tag:theconversation.com,2011:/us/topics/heart-attacks-27547/articlesHeart attacks – The Conversation2024-02-11T19:05:40Ztag:theconversation.com,2011:article/2219792024-02-11T19:05:40Z2024-02-11T19:05:40ZA new emergency procedure for cardiac arrests aims to save more lives – here’s how it works<p>As of January this year, Aotearoa New Zealand became just the second country (after Canada) to adopt a groundbreaking new procedure for patients experiencing cardiac arrest.</p>
<p>Known as “double sequential external defibrillation” (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9907872/">DSED</a>), it will change initial emergency response strategies and potentially improve survival rates for some patients.</p>
<p>Surviving cardiac arrest hinges crucially on effective resuscitation. When the heart is working normally, electrical pulses travel through its muscular walls creating regular, co-ordinated contractions.</p>
<p>But if normal electrical rhythms are disrupted, heartbeats can become unco-ordinated and ineffective, or cease entirely, leading to cardiac arrest.</p>
<p>Defibrillation is a cornerstone resuscitation method. It gives the heart a powerful electric shock to terminate the abnormal electrical activity. This allows the heart to re-establish its regular rhythm.</p>
<p>Its success hinges on the underlying dysfunctional heart rhythm and the proper positioning of the defibrillation pads that deliver the shock. The new procedure will provide a second option when standard positioning is not effective.</p>
<h2>Using two defibrillators</h2>
<p>During standard defibrillation, one pad is placed on the right side of the chest just below the collarbone. A second pad is placed below the left armpit. Shocks are given every two minutes.</p>
<p>Early defibrillation can dramatically <a href="https://pardot.stjohn.org.nz/l/182252/2023-02-08/63fwb2/182252/1675908603ZVeUnZBf/Hato_Hone_St_John_OHCA_Summary_Feb23.pdf">improve the likelihood</a> of surviving a cardiac arrest. However, around 20% of patients whose cardiac arrest is caused by “<a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/ventricular-fibrillation">ventricular fibrillation</a>” or “<a href="https://my.clevelandclinic.org/health/diseases/23254-pulseless-ventricular-tachycardia">pulseless ventricular tachycardia</a>” do not respond to the standard defibrillation approach. Both conditions are characterised by abnormal activity in the heart ventricles.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cardiac-arrests-in-young-people-what-causes-them-and-can-they-be-prevented-or-treated-a-heart-expert-explains-163276">Cardiac arrests in young people — what causes them and can they be prevented or treated? A heart expert explains</a>
</strong>
</em>
</p>
<hr>
<p>DSED is a novel method that provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back.</p>
<p>A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. According to a recent <a href="https://pubmed.ncbi.nlm.nih.gov/36342151/">randomised trial</a> in Canada, this approach could more than double the chances of survival for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard shocks.</p>
<p>The second shock is thought to improve the chances of eliminating persistent abnormal electrical activity. It delivers more total energy to the heart, travelling along a different pathway closer to the heart’s left ventricle.</p>
<h2>Evidence of success</h2>
<p>New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14%.</p>
<p>Recognising the potential for DSED to dramatically improve survival for these patients, the National Ambulance Sector Clinical Working Group updated the <a href="https://cpg.stjohn.org.nz/tabs/guidelines">clinical procedures and guidelines</a> for emergency medical services personnel.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/arrested-development-can-we-improve-cardiac-arrest-survival-in-hospitals-100079">Arrested development: Can we improve cardiac arrest survival in hospitals?</a>
</strong>
</em>
</p>
<hr>
<p>The guidelines now specify that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.</p>
<p>Though the existing evidence for DSED is compelling, until recently it was based on theory and a small number of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0300957220302446?via%3Dihub">potentially biased observational studies</a>. The Canadian trial was the first to directly compare DSED to standard treatment.</p>
<p>From a total of 261 patients, 30.4% treated with this strategy survived, compared to 13.3% when standard resuscitation protocols were followed.</p>
<p>The <a href="https://link.springer.com/content/pdf/10.1007/s00134-023-06993-1.pdf">design of the trial</a> minimised the risk of other factors confounding results. It provides confidence that survival improvements were due to the defibrillation approach and not regional differences in resources and training.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-pacemakers-and-defibrillators-work-a-cardiologist-explains-how-they-interact-with-the-electrical-system-of-the-heart-217429">How do pacemakers and defibrillators work? A cardiologist explains how they interact with the electrical system of the heart</a>
</strong>
</em>
</p>
<hr>
<p>The study also corroborates and builds on existing theoretical and clinical scientific evidence. As the trial was stopped early due to the COVID-19 pandemic, however, the researchers could recruit fewer than half of the numbers planned for the study.</p>
<p>Despite these and other limitations, the international group of experts that advises on best practice for resuscitation <a href="https://pubmed.ncbi.nlm.nih.gov/37937881/">updated its recommendations</a> in 2023 in response to the trial results. It suggested (with caution) that emergency medical services consider DSED for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard treatment.</p>
<h2>Training and implementation</h2>
<p>Although the evidence is still emerging, implementation of DSED by emergency services in New Zealand has implications beyond the care of patients nationally. It is also a key step in advancing knowledge about optimal resuscitation strategies globally.</p>
<p>There are always concerns when translating an intervention from a controlled research environment to the relative disorder of the real world. But the balance of evidence was carefully considered before making the decision to change procedures for a group of patients who have a low likelihood of survival with current treatment.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/anyone-can-save-a-life-including-kids-heres-why-they-should-learn-cpr-and-basic-life-support-200337">Anyone can save a life, including kids. Here's why they should learn CPR and basic life support</a>
</strong>
</em>
</p>
<hr>
<p>Before using DSED, emergency medical personnel undergo mandatory education, simulation and training. Implementation is closely monitored to determine its impact.</p>
<p>Hospitals and emergency departments have been informed of the protocol changes and been given opportunities to ask questions and give feedback. As part of the implementation, the St John ambulance service will perform case reviews in addition to wider monitoring to ensure patient safety is prioritised.</p>
<p>Ultimately, those involved are optimistic this change to cardiac arrest management in New Zealand will have a positive impact on survival for affected patients.</p><img src="https://counter.theconversation.com/content/221979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vinuli Withanarachchie is a Clinical Research Assistant at Hato Hone St John. </span></em></p><p class="fine-print"><em><span>Bridget Dicker is Head of Clinical Audit and Research at Hato Hone St John. She is a member of the International Liaison Committee on Resuscitation Basic Life Support (BLS) Task Force.</span></em></p><p class="fine-print"><em><span>Sarah Maessen is a Clinical Research Fellow at Hato Hone St John.</span></em></p>New Zealand is just the second country to approve a novel defibrillation procedure for some patients. With current survival rates very low, it is hoped the new method will save many more lives.Vinuli Withanarachchie, PhD candidate, College of Health, Massey UniversityBridget Dicker, Associate Professor of Paramedicine, Auckland University of TechnologySarah Maessen, Research Associate, Auckland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2214092024-01-29T19:05:48Z2024-01-29T19:05:48ZThis salt alternative could help reduce blood pressure. So why are so few people using it?<figure><img src="https://images.theconversation.com/files/571786/original/file-20240128-19-x7pm9f.jpg?ixlib=rb-1.1.0&rect=1207%2C421%2C4190%2C3185&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/shallow-focus-photo-of-elderly-woman-buying-groceries-8422682/">Kampus Production/Pexels</a></span></figcaption></figure><p><a href="https://www.aihw.gov.au/reports/risk-factors/high-blood-pressure/contents/summary">One in three</a> Australian adults has high blood pressure (hypertension). Excess salt (sodium) increases the risk of high blood pressure so everyone with hypertension is advised to reduce salt in their diet.</p>
<p>But despite decades of strong recommendations we have <a href="https://www.who.int/publications/i/item/9789240081062">failed</a> to get Australians to cut their intake. It’s hard for people to change the way they cook, season their food differently, pick low-salt foods off the supermarket shelves and accept a less salty taste. </p>
<p>Now there is a simple and effective solution: potassium-enriched salt. It can be used just like regular salt and most people don’t notice any important difference in taste. </p>
<p>Switching to potassium-enriched salt is feasible in a way that cutting salt intake is not. Our <a href="https://www.ahajournals.org/doi/abs/10.1161/HYPERTENSIONAHA.123.21343">new research concludes</a> clinical guidelines for hypertension should give patients clear recommendations to switch.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-how-much-salt-is-ok-to-eat-58594">Health Check: how much salt is OK to eat?</a>
</strong>
</em>
</p>
<hr>
<h2>What is potassium-enriched salt?</h2>
<p>Potassium-enriched salts replace some of the sodium chloride that makes up regular salt with potassium chloride. They’re also called low-sodium salt, potassium salt, heart salt, mineral salt, or sodium-reduced salt. </p>
<p>Potassium chloride looks the same as sodium chloride and tastes very similar.</p>
<p>Potassium-enriched salt works to lower blood pressure not only because it reduces sodium intake but also because it <a href="https://www.ahajournals.org/doi/10.1161/CIR.0b013e318279acbf?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">increases</a> potassium intake. Insufficient potassium, which mostly comes from fruit and vegetables, is another big cause of high blood pressure.</p>
<h2>What is the evidence?</h2>
<p>We have strong evidence from a <a href="https://www.nejm.org/doi/full/10.1056/nejmoa2105675">randomised trial</a> of 20,995 people that switching to potassium-enriched salt lowers blood pressure and reduces the risks of stroke, heart attacks and early death. The participants had a history of stroke or were 60 years of age or older and had high blood pressure.</p>
<figure class="align-right ">
<img alt="Adding salt to avocado toast" src="https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571788/original/file-20240128-29-z46ahg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Too much salt increases the risk of high blood pressure.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/dash-of-salt-over-avocado-toasts-7936678/">Nicola Barts/Pexels</a></span>
</figcaption>
</figure>
<p><a href="https://heart.bmj.com/content/108/20/1608">An overview</a> of 21 other studies suggests much of the world’s population could benefit from potassium-enriched salt. </p>
<p>The World Health Organisation’s 2023 <a href="https://www.who.int/publications/i/item/9789240081062">global report on hypertension</a> highlighted potassium-enriched salt as an “affordable strategy” to reduce blood pressure and prevent cardiovascular events such as strokes.</p>
<h2>What should clinical guidelines say?</h2>
<p>We teamed up with researchers from the United States, Australia, Japan, South Africa and India to review 32 clinical guidelines for managing high blood pressure across the world. Our findings are <a href="https://www.ahajournals.org/doi/abs/10.1161/HYPERTENSIONAHA.123.21343">published today</a> in the American Heart Association’s journal, Hypertension.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/slashing-salt-can-save-lives-and-it-wont-hurt-your-hip-pocket-or-tastebuds-213980">Slashing salt can save lives – and it won’t hurt your hip pocket or tastebuds</a>
</strong>
</em>
</p>
<hr>
<p>We found current guidelines don’t give clear and consistent advice on using potassium-enriched salt. </p>
<p>While many guidelines recommend increasing dietary potassium intake, and all refer to reducing sodium intake, only two guidelines – the Chinese and European – recommend using potassium-enriched salt.</p>
<p>To help guidelines reflect the latest evidence, we suggested specific wording which could be adopted in Australia and around the world:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=175&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=175&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=175&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=220&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=220&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571334/original/file-20240125-27-fx7wob.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=220&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Recommended wording for guidance about the use of potassium-enriched salt in clinical management guidelines.</span>
</figcaption>
</figure>
<h2>Why do so few people use it?</h2>
<p>Most people are unaware of how much salt they eat or the health issues it can cause. Few people know a simple switch to potassium-enriched salt can help lower blood pressure and reduce the risk of a stroke and heart disease.</p>
<p>Limited availability is another challenge. Several Australian retailers stock potassium-enriched salt but there is usually only one brand available, and it is often on the bottom shelf or in a special food aisle. </p>
<p>Potassium-enriched salts also cost more than regular salt, though it’s still low cost compared to most other foods, and not as expensive as many fancy salts now available.</p>
<figure class="align-center ">
<img alt="Woman gets man to try her cooking" src="https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571789/original/file-20240128-15-i200b.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">It looks and tastes like normal salt.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-white-and-orange-long-sleeve-shirt-holding-chopsticks-TYQ6fyF3Amc">Jimmy Dean/Unsplash</a></span>
</figcaption>
</figure>
<p>A 2021 review found potassium-enriched salts were marketed in only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319774/">47 countries</a> and those were mostly high-income countries. Prices ranged from the same as regular salt to almost 15 times greater. </p>
<p>Even though generally more expensive, potassium-enriched salt has the potential to be <a href="https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.122.059573">highly cost effective</a> for disease prevention.</p>
<h2>Preventing harm</h2>
<p>A frequently raised concern about using potassium-enriched salt is the risk of high blood potassium levels (hyperkalemia) in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177747/">approximately 2% of the population</a> with serious kidney disease.</p>
<p>People with serious kidney disease are already advised to avoid regular salt and to avoid foods high in potassium. </p>
<p>No harm from potassium-enriched salt has been recorded in any trial done to date, but all studies were done in a clinical setting with specific guidance for people with kidney disease. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-salt-good-for-you-after-all-the-evidence-says-no-168743">Is salt good for you after all? The evidence says no</a>
</strong>
</em>
</p>
<hr>
<p>Our current priority is to get people being managed for hypertension to use potassium-enriched salt because health-care providers can advise against its use in people at risk of hyperkalemia. </p>
<p>In some countries, potassium-enriched salt is recommended to the entire community because the potential benefits are so large. <a href="https://www.bmj.com/content/369/bmj.m824">A modelling study</a> showed almost half a million strokes and heart attacks would be averted every year in China if the population switched to potassium-enriched salt. </p>
<h2>What will happen next?</h2>
<p>In 2022, the health minister launched the <a href="https://ozheart.org/the-national-hypertension-taskforce-is-launched-by-the-honourable-mark-butler-mp-minister-for-health-and-aged-care/">National Hypertension Taskforce</a>, which aims to improve blood pressure control rates from 32% to 70% by 2030 in Australia. </p>
<p>Potassium-enriched salt can play a key role in achieving this. We are working with the taskforce to update Australian hypertension management guidelines, and to promote the new guidelines to health professionals. </p>
<p>In parallel, we need potassium-enriched salt to be more accessible. We are engaging stakeholders to <a href="https://thehill.com/opinion/healthcare/474835-pass-less-salt-and-when-you-pass-it-make-it-potassium-salt/">increase the availability</a> of these products nationwide. </p>
<p>The world has already changed its salt supply once: from regular salt to iodised salt. Iodisation efforts began in the 1920s and took the best part of 100 years to achieve traction. <a href="https://www.who.int/publications/i/item/9789240053717">Salt iodisation</a> is a key public health achievement of the last century preventing <a href="https://www.racgp.org.au/afp/2012/august/goitre">goitre</a> (a condition where your thyroid gland grows larger) and enhancing educational outcomes for millions of the poorest children in the world, as iodine is <a href="https://www.healthdirect.gov.au/iodine">essential for</a> normal growth and brain development.</p>
<p>The next switch to iodised and potassium-enriched salt offers at least the same potential for global health gains. But we need to make it happen in a fraction of the time.</p><img src="https://counter.theconversation.com/content/221409/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alta Schutte receives funding from the National Health and Medical Research Council of Australia, the Medical Research Future Fund, and NSW Health. She is Company Secretary of the Australian Cardiovascular Alliance, Board Member of Hypertension Australia, and Co-Chair of the National Hypertension Taskforce of Australia.</span></em></p><p class="fine-print"><em><span>Bruce Neal receives salary support from the National Health and Medical Research Council of Australia, The George Institute for Global and Imperial College London. He receives research funding from multiple other national and international agencies but from none that represent a conflict of interest with this work.</span></em></p><p class="fine-print"><em><span>Xiaoyue Xu (Luna) 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>Potassium-enriched salt tastes like regular salt and you don’t need to change how you cook or season your food. You just need to switch the type of salt you buy.Xiaoyue Xu (Luna), Scientia Lecturer, UNSW SydneyAlta Schutte, SHARP Professor of Cardiovascular Medicine, UNSW SydneyBruce Neal, Executive Director, George Institute Australia, George Institute for Global HealthLicensed 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>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/47757IZRc5c?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">“Be Healthy,” from the 2000 album “Let’s Get Free”</span></figcaption>
</figure>
<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>
<figure class="align-center ">
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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>
<figure class="align-center ">
<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">
<figcaption>
<span class="caption">Before and after death sales.</span>
<span class="attribution"><span class="source">The Economist</span></span>
</figcaption>
</figure>
<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>
<figcaption>
<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>
</figcaption>
</figure>
<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>
</figcaption>
</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/1971772023-01-03T23:57:33Z2023-01-03T23:57:33ZDamar Hamlin’s cardiac arrest during ‘Monday Night Football’ could be commotio cordis or a more common condition – a heart doctor answers 4 questions<figure><img src="https://images.theconversation.com/files/502998/original/file-20230103-14-tb6hos.jpg?ixlib=rb-1.1.0&rect=66%2C104%2C6264%2C3843&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Damar Hamlin, #3, collapsed on the field after making a tackle during a game on January 2, 2023.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/hayden-hurst-of-the-cincinnati-bengals-runs-with-the-ball-news-photo/1454020920?phrase=damar%20hamlin&adppopup=true">Dylan Buell via Getty Images</a></span></figcaption></figure><p><em>Damar Hamlin, a safety for the Buffalo Bills, <a href="https://www.cnet.com/culture/sports/buffalo-bills-damar-hamlin-suffered-cardiac-arrest-during-monday-night-football/">collapsed on the field</a> during a Monday night football game against the Cincinnati Bengals on Jan. 2, 2023.</em></p>
<p><em>Medical staff gave Hamlin CPR and shocked him with a defibrillator, restarting his heart’s normal rhythm. News outlets immediately began speculating that <a href="https://www.poynter.org/reporting-editing/2023/covering-the-possible-causes-and-diagnoses-of-damar-hamlins-injury/">Hamlin may have suffered from commotio cordis</a> – a potentially lethal stoppage of the heart caused by a strong impact to a person’s chest. The next day, the <a href="https://www.cnet.com/culture/sports/buffalo-bills-damar-hamlin-suffered-cardiac-arrest-during-monday-night-football/">Bills announced</a> that Hamlin had indeed experienced “cardiac arrest” but did not confirm whether the cause was commotio cordis.</em></p>
<p><em><a href="https://www.cumedicine.us/providers/medicine/wendy-tzou">Dr. Wendy Tzou</a> is Associate Professor of Medicine and the Medical Director of Cardiac Electrophysiology at the University of Colorado Anschutz Medical Campus and was watching the game when Hamlin collapsed. The Conversation asked Tzou four questions about what may have happened. Her answers are adapted below.</em> </p>
<h2>1. What is commotio cordis?</h2>
<p>Commotio cordis can happen to a person with a normal heart and occurs when a blunt trauma to a person’s chest – often while playing sports – leads to cardiac arrest where their heart stops pumping blood. Commotio cordis typically occurs in children and adolescents. The impact needs to be forceful and occur at a <a href="https://doi.org/10.1056/NEJMra0910111">very particular moment in the heart’s electrical cycle</a>. When this happens, the normally well-organized electrical signals that control the heart become chaotic. The uncoordinated electrical pulses cause the heart, and in particular the large blood-pumping chambers called the ventricles, to twitch and spasm in what is known as <a href="https://europepmc.org/article/med/1182966">ventricular fibrillation</a>, a type of heart arrhythmia.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Six squiggly, erratic lines against a pink backdrop." src="https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=334&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=334&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=334&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=420&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=420&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502995/original/file-20230103-16-g82vdx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=420&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This ECG diagram shows the electrical signals of a heart in ventricular fibrillation. Compared to the ordered, repeating electrical pulses of a normal heartbeat, this ECG is much more chaotic.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Ventricular_fibrillation.png">Jer5150/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>When a heart is in ventricular fibrillation, it is no longer able to pump blood throughout a person’s body, and their organs begin to suffer damage due to lack of oxygen. Heart attacks, abnormal heart or artery structure, and many other issues can lead to ventricular arrhythmia. Regardless of the cause, if a person’s heart stops beating, the result can be deadly.</p>
<h2>2. How can a physical impact cause a lethal arrhythmia?</h2>
<p>A single heartbeat is a very coordinated series of muscle contractions that are all controlled by precise electrical signals. After the muscles in a heart contract, they need to reset and prepare for the next beat. This process, <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/cardiac-action-potential">called repolarization</a>, involves moving electrically charged ions to different parts of a cell so that the cell can effectively contract when it receives an electrical signal.</p>
<p>If a person gets hit in the chest during the fraction of a second that repolarization is occurring, the impact can trigger some of the electrical signals <a href="https://www.proquest.com/docview/222525976?pq-origsite=gscholar&fromopenview=true">before the heart is ready</a>. This disrupts the whole system, resulting in a chaotic electrical storm that throws the heart into spasms.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/IFIu0QBwM0I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Commotio cordis is just one potential cause of ventricular arrhythmia, where the heart spasms and twitches instead of beating normally.</span></figcaption>
</figure>
<h2>3. Are doctors sure it was commotio cordis?</h2>
<p>Although Hamlin was able to stand upright immediately after the impact, it was only briefly. It was clear from the way he collapsed without making any effort to protect himself that no blood was getting to his brain. The fact that he received CPR and a shock from a defibrillator also showed that he was experiencing an arrhythmia or electrical disturbance of the heart. But it is not possible to diagnose commotio cordis from a video alone.</p>
<p>The reason many doctors are speculating that commotio cordis was the reason for Hamlin’s heart failure is that it occurred right after he collided with another player and that the impact could have been responsible. But, in most cases, a diagnosis is <a href="https://doi.org/10.1056/NEJMra0910111">only made after an autopsy</a> when all other potential causes of arrhythmia have been ruled out. Though more common among among children and adolescents than adult athletes, commotio cordis is so rare that it is hard to get reliable information on the number of occurrences. In a registry of patients who died from sudden arrhythmia in Minnesota, only <a href="https://doi.org/10.1056/NEJMra0910111">224 cases over a 15-year period</a> were caused by commotio cordis.</p>
<p>Usually when a <a href="https://doi.org/10.14797%2Fmdcj-12-2-76">healthy athlete experiences sudden cardiac arrest</a>, the cause is one of two more common conditions. <a href="https://www.mayoclinic.org/diseases-conditions/hypertrophic-cardiomyopathy/symptoms-causes/syc-20350198">Hypertrophic cardiomyopathy</a> is when the walls of a person’s heart thicken and can cause sudden arrhythmia with no prior symptoms. Roughly <a href="https://doi.org/10.14797%2Fmdcj-12-2-76">1 in 200 U.S. residents</a> have hypertrophic cardiomyopathy. A person usually inherits the condition and multiple family members are often affected, so many people are diagnosed well before they begin playing competitive sports. However, some cases do slip through the cracks, and hypertrophic cardiomyopathy is responsible for about <a href="https://doi.org/10.1016/j.tcm.2021.06.001">21% of sudden arrhythmia deaths in athletes</a>. </p>
<p>The second most common cause of fatal heart rhythms in athletes are abnormalities in the structure of a coronary artery. These abnormalities are present at birth and can compromise blood flow to the heart, sometimes resulting in issues during exercise. Around 1% of people have an issue with the structure of their coronary artery, and the problem is responsible for about <a href="https://doi.org/10.1016/j.tcm.2021.06.001">14% of cardiac deaths in athletes</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An open yellow box with wired and a red button." src="https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=763&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=763&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=763&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=959&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=959&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502994/original/file-20230103-22-4gmk42.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=959&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An automated external defibrillator, or AED, can restart a heart’s normal rhythm.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:AED_open_cutout.jpg#/media/File:AED_open_cutout.jpg">Owain Davies/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>4. How can people protect themselves from sudden and fatal arrhythmia?</h2>
<p>Commotio cordis is a rare occurrence, but does happen in sports <a href="https://doi.org/10.1161/CIRCULATIONAHA.111.023861">including boxing, baseball or football</a> where blunt trauma directly to the chest is common. Appropriate precautions, like using chest padding, are the most effective way to prevent commotio cordis. </p>
<p>Hypertrophic cardiomyopathy, coronary artery problems and other heart problems that may predispose someone to dangerous heart rhythms may be found through screening. Your doctor can offer advice on whether a screening could be beneficial to you or your family members.</p>
<p>No matter the cause, if a person’s heart stops pumping blood and oxygen isn’t getting to their brain, time is everything. Call 911 and start CPR immediately to delay the onset of brain damage or death until a defibrillator can hopefully restart the heart’s normal rhythm.</p><img src="https://counter.theconversation.com/content/197177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Tzou 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>Disruptions to the electrical signals that control a person’s heartbeat are dangerous, no matter the cause. A heart doctor explains the biology of cardiac arrest and what might have happened on the field.Wendy Tzou, Associate Professor of Medicine, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1792922022-03-16T04:57:37Z2022-03-16T04:57:37ZHow often do young women die of heart attacks and what can you do to improve your heart health?<figure><img src="https://images.theconversation.com/files/452343/original/file-20220316-19-15waxa7.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/image-photo/adult-charming-brunette-woman-plus-size-1772578493">Shutterstock</a></span></figcaption></figure><p>The news of 52-year-old Senator Kimberley Kitching’s death from a suspected heart attack is a tragic loss that has <a href="https://www.smh.com.au/healthcare/women-can-t-believe-it-when-i-tell-them-they-ve-had-a-heart-attack-20220311-p5a3vk.html">shocked many women</a>. </p>
<p>At a time when the community was grappling with the <a href="https://theconversation.com/vale-shane-warne-a-cricketing-genius-who-lived-a-life-of-no-regrets-178603">sudden death of Shane Warne</a> – and we asked the men in our lives to pay attention to their heart health – Kitching’s sudden death served as a stark <a href="https://herheart.org/">warning</a> of the <a href="https://www.heartfoundation.org.au/conditions/heart-conditions-in-women">risk of heart disease to women</a>.</p>
<p>These <a href="https://www.aihw.gov.au/getmedia/2ba74f7f-d812-4539-a006-ca39b34d8120/aihw-21213.pdf">risks</a> are often overlooked, particularly in younger women, and the warning signs may differ from those typically seen in men. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1503166994345971713"}"></div></p>
<h2>What’s the risk of having a heart attack?</h2>
<p>Heart disease is a <a href="https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/hsvd-facts/contents/about">leading cause of death and disability</a> in both women and men in Australia. </p>
<p>The <a href="https://www.aihw.gov.au/getmedia/25915222-41b7-4697-b877-8a8d7daaa836/aihw-cdk-15.pdf.aspx?inline=true">risk of an acute event</a> (including heart attack) increases with age for both men and women: from five per 100,000 for women aged 25–34 (13 per 100,000 for men) to 2,100 per 100,000 for women aged 85 and over (2,900 per 100,000 for men).</p>
<p>Around 14% of women aged 45-74 years <a href="https://www.mja.com.au/journal/2016/204/8/absolute-risk-cardiovascular-disease-events-and-blood-pressure-and-lipid">are at high risk</a> of a heart attack over the following five years.</p>
<p>Across all age groups, 20 Australian women <a href="https://www.heartfoundation.org.au/conditions/heart-conditions-in-women">die from heart disease each day</a>. </p>
<h2>How do women experience heart attacks?</h2>
<p>Women’s experience of a heart attack can be different to men’s – they are less likely to have chest pain. </p>
<p>Women are <a href="https://www.ahajournals.org/doi/10.1161/JAHA.119.014733">more likely</a> to suffer shortness of breath and have pain between the shoulder blades. They’re also likely to have nausea or vomiting.</p>
<p>We often hear of women delaying calling an ambulance or waiting to see if the discomfort eases before they seek care. </p>
<p>Women are also <a href="https://www.mja.com.au/journal/2018/209/3/differences-management-and-outcomes-men-and-women-st-elevation-myocardial">less likely to receive timely treatment</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-who-have-heart-attacks-receive-poorer-care-than-men-100161">Women who have heart attacks receive poorer care than men</a>
</strong>
</em>
</p>
<hr>
<p>Effective treatment is available in hospital. But delaying treatment may reduce the benefit of therapies and lead to poorer outcomes. </p>
<h2>How to reduce your risk of heart attacks</h2>
<p>Taking steps to reduce the risk of heart disease and a heart attack is important for all women. Here are four things you can do today:</p>
<p><strong>1. Get your heart health checked</strong></p>
<p>Australians aged 45 years and older and Indigenous Australians aged 30 years and older can have a Medicare-funded <a href="https://www.heartfoundation.org.au/heart-health-education/heart-health-checks">heart health check with a GP</a>. </p>
<p>During this appointment, your GP will calculate your risk of having a heart attack in the next five years. This will be done using information from your medical history, family history, lifestyle factors, and measurements such as your blood pressure and a blood test. </p>
<figure class="align-center ">
<img alt="Woman gets her blood pressure check." src="https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/452365/original/file-20220316-21-1cy9sz5.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 heart health check includes getting your blood pressure checked.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-uses-sphygmomanometer-stethoscope-check-patients-1686741997">Shutterstock</a></span>
</figcaption>
</figure>
<p>Tests may also include an <a href="https://www.heartfoundation.org.au/heart-health-education/medical-tests-coronary-artery-calcium-score">ECG</a> (electrocardiogram) and <a href="https://www.mja.com.au/journal/2021/214/9/national-heart-foundation-australia-position-statement-coronary-artery-calcium">CT calcium score</a>. An ECG looks at your heart rhythm, while a CT calcium score measures the amount of calcium inside the walls of your heart’s arteries. This can indicate a build-up of plaque (a blockage) inside the blood vessel that could increase your risk of a heart attack. </p>
<p>Based on your risk score, the GP will be able to provide treatment advice to reduce your risk of a heart attack. If the risk score is high, they may recommend specific medicines. At lower risk scores, lifestyle modifications – such as changes to diet, exercise and quitting smoking – may be recommended as the initial approach. </p>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<p><strong>2. Quit smoking</strong></p>
<p>Smoking substantially increases the risk of heart disease. It narrows and clogs the blood vessels, reducing blood supply and oxygen throughout the body. Smoking also makes the blood vessels stiff and unable to stretch. </p>
<p>People who smoke are four times more likely to die of heart disease and <a href="https://prod.heartfoundation.org.au/heart-health-education/smoking-and-your-heart">three times more likely</a> to die of a heart attack. </p>
<p>Stopping smoking leads to better overall health at any age, and especially heart health. <a href="https://www.quit.org.au/">Support to stop smoking</a> is available through Quit Line – it’s never too late to stop.</p>
<p><strong>3. Get moving</strong></p>
<p>Exercise has many physical and mental health benefits, <a href="https://www.heartfoundation.org.au/Heart-health-education/Physical-Activity-and-Exercise">including</a> lowering blood pressure and cholesterol. </p>
<p>If you have heart disease, physical activity can help you manage the condition, lower the risk of type 2 diabetes and keep your weight in check. Achieving a healthy weight also <a href="https://www.heartfoundation.org.au/heart-health-education/physical-activity-and-exercise">reduces your risk for heart disease</a>. </p>
<p>Walking is a great way to start exercising and can be done with a friend to provide peer support, or within community <a href="https://walking.heartfoundation.org.au/">walking groups</a>.</p>
<p><strong>4. Swap unhealthy food</strong></p>
<p>Swap out less healthy food for healthier options, including vegetables and fruits, and cut down on salt and soft drinks. </p>
<p>Making changes can be challenging, but start with a few achievable changes and <a href="https://www.heartfoundation.org.au/search/%22recipe-categories%22">low-cost, healthy recipes</a>.</p>
<figure class="align-center ">
<img alt="Woman pushes a shopping trolly of healthy food." src="https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/452370/original/file-20220316-17-udw2py.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">Start with small changes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-buy-products-her-trolley-supermarket-299082896">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Improving access to care</h2>
<p>Access to preventative care, specialist support and rehabilitation following a heart attack is critical to reducing death and disability of heart disease.</p>
<p>More can be done to improve access to care, especially in priority groups such as women from culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander women, and women living in rural and remote Australia. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/according-to-tv-heart-attack-victims-are-rich-white-men-who-clutch-their-hearts-and-collapse-heres-why-thats-a-worry-120894">According to TV, heart attack victims are rich, white men who clutch their hearts and collapse. Here's why that's a worry</a>
</strong>
</em>
</p>
<hr>
<p>Better access to care requires ensuring primary care workforce capacity, especially in rural and remote areas, as well as funding and policies to increase access to primary care nurses, nurse practitioners and cardiac rehabilitation services. </p>
<p>Telehealth is a valuable tool to improve access to GPs and specialist cardiac services, especially in rural and remote areas. </p>
<p>All Australians have had a wake-up call to be aware of their heart health. Reducing your risk of heart disease begins with making a GP appointment for a heart health check to get personalised support to live a healthy life.</p><img src="https://counter.theconversation.com/content/179292/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sally Inglis currently receives funding from the Heart Foundation in the form of a Future Leader Fellowship. Sally is Chair of the Cardiovascular Nursing Council of the Cardiac Society of Australia and New Zealand (CSANZ) and Deputy Chair of the NSW Cardiovascular Research Network. </span></em></p><p class="fine-print"><em><span>Clara Chow has an NHMRC Investigator grant. She is President of the Cardiac Society Australia and New Zealand, a board member of the Western Sydney Local Health District, and on a steering group of the National Health Foundation, which is writing guidelines on cardiovascular risk assessment.
</span></em></p><p class="fine-print"><em><span>Patricia Davidson has received funding from the ARC, NHMRC and National Institutes of Health in the United States.</span></em></p>One in seven women aged 45 to 74 years are at high risk of a heart attack in the next five years. But there are some things you can do today to reduce your risk of heart disease.Sally Inglis, Professor, Heart Foundation Future Leader Fellow, IMPACCT, Faculty of Health, University of Technology SydneyClara Chow, Cardiologist at Westmead Hospital; Director of the Westmead Applied Research Centre, University of SydneyPatricia Davidson, Vice-Chancellor, University of WollongongLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1786312022-03-07T08:45:41Z2022-03-07T08:45:41ZConcerned about your risk of a heart attack? Here are 5 ways to improve your heart health<p>The news of Shane Warne’s untimely death of a suspected heart attack at the age of only 52 years has left many cricket fans reeling.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1499750949060956161"}"></div></p>
<p>Heart disease is the leading cause of death in <a href="https://www.abs.gov.au/statistics/health/causes-death/causes-death-australia/latest-release#australia-s-leading-causes-of-death-2020">Australia</a> – and worldwide, including in the <a href="https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm">United States</a>, where two in ten people who die of heart disease are <a href="https://www.cdc.gov/heartdisease/facts.htm">aged under 65</a>. </p>
<p>Heart disease is highly preventable, so it’s never too early to consider what you can do to improve the health of your heart. Here are five evidence-based ways to do this.</p>
<h2>1. Get a heart health check</h2>
<p>When someone dies suddenly and unexpectedly of heart disease, people will often say “but they exercised regularly, didn’t smoke and ate well”. </p>
<p>But some of the main risk factors for heart disease – including high blood pressure and high LDL cholesterol – are things you need to have checked by a doctor.</p>
<p>If you’re aged 45 years or older and do not already have heart disease, <a href="https://www.heartfoundation.org.au/getmedia/4342a70f-4487-496e-bbb0-dae33a47fcb2/Absolute-CVD-Risk-Full-Guidelines_2.pdf">Australia’s current guidelines</a> recommend having a heart health check by your GP. </p>
<p>A heart health check combines information on your risk factors and estimates how likely you are to develop heart disease in the next five years. </p>
<figure class="align-center ">
<img alt="Doctor listens to man's chest with stethoscope." src="https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450274/original/file-20220307-83652-1w10scm.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">Medications can reduce the risk of heart disease for some people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/crop-close-female-doctor-hold-stethoscope-1930960433">Shutterstock</a></span>
</figcaption>
</figure>
<p>Your GP can use this information to identify whether you need to make lifestyle changes, and whether you would benefit from preventive medications to lower your blood pressure and cholesterol.</p>
<p><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61212-5/fulltext">Blood pressure</a>- and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960367-5/fulltext">cholesterol-lowering</a> medications each lower the risk of developing heart disease by around 25%. So if they’re recommended for you, using them long-term is an effective way to reduce your risk. </p>
<p>However, a <a href="https://www.mja.com.au/journal/2016/204/8/absolute-risk-cardiovascular-disease-events-and-blood-pressure-and-lipid">study</a> using data from 2012 found around 76% of Australians aged 45 to 74 years at high risk of a first-time heart attack or stroke weren’t using these life-saving treatments.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cervical-breast-heart-bowel-heres-what-women-should-be-getting-screened-regularly-148575">Cervical, breast, heart, bowel: here’s what women should be getting screened regularly</a>
</strong>
</em>
</p>
<hr>
<p>Diabetes is another important <a href="https://www.heartfoundation.org.au/heart-health-education/diabetes-and-heart-disease#:%7E:text=Over%20time%2C%20high%20blood%20sugar,diabetes%20also%20have%20CVD1.">cause of heart disease</a>. Your GP will be able to guide you about whether or not you need a check for diabetes. </p>
<p>If you have diabetes, your GP will help to ensure it’s managed well, to reduce your risk of heart disease. </p>
<h2>2. Quit smoking</h2>
<p>Although Australia has some of the lowest smoking rates in the world, <a href="https://www.aihw.gov.au/getmedia/b0cbb555-ebec-4bc1-8ca1-0d6b567e321f/aihw-phe-271-NDSHS-2019-in-brief.pdf.aspx?inline=true">around 11%</a> of Australians still smoke daily. </p>
<p>Smoking damages blood vessels and contributes to the underlying processes that lead to heart disease. </p>
<p>People who are current smokers are around <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1351-4">two times</a> as likely to have a heart attack or stroke than people who have never smoked. </p>
<p>A <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0281-z">landmark Australian study</a> showed people who smoked died around ten years earlier than people who have never smoked, and up to two-thirds of ongoing smokers died from their habit. </p>
<p>But quitting smoking can reverse these effects. Quitting at any age was found to be beneficial – the earlier the better. In the long term, those who quit before the age of 45 had a <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0281-z">similar life expectancy</a> as people who had never smoked. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-happens-during-a-heart-attack-and-how-is-one-diagnosed-55874">Explainer: what happens during a heart attack and how is one diagnosed?</a>
</strong>
</em>
</p>
<hr>
<h2>3. Improve your nutrition</h2>
<p>In Australia, poor diet, excess weight and obesity are <a href="http://ihmeuw.org/5pee">leading causes</a> of heart disease. </p>
<p>However, many popular diets are not supported by science. </p>
<p>A healthy diet is important for heart health. For most people, small <a href="https://www.heartfoundation.org.au/heart-health-education/healthy-eating">changes to your diet</a>, such as increasing your intake of fruit, vegetables and wholegrains and reducing salt intake, can have large benefits. </p>
<p>For suggestions on healthier alternatives when you’re grocery shopping, try The George Institute’s <a href="https://www.georgeinstitute.org/projects/foodswitch">FoodSwitch</a> app.</p>
<h2>4. Cut your salt</h2>
<p>On average, Australians consume almost twice the World Health Organization’s recommended <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3082">daily maximum of 5g salt</a>. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/23558162/">Randomised trials</a> of salt reduction show clear effects on reducing blood pressure, a leading contributor to heart disease. </p>
<p>To reduce your salt intake, you can try reducing the amount of processed foods you eat and cutting down on the amount of salt you add to your food. </p>
<p>Salt substitutes, although not widely available on supermarket shelves, can <a href="https://www.nejm.org/doi/full/10.1056/nejmoa2105675">also play a role</a>. Salt is made up of sodium chloride; salt substitutes involve replacing a portion of the sodium chloride with potassium chloride which acts to lower blood pressure. </p>
<figure class="align-center ">
<img alt="Older woman sitting in a chair puts a hand to her chest." src="https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450273/original/file-20220307-85901-1s3djjz.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">Reducing your salt intake will also reduce your risk of heart disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/good-looking-aged-woman-having-heart-1131954146">Shutterstock</a></span>
</figcaption>
</figure>
<h2>5. Get moving</h2>
<p>Physical activity, in addition to being good for the waistline, helps improve cardiac functioning. Studies have linked regular exercise with a lower risk of having a <a href="https://www.ahajournals.org/doi/10.1161/JAHA.117.007725">heart attack</a>. </p>
<p><a href="https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians">Australian guidelines</a> recommend adults get at least 30 minutes of moderate intensity exercise most days, but even smaller amounts are beneficial. </p>
<p>Any kind of movement is good, so if you are just starting out, choose an activity you like and get moving. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-a-heart-check-early-can-prevent-heart-attack-and-stroke-in-indigenous-australians-97699">Getting a heart check early can prevent heart attack and stroke in Indigenous Australians</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/178631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ellie Paige has received funding from the National Heart Foundation of Australia, the National Health and Medical Research Council of Australia and the Australian Government Department of Health.</span></em></p><p class="fine-print"><em><span>Bruce Neal s the Executive Director of The George Institute Australia which advocates strongly for healthier diets. Through The George Institute he receives funding from health and medical research councils and philanthropy in support of work to optimize diets for human health. He is an inventor of the FoodSwitch smartphone application.</span></em></p><p class="fine-print"><em><span>Through the Australian National University, Emily Banks has received research funding from the National Health and Medical Research Council of Australia, the National Heart Foundation of Australia and the Australian Government Department of Health</span></em></p><p class="fine-print"><em><span>Jason Wu 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>Shane Warne’s untimely death from a suspected heart attack has prompted some people to consider their own heart health and what improvements they can make.Ellie Paige, Senior Research Fellow, George Institute for Global HealthBruce Neal, Executive Director, George Institute Australia, George Institute for Global HealthEmily Banks, Professor of Epidemiology and Public Health, Australian National UniversityJason Wu, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671552021-09-23T10:00:51Z2021-09-23T10:00:51ZDiabetes targets would cost more but the impact would be worth it: here’s how<figure><img src="https://images.theconversation.com/files/421845/original/file-20210917-15-1alo6s0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Early detection of diabetes is important in setting treatment targets </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nov-14-2019-a-doctor-makes-free-blood-sugar-test-on-world-news-photo/1182443866?adppopup=true">Xinhua/Mohamed Khidir via Getty Images</a></span></figcaption></figure><p>Setting global health targets, which is often done by multinational organisations, such as the United Nations or World Health Organisation (WHO), is commonly used to improve health outcomes. For example, the United Nations <a href="https://www.avert.org/global-hiv-targets">target</a> to improve access to treatment for HIV has resulted in many more people receiving the treatment that they need, which has <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/july/20200706_global-aids-report">saved</a> lives. </p>
<p>Now, the WHO <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">Diabetes Compact</a> to support people living with diabetes is under development. The content of the Compact will not be finalised until 2022. However, to help inform whether targets should be part of the Compact, we asked what the health benefits from achieving various targets for people with diabetes would be, and whether these could be cost-effective over the next 10 years. </p>
<p>The WHO is considering whether targets should be set, and our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00340-5/fulltext">analysis</a> feeds into that process as there was little previous evidence to inform what the targets should be. We were involved in some of the WHO processes for the Compact, and our results have been shared with WHO, but the analysis we did was independent. Similar to the UN targets for HIV/AIDS, the targets we considered were the percentages of people with diabetes and its associated cardiovascular disease risk factors (for example high blood pressure and choesterol) who were diagnosed, treated and controlled.</p>
<p>Our study was based on data from 23,678 people with diabetes living in 67 low- or middle-income countries. These countries were chosen as they had data available and they are home to <a href="http://www.healthdata.org/gbd/data">80% of the world’s people</a> with diabetes. </p>
<p>We found that setting targets for 80% of people with diabetes to have the condition (and other risk factors) diagnosed, treated, and controlled would substantially reduce death and improve healthy-years lived. And it would also be highly cost effective. </p>
<h2>Diabetes is often overlooked</h2>
<p>The most common form of diabetes, type 2 diabetes, is often associated with obesity and usually starts in later life. It is seldom noticed unless picked up by a medical professional. Over time it causes complications such as cardiovascular diseases (like heart attacks and strokes), kidney disease and blindness. These complications are far more likely to happen if a person with diabetes also has high blood pressure (hypertension), another condition that often goes unnoticed. </p>
<p>Treating diabetes and raised blood pressure markedly reduces the risk of future complications. Whether or not cholesterol is raised, giving a medication called a statin to lower it also <a href="https://journals.plos.org/plosmedicine/peerReview?id=10.1371/journal.pmed.1003485.r005">reduces</a> risk. These treatments to reduce risk in people with diabetes are also <a href="https://www.who.int/nmh/publications/essential_ncd_interventions_lr_settings.pdf">recommended</a> by the WHO. </p>
<p>However, our research has <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(21)00089-1/fulltext">previously shown</a> that fewer than 6% of people with diabetes get all the treatment they need to reduce risk of future complications.</p>
<h2>Three targets</h2>
<p>We therefore asked two questions. How would achieving certain targets reduce future complications from diabetes? And, in looking at costs relative to the health benefits, could achieving these targets be cost effective?</p>
<p>Reducing complications from diabetes requires interventions to reduce elevated blood sugar, blood pressure and cholesterol. We asked what benefits would be seen, and at what cost, for all three of these interventions combined.</p>
<p>We studied combinations of three targets. The first is that patients with diabetes are actually diagnosed, and their high blood pressure, if present, is also diagnosed. Second, that they are on treatment for blood sugar, blood pressure and cholesterol using a statin medication. And third, that their blood sugar and blood pressure are controlled to below internationally recommended levels. We tested these at targets of 60%, 70%, or 80% for each of diagnosis, treatment, or control. In other words, what would happen if 80% of people with diabetes and high blood pressure were diagnosed, 80% of those patients were treated and 80% of them were controlled.</p>
<p>We compared this to a baseline scenario in which diagnosis, treatment and control continued at current levels. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-changing-blood-pressure-targets-in-south-africa-could-save-costs-and-lives-153674">How changing blood pressure targets in South Africa could save costs and lives</a>
</strong>
</em>
</p>
<hr>
<p>We found that achieving each of these targets dramatically reduced deaths and improved the number of years people could live in good health. The number of years that people can live in good health is captured by a measure called <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158">Disability Adjusted Life Years or DALYs</a>. One DALY is equivalent to the loss of a year in full health, hence it captures both early death and being unwell due to a disease.</p>
<p>We found that the greatest impact of achieving the targets would be from reducing the risk of cardiovascular diseases. Other risks like blindness and kidney diseases would be less affected by achieving the targets. </p>
<p>In addition, most of the benefits came from improving treatment of high blood pressure and giving a statin for cholesterol, rather than from treating or controlling high blood sugar.</p>
<p>Overall, at the highest target of 80% diagnosis, 80% treatment, and 80% control, we found that healthy-years-lived were improved by around 6%. This means that around 6% more people with diabetes would be expected to live healthier lives. Even achieving the lower targets of 60% resulted in substantial improvements. </p>
<p>We also showed that achieving the 80% targets would greatly reduce deaths, especially those from cardiovascular diseases.</p>
<p>There was substantial variation in benefits by world regions. For example, reduction in deaths due to cardiovascular diseases was greatest in east sub-Saharan Africa. In this region, deaths would fall from around 46 per 1,000 people in the baseline scenario to 27 per 1,000 with a target of 80% for diagnosis, treatment, and control. In central Latin America deaths fell from around 18 per 1,000 people at baseline to 14 per 1,000 with this target.</p>
<h2>Achieving targets is cost effective</h2>
<p>In our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00340-5/fulltext">study</a>, we considered the costs of diagnosing and treating diabetes and hypertension, and giving a statin, and the costs of treating the complications of diabetes, for the baseline scenario (current diagnosis, treatment, and control levels continued for the next 10 years) and each of the targets. </p>
<p>In the baseline scenario, the costs of managing diabetes in the countries in the study would be $2,222,882 per 1,000 people with diabetes over the next 10 years. </p>
<p>If diagnosis, treatment, and control were scaled up to achieve 80% targets for each, the costs would increase by a small amount, to $2,832,000 per 1,000 people with diabetes. Most of the increased costs would come from achieving the target for increasing treatment of hypertension. But the costs of treating cardiovascular disease complications would fall. </p>
<p>Overall this gave an incremental cost-effectiveness ratio (effectively the costs per extra healthy-life-year lived, or DALY averted) of $1,362. These costs are well below the WHO <a href="https://www.valueinhealthjournal.com/article/S1098-3015(15)00574-4/fulltext#relatedArticles">thresholds</a> for cost effectiveness of three times GDP per capita for each country. So, each extra year of healthy life would cost $1,362, but the WHO has a benchmark of three times GDP per capita as a worthwhile investment in a year of healthy life. For example, GDP per capita in Angola is $2,790, therefore an intervention would be considered cost effective (by WHO) if it cost less than $8,370 per DALY.</p>
<p>We have shown that targets for diabetes would improve healthy lives and reduce deaths, and that they would be cost effective. But these targets should not be for managing the blood sugar element of diabetes alone; they must include treating hypertension and giving statins to patients with diabetes. </p>
<p><em>This study was done by multiple co-investigators, and this article is written on behalf of the co-investigator team.</em></p><img src="https://counter.theconversation.com/content/167155/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Ina Davies receives funding from the UK National Institute for Health Research, the UK Medical Research Council, and the US National Institute of Health. </span></em></p><p class="fine-print"><em><span>David Flood receives funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). He also serves as an unpaid Staff Physician for Maya Health Alliance and GlucoSalud, which are two non-governmental health organizations in Guatemala; in his role with these organizations, he occasionally carries out diabetes advocacy and solitics funding for clinical diabetes programs.</span></em></p><p class="fine-print"><em><span>Sanjay Basu receives funding from the US Centers for Disease Control and Prevention, the Clinton Global Health Access Initiative, and the US National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Jennifer Manne-Goehler 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>Targets for diabetes would improve healthy lives, reduce deaths, and be cost effective. But they should not be for managing diabetes alone; they must include treating hypertension.Justine Ina Davies, Professor of Global Health, Institute for Applied Research, University of BirminghamDavid Flood, Research Fellow, University of MichiganJennifer Manne-Goehler, Research Fellow in Medicine, Harvard UniversitySanjay Basu, Director of Research, Center for Primary Care, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1668112021-09-07T12:52:18Z2021-09-07T12:52:18ZMedicine is an imperfect science – but you can still trust its process<figure><img src="https://images.theconversation.com/files/418963/original/file-20210901-25-big4r.jpg?ixlib=rb-1.1.0&rect=0%2C72%2C2039%2C1085&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intensive care physicians are yet again facing ICU bed and staff shortages as severe COVID-19 cases rise.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hospital-coronavirus-emergency-department-ward-royalty-free-image/1321692378?adppopup=true">gorodenkoff/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The Conversation is running a series of dispatches from clinicians and researchers operating on the front lines of the coronavirus pandemic. You can <a href="https://theconversation.com/us/topics/covid-19-front-lines-84846">find all of the stories here</a>.</em> </p>
<p>As an intensive care physician in Southern California who endured the onslaught of COVID-19 in 2020, it has been deeply disheartening to experience chillingly familiar scenes all over again. The ICUs in the University of California San Diego Health hospital network where <a href="https://profiles.ucsd.edu/venktesh.ramnath">I work</a> are again overflowing – especially with patients who need ventilators. Families peer through tinted hospital windows for glimpses of loved ones. And <a href="https://www.washingtonpost.com/health/staff-shortages-hospitals-covid/2021/08/12/85f636b4-fa97-11eb-8a67-f14cd1d28e47_story.html">hospital administrators scramble</a> to keep up with necessary staffing and beds to accommodate the influx of patients.</p>
<p>What is so vexing is that COVID-19 is still the culprit, despite the availability of <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7034e2.htm">highly effective vaccines</a> that <a href="https://doi.org/10.1038/d41586-021-02054-z">slashed U.S. COVID-19 daily case numbers and hospitalizations</a> within months. The vaccines also allowed economies to <a href="https://budgetmodel.wharton.upenn.edu/issues/2021/3/1/epidemiological-and-economic-effects-of-covid-19-vaccine">begin to recover</a> and provided a way for people to experience some sense of normalcy again. </p>
<p>In early spring, the efficacy of the vaccine engendered hope that herd immunity – in which infectious viral spread is prevented through a high proportion of the population’s being immune to the disease – <a href="https://www.wsj.com/articles/well-have-herd-immunity-by-april-11613669731">could be within reach</a> in months. Instead, pandemic panic is again suffocating us, largely because a large part of the public <a href="https://www.nytimes.com/2021/07/31/us/virus-unvaccinated-americans.html">still shuns vaccination</a> – with only 62% of the eligible U.S. population <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total">fully vaccinated</a> as of early September 2021.</p>
<p>I wanted an answer to the obvious question: Why?</p>
<h2>Straight from the source</h2>
<p>So I turned to my patients for answers. At the bedside in their hospital rooms, I first asked about how they were feeling and performed detailed exams before addressing the elephant in the room. “Did you receive the COVID-19 vaccine?” And if not, I gently asked, “Did you have a specific reason you could share with me, so I can understand better?”</p>
<p>Somewhat surprisingly, patients candidly told me their reasons for avoiding the vaccine.</p>
<p>A common response I heard was that it was simply inconvenient. “I was too lazy and I didn’t get around to it,” some admitted, looking away sheepishly as they did so. Curiously, they did not consider the myriad “inconveniences” of becoming infected, such as medical complications – including death – and associated costs for treatment, lost work, dependence on others for basic necessities such as child care, the risk of infecting family members, the potential for developing <a href="https://theconversation.com/deciphering-the-symptoms-of-long-covid-19-is-slow-and-painstaking-for-both-sufferers-and-their-physicians-164754">long-haul COVID-19</a> and more.</p>
<p>Others expressed a fervid distrust of vaccine-testing methods, stating that people had been “guinea pigs in past vaccine experiments that later caused autism.” Yet more than 25 studies in the past 20-odd years have disproved any <a href="https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Studies-Examine-the-Evidence.aspx">causal link between vaccines and autism</a>. </p>
<p>Some felt that the forceful public messaging to get vaccinated belied true motivations of the authorities, adding: “I mean, why are they pushing this so hard? Something must be wrong with it.” Yet few question the strong public health stance on healthy eating practices and exercise, or wearing seat belts while driving. </p>
<p>Still others feared the possibility of life-threatening side effects: “Thousands had heart attacks from the vaccine – it’s all on the CDC website,” they told me. So I took <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html?s_cid=11374:covid%20vaccine%20heart%20problems:sem.ga:p:RG:GM:gen:PTN:FY21">a close look</a> at the CDC website to understand their claims better. </p>
<p>Reports of heart inflammation occurred in 699 cases out of 177 million vaccinated people, or 0.0004%, with causal links to the vaccines still being investigated. Development of blood clots causally associated with the Johnson & Johnson vaccine are <a href="https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-05-12/07-COVID-Shimabukuro-508.pdf">also extremely rare</a>, occurring in 28 cases out of 8.73 million doses given as of May 7, 2021 – a rate of 0.0003%. This extremely low risk of blood clots is still significantly lower than the <a href="https://doi.org/10.1136/bmj.n1931">risk of blood clots</a> from an <a href="https://www.nytimes.com/2021/08/27/health/blood-clots-coronavirus.html">actual COVID-19</a> infection.</p>
<h2>Medicine as art and imperfect science</h2>
<p>In some cases, political affiliation can <a href="https://www.economist.com/united-states/2021/07/27/americas-vaccination-woes-cannot-be-blamed-only-on-politics">partially explain</a> vaccine antipathy. But my patients’ responses highlighted two other themes to me.</p>
<p>First, people often forget that medicine is an art <a href="http://dx.doi.org/10.1136/mh.26.1.18">based on applied science</a>, not a deductive science based on irrefutable forces in nature like gravity. Patients and families often ask me in the ICU to predict what will happen to loved ones unequivocally, only to be disappointed when I avoid speaking in certainties.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An ICU doctor hugs and comforts a patient in a COVID-19 ICU" src="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.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">Having to deliver devastating news and uncertainties about patient outcomes has taken a heavy toll on ICU physicians during the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/dr-joseph-varon-hugs-and-comforts-a-patient-in-the-covid-19-news-photo/1229807339?adppopup=true">Go Nakamura/Getty Images News</a></span>
</figcaption>
</figure>
<p>Once viewed as <a href="https://doi.org/10.1136/bmj.317.7174.1729">omniscient authorities</a>, doctors now openly acknowledge that limitations of medical data require scrutiny and careful application to particular circumstances. COVID-19 has reinforced our appreciation that there are no perfect cures or 100% guarantees of success. Rather, medicine is governed by what is probable. What are the chances I still may have cancer if the test result returns negative? Am I more or less likely to survive pneumonia by taking this specific antibiotic?</p>
<p>Doctors must then engage in <a href="https://doi.org/10.1016/j.chest.2020.05.548">thoughtful analysis</a> of the strengths and weaknesses of scientific methods and data to optimize and tailor our recommendations for individual patients – without the luxury of perfect or even complete datasets to rely on. The vaccine has clearly been shown – its rare side effects notwithstanding – to provide an overwhelmingly high likelihood of benefit over potential risks to almost all individuals. This <a href="https://doi.org/10.1001/jama.2021.11717">includes people</a> who have been <a href="https://apnews.com/article/science-health-coronavirus-pandemic-ad52011f4ca1853fad6eee41a7310c2e">previously infected with COVID-19</a>. Yet the unvaccinated continue to fixate on rare side effects to justify skipping the shot.</p>
<h2>Vaccines are medicines too</h2>
<p>Many of my patients also seem to view vaccines and other public health-based recommendations like offers to buy a used car – with skepticism and independence, threatening to walk away at any moment. Doing one’s part to stop the spread of disease is a culturally nuanced civic virtue, like <a href="https://doi.org/10.1016/j.trf.2014.01.004">safe driving</a>, which transcends absolute autonomy. In the U.S., most drivers willingly do not drive while intoxicated, cross lanes without warning or block other cars that are trying to merge. These are norms that make driving in the U.S. relatively efficient, safe and even pleasant compared with some other countries. </p>
<p>The path to herd immunity, like highway safety, requires majority participation without immediate guarantees of complete personal freedom. Vaccines succeed not because they are 100% risk-free to the individual but because collective efforts focus on achieving the common good.</p>
<p>Oddly, at the same time that my patients rejected the vaccine, they showed strong interest in receiving other types of medicine “shots” like monoclonal antibodies – which mimic natural antibodies – or anti-inflammatory medications. While <a href="https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/">some of these treatments</a> have demonstrated benefits in certain situations – <a href="https://doi.org/10.1001/jama.2021.2747">others</a> <a href="https://doi.org/10.1056/NEJMoa2028700">have not</a>. And some present the risk of <a href="https://www.fox19.com/2021/08/21/seriously-yall-stop-it-fda-dispels-myth-about-ivermectin-covid-cure/">very serious harm</a>. </p>
<p>I reminded my patients that the COVID-19 vaccine stimulates a person’s own immune system to make <a href="https://theconversation.com/what-happens-when-the-covid-19-vaccines-enter-the-body-a-road-map-for-kids-and-grown-ups-164624">antibodies that can neutralize the virus</a> and that surpass the capabilities of <a href="https://www.webmd.com/vaccines/covid-19-vaccine/news/20210826/monoclonal-antibodies-vs-vaccines-vs-covid-19">commercially created antibody formulations</a>. So the vaccines help prevent infection and development of serious illness from COVID-19 in the first place. People who experience the <a href="https://theconversation.com/what-is-a-breakthrough-infection-6-questions-answered-about-catching-covid-19-after-vaccination-164909">rare breakthrough infections</a> following vaccination generally have a <a href="https://www.wsj.com/articles/breakthrough-cases-covid-19-delta-variant-11627596643">shorter and milder course of COVID-19 infection</a> and are far less likely to <a href="https://doi.org/10.1093/cid/ciab543">end up hospitalized</a> than those who are unvaccinated. Vaccines <a href="https://doi.org/10.1038/s41586-021-03738-2">also confer</a> <a href="https://www.npr.org/sections/goatsandsoda/2021/08/30/1032520934/immunity-to-covid-19-could-last-longer-than-youd-think?ft=nprml&f=1032520934">longer-term protection</a>, whereas the other medications are used reactively – when a serious infection has already begun – and those medications have <a href="https://www.coronaviruspreventionnetwork.org/coronavirus-vaccine-and-antibody-science">shorter-term results</a>.</p>
<h2>How past vaccination efforts succeeded</h2>
<p>In the past, many vaccines that successfully vanquished societal outbreaks of <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">polio</a>, <a href="https://www.historyofvaccines.org/timeline/measles">measles</a> and <a href="https://www.historyofvaccines.org/content/articles/mumps">mumps</a> are now routinely administered in childhood with minimal objection, despite the fact that there is no such thing as <a href="https://www.cdc.gov/vaccines/vac-gen/side-effects.htm">zero risk</a>.</p>
<p>As I continue to have conversations with patients who suffer greatly from COVID-19 illness as a direct consequence of having avoided the vaccine, my own pain – for being an ineffective healer and witness to such loss – is inexorable. Overcoming this fourth wave of COVID-19 still feels out of reach until our vaccination efforts can somehow better emphasize the effectiveness of vaccines, even when scientifically imperfect, and prioritize civic health care responsibilities over pure autonomy. If not, I fear that our battle against COVID-19 will rage on.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/166811/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Venktesh Ramnath 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 critical care doctor brings a frontlines perspective to the frustration of dealing firsthand with vaccine hesitancy and discusses the limitations of science and medicine.Venktesh Ramnath, Associate Clinical Professor of Medicine, University of California, San DiegoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1654462021-08-12T20:03:00Z2021-08-12T20:03:00ZHow COVID affects the heart, according to a cardiologist<figure><img src="https://images.theconversation.com/files/415607/original/file-20210811-17-1owq1qz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C998%2C435&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>As the pandemic has progressed, researchers have begun to understand how COVID-19 impacts our bodies.</p>
<p>Early in the pandemic, risk factors such as heart disease, high blood pressure and diabetes were <a href="https://www.ijidonline.com/article/S1201-9712(20)30136-3/fulltext">quickly associated</a> with an increased risk of <a href="https://jamanetwork.com/journals/jama/fullarticle/2762130">severe illness and death</a> from COVID.</p>
<p>We now know that, among the myriad ways it can damage our health, the virus can affect the heart and directly cause a range of <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013879/full">heart complications</a>.</p>
<p>Also, mRNA COVID vaccines like those from Pfizer and Moderna have been linked with heart inflammation. But this is very rare, and you’re much more likely to get heart inflammation from COVID infection than the vaccines.</p>
<p>Here’s what we know so far.</p>
<h2>How does COVID affect the heart?</h2>
<p>The SARS-CoV-2 virus can directly invade the body causing inflammation. This can impact the heart, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199677/">causing myocarditis and pericarditis</a> — inflammation of the heart muscle or outer lining of the heart. </p>
<p>Inflammation from COVID <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013879/full">can also cause</a> blood clotting, which can block a heart or brain artery causing a heart attack or stroke.</p>
<p>COVID can also cause abnormal heart rhythms, blood clots in the legs and lungs, and heart failure. Our understanding of how COVID causes <a href="https://www.jacc.org/doi/abs/10.1016/j.jacc.2020.08.059">heart inflammation and injury to the heart muscle</a> is becoming clearer, though there’s more to learn.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1422544670719025156"}"></div></p>
<p>Persistent symptoms from the virus, called “<a href="https://theconversation.com/the-mystery-of-long-covid-up-to-1-in-3-people-who-catch-the-virus-suffer-for-months-heres-what-we-know-so-far-161174">long COVID</a>”, have been reported in about 10-30% of people who’ve contracted COVID.</p>
<p><a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00299-6/fulltext">One study</a> on long COVID, published in July, found common cardiovascular symptoms include heart palpitations, fast heart rate, slow heart rate, chest pain, visible bulging veins, and fainting.</p>
<p>Of roughly 3,700 study participants, over 90% reported their recovery lasted more than eight months.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-mystery-of-long-covid-up-to-1-in-3-people-who-catch-the-virus-suffer-for-months-heres-what-we-know-so-far-161174">The mystery of 'long COVID': up to 1 in 3 people who catch the virus suffer for months. Here's what we know so far</a>
</strong>
</em>
</p>
<hr>
<p>The Delta variant, first identified in India in October 2020, is <a href="https://apps.who.int/iris/bitstream/handle/10665/341622/CoV-weekly-sitrep1Jun21-eng.pdf?sequence=1&isAllowed=y">highly transmissible</a>. It’s the variant responsible for lockdowns in New South Wales, Victoria and Queensland. </p>
<p>Although data is still emerging, it may cause more severe disease, and <a href="https://www.abc.net.au/news/2021-08-07/delta-variant-of-covid-19-causing-heart-problems-young-people/100352868">anecdotally may increase the chances of heart complications</a>.</p>
<p>A <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01358-1/fulltext#sec1">Scottish study</a> found the risk of hospital admission from COVID was around double in those with Delta variant compared to the Alpha variant (which originated in the UK). It also found Delta was spreading most commonly in younger people.</p>
<p>The good news is two doses of either the Pfizer or AstraZeneca vaccines <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2108891">remains effective</a> in preventing Delta complications.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1423941243227099138"}"></div></p>
<h2>COVID vaccines and the heart</h2>
<p>Scientists have discovered a link between the Oxford-AstraZeneca vaccine and <a href="https://theconversation.com/what-is-thrombocytopenia-the-rare-blood-condition-possibly-linked-to-the-astrazeneca-vaccine-158522">a rare blood clotting syndrome</a>.</p>
<p>There’s also a link between mRNA COVID vaccines and a rare side effect of <a href="https://jamanetwork.com/journals/jamacardiology/fullarticle/2781602">heart inflammation</a> (myocarditis and pericarditis). This seems to be most common in males under 30 and after the second vaccine dose. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-benefits-of-a-covid-vaccine-far-outweigh-the-small-risk-of-treatable-heart-inflammation-163970">The benefits of a COVID vaccine far outweigh the small risk of treatable heart inflammation</a>
</strong>
</em>
</p>
<hr>
<p>But this is very rare. Of the <a href="https://www.tga.gov.au/periodic/covid-19-vaccine-weekly-safety-report-05-08-2021">5.6 million Pfizer vaccine doses</a> administered to Australians so far, there have only been <a href="https://www.tga.gov.au/periodic/covid-19-vaccine-weekly-safety-report-05-08-2021">111 cases</a> of suspected (not confirmed) heart inflammation reported up to August 1. There have been no reported deaths associated with this vaccine side effect in Australia. </p>
<p>Recovery from this heart inflammation is generally good. The benefits of vaccination against COVID far outweigh the potential risks of these generally mild conditions. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1423944616127209472"}"></div></p>
<p>Nevertheless, if you experience any change in symptoms after having a COVID vaccine, including chest pain, an irregular heartbeat, fainting or shortness of breath, you should seek prompt medical attention.</p>
<p>The vast majority of people with heart conditions are safe to get vaccinated. But if you have had myocarditis or pericarditis in the past six months then speak with your doctor or cardiologist.</p>
<h2>Don’t delay getting your heart checked</h2>
<p>Many people have been reluctant to seek medical attention amid the pandemic. This includes for both urgent and routine care of heart disease. Longer delays between the onset of the symptoms and hospital treatment <a href="https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwaa155/6145858">are being reported</a> in countries including England, Italy and China. This makes long-term heart damage more likely. </p>
<p><a href="https://academic.oup.com/ehjqcco/article/7/1/18/5956768">One study</a> found global hospital admissions for heart attacks have decreased between 40% and 50%. <a href="https://www.heartlungcirc.org/article/S1443-9506(21)01041-6/fulltext">An Australian study</a> found a 21% reduction in cardiac surgery at Sydney’s Royal Prince Alfred Hospital between March and June 2020.</p>
<p>It’s important you don’t neglect your heart health even amid the pandemic. If you ever think you’re <a href="https://www.heartfoundation.org.au/conditions/heart-attack">having a heart attack</a>, call triple zero (000) immediately.</p>
<hr>
<p><em>The author would like to thank the National Heart Foundation’s Amanda Buttery and Brooke Atkins for their help with this article.</em></p><img src="https://counter.theconversation.com/content/165446/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Garry Jennings receives funding from the National Health and Medical Research Council. He is Chief Medical Advisor for the Heart Foundation and Interim CEO. He has part time positions with the Baker Heart and Diabetes Institute and Sydney Health Partners, and is Honorary Professor of Medicine at the University of Sydney and Monash University.</span></em></p>COVID can cause heart inflammation, abnormal heart rhythms, blood clots in the legs and lungs, stroke, and heart failure.Garry Jennings, Professor of Medicine, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1310892020-02-12T12:41:57Z2020-02-12T12:41:57ZAfrica is way behind the curve in managing heart disease: here’s a new approach<figure><img src="https://images.theconversation.com/files/314699/original/file-20200211-146674-rv4fct.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">Stephen Barnes/Shutterstock</span></span></figcaption></figure><p>The burden of <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30370-5/fulltext">noncommunicable diseases</a> in sub-Saharan African is growing because of factors such as demographic changes and increases in life expectancy. These <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">diseases</a> include heart attacks, stroke, cancer, respiratory diseases and diabetes.</p>
<p>Poor people are more vulnerable to noncommunicable diseases and generally develop them at <a href="https://www.healthdata.org">a younger age</a> than their peers from high-income countries. Globally, more than half of the people with these diseases die before the age of <a href="https://www.who.int/gho/ncd/en/">70</a>. Over <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">80%</a> of those premature deaths occur in low-income countries.</p>
<p>Public health care in sub-Saharan Africa is largely unequipped to handle the strain caused by noncommunicable diseases. The burden is therefore likely to <a href="https://theconversation.com/weighing-up-the-costs-of-treating-lifestyle-diseases-in-south-africa-110456">impede poverty reduction</a> and hamper economic growth.</p>
<p>One of the noncommunicable diseases that make up the burden is heart disease. This is a long-term medical condition and does not have to be fatal. About <a href="https://www.healthdata.org">7 million</a> patients in sub-Saharan Africa are affected by heart disease.</p>
<p>Ideally, patients with heart disease should be offered <a href="https://www.bmj.com/content/351/bmj.h5000">cardiac rehabilitation</a>. It is designed to help patients overcome physical inactivity, mental health problems, poor diet and smoking. These are all risk factors for cardiovascular disease.</p>
<p>There is growing <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003331.pub5/full">evidence</a> that cardiac rehabilitation helps reduce disability, prevent readmission to hospital and improve physical fitness. As a result, it’s offered as a standard part of care for many patients in developed countries. </p>
<p>The British Association for Cardiovascular Prevention and Rehabilitation <a href="https://heart.bmj.com/content/105/7/510">recommends</a> that certain “core components” form part of cardiac rehabilitation. These include health behaviour change and education; lifestyle risk factor management; psychosocial health; medical risk management; and evaluation.</p>
<p>In a standard cardiac rehabilitation programme, these components are delivered by a qualified multidisciplinary team, and led by a clinical coordinator. Cardiac rehabilitation is tailored to each individual’s goals and, if possible, delivered in a way that’s convenient to the patient, for example partly at home. </p>
<h2>Our study</h2>
<p>We <a href="https://journals.co.za/content/journal/10520/EJC-168a6c2da9">looked</a> at the availability and characteristics of cardiac rehabilitation in sub-Saharan Africa. Our study shows that cardiac rehabilitation availability in Africa was one of the worst of all the world’s regions.</p>
<p>We could find only 32 cardiac rehabilitation programmes. They had some form of individual screening of risk factors, some form of exercise, and at least one of the other core components recommended by the British Association. These 32 programmes could, on average, provide cardiac rehabilitation to 63 patients a year. Considering the burden of heart disease in sub-Saharan Africa, we estimated that 1.4 million more cardiac rehabilitation spots are needed annually.</p>
<p>What was particularly worrying was that three quarters of the programmes were in South Africa and 82% were in urban settings. None were in the public health sector. We concluded that there is a high level of inequality in the availability of cardiac rehabilitation. This is especially true for patients who rely on public health care and those in rural settings. In South Africa, <a href="http://www.statssa.gov.za/?p=10548">87%</a> of the population is without medical insurance and reliant on public health care. </p>
<p>The 1.4 million spots needed annually seem an insurmountable hurdle. So how do we move forward? </p>
<h2>Way forward</h2>
<p>As illustrated, Africa is far behind the curve in managing heart disease, among others. This may contribute to African countries experiencing some of the highest levels of disability worldwide. People with disabilities are <a href="https://social.un.org/publications/UN-Flagship-Report-Disability-Final.pdf">at a disadvantage</a> in almost any sustainable development target, including food security, poverty and access to health care.</p>
<p>In light of this complex and high burden of disease, we propose to take the “cardiac” out of “cardiac rehabilitation” and find a way to care for patients who are at risk of a number of related conditions. </p>
<p>Many of the core components of cardiac rehabilitation (such as managing medical risk and supporting lifestyle changes) are equally relevant in reducing the impact of other medical conditions. An approach that centres on <a href="https://bmjopen.bmj.com/content/9/4/e025732.info">patients</a> rather than diseases should be considered as a way forward. Let’s call it “health optimisation” therapy for now.</p>
<p>It could make better and more flexible use of resources and the health-care workforce. Community health workers could be involved. So could health professionals such as physiotherapists, by looking out for risk factors such as high blood pressure and obesity. The approach could take local challenges and cultural differences into account. </p>
<p>But cardiac rehabilitation or health optimisation are not the holy grail in the primary prevention of disease. The biggest reduction in disease burden will come through progress in the other sustainable development goals such as ending poverty, improving food security, quality education, water and sanitation. So the way forward is a concerted interdisciplinary effort to prevent disease and reduce disease impact.</p>
<p>From a research perspective, the field of rehabilitation medicine can provide high-quality evidence to support “health optimisation” programmes. Ideally, this research should be done in close collaboration with patients and communities. It should also provide evidence on the health benefits of interventions not directly related to health.</p><img src="https://counter.theconversation.com/content/131089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martin Heine receives funding from the AXA Research Fund. </span></em></p>Cardiac rehabilitation is not available in many African countries and the way forward may be to focus on patients rather than specific diseases.Martin Heine, Post-doctoral Research Fellow, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1191692019-07-03T19:58:29Z2019-07-03T19:58:29ZSmoking at record low in Australia, but the grim harvest of preventable heart disease continues<figure><img src="https://images.theconversation.com/files/281531/original/file-20190627-76734-htbpzo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The latest statistics show smoking's legacy when it comes to preventable deaths from cardiovascular diseases like heart attack and stroke.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/82970389?src=Xy6ZiUaaPKINAH02Ov3M_Q-1-24&studio=1&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Smoking rates in Australia are at an all-time low. And yet, nearly 11,500 people are hospitalised from smoking-related cardiovascular (heart and blood vessel) disease each year, while almost 6,500 die as a result.</p>
<p>And it’s not just older people dying from their addiction. More than one-third of deaths from cardiovascular disease, such as heart attack or stroke, in people under the age of 65 in Australia can be attributed to smoking.</p>
<p>A recent publication of the largest and most comprehensive <a href="https://doi.org/10.1186/s12916-019-1351-4">study of smoking and cardiovascular disease</a> in Australia is a reminder we can’t be complacent.</p>
<p>The study, published this week in BMC Medicine, found current smokers have a five-fold increase in the risk of peripheral vascular disease, such as gangrene. Smoking also doubles the risk of heart attack, stroke and heart failure and triples the risk of dying from these diseases. This is compared to people who have never smoked.</p>
<p>The study’s authors said the findings suggest that if a smoker has a heart attack or a stroke, it’s highly probable smoking caused it. </p>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<h2>Our smoking rates</h2>
<p>The table below shows how <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012017-18?OpenDocument">Australia’s smoking rates</a> compare with four other nations with which we are often benchmarked: <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6744a2.htm#T1_down">USA</a>, <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2018001/article/54974-eng.htm">Canada</a>, <a href="https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data-explorer/_w_fa9587ac/#!/download-data-sets">New</a> <a href="https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data-explorer/_w_fa9587ac/_w_90d53eb9/#!/explore-topics">Zealand</a> and the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017">UK</a>.</p>
<p><iframe id="FFDOs" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/FFDOs/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>So at 15.1%, we are level with the UK. But we are almost certainly ahead of them because their 15.1% only includes people who smoke cigarettes (including rollies). It excludes people who only smoke other tobacco products, such as cigars or pipes.</p>
<p>The <a href="https://www.cancervic.org.au/downloads/cbrc/2019_Brief_1_daily_smoking_15to18_subgrps.pdf">very latest data</a> from Victoria are even more promising with only 10.7% smoking daily, down from 13.5% in 2015.</p>
<p>But the new research shows the impacts of past decades of smoking.</p>
<h2>What the researchers did and found</h2>
<p>Researchers followed 188,167 people aged 45 and over for an average of 7.2 years. </p>
<p>At the start of the study, none had been diagnosed with cardiovascular disease, 8% smoked and 34% had given up smoking. </p>
<p>The researchers used questionnaires, as well as hospitalisation and death data, to the end of 2015 and examined 36 sub-types of cardiovascular disease.</p>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<p>Current smokers were significantly more likely to have a diagnosis or an event (a heart attack or stroke) in 29 out of the 36 cardiovascular disease types.</p>
<p>The new paper estimates that every year, smoking-related cardiovascular disease results in 11,400 people being sent to hospital and 6,400 people dying. This translates to 17 preventable deaths and 31 preventable hospitalisations a day.</p>
<p>The authors report one-third of premature cardiovascular deaths are attributable to smoking. The same researchers earlier calculated long-term smokers have a <a href="https://theconversation.com/smoking-new-australian-data-to-die-or-live-for-37962">two in three chance of dying from a smoking-caused disease</a>.</p>
<h2>How about those who cut back smoking?</h2>
<p>Australians who smoke daily smoke <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001%7E2017-18%7EMain%20Features%7ESmoking%7E85">an average 12.3 cigarettes a day</a>. Many smokers believe cutting back instead of quitting will reduce much of the health risk.</p>
<p>But in this study, people who smoked four to six cigarettes a day had double the risk of dying from cardiovascular disease compared to people who had never smoked.</p>
<p>These results are similar to those found in smokers followed for years who had cut back rather than quit.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ten-myths-about-smoking-that-will-not-die-56076">Ten myths about smoking that will not die</a>
</strong>
</em>
</p>
<hr>
<p>For example, a <a href="http://tobaccocontrol.bmj.com/content/15/6/472.full.pdf+html">Norwegian cohort</a> of 51,210 people followed from the 1970s until 2003 found “no evidence that smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly”.</p>
<p>Another study from <a href="http://jco.ascopubs.org/content/26/31/5101.full.pdf">Korea</a>, involving nearly half a million men followed for 11 years, found no link between smoking less and the risk of all types of cancer. While there was a significant decrease in the risk of lung cancer, this was “disproportionately smaller than that expected”.</p>
<h2>And now, the good news</h2>
<p>Finally, some good news for <a href="https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.83.2.215">smokers who think the damage may have already been done</a>. Quitting smoking dramatically reduces the risk of cardiovascular disease compared with continuing to smoke: the earlier the better. </p>
<p>People who quit smoking by age 45 avoid more than 95% of the cardiovascular disease risks related to smoking. Quitting at any age reduced their risk.</p>
<h2>Looking to the future</h2>
<p>Health minister Greg Hunt’s recently announced <a href="https://croakey.org/calls-for-national-preventive-health-strategy-to-address-poverty-and-other-determinants-of-health/">national prevention strategy</a> must give high priority to tobacco control. </p>
<p>The <a href="https://www.directory.gov.au/portfolios/health/australian-national-preventive-health-agency">Australian National Preventive Health Agency</a>, set up by Labor’s health minister Nicola Roxon in the Rudd government and then axed by the Abbott government, <a href="https://www.researchgate.net/publication/329234114_A_PRIORITY-DRIVEN_RESEARCH_AGENDA_FOR_TOBACCO_CONTROL_IN_AUSTRALIA">produced a report</a> on how best to drive tobacco control in Australia, which I co-authored. This followed a lengthy national and international evidence-based assessment and consultation on how to best accelerate the historical decline in smoking. </p>
<p>This report can be used to drive research and action to get smoking in Australia well below 10%.</p><img src="https://counter.theconversation.com/content/119169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman 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>Smoking-related cardiovascular disease like heart attack and stroke results in 11,400 people being sent to hospital and 6,400 people dying in Australia each year, new research shows.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921142018-02-22T08:42:17Z2018-02-22T08:42:17ZThinking of taking a walk everyday? Six reasons why it’s good for you<figure><img src="https://images.theconversation.com/files/207460/original/file-20180222-152348-7vxv1u.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">Shutterstock</span></span></figcaption></figure><p>South Africa’s new president Cyril Ramaphosa has been the talk of social media with his early morning walking routine. In addition to personal walks along a Cape Town beachfront, Ramaphosa has also <a href="https://www.iol.co.za/news/politics/pics-ramaphosas-tummymustfall-walk-attracts-scores-13378660">led a walk</a> in the city from the townships of Gugulethu to Athlone to promote exercise as a key part of healthy living.</p>
<p>While many South Africans have been bemused by the fact that the busiest man in the country has time for a morning walk, studies show that walking is a good way to tackle burgeoning rates of obesity and other lifestyle diseases. These have reached epidemic proportions in developed countries and are dangerously on the rise in developing countries like South Africa which has the highest levels in Africa. With more than 8 million people diagnosed as obese, it’s joined the likes of global heavyweights such as Mexico and the US.</p>
<p>These diseases are linked to specific dietary and lifestyle changes which include patterns of increased eating, drinking and smoking along with reduced physical activity, and a shift to a diet high in sugar, salt and saturated fat.</p>
<p>There is no doubt that movement is essential for well being. The general guidelines are that 30 minutes or more of walking every day at a speed of between <a href="http://bjsm.bmj.com/content/bjsports/49/11/710.full.pdf">five and eight kilometres per hour</a> can improve health. </p>
<p>And studies show that even when people don’t quite manage to walk for the recommended 30 minutes a day the <a href="https://www.academia.edu/14725829/The_association_between_daily_steps_and_health_and_the_mediating_role_of_body_composition_a_pedometer-based_cross-sectional_study_in_an_employed_South_African_population">benefits</a> can still accrue. This proves that some walking is better than none at all. </p>
<p>For those who still need convincing, here are six reasons to take up a daily outdoor walk.</p>
<h2>It doesn’t cost a thing</h2>
<p>Walking outdoors is ideal when resources are limited, as a <a href="https://espace.library.uq.edu.au/view/UQ:323162">study</a> in low income communities in South Africa shows. The community the research focused on was a high risk area for chronic lifestyle diseases. </p>
<p>The study showed how physical activity that promoted participation of rural communities is feasible – and accessible. The activities in turn addressed the growing burden of chronic diseases.</p>
<p>Walking in groups also adds an important element of safety. And it helps with motivation, as another <a href="http://bjsm.bmj.com/content/bjsports/49/11/710.full.pdf">meta-analysis</a> which evaluated 42 studies found: when people walk in groups outdoors, they are less likely to give up too easily. </p>
<h2>It prevents (or delays) Type 2 diabetes</h2>
<p>The American Diabetes Association provides strong <a href="http://care.diabetesjournals.org/content/39/11/2065">evidence</a> of the benefits of walking for people who have pre-diabetes, Type 2 Diabetes, or even Type 1 Diabetes. </p>
<p>Type two diabetes is the most common and is linked to insulin resistance (or a lack of it). Type one diabetes occurs when the body does not naturally produce sufficient insulin, and generally presents in childhood. It is not necessarily related to lifestyle habits.</p>
<p>About 7%, or 3.85 million South Africans between the ages of 21 and 79, have diabetes. A large proportion remain undiagnosed.</p>
<h2>Decreases blood pressure</h2>
<p>High blood pressure is a direct risk for stroke and heart-related illnesses and threats. Walking demonstrably <a href="http://bjsm.bmj.com/content/bjsports/49/11/710.full.pdf">reduces</a> systolic and diastolic blood pressure. Systolic blood pressure is the “first number” obtained when blood pressure is measured, and represents the pressure in the arteries at the moment the heart is actively pumping blood into the system. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&rect=0%2C17%2C1128%2C940&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207296/original/file-20180221-132660-4jcl4o.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">South African president Cyril Ramaphosa takes a morning walk in Cape Town.</span>
<span class="attribution"><span class="source">Twitter</span></span>
</figcaption>
</figure>
<p>Diastolic, the “second number”, represents pressure in the arteries during the heart’s rest period. In other words, it stands to reason that this pressure should be considerably lower than systolic and if it isn’t, it represents certain risk for cardiovascular event.</p>
<p>The reduction can be statistically significant enough to save a life. For example, if a person’s diastolic blood pressure is 90 mm Hg they would be at considerable risk of blood pressure related events. Reducing the figure by 5 mm Hg shifts them from the “mild hypertension” category of risk to “high normal”. </p>
<p>Current <a href="http://www.heartfoundation.co.za/blood-pressure/">statistics</a> show that one in three South African adults have high blood pressure. <a href="http://www.heartfoundation.co.za/">Ten</a> South Africans suffer a stroke every hour. </p>
<h2>It decreases body fat</h2>
<p>Humans were designed to move for optimal functioning, and were designed to handle walking great distances over many hours.</p>
<p>Walking can contribute to improved body composition, with statistically significant <a href="http://bjsm.bmj.com/content/bjsports/49/11/710.full.pdf">reductions</a> in body fat. To put this into perspective, this doesn’t include any dietary changes, and evidence shows that exercise <a href="https://www.sciencedirect.com/science/article/pii/S2212267214010557">combined</a> with a change in diet produces greater changes to body composition than exercise alone.</p>
<h2>Reduces symptoms of depression</h2>
<p>Rates of depression have risen <a href="http://www.sadag.org/index.php?option=com_content&view=article&id=2782:20-increase-in-global-depression-in-a-decade&catid=61&Itemid=143">20%</a> globally in a decade. This places depression as one of the leading causes of disability worldwide. </p>
<p>Walking has been recommended for managing symptoms of depression for a long time. It’s been identified as an <a href="http://bjsm.bmj.com/content/bjsports/49/11/710.full.pdf">effective strategy</a>, particularly when combined with the positive effects of sunshine and fresh air, as well as the social cohesion experienced when in a group.</p>
<h2>No adverse side effects</h2>
<p>Probably the best news: when individuals around the world participated in various walking programmes based on the <a href="http://bjsm.bmj.com/content/bjsports/49/11/710.full.pdf">review of these studies</a>, no notable adverse side effects were reported.</p>
<p>Walking is safe for children, adults and older adults alike. The take home message here is that there is nothing to lose from trying it out, and plenty to gain.</p><img src="https://counter.theconversation.com/content/92114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Viljoen 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>There are many benefits to walking - whether you do it in a group or on your own.Janet Viljoen, Course coordinator for postgraduate level Certificate in Ergonomics, Rhodes UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/781022017-05-29T20:08:36Z2017-05-29T20:08:36ZHow old is too old for cholesterol lowering medications?<figure><img src="https://images.theconversation.com/files/171258/original/file-20170529-6389-1m07ivg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The benefits of healthy older people taking statins to prevent heart disease and stroke needs to be balanced with the risk of side effects.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/553402195?src=NeI1SCLJF787TeqJ22xBiA-3-23&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>There is growing debate about whether doctors should prescribe statins to otherwise healthy older people to reduce their risk of developing their first <a href="https://www.heartfoundation.org.au/about-us/what-we-do/heart-disease-in-australia">heart attack or stroke</a>.</p>
<p>Now the debate has reignited with the publication of a <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2628971">new analysis</a> that casts doubt on their benefit for people over the age of 65, and raised concern of the potential for harm in people aged over 75.</p>
<p><a href="https://www.healthdirect.gov.au/statins">Statins</a> are the most commonly used cholesterol lowering medications in Australia. In <a href="http://www.pbs.gov.au/info/statistics/expenditure-and-prescriptions-30-06-2011">2010-2011</a> they were taken by 2.6 million Australians with 16 million scripts dispensed from June 2011 to June 2012.</p>
<p>They are prescribed to <a href="https://theconversation.com/some-things-you-should-know-about-statins-and-heart-disease-19655">lower blood lipid levels</a> and so reduce people’s chances of heart disease, including stroke, and to prolong life.</p>
<p>In particular, this class of drugs inhibits how the body makes <a href="https://www.heartfoundation.org.au/your-heart/know-your-risks/blood-cholesterol">low-density lipoprotein cholesterol</a> or bad cholesterol.</p>
<p>Different statins reduce bad cholesterol to different extents. For example, <a href="https://theconversation.com/weekly-dose-lipitor-the-highest-selling-drug-of-all-time-55706">atorvastatin</a> and rosuvastatin produce larger reductions in bad cholesterol per milligram of drug than a different statin, pravastatin (<a href="http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)31357-5/fulltext">about 50% vs 30%</a>).</p>
<hr>
<p><em>Further reading: <a href="https://theconversation.com/some-things-you-should-know-about-statins-and-heart-disease-19655">Some things you should know about statins and heart disease</a></em></p>
<hr>
<p>The issue of whether to prescribe statins for older people is particularly important given the growing segment of our population living into their <a href="http://www.aihw.gov.au/australias-health/2016/">70s and 80s</a>.</p>
<p>About <a href="https://www.mja.com.au/journal/2012/196/1/national-census-medicines-use-24-hour-snapshot-australians-aged-50-years-and?0=ip_login_no_cache%3Db2b572005b77c06053d179b7c8ddb535https://www.mja.com.au/journal/2012/196/1/national-census-medicines-use-24-hour-snapshot-australians-aged-50-years-and?0=ip_login_no_cache%3Db2b572005b77c06053d179b7c8ddb535">one third</a> of Australians over the age of 70 years are taking statins. And they could potentially be used by more older people as, based on their age alone, these are the people at highest risk of heart disease or stroke.</p>
<p>In people who already have heart disease or who have had a stroke, the benefits of statins are clear. Taking statins <a href="http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)31357-5/fulltext">reduces your chance</a> of another cardiovascular event whatever your age.</p>
<p>Doctors justify prescribing statins for this group by looking at a figure called the “<a href="http://www.thennt.com/thennt-explained/">number needed to treat</a>”. In the case of statins, researchers <a href="https://doi.org/10.1016/j.jacc.2007.06.063">calculate</a> 28 people with existing heart disease or who had had a stroke would need to be treated for five years to prevent one death, a figure low enough to warrant treatment.</p>
<h2>Mixed evidence</h2>
<p>In people <em>without</em> heart disease or who have not had a stroke, <a href="http://insights.ovid.com/pubmed?pmid=24866986">the benefits of statins are less clear for those aged 70 years or older</a>. Most national and international guidelines, including those from the <a href="https://www.heartfoundation.org.au/">Heart Foundation</a>, have not been able to make strong recommendations to guide prescribing for older people. And any recommendations they do make are mostly based on trials of statins in people under the age of 70.</p>
<p>Some trials including older people without heart disease have reported <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)11600-X/fulltext">no</a> <a href="http://www.nejm.org/doi/10.1056/NEJMoa1600175">benefits</a> whereas others have reported <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2946369/pdf/nihms174735.pdf">large benefits</a>.</p>
<p>To complicate things further, <a href="http://circ.ahajournals.org/content/135/20/1979.long">pooling</a> results of two of these trials finds statins reduce cardiovascular events in people aged under 65 years (by about 25%), 65-70 years (by about 50%) and over 70 years (by about 25%).</p>
<p>Due to the conflicting figures, researchers have not pooled the results to calculate a “number needed to treat” for healthy older people taking statins to prevent their first heart attack or stroke.</p>
<p>The debate about the benefits of statins for older people also needs to take into account the increased likelihood of side-effects from medications in this age group.</p>
<p>Researchers have not well studied side effects with statin use in older people. However, the issues <a href="https://www.fda.gov/Drugs/DrugSafety/ucm293101.htm">most likely</a> to be of concern to older people are muscle aches and weakness, muddled thinking and diabetes.</p>
<h2>What does the latest evidence say?</h2>
<p>The latest <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2628971">analysis</a> revisits selected results from a large trial completed some 13 years ago. The researchers considered data from 2,867 participants over 65 without any evidence of heart disease who were randomly assigned to the statin pravastatin or usual care, then followed for over 4.5 years.</p>
<p>The researchers looked at the effects of the statin on deaths from any cause, and deaths from heart disease and heart attacks in people aged 65-75 and over 75. They found no difference in any of these outcomes for either of the age groups and even raised concern of the potential for harm in people aged over 75. </p>
<p>The study authors concluded that the benefits previously ascribed to statins may have been overstated for older people.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171259/original/file-20170529-6408-1wua8an.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">The latest study, which casts doubt on statin use in the elderly, had several flaws.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=ZORffPxg2ASpRzkgZNeVTw-1-3">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>To gauge what these new findings mean, we first need to consider the statin used in the study, pravastatin. Doctors don’t prescribe this so commonly to lower cholesterol nowadays because it has been replaced by stronger statins. </p>
<p>Second, by the end of the study many people in the statin group had stopped their treatment while people in the usual care group had started treatment, either on pravastatin or another statin. This makes it very hard to see which outcome could be the result of the drug itself.</p>
<p>Also, the study may not have included enough older people. Studies aiming to prevent disease in healthy people need many thousands as most will not suffer heart attacks and strokes irrespective of which treatment group they are in.</p>
<h2>So where does that leave us?</h2>
<p>To plug this gap in the research, we are are conducting the <a href="http://www.staree.org.au/">first trial</a> of its kind in the world to look at the effects of statins on healthy ageing.</p>
<p>This statin trial, which is unusual as it is not funded by the pharmaceutical industry, is the first randomised controlled trial of statins in healthy older Australians (aged 70 or older) living independently in the community. </p>
<p>When the results from its 18,000 participants are in, we will have a clearer picture of the effects of statins on overall survival, survival free of dementia and disability, as well as cardiovascular events over an average five years of treatment. </p>
<h2>If you’re on statins, what should you do?</h2>
<p>Older people <em>with</em> heart disease or who’ve had a stroke should continue taking their prescribed statin as the benefits are clear. However, they should discuss any side effects with their doctor.</p>
<p>Older people <em>without</em> heart disease or who have not had a stroke should discuss the potential benefits and harms of statins with their doctor before starting or continuing treatment. </p>
<p>This discussion should take into account a person’s preference for statins and other measures to reduce their risk of heart disease, include having a healthy diet, being physically active and stopping smoking.</p><img src="https://counter.theconversation.com/content/78102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sophia Zoungas receives funding from the NHMRC and is the Principal Investigator of the StarEE Trial mentioned in the article.</span></em></p>An Australian trial will give us a clearer picture of whether healthy old people benefit from taking statins to prevent heart disease and stroke.Sophia Zoungas, Professor and Head, Diabetes and Vascular Medicine Research Program, School of Public Health and Preventive Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/686822016-11-23T21:02:24Z2016-11-23T21:02:24ZHow South Africa can beat its sugar-fuelled diabetes epidemic<p>Four times as many people have Type II diabetes today as 36 years ago, <a href="http://www.who.int/mediacentre/factsheets/fs312/en/">according to the World Health Organisation</a>.
In 1980, 108 million people were diagnosed with diabetes worldwide. By 2014, the figure was 422 million. </p>
<p>In South Africa, <a href="http://www.idf.org/membership/afr/south-africa">7% of adults aged 21 to 79</a> – 3.85 million people – have diabetes. A large proportion of these remain undiagnosed. </p>
<p>The global prevalence of adult diabetes has nearly doubled – and is rising more rapidly in middle- and low-income countries. Globally, about 1.5 million people died as a direct result of diabetes in 2012. </p>
<p>Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. Stringent glucose control has reduced some small-vessel complications such as blindness and kidney failure. The residual risk of large-vessel complications such as heart attacks and stroke remains high. </p>
<h2>Cause and effect</h2>
<p>Excessive calorie consumption and sedentary lifestyles are the main contributors to the development of diabetes. Some people with a genetic predisposition to the disease are considered high risk, but it is largely preventable.</p>
<p>As South Africans become more urbanised, exposure to high-caloric, processed foods has increased, and rates of diabetes with it. </p>
<p>Being able to buy processed “food-like” products is often seen as a mark of personal and material success. Little attention is paid to having a healthy diet. Intense <a href="http://care.diabetesjournals.org/content/34/6/1249.short">advertising</a> campaigns by the beverage and “<a href="http://www.nytimes.com/2013/02/24/magazine/the-extraordinary-science-of-junk-food.html">food product</a>” industries exacerbate the problem. </p>
<p>An <a href="https://www.ncbi.nlm.nih.gov/pubmed/26429086">abundance of evidence</a> links the intake of <a href="https://theconversation.com/the-amount-of-hidden-sugar-in-your-diet-might-shock-you-21867">beverages high in sugar</a> – like soft drinks and energy drinks – to a high risk of developing diabetes and obesity. </p>
<p>The average South African is unaware that a can of a cool drink typically <a href="http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/">contains nearly 10 teaspoons of sugar</a>. The World Health Organisation <a href="http://apps.who.int/iris/bitstream/10665/149782/1/9789241549028_eng.pdf?ua=1">recommends</a> that people not consume more than 12 teaspoons of added sugar per day. Keeping the daily intake under six teaspoons has further health benefits.</p>
<p>Lifestyles have become more sedentary and work environments are not conducive to physical activity. Patients often quote crime, road safety concerns and poorly maintained parks and recreational areas as reasons for not exercising outdoors.</p>
<p>The South African government has taken a great interest in non-communicable diseases. But its focus is on tuberculosis and HIV, which have individual budget allocations. Diabetes is under the general non-communicable diseases <a href="http://www.idf.org/sites/default/files/attachments/South%20Africa_Scorecard.pdf">budget</a>. Non-governmental organisations receive little to no funding for diabetes education, prevention or supplies.</p>
<h2>The challenges with treatment</h2>
<p>The health system offers comprehensive services for diabetes care and prevention. But these are not universally implemented, possibly due to lack of funds or maladministration. </p>
<p>As a result, the quality of treatment is poor. Drug shortages are common in the public sector. Newer therapies with fewer side effects have yet to make it into this sector. </p>
<p>A further problem is the high cost of treatments in both the private and public sectors. The heath care system covers 50% to 80% of the cost. </p>
<p>Self-management education is limited and the role of diabetic nurse educators is underplayed. There are no specialised services for vulnerable population groups.</p>
<h2>Modifying the present to change the future</h2>
<p>The complexities of the epidemic require a multipronged response.</p>
<p>Those diagnosed with diabetes need nothing short of the best available health care. That includes patient education to improve their lifestyle: eating well, exercising and not smoking or drinking. </p>
<p>Screening rates need to be increased to detect the undiagnosed. <a href="http://www.rxfiles.ca/rxfiles/uploads/documents/CHT-Diabetes-Landmark-Trials-Links.pdf">Multiple studies</a> show that early detection and treatment can offer a normal quality of life by reducing complications and death. Screening for complications such as diabetic eye disease should be done regularly.</p>
<p>The government also needs to review the dietary guidelines in line with emerging evidence that previous guidelines were manipulated by industry. In the developed world, several countries have introduced low-carb diets based on new <a href="//phcuk.org/wp-content/uploads/2016/05/Healthy-Eating-Guidelines-Weight-Loss-Advice-For-The-United-Kingdom-Public-Health-Collaboration.pdf">evidence</a>. South Africa is yet to catch up. </p>
<p>Secondly, healthcare facilities have to be improved and medical practitioners provided with the resources they need to provide the correct assessments and treatment. </p>
<p>Great strides have been made in developing new treatments. Two drugs, <a href="https://www.drugs.com/cdi/liraglutide.html">liraglutide</a> and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1504720#t=article">empagliflozin</a>, have shown life-saving benefits of reduced cardiovascular risk and a favourable side-effect profile. Other drugs from these classes (Incretins and SGLT2 inhibitors) help manage diabetes effectively but have yet to show cardiovascular benefit. These newer agents also reduce weight and lower the risk of hypoglycemia as a side effect.</p>
<p>New oral agents such as DPP 4 inhibitors combined with existing treatments such as metformin allow for minimal to no risk of hypoglycemia. This makes them ideal for prescription by nurses at primary health clinics as first and second line treatments.</p>
<p>Insulin technology has evolved too, which may help patients achieve diabetic targets. Newer insulins require less frequent injections and monitoring and lower the risk of low blood glucose.</p>
<p>The <a href="http://www.semdsa.org.za">Society for Endocrinology, Metabolism and Diabetes of South Africa</a> is set to release new evidence-based treatment guidelines early in 2017. </p>
<p>These will guide health practitioners, inform patients and be a useful tool to teach medical undergraduate and postgraduate students. The guidelines will contain individualised approaches to treat the diverse diabetic population and allow for evolution in treatments.</p>
<p>Currently, we are engaged in an industrialised version of medical practice that focuses on treatment. While this is life-saving and essential, anyone experienced in the field of diabetes understands the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2009.00550.x/full">benefit of preventing</a> the epidemic altogether.</p>
<p>The structural <a href="http://jpl.sagepub.com/content/16/2/202.short">urban environment challenges</a> require government action. Also, better funding and specialist training in the field of diabetes are needed. Centres of excellence in diabetes with an emphasis on research and promotion of local scientists and diabetes nurse educators are essential.</p>
<p>Issues of food and agriculture also demand attention. Farming techniques to produce real food at cheaper costs must be developed. The promotion and protection of current farmers and development of skilled new farmers should be part of the preventative health discussion.</p>
<p>Advocacy groups such as the <a href="http://heala.org">Healthy Living Alliance</a> are emerging. Civil rights associations are also getting involved in the conversation. These, together with public health entities such as <a href="http://www.pricelesssa.ac.za">Priceless SA</a>, require support and <a href="http://www.idf.org/sites/default/files/attachments/South%20Africa_Scorecard.pdf">funding</a>. </p>
<p>The imminent <a href="https://theconversation.com/why-africa-should-resist-the-power-of-big-sugar-to-undermine-public-health-68295">sugar tax</a> is a step in the right direction towards reducing consumption of sugar-sweetened beverages. </p>
<p>The tax revenue could be used to improve health care facilities and the stock and distribution of diabetes drugs. It could also be directed to organisations working to improve the country’s diabetes landscape. </p>
<p>Prevention and early treatment of diabetes will result in enormous <a href="http://www.samj.org.za/index.php/samj/article/view/8727/6218">economic benefits</a>. These include not just the savings on the costs of treatment, complications and disability, but also the economic growth generated by a healthy working population.</p><img src="https://counter.theconversation.com/content/68682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sundeep Ruder 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>Being able to buy processed “food-like” products is often seen as a mark of personal and material success. Little attention is paid to having a healthy diet.Sundeep Ruder, Clinical Endocrinologist & Associate Lecturer, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/589622016-06-12T17:42:46Z2016-06-12T17:42:46ZWhy African genomic studies can solve the continent’s health issues<figure><img src="https://images.theconversation.com/files/125892/original/image-20160609-7093-9835mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Genomic research in Africa will help explain the genetic risk factors of diseases that affect the world's poorest people.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Genomic research has proven to be a considerably valuable tool in global attempts to tackle disease. </p>
<p>One crucial part of this research has been identifying diseases and health problems that are more likely to be influenced by genetic factors and assessing the risk of a particular disease in an individual. </p>
<p>Eventually scientists will be in a position to develop new ways to treat, cure or even prevent the thousands of diseases that afflict humankind. And it will also allow them to assess the risk that exposure to toxic agents poses to individuals.</p>
<p>But for the world’s poorest people, the diseases that affect them have remained understudied. This is mainly due to most of these studies focusing on the genetic risk factors for disease in European populations. </p>
<p>For example, recent <a href="http://www.ncbi.nlm.nih.gov/pubmed/27231129">studies</a> from Sweden’s Uppsala University show men with blood cells that don’t carry the Y chromosome – a sex chromosome normally only present in male cells – are at greater risk of being diagnosed with Alzheimer’s disease. They also have an increased risk of death from other causes, including many cancers. </p>
<p>But will African men be affected in the same way? African populations have evolved significantly over time. Their genetic composition is more diverse than that of European and other populations so this may not be the case. Very little is known about the nature and extent of this diversity. </p>
<p>With the high burden of disease in sub-Saharan Africa, medical research needs a significant boost on the continent to identify genetic risk factors for diseases and to tackle the spread of drug resistance and emerging infections. </p>
<p>Genomic research has gained considerable momentum on the continent in the past decade. But challenges, such as a lack of high-quality clinical and epidemiological data across all countries, still hamper efforts. </p>
<h2>A different genetic makeup</h2>
<p>Genetic research taking place in Africa has focused on the genomic and environmental risk factors for cardiometabolic disease in Africans. Cardiometabolic diseases are those associated with the heart and include strokes, heart attacks and diabetes. </p>
<p>According to the statistics, non-communicable diseases such as diabetes, cancer, heart disease and chronic respiratory illness have all <a href="http://www.afro.who.int/en/clusters-a-programmes/dpc/non-communicable-diseases-managementndm/npc-features/1236-non-communicable-diseases-an-overview-of-africas-new-silent-killers.html">skyrocketed</a> in sub-Saharan Africa in the past ten years. </p>
<p>Globally, more than 16 million people die from non-communicable diseases. Of these, 80% are in low- and middle-income countries. </p>
<p>Research teams are trying to understand the interplay between genetic factors, the changes in the way the gene expresses itself, or <a href="http://www.whatisepigenetics.com/fundamentals/">epigenetics</a>, and environmental risk factors for obesity and related heart diseases. They are using existing longitudinal cohorts from four countries: Kenya, South Africa, Ghana and Burkina Faso. And they have six study sites across these countries, which have undergone different population changes as a result of their individual burdens of disease.</p>
<p>The goal of this initiative, the first of its kind in Africa, is to develop the capacity to carry out these kinds of studies in populations around the continent. This would help scientists better understand the genetic and genomic markers for disease. </p>
<p>One of the diseases that the study is attempting to understand is alcoholism. </p>
<p>Global studies have shown that the amount of alcohol one drinks and whether this progresses to alcoholism has a <a href="http://journals.cambridge.org/download.php?file=%2FPSM%2FPSM41_07%2FS003329171000190Xa.pdf&code=fc8c518b7edd5761e6bbfbf916a408e1">genetic influence</a>. Separate <a href="http://www.wales.nhs.uk/sitesplus/documents/888/%2812%29%20Graham%20Burdge.pdf">findings</a> show that processes that are related to factors in the gene, but that do not change the sequence of the DNA, also play a role. These are known as epigenetic processes.</p>
<p>And in European, North American and Asian populations, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181942/">research</a> has drawn a correlation between genetic variations for drugs and dependence. </p>
<p>Alcohol consumption and problems related to alcohol vary widely around the world but the burden of disease and death remains significant in most countries. It is the world’s third largest risk factor for disease and disability. </p>
<p>It is also one of the four risk factors that lead to people developing non-communicable diseases such as heart attacks and strokes. In middle-income countries, it is the greatest risk factor. </p>
<p>But very little is known about the risk of alcohol consumption in sub-Saharan African populations. This is despite statistics from the World Health Organisation listing 17 countries on the continent as <a href="http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf">heavy drinking countries</a>. Nigeria takes the lead. </p>
<p>The high toll of alcohol and drug over-consumption among African populations means that this must become a priority. Understanding the genetic and genomic markers of diseases such as alcoholism would lead to research interrogating whether drug use and abuse are genetically linked. </p>
<p>And this could lead to an evidence-based approach to control drug use and abuse that fits the African context. It would help the continent improve its efforts to eliminate one of the four main risk factors for non-communicable disease.</p>
<h2>Challenges and solutions</h2>
<p>The amount of available genomic information has grown rapidly in the past decade, mainly due to the falling cost and increasing efficiency of DNA sequencing technologies. </p>
<p>But DNA sequencing is still relatively expensive for large-scale studies. Africa lags behind other continents with such studies. This is mainly due to: </p>
<ul>
<li><p>a shortage of African scientists with genomic research expertise; </p></li>
<li><p>lack of biomedical research infrastructure; </p></li>
<li><p>limited computational expertise and resources; </p></li>
<li><p>lack of adequate support for biomedical research by African governments; and</p></li>
<li><p>the participation of many African scientists in collaborative research at no more than the level of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4138491/">sample collection</a>. </p></li>
</ul>
<p>Although scientists on the continent are unable to match the scale of research produced on other continents, they are continuously attempting large-scale genome-sequencing studies focused on specific diseases. </p>
<p>The <a href="http://h3africa.org/">H3Africa project</a>, funded by the <a href="https://www.nih.gov">National Institutes of Health</a> and the Wellcome Trust, supports several studies involving collaborative centres on the continent.</p>
<p>In addition, ongoing genomic projects in Africa are both establishing infrastructure for genomic research and training local researchers, as well as generating genomic datasets. </p>
<p>Many of these projects have made capacity building one of their core missions. This will in the long run build a critical mass of highly skilled individuals in the field shaping the future of genomic studies in Africa.</p><img src="https://counter.theconversation.com/content/58962/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas N Ngomi 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>Genomic research must take place in Africa because African populations have evolved significantly and their genetic composition is more diverse than that of populations elsewhere.Nicholas N Ngomi, Research officer, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/592962016-05-17T15:40:47Z2016-05-17T15:40:47ZHypertension: why the approach to tackle the silent killer has changed<figure><img src="https://images.theconversation.com/files/122862/original/image-20160517-9471-1vwcbny.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">Shutterstock</span></span></figcaption></figure><p>Traditionally, someone who suffered from hypertension – or high blood pressure – would only receive treatment when his or her blood pressure was measured and the reading was found be higher than normal. But this meant that the condition was often picked up only when the person had a stroke or a heart attack – and in many instances this was too late. </p>
<p>As a result of this, the thinking on when to treat hypertension has changed in the past few years. Research has shown that hypertension should not only be diagnosed on the basis of one blood pressure reading, as this reading could vary and be raised by other triggers such as stress.</p>
<p>Instead, doctors make use of a <a href="http://cvdrisk.nhlbi.nih.gov/">risk assessment tool</a> that measures the overall cardiovascular risk of a patient. The tool estimates the risk that a person faces over the next ten years of having a heart attack. </p>
<p>They do this by looking at the risk factors patients are exposed to: what is their age and gender? Do they smoke? Are they overweight or obese and do they have high cholesterol levels or diabetes? The tool determines a patient’s risk of developing cardiovascular disease in the next ten years and guides doctors on whether or not they should prescribe high blood pressure treatment to reduce the patient’s risk.</p>
<p>This is because hypertension rates and associated risky lifestyle behaviours are on the rise – especially in the developing world. </p>
<p>Globally about <a href="http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/blood_pressure_prevalence/atlas.html">22%</a> of adults over the age of 18 suffer from hypertension, according to statistics from the World Health Organisation in 2014. But in Africa, this figure is higher and sits at 30%.</p>
<p>In South Africa, <a href="http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/blood_pressure_prevalence/atlas.html">28% of the adult population</a> suffers from hypertension compared with 23% in Brazil and 25% in China. And among adults older than 50 the rate of hypertension is as high as 70%. </p>
<p>Hypertension is one of the leading causes of cardiovascular diseases such as stroke, heart attacks, heart failure, peripheral vascular disease and kidney disease. </p>
<h2>Why treatment methods have changed</h2>
<p>The challenge with hypertension is that there are usually no warning signs or symptoms for someone suffering from hypertension. Hypertension is often referred to as the “silent killer”, as a heart attack or a stroke may be the first warning sign. </p>
<p>But patients do classically have a combination of other risk factors. These include having an unhealthy diet, not exercising, and smoking and drinking too much. And it is the effects of these behavioural risk factors that may show up in patients as hypertension, raised blood glucose, raised cholesterol, and being overweight and obese.</p>
<p>As a result, it is estimated that in South Africa only 26% of men and 51% of women <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721893/">are aware</a> that they suffer from hypertension.</p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721893/">research</a> shows that in South Africa hypertension is the leading reason that people seek help from primary care facilities such as clinics. It is also the most common diagnosis in primary care in the country. </p>
<h2>Changing your lifestyle can help</h2>
<p>Treating hypertension is not only about taking tablets. Someone with raised blood pressure can also reduce it by changing their behaviour. There are several guidelines that should be followed:</p>
<ul>
<li><p>Reduce salt intake as it raises blood pressure. The South African government has recently <a href="https://theconversation.com/south-africas-bold-move-on-salt-gets-off-to-a-shaky-start-42256">legislated</a> salt intake, ruling that salt content in common foods such as bread should be reduced. As an extra measure, people should not add extra salt to their food and avoid very salty processed foods such as packet soups, stock cubes or gravies. </p></li>
<li><p>Lose weight. People who are overweight or obese have a higher risk of suffering from hypertension. The key is to eat healthily, exercise and reduce meal portions. Instead of large amounts of starchy food, fruit and vegetable intake must be increased and fatty foods and sugar reduced. </p></li>
<li><p>Drink less. Alcohol also increases blood pressure so it is important to only drink in moderation. Men should not exceed two drinks a day and women one drink a day. </p></li>
<li><p>Exercise more. At least 150 minutes of exercise a week translates into 30 minutes a day, which raises the heart rate. </p></li>
<li><p>Smoke less. A person who smokes can reduce their cardiovascular risk further by cutting down or stopping smoking altogether. </p></li>
</ul>
<p>Even when patients are on treatment for hypertension it is still important for them to try to change their behaviour as this reduces the amount of medication they need to control their blood pressure. </p>
<p>But most importantly, diagnosis is important. Many people are unaware of their cardiovascular risk and raised blood pressure. People should check their blood pressure at least once every five years to ensure that it is normal. This can be done at a clinic or even a pharmacy.</p><img src="https://counter.theconversation.com/content/59296/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>Hypertension is one of the leading causes of cardiovascular diseases such as stroke, heart attacks, heart failure and peripheral vascular disease. And in the developing world, it is on the rise.Bob Mash, Division of Family Medicine and Primary Care, Stellenbosch UniversityZelra Malan, Senior Lecturer, Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.