Dr. Pradip Jamnadas MD. In his own words.
Bicuspid aortic valve
This is a common congenital cardiac malformation and it is associated with thoracic ascending aortic aneurysm, dissection, infective endocarditis, sudden death, and progression to aortic stenosis or aortic regurgitation.
It is inherited in a autosomal dominant pattern; however there are also isolated cases, therefore, family members must be screened.
The examination should also look for coarctation of the aorta, and be heard for a heart murmur.
Aortic stenosis tends to occur at a young age, often in the 40s and 50s. If the ascending aorta and aortic root are not well imaged on echocardiography, then a transesophageal echocardiogram should be done. In most cases, I prefer to do the transesophageal echocardiogram for a more complete examination.
Bacterial endocarditis prophylaxis is not needed for dental and surgical procedures unless they have had endocarditis before. However, in a patient with a bicuspid aortic valve with clinical suspicion of endocarditis, a transesophageal echocardiogram should be done.
The ascending aortic imaging should be done to look for an aneurysm and progression of its size. This can be done using CT scan or MRI. Depending on the size of the aneurysm, there are recommendations to avoid intense weight training or exercise.
Surgery is the mainstay of therapy, and the indications for aortic stenosis and aortic regurgitation are defined elsewhere. Repairing the aortic sinuses and replacing the ascending aorta is indicated if the diameter is greater than 5.5 cm. However, if the valve is also going to be replaced or if there is a dissection, then, 5.0 cm is the cutoff. Also, if there is an increase of more than 0.5 cm in 1 year, it indicates progression and replacement is recommended.
Dr. Pradip Jamnadas, MD FACC FACP FSCAI
Clinical assistant Professor of Medicine at University of Central Florida and Florida State University
Guidelines for hypertension
In 2017, the American College of Cardiology, American Heart Association and 9 other professional organizations published new guidelines on high blood pressure. It incorporated the evidence from randomized control trials including the systolic blood pressure intervention trial (Sprint) as well as expert opinions.
The category of pre-hypertension was eliminated and it should have been.
Stage I Hypertension is defined as a lower blood pressure threshold of 130/80 mmHg or higher. The earlier threshold was 140/90, but that is now considered stage II hypertension.
According to this definition, 46% of the US population has stage I or stage II hypertension.
Hypertension, in my opinion, is not an isolated diagnosis. It usually keeps company with cardiometabolic syndrome and other factors certainly influence the management of hypertension. If hypertension was treated in isolation with pharmacological management, then a lot more patients will be on blood pressure medications, and other associated factors would not be treated, and the overall benefit to the patient will be limited.
It is my expert opinion, I believe hypertension is associated and probably etiologically related to insulin resistance. Management of insulin resistance will therefore, in turn, reduce hypertension. High blood pressure is also associated with obesity, sedentary lifestyle, obstructive sleep apnea, chronic inflammatory states such as connective tissue diseases, nutritional deficiencies such as Magnesium and Vitamin-D and we ought to look at all these factors as well.
Ambulatory monitoring provides additional information such as the presence or absence of nocturnal dipping (normal defined as a nighttime drop in blood pressure of 10-20%) we must do more than one reading before we label the patient as hypertensive. Echocardiograms will demonstrate left ventricular hypertrophy even if it is mild. Left ventricular hypertrophy predicts congestive heart failure and cardiovascular death in the future. Do not label patients as having white coat syndrome unless you have clearly documented low-end normal readings at home and done ambulatory blood pressure recordings. You must do multiple blood pressure readings on numerous occasions and have a conversation with the patients to let them know your concerns and your desire to make an accurate diagnosis.
The American College of Cardiology encourages the use of their risk estimator which includes age, sex, race, total cholesterol, HDL level, systolic blood pressure, use of blood pressure medications, diabetes, smoking status and it is available at http:/tools.acc.org/ASCVD-Risk-Estimator. I am not particularly fond of it. If the patient already has cardiovascular disease, then it is straightforward that we need aggressive blood pressure management. The guidelines recommend a blood pressure of less than 130/80 for patients including elderly patients, and patients with chronic renal failure as well as diabetes. In my opinion, low-risk patients with a blood pressure of 135/85 in the office can be followed with aggressive lifestyle changes especially dietary changes and exercise weight loss intermittent fasting and treatment of Obstructive Sleep Apnea, and we can avoid pharmacological management in these patients unless there is left ventricular hypertrophy. In very elderly patients over the age of 80 who are frail and at risk of falls or have renal insufficiency, low diastolic blood pressures due to stiff arteries, the mean blood pressure may be too low, and we must individualize these patients because they will have a high systolic blood pressure very low diastolic pressure and the mean pressure will be normal. Although they are at high risk of cardiovascular complications by virtue of a large pulse pressure, chasing the systolic hypertension can be more harmful with pharmacological interventions.
Although most of the recommendations for salt restrictions are dating back to the 1970s, and the recommended optimal dose of sodium is less than 1.5 g a day, recent data suggest that the intake should be liberalized, so I do not make a specific recommendation to reduce salt unless the patient has nephrotic syndrome or overt congestive heart failure with hypervolemia and edema.
In the pharmacological management of hypertension, the use of a RAAS inhibitor is recommended and preferable over a calcium channel blocker or diuretics. Try to avoid Clonidine because of rebound hypertension as well as orthostatic hypotension. Do not combine ACE inhibitors and angiotensin receptor blockers. You may use beta-blockers if there is evidence of arrhythmias, coronary artery disease, and most patients will require two or maybe even three medications to control blood pressure. This conversation must happen early on because monotherapy for hypertension is the exception and not the rule.
Dr. Pradip Jamnadas, MD FACC FACP FSCAI
Clinical assistant Professor of Medicine at University of Central Florida and Florida State University
How to reverse type 2 Diabetes Mellitus using intermittent fasting:
The fundamental pathology in type 2 diabetes mellitus is insulin resistance. This means that the insulin molecule cannot act upon the insulin receptors in the body because the receptors have become insensitive. Therefore, it takes a lot of insulin production by the pancreas to stimulate the insulin receptors and thereby reduce the blood glucose to normal. In many patients, the blood sugar levels are kept in range at the expense of very high insulin levels. Insulin is an anabolic hormone that instructs the body to gain weight, increase fat storage, inhibit lipolysis – the breakdown of fat. It is atherogenic, promoting vascular inflammation, which is undesirable. High levels of insulin production by the pancreas will eventually lead to pancreatic endocrine failure, which then leads to dependence on insulin injections. Restoring insulin receptors sensitivity results in less insulin needs because the receptors are now sensitive to insulin. To restore insulin receptors sensitivity, the receptors must not be exposed to high insulin levels. The best way to do that is fasting.
The pancreas produces most of the insulin upon eating with simple sugars stimulating insulin production the most. When the insulin level drops because of fasting, the receptors are no longer bombarded by so much insulin, and the insulin receptor sensitivity improves. This phenomenon is seen in multiple other areas of medical physiology. Therefore, the fasting allows your body to change its response to insulin, improve receptor sensitivity and thereby your body’s hormonal state changes. Hormones are the master manipulator of physiology. Therefore, fasting is a profound way to change your body’s hormonal response to food. After fasting, in the next few days too, your insulin requirements will fall. With less insulin, you will lose weight, need fewer medications, have a lower sugar level in the blood, the hemoglobin A1c will come down, the triglyceride levels drop, and you will also feel better.
Other methods to improve insulin sensitivity includes metformin medication and elimination of all sugar products in the diet. For information on how to fast, please read the section on how to start fasting.
How to fast
We all fast. An overnight fast terminates with a breakfast. Fasting has always been a part of the human species. We are all supposed to feast and fast. When food was available, we had a feast, and when it was not available, we fasted for days at a time. If we could not survive this fast, we would not have survived as a species. The fasting did not weaken the organism because that would have facilitated the demise of that person.
On the contrary, it appeared to give the organism added benefits to survive, and even emerge as a more resilient organism. We notice this in the animal species too, fasting appears to lengthen life span and induce other beneficial metabolic changes. When animals are sick, they do not eat. This fasting is also noted to benefit that animal by changing its physiology. Even Hippocrates is quoted as saying that if you feed the patient, you feed the illness. Fasting has been advocated as a means of treatment of multiple diseases including inflammatory conditions, inflammatory bowel disease, dementia, psychiatric illnesses, infections, hyperlipidemia, and diabetes mellitus, to name a few.
Today, we eat very differently from our ancestors. Our genetic material has not caught up to our current feeding frenzy eating every 2 hours. We cannot evoke the physiology of fasting in our bodies if we are constantly in the fed state. It is almost like having daytime all the time with no nighttime. We now know that eating is followed by inflammation in our body. Profound changes occur within the microbiota in our gut lining, inflammatory cells in the gut, hormonal production by various organs at every meal. Episodes of rest should follow these changes.
Eating frequently results in psychological addiction to the act of eating. Rather than eating only when one is hungry, eating is initiated by the social circumstances; the time of the day, the company, and the environment amongst other things.
Further, certain food constituents are known to have addictive properties. These include sugar as the biggest culprit, resulting from the stimulation of the pleasure Center in the brain, very similar to the pleasure received from narcotics. Hence, abstinence from sugar can result in withdrawal symptoms that are often very powerful. Therefore, we can see that changing the frequency of eating and the circumstances around meals, can be quite a challenge. It is for this reason that I have outlined a method to initiate this intermittent fasting program. I have asked the patients to become mindful of the symptoms that they are experiencing before eating. Are they eating because they are hungry, or are they eating because of habit, time of the day, social cues, or withdrawal symptoms? This in itself can be quite challenging.
Firstly, for the first 1-2 weeks, we must stop eating all sugars, processed foods, and eat mostly whole foods with an emphasis on whole plants.
Then, I encourage patients to skip meals. This is done randomly. If you not hungry, skip the meal. Notice how you feel. Notice that there was no adverse effect from skipping a meal. These should be random for the first week and one should be occasionally skipping dinner, lunch, or breakfast. This leads to the next step.
After this two-week introduction, choose 1-2 days a week where you choose to skip 2 meals in succession. This results in a 24 hour fast. During the subsequent meal, I encourage my whole food predominantly plant-based diet, with no restrictions in calories. That meal should be very satisfying. Once you feel comfortable with this, you should try to have only one meal a day. It is important not to snack in between meals. Remember that every snack stimulates insulin and changes your physiology. Any time you eat something you are changing your hormonal physiology. You should drink plenty of water. 6-8 glasses of water is recommended per day. Soft drinks must be avoided. Caffeinated drinks are allowed in small quantities such as tea and coffee. Sometimes some patients feel very tired and fatigued during this fast. In the beginning, this could be a withdrawal from sugar. Later on, it is probably related to dehydration and electrolyte loss. If the blood pressure is low, rehydration and electrolyte replacement is needed with a small pinch of salt in a glass of water. If you are taking medications, you should be monitoring your blood pressure and your blood sugar anyway. You should call the office with any questions.
What about medications? One should discuss this very carefully with your physician/provider. Antihypertensive medications, anticoagulants, psychotropic drugs, antianginal medications, are all allowed. However, diabetes is a unique situation. Insulin taken during a fast can result in low blood sugar levels. If you are taking insulin, you have to discuss the program with your physician. In general, my recommendation has been to reduce the insulin intake by 50% on the day of the fast and to take your blood sugar readings frequently during the day to make sure that you are not developing hypoglycemia. Document the results and present them to your provider. I usually allow Metformin to be continued, but typically discontinue all sulfonylureas agents.