the heavy emphasis on healthy oils such as olive oil and fish oil, in the form of saltwater fish consumption, as their primary source of fat.  I won’t focus on the specifics of the diet. You should check our diet and exercise segment regularly as a post will be coming soon.

There is no doubt that a Mediterranean diet is very good for you and one should strongly consider incorporating some of its philosophies into your own diet. There general consensus regarding replacing meat with fish at least twice weekly is also generally positive and should also be strongly considered in dietary choices. What is in doubt is whether adding fish oil supplements without otherwise altering your American-type diet with will be of benefit (For clarification when I speak of an American or Western-type diet I mean one that is low in fruits, vegetables and whole grains but high in processed food, sodium unhealthy fats and red meat). We will discuss this in part to of the Fish oil diaries.

*For those of you that concerned about mercury, the benefits of eating fish far outweigh the potential risks of mercury in everyone other than pregnant women.

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Can Medicines Help My Mitral Valve?

By Mustafa I. Ahmed MD

Medicine for mitral valve prolapse

Can Medicines Help My Mitral Valve?

The mitral valve is there to stop blood flowing backwards in the left side of the heart, and so allows blood to travel the correct way, forward, to supply the body! Most of my posts to far have been about mitral valve prolapse (MVP). In mitral valve prolapse the degenerated valve may lead to leakiness, as it can no longer function as a valve. So MVP is a mainly a disease of the valve itself. In other cases the valve tissue itself is relatively normal, but the heart is so enlarged that it stretches the valve, so that it can no longer act as a valve, leading to leakiness. Although this post is about medicines, of course in the case of a severely leaking valve, especially in patients with symptoms or signs of heart failure, surgery is typically required.

Is There a Medicine To Stop The Valve Degenerating?

The best way to develop a medicine to treat the disease is to understand exactly what’s happening, down to most basic of cell details, then target therapy towards those processes. For example, if MVP was down to a virus, and we knew which one, we could direct an anti-viral treatment towards it. When it comes to developing medicines to prevent degeneration of the mitral valve however, we have a huge problem in that we know something is wrong, but we don’t know exactly what it is!

I’ve outlined some of the mechanisms underlying the valve degeneration in a previous post. The unfortunate truth is that we don’t really appear to be close to a therapy to stop the valve itself degenerating at the moment, although physicians and investigators such as myself are working on it.  The good news is that we are making some progress in terms of medicine to stop the heart failing from a leaky mitral valve.

Are There Medicines To Stop The Heart Failing From the Leaky Valve in MVP? Can Beta-blockers Help?

In MVP, the degenerated valve leads to leakiness. It’s called mitral regurgitation. When that leak becomes serious enough, it causes the heart to enlarge and eventually fail. We have learned a lot about the process of the heart failing from the leaky valve, a process known as ‘volume overload’.  I’ve spent a good part of my career as a physician investigator dealing with exactly this issue. In fact the lab in which I learned my trade was award the largest ever government grant ($18,000,000) dealing with this issue amongst other aspects of MVP.

In mitral regurgitation the valve allows blood to leak backward from the main chamber of the heart, which results in more blood than usual pumped back in to this chamber with each beat. This increased volume of blood leads to what we call a ‘volume overload state.’ Of course when the valve is leaking severely then surgery is often required, but many patients have moderate or moderately severe leaks and no symptoms and of course the hope is that surgery be delayed or not required! For years we treated the leaky mitral valve with medicines that we typically used for other forms of heart failure but this did not work. Then we examined the heart more closely and noticed that volume overload failure had a very distinct pattern that was different. One of the things we noticed is that, there were abnormally high levels of certain hormones in the heart tissue of patients with moderate or severely leaking valves and that these high levels were associated with the heart eventually failing.

This work led to a landmark study in which we used the beta-blocker metoprolol in patients to see if they could block these hormones. I was the first author on that study and we found that in patients with MVP and a leaky valve the use of the beta-blocker metoprolol could potentially prevent the heart function worsening over time. In fact there was a suggestion that those patients taking metoprolol were less likely to need surgery during the study period. These findings were published in the Journal of the American College of Cardiology and suggest that beta-blocker therapy may be helpful in patients with MVP and leaky valves. Before this can be routinely recommended to all patients, we need to do a large trial, across several countries and centers to see if the findings remain the same. Our study set the stage to do just that! Many cardiologists use beta-blockers in MVP patients anyway, often to help symptoms such as palpitations.

A survey of cardiologists in 2009 showed that despite the fact there is no evidence for most medicines in mitral regurgitation, there is a wide variation in medicines prescribed for this. Other than our beta-blocker trial; there as been no medicine shown to be useful in preventing heart failure from MVP and a significantly leaky mitral valve. However up to 60% of cardiologists are prescribing medicines such as an ACE inhibitor for this purpose. For all we know that could worsen the situation! Of course though, using those other medicines to treat conditions such as high blood pressure in these patients is probably ok.

What About Medicines from a Leaky Mitral Valve not due to MVP

As I mentioned at the beginning, other than MVP, causes of a leaky mitral valve include an enlarged heart for example in many forms of heart failure or even from a scarred heart for example in those people that have had a heart attack. In these cases medicines may be very useful. There are many medicines that have shown to be beneficial in heart failure patients; these include beta-blockers and ACE inhibitors among others. In these patients, medications work by a process known as reverse remodeling, in that they may help the heart reduce in size back towards normal, and therefore stop stretching the valve as much and maybe even reduce the amount of leak!

 Final Word

When it comes to developing a treatment for stopping the valve itself degenerating in MVP, we have a long way to go. Fortunately we are making headway when it comes to medicines to prevent heart damage, with the beta-blocker metoprolol showing early promise, although more work is needed to be certain of that. The good news is that we are working on it, and for most people, when surgery is required; it is a safe and effective option.

Mitral Valve Prolapse – Part 1 – Lets Start With the Basics

Mitral Valve Prolapse 2 – Whats hapenning to the valve?

Mitral Valve Prolapse 3 – The Dreaded flail leaflet

Mitral Valve Prolapse 4 – Introduction to Mitral Regurgitation; The Leaky Mitral Valve

Mitral Valve Prolapse 5 – From Fiasco to Sensibility; How Common is it

Mitral Valve Prolapse 6 – Alarm, Confusion, Controversy, Frustration and Getting to Where We Need to be.

Mitral Valve Prolapse 7 – Do I Need Antibiotics for my Dental Procedure

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Excuses not to Exercise – Part 1 – Knee Pain and Osteoarthritis



By Murtaza Ahmed MD

As a doctor I spend a lot of my day listening to excuses as to why people can’t exercise.  As I have repeatedly reinforced in previous posts, exercise is one of the most important treatments for many common diseases we see, and as such I find it hard when I see people missing out because they feel they are not able to get involved.  My aim in this series of articles is to hopefully help you understand that there is almost always a safe to carry out some form of exercise and that a lot of the common misconceptions as to why you think you can’t exercise are nothing but a myth.

I do want to stress here that I am in no way blaming you, the patient for feeling you can’t exercise.  Unfounded ideas and misconceptions are rife in the world of healthcare and sadly these have a way of filtering into common belief and simply become accepted as truths.  When we look for any actual evidence to substantiate these claims we often struggle to find anything.  It is not only healthcare professionals who are guilty of passing on these misconceptions, but in the modern age the internet has a lot to answer for.  A lot of the information out there is unregulated, unfounded and often biased.

Here on we have an ever growing  team of specialists who are contributing material with the sole goal of improving patient care.  The information we give is well researched, evidence based and tried and tested.  Sadly I cannot say the same for many of the other sites out there, and you should assess the validity of any material before you choose to believe it.

So back to the topic of excuses.  I want to go through some of the most common excuses that I come across on a daily basis and explain to you why they exist and more importantly why they may not be valid.

 I can’t exercise because my knees hurt

Osteoarthritis (OA) is a common condition that is becoming more prevalent in society.  The incidence of knee pain is rising.  We all know somebody who has ‘bad knees’!  Many people who have been given the diagnosis of knee OA are led to think that their knees are worn out and that their exercise ability will be forever limited.  Even more concerning is when people are told that they may in fact make their knees worse by exercising.

I’ll start by explaining a little bit about what OA is, as this is where the problem often originates.  OA is essentially loss of the cartilage and changes in the underlying bone.  The  cartilage is responsible for providing a friction free surface allowing the bones to glide on one another, so when it is lost the joint collapses and the result is bone rubbing on bone.  The smooth surface now feels more like sandpaper and as a result movement can result in pain.

So what causes OA?  It is commonly believed that it is just due to wear and tear over the years.  This however has now been shown to not necessarily be true.  People who run several marathons a year do not have an increased risk of OA, and those that live a sedentary life with minimal stresses on the knees can develop severe OA.  It seems that it is not due to simply wearing out the joint, and that there is actually a genetic component involved.

Surely if there is no cartilage left it isn’t safe to exercise as I will be doing more damage?  This is what a lot of people think, but it simply isn’t true.  Although the cartilage is worn down it takes a while for it to completely go, and even when this happens the rubbing of bone on bone isn’t necessarily doing damage.  The fact is that osteoarthritis is not wear and tear but is instead a disease process.  If you use the knee it will progress and if you don’t use the knee it will still progress.  You are not going to speed up the disease by using your knee more.

So what is the treatment for OA of the knee?  I’m sure most people are thinking the answer to this question is knee replacement.  Although this is certainly an option, it is by no means the first treatment you should consider.  Many surgeons will try to push you towards this option but be very cautious.  Surgery is not without significant risks and should be kept as a last resort when the symptoms are no longer tolerable despite all treatments.    Although the knee is wearing away, there are several things you can do do before surgery to improve the symptoms.  And surprise surprise exercise is one of the most beneficial.

As OA progresses the knee becomes increasingly weak.  This results in the joint becoming less stable and as a result increasing pain.  As a result people will often find ways to bend or use the knee less, resulting in further wasting of the important leg muscles.  This only leads to an even weaker joint and more pain.  One of the best interventions for knee OA is strength training.  A directed program, often initiated by a physiotherapist or well qualified and experienced trainer, aims to improve on leg strength and movement by progressively increasing leg strength through a variety of movements and exercises.  This intervention has been shown to significantly decrease pain in OA and should be done by all sufferers.  Just as significant is the impact it can have on mobility and quality of life.  As you regain strength you can start to do things that you thought you couldn’t do anymore.

Aerobic (cardiovascular) exercise is just as important in the treatment of OA for some people as strength training.  As OA progresses, the pain and restriction felt causes one to exercise less.  This inactivity can result in steady weight gain, and as a result a lot more pressure on the knees.  This increased weight can significantly worsen the pain felt.  If you suffer from knee OA, imagine picking up 2 heavy shopping bags and going for a walk.  I’m sure that just the thought of it makes you feel pain in your knee(s).  Now imagine if you not only took away those bags, but also the equivalent in excess bodyweight.  I don’t have to convince you that your pain would be significantly reduced.  By doing regular exercise (remember it is safe in knee OA and not damaging the joint) you can help prevent the extra weight gain from happening and also reduce any excess you already have.

And lets not forget the fact that exercise has far more health benefits associated with it than improving knee pain, such as reduction in diabetes, heart disease, stroke and many more conditions.  So if you are using your knees as an excuse to not exercise, you are actually increasing your chance of suffering from several other diseases and actively damaging your own health.

It is all very well me telling everyone with knee OA to get out there and exercise, but some of you will be thinking what about the pain???  Knee OA can be a very painful condition, especially when advanced.  Some people will find it difficult to go out for a walk, whilst others are less restricted.  It is certainly true that as knee OA progresses people will become more restricted in what they can comfortably do, but what is important is that you realise that there is always a way to exercise.

Strength training is great because you can vary the weight and range of motion to ensure it is within your comfort levels, and as you improve, so will the pain and you will be able to do more and more.  Any physiotherapist or good trainer will be able to tailor a program to suit, and if they say you shouldn’t be doing anything because of your knees then they are no good and find a new one.

Aerobic training can become a little more tricky.  There are certain activities such as running that some people will never be able to do again, but this should not dishearten you.  Regular walking, with a stick if necessary, is a great way to get out and exercise.  Gyms are now full of fancy equipment and machines such as the cross trainer provide many of the benefits of running without the impact, and incorporate the upper body as well allowing you to do more.  Cycling at a low resistance is a great way to help the knees and cardiovascular system, and some gyms even have arm cycles so you can leave out the legs altogether.  In a well equipped gym you will always be able to find something you can do, just ask the staff for assistance.

As knee OA is a progressive disease, eventually you may find yourself at the stage where your pain is so severe that after discussion with your surgeon you decide on operative treatment with a knee replacement.  At this point you may feel that there is no point starting or continuing with exercise as you just need a new knee, but this is not the case.  In reality the opposite.  Although a knee replacement will provide you with a new joint, to get the best, or even a good result, a pre-operation exercise program is mandatory.

Just replacing the bone is not enough to ensure a good result with a knee replacement.  A joint is made up of many different structures and amongst the most important are the muscles.  As I have explained OA can often result in weakening of the muscles secondary to reduced usage.  If you then simply do a knee replacement, although the joint is nice and new, the muscles that power it are weak.  This can result in a poor outcome after the operation and people not gaining their anticipated results.  It is very important to spend several months before a knee replacement strengthening the muscles around the knee as this will improve the result you get from the operation.

Also the period after a knee replacement is crucial to the result you will end up with for the rest of your life.  It often involves several exercises on a daily basis.  If you have invested the time before surgery mastering these exercises and getting used to them, it will be a lot easier to conduct them after the procedure as you will be familiar with what is required, which will result in a much better outcome.

It is also important to remember that surgery often requires a general anaesthetic, which carries its own risks.  One of the ways to reduce this risk is to lose any excess bodyweight before the operation.  This is another reason why exercising is very important, as together with a good diet it can go a long way to helping you lose weight.

So I hope after reading this article you now realise the importance of exercise in the treatment on knee pain and osteoarthritis.  It is beneficial in reducing pain, increasing function, maintaining independence, preparing for surgery and recovering from surgery, as well as providing all the general health benefits that come with regular exercise.  Everyone has their limitations but there are always ways around them and there is rarely a reason why someone can’t exercise at all.

So if you suffer from knee OA, don’t use it as an excuse to allow your health and knees to deteriorate further.  Don’t be scared to get out there and exercise, and if you are unsure what to do, find a good trainer or go and see your Physician who can point you in the right direction.

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Exercise and Coronary Artery Disease – Is it Safe and Should I Be Doing It?


By Murtaza Ahmed MD

Time after time I come across patients who are suffering from stable coronary artery disease (CAD) who, through no fault of their own, are under the impression that they can’t partake in any form of ‘strenuous’ activity, as it would be detrimental to their health.  When I broach the subject of why they are under this impression, I commonly discover that they have have not been informed of the merits or safety of exercise or even worse, have been told not to by a health professional.  As a Doctor I feel that these patients have been failed by the system and it is my duty to make sure I rectify the situation and their understanding.  Hopefully by writing this article I can ensure that this message I tell people everyday is conveyed to as many people as possible.

The fact of the matter is that exercise is one of the most effective treatments on the market, and that is no lie.  I would go as far as to say that it is a ‘wonder drug’.  If exercise were a pill, it would receive global applause and its inventors would be in line for a Nobel Prize.  But instead, time after time, we continue to shun this miracle treatment in preference for pills and surgical intervention.  Don’t get me wrong.  I am not saying that these treatments are not important, but am instead emphasizing that exercise can be just as, if not sometimes more beneficial, and when carried out in combination, the effects are amplified.

Stable CAD afflicts millions of people throughout the world.  Everyone knows someone who has heart disease, and many people have been affected by its effects on loved ones.  The possibility of having a heart attack or dying from the same is always a worry, but is not the only concern.  The effect on everyday life can be devastating to individuals who, after given the diagnosis, feel a part of their life has been taken away from them.  The truth however is that if treated correctly, this condition doesn’t have to be disabling, and a person can lead a very happy and active life in conjunction with the disease. This is where exercise comes in!

When it comes to CAD, so much emphasis is placed on the commonly known risk factors such as hypertension, smoking and cholesterol.  We hammer into our patients the need to bring blood pressure down, cholesterol in check and throw cigarettes in the trash, but often neglect the need to encourage exercise.  What we also need to start emphasizing is the fact that exercise is a medicine.  It is true that exercise is beneficial in heart disease sufferers, but it should also be noted that INACTIVITY IS HARMFUL.  By not doing any exercise, individuals are in fact  putting themselves at more risk of suffering.

So if exercise is such a beneficial tool in the treatment of stable CAD, why is it so under-utilized and under-promoted?  One of the main answers to this is lack of awareness by health providers.  Although research has conclusively shown the positive effects of exercise on outcomes in stable CAD, this information is sometimes not adequately conveyed to those providing the treatment and as a result, the patients.  Another reason is, as always, funding.  Cardiac rehabilitation programs have been around for some time, but in many instances hospitals fail to offer them to patients, and insurance companies may not be willing to foot the bill.  This is a shame as if emphasis was placed on this simple intervention, the result would be less money having to be spent on the consequences of not carrying out regular exercise.

A very important study revealed that in patients with stable CAD, there was no difference in clinical outcomes (death rates, heart attacks, hospitalization) between those who underwent aggressive medical therapy with lifestyle modification and those who underwent aggressive medical therapy and percutaneous coronary intervention (stenting, angioplasty etc).  Despite this many stable patients are still directed towards the interventional suite, at significant cost, even though it may be of little, if any, benefit to them.  I’ll let you decide the reasons for this, but the important thing is that many of these patients are not offered simple exercise programs.

Exercise is POWERFUL as a treatment for CAD.  The effects it has are numerous and include anti-atherosclerotic (reduce plaque formation), anti-thrombotic (reduce clot formation – one of the causes of heart attacks), anti-ischemic (reduces angina) and anti-depressive effects.  When carried out in patients with stable IHD, it has in fact been shown to reduce mortality (death), and non-fatal myocardial infarction (heart attacks that don’t result in death).

One of the common reasons behind people with stable IHD not exercising is the fear that it will be doing them harm.  Often they feel that exercise will bring on their angina and this will be conferred as feeling they are doing themselves damage or bringing on a heart attack.  The fact is that this is not true.  If this is you, one of the ways to help overcome this fear is to reduce the amount or intensity of the exercise, even below recommended levels, until confidence increases and you can build up to more.  After all, as I have said in previous articles, any exercise is better than no exercise.  If you really struggle with the thought of angina preventing you from exercising, your doctor may be able to prescribe you anti-angina medications to help prevent it occurring.

The risk of stable CAD sufferers having a cardiovascular event in the rehabilitation setting has been repeatedly shown to be minimal.  There are many effective supervised programs available and it is important to know that they are safe.  There are also many telephone and internet based programs for those who may be limited by distance, travel or financial constraints, and these provide the same benefits.

It is also important that you know that resistance exercise is also safe for those suffering from CAD.   There is a grave misconception that the stress from lifting weights puts increased strain on the heart and should be avoided.  Let me tell you now that this is NOT TRUE.  Resistance exercise is safe in those with stable CAD, and should form part of any cardiac exercise program.  Not only does it confer several positive muscular effects, but also may reduce cardiac demand during everyday activities.

So in conclusion there is NO DOUBT that exercise is hugely beneficial in those suffering from stable coronary artery disease.  Medical education of health professionals is increasing, but don’t let lack of awareness hold you back from improving your health and quality of life.  If you suffer from CAD and are not already partaking in a regular exercise program, go and see your doctor and ask them about cardiac exercise programs.  Although exercise is safe in stable CAD, I would recommend that you see your Physician rather than just jumping into a program.  It is important that your individual circumstance it taken into account and that your disease is deemed as stable before commencing increased activity levels.  It is best that you begin exercise as part of a supervised program, and when you feel confident you know what you are doing you can go ahead and form your own exercise regimes.  If your Physician seems unsure, you are now armed with the information to educate them.  If they refuse to listen, then go and find another doctor, but whatever you do, DON’T TAKE NO FOR AN ANSWER!

Don’t let heart disease stop you living your life to the full.  Get out there and exercise!

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Is Vitamin D Important for your Heart?

By Stephen Russell, MD

            Evan a casual glance at health magazines and medical journals reveals widespread interest in vitamin D. A common theme of these articles is that most people are not getting enough of “the sunshine vitamin.” Studies over the last 15 years have consistently demonstrated an epidemic of low vitamin D levels, highest among elderly adults but also seen in up to half of adolescents. Many medical conditions increase a person’s risk for vitamin D deficiency, including osteoporosis, kidney disease, gastrointestinal disorders, and even obesity. It has long been established that adequate amounts of vitamin D support healthy bones; but, can vitamin D be considered a heart healthy vitamin as well?

To answer the question, it helps to know just how we get the vitamin D we need. Our bodies produce vitamin D when exposed to the sun and absorb vitamin D when ingested in our diet. Most Americans, though, do not eat the necessary amounts of vitamin D to maintain healthy levels (defined by the Institute of Medicine’s 2010 report as at least 20 ng/ml). Two of the most potent sources of dietary vitamin D, cod liver oil and sun-dried Shitake mushrooms, are not staples in the American diet. Other dietary sources, such as egg yolks and fortified dairy products, provide only modest amounts of vitamin D with each serving. According to the Institute of Medicine, we need between 600 and 1000 units of vitamin D just to maintain our current blood levels. Vitamin D pills can supplement the lack of dietary intake. So can sensible sun exposure.

Our bodies naturally produce vitamin D when exposed to sunlight, and this remains the most efficient way to build up our vitamin D stores. When the body is exposed to natural sunlight for 5 to 15 minutes a day (termed the “minimal erythrodermal dose” since this is the amount of sun most people need to lightly pinken the skin) the amount of vitamin D produced is between 10,000-25,000 units, the equivalent to drinking ¼ cup of cod liver oil or eating 2 pounds of sun-dried Shitake mushrooms.

Which brings us back to questions of the heart. Basic science trials in the lab tell us that vitamin D can reduce blood vessel inflammation, regulate blood pressure, and reinforce blood sugar control. The trouble seems to be translating those mechanisms into meaningful outcomes for patients. Now, that seems to be changing.

In the April 2013 edition of the journal Hypertension, investigators demonstrated that in African American patients with low vitamin D levels and high blood pressure, simply supplementing them with 2000 units of vitamin D can significantly improve their systolic blood pressure. Some have argued that the results were modest and the sample size small, but this trial offers encouragement. Some investigators aim to answer these criticisms. Since 2010, recruitment has been underway to enroll over 20,000 patients in the VITAL Trial, comparing vitamin D and fish oil against placebo to look for beneficial effects on the body, including the heart. Wouldn’t it be great this summer if a little sun could go a long way to improving your health?

To be sure, vitamin D from sun exposure must be measured. Sunburned skin does not produce more vitamin D, and only modest sun exposure is needed to maximize vitamin D production. Even the 2011 Endocrinology Clinical Practice Guidelines on Vitamin D Deficiency acknowledge that while “the major source of vitamin D for children and adults is exposure to natural sunlight,” that exposure must be sensible. Keep sun exposure to the uncovered arms and legs, and limit exposure to no more than 15 minutes a day. Keeping the face covered and applying sunscreen after fifteen minutes (sooner for those prone to sunburn) can balance the body’s needs for vitamin D production while not increasing the risk of skin cancer. Sensible sun exposure is just one more way to stay healthy this summer, and might prove to be a heart healthy habit.

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Hypertension – Part 2 – treatment with lifestyle modification

By Julian Booker, MD

You have been to see your healthcare provider and much to your chagrin, you have been diagnosed with high blood pressure. Naturally, the first thing that goes through your mind is “what does this mean for me?” Fortunately, you can get that answer in some of our earlier posts. The second thing that you ask is “how are we going to treat this?” If these were not two of the first questions on your list, then I would encourage you to reevaluate your list.

The most important therapeutic intervention for most people with cardiovascular disease is lifestyle modification. Lifestyle modification is centered on weight loss, diet and exercise. Benefits of improved lifestyle are not limited to cardiovascular health and should be the focus of any good preventative approach. These lifestyle modifications should not be considered independently as they all can work together; their effects can be additive.

Weight loss

It has long been established that obesity is directly related to hypertension. The most common tool to estimate the level of obesity is the body mass index. There are a number of online tools to calculate BMI including A “normal” BMI is considered 18.5-25 kg/m2. The BMI can be a little misleading in people that are heavily muscled with little fat in that a high BMI is not necessarily indicative a weight problem. If you are having to debate whether your BMI is elevated because of your Adonis-like physique, then we can make two assumptions: 1) you do not have an Adonis-like physique 2) you are probably obese. Although BMI is not perfect, it does a pretty good job of identifying individuals that would be better served to lose weight.

Modest weight loss can be a powerful anti-hypertensive therapy. There is data that suggests that weight loss can be as powerful as some blood-pressure pills.  Generally, the more weigh you lose, the better your blood pressure will become. Moreover, the effect of any blood pressure medicines that you might take will be more potent.


Eating a healthy diet can be particularly effective at improving blood pressure. Like, weight loss and exercise, the effects are at least comparable to a blood pressure pill. A healthy diet will also help you lose weight (if you have forgotten about weight and blood pressure please refer to the above section).  You should include lots of fruits, vegetables and whole grains and limit fatty and processed foods.

When it comes to blood pressure, sodium chloride or “salt,” is a major player. Salt is an important component to our body’s normal physiology. Unfortunately excessive salt can be detrimental to our health. A western diet filled with red meat, fried foods and processed foods and low quantifies of fruits and vegetables tends to be brimming with salt. As a matter of fact nearly 80% of our sodium intake comes from restaurant and processed foods. People that cook for themselves tend to do a pretty good job managing sodium intake. There has been some debate on the internet as to whether sodium does in fact affect blood pressure and should you limit your sodium intake. It turns out that it does affect blood pressure and certain groups such as African Americans, persons with diabetes, high blood pressure and kidney disease should definitely limit sodium intake. Since you are reading this post, I assume that either you or a loved one has high blood pressure.


The third of our big three lifestyle modifications is exercise. The American Heart Association recommends 150 minutes of moderate intensity aerobic exercise or 75 minutes of vigorous aerobic exercise each week or some combination of the two. Two days of moderate to high intensity strength training is also recommended. A good rule of thumb is 30 minutes of aerobic exercise, most days of the week.  If you can’t make it 30 minutes of continuous exercise, then it can be broken down into 2-3  10-15 minute sessions each day. Again, you can expect significant improvements in your blood pressure.

For more information about diet and exercise, please review some of the posts from our own Dr. Murtaza Ahmed.

Other stuff

There are other things that fit in to the category of lifestyle modification that can play an important role in managing high blood pressure, but we will only review two or three biggies here.

We all know that alcohol in moderation is good for your heart. We also know that alcohol in excess is bad for you. What you may not have known is that too much alcohol can encourage high blood pressure. Try to keep your alcohol consumption to one drink per day and at most two drinks per day for men younger than 65 years old.

In contrast to alcohol, smoking is never good for you. All the television commercials speak about tobacco abuse and how it causes lung disease and cancer. Smoking is probably just as bad on your cardiovascular system. Smoking leads to heart attacks, peripheral artery disease (PAD), and stroke. Seeing as how this series of posts is about hypertension, you probably guessed that smoking can markedly increase your blood pressure too. STOP SMOKING. If you don’t smoke yourself but are around someone who does, remember that secondhand smoke can be just as bad for you.


The next in the series will discuss how your physician may choose to treat your blood pressure using medicines.


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Mitral Valve Prolapse – Part 7, Do I need Antibiotics for my Dental Procedure?

By Mustafa I. Ahmed MD

The Controversy.. Take Them .. Take Them ..Take Them …. Don’t take them

Mitral valve prolapse, antibiotics, dental procedures,

In 2007 the American Heart Association (AHA) released an updated set of guidelines regarding the use of antibiotics to prevent heart valve infection in patients undergoing procedures such as certain dental procedures. The guidelines caused a great deal of controversy at the time, but why? Whereas guidelines before that had advised that most patients with mitral valve prolapse (MVP) to take antibiotics around the time of many dental procedures, the new set of recommendations, in a dramatic turnaround, advised against this. But the AHA had been advising the use of antibiotics in this setting since 1955! Of course this was difficult to understand for patients that had been taking antibiotics, felt comfortable with this, and wanted to continue to do so, and did not easily understand the new stance of their physicians. To the same tune, this was difficult to comprehend for many physicians that had been advocating antibiotics all that time, to suddenly accept the new recommendations and change their views.

Why did the old guidelines say what they did?

Infective endocarditis, which is infection within the heart (usually of the valves), is a serious complication of MVP. In fact in most studies looking at these infections, MVP was reported as the major heart diagnosis in those patients going on to develop these infections, and this was the main drive behind using antibiotics to try and prevent infection. However, it’s very important to realize that when looking at the entire population of patients with MVP, very few would ever develop such infections, in fact less than 2 in 1000. These patients were more likely to have thickened, heavily prolapsing and leaky valves. In those patients with a MVP and a leaky valve (murmur), the rate of infection approaches 5 in 1000, but in those without a leaky valve it is about the same as the general population.

One article in the Lancet in 2005, reviewing the topic of mitral valve prolapse, reported that ‘antibiotic prophylaxis remains one of the most important medical interventions in patients with MVP.’ Particularly pertaining to those with murmurs and high-risk features (can be determined from the echocardiogram). Those that had prolapsing valves that were not particularly degenerated and that did not leak were not felt to require antibiotics.

The amazing thing is that unlike a lot of major topics in cardiology such as treatment of heart attacks, there were actually no good studies that these recommendations were based on. Part of that reason is that such a study would be almost impossible to do given the extremely low number of people that actually developed these infections. To put it simply the recommendations were made by a group of ‘experienced experts’ sitting at a round table (in a smoky room of course!). But most people would agree that is better than no guidance whatsoever.

Why did the guidelines change?

In 2007 the new guidelines came out. Suddenly most people with MVP were told not to take antibiotics when undergoing dental procedures but why? It’s those ‘experts’ in a smoky room again, but this time they were trying to be a little more scientific with their recommendations.

It was now determined that although we were routinely giving antibiotics to many patients with MVP, that there was no evidence to do so because we had never done any good trials proving that they were a) useful and b) not harmful and c) justified given the very small number of people that would ever develop these infections. It was also felt that the usefulness of antibiotics for dental procedures in MVP was limited because in fact someone is more likely to be exposed to the bacteria that cause the heart infections from routine daily activities like brushing teeth, chewing gum or flossing, and were were certainly not giving antibiotics for those activities! It was also recognized that there were some potential serious effects from antibiotics such as reactions and other side effects and so they couldn’t justify recommending a treatment that wasn’t proven to work and may even be harmful.

So what now?

As I’ve stated above the biggest problem here is that there are no good studies guiding what we do in the case of antibiotics for MVP. There is no doubt that MVP patients with degenerated and / or leaky valves are at increased risk of developing infections of the heart. The truth is the chance of developing an infection for these people is tiny, however the consequences of developing an infection are very serious. Can we justify using antibiotics in all patients with MVP at risk of developing an infection, when we don’t know if they work, especially when the chance of side effects from antibiotics may be more serious? On the other hand, the true risk of antibiotics is very small, and some think that it is more than justifiable in some high-risk patients.

The truth is that the new guidelines are likely a safe approach, there’s no way the writers of them would allow it to be any other way. There is recognition in the guidelines that some clinicians may feel more comfortable continuing to prescribe antibiotics particularly in those patients with severe MVP, very degenerated valves and a significant leak. At the same time if antibiotics are not prescribed, as per the guidelines, you can be reassured that no one is taking an unnecessary risk with your health and that the guidelines are created and endorsed by the major heart societies who tend to have your best interests at heart.

Final word

I’m going to stop short of making generalized recommendations here; I don’t feel a blog is the right place to do that. If there are any concerns or doubts then these should be discussed with a physician who you are comfortable with and that is knowledgeable about the subject. The information in this post should certainly leave you in a position to have a reasoned discussion about the matter. If you have had a heart infection before and you have MVP you should certainly make sure you take antibiotics before dental procedures. If you have MVP and your physician, (like most physicians now), has decided not to give you antibiotics, be reassured that he is acting within current guideline recommendations. If your physician does prescribe antibiotics then they should know why they are doing so and have their reasons. They consider you to be at high risk and you should certainly discuss this with them.


Mitral Valve Prolapse – Part 1 – Lets Start With the Basics

Mitral Valve Prolapse 2 – Whats hapenning to the valve?

Mitral Valve Prolapse 3 – The Dreaded flail leaflet

Mitral Valve Prolapse 4 – Introduction to Mitral Regurgitation; The Leaky Mitral Valve

Mitral Valve Prolapse 5 – From Fiasco to Sensibility; How Common is it

Mitral Valve Prolapse 6 – Alarm, Confusion, Controversy, Frustration and Getting to Where We Need to be.

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