Cochin Cardiac Club

Health Blog by Dr.Uday Nair

MEDICINES FOR HYPERTENSION

 

 

 

Which medicines are used to treat hypertension?


  • ACE inhibitors stop the production of a hormone called angiotensin II that makes the blood vessels narrow. As a result, the vessels expand, improving blood flow. Tension in the circulation is also lowered by the kidneys filtering more fluid from the blood vessels into urine. This also helps reduce blood pressure. If your blood pressure is not easily controlled on simple medication, your doctor will probably use a medicine of this type.

What are ACE inhibitors, and how do they work?


Angiotensin II is a very potent chemical that causes the muscles surrounding blood vessels to contract, thereby narrowing the vessels. The narrowing of the vessels increases the pressure within the vessels causing high blood pressure (hypertension). Angiotensin II is formed from angiotensin I in the blood by the enzyme angiotensin converting enzyme (ACE). ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, the blood vessels enlarge or dilate, and blood pressure is reduced. This lower blood pressure makes it easier for the heart to pump blood and can improve the function of a failing heart. In addition, the progression of kidney disease due to high blood pressure or diabetes is slowed.

For what conditions are ACE inhibitors used?


ACE inhibitors are used for controlling blood pressure, treating heart failure, preventing strokes, and preventing kidney damage in people with hypertension or diabetes. They also improve survival after heart attacks. In studies, individuals with hypertension, heart failure, or prior heart attacks who were treated with an ACE inhibitor lived longer than patients who did not take an ACE inhibitor. Because they prevent early death resulting from hypertension, heart failure or heart attacks, ACE inhibitors are one of the most important group of drugs. Some individuals with hypertension do not respond sufficiently to ACE inhibitors alone. In these cases, other drugs are used in combination with ACE inhibitors.

Are there any differences among the different types of ACE inhibitors?


ACE inhibitors are very similar. However, they differ in how they are eliminated from the body and their doses. Some ACE inhibitors need to be converted into an active form in the body before they work. In addition, some ACE inhibitors may work more on ACE that is found in tissues than on ACE that is present in the blood. The importance of this difference or whether one ACE inhibitor is better than another has not been determined.

What are the side effects of ACE inhibitors?


ACE inhibitors are well-tolerated by most individuals. Nevertheless, they are not free of side effects, and some patients should not use ACE inhibitors.
ACE inhibitors usually are not prescribed for pregnant patients because they may cause birth defects.
Individuals with bilateral renal artery stenosis (narrowing) may experience worsening of kidney function, and people who have had a severe reaction to ACE inhibitors probably should avoid them.
The most common side effects are:
  • cough,
  • elevated blood potassium levels,
  • low blood pressure, dizziness,
  • headache,
  • drowsiness,
  • weakness,
  • abnormal taste (metallic or salty taste), and
  • rash.


It may take up to a month for coughing to subside, and if one ACE inhibitor causes cough it is likely that the others will too. The most serious, but rare, side effects of ACE inhibitors are kidney failure, allergic reactions, a decrease in white blood cells, and swelling of tissues (angioedema).


With which drugs do ACE inhibitors interact?


ACE inhibitors have few interactions with other drugs. Since ACE inhibitors may increase blood levels of potassium, the use of potassium supplements, salt substitutes (which often contain potassium), or other drugs that increase the body's potassium may result in excessive blood potassium levels. ACE inhibitors also may increase the blood concentration of lithium (Eskalith) and lead to an increase in side effects from lithium. There have been reports that aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever etc.), indomethacin (Indocin, Indocin-SR), and naproxen (Anaprox, Naprelan, Naprosyn, Aleve) may reduce the effects of ACE inhibitors.

What are some examples of ACE inhibitors


The following is a list of the ACE inhibitors that are available in the United States:
  • benazepril (Lotensin),
  • captopril (Capoten),
  • enalapril (Vasotec),
  • fosinopril (Monopril),
  • lisinopril (Prinivil, Zestril)
  • moexipril (Univasc), and
  • perindopril(Aceon),
  • quinapril (Accupril),
  • ramipril (Altace),
  • trandolapril (Mavik).





  • Angiotensin-II receptor antagonists work in a similar way to ACE inhibitors. But instead of stopping the production of angiotensin II, they block its action. This allows the blood vessels to expand, improving blood flow and reducing blood pressure. Angiotensin II is a very potent chemical that causes muscles surrounding blood vessels to contract, thereby narrowing blood vessels. This narrowing increases the pressure within the vessels and can cause high blood pressure (hypertension). Angiotensin II receptor blockers (ARBs) are medications that block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced. Reduced blood pressure makes it easier for the heart to pump blood and can improve heart failure. In addition, the progression of kidney disease due to high blood pressure or diabetes is slowed. ARBs have effects that are similar to angiotensin converting enzyme (ACE) inhibitors, but ACE inhibitors act by preventing the formation of angiotensin II rather than by blocking the binding of angiotensin II to muscles on blood vessels.

    For what conditions are ARBs used?


    ARBs are used for controlling high blood pressure, treating heart failure, and preventing kidney failure in people with diabetes or high blood pressure. They may also prevent diabetes and reduce the risk of stroke in patients with high blood pressure and an enlarged heart. ARBs may also prevent the recurrence of atrial fibrillation. Since these medications have effects that are similar to those of ACE inhibitors, they often are used when ACE inhibitors are not tolerated by patients (for example, due to excessive coughing).

    Are there any differences among the different types of ARBs?


    ARBs are similar in actions and side effects. They differ in how they are eliminated from the body and the extent to which they are distributed throughout the body. Some ARBs need to be converted to an active form in the body before they can lower blood pressure. In addition, some ARBs are better at lowering blood pressure. In some studies, irbesartan (Avapro) and candesartan (Atacand) reduced blood pressure better than losartan (Cozaar).

    What are the side effects of ARBs?


    ARBs are well tolerated by most individuals. The most common side effects are cough, elevated potassium levels in the blood (hyperkalemia), low blood pressure, dizziness, headache, drowsiness, diarrhea, abnormal taste sensation (metallic or salty taste), and rash. Compared to ACE inhibitors, cough occurs less often with ARBs. The most serious, but rare, side effects are kidney failure, liver failure, allergic reactions, a decrease in white blood cells, and swelling of tissues (angioedema). ARBs usually are not prescribed for pregnant patients because they may cause birth defects. Individuals who have narrowing of both kidney arteries or have had a severe reaction to ARBs should avoid them. Like other antihypertensives, ARBs have been associated with sexual dysfunction.

    With which drugs do ARBs interact?


    ARBs have few interactions with other drugs. Since ARBs may increase blood levels of potassium, the use of potassium supplements, salt substitutes (which often contain potassium), or other drugs that increase potassium may result in excessive blood potassium levels and cardiac arrhythmias. ARBs may also increase the blood concentration of lithium (Eskalith) and lead to an increase in side effects from lithium. Rifampin (Rifadin) reduces the blood levels of losartan, and fluconazole (Diflucan) reduces the conversion of losartan to its active form. These effects could decrease the effects of losartan.

    What are the available ARBs?


    The following is a list of currently available ARBs:
    • candesartan (Atacand),
    • eprosartan (Teveten),
    • irbesartan (Avapro),
    • telmisartan (Micardis),
    • valsartan (Diovan),
    • losartan (Cozaar), and
    • olmesartan (Benicar).



  • Beta-blockers block the effect of the hormone adrenaline and the sympathetic nervous system on the body. This relaxes the heart so that it beats more slowly, lowering the blood pressure.
Beta blockers, also known as beta-adrenergic blocking agents, are drugs that block norepinephrine and epinephrine (adrenaline) from binding to beta receptors on nerves. There are three types of beta receptors and they control several functions based on their location in the body.
  • Beta-1 (β1) receptors are located in the heart, eye, and kidneys;
  • beta (β2) receptors are found in the lungs, gastrointestinal tract, liver, uterus, blood vessels, and skeletal muscle; and
  • beta (β3) receptors are located in fat cells.
Beta blockers primarily block β1 and β2 receptors. By blocking the effect of norepinephrine and epinephrine, beta blockers reduce heart rate; reduce blood pressure by dilating blood vessels; and may constrict air passages by stimulating the muscles that surround the air passages to contract.

For what conditions are beta blockers used?


Beta blockers are used for treating:
  • abnormal heart rhythm,
  • high blood pressure,
  • heart failure,
  • angina (chest pain),
  • tremor,
  • pheochromocytoma, and
  • prevention of migraines.
They also have been found to prevent further heart attacks and death after a heart attack. Other uses include the treatment of hyperthyroidism, akathisia (restlessness or inability to sit still), and anxiety. Some beta blockers reduce the production of aqueous humor in the eye and therefore are used for reducing pressure in the eye caused by glaucoma.

Are there any differences between beta blockers?


Beta blockers differ in the type of beta receptors they block and, therefore, their effects.
  • Non-selective beta blockers, for example, propranolol (Inderal), block β1 and β2 receptors and, therefore, affect the heart, blood vessels, and air passages.
  • Selective beta blockers, for example, metoprolol (Lopressor, Toprol XL) primarily block β1 receptors and, therefore, mostly affect the heart and do not affect air passages.
  • Some beta blockers, for example, pindolol (Visken) have intrinsic sympathomimetic activity (ISA), which means they mimic the effects of epinephrine and norepinephrine and can cause an increase in blood pressure and heart rate. Beta blockers with ISA have smaller effects on heart rate than agents that do not have ISA.
  • Labetalol (Normodyne, Trandate) and carvedilol (Coreg) block beta and alpha-1 receptors. Blocking alpha receptors adds to the blood vessel dilating effect of labetalol (Normodyne, Trandate) and carvedilol (Coreg).

What are the side effects of beta blockers?


  • Beta blockers may cause:

    • diarrhea,
    • stomach cramps,
    • nausea, and
    • vomiting.
  • Rash, blurred vision, muscle cramps, and fatigue may also occur.
  • As an extension of their beneficial effect, they slow heart rate, reduce blood pressure, and may cause heart failure or heart block in patients with heart problems.
  • Beta blockers should not be withdrawn suddenly because sudden withdrawal may worsen angina (chest pain) and cause heart attacks or sudden death.
  • Central nervous system effects of beta blockers include:

    • headache,
    • depression,
    • confusion,
    • dizziness,
    • nightmares, and
    • hallucinations.
  • Beta blockers that block β2 receptors may cause shortness of breath in asthmatics.
  • As with other drugs used for treating high blood pressure, sexual dysfunction may occur.
  • Beta blockers may cause low or high blood glucose and mask the symptoms of low blood glucose (hypoglycemia) in diabetic patients.

With which drugs do beta blockers interact?


  • Combining propranolol (Inderal) or pindolol (Visken) with thioridazine (Mellaril) or chlorpromazine (Thorazine) may result in low blood pressure (hypotension) and abnormal heart rhythms because the drugs interfere with each others' elimination and result in increased levels of the drugs.
  • Dangerous elevations in blood pressure may occur when clonidine (Catapres) is combined with a beta blocker, or when clonidine (Catapres) or beta blocker is discontinued after their concurrent use. Blood pressure should be closely monitored after initiation or discontinuation of clonidine (Catapres) or a beta blocker when they have been used together.
  • Phenobarbital and similar agents may increase the breakdown and reduce blood levels of propanolol (Inderal) or metoprolol (Lopressor, Toprol XL). This may reduce effectiveness of the beta blocker.
  • Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) (for example, ibuprofen) may counteract the blood pressure reducing effects of beta blockers because they reduce the effect of prostaglandins. Prostaglandins play a role in control of blood pressure.

What are some examples of beta blockers?


  • acebutolol (Sectral)
  • atenolol (Tenormin)
  • betaxolol (Kerlone)
  • betaxolol (Betoptic, Betoptic S)
  • bisoprolol fumarate (Zebeta)
  • carteolol (Cartrol)
  • carvedilol (Coreg)
  • esmolol (Brevibloc)
  • labetalol (Trandate, Normodyne)
  • metoprolol (Lopressor, Toprol XL)
  • nadolol (Corgard)
  • nebivolol (Bystolic)
  • penbutolol (Levatol)
  • pindolol (Visken)
  • propranolol (Inderal, InnoPran)
  • sotalol (Betapace)
  • timolol (Blocadren)
  • timolol ophthalmic solution (Timoptic)



  • Alpha-blockers cause the blood vessels to relax and widen. Combining them with beta-blockers has a greater effect on the resistance in the circulation.
Alpha blockers are a type of medicine sometimes used to treat high blood pressure. They are not usually used alone, and many patients are more familiar with alpha blockers because they are used to treat other illnesses, including:
  • Enlarged Prostate (benign prostatic hypertrophy)
  • Pheochromocytoma (a type of hormone-secreting tumor)
  • Peripheral artery disease (poor circulation, usually in the legs)

While other medicines are usually tried before considering alpha blockers, for some patients they represent an important treatment option.
How Alpha Blockers Work:
Alpha blockers, also called alpha adrenergic blocking agents, work by interferring with the transfer of messages to specific parts of the body. Like other "blocker" medications, alpha blockers attach themselves to molecules in the body that serve as receptors for certain chemical messages. Because the chemical message is then prevented from reaching its target, it is said to be blocked.
Alpha blockers block targets called alpha receptors, which are found on blood vessels, in the prostate, and in special blood pressure sensors called baroreceptors.
Patients are usually told to take alpha blockers before bed.
Names of Common Alpha Blockers:
Many different alpha blockers are available. Some commonly prescribed alpha blockers include:
  • Doxazosin (Cardura)
  • Phentolamine
  • Tamsulosin (Flomax)
  • Terazosin

Other alpha blockers are availabe, both within the U.S. and around the world. However, the vast majority of prescriptions in the U.S. are for the drugs listed above. Other types of alpha blockers are used mainly in special circumstances or controlled hospital settings.
Side Effects of Alpha Blockers:
Alpha blockers tend to be well tolerated, but have some important side effects. These include:
  • Dizziness
  • Fainting
  • Low blood pressure
  • Sudden blood pressure changes when standing after sitting
In addition to these side effects, an important research  found that long-term use of alpha blockers seems to increase the risk of heart failure. While this risk is real, it is small, and the main reason that alpha blockers are not used as "first choice" drugs is that, unlike other high blood pressure medicines, they have not been shown to reduce the risk of stroke and heart attack.
Notes:
Only you and your doctor can decide on a proper medication for treatment of high blood pressure. Be sure to notify your doctor if you are pregant or breastfeeding, and to supply the names of any other medicines and/or suppliments you are taking. Remember to include over-the-counter medicines like aspirin or Advil and herbal/natural suppliments.

  • Calcium-channel blockers reduce muscle tension in the arteries, expanding them and creating more room for the blood flow. In addition, they slightly relax the heart muscle so it beats more slowly, reducing blood pressure. In order to pump blood, the heart needs oxygen. The harder the heart works, the more oxygen it requires. Angina (heart pain) occurs when the supply of oxygen to the heart is inadequate for the amount of work the heart must do. By dilating the arteries, CCBs reduce the pressure in the arteries. This makes it easier for the heart to pump blood, and, as a result, the heart needs less oxygen. By reducing the heart's need for oxygen, CCBs relieve or prevent angina. CCBs also are used for treating high blood pressure because of their blood pressure-lowering effects. CCBs also slow the rate at which the heart beats and are therefore used for treating certain types of abnormally rapid heart rhythms.

    For what conditions are calcium channel blockers used?

    CCBs are used for treating high blood pressure, angina, and abnormal heart rhythms (for example, atrial fibrillation, paroxysmal supraventricular tachycardia).
    They also may be used after a heart attack, particularly among patients who cannot tolerate beta-blocking drugs, have atrial fibrillation, or require treatment for their angina.
    Unlike beta blockers, CCBs have not been shown to reduce mortality or additional heart attacks after a heart attack.
    CCBs are as effective as ACE inhibitors in reducing blood pressure, but they may not be as effective as ACE inhibitors in preventing the kidney failure caused by high blood pressure or diabetes.
    They also are used for treating:
    • pulmonary hypertension,
    • Raynaud's syndrome,
    • cardiomyopathy, and
    • subarachnoid hemorrhage.
    CCBs are also used in the prevention of migraine headaches.

    Are there any differences among calcium channel blockers?

    CCBs differ in their duration of action, the process by which they are eliminated from the body, and, most importantly, in their ability to affect heart rate and contraction. Some CCBs [for example, amlodipine (Norvasc)] have very little effect on heart rate and contraction so they are safer to use in individuals who have heart failure or bradycardia (a slow heart rate). Verapamil (Calan, Isoptin) and diltiazem (Cardizem) have the greatest effects on the heart and reduce the strength and rate of contraction. Therefore, they are used in reducing heart rate when the heart is beating too fast.

    What are the side effects of calcium channel blockers?

    • The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness.
    • Liver dysfunction and over growth of gums may also occur. When diltiazem (Cardizem) or verapamil (Calan, Isoptin) are given to individuals with heart failure, symptoms of heart failure may worsen because these drugs reduce the ability of the heart to pump blood.
    • Like other blood pressure medications, CCBs are associated with sexual dysfunction.

    With which drugs do calcium channel blockers interact?

    Most of the interactions of CCBs occur with verapamil (Calan, Isoptin) or diltiazem (Cardizem). The interaction occurs because verapamil and diltiazem decrease the elimination of a number of drugs by the liver. Through this mechanism, verapamil and diltiazem may reduce the elimination and increase the blood levels of carbamazepine (Tegretol), simvastatin (Zocor), atorvastatin (Lipitor), and lovastatin (Mevacor). This can lead to toxicity from these drugs.
    Grapefruit juice (approximately 200 ml) may elevate serum concentrations of felodipine (Plendil), verapamil (Calan, Isoptin), nisoldipine (Sular), nifedipine (Adalat, Procardia), nicardipine (Cardene), and possibly amlodipine (Norvasc). Grapefruit juice should not be consumed within 2 hours before or 4 hours after administration of affected CCBs.

    What calcium channel blockers are available?

    The CCBS that have been approved  include:
    • amlodipine (Norvasc)
    • clevidipine (Cleviprex)
    • diltiazem (Cardizem),
    • felodipine (Plendil),
    • isradipine (Dynacirc),
    • nifedipine (Adalat, Procardia),
    • nicardipine (Cardene),
    • nimodipine (Nimotop),
    • nisoldipine (Sular), and
    • verapamil (Calan, Isoptin).


  • Diuretics help the body get rid of excess salt and fluids via the kidneys. In certain cases, they relax blood vessels, reducing the strain on your circulation. For high blood pressure, diuretics, commonly known as "water pills," help your body get rid of unneeded water and salt through the urine. Getting rid of excess salt and fluid helps lower blood pressure and can make it easier for your heart to pump. Diuretics may be used to treat a number of heart-related conditions, including high blood pressure, heart failure, kidney and liver problems, and glaucoma.
    While diuretics are used to remove fluid, only thiazide diuretics, such as Esidrix or Zaroxolyn, are used to lower blood pressure.
    Loop diuretics (Lasix, Bumex) are more powerful and are often used when people have congestive heart failure symptoms and are especially useful in emergencies but do not significantly lower blood pressure.
    Potassium-sparing diuretics (like Aldactone) help your body retain potassium and are used more often in congestive heart failure patients. They are often prescribed in conjunction with the other two types of diuretics, but also do not significantly lower blood pressure.

    What Are the Side Effects of Diuretics?

    Like any drug, diuretics come with potential side effects. They include:
    • Frequent urination. This may last for several hours after a dose.
    • Arrhythmia (abnormal heart rhythm)
    • Electrolyte abnormalities -- Blood test monitoring of electrolytes is important before and during drug use.
    • Extreme tiredness or weakness. These effects should decrease as your body adjusts to the medication. Call your doctor if these symptoms persist.
    • Muscle cramps or weakness. Be sure that you are taking your potassium supplement correctly, if prescribed. Contact your doctor if these symptoms persist.
    • Dizziness, lightheadedness. Try rising more slowly when getting up from a lying or sitting position.
    • Blurred vision, confusion, headache, increased perspiration (sweating), and restlessness. If these effects are persistent or severe, contact your doctor.
    • Dehydration. Signs include dizziness, extreme thirst, excessive dryness of the mouth, decreased urine output, dark-colored urine, or constipation. If these symptoms occur, don't assume you need more fluids, call your doctor.
    • Fever, sore throat, cough, ringing in the ears, unusual bleeding or bruising, rapid and excessive weight loss. Contact your doctor right away.
    • Skin rash. Stop taking the medication and contact your doctor right away.
    • Loss of appetite, nausea, vomiting, or muscle cramps. Be sure that you are taking your potassium supplement correctly, if prescribed.
    Rarely, potassium-sparing diuretics like Aldactone can cause breast enlargement in men and women, deepening of the voice, increased hair growth and irregular menstrual cycles.
    In addition, most diuretics are sulfa drugs.If you are allergic to sulfa drugs, tell your doctor.
    Contact your doctor if you have any other symptoms that cause concern.

    Guidelines for Taking Diuretics

    Here are some general guidelines if you're taking a diuretic:
    • Before a diuretic is prescribed, tell your doctor if you are taking any other medications that may have been prescribed by another physician or any over-the-counter or herbal remedies. Also, tell your doctor if you have any other medical problems.
    • Follow your doctors instructions on how often you should take the diuretic. If you are taking a single dose a day, it might be better to take it in the morning instead of at night, so that you will not have your sleep interrupted by frequent trips to the bathroom. (This is more pertinent for patients with congestive heart failure or patients with cirrhosis and portal hypertension.)
    • While taking a diuretic, have your blood pressure and kidney function tested regularly, as advised by your doctor.
    • Keep all appointments with your doctor and the laboratory so that your response to this drug can be monitored.




The following medicines are used less frequently.
  • Indapamide (eg Natrilix) is a mildly diuretic preparation that also relaxes the peripheral arteries.
  • Hydralazine (eg Apresoline) relaxes the vascular walls in the peripheral arteries thereby reducing the blood pressure.
  • Methyldopa (eg Aldomet) stimulates the alpha receptors in the brain that relax the blood vessels, causing the blood pressure to drop.
  • Moxonidine (eg Physiotens) is another medicine that acts on receptors in the involuntary part of the brain, causing blood pressure to decrease.
  • Minoxidil (Loniten) relaxes the small arteries so that blood pressure drops. It must be used in combination with other hypertension medicines



ORAL HYGIENE AND HEART DISEASE



Gum Disease
Teeth are covered by sticky plaque, made up of food, bacteria and bacterial waste products. If plaque is left on the teeth the gums become irritated and may bleed when you brush. This early stage of gum disease is called gingivitis.
If gum disease is not treated, the gums may swell, forming a little pocket around the tooth. Plaque collects in this and cannot be removed by a toothbrush. When plaque is left on the teeth it may harden to form tartar (calculus).
As time goes on the pockets get deeper, trap even more plaque and tartar and may become infected. Over time gingivitis can develop into chronic (long term) periodontitis, in which the jaw bone can become infected and damaged, causing teeth to loosen or fall out.
Also researchers found diseased gums released significantly higher levels of bacterial pro-inflammatory components, such as endotoxins, into the bloodstream in patients with severe periodontal disease compared to healthy patients. As a result, these harmful bacterial components in the blood could travel to other organs in the body, such as the heart, and cause harm.
The disease is called subacute bacterial endocarditis, a severe infection of the heart lining. In this condition bacteria collect at a previously-damaged site within the heart. The prior damage can be from rheumatic fever, congenital defects, and other causes. Frequently, victims are unaware of this pre-existing damage.


Bacteria enter the body through a failure of natural defensive barriers. One such barrier is skin. Another is the tooth structure. These surfaces are not, themselves, vulnerable to germs; and they prevent germs from access to inner tissues which have no natural immunity, no defense.

 

What's the connection between oral health and overall health?


Your mouth is teeming with bacteria — most of them harmless. Normally the body's natural defenses and good oral health care, such as daily brushing and flossing, can keep these bacteria under control. However, harmful bacteria can sometimes grow out of control and cause oral infections, such as tooth decay and gum disease. In addition, dental procedures, medications, or treatments that reduce saliva flow, disrupt the normal balance of bacteria in your mouth or breach the mouth's normal protective barriers may make it easier for bacteria to enter your bloodstream.

 

What conditions may be linked to oral health?

 

Your oral health may affect, be affected by or contribute to various diseases and conditions, including:


  • Endocarditis. Gum disease and dental procedures that cut your gums may allow bacteria to enter your bloodstream. If you have a weak immune system or a damaged heart valve, this can cause infection in other parts of the body — such as an infection of the inner lining of the heart (endocarditis).
  • Cardiovascular disease. Some research suggests that heart disease, clogged arteries and stroke may be linked to oral bacteria, possibly due to chronic inflammation from periodontitis — a severe form of gum disease.
  • Pregnancy and birth. Gum disease has been linked to premature birth and low birth weight.
  • Diabetes. Diabetes reduces the body's resistance to infection — putting the gums at risk. In addition, people who have inadequate blood sugar control may develop more-frequent and severe infections of the gums and the bone that holds teeth in place, and they may lose more teeth than do people who have good blood sugar control.
  • HIV/AIDS. Oral problems, such as painful mucosal lesions, are common in people who have HIV/AIDS.
  • Osteoporosis. Osteoporosis — which causes bones to become weak and brittle — may be associated with periodontal bone loss and tooth loss.
  • Alzheimer's disease. Tooth loss before age 35 may be a risk factor for Alzheimer's disease.
  • Other conditions. Other conditions that may be linked to oral health include Sjogren's syndrome — an immune system disorder — and eating disorders.

Be sure to tell your dentist if you're taking any medications or have had any changes in your overall health — especially if you've had any recent illnesses or you have a chronic condition.

 

Can poor oral health cause heart disease? Will taking care of my teeth help prevent heart disease?

 


Poor oral health — not regularly brushing or flossing — is unlikely to be the primary cause of heart disease. But poor oral health combined with other risk factors may contribute to heart disease.Bacteria on your teeth and gums could travel through your bloodstream and attach to fatty plaques in your arteries (atherosclerosis), making the plaques become more swollen (inflamed). If one of the plaques bursts and causes a blood clot to form, you can have a heart attack or stroke.

It's possible that swelling in gums leads to swelling in other parts of your body, including your arteries. This swelling can also contribute to heart disease.

Regardless of whether you have heart disease, it's important to take care of your teeth and gums.



So a Dentist can detect a heart problem?

A dentist may be the first one to suspect health problems, including heart disease. A sore or painful jaw is one indicator of heart disease. There's also a connection between gum disease and heart problems. By eliminating a local infection involving a tooth or the gums, patients have been able to decrease blood pressure medications and improve overall health. New research is suggesting that people with gum disease are at higher risk for heart attacks. If bacteria in the infected gums dislodge, they can enter the bloodstream, attach to blood vessels and increase clot formation. That in turn decreases the blood flow to the heart, increasing chances of a heart attack and aggravating high blood pressure


When to Have Dental Treatment After a Heart Attack?


The percentage of reinfarction is unusually high for the first 6  months after an MI.  During this time avoid anything but absolutely necessary emergency dental treatment and with close consultation with the cardiologist. While the six month rule is a good starting point checking with the cardiologist is a good rule to follow. If treatment is really absolutely needed before the 6 month time period,  hospital dentistry then becomes the location to have the emergency procedures done.

 How can I protect my oral health?





To protect your oral health, resolve to practice good oral hygiene every day. For example:
  • Brush your teeth at least twice a day.
  • Replace your toothbrush every three to four months.
  • Floss daily.
  • Eat a healthy diet and limit between-meal snacks.
  • Schedule regular dental checkups.
Also, watch for signs and symptoms of oral disease and contact your dentist as soon as a problem arises. Remember, taking care of your oral health is an investment in your overall health.



Please Note-

Before any kind of dental procedures,please inform your dentist if you are taking any anti-platelet or blood thinning drugs like clopidogrel.

People who have had surgeries, especially surgeries that used artificial valves, conduits or stents absolutely need antibiotic treatment prior to receiving any type of dental  treatment, even a teeth cleaning. It is always important to talk to your dentist about heart conditions or surgeries you’ve had, and to ask your cardiologist if you need what are called prophylactic antibiotics prior to seeing the dentist. This large single dose of antibiotics taken an hour prior to dental work does prevent the greater risk of developing bacterial endocarditis.

Tell your dentist if your health status has changed since your last dental visit or if any of the following apply to you:

    Had heart surgery within the past six months;
    Had vascular surgery within the past six months;
    Have a pacemaker;
    Have a history of rheumatic fever
    Have a history of heart murmur
    Had previous bacterial endocarditis
    Have a systemic pulmonary shunt
    Have a congenital heart defect
    Have acquired valvular dysfunction
    Have been diagnosed with other heart ailments

    Your dentist may consult with your physician or cardiologist to determine which antibiotics you should take.
    As you know all things in our organism are bound up and it’s not astonishing that gum disease can cause heart problems.So,



    Take care of your teeth and gums, take care of your heart.




    DELAY IN GETTING TREATMENT IN INDIA AND ROLE OF THROMBOLYTIC THERAPY



    Medical Delay in getting treatment


    For Indians, genetically predisposed to heart diseases at least ten years ahead of those in the West, what finally proves fatal during strokes is the delay in reaching a hospital and getting to the life-saving 'clog busters'.Heart specialists across the country are in agreement on this point.Indian researchers has found that the biggest problem in India is that people in need of emergency care are unable to reach hospitals quickly. This could add to a rise in the number of heart fatalities.




    On an average, it takes 300 minutes to reach a hospital in India, more than twice the response time in developed nations. Few patients use an ambulance to reach a hospital. Most use private or public transport because they do not have money to hire an autorickshaw or a car.


    Time is muscle.The window of best opportunity (to save a patient) is the first 60 minutes. A delay of 300 minutescould mean severe damage to heart muscles, sometimes irreparable. There is an urgent need to educate people about this.




    Majority of hospitals in India delay even first-aid.Even after the person reaches a hospital, there is an average delay of 50 minutes.
    The delay in medical treatment is largely due to people's inability to pay.Many may not have the money ready. Several hospitals delay the administration of even first-aid until the victim pays for it.

    Nearly 40% of heart attack victims die before they can reach a hospital for treatment. More than 75% of heart attack victims are not covered by medical insurance.


    Majority of patients can be saved if they contact a cardiologist in time.It's important to meet a cardiologist within the first 15 minutes of the attack. Patients should take an aspirin in water before they call the ambulance.

    In the end we would like to add in case of emergencies, hospitals should show compassion and kindness to save lives.
    Delaying in the name of administrative rules and regulation can cause valuable waste of time.

    Every instituition should have flexible rules to accomodate common people and save human lives.



    Thrombolytic therapy



    Thrombolytic therapy is the use of drugs to break up or dissolve blood clots, which are the main cause of both heart attacks and stroke.

    Information

    Thrombolytic medications are approved for the immediate treatment of stroke and heart attack. The most commonly used drug for thrombolytic therapy is tissue plasminogen activator (tPA), but other drugs can do the same thing.

    You have a better chance of surviving and recovering from a heart attack if you receive a thrombolytic drug within 12 hours after the heart attack starts.

    Ideally, you should receive thrombolytic medications within the first 90 minutes after arriving at the hospital for treatment.

    FOR HEART ATTACKS

    A blood clot can block the arteries to the heart. This can cause a heart attack, when part of the muscle dies due to a lack of oxygen being delivered by the blood.
    Thrombolytics work by dissolving a major clot quickly. This helps restart blood flow to the heart and helps prevent damage to the heart muscle. Thrombolytics can stop a heart attack that would otherwise be deadly.
    The drug restores some blood flow to the heart in most patients. However, the blood flow may not be completely normal and there may still be a small amount of muscle damaged. Additional therapy, such as cardiac catheterization or angioplasty, may be needed.
    Your doctor will base the decisions about whether to give you a thrombolytic medication for a heart attack on many factors. These factors include your history of chest pain and the results of an ECG test.
    Other factors used to determine if you are a good candidate for thrombolytics include:
    • Age
    • Gender
    • Medical history (including your history of a previous heart attack, diabetes, low blood pressure, or increased heart rate)
    Generally, thrombolytics will not be given if you have:
    • A recent head injury
    • Bleeding problems
    • Bleeding ulcers
    • Pregnancy
    • Surgery
    • Taken blood thinning medications such as Coumadin
    • Trauma
    • Uncontrolled high blood pressure

    FOR STROKES

    Most strokes are caused when blood clots move to a blood vessel in the brain and block blood flow to that area. For such strokes (ischemic strokes), thrombolytics can be used to help dissolve the clot quickly. Giving thrombolytics within 3 hours of the first stroke symptoms can help limit stroke damage and disability.
    The decision to give the drug is based upon:
    • A brain CT scan to make sure there is no bleeding
    • A physical exam that shows a significant stroke
    • Your medical history
    As in heart attacks, a clot-dissolving drug isn't usually given if you have one of the other medical problems listed above.
    Thrombolytics are not given to someone who is having a hemorrhagic stroke. They could worsen the stroke by causing increased bleeding.

    RISKS

    There are various drugs used for thrombolytic therapy, but thrombolytics are used most often. Others drugs include:
    • Lanoteplase
    • Reteplase
    • Staphylokinase
    • Streptokinase (SK)
    • Tenecteplase
    • Urokinase
    Hemorrhage or bleeding is the most common risk. It can be life-threatening.
    Minor bleeding from the gums or nose can occur in approximately 25% of people who receive the drug. Bleeding into the brain occurs approximately 1% of the time. This risk is the same for both stroke and heart attack patients.

    PLEASE NOTE:

    Heart attacks and strokes are medical emergencies. The sooner treatment with thrombolytics begins, the better the chance for a good outcome.


    MUSIC AND HEALTH


    MUSIC TO BOOST HEALTH




    We all know that music greatly affects our mood. Music that we hear in passing and that which we do not like irritates us. On the other hand, music that we love listening to either makes us rest or energizes us depending on its beat, but nonetheless makes us feel good.

    Researchers have taken this cue for their studies and found that there are actually some health benefits to listening to music. Music stimulates brainwaves, with fast beats making the mind more awake, alert and sharp. Slow music, on the other hand, calms the brain and makes it relax. Music also induces the autonomous nervous system to slow down breathing and heart rate, bringing the body to a more relaxed state. And with the body and mind relaxed, feelings of anxiety and depression are lessened.


    Music can make you laugh or cry, rile you up or calm you down. Some say it’s good for the soul. It just might be good for the heart, too.

    Make no mistake—daily doses of Mozart won’t clean out your arteries or fix a faulty heart valve. But music can help ease your recovery from a cardiac procedure, get you back to normal after a heart attack or stroke, relieve stress, and maybe even lower your blood pressure a tad.


    As researchers have turned their attention to the effects of music on the cardiovascular system, they have found that listening to music can lower blood pressure, slow the heart rate, and lessen anxiety in people hospitalized for heart ailments. It can ease pain and distress after cardiac surgery. In otherwise healthy people, music can lower blood pressure and ease stress.

    Music was able to activate the limbic system associated with emotion. When activated the limbic system, the brain becomes more relax. The music can also stimulate the body to produce the molecule nitric oxide (NO). This molecule works on the tonus of blood vessels which can reduce blood pressure.



    Studies have found that music therapy is effective at promoting relaxation, relieving anxiety and stress, and treating depression. Music therapy allows people with emotional problems to explore feelings, make positive changes in mood, practice problem solving, and resolve conflicts. It can strengthen communication and physical coordination skills, and improve the physical and mental functioning of those with neurological or developmental disorders.

    Music therapy can also improve the quality of life of terminally ill patients and enhance the well-being of the elderly, including those suffering from Alzheimer's disease and other forms of dementia. It has also been used to complement the treatment of AIDS, stroke, Parkinson's, and cancer. Those with learning disabilities and speech and hearing problems may also find music therapy helpful.

    However,only the right song which can heal the pain. Choose the type of music that is relaxing with a tempo of 60 beats per minute such as Mozart’s classical music.




    Today, music therapy is most commonly used for people undergoing a cardiac procedure and for those recovering from a heart attack or learning to cope with heart failure or another cardiovascular condition, like angina or heart failure. For them, music therapy can alleviate stress, provide a pleasant coping strategy, and impart a feeling of control.

    There are several ways to let music into your heart. One is to work with a music therapist. If you can’t find one through your cardiologist. Do-it-yourself music therapy is another option. Find some music that makes you feel good.

    You can try to listen to the music for about 20-30 minutes each day while sitting or lying and close the eyes and make your body relax. It will be better to use headphones, so the music can be heard clearly


    Listen to some Music Ladies

    Whether it’s time alone with a good book or a trip to the salon, many women develop personal relaxation routines to cope with the stresses related to work, family and children.
    But for many women of color, coping is not always easy.Women of color are more likely to suffer from stress-related heart illness than their counterparts.

    Music has a direct effect on the heart rate, respiration rate, blood pressure, pain and anxiety of cardiac patient.
    However, there is no “one-size-fits-all” approach; a consideration of gender and cultural factors is of utmost importance in designing and implementing music therapy interventions for this population.


    Music therapy has been shown to have a positive effect on the mind and body.Through music therapy sessions that use culturally-relevant approaches, we hope to help women learn to cope with their stress, develop an avenue for self-expression within a supportive environment, acquire information about healthy lifestyles and reduce their risk factors for cardiovascular disease.

    Because of the healing properties of music, a kind of health care method called music therapy is now growing in popularity. Music therapy is now being used in some hospitals to calm down patients, to speed up healing and to alleviate pain. It is also used to treat people suffering from clinical depression or anxiety, as well as children afflicted with attention deficiency disorder.


    A relaxed and well-rested mind and body is an essential ingredient to being beautiful. We do not have to be sick in order to avail of the benefits music can bring to us.

    What can we do to bring the healing power of music into our lives? It is just a matter of putting some music into our day-to-day routine, which we already do on most times.

    We can start our day with some upbeat music to wake ourselves up and prepare for the day ahead. Listening to music in the morning sets us up to be more ready to face and deal with stress for the duration of the day.

    On the commute to work, you can play a CD of your favorite artist or band on your car stereo as you drive. Or you can have your iPod play some cool mp3's. This will relieve us of possible road rage as we plod through the traffic, as well as take our minds away from the tasks we have to accomplish once we get to the office.

    When you do your work or your chores, you can either play some soothing music to aid your concentration or some fast tunes to keep your energy level high, depending on the kind of chore you have to do. In this way, a task becomes less of a chore and more of an activity filled with fun, something you may start to love doing.

    On mealtimes, it is held that listening to some soothing music, particularly classical music, helps our bodies digest food better. This is because music induces the body to reduce the levels of cortisol, also known as the stress hormone, in our bloodstream. This then makes our bodies relax and able to absorb the nutrients of our food a lot better. It also enables us to enjoy our food more.

    Lastly, listening to music as we drift off to sleep ensures that we get the rest that we need from our sleep. Sometimes, the tiredness and the stress from the day keep us awake even though we have lain for a long time in our beds. Soothing music calms the stress and the tiredness from our minds and aids us in falling asleep.




    Music is a panacea to the mind, body and soul. A relaxed and rested body and mind, relatively free from the clutches of stress, is essential to beauty. Let the healing power of music give the rest your body and mind deserve.


    Introduction to Music Therapy




    Music therapy is the use of music to induce relaxation, promote healing, enhance mental functioning, and create an overall sense of well-being. Individuals doing music therapy typically listen to or perform music under the guidance of a specially trained and certified music therapist. Considered one of the "creative arts therapies" or "expressive therapies" (which include art therapy, dance therapy, writing therapy, and drama therapy), music therapy can be used alone or in conjunction with other therapies or healing treatments.
    Music therapists work with all age groups, from infants to the elderly, and can be found in a variety of settings, including private practice, schools, senior centers and nursing homes, outpatient clinics, psychiatric and medical hospitals.
    Music as therapy is almost as old as civilization itself.


    What to Expect from Music Therapy?



    Because music therapists work in many different settings and with many different kinds of patients, treatment programs and durations vary.
    If you consult a music therapist for a particular condition, the therapist will first talk to you about your symptoms and needs. In addition, the therapist will assess your emotional well-being, physical health, social functioning, communication abilities, and cognitive skills through your musical responses. Using this information, an appropriate treatment program will the be designed, which will probably include playing music, listening to music, analyzing lyrics, composing songs, improvising, and/or using rhythmic movement. During your regular sessions, the therapist may participate in these activities with you or simply guide you. You may also be encouraged to talk about the images or feelings that are evoked by the music.

    You and your therapist will select the music used for your therapy according to your needs and tastes. You can choose any kind of music, from classical or New Age to jazz or rock. You do not need to have previous musical experience or even musical ability to undergo music therapy.

    Some music therapy is conducted in a group setting. You might perform music with others who have the same ailment or condition as you, or interact and relax with others as music plays in the background. If you are in the hospital for surgery or to give birth, your music therapy might simply entail listening to your favorite songs to help you relax and reduce pain.

    How Does Music Therapy Work?




    Most people tend to experience a visceral reaction to music: a burst of energy upon hearing an upbeat song or a sense of calm during a soothing classical piece. Music therapy harnesses this connection between music and mood. Moreover, scientific studies show that music can affect physiological functions, such as respiration, heart rate, and blood pressure, as well. Music has also been shown to lower amounts of the hormone cortisol, which becomes elevated under stress, and to increase the release of endorphins, the body’s natural "feel-good" hormones.

    Music therapists often use music to communicate. With its beat, melody, and lyrics, music is a kind of language in and of itself. Because of this, music therapy can be used to help the mentally and physically disabled express themselves. It can also encourage introverted patients to become more outgoing and can be used to draw schizophrenic and autistic patients out of their isolated worlds.

    Music therapy can also be beneficial for stroke victims and other patients with neurological problems through a process called "entrainment." When patients listen to rhythmic music, their muscle movements become synchronized with the beat. As their motions become more regular and efficient, their motor skills improve in turn. Entrainment can also induce a sedative, relaxing response if the music has a slow, steady rhythm.

    Music therapy can also distract patients from negative thoughts, feelings, and experiences. For example, the therapy has been effective at helping keep people's minds from dwelling on the pain of dental work, surgery, and labor


    Other Mind-Body Methods


    Music is just one of many techniques that have been promoted for healing the mind and body. Others include:

    Transcendental meditation. Practicing the art of transcendental meditation can lower blood pressure, improve blood sugar and insulin levels, and ease stress. Other calming strategies, such as yoga or the relaxation response, can do the same.

    Massage. After heart surgery, a simple massage decreased pain levels. Whether massage affects the heart in other ways isn't well known, but a gentle massage is  certainly relaxing and stress releasing.

    Tai chi. The combination of simple, flowing movements and deep breathing in tai chi offers a safe, rejuvenating form of exercise for people with heart failure.

    Guided imagery. A program of directed thoughts and suggestions that help you imagine a relaxed, focused state can lower blood pressure and reduce other problems related to stress.

    Prayer. Personal prayer can help evoke the relaxation response, which can reduce your own stress, while praying for a loved one or friend may provide emotional or spiritual support that reduces his or her stress.

    Humor. Laughter may be good medicine for the heart and circulation.It is known to reduce tension and stress in our day to day life.

    AIR TRAVEL FOR PATIENTS-PRECAUTIONS

    Flying with Medical Conditions

    Over one billion people travel by air each year.The information in this article refers to considerations regarding fitness to fly as a passenger.

    The information given is general and not exhaustive; the links to the individual guidelines should be used to examine issues in more detail. Individual patients may need to have several conditions taken into account and different airlines have varied policies. More difficult cases are best considered with specialist advice and/or liaison with the particular airline's medical advisors. The sources of advice used are only guidelines and clinical judgement should always be used in their interpretation.

    Some airlines require medical certificates confirming that a patient is currently stable and fit to fly. Most have medical advisors who provide advice and 'clear' passengers as fit to fly.They may ask for a medical information form (MEDIF). The  Medical Association's advises doctors 'to word statements on a person's fitness to fly carefully, indicating the information on which the advice is based, rather than positively certifying a person's fitness'. For example:
    • 'I know of no obvious reason why this person should not fly'; OR
    • 'There is nothing in the medical record to indicate that flying is risky for this patient'.
    This ensures that the doctor is not guaranteeing in any way that this patient can travel without any problem but rather saying that, on the available evidence, there is nothing to indicate a greater risk for this person than for others. However, the doctor is partly dependent on what the patient chooses to disclose to them about past health problems.

    The main factors to take into account are whether air travel could adversely affect a pre-existing medical condition and whether or not a patient's condition could adversely affect the comfort and safety of the other passengers, or the operation of the flight. Regardless of a doctor's opinion on this latter question, the ultimate sanction to refuse travel lies with the airline and captain of the flight. If they consider there is a risk to the aircraft or its passengers, they may refuse to carry a particular passenger.





    Physiology during flight
    Modern aircraft are not pressurised to sea level equivalent. Cabin altitude equivalent is usually between 5,000 and 8,000 feet which means that there is a reduction in barometric pressure and a reduction in the partial pressure of alveolar oxygen (PaO2). Sometimes during flight, although not usually for long periods, oxygen saturation levels can fall to around 90%. A healthy individual can usually tolerate this with no problems but it may not be the same for someone with cardiac or respiratory conditions or with anaemia.

    Aircraft cabins also have low humidity levels which can cause dryness of mucous membranes and also the skin. Reduced cabin pressure can also cause gas volume expansion. This can be a problem if there has been recent surgery that has introduced gas into the abdominal cavity or the eye. Gas can also expand if it has been trapped in the ear.

    Basic considerations
    Basic considerations when assessing a patient's fitness-to-fly include:
    • The effect of mild hypoxia and decreased air pressure in the cabin.
    • The effect of immobility.
    • The ability to adopt the brace position in emergency landing.
    • The timing of regular medication for long-haul/transmeridian travel.
    • The ability of the patient to cope mentally and physically with travel to and through the airport to reach the flight and on disembarkation.
    • Will the patient's medical condition adversely affect the comfort or safety of the other passengers and the operation of the aircraft?
    • What health insurance cover does the patient have in case of problems?



    Cardiovascular disease
    Cardiovascular contra-indications to commercial airline flight include:
    • Uncomplicated myocardial infarction (MI) within 7 days (exercise testing to show that there is no residual ischaemia or symptoms is not mandatory before travel).
    • Complicated MI within 4-6 weeks.
    • Unstable angina.
    • Decompensated congestive cardiac failure.
    • Uncontrolled hypertension.
    • Coronary artery bypass graft within 10 days.
    • Cerebrovascular accident within 10 days (some can travel after 3 days if assessed and stable).
    • Uncontrolled cardiac arrhythmia.
    • Severe symptomatic valvular heart disease.
    • Uncomplicated percutaneous coronary interventions (e.g. angioplasty with stent placement) within 5 days - individual assessment is needed after that to ensure fitness and stability.
    The decrease in oxygen saturated during air travel may affect those with cardiovascular disease. Indications for in-flight oxygen in cardiovascular disease include:
    • Need for oxygen at baseline altitude.
    • Heart failure -  Class III-IV or baseline PaO2 <70 mm Hg
    • Angina Class III-IV.
    • Cyanotic congenital heart disease.
    • Primary pulmonary hypertension.
    • Other cardiovascular diseases associated with known baseline hypoxia.
    It is unusual for patients to be allowed to take their own oxygen supply and oxygen is usually arranged by the airline who must be aware in advance. A fee is usually charged. This may change in the future and there are ongoing discussions regarding this.

    Patients with pacemakers and implantable cardioverter defibrillators can fly once medically stable.


    Deep vein thrombosis
    • The World Health Organization (WHO) published the results of phase I of their WRIGHT (= WHO research into global hazards of travel) project in 2007.
    • These results show that the risk of venous thromboembolism (VTE) approximately doubles after a long-haul flight (>4 hours).The risk increases with the duration of the travel and with multiple flights within a short period.
    • It is immobilisation rather than any cabin environment effects of the coagulation system that is thought to be the cause of the increased risk.
    • The risk also increases significantly in the presence of other known risk factors for VTE (obesity, extremes of height, use of oral contraceptives and the presence of prothrombotic blood abnormalities).
    • The absolute risk of VTE per flight longer than 4 hours in a cohort of healthy individuals was 1 in 6,000.
    • Effective preventative measures will comprise phase II of the WRIGHT project.

    Deep vein thrombosis (DVT) prophylaxis

    It is wise for anyone undertaking a long-haul flight to take sensible precautions, such as to:
    • Remain adequately hydrated.
    • Exercise the calves.
    • Spend periods out of their seat.
    • Avoid excess alcohol.
    • Avoid tight-fitting socks or stockings.
    • Perhaps use graduated compression stockings.
    Advice about any more specific DVT prophylaxis should be based on relevant risk stratification and clinical judgement.
    Risk categoryRelevant risk factorsSuggested prophylaxis
    Minimal riskAge <40; otherwise fit and healthy.General advice.
    Low riskAge >40; obesity; active inflammation; minor surgery within 3 days.As above ± graduated compression stockings.
    Moderate riskVaricose veins; poorly controlled heart failure; MI within 6 weeks; oestrogen therapy (including oral contraception); polycythaemia; pregnancy/puerperium; lower limb paralysis/trauma within 6 weeks.Consider aspirin if there is no contra-indication ± graduated compression stockings.
    High riskPrevious VTE; known thrombophilia; major surgery within 6 weeks; previous stroke; malignancy; family history of VTE.As above but consider low molecular weight (LMW) heparin in place of aspirin.

    Respiratory disease
    • Deciding on fitness to fly for those with pre-existing respiratory disease can be difficult.
    • Those breathless at rest should not fly without oxygen.
    • A simple fitness-to-fly test is the ability of a patient to walk 50 metres unaided at a normal pace, or to ascend one flight of stairs, without becoming severely dyspnoeic.However, there is no evidence base to support this test.
    • If a person's oxygen saturation is equal to, or more than 95%, they do not need oxygen for flying, and there is no need for a referral to a respiratory specialist.
    • Anyone with an active exacerbation of respiratory disease would be wise to wait until their respiratory condition has improved, before flying.
    • Those with active respiratory infection, including both pneumonia and viral infections, should be clinically recovered and no longer infectious before they travel.
    • It is often worth seeking the advice of a respiratory physician in severe or complex cases, to define criteria and relevant investigations on which a patient should be judged as fit to fly, particularly with regard to the need for oxygen during flight. A combination of history, examination, lung function tests, hypoxic challenge testing and arterial blood gases may be needed in difficult cases and in deciding on whether in-flight oxygen is needed.
    • The hypoxic challenge test simulates the cabin environment in the laboratory using oxygen-nitrogen mixes. If the challenge results in a PaO2 of less than 55 mm Hg, oxygen is indicated during flight.
    • Untreated pneumothorax is an absolute contra-indication to air travel. Travel can usually be carried out two weeks after effective treatment, provided there has been full expansion of the lung.
    • Patients with stable asthma should be able to fly with no problems. However, they should keep their medication to hand. It may be advisable to prescribe a course of oral steroids for them to start if their condition deteriorates.

    It is unusual for patients to be allowed to take their own oxygen supply and oxygen is usually arranged by the airline who must be aware in advance.

    Pregnancy
    • Due to the increasing risk of an in-flight delivery, most airlines prohibit travel after the end of the 36th week in uncomplicated singleton pregnancies. Earlier limits apply for multiple/complicated pregnancies or with a history of premature delivery. The limit for multiple pregnancy is generally 32 weeks.
    • Most airlines require confirmation of dates from doctors for pregnancies >28 weeks. This should include the expected date of delivery and details that the pregnancy is progressing normally with no expected complications.
    • The risk of DVT is increased in pregnancy but it is unclear how this risk is affected by flying. Sensible precautions should be taken as for any traveller and compression stockings should be considered. If there are additional risk factors for thrombosis, specialist advice may need to be taken.
    • The risk of increased exposure to cosmic ionising radiation for the fetus is not thought to be significant, but is unquantifiable and must be taken at the mother's discretion. The risk may be increased if flying several times a week.
    Infants and children
    • The BTS advises waiting 1 week after birth before flying to ensure the infant is healthy.
    • Infants born prematurely who have had complications should probably not fly under the age of 6 months post-expected date of delivery.
    • Infants with a history of neonatal respiratory illness and children with chronic lung disease should have pre-flight hypoxic challenge testing.
    Anaemia
    • Someone with a haemoglobin <7.5 g/dL has a risk of hypoxia and an assessment of their fitness to fly should be carried out. In-flight oxygen should be considered.
    • The degree of adaptation to the anaemia will affect the likelihood of problems. Patients with chronic anaemia will tolerate hypoxia better than those who have had a recent haemorrhage.
    • Patients with sickle cell disease should have access to in-flight oxygen. They should not travel for 10 days following a crisis. Patients with sickle cell trait can usually travel without restriction.
    Ear, nose and throat problems
    • Active middle-ear infections, effusions, or recent ear surgery are contra-indications to flying unless the patient is deemed fit-to-fly by an ear, nose and throat (ENT) specialist.
    • Acute sinusitis, large nasal polyps and recent nasal surgery are relative contra-indications.
    • Seek advice from an otolaryngologist if uncertain.
    Postsurgical patients
    • Patients should not fly for 10 days following abdominal surgery.
    • Flying is not advised for 24 hours after a colonoscopy or other procedures where a large amount of gas has been introduced into the colon.
    • Flying is not advised for 24 hours after a laparoscopy.
    • Travellers with colostomies may need to use a larger bag as intestinal distension during the flight may increase faecal output.
    • Air travel should be avoided for 7 days following neurosurgery due to the possibility of residual gas being trapped in the skull.
    • Interventions for retinal detachment usually involve the introduction of gas by intra-ocular injections and can cause an increase in intra-ocular pressure. Air travel should not be undertaken for 2-6 weeks depending on the type of gas used.
    • Flight should be delayed for one week after other ophthalmological procedures or penetrating eye trauma.
    •  Airlines have a list of guidelines outlining the minimum time before it is advisable to travel after surgery. Different airlines may have different policies.
    Trauma/orthopaedics
    • Patients should wait for 24 hours following application of a plaster cast, for flights of less than 2 hours and for 48 hours on longer flights because air may be trapped beneath the cast.
    • If urgent travel is necessary, a bi-valved plaster cast can be used.
    Neurological/psychiatric illness
    • Fitness-to-fly is best considered on an individual basis and with expert advice if there is uncertainty. The freedoms of the affected individual to travel must be balanced against those of other passengers and safety considerations.
    • Acutely disturbed or psychotic patients should not travel.
    • Patients with controlled epilepsy can generally fly safely. However, they should be made aware of the potential seizure threshold-lowering effects of fatigue, delayed meals, hypoxia and disturbed circadian rhythm. Care should be taken that medication should not be omitted inadvertently when travelling through different time zones.
    Contagious infectious disease
    • This is a relative contra-indication to travel depending on the nature of the condition and its transmissibility at that phase of the illness.
    • Tuberculosis is a particular concern. A passenger should have had adequate treatment and be non-infectious prior to the flight.
    Diabetes mellitus
    • There are no restrictions on flying with well-controlled diabetes.
    • Insulin-dependent diabetics are normally required to have a letter of authorisation from their doctor to allow carriage of needles in their hand luggage. Insulin should be carried in a cool bag or pre-cooled vacuum flask.
    • Insulin should not be stored in the hold as temperatures may cause it to freeze and denature.
    • Special consideration needs to be given to insulin dosing regimens on long-haul flights, depending on the direction of travel and movement across time zones. Advice from a diabetes specialist may be needed. However, as a general rule:
      • When travelling east and if more than 2 hours are lost, it may be necessary to take fewer units with intermediate or long-acting insulin.
      • When travelling west and the day is extended by more than 2 hours, supplemental short-acting insulin, or an increased dose of intermediate-acting insulin may be needed.
    • Sugar tablets and snacks to prevent episodes of hypoglycaemia should be carried.