ACUTE CORONARY SYNDROME- DO YOU KNOW THE SYMPTOMS?

The acute coronary syndrome (ACS) describes patients who are experiencing symptoms of inadequate blood flow to the heart (myocardial ischemia), or who are experiencing an actual heart attack (myocardial infarction).  Patients who are experiencing ACS should see a qualified emergency room or cardiology physician immediately, as there is abundant research evidence showing that the early diagnosis and treatment of ACS leads to improved survival, and improved heart function in survivors.

Most of us know the classic g and symptoms of ACS, including the acute onset of crushing chest pain, which sometimes radiates to the left arm or the left jaw.  However, for many patients with heart disease, ACS can present without these classic “textbook” symptoms.  These atypical ACS symptoms can include any of the following: isolated pain (i.e., without chest pain) in the right or left arm, upper back, neck, jaw or upper abdomen (the latter is often perceived as “indigestion”); shortness of breath; the new onset of weakness or extreme fatigue; fainting or the feeling that one is about to faint; nausea or vomiting; and palpitations or other abnormal heart rhythms (patients with diabetes and elderly patients are more likely to experience these atypical signs and symptoms, rather than the classic signs and symptoms associated with ACS).

Certainly, it is understandable that many lay people who have no personal history of coronary artery disease might not be aware of the atypical signs and symptoms of ACS, but one would think that patients with a known history of myocardial ischemia or prior myocardial infarction would have a pretty fair idea regarding both the typical and atypical signs and symptoms of ACS.  However, a clinical study, just published in the journal Archives of Internal Medicine, suggests that almost half of patients with a history of ischemic heart disease were ill-informed about the signs and symptoms of ACS.

This multi-institutional study was conducted by researchers at the University of California (the San Francisco and Los Angeles campuses), the University of Pennsylvania, the University of Washington, the University of Kentucky, the University of Nevada (Reno), and other institutions in the United States and Australia.  In this clinical study, 3,522 patients with a history of either heart attack or a prior medical intervention for coronary artery disease participated in a survey designed to assess their knowledge about the symptoms of ACS, as well as the appropriate steps that should be taken by patients experiencing the symptoms of ACS.  The average age of these patients was 67, and 68% of these study volunteers were men.

The researchers defined a score of less than 70% on the survey as being representative of a low level of knowledge.  The average score among all of these adults with a history of significant coronary artery disease was only 71%.  Moreover, the scores of 46% of the participating patients, or nearly half of the patients, fell within the “low knowledge” range!  When the researchers analyzed factors that were associated with higher knowledge scores on the survey, they found that the following factors were statistically significant predictors of adequate or excellent knowledge about the symptoms of ACS:  female gender, younger age, higher levels of education, previous participation in a cardiac rehabilitation program, and receiving care by a cardiologist rather than an internist or general practitioner.  A prior history of heart attack or coronary artery bypass surgery (ABG) was not associated with a higher level of knowledge as tested by the survey, however. 

The results of this clinical study are rather provocative, and suggest that more needs to be done to educate patients at high risk of experiencing ACS, including those who have already experienced episodes of ACS in the past.  When ACS occurs, delays in diagnosis and treatment can truly become a matter of life-and-death.  If you believe that you are experiencing the symptoms of ACS, then please do not ignore them.  Instead, you should seek appropriate medical assistance, and without delay!

 

GREEN TEA & LUNG CANCER

Lung cancer remains the most common cause of cancer-associated death in the United States more than 40 years after the link between smoking and lung cancer was first publicly disclosed by the US Surgeon General.  In 2008, the American Cancer Society estimates that approximately 215,000 new cases of lung cancer will be diagnosed (almost evenly split between men and women), and about 166,000 Americans will die of this highly lethal cancer.  The greatest tragedy surrounding this greatest of cancer killers is that more than 95% of lung cancer cases could be preventing simply by eliminating smoking.  When I hear people complain that the war on cancer has not delivered dramatic reductions in the incidence of most cancers, I immediately think about lung cancer.  In 2008, and there will be an estimated 566,000 deaths due to cancer in the United States, and more than 166,000 of these deaths, or 29% of all cancer deaths, will be due to a cancer that is almost completely preventable (i.e., simply by leading a reasonably healthy lifestyle)….  For these reasons, and because the available treatments for most cases of lung cancer are rarely successful in eradicating all traces of cancer, I rarely include reviews of lung cancer research clinical studies in this column.  However, an intriguing research paper, just published in the journal Carcinogenesis, looks at the effects of an extract of green tea upon lung cancers induced in laboratory mice.  This study was conducted by researchers from the University of Cincinnati, the University of Minnesota, and Washington University.

In this laboratory study, a decaffeinated extract of green tea leaves was added to the diet of mice after they were injected with a mutagenic chemical known to cause lung cancer in mice. A control group of additional mice received injections of the cancer-causing chemical, but did not receive the green tea extract in their diet.  While green tea extract supplementation did not appear to reduce the overall number of lung cancer tumors that developed in the mice, it did appear to significantly reduce the maximum size of the lung tumors when compared to the tumors that developed in the control group of mice.  Using both MRI scans of the lung tumors and microscopic evaluation of lung tumors after the mice were euthanized, the researchers confirmed that the mice that had received green tea extract supplementation had significantly smaller tumors than the untreated control group mice.

While green tea extract did not appear to prevent the development of lung cancer in mice treated with a chemical (benzo[a]pyrene, which is also present in cigarette smoke) known to induce this type of cancer in laboratory mice, dietary green tea did appear to reduce the progression of the resulting lung tumors.  As with all animal-based research studies, however, extrapolating the effects of various treatments on laboratory animals to humans requires a big leap of faith.  In some cases, humans do respond in similar ways as has been observed in laboratory animals.  In many other cases, what appears to work in mice turns out not to work (at least to any clinically significant degree) in people.  However, this research article joins hundreds of others that suggest a modest-to-moderate anti-tumor effect associated with green tea polyphenols for at least some types of cancer.  Currently, there are 25 registered clinical research trials underway in the United States that are looking at the effects of green tea supplements on the development and progression of various types of cancer, including lung cancer.  Hopefully, at least some of these trials will confirm a beneficial effect of green tea supplementation in humans, as has previously been observed in cell cultures and animal studies.  Meanwhile, please do your part in the war against cancer.  If you don’t currently smoke, then please don’t start.  If you already smoke, then please quit, now.

EPISIOTOMY & SUBSEQUENT DELIVERIES- AN UNKIND CUT

Increasingly, obstetricians, and their patients, are questioning the traditional wisdom about routinely performing episiotomies in the delivery room.  An episiotomy involves making an incision on the edge of the vaginal wall and perineum as the baby’s head descends within the vaginal birth canal.  In theory, the episiotomy is a “controlled” laceration of the highly sensitive perineal tissues between the vagina and rectum, and was originally thought to reduce the incidence of deep tears of these tissues, including the sphincter muscles of the anus and rectum.  (After the baby is born, the episiotomy is then repaired by the obstetrician with sutures.)  However, in recent years, the beneficial effects of episiotomy, if any, have increasingly been called into question.  In fact, recent clinical research studies have confirmed what many new mothers, their husbands, and even many obstetricians, have long suspected, and that is that episiotomies often appear to cause the very same injuries and long-term complications that they are intended to prevent.  These complications can leave women incontinent, and with chronic perineal pain that often interferes with their ability to comfortably have intercourse for months, and sometimes for years.  Ask any new mother (or her husband) who has delivered children both with and without an episiotomy which delivery left her with the greatest amount of perineal pain, and for the longest amount of time…. 

If, as it is becoming apparent, episiotomies do not prevent perineal and anal sphincter complications during most routine deliveries, then what might the effects of episiotomies be during subsequent births?  A new research paper in the journal Obstetrics & Gynecology provides some answers to this question.  The researchers reviewed the medical records of more than 6,000 women who underwent at least two consecutive vaginal deliveries at the University of Pittsburgh.  They found that 48% of these women underwent episiotomy with their first delivery.  The researchers then compared the incidence of complications among these women who had received episiotomies with the remaining 52% of women who did not undergo episiotomy during their first delivery.  The results were both striking and concerning.

Among the women who had previously received an episiotomy, 51% experienced moderately severe perineal lacerations during their subsequent second vaginal delivery, while only 27% of the mothers who had not undergone a previously episiotomy suffered similar perineal lacerations.  Severe lacerations that involved the anal sphincter muscle (and which can lead to painful bowel movements and incontinence) occurred in almost 5% of the women who had previously undergone an episiotomy versus just under 2% of the women who had not received a previous episiotomy. 

In summary, this retrospective clinical study adds to a growing body of research suggesting that episiotomy almost certainly does more harm than good, at least for relatively routine deliveries.  In fact, the very birth-associated complications that episiotomy is supposed to prevent are actually more common in women who have been subjected to this procedure than in those who have not received an episiotomy.  While there may still be an occasional indication for episiotomy if the vaginal canal cannot safely accommodate and deliver a large or malpositioned baby, in the vast majority of cases of otherwise normal and spontaneous vaginal delivery, there appears to be no clinically valid reason, any longer, for episiotomy. 

If you are pregnant, it might be wise to raise this issue with your obstetrician, as many obstetricians who continue to routinely perform episiotomy consider the procedure to be an integral part of their obstetric care, and some obstetric physicians may, therefore, plan to perform this generally unnecessary, and potentially harmful, surgical procedure without first discussing it in detail with their patients. 

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

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

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