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    <recommendedItem id="20100101_19_361"
                     title="Hidden Dangers of Herbal Meds Reviewed"
                     score="0.011"
                     href="http://www.medpagetoday.com/PrimaryCare/AlternativeMedicine/tb/18244?impressionId=1265740840003"
                     
      Herbal medicines are not always the harmless nostrums that many patients and even some physicians think, but may actually contribute to cardiovascular morbidity and mortality, researchers warned in a review covering 44 years of research into the subject.&lt;br&gt;
&lt;br&gt;Many such products, including aloe vera, ginkgo biloba, ginseng, and green tea, can interact with conventional cardiovascular drugs and lead to serious adverse reactions, according to Arshad Jahangir, MD, of the Mayo Clinic in Scottsdale, Ariz., and two other Mayo physicians.&lt;br&gt;
&lt;br&gt;&quot;There is a clear need for better public and physician understanding of herbal products through health education, early detection and management of herbal toxicities, scientific scrutiny of their use, and research on their safety and effectiveness,&quot; they wrote in the Feb. 9 &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Jahangir and colleagues also called for increased regulation of such products, at least requiring manufacturers of herbal medicines to register with the FDA and provide evidence of good manufacturing practices.&lt;/p&gt;
&lt;p&gt;&quot;Some of these adverse drug reactions are preventable,&quot; Jahangir told &lt;em&gt;MedPage Today&lt;/em&gt; in a telephone interview. &quot;Simple things like taking a good history or giving that history and discussing these issues, probably we can avoid [such reactions].&quot;&lt;/p&gt;
&lt;p&gt;Other physicians contacted by &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News agreed that the growth in popularity of herbal medicines poses problems for physicians and patients.&lt;/p&gt;
&lt;p&gt;&quot;Because these remedies are &apos;natural,&apos; their potential dangers are not considered the same way they would be if they were medication,&quot; commented Suzanne Steinbaum, MD, a cardiologist at Lenox Hill Hospital in New York City, in an e-mail.&lt;/p&gt;
&lt;p&gt;&quot;For many reasons, patients tend not to disclose to their doctors if they are taking herbal remedies, including fear that their doctors won&apos;t approve or they will be told to stop them,&quot; Steinbaum added. &quot;This lack of knowledge and full-disclosure, for some, might be a fatal omission.&quot;&lt;/p&gt;
&lt;p&gt;Jahangir and colleagues reviewed nearly 90 publications that have addressed herbal or complementary therapies and cardiovascular effects since 1966.&lt;/p&gt;
&lt;p&gt;Their &lt;em&gt;JACC&lt;/em&gt; article listed 15 common herbal medicines known to interact adversely with conventional cardiovascular drugs.&lt;/p&gt;
&lt;p&gt;In many cases, the herbal products compete with the regular medicines for the same drug-metabolizing cytochrome P450 enzymes, potentiating the latter&apos;s effects. In other cases, the herbal products have their own cardiovascular effects.&lt;/p&gt;
&lt;p&gt;Many physicians already know that grapefruit juice occupies the CYP3A4 enzyme, leading to slower-than-expected metabolism and, therefore, higher blood levels of a host of pharmaceuticals.&lt;/p&gt;
&lt;p&gt;These include the statins, calcium channel antagonists, several common anti-arrhythmic drugs, and the angiotensin receptor blocker irbesartan (Avapro), Jahangir and colleagues noted.&lt;/p&gt;
&lt;p&gt;Garlic is one of several common herbal remedies with specific cardiovascular effects in its own right (others include ginkgo biloba, ginseng, and saw palmetto). Garlic inhibits platelet aggregation and thus can lead to increased bleeding risks when combined with aspirin, clopidogrel (Plavix), or warfarin (Coumadin), the researchers noted.&lt;/p&gt;
&lt;p&gt;The Mayo group identified 10 herbal products that increase bleeding risks with anticoagulant and antiplatelet drugs, as well as 14 that can induce arrhythmias.&lt;/p&gt;
&lt;p&gt;In all, Jahangir and colleagues listed 27 herbal products that patients with cardiovascular diseases would do well to avoid. These include such common and harmless-seeming products as green tea, capsicum pepper, licorice, and kelp, as well as grapefruit juice and garlic.&lt;/p&gt;
&lt;p&gt;&quot;We need to check with our patients what type of products they are using, to identify these potential interactions,&quot; Jahangir told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;He cited the previously reported figure of 100,000 deaths annually from drug interactions, adding, &quot;We don&apos;t even know how many of these are due to use of compounds that we are not aware that our patients are taking.&quot;&lt;/p&gt;
&lt;p&gt;Jahangir said he was surprised, in preparing the review, at the scale of hebal medicine use in the U.S.&lt;/p&gt;
&lt;p&gt;He and his colleagues found data from the 1990s suggesting that more patients consult complementary and alternative medicine providers than regular physicians.&lt;/p&gt;
&lt;p&gt;The total annual out-of-pocket expenditure on complementary and alternative medicine services and products also was greater than for conventional physician services.&lt;/p&gt;
&lt;p&gt;&quot;The surprise for me was . . . how much people are willing to spend on a type of therapy which has not shown, in any scientific way, to be effective or safe,&quot; Jahangir said.&lt;/p&gt;
&lt;p&gt;He added that the trend may reflect shortcomings of the conventional medical system.&lt;/p&gt;
&lt;p&gt;&quot;What is the reason people are going there? Is it because there is some unmet type of need that we are not recognizing as practitioners of conventional medicine?&quot;&lt;/p&gt;
&lt;p&gt;Jahangir said it may be that physicians aren&apos;t spending enough time with patients to understand their true needs. He said it appears that, &quot;despite the advancement in our technology and new medicines, there is a demand for alternative therapies that is increasing.&quot;&lt;/p&gt;
&lt;p&gt;He recommended that, in addition to asking patients in detail about herbal and other alternative therapies they may be using, physicians should educate themselves on what these therapies purport to do and what is known about their real biological effects.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://nccam.nih.gov&quot; mce_href=&quot;http://nccam.nih.gov&quot; target=&quot;_blank&quot;&gt;National Center for Complementary and Alternative Medicine&lt;/a&gt; at the National Institutes of Health is a good starting point for such information, both for physicians and for patients, Jahangir said.&lt;/p&gt;
&lt;p&gt;Lenox Hill&apos;s Steinbaum said it was important that conventional physicians &quot;become more open-minded and accepting&quot; of alternative medicine, if only because so many of their patients are already practicing it.&lt;/p&gt;
&lt;p&gt;David Meyerson, MD, JD, a Johns Hopkins University cardiologist, told &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News in an e-mail that he advises patients to limit their use of &quot;unstudied and unproven and FDA-unregulated herbal medications.&quot;&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s unfortunately very big business, and potential drug interactions and potential harmful effects abound,&quot; he wrote.&lt;/p&gt;
&lt;p&gt;But another physician criticized the Mayo physicians&apos; emphasis on adverse effects in their review.&lt;/p&gt;
&lt;p&gt;&quot;For many of products listed, evidence for side effects seems to be minimal,&quot; Scott Grundy, MD, of the University of Texas Southwestern Medical Center in Dallas, argued in an e-mail.&lt;/p&gt;
&lt;p&gt;He agreed that the efficacy and safety of such drugs remains largely unproven, but added, &quot;It is mainly for these reasons that they cannot be recommended for use.&quot;&lt;/p&gt;
&lt;p&gt;Creating alarm about side effects &quot;may not be the appropriate way to discourage their use,&quot; Grundy said.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_198"
                     title="Fish Oils May Slow Genetic Aging (CME/CE)"
                     score="-0.001"
                     href="http://www.medpagetoday.com/PrimaryCare/DietNutrition/tb/18043?impressionId=1265740840003"
                     
      For heart disease patients, omega-3 fatty acids may protect against morbidity and mortality by slowing biological aging, researchers say.&lt;br&gt;
&lt;br&gt;Patients who had the highest omega-3 fatty acid blood levels also had telomeres that shortened at a significantly slower rate than patients with lower intake, Ramin Farzaneh-Far, MD, of the University of California San Francisco, and colleagues reported in the Jan. 20 &lt;em&gt;JAMA&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Patients in the lowest quartile of omega-3 fatty acid blood levels had the fastest rate of telomere shortening over five years: 0.13 telomere-to-single-copy gene ratio (95% CI 0.09 to 0.17).&lt;br&gt;
&lt;br&gt;Those who had the highest omega-3 fatty acid blood levels had the slowest rate of telomere shortening: 0.05 telomere-to-single copy ratio (95% CI 0.02 to 0.08, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Telomeres are the protective caps at the end of chromosomes that reveal how biological stress ages a person.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;Patients with the highest levels of omega-3 fish oils were found to display the slowest decrease in telomere length, whereas those with the lowest levels of omega-3 fish oils in the blood had the fastest rate of telomere shortening,&quot; Farzaneh-Far said. &quot;This suggests that these patients were aging faster than those with higher fish oil levels.&quot;&lt;/p&gt;
&lt;p&gt;They said omega-3s may protect against oxidative stress, or increase the activity of the telomerase enzyme, which would decrease telomere shortening by creating more accurate telomere copies.&lt;/p&gt;
&lt;p&gt;But some cardiologists were quick to point out that the results are preliminary and need to be replicated before physicians can use them in practice.&lt;/p&gt;
&lt;p&gt;Since the study was observational and couldn&apos;t prove cause-and-effect, &quot;we don&apos;t really know whether ingestion of omega-3 fatty acids resulted in this &apos;benefit,&apos;&quot; Steven E. Nissen, MD, of the Cleveland Clinic, noted in an e-mail. &quot;It remains entirely possible that individuals who consume more fish also have other favorable healthy habits.&quot;&lt;/p&gt;
&lt;p&gt;Nissen also pointed out that the study was not randomized to compare fish oil directly with a placebo treatment, and cautioned that &quot;the relationship between telomere shortening and cardiovascular health is not well established.&quot;&lt;/p&gt;
&lt;p&gt;Studies have shown that omega-3s appear to be effective for patients with coronary artery disease. Yet the underlying mechanisms are not well understood. Some researchers think it may have something to do with anti-inflammatory, triglyceride-lowering, antihypertensive, antiplatelet, or antiarrhythimic effects.&lt;/p&gt;
&lt;p&gt;Research has shown that the length of telomeres  --  chromosome caps that have long been compared to the plastic ends of shoelaces  --  may be a marker of biological age. Biological age is independent of chronological age, and takes into account genetic and environmental stressors that may wreak havoc on cells.&lt;/p&gt;
&lt;p&gt;Since there&apos;s been increasing evidence that omega-3s exert direct effects on aging and age-related diseases, the researchers decided to investigate them as a potential mechanism for protective effects in heart patients.&lt;/p&gt;
&lt;p&gt;So they conducted a prospective cohort study of 608 patients in California with stable coronary artery disease. Patients were recruited from the Heart and Soul Study between September 2000 and December 2002.&lt;/p&gt;
&lt;p&gt;They were followed for five years, and the researchers assessed telomere length of their leukocytes at baseline and again at the end of follow-up.&lt;/p&gt;
&lt;p&gt;&quot;By measuring telomere length at two different times,&quot; Farzaneh-Far said, &quot;we were able to see the speed at which the telomers are shortening and that gives us some indication of how rapidly the biological aging process is taking place in these patients.&quot;&lt;/p&gt;
&lt;p&gt;The researchers found that baseline omega-3 fatty acid levels were positively correlated with changes in telomere length over five years (&lt;em&gt;P&lt;/em&gt;=0.001).&lt;/p&gt;
&lt;p&gt;The relationships remained after controlling for potential confounders including demographics, blood pressure, serum lipids, and inflammatory biomarkers.&lt;/p&gt;
&lt;p&gt;The researchers noted that each standard-deviation increase in fatty acid levels was associated with a 32% reduction in the odds of telomere shortening (95% CI 0.47 to 0.98).&lt;/p&gt;
&lt;p&gt;So how do omega-3s stop telomeres from getting smaller?&lt;/p&gt;
&lt;p&gt;They may protect against oxidative stress, which is a major driver of telomere shortening and aging. Or, fatty acids may increase the activity of the enzyme telomerase, which can result in more accurate copying and hence, longer telomeres, the researchers suggested.&lt;/p&gt;
&lt;p&gt;The researchers agreed that the study was limited by its observational nature, which leaves no room for definitive conclusions about causality. Also, they only measured telomere length in leukocytes, which means the findings may not translate to other cell types, including myocardial or endothelial cells.&lt;/p&gt;
&lt;p&gt;Researchers who were not involved in the study noted that omega-3s have been shown to have effects on other factors that contribute to heart disease risk.&lt;/p&gt;
&lt;p&gt;&quot;Omega-3 fatty acids have a potent positive impact on lipids that circulate in the blood stream and damage the heart,&quot; said Cam Patterson, MD, of the University of North Carolina Chapel Hill McAllister Heart Institute. &quot;The effects of omega-3 fatty acids on lipids are still the best advertisement for their use to prevent heart disease.&quot;&lt;/p&gt;
&lt;p&gt;Merle Myerson, MD, of Columbia University, agreed. &quot;[The researchers] don&apos;t mention that omega-3 fatty acids lower triglycerides and non-HDL cholesterol, and stabilize cell membranes  --  all of which may reduce risk for coronary artery disease and sudden cardiac death.&quot;&lt;/p&gt;
&lt;p&gt;Myerson said the findings need to be replicated in future studies.&lt;/p&gt;
&lt;p&gt;While their study may not have implications for intake of omega-3s among the general population, the researchers said it upholds recommendations for patients with heart disease.&lt;/p&gt;
&lt;p&gt;&quot;The results of our study underscore the recommendations of the American Heart Association, that patients with known coronary artery disease should be getting at least one gram a day of omega-3 fish oil,&quot; Farzaneh-Far said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by grants from the American Heart Association and the Bernard and Barbro Foundation.&lt;/p&gt;&lt;p&gt;The Heart and Soul Study was supported by the Department of Veterans Affairs, the National Heart, Lung, and Blood Institute, the Robert Wood Johnson Foundation, the American Federation for Aging Research, the Ischemia Research and Education Foundation, and the Nancy Kirwan Heart Research Fund.&lt;/p&gt;&lt;p&gt;A co-author reported financial conflicts with GlaxoSmithKline and Monsanto, and founded OmegaQuant Analytics to offer blood omega-3 fatty acid testing.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
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                     title="ALA Linked to Reduced Cardiac-Related Mortality"
                     score="-0.005"
                     href="