Health Report:

Medication Compliance & Risk of Death After Heart Attack

Hormone Replacement Therapy (HRT) & Mammogram Results

Selenium: Cancer, Heart Disease & Death

"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS

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Last Updated: 3/2/2008

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.


It would seem logical that anyone who has survived a heart attack would be extra careful to take all of their medications in hopes of staving off another heart attack or other potential cause of death.  However, human nature being what it is, not everyone who has been through a near-death heart attack experience will remain compliant with their prescribed medications.

A new study in the journal Circulation has now put this issue into perspective by calculating the risk of dying within one year of a heart attack among patients who were compliant with getting their prescriptions filled and among those who were not.  Nearly 4,600 Canadian patients who had recently experienced a heart attack were studied, all of them more than 65 years of age.  Among all of these patients, 73% faithfully had their first “post-heart-attack” prescriptions filled within one week of receiving them, and 79% of the patients had obtained their medications within 120 days of receiving their initial prescriptions.  When looking at patient compliance according to the type of medication prescribed, within 120 days after the prescriptions were written, 83% of the heart-related medications were filled by these patients’ pharmacists, while only 35% of the non-cardiac prescriptions were filled.  One year after experiencing their first heart attack, the likelihood of death as a function of patient compliance with having their prescriptions filled was calculated for all patients in this study.

When comparing patients who filled only some of their prescriptions with those who had all of their prescription medications dispensed by a pharmacist, the patients who did not have all of their medications filled had a 44% greater risk of not being alive one year after their initial heart attack.  For those patients who, inexplicably, chose not to have any of their prescriptions filled, there was a whopping 80% increase in the risk of death within a year of their initial heart when compared to those patients who faithfully had all of their prescriptions filled. 

The results of this clinical trial are a sobering reminder of two indisputable facts: (1) that modern medical treatment for cardiovascular disease has become very effective in reducing death rates, and (2) that choosing not to be compliant with your cardiologist’s treatment plan following a heart attack can be a lethal mistake.  While this study cannot tell us if other factors associated with poor prescription medication compliance might also have played a role in the mortality outcomes reported (for example, patients who chose not to be compliant with their medications are also very likely to not have been compliant with other “good heart health” behaviors as well), nonetheless, it is clear that those patients who fail to adhere to their prescribed treatment regimens after experiencing a heart attack do so at the potential risk of their very lives.



I have already written extensively about the risks now known, unequivocally, to be associated with hormone replacement therapy (HRT), and so-called combination HRT in particular, in women who have passed through menopause.  Chief among these is a significant increase in the risk of breast cancer, coronary artery disease, stroke and potentially fatal blood clots.  However, another area of concern related to HRT use in postmenopausal women is the density-increasing effects of HRT on breast tissue, and the subsequent impact, if any, of this increased density on the accuracy of screening mammograms.

A new clinical study in the Archives of Internal Medicine takes a look at this issue, using data collected from the landmark Women’s Health Initiative Study, which, in 2002, finally confirmed what many of us in the cancer research and treatment community had suspected for decades: combination HRT increases the risk of a women developing breast cancer, and that risk continues to rise with increasing durations of HRT use.

In this study of 16,608 postmenopausal women, a significantly greater incidence of breast abnormalities were detected by annual screening mammograms in women taking combination HRT when compared to women not using HRT (35% vs. 23%, respectively).  Because of the greater breast tissue density present in the women taking HRT, the sensitivity of screening mammography was significantly reduced in this group when compared to the women not using HRT, and this resulted in a higher incidence of breast biopsies being performed in the HRT-using women (10% of the women in the HRT group required breast biopsies for mammographic abnormalities, compared with 6% in the group of women not taking HRT).

As expected, breast cancers were more common in the group of women using HRT (and were diagnosed at a more advanced stage, as well).  However, due to the decreased sensitivity of mammograms in the women using HRT, breast biopsies in the HRT-using women were actually less likely to reveal cancer when compared to the non-HRT-users (15% vs. 20%, respectively), indicating that more unnecessary biopsies were performed in the women taking HRT, due to the presence of more abnormalities seen on their mammograms, and the reduced sensitivity and accuracy of mammograms in these patients.  Even after discontinuing HRT for 12 months, these clinically significant differences between the two groups of women persisted.

In this study, more than 1 in 10 women who used combination HRT developed otherwise avoidable abnormalities in their mammograms (when compared to women not taking HRT), while 1 in 25 HRT-users went on to have completely unnecessary breast biopsies in order to prove that the abnormalities on their mammograms were not due to cancer.  These risks are, of course, in addition to the increased risk of developing breast cancer, heart disease, strokes, and dangerous blood clots with combination HRT use. 

While women already taking HRT, or considering HRT for the first time, should speak with their physicians before making any new decisions, the accumulating clinical data increasingly suggests that HRT, and the combination HRT medications prescribed for women who have not had a hysterectomy in particular, is associated with an increased risk of significant adverse health effects.  My advice to my own patients is to avoid HRT if at all possible, and in those 2% to 5% of women with severe, refractory menopausal symptoms, a brief course of low-dose HRT may be considered, but should be tapered and discontinued as quickly as possible.



Selenium, an essential dietary trace element, is known to play an important role in immune system function and in other physiological functions, and is also thought to have antioxidant properties as well.  There has been great interest in the role of selenium, if any, in the prevention of some cancers (and, most notably, for prostate cancer) and cardiovascular diseases.  However, the results of laboratory and clinical selenium research to date, as is often the case, has provided a mixed bag of favorable and unfavorable findings.

A new study, in the Archives of Internal Medicine evaluated almost 14,000 participants in the National Health and Nutrition Examination Survey study.  Volunteers joined this study between 1988 and 1994, and were followed for as long as 12 years in this huge public health study.  All participants had blood tested for selenium levels as part of this research study.  The researchers then matched blood levels of selenium against the likelihood of death due to cancer, heart disease, or due to any cause, with some intriguing results.

When the study volunteers were separated according to the level of selenium in their blood, the group of patients with the highest levels of selenium had a 17% lower risk of death, due to any cause, when compared to patients with the lowest levels of selenium in their blood.  Looking at the risk of death due to cancer, specifically, high levels of selenium in the blood appeared to be even more protective, as the patients with the highest selenium levels experienced an apparent 31% reduction in the risk of death due to cancer when compared to the patients with the lowest selenium levels.   With regards to the risk of death due to cardiovascular events such as heart attack and stroke, high levels of selenium in the blood did not appear to offer any protection at all.

Two important caveats about the results of this study must be emphasized before anyone goes to their local pharmacy and downs a bottle of selenium tables.  This study also found that patients with extremely high levels of selenium in their blood (>150 ng/ml) actually had a slightly increased risk of death, from cancer and from any cause, during the course of this study.  The second caveat relates to potential weaknesses associated with these types of epidemiological studies in general, including the possibility that other factors may actually directly explain the results observed, and not the factors (in this case, the level of selenium in the blood) actually measured or tested in the research study itself.  So, for now anyway, Mom’s advice about diet and nutrition is still probably the safest route to go—eat a healthy diet low in fat and rich in fresh fruits and vegetables.  (By the way, excellent, healthy, and natural dietary sources of selenium include whole grains, wheat germ, garlic, fish and shellfish, and poultry.)


Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity.

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center


Send your feedback to Dr. Wascher at rwascher@doctorwascher.net

Links to Other Health & Wellness Sites

Copyright 2008.  Robert A. Wascher, MD, FACS.  All rights reserved.

Dr. Wascher's Archives:

2-23-2008:  Universal Healthcare Insurance Study; Glucosamine & Arthritis

2-17-2008:  Exceptional Longevity in Men; Testosterone & Risk of Prostate Cancer; Smoking & Pre-malignant Colorectal Polyps

2-10-08:  Thrombus Aspiration from Coronary Arteries; Intensive Management of Diabetes & Death; Possible Cure for  Down's Syndrome?

2-3-2008:  Vitamin D & Cardiovascular Health; Vitamin D & Breast Cancer; Green Tea & Colorectal Cancer

1-27-2008:  Colorectal Cancer, Esophageal Cancer & Pancreatic Cancer: Update from the 2008 American Society of Clinical Oncology's Gastrointestinal Cancers Symposium

1-20-2008:  Testosterone Levels & Risk of Fractures in Elderly Men; Air Pollution & DNA Damage in Sperm; Statins & Trauma Survival in the Elderly

1-12-2008:  Statins, Diabetes & Stroke and Obesity; GERD & Esophageal Cancer

1-7-2008:  Testosterone Supplements in Elderly Men; Colorectal Cancer-- Reasons for Poor Compliance with Screening Recommendations

12-31-2007:  Minority Women, Hormone Replacement Therapy & Breast Cancer; Does Health Insurance Improve Health?

12-23-2007:  Is Coffee Safe After a Heart Attack?; Impact of Divorce on the Environment; Hypertension & the Risk of Dementia; Emotional Vitality & the Risk of Heart Disease

12-16-2007:   Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality 

12-11-2007:  Bias in Medical Research; Carbon Nanotubes & Radiofrequency: A New Weapon Against Cancer?; Childhood Obesity & Risk of Adult Heart Disease

12-2-2007:  Obesity & Risk of Cancer; Testosterone Level & Risk of Death; Drug Company Funding of Research & Results; Smoking & the Risk of Colon & Rectal Cancer 


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