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Does diet soda raise stroke risk? INSIDE

Ask the Doctor. . . . . . . . . . . 2
Some studies suggest a possible link. But dont switch to regular Heart failure with a normal

sugary sodastry infused water instead. ejection fraction

Ways to learn CPR. . . . . . . . 3

F or diet soda fans, re-

cent news reports link-
ing these popular drinks to
drinking diet soda, says Dr.
Kathryn Rexrode, an assoc
iate professor of medicine at
Torn neck arteries: Causes
and consequences. . . . . . . . 4
Marijuanas effects
a higher risk of stroke may Harvard-affiliated Brigham
on the heart. . . . . . . . . . . . . 5
have been alarming. A closer and Womens Hospital who
look at the study behind the co-authored an earlier, larger Is there enough effort
in your exercise? . . . . . . . . . 6
headlines suggests theres no study looking at soda con-
klenova | Thinkstock

need to panic. But beverages sumption and stroke risk. Research briefs. . . . . . . . . . 8
Heart attack risk from
naturally low in calories are
probably a healthier option Stroke risk from Alcohol: Maybe not so good
than artificially sweetened allsodas? foryour heart?
drinks. That 2012 studywhich fol- Exercise therapy for blocked
For starters, observa- lowed more than 127,000 leg arteries
tional studies like this one Quench your thirst with infused people for more than two
(see Diet soda and the water instead of soda. decadesdetected a slightly
A Guide to Cognitive Fitness:
brain: The latest findings) higher risk of stroke in peo- 6 Steps to optimizing brain function
cannot prove cause and effect. Also, only ple who drank more than one soda per day, and improving brain health
97 people had strokes during the 10-year regardless of whether it contained sugar or an www.health.harvard.edu/cogfit
follow-up, which means only two or three of artificial sweetener.
those strokes could possibly be attributed to continued on p.7 FIVE THINGS TO

Diet soda and the brain: The latest findings 1 Sign up for a CPR class.
Fewer than one in five people
know how to do this simple,
A study in the April 20, 2017, issue of Stroke examined how soft drink choices might affect the lifesaving technique. (page 3)
brain. Heres a summary:
Who: 2,888 people ages 45 and older and
1,484 people ages 60 and older from the
How: Participants filled out diet questionnaires
up to three times over a seven-year period and
2 Learn why you should be
nice to your neck. A torn
artery in the neck can trigger a
tongpatong | Thinkstock

long-running Framingham Heart Study. were followed over the next decade. stroke. (page 4)
Why: To see whether drinking either artificially
sweetened or sugar-sweetened soft drinks 3 Check if youre exercising
hard enough to help your
heart. Rating your perceived
influenced the risk of stroke and dementia.
exertion can help. (page 6 )
What happened: During the follow-up,
3%of the participants had a stroke, and
5%developed dementia.
4 Swap diet soda for infused
water. Fruit, cucumber, or
mint can enhance the flavor of
Key findings: People who reported drinking plain or sparkling water. (page 7)

at least one artificially sweetened soda a day Be cautious when taking
compared with less than one a week were ap- pain pills. Common over-the-
proximately twice as likely to have a stroke. counter drugs may raise heart
attack risk. (page 8)
This Harvard Health Publication was prepared exclusively for Lars Ekstroem - Purchased at http://www.health.harvard.edu
by DEEPAK L. BHATT, M.D., M.P.H., Editor in Chief

When the heart pumps normally but struggles

Editor in Chief Deepak L. Bhatt, MD, MPH
Executive Editor Julie Corliss
Q I was recently admitted to the hospital with heart fail-
ure and received a heart ultrasound. The test report
stated that my hearts pumping ability is normal. I dont
Contributor Stephanie Slon
understand. Was my diagnosis wrong, or is the test wrong?

A If you were diagnosed with heart failure in the hospital,

Editorial Board

Board members are associated with Harvard Medical School
and affiliated institutions. Im presuming that you were admitted with symptoms
Heart Paula A. Johnson, MD, Peter Zimetbaum, MD such as shortness of breath, fatigue, and difficulty doing ev-
Bone Disease Scott Martin, MD, Donald T. Reilly, MD, PhD
eryday activities. Other common symptoms include swell-
Cancer Marc Garnick, MD
Dermatology Kenneth Arndt, MD, Suzanne Olbricht, MD
ing in your legs and feet and trouble breathing at night.
Endocrinology Alan Malabanan, MD Heart failure means that the heart cannot pump well
Exercise/Lifestyle I-Min Lee, MD, ScD, JoAnn E. Manson, MD, DrPH enough to meet the bodys need for blood. To diagnose the condition, doctors rely
Gastroenterology Jacqueline Lee Wolf, MD on several tests, including blood tests, an electrocardiogram (ECG), and a chest x-ray.
Geriatrics Suzanne E. Salamon, MD
Neurology Gad Marshall, MD
An ultrasound of the heart (echocardiogram) shows how well the heart can pump.
Nutrition Eric B. Rimm, ScD A measurement known as the ejection fraction, or EF, refers to the amount of blood
Psychiatry Ann R. Epstein, MD, Michael Miller, MD, pushed out (ejected) with each heartbeat. A normal EF is 50% to 70%.
Ronald Schouten, MD, JD
An EF in the range of 41% to 49% is considered borderline low. An EF of 40% or
Urology William C. DeWolf, MD
Womens Health Karen Carlson, MD, Martha K. Richardson, MD, lower suggests heart failure with reduced ejection fraction. This type of heart failure,
Isaac Schiff, MD which used to be called systolic heart failure, happens because the heart muscle
doesnt contract effectively. It can occur after a heart attack, but there are many other
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possible causes, including severe, untreated valve disease or a viral infection.
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Email harvardHH@strategicfulfillment.com However, about half of people with chronic
Online www.health.harvard.edu/customer-service heart failure have a normal EF. Formerly known
Letters Harvard Heart Letter as diastolic heart failure, this condition is now
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Big Sandy, TX 75755-9308 referred to as heart failure with preserved ejec-
Subscriptions $32 per year (U.S.) tion fraction. The heart contracts normally, but
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Email HHP_licensing@hms.harvard.edu thickened, so they do not relax and refill nor-

Illustration by Scott Leighton

Online www.content.health.harvard.edu
mally. This type of heart failure is more com-
Editorial Correspondence mon in older people, especially women, as well
Email heart_letter@hms.harvard.edu A heart ultrasound (echocardiogram) as people who have high blood pressure or the
Letters Harvard Heart Letter reveals the hearts pumping ability.
Harvard Health Publications
irregular heart rhythm called atrial fibrillation.
Harvard Institutes of Medicine, 4th Floor People with either type of heart failure usually need to take blood pressure drugs
4 Blackfan Circle
Boston, MA 02115 known as diuretics (sometimes called water pills) to eliminate excess fluid from the
Permissions body. Common examples include chlorothiazide (Diuril), chlorthalidone (Hygroton),
Online www.health.harvard.edu/permissions and furosemide (Lasix). However, people like you who have a preserved ejection
PUBLICATIONS MAIL AGREEMENT NO. 40906010 fraction need to be alert to dangerously low blood pressure, which can occur if your
diuretic dose is too high. While other blood pressure drugs such as ACE inhibitors
seem to help people with reduced ejection fraction, thats not the case for those with
Published monthly by Harvard Health Publications, preserved ejection fraction. But a number of clinical trials studying new therapies for
a division of Harvard Medical School
heart failure with preserved ejection fraction are currently under way.
Editor in Chief Gregory D. Curfman, MD
A healthy, low-salt diet appears to be important for people with heart failure. Los-
In association with
ing weight (if needed) and avoiding alcohol can also help improve your symptoms. Its
Belvoir Media Group, LLC, 535 Connecticut Avenue,
Norwalk, CT 06854. Robert Englander, Chairman and also a good idea to engage in regular physical activity, but ask your doctor for advice
CEO; Timothy H. Cole, Executive Vice President, Editorial
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on how much and how often you should exercise.
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2 | Harvard Heart Letter | August 2017 www.health.harvard.edu

This Harvard Health Publication was prepared exclusively for Lars Ekstroem - Purchased at http://www.health.harvard.edu
The push you need to learn CPR is recommended for vicitims of drown-
ing or drug overdose.
After calling 911, do you know what to do if a person is You can learn CPR basics from a one-
unresponsive and not breathing? minute AHA video at www.heart.org/
HandsOnlyCPR. But theres no substi-

E ach year, an estimated

600,000 Americans
suffer a cardiac arrest, dur-
tute for hands-on practice to give you a
sense of the correct pressure and rate of
compressions, says Dr. Pozner. Another
ing which the heart sud- place to practice is at one of the training
denly and unexpectedly kiosks that are currently located at six
Rawpixel Ltd | Thinkstock

stops beating. If someone airports in the United States: Dallas/Fort

nearby immediately be- Worth, Chicago OHare, Indianapolis,
gins cardiopulmonary Las Vegas McCarran, Hartsfield-Jack-
resuscitation (CPR), the son Atlanta, and Baltimore-Washington
chest compressions can Thurgood Marshall.
keep blood flowing to the
persons brain and other vi- Dont hesitate to help
tal organsand more than To perform hands-only CPR, you push hard and fast on a Less than one-third of people who expe-
double the odds of survival. persons chest. No mouth breathing is required. rience sudden cardiac arrest receive CPR
About 70% of cardiac from a bystander. While increased CPR
arrests happen at home. If this happened Red Cross. Youll practice hands-only training rates will likely help, another
to your spouse or loved one, wouldnt it CPRpushing hard and fast on the cen- possible barrier is the fear of doing
be awful if you didnt know what to do? ter of the cheston a rubber torso. The incorrect or unneeded CPR, according
says Dr. Charles Pozner, associate pro- action can keep blood circulating until to Dr. Pozner. We used to train people
fessor of emergency medicine at Har- the persons heart can be shocked back to spend time checking for breathing
vard-affiliated Brigham and Womens into a normal rhythm with a defibrillator. and a pulse. But if you cant easily find
Hospital. But only 18% of adults in the Emergency personnel will bring and use a pulse and the person isnt breathing
United States have been trained in CPR this device. But airports, malls, casinos, normally, assume that he or she is in
within the past two years, according to sports arenas, and many office buildings cardiac arrest. A quick response is more
a recent nationwide survey of 9,022 peo- also have automatic external defibrilla- important, he says.
ple, published in the May 24, 2017, Jour- tors (AEDs). So if you witness a cardiac If youre not sure if someone needs
nal of the American Heart Association. arrest in a public place, ask a bystander CPR, err on the side of caution. Its bet-
There was some encouraging news, to find one. AEDs use voice prompts, ter do CPR on someone who doesnt
however: 65% of the survey respondents lights, and text messages to guide users need it rather than not do it on someone
said theyd been trained at some point through the needed steps. Most CPR who does, Dr. Pozner says. Yes, properly
previously. People who are required classes also include defibrillator training; done CPR can break a persons ribs, but
to know CPR for their jobs need to be some also teach CPR with breaths, which thats very unlikely to be fatal.
recertified every one to two years. For
everyone else, that frequency probably
isnt realistic. But all adults should take CPR coaching from your phone or virtual assistant
an in-person CPR class at least once, About half of the 911 operators in the United States are trained to pro-
milindri | Thinkstock

says Dr. Pozner. In many states, learn- vide verbal cues for CPR, according to the American Heart Association
ing CPR is mandatory to graduate from (AHA). If you reach a trained operator, put your phone on speaker to
high school, which may explain why hear the instructions; he or she will count out loud to help you adminis-
younger people are more likely to have ter compression at the correct rate (about 100 beats per minute).
CPR training than older people are. You can also get CPR coaching and other science-based information from the AHA
from an Amazon Echo, a so-called virtual assistant device that you control with
CPR training: A vital step your voice. More than eight million people in the United States have these devices,
If youve never taken a CPR class (or its which respond to the name Alexa. To use it, you need to enable the skill in the Alexa
been many years since you have), you can app or by saying, Alexa, enable American Heart Association. Then, in an emergency,
find one through the American Heart you would say: Alexa, ask American Heart how do I perform CPR?
Association (AHA) or the American
www.health.harvard.edu August 2017 | Harvard Heart Letter |3
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When a pain in the neck is serious yoga. If not done properly, certain posi-
tions such as a shoulder stand can cause
A tear in one of the main arteries of the neck hyperextension of the neck.
is a rare cause of stroke.
Hairdresser and

Y ou probably dont give much

thought to your neck, unless some-
thing goes wrong and it starts to hurt.
in the journal Neurology found that one
in 14 people diagnosed with a cervical
artery dissection was age 60 or older.
You can also hyperextend your neck
while tipping your head back to have
This underappreciated body part has The second (and perhaps bigger rea- your hair washed at a salon sink. Even
to be strong enough to support a heavy son) artery dissections are more com- though there are only a dozen or so such
weight (your head) yet still allow you to mon before age 50? Younger adults are cases described in the medical literature,
tilt, turn, and nod your head easily. theres a name for this phenomenon:

Image courtesy of N. Rost, MD, Massachusetts General Hospital

Most of the time, neck pain beauty parlor stroke syndrome. To
doesnt signal a serious medical What is a cervical artery play it safe, do as Dr. Rost does. Ask
problem. But its worth learning dissection? your hairdresser for a neck exten-
about one of the rare exceptions: sion, which is a little cushion that
a tear in one of the arteries of the Cervical arteries props up your head so you dont feel
neck, known as a cervical artery any strain on your neck, she advises.
dissection (see What is a cervical Not surprisingly, whiplash sus-
artery dissection?). Although these tained during a car accident can
occur in only about two in 100,000 also cause a cervical artery dissec-
people per year, they are one of the Vertebral tion. And in rare cases, so can the
most common causes of stroke in arteries quick, thrusting neck movements
people under age 50. some chiropractors and other health
Over the past two decades, arteries care professionals use to treat neck
awareness of cervical artery dissec- pain, known as cervical manipula-
tion has grown tremendously, says tive therapy or adjustment. How-
Dr. Natalia Rost, associate professor ever, its not clear whether the neck
of neurology at Harvard-affiliated therapy itself causes the tear, or
Massachusetts General Hospital. whether the pain from an existing
This may stem in part from the rec- tear might prompt people to seek
ognition that stroke rates seem to Two pairs of blood vessels in the neck out such treatment. Still, the Ameri-
be rising among younger people, the carotid and vertebral arteries, known can Heart Association warns people
despite an overall downward trend collectively as the cervical arteriescarry to be extra cautious about getting
blood to the brain.
in deaths caused by stroke. cervical manipulative therapy.
A tear in the lining of one of these vessels is
called a cervical artery dissection.
More common before Unusual, persistent pain
age50 Blood leaks between the layers of the artery With a cervical artery dissection,
wall and forms a clot. The clot may completely
Cervical artery dissections are seen block blood flow through the artery, or break the pain is unusual, persistent, and
more often in younger adults for off and lodge in an artery in the brain. If either often accompanied by a severe
two main reasons. First, a small happens, the result is a stroke. headache, says Dr. Rost. The pain
percentage of people have under- from a carotid artery tear often
lying inherited connective tis- spreads along the side of the neck
sue disorders that make their arteries more likely to engage in exercise that in- and up toward the outer corner of the
more likely to tear. For these people, volves neck movements that can precip- eye. A vertebral artery tear may feel like
an artery tear is more likely to mani- itate a tear. Dr. Rost has seen a number something sharp is stuck in the base
fest at a younger age, explains Dr. Rost. of artery tears in people who do high- of your skull. If you experience such
In older people, other types of strokes intensity fitness programs that combine painespecially if you also have stroke
(such as those associated with brain elements from several sports and types symptoms such as dizziness, double
arteries narrowed by fatty plaque) are of exercise. Dissections have also been vision, jerky eye movements, unsteadi-
more common. But dissections can still reported after strenuous weight lifting, ness while walking, or slurred speech
happen in older people. A recent study head-flinging dance moves, and even call 911 immediately.
4 | Harvard Heart Letter | August 2017 www.health.harvard.edu
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Marijuana and heart health: colleagues also suggest that marijuana
smoking may increase the long-term
What you need to know death rate among heart attack survivors.
Access to marijuana is growing, but its risks and benefits Questions remain
have not been carefully studied. Most of the evidence linking marijuana
to heart attack and stroke is based on

I n 28 states in this country, you can

legally use marijuana for a range of
health problems, including chronic pain,
reports from people who smoked it. So
its hard to separate the effects of can-
nabinoid compounds on the cardiovas-
anxiety, and nausea. Smoking is the fast- cular system from the hazards posed by
est way to feel the effects of marijuana, the irritants and carcinogens contained
UrosPoteko | Thinkstock

which is derived from the Cannabis sa- in the smoke. Because cannabis smoke
tiva plant. Yet marijuana smoke contains is known to cause airway inflammation,
many of the same toxins, irritants, and wheezing, and chest tightness, people
carcinogens found in cigarette smoke with lung diseases should not smoke it.
a known contributor to heart disease as As is true for other legal but unregulated herbal Other people who should just say no to
well as cancer. products, the potential benefits and risks of marijuana include those who may be
medical marijuana are not well studied.
Marijuana cultivation and use dates vulnerable to developing schizophrenia
back some 6,000 years. However, the and others who are in danger of unin- or addiction.
cardiovascular and other health effects of tended weight loss. However, in condi-
cannabis arent well studied. Thats partly tions where gaining extra weight might Cannabis 101
because under federal law, cannabis is exacerbate existing health problems,
a Schedule I substance, meaning it has such as diabetes, appetite stimulation The cannabis plant contains more than
no currently accepted medical use and would be counterproductive. 100 unique chemical components clas-
a high potential for abuse. That designa- sified as cannabinoids. These are the
active ingredients that bind to specific
tion places numerous restrictions on re- Cardiovascular effects
receptors in the brain and other parts
searchers, making it difficult to carry out One of the few things scientists know
of the body. The two most prevalent
rigorous research on marijuana. for sure about marijuana and cardio- types are tetrahydrocannabinol (THC),
As a result, everything were told vascular health is that people with estab- which is primarily responsible for the
about what marijuana does or doesnt do lished heart disease who are under stress mind-altering properties sought out
should be viewed with a certain amount develop chest pain more quickly if they by recreational users, and cannabidiol
of caution. This holds equally true for have been smoking marijuana than they (CBD), which has no psychoactive effect.
the risks as well as the benefits, says Dr. would have otherwise. This is because Cannabidiol may actually work to offset
Kenneth Mukamal, associate professor of complex effects cannabinoids have the psychoactive properties of THC.
of medicine at Harvard-affiliated Beth on the cardiovascular system, including The magnitude of marijuanas psycho-
Israel Deaconess Medical Center. raising resting heart rate, dilating blood active effect depends on the THC level
vessels, and making the heart pump in the particular strain of plant, which
Pot and pain harder. Research suggests that the risk parts of the plant are used, and the
Some of the strongest evidence sup- of heart attack is several times higher in route through which the drug enters
porting the medical use of marijuana the hour after smoking marijuana than the body. Legalization in some states
is for managing chronic pain. Cannabi- it would be normally. While this does has led to the breeding of strains that
noid compounds (see Cannabis 101) not pose a significant threat to people are three to seven times more potent
CreativeFire | Thinkstock

interact with receptors in nerve cells to who have minimal cardiovascular risk, than those available three decades ago.
slow down pain impulses and ease dis- it should be a red flag for anyone The impact of smoked or
comfort. Cannabinoids also have been with a history of heart disease. inhaled marijuana is gener-
shown to be effective in quelling nausea Although the evidence is weaker, ally felt within a few minutes
and vomiting. In addition, marijuana is a there are also links to a higher risk and lasts two to four hours.
powerful appetite inducer. The combina- of atrial fibrillation or ischemic Marijuana ingested in food
tion of these attributes makes marijuana stroke immediately following mar- or beverages kicks in more
a therapeutic option for people coping ijuana use. Consistent with these slowly and lasts longer.
with the side effects of chemotherapy links, studies by Dr. Mukamal and
www.health.harvard.edu August 2017 | Harvard Heart Letter |5
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Prescribing the best medicine lemsespecially diabetes and obesity
that contribute to heart disease. So be
Are you exercising enough to prevent heart disease? sure you know how much and how hard
you should be exercisingand how to

I t can help you lose weight; decrease

your blood pressure, cholesterol, and
blood sugar; and reduce your stress.
address any barriers that are keeping
you from doing it, says Dr. Skali.

But wait, theres more: it also lowers Enough exertion?

your odds of a heart attack or other For people without heart disease, the
cardiovascular event and may even American Heart Association recom-

Wavebreakmedia | Thinkstock
extend your life. mends at least 150 minutes per week
This wonder drug isnt a drug at all, of moderate exercise or 75 minutes per
of courseits exercise. Yet only about week of vigorous exercise (or a com-
half of all American adults do enough bination of the two). Walking is often
physical activity to benefit their health. championed as a great way to get exer-
And exercise is especially vital for peo- cise, but check that youre actually walk-
ple who are at risk for heart disease or ing briskly enough to raise your heart
already have it. rate. People will tell me, Well, I dont
Doctors are good at prescribing go the gym, but Im pretty activeI do
statins and aspirin, but were not very yard work and walk my dog every day,
good at prescribing one of the most Talking while walking: says Dr. Skali. But as people get older,
powerful therapies available, which is Assessing your effort their dogs tend to get smaller, and the
exercise, says Dr. Hicham Skali, a car- Use this rate of perceived exertion (RPE) outing ends up being more of a stroll
diologist at Harvard-affiliated Brigham scale to gauge whether you are exercising than a brisk walk, he notes.
and Womens Hospital. intensely enough. Wearable fitness trackers have made
Scale Intensity Breathing/ heart rate tracking popular in recent
Expert advice speaking pattern years. But you dont really need to mea-
One issue is that doctors arent always 1 Extremely Restful breathing; sure your heart rate to know if youre
sure how to offer specific exercise easy able to sing exercising hard enough. Instead, Dr.
advice to people with different heart- 2 Very Can easily speak in Skali recommends paying attention
related conditions and risk factors. In easy completesentences to your rate of perceived exertion, or
the future, a new computer program 3 Easy RPE (see Talking while walking: As-
developed by European cardiac rehabil- sessing your effort). Aim for an exer-
4 Easy to Speech becomes
itation experts may help. Called Exer- moderate broken tion level around 5 or 6about halfway
cise Prescription in Everyday Practice between sitting still and exercising as
5 Moderate Breathing becomes
and Rehabilitative Training (EXPERT), heavier hard as you possibly can. Start slowly
the program prompts a clinician to and build up to 30 minutes a day, five
6 Talking is difficult
enter information such as the persons days a week. As your fitness level im-
age, weight, and resting heart rate, 7 Moderate Deep, forceful proves, you may be able to save time
to breathing, butstill
along with any health conditions and vigorous sustainable by adding short bouts of more vigorous
medications. The program then gen- activity. As a general rule of thumb, one
8 Vigorous Labored breathing;
erates a tailored exercise routine that cannot talk
minute of vigorous-intensity activity
includes the type of exercise, intensity, counts about as much as two minutes
9 Very labored
frequency, and duration, along with of moderate-intensityactivity.
breathing; borderline
any safety precautions. breathless Focusing on RPE also makes sense
For physicians, using this program if you take a beta blocker, which helps
10 Very Gasping for air
could be a good way to get a conver- vigorous lower blood pressure and slows the
sation started, says Dr. Skali. But since heart rate. Common examples include
most doctors dont have the tool (it still a detailed discussion about exercise. If metoprolol (Lopressor, Toprol) and
needs to be validated in a study), where you have specific exercise-related con- atenolol (Tenormin). People often no-
does that leave you? During most office cerns, however, bring them up. Regular tice that their heart rate does not rise
visits, doctors often dont have time for exercise improves many of the prob- continued on the bottom of p.7

6 | Harvard Heart Letter | August 2017 www.health.harvard.edu

This Harvard Health Publication was prepared exclusively for Lars Ekstroem - Purchased at http://www.health.harvard.edu
Diet soda and strokefrom p. 1
Plain water too boring? Try these options
However, the new study found Looking for an alternative to diet sodas, but still want something
no higher stroke risk from drinking lowcalorie? Try flavored water, which you can buy in cans or bottles
sugar-sweetened soft drinks or other inmany flavors, in both sparkling and flat varieties. Or, just make your
sugary beverages, says Dr. Rexrode. own at home.
That certainly doesnt suggest theyre a If youre on the go a lot, you might want to purchase a fruit infuser water
better choice than diet sodas, though. bottle, which features a special inner chamber to hold pieces of fruit
Many studies have already shown that (orother flavor boosters such as mint or cucumber slices) to enhance
drinking sugary beverages on a regular the taste. Here are some other ideas to liven up your beverage choices.
VeliborZitarevic | Thinkstock

basis can lead to weight gain, diabetes, SWEET: Add frozen fruit to ice water, such as strawberries, blueberries,
heart disease, and stroke, she notes. or pineapple, or use the juice from a slice of orange to sweeten
sparkling water.
Possible explanations REFRESHING: Add a few sprigs of fresh mint to ice water.
In fact, one possible explanation why
sugary beverages werent linked to
ROBUST: Drink unsweetened black tea or coffee (decaffeinated
stroke in the recent study might be a orregular) over ice.
phenomenon known as survival bias. In FLAVORFUL: Try chilled herbal teas. They come in many flavors
this case, that would mean that people andvarieties, such as pear, peach, raspberry, licorice, and mint.
who drank a lot of sugar-sweetened POWERFUL: Drink vegetable juice blends, such as tomato, cucumber, and celery.
beverages may have died earlier from You can make your own using a blender or juicer. If you buy prepackaged vegetable
other illnesses such as heart disease. juice, choose a low-sodium variety.
Conversely, diet beverages may have SPICY: Add a few drops of honey to hot water, then sprinkle a dash of your favorite
shown a link to stroke because of a spice, such as cinnamon or cayenne pepper, then pour over ice.
different issue, called reverse causation.
In an attempt to be healthier, people
who are overweight or have diabetes If you use artificial sweeteners to on the many heart-protecting nutrients
may be more likely to choose diet drinks control your weight, you should know found in fresh, natural foods.
over sugary ones. Their heightened that the support for that strategy is But Dr. Rexrode isnt a stickler when
stroke risk may result from their health pretty shaky. Some evidence suggests it comes to diet soda. I encourage my
problems rather than their beverage that artificial sweeteners make people patients to eliminate regular soda and
choice. We might just be measuring the crave sugary, high-calorie foods, thereby other sugar-sweetened drinks to avoid
residual impact of obesity and diabetes, negating the sweeteners potential to cut empty calories, she says. But if some-
says Dr. Rexrode. your overall calorie intake. one says they cant do without a Coke in
Also, some experts believe that the morning to wake up, Ill encourage
Artificial sweeteners: people who use these high-intensity them to switch to coffee or diet Coke.
Othershortcomings sweeteners (which are hundreds of Water is an even better choice, how-
Another conundrum: researchers dont times sweeter than sugar) may come to ever. There are a lot of ways to make it
have any plausible explanation for why find naturally sweet foods, such as fruit, more appealing, both visually and taste-
artificial sweeteners might increase less appealing and less-sweet foods, such wise, such as using an infusion water
stroke risk. Still, there may be other as vegetables, downright unpalatable. If bottle, she adds. (See Plain water too
reasons to ditch them. so, those people might be missing out boring? Try these options).

Exercise effortfrom p. 6 Alternatives to walking peripheral artery disease (PAD). How-

For people who have low back pain or ever, walking is as effective asand less
as high during exercise after they start creaky knees or hips, walking may be risky thangetting a leg artery stent, a
taking these drugs and may wonder if difficult. Swimming, doing water aero- tiny mesh tube to open up the artery.
theyre exercising at the right intensity. bics, or using a recumbent bike may Even if your calves hurt after walking
Its fine to go by how you feel rather be better options. Walking may also just one block, take a rest, recover, and
than trying to reach a certain target be painful for people with narrowed repeat. Eventually, youll be able to walk
heart rate, says Dr. Skali. arteries in the legs, a problem known as farther without pain.
www.health.harvard.edu August 2017 | Harvard Heart Letter |7
This Harvard Health Publication was prepared exclusively for Lars Ekstroem - Purchased at http://www.health.harvard.edu

Pain relievers and heart attack risk

H eart attack risk may rise within a week of
taking daily high doses of certain over-the-
counter pain relievers, according to a new study.
than 1,200 milligrams (mg) of ibuprofen (Motrin,
Advil) and more than 750 mg of naproxen (Aleve,
Naprosyn) per day. Compared with people who
Previous research has linked didnt take NSAIDs, those who
the use of pain relievers known as did had 20% to 50% higher odds
nonsteroidal anti-inflammatory of having a heart attack while

FinStock | Thinkstock
drugs (NSAIDs) to a heightened taking the drugs.
risk of heart attack. The new For healthy people, whose
report, published in the May 9, baseline risk of heart attack is
2017, issue of The BMJ, analyzed very low, that level of added risk
data from nearly half a million people, of whom is minimal. But for older people, especially those
about 61,000 had heart attacks. with high blood pressure or a previous heart attack,
Researchers found that the risk began to its more worrisome. Dont use these drugs unless
increase within the first week of taking an NSAID. you really need them, and then at the lowest pos-
The most harmful doses appeared to be more sible dose for the least amount of time.

Alcohols heart advantages under scrutiny

C onventional wisdom holds that a drink or two What might explain the findings? Older

i_frontier | Thinkstock
a day protects against heart disease. But this people who avoid alcohol may be less healthy
assumption may be wishful thinking, than moderate drinkersbut not
a new analysis suggests. because they never drank alcohol.
For the paper, researchers scruti- Rather, they may have quit drinking
nized findings from 45 studies that because their health problems
involved a total of nearly three million require them to take medications
people. Current moderate drinkers (up that can interact with alcohol. In
to two drinks a day) were less likely contrast, seniors who drink arent
than nondrinkers to die of heart disease. But studies healthy because of that habit. Instead, their good
that looked at drinking over the lifespan suggest a health means they arent taking medications, so
different conclusion. These studies, as well as those they have no reason to avoid alcohol. The study
that accounted for peoples baseline heart health, appears in the May 2017 issue of the Journal of
found no benefit from moderate drinking. Studies on Alcohol andDrugs.

Medicare now covers exercise training for blocked leg arteries

A bout 8.5 million Americans have peripheral
artery disease, or PAD, in which fatty plaque
clogs arteries outside of the heart, most commonly
to 60 minutes each over a period of three months.
But in late May, Medicare announced that it will
now cover supervised exercise therapy for PAD,
in the legs. The hallmark symptom is calf or thigh which means other insurers will likely follow suit.
pain while walking that goes away when you rest. Under the new policy, you will need to see a doctor
The safest, most effective treatment for PAD is for a referral and receive information about other
supervised exercise training, in which youre mon- ways to lower your risk of PAD. These include
itored while walking on a treadmill. Few people stopping smoking and losing weight (if needed)
participate, however, partly because of the expense and controlling your blood pressure, blood sugar,
of the regimen. It involves up to 36 sessions of 30 and cholesterol levels.

How food industry trends might affect your heart health

Whats coming up: Thelatest on the genetics of cardiovascular disease
Why too little sleep may be bad for your heart
Ways to manage side effects from blood pressure drugs

8 | Harvard Heart Letter | August 2017 www.health.harvard.edu

This Harvard Health Publication was prepared exclusively for Lars Ekstroem - Purchased at http://www.health.harvard.edu