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June Newsletter
In This Issue
Heartburn Medications May Raise Risk of Heart Attacks
Early CPR Improves Survival
The Facebook Phenomenon...
A New Model of Medical Care
Dr. Niedfeldt
Old-fashioned medicine with 21st Century convenience and technology
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I hope this newsletter finds you and your family well. It's Summerfest time and I hope you are enjoying our summer(ish) weather. It's always great to be active outside this time of year. 


The first article this month looks at a very common medication class, one that generates over $13 billion in income for pharmaceutical companies. Proton pump inhibitors (PPI) are commonly used by many people for heartburn and some are now over-the-counter. This study looked at over 1.8 million records and found a disturbing risk for people taking these medications. If you are taking one of these medications, it is worth a read. 


Survival rates for cardiac arrest outside the hospital are generally, quite low. However, there is a 'new' type of CPR that has been shown to double the rate of survival. The best part, you can learn it in about 2 minutes. If you don't already know CPR, I hope you will give this a look. 


Finally, as the father to a couple of teenagers, social media is everywhere. How many 'followers' people have on Twitter or Instagram are sources of pride for some. However, when do people cross the line and just get annoying? This study found that most of us may not know when we cross that line. 


Click on the links the the left to check out our web site...

Heartburn Medications May Raise Risk of Heart Attacks

Proton pump inhibitors increase incidence 
Proton pump inhibitors (PPI) like omeprazole (Prilosec), lansoprazole (Prevacid), Esomeprazole (Nexium), pantoprazole (Protonix) and others are often prescribed or taken due to heartburn and over $13 billion is spent on these medications annually. These medications work by completely blocking the gastric proton pump which is the final stage in the release of gastric acid and are very effective in healing gastric ulcers and reducing heartburn. In this study, from the journal PLOS ONE, researchers that found people taking these medications were 16% more likely to have a heart attack than people taking other heartburn medications.      

Summary of findings:

  • Background and Aims: Proton pump inhibitors (PPIs) have been associated with adverse clinical outcomes amongst clopidogrel users after an acute coronary syndrome. Recent pre-clinical results suggest that this risk might extend to subjects without any prior history of cardiovascular disease. We explore this potential risk in the general population via data-mining approaches. 

  • Methods: Using a novel approach for mining clinical data for pharmacovigilance, we queried over 16 million clinical documents on 2.9 million individuals to examine whether PPI usage was associated with cardiovascular risk in the general population.
  • Results: In multiple data sources, we found gastroesophageal reflux disease (GERD) patients exposed to PPIs to have a 1.16 fold increased association (95% CI 1.09-1.24) with myocardial infarction (MI). Survival analysis in a prospective cohort found a two-fold (HR = 2.00; 95% CI 1.07-3.78; P = 0.031) increase in association with cardiovascular mortality. We found that this association exists regardless of clopidogrel use. We also found that H2 blockers, an alternate treatment for GERD, were not associated with increased cardiovascular risk; had they been in place, such pharmacovigilance algorithms could have flagged this risk as early as the year 2000.
  • Conclusions: Consistent with our pre-clinical findings that PPIs may adversely impact vascular function, our data-mining study supports the association of PPI exposure with risk for MI in the general population. These data provide an example of how a combination of experimental studies and data-mining approaches can be applied to prioritize drug safety signals for further investigation.

Electronic medical records present opportunities to perform large "data mining" studies. This is one study in this format where over 1.8 million patients were evaluated to come up with their conclusion. It is interesting that H2-blockers, which are often taken for heartburn as well did not show any increased risk. H2 blockers include ranitidine (Zantac) and famotadine (Pepcid).This looks like it may be a change in vascular dilatation which may be causing the problems through a decrease in nitric oxide when people take the PPI. Nitric oxide dilates blood vessels and lowers blood pressure. This leads to many other questions. Does taking a PPI cause an increase in blood pressure as well as the increase in heart attacks? Do people taking these medications require more blood pressure medication? And since the "little blue pill" works by increasing nitric oxide, does taking PPI increase problems in the bedroom? While large studies like this can't absolutely prove causation since every confounding factor can't be taken into consideration, it certainly looks like the PPI should be used with caution. They have previously also been linked with more infections and c.difficile colitis. So t
he next time you feel some heartburn, consider taking some TUMS or an H2-blocker instead of a PPI. Don't forget other treatments such as avoiding food triggers. 
Early Compression-only CPR Improves Survival
Performing CPR more than doubled survival rate


In a cardiac arrest situation, The American Heart Association estimates that the chance of survival falls by 10% with each passing minute the patient remains in ventricular fibrillation. This study looked at data from Sweden and was published in The New England Journal of Medicine. They analyzed over 30,000 out of hospital cardiac arrests of which 51% had CPR performed and almost 49% did not. Survival rates were 10.5% vs 4.0%. Early CPR makes a very significant difference in survival rates. 

Summary of findings   

  • Background:  Three million people in Sweden are trained in cardiopulmonary resuscitation (CPR). Whether this training increases the frequency of bystander CPR or the survival rate among persons who have out-of-hospital cardiac arrests has been questioned.
  • Methods:  We analyzed a total of 30,381 out-of-hospital cardiac arrests witnessed in Sweden from January 1, 1990, through December 31, 2011, to determine whether CPR was performed before the arrival of emergency medical services (EMS) and whether early CPR was correlated with survival.
  • Results:  CPR was performed before the arrival of EMS in 15,512 cases (51.1%) and was not performed before the arrival of EMS in 14,869 cases (48.9%). The 30-day survival rate was 10.5% when CPR was performed before EMS arrival versus 4.0% when CPR was not performed before EMS arrival (P<0.001). When adjustment was made for a propensity score (which included the variables of age, sex, location of cardiac arrest, cause of cardiac arrest, initial cardiac rhythm, EMS response time, time from collapse to call for EMS, and year of event), CPR before the arrival of EMS was associated with an increased 30-day survival rate (odds ratio, 2.15; 95% confidence interval, 1.88 to 2.45). When the time to defibrillation in patients who were found to be in ventricular fibrillation was included in the propensity score, the results were similar. The positive correlation between early CPR and survival rate remained stable over the course of the study period. An association was also observed between the time from collapse to the start of CPR and the 30-day survival rate.
  • Conclusions: CPR performed before EMS arrival was associated with a 30-day survival rate after an out-of-hospital cardiac arrest that was more than twice as high as that associated with no CPR before EMS arrival. (Funded by the Laerdal Foundation for Acute Medicine and others.)
This study shows the importance of early CPR. I would add, early access to an AED (defibrillator) is very important as well. In Sweden, as more people were trained in CPR, the incidence of CPR being performed went up, thus survival improved. This shows that public health efforts to get more people to learn CPR (and AED use) is very important for survival. My teenagers both learned CPR and AED use in school. This is a great place to teach this life-saving skill and it really should be a mandatory part of every high school health class. Many police vehicles are now equipped with AEDs which will increase the chance of quick access to this life-saving device.  

Hands-only CPR has been shown to be as effective as CPR with breaths. This makes the skill even easier to learn. Here is a link to a 2 minute video that can show you how to do hands-only CPR. If you don't already know CPR, please, give it a look. You could save a life. Also, consider a course in CPR and AED use. Many employers offer this. If yours doesn't, classes are available locally through the Red Cross or The American Heart Association. 


Early Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest Ingela Hasselqvist-Ax, R.N., Gabriel Riva, M.D., Johan Herlitz, M.D., Ph.D., M?rten Rosenqvist, M.D., Ph.D., Jacob Hollenberg, M.D., Ph.D., Per Nordberg, M.D., Ph.D., Mattias Ringh, M.D., Ph.D., Martin Jonsson, B.Sc., Christer Axelsson, R.N., Ph.D., Jonny Lindqvist, M.Sc., Thomas Karlsson, B.Sc., and Leif Svensson, M.D., Ph.D. N Engl J Med 2015; 372:2307-2315June 11, 2015DOI: 10.1056/NEJMoa1405796 

The Facebook Phenomenon...
Self-promotional behavior gets annoying


Ok, I'm not sure we needed a study to prove this. The researchers did three experiments and found that people overestimate how happy and proud others will be of their accomplishments.  

Summary of findings:  

  • People engage in self-promotional behavior because they want others to hold favorable images of them. Self-promotion, however, entails a trade-off between conveying one's positive attributes and being seen as bragging. We propose that people get this trade-off wrong because they erroneously project their own feelings onto their interaction partners. As a consequence, people overestimate the extent to which recipients of their self-promotion will feel proud of and happy for them, and underestimate the extent to which recipients will feel annoyed (Experiments 1 and 2). Because people tend to promote themselves excessively when trying to make a favorable impression on others, such efforts often backfire, causing targets of self-promotion to view self-promoters as less likable and as braggarts (Experiment 3).      


In this age of social media, it isn't hard to see this study in effect. Previous studies have addressed the effect of 'the perfect life' some try to portray in the context of creating unrealistic expectations for others who are "less" successful. This study looked mainly at the annoyance factor. People who tried the hardest to make a favorable impression on others, tended to actually make themselves less likable. Shocker...
Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health. 


Proton pump inhibitors are needed by some people for certain conditions. However, there are estimates that of 60-70% of people taking them may not need them. Given the significantly increased risk of heart attack, it seems prudent to review whether or not everyone taking one of these medications actually needs them and if behavioral changes and an alternate medication may be useful. 


CPR saves lives. AEDs save lives. Please, learn to use both. 


Nobody likes a braggart. From the last study, it sounds like we should get some occasional feedback on our social media posts. 


As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email, phone, or just stop by! 

To Your Good Health,
Mark Niedfeldt, M.D.