Heart Rate Recovery: A Simple and Powerful Predictor of Mortality Now Available On Your Apple Watch

Apple Watch and other fitness trackers have the capability to provide us with information on cardiovascular parameters which reflect the activity of the autonomic nervous system (ANS). Measures of the activity of the ANS reflect the balance between the sympathetic nervous system (which activates fight and flight responses) and the parasympathetic nervous system (which activates “rest and digest” activities) and have been shown to be powerful predictors of mortality.

Most of the attention in this areas has been on heart rate variability (HRV) with various wearables trying to promote HRV as a surrogate marker for stress. The OURA ring people for example state without evidence that “high heart rate variability is an indication of especially cardiovascular, but also overall health as well as general fitness.”

Although unimpressed with the HRV data from Apple Watch or the OURA ring I have recently discovered that I can get a more useful parameter of ANS tone from my Apple Watch-Heart Rate Recovery.

What Is Heart Rate Recovery?

Heart Rate Recovery (HRR) is the rate of decline in heart rate after the cessation of exercise. Basically you measure heart rate right when you stop exercising and again a minute later (and/or two minutes later) and subtract one from the other.

Unlike HRV you don’t really need any high tech devices to make this simple but highly reproducible measurement. You can simply measure your pulse the old-fashioned way by putting a finger on your carotid or radial artery and counting the beats.

What happens to the heart rate during exercise has long been considered to be due to the combination of parasympathetic withdrawal and sympathetic activation.

The fall in heart rate immediately after exercise has been shown to be a function of the reactivation of the parasympathetic nervous system. It is accelerated in athletes and blunted in patients with heart failure.

Heart Rate Recovery As A Predictor Of Mortality

A 1999 study published in the New England Journal of Medicine found that abnormally low HRR doubled the risk of dying over 6 years.

The study examined outcomes in 2428 consecutive adults (mean age 57 years, 63 percent men) without significant prior cardiac disease who were referred to the Cleveland clinic cardiac lab for nuclear stress testing.  Patients underwent symptom-limited exercise on a treadmill using a standard or modified Bruce protocol.

Heart rate was recorded at peak exercise and then patients walked upright and were walking at a speed of 1.5 miles per hour at a grade of 2.5 percent when heart rate was checked a minute later.

Median HRR was 17 beats per minute, with a range from the 25th to the 75th percentile of 12 to 23 beats per minute. Abnormally low HRR was selected as <13 beats/min and was found in 639 patients (26 percent).

In univariate analyses, a low value for the recovery of heart rate was strongly predictive of death, conferring a four-fold increased risk. After adjustment for multiple confounding factors including age and exercise capacity, patients with HRR <13 beats/min had a two-fold risk of dying.

This 20 year old study and HRR remain highly relevant. The paper has been cited 1001 times since publication and thus far in 2019 58 papers have referenced it.

In a follow up study this same Cleveland Clinic group looked at nearly 10 thousand patients undergoing treadmill ECG testing and found HRR <13 beats/min doubled the 5 year risk of death. In the figure below mortality jumps markedly as HRR drops below 13 and quite dramatically if <10 beats/min.

m_joc00680f2

 

 

 

 

 

Subsequent studies from different investigators confirmed that HRR is associated with mortality, independent of workload and myocardial perfusion defects, treadmill risk score, and even after adjusting for left ventricular function and angiographic severity of coronary disease.

There has been a lack of consistency in these studies in stress protocols, activity post-exercise and optimal duration of heart beat measurement post exercise.

This 2001 JACC paper determined that a 2 minute HRR <22 beats/min provided a better cut-point than one minue HRR <13 beats/min in predicting mortality at 7 years in male veterans. Individuals underwent maximal treadmill followed by lying down and those with an abnormal HRR were 2.6 times more likely to die. The HRR was equivalent to age and exercise capacity for predicting death.

Apple Watch and Heart Rate Recovery

It’s not entirely obvious how to view the heart rate recovery data on your Apple Watch but it is routinely logged if you record an activity and end it precisely at the end of the activity.  To see it you must leave the activity app and open the Heart Rate APP.

Scroll to the bottom of the screen and you will see HR data on your most recent activity including the peak HR and one minute recovery heart rate.

Click on that tab and the full and awe-inspiring graph of your recovery heart rate over 3 minutes is revealed. Here is mine which followed a 1.5 mile run at 6-7 MPH. I did not walk at 1.5 MPH on a 2.5% grade in recovery which would be needed if one wanted to more carefully compare a personal HRR to the numbers from the 1999 NEJM study.

My data shows a peak HR of 121 BPM which dropped to 90 BPM at one minute (121-90=31). Two minute recovery is 121-78 or 43 bpm. Both values are WNL

 

IMG_2A2C306430A7-1

The Watch only stores data on your last workout but if you go to the Activity app on your iPhone (something I had never previously done)  you will find under the workouts tab a complete listing of all previous workouts.

 

 

 

 

Click on the workout of interest and all the data from the workout is wondrously revealed including cadence, pace and  near the bottom heart rate changes. Swipe the heart rate changes during exercise to the left and the heart rate recovery graph is revealed. This time you will have to do the subtraction for yourself

Heart Rate Recovery-Simple, Powerful And Intuitive Measure of Autonomic Tone

So there you have it. Heart Rate Recovery (unlike HRV) is a simple parameter, easy to understand and measure. It yields information on your vagal/parasympathetic tone and has been proven to be a powerful and independent predictor of your overall mortality.

It makes more sense to pay attention to HRR if one wants a measure of your body’s autonomic tone than HRV.

If your one minute HRR is <13 beats per minute or two minute HRR <22 beats per minute this is a bad prognostic sign. If you have not been diagnosed with significant cardiovascular disease consider seeing a physician for evaluation..

For those who have been sedentary and are deconditioned or overweight, consider an abnormal HRR as a wake-up call to modify your lifestyle and improve your mortality.

For  healthy, asymptomatic individuals the HRR can serve as a marker for your overall cardiovascular fitness. Monitor it along with your exercise capacity, peak heart rate and resting heart rate to raise your awareness of how your exercise is influencing your overall autonomic nervous system balance.

Autonomously Yours,

-ACP

Taking Blood Pressure Medication At Bedtime Lowers Risk Of Death, Stroke And Heart Attack

When should you take your once daily BP meds?

Increasingly, the skeptical cardiologist has been recommending to patients that they take BP meds at bedtime as evidence has mounted  that this does a better job of normalizing asleep blood pressure and minimizing daytime side effects.

Now a study published in European Heart Journal in October has demonstrated that routine ingestion of BP meds at bedtime as opposed to waking results in improved 24 hour BP control with enhanced decrease in asleep BP and increased sleep-time relative BP decline (known as BP dipping.)

More importantly, bedtime BP med ingestion in this randomized trial of over 19 thousand hypertensive Spaniards resulted in highly significant reductions in cardiovascular events including death, heart attack, heart failure and stroke over a 6 year median follow-up

The so-called Hygia Chronotherapy Trial was extremely well done and the results are powerful and should modify clinical practice immediately.

This figure demonstrates the dramatic and highly significant 45% reduction in all types of cardiovascular events measured. Note that stroke rate was halved!

Screen Shot 2019-11-05 at 7.56.12 AM

Here are the Kaplan-Meier curves showing early and progressive separation of the treatment curves.

Screen Shot 2019-11-05 at 7.50.10 AM

There was no difference side effects or compliance between the two groups.

The remarkable aspect of this intervention is that it costs nothing, introduces no new medications and has no increased side effects.

This study is practice-changing for me. We will be advising all hypertensive patients to take their once daily BP meds at bedtime.

Chronotherapically Yours,

-ACP

h/t Reader Lee Sacry for bringing this study to my attention

 

 

The Skeptical Cardiologist’s 2019 Guide to Self-Monitoring Hypertension (High Blood Pressure)

Because uncontrolled high blood pressure (hypertension) is a well documented risk factor for stroke, heart attack and heart failure I discuss it a lot on this site and with my patients.

I just updated my page on hypertension which summarizes my thoughts and recommendations on home BP self-monitoring along with the latest on the optimal BP goal.

What To Monitor and How To Measure

I primarily makes decisions on blood pressure treatment these days based on patient self-monitoring. I discuss this in detail in a post entitled  (Why I Encourage Self-Monitoring Of Blood Pressure In My Patients With High Blood Pressure.)

I have found self-monitoring of patient’s BP to substantially enhance patient engagement in the process. Self-monitoring patients are more empowered to understand the lifestyle factors which influence their BP and make positive changes.

Blood pressures are amazingly dynamic and as patient’s gain understanding of what influences their BP they are going to be able to take control of it.

If high readings are obtained in the office I instruct patients to use an automatic BP cuff at home and make a measurement when they first get up and again 12 hours later. After two weeks they report the values to me (preferably through the electronic patient portal or by Kardia Pro.)

I discuss in detail the recommended technique for BP measurementin my 2018 post entitled  “Optimal Home Blood Pressure Monitoring: Must The Legs Be Uncrossed and The Feet Flat?

The 2018 ACC/AHA guidelines on hypertension  specify in detail how to optimally make home BP measurements as follows:

• Remain still:

• Avoid smoking, caffeinated beverages, or exercise within 30 min before BP measurements.

• Ensure ≥5 min of quiet rest before BP measurements.

• Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa).

• Sit with feet flat on the floor and legs uncrossed.

• Keep arm supported on a flat surface (such as a table), with the upper arm at heart level.

• Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow).

• Take at least 2 readings 1 min apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings beginning 2 weeks after a change in the treatment regimen and during the week before a clinic visit.

• Record all readings accurately:

• Monitors with built-in memory should be brought to all clinic appointments.

And, spoiler alert, it does matter if you cross or uncross your legs.

What Should The BP Goal Be?

For many patients with hypertension, SPRINT trial data published in 2015 suggest that a systolic blood pressure target of <120 mm Hg (intensive therapy) is preferable to a target of <140 mm Hg.

The SPRINT trial found that cardiovascular events like stroke and heart attack and death from these cardiovascular causes was lower by 25% in those patients treated intensively.  Overall death was lower by 27%

Read my post on SPRINT here and have a discussion with your physician about whether these more stringent BP goals are right for you. Keep in mind that the technique used in SPRINT likely gives us lower BP than home self-monitoring.

I discuss recent European and American BP guidelines which came to different BP goals after SPRINT in a post entitled “Becoming Enlightened About More Stringent Blood Pressure Goals: Sapere Aude”.

“As a 64 year old who has emerged from his nonage with hypertension, I have carefully examined the latest American hypertension guidelines especially in light of the SPRINT study and elected to add a third anti-hypertensive agent to get my average BP below 130/80. It’s worked for me with minimal  side effects but I carefully monitor my BP.

If I notice any symptoms (light-headed, fatigued) suggesting hypotension associated with systolic BP <120 mm Hg I tweak my medical regimen to allow a higher BP.

Like all of my patients I would prefer to be on less medications, not more but when it comes to enlightenment about the effects of hypertension, it is now clear that lower is better for most of us in our sixties down to at least 130/80*

Home Blood Pressure Monitoring Devices

You can get a good validated automatic BP monitor at Walgreens or CVS for around 35-40$.

But if you want to spend a little more you can get  BP devices which have added features such as style, portability, BlueTooth communication with smartphone apps and perhaps most importantly connection through the cloud with your physician.

My favorite BP cuff used to be the QardioArm (QardioArm: Stylish, Accurate and Portable. Is It the iPhone of Home Blood Pressure Monitors?)

I still love the QardioArm but lately I’ve been recommending the Omron Evolv for my patients who need monitoring as their recordings can be connected with me through Omron/Alivecor’s smartphone app:

The Omron Evolv One-Piece Blood Pressure Monitor: Accurate, Quick And Connected

For my patients using Omron Bluetooth BP monitors plus Alivecor’s Kardia Mobile ECG and the KardiaPro cloud connection I can view their rhythm and blood pressure at any time and analyze summary data via my patient dashboard as below.Finally, be aware that scam methods of BP measurement are being promoted to the public.

I wrote about one such  smartphone app called “Instant blood pressure”

Sphygmomanometrically Yours,

-ACP

Should You Choose The High-Dose Flu Vaccine?

Between patients last week the skeptical cardiologist skipped over to the employee health office at St. Luke’s and requested he be given a flu shot.

To my surprise, I was given a choice between a “high dose” flu shot which was “recommended for individuals 65 and older” and the regular quadrivalent flu vaccine.

I hadn’t been aware of this “high dose” flu shot previously thus had not had a chance to research it.  My time was limited and I decided to go with the high dose flu vaccine hoping that high dose did not also mean more chance for side effects.

Fortunately, I had no side effects and thus far have not contracted the flu.

Influenza More Deadly In Elderly But Vaccine Less Effective

Influenza, of course, is a huge killer which causes around 36,000 deaths per year in the United States. We adults 65 and older particularly vulnerable to complications of influenza and we are the ones that account for most of the more than 200,000 hospitalizations per year from the disease.

Hospital cardiology consultations typically spike during flu season as a bad case can worsen heart failure or trigger heart attacks and arrhythmias.

Although vaccination is the most effective intervention against influenza and associated complications, older individuals mount a lower antibody response to the vaccine compared to younger individuals.

Fluzone HD: High Dose Antigen Which Increases Antibody Reponse

To improve protect strategies to improve antibody responses to influenza vaccine in the older population, such as increasing the amount of antigen in the vaccine have been developed.

The vaccine I received is called Fluzone HD and is manufactured by the French pharmaceutical company Sanofi. It is a high-dose, trivalent, inactivated influenza vaccine (IIV3-HD) and contains four times as much hemagglutinin (HA) as is contained in standard-dose vaccines.

AFter studies demonstrating an acceptable safety profile and superior immunogenicity as compared with a standard-dose vaccine, IIV3-HD was licensed for use in the United States in December 2009,

Studies Show Improved Relative Efficacy Of Fluzone Compared to Standard Dose Flu Vaccine

A study published NEJM in 2014 proved the clinical superiority of Fluzone. It has a relative efficacy compared to standard vaccines of around 24%.

The CDC summarizes it as follows

Fluzone High-Dose (HD-IIV3) met prespecified criteria for superior efficacy against laboratory-confirmed influenza to that of SD-IIV3 in a randomized trial conducted over two seasons among 31,989 persons aged ≥65 years, and might provide better protection than SD-IIV3 for this age group . For the primary outcome (prevention of laboratory-confirmed influenza caused by any viral type or subtype and associated with protocol-defined ILI), relative efficacy of HD-IIV3 compared with SD-IIV3 was 24.2% (95% CI = 9.7–36.5%).

Subsequent studies have provided further support for the improved efficacy of Fluzone according to the CDC:

These findings are further supported by results from retrospective studies of Centers for Medicare and Medicaid Services (CMS) and Veterans Administration data, as well as a cluster-randomized trial of HD-IIV3 versus SD-IIV among older adults in nursing homes  A meta-analysis reported that HD-IIV3 provided better protection than SD-IIV3 against ILI (relative VE = 19.5%; 95% CI = 8.6–29.0%); all-cause hospitalizations (relative VE = 9.1%; 95% CI = 2.4–15.3); and hospitalizations due to influenza (relative VE = 17.8%; 95% CI = 8.1–26.5), pneumonia (relative VE = 24.3%; 95% CI = 13.9–33.4), and cardiorespiratory events (relative VE = 18.2%; 95% CI = 6.8–28.1)

Should You Choose Fluzone?

Most likely, now that I have had a chance to look in detail at the studies supporting Fluzone HD for the elderly and review the CDC recommendations, I would choose it for myself for  vaccination this year.

This is not a slam dunk decision and the CDC is actually quite wishy washy in its recommendations basically saying any formulation of vaccine is OK with them

For persons aged ≥65 years, any age-appropriate IIV formulation (standard-dose or high-dose, trivalent or quadrivalent, unadjuvanted or adjuvanted) or RIV4 are acceptable options.

As the CDC points out, we need more studies comparing these different flu vaccines to help guide decision-making.

Skeptically Yours,

-ACP

Addendum. Dr. Chelsea Pearson, the prominent St. Louis internist,tells me she recommends Fluzone or Flublok to her patients 65 or older.

Flublok is a quadrivalent recombinant vaccine of standard dosage.

A head to head comparison of these two vaccines would be nice to help patients and physicians decide which to take.

Cost was not an issue in my decision but a year ago Canadian health officials felt the five-fold greater cost of flu zone HD was not warranted (see here.)

N.B. Be aware there is a quadrivalent flu vaccine from Sanofi also called fluzone.  From the FDA:

Tradename: Fluzone, Fluzone High-Dose and Fluzone Intradermal
Manufacturer: Sanofi Pasteur, Inc (for Fluzone High-Dose and Fluzone Intradermal only)
Indication:

  • Fluzone is indicated for active immunization of persons 6 months of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.
  • Fluzone High-Dose is indicated for active immunization of persons 65 years of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.
  • Fluzone Intradermal indicated for active immunization for use in adults 18 through 64 years of age against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.

 

You Should Stop Taking Zantac (Ranitidine) Now

On September 13 of this year Valisure, an online pharmacy, submitted a  Citizen Petition to the FDA and urged it to  pull all ranitidine (brand name Zantac) from the market. Ranitidine, an H-2 blocker, is widely utilized both by prescription and over the counter for gastric acid suppression in the treatment of acid reflux and peptic ulcer disease.

According to CEO, David Light, based on Valisure’s testing and review of the scientific literature, ranitidine is an inherently unstable molecule which degrades directly and with high efficiency to the known carcinogen N-nitrosodimethylamine (NDMA).

The FDA issued a notice that same day “alerting patients and health care professionals that NDMA had been found in samples of ranitidine.” but did not call “for individuals to stop taking ranitidine at this time” stating:

Although NDMA may cause harm in large amounts, the levels the FDA is finding in ranitidine from preliminary tests barely exceed amounts you might expect to find in common foods.

By September 17, Health Canada asked companies to stop distributing the drug and at this time 30 countries have stopped sales of the drug. The FDA has yet to tell Americans not to take the drug indicating that it is awaiting more definitive studies.

In the meantime all major drug store chains and Amazon have voluntarily removed the drug from their shelves.

After listening to interviews with David Light of Valisure I’m convinced that everyone should stop taking ranitidine in any form because:

  1. The NDMA is not a contaminant but a breakdown product of an unstable ranitidine molecule and will be present regardless of which company makes it.
  2. NDMA is a highly significant carcinogen. Although not proven to cause cancer in humans it very reliable at causing it in mice. The levels Valisure detected are way above the levels the FDA considers acceptable.

Fortunately, there are many alternatives to ranitidine for acid suppression including PPIs (prilosec/omeprazole, pantoprazole, etc.) and an H2 receptor antagonist which does not have NDMA problems, famotidine.

Famotidine , according to this review:

is approximately 7.5 times more potent than ranitidine and 20 times more potent than cimetidine on an equimolar basis. Therapeutic trials indicate that famotidine 20 mg b.i.d. or 40 mg at bedtime is as effective as standard doses of cimetidine and ranitidine for healing duodenal ulcers. A dose of 40 mg at bedtime appears to heal benign gastric ulcers.

Skeptically Yours,

-ACP

N.B. I recommend this Peter Attia podcast interview with David Light (#75 – David Light: Zantac recall due to cancer concerns – what you need to know) if you want more details on Valisure and NDMA.

Also, check out Valisure’s description of the NDMA problem here.

Valisure is a unique pharmacy which per its website:

“sells the same meds that all American pharmacies use, but first put the batches through rigorous chemical analysis so the bad batches are screened out. We summarize our analytics in an easy-to-understand certificate of analysis specific to that batch. We are the only pharmacy to do this.”

 

48 Hours In Asheville: Chill Tonics, Moogs, Mountains, and Music

In order to escape Hurricane Dorian’s imminent arrival at Wrightsville Beach, NC the skeptical cardiologist and the wife formerly known as the eternal fiancee’ (WFKATEF) fled to Asheville, North Carolina.

There we spent a delightful 48 hours before heading to Mt. Airy, NC to participate in my daughter’s wedding.

We had never been to Asheville but found it to be a cozy town full of great food, music, booze, art, architecture, and books-surrounded by beautiful mountains with intriguing hiking trails.

We were lucky enough to snag a room at the Cambria hotel which is perfectly centered in downtown Asheville.

While the WFKATEF napped I strolled across the street and
investigated a gorgeous old building. This former and current shopping arcade was built by EW Grove.

A Tasteless Quinine Chill Tonic

Grove created a tasteless quinine (which for 300 years was the only effective malaria treatment ) tonic and by 1890 according to the Grove arcade website:

The chill tonic was so popular the British army made it standard issue for every soldier going off to mosquito infested lands and, by 1890, more bottles of Grove’s Tasteless Chill Tonic were sold than bottles of Coca-Cola.

Grove moved his tonic operations from Paris, Tennessee to St. Louis in 1890 but “the heavy pollution of the factory district caused Grove to develop lifelong breathing issues”.  As a result, Grove visited Asheville for its climate, which he found was good for his health and relieved his bronchitis.

Lots of wealthy individuals with tuberculosis visited Asheville between the 1880s and the 1930s due to a widespread perception in that era that its climate was optimal for curing the disease.

When Grove Arcade held its Grand Opening in 1929, it quickly became home to a fine collection of local shops and services. Following a period as the home of the National Weather Records Center it reopened in 2002 in its current incarnation.

A Delightful Book Exchange And Champagne Bar

My first discovery at the Grove was  the Battery Park Book Exchange  and Champagne Bar. I was intrigued by the combination of fine wine and champaign and old books.

Wandering through the various nooks and crannies of the Book Exchange one encounters delightful tables and chairs where one can consume a beverage and peruse classic literature. In one nook (or perhaps it was a cranny) I came across two of my all-time favorite books in a wonderful leather-bound format.58932518484__BADA9D50-717E-41B0-82C0-B3C87542082A No, I’m not a Eugene O’Neill fan but I strongly considered buying this gorgeous Franklin Library First edition of Barbara Tuchman’s description of the calamitous 14th century to replace my dog-eared and coffee-stained paperback edition.

Cool Random Art

Wandering around downtown Asheville we encountered sseemingly  random cool art such as this ironwork arbor of medicinal herbs featuring a bust of Elizabeth Blackwell the first woman to be awarded a medical degree in the United States..

The medicinal plants represent wild yam, Virginia creeper, sycamore, sweet gum maple, oak sassafras, witch hazel, and tulip poplar. Each of the plants incorporated are native to North Carolina and were used for medicinal purposes. The seats on the bench are made to look like gingko leaves. The monument is part of Asheville’s Urban Trail, a walking tour of the city’s downtown, highlighting historic people and events relevant to Asheville.

Elsewhere we encountered a giant iron.

Apparently this giant replica of an antique iron refers to the Asheville Flat Iron Building (1926)  designed by Albert Wirth and reminiscent of the ground-breaking 1902 skyscraper that graces Fifth Avenue in Manhattan.

In putting this post together I realized that these features are part of the Asheville Urban Trail which features various artistic references to” George Vanderbilt, E.W. Grove, Thomas Wolfe, F. Scott Fitzgerald, Douglas Ellington, and a short story writer calling himself O. Henry ~ just to name a few.”

Musical Jams At Jack of the Wood

As I rambled past an interesting looking Irish pub, Jack of the Wood, I noticed a flyer indicating that  old time music jam sessions occurred there every Wednesday night. We ended up there that night mesmerized by  a rotating group of locals playing banjos, guitars, fiddles, and a string bass.

We liked Jack of the Wood so much we came back the next night for the bluegrass jam.

Excellent Beer, Booze, Farm To Table Food

That night we Ubered to west Asheville and had a wonderful meal at Jargon. The WFKATEF ordered a cocktail named the Icebreaker 2.0 predominantly because it involved smashing a “hollow smoked ice ball” in our presence.

(Ice Breaker 2.0 – Knob Creek Bourbon, Carpano Antica vermouth, Ramazzotti Amaro, Angostura bitters, hollow smoked ice ball )
Asheville has a thriving craft beer scene but as I was in a keto frame of mind I didn’t partake extensively. It is also known for its excellent farm to table and foodie restaurants.
I won’t bore you with the details of a food and booze tour that we took or random rum tasting but if you are interested in such things Food and Wine has their own “48 hours in Asheville” which focuses on (shocker) food and booze in Asheville here.

Gorgeous Blue Ridge Mountains and Trails

Asheville is surrounded by the Blue Ridge Mountains which offer lots of great hiking opportunities. Our time was limited but we managed a short drive on the Blue Ridge Parkway to take a brief hike at Craggy Pinnacle 

The Blue Ridge Parkway  is a 500 mile road stretching from Virginia to North Carolina and managed by the National Park Service. It is a “series of parks providing the visitor access to high mountain passes, a continuous series of panoramic views, the boundaries of its limited right-of-way rarely apparent and miles of the adjacent countryside seemingly a part of the protected scene.”

Moog Factory Tour

A highlight of Asheville for me was the Moog factory tour

Moog Music synthesizers are deisgned and handcrafted in the Moog factory in downtown Asheville, NC and they offer a free tour daily.

While waiting for the formal tour to begin you find yourself in a room containing a painstakingly recreated version of the Moog modular that Keith Emerson played on tours and on fantastic albums with Emerson, Lake and Palmer..

You are also surrounded by every Moog synthesizer and processor that Moog sells. Even more fun, if you get there early like I did you can play every single one.

I own several Moogs and I could talk forever about the history of Bob Moog and Keith Emerson but I will leave that for another post.

Keith Emerson discovered the Moog synthesizer with his band The Nice in 1969. Shortly thereafter, he reached out to Bob Moog and acquired one of the first Moog modular synthesizers, which was built for the Museum Of Modern Art’s “Jazz In The Garden” public performance.  From then on, the names Emerson and Moog were entwined forever. Keith became the most-visible proponent of the synthesizer revolution, using the Moog loyally onstage for almost every show of his career. Emerson became the brightest name in the world of progressive rock music, his influence and creativity rivaled only by Jimi Hendrix. He was a masterful musician in many styles, but also a renowned showman who understood that elaborate theatrics would elevate the experience of the audience to a fever pitch. Part of his “show” was to faithfully include the monstrous wall of modules and cables that his Moog had become over the years, as it had developed an instantly recognizable sound that no other instrument could duplicate.

The Unseen Biltmore Estate

The leading tourist attraction in Asheville is the Biltmore estate. It is apparently the largest house in America but as I am a little burned out on fancy large palaces in Europe we decided not to go there.

I did want to wander through the gardens at Biltmore but you can’t purchase a ticket to do just that. You must purchase the $69 ticket and

Escape from everyday life to George Vanderbilt’s 8,000-acre estate in Asheville, NC. Your admission includes a self-guided visit of the breathtaking Biltmore House & Gardens, Antler Hill Village, and a complimentary wine tasting at our Winery.

All in all I would rate our visit to Asheville as one of the best 48 hours I’ve had in any American city.

Serendipitously Yours,

-ACP

Atrial Fibrillation Detection, Personal ECG Monitoring and Ablation: A Patient’s Story

One of the joys of writing this blog is the communication it allows me with discerning  individuals and patients across the planet. One such reader, Mark Goldstein, discovered he was in atrial fibrillation after purchasing an Apple Watch 4.

He now utilizes both the Kardia Mobile ECG and the Apple Watch to aid in his personal monitoring of his atrial fibrillation and has been actively pursuing a rhythm control strategy under the care of his electrophysiologist.

I asked him to share with my readers his experience which recently culminated in an ablation.

What follows is his description with my editorial comments in green.


December 2018 I bought a crazy, expensive Apple Watch. That watch may have saved my life. I spend much of my days at a treaddesk (a combination desk and treadmill). I was curious to find out how much exercise I was doing. I bought the watch, put it on, and starting walking as I do almost every day. Two hours later the watch had an alarm. It was warning me about something called “atrial fibrillation,” It said, “your heart has shown signs of an irregular rhythm.” What! I never heard of afib before. I quickly learned about it. Heart palpitations, no. Pain/pressure in the chest, no. Sweaty, faint, dizzy, etc., no, no. no. I checked the box for tired but I assumed it was because of the amount of exercise I was doing.

The next day I was fortunate that I had a physical scheduled a year ago. I told my doctor that my “crazy, expensive watch” thinks I have afib. My doctor laughed, telling me about how he had checked and probed every part of my body for the last 20 years (the probing part I remembered well). As the exam was concluding, he was puzzled by the afib warning so he grabbed my wrist to check my pulse. A few seconds later he was asking the nurse to give me an EKG. Darn, the watch was correct (and for me it was correct 99% of the time when I had afib and when I was normal – praise to Apple).

Recording from Mark’s Apple Watch 4 showing atrial fibrillation with controlled ventricular response. Heart rate is only 82 beats per minute. The AW algorithm correction identifies atrial fibrillation.

(This is a great example of how atrial fibrillation can be missed by the routine office physical examination. Some patients, especially those with non-rapid heart rates (due to rate slowing meds like beta-blockers or to intrinsically  slow conduction of electrical impulses) are minimally symptomatic and their pulses don’t feel that irregular. Because the first symptom of afib can be stroke I am an advocate of screening)

Shortly I got to meet a cardiologist (like Dr. Pearson, they are all nice people). Another EKG, afib confirmed. As we were talking about my symptoms or lack of symptoms, he said that afib was a bit like Eskimo’s describing snow. Each snowflake is unique and each afib patient is unique. I was in persistent afib. Probably had been in this state for two or three years since my heart rate jumped while sleeping, exercising, and at rest.

(Each afib experience is unique but not all cardiologists are nice people. Mark has been fortunate.)

The treatment plan was a cardioversion, an electrical shock to the heart, or as my cardiologist described it “like rebooting a computer.”

(See my post on cardioversion here.)

As a tech person, I understood that. The risk of not fixing my afib was five times the likelihood of a stroke. The risks were minimal so I chose the cardioversion.

(A common misconception is that ablation or cardioversion eliminates or substantially lowers the risk of stroke in afib. This is not the case. I’ll devote a future post to delve into this issue.)

Cardioversion one lasted four days before my Apple Watch started to detect afib.

(I’ve described in detail how helpful patient utilization of personal ECG monitoring is in letting me know the rhythm status of patients prior to and following cardioversion here.)

The cardiologist next step was cardioversion two along with a drug to help with rhythm control. Number two lasted a month before I saw my heart rate jump again. I thought something was wrong even though my watch was not detecting afib. Another EKG, this time the result was aflutter. The cardioversions were indeed like a reboot of the computer. If you have a virus on your computer, a reboot may be a temporary fix but eventually the virus will return.

(There are many drugs whose purpose is to suppress the recurrence of atrial fibrillation. Mark was prescribed the extended release version of propafenone, a Type IC antiarrhythmic drug (AAD)  similar in efficacy and side effects to flecainide. Type IC AADs should only be used in patients with normal left ventricular function (which was demonstrated in Mark by an echo) and without significant coronary artery disease (typically proven by a negative stress test).

To Ablate Or Not To Ablate

Now I got to meet an electrocardiologist. He said my afib would return and recommended an ablation. He said it was unlikely to be a permanent cure but it would help.

The aflutter disappeared after a day or so. I thought my afib was gone too but should I have an ablation? Ablations are relatively safe but since I was afib free why have the procedure?

I purchased the new Kardia Mobile six-lead portable EKG, a miracle of technology. Highly recommended for peace of mind. Just like my watch, I was seeing normal sinus rhythm. So why get an ablation?

A cardiologist had a YouTube video talking about the decision to have an ablation or any medical procedure. How will it affect the quality of your life or the quantity (how long will you live). This was a simple analysis and I like simple. I heard from my cardiologist that the evidence is that an ablation will unlikely extend my life nor will it reduce my lifespan. It was likely to not affect my lifespan. I confirmed this via independent research (be an informed patient, your outcomes will be better). See Dr Pearson’s articles about the CABANA study and the scientific evidence on ablation).  So an ablation and quantity of life were neutral.

Importance Of Quality Of Life

Quality of life was more interesting. Could I do the things wanted to do with my life? Did afib affect my day-to-day life? Could I walk up a couple of flights of stairs without breathing hard? Was I getting tired at 10AM? Could I exercise? At the time, the answer was easy. I could do everything I wanted to do. The afib affect was just about zero except for blood thinner drugs which I suspect I will take forever. No ablation.

Then “the day.” I woke and checked my sleep app on my phone. Heart rate at night jumped. Hmm! I went to the gym. My heart rate while walking jumped too. I did 30 seconds of high-intensity exercise and my heart rate monitor said 205 beats per minute. My heart was beating so hard I had to sit for five minutes. I knew something was wrong. Then I climbed a couple of flights of stairs, something that would never bother me. I felt a shortness of breath. I knew my afib was back. I also knew that the quality of my life was now being affected. I could not do things I wanted to do. My watch and Kardia Mobile EKG confirmed what I knew.

I called my electrocardiologist and scheduled an ablation. He was right. Afib would return.

(Mark tells me that he was taken off his propafenone one month after the second cardioversion because “the PA said I no longer needed it since I was in sinus rhythm.” My practice would have been to continue the propafenone as long as well tolerated and effective in suppressing afib recurrence. In my experience, the recurrence of Mark’s afib may not have been a failure of medical therapy. I treat patients similar to Mark by continuing the anti-arrhythmic drug since the minimal risks are lowered by regular monitoring and I regularly see maintenance of SR.”)

(Other antiarrhythmic medications were mentioned to Mark but as they required a 3 day hospital stay he was not interested.)


Stay tuned: Part two Of Mark’s post will be about the ablation procedure which he recently underwent.

Skeptically Yours,

-ACP

Mark Goldstein works in the field of cybersecurity in the WashingtonDC area and can be contacted at https://www.linkedin.com/in/markhgoldstein/

Very Cool Cartoon On Side Effects Of Proton Pump Inhibitors (PPI) For GERD

The skeptical cardiologist not uncommonly recommends OTC Prilosec (omeprazole), a proton pump inhibitor for cardiac patients with chest pain that is from acid reflux (GERD).

Lately, however, some studies have raised concerns about the long term side effects of taking PPIs.

I came across a very cool cartoon which reviews one patient’s history with respect to PPIs in today’s Annals of Internal Medicine.

I’ve been meaning to delve more deeply into the literature on PPI side effects but until then I think this cartoon does a great job of summarizing what patient’s should be considering.

You can view the entire cartoon for free on the Annals website here

Here is the first panel which describes a patient who has been taking the PPI pantoprazole for decades:

And this is the last panel

It’s ironic that at one point in this patient’s treatment he is put on Zantac (ranitidine). In recent weeks the FDA has issued warnings about a possible carcinogen in generic ranitidine and CVS and Walgreens have pulled it from their shelves.

Antirefluxively Yours,

-ACP

A Call To Reconsider The Heimlich Experiment: Part II, The Complications of The Maneuver

The Heimlich Maneuver (HM) has entered the American public’s consciousness as the method of choice for saving the life of a conscious choking victim.

In my first post on the Heimlich Experiment (A Call To Reconsider The Heimlich Experiment: Let’s Scientifically Determine The Best Approach To Choking Victims) I showed:

-that the the maneuver was accepted as the optimal treatment of chokers due to a promotional campaign by its developer, Henry Heimlich.

-that the experimental evidence actually supports chest thrusts as the optimal treatment.

-that unbiased reviews of the clinical literature do not provide evidence that the Heimlich Maneuver should be the first treatment for chokers.

Despite these facts, it is clear to me that thousands of people have utilized what they consider to be the Heimlich Maneuver on what they believed to be  a conscious choking victim with what they thought was a positive outcome as a result.

Unfortunately without proper documentation it  is impossible to know in these anecdotal cases:

-that a true Heimlich was applied

-that he victim would have died from foreign body airway obstruction if the maneuver had not been applied

-that the outcome was positive.

In addition, given that individuals are much more motivated to report positive outcomes we do not know how many cases there are where the Heimlich maneuver failed or resulted in adverse outcomes.

Heimlich and Koop: “Back Blows Are Lethal”

Heimlich promoted his maneuver while simultaneously doing his best to characterize alternative treatments as dangerous, frequently quoting C. Everett Koop, then Surgeon General of the United States.

Despite a total lack of scientific evidence,  Koop wrote an opinion piece in the journal of the Public Health Service in 1985 advocating the “Heimlich Maneuver” as the “best rescue techniqe in any choking situation.”

“Millions of Americans have been taught to treat persons whose airways are obstructed by a foreign body by administering back blows, chest thrusts and abdominal thrusts. Now they must be advised that these methods are hazardous, even lethal. A back slap can drive a foreign object even deeper into the throat. Chest and abdominal thrusts, because they refer to blows to unspecified locations on the body, have resulted in cracked ribs and damaged spleens and liver, among other injuries.”

Koop was prodded to make these totally unsubstantiated proclamations in a government funded journal by none other than Heimlich and his protege Ed Patrick (who has claimed co-creation credit for the HM). Koop’s comments are quite ironic given that we now know that the Heimlich maneuver has caused dozens of injuries with some resulting in death .

What’s even more striking about Koop’s statement is how confusing and sloppy it is. It appears that he doesn’t even understand what the Heimlich is,  grouping abdominal thrusts (the generic name for the HM) along with back blows and chest thrusts as methods which are “hazardous, even lethal.” In one sentence he says that abdominal thrusts have resulted in cracked ribs and damaged spleens and liver, among other injuries”.

Complications Of The Maneuver

Given that the public has been told to perform the HM on conscious, choking victims with little or no precise guidance on how much force to apply it is not surprising that significant complications have routinely been reported after HM application.

A 2018  case report describes one of the many possible complications that can ensue when one pushes forcefully on the abdomen of a choking person. The setting is a familiar one-an elderly individual begins choking on her food:

An 85-year old woman was in the hospital recovering from knee arthroplasty. While eating, she began to choke on her food. The event was noticed by a nurse who immediately performed HM. The episode resolved.

The next day  the woman became short of breath and had difficulty swallowing and the chest x-ray below was obtained showing a large incarcerated hiatal hernia.

(a) Large hiatal hernia occupying most of the lower right chest cavity. (b) Baseline chest film, where the diaphragmatic hernia cannot be appreciated. (c) Postoperative chest film, with resolution of the diaphragmatic hernia.

Following surgery to repair the hernia the patient developed septic shock and severe malnutrition and spent 50 days in the hospital before being discharged to a rehab facility.

Shawn Chillag’s  paper in 2010 (entitled The Heimlich Maneuver: Breaking Down The Complications) summarized the then current literature of case reports on complications of the Heimlich Maneuver.

There were 41 cases of significant injury with 27 cases of injury in the abdomen or diaphragm and 14 cases of injury in the thorax.

Among the 14 thorax injuries, 3 involved the esophagus, 4 the mediastinum, 5 the rib cage, and 2 the aortic valve.

Of the 27 abdominal injuries, 13 were severe lacerations or ruptures of the stomach, all on the lesser curvature ranging from 2 cm to 10 cm long.All were in adults from age 39 to 93 with 9 older than 60 years; one report gave no age. All but one, who died rapidly, underwent emergency surgery with 4 expiring and 8 doing well.

An 11 year old boy suffered a pancreatic transection and survived surgery

A 3 year old boy developed pancreatitis and a pseudocyst

An 88 year old man suffered a laceration of the liver

A 51 year old man died from asphyxiation post HM with autopsy showing laceration of the mesentery.

Severe Injuries To The Aorta

Patients who have aneurysms of the thoracic or abdominal aorta are at risk for complications when extreme pressure is applied to the abdomen. The 2010 review noted:

There were 8 major aorta injuries with 6 deaths. One survivor had displacement of a prior stent endograft and was doing well heimlichwith surgery. The other survivor had surgery for thrombosis of a 4.5 cm aneurysm with a leg amputation and permanent hemodialysis. One man had an incorrect applica- tion of the HM resulting in thrombosis in an abdominal aneu- rysm; he expired. One thrombosis of the aorta without aneurysm was treated with tissue plasminogen activator with a poor out- come. Another died from ruptured aortic dissection without an aneurysm. The HM definitely seemed needed in 6 of the 8. Aneurysms were present in 5, and an atherosclerotic aorta was present in all. The age range was from 62 to 84 years; 6 of the 7 were men.

The most recent HM case report was in February of this year and described a 67 year old man who developed left sided weakness immediately following application of the HM. The cause-dissection of the proximal thoracic aorta, a life-threatening condition.

Since that 2010 review I am also aware of case reports describing a fatal splenic rupture, a gastric perforation and another incarcerated hernia following HM.

These case reports likely represent only the tip of the iceberg-we basically have no idea what the complication rate of HM performance is.

Heimlich Maneuver Often Credited For Saving Life When It Is Really  A Guildner Maneuver (Chest Thrust)

Chillag, et al in their 2010 paper pointed out that:

In many of these reports it was difficult to ascertain if the HM was definitely indicated or performed correctly.

In 8, the HM was definitely needed; in 5 it was unknown. It is not clear if the HM was performed properly in any of the 13. Seven of these had repeated efforts which may be appropriate, but some descriptions seemed excessively zealous.

Just as it is difficult to know whether it was a Heimlich or a chest thrust that resulted in success it is difficult to say  which caused complications.

The recent report that Senator Joe Manchin of West Virginia “saved the life” of Missouri Senator Claire McCaskill illustrate sthis problem. McCaskill is reported to have suffered a fractured rib as a result of Manchin’s actions.

A true Heimlich Maneuver would not have fractured her rib. On the other hand, a chest thrust would have. Was McCaskill saved (and injured) by a chest thrust or a Heimlich maneuver? Given that these events occurs in a chaotic, confused and hectic way it is typically impossible to know with certainty.

The Elderly: High Risk For Both Choking And HM Complications

According to Injury Facts 2017, choking is the fourth leading cause of unintentional injury death. Of the 5,051 people who died from choking in 2015, 2,848 were older than 74.

Chillag, et al speculated that altered skeletal anatomy in the elderly might contribute to difficulty in properly applying the HM:

The significant loss of height that occurs with aging is axial; the lower rib to pelvis distance may decrease significantly with aging, perhaps making the xiphoid to umbilicus target for the usual HM not always achievable.

Chillag, et al advised caution in using the HM on the elderly:

Particular care seems indicated in the frail elderly with altered anatomy, vascular disease, fragile bones, and frequent esophageal swallowing problems.

The authors of the 2018 case report described above concluded:

Though HM is a life-saving procedure, we believe it would be wise to not only exercise caution when performing abdominal thrusts on the elderly and ensuring that it is indeed indicated, but also closely monitoring the individuals for dysphagia, odynophagia, respiratory distress, or shock after the maneuver.

What Do Countries Who Have Not Been Influenced By Henry Heimlich Recommend?

The Australia  and New Zealand Committe on Rescucitation (ANZOR) guidelines for choking (PDF accessed 10/13/2019 anzcor-guideline-4-airway-jan16) specifically advise against using abdominal thrusts stating:

Life-threatening complications associated with use of abdominal thrusts have been reported in 32 case reports. (see reference1 below )[Class A not recommended; LOE IV] Therefore, the use of abdominal thrusts in the management of FBAO is not recommended and, instead back blows and chest thrusts should be used.

the ANZOR guidelines recommend starting with back blows

If the person is conscious send for an ambulance and perform up to five sharp, back blows with the heel of one hand in the middle of the back between the shoulder blades. Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than to give all five blows. An infant may be placed in a head downwards position prior to delivering back blows, i.e. across the rescuer’s lap [Class B; LOE IV].

After the five back blows ANZOR advises moving on to try five chest thrusts.

If back blows are unsuccessful the rescuer should perform up to five chest thrusts.

Heimlich Maneuver: Time For A Reconsideration 

Thus, it is clear the Heimlich maneuver was recommended by Henry Heimlich for general usage without any human clinical studies to support its safety and efficacy. With Heimlich’s aggressive promoting of the technique it became the recommended way to treat choking conscious individuals despite experimental evidence showing it inferior to chest thrusts and no controlled human trials to support its safety and effectiveness.

Australia and New Zealand, countries free of Heimlich’s influence, do not recommend the Heimlich maneuver for choking victims.

It is entirely possible that chest thrusts are a safer and more effective maneuver for removing foreign bodies from choking victims. Since Dr. Heimlich died in December, 2016 perhaps the organizations that teach CPR can reevaluate their recommendations in this area without fear of public shaming or retribution.

Given the uncertainty in the treatment of choking victims and the number of deaths a national trial comparing chest thrusts versus abdominal thrusts as the initial procedure should be initiated as soon as possible.

Skeptically Yours,

-ACP

Special thanks to investigative blogger Peter M. Heimlich  for providing his unique archive of information on Henry Heimlich to assist me in this post and putting me in touch with Charles Guildner MD, the retired anesthesiologist (turned fine arts photographer) who published research showing chest thrusts produce greater airflow than abdominal thrusts. Dr. Guildner’s photos of the landscape and the lives of the people of the rural heartland are wonderful and  can be found here. Research by Peter and his wife  Karen M. Shulman has  resulted in scores of exposes  in the lay press about what they term Dr. Heimlich’s “wide-ranging unseen history of fraud,” and is documented on their website: http://medfraud.in

 

Reference 1. Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT, Nola JP, Travers AH. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e48–e70. http://www.resuscitationjournal.com

 

 

Is Bernie Sanders Fit To Be President After His Heart Attack?

While campaigning in Las Vegas on Tuesday of last week, Vermont Senator Bernie Sanders began experiencing tightness in his chest. He was rushed to a hospital where he was diagnosed with a heart attack and had two stents implanted to open blocked arteries.

Little to nothing beyond these bare details of his health condition is known but, as Politico put it, this event has “cast a cloud over his candidacy.”

Is it appropriate for voters to lose confidence in Sanders at this point? He was already the oldest candidate in the race at age 78 years. Would he survive a 4 year term in the grueling position of head of the free world?

An American Federation of Aging white paper, Longevity and Health of U.S. Presidential Candidates for the 2020 Election, used data from national vital statistics to estimate lifespan, healthspan (years of healthy living), disabled lifespan, and four- and eight-year survival probabilities for U.S. citizens with attributes matching those of the 27 then candidates for Presidency.

Its conclusions:

Given the favorable health and longevity trajectories of almost all of the presidential candidates relative to the average member of the same age and gender group in the U.S., and the apparent current good health of all of the candidates, there is reason to question whether age should be used at all in making judgments about prospective presidential candidates

I would agree that individual health is more important than  chronological age in evaluating longevity and in Sanders’ case the heart attack may be an indicator of a poor prognosis and an inability to withstand the rigors of campaigning for and serving as president.

Unfortunately we need to know a lot more about Sanders’ heart attack and overall health to make this determination.

Big Heart Attack Or Little Heart Attack?

A heart attack or  myocardial infarction (MI) occurs when heart muscle does not get enough blood/oxygen to keep the myocardial cells alive. This typically is due to a tight blockage in one of the coronary arteries supplying blood to the heart, thus constricting the blood flow to a segment of heart muscle (myocardium).

The size of Sanders’ heart attack is an important determinant of his prognosis. The more myocardial cells that died the larger the damage. We can detect and quantify heart attacks with a blood test using a cardiac specific protein called troponin.

Some heart attacks are tiny and only detected by very slight increases in the troponin in the blood whereas larger ones result in large increases in the troponin. What kind did Sanders have?

The more damage to the main pumping chamber of the heart, the left ventricle, the weaker the pumping action as measured by the ejection fraction.  The lower the ejection fraction the more likely the development of heart failure. What is Sanders ejection fraction? Does he have any evidence of heart failure?

Stunned or Hibernating Myocardium?

With some heart attacks the heart muscle doesn’t die but becomes stunned-weakened but still living. Under other circumstances a tightly blocked coronary artery doesn’t cause a heart attack but the reduced oxygen supply causes the muscle to stop working-in effect hibernating.  Thus, 3 months from now Sanders’ heart muscle function may improve as these stunned or hibernating myocardial cells come back to full function. What will Sanders’ ejection fraction be 3 months from now.? Will he have evidence of heart failure at that time?

Troponin levels and EF are just two of many factors that will determine Sanders’ prognosis.

A recent review of such factors on the one year post MI prognosis concluded

Secular trends showed a consistent decrease in mortality and morbidity after acute MI from early to more recent study periods. The relative risk for all-cause death and cardiovascular outcomes (recurrent MI, cardiovascular death) was at least 30% higher than that in a general reference population at both 1–3 years and 3–5 years after MI. Risk factors leading to worse outcomes after MI included comorbid diabetes, hypertension and peripheral artery disease, older age, reduced renal function, and history of stroke.

Hopefully, prior to the Iowa caucases all the candidates will release their medical records for the public to review. Only by learning more details about Senator Sanders’ heart attack and his overall medical condition can we answer whether he is fit to serve as President. Similarly, heretofore unknown individual health conditions could markedly effect the prognosis of any of the other candidates and their medical records should be equally scrutinized.

Skeptically Yours,

-ACP

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

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