Internal Medicine Of Southwest Florida Newsletter
In This Issue
Atrial Fibrilation - A Common Problem
New Food Plate - Replaces the Pyramid
Plant Based Morning Shake
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Dr. Kordonowy MD
Dr. Raymond Kordonowy MD
If you haven't been on the blog page of our website I do encourage you to give it a try. It is the spot that I post newsworthy items as well as some of my editorials.  I consider many of my commentaries about the economics of health care to be necessary and informative. I am sure others in the audience might characterize them as "rants". In either case, I assure you they are heartfelt concerns that I feel compelled to share as in the end even your doctor is eventually a consumer of health care.  The blog postings run from the most recent at the top and the later items go downward. At the bottom of the page there is a previous icon you can click to go further back in time to see prior postings.
Issue: # 14December2011/Januarry/2012

I am resending this newsletter because the link for the synchronized heart beat in the first article had the video component pulled from the site. This newsletter provides a functioning link which after it fully loads, allows you to click a play button that will demonstrate by a video cartoon the proper synchronized heart beat. I feel this link is essential to enhancing your understanding and so I am resending the newsletter. I also fixed the In This Issue headline as well. 
I apologize for being unable to provide a newsletter these past three months. I had mentioned in a prior e-mail that I was busy with a couple of other projects. I served as a delegate at the Florida Medical Association's annual meeting in Orlando, Florida. It went very well and was quite an eye opening experience for me. I was encouraged to see such excellent physician talent lobbying hard for our profession as well as our patients. Dr. Miguel A. Machado MD was sworn in as the FMA's new president for 2011-12. I was also privileged with the opportunity to speak at the National Lipid Association's Clinical Lipid Update meeting in Orlando, Florida. I spoke on the management of chronic kidney disease to an audience of physicians, ARNP's, PA's and dietitians.There were also representatives from pharmaceutical industry in attendance.

The National Lipid Association has a new publication titled 100 Questions & Answers About Managing Your Cholesterol which I would recommend for interested readers.  Some of the proceeds from this book will go towards supporting the Foundation of the NLA. This foundation supports clinician education, public education and projects to raise awareness of lipid disorders and cardiovascular disease, the number one killer in the US.


In this newsletter I have first decided to write on the subject of atrial fibrillation because it is a very common problem and there are have been new studies regarding treatment options for stroke prevention related to this condition.  The second article was chosen because of a lecture provided at the NLA meeting mentioned above. There are now new guidelines for educating the public on nutrition and this is very important. The obesity epidemic continues to ravage the United States population. Being overweight and/or obese results in multiple health problems. Weight management is a behavioral issue and requires proper information in order to allow individuals to take control of their health.

As has become customary for my newsletters, I have included another recipe. This is a morning "blenderized" breakfast drink full of nutrients and fiber to help get your day started quickly.
Atrial Fibrillation- A Common Problem
 Left Atrial AppendageThe Most Common Heart Rhythm Problem


Atrial fibrillation (AF), the most common clinically relevant arrhythmia is found in 1-2% of the population and affects an estimated 2.2 million individuals in the US. The incidence of this problem rises as we age and statistics indicate it is present in approximately 11% of people 70 years of age and higher.

It is not uncommon for atrial fibrillation to be without symptoms, especially if patients are on certain blood pressure medications that lower heart rates.  In our practice this is sometimes "picked up" during our vital sign assessment during an examination or when an annual EKG is done to monitor blood pressure medications. If atrial fibrillation is symptomatic. it often causes significant cardiovascular symptoms such as a "racing heartbeat", shortness of breath or faintness. Atrial fibrillation is most notorious for having a significantly high rate of stroke associated with the rhythm.  There are significant costs related to this condition as well. Estimated total annual medical costs for AF treatment in US inpatient, emergency room and outpatient hospital settings were $US6.65 billion (2005 expenditures). This tabulation doesn't appear to include physician office costs as that data apparently wasn't available in the database.

To get readers oriented as to what goes wrong in atrial fibrillation, I will start by explaining a normal heartbeat cycle. In the heart there is a section of anatomy known as the AtrioVentricular Node which is a special bundle of muscle being responsible for atrioventricular conduction. The heart can be viewed as having 2 halves, the left and right portion. Each halve has a top and bottom chamber. The top chamber is called the atrium and the bottom chamber is called the ventricle. The term atrioventricular comes from this idea of the atrium starting the heartbeat down to the ventricle (atria + ventricle = atrioventricular).  A normal sinus (synchronized) heart beat starts with/from an organized electrical impulse from the atrial tissue and then is sent (conducted) down to the ventricle. This results in a nice "push" of blood that is directional- from the top of the heart down to the bottom and then out to the rest of the body. The left side is where recently oxygenated blood is "pumped" out to the body's tissues so they may receive life-giving oxygen for cell function. The right side of the heart receives "used up", oxygen poor blood and sends it to our lungs to be replenished with oxygen when we take in a new breath. The AV node arises from the top chambers of the heart called the atria.  Hit the link and you can see in a cartoon video what a synchronized heartbeat"looks like".  You can see that when the heartbeat is synchronized the body has the best function as it relates to efficiently pumping all the blood into all the right places. 


In atrial fibrillation, the normal synchronized heartbeat doesn't occur. This results in chaotic randomly conducted beats which are often very fast thus inefficient. This inefficient beating results in potential symptoms. Treatment issues related to atrial fibrillation start with controlling the patients symptoms (if present). This usually starts with medications that will lower/control the heart rate. There are also medications that can be used to try to promote the body to return to a normal synchronized rhythm. To date these medications don't work that well and appear to be more "dangerous" as patients get older.  Large studies have shown that using medications to control heart rate along with blood thinners to lower risk of stroke significantly lowers stroke risk, improves survival by several mechanisms and is actually safer than using medications that try to return the heart to a normal rhythm. Persons who are younger and have atrial fibrillation may benefit from medications to get them back to normal rhythm.  There are also procedures that can be done to try to eliminate atrial fibrillation and if done in the proper hands (centers of excellence) can be quite effective. The effectiveness for these procedures are less in patients who are older due to the fact that the heart tissue degenerates some as we age and thus the tendency for atrial fibrillation recurrence is higher.
Besides the potential to develop heart failure in non rate controlled atrial fibrillation, the biggest treatment issue is stroke prevention. The biggest source of stroke in atrial fibrillation is from a clot developing due to the lack of an organized heart beat. Rather than the atrial chamber/tissue beating in a normal fashion it "quivers"/fibrillates instead. This leads to clot formation especially along the left atrial appendage. If a clot forms it can move (medical term for this "clot moving" is "embolize") into the blood stream until it clogs up a smaller artery. If the artery it stops in is in the brain, the patient will experience a stroke. There is a huge body of data following this condition and thus my comments in this newsletter are a result of a very thorough and recent review along with information from a medical education program for physicians called MKSAP. You may go to this review via the link if you wish to see study references and more detailed information. Stroke risk is increased five-fold in patient who experience atrial fibrillation. The risk of stroke increases more as a person gets older (75 years and over has a much higher risk of stroke) and if they have other diagnosis such as hypertension (abnormally high blood pressure), diabetes, a history of congestive heart failure, peripheral vascular disease or a prior history of stroke or TIA (symptoms of stroke that go away within 24 hours). Persons with several risk factors as mentioned have annual stroke risks as high as 18% per year!  There are medications available that greatly lower the risk of stroke in atrial fibrillation. 
The first medication that lowers risk is simply aspirin. This was the main recommendation until definitive data proved warfarin (Coumadin) was much more effective for atrial fibrillation related stroke. If a patient is young, has normal heart function and no other risk factors the risk of stroke is around 2-3% per year and aspirin is still the proper recommendation to lower stroke risk in these low risk individuals. As more risk factors are added (remember one of them is age) then the recommendation to use warfarin becomes "standard of care", assuming the patient isn't at high risk for bleeding. In my latest review the recommendation is that even if a person goes from being in atrial fibrillation to not, it is still recommended that they remain on warfarin (if that had been the prior recommendation). The reason for this is that the probability of recurrence of atrial fibrillation and stroke is still very high in persons with history of atrial fibrillation.  Some conditions promote temporary atrial fibrillation such as heart surgery, pneumonia and acute physical stress- assuming the problem was in these situations then warfarin would not be recommended long term.
Recently the traditional recommendation for using warfarin has been brought into question. Warfarin is a wonderful drug and has/is servicing patients and doctors very well. It is, however, a very fussy medication fraught with food and medication interactions that requires continuous monitoring to keep it both effective and safe to use. Earlier, I had discussed a potential "game-changer" medication in a prior newsletter (see Jan 08, 2011 archive, article titled Newsworthy Medications). That game-changing medication is now available in the market branded as Pradaxa.  The generic name is Dabigatran etexilate and it works differently than warfarin as a blood thinner.  The trial which won it it's FDA approval showed that when compared to warfarin it was superior for reducing stroke risk. It also was associated with a statistically lower risk of intracranial hemorrhage which is the most serious risk associated with blood thinners. The risk of intracranial hemorrhage is nearly 6 fold higher when a person's warfarin dose results in too much effect. Dabigatran has no monitoring requirements and has far fewer drug interaction issues than warfarin. Being new, it is not available in a generic version and thus the out of pocket expense is higher on a personal use basis. Globally it should reduce costs due to improved outcomes, no monitoring required and less drug interaction issues. The main point is- taken properly it is superior to our current "standard recommendation".
Two new medications have hit the news lately and these two appear to be potential "game-changers".  They work as blood thinners but in a different manner than Dabigatrin which inhibits something called thrombin (which when activated promotes clotting).  The two medications more recently in the news work by inhibiting a coagulant factor called Xa (factor ten (a)). There are two others in this class still being studied. The FDA recently approved (9-2 vote in favor by the panel) the first Xa inhibitor generic name called rivaroxaban, brand name Xarelto owned by Johnson and Johnson. It is available currently for prevention of clots following hip and knee surgery and while approved for atrial fibrillation it is not yet available to the market for this indication. There is some controversy brought out during the panel vote but the data from the main trial (ROCKET-AF) indicates this product is "comparable to warfarin) for bleeding risk but again intracranial and fatal bleeding was less in the rivaroxaban group.  Overall risk of stroke and embolism was less in the rivaroxaban group and the conclusion is the product is "non-inferior" to warfarin. The medication was dosed once a day (making compliance easy) at 20 mg.  This was a "real-world" study and this led to some of the controversy.  One of the panel physicians argued that the warfarin group weren't therapeutic at the same frequency of other studies and thus suggested some of the benefit favoring the new medication was due to lack of effectiveness in the warfarin arm. This study involved over 14 thousand patients in 45 countries.  It might be true that in some countries the care could result in less effective use of warfarin but that is "real world". Even in our country that ability for different physicians and warfarin clinics vary significantly- that is the real world problem with warfarin.  The second medication that functions as a Xa inhibitor is called apixaban and it was dosed  5 mg twice daily.  It is a joint effort medication with companies Eliquis, Bristol-Myers Squibb/Pfizer involved in its development. The study showing efficacy is known as the ARISTOTLE trial and a 21% real rate of stroke reduction compared to warfarin was shown (1.27% vs 1.6%). There was again a significant reduction is bleeding risk between the two.
There are other medications being studied to possible replace or provide an option to warfarin two of which are also Xa inhibitors, they are edoxaban and betrixabanA different compound, tecarfarin works like warfarin but is supposed to have far less medication interactions due to the metabolic pathway that is used to eliminate it by the body. It would still have issues with some dietary interactions because these medications interfere with vitamin K effects. Vitamin K is used to make several clotting factors and warfarin and tecarfarin thin the blood by blocking vitamin K uptake in the clotting pathways. Vitamin K is affected by its intake in the diet as well as its production by some of our bacteria in our bowel.
The New Food Plate- Replaces the Pyramid

myplateUSDA's New Dietary Guidelines


At the recent August, 2011 NLA sponsored Clinical Lipid Update conference, Dr. Penny M. Kris-Etherton, PhD, RD, FNLA presented an update and historical review of the recent dietary guidelines for Americans USDA policy recommendations were discussed. She is a Fellow of the National Lipid Association and an authority in the Dietary and Nutrition field. 
She explained that the history of dietary guidelines in the US were born out of a CBS documentary from 1968 titled: Hunger in America".  This report showed "starving" children in the Appalacian mountain region of the US. and apparently bore out the shortcomings in the government food programs, indicating 1 in 4 American children were in the "brink of hunger". This report was the impetus for raising an ensuing $200 million and a US senate inquiry. By 1980 formal guidelines were intially made, the guideline was titled Dietary Guidelines For Americans. In 1985, the Departments of Agriculture (USDA) and the Health and Human Services(HHS) appointed a Dietary Guidelines Advisory Committee (DGAC) of experts to recommend periodic updates to the secretaries. In 1990 additional legislation mandated 5 year interval updates (National Nutrition Monitoring and Related Research Act).

The food pyramid that most of us are familiar with was developed in 1992. This was a graphical depiction of the USDA guidelines. This food pyramid was modified in 2005 to incorporate the idea of exercise as being part of proper nutrition/weight management.  Now the latest visual aid is the new "MyPlate".  This visual aid is to help us get the concept of what proportion of the main food sources should make up our plate at mealtime.  The main food sources are: protein (meat and fish), vegetables, grains, fruit and dairy. 

As biologic organisms, we eat for 2 main reasons (I realize pleasure is the emotional/sensory reason we eat but I am talking scientifically now). First is to get nutrients which are essential vitamins and minerals.  The second is to get energy to run our closed energy systems (known less formally as our bodies). All the food groups have varying amounts of nutrients and energy.  When doctors and nutritionists/dietitians discuss diet we spend a lot of time looking at energy intake because usually we are trying to help people with weight control. When we talk of energy we talk about calories. We get calories from carbohydrates, protein and fat. Carbohydrates include: sugars and more complex compounds known as starches. Protein is found most concentrated in meat, fish, eggs,nuts and legumes (beans and peas).  Fats are found in highest concentration in oils, butter,lard,nuts, meats and fish. Ounce for ounce we get the same amount of energy when we digest carbohydrates and protein.  Fat, on the other hand, has twice the energy availability as carbohydrates and protein. That is one of the reasons, we often ask people to eat less fats. Meat, especially large animal sources are the most calorie dense-this makes sense as large animals are at the end/top of the food chain and steak for instance is all protein and fat. Meat then is an area where portion reduction can be very effective in helping reduce calories.  In an small office presentation where I discussed protein meal replacement, I had explained to those in attendance, that a person can only use about 25-35 grams of protein at any one meal. Any portion larger than this is just "excessive" and will promote weight gain but not add meaningful nutrient potential. Dairy fat is widely available and calorie dense (and potentially harmful to cholesterol metabolism). This is another source of calories where the best bang for the buck lies in regards to cutting caloric/energy intake.

There are some terrific tools on the USDA approved, Center for Nutritional Policy and Promotion sponsored sites to help individuals track and learn about what different food contain in terms of energy and nutrients. These tools incorporate a large body of scientific information that went into their development.  I encourage readers to explore these sites and see if you can utilized them in designing meal plans and menus. The MyPlate site provides the visual depiction of a properly loaded plate and has a tip of the day section. The MyFood-a-pedia site can be used to look up a food and get nutritioinal information about a food. It has a drop down box once you start your search to help refine further what you are looking for (try looking up steak for instance). There is daily food plan interactive tool which will help you design/count your caloric intake and you food intake for the day.  There is another MenuPlanner tool which can help you plan a week's menu for several individuals.  I believe this tool can keep menu plans for you so that once you design a menu you can refer back to it.  Recently we also have found another calorie tracking tool which the group thinks is user friendly.
Plant Based Breakfast Drink
Breakfast shakeA Quick, Tasty, Nutritious Start
It is important to start your day on the right foot. While this recipe sounds and looks "terrible", it is surprisingly tasty and full of nutrition.  It is taken/modified from the Food for Life Cancer Resources.  I recommend adding some protein powder to fortify this with some important protein intake.  I recommend the Pure Encapsulations protein product line as the "Purina for People".  Those who wish to lose weight should use the PureLean product.  Those who are whey/dairy sensitive can use the IsoProtein Plus product. Those who are at a good weight can use the PureWeigh protein product.  Those who are looking to just increase protein intake (weight training or those who have low protein stores on their blood work) can use WheyBasics which has 21 grams of whey protein per serving. If you wish to go over the counter consider simple whey protein, or use whichever favorite product you might already be using.

Kale is one of the ingredients in this recipe. Kale is in the cabbage family and is readily available in the produce aisle of most grocery stores. Kale is a great source of beta carotene, vitamin C and E. It also is a decent plant source for calcium (135 mg in a cup of cooked Kale), folate and iron.  It is also loaded with potassium and those of you with kidney insufficiency might avoid this particular recipe. Kale also is a good source of bioflavonoids (antioxidants) and indoles (which can lesson the cancer-causing potential of estrogen).
Green Goddess Breakfast Drink
1 orange, peeled (or not if cleaned well, cut into quarters if you keep the peel)
1 bunch of grapes
1 banana (frozen recommended)
1 pear
1 cup of soy, almond,or rice milk (low fat regular milk is fine)
2 cups of Kale
Recommended serving scoop for protein powder (optional)
Ice cubes (optional)

Wash all food and place in a blender for 1 minute or until desired smoothness is achieved.
As the Holiday Season comes upon us I, my partners and the staff at Internal Medicine of Southwest Florida wish you Joy, Peace, Happiness, Properity and Health.  We appreciate your years of patronage and continue to consider it an honor to be of service in meeting your health care needs.


Raymond Kordonowy MD
Internal Medicine Of Southwest Florida
You can order your supplements on line.
While we are happy to offer Pure Encapsulation vitamins and supplements at the office, we have also arranged for you to conveniently order products from the comfort of your computer. Individual orders can be arranged via Internal Medicine of Southwest Florida's personalized storefront which is available on our website via the link on the navigation bar at the top of the page entitled "vitamins" or (just click the Pure Encapsulations logo seen at the bottom of the home page).  You can hit this link to take a shortcut to the store now.  Bookmark the link for easier future use. Only products that have been ok'd by Dr. Kordonowy are available to our patients. It is updated periodically.  Pure Encapsulations is a very high quality supplement line that follows rigorous production and quality protocols. It's the line Dr. Kordonowy and his family have personally used for years.