Tag Archives: Cardiovascular

Lifestyle reduction of cardiovascular risk factors improves erectile dysfunction

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While hormone balance, autonomic nervous system function, anatomic and other factors are necessary aspects of case management for erectile dysfunction, the capacity of the local vascular system to regulate blood delivery to the tissues of interest is as important for sexual as it is for cardiac function. No wonder a paper just published in the Archives of Internal Medicine provides evidence that lifestyle modification of cardiovascular function improves erectile dysfunction. The authors state:

“Erectile dysfunction (ED) shares similar modifiable risks factors with coronary artery disease (CAD). Lifestyle modification that targets CAD risk factors may also lead to improvement in ED. We conducted a systematic review and meta-analysis of randomized controlled trials evaluating the effect of lifestyle interventions and pharmacotherapy for cardiovascular (CV) risk factors on the severity of ED.”

They examined multiple electronic databases from randomized controlled clinical trials with follow-up of at least 6 weeks of lifestyle modification intervention or pharmacotherapy for cardiovascular risk factor reduction. Their main outcome measure was differences in the International Index of Erectile Dysfunction (IIEF-5) score. Their data demonstrated significant effectiveness:

“A total of 740 participants from 6 clinical trials in 4 countries were identified. Lifestyle modifications and pharmacotherapy for CV risk factors were associated with statistically significant improvement in sexual function (IIEF-5 score): weighted mean difference, 2.66. If the trials with statin intervention (n = 143) are excluded, the remaining 4 trials of lifestyle modification interventions (n = 597) demonstrate statistically significant improvement in sexual function: weighted mean difference, 2.40.”

Readers may wish to search this site for several reports on the cautions and limitations associated with statin use. There are, however, no risks associated with skillful lifestyle modification of CV risk factors. The authors conclude:

“The results of our study further strengthen the evidence that lifestyle modification and pharmacotherapy for CV risk factors are effective in improving sexual function in men with ED.”

High cortisol and low DHEA both predict increased cardiovascular mortality

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More evidence for the link between adrenal dysregulation and death from cardiovascular disease is reported in a study recently published in the Journal of Clinical Endocrinology & Metabolism. The authors observe:

“The stress hormone cortisol has been linked with unfavorable cardiovascular risk factors, but longitudinal studies examining whether high levels of cortisol predict cardiovascular mortality are largely absent…The aim of this study was to examine whether urinary cortisol levels predict all-cause and cardiovascular mortality over 6 yr of follow-up in a general population of older persons.”

They studied 861 subjects by assessing 24 hour urinary cortisol levels at the beginning, then followed them for 6 years during which they documented death from all causes and death from ischemic and cerebrovascular disease in particular. What did the data show?

“After adjustment for sociodemographics, health indicators, and baseline cardiovascular disease, urinary cortisol did not increase the risk of noncardiovascular mortality, but it did increase cardiovascular mortality risk. Persons in the highest tertile of urinary cortisol had a five times increased risk of dying of cardiovascular disease. This effect was found to be consistent across persons with and without cardiovascular disease at baseline.”

Their concluding comments express the robustness of their findings and suggest that circulatory damage may be an important mechanism by which high cortisol is so harmful for the brain:

“High cortisol levels strongly predict cardiovascular death among persons both with and without preexisting cardiovascular disease. The specific link with cardiovascular mortality, and not other causes of mortality, suggests that high cortisol levels might be particularly damaging to the cardiovascular system.”

Interestingly, we find another paper just published in the same journal that ‘fleshes out’ the connection between adrenal dysregulation and death from cardiovascular disease. The authors state:

“The age-related decline in dehydroepiandrosterone (DHEA) levels is thought to be of importance for general and vascular aging…We tested the hypothesis that low serum DHEA and DHEA sulfate (DHEA-S) levels predict all-cause and cardiovascular disease (CVD) death in elderly men.”

Both cortisol and DHEA, an important androgen for vitality, body composition, mood and immune regulation, are produced in the adrenal glands. Excessive production of cortisol typically depletes the resources to produce DHEA, a phenomenon call the ‘pregnenolone steal’. The authors analyzed baseline levels of DHEA in 2644 Swedish men, then correlated this with mortality data:

“Low levels of DHEA-S predicted death from all causes; but not cancer. Analyses with DHEA gave similar results.”

It was particularly interesting to note that…

“The association between low DHEA-S and CVD death remained after adjustment for C-reactive protein and circulating estradiol and testosterone levels. When stratified by the median age of 75.4 yr, the mortality prediction by low DHEA-S was more pronounced among younger  than older men.”

The discerning clinician will recognize that for cardiovascular risk assessment to be complete, cortisol and DHEA levels should be evaluated—ideally by salivary hormone collections that delineate the important diurnal cortisol rhythm.

Incorrect testosterone supplementation can increase cardiovascular risk

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New England Journal of MedicineAn important paper just published in The New England Journal of Medicine is a reminder that supplementing any hormone to levels above the normal physiological range can backfire. The authors intent was to investigate the safety and efficacy of testosterone treatment in older men with mobility limitations.

“Community-dwelling men, 65 years of age or older, with limitations in mobility and a total serum testosterone level of 100 to 350 ng per deciliter or a free serum testosterone level of less than 50 pg per milliliter were randomly assigned to receive placebo gel or testosterone gel, to be applied daily for 6 months.”

Things turned out so poorly that…

“The data and safety monitoring board recommended that the trial be discontinued early because there was a significantly higher rate of adverse cardiovascular events in the testosterone group than in the placebo group.”

As the data came in a worrisome picture clearly emerged:

“…the testosterone group had higher rates of cardiac, respiratory, and dermatologic events than did the placebo group…The relative risk of a cardiovascular-related adverse event remained constant throughout the 6-month treatment period.”

There is an extremely important practical message here buried in the data for anyone interested in hormone replacement/supplementation and the practitioners caring for them. The authors made a supplementary appendix available with more detailed data. It showed what we always see when hormones are applied transdermally (through the skin by gel, cream or patch): in time they accumulate to levels of elevated beyond the range of what is physiologically normal (when we properly measure the bioactive free-fraction hormones). Higher than normal hormone levels cause problems, including symptoms similar to hormone deficiency due to receptor desensitization. This applies to any hormone. Deep in the supplemental appendix we find that the free testosterone went as high as 82 pg/mL during gel supplementation. The functional (physiological) range we use for males age 51-60 is 36-65 pg/mL, for males over 70 years it’s 15-45 pg/mL.

Another important point: the protocol for this study did not even include how much testosterone was being converted into estrogen by aromatase activity. Elevated estrogen is a serious risk factor for men. For hormone supplementation to be effective and safe we must properly assess all aspects of production, accumulation, receptor function, metabolism and elimination.

Moderate-intensity exercise more effective than vigorous intensity for cardiovascular risk

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A surprising paper of great practical significance was just published in the journal Obesity that documents a significantly greater improvement in cardiovascular risk-related variables (triglycerides, insulin, metabolic syndrome score) with moderate-intensity exercise than with vigorous exercise. The authors offer this life-style pearl: “That all three of these strong, independent, cardiovascular risk factors were significantly affected by moderate-intensity exercise suggests that regular walking exercise might be as effective, if not more so, than more vigorous exercise in favorably modifying cardiovascular risk.” Further research will have to validate my expectation that the adrenocortical stress response plays a role here. Don’t forget the importance of interval training (see earlier posts), but at least get out for a walk.

Fat accumulation around organs linked to decreased heart function

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There are a few newsworthy findings reported in this study, recently published in the journal Obesity, that used MRI and MRS (proton MR spectroscopy) to measure the accumulation of fat around the heart and in the liver.

  1. Fat accumulation around organs is linked to decreased heart function
  2. Body mass index (BMI) is not a reliable predictor of fat accumulation
  3. Fat in the liver was associated with insulin resistance and triglycerides.

I have seen numerous individuals who do not appear overweight and whose BMI was normal, but bioelectric impedance analysis (an objective measurement of body fat percentage) revealed that they were ‘metabolically obese’—there was excess fat around their organs. Insulin resistance was a factor in each case.

Aspirin does not reduce heart attacks with diabetes

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The investigators who conducted this meta-analysis published in the British Medical Journal selected 6 eligible studies comprising 10,117 participants with diabetes and found: “When aspirin was compared with placebo there was no statistically significant reduction in the risk of major cardiovascular events…A clear benefit of aspirin in the primary prevention of major cardiovascular events in people with diabetes remains unproved. Sex may be an important effect modifier.” Some benefit was found for men (none for women) but “the expected benefits might not exceed the risk of major bleedings….We cannot recommend using aspirin in the primary prevention of cardiovascular events in all patients with diabetes without additional evidence…”

Men, alcohol may help prevent coronary heart disease

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Don’t let this research go to your head, but an interesting study was just published in Heart, the journal of the British Cardiovascular Society. The investigators followed 15,630 men and 25,808 women for 10 years and found that moderate, high and very high alcohol consumption (1 to 6 standard drinks per day) was associated with 30% less CHD (coronary heart disease). The authors conclude: “In men aged 29-69 years, alcohol intake was associated with a more than 30% lower CHD incidence.” Sorry ladies, the data did not show a similar benefit for you. Gentlemen, before rushing to the liquor cabinet bear in mind that there are also important reasons for individuals to limit or abstain from alcohol (such as high insulin levels, etc). This is what the data in this study shows, but discuss it with your functional medicine doc.

Niacin superior to ezetimibe for vascular health with coronary artery disease

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In this study just published in the New England Journal of Medicine, niacin did a better job of increasing HDL (“good”) cholesterol, reducing the thickness of the blood vessel wall (which thickens with pathology), and reducing “major cardiovascular events”. Interestingly, greater reductions in LDL by ezetimibe (which blocks cholesterol absorption in the gut) was associated with an undesirable increase in blood vessel thickness. Cholesterol is the precursor for every steroid hormone and a component of all cell membranes. Blocking cholesterol and other sterol absorption in the gut can have unforeseen consequences.

Diabetes has increased rapidly in Asian populations

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From the recent paper in The Lancet: “Prevalence of type 2 diabetes has rapidly increased in native and migrant Asian populations. Diabetes develops at a younger age in Asian populations than in white populations, hence the morbidity and mortality associated with the disease and its complications are also common in young Asian people. The young age of these populations and the high rates of cardiovascular risk factors seen in Asian people substantially increase lifetime risk of cardiovascular disease.”

Thyroid and menopause: caution

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Thyroid function is critical during every stage of life  but is especially vulnerable at menopause. As this paper from the journal of the International Society of Gynecological Endocrinology states: “The symptoms of thyroid disease can be similar to postmenopausal complaints and are clinically difficult to differentiate…It is of importance that even mild thyroid failure can have a number of clinical effects such as depression, memory loss, cognitive impairment and a variety of neuromuscular complaints…There is also an increased cardiovascular risk.” Inadequate assessment and calibration of estrogen support is another menopausal hazard for the thyroid as this research concludes: “Low estrogen level may lead to mild thyroidal hypofunction while estradiol treatment may lead to hyperactivity so it should be used very cautiously in the treatment of postmenopausal symptoms to avoid its undesirable stimulatory effect on the thyroid.”