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..."
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
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.
MEDICATION
COMPLIANCE AFTER HEART ATTACK & RISK OF DEATH
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.
HORMONE
REPLACEMENT THERAPY (HRT) & MAMMOGRAM RESULTS
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:
CANCER, HEART DISEASE & DEATH
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
http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html
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
2-3-2008: Vitamin D
& Cardiovascular Health; Vitamin D & Breast Cancer;
Green Tea & Colorectal Cancer
1-12-2008: Statins,
Diabetes & Stroke and Obesity; GERD & Esophageal Cancer
12-31-2007: Minority Women, Hormone Replacement Therapy
& Breast Cancer; Does Health Insurance Improve Health?