PodMed is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include risks of just one cigarette per day, birth defects and thyroid medicines, overtreatment of diabetes in the elderly, and heart attack after the flu. A transcript of the podcast is below.
0:35 The flu and heart attacks
1:33 Much more likely to have an MI
2:31 Everybody with CVD should get vaccine
2:45 Even one cigarette per day dangerous
3:44 About half of 20 per day
4:38 Thyroid drugs and congenital defects
5:38 Need to plan pregnancy
6:35 Need to have tens of thousands
6:47 Overtreatment of older people with diabetes
7:45 Personalized treatment
8:39 HbA1c 6.5%
Elizabeth Tracey: Smoking even one cigarette a day is not even a good idea.
Rick Lange: Heart attacks after the flu.
Elizabeth: Are we overtreating people with diabetes?
Rick: … and drugs to treat thyroid disorders causing birth defects.
Elizabeth: That’s what we’re talking about this week on PodMed TT, the weekly look at the medical headlines from Texas Tech University Health Sciences Center at El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins.
Rick: I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso and Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, since we’re having such a really ferocious flu season — I saw it just this morning in the medical headlines, this issue relative to, goodness, since 2009, it hasn’t been this bad — why don’t we turn right to the New England Journal of Medicine and look at do we get sequelae of the flu that may include heart attack?
Rick: These investigators looked at 364 different hospitalizations for heart attack that occurred within 1 year before or 1 year after the flu. What they recognized is that when people have the flu, the week following the diagnosis they are six times more likely to have a heart attack than during periods where they don’t have the flu.
Elizabeth: Here is a truly astonishing number. I need to hear a little more about this. What exactly did they assess?
Rick: They identified individuals who presented with a heart attack and also had laboratory-confirmed flu. What they said was, “Is there a temporal relationship between those two events?” What they discovered was when people developed the flu — or more broadly, even other respiratory viral conditions — they were much more likely to have a heart attack than when they didn’t have the viral infection. By the way, this is true for influenza A and influenza B, but also true for other viral infections like respiratory syncytial virus.
Now, this shouldn’t be terribly surprising because we know that these viral respiratory conditions cause an inflammatory condition, and we know that inflammation can actually cause heart attacks. That is rupture of a plaque, followed by a clot forming inside that artery. But what maybe most surprising is how robust it is; a 6-fold increase in the risk of heart attacks within a week of the flu is pretty significant.
Elizabeth: No assessments of inflammatory factors?
Rick: No, not in this particular study. This is a retrospective study, but other studies have clearly shown that flu and other respiratory viral diseases caused an increase in inflammation.
Elizabeth: My guess is about the only thing we can do about this is get a flu vaccine.
Rick: In fact, the evidence is very good for people with heart disease that flu vaccine actually decreases their mortality. Everybody with cardiovascular disease should be getting their flu vaccine. I’m glad you mentioned that.
Elizabeth: Okay. From here, why don’t we go to one I’m going to surf up. I said, “Wow! Even one cigarette a day, what a bad idea.” This was in the British Medical Journal. It was a meta-analysis of 55 publications and 141 cohort studies. Basically, once they crunched all the numbers, they found that there was still an increased risk of cardiovascular disease, even among those who only smoked a single cigarette. That was in comparison to those who smoked 20 cigarettes a day.
The risk was about half among those who only smoked one in comparison to those who smoked 20, which seems really disproportional. The risk was higher for women in general than it was for men, and I love the authors’ conclusion. They say there is no safe level of smoking that exists for cardiovascular disease.
Rick: Let’s look at it a different way, Elizabeth. Men who smoke one cigarette per day have an almost 50% higher risk of heart disease, and a 25% higher risk of stroke than people who smoked nothing. That’s just with one cigarette. As you mentioned, the risk is even higher in women, almost a 60% increased risk of heart disease and a 31% increased risk for stroke by just smoking one cigarette a day.
That is pretty remarkable. I think most people would say, “Gosh, if I just smoked one cigarette per day, or two or three, it can’t be that bad compared to smoking a pack or two.” But what the evidence shows is that there is still a significantly increased risk of heart disease and stroke with even one cigarette.
Elizabeth: The study, of course, makes me happy because it just agrees with my public health message of all cigarettes should be abolished.
Rick: For those individuals that are already smoking, they say, “I’ll do well if I can just decrease the amount.” There is some truth to that, but what you have to do is you have to be committed to actually stopping smoking altogether if you’re going to lower your risk substantially.
Elizabeth: I guess a follow-up study to this one would be is there a dose response relative to the risk of COPD [chronic obstructive pulmonary disease] and lung cancer?
Rick: There is an association between the number of cigarettes smoked in COPD and with lung cancer as well. But, again, there is no safe amount.
Elizabeth: Let’s move on then to your other one, and that’s this look at thyroid drugs and, gosh, do they increase birth defects? That’s the Annals of Internal Medicine.
Rick: Since up to 1% of pregnant women can have Graves’ disease, that’s hyperthyroidism, the treatment of that and how it might cause birth defects is really important.
In this Korean study, they looked at almost 3 million completed pregnancies between 2008 and 2014, and identified almost 13,000 women that were taking these antithyroid medications to treat Graves’ disease. What they discovered was in fact that the use of them does increase the risk of birth defects. The two biggest medications used are ones called propylthiouracil (PTU) and the other called methimazole (MMI). The risk is lower with PTU. It increases the risk for birth defects for about 20%, versus 40% with MMI. But both of them are associated with an increased risk for birth defects.
It’s important not to avoid treating it because untreated hyperthyroidism can also cause birth defects and stillbirths as well. What this tells us is that we need to actually plan pregnancies. We need to talk about contraception during the time when women are receiving treatment or look at alternative ways of treating it that don’t involve medications. For example, surgery. We’re using radioactive iodine during the time that contraception is given.
Elizabeth: Is it safe for women to go off of these thyroid medicines while they are pregnant?
Rick: No. In fact, they are probably most teratogenic or most likely to cause birth defects during the first trimester. That’s why I mentioned that we need to actually do planning beforehand.
Elizabeth: How is it that we haven’t known this before?
Rick: There actually have been some studies that have suggested — relatively small studies in case controlled trials — that I have seen, [but the thing] about this study is it captures all births across Korea, because they have a national health system and medical care is relatively inexpensive. Looking at 13 million births allows you to detect even small increases. For example, the normal rate of birth defects in this population was about 6%. With the use of these medications, it increased 7.3%. You need to have millions of births or tens of thousands of women taking this medication to detect it.
Elizabeth: Powerful stuff. Finally, let’s turn to our last one. It’s fairly powerful also, but not quite that powerful. In Diabetes, Obesity and Metabolism, a BMJ journal, they took a look at over 1,000 Dutch patients who had diabetes. They were over the age of 70 years and they found some pretty remarkable stuff. In spite of changes in the guidelines with regard to management of diabetes and the necessity to really personalize treatment, they found that a large number of these folks were on five or more medicines. A lot of them were frail.
Those who had those particular constellations of findings also experienced more hypoglycemic events and falls. Even when those things took place — the falls and the hypoglycemic events — their treatment was not deintensified following that. These Dutch researchers conclude that in spite of the fact that we are personalizing treatments for people with diabetes, that hasn’t really penetrated the common [usage] yet.
Rick: The Diabetes Association recommended personalized treatment. If you are over the age of 70 and you’re only using metformin, your goal for hemoglobin A1c should be 7 or less. If you’re using more medications, but you’ve had diabetes for less than 10 years and you’re over the age of 70, then the goal should be a hemoglobin A1c of less than 7.5. If you have multiple medications, you’ve had diabetes for more than 10 years, then the goal should be 8 or less. It should be very personalized.
But what this study shows is we don’t personalize it. Oftentimes, we give intensive therapy to the populations that are most vulnerable, the frail that are on multiple medications. As you mentioned, it causes significant problems, hypoglycemia and falls in the elderly. Those can be life-threatening. Even when we recognize it, we don’t alter our therapy. This is really important news for the elderly individuals who have diabetes is their diabetes care should be personalized to try to prevent complications.
Elizabeth: I thought it was really noteworthy in this study among those patients they identified as overtreated, their hemoglobin A1c was an average of 6.5%, well below the guidelines.
Rick: Exactly. The guidelines suggest 8 or less because you say, “Why not treat a more intense flu?” Well, because it causes more complications. This increases the risk to the patient.
Elizabeth: I guess one of my concerns is it’s hard to put the onus on a patient, especially a frail and older person with multiple comorbidities who is on five plus medicines, to go to their primary care doc and say, “Hey, wait. I think I’m taking too much stuff. Maybe we need to relax some of this.”
Rick: You’re right. The onus really falls on the healthcare provider, but it’s important for our listeners who are patients to be aware of this as well. We talk about personalized medicine when we think about genetic issues and how do we assign what so much genetic risk is. This is also personalized medicine based upon a person’s age and their risk factors as well. Every bit is as important as any genetic information.
Elizabeth: On that note, “I’m going to do the just one cigarette.” Just say no. This week on the blog, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: I’m Rick Lange. You all listen up and make healthy choices.