Body

Munich, Germany - UNDER EMBARGO UNTIL 26 Aug 2018: Are wrinkles just an inevitable consequence of ageing, or could they signal something more sinister?

According to research presented in Munich today at the ESC Congress 2018, the annual conference of the European Society of Cardiology (1), people who have lots of deep forehead wrinkles, more than is typical for their age, may have a higher risk of dying of cardiovascular disease (CVD).

Assessing brow wrinkles could be an easy, low-cost way to identify people in a high-risk category for CVD.

"You can't see or feel risk factors like high cholesterol or hypertension," says study author Yolande Esquirol, associate professor of occupational health at the Centre Hospitalier Universitaire de Toulouse in France. "We explored forehead wrinkles as a marker because it's so simple and visual. Just looking at a person's face could sound an alarm, then we could give advice to lower risk."

That advice could include straightforward lifestyle changes like getting more exercise or eating healthier food. "Of course, if you have a person with a potential cardiovascular risk, you have to check classical risk factors like blood pressure as well as lipid and blood glucose levels, but you could already share some recommendations on lifestyle factors," Dr Esquirol points out.

Risk of heart disease increases as people age, but lifestyle and medical interventions can mitigate the danger. The challenge is in identifying high-risk patients early enough to make a difference.

According to the study authors, previous research has analysed different visible signs of ageing to see if they can presage cardiovascular disease. In prior studies, crow's feet showed no relationship with cardiovascular risk but these tiny wrinkles near the eyes are a consequence not just of age but also of facial movement. A link has been detected between male-pattern baldness, earlobe creases, xanthelasma (pockets of cholesterol under the skin) and a higher risk of heart disease, but not with an increased risk of actually dying (2).

The authors of the current prospective study investigated a different visible marker of age - horizontal forehead wrinkles - to see if they had any value in assessing cardiovascular risk in a group of 3,200 working adults. Participants, who were all healthy and were aged 32, 42, 52 and 62 at the beginning of the study, were examined by physicians who assigned scores depending on the number and depth of wrinkles on their foreheads. A score of zero meant no wrinkles while a score of three meant "numerous deep wrinkles."

The study participants were followed for 20 years, during which time 233 died of various causes. Of these, 15.2% had score two and three wrinkles. 6.6% had score one wrinkles and 2.1% had no wrinkles.

The authors found that people with wrinkle score of one had a slightly higher risk of dying of cardiovascular disease than people with no wrinkles. Those who had wrinkle scores of two and three had almost 10 times the risk of dying compared with people who had wrinkle scores of zero, after adjustments for age, gender, education, smoking status, blood pressure, heart rate, diabetes and lipid levels,

"The higher your wrinkle score, the more your cardiovascular mortality risk increases," explains Dr Esquirol.

Furrows in your brow are not a better method of evaluating cardiovascular risk than existing methods, such as blood pressure and lipid profiles, but they could raise a red flag earlier, at a simple glance.

The researchers don't yet know the reason for the relationship, which persisted even when factors like job strain were taken into account, but theorise that it could have to do with atherosclerosis, or hardening of the arteries due to plaque build-up. Atherosclerosis is a major contributor to heart attacks and other cardiovascular events.

Changes in collagen protein and oxidative stress seem to play a part both in atherosclerosis and wrinkles. Also, blood vessels in the forehead are so small they may be more sensitive to plaque build-up meaning wrinkles could one of the early signs of vessel ageing.

"Forehead wrinkles may be a marker of atherosclerosis," says Dr Esquirol.

"This is the first time a link has been established between cardiovascular risk and forehead wrinkles so the findings do need to be confirmed in future studies," cautions Dr Esquirol, "but the practice could be used now in physicians' offices and clinics."

"It doesn't cost anything and there is no risk," concluded Dr Esquirol.

Munich, Germany - 26 Aug 2018: Body scanners used for security checks are safe for patients with pacemakers and defibrillators, according to late breaking research presented today at ESC Congress 2018.1

Across the globe more than four million patients with heart failure or cardiac arrhythmias rely on pacemakers and defibrillators to keep their hearts beating regularly. It has been unclear whether body scanners used for security checks at airports interfere with the function of cardiac devices.

Dr Carsten Lennerz, study author, of the German Heart Centre Munich, Technical University of Munich, and German Centre for Cardiovascular Research (DZHK), said: "A multicentre survey of 800 patients with cardiac devices revealed that eight out of ten worry about the safety of security body scanners and would refuse the scan, preferring a manual check.2 This takes more time and requires giving medical details to security staff."

This study assessed the safety of full body scanners for patients with implanted cardiac devices. The scanners emit millimetre waves which bounce off the skin and create an image of the body and any concealed objects. These scanners were introduced in the mid-2000s and most airports with full body scanners now use millimetre wave imaging. They are also used in train stations and some public buildings for security screening.

The study included 300 patients with a pacemaker, implantable cardioverter defibrillator (ICD), or cardiac resynchronisation therapy (CRT) device attending a routine check-up at the German Heart Centre Munich. Patients underwent a body scan mimicking the scans at airport security (figure). An electrocardiogram (ECG) was recorded during the scan to detect potential malfunctions of the cardiac device caused by electromagnetic interference.

Dr Lennerz said: "We found no evidence of electromagnetic interference or device malfunction with the full body scanner we tested and can conclude that scanning is safe for patients with implanted cardiac devices. This may be because cardiac devices filter out high frequency signals such as millimetre waves, the waves hardly penetrate the body at all, and the scan time is very short (usually around 100 milliseconds)."

The premise of the study was that the electromagnetic fields generated by body scanners could be misinterpreted by cardiac devices as signals from the heart, causing a pacemaker to stop pacing or pace incorrectly, or a defibrillator to mistakenly deliver shock therapy. Electromagnetic interference could also alter the cardiac device's programming, which is tailored to a specific patient, with unpredictable results. However, the research found no indication of electromagnetic interference or device malfunction.

Dr Lennerz noted that a strength of the study was that patients underwent a security body scan with the same electromagnetic fields used in real life, but in a controlled hospital environment.

He concluded: "The study suggests that millimetre wave body scanners pose no threat to patients with pacemakers, ICDs, and CRT devices and there is no need for specific protocols or restrictions on their use."

Munich, Germany - Aug. 26, 2018: Researchers have found a sweet spot of six to eight hours sleep a night is most beneficial for heart health. More or less is detrimental. Their findings are presented today at ESC Congress 2018.1

Study author Dr Epameinondas Fountas, of the Onassis Cardiac Surgery Centre, Athens, Greece, said: "We spend one-third of our lives sleeping yet we know little about the impact of this biological need on the cardiovascular system."

The study investigated the relationship between sleep duration and cardiovascular disease using a meta-analysis, a statistical tool for combining the results of previous studies on the same topic. The meta-analysis included 11 prospective studies of more than one million adults (1,000,541) without cardiovascular disease published within the last five years.

Two groups, one with short (less than six hours) and another with long (more than eight hours) nightly sleep duration, were compared to the reference group (six to eight hours).

The researchers found that both short and long sleepers had a greater risk of developing or dying from coronary artery disease or stroke. Compared to adults who slept six to eight hours a night, short and long sleepers had 11% and 33% greater risks, respectively, of developing or dying from coronary artery disease or stroke during an average follow-up of 9.3 years.

Dr Fountas said: "Our findings suggest that too much or too little sleep may be bad for the heart. More research is needed to clarify exactly why, but we do know that sleep influences biological processes like glucose metabolism, blood pressure, and inflammation - all of which have an impact on cardiovascular disease."

A strength of the current analysis is that only prospective studies were included, noted Dr Fountas. This avoids recall bias, a source of systematic error in statistics arising from the inability of participants to accurately recall information.

Dr Fountas concluded: "Having the odd short night or lie-in is unlikely to be detrimental to health, but evidence is accumulating that prolonged nightly sleep deprivation or excessive sleeping should be avoided. The good news is that there are plenty of ways to get into the habit of getting six to eight hours a night - for example by going to bed and getting up at the same time every day, avoiding alcohol and caffeine before bed, eating healthily, and being physically active. Getting the right amount of sleep is an important part of a healthy lifestyle."

Munich, Germany - 26 Aug 2018: The jury is still out on whether people at moderate risk of a first heart attack or stroke should take daily aspirin to lower their risk, according to late breaking results from the ARRIVE study1 presented today in a Hot Line Session at ESC Congress 20182 and with simultaneous publication in the Lancet.

Professor J. Michael Gaziano, principal investigator, of the Brigham and Women's Hospital, Boston, US, said: "Aspirin did not reduce the occurrence of major cardiovascular events in this study. However, there were fewer events than expected, suggesting that this was in fact a low risk population. This may have been because some participants were taking medications to lower blood pressure and lipids, which protected them from disease."

The benefit of aspirin for preventing second events in patients with a previous heart attack or stroke is well established.3 Its use for preventing first events is controversial, with conflicting results in previous studies and recommendations for and against its use in international guidelines. Recommendations against its use cite the increased risk of major bleeding.3

The ARRIVE study assessed the impact of daily aspirin on heart attacks, strokes, and bleeding in a population at moderate risk of a first cardiovascular event. Moderate risk was defined as a 20-30% risk of a cardiovascular event in ten years. The study enrolled individuals with no prior history of a vascular event, such as stroke or heart attack. Men were at least 55 years old and had two to four cardiovascular risk factors, while women were at least 60 years old with three or more risk factors. Risk factors included smoking, elevated lipids, and high blood pressure.

A total of 12,546 participants were enrolled from primary care settings in the UK, Poland, Germany, Italy, Ireland, Spain, and the US. Participants were randomly allocated to receive a 100 mg enteric-coated aspirin tablet daily or placebo. The median follow-up was 60 months. The primary endpoint was time to first occurrence of a composite of cardiovascular death, myocardial infarction, unstable angina, stroke, and transient ischaemic attack.

The average age of participants was 63.9 years and 29.7% were female. In the intention-to-treat analysis, which examines events according to the allocated treatment, the primary endpoint occurred in 269 (4.29%) individuals in the aspirin group versus 281 (4.48%) in the placebo group (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.81-1.13, p=0.60). In the per-protocol analysis, which assesses events only in a compliant subset of the study population, the primary endpoint occurred in 129 (3.40%) participants of the aspirin group versus 164 (4.19%) in the placebo group (HR 0.81, 95% CI 0.64-1.02, p=0.0756).

In the per-protocol analysis, aspirin reduced the risk of total and nonfatal myocardial infarction (HR 0.53, 95% CI 0.36-0.79, p=0.0014; HR 0.55, 95% CI 0.36-0.84, p=0.0056, respectively). The relative risk reduction of myocardial infarction in the aspirin group was 82.1%, and 54.3% in the 50-59 and 59-69 age groups, respectively.

All safety analyses were conducted according to intention-to-treat. Gastrointestinal bleedings, which were mostly mild, occurred in 61 (0.97%) individuals in the aspirin group versus 29 (0.46%) in the placebo group (HR 2.11, 95% CI 1.36-3.28, p=0.0007). The overall incidence of adverse events was similar between treatment groups. Drug-related adverse events were more frequent in the aspirin (16.75%) compared to placebo (13.54%) group (p

Professor Gaziano said: "Participants who took aspirin tended to have fewer heart attacks, particularly those aged 50-59 years, but there was no effect on stroke. As expected, rates of gastrointestinal bleeding and some other minor bleedings were higher in the aspirin group, but there was no difference in fatal bleeding events between groups."

He concluded: "The decision on whether to use aspirin for protection against cardiovascular disease should be made in consultation with a doctor, considering all the potential risks and benefits."

Munich, Germany - Aug. 26, 2018: Middle-aged men who sleep five hours or less per night have twice the risk of developing a major cardiovascular event during the following two decades than men who sleep seven to eight hours, according to research presented today at ESC Congress 2018.1

Study author Ms Moa Bengtsson, of the University of Gothenburg, Sweden, said: "For people with busy lives, sleeping may feel like a waste of time but our study suggests that short sleep could be linked with future cardiovascular disease."

Previous studies have generated conflicting evidence on whether short sleep is associated with a greater chance of having a future cardiovascular event. This study investigated this relationship in 50-year-old men.

In 1993, 50% of all men born in 1943 and living in Gothenburg were randomly selected to participate in the study. Of the 1,463 invited, 798 (55%) men agreed to take part. Participants underwent a physical examination and completed a questionnaire on current health conditions, average sleep duration, physical activity, and smoking. The men were divided into four groups according to their self-estimated average sleep duration at the start of the study: five or less hours, six hours, seven to eight hours (considered normal sleep duration), and more than eight hours.

Participants were followed-up for 21 years for the occurrence of major cardiovascular events, which included heart attack, stroke, hospitalisation due to heart failure, coronary revascularisation, or death from cardiovascular disease. Data on cardiovascular events were collected from medical records, the Swedish Hospital Discharge Registry, and the Swedish Cause of Death Register.

Men with incomplete data on sleep duration, incomplete follow-up information, or who had a major cardiovascular event before the start of the study were excluded, leaving a total of 759 men for the analyses.

High blood pressure, diabetes, obesity, current smoking, low physical activity, and poor sleep quality were more common in men who slept five or fewer hours per night compared to those who got seven to eight hours.

Compared to those with normal sleep duration, men who slept five or fewer hours per night had a two-fold higher risk of having a major cardiovascular event by age 71. The risk remained doubled after adjusting for cardiovascular risk factors at the start of the study including obesity, diabetes, and smoking.

Ms Bengtsson said: "Men with the shortest sleep duration at the age of 50 were twice as likely to have had a cardiovascular event by age 71 than those who slept a normal amount, even when other risk factors were taken into account."

She continued: "In our study, the magnitude of increased cardiovascular risk associated with insufficient sleep is similar to that of smoking or having diabetes at age 50. This was an observational study so based on our findings we cannot conclude that short sleep causes cardiovascular disease, or say definitively that sleeping more will reduce risk. However, the findings do suggest that sleep is important - and that should be a wake-up call to all of us."

Munich, Germany - Aug. 25, 2018: Pregnant women with heart disease should give birth at no later than 40 weeks gestation. That is one of the recommendations in the 2018 European Society of Cardiology (ESC) Guidelines for the management of cardiovascular diseases during pregnancy published online today in European Heart Journal,1 and on the ESC website.2

"Beyond 40 weeks, pregnancy has no added benefit for the baby and may even have negative effects," said Professor Jolien Roos-Hesselink, Co-Chairperson of the Guidelines Task Force and Cardiologist, Erasmus Medical Centre Rotterdam, the Netherlands. "Pregnancy is a risky period for women with heart disease because it puts additional stress on the heart, so the guidelines advise inducing labour or a caesarean section at 40 weeks."

Heart disease is the main reason women die during pregnancy in western countries. Compared to healthy pregnant women, those with heart disease have a 100-fold greater risk of death or heart failure. Most women with heart disease have a healthy pregnancy. However, they should be aware that they have a higher risk of obstetric complications including premature labour, pre-eclampsia, and post-partum bleeding. An estimated 18-30% of offspring have complications and up to 4% of neonates die.

Heart disease in pregnancy is increasing as more women with congenital heart disease reach adulthood due to improved treatment and as the age at first pregnancy rises, accompanied by the higher rates of ischaemic heart disease in older, compared to younger, women. Cardiovascular risk factors including hypertension, diabetes and overweight are also on the rise in pregnancy as older women become pregnant and women now acquire risk factors at a younger age.

The guidelines provide recommendations on in vitro fertilisation (IVF), contraception, and termination of pregnancy in women with heart disease. IVF often uses high doses of hormones, which increase the risk of thrombosis and heart failure, so women with heart disease need a cardiologist's confirmation that the chosen method is safe. Since carrying more than one baby puts more stress on the heart, women with heart disease undergoing IVF are strongly advised to transfer a single embryo. Girls with congenital heart disease need contraception advice to avoid unplanned pregnancy. Some contraception methods are contraindicated in patients with certain types of heart disease.

For drugs used to treat heart disease, the guidelines list information on adverse events obtained from human and animal studies. In addition, the guidelines state: "In the case of an emergency, drugs that are not recommended by the pharmaceutical industry during pregnancy and breastfeeding should not be withheld from the mother. The potential risk of a drug and the possible benefit of the therapy must be weighed against each other."

Professor Vera Regitz-Zagrosek, Chairperson of the Guidelines Task Force and Director of the Institute for Gender Medicine, Charité University Medical Centre Berlin, Germany, said: "When drug companies have no data on whether a drug is safe during pregnancy and breastfeeding they tend to say it is not recommended. It may be appropriate to give a drug to a severely ill woman if there are no harmful side effects noted in the databases listed in the guidelines."

Pregnancy is not recommended in patients with certain types of heart disease - for example, pulmonary arterial hypertension, severely dilated aorta, or severely reduced ability of the heart to pump blood.

Women with heart disease who want to have a baby need pre-pregnancy risk assessment and counselling. Those at moderate to high risk of complications should be reviewed by a pregnancy heart team with a cardiologist, obstetrician, gynaecologist, and anaesthesiologist. A delivery plan should be devised at 20-30 weeks specifying vaginal or caesarean delivery, whether an epidural or forceps will be used, and the duration of hospital stay after delivery.

Professor Roos-Hesselink said: "The delivery plan should be available 24 hours a day so that when a pregnant woman with heart disease arrives at hospital in labour hospital staff know exactly what to do."

Professor Regitz-Zagrosek: "We hope the guidelines will improve doctors' awareness of the risks of heart disease in pregnancy but also the therapeutic options that are available to guide pregnancy in these women."

Heart scans for patients with chest pains could save thousands of lives in the UK, research suggests.

The life-saving scans helped to spot those with heart disease so they could be given treatments to prevent heart attacks.

Researchers say current guidelines should be updated to incorporate the scans into routine care.

The SCOT-HEART study tracked more than 4000 patients who were referred to a hospital clinic with symptoms of angina - a condition that restricts the blood supply to the heart.

Half of the patients were given a scan called a computed tomography angiogram, or CTA, in addition to standard diagnostic tests.

After receiving the scan, the number of patients suffering a heart attack within five years dropped by 40 per cent, the study found.

The number of patients undergoing additional procedures increased within the first year but had levelled out by the end of the five-year period. This suggests that including the scans in routine care would not lead to a surge in costly tests or additional heart surgery, the researchers say.

Patients who are at risk of a heart attack are frequently diagnosed with a test called an angiogram. This involves inserting tubes into the body and heart to check the flow of blood and identify any obstructions that could pose a heart attack risk.

CTA scans enable doctors to look at the blood vessels from the outside the body, without the need to insert tubes into the heart. The scans are cheaper, quicker and safer than angiograms.

The study had previously found that around a quarter of patients had their diagnoses reclassified after receiving the scan, prompting new treatments in many cases.

This is the first study to look at the impact of the scans on long-term survival rates.

Lead researcher Professor David Newby, of the BHF Centre for Cardiovascular Science at the University of Edinburgh, said: "This relatively simple heart scan ensures that patients get the right treatment. This is the first time that CT guided management has been shown to improve patient outcomes with a major reduction in the future risk of heart attacks. This has major implications for how we now investigate and manage patients with suspected heart disease."

Munich, Germany - UNDER EMBARGO UNTIL 25 Aug 2018: Very high levels of high-density lipoprotein (HDL or "good") cholesterol may be associated with an increased risk of heart attack and death, according to research presented today at ESC Congress 2018.1

Study author Dr Marc Allard-Ratick, of Emory University School of Medicine, Atlanta, US, said: "It may be time to change the way we view HDL cholesterol. Traditionally, physicians have told their patients that the higher your 'good' cholesterol, the better. However, the results from this study and others suggest that this may no longer be the case."

HDL cholesterol has been considered "good" because the HDL molecule is involved in the transport of cholesterol from the blood and blood vessel walls to the liver and ultimately out of the body, thereby reducing the risk of clogged arteries and atherosclerosis. People with low HDL cholesterol have a greater risk of atherosclerosis and cardiovascular disease. But the protective effect of very high HDL cholesterol has been unclear.

This study, conducted as part of the Emory Cardiovascular Biobank, investigated the relationship between HDL cholesterol levels and the risk of heart attack and death in 5,965 individuals, most of whom had heart disease. The average age of participants was 63 years and 35% were female.

Participants were divided into five groups according to their HDL cholesterol level: less than 30 mg/dl (0.78 mmol/L), 31-40 mg/dl (0.8-1 mmol/L); 41-50 mg/dl (1.1-1.3 mmol/L); 51-60 mg/dl (1.3-1.5 mmol/L); and greater than 60 mg/dl (1.5 mmol/L).

During a median follow-up of four years, 769 (13%) participants had a heart attack or died from a cardiovascular cause. Participants with HDL cholesterol 41-60 mg/dl (1.1-1.5 mmol/L) had the lowest risk of heart attack or cardiovascular death. Risk was increased both in participants with low levels (less than 41 mg/dl) and very high levels (greater than 60 mg/dl) of HDL cholesterol, which produced a U-shaped curve when plotted graphically.

Participants with HDL cholesterol levels greater than 60 mg/dl (1.5 mmol/L) had a nearly 50% increased risk of dying from a cardiovascular cause or having a heart attack compared to those with HDL cholesterol levels 41-60 mg/dl (1.1-1.5 mmol/L).

The associations were consistent even after controlling for other risk factors for heart disease such as diabetes, smoking, and low-density lipoprotein (LDL or "bad") cholesterol, as well as other factors linked with high HDL cholesterol such as alcohol intake, race, and sex.

The results support findings from several large population-based studies, including a recent publication which found increased cardiovascular and all-cause death when HDL cholesterol reached extremely high levels.2 Dr Allard-Ratick said: "Our results are important because they contribute to a steadily growing body of evidence that very high HDL cholesterol levels may not be protective, and because unlike much of the other data available at this time, this study was conducted primarily in patients with established heart disease."

He noted that more research is needed to elucidate the mechanisms of this paradoxical association. "While the answer remains unknown, one possible explanation is that extremely elevated HDL cholesterol may represent 'dysfunctional HDL' which may promote rather than protect against cardiovascular disease," he said.

Dr Allard-Ratick concluded: "One thing is certain: the mantra of HDL cholesterol as the 'good' cholesterol may no longer be the case for everyone."

Bottom Line:  Medicaid expansion under the Affordable Care Act (ACA) was associated with a decline in the proportion of uninsured hospitalizations for major cardiovascular events such as heart attack, stroke and heart failure.

Why The Research Is Interesting: Cardiovascular disease is the leading primary hospital discharge diagnosis and the most common cause of death in the United States. This study examined how state decisions about whether to expand Medicaid under the ACA were associated with changes in uninsured hospitalizations for these major cardiovascular events.

What and When: More than 3 million non-Medicare hospitalizations between 2009 and 2014 from inpatient databases in 30 states (17 expanded Medicaid; 13 didn't)

What (Study Measures and Outcomes): State Medicaid expansion as of January 2014 (exposure); comparison of the average payer mix proportions (uninsured, Medicaid, and privately insured) and in-hospital mortality between expansion and nonexpansion states before the ACA Medicaid expansion (2009-2013) and in the year (2014) after the expansion (outcomes)

How (Study Design): This was an observational study. Researchers were not intervening for purposes of the study and cannot control all the natural differences that could explain the study findings.

Authors:  Ehimare Akhabue, M.D., of the Northwestern University Feinberg School of Medicine, Chicago, Illinois, and co-authors

Study Limitations: Total number of hospitalizations for cardiovascular events could have been underestimated; data were only available for one year after ACA implementation; and only 30 states were included in the analysis

Related Material: The invited commentary, "Medicaid Expansion and In-Hospital Cardiovascular Mortality: Failure or Unrealistic Expectations," by Rishi K. Wadhera, M.D., M.Phil., of Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, and Karen E. Joynt Maddox, M.D., M.P.H., of the Washington University School of Medicine in St. Louis, Missouri, also is available on the For The Media website.

To Learn More: The full study is available on the For The Media website.

(doi:10.1001/jamanetworkopen.2018.1296)

Editor's Note: The article contains funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Kaiser Permanente research published today in the American Journal of Preventive Medicine found if patients with hypertension taking prescribed medications experience unusually low blood pressures -- systolic blood pressure under 110mmHg -- they are twice as likely to experience a fall or faint as patients whose treated blood pressure remains 110mmHg and above.

This research is timely because late last year the American Heart Association and the American College of Cardiology lowered its definition of high blood pressure from a systolic blood pressure of at least 140 to a systolic of at least 130, said the study's lead author John J. Sim, MD, a nephrologist with the Kaiser Permanente Los Angeles Medical Center.

"Efforts to reduce blood pressures for patients with hypertension are an important factor in reducing the risk of heart attack and stroke," Dr. Sim said. "But our study shows that attaining a lower blood pressure could create to a subpopulation of patients whose blood pressures may go too low, which can pose risk for serious falls and fainting."

To determine the effects of blood pressure reduction among hypertension on patients, Dr. Sim and a team of researchers studied the electronic health records of more than 475,000 Kaiser Permanente patients in Southern California who were prescribed medication to treat hypertension. Over a one-year period, both mean and minimum systolic blood pressure readings of less than 110 mmHg were associated with higher rates of serious falls and fainting that resulted in emergency department visits or inpatient encounters.

Among the patients with treated blood pressure:

27 percent had a systolic blood pressure under 110mmHg during at least one visit

3 percent of patients had an average systolic pressure reading of less than 110mmHg over the one-year study period

Patients with a single episode of systolic pressure lower than or equal to 110mmHg during the one-year period were twice as likely to experience a serious fall or faint

Patients who had an average systolic blood pressure lower than 110mmHg over the one-year study period had a 50 percent greater risk of serious falls and fainting than those who had an average systolic blood pressure higher than 110mmHg

"Physicians considering lower blood pressure targets for their patients should weigh the risks and benefits of aggressive blood pressure lowering on an individual basis, especially in older patients," said Dr. Sim.

He noted that older patients are more likely to have acute reductions in blood pressure, such as orthostatic hypotension, which is when a patient's blood pressure drops substantially when they stand or get upright, and have slower reflexes to compensate and normalize their blood pressure. They also are more susceptible to side effects of low blood pressure, he said.

Some characteristics physicians should watch out for before considering lowering a patient's blood pressure are acute illness, blood pressure variation throughout the day, and orthostatic hypotension, Dr. Sim said.

Globally, one in three people drink alcohol (equivalent to 2.4 billion people), and 2.2% of women and 6.8% of men die from alcohol-related health problems each year.

Alcohol use was ranked as the seventh leading risk factor for premature death and disability worldwide in 2016, and was the leading cause for people aged 15-49 years old. In this age group, it is associated with tuberculosis, road injuries, and self-harm.

For people aged 50 years and older, cancers were a leading cause of alcohol-related death, constituting 27.1% of deaths in women and 18.9% of deaths in men.

The authors suggest there is no safe level of alcohol as beneficial effects against ischemic heart disease are outweighed by the adverse effects on other areas of health, particularly cancers.

Alcohol is a leading risk factor for death and disease worldwide, and is associated with nearly one in 10 deaths in people aged 15-49 years old, according to a Global Burden of Disease study published in The Lancet that estimates levels of alcohol use and health effects in 195 countries between 1990 to 2016.

Based on their analysis, the authors suggest that there is no safe level of alcohol as any health benefits of alcohol are outweighed by its adverse effects on other aspects of health, particularly cancers.

They estimate that, for one year, in people aged 15-95 years, drinking one alcoholic drink a day [1] increases the risk of developing one of the 23 alcohol-related health problems [2] by 0.5%, compared with not drinking at all (from 914 people in 100,000 for one year for non-drinkers aged 15-95 years, to 918 in 100,000 people a year for 15-95 year olds who consume one alcoholic drink a day) [3].

Alcohol has a complex association with health, affecting it in multiple ways. Regular consumption has adverse effects on organs and tissues, acute intoxication can lead to injuries or poisoning, and alcohol dependence may lead to frequent intoxication, self-harm or violence. Some previous research has suggested that low levels of consumption can have a protective effect against heart disease and diabetes.

"Previous studies have found a protective effect of alcohol on some conditions, but we found that the combined health risks associated with alcohol increase with any amount of alcohol. In particular, the strong association between alcohol consumption and the risk of cancer, injuries, and infectious diseases offset the protective effects for ischaemic heart disease in women in our study. Although the health risks associated with alcohol starts off being small with one drink a day, they then rise rapidly as people drink more," says lead author Dr Max Griswold, Institute for Health Metrics and Evaluation, University of Washington, USA. "Policies focussing on reducing alcohol consumption to the lowest levels will be important to improve health. The widely held view of the health benefits of alcohol needs revising, particularly as improved methods and analyses continue to shed light on how much alcohol contributes to global death and disability." [4]

Robust estimates of alcohol consumption and related risks

The study used data from 694 studies to estimate how common drinking alcohol is worldwide and used 592 studies including 28 million people worldwide to study the health risks associated with alcohol [2] between 1990 to 2016 in 195 countries. In the study, a standard alcoholic drink is defined as 10g alcohol [1].

Previous studies looking at these risks rely on self-reported surveys and alcohol sales data to estimate consumption levels. These have limitations, including that non-drinkers may avoid alcohol as they have health issues, they do not take into account types of alcohol that are not purchased (such as illicit trade and home brewing), and most studies assume that not drinking minimises risk but do not study the association to confirm this.

The new study provides more robust estimates of alcohol consumption by combining alcohol sales data with the prevalence of alcohol drinking and abstinence, self-reported data on the amount of alcohol drank, tourism data to estimate the number of alcohol-drinking visitors to an area, and estimating levels of illicit trade and home brewing.

It also includes a new, more robust systematic review and meta-analysis of alcohol consumption and the associated health problems, which used specific controls to reduce confounding factors. It also used a new statistical method to more accurately estimate the risks related to drinking between 0-15 standard drinks each day. The authors used this to estimate the amount of alcohol exposure that would minimise an individual's risk of alcohol-related health problems.

Global alcohol consumption

Globally, one in three people (32.5%) drink alcohol - equivalent to 2.4 billion people - including 25% of women (0.9 billion women) and 39% of men (1.5 billion men). On average, each day women consumed 0.73 alcoholic drinks, and men drank 1.7 drinks.

Drinking patterns varied globally [5], the highest number of current alcohol drinkers was in Denmark (95.3% of women, and 97.1% of men) while the lowest were in Pakistan for men (0.8%) and Bangladesh for women (0.3%). Men in Romania and women in Ukraine drank the most (8.2 and 4.2 drinks a day respectively), whereas men in Pakistan and women in Iran drank the least (0.0007 and 0.0003 drinks a day respectively).

Risks associated with alcohol

Globally, drinking alcohol was the seventh leading risk factor for premature death and disease in 2016, accounting for 2.2% of deaths in women and 6.8% of deaths in men. However, in people aged 15-49 years old, alcohol was the leading risk factor in 2016, with 3.8% of deaths in women and 12.2% of deaths in men attributable to alcohol.

The main causes of alcohol-related deaths in this age group were tuberculosis (1.4% of deaths), road injuries (1.2%), and self-harm (1.1%). For people aged 50 years and older, cancers were a leading cause of alcohol-related death, constituting 27.1% of deaths in women and 18.9% of deaths in men.

The health problems associated with alcohol at age 50 or older varied depending on region. In high-income countries, cancers were the most common alcohol-related premature death and disease, while in low-income countries tuberculosis was the leading cause, followed by cirrhosis and chronic liver diseases. In middle- and high-to-middle income countries stroke was the main alcohol-related burden.

The authors found that there was only a protective effect between alcohol and ischemic heart disease, and there were possible protective effects for diabetes and ischemic stroke but these were not statistically significant. The risk of developing all other health problems increased with the number of alcoholic drinks consumed each day.

Combining these findings, the protective effect of alcohol was offset by the risks and overall the health risks associated with alcohol rose in line with the amount consumed each day. Therefore, the authors conclude that there is no safe level of alcohol.

Specifically, comparing no drinks with one drink a day the risk of developing one of the 23 alcohol-related health problems was 0.5% higher – meaning 914 in 100,000 15-95 year olds would develop a condition in one year if they did not drink, but 918 people in 100,000 who drank one alcoholic drink a day would develop an alcohol-related health problem in a year.

This increased to 7% in people who drank two drinks a day (for one year, 977 people in 100,000 who drank two alcoholic drinks a day would develop an alcohol-related health problem) and 37% in people who drank five drinks every day (for one year, 1252 people in 100,000 who drank five alcoholic drinks a day would develop an alcohol-related health problem) [3].

Professor Emmanuela Gakidou, Institute for Health Metrics and Evaluation, University of Washington, USA, says: "Alcohol poses dire ramifications for future population health in the absence of policy action today. Our results indicate that alcohol use and its harmful effects on health could become a growing challenge as countries become more developed, and enacting or maintaining strong alcohol control policies will be vital."

"Worldwide we need to revisit alcohol control policies and health programmes, and to consider recommendations for abstaining from alcohol. These include excise taxes on alcohol, controlling the physical availability of alcohol and the hours of sale, and controlling alcohol advertising. Any of these policy actions would contribute to reductions in population-level consumption, a vital step toward decreasing the health loss associated with alcohol use." [4]

The authors note some limitations, including that it is difficult to estimate illicit alcohol production and unrecorded consumption so their results may not fully capture this. The study also does not include drinking data for people under the age of 15 years, and does not include links to health problems such as dementia and psoriasis where evidence suggests alcohol could be a risk factor. The authors say that this may mean their study underestimates the number of people drinking alcohol and the risks associated.

In addition, there was little robust data on interpersonal violence due to alcohol, and the data for road accidents due to alcohol that cause harm to others were based on USA data only. While patterns are unlikely to vary around the world, this needs to be confirmed.

Because more in-depth information is not available, the study assumes that drinking patterns are the same across the year, but previous research suggests that changing drinking patterns, such as binge-drinking, could be linked to different levels of risk.

Writing in a linked Comment, Dr Robyn Burton, King's College London, UK, calls the study the most comprehensive estimate of the global burden of alcohol use to date. She says: "The conclusions of the study are clear and unambiguous: alcohol is a colossal global health issue and small reductions in health-related harms at low levels of alcohol intake are outweighed by the increased risk of other health-related harms, including cancer. There is strong support here for the guideline published by the Chief Medical Officer of the UK who found that there is "no safe level of alcohol consumption". The findings have further ramifications for public health policy, and suggest that policies that operate by decreasing population-level consumption should be prioritised... These diseases of unhealthy behaviours, facilitated by unhealthy environments and fuelled by commercial interests putting shareholder value ahead of the tragic human consequences, are the dominant health issue of the 21st century. The solutions are straightforward: increasing taxation creates income for hard-pressed health ministries, and reducing the exposure of children to alcohol marketing has no downsides."

Stanford University researchers have developed a mathematical model that could help public health officials and policymakers curb an opioid epidemic that took the lives of an estimated 49,000 Americans last year.

The model includes data about prescriptions, addictions and overdoses in the United States. It can be used to consider "what if" scenarios similar to those that business leaders run through to project how changing product features or prices are likely to affect sales and profits, said Margaret Brandeau, PhD, professor of management science and engineering.

Brandeau is the senior author of a paper that describes how the model analyzes opioid use and addiction among Americans whose initial exposure to these drugs came either from being prescribed pills or gaining illicit access to pills.

The paper will be published Aug. 23 in the American Journal of Public Health. The lead author is graduate student Allison Pitt.

'Like squeezing a balloon'

Using models is relatively new in the realm of public health, where responsibility for solving problems is widely diffused among a variety of governmental and private sector decision-makers, said co-author Keith Humphreys, PhD, the Esther Ting Memorial Professor and a professor of psychiatry and behavioral sciences.

"Confronting this crisis is like squeezing a balloon," said Humphreys, an expert on substance abuse. "When you touch one aspect of the situation, an unpleasant consequence often pops up somewhere else."

The paper cites the daunting facts of the opioid crisis: Between 1990 and 2010, there was a 400 percent spike in prescriptions for opioid painkillers. Today, roughly 3.5 million Americans have become addicted to opioids as a result of an initial exposure to opioid pills. Yet, as doctors have begun responding to the crisis by reducing prescriptions, overdose deaths have increased because former pill addicts, unable to get the quality-controlled drug, have started buying and overdosing on heroin.

Against this bleak backdrop, the Stanford model projects that if doctors can cut prescriptions by 25 percent over a 10-year period, while policymakers expand drug treatment programs, addictions and deaths will start falling by 2026.

"People want this to be over sooner, but the model shows that we've dug ourselves such a deep hole that it will take time to climb out," said Brandeau, who also holds the Coleman F. Fung Professorship in the School of Engineering.

Putting the puzzle together

Humphreys said the model puts multiple parts of the opioid-crisis puzzle together so that government and private-sector officials can see how addressing any given aspect of the crisis will affect the big picture.

"This is perhaps the most complex public health challenge we've ever faced," Humphreys said. "We need this tool to avoid policy paralysis."

Pitt, the lead author, spent the last two years collecting data on opioid use and addiction and other variables. The researchers based their model on data from 2015. Thereafter the model made projections for such variables as what fraction of American adults experience moderate to severe pain each year; how many opioid painkillers are prescribed; how many people have become addicted to opioids by starting with pills; and how many Americans who initially became addicted through exposure to pills die each year from overdoses of pharmaceutical opioids or heroin.

In 2015, when 188 million opioid prescriptions were issued, 3.5 million Americans were already addicted to opioids through initial exposure to pills. Of these, the researchers estimated that roughly 16,000 died as a result of a pill overdoses. Another 22,000 who were initially hooked on pills died that year from heroin overdoses. This crossover from pills to street drugs, which often occurs when pill addicts can no longer get prescription medications, is one tragic aspect of the opioid crisis. In addition to these 38,000 deaths related to pill exposure, an estimated 26,000 more Americans died of overdoses from other drugs, mainly from cocaine and methamphetamine in 2015. But the Stanford study does not factor these deaths into the model.

Instead, the researchers focused on overdoses that could be traced to pill exposure and projected forward 10 years to make educated guesses about how different scenarios would be likely to decrease addiction and death rates stemming from pharmaceutical opioids. The first, or baseline, scenario was to project the status quo. If current trends prevail, the model projects that 188 million prescriptions would still be written in 2026, and that by then an estimated 4.3 million Americans would have become addicts through an initial exposure to pills. Pill-connected overdose deaths would likely soar to an estimated 50,000, compared with 38,000 in 2015.

Considering the 'what ifs'

After establishing this baseline, the researchers considered various scenarios by which the epidemic might be slowed: What if physicians reduced new prescriptions across the board? What if there were controls on refills? What if there were easy ways for patients to get rid of their excess pills so they don't get misused? What if various post-addiction treatments were made more available?

The scenario that assumes physicians reduce opioid prescriptions by 25 percent resulted in 2,500 fewer overdoses over 10 years than the status quo. "We must restrict the supply of pills to have any hope of bringing this crisis under control," Brandeau said.

The model considers the likelihood that as pills become unavailable, more opioid addicts will buy street heroin -- a deadlier opioid with a higher chance of overdose. The researchers highlighted two treatment measures that, when combined with prescription cutbacks, seem most effective at reducing overdose deaths. The first policy is to greatly increase the availability of naloxone, a drug that can reverse the effects of an overdose if administered before the person's body shuts down from what physicians call opioid poisoning. "Emergency rooms can administer naloxone if a person is brought to them in time, but we have to get this life-saving treatment more broadly into the hands of first responders," Humphreys said.

The researchers also advocate greatly expanding post-addiction drug treatment programs by, for instance, helping opioid addicts quit by providing them with methadone to alleviate the physical symptoms of withdrawal.

The researchers say that these three measures -- a 25 percent reduction in prescriptions, greater access to naloxone and greatly expanded methadone treatment -- could together reduce overdose deaths by 6,000 over 10 years compared with the status quo estimate of roughly 50,000.

"To effectively combat the epidemic, we need a portfolio of interventions," said Brandeau. "We need policies to prevent individuals from becoming addicted in the first place, but we also need policies to treat addiction and mitigate its effects."

The paper's daunting conclusion that all of these measures can only make a small dent in the death toll is a measure of the magnitude of the crisis. The researchers hope the model could become a springboard for policymakers to take more vigorous action.

"It took us more than a decade to prescribe our way into this crisis," Brandeau said, "and it will take more than a decade to prescribe and treat our way out."

SEATTLE - A new scientific study concludes there is no safe level of drinking alcohol.

The study, published today in the international medical journal The Lancet, shows that in 2016, nearly 3 million deaths globally were attributed to alcohol use, including 12 percent of deaths in males between the ages of 15 and 49.

"The health risks associated with alcohol are massive," said Dr. Emmanuela Gakidou of the Institute for Health Metrics and Evaluation at the University of Washington and the senior author of the study. "Our findings are consistent with other recent research, which found clear and convincing correlations between drinking and premature death, cancer, and cardiovascular problems. Zero alcohol consumption minimizes the overall risk of health loss."

The paper and videos of experts commenting on it may be found at http://www.healthdata.org

The study does not distinguish between beer, wine, and liquor due to a lack of evidence when estimating the disease burden, Gakidou said.

However, researchers used data on all alcohol-related deaths generally and related health outcomes to determine their conclusions.

Alcohol use patterns vary widely by country and by sex, the average consumption per drinker, and the attributable disease burden. Globally, more than 2 billion people were current drinkers in 2016; 63% were male.

"Average consumption" refers to a standard drink, defined in the study as 10 grams of pure alcohol, consumed by a person daily, about the equivalent of:

A small glass of red wine (100 ml or 3.4 fluid ounces) at 13% alcohol by volume;

A can or bottle of beer (375 ml or 12 fluid ounces) at 3.5% alcohol by volume; or

A shot of whiskey or other spirits (30 ml or 1.0 fluid ounces) at 40% alcohol by volume.

"Standard drinks" are different by country. For example, in the UK a standard drink is 8 grams of alcohol, whereas in Australia, the US, and Japan, it is 10 grams, 14 grams, and 20 grams, respectively.

The study, part of the annual Global Burden of Disease (GBD), assesses alcohol-related health outcomes and patterns between 1990 and 2016 for 195 countries and territories and by age and sex.

It provides findings on prevalence of current drinking, prevalence of abstention, alcohol consumption among current drinkers, and deaths and overall poor health attributable to alcohol for 23 health outcomes, such as communicable and non-communicable diseases and injuries, including:

Cardiovascular diseases: atrial fibrillation and flutter, hemorrhagic stroke, ischemic stroke, hypertensive heart disease, ischemic heart disease, and alcoholic cardiomyopathy;

Cancers: breast, colorectal, liver, esophageal, larynx, lip and oral cavity, and nasal;

Other non-communicable diseases: cirrhosis of the liver due to alcohol use, diabetes, epilepsy, pancreatitis, and alcohol use disorders;

Communicable diseases: lower respiratory infections and tuberculosis;

Intentional injuries: interpersonal violence and self-harm;

Unintentional injuries: exposure to mechanical forces; poisonings; fire, heat, and hot substances; drowning; and other unintentional injuries; and

Transportation-related injuries.

"We now understand that alcohol is one of the major causes of death in the world today," said Lancet Editor Richard Horton. "We need to act now. We need to act urgently to prevent these millions of deaths. And we can."

This study used 694 data sources on individual and population-level alcohol consumption, along with 592 prospective and retrospective studies on the risk of alcohol use. More than 500 GBD collaborators, such as researchers, academics, and others from more than 40 nations contributed to the study, according to Max Griswold, senior researcher and lead author.

"With the largest collected evidence base to date, our study makes the relationship between health and alcohol clear - drinking causes substantial health loss, in myriad ways, all over the world," Griswold said.

In 2016, eight of the leading 10 countries with lowest death rates attributable to alcohol use among 15- to 49-year-olds were in the Middle East: Kuwait, Iran, Palestine, Libya, Saudi Arabia, Yemen, Jordan, and Syria. The other two were Maldives and Singapore.

Conversely, seven of the leading 10 countries with highest death rates were in the Baltic, Eastern European, or Central Asian regions, specifically Russia, Ukraine, Lithuania, Belarus, Mongolia, Latvia, and Kazakhstan. The other three were Lesotho, Burundi, and Central African Republic.

Health officials in those nations, Gakidou said, would be well served by examining the study's findings to inform their policies and programs to improve the health and well-being of their constituents.

"There is a compelling and urgent need to overhaul policies to encourage either lowering people's levels of alcohol consumption or abstaining entirely," she said. "The myth that one or two drinks a day are good for you is just that - a myth. This study shatters that myth."

Rockville, Md. (August 23, 2018)--Individual variations in genetic makeup and gut bacteria may explain the different effects of antibiotics on blood pressure, a new rat study suggests. The findings are published ahead of print in Physiological Genomics.

Gut microbiota--bacteria that populate the gastrointestinal tract--are a mixture of organisms that play a role both in health and in the development of illness or disease, including high blood pressure (hypertension). Just as individuals' genes vary, each person's gut microbiota is diverse. As antibiotics kill harmful bacteria to cure infections, they may also eliminate helpful bacteria that maintain good health. Because gut microbiota are linked to an individual's high blood pressure, University of Toledo College of Medicine and Life Sciences researchers explained, "individual hypertensive responses to antibiotics may vary depending on the host and its microbiota."

The research team studied two strains of rats that have different gut microbiota but both have a genetic tendency for hypertension. Dahl salt-sensitive rats ("Dahl rats") develop high blood pressure in response to a high-salt diet, while spontaneously hypertensive rats ("SHR rats") are seen as an animal model of high blood pressure unrelated to dietary salt. The researchers treated both strains with three common antibiotics:

vancomycin, which treats inflammation and infection of the colon (colitis);

minocycline, which treats urinary tract infections, acne and certain types of sexually transmitted infections; and

neomycin, which is used to prevent high cholesterol and is an active ingredient in many medicated creams, ointments and eye drops.

Antibiotic use caused different responses in the Dahl rats and SHR rats, including the way that each drug affected the rats' blood pressure. Systolic blood pressure--the force of blood pushing through the arteries while the heart beats--increased in Dahl rats when treated with minocycline and neomycin but not when given vancomycin. Minocycline also caused the diastolic blood pressure--the pressure in the arteries while the heart is at rest--to rise in the Dahl rats. SHR rats treated with any of the antibiotics experienced either a drop in systolic blood pressure, or no change, as with neomycin.

These findings suggest that "the host [genetic makeup] plays an important role in how blood pressure will be affected differentially by antibiotic treatment. This highlights the importance of further studies to determine the mechanism behind these different effects," the researchers wrote. "This raises the question of safety in the usage of antibiotics by patients with such modern ailments [as hypertension]."

Results from a Movement Disorders study suggest that occupational stress is associated with Parkinson's Disease risk, such that having a high-demand occupation is a risk factor and low control is protective.

High job demands were associated with increased Parkinson's Disease risk among men, especially in men with high education. High control was associated with increased risk among individuals with low education, and this association was more pronounced in women.

The study included 2,544,748 Swedes born in 1920 to 1950. During an average follow-up time of 21.3 years, 21,544 new cases of Parkinson's Disease were identified.