tag:theconversation.com,2011:/fr/topics/heart-failure-22728/articlesHeart failure – The Conversation2023-09-01T10:18:20Ztag:theconversation.com,2011:article/2122942023-09-01T10:18:20Z2023-09-01T10:18:20ZIs Wegovy really a gamechanger for heart health? A consultant cardiologist gives his verdict<p>The weight-loss jab Wegovy has been <a href="https://insidemedicine.substack.com/p/breaking-news-semaglutide-ozempic">hailed as an “absolute game-changer”</a> after a new study showed that it relieved symptoms and improved the quality of life in people with a common form of heart failure.</p>
<p>The participants in the trial had “heart failure with preserved ejection fraction”, a very common condition in which the heart stiffens, leading to breathlessness, fatigue and fluid retention. It is very hard to treat and doctors mainly focus on alleviating the patient’s symptoms. </p>
<p>Many people with heart failure are obese, so the thought that a weight-loss jab might offer a new treatment for people with this condition is appealing. When a clinical trial of semaglutide (brand name Wegovy) for treating heart failure with preserved ejection fraction was presented at the <a href="https://www.escardio.org/The-ESC/Press-Office/Press-releases/Weight-loss-medication-benefits-patients-with-heart-failure-and-obesity">European Society of Cardiology Congress</a> this month, it was met with overwhelming enthusiasm.</p>
<p>In this trial, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2306963">called STEP-HFpEF</a>, 529 people with heart failure and obesity were randomly allocated to receive either a weekly self-administered injection of 2.4mg semaglutide or a placebo. Over a year, the participants receiving semaglutide lost 13.3% of their body weight compared with 2.6% in those receiving a placebo. </p>
<p>The extra weight loss from semaglutide led to improvements in the participants’ quality of life and very small improvements in the distance they could walk in six minutes (a standard test to assess aerobic capacity and endurance).</p>
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<figcaption><span class="caption">Heart failure explained.</span></figcaption>
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<p>In recent years, we have become used to seeing clinical trials of semaglutide and similar therapies <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032183">resulting in 10-20% weight loss</a>, and these new findings continue the trend. The effect of this drug on weight, quality of life and exercise capacity is impressive, but there are a few other factors to consider. </p>
<p>STEP-HFpEF was a double-blind trial, meaning that neither participants nor their doctors knew whether they were receiving semaglutide or a placebo (this is done to prevent “bias” in a trial). However, those receiving semaglutide would have noticed weight loss after just a few weeks and be able to work out which arm they were in. </p>
<p>The measures chosen – quality of life and distance walked in six minutes – could easily be influenced by knowing whether you were receiving semaglutide or a placebo. The real test of semaglutide in heart failure will be whether it can change less subjective measures, such as the need to take diuretics (a standard treatment for heart failure), the risk of being admitted for heart failure or even death. </p>
<p>Participants in this study, 96% of whom were white, had relatively mild heart failure. Only a small proportion had ever been admitted to a hospital with heart failure, and just over half took diuretics (also known as water tablets). It is not clear if the findings of the study are specific to heart failure or are merely a consequence of weight loss. Most of us would report improvements in our quality of life and exercise capacity if we lost 10-15% of body weight. </p>
<p>What happens to patients once they stop taking these drugs? Most of the research so far suggests that <a href="https://doi.org/10.1111/dom.14725">patients put most of the weight back on</a>. It’s hard to believe that the improvements in quality of life and exercise capacity would persist once the weight is back. The most likely scenario is that, for a sustained benefit, patients would need to take these drugs indefinitely. This is less appealing given the cost and limited availability of these drugs.</p>
<h2>Cheaper alternatives</h2>
<p>Even allowing for these limitations, the effect of semaglutide on weight loss in people with heart failure and obesity is undeniable, and it is likely to be a powerful treatment for certain patients. Until semaglutide is more widely available and affordable, we are going to have to keep reinforcing the cheaper alternatives of healthy diet and exercise. </p>
<p>The weight loss seen in the randomised controlled trials of various diets (typically <a href="https://doi.org/10.1001/jama.2014.10397">less than 10% weight loss</a>) is not as impressive as with semaglutide, and most patients have often tried several diets by the time they are seen in cardiology clinics or wards with heart failure. </p>
<p>The increase in exercise capacity (about 6%) with semaglutide in this trial was less impressive. With regular exercise, even without weight loss, much greater increases in exercise capacity can be achieved. </p>
<p>If your body mass index is greater than 30, irrespective of whether you have heart failure or not, don’t wait until you need semaglutide. Instead, change your diet and make exercise part of your weekly routine. A few simple lifestyle changes might have a massive effect on your health and your heart.</p><img src="https://counter.theconversation.com/content/212294/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Swoboda receives funding from the British Heart Foundation and Heart Research UK</span></em></p>Weight-loss jabs might help with certain heart conditions, but their benefit is being overstated.Peter Swoboda, Senior Lecturer, Cardiology, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2000362023-07-19T12:22:54Z2023-07-19T12:22:54ZHip-hop and health – why so many rap artists die young<figure><img src="https://images.theconversation.com/files/537895/original/file-20230717-17-u3sao8.png?ixlib=rb-1.1.0&rect=30%2C38%2C2502%2C2483&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hip hop artists, from top left, clockwise, DMX, Lexii Alijai, Prince Markie Dee and Trugoy the Dove have all passed away within the past decade. </span> <span class="attribution"><span class="source">Getty Images </span></span></figcaption></figure><p>The song “Be Healthy” from the 2000 album by hip-hop duo dead prez, “<a href="https://pitchfork.com/reviews/albums/dead-prez-lets-get-free/">Let’s Get Free</a>,” is a rare rap anthem dedicated to diet, exercise and temperance:</p>
<p><em>“They say you are what you eat, so I strive to eat healthy / My goal in life is not to be rich or wealthy / ‘Cause true wealth come from good health and wise ways / We got to start taking better care of ourselves”</em> </p>
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<figcaption><span class="caption">“Be Healthy,” from the 2000 album “Let’s Get Free”</span></figcaption>
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<p>In what’s widely recognized as <a href="https://www.grammy.com/news/2023-grammys-celebrate-50-years-hip-hop-star-performance-segment">hip-hop’s 50th anniversary</a>, an unfortunate reality is that several of its pioneering artists aren’t here to celebrate. The number of rappers who never live to see much more than 50 years themselves is astounding.</p>
<p>Rappers and rap fans can’t help but take notice that their peers and favorite rappers are dying young. Trugoy the Dove of De La Soul, 53, <a href="https://www.vulture.com/2023/02/de-la-soul-trugoy-the-dove-dead-at-54.html">passed away in February 2023</a> after a <a href="https://www.thedailybeast.com/trugoy-the-dove-member-of-hip-hop-trio-de-la-soul-dies-at-54">battle with congestive heart failure</a>. Gangsta Boo, hailed as the “<a href="https://www.commercialappeal.com/story/entertainment/music/2023/01/14/gangsta-boo-celebration-of-life-memphis-rap-railgarten/69804248007/">Queen of Memphis</a>” and known for her work with Three 6 Mafia, <a href="https://www.billboard.com/music/music-news/gangsta-boo-dead-former-three-6-mafia-rapper-dies-obituary-1235192876/">died at the age of 43</a> of a drug overdose in January 2023. Takeoff, a member of the Atlanta trio Migos, was <a href="https://www.nytimes.com/2022/11/01/arts/music/takeoff-migos-dead.html">killed in November 2022</a>. He was 28 years old. </p>
<p>Rapper <a href="https://www.vibe.com/news/entertainment/jim-jones-stands-on-rappers-have-the-most-dangerous-job-comment-1234672569/">Jim Jones has claimed</a> that rap is the most dangerous profession due to rappers <a href="https://www.theatlantic.com/ideas/archive/2022/11/takeoff-death-hip-hop-rap-violence/672117/">being violently killed so frequently</a>. Similarly, <a href="https://www.complex.com/music/a/backwoodsaltar/fat-joe-rappers-endangeed-species-pnb-rock-death">rapper Fat Joe believes</a> rappers are an endangered species. In the 2022 song “On Faux Nem,” Lupe Fiasco put it more succinctly: “Rappers die too much.”</p>
<p>As a rapper, a fan of hip-hop’s art and artists, and a <a href="https://news.virginia.edu/content/meet-ad-carson-uvas-professor-hip-hop">professor of hip-hop</a>, I agree with Lupe Fiasco: Rappers die too much. Whether it’s from gun violence, heart disease, cancer, self-harm or drugs, the number of rappers whose lives have ended prematurely is alarming.</p>
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<img alt="Rap star Nipsey Hussle looks out." src="https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=505&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=505&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=505&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=635&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=635&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537537/original/file-20230714-17-t3lnuk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=635&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Rap star Nipsey Hussle was shot and killed in Los Angeles in 2019.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/rapper-nipsey-hussle-attends-a-craft-syndicate-music-news-photo/1080924940?adppopup=true">Prince Williams/WireImage via Getty Images</a></span>
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<h2>The (un)exceptional spectacle of American gun violence</h2>
<p>Stories of rappers who die violently are well known. News media are quick to report on <a href="https://www.mercurynews.com/2022/11/01/gun-violence-has-killed-at-least-1-rapper-every-year-since-2018-2/">violence in hip-hop</a> to <a href="https://theconversation.com/scapegoating-rap-hits-new-low-after-july-fourth-mass-shooting-186443">support their view</a> that the music and the people who make it are exceptionally violent. Violence, death and conflict attract attention. Pair any of those with racial stereotyping and scapegoating and it’s easy to see why the murders of hip-hop stars such as Nipsey Hussle, the Notorious B.I.G., Tupac Shakur and countless other artists garner so much attention.</p>
<p>Though they were all taken by the <a href="https://theconversation.com/rappers-are-victims-of-an-epidemic-of-gun-violence-just-like-all-of-america-194429">very American plague of gun violence</a>, news and historical accounts often amplify the spectacle of violent Black death, even when they claim to honor those who are killed. </p>
<p>I’ve <a href="https://www.npr.org/sections/codeswitch/2021/05/24/173838383/a-letter-to-my-mother-just-in-case">written extensively</a> about the trend of scapegoating rappers. It is also the topic addressed in the song “<a href="https://aydeethegreat.bandcamp.com/track/ankh-featuring-nathaniel-star">ANKH</a>” from my forthcoming mixtap/e/ssay, “<a href="https://aydeethegreat.com/wp-content/uploads/2023/06/Illicit-Press-Release-6-23-pdf-232x300.jpg">V: ILLICIT</a>”:</p>
<p><em>“He died by the gun but they blamed the music. / They said, ‘What he said was evidence.’ And used it. …/ No compassion for the life torn apart when the bullets hit him, / cause he talked about the block in his art, so he’s not a victim. / Cameraman said, ‘They don’t value life too much.’ / He reported here before. Even twice some months. / Somewhere in his mid-twenties was his deadline (dying). / ‘Another N— Killed Here’ was the headline (crying).”</em></p>
<iframe style="border: 0; width: 350px; height: 442px;" src="https://bandcamp.com/EmbeddedPlayer/track=594009146/size=large/bgcol=ffffff/linkcol=de270f/tracklist=false/transparent=true/" seamless="" width="100%" height="400"><a href="https://aydeethegreat.bandcamp.com/track/ankh-featuring-nathaniel-star">ANKH (featuring Nathaniel Star) by A.D. Carson</a></iframe>
<p>An awful byproduct of this culture of consuming carnage is that the kinds of violent gun tragedies people are experiencing <a href="https://www.washingtonpost.com/nation/interactive/2022/gun-deaths-per-year-usa/">all across the U.S.</a> are being spotlighted in hip-hop and used as <a href="https://theconversation.com/scapegoating-rap-hits-new-low-after-july-fourth-mass-shooting-186443">excuses to criminalize and pathologize</a> certain people and the music they enjoy, the art they create, the neighborhoods they live in or the places they grew up.</p>
<p>Another heartbreaking consequence is that some rappers only gain wide popularity and realize financial success <a href="https://www.economist.com/graphic-detail/2020/07/23/posthumous-albums-by-young-rappers-are-topping-the-charts">after they’ve died</a>. Deceased rappers are an unfortunately abundant commodity. Juice WRLD and Pop Smoke are prime examples: They both sold four to five times as much music after their deaths than when they were alive.</p>
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<img alt="" src="https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=354&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=354&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=354&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=445&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=445&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538103/original/file-20230718-21-dohcve.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=445&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Before and after death sales.</span>
<span class="attribution"><span class="source">The Economist</span></span>
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<p>Along with being alarmed by these tragedies, it’s important to examine the conditions that affect mortality and attempt to get to the actual causes rather than scapegoating a musical form.</p>
<h2>Deadly diseases</h2>
<p>While violence brings about headlines, guns are not the only cause for concern. Diseases – many of them preventable – are also a factor.</p>
<p>Heart disease, lung disease, cancer, diabetes, strokes and renal disease are among the top 10 causes of death <a href="https://www.cdc.gov/minorityhealth/lcod/men/2017/nonhispanic-black/index.htm">among Black men</a> and <a href="https://www.cdc.gov/minorityhealth/lcod/men/2018/byrace-hispanic/index.htm">Hispanic men</a>, according to the Centers for Disease Control and Prevention. It makes sense that these causes also prominently figure in the deaths of hip-hop artists. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Rapper Big Pun performs on stage." src="https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537899/original/file-20230717-210016-dd9z7i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Rapper Big Pun, who sold a million albums, died at 28.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/big-pun-and-fat-joe-performing-at-les-poulets-on-may-13-news-photo/547402373?adppopup=true">Hiroyuki Ito/Hulton Archive via Getty Images</a></span>
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<h2>Gone before retirement</h2>
<p><a href="https://www.nytimes.com/2006/02/14/arts/music/james-yancey-producer-known-for-soulful-hiphop-dies-at-32.html">Rapper and producer J-Dilla</a> (32), rappers <a href="https://www.chron.com/entertainment/music/article/houston-rappers-remember-big-moe-dead-at-33-1797262.php">Big Moe (33)</a>, <a href="https://www.complex.com/music/a/complex/black-the-ripper-dead-at-32">Black the Ripper (32)</a> from the U.K., <a href="https://www.vibe.com/news/entertainment/founding-three-6-mafia-member-lord-infamous-dead-40-199175/">Lord Infamous (40)</a>, <a href="https://hiphopdx.com/news/id.20369/title.big-hutch-releases-statement-on-passing-of-above-the-law-member-kmg?utm_source=twitterfeed&utm_medium=twitter#">KMG the Illustrator (43</a> from Above the Law, <a href="https://www.usatoday.com/story/entertainment/celebrities/2021/04/09/dmx-hip-hop-legend-dies-50-after-heart-attack/7074550002/">DMX (50)</a>, <a href="https://www.independent.co.uk/arts-entertainment/music/news/big-t-death-cause-texas-rapper-age-52-wanna-be-a-baller-a8343506.html">Big T (52)</a>, <a href="https://onthisdateinhiphop.com/news/april-3-tweedy-bird-loc-passes-away-2020/">Tweedy Bird Loc (52)</a>, <a href="https://www.rollingstone.com/music/music-news/black-rob-dead-1157364/">Black Rob (52)</a> and <a href="https://www.nytimes.com/2000/02/09/arts/christopher-rios-28-rapper-recorded-under-name-big-pun.html">Big Pun (28)</a> all died from heart attacks. <a href="https://www.hollywoodreporter.com/news/music-news/heavy-d-cause-death-pulmonary-embolism-276405/">Heavy D (44) experienced a pulmonary embolism</a> that led to his death. <a href="https://www.nytimes.com/2021/02/19/arts/music/prince-markie-dee-fat-boys-dead.html">Prince Markie Dee (52) of the Fat Boys</a> passed away from congestive heart failure. <a href="https://www.rollingstone.com/music/music-news/craig-mack-flava-in-ya-ear-rapper-dead-at-47-127656/">Craig Mack (47)</a> died from heart failure. And Brax (21) <a href="https://variety.com/2020/music/news/brax-dead-influencer-rapper-1234823912/#">died from cardiac arrhythmia</a>. </p>
<p><a href="https://ew.com/article/2016/03/23/phife-dawg-dead-dies/#">Phife Dawg (45)</a> of A Tribe Called Quest, <a href="https://www.rollingstone.com/music/music-news/tim-dog-f-k-compton-rapper-dead-at-46-98451/">Tim Dog (46)</a> and <a href="https://www.rollingstone.com/music/music-news/biz-markie-dead-1191772/">Biz Markie (57)</a> all passed away from complications related to diabetes. </p>
<figure class="align-center ">
<img alt="Phife Dawg of A Tribe Called Quest performs at a music festival." src="https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537822/original/file-20230717-210447-vwdxnq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In 2016, Phife Dawg of A Tribe Called Quest died at 45 after a long battle with Type-1 diabetes.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/phife-dawg-of-a-tribe-called-quest-performs-at-2013-h2o-news-photo/176730972?adppopup=true">Rodrigo Vaz/FilmMagic via Getty Images</a></span>
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</figure>
<p><a href="https://www.nytimes.com/2010/04/21/arts/music/21guru.html">Guru (48) of Gangstarr</a>, <a href="https://www.rollingstone.com/music/music-news/bushwick-bill-geto-boys-rapper-dead-obituary-846047/">Bushwick Bill (52) of the Geto Boys</a>, <a href="https://www.latimes.com/entertainment-arts/story/2022-11-07/hurricane-g-death-rapper-lung-cancer">Hurricane G (52)</a> and <a href="https://www.nytimes.com/2021/12/18/arts/music/kangol-kid-dead.html#">Kangol Kid (55)</a> died from cancer. <a href="https://www.billboard.com/music/rb-hip-hop/dj-kay-slay-55-dead-covid-19-battle-obituary-1235060195/">DJ K Slay passed away at 55</a> from what was described as COVID-19 complications.</p>
<p>Eazy-E <a href="https://deadline.com/2021/07/the-mysterious-death-of-eazy-e-docuseries-wetv-1234793623/">died of AIDS at 30</a>.</p>
<p><a href="https://www.nytimes.com/2011/03/17/arts/music/nate-dogg-hip-hop-collaborator-dies-at-41.html#:%7E:text=He%20was%2041.,on%20the%20songs%20of%20rappers.">Nate Dogg’s death at 41</a> was attributed to a stroke. </p>
<p><a href="https://www.latimes.com/local/la-me-pimpc5feb05-story.html">Pimp C’s death at 33</a> was attributed to sleep apnea and an <a href="https://www.nytimes.com/2008/02/06/arts/06arts-DRUGSKILLEDP_BRF.html">overdose of cough syrup</a>. <a href="https://www.mprnews.org/story/2020/01/28/autopsy-st-paul-rapper-lexii-alijai-died-of-accidental-overdose">Lexii Alijai (21)</a>, <a href="https://www.nbcnews.com/pop-culture/pop-culture-news/philadelphia-rapper-chynna-rogers-dies-25-n1180051">Chynna (25)</a>, and <a href="https://www.billboard.com/music/rb-hip-hop/digital-underground-shock-g-cause-of-death-9585758/">Shock G (57)</a> all reportedly died of accidental drug overdose.</p>
<p><a href="https://ew.com/article/2012/07/19/ms-melodie-rapperdead-at-43/">Ms. Melodie passed away</a> in her sleep at the age of 43. <a href="https://www.latimes.com/entertainment-arts/music/story/2023-06-18/big-pokey-death-houston-rapper-texas#">Big Pokey collapsed onstage</a> and passed away at 48. <a href="https://www.rollingstone.com/music/music-news/whodini-john-fletcher-dead-1107571/">Ecstasy of Whodini died at 56</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Artist Ms. Melodie performs on stage." src="https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1119&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1119&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537824/original/file-20230717-243941-wecfnd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1119&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ms. Melodie of Boogie Down Productions passed away in 2012.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/late-rapper-ms-melodie-of-boogie-down-productions-performs-news-photo/465938029?adppopup=true">Raymond Boyd/Michael Ochs Archives via Getty Images</a></span>
</figcaption>
</figure>
<h2>A renewed focus on health</h2>
<p>Unfortunately, this list of tragic lives halted from ages 21 to 57 is not a comprehensive account of all the rappers who have passed away well before the age of retirement.</p>
<p>The occasion of celebrating 50 years of hip-hop provides a moment to reflect and honor some of the artists who contributed to the culture and are not here to celebrate this golden anniversary. It’s also, perhaps, an opportunity to consider some of the outcomes of systemic barriers to health and wellness, such as <a href="https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-health-services">access to affordable health care</a>, varied dietary options and mental wellness resources.</p>
<p>Given the number of rappers and other prominent hip-hop artists who have died young, ultimately it may come down to seriously taking heed to dead prez’s instructions from “Be Healthy”: “We got to start taking better care of ourselves.”</p><img src="https://counter.theconversation.com/content/200036/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>A.D. Carson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As hip-hop turns 50, an unfortunate reality is that so many of its pioneering artists never live to see much more than 50 years themselves, a professor of hip-hop writes.A.D. Carson, Associate Professor of Hip-Hop, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1997332023-03-13T12:28:11Z2023-03-13T12:28:11ZWhat the research shows about risks of myocarditis from COVID vaccines versus risks of heart damage from COVID – two pediatric cardiologists explain how to parse the data<figure><img src="https://images.theconversation.com/files/513789/original/file-20230306-1219-13tezh.jpg?ixlib=rb-1.1.0&rect=0%2C10%2C7085%2C3489&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Inflammation of the heart (shown here), known as myocarditis, can be triggered by viral infection, including COVID-19, as well as from COVID-19 vaccination, in rare cases.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/viral-myocarditis-royalty-free-image/1328356422?phrase=myocarditis&adppopup=true">wildpixel/iStock via Getty Images Plus</a></span></figcaption></figure><p>Soon after the first COVID-19 vaccines appeared in 2021, reports of <a href="https://doi.org/10.1126/science.abj7796">rare cases of heart inflammation</a>, or myocarditis, began to surface. </p>
<p>In most instances, the myocarditis has been <a href="https://doi.org/10.1542/peds.2021-053427">mild and responded well to treatment</a>, though up to four potentially mRNA vaccine-related deaths from myocarditis in adults <a href="https://doi.org/10.1002/clc.23828">have been reported</a> <a href="https://www.jacc.org/doi/full/10.1016/j.jacc.2022.09.049">worldwide</a>. No known verified deaths of children have been reported based upon publicly available data. The exact number remains a topic of very heated debate because of variability in the reporting of possible myocarditis-related deaths. </p>
<p>Studies have largely confirmed that the overall myocarditis risk is significantly <a href="https://doi.org/10.1056/NEJMoa2110475">higher after an actual COVID-19 infection</a> compared with vaccination, and that the prognosis following <a href="https://www.jacc.org/doi/full/10.1016/j.jacc.2022.09.049">myocarditis due to the vaccine is better</a> than from infection. The specific myocarditis risk varies by age and has been debated because of differing views among a small group of physicians related to risk tolerance and support for or against COVID-19 immunization for specific age groups.</p>
<p>As <a href="https://www.ohsu.edu/people/jennifer-huang-md">pediatric cardiologists</a>, we <a href="https://www2.osfhealthcare.org/providers/frank-han-1602115">specialize in heart issues </a> relevant to kids of all ages. We believe it is important to weigh the risk of myocarditis caused by COVID-19 immunization against not only viral myocarditis from COVID-19, but also all the <a href="https://doi.org/10.1111/jpc.15811">other complications</a> that COVID-19 can lead to.</p>
<p>Comparing risks of myocarditis from severe disease <a href="https://doi.org/10.1111/eci.13759">versus COVID-19 vaccination</a> or infection is difficult to do well, <a href="https://doi.org/10.1001/jama.2021.24110">and debate</a> <a href="https://doi.org/10.1136/jme-2022-108449">continues</a> over which of those outcomes poses a higher risk. </p>
<h2>Myocarditis explained</h2>
<p>Myocarditis is any condition that <a href="https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/10/21/15/57/myocarditis-review">causes heart inflammation</a>. A closely related condition called pericarditis refers to inflammation of the outside lining of the heart. For the purpose of this article, we focus primarily on myocarditis, since it has the potential for being a more severe condition. Most cases of myocarditis are <a href="https://www.mayoclinic.org/diseases-conditions/myocarditis/symptoms-causes/syc-20352539">caused by infections, particularly viral ones</a>.</p>
<p>Myocarditis can be confirmed by a combination of an electrocardiogram, an ultrasound heart picture called an echocardiogram and some blood testing. When it is available, cardiac magnetic resonance imaging, or MRI, is the most accurate method to diagnose myocarditis <a href="https://doi.org/10.1186/s12968-022-00873-1">that doesn’t involve an invasive procedure</a>. </p>
<p>A mistaken assumption is that all myocarditis is severe, since it implies damage to the heart. However, mild cases in which there is very little swelling and only <a href="https://www.myocarditisfoundation.org/research-and-grants/faqs/types-of-myocarditis/">temporary damage to the heart</a> are more common than severe cases that require a machine to support heart function.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/I3kd5SyYHEE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Symptoms of myocarditis include chest pain and shortness of breath.</span></figcaption>
</figure>
<h2>Vaccination versus infection risk</h2>
<p>The challenge of <a href="https://doi.org/10.1161/CIRCULATIONAHA.121.056135">parsing risks of myocarditis</a> from viral infection compared with COVID-19 vaccination is due in part to the difficulty of establishing a diagnosis of myocarditis and its population rates accurately. </p>
<p>The United States <a href="https://vaers.hhs.gov/">Vaccine Adverse Event Reporting System, or VAERS</a> – which is an initial reporting system for vaccine side effects – is by itself inadequate to <a href="https://publichealth.jhu.edu/2022/what-vaers-is-and-isnt">determine the rate of any vaccine-associated side effect</a>. This is because any side effect can be reported, and verification of a reported event only takes place afterward by the Centers for Disease Control and Prevention. </p>
<p>That vetted data is then reported in more robust databases like the <a href="https://www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vsd/index.html">Vaccine Safety Datalink</a>. A very small number of the myocarditis events following COVID-19 vaccination have resulted in significant long-term consequences <a href="https://doi.org/10.1016/j.jacc.2022.09.049">like heart rhythm troubles</a>. However, such cases do not reflect the majority.</p>
<p>Thankfully, severe myocarditis after mRNA vaccination for COVID-19 is extremely rare. A 2021 study from Nordic scholars, which looked at comparative risks of myocarditis and heart arrhythmia in patients who experienced myocarditis after COVID-19 infection versus immunization found that the <a href="https://doi.org/10.1136/bmj-2021-068665">risks vary significantly by age group</a>. </p>
<p>This has been touted as a reason not to vaccinate healthy young men against COVID-19. The follow-up study, however, found that the <a href="http://dx.doi.org/10.1136/bmjmed-2022-000373">comparative risks of negative outcomes</a> were worse from myocarditis from COVID-19 infection and other viral myocarditis than from vaccination in all patients older than 12 years of age. </p>
<p>And it’s worth noting that, as of mid-March 2023, the U.S. still leads the world in <a href="https://ourworldindata.org/covid-hospitalizations">COVID-19 hospitalizations</a>.</p>
<p>There have also been <a href="https://doi.org/10.1007/s40801-023-00355-5">rare myocarditis cases reported</a> with the <a href="https://www.novavax.com/home/usa">newer non-mRNA Novovax vaccine</a>, though we researchers do not yet know population-level rates.</p>
<h2>Myocarditis risk by age and gender</h2>
<p>A survey of all currently available research reveals that the risk of myocarditis after COVID-19 vaccination is highest in young men between the ages of 18 and 39 and older teen boys in the age range of 12 to 17, with the highest risk <a href="https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-06-22-23/03-covid-shimabukuro-508.pdf">after the second dose of vaccine</a>. The cause appears to be related to how the immune system processes the mRNA and <a href="https://doi.org/10.1161/CIRCULATIONAHA.122.061025">sometimes generates an excessive immune response</a>.</p>
<p>Myocarditis risk related to COVID-19 immunization is markedly lower in children <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7116e1.htm">younger than 12 years of age</a> and much lower in <a href="https://doi.org/10.1038/s41467-022-31401-5">adult males older than 50</a>. The risk of severe disease from COVID-19, particularly in those older than 50 years, has been far higher throughout the pandemic than the risk of myocarditis from COVID-19 vaccination. The risk of vaccination myocarditis is <a href="https://doi.org/10.1056/NEJMc2207270">uniformly lower in girls than in boys</a>. </p>
<p>Infants younger than 6 months can get immunity only from their mother’s antibodies unless they are exposed to COVID-19 themselves, as vaccines for this age group are not available.</p>
<h2>How to parse the risks</h2>
<p>While the risks of myocarditis have been highest in <a href="https://doi.org/10.1136/bmjmed-2022-000373">teen boys and young men</a> regardless of cause, the severity and outcome of myocarditis was much worse at the 90-day mark when it stemmed from COVID-19 infection or other viral diseases. This mirrors <a href="https://doi.org/10.1542/peds.2021-053427">our team’s research on this same topic</a>. </p>
<p>This discussion also doesn’t take into account the clot and heart attack <a href="https://doi.org/10.1038/s41591-022-01689-3">risks from COVID-19 itself</a>. Because COVID-19 damages blood vessels in all parts of the body, some organ damage such as kidney failure, blood clots, heart attacks and strokes can occur. </p>
<p>We recognize a need for more research into how people fare over the medium and long terms following a case of immunization-related myocarditis. This is why research is ongoing, and researchers like us are committed to following the data for years to come.</p>
<h2>COVID-19 risks in children</h2>
<p>While there have been far fewer deaths from COVID-19 in children than adults, COVID-19 is still one of the <a href="https://doi.org/10.1001/jamanetworkopen.2022.53590">leading causes of childhood death in the U.S.</a>, based on an early 2023 study. But COVID-19 deaths are <a href="https://publications.aap.org/pediatrics/article/148/6/e2021053760/183446/COVID-19-Associated-Orphanhood-and-Caregiver-Death">not the only relevant measure</a> of its effect in kids. COVID-19 has also killed more children in a shorter time period than <a href="https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-06-17-18/02-covid-fleming-dutra-508.pdf">several other vaccine-preventable diseases</a>, such as <a href="https://www.cdc.gov/hepatitis/hav/index.htm">hepatitis A</a> and <a href="https://www.cdc.gov/meningitis/index.html#">meningitis</a> before the availability of their vaccines. </p>
<p>The argument that some have made that <a href="http://dx.doi.org/10.1136/archdischild-2020-320338">fewer children than adults die from COVID-19</a>, or that it is often mild in children, has never been an acceptable justification to not do everything possible to protect children from it. For instance, doctors don’t stop treating pediatric cancer patients <a href="https://www.bannerhealth.com/healthcareblog/teach-me/how-childhood-cancers-differ-from-adult-cancers#">purely because there are fewer of them</a> than adult cancer patients. And we don’t retire the measles vaccines only because <a href="https://www.cdc.gov/globalhealth/newsroom/topics/measles/index.html#">most kids who get measles get only a mild case</a>.</p>
<p>The primary risk that COVID-19 presents now to children is <a href="https://doi.org/10.1038/s41579-022-00846-2">long COVID</a>, followed by the risk of severe disease. The estimated percentage of children acquiring long COVID is still being debated, but the symptoms from long COVID <a href="https://doi.org/10.1038/s41598-022-13495-5">can be extraordinarily debilitating</a>. These include severe fatigue, brain fog, sleep disturbance, dizziness, nerve pain and more. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/knPZHn_zFBA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Many children with long COVID-19 report lingering fatigue and frequent headaches.</span></figcaption>
</figure>
<h2>Weighing the decision to vaccinate</h2>
<p>We believe that the decision of whether to vaccinate against COVID-19 should be based upon the patient’s age, other health problems, relative risk from vaccines, how much and what type of COVID-19 is in your community, and the patient’s and family’s preference. </p>
<p>Two ways that have been suggested by the CDC and the Public Health Agency of Canada to decrease the risk of COVID-19 vaccine myocarditis are to opt for Pfizer and to space your doses out by <a href="https://www.canada.ca/content/dam/phac-aspc/documents/services/immunization/national-advisory-committee-on-immunization-naci/recommendations-use-bivalent-Omicron-containing-mrna-covid-19-vaccines.pdf">at least eight weeks</a>. This is because Pfizer has slightly lower rates of myocarditis than Moderna.</p>
<p><a href="https://publichealth.jhu.edu/2022/one-size-doesnt-fit-all-covid-19-vaccines-and-immunocompromised-patients">Adults who are immunocompromised</a> or have other medical problems known to <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#:">worsen COVID-19 disease severity</a> still carry the highest risk of severe disease. They should therefore <a href="https://www.acc.org/latest-in-cardiology/articles/2021/08/13/16/21/cardiac-transplant-patients-should-receive-a-booster-for-covid-19-vaccination">follow the CDC COVID-19 vaccination schedule</a> with additional boosters, if advised by their physician. </p>
<p>While COVID-19 immunizations are not as efficient at preventing viral transmission now as they were with the earliest variant, they remain highly effective at <a href="https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2022-059513/190808/COVID-19-Vaccine-Effectiveness-Against-Omicron?autologincheck=redirected">reducing severe illness and hospitalization, even in kids</a>, and particularly in the <a href="https://doi.org/10.1016/S0140-6736(22)02613-7">high-risk state of pregnancy</a>. </p>
<p>Thankfully kids have <a href="https://doi.org/10.1183/13993003.01601-2020">fared far better</a> from COVID-19 infection than adults. The primary risks of severe COVID-19 for children are among babies and infants, as well as children with health problems <a href="https://doi.org/10.1001/jamanetworkopen.2021.42322">that put them at high risk</a>, children with the most <a href="https://doi.org/10.1016/j.jacc.2021.02.023">significant types of congenital heart disease</a> or those with other medically complex conditions. Children in those groups derive the most benefit from the primary COVID-19 vaccine series; therefore, the decision to vaccinate in their case should be easier.</p>
<p>Informed consent that comes with vaccination should involve discussion of infection risks. The risk of immunization will never be zero because of variability in immune system responses; therefore, making the decision should always involve considering the most-up-to date information available.</p><img src="https://counter.theconversation.com/content/199733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I am a professional member of the Society of Cardiovascular Magnetic Resonance and have participated in peer reviewed research (not as lead author) now published in the Journal of Pediatrics. No funding was used in the creation of this article.</span></em></p><p class="fine-print"><em><span>Jennifer H. Huang does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Parsing the risk of myocarditis from viral infection versus vaccination is challenging, and researchers are intensely studying the various factors that are at play.Frank Han, Assistant Professor of Pediatric Cardiology, University of Illinois ChicagoJennifer H. Huang, Associate Professor of Pediatric Cardiology, Oregon Health & Science UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1894822022-08-31T15:28:20Z2022-08-31T15:28:20ZCoronary artery stents show no benefit in treating heart failure – landmark trial<figure><img src="https://images.theconversation.com/files/481752/original/file-20220830-17833-pzwvfq.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5501%2C3645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/heart-stent-366083738">Photo Oz/Shutterstock</a></span></figcaption></figure><p>Every year, <a href="https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/heart-failure.pdf">60,000 people in the UK</a> are diagnosed with heart failure, and many are treated with stents. In a <a href="https://www.nejm.org/doi/pdf/10.1056/NEJMoa2206606">large new study</a> published in the New England Journal of Medicine, my colleagues and I discovered that these procedures are unnecessary.</p>
<p>Heart failure is where the heart muscle becomes weakened, leading to symptoms of severe breathlessness that may cause premature death. The commonest cause is blocked blood vessels that reduce blood supply to the heart muscle. This is known as coronary artery disease. </p>
<p>A person with heart failure is treated with medication and sometimes with specialised pacemakers. Despite this treatment, many patients die prematurely or are admitted to hospital with worsening symptoms. </p>
<p>People with heart failure also sometimes have a procedure to insert a stent – a small metal tube that is used to unblock a coronary artery. Stents are placed into the heart arteries by a cardiologist through tubes inserted either into the wrist or the groin and guided by X-rays. Trials have shown that stents are a very effective treatment for people with <a href="https://pubmed.ncbi.nlm.nih.gov/12241831/">heart attacks</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/20231568/">angina</a>, but their effects in patients with heart failure have remained uncertain. </p>
<p>Some cardiologists had noticed improvements in patients’ symptoms and heart function after stenting, but researchers could not tell if these improvements were directly linked to the stents, or would have happened anyway with medications. Without proper research, treatment guidelines for the use of stents in patients with heart failure varied, with the <a href="https://www.nice.org.uk/guidance/ng106">NHS recommending against stenting</a> and <a href="https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/ESC-EACTS-Guidelines-in-Myocardial-Revascularisation-Guidelines-for">European guidelines recommending it</a> in certain patients.</p>
<p>In this latest study, the <a href="https://clinicaltrials.gov/ct2/show/NCT01920048">REVIVED-BCIS2 trial</a>, led by Professor Divaka Perera, we tested whether treatment with stents helped patients to live longer or to stay out of hospital. The trial was a collaboration of 40 NHS Hospitals in the UK and ran from 2013 to 2020.</p>
<p>Patients could be included in the trial if they had severely weakened heart muscle and extensive blockages of the coronary arteries. They also had specialised heart scans performed, so that stenting could be targeted to the areas of heart muscle that were most likely to recover. </p>
<figure class="align-center ">
<img alt="A graphic depicting how a stent keeps an artery open." src="https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/481790/original/file-20220830-21491-ikzhuh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A stent is a short wire-mesh tube that acts like a scaffold to help keep your artery open.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendering-balloon-angioplasty-procedure-stent-1510849454">Phonlamai Photo/Shutterstock</a></span>
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</figure>
<p>Seven hundred patients took part and half were randomly chosen to receive stents, while all patients received standard heart failure treatment. The patients attended follow-up appointments for up to eight years so that their health and heart function could be monitored closely.</p>
<p>An average of 3.4 years after treatment, patients who received stents were just as likely as those who did not to have died or been admitted to hospital with heart failure, showing that the treatment was not effective. </p>
<p>Heart scans and blood tests also showed no difference in the heart’s pumping strength, supporting the main trial findings. </p>
<p>Our study did show that patients who had stents had a better quality of life in the first year, but after two years the difference disappeared and patients reported similar health. Although there was no benefit to inserting stents, there was also no sign that stents caused harm.</p>
<h2>More research is not needed</h2>
<p>The results of the trial mean that stents should not be used to treat patients with heart failure caused by coronary artery disease unless they have another condition, such as angina or a recent heart attack. </p>
<p>The design and the number of patients involved in the trial mean the answer is clear and further research to address this question is not needed at the moment. We will spend time looking at the results to try to understand why stenting did not work. Though no benefit was shown, the findings are important as they mean patients with heart failure will not undergo unnecessary procedures. The cost of stenting procedures can also be redirected to providing other treatments and better care for patients with heart failure.</p><img src="https://counter.theconversation.com/content/189482/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Ryan receives funding from the National Institute for Health Research (UK), British Heart Foundation and National Institute for Health (USA).</span></em></p>The effect of stents in patients with heart failure has been unknown – until now.Matthew Ryan, Clinical Lecturer, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1867972022-07-14T18:35:13Z2022-07-14T18:35:13ZY chromosome loss through aging can lead to an increased risk of heart failure and death from cardiovascular disease, new research finds<figure><img src="https://images.theconversation.com/files/474141/original/file-20220714-32290-2fajn7.jpg?ixlib=rb-1.1.0&rect=3%2C9%2C2106%2C1404&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chromosomes change over time, whether through the process of aging or exposure to harmful substances in the environment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/and-y-chromosomes-royalty-free-image/88179880">Steven Puetzer/The Image Bank</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>The Y chromosome can be lost through the process of aging, and this can lead to an increased risk of heart failure and cardiovascular disease, according to a 2022 study my colleagues <a href="https://scholar.google.com/citations?user=hM9Ve60AAAAJ&hl=en">and I</a> published in the journal <a href="https://science.org/doi/10.1126/science.abn3100">Science</a>.</p>
<p>While most women have two X chromosomes, most men have one X and one Y. And many people with Y chromosomes start to lose them in a fraction of the cells in their body as they age.</p>
<p>While loss of the Y chromosome was <a href="https://doi.org/10.1038/1971080a0">first observed in 1963</a>, it was not <a href="https://doi.org/10.1038/ng.2966">until 2014</a> that researchers found an association between loss of the Y chromosome and shorter life span. Y chromosome loss has since been linked to a number of <a href="https://doi.org/10.1038/ng.2966">age-related diseases</a>, such as cancer and Alzheimer’s disease. However, it has been unknown whether this loss is just another benign indicator of aging, like gray hair or skin wrinkles, or whether it has a direct role in promoting disease.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/of7vrIIcTa0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Over time, the degrading Y chromosome may play an increasingly smaller role in development.</span></figcaption>
</figure>
<p>My colleagues and I wanted to figure out if Y chromosome loss directly causes disease and, if so, how. Historically, the Y chromosome has been difficult to study because much of its genetic material is repetitive – it’s easy to get “lost” trying to decipher the sequence.</p>
<p>However, we were able to take advantage of these repeat sequences by targeting them with the DNA-editing tool <a href="https://medlineplus.gov/genetics/understanding/genomicresearch/genomeediting/">CRISPR</a>. We used CRISPR to introduce breaks into the Y chromosome DNA of white blood cells in mice, destroying and eliminating the Y chromosome. We chose white blood cells in particular because they tend to have a <a href="https://doi.org/10.1038/s41598-020-59963-8">high prevalence</a> of Y chromosome loss.</p>
<p>We found that while loss of the Y chromosome did not have immediate effects on the young mice, they ended up aging poorly, dying at an earlier age than mice that still had Y chromosomes. They also had more buildup of scar tissue in the heart, a condition called <a href="https://doi.org/10.1038%2Fnri1412">fibrosis</a>, as well as a stronger decline in heart function after induced heart failure. Treating the mice with a drug that blocks heart scarring, however, was able to restore lost heart function. </p>
<p>We then evaluated the effects of Y chromosome loss in people. We analyzed data from the <a href="https://www.ukbiobank.ac.uk">U.K. Biobank</a>, a large database of medical and genetic data from 500,000 participants in the U.K. We found that men who had lost their Y chromosomes in over 40% of their white blood cells had a 31% increased risk of dying from cardiovascular disease compared with men who hadn’t lost their Y chromosomes, including a two- to threefold increased risk of dying from congestive heart failure or heart disease. In other words, those with the greatest Y chromosome loss had the greatest risk of death from cardiovascular disease.</p>
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<a href="https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Human karyotype missing a Y chromosome" src="https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=491&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=491&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=491&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=617&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=617&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474167/original/file-20220714-32349-yfkrfr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=617&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Screening for Y chromosome loss could help lead to earlier treatments for age-related conditions.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/digitally-generated-image-of-karyotype-over-white-royalty-free-image/649121991">Olympia Valla/EyeEm via Getty Images</a></span>
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</figure>
<h2>Why it matters</h2>
<p>Men are reported to have shorter life spans than women in many countries. In industrialized countries like the U.S., this is typically a <a href="https://www.census.gov/library/publications/2020/demo/p25-1145.html">difference of five years</a>. While <a href="https://time.com/5538099/why-do-women-live-longer-than-men/">social, behavioral and other genetic factors</a> may also be at play, they don’t entirely account for the differences in life span.</p>
<p>Our work shows that loss of the Y chromosome can directly contribute to age-related diseases like heart disease through tissue scarring. We believe that a better understanding of how the Y chromosome may contribute to age-related diseases, and potentially the process of aging itself, could lead to ways to screen and prevent excessive tissue scarring that can lead to cardiovascular disease.</p>
<h2>What still isn’t known</h2>
<p>While our study primarily focused on the heart, we also found that mice with Y chromosome loss also had scarring in their kidneys and lungs as well as accelerated cognitive impairment as they aged. Further research can help clarify the role of Y chromosome loss in diseases affecting other parts of the body.</p>
<h2>What’s next</h2>
<p>We are currently searching for specific genes that are lost with the Y chromosome that may be responsible for the disease-causing effects of Y chromosome loss. This information can help us better analyze exactly how loss of the Y chromosome can lead to disease and aid in the development of treatments for it.</p><img src="https://counter.theconversation.com/content/186797/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth Walsh receives funding from the National Institutes of Health and the National Aeronautics and Space Administration. </span></em></p>The negative health effects of Y chromosome loss could be one potential reason women tend to live longer than men.Kenneth Walsh, Professor of Internal Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826242022-05-10T18:25:19Z2022-05-10T18:25:19ZPig-human transplants may be a misguided attempt to address the organ shortage<figure><img src="https://images.theconversation.com/files/461887/original/file-20220509-20-agjzud.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C4500&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cross-species transplants require us to examine the relationships between humans and animals.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/pig-human-transplants-may-be-a-misguided-attempt-to-address-the-organ-shortage" width="100%" height="400"></iframe>
<p>At the end of 2021, 57-year old David Bennett Sr. was bedridden and on life-support with irreversible heart failure. He was not eligible for a human heart transplant or an implanted mechanical heart pump because of his underlying health condition and, allegedly, “<a href="https://www.technologyreview.com/2022/05/04/1051725/xenotransplant-patient-died-received-heart-infected-with-pig-virus/">a history of disregarding medical advice</a>.”</p>
<p>Certain death was on the horizon and this fatal prognosis made Bennett a candidate for a highly experimental and never-before-attempted surgical procedure involving the transplantation of a heart from a genetically modified pig.</p>
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Read more:
<a href="https://theconversation.com/pig-heart-transplant-was-david-bennett-the-right-person-to-receive-groundbreaking-surgery-174991">Pig heart transplant: was David Bennett the right person to receive groundbreaking surgery?</a>
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<p>The pig-to-human cardiac transplant — or xenotransplant — was <a href="https://www.technologyreview.com/2022/01/11/1043374/gene-edited-pigs-heart-transplant/">authorized by the U.S. Food and Drug Administration on compassionate grounds on New Year’s Eve 2021</a> and the surgery was performed on Jan. 7, 2022.</p>
<p>Initial reports following the experimental surgery suggested that <a href="https://doi.org/10.1038/d41586-022-00111-9">the genetically modified, human-compatible pig heart was functioning well and infection was not a problem</a>. </p>
<p>Bennett died on March 8 — at the time, “no obvious cause” of death was identified. Now, it has been reported that the pig heart was <a href="https://www.newscientist.com/article/2319108-man-who-received-pig-heart-transplant-has-died-after-pig-virus-found/">infected with a virus called porcine cytomegalovirus and that this virus may have contributed to Bennett’s death</a>. </p>
<p>Though the cause of death remains unclear, infection has been implicated in previous xenotransplantation failures involving baboons as the recipients.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/42bwa85g1DM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The BBC reports on the initial pig-to-human heart transplant surgery.</span></figcaption>
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<h2>More demand than supply</h2>
<p>There is an ongoing chronic <a href="https://hillnotes.ca/2021/04/16/organ-donation-in-canada-2/">shortage of suitable human organs for life-saving transplantation</a>. Indeed, many <a href="https://www.cihi.ca/en/organ-transplants-in-canada-2020-donations-and-need-infographic">Canadian transplant candidates die waiting for an organ donation</a>.</p>
<p>Attempts to increase the limited supply of human organs have included changes to consent rules: <a href="https://doi.org/10.1016/S2468-1253(17)30037-7">moving to an opt-out system</a>, <a href="https://doi.org/10.1016/S0140-6736(18)31870-1">introducing directed living donation and deceased donor-initiated chains</a> and, in some countries, <a href="https://doi.org/10.1097/MOT.0000000000000617">offering financial compensation</a>. </p>
<p>Still, patients die on transplant waiting lists. For this reason, there is ever increasing interest in xenotransplantation — an ethically controversial practice. </p>
<h2>Nonhuman primates and pigs</h2>
<p>In 1984, <a href="https://time.com/4086900/baby-fae-history/">the heart of a young baboon was transplanted into Baby Fae</a>, an infant born with a fatal heart defect called <a href="https://www.mayoclinic.org/diseases-conditions/hypoplastic-left-heart-syndrome/symptoms-causes/syc-20350599">hypoplastic left heart syndrome</a>. Baby Fae lived for three weeks, but eventually died of heart failure caused by rejection of the transplanted baboon heart.</p>
<p>Prior to this, there had been three other experimental nonhuman heart transplants, <a href="https://dx.doi.org/10.1080/08998280.2012.11928783">the earliest in 1964 using a chimpanzee heart</a>.</p>
<p>More recent efforts at xenotransplantation have involved the <a href="https://www.uab.edu/news/campus/item/12566-uab-announces-first-clinical-grade-transplant-of-gene-edited-pig-kidneys-into-brain-dead-human">transplantation of pig kidneys into brain-dead humans</a>. The most dramatic recent example, however, remains Bennett’s first-in-human cardiac xenotransplant using a genetically modified pig heart.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a baboon behind a cage" src="https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462150/original/file-20220510-17-ol00fx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">One of the earliest xenotransplants involved a baboon heart transplanted into an infant.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>For some, the use of pig hearts for xenotransplantation may be ethically preferable to the use of nonhuman primate hearts because pigs are already used for medicine: for example, <a href="https://www.npr.org/2021/10/20/1047560631/in-a-major-scientific-advance-a-pig-kidney-is-successfully-transplanted-into-a-h">pig heart valves, corneas and skin are used in various treatments</a>.</p>
<p>Or it could be that pigs are preferable “organ donors” because they are already used for food. When it comes to food animals — those who are consumed by humans — people can be biased against accurately seeing the subjectivity of the animal. This is referred to as the “<a href="https://dx.doi.org/10.3390/ani9121125">meat paradox</a>,” where people perceive food animals as “<a href="https://www.bbc.com/future/article/20190206-what-the-meat-paradox-reveals-about-moral-decision-making">objects and thereby avoid the discomfort caused by knowing about the suffering behind consumer goods</a>.”</p>
<p>A third reason to prefer killing pigs for human benefit instead of killing nonhuman primates is that pigs are biologically less similar to humans.</p>
<h2>Prioritizing humans</h2>
<p>Moral worth — <a href="https://impactethics.ca/2014/09/05/which-lives-are-you-pro/">the value assigned to others in ways that affect how we treat them</a> — is not species specific. Rather, it is associated with specific capacities such as the ability to think, make choices, experience pain, communicate and have social relationships.</p>
<p>Because a human zygote lacks such capacities, not many believe that they have the same moral worth as a human two-year old, and there is nothing obviously irrational about this belief. Though a zygote may have the potential to reach a comparable level of development as a two-year old, they are not yet comparable. Their shared human identity is beside the point. </p>
<p>On occasion, humans may choose to prioritize the interests of their companion animals without doing something obviously wrong. For example, it is not irrational to spend money on the care of pets, even if that money could have gone towards helping fellow humans. This choice may reflect a shared social relationship and the emotional bonds that come with it. It may also reflect a sense of duty toward nonhuman animals that are dependent on the care provided by humans. </p>
<p>Having said this, clearly, there are times when it is appropriate to prioritize the interests of humans over other animals; it is just that <a href="https://aeon.co/essays/human-exceptionalism-is-a-danger-to-all-human-and-nonhuman">this perspective shouldn’t be the default position</a>. In any case, it is not clear, nor is it easy to determine, that Bennett’s extraordinary xenotransplant falls into this category.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pigs standing at a trough in a shed" src="https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462152/original/file-20220510-16-xxiv1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The killing and consumption of pigs is normalized as they are produced for food.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<h2>Animal welfare</h2>
<p>In Canada, support for animal-based research is anchored in a commitment to <a href="https://www.ccac.ca/Documents/2013_National_Survey.pdf">prevent — or at the very least reduce — unnecessary suffering</a>. The problem with this stance is that current animal welfare considerations do not typically support strong constraints on the scientific use of animals. </p>
<p>Notably, there are pressures to limit, but <a href="https://ccac.ca/en/facts-and-legislation/animal-data/annual-animal-data-reports.html">not to eliminate</a>, the use of animals in research likely to have severe welfare impacts. Also, common animal welfare considerations do not prohibit killing the animals, they just constrain how they are killed. </p>
<p>Part of the problem here is that there are <a href="https://doi.org/10.1017/S0963180119000732">no substantive ethical principles governing animal use in science</a>. The three Rs, which are pervasive in regulated animal use in science, emphasize <em>replacing</em> sentient animals (animals capable of experiencing pain and pleasure) where possible, <em>reducing</em> the number of sentient animals used in studies to a “bare minimum” and <em>refining</em> their experiences of use to minimize suffering. </p>
<p>As such, the three Rs seem to assume something like a principled commitment to non-maleficence — <a href="https://doi.org/10.1093/ilar/ilaa014">avoiding unnecessary harm</a>. However, the continued dependency on harmful animal-based research that almost always ends with the killing of the animals belies this claim, given the known <a href="https://www.cbc.ca/radio/quirks/may-7-endangered-tiny-porpoise-mars-quakes-thermal-batteries-and-more-1.6443011/meet-the-canadian-researcher-determined-to-take-the-animals-out-of-lab-testing-1.6443917">significant problems of extrapolation of research findings</a>.</p>
<p>Given the ethical challenges with animal-based research in general and more specifically the ethical challenges with animal-to-human xenotransplantation, there is good reason to look for <a href="https://www.thehastingscenter.org/xenotransplantation-three-areas-of-concern/">other strategies to increase the supply of organs</a> for transplantation.</p><img src="https://counter.theconversation.com/content/182624/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Fenton is a member of the (Canadian) Society for Humane Science and is currently serving on a subcommittee for the Canadian Council on Animal Care (revising their core ethics document) and a panel on nonhuman primate research for the National Anti-Vivisection Society. </span></em></p><p class="fine-print"><em><span>Françoise Baylis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The heart used in the first pig-human transplant was infected with a pig virus. This reveals that using other species as organ donors may not provide a solution for organ shortages.Françoise Baylis, University Research Professor, Philosophy, Dalhousie UniversityAndrew Fenton, Associate Professor, Philosophy, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1765372022-02-13T18:49:12Z2022-02-13T18:49:12ZIs this love … or an arrhythmia? Your heart really can skip a beat when you’re in love<figure><img src="https://images.theconversation.com/files/445828/original/file-20220210-23-s1oys3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C9156%2C6328&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>We’ve seen it in our favourite romantic comedy – and for many of us, we’ve even felt it in real life. The door of the café swings open, in walks the person of your dreams. Momentarily you’re paralysed. Temporarily overwhelmed. And then you feel it, in your chest. </p>
<p>Is it love at first sight? Is your heart really beating faster than normal? Does it feel – even just for a second – like it’s skipped a beat? </p>
<p>It turns out the movie scenes, songs and poems are right to some extent. Feelings of love and attraction do affect the heart. </p>
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Read more:
<a href="https://theconversation.com/friday-essay-3-ways-philosophy-can-help-us-understand-love-155374">Friday essay: 3 ways philosophy can help us understand love</a>
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<hr>
<h2>A heartful of feelings … also blood affected by hormones</h2>
<p>It’s actually quite normal for your heart to beat faster (or race) – and can happen when you are <a href="https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/racing-heart-beat-heart-arrhythmia-101">excited</a>, <a href="https://www.medicalnewstoday.com/articles/anxiety-with-heart-palpitations">nervous</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/35006474/">angry</a> or even if you’ve had <a href="https://pubmed.ncbi.nlm.nih.gov/19083466/">too many coffees</a>. </p>
<p>You’ve probably heard of the <a href="https://theconversation.com/global/topics/fight-or-flight-28153">fight or flight response</a>. Well, that also explains the feeling of your heart racing during a romantic moment. </p>
<p>Your brain sends a signal to your adrenal glands, two little hormone-producing organs that sit on top of your kidneys. This produces a small boost of the hormone <a href="https://www.endocrineweb.com/adrenaline">adrenaline</a>. It moves via your bloodstream directly to your heart, where its action is to temporarily make your heart beat faster. </p>
<p>The body appears to react this way, even though you’re not necessarily in danger. If you were running away from a bear, the increased heart rate would prepare your muscles to run. When love or attraction strikes, this might be your body’s way of preparing you to run into the arms of your perfect match.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2REkk9SCRn0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The heart wants what the heart wants.</span></figcaption>
</figure>
<h2>Phew! So, it’s not life threatening?</h2>
<p>Probably not. Particularly if you don’t notice it happening frequently and are otherwise in good health. </p>
<p>In response to a surge of adrenaline, your heart racing is almost certainly due to sinus tachycardia. This is when your heart is still beating in a normal rhythm, but faster – like what happens during a good gym session or a run around the block. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two women cuddle in a kitchen." src="https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445827/original/file-20220210-41044-wdggrp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In response to a surge of adrenaline, your heart racing is almost certainly due to sinus tachycardia.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>There are other conditions which can cause someone to feel their heart is racing. Supraventricular tachycardia (SVT) is a condition which results from someone having an <a href="https://www.mja.com.au/journal/2009/190/5/supraventricular-tachycardia">extra electrical circuit</a> in the heart. We are all born with natural electrical circuits, but some people have an extra circuit. In certain situations, that circuit activates and causes palpitations. While the symptoms of SVT can be disconcerting, it is usually benign and can be easily treated with a <a href="https://pubmed.ncbi.nlm.nih.gov/33855753/">small surgical procedure</a>. </p>
<p>Another condition is atrial fibrillation (AF), which results in an irregular and sometimes very rapid heart rhythm. AF is the most common arrhythmia seen in clinical practice by cardiologists and its prevalence increases with age. </p>
<p>Approximately <a href="https://pubmed.ncbi.nlm.nih.gov/25588442/">5-10% of Australians</a> will develop AF in their lifetimes. AF can vary in severity, from occasional episodes of electrical disturbance, to a more serious condition that can result in impairment of how the heart pumps, leading to poorer quality of life and a risk of stroke or heart failure. Some AF is <a href="https://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/diagnosis-treatment/drc-20350630">effectively managed with medication</a>, while other people may require cardioversion (delivering a small shock to the heart) or ablation (a procedure which deactivates cells in the heart that cause AF). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="two hands make love heart" src="https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445831/original/file-20220210-26283-ne7nkc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The best thing you can do for your love life is stay heart healthy.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1586807480822-0e95ba6666ad?ixlib=rb-1.2.1&ixid=MnwxMjA3fDB8MHxzZWFyY2h8MjN8fGxvdmUlMjBoZWFydHxlbnwwfHwwfHw%3D&auto=format&fit=crop&w=800&q=60">Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-write-a-love-poem-155161">How to write a love poem</a>
</strong>
</em>
</p>
<hr>
<h2>That explains the electricity. But can it actually skip a beat?</h2>
<p>Yes. It’s absolutely possible for the heart to skip a beat. That can be <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/heart-arrhythmias-and-palpitations">triggered</a> by the same things that make your heart race – stress, anxiety, dehydration and a range of other things. These premature beats are almost always benign, meaning they aren’t life-threatening or the sign of a heart attack in the making. </p>
<p>So, whether it’s love, or the excited thrill in anticipation of love – your heart really does behave differently when romance walks in the door. The best thing we can do for our hearts is <a href="https://www.heartfoundation.org.au/heart-health-education/keeping-your-heart-healthy">maintain a healthy lifestyle</a>. That means exercising regularly, quitting smoking and checking in with your doctor for a heart health screen to make sure it’s just love, and nothing more sinister.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman clutches her heart while smiling." src="https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445835/original/file-20220210-25-1vicpg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Your heart really does behave differently when love walks in the door.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/176537/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s a love song cliché and a Hollywood staple, but your heart really might race or skip a beat when you feel love and attraction.Hannah Brown, Science Strategy and Operations Manager, Victorian Heart Institute, Monash UniversityHui-Chen Han, Research affiliate, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1731682021-12-03T15:28:44Z2021-12-03T15:28:44ZDiabetes drug may help improve symptoms for people with heart failure – new research<figure><img src="https://images.theconversation.com/files/435609/original/file-20211203-15-1eux98t.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C3894%2C2673&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Half of people with heart failure have a type called preserved ejection fraction.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/human-heart-blood-vessels-3d-illustration-1576424071">Explode/ Shutterstock</a></span></figcaption></figure><p><a href="https://www.bhf.org.uk/informationsupport/conditions/heart-failure">Heart failure</a> is one of the most common cardiac diseases, affecting more than 30 million people worldwide. It happens when the heart can’t deliver enough blood and oxygen to meet the demands of the body’s essential organs. </p>
<p>There are two types of heart failure. About half of patients have a type called reduced ejection fraction, where the heart does not pump properly. The other half of heart failure patients have a type called preserved ejection fraction. This is where the heart still appears to be pumping well, but it cannot relax properly between each heartbeat – meaning it’s still unable to meet the body’s oxygen demands. This type is more difficult to diagnose as it appears to pump normally during an ultrasound – therefore requiring additional tests to diagnose.</p>
<p>Typically, patients with the first type of heart failure are given medications that can improve symptoms and reduce risk of cardiac events – such as heart attacks, hospitalisations or death. But for patients with preserved ejection fraction, researchers have until now been unsuccessful in finding a medication which can improve prognosis and reduce risk of cardiac events for patients. </p>
<p>But our <a href="https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwab189/6447088">recent study</a> has found that a common type of diabetes drug may help improve the health of patients with this type of heart failure by reducing risk of death and hospitalisation from a cardiac cause.</p>
<p>In recent years, researchers have shown that medications initially designed to treat patients with diabetes – called SGLT2 inhibitors – have been found to benefit people <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2022190">with reduced ejection fraction</a>. Now, our recent study, which has combined data from other, smaller studies on the topic, has shown that SGLT2 inhibitors can also be used to treat patients with preserved ejection fraction. We found that patients who were given SGLT2 inhibitors were <a href="https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwab189/6447088">22% less likely</a> to die from heart-related causes or be hospitalised for heart failure than those who didn’t take them. </p>
<h2>Diabetes drug</h2>
<p>To conduct our study, we looked at data from almost 10,000 patients with heart failure and preserved ejection fraction. Half of the patients were treated with an SGLT2 inhibitor while the other half received a placebo – a tablet that looked similar to the new drug but didn’t have any medicine in it. Patients either took the SGLT2 inhibitor or a placebo continuously for an average of around two years, at which point the follow up stopped.</p>
<figure class="align-center ">
<img alt="Three boxes of the SGLT2 inhibitor dapagliflozin, commonly used to manage diabetes." src="https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435610/original/file-20211203-19-1djn4sg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dapagliflozin is one type of SGLT2 inhibitor.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/johormalaysia-jan-032018-forxiga-dapagliflozin-diabetes-785424157">Raihana Asral/ Shutterstock</a></span>
</figcaption>
</figure>
<p>SGLT2 inhibitors have only been recently found to be highly beneficial in patients with heart failure. Initially, they were designed to help lower blood sugar levels in people with type 2 diabetes. </p>
<p>It’s thought SGLT2 inhibitors work for people with heart failure for a number of reasons. One theory is because they promote diuresis, which helps the body <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2107038">rid itself of extra fluid</a>, as fluid overload can be a significant problem for these patients. SGLT2 inhibitors also improve blood pressure and increase the production of red cells, which help <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315190/">deliver blood supply and oxygen</a> to the body’s major organs. Research also suggests that they also reduce the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6359811/">formation of scarring</a> in the heart muscle. Managing all of these factors is critical as they can lead to the formation or exacerbate of heart failure. </p>
<p>A further benefit of using this drug to treat heart failure with preserved ejection fraction is that they’re already shown to be safe as they’ve been used to manage diabetes for many years. They also have relatively few side effects – though urinary infection or abnormal blood sugars may rarely be seen.</p>
<p>Currently, SGLT2 inhibitors are recommended by the <a href="https://academic.oup.com/eurheartj/article/42/36/3599/6358045">European Society of Cardiology</a> to treat patients with heart failure and reduced ejection fraction, with and without diabetes. Our research is the first to suggest that it can also be used to substantially improve outcomes for patients with heart failure and preserved ejection fraction. This could mean that patients with both types of heart failure can have treatment that improves their quality of life, symptoms and prognosis. </p>
<p>However, this drug won’t be prescribed for use in patients with preserved ejection fraction until it’s been reviewed and approved by the National Institute for Health and Care Excellence.</p><img src="https://counter.theconversation.com/content/173168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Heart failure patients who took this drug were 22% less likely to die from heart-related causes.Vassilios Vassiliou, Professor of Cardiac Medicine, University of East AngliaVasiliki Tsampasian, Cardiology SpR & NIHR Academic Clinical Fellow, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1408682020-07-07T13:22:00Z2020-07-07T13:22:00ZBabies born prematurely are at higher risk of heart problems throughout life – new study<figure><img src="https://images.theconversation.com/files/345566/original/file-20200703-33931-8alznn.jpg?ixlib=rb-1.1.0&rect=4%2C4%2C2891%2C1949&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/premature-baby-incubator-chamber-reaching-his-531482251">goodbishop/Shutterstock</a></span></figcaption></figure><p>The weeks and months after a baby is born are a critical time for the growth of the heart of premature babies. This is largely because they are faced with major blood flow changes and increased oxygen demands as they transition to the outside environment during a time where they would normally be developing inside their mother. </p>
<p>A lot of research has identified preterm birth (born before 37 weeks gestation) as a risk factor for developing early heart disease, including <a href="https://www.nhs.uk/conditions/heart-failure/">heart failure</a>. Heart failure is when the heart can’t pump blood around your body as effectively as it should. </p>
<p>Several studies have shown that preterm birth is linked to abnormalities in the structure and function of their heart, yet the extent and evolution of these changes throughout development, from birth to adulthood, are not well defined. However, it’s important that they are defined as <a href="https://www.who.int/news-room/fact-sheets/detail/preterm-birth">one in ten people worldwide</a> are born preterm. </p>
<p>In our <a href="https://pediatrics.aappublications.org/content/early/2020/07/03/peds.2020-0146">latest study</a>, we performed a meta-analysis of data from published studies that compared the heart’s structure and function using echocardiography or cardiovascular magnetic resonance imaging for people born preterm versus those born at term. We included 32 studies in our analysis, with comparisons between groups made in newborns, infants, children, adolescents and young adults. </p>
<p>The results of our study showed that the left and right pumping chambers of the heart, known as the ventricles, are smaller across all developmental stages in people born preterm. Also, the right ventricle’s contractile pump function is impaired across all developmental stages. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=515&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=515&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=515&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=647&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=647&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345742/original/file-20200706-4000-1bri0tu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=647&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/anatomy-human-heart-illustration-131979947">BlueRingMedia/Shutterstock</a></span>
</figcaption>
</figure>
<p>Although the left ventricle’s ability to relax and fill with blood was found to be lower in preterm newborns, this appears to worsen with age. Also, the level of thickening of the left ventricle’s muscle wall from childhood to adulthood is accelerated in people born preterm. Many of these changes were shown to be worse in those born the earliest or most prematurely.</p>
<p>These changes in the hearts of people born preterm have been linked to developing heart disease in later life, but may also put them at more immediate heart disease risk than their term-born peers. Studies show that these physical changes in the heart make people born preterm less able to cope with physiological stress demands, <a href="https://academic.oup.com/ehjcimaging/article/doi/10.1093/ehjci/jeaa060/5821314">such as exercise</a>. </p>
<h2>A lot still to be learned</h2>
<p>The reason for these changes are not known. Work from different animal models of preterm birth, including in sheep, pigs and rats, has shown that a likely reason is <a href="https://academic.oup.com/eurheartj/article/31/16/2058/431785">the early transition from the womb</a>. This is believed to be because the heart undergoes flow and pressure changes around the time of birth, as well as major shifts in oxygen levels (which are much higher outside the womb), causing changes to cells and the shape of the heart. </p>
<p>Ultimately, this results in the heart muscle cells, known as cardiomyocytes, growing differently (switching from rapid division, known as hyperplasia, to increasing cell size, known as hypertrophy) and the structural and functional properties of the heart to change in order to meet the body’s demands. While this is a normal event for all births, the immature preterm heart appears to be less able to cope with these changes, with harm seen at a cellular and structural level.</p>
<p>Given that such a large proportion of the population is born preterm, steps should be put in place to maintain and promote long-term heart health. This includes further research into the best strategies for newborn and infant care to promote healthy heart development, such as early feeding and best practices to support normal lung function, including mechanical ventilation using a machine to move air in and out of the lungs (invasive) and CPAP to provide air through a mask (non-invasive). It also includes lifestyle approaches, such as exercise and nutrition, beginning as early as childhood.</p><img src="https://counter.theconversation.com/content/140868/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Lewandowski receives funding from the British Heart Foundation. </span></em></p>One in ten people are born prematurely.Adam Lewandowski, Research Lecturer, Cardiology, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1162192019-05-01T10:38:32Z2019-05-01T10:38:32ZErectile dysfunction drug could treat heart failure – new study<figure><img src="https://images.theconversation.com/files/271960/original/file-20190501-113835-sccfdw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?u=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTU1NjczMDk0OSwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfNzkxMTM5MDc2IiwiayI6InBob3RvLzc5MTEzOTA3Ni9tZWRpdW0uanBnIiwibSI6MSwiZCI6InNodXR0ZXJzdG9jay1tZWRpYSJ9LCJJUWkvKzV0ZUI0djU1MGlGd3gvZFBZVVg0MVEiXQ%2Fshutterstock_791139076.jpg&pi=33421636&m=791139076&src=IPc7Zx3Fg0NhxPOXnP6Srw-1-13">PureRadiancePhoto/Shutterstock</a></span></figcaption></figure><p>In the 1990s, the US drug firm Pfizer was developing drugs to treat <a href="https://www.nhs.uk/conditions/angina/">angina</a>. During early trials of these drugs, male participants reported a striking side effect: they were getting erections. This discovery led to the development of drugs to treat erectile dysfunction. Our <a href="https://www.nature.com/articles/s41598-019-42592-1">latest study</a> shows that one of these erectile dysfunction drugs (Cialis) is very effective at treating a particular type of heart failure in sheep.</p>
<p><a href="https://www.nhs.uk/conditions/heart-failure/">Heart failure</a> is a devastating condition that occurs when the heart is too weak to pump blood around the body. People with heart failure often cannot complete basic tasks without becoming breathless and developing a cough. It is also a condition where <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.822">survival</a> is worse than for many of the common forms of cancer. The high rates of heart failure and the fact that survival is poor highlights the need for newer and more effective treatments for this condition. </p>
<p>In a normal healthy person, the heart pumps more blood around the body when we exercise. This increase in the work performed by the heart is brought about by the hormone adrenaline which makes the heart beat more quickly and pump more strongly. In heart failure, the heart no longer responds properly to adrenaline which means it cannot increase the amount of work it does or pump blood effectively when we exercise.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/271965/original/file-20190501-113830-1d39mn8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Coughing brought about by even light activity is one of the signs of heart failure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/558060511?src=ehSmTkgWIiaQOFL7cCw28g-1-1&size=medium_jpg">UV70/Shutterstock</a></span>
</figcaption>
</figure>
<p>We discovered that tadalafil (the generic name for Cialis) was very good at stopping heart failure getting worse. It was also surprisingly effective at reversing some changes that had already occurred in the failing heart before the drug was given. In particular, the heart could again respond properly to adrenaline and contract harder. Also, tadalafil reversed changes that had occurred to the structure of the muscle cells in the heart during the development of heart failure.</p>
<p>The findings from this study, published in Nature, <a href="https://www.nature.com/articles/s41598-019-42592-1">Scientific Reports</a>, may also help explain why people who have been intermittently taking drugs to treat their erectile dysfunction seem to be less likely to have a heart attack or die following a <a href="http://dx.doi.org/10.1136/%20heartjnl-2015-309223">heart attack</a>. Our research adds to the small number of clinical studies that have been performed in patients with heart failure where the related drug sildenafil (Viagra) was reported to <a href="https://doi.org/10.1016/j.jacc.2007.07.078">improve the patients’ ability to exercise</a>, but the mechanisms behind these positive effects remained elusive. </p>
<h2>Cautious optimism</h2>
<p>Despite the encouraging results from our study and the fact that drugs to treat erectile dysfunction are now available without a prescription, we need to remain cautious. The <a href="https://jamanetwork.com/journals/jama/fullarticle/1663257">RELAX</a> trial, which reported results in 2013, showed no improvement in exercise capacity in patients receiving sildenafil. </p>
<p>The reason for these differences is probably because two types of heart failure were being investigated in these clinical trials with the positive trials studying patients with systolic heart failure and the neutral trials studying patients with diastolic heart failure. In systolic heart failure, the heart does not contract (pump) adequately whereas in diastolic heart failure the heart still contracts normally but relaxation between heartbeats is impaired.</p>
<p>Still, the experimental findings in our study using tadalafil and those clinical trials in patients with systolic heart failure offer new hope for an effective treatment for heart failure. </p>
<p>While the work in our study was done using sheep, the strong similarities between the sheep and human hearts in the way they work and respond to disease gives us confidence that these findings will be replicated in humans. Indeed, clinical trials using tadalafil in patients with heart failure are a next step in the process of adding tadalafil to our toolkit to treat patients with heart failure, and we hope to be able to begin these in the near future.</p><img src="https://counter.theconversation.com/content/116219/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Trafford received funding for this study from The British Heart Foundation</span></em></p>Cialis may be able to stop heart failure worsening and even reverse some of the disease.Andrew Trafford, Professor of Cardiac Pathophysiology, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1157502019-04-19T10:45:49Z2019-04-19T10:45:49ZWhen is dead really dead? Study on pig brains reinforces that death is a vast gray area<figure><img src="https://images.theconversation.com/files/270045/original/file-20190418-28097-1qmsb2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A recent study of the brains of decapitated pigs showed activity in their brains four hours later. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-pig-posing-farm-141750778?src=4Ach7rg5QeRED6FtHaA3PA-1-6">Ivan Loran/Shutterstock.com</a></span></figcaption></figure><p>For the longest time, “death” used to be when the heart stopped beating and breathing stopped. Then, machines were invented in the 1930s that enabled people to receive air even if they could not take in the air themselves. In the 1950s, machines were developed to help sustain heartbeat. </p>
<p>But no machine could bring back an irreversibly brain-damaged patient to have a functioning brain. As a result, <a href="https://www.worldcat.org/title/definition-of-irreversible-coma-report-of-the-ad-hoc-committee-of-the-harvard-medical-school-to-examine-the-definition-of-brain-death/oclc/41768230">the concept of “brain death”</a> was introduced as an additional definition of death to complement death by heart-lung failure.</p>
<p>The concept of brain death, while legally adopted in the U.S. and in large parts of the world, has remained an area of <a href="https://www.newyorker.com/magazine/2018/02/05/what-does-it-mean-to-die">ongoing discussion</a>. It often centers on how someone can be dead when the heart is beating and the body is warm, even if this function is entirely reached through artificial support. Brain death also is more difficult to conceptualize, as it is a less visible form of death. And isn’t it so much easier to believe what we can see?</p>
<p>On April 17, 2019, a <a href="https://www.nature.com/articles/s41586-019-1099-1">study published in Nature</a> that showed signs of activity in pig brains after they were killed added more fuel to the discussion. I am a neurologist specializing in neurocritical care, with both clinical and research interests in acute brain damage, and broad exposure to catastrophic brain injury and brain death. My analysis of the study is that it reinforces much of what we already know, that death is a continuum.</p>
<h2>When pigs die, can their brains be revived?</h2>
<p>In the study, scientists took brains from pigs that had been slaughtered at USDA-regulated facilities, connected them to a machine that pumped an artificial blood-like nutritional fluid through the brains four hours after their “death,” and measured activity of brain cells. They found that even hours after death, blood circulation – or circulation of the artificial blood – and certain brain cell functions could be restored in this experimental setting. </p>
<p>The conclusion was that demise in the brain after the heart stops beating follows an extended process rather than occurring at a defined moment in time, and that perhaps our brains have a better capacity to heal than is currently known.</p>
<p>Is this news? Yes, on a scientific level – that is, under the microscope, because an experiment like this has not been done before. But, have we not known for a long time that death does not occur within the blink of an eye? </p>
<p>Historic accounts of <a href="https://www.theguardian.com/notesandqueries/query/0,5753,-8010,00.html">decapitated bodies vividly describe</a> decapitated bodies taking a few steps or even running. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=771&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=771&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=771&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=969&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=969&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270075/original/file-20190418-28084-kzd1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=969&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A painting by Sir Peter Paul Rubens illustrates the story of the 9-year-old martyr Justus, who is said to have held his head in his hands after being decapitated.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Het_Mirakel_van_Sanctus_JUSTUS-Sir_Peter_Paul_Rubens.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>That means that such a body was not immediately dead. And, conceivably, if one hooked up such a body to blood supply and healed the wounds, most people could likely imagine that it could continue to be maintained with living body parts or cells. </p>
<h2>Can a head still be alive after decapitation?</h2>
<p>Even worse to imagine: Could the decapitated head still be conscious for a bit? Perhaps yes.</p>
<p>After the heart stops beating, we consider that someone has died. But, after the heartbeat stops, we also know that sometimes, the heartbeat can come back by itself. This is called <a href="https://www.ncbi.nlm.nih.gov/pubmed/29286944">autoresuscitation</a>. In this case, someone that appeared dead for a few minutes may not have actually died. </p>
<p>But the situation is different for the brain than for the heart. When there is a lack of blood flow in the absence of a heart that pumps it, or when there is intrinsic brain injury and blood cannot get in, the situation is tricky. Brains are very sensitive to being deprived of oxygen and energy supply, and <a href="https://content.iospress.com/articles/neurorehabilitation/nre00531">various degrees of brain injury</a> occur. Depending on how long the energy fuel to the brain is absent, brain function can remain alive to various degrees and be rekindled to a degree we neuroscientists do not yet fully know. We know that brain function is seriously disturbed, with variable permanence of function loss depending on how long the brain has not had energy.</p>
<p>The end result of how functional such a damaged brain will come out is one of the biggest challenges we have to learn more about.</p>
<p>After an injury, a whole sequence of consecutive processes occurs that is called <a href="https://www.ncbi.nlm.nih.gov/pubmed/9707338">secondary brain injury</a> and is triggered by the insult to the brain in the first place. And these processes often cause tremendous damage, and sometimes more than the actual first injury. </p>
<p>For example, a hard blow to the head can result in a bruise or bleeding in the brain, which can be removed by surgery in certain cases. Despite the bleeding being stopped or removed, however, the surrounding brain will sometimes start swelling and bruising even more over the subsequent days, like a big bruise on the thigh goes through stages and color changes. There is not yet a preventive therapy for this, but we know that some factors can make this process worse, such as blood pressure that is too low or lack of oxygen to the brain during the healing phase.</p>
<p>Imagine a broken bone: The cast is just the first step, and there is swelling, pain and weakness for weeks to come. In the brain, the process is more granular. And in neuroscience, we are just now beginning to understand this cascade of events.</p>
<h2>What to learn from the pig study</h2>
<p>The study of revived pig brain cells does not even come close to touching on this much bigger picture. It is limited to showing that the time span and spectrum of nerve cell function that can persist and at least partially be restored is longer than had been shown so far. Hence, it supports the idea that dying is a process, and puts an additional piece of data on the length of this process. </p>
<p>But it does not show that these brain cells were able to function as a nerve cell network leading to higher brain function such as consciousness or awareness – the features that set us apart as humans. It also just looks at the immediate restoring of cell function, and not at how these brains do days out, when the continuing processes of secondary brain damage set in.</p>
<p>To summarize, in the absence of blood flow, the brain, including all its individual cells will die – eventually. And this study has perhaps expanded the understanding of “eventually.” </p>
<p>Death is a process, and not a moment in time. It is the human desire to put things in categories of black and white, and to have definitions that let us operate in daily life. Death – this is becoming more and more clear – is a large gray zone, and we will have to expect that this gray zone grows as science progresses.</p><img src="https://counter.theconversation.com/content/115750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katharina M. Busl does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent study on the brains of pigs suggested that some activity could be restored even after the porkers had been dead for four hours. A neuroscientist who specializes in brain death explains.Katharina M. Busl, Associate Professor of Neurology; Chief of the Division of Neurocritical Care, Department of Neurology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/852452017-10-06T00:43:33Z2017-10-06T00:43:33ZTom Petty died from a cardiac arrest – what makes this different to a heart attack and heart failure?<p>Rolling Stone magazine landed in a spot of bother on Monday after publicising news of rock star Tom Petty’s <a href="http://money.cnn.com/2017/10/03/media/tom-petty-death-media/index.html">death prematurely</a>, while others said it was the <a href="http://www.independent.co.uk/arts-entertainment/music/news/tom-petty-dead-dies-death-latest-cause-age-life-career-music-heartbreakers-a7979696.html">result of a heart attack</a> rather than a cardiac arrest. Petty unfortunately did subsequently pass away, from a <a href="http://www.abc.net.au/news/2017-10-03/tom-petty-dies-aged-66-after-cardiac-arrest-manager-says/9011538">cardiac arrest</a>, but it’s important to note neither a cardiac arrest nor a heart attack is synonymous with death.</p>
<p>Albeit infrequently, sufferers of cardiac arrest <a href="https://www.bhf.org.uk/heart-health/conditions/cardiac-arrest">can be revived</a> and a heart attack is associated with a <a href="https://www.mja.com.au/journal/2015/203/9/survival-after-acute-coronary-syndrome-18-month-outcomes-australian-and-new">relatively low</a> risk of dying within 18 months with current treatment in Australia. Both are types of heart disease, as is heart failure. So what are the differences between cardiac arrest, heart attack and heart failure?</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=601&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=601&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=601&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=755&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=755&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188895/original/file-20171005-21985-173tgw5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=755&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The heart beats in a very controlled and synchronised manner.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<h2>Cardiac arrest</h2>
<p>The easiest way to understand these conditions is to think of the heart like a building and approach it like a tradesman. Cardiac arrest is the sparkie’s domain because it’s essentially an electrical failure. The heart beats in a very controlled and synchronised manner, due to a flow of electricity from the “pacemaker” cells at the top of the heart (sinoatrial node) steadily down to the base.</p>
<p>The wiring is present throughout the heart, because the heart muscle cells themselves transmit and respond to this electrical signal, beating as it travels through and powers them. But there are also “mains” electricity circuits that direct the flow of energy and can act as backups along the way if one part of the circuit fails. These are the atrioventricular node, “bundle of His” and “Purkinje fibres” – all can cause the heart to beat, but at a slower rate than the sinoatrial node.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">How Australians Die: cause #1 – heart diseases and stroke</a>
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</em>
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<p>All this doesn’t always go according to plan. Diseases such as blocked arteries, genetic conditions and degeneration of the heart with ageing can cause disruptions to the circuit. </p>
<p>This may result in two things. The first is a power failure, with no electricity whatsoever – called “asystole”. The second is a surge of electricity from an area of the heart muscle that is disruptive and prevents the heart from pumping properly – the most dangerous of these surges are commonly referred to as ventricular arrhythmias. These are the two main types of cardiac arrest.</p>
<p>Both these conditions will stop the heart pumping. Because blood can no longer travel to the brain, the person will lose consciousness. </p>
<p>In the movies, they are treated with defibrillator paddles delivering electric shocks in a dramatic manner. But while this is an important treatment for ventricular arrhythmias, as it is able to re-organise the surge of electricity, it is ineffective for asystole (where there is no electricity at all). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188889/original/file-20171005-21980-1b9ascl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In the movies, people with cardiac arrest are treated with paddles delivering electric shocks in a dramatic manner.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>In this case, <a href="https://resus.org.au/guidelines/">good-quality CPR</a> is crucial. If someone is left too long without blood supply to their brain and the rest of the body, they will die. Survival from cardiac arrest occurring outside of a hospital setting <a href="https://www.ncbi.nlm.nih.gov/pubmed/17227269">in Australia</a> is 24% after the day of event, dropping to 11.5% at one year later.</p>
<h2>Heart attack</h2>
<p>This is the plumber’s area. While a heart attack is often used to describe a range of heart problems, it actually refers to what is medically termed an acute myocardial infarction, or AMI. </p>
<p>The heart provides blood to the rest of the body, but it also needs its own blood supply and does not get it from the blood that flows through its chambers. Instead, the heart is supplied with blood, giving oxygen and taking away carbon dioxide, by arteries and veins that sit on the outside of the heart.</p>
<p>But our Western diet and lifestyle have contributed to extremely high rates of disease inside these arteries, termed “<a href="https://www.bhf.org.uk/heart-health/conditions/atherosclerosis">atherosclerosis</a>”. This causes the arteries to narrow and can lead to sudden blockages, which result in heart attacks. </p>
<p>AMIs usually occur when there is a sudden rupture of the atherosclerotic plaque, containing cholesterol, fatty cells and immune cells. This causes a large blood clot to form, blocking off the blood flow.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188898/original/file-20171005-21999-197eo17.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The heart is supplied with blood, giving oxygen and taking away carbon dioxide, by arteries and veins that sit on the outside of the heart.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>When the heart muscle tissue that is usually supplied by these arteries no longer receives blood and oxygen, it starts to die within minutes, causing intense pain. Within <a href="https://www.ncbi.nlm.nih.gov/pubmed/3154690">90 minutes</a>, that whole section of heart wall can die, meaning it will not beat. This reduces the overall performance of the heart and predisposes it to the aforementioned ventricular arrhythmias (the dangerous surge of electricity).</p>
<p>Fortunately, modern medicine has markedly improved survival from heart attacks. In 1960, <a href="https://www.ncbi.nlm.nih.gov/pubmed/1831213">one-third</a> of people died within a month of having a heart attack. This improved to <a href="https://www.mja.com.au/journal/2015/203/9/survival-after-acute-coronary-syndrome-18-month-outcomes-australian-and-new">16% 18 months after having one</a> in Australia in 2012. </p>
<hr>
<p><strong><em>Read more: <a href="https://theconversation.com/women-have-heart-attacks-too-but-their-symptoms-are-often-dismissed-as-something-else-76083">Women have heart attacks too, but their symptoms are often dismissed as something else</a></em></strong></p>
<hr>
<p>Even though the survival rate from heart attacks is quite high, the burden of disease is heavy. Heart attacks are responsible for 12% of all deaths in Australia, and one Australian dies from a “heart attack” <a href="https://www.heartfoundation.org.au/about-us/what-we-do/heart-disease-in-australia/heart-disease-fact-sheet">every 27 minutes</a>.</p>
<h2>Heart failure</h2>
<p>Heart failure is a structural issue, so it’s the carpenter’s problem. It results from the heart being unable to adequately supply the body with blood, so the tissues don’t receive oxygen and other nutrients, and blood pools in the legs, abdomen and lungs. Heart failure either results from weakness in the strength of the pump, or stiffening of the heart so it loses elasticity and can’t fill with blood in the first place. </p>
<p>It is the end result of a <a href="http://blogs.plos.org/globalhealth/2017/08/taking-the-pulse-of-heart-disease/">myriad of conditions</a>, from genetic disorders, to heart attacks, to infections and high blood pressure.
Heart failure is more chronic than the other two. People with heart failure see a gradual worsening of shortness of breath, fatigue, swelling and light-headedness, with a significant impact on quality of life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-heart-failure-its-not-as-common-a-cause-of-death-as-reports-would-have-us-believe-71151">What is heart failure? It's not as common a cause of death as reports would have us believe</a>
</strong>
</em>
</p>
<hr>
<p>Death from heart failure is often as a result of cardiac arrest, as disruption to the construction of the house causes electricity problems too; along with organ failure from lack of oxygen supply due to failure to pump the blood and also fluid in the lungs reducing oxygen transfer.</p>
<p>The good news is all three of these conditions can <a href="https://www.heartfoundation.org.au/your-heart/know-your-risks">largely be prevented</a> and treated with a healthy lifestyle, seeing your doctor and taking medications to reduce your risk of heart disease.</p><img src="https://counter.theconversation.com/content/85245/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Beale does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People generally assume all heart-related death is due to heart attack. But there are differences between cardiac arrest, heart attack and heart failure – and none are synonymous with death.Anna Beale, Medical doctor, PhD candidate in cardiology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/757292017-05-30T08:51:12Z2017-05-30T08:51:12ZMany heart attack patients prescribed beta-blockers may not benefit<figure><img src="https://images.theconversation.com/files/165094/original/image-20170412-25888-78mhjn.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3024%2C2014&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-office-uniform-having-heart-attack-345818213?src=vjb0DxUuGqtyfXMHYHYXKg-1-22">Shutterstock/Twinsterphoto</a></span></figcaption></figure><p>People who have had a heart attack are prescribed a number of drugs, often for life. Our <a href="http://www.onlinejacc.org/content/69/22/2710">latest research</a> shows that one of those drugs – a beta-blocker – may offer no survival benefit to heart attack patients who do not have heart failure.</p>
<p>This may not seem important, but research shows that the more drugs a person is prescribed, the <a href="http://onlinelibrary.wiley.com/wol1/doi/10.1111/j.1472-8206.2009.00757.x/full">less likely they are to take them</a>. And this includes the important pills, such as statins and aspirin, which really could save a person’s life. What’s more, drugs have side effects, which, for beta-blockers, may include dizziness, tiredness, blurred vision and nausea.</p>
<p>Beta-blockers were invented <a href="https://www.mcgill.ca/reporter/37/03/black/">in the 1960s</a>, a time when deaths from heart attacks were very common. Scientists knew that stress (through increased adrenaline) could trigger a heart attack. This led to the development of the drug that works by blocking the effects of adrenaline and lowering the heart rate and blood pressure. Nowadays, beta-blockers are often prescribed as part of routine heart attack care. </p>
<h2>How heart attacks and heart failure differ</h2>
<p>A heart attack occurs when there is a loss of blood flow to part of the heart, causing the heart muscle to be damaged. Heart failure, on the other hand, occurs when the heart is unable to effectively pump blood through the body due to weakened heart muscles. One of the most common reasons for heart failure is a previous heart attack. </p>
<p>Earlier <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2385120/?page=1">evidence showed</a> that beta-blockers can increase a person’s lifespan after a heart attack. But this evidence predates other advances in heart attack treatment. These advances include the introduction of operations such as angiograms, stents and bypass grafts. The use of these operations has led to significant <a href="http://jamanetwork.com/journals/jama/fullarticle/2546640">improvements in survival</a> following a heart attack. </p>
<p>Although more modern <a href="http://www.sciencedirect.com/science/article/pii/S0140673600045608">evidence from clinical trials</a> about the use of beta-blockers exists, the evidence is focused on heart attack patients who also have heart failure. So doctors are unsure about the use of beta-blockers for heart attack patients who do not also have heart failure. This uncertainty is reflected by various national treatment guidelines which differ in their recommendation for the use of beta-blockers. </p>
<h2>Better than an observational study</h2>
<p>Due to the availability of <a href="https://www.ucl.ac.uk/nicor/audits/minap">national clinical data</a> on heart attacks in the UK, we were able to assess the effectiveness of beta-blockers in heart attack patients who did not have heart failure. Importantly, we were able to assess the effectiveness of beta-blockers in a modern treatment era at relatively low cost and in a timely manner compared with a clinical trial. </p>
<p>We used two methods to analyse the data – <a href="http://www.bmj.com/content/347/bmj.f6409">propensity score analyses</a> and <a href="http://jamanetwork.com/journals/jama/fullarticle/205172">instrumental variable analyses</a> – which allowed us to take into consideration the differences between patients who received beta-blockers and those who did not, such as their age, sex, type of heart attack and any other medications and treatments they received. The methods also allowed us to mimic the random treatment allocation of a clinical trial to get results that are more robust than a conventional observational study. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165100/original/image-20170412-25862-1thb9gu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Beta-blockers: prescribe with care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-statin-betablocker-pills-capsules-bottle-329877359?src=yFKda0SGRugnoORnP9EtEw-1-2">Shutterstock/roger ashford</a></span>
</figcaption>
</figure>
<p>We found that, for nearly 180,000 patients with a heart attack who did not have heart failure, 95% of patients were prescribed beta-blockers when they left hospital. But there was no survival benefit for these patients.</p>
<p>This study now raises questions over whether patients who do not have heart failure should continue to be routinely prescribed beta-blockers following their heart attack. </p>
<p>Although we provide strong evidence that beta-blockers may not improve survival following a heart attack for patients without heart failure, modern clinical trials are still needed to confirm the findings and provide conclusive evidence to change treatment guidelines. This work has the potential to save patients from being overtreated while also saving them money on the cost of prescriptions.</p><img src="https://counter.theconversation.com/content/75729/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marlous Hall has received funding from the British Heart Foundation. </span></em></p>Big data shows that we may need to rethink heart attack treatments.Marlous Hall, Senior Epidemiologist, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/747612017-03-23T19:14:16Z2017-03-23T19:14:16ZPainkillers like ibuprofen can increase the risk of heart disease and should be restricted<figure><img src="https://images.theconversation.com/files/161953/original/image-20170322-31180-nre29d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over-the-counter medicines such as Ibuprofen and Voltaren are not without some risk.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Medications such as ibuprofen and aspirin, known as non-steroidal anti-inflammatory drugs or NSAIDs, are widely available over the counter from pharmacies and supermarkets. But health providers have <a href="https://www.theguardian.com/uk/2006/oct/25/science.health">known for some time</a> they can be unsafe for people with chronic health problems such as kidney disease, high blood pressure or heart failure. </p>
<p>NSAIDs can also have dangerous <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508078/">interactions with other commonly taken medications</a>, notably many types of blood pressure and blood-thinning pills such as warfarin and aspirin. </p>
<p>Two recently published studies have brought back into the spotlight the possible heart-related side effects of NSAIDs. One found an increased risk of <a href="http://www.bmj.com/content/354/bmj.i4857">heart failure</a> in users of NSAIDs, while another an increased risk of <a href="https://academic.oup.com/ehjcvp/article/3/2/100/2739709/Non-steroidal-anti-inflammatory-drug-use-is">cardiac arrest</a>.</p>
<p>Heart failure is a disease that presents with symptoms such as shortness of breath, fluid retention, leg swelling, and fatigue. This is a result of the heart not being able to pump blood around the body effectively. There are many causes of heart failure, including heart attacks, high blood pressure and excessive alcohol consumption. </p>
<p>A cardiac arrest occurs when the heart stops functioning abruptly and results in complete loss of effective blood flow through the body. The most common cause of a cardiac arrest is a heart attack, where heart muscle is damaged from loss of blood supply due to a blockage in a heart blood vessel. There are many other causes of a cardiac arrest that include structural heart abnormalities and inherited heart diseases of muscle and electrical function. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=698&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=698&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=698&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=877&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=877&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162106/original/image-20170322-25776-ed2kf5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=877&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Heart failure is when the heart isn’t able to pump blood around the body effectively.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The recent studies are an important reminder that over-the-counter medicines are not without risk. This class of anti-inflammatory pain killers should no longer be available for sale in grocery stores, but instead restricted to prescription-only or behind-the-counter status in pharmacies. </p>
<h2>How they work</h2>
<p>Non-steroidal anti-inflammatory drugs are commonly used to relieve pain. They can be either prescribed by a doctor or purchased by the patient over the counter from a supermarket or pharmacy.</p>
<p>NSAIDs are used in a broad range of health conditions associated with pain and inflammation, including types of arthritis, headaches, musculoskeletal injuries and menstrual cramps. Their easy availability, effectiveness and presumption of safety contribute to their widespread use. </p>
<p>They work by inhibiting enzymes called cyclooxygenase 1 (COX-1) and 2 (COX-2). These are involved in a number of internal pathways that result in production of hormone-like substances called prostaglandins, which promote inflammation and increase pain perception.</p>
<p>Prostaglandins also protect the stomach lining from acid, by decreasing acid production and increasing mucus secretion and its neutralising properties. So inhibiting prostaglandins also reduces their protective functions. This is why <a href="https://theconversation.com/do-you-need-to-take-some-painkillers-with-food-to-protect-your-stomach-47156">frequent users of anti-inflammatories</a> may suffer from gastric ulcers.</p>
<p>NSAIDs can either inhibit both COX-1 and COX-2 (non selective) or inhibit COX-2 only (selective). Drugs like ibuprofen and aspirin are <a href="https://en.wikipedia.org/wiki/Ibuprofen">non selective</a> and inhibit both the COX enzymes.</p>
<p>COX-1 mediates gastrointestinal, kidney, and clotting function, while COX-2 is induced primarily in states of inflammation and tissue repair. That’s why blocking the COX-2 pathway reduces the effects of inflammation such as fever, swelling, redness and pain.</p>
<p>Importantly, COX-2 inhibition accounts for the anti-inflammatory drug effects of NSAIDs, while COX-1 inhibition can lead to side effects including gastrointestinal ulcers, prolonged bleeding and impaired kidney function. However, it’s not entirely safe for the drugs to inhibit COX-2 only. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=584&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=584&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163250/original/image-20170330-15581-1y5jd5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=584&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ibuprofen works by inhibiting both COX enzymes.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p><a href="http://circ.ahajournals.org/content/115/3/326.long">Animal studies</a> have shown blocking COX-2 and the subsequent pathway of prostaglandin production may have the unwanted effects of increasing the tendency of blood to clot inside arteries, and a reduced ability of the heart to heal after a heart attack. </p>
<p>In the early 2000s, a number of large studies found a significant association of negative heart events, such as <a href="http://www.nejm.org/doi/full/10.1056/NEJM200011233432103">heart attack</a> and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa050493">stroke</a>, with the use of <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa050330">selective COX-2 inhibitors</a>. This resulted in two of these drugs, Valdecoxib and Rofecoxib or Vioxx, being <a href="https://www.tga.gov.au/media-release/regulator-takes-tough-action-arthritis-drugs-amended">withdrawn from the market</a>. </p>
<p>In Australia there are only a small number of COX-2 inhibitors available, including Celecoxib and Meloxicam. These are prescription-only medicines and the maximum prescribed dose is at a level at which the heart risks are minimal. </p>
<p>COX-2 inhibitors are used in people who require a non-steroidal anti-inflammatory but have a history of stomach upset or ulcers, or who were thought to be at risk of developing stomach ulcers. </p>
<h2>Risk of heart failure</h2>
<p>Non-steroidal anti-inflammatory drugs are associated with elevating blood pressure as well as sodium and fluid retention. Both of these effects may unmask previously undiagnosed heart failure, or worsen the symptoms in people known to already have heart failure.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=814&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=814&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=814&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1023&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1023&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162121/original/image-20170323-25783-o1wn3m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1023&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vioxx was a selective inhibitor and take off the market for its adverse effects on the heart.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/en/9/97/VIOXX_sample_blister_pack.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>Research published in the <a href="http://www.bmj.com/content/354/bmj.i4857.long">British Medical Journal in September 2016</a> studied 92,163 people admitted to hospital with heart failure, and found NSAID use in the two weeks prior to admission was associated with a 19% increased risk of hospital admission for heart failure. This was compared with people who had not used NSAIDs prior to admission. </p>
<p>The association of NSAIDs with an exacerbation of heart failure was also seen in many older studies. For example, an <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485256">Australian study in 2000</a>, suggested almost 20% of all heart failure related admissions to hospital may be attributed to recent NSAID use. </p>
<h2>Risk of cardiac arrest</h2>
<p>Further heart safety concerns with NSAIDs were raised in a recent study from the University of Copenhagen, published in the <a href="https://academic.oup.com/ehjcvp/article/3/2/100/2739709/Non-steroidal-anti-inflammatory-drug-use-is">European Heart Journal</a>. </p>
<p>Data was collected from nearly 30,000 patients who had suffered cardiac arrest between 2001 and 2010. Of these, around 3,500 were found to have been treated with an NSAID within 30 days of having a cardiac arrest. </p>
<p>Use of any NSAID was associated with a 31% increased risk of cardiac arrest. The commonly used non-selective NSAIDs, diclonenac (Voltaren) and ibuprofen were associated with a 50% and 31% increased risk respectively. </p>
<p>A large proportion of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5248660/">cardiac arrest is a result of clot formation in the arteries of the heart</a> and underlying plaque formation which can rupture. NSAIDs may increase the risk of cardiac arrest by raising blood pressure, forming blood clots and blocking the heart’s own blood vessels. </p>
<p>It is important to emphasise that in people with no known heart disease and who don’t have any heart risk factors, short term use of these anti-inflammatories carries a minimal increase in heart-related risk.</p>
<p>These recent studies should not create community panic about the safety of NSAIDs when used for short periods of time and at low dosage.</p>
<p>But the high burden of heart disease and heart disease risk factors, such as high blood pressure, obesity and diabetes (which are often unrecognised), warrant a personalised approach to NSAIDs, which weighs the benefits and risks of their use.</p>
<p>This was recommended in the <a href="https://www.tga.gov.au/review-cardiovascular-safety-non-steroidal-anti-inflammatory-drugs">Therapeutic Goods Administration review</a> of the heart related effects of NSAIDs in 2014. These anti-inflammatories should be available for purchase through prescription by a medical practitioner or behind the counter at the pharmacy.</p><img src="https://counter.theconversation.com/content/74761/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Stokes receives scholarship funding from the Royal Adelaide Hospital Research Committee.</span></em></p><p class="fine-print"><em><span>Peter Psaltis receives research funding from the National Health and Medical Research Council of Australia, National Heart Foundation of Australia and Abbott Vascular Pty Ltd. </span></em></p>Anti-inflammatory pain killers such as ibuprofen should no longer be available for sale in grocery stores, but instead restricted to pharmacies.Michael Stokes, Cardiologist and PhD Candidate, University of AdelaidePeter Psaltis, Co-director, Vascular Research Centre, South Australian Health & Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/711512017-01-12T23:56:02Z2017-01-12T23:56:02ZWhat is heart failure? It’s not as common a cause of death as reports would have us believe<figure><img src="https://images.theconversation.com/files/152349/original/image-20170111-6425-1fwy68k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people erroneously believe 'heart failure' is when the heart suddenly stops. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>When George Michael died last year <a href="http://www.news.com.au/entertainment/celebrity-life/george-michaels-long-battle-with-health-issues/news-story/45101ac02ba9f7716d6c55c440e460c2">news reports</a> all over the <a href="http://hollywoodlife.com/2016/12/25/george-michael-cause-of-death-heart-failure/">world</a> announced the cause as heart failure.</p>
<p>The same condition was cited as the cause of death of 61 year old Devo band member <a href="http://edition.cnn.com/2014/02/18/showbiz/devo-bob-casale-dead/">Bob Casale</a>, 27 year old Ecuadorian footballer <a href="http://edition.cnn.com/2013/07/31/sport/football/football-christian-benitez-dies/">Christian Benitez</a>, actor <a href="http://www.nydailynews.com/news/national/actor-river-phoenix-dies-23-1993-article-1.2762206">River Phoenix</a>, The Doors lead singer <a href="https://en.wikipedia.org/wiki/Jim_Morrison">Jim Morrison</a>, former First Lady <a href="http://www.mirror.co.uk/news/world-news/nancy-reagan-dead-former-first-7506681">Nancy Reagan</a> and Lord of the Rings’ <a href="https://www.theguardian.com/film/2015/jun/11/christopher-lee-dies-at-the-age-of-93-dracula">Christopher Lee</a>, well known for playing Saruman the White. </p>
<p>There is even a <a href="http://www.ranker.com/list/famous-people-who-died-of-heart-failure/reference">website</a> that lists celebrities who have died of heart failure. As a general physician I know “heart failure” was unlikely to be the cause of death of most of these people.</p>
<h2>What actually is heart failure?</h2>
<p>While they are all related to each other, “heart failure”, “heart attack” and “sudden cardiac arrest” are not synonyms. A lay person could be excused for thinking a heart that has “failed” has suddenly stopped, but this is not the medical meaning. </p>
<p>Heart failure occurs when the heart is unable to pump enough blood to the other organs to satisfy their need for oxygen and nutrients. It usually manifests as tiredness and weakness, breathlessness and swelling of the legs and abdomen. Sudden death may occur as a consequence of heart failure, but it is not a feature of the disease.</p>
<p>The most important causes of heart failure are coronary artery disease (which causes a heart attack) and high blood pressure, but it can also be the result of damage to the heart muscle itself (cardiomyopathy), problems with the valves (such as “aortic stenosis”) or when the heart’s rhythm is disturbed and it beats too fast, too slow or irregularly (“atrial fibrillation”).</p>
<h2>What’s a heart attack?</h2>
<p>A “heart attack” occurs when one of the arteries in the heart suddenly blocks, depriving the heart muscle of oxygen. Typically, a heart attack produces severe, central, crushing chest pain. How much heart muscle dies depends on the extent of the blockage and how quickly the blood flow can be restored through medical intervention. </p>
<p>An oxygen-starved heart is unstable and prone to rhythm abnormalities, so a heart attack is one of the common triggers of a “sudden cardiac arrest” which means the heart suddenly and unexpectedly stops.</p>
<p>The vast majority of people who have a heart attack do not suffer a sudden cardiac arrest but many will subsequently develop heart failure if sufficient muscle has been damaged. </p>
<h2>So if not heart failure, what do they really mean?</h2>
<p>Heart failure is a major public health problem. It affects <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737418530">approximately 300,000 Australians</a> and, as it is a disease mainly of older people, numbers will significantly rise as the population ages. </p>
<p>The condition increases your risk of dying from a sudden cardiac arrest. Around 50% of people will be dead five years after they receive a heart failure diagnosis, probably from sudden cardiac arrest but other complications are often implicated. This makes the illness <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa020265">as deadly as many cancers</a>.</p>
<p>Many of the celebrity deaths, especially the middle aged ones, reported as being due to heart failure were probably the result of a sudden cardiac arrest caused by underlying coronary artery disease. </p>
<p>But sudden death can have other causes: these include a clot of blood that travels to the lungs (pulmonary embolism), rupture of the aorta (main artery of the body), intentional or unintentional poisoning or brain haemorrhage. George Michael’s post mortem was “inconclusive” and failed to reveal a specific reason for his death, a surprisingly common finding in this context. </p>
<p>On the other hand, 93 year old Christopher Lee had been unwell for some time before he died. He had been admitted to hospital with “respiratory problems and heart failure”, a diagnosis in keeping with his advanced age and reported symptoms. Unlike the others, Saruman the White’s end would have been slower and, hopefully peaceful.</p><img src="https://counter.theconversation.com/content/71151/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frank Bowden does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When George Michael passed away last year news reports all over the world announced the cause as heart failure. It’s unlikely this really was the cause.Frank Bowden, Professor at ANU Medical School; Senior Staff Specialist Infectious Diseases; General Physician, ACT HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/605962016-07-15T12:19:34Z2016-07-15T12:19:34ZBillions are spent on clinical research that gets ignored – here’s the answer<figure><img src="https://images.theconversation.com/files/130048/original/image-20160711-9295-1reuklr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Worth the effort?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=health%20research&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=341386256">Paradise Picture</a></span></figcaption></figure><p>Heart failure is a major killer, <a href="https://www.nice.org.uk/guidance/cg108/chapter/introduction">affecting</a> well over a million people in the UK alone. We now have over 20 years’ worth of evidence from clinical trials that show strong benefits for a package of treatment involving not only drugs and devices but also where patients stay, how they are cared for and how the different healthcare professionals work with one another. Yet in many cases, doctors <a href="http://www.ncbi.nlm.nih.gov/pubmed/21159794">are not</a> acting on the findings. </p>
<p>This is just one example of a major problem in healthcare across the world. Billions of pounds are spent each year researching clinical treatments, but a staggering <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673609603299/fulltext?rss=yes">85% of all research ends up</a> not being put into practice – much of it passed over for reasons that could be avoided. Even when research findings are taken up by clinicians and those in charge of health policy, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22179294">the average delay</a> between publication and practice is 17 years. </p>
<p>The more medical conditions you consider, the more examples crop up. Research into a new care package for chronic kidney disease <a href="http://fampra.oxfordjournals.org/content/early/2016/06/12/fampra.cmw049.abstract">was shown</a> to be effective, for example, but it is not implemented by GPs because they are struggling to prioritise it over other conditions and competing demands.</p>
<p>Or take Bell’s palsy, a condition where muscle weaknesses cause a sufferer’s facial features to droop on one side. Many patients are not <a href="http://bmjopen.bmj.com/content/3/7/e003121.short">being given</a> the treatment shown in trials to be the most effective. In lung cancer of the non-small cells, meanwhile, a new radiotherapy treatment <a href="http://www.ncbi.nlm.nih.gov/pubmed/10577699">has been proven</a> to be a better cure than conventional radiotherapy. Yet it is not widely given because of doctors’ preferences and the practicalities of providing it in hospitals. </p>
<h2>Trials and context</h2>
<p>So what’s the problem? This gap between evidence and practice has produced a whole field of research in its own right called <a href="http://implementationscience.biomedcentral.com">implementation science</a> or knowledge transfer, which has identified various issues. Some trials <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0917-5%20Pearce%20et%20al">are not</a> of high enough quality. This can be for any number of reasons including problems with the way participants are selected, conducting the wrong trials or conducting the right trials the wrong way. </p>
<p>Other trials are <a href="http://www.economist.com/news/science-and-technology/21659703-failure-publish-results-all-clinical-trials-skewing-medical">not published</a> because they did not produce a result in favour of the new treatment being tested. Initiatives such as the <a href="http://www.alltrials.net/">All Trials campaign</a> aim to get all trials registered and their results published so that we can see the full picture, not a distorted one.</p>
<p>Yet this won’t solve everything. This is because one of the biggest problems, which has perhaps not received enough attention in the past, is that research findings are frequently much less meaningful to clinicians and policymakers in the real world than they could be. </p>
<p>Trials <a href="http://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-13-95">don’t collect</a> sufficient information about the context in which they were conducted, or about how contextual factors affected the results. So outside the direct trial setting, the results can either be less useful or it <a href="http://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-11-79">can be</a> hard to judge whether they will be useful or not.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=722&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=722&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=722&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=908&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=908&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=908&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Never simple.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=fWFKwxQHilRDHgQfoDh61A&searchterm=medication&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=392709652">Jaroon Magnuch</a></span>
</figcaption>
</figure>
<p>Even a seemingly simple switch from one pill to another can stumble because of things like its cost and availability, patient preferences, or beliefs among staff as to the benefits of the old drug. And when it comes to complex team-delivered treatments such as surgery or rehabilitation, the scope for context to matter increases enormously. </p>
<h2>The need to look closer</h2>
<p>Many <a href="http://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-14-15">specialists believe</a> the answer is to run separate studies alongside clinical trials that aim to understand their context, their processes and
all the relevant variables that come into play. These are expensive, though not prohibitively so, and <a href="http://www.trialforge.org/">work is going on</a> into how to make them cheaper. The UK Medical Research Council last year <a href="https://www.mrc.ac.uk/documents/pdf/mrc-phsrn-process-evaluation-guidance-final/">published guidance</a> on how such studies should be conducted. </p>
<p>One thing lacking from this guidance, however, was much explanation of how context should be explored in these studies. This is because we’ve yet to fully understand the problem. An <a href="http://bmjopen.bmj.com/content/5/12/e009993.abstract">overview of 70 reviews</a> looking at why GPs and other professionals in primary care don’t put research findings into practice recently concluded that future research needs to concentrate on how and why contextual factors play a part. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=494&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=494&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=494&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">GP’s perspective still poorly understood.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=fWFKwxQHilRDHgQfoDh61A&searchterm=medication&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=323840159">Nonwarit</a></span>
</figcaption>
</figure>
<p>There also appears to be another obstacle. There is growing pressure to prioritise funding for research that has the greatest impact on clinical care. Methodology research into the context problem doesn’t have an immediate impact on clinical care, which makes it harder to attract funding. It currently attracts only a small part of the <a href="http://www.hrcsonline.net/pages/uk-health-research-analysis-2014">overall budget</a> for healthcare research. </p>
<p>The paradox is that until we properly understand how context influences trials, their results will continue failing to achieve their potential impact on clinical care. In other words, 85% of research will continue to be wasted. When the alternative is that millions of people do not get the best treatment available, the only logical move is to make this a top priority.</p><img src="https://counter.theconversation.com/content/60596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aileen Grant has received funding from NHS Research Scotland, part of the Chief Scientist’s Office, The Tayside Centre for Academic Sciences, NHS Tayside and NHS Lothian. The views in this piece are entirely her own. </span></em></p><p class="fine-print"><em><span>Mary Wells has in the past received funding from Chief Scientist Office, Macmillan Cancer Support, Cancer Research UK, World Cancer Research Fund, Tenovus Scotland, Dundee Cancer Centre, University of Dundee, Tayside Oncology Fund, Big Lottery Fund, NHS Tayside and Molnlyke Healthcare. </span></em></p><p class="fine-print"><em><span>Shaun Treweek has received funding from the Chief Scientist's Office, European Union, National Institute for Health Research, Medical Research Council and the University of Aberdeen’s Development Trust.
</span></em></p>Some 85% of research into drugs and treatments ends up on the cutting room floor but not all of that should.Aileen Grant, Research Fellow, University of StirlingMary Wells, University of StirlingShaun Treweek, Professor of Health Services Research, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/574422016-04-11T14:31:30Z2016-04-11T14:31:30ZYou really can die of a broken heart – here’s the science<figure><img src="https://images.theconversation.com/files/118133/original/image-20160411-21959-ps6nll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A fatal flaw?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=broken%20heart&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=112793704">Shutterstock</a></span></figcaption></figure><p>When you think of a broken heart, you probably picture something out of a romantic movie or a cartoon heart, cracked like a fragile piece of china. Indeed, so-called <a href="http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Is-Broken-Heart-Syndrome-Real_UCM_448547_Article.jsp">“broken heart syndrome”</a> has a certified place in popular culture, and has been eloquently used in films such as <a href="http://www.imdb.com/title/tt0332280/">The Notebook</a>. But while we certainly feel “heartbreak” during periods of emotional upheaval, can you actually die of a broken heart? </p>
<p>The answer is never going to be simple, so first we should start with a bit of science. In the last two decades, <a href="http://www.nhs.uk/Conditions/atrial-fibrillation/Pages/Introduction.aspx">atrial fibrillation (AF)</a>, a form of irregular heartbeat, has become one of the most important public health problems and a significant cause of increasing healthcare costs in western countries. </p>
<p>Individuals with AF have a five-fold and two-fold increased risk of stroke and death, respectively. It is <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4064952/">estimated</a> that there will be 14-17m AF patients in Europe by 2030; with 120,000–215,000 new cases diagnosed each year. In the United States, AF prevalence is <a href="http://www.ajconline.org/article/S0002-9149(13)01288-5/abstract">projected</a> to increase from 5.2m in 2010 to 12.1m cases in 2030. </p>
<p>The exact cause of AF is still unresolved and is likely to involve multiple components such as genetic and environmental factors. Atrial fibrillation is a progressive condition, whereby the arrhythmia begins in a “sudden onset” form, progressing through “persistent” to so-called “permanent” AF. These steps can take many years to develop, but an essential element in this progression are the so-called “triggers”, which can be anything from illness and fatigue, to alcohol, caffeine and emotional stress.</p>
<h2>Bereavement and ‘broken hearts’</h2>
<p>But what does this have to do with a broken heart? Well, it appears that the two are linked. In a <a href="http://openheart.bmj.com/content/3/1/e000367.abstract">recent article</a> published in the online journal Open Heart, a Danish research team based at Aarhus University reported findings showing that the death of a partner is linked to heightened risk of developing AF for up to a year after the bereavement. </p>
<p>This retrospective study examined hospital records of 88,612 people in Denmark (19.72% of whom had lost a partner) and identified persons that were diagnosed with AF for the first time between 1995 and 2014. For comparison, the team also randomly selected a control group (without AF) of 886,120 people (19.07% of whom had lost a partner) which was matched with the AF group on age and gender. Other factors that were controlled included civil status and education level, and whether the subjects had cardiovascular disease, diabetes or were taking medication for cardiovascular disease.</p>
<p>The study revealed that individuals whose cohabiting partner or spouse had died had an increased risk of getting AF within 30 days of the bereavement – a risk estimated to be 41% higher than average.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118141/original/image-20160411-21950-1v8t940.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Bereavement: can be bad for your health.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=bereavement&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=249465919">Shutterstock</a></span>
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<p>The risk was highest 8-14 days after the loss (90% higher than average) and gradually declined to a level close to that of non-bereaved population after one year. This risk was higher among people under the age of 60 and among those whose death was unexpected. Interestingly, where deaths were likely due to ill health, there was no increased risk of AF in the partners after the loss.</p>
<p>The main strengths of this study are the large sample size and the population-based design, but it is an observational study and they can’t prove the cause or the effect. Other contributory factors such as lifestyle or family history of AF could have affected the results, which the authors have acknowledged. </p>
<p>What would have provided more insight to this study is if blood biomarkers (indicating heart damage) or stress hormones (such as adrenaline) were monitored during hospital admission, or whether there were other more serious heart problems, such as heart failure, which would have been detectable with the use of <a href="https://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300438.pdf">echocardiography</a>.</p>
<h2>The origins of a broken heart</h2>
<p>Scientific findings accumulated over the past 25 years seem to support the notion that a real-life broken heart can lead to subsequent heart problems. “Broken heart syndrome”, also known as stress-induced cardiomyopathy or Takotsubo cardiomyopathy, was first described in 1990 in Japan and has recently been globally recognised as a <a href="https://www.bhf.org.uk/heart-health/conditions/cardiomyopathy/takotsubo-cardiomyopathy">real medical condition</a>. </p>
<p>It should be noted here that without echocardiography, blood markers and other evidence, we can’t say for sure whether those in the published Danish cohort had “broken heart syndrome” or not. Nevertheless, roughly in keeping with the condition described in the Danish study, Takotsubo cardiomyopathy starts abruptly and unpredictably (even in healthy individuals). Symptoms include chest pains, often with shortness of breath, and an abnormal electrocardiogram, which resembles a heart attack but is notable for the absence of blocked heart blood vessels. </p>
<p>Indeed, Takotsubo syndrome <a href="http://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome">accounts</a> for about 2-5% of heart attack cases seen by doctors, with a higher predilection for women over 50 years of age (only 10% in men). The significance of Takotsubo cardiomyopathy is reflected to the fact that there is an <a href="http://www.takotsubo-registry.com">international registry for this disorder</a>. </p>
<p>What is interesting is that Takotsubo cardiomyopathy is usually triggered by an emotionally or physically stressful event such as bereavement, major surgery or being involved in a disaster such as an earthquake. The exact mechanisms leading to Takotsubo cardiomyopathy are unknown but some evidence suggests excessive release of stress hormones, such as adrenaline, acts as a trigger during the initial onset which causes the weakening of the heart muscle. </p>
<p>In fact, the strong emotion doesn’t have to be negative – <a href="http://www.ncbi.nlm.nih.gov/pubmed/26935270">“happy heart syndrome”</a> is initiated by happy events, such as the birth of grandchildren or a birthday, and accounts for 1.1% of <a href="http://www.readcube.com/articles/10.1038/nrcardio.2016.41">broken heart syndrome cases</a>.</p>
<p>The long-term affects of Takotsubo cardiomyopathy are unclear, but it does appear to be temporary and reversible. Nevertheless, it is certain that we can have our hearts broken – and that, for some, this can be very dangerous indeed.</p><img src="https://counter.theconversation.com/content/57442/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nelson Chong does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In fact, even a happy heart can break.Nelson Chong, Senior Lecturer, Department of Life Sciences, University of WestminsterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/572842016-04-07T06:54:37Z2016-04-07T06:54:37ZDeath of a partner can endanger your heart health<figure><img src="https://images.theconversation.com/files/117774/original/image-20160407-13972-19thc75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We found those grieving for a lost spouse are at an increased risk of atrial fibrillation.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ashleyrosex/4577243908/in/photolist-7Ytz9q-nqecf5-6fSWMq-7cUQZM-9Q8baK-8Ydz7H-7yNvq-atMLeP-tEsAP-3UN759-nqegpi-rk2DxK-dCCU93-6ifHvf-its39H-6fNCyF-iyN7iY-djmoj-6zSE6S-4nBGW8-3dkpS-6pypTD-ap6JhZ-4TLkM-pCeAiK-6ZkSPD-cFv3YL-6pCvB7-6fSNKq-3bJA4o-nB5JZn-6fNEBM-dths1d-DMGaWC-2fqC2-4Mg1sk-kiPm9T-dugcss-4Qt7vT-5AJiDA-5LH3Kw-6kGpox-6fSNBA-CyKEvL-fhV7-4VuKNr-5RZ7Rr-4rr4WT-nqerw3-rWbZY">ashley rose,/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>For decades, medicine has recognised the powerful way grief can influence the heart. It’s been called <a href="https://theconversation.com/fact-or-fiction-can-we-die-from-a-broken-heart-46131">Broken Heart syndrome</a> or <a href="http://www.ncbi.nlm.nih.gov/pubmed/24552225">Takotsubo cardiomyopathy</a> and evidence that severely stressful life events <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1832196">increase the risk of acute cardiovascular incidence</a>, like a heart attack, continues to grow.</p>
<p>Meanwhile, anecdotal reports and <a href="http://www.internationaljournalofcardiology.com/article/S0167-5273(13)00658-X/abstract">case studies</a> have long described the relationship between acute stress and the <a href="http://jama.jamanetwork.com/article.aspx?articleid=207958">development of an irregular heartbeat</a>, known as cardiac arrhythmia. </p>
<p>The most common form of cardiac arrhythmia in the western world is atrial fibrillation, where the heart beats improperly (usually more rapidly) and irregularly. But, so far, no large studies had examined the link between stressful life events and atrial fibrillation.</p>
<p>Our study, conducted at Aarhus University and published in the journal <a href="http://openheart.bmj.com/content/3/1/e000367">Open Heart</a> this week, was based on data from nearly one million patients. It has shown a significant link between loss of a partner and development of atrial fibrillation. </p>
<p>We found the risk of developing an irregular heartbeat for the first time was 41% higher among those grieving a partner’s loss compared to those who hadn’t experienced such loss.</p>
<p>We also found the condition could persist for up to a year after the tragic event.</p>
<p>This is concerning as atrial fibrillation is associated with <a href="http://circ.ahajournals.org/content/98/10/946.full">increased risk of death</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/15879330">stroke</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12771006">heart failure</a>. An irregular heartbeat has also been linked to lower <a href="http://www.ncbi.nlm.nih.gov/pubmed/23265334">quality of life</a>. A person’s estimated lifetime risk of atrial fibrillation is between 22% and 26% and the condition is <a href="http://www.ncbi.nlm.nih.gov/pubmed/24763464">one of the few heart diseases</a> with increasing incidence. </p>
<h2>A closer look at our study</h2>
<p>In our population-based case-control study, we took information about 88,612 patients in Denmark who were newly diagnosed with atrial fibrillation between 1995 and 2014 and compared it with 886,120 healthy people. </p>
<p>Both groups were matched on age and sex. Among those with atrial fibrillation, 17,478 had lost a partner. In the control group, this number was 168,940.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/117777/original/image-20160407-13975-18p7jwq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Death of a partner is considered one of the most stressful life events.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>We looked at several factors that might influence the risk of atrial fibrillation, including age, sex, patients’ underlying health conditions and the health of their partner a month before the death.</p>
<p>We found the risk of developing atrial fibrillation was highest eight to 14 days after a partner’s loss and remained elevated for a year. The risk was higher in those under 60 years olds and the effect was most dramatic in those who had unexpectedly lost a healthy partner.</p>
<p>The heightened risk was apparent irrespective of gender and other underlying health conditions.</p>
<p>Those with partners who were relatively healthy in the month before death were 57% more likely to develop an irregular heartbeat, but no increased risk was seen among those whose partners were ill and expected to die soon.</p>
<h2>The link between body and mind</h2>
<p>Our study is the first to show that severe stress could play a significant role in the development of atrial fibrillation. </p>
<p>The exact mechanisms linking the mind and heart, however, aren’t certain.</p>
<p>Studies have suggested acute stress may directly disrupt normal heart rhythms and prompt the <a href="http://www.ncbi.nlm.nih.gov/pubmed/0010217662">production of chemicals involved</a> in inflammation, which is a physical response to injury or infection.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/117778/original/image-20160407-13980-o66moi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The central nervous system modules heart rhythm.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Bereavement, such as after the loss of a partner, <a href="http://www.sciencedirect.com/science/article/pii/S0140673607618169">often brings about symptoms of mental illness</a> such as depression, anxiety, guilt, anger and hopelessness. Losing a partner to death <a href="http://www.sciencedirect.com/science/article/pii/0022399967900104">ranks highly</a> on a psychological scale of severely stressful life events. </p>
<p>Such stress could affect basic hormonal processes. The release of adrenalin, for instance, is useful in acute danger – as it increases your heart rate and diverts blood to your muscles so you can run or fight – but it can disrupt heart rhythm if the release is excessive and prolonged.</p>
<p>Acute mental stress may also create imbalance in the central nervous system – the autonomic nervous system – that controls many basic functions. It also <a href="http://www.ncbi.nlm.nih.gov/pubmed/22853984">modulates our heart frequency</a> and the electrical nerve pathways that run through the heart to the muscle, <a href="http://www.ncbi.nlm.nih.gov/pubmed/14522493">facilitating a synchronised contraction</a> of the heart chambers.</p>
<h2>Those grieving need special attention</h2>
<p>Our study indicates that people experiencing severe mental stress from bereavement are a vulnerable group that might need more medical attention. </p>
<p>With a biologically plausible association, early identification of this group is currently a major challenge in the health-care system.</p>
<p>The study’s findings don’t just have significant clinical relevance though. We are currently experiencing substantial levels of stress in modern society. And while stress is a potentially modifiable risk factor, many people develop stress-related illnesses, that are a key driver to growing health-care costs.</p><img src="https://counter.theconversation.com/content/57284/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Graff have recieved funding from The Lundbeck Foundation. </span></em></p>The risk of developing an irregular heartbeat was 41% higher among those who were grieving a partner’s loss than among those who hadn’t experienced such loss. And this could last up to a year.Simon Graff, Research assistant, Institute for Public Health, Aarhus UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/502882015-11-18T11:13:53Z2015-11-18T11:13:53ZDo sweetened drinks really cause heart failure?<figure><img src="https://images.theconversation.com/files/100967/original/image-20151105-16263-1b5fcc4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">www.shutterstock.com</span></span></figcaption></figure><p>Drinking two or more sweetened drinks a day increases the risk of developing heart failure by 23%, according to a <a href="http://www.ncbi.nlm.nih.gov/pubmed/26526418">recent study</a>. This sounds very precise and very alarming. The problem with nutrition studies is that they’re usually reported with more certainty than they warrant. And the relative dangers of consuming a particular food or drink are usually not that alarming when presented as absolute figures.</p>
<p>The reported 23% increase in risk was calculated as a “hazard ratio”, which represents the study participants’ risk of having heart failure at any point in time over the average 12-year period they were studied for. </p>
<p>Hazard ratios can be misleading. To make sense of this information we need to know what specific group of people we are discussing, their baseline risk of heart failure and the increase in risk. </p>
<p>Using hypothetical figures: in 50-year-old men, if the baseline risk of having heart failure is 4 in 1000, a 23% increase in risk means one more person in 1000 will die at the age of 50 if they drink two or more sweet drinks a day. </p>
<p>Discussing the risk in absolute terms is much less alarming than the relative risk, but it doesn’t make for good headlines. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=585&fit=crop&dpr=1 600w, https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=585&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=585&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=735&fit=crop&dpr=1 754w, https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=735&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/102042/original/image-20151116-4964-1bnea0s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=735&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Absolute figures don’t make good headlines.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=HwuCDnil5gtdy99e8cZHFg&searchterm=medical%20news&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=84849004">www.shutterstock.com</a></span>
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</figure>
<h2>Fallible memory</h2>
<p>Studying nutrition is difficult. The gold standard of trial design is the randomised placebo-controlled trial (RCT). RCTs are great for studying medicines, but they’re not so great for studying nutrition – at least, not for long periods of time. They are expensive to run and they lack “ecological validity”. In other words, they don’t represent real life very well because they often add a level of control not present in everyday life – people tend to make different choices when they know they are being studied. </p>
<p>Some nutrition studies do use the RCT design, but most are observational studies where people are not randomly assigned to one treatment group or another. These types of studies can usually afford to recruit way more people than RCTs.</p>
<p>But large observational studies come with their own problems. They depend on surprisingly simplistic and naïve data collection methods such as recollection and self-reporting, which produce notoriously unreliable data. </p>
<p>Not only is memory fallible, but people tend to <a href="http://nutritionreviews.oxfordjournals.org/content/48/10/373">under report</a> what they consume. In this study, data was collected using a “food frequency questionnaire”. Participants were asked: “How many soft drinks or sweetened juice drinks do you drink per day or per week?” It does not take a disciple of science, to realise that this might not be reliable.</p>
<p>Any study that uses self-reported data, such as this latest study from Sweden, should be treated with caution.</p>
<h2>Accounting for everything</h2>
<p>What an observational study can’t do is prove that consuming sweetened drinks causes heart failure. It can only prove that the two things are associated. </p>
<p>Lots of things are associated with heart failure, such as diabetes, high blood pressure, smoking, and body mass index. These “confounders”, and others, were taken into account by the researchers when calculating the hazard ratios. </p>
<p>But what if they missed something out in their analysis? Perhaps people who consume lots of sweetened drinks have worse diets overall. It seems likely that people who consciously choose not to drink sweetened drinks are more health conscious overall. </p>
<p>The predictive power of any observational study is limited by potentially unaccounted for confounders.</p>
<h2>Sugar is not a poison</h2>
<p>This study doesn’t differentiate between drinks that are sweetened with sugar and those that are sweetened with artificial sweeteners, such as aspartame and sucralose, so we can’t tell what role – if any – these artificial sweeteners played in increasing the risk of heart disease. </p>
<p>Previous studies have shown that sugar sweetened drinks are associated with a number of health problems, including <a href="http://www.ncbi.nlm.nih.gov/pubmed/24583500">coronary heart disease</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/24932880">type 2 diabetes</a>. However, even if the people in this study did mainly consume sugar sweetened drinks, we should be careful about linking one aspect of nutrition to a particular health outcome. </p>
<p>Sugar is not intrinsically bad – it is not a poison – but it contributes to surplus energy intake which, in turn, is associated with a range of metabolic problems. </p>
<p>Consumption of sweetened beverages may be associated with increased risk of heart failure, but this needs to be viewed alongside diet as a whole – as well as a person’s broader lifestyle. Focusing on one nutrient at a time can be misleading and even counterproductive. It contributes to the seemingly endless controversies about what we should eat and how much we should eat. These controversies might sell newspapers and bogus health products, but they don’t do anything to help the consumer make informed choices.</p><img src="https://counter.theconversation.com/content/50288/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Haines does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new study linking sweetened drinks to heart disease is more confusing than enlighteningMatthew Haines, Senior Lecturer in Health and Wellbeing, University of HuddersfieldLicensed as Creative Commons – attribution, no derivatives.