Cardiovascular Medicine and Surgery
Omega-3 fatty acids
Omega-3 fatty acids (n-3 fatty acids) are commonly used to reduce triglyceride levels.1 Their place in therapy for treating cardiovascular disease has been established by notable landmark studies such as GISSI-Prevenzione trial, GISSI Heart Failure study, and the Japan EPA Lipid Investigation Study (JELIS). 2-4
In a recent randomized, placebo-controlled study published in the New England Journal of Medicine,5 n-3 fatty acids did not reduce the revised primary endpoint of time to death from cardiovascular (CV) causes or hospital admission for CV causes. Unlike previous trials that studied patients with a history of myocardial infarction2, 4 and heart failure,3 this study was conducted in a primary prevention population of patients with multiple risk factors for CV disease or clinical evidence of atherosclerotic vascular disease.
Over 12,000 patients in Italy were randomized to receive either 1 g of n-3 fatty acids or placebo (olive oil). After 5 years of follow-up, the primary endpoint occurred in 733 of 6,239 (11.7%) patients who received n-3 fatty acids compared with 745 of 6,266 (11.9%) patients in the placebo group (adjusted HR 0.97; 95% CI 0.88 to 1.08; P = .58). Additionally, the two groups did not differ significantly in the study\'s secondary endpoints, such as sudden death from cardiac causes and death from CV causes. Rates of adverse events were similar between the two groups. It must be noted that the investigators had to change their primary endpoint 1 year into the study due to a lower than expected event rate. The primary efficacy endpoint as defined in the beginning of the trial was the cumulative rate of death, nonfatal MI, and nonfatal stroke. The endpoint was then changed to the composite of time to death from CV causes or hospital admissions for CV causes. The applicability of this study to the American population is debatable since this was conducted exclusively in the Italian population. It is possible that the study population already had a diet reflective of the "Mediterranean diet," which is higher in polyunsaturated fatty acids, fruits, vegetables, nuts, and seeds and lower in saturated fat and red meat compared with the typical American diet.
Dr. Jun R. Chiong, FCCP
Ex Officio NetWork Member
References
1. National Cholesterol Education Program. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. NIH Pub. No. 02-5215. Bethesda, MD: National Heart Lung, and Blood Institute, 2002.
2. Gruppo Italiano per lo Studio della Sopravvienza nell’Infarto Miocardico. Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Lancet. 1999;354(9177):447-455.
3. Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial. Lancet. 2008;372(9645):1223-1230.
4. Yokoyama M, Origasa H, Matsuzaki M, et al. Effects of eicosopentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet. 2007;(9567):369:1090-1098.
5. The Risk and Prevention Study Collaborative Group. N-3 fatty acids in patients with multiple cardiovascular risk factors. N Engl J Med. 2013;368(19):1800-1808.
Chest Infections
Aerodigestive chest infections in the elderly: when reflux is more than reflux
Mrs. Smith is a delightful and spunky 78-year-old woman who lives in Palm Springs, California,; enjoys playing bridge,; and watches reruns of Matlock. She has a chronic cough that alienates her from her friends. She has no gag reflex, speaks with a gurgling voice, and coughs when drinking. She was admitted four times last year for pneumonia.
Many elderly patients have aspirations that land them in the hospital with pneumonia. They carry the diagnosis of reflux, but their studies show "little aspiration," underestimating their problem. Impaired secretion clearance, medication-related diminished production of saliva, dental disease due to poor oral hygiene, chronic pharmacologic acid suppression, late dinners, and sleep aids that change their sleep architecture are all factors that make cough due to oropharyngeal dysfunction in elderly patients quite frequent.
Such disorders can constitute a threat for life due to malnutrition, dehydration, hypoxia, respiratory failure, and cardiac arrest. The provider is challenged by the desire to alleviate a symptom that alters quality of life while not subjecting the patient to invasive diagnostics.
Effective management requires a multidisciplinary aerodigestive team approach. This includes a careful assessment of the oropharyngeal anatomy; nutritional status; cognition; swallowing retraining; lifestyle modifications (eg, elevation of the head of bed); separation of phonation and deglutition; eating small, thickened meals several times a day; and aggressive oral care. It may be time for aerodigestive centers akin to the ones already in place for children.