Salt, adult beverages, statins and stents

Published 3.15.2017
Two postings today because the first was supposed to be yesterday's entry. However, the mid-March blizzard upended many a schedule, and mine was no exception. The topic today is recent news or items related to heart health.

Heart disease, which I have been calling cardiovascular disease or CVD, an ongoing interest for me. Not because I have the disease (I don't) but because I'd like to avoid acquiring it if possible. Recently I learned that the term CVD represents more than simply heart disease. Any type of vascular disease, such as stroke, is included under the term CVD.

That doesn't make a difference in how I will write about it, I'm no more interested in dying of a stroke than dying of a heart attack. As it's often said that what's good for the heart is good for the head, I don't see a reason to alter my terminology usage, unless it's specific to the heart or the brain or whatever.

If you don’t have CVD, don’t take statins. Taking statins didn’t lower the risks for developing CVD in future, and worse, increased the risk for type two diabetes (T2D) in what had been otherwise healthy, physically active patients.

As if I needed more incentive to stay out of a cardiologist’s office… Bottom line, unless you’re having a heart attack, say no to a stent.

This isn’t to say that seeing a cardiologist isn’t sometimes necessary… but if it can be avoided, it should be. When it can’t be avoided, the bias should be towards the most conservative treatment option. Stents are not conservative, nor do they seem to have proven to be very helpful except in the most extreme conditions (as in the case of an actual heart attack where the afflicted person is actively heading towards that final good night).

CVD incidence is growing faster than expected in the US.

The growth in cardiovascular disease has outpaced expectations, reaching a prevalence of 41.5% in 2015 -- 15 years ahead of schedule, according to a report from the American Heart Association (AHA).

A drug that works better than aspirin against anti-coagulation is found.

The first large trial of a newer oral anticoagulant (NOAC) for prevention among coronary artery disease (CAD) and peripheral artery disease (PAD) -- the COMPASS study -- has been stopped early for "overwhelming efficacy," Bayer AG and Janssen, manufacturers of rivaroxaban (Xarelto), announced.

The phase III trial randomized 27,402 CAD and PAD patients to receive either rivaroxaban 2.5 mg twice daily in addition to aspirin 100 mg once daily, rivaroxaban 5 mg twice daily alone, or aspirin 100 mg once daily alone.

The trial was stopped a year ahead of its scheduled completion date following a recommendation by the Data Monitoring Committee. That committee said the trial reached its prespecified criteria for superiority on the primary endpoint of first occurrence of either MI, stroke, or cardiovascular death.

Adult beverages and CVD

Heavy drinking may age the arteries. However, if you look at the study… none of the results were statistically significant. Drinking too much has obvious risks, but artery stiffness doesn’t seem to be one of them.

The study, at this link, was based on a survey of UK government workers. So this is diary reporting as to drinking level, which is always suspect. How did they measure artery stiffness?

The importance of arterial stiffness to cardiac health has led to proposals that it can be used as a surrogate endpoint for studies of cardiovascular disease.6 It can be assessed accurately and noninvasively using pulse wave velocity (PWV) estimation.7 Arterial waveforms travel faster in less‐elastic vessels, so PWV values are inversely related to such elasticity.

Not only did they use self-reported intake, they made assumptions about how many grams of ethanol were in each drink.

Self‐reported alcohol consumption was assessed at phases 1, 3, 5, 7, and 9. Participants reported the number of glasses of wine, pints of beer/cider, and measures of spirit/liqueur consumed in the week preceding each assessment. These values were then converted into ethanol volumes. In terms of conversion ratios, 8 g of ethanol was assumed for each measure of spirit and 16 g for each pint of beer/cider.24 The ethanol content of wine was estimated in line with recent guidance regarding the increased alcohol content in a standard wine glass since 1995.25, 26 Each wine glass consumed pre‐1995 was assumed to contain 8 g of ethanol and 16 g after this date.

Interesting that the wine shifted in 1995. Why was that?

Up to 112 g per week was considered moderate. That math works out to one beer or one glass of wine a day. Most of their p-values were huge, meaning the differences weren't statistically significant. They found very little of significance here. So WTF with the headline?

Stable moderate drinkers had the best arteries… but look at the p-values… There’s nothing to see here folks.

Salt battles

“Experts” disagree with the salt restriction called for in current guidelines, which of course, are written by other “experts.”

In a new paper, published online in the European Heart Journal, they also focused on the broad gaps of knowledge in the field and drew attention to the paucity of high-quality evidence and research. Again, this approach represented a rebuke of current guidelines, which authoritatively assert the benefits of dramatic reductions in salt consumption.

Worldwide, sodium intake is estimated to average about 3.95 g/day, though there are wide geographical and cultural variations. Most guidelines recommend that sodium consumption be reduced to levels below 2.3 g/day, though the American Heart Association goes further and recommends reductions to 1.5 g/day or lower.

The dissenting experts say that keeping sodium intake to 5g/day is good enough.

For reference, 5g of salt (sodium chloride or NaCl) is about 2g (2000 mg) of sodium (Na). That’s about 1 teaspoon of regular salt (not kosher or sea salt which tend to have large grains).

The full title of the paper is "The technical report on sodium intake and cardiovascular disease in low- and middle-income countries by the joint working group of the World Heart Federation, the European Society of Hypertension and the European Public Health Association." Among the authors of the report are well-known hypertension experts like Giuseppe Mancia, Suzanne Oparil, and Paul Whelton.

Too much sodium can be bad, no one disputes that, but measuring sodium intake can be difficult, and there are differences as to how people react to sodium.

Here’s the deal on sodium— at least in my view: generally, it’s really only a problem if you eat a lot of ultra-processed foods. The little bit of salt you shake on your homemade food at the table isn’t (typically) going to be a teaspoon. And in recipes that call for a teaspoon (or more) of salt to be added are usually for numerous servings. So unless you’re ingesting the entire product in one go on your own, you’re probably not getting that much sodium.

However, and I’ve made this point numerous times previously, mass produced food (and don’t fool yourself, many mid-range restaurants cut costs by using mass produced products as ingredients) have to be higher in sodium so that they have flavor. Preparing foods on a massive scale introduces heat transfer, viscosity and uniformity issues. Those are material science terms because at that scale, the issues are similar to any other material processing. Procedures that Flavors that get eliminated in the cooking process can be chemically added back, or the ones that remain can be augmented by adding salt. A lot of salt. Since many consumers now look askance at chemical additives in food, salt becomes the additive of choice.

If in contrast you start with unlabeled ingredients (you know, things where the ingredient list would a single word) then the only salt in the final product is that which you add. Low sodium defenders were not impressed by the arguments of the "pro" sodium side. In the end, of course, the answer is to do more studies.


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