Attending my first “live” medical conference since COVID-19, I must say that this annual symposium, sponsored by Cedars-Sinai Medical Center, certainly met my expectations for the most part.

Reviewing the role of inflammation and its various triggers as it relates to heart disease was certainly time-honored. Also covered were the controversies of using fish oil, and the highly acclaimed ISCHEMIA trial; should we stent the artery or exhaust medical therapy? After all, the desired result should always be patient outcomes, and not the procedure.

We were updated on the latest in cardiac imaging techniques including echocardiography, CT scanning and CMR (Cardiac Magnetic Resonance), which is MRI with the heart being the targeted image.

If you think women are from Venus and men from Mars, you are correct. It’s not only about the difference in a woman’s presentation that matters but appreciating the role of various risk factors that we don’t generally consider: risks experienced in pregnancy, such as gestational diabetes or pregnancy-induced hypertension, autoimmunity, and depression to name a few. Furthermore, pregnancy totally challenges the cardiovascular system in ways many of us fail to realize.

Being an integrative cardiologist, I like to focus on lifestyle. As expected, this symposium was totally based on the traditional model. Despite this being a full 2-day conference, there was a mere one lecture on nutrition: What Diet is Best for Cardiovascular Health? The speaker recommended a plant-based diet. He outwardly admitted that most nutritional studies are limited in scope, because they tend to be observational in design. He quicky projected slides on a few of these studies, before concluding that the best diet for heart health and longevity was clearly vegan.

My response: Really? Such unequivocal evidence does not exist. There was no mention of the Mediterranean Diet which made headlines years ago with the PREDIMED study. I was majorly disappointed.

My other point of contention was the never-ending argument touting the benefits of statins and new drugs to get the LDL (lousy) cholesterol to levels lower than ever. The concluding recommendation: any patient with any level of coronary disease, as noted on a coronary artery calcium scan, should have LDL cholesterol no higher than 70. Even if the score is a one!  Obviously, drugs would be needed to achieve values this low.

A bit short-sighted, but again this is traditional cardiology.

In summary, I rank this symposium quite favorably despite a few disappointments. I endeavor to take in what I can while appreciating the limitations of traditional cardiology/medicine

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this site. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2021

The good, bad and the ugly!

Let’s start with the ugly. 2021 has been a sad year for the professional bodybuilding world. There have been at least 15 deaths in top level professionals, and high-ranking amateurs. Why did this happen, and could it have been prevented?

• Shawn Roden, aka Flexatron, age 46 died unexpectedly on 11/10/21 from a “suspected heart attack.” He won Mr. Olympia at age 43 (oldest bodybuilder to capture the title). According to reports, Roden had suffered a previous heart attack.

• Vic “Mr. Big” Richards, age 56, passed away from heart failure on 11/14/21

• George “Da Bull” Peterson, age 37. He was found dead in hotel room 10/7/21 

• John “Mountain Dog” Meadows, age 49, died on 8/8/21. He had sustained a major heart attack with permanent heart damage 5/2020 but went back to heavy training. According to reports he “suffered a heart attack due to massive blood clots in his coronary arteries”

• Megan Elizabeth, age 28, died 8/25/21. Cause of death is unknown

• Phil Hernon, age 55, died on 8/19/21 due to “sudden decline in health”. He had been on dialysis

• Orlando Galluci, age 38, died on 8/18/21 of a heart attack. Found dead just before competing in 2021 NPC European Championship

• Alena Hatvani, age 46, died 8/15/21. The cause of death is unknown. She was getting her final tan and started to faint before competing in Europa Pro2021

• Sofia Grahm, age 27, died in her sleep on 7/31/21. The cause of death is unknown. She was prepping for a show 

• Salah Hussein, age 39, died of stroke on 7/21/2021 

• Jenny Lynn, age 49, died in her sleep on 7/18,2021

• Melissa Coates, age 50, died on 6/23/21 of unknown cause (8 months prior to her death her leg was amputated “due to blood clots obstructing the blood flow to her lower leg.”

• Andy Haman, Age 55, died on 3/19/21 due to “complications of elbow joint surgery.” Reports read “pulmonary embolism”

• Michael “Big Kentucky” Thier, age 50, died on 2/21/21 of kidney failure

• Richard “Dustin” Cosman, age 39, “passed away in his sleep” on 1/1/21

Death in the line of duty is not new in bodybuilding. The many premature deaths of promising bodybuilders should be a wake-up call to such athletes to be careful. They should be wary of what they consume and generally the kind of lifestyle they lead.

Bodybuilding is indeed a sport. The discipline, focus and sacrifice to succeed in competition is incredible. I should know, because I competed for several years, working my way up the ladder to the Masters National level. I loved it, because it afforded me an opportunity to make a personal goal and to create an action plan to achieve that goal.  Regardless of my placing, I always entered each contest in my best possible condition.

Was it healthy? I can honestly say that is questionable. I mean losing 30 pounds in a span of 12 weeks sounds drastic to me today. Shunning all carbs and fat leaves you with essentially no energy. But to win contests you do what you must do. What I greatly respect is the commitment required. I had and still have that mentality, but I also knew when to draw the line.

What about all these recent bodybuilding deaths. What are the dangers of competitive bodybuilding? Well, it’s not the heavy lifting, vigorous training, or even the diet, despite how drastic that might be. It boils down to misuse of drugs: anabolic steroids, human growth hormone, insulin, and diuretics.

These dangers are not unique to competitors. There are countless athletes and non-athletes alike who have no intention of competing, but who use these drugs to look good, to overcome body dysmorphia, to enhance athletic performance, or simply to achieve that edge. The pity is that such folks often obtain and abuse drugs from unsafe sources and without any medical supervision.

The following are the long-term effects of anabolic steroids on such individuals.

    MOST DAMAGING:

• Kidney problems or failure

• Liver damage and tumors

• Enlarged heart, high blood pressure, and changes in blood cholesterol, all of which can increase the risk of stroke and heart attack, even in young people

• Increased risk of blood clots

Less dangerous but nonetheless other adverse effects include acne, oily skin and scalp, male pattern baldness, insomnia, mood changes, and tendon ruptures.

Heart disease is the most feared risk of prolonged steroid use. The following constitutes the complications that may be encountered:

• Abnormalities in blood lipids (total cholesterol, LDL (lousy cholesterol) and HDL (healthy cholesterol)

• Hypertension

• Coagulation disorders (such as platelet aggregation, leading to blood clots)

• Cardiomyopathy (often a heart that is either thickened, enlarged and often with impaired relaxation, known as diastolic dysfunction)

• Myocardial infarction and fatal arrhythmias that could lead to sudden cardiac death

I have evaluated several top-level pro bodybuilders and fitness competitors in my practice. Because of their awareness of these cardiac and other risks, they have done quite well as a whole. However, most competitors never see a physician.

I have no details as to the medical history on any of the individuals listed above. However, I venture to say that most of these fatalities could have been prevented. Let’s face it; how often do we see heart attacks, strokes, and both heart and kidney failure in the healthy young adult population?

For those who choose to use steroids, I recommend practicing prevention to mitigate the cardiac risks secondary to anabolic steroids.

WHAT ABOUT INSULIN?

Insulin is an anabolic hormone which promotes storage of nutrients such as carbohydrates in the form of glycogen and amino acids for protein synthesis. Therefore, such nutrient storage fuels the muscles and boosts muscle mass

Insulin abuse is the latest deadly trend. Bodybuilders use it -- often in combination with steroids -- to pump their muscles full of staying power. It's estimated that one in four steroid abusers also take insulin.

The insulin helps feed muscles during intense exercise, prevents muscle breakdown, and helps performance. The International Olympic Committee bans insulin. However, it's impossible to detect. Cheaters can take it just before an athletic competition and not get caught.

 Insulin just might boost athletic performance. And it just might kill. Bodybuilders are generally insulin sensitive as it is. By taking exogenous insulin and not knowing how and when to ingest carbs can seriously lower blood sugar. COMA and DEATH can result.

Insulin also promotes fat storage.  As powerful as insulin is, it also has a major flaw. It can build up fat cells and muscle cells in equal measure. If you eat sugary carbs at the same time as you eat fat, your body transports the carbs into the cells right along with the fat.

HUMAN GROWTH HORMONE (HGH)

Combining steroids with HGH is certainly not new. While steroids are best known for increasing muscle mass and strength, HGH, on the other hand, impacts body composition. It directly promotes fat burning. It is involved with the turnover of muscle tissue, which is important for adding lean muscle mass. HGH helps to maintain, build, and repair healthy tissue in the brain and other organs. This hormone can help to speed up healing after an injury and repair muscle tissue after exercise. This helps to build muscle mass, and boost metabolism,

While all this sounds great, there are some major drawbacks:

• Carpal tunnel syndrome.

• Increased insulin resistance.

• Type 2 diabetes.

• Swelling in the arms and legs (edema)

• Joint and muscle pain.

• For men, enlargement of breast tissue (gynecomastia)

• Increased risk of certain cancers.

If you’ve observed top level pro bodybuilders lately, you might notice that their abdomens are grossly distended, despite having ripped abs. This is anything but aesthetically pleasing and is a result of overuse of HGH and insulin. Indeed, the liver and spleen can enlarge as well as the kidneys and loops of bowel. What’s worse is that these changes are generally permanent. Don’t expect internal organs to shrink back to their normal size once HGH is discontinued!

DIURETICS:

Competitive bodybuilders strive for that hard shredded, dry look at contest time. Diuretics are often used to achieve this goal. However, severe dehydration, kidney failure, electrolyte derangements, cardiac arrhythmias and sudden death can result. Talking about death in bodybuilding, most hospitalizations and deaths are, in fact, overwhelmingly due to the use and abuse of diuretic supplements.

NOW THE GOOD!

The focus thus far in this article may seem negative, but being prompted by the recent deaths in bodybuilders, I felt the need to come forward and bring this discussion to light.

But there is mostly good in bodybuilding and strength training. I may be a cardiologist and I do recommend aerobic exercise, but if I only had a few minutes to train, I would favor weight training.

Weight training helps increase your strength while improving the tone and amount of muscle you have. This is vital for long-term health since inactive adults lose anywhere between 3-8% of their muscle mass per decade.

Resistance training for the older adult, age 65-and above has been extensively studied. The health benefits are well known and include the following:

• Increases muscle strength and endurance.

• Increases muscle mass which translates into improvements in functional capacity (combatting sarcopenia or muscle wasting).

• Increases bone density (combatting osteoporosis).

• Increases insulin sensitivity (combatting diabetes and metabolic syndrome).

• Mitigates pain from arthritis.

• Improves sleep.

• Reduces depression.

There are additional cardiac benefits of weight training that are becoming increasingly well appreciated.

In conclusion, weight or resistance training should be a permanent component of your exercise regimen. Each one of us could benefit.

As your own Medical Advocate, choose what’s best for your individual health and wellness. You will never go wrong with strength training.

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this site. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2021

There has been a lot of hoopla lately regarding a possible connection between the COVID -19 vaccine and myocarditis in young people under the age of 30. Is there truly a causal link here and how concerned should we be?

How did this evolve?

In early June, the CDC issued a note to healthcare providers raising awareness of myocarditis and pericarditis after vaccination, particularly in younger males. That guidance stated that, since April, there had been an increase in reports of myocarditis and pericarditis after getting the Pfizer or Moderna vaccines, but that there had not been a similar reporting pattern following the Johnson & Johnson vaccine.

The CDC's "clinical considerations" update followed a May 24 report from Advisory Committee on Immunization Practices (ACIP)'s COVID-19 Vaccine Safety Technical (VaST) Work Group, which found "a higher number of observed than expected myocarditis/pericarditis cases in 16- to 24-year-olds" in Vaccine Adverse Event Reporting System (VAERS) data within 30 days of dose 2, though it didn't see the same pattern in data from Vaccine Safety Datalink.

The data is a bit confusing, but obviously there needs to be more surveillance as more persons in these younger age groups get vaccinated. Important meetings will be held this week as the CDC’s vaccine safety team provides more data on myocarditis and pericarditis.

The country saw 275 cases of myocarditis from December 2020 to May 2021 among more than 5 million vaccinated people, according to Reuters. Most of these patients spent no more than 4 days in the hospital, and 95% of cases were classified as mild. The association appeared strongest among men ages 16 to 19 and was more common after the second dose.

Symptoms of myocarditis and pericarditis include chest pain, shortness of breath or palpitations. In most cases, patients responded well to medications and rest, and their symptoms improved quickly.

How to make sense of it all?

Though a causal relationship between vaccination and myocarditis has yet to be established, the possibility for a relationship does exist and obviously we need more data. In the interim, we continue to recommend vaccinations because the benefits outweigh the risks.

We must remember that there have been more then 4 million COGVID-19 cases in children under the age of 18 that have resulted in over 15,000 hospitalizations and between 300 and 600 deaths.

My take on all this:

Don’t overthink these findings. Have faith that true science won’t fail us. We will learn more in the coming weeks. Also be aware of the anti-vaxer activists who attempt to spread disinformation about COVID-19 vaccines.

There exists a huge database for detecting rare but potentially serious vaccine side effects. Epidemiologists consider this a starting point in their search for causal events. Known as the Vaccine Adverse Event Reporting System, or VAERS, this database has played a major role in the spread of misinformation about COVID-19 vaccines.

As your own Medical Advocate, weigh your options carefully before making judgment. It’s all about staying in the driver’s seat when it comes to your health.

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this site. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2021

The FDA approved 2 new medications in the last few days. Are these additions truly medical advancements, otherwise known as “gamechangers”? What about the drawbacks?

DRUG #1

A 2.4 mg /week subcutaneous dose of the glucagon-like peptide (GLP-1) receptor agonist semaglutide (Wegovy by Novo Nordisk) has been approved for weight loss. Indications: to be used as an adjunct to a reduced-calorie diet and increased physical activity for adults with obesity.

This medication works by reducing hunger while promoting feelings of fullness. It is being hailed as a paradigm changer in the war against weight loss.

The favorable decision is based on results of a four phase 3 clinical trials that tested the drug’s efficacy and safety in more than 4,500 patients who were randomized to receive a reduced calorie meal plan and an exercise program OR the lifestyle intervention plus semaglutide. Studied subjects attained a 15-18% weight loss over 68 weeks.

What’s interesting is that this is not a new drug. Under the name of Ozempic, it is used in control of type 2 diabetes. However, the dose studied for weight loss is significantly higher.

Drawbacks include GI side effects including nausea, vomiting, and epigastric distress from fullness. Side effects such as abdominal cramping, constipation and diarrhea can be exacerbating symptoms in those who suffer from irritable bowel syndrome. Then there is the subject of cost which is estimated to be about $1350 which more than likely will not be covered by insurance.

This is not a small deal. With 70% of the US population overweight and 42% obese, we are clearly losing the battle of the bulge. There may well be a role for this medication (first weight loss drug introduced since 2014). The hope is that it might also cut down on attendant diseases such as heart disease, hypertension, lipid abnormalities, cancer and diabetes often seen in the obese population.

My view: I don’t think of this as a miracle drug, but it could represent a paradigm shift in weight loss drugs where we target the gut as opposed to the brain. However, this shift should NEVER be a solution without altering lifestyle (diet and exercise), which remains my modus operandi.

DRUG #2

A 170 mg monthly intravenous drug aducanumab (Aduhelm by Biogen), has been approved for Alzheimer’s disease. This is a monoclonal antibody that selectively binds to accumulated amyloid plaque in the brain (a hallmark of Alzheimer’s disease).

This medication is certainly more controversial, than the weight loss drug discussed above. Two trials EMERGE and ENGAGE were terminated 3/2020 when it became obvious that the drug was unlikely to outperform placebo. Then in 11/20, in an ongoing battle with Biogen, the FDA overwhelmingly voted against the drug, after a second analysis determined that positive results were seen in only one of the two trials.

CONFUSED YET?

The FDA eventually approved the drug earlier this week through the agency’s accelerated approval pathway (a fast-track method). This allows the approval of a drug for serious conditions that fill an unmet need. This approval assumes but does not prove that the drug will produce a clinical benefit. The endpoint here is the ability for the drug to reduce beta-amyloid in the brain.

What we know is that there have been several anti-amyloid drugs in the past that reduced plaque but showed no benefit on cognition.

Well, Aducanumab might have been approved, but Biogene is required to conduct a post-approval trial to demonstrate clinical benefit. If expectations are not met, the FDA may withdraw the drug’s approval.

Does any of this make sense? Here a drug is marginally approved via fast track after being denied such status just a few months prior. And the conditions for ultimate approval are great.

Aducanumab is to be administered intravenously every 4 weeks at a cost of about $56,000 per year. Not included is the price of ongoing MRIs, which the FDA advises to monitor patients.

Now accelerated approval based on ongoing clinical benefits requiring a confirmatory trial is not new. It’s been used in the past for cancer drugs.

The problem as I see it is that functional medical practitioners like myself see Alzheimer’s disease as a multipronged disease. There more than likely will never be a medication that will either reverse the disease or stop it in its tract. Many believe that the deposition of amyloid plaque in the brain is more likely the body’s response to quell ongoing inflammation.

My view: There appears to be too much hope on a drug to alter the course of Alzheimer’s disease. There is more to this disease than amyloid plaque. Let’s not forget about diet, exercise and lifestyle. There are several integrative neurologists that believe Alzheimer’s can actually be prevented.

So here you have 2 new medications approved within one week. You will no doubt be hearing a lot about these soon. Keep an open mind. As a Medial Advocate, do your part to stay in the driver’s seat as it relates to your health.

 Links to articles referenced:
A Drug to Treat Alzheimer's Was Approved. Now What?
FDA Approves 'Game Changer' Semaglutide for Weight Loss

Although light drinking has been touted as beneficial by many, a large observational study recently reported that small amounts of alcohol were linked to a common heart rhythm disturbance (arrhythmia) known as atrial fibrillation (Afib).

This is no small deal, as Afib is the most common arrhythmia in those over the age of seventy. However, it has increasingly been noted in younger folks as well. As a matter of fact, two of my best friends had refractory a fib in their early 50s, eventually requiring a definitive procedure known as an ablation. Furthermore, a 29-year-old athletic male patient of mine recently underwent an ablation for the same problem.

ABOUT THIS STUDY: Increase risk of a fib was observed in just one daily drink containing 12 g ethanol, whether the beverage was 120 mL wine (four-fifths of a standard glass, 330 mL of beer (nearly a can’s worth), or 40 mL of spirits (roughly one shot). Findings were consistent for both men and women.

Even very low alcohol consumption, at a mere 2 g per day, was marginally associated with risk of a fib over nearly 14 years of follow-up. (see link below from the European Heart Journal, January 2021).

This study from Hamburg, Germany pooled five community cohorts from Europe totaling 100,092 subjects. Based on questionnaires and hospital records, 5,854 individuals developed Afib over a median period of 13.9 years.

Limitations of the trial included reliance on self-reported drinking patterns in an observational study. We know from a randomized trial in 2019 that a reduction in alcohol intake led to a reduction in a fib recurrence. The current study adds that lowering alcohol consumption may be important for both prevention and management of Afib.

Further reading for those interested: Link to the study published in the European Heart Journal, Jan 2021: Alcohol consumption, cardiac biomarkers, and risk of atrial fibrillation and adverse outcomes

To learn more about this troublesome arrhythmia, it’s adverse consequences, and identifying those at risk, please join me for my next YouTube Live on Thursday February 4th at 7:00 pm PST. Simply subscribe to my channel: The Medical Advocate, Howard Elkin, MD

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this site. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2020