The prevalence of type 2 diabetes is increasing in the United States according to Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center and a cardiologist in New York City. Pre-diabetes is usually defined as an elevation of fasting or post-prandial glucose levels. The American Diabetes Association has defined impaired fasting glucose as a level of 100 to 125 mg/dl. Also, an elevation in hemoglobin A1c or glycosylated hemoglobin (HbA1c) at a level of 5.7% to 6.4% may also represent pre-diabetes.

Metabolic Syndrome is related to pre-diabetes. Metabolic Syndrome is defined as any three of the following five components. These components include an elevated glucose level, abdominal obesity, elevated blood pressure, elevated triglycerides, and reduced high-density lipoprotein (HDL) cholesterol. Most individuals with metabolic syndrome have abdominal obesity. It is felt that insulin resistance may be mediating the metabolic risk factors of the metabolic syndrome. Most people with metabolic syndrome have insulin-resistance. It should be noted that the prevalence of pre-diabetes and metabolic syndrome overlap but not exactly. One can consider the metabolic syndrome as a pre-diabetic state. When comparing individuals without metabolic syndrome, those with this syndrome have an approximate 5-fold increase in diabetes risk. Once pre-diabetes is combined with metabolic syndrome, the risk is increased even more for diabetes.

The major adverse outcomes in individuals with pre-diabetes are macrovascular disease and type 2 diabetes, the leading contributors to microvascular disease. Macrovascular disease occurs both before and after the onset of diabetes, whereas microvascular disease occurs predominately several years after becoming diabetic. Metabolic Syndrome is a risk factor for macrovascular disease. Initial management is lifestyle intervention including weight reduction in obese subjects, reduced intake of dietary saturated and trans-fatty acids, cholesterol, and sodium along with increased physical activity.

According to Dr. Steven Reisman the Director of the New York Cardiac Diagnostic Center and a cardiologist in New York City these initial steps of lifestyle intervention in first line management should be emphasized to this group of individuals along with a thorough assessment of cardiovascular risk.

According to Dr. Steven Reisman, one of the best cardiologists in New York City and the Director of the New York Cardiac Diagnostic Center, obesity and overweight affect greater than 60% of the United States public. It is estimated that the United States government spends in excess of $200 billion per year on obesity associated conditions and diseases.

Obesity is the result of an accumulation of excess body fat. Obesity is not just excess body weight because overweight can occur from either muscle or fat deposition. Diet composition can affect the relationship between total body fat and body weight. Obesity related medical conditions may be associated with an accumulation of excess fat while increased muscle mass is beneficial because of its positive effect on metabolism.

There is a large body of scientific evidence that indicates that protein is the most satisfying of the macronutrients. High protein diets providing 25% of total energy compared to diets with low protein may lead to greater weight loss. Reduced total caloric intake with an increase in the intake of low-fat protein-rich foods may result in more successful weight loss in the long term secondary to the effects on resting energy expenditure.

It is possible that patients who exercise and eat adequate protein may build lean body mass more efficiently than those who are on a low protein diet. Because muscle weighs more than fat per unit of volume it is possible for patients to gain weight with muscle mass while reducing weight circumference and overall fat.

In addition to a healthy long term diet, it is important to increase the proportion of omega-3 fats, increase the intake of colorful fruits and vegetables, and limit the intake of refined carbohydrates from soft drinks, cookies, cakes, pastries, candies, and many processed foods with both hidden fat and sugar. In addition, physical activity is important along with behavioral interventions including self-monitoring stimulus control, stress reduction, and social support that may be helpful in weight loss.

Clinicians should consider evaluating a patient’s overall fatness rather than simply by measuring body weight or body mass index and concentrate on the potential complications of excessive fat accumulation. The goals for treatment of obesity should involve fat reduction rather than simply weight loss, along with a better understanding of nutrition.

Dr. Steven Reisman director of New York Cardiac Diagnostic Center and a leading cardiologist in New York City advocates and promotes a healthy lifestyle in the prevention of heart disease and the reduction of obesity.

Sudden Cardiac Death (SCD) refers to an unexpected death from a cardiovascular cause in an individual with or without pre-existing heart disease according to Dr. Steven Reisman, a Manhattan Cardiologist. This usually is a death occurring within one hour of an acute change in clinical status or an unexpected death that occurred within the previous 24 hours.

In the United States the incidence of sudden cardiac death varies between an 180,000 to 450,000 deaths per year. SCD still accounts for greater than 50 percent of all coronary heart disease (CHD) deaths, and approximately 15-20 percent of all deaths in the United States.

The incidents of SCD increases with age regardless of race or sex. Women, at any age have a lower incidence in SCD than men. Approximately two-thirds of women who present with SCD have no known history of heart disease compared with 50 percent of men.

A variety of risk factors have been proposed for the pathophysiology of SCD. CHD is the most common underlying disease associated with SCD in the western world being responsible for approximately 75 percent of SCD. Cardiomyopathies such as dilated and hypertrophic along with primary electrical disorders are responsible for the remainder. CHD in relation to SCD occurs in three settings including acute myocardial infarction, ischemia without infarction, and structural alteration such as scar formation with ventricular dilatation.  The mechanism of SCD in cases without acute myocardial infarction is likely an electrical event due to a ventricular arrhythmia which is a caused by ischemia or other arrhythmogenic stimuli in a chronically diseased heart. It is suggested that approximately 90 percent of deaths that occur within one hour of symptom onset are arrhythmic in nature.

Coronary heart disease or congestive heart failure significantly increases SCD risk of the population. SCD risk factors may be similar to CHD risk factors. Risk factors for sudden cardiac death include smoking, diabetes mellitus, and hypertension. There are certain measurements on the standard resting electrocardiogram that may serve as risk factors for SCD including an elevated resting heart rate, prolonged QT interval and prolonged QRS duration. Some studies have suggested early repolarization as a risk factor for sudden cardiac death.

Certain nutritional patterns may provide protection for the risk of SCD. In some studies consuming fish one to two times per week was associated with approximately a 50 percent reduction in SCD risk. Light to moderate levels of alcohol consumption may be associated with reduced risk of SCD. In some studies it is suggested that an increase in plasma magnesium levels may provide protection for SCD. In addition, a mediterranean diet appears to provide some protection for SCD.

There are certain triggers that may be associated with SCD. There may be a certain diurnal variation to SCD with the greatest incidence occurring in the morning hours from 6am to noon. Certain studies have suggested the highest risk of out of hospital arrest may be on Mondays. These patterns may suggest activity with psychological exposure playing a role in triggering SCD. Although there are long term benefits of exercise, it is also suggested that SCD occurs with a higher than average frequency during or shortly after vigorous exertion. Chronic habitual exertion may result in increase cardiac electrical stability but transient vigorous exercise may have an increased risk for SCD. Both depression and acute mental stress may trigger SCD and acute increases have been seen in situations such as populations experiencing disaster such as earthquake along with life stresses such as the death of a spouse or loss of a job.

The New York Cardiac Diagnostic Center along with Dr. Steven Reisman, a Manhattan Cardiologist, promotes early diagnosis of heart disease and strategies to increase both awareness and prevention of triggers and risk factors related to both coronary heart disease and sudden cardiac death.

An increase in resting heart rate during middle age can signify an increase in risk of dying from heart disease HealthDay (12/21, Gordon) has reported in a recent large study from Norway. Previous studies have noted that there is a relationship between an increase in resting heart rate and an increase in cardiovascular death and sickness in the general population.

A group of approximately thirty thousand men and women who live in Norway with no known heart disease at the beginning of study were followed greater than ten years. The average age of the participants at the beginning of the study was 52 years old and they had no evidence of heart disease at that time period.

People whose heart rates had increased from under 70 beats per minute to greater than 85 beats per minute over ten years had a 90% increased risk of dying from heart disease in comparison with those whose heart rate stayed around 70 beats per minute. These findings may suggest that an important marker of prognosis for coronary artery disease or ischemic heart disease may be both resting heart rate and the change in heart rate over time. This study also showed that individuals who had a relatively low resting heart rate at the beginning of the study had generally a healthier lifestyle than those with a higher resting heart rate. In other studies, an increase in resting heart rate over time was also associated with a worse outcome in patients with both hypertension and coronary artery disease. The importance of this study from Norway is that it was done in a very large group of healthy men and women with very good follow up and excellent statistical analysis. It is possible that this may also indicate that healthy lifestyle including physical activity, exercise and a low prevalence of smoking may go along with this lack of increase in heart rate to help represent improvement in prognosis.

Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center states that a cardiology consultation along with analysis of risk factors including hypertension, diabetes mellitus, smoking, elevated lipids including an elevation in cholesterol or triglycerides along with family history is important in overall evaluation of risk for heart attack.

Type 2 diabetes is also known as adult-onset diabetes and is a chronic condition that affects the way your body metabolizes sugar or glucose. With type 2 diabetes one’s body is resistant to the effects of insulin or the body does not produce enough insulin to maintain a normal glucose level. Type 2 diabetes symptoms may develop slowly. Some of the symptoms include an increase in thirst, frequent urination, increased hunger, weight loss, fatigue, blurry vision, and slow healing sores. Importantly, this condition may be asymptomatic.

The risk factors for type 2 diabetes include being overweight which is a primary risk factor, inactivity, family history, and a condition known as pre-diabetes in which the blood sugar level is higher than normal but not high enough to be classified as type 2 diabetes. The most important complications of type 2 diabetes include an increase in risk for various cardiovascular disease entities such as coronary artery disease, heart attack, stroke, and narrowing of the arteries along with high blood pressure.

Type 2 diabetes can be diagnosed by a simple blood test. There are two commonly done tests: one is called the A1C test and the other one is a fasting blood sugar test. The American Diabetes Association recommends routine screening for type 2 diabetes after age 45 especially if one is overweight. Screening is also recommended for those under 45 who are overweight and if there is other heart disease or diabetes risk factors such as a family history of type 2 diabetes or an elevated blood pressure.

In a recent article, HealthDay (3/2/11, Gordon) describes the findings of the ACCORD Study. This study evaluated “intensive” glucose therapy compared to “standard” therapy in patients with type 2 diabetes and heart disease. This study found that intensive blood sugar control in a very aggressive manner does not benefit people with type 2 diabetes and heart disease and, in fact, may harm them. This study found that very aggressive attempts to control A1C may result in a decrease in the rate of heart attack but an increase in mortality. This study was published in the New English Journal of Medicine on March 3, 2011 and involved a large group of patients. One finding in this study appears to be that it is important to decrease blood glucose levels to the recommendation of below 7% A1C but possibly not below 6% A1C.

Initial treatment for type 2 diabetes includes blood glucose monitoring along with healthy eating and regular exercise. Healthy eating should emphasize plenty of fruits, vegetables, and whole grains. In addition, counting carbohydrates is important and this can be done with the help of a dietician.  Aerobic exercise is important and one should aim for 30 minutes of vigorous aerobic exercise most days of the week. In addition, if one is overweight, losing excess pounds is part of the treatment regimen in type 2 diabetes. In some instances, diabetes medication may be necessary if this initial treatment program does not work.

Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center, advocates prevention of type 2 diabetes with emphasis on eating healthy foods, increasing physical activity and losing excess pounds. This can be done after an initial consultation to evaluate the individual’s blood sugar level and can also be done in conjunction with a registered dietician.

Dr. Steven Reisman, a New York City Cardiologist and Director of the New York Cardiac Diagnostic Center announces the acquisition and implementation of a more accurate automatic device for the detection of high blood pressure also known as hypertension.

Hypertension is a major risk factor for people developing cardiovascular disease including heart attack and stroke. The problem with the detection of hypertension is the lack of symptoms at earlier stages. In addition, the difficulty in diagnosis occurs partly because of a variation in blood pressure and a phenomenon known as the “white coat effect” or “white coat hypertension”. The white coat effect is a tendency of some patients to have a higher blood pressure when medical personnel are present versus blood pressure being measured in the individual’s natural environment. White coat effect can lead to misdiagnosis of hypertension and unnecessary treatment.

Since patients may have an elevated blood pressure when being seen for the first time in a physician’s office, multiple visits may be required to make a definitive diagnosis. It has been reported that white coat hypertension may account for 20%-25% of hypertensive patients. Therefore, hypertension may be overdiagnosed. Some studies have reported that 24-hour ambulatory blood pressure monitoring and self measurement at home are more accurate in diagnosis. One problem with ambulatory blood pressure monitoring is that it is not always covered by insurance. Over the last several years a relatively new device called the BpTRU blood pressure device has found acceptance in several medical centers around the country and has recently been shown by the Cleveland Clinic Journal of Medicine to yield a significant increase in accuracy in the detection of hypertension over standard physician measured blood pressure. BpTRU readings have been shown to correlate with average awake ambulatory blood pressure. This device works by automatically recording blood pressure without any medical personnel in the room. It can record automatic blood pressures every two minutes with a readout of five blood pressures along with an average blood pressure in a single office visit.  This has been shown to be an improved method for the diagnosis of hypertension.

Dr. Reisman, Director of the New York Cardiac Diagnostic Center, states that the New York Cardiac Diagnostic Center has begun using this device to accurately diagnose high blood pressure and is one of the few outpatient offices in Manhattan using it for the accurate diagnosis of hypertension.

In an article in HealthDay (3/21, Reinberg) a report from the online edition of the American Heart Association suggests that doctors should treat cases of potentially life threatening blood clots that form in the legs more aggressively.

Deep vein thrombosis (DVT) occurs when a blood clot forms in one of the deep veins in the body frequently in the legs. It can cause leg pain but also can occur without symptoms. This condition can occur, at times, when sitting for a long time such as traveling on a long trip by plane or car and also if one has certain medical conditions that changes how the blood clots.

One of the serious conditions that DVT can result in is when a blood clot breaks loose and travels to a different part of the body such as the lungs-this is called a pulmonary embolism. A pulmonary embolism can be fatal so it is important to look for the symptoms of this condition which may include unexplained shortness of breath, chest pain or discomfort, lightheadedness or dizziness, coughing up blood, or an extreme sense of anxiety or nervousness.  If any symptoms suggesting pulmonary embolism occur this is a medical emergency and one should consider seeking medical attention immediately.

Deep vein thrombosis when it occurs presents in several ways including swelling in one of the legs, pain in the leg, at times along with redness and warmth over the area of the leg.

In the United States more than 250,000 people annually are hospitalized for deep vein thrombosis. The American Heart Association is presently suggesting more aggressive treatment with clot busting medications and intervention with catheters to break up the clots.

Dr. Steven Reisman, Director of The New York Cardiac Diagnostic Center advises several preventative maneuvers to try to help prevent blood clots. These include if one is going on a long trip whenever possible get up and walk around. Raise and lower your heels while keeping your toes to the floor and then raise your toes keeping your heels on the floor. Make lifestyle changes such as lose weight, quit smoking, and control your blood pressure. Wear compression stockings to help prevent blood clots if your doctor recommends them.

In an article in WebMD (1/24, Hendrick), review of a recent study suggested that middle-aged and older women who lower their blood pressure could reduce the risk of having a stroke, heart attack, or developing heart failure.

This study conducted in over 9,000 adults follow for a median of 11 years found that three risk factors accounted for 85% of reversible risk for women and men. This included high systolic blood pressure, high cholesterol, and smoking. The most important risk factor in this study was felt to be high systolic blood pressure.

By lowering systolic blood pressure by 15 mmHg in hypertensive women, the study found there would be an increased benefit in quality of life by prevention of cardiovascular disease in about 40% of women. In this study, the researchers used 24 hour ambulatory blood pressure monitoring. This device measures blood pressure both during the day and at night at certain intervals.

Dr. Steven Reisman, a New York City Cardiologist states that at the New York Cardiac Diagnostic Center the doctors have recently been using a new in office automatic blood pressure device called BPTru to diagnose hypertension. This may also prove to be an excellent and more practical way to measure and treat high blood pressure in the prevention of heart disease.

Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center, discusses the recent CDC report that approximately one in three American adults have the condition called pre- diabetes. Pre-diabetes is a condition with blood sugar levels that are higher than normal but not high enough to be diagnosed as diabetes. Individuals with pre-diabetes have a greater likelihood of developing type II diabetes along with heart disease and stroke.

In a recent report in HealthDay (1/26, Preidt) the CDC reported that approximately 26 million Americans have diabetes and about 79 million Americans have pre-diabetes. This is a significant increase over estimated levels of pre-diabetes in 2008. It is felt that the increasing rates of obesity are related to the rising rates of both diabetes and pre-diabetes. Those who develop diabetes are not able to use the insulin that their body produces properly and therefore the amount of blood sugar increases. High blood sugar can have adverse effects leading to heart disease, stroke, blindness, kidney disease, nerve problems, and other vascular diseases.

Anther reason that there appeared to be an increase in the finding of diabetes and pre-diabetes may have to do with a relatively new testing procedure called hemoglobin A1c which measures the level of blood sugar over a period of several months from a simple blood test.

Dr. Steven Reisman, a Manhattan Cardiologist, advises that a simple blood test and consultation can determine whether an individual has either diabetes or pre-diabetes. If one of these conditions is found an aggressive regimen of weight reduction, exercise, and if necessary medication can be prescribed.

A recent study has suggested that obesity alone can increase the risk of a fatal heart attack even excluding the effect of other risk factors such as hypertension and diabetes. Healthday (2/14 Mozes) has reported that obese men have a dramatically higher risk of dying from a heart attack. In the study of 6,000 middle age men followed for about 15 years, there was an increased risk of fatal heart attack independent of risk factors such as high blood pressure, diabetes, and high cholesterol.

Obese middle-aged men had a 60% increased risk of dying from a heart attack compared to non-obese middle age men after taking out the effect of these risk factors. This suggests that obesity itself may be causing the heart attack. One theory is that obesity may be related to inflammation as a factor in a fatal attack. In addition, obese individuals have larger hearts because of their increase in body size and their hearts may already be “stressed” prior to a heart attack.

Dr. Steven Reisman, Director of the New York Cardiac Diagnostic Center, states that our office advocates an aggressive approach about not only treating traditional risk factors but also obesity with nutrition counseling and also early diagnostic testing to detect heart disease prior to the development of a heart attack.