Heart Healthy Breakfast Choices?: Cheerios, Honey-Nut Cheerios and Soluble Fiber Revisited

A reader commenting on my Plant Paradox post questioned nutritional  recommendations to consume fiber. This has prompted me to revisit a post I wrote in 2014 on Cheerios and Soluble Fiber.

I mentioned at that time that Honey-Nut Cheerios was the #1 selling ready-to-eat breakfast cereal and Cheerios #4. This update Screen Shot 2018-07-15 at 7.22.55 AMindicates little has changed in the rankings or consumption of breakfast cereal since then despite a more widespread recognition that added sugar is the major toxin in our diet and that these food items are basically a vehicle for sugar.

Apparently, Americans believe honey is not sugar. But Honey Nut Cheerios contain 9 times as much sugar as cheerios. Here are the top ingredients:

Whole Grain Oats, Sugar, Oat Bran, Corn Starch, Honey, Brown Sugar Syrup, Salt, Tripotassium Phosphate, Rice Bran Oil and/or Canola Oil,

General Mills tries to emphasize the healthiness of Honey Nut Cheerios, focusing on their close relationship with bees and the natural goodness of honey in its advertising along with other factors that we now know are not important (low fat, 12 vitamins and minerals, source of iron).Screen Shot 2018-07-15 at 7.56.32 AM

Little has changed with respect to the science supporting fiber consumption to reduce cardiovascular disease since 2014.  It is still weak and based on observational studies and surrogate biomarkers.

Between the lines below is my original post with current annotations in red.


The skeptical cardiologist usually eschews the breakfast offerings in the Doctor’s lounge. I’m not really interested in consuming donuts, muffins, or bagels with their high carbohydrate load. As I’ve ranted out about previously, the only yogurt available is Yoplait low fat , highly sugared-up yogurt which is arguably worse than starting the day with a candy bar.

A selection of breakfast cereals is available including Cheerios, Raisin Bran, and Frosted Flakes. Occasionally, when I have neglected to bring in my own full-faty yogurt, granola and/or fruit I will open up one of the Cheerios containers and consume a bowl mixed with 2% milk (full-fat, organic milk which I passionately advocate here and here is not available) (2018 update, I have said “cheerio” to all breakfast cereals and no longer eat Cheerios in the doctor’s lounge). 

Pondering the Cheerios packaging and the cute little O’s made me wonder whether this highly processed and packaged food with a seemingly endless shelf life was truly a healthy choice.

The “Ready-To-Eat”  And Allegedly Heart-Healthy Cereal

Cheerios and Honey-nut cheerios were  the #4 and #1 breakfast cereals in the US in 2013, generating almost a billion dollars in sales. Both of these General Mills blockbusters undoubtedly have reached their popularity by heavily promoting the concept that they are heart healthy.

The Cheerios label is all about the heart. The little O’s sit in a heart-shaped bowl. A prominent red heart with a check inside it attests to the AHA having certified Cheerios as part of its checkmark.heart.org program. Additional text states “low  in Saturated fat and cholesterol” and “diets low in saturated fat and cholesterol may reduce the risk of heart disease.”

Is The Fiber In Cheerios “Heart-Healthy” ?

Beta-glucan is a soluble fiber primarily located in the endosperm cell wall of oats. Early studies showed that oats and beta-glucan soluble fiber could reduce total and LDL (bad cholesterol) levels. The mechanism isn’t really known. (see the end of post for possible mechanisms). The Quaker oats web site oversimplifies the mechanism thusly :

“In your digestive tract, it acts as a sponge, soaking up cholesterol and carrying it out of the body”

This narrative fits with the oversimplified and now discredited descriptions of atherosclerosis which attribute it directly to consumption of cholesterol and fatty acids. See here if you’d like to appreciate how complex the process truly is.

The FDA Sanctions Oats As Heart Healthy

In 1997, the FDA reviewed 33 studies (21 showing benefit and 12 not) and decided to allow a health claim for foods that contain oats and soluble fiber. A minimum dose of 3 grams/day of oat beta-glucan was suggested for a beneficial reduction in blood cholesterol and (presumably, although never documented) a subsequent decline in coronary heart disease.

In 1998 Johnson, et al, published the results of a study funded by a grant from General Mills that showed that  inclusion of whole grain oat ready to eat cereal providing 3 grams of beta-glucan as part of a low fat diet reduced  LDL cholesterol by 4% after 6 weeks. HDL was unchanged. Patients in this study consumed 45 grams (1.5 oz) of cheerios at breakfast and then again in the evening. There was a total of 3 grams of soluble fibre in this amount of Cheerios. A control group consumed corn flakes in a similar fashion without change in LDL.

General Mills took this weak data and ran with it and began posting on Cheerios the following statements

 “Did you know that in just 6 weeks Cheerios can reduce bad cholesterol by an average of 4 percent? Cheerios is … clinically proven to lower cholesterol. A clinical study showed that eating two 1 1/2 cup servings daily of Cheerios cereal reduced bad cholesterol when eaten as part of a diet low in saturated fat and cholesterol.”

Although the FDA had approved verbiage indicating oats may reduce heart disease “when eaten as part of a diet low in saturated fat and cholesterol” the agency objected to General Mills claiming that Cheerios lowers cholesterol “when eaten as part of a diet low in saturated fat and cholesterol”.

The FDA  issued a warning letter to General Mills in 2009 in which the agency alleged “serious violations” of the FDC Act in the label and labeling of Cheerios cereal.

Based on claims made on your product’s label, we have determined that your Cheerios® Toasted Whole Grain Oat Cereal is promoted for conditions that cause it to be a drug because the product is intended for use in the prevention, mitigation, and treatment of disease.

Lowering Cholesterol Is Not The Same As Preventing Heart Disease

The FDA was telling General Mills that it was OK to say that Cheerios may reduce heart disease but not that it can reduce cholesterol because that made it a drug. It makes no sense.

The only thing that had been demonstrated for oat soluble fiber and Cheerios in particular was a reduction in cholesterol. There has never been a study with oats showing a reduction in heart disease..

It’s the heart disease, the atherosclerosis clogging our arteries and causing heart attacks and strokes that we want to prevent. We could care less about lowering cholesterol if it doesn’t prevent atherosclerosis.

A recent review of studies since the FDA ruling shows that 70% of studies show some reduction in LDL with beta-glucan. Interstingly, the studies which added beta-glucan to liquids were generally positive whereas addition to solids such as muffins usually did not show benefit.

I’m going to accept as evidence-based the claim that whole oats can lower your LDL about 7% if you consume a very large amount of them on a daily basis.

However, the critical question for any drug or dietary intervention is does it prevent atherosclerosis, the root cause of heart attacks and strokes. There has been in the past an assumption that lowering cholesterol by any means would result in lowering of atherosclerosis.

This theory has been disproven by recent studies showing that ezetimibe and niacin which significantly lower LDL do not reduce surrogate markers of atherosclerosis or cardiovascular events any more than placebo when added on to statin drugs. (There is now weak evidence that ezetimibe does lower cardiovascular events ). The recently revised cholesterol guidelines endorse the concept of treating risk of atherosclerosis rather than cholesterol levels.


 

I do like the food writer Michael Pollan’s simple rules to “Eat Food. Mostly Plants. Not Too Much.” and this NY Times piece summarizes much of what is in his short, funny and helpful Food Rules book:

you’re much better off eating whole fresh foods than processed food products. That’s what I mean by the recommendation to eat “food.” Once, food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket. These novel products of food science often come in packages festooned with health claims, which brings me to a related rule of thumb: if you’re concerned about your health, you should probably avoid food products that make health claims. Why? Because a health claim on a food product is a good indication that it’s not really food, and food is what you want to eat.

If you follow Michael Pollan’s simple dictum you will get plenty of fiber, soluble or otherwise and you will avoid the necessity to obsess over the macronutrients in your diet, fiber or otherwise. Throw in some Cheerios and oatmeal every once in a while if you like them;  in their unadulterated state they are a heart-healthy food choice.

Cheerio,

-ACP

Why You Should Ignore “The Plant Paradox” by Steven Gundry

The skeptical cardiologist first encountered the blather of Dr. Steven Gundry while researching and writing a post entitled  The #1 Red Flag of Quackery.

Gundry came across my quack radar screen due to the popularity of his useless supplements and his pseudoscientific justifications. He is also widely described as a cardiologist but he is not, He is (or was) a cardiac surgeon (like, strangely enough, the celebrity prince of quackery, Dr. Oz)

Gundry is also a Goop doctor, which means Gwyneth Paltrow, the  celebrity queen of weird quackery endorses him.

I’ve been meaning to write specifically about his most popular useless supplement, Vital Reds.

In the meantime, Gundry has  come out with a best-selling.  book entitled  “The Plant Paradox: The Hidden Dangers in Healthy Foods That Cause Disease and Weight Gain”.

This book claims to reveal to its readers the great dietary “secret” that is causing almost all chronic diseases. Of course, Gundry is the only person with the brilliance and insight to have recognized this. Only those who are willing to plunk down the money to buy his book will learn this secret and the (mostly gobbledook) science behind it.

This  technique of convincing the naive that only you are aware of the “hidden” factor which is  the cause of their various maladies can probably be considered the #2 Red Flag of Quackery.

The Plant Paradox would have you believe that lectins are the major danger in our diet.

I’ve come across two well-researched pieces which destroy any validity to the concepts put forth by Gundry in The Plant Paradox.

Campbell: Is It Possible Gundry Is Out To Make A Quick Buck?

The first is from T. Colin Campbell of China Study fame. While I don’t agree with his overall dietary philosophy (see here) in his article he has taken the time to read Gundry’s book in detail and address in great detail the multiple bogus claims and the lack of scientific support. Campbell begins:

The claims come fast and furious in this book, stated with a degree of certainty, without nuance, that undoubtedly appeals to many readers. But the referencing is so lacking and sloppy that Dr. Gundry should be embarrassed. The references that are cited in this book do a poor job of trying to justify its claims. And the bulk of the author’s wild claims lack references at all, with several examples of easily verifiable falsehoods. Because his claims are quite profound and novel, referencing of the findings of others and his own results are especially important. This is especially troubling for an author who touts his own research experience.

After debunking Gundry’s lectin claims , Campbell suggests that Gundry’s major goal is selling more useless supplements, including one that will protect readers from the dreaded lectin:

In conclusion, there are many people who desire good health and deserve good information and we resent that they must suffer such poor quality and confusing information under the assumption that it is good science. Is it possible that Dr. Gundry is just out to make a quick buck? He admits that his patients give up to a dozen vials of blood for testing every couple of months at his clinic. Overtesting is common practice in supplement-driven clinics. This extensive testing, (which are another topic), is almost always used to demonstrate some type of nutritional pathology, which of course can only be corrected by taking the suggested supplements. And of course, Dr. Gundry sells supplements, including “Lectin Shield” for about $80 a month. According to his website, “This groundbreaking new formula was created to offset the discomforting effects of lectins (proteins commonly found in plants that make them harder to digest). Lectin Shield works to protect your body from a pile-up of lectins and to promote full-body comfort.”

Are Lectins The Next Gluten?

The second article I highly recommend was written for The Atlantic last year by one of my favorite medical writers, James Hamblin, MD.

Entitled, “Lectins Could Become the Next Gluten“, the article combines a tongue–in-cheek commentary with interviews with scientists who debunk Gundry’s claims. Hamblin also interviews Gundry which is particularly revelatory as to Gundry’s lack of credibility.

Although Gundry claims his writing is not motivated by money, Hambling notes:

Yes, he also sells supplements he recommends. The last 20 or so minutes of his infomercial is a string of claims about how supplies are running low, and it’s important that you act immediately, and that if you do manage to get through to a customer representative you should order as much as you have room to store—the shelf life is great, etc. And the necessity of supplements is the crucial argument of the book. He writes, “Getting all of the nutrients you need simply cannot be done without supplements.”

The GundryMD line of products includes something he invented called vitamin G6. Another is a “lectin shield” that’s “designed to neutralize the effects of lectins.” These are available on his website for $79.99. There you can also get six jars of Vital Reds for $254.70.

Fake Dietary Science Undermines Valid Dietary Recommendations

Hambling closes his piece by noting that book publishers have no accountability for publishing dietary/health misinformation as they are incentivized to publish and profit from the most outrageous claims.

This is a problem much bigger than any plant protein. Cycles of fad dieting and insidious misinformation undermine both public health and understanding of how science works, giving way to a sense of chaos. It seems that every doctor has their own opinion about how to protect your body from calamity, and all are equally valid, because nothing is ever truly known.

Lectiophilically

-ACP

N.B. Gwyneth Paltrow (GOOP) deserves a prominent place in the Quackery Hall of Shame.

Julia Belluz of Vox has a typically spot-on piece about GOOP which begins:

Gwyneth Paltrow has made a career out of selling pseudoscience on her lifestyle website, Goop. Over the years, the actress has proclaimed women should steam their vaginas, that water has feelings, and that your body holds secret organs. Mixed into these absurd assertions is her bogus detox diet and cleansing advice, all of it in service of promoting Goop’s beauty and wellness products

Is It Safe To Consume Grapefruit If You Take The Blood Thinner Apixiban (Eliquis)?

A patient of mine with atrial fibrillation taking the blood thinner eliquis told me that she had eaten grapefruit for two days in a row and then developed a nose bleed. She had heard of the interaction between grapefruit and certain medications and wondered if this had caused her nose bleed.

I was unaware of any eliquis/grapefruit interaction but thought this was a remarkably astute observation and question and set about to research it properly.

Among other things, I discovered that some researchers believe the grapefruit-drug interaction to be a widespread , underreported and  highly significant problem while others feel it is overblown and a rare cause of clinically important side effects.

For those, who prefer not to delves into the gory details I give you the crux of what BMS/Pfizer, the makers of apixiban (Eliquis) told me and with which I agree:

When consumed in usual dietary volumes, grapefruit juice is considered a moderate inhibitor of CYP3A4. Therefore a dose adjustment of apixaban is not expected to be required.

In other words, although not formally studied, there is no evidence that apixiban levels are increased by moderate grapefruit juice ingestion to a degree that would cause significant bleeding complications.

Although multiple sites on the internet (including the unreliable Web MD) will tell you of a potentially dangerous interaction between grapefruit and apixiban this theoretical interaction has not proven clinically significant.

Interactively Yours,

-ACP

Below is the full text of the letter BMS sent me

Bristol-Myers Squibb and/or Pfizer have not conducted any studies evaluating the concomitant use of apixaban and grapefruit juice. The decision to prescribe apixaban in patients who are concomitantly taking grapefruit juice is a clinical decision for the treating physician based on the individual’s circumstances and inaccordance with the full prescribing information for apixaban.

While in vitro data indicates grapefruit juice can inhibit both cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), clinical evidence suggests that grapefruit juice mediated interactions would be primarily due to the inhibition of CYP3A4 and the contribution of P-gp inhibition may be limited.1, 2 When consumed in usual dietary volumes, grapefruit juice is considered a moderate inhibitor of CYP3A4.1 Therefore a dose adjustment of apixaban is not expected to be required.

Apixaban is eliminated from the body through multiple pathways, with approximately 25% of the administered dose recovered as metabolites. The main metabolic pathway for apixaban is through CYP3A4/5, with minor contributions from other CYP isoenzymes. Apixaban is also a substrate of transport proteins P-gp and breast cancer resistance protein.3

  1. [1]  Hanley MJ, Cancalon P, Widmer WW,et al. The effect of grapefruit juice on drug disposition. Expert Opin Drug Metab Toxicol. 2011; 7(3):267-286.
  2. [2]  Farkas DG and Greenblatt DJ. Influence of fruit juices on drug disposition: discrepancies between in vitro and clinical studies. Expert Opin Drug Metab Toxicol. 2008;4(4):381-393.
  3. [3]  Eliquis® (apixaban) Package Insert. Bristol-Myers Squibb Company, Princeton, NJ and Pfizer Inc, New York, NY

Why I Favor The Early Restoration and Maintenance of Sinus Rhythm In Most Patients With Atrial Fibrillation

When your heart stops beating synchronously and goes into atrial fibrillation all sorts of bad things begin happening. The normal mechanisms for controlling how fast your heart is beating are lost and in most individuals the rate accelerates inappropriately. The strength of the atria’s pumping force and the normal precise synchronization of the upper and lower chambers  deteriorates.

You might logically conclude then, that all efforts should be focused on converting the rhythm back to normal,  for in the normal rhythm the heart can go back to beating regularly, efficiently  and synchronously the way nature intended.

Maintenance of this normal (sinus) rhythm (NSR), presumably, will eliminate the high risk of clot formation and stroke associated with atrial fibrillation (AF) , prevent heart failure, and prolong life.

AF is abnormal. the thinking goes, and normality is the state in which we were born and to which we should seek to return.

Is Normal Sinus Rhythm Superior to Atrial Fibrillation?

It would be hard to find a cardiologist who doesn’t believe that patients are better off in NSR than AF but the more difficult question and more clinically relevant question is “if your heart has gone into atrial fibrillation will you do better in the long run with a strategy of trying to convert the rhythm back to normal and keep it there (which involves medications (anti-arrhythmic drugs) and/or procedures) versus just controlling the heart rate and letting the atria fibrillate to their heart’s content.

Unfortunately, studies that have compared the  strategy of maintaining NSR (rhythm control) with leaving the heart to fibrillate have not shown a benefit in preventing stroke or death in the patients randomized to rhythm control

To quote the 2016 European Society of Cardiology  guidelines on AF

Although many clinicians believe that maintaining sinus rhythm can improve outcomes in AF patients, all trials that have compared rhythm control and rate control to rate control alone (with appropriate anticoagulation) have resulted in neutral outcomes.

(see references for this below)

However, findings from these studies can only be applied to the population studied, thus younger patients without structural heart disease and patients over age 80, who combined constitute up to 50% of the AF group were not represented in these comparison studies.

The elderly are more dependent on normal atrial function for maintenance of cardiac output and are more likely to have issues with anticoagulation, thus they may benefit more from maintenance of NSR than the young.

In addition, much of the morbidity and mortality in these trials was related to failure to anticoagulate patients who were in NSR. The stroke risk persists in this group, we have learned, because they may not recognize when AF occurs. Therefore, most authorities recommend lifelong  anticoagulation for those who have had  AF and have significant risk factors for stroke whether they

These and other  reasons for the  failure of the so-called rhythm strategy have long been debated but most experts blame it on the absence of a safe and effective method for maintaining NSR: the drugs  and procedures (catheter ablations) we have used create their own problems and don’t always work.

Why Then, Do I And Most Cardiologists Recommend Efforts To Maintain Normal Sinus Rhythm?

This is a question almost no AF patients ask. It is quite easy for a treating cardiologist to invoke the “normality” of NSR and the dangers of AF and most AF patients require no more justification. But they really should demand a compelling rationale.

For those who feel badly in AF despite treatment with medications to keep the heart rate normal cardiologists can justify the efforts because we are making patients feel better

The ESC guideline summarizes this as follows

For now, rhythm control therapy is indicated to improve symptoms in AF patients who remain symptomatic on adequate rate control therapy.

However, there are important limitations to letting symptoms guide our approach.

For one, symptoms are in the mind of the patient and cannot be measured objectively. For another, the symptoms a patient experience could be from something other than AF.

You might think that we can objectively verify that symptoms are due to atrial fibrillation if they resolve after converting the patient to sinus rhythm but symptoms can be heavily influenced by the patient’s perception that something has been done to fix them. This placebo effect is well-known from clinical trials of medications but may be even more prominent after procedures.

It is not uncommon for me to perform a cardioversion on a patient , see the patient in follow-up in AF and have them tell me how tremendous they have felt since the cardioversion.

The difficulty of objective symptom measurement is one of many factors contributing to  a tremendous variability in how cardiologists approach rhythm control  for AF.

Some cardiologists have concluded that maintaining SR is rarely worth the trouble and they add rate controlling medications and anticoagulants and see the patient back once a year. Let’s call these NSR Nihilists

On the other end of the spectrum, cardiologists who are true believers in the value of NSR run their patients through multiple anti-arrhythmic drugs, cardioversions and ablations to achieve that goal. When this is done excessively such cardiologists become NSR Overtreaters.

I put myself somewhere in between the Nihilists and the Overtreaters and consider myself a rational NSR advocate or enthusiast but one who has a very clear understanding of the dangers of over treatment and who recognizes that many patients have done well for decades in permanent AF.

Recording and observation of symptoms depends heavily  on the recorder and observer: the Nihilists are loath to find symptoms attributable to AF whereas the Overtreater may see any and all symptoms as due to AF.

Like other areas in life and medicine we have to look closely at hidden motivations and conflicts of interest to fully understand variations in behavior.

If one were to analyze the financial benefit from testing and procedures to treating cardiologists I have no doubt that the Overtreaters are getting a lot more than the Nihilists.

In an ideal world, cardiologists would not benefit more financially based on what procedures they recommend be performed on their patients but this is not the reality.

Reasons For NSR Maintenance Beyond Symptoms

 I’ve mentioned two solid reasons for aggressively trying to maintain NSR in a previous post:

A second group of patients, I think, benefits the most from maintaining sinus rhythm (rhythm control strategy): patients who develop heart failure when they go into AF.

These patients may not even know they are in AF because they don’t feel the typical symptoms initially.  After a few days or weeks or months of being in afib silently, however, they develop shortness of breath, weakness and leg  swelling – classic signs of heart failure.

When we look at the heart of such a patient by echocardiography, we often find one of two things causing the heart failure: a weakening of the heart muscle (cardiomyopathy) or significant leakage/backflow from the mitral valve (mitral regurgitation). Following cardioversion and maintenance of SR for weeks to months, the heart muscle strengthens back to normal and/or the mitral regurgitation improves dramatically and the heart failure resolves.

The 2014 ACC guidelines for management of AF admit the lack of randomized trials supporting maintenance of NSR but cite several factors that would “favor attempts at rhythm control” with which I generally agree. These are:

  • difficulty in achieving adequate rate control,
  • younger patient age,
  • tachycardia-mediated cardiomyopathy,
  • first episode of AF,
  • AF precipitated by an acute illness
  • patient preference.

If, after discussion of the options, a patient decides they prefer no attempts at maintaining NSR,  I try to make them aware that AF begets AF. The longer they stay in AF the larger and more diseased their atria become and the harder it is to stay in NSR with any techniques. In other words, this not a decision that can easily be reversed a few years from now if they start feeling poorly.

The ACC guidelines put it this way:

AF progresses from paroxysmal to persistent in many patients and subsequently results in electrical and structural remodeling that becomes irreversible with time . For this reason, acceptance of AF as permanent in a patient may render future rhythm-control therapies less effective. This may be more relevant for a younger patient who wishes to remain a candidate for future developments in rhythm-control therapies. Early intervention with a rhythm-control strategy to prevent progression of AF may be beneficial.

Many of the factors cited for leaning toward NSR maintenance are, of course, soft and vague.  One doctor’s young patient is another doctor’s old patient. The definition of adequate rate control is unclear. What qualifies as an acute illness?

My Approach to Maintenance of NSR

I favor a more aggressive approach to maintenance of NSR. I justify this because in my experience with meticulous attention to detail and with close monitoring of patients on anti-arrhythmic drugs I have observed that most patients do better in the long run with NSR Than AF.

Over thirty years of managing patients with AF and comparing those who are left to permanently be in AF versus those who maintain NSR  I see substantial differences. Let me cite two case examples to buttress my argument.

A 75-year-old man with permanent atrial fibrillation came under my care after his cardiologist retired. He had been in AF with rate well controlled and on anticoagulation since 2008. He is active without any symptoms.

He had an echocardiogram in 2008 with the new onset of AF and it showed a normal sized left and right atria and no valvular problems.

Over 10 years,  however, the size of both his atria have dramatically increased. His current echo shows severe enlargement of his left atrium (LA volume index=72 cm3/M2) and right atrium (RA area=26 cm2). He has developed significant leakage (regurgitation)  from both his mitral and tricuspid valves.

afmrlae

This is the norm for most patients who have been in AF for a long time.

The larger the left atrium gets over time, the more dysfunctional it becomes and the more likely clots are to form in the LA appendage. Although anticoagulation dramatically reduces the formation of LA clots, patients frequently have to come off anticoagulation for surgeries, spine injections, bleeding and other issues.

Would you rather have a left atrium that has been maintained in NSR or one that is massively enlarged and dysfunctional if you have to stop your anticoagulation?

The other exam example is of a 74 year old man whose AF was detected at the time of a colonoscopy. When I saw him he was without symptoms with normal lab and cardiac testing. We attempted one cardioversion without anti-arrhythmic drugs and within two weeks he reverted back AF. He elected not to start any anti-arrhythmic drugs and repeat the cardioversion and was doing fine when I saw him 6 months later.

However, shortly after that visit he ended up in severe heart failure with severe left ventricular  dysfunction and severe mitral regurgitation at an outside hospital. This time he agreed with a more aggressive approach to maintenance of SR and after prolonged amiodarone loading and a repeat cardioversion he has maintained SR for 6 months. The function of his left ventricle has improved to near normal (LVEF has increased to 49%) and there is no significant leakage from his mitral valve.

Whereas, most patients who feel fine in AF and elect to stay in it do well there is an unpredictable but significant number who despite adequate rate control develop cardiomyopathy and valvular regurgitation with resulting heart failure.

Medical Maintenance of SR

Yes, I’m convinced that patients can safely and effectively be maintained in SR with medical therapy and the occasional cardioversion.

I try not to fall in the camp of Overtreaters but consider myself a Rational Normal Sinus Rhythm Enthusiast and Advocate.

In my practice when atrial fibrillation reaches a point that requires addition of an anti-arrhythmic medication  I predominantly utilize two such drugs: amiodarone and flecainide.

Patients with structurally  normal hearts do well with flecainide and those with structural heart disease (heart failure, left ventricular hypertrophy, or significant coronary artery disease ) do well with amiodarone when they are monitored closely by a cardiologist with extensive experience using the drugs.

I’ll talk about each of these options  as well as cardiac ablation in detail in subsequent posts.

Antifibrillatorily Yours,

-ACP

Six studies showing no difference in outcomes between rhythm and rate control strategies.

Upon Reaching The Century Mark, Eugene Shares His Keys To Longevity

We threw a birthday party  a few weeks ago in our Winghaven satellite office (O’Fallon, Missouri)  for our patient, Eugene.

In the back row are the wonderful staff of our Winghaven office (from left to right) my MA Jenny, sonographer Sandy, and nuclear medicine tech Robert. You can probably figure out the characters in the front row.

Eugene is the first patient of mine that I can recall celebrating a 100th birthday party. I mentioned him previously on this blog on a post about longevity, the art of living long and prosperously, which he had mastered.

He’s still doing remarkably well and his family shared this video of him dancing with his wife, Naomi (also our patient), at an earlier centennial birthday party.

Eugene told me that he met Naomi at a VFW dance when he was 85 years old and swept her off her feet.

The cake that Sandy had made for him features his love of dancing and swimming.

 

While we ate sandwiches and cake I asked him about his 100 years.

Wadlow standing next to his normal sized dad. Be sure to visit bucolic Alton, Illinois where you can stand next to a life-size statue of Robert Wadlow (who suffered from excess human growth hormone (pituitary gigantism) a disease which is now treatable which means that his claim to tallest man ever will likely never be challenged.

He was born and raised in Alton Illinois and went to high school with the  Alton Giant, Robert Wadlow. Depicted to the right next to his normal sized father, Wadlow was the tallest man in the world, reaching 8 ft, 11 inches.

Eugene graduated with a degree in chemistry and physics from Shurtleff University  then went on to get his masters and PhD degrees. He played in a 10 piece band in 1940.

During World War II he served as a navigator for an LST boat (which, he says, was nicknamed large slow target).

After tracking down his LST boat in Panama, he served in the Pacific and  at the Battle of Okinawa.

After retiring at age 65 he picked up running at the age of 65 and ran long distances frequently for 20 years.

I asked Eugene “To what do you attribute your longevity?”.

Here is his reply.

Happy Birthday To All Centenarians!

-ACP

“Should You Get A Routine Annual Electrocardiogram?”, Revisited

Four years ago the skeptical cardiologist wrote a post which outlined the reasons why most people should avoid getting a routine annual electrocardiogram.

I pointed out that

If you …feel fine (meaning without symptoms or asymptomatic), exercise regularly, have never had heart problems,  and have a pulse between 60 and 90, the value of the routine annual ECG is very questionable. In fact, the United States Preventive Services Task Force (USPFTF)

“recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events”

(for asymptomatic adults at intermediate or high risk for CHD they deem the evidence insufficient). The USPSTF feels that that the evidence only supports an annual BP screen along with measurement of weight and a PAP smear.

Yesterday, the USPSTF published an updated analysis which confirmed this recommendation:

The U.S. Preventive Services Task Force (USPSTF) recommends against preventative screening with resting or exercise electrocardiography (ECG) in asymptomatic adults at low risk of cardiovascular disease events in an updated recommendation statement published June 12 in the Journal of the American Medical Association (JAMA).

I should point out that I still believe (although some would disagree) screening for atrial fibrillation with methods other than a 12-lead ECG (including taking the pulse or checking a single lead ECG with a Kardia device) is worthwhile.

Below, I’ve reposted relevant sections of my 2014 post which emphasizes the problem of false positives and false negatives which are quite frequent with any screening test but are particularly worrisome with the routine 12-lead ECG.

 


To many, this seems counter-intuitive: how can a totally benign test that has the potential to detect early heart disease or abnormal rhythms not be beneficial?

There is a growing movement calling for restraint and careful analysis of the value of all testing that is done in medicine. Screening tests, in particular are coming under scrutiny.
Even the annual mammogram, considered by most to be an essential tool in the fight against breast cancer, is now being questioned.

My former cardiology partner, Dr. John Mandrola, who writes the excellent blog at http://www.drjohnm.org, has started an excellent discussion of a recent paper that shows no reduction of mortality with the annual mammogram. He looks at the topic in the context of patient/doctor perception that “doing something” is always better than doing nothing, and the problem of “over-testing.”

In my field of cardiology there is much testing done. It ranges from the (seemingly) benign and (relatively) inexpensive electrocardiogram to the invasive and potentially deadly cardiac catheterization. For the most part, if patients don’t have to pay too much, they won’t question the indication for the tests we cardiologists order. After all, they want to do as much as possible to prevent themselves  from dropping dead from a heart attack and they reason that the more testing that is done, the better, in that regard.

The Problem of False Positives and False Negatives

But all testing has the potential for adverse consequences because of the problem of false positives and negatives. To give just one example: ECGs in people with totally normal hearts are regularly interpreted as showing a prior heart attack. This is a false positive. The test is positive (abnormal) but the person does not have the disease.

12 lead ECG routinely performed prior to surgery and interpreted by computer as ASMI or anteroseptal myocardial infarction ( heart attack).Patient with totally normal heart. Often such false positives are due to poor placement of the ECG leads

False positives lead to unnecessary worry, anxiety, and testing. More testing is highly likely to be ordered; specifically, a stress test. Stress tests in low risk, asymptomatic individuals often result in false positive results. After a false positive stress test, it is highly likely that a catheterization will be ordered. This test carries potential risks of kidney failure, heart attack, stroke and death. It is bad enough that the cascade of testing initiated by an abnormal, false positive,  screening test results in unnecessary radiation, expense and bother but  in some cases it end up killing patients rather than saving lives.

On the other end of the spectrum is the false negative ECG. Most of my patients believe that if their ECG is normal then their heart is OK. Unfortunately the ECG is very insensitive to cardiac problems that are not related to the rhythm of the heart or an acute heart attack.

Patients who have 90% blockage of all 3 of their major coronary arteries and are at high risk for heart attack often have a totally normal ECG. This is a false negative. The patient has the disease (coronary artery disease), but the test is normal. In this situation the patient may be falsely reassured that everything is fine with their heart. The next day when they start experiencing chest pain from an acute heart attack, they may dismiss it as heart burn instead of going to the ER.

More and more, screening tests like the ECG and the mammogram  are rightfully being questioned by patients and payers. For a more extensive discussion about which tests in medicine are appropriate check out the American Board of Internal Medicine’s http://www.choosingwisely.org.

Keep in mind: not uncommonly,  doing more testing can result in worse outcomes than doing less.

Skeptically Yours,

-ACP

h/t Jerry , the life coach of the skeptical cardiologist , who originally posed this question to me.

 

Dr. P’s Heart Nuts and The Flawed But Still Relevant PREDIMED Trial

The skeptical cardiologist was somewhat disheartened to read  the New York Times headline today that the  PREDIMED study was flawed. I frequently reference this landmark randomized trial of the mediterranean diet when I’m citing the cardiovascular benefits of nuts and EV olive oil.

Science mag summarizes the problem which prompted a re-analysis of the study:

A months-long inquiry by the Spanish researchers and NEJM staff uncovered that up to 1588 people in the trial hadn’t been properly randomized: Some were assigned to the same diet as someone else in their household (a common feature of diet studies, but not reported in the original paper). Others, who lived in a rural area, were assigned to different diets based on the clinic closest to them—for example, one group had to pick up a liter of olive oil each week. “The investigator realized he couldn’t get people to travel as far as they needed so he made his study ‘cluster randomized,’” by clinic rather than by individual, Drazen says.

The authors reanalyzed their data without those 1588 participants and found that despite the missteps, the conclusion held: Nuts, olive oil, and fatty fish remained a net positive on heart health, though the conclusions came with somewhat less statistical oomph than in the original paper.

Here’s what I wrote about nuts and the PREDIMED study when I first started distributing Dr. P’s Heart Nuts to my patients.

The skeptical cardiologist has finally prepared Dr. P’s Heart Nuts for distribution. IMG_8339The major stumbling block in preparing them was finding almonds which were raw (see here), but not gassed with proplyene oxide (see here), and which did not contain potentially toxic levels of cyanide (see here).

During this search I learned a lot about almonds and cyanide toxicity, and ended up using raw organic almonds from nuts.com, which come from Spain.

I’ll be giving out these packets (containing 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts) to my patients because there is really good scientific evidence that consuming 1/2 packet of these per day will reduce their risk of dying from heart attacks, strokes, and cancer.

IMG_7965The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (PREDIMED, in which participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30g of mixed nuts per day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) at no cost, and those in the control group received small nonfood gifts).

After 5 years, those on the Mediterranean diet had about a 30% lower rate of heart attack, stroke or cardiovascular death than the control group.

It’s fantastic to have a randomized trial (the strongest form of scientific evidence) supporting nuts, as it buttresses consistent (weaker, but easier to obtain), observational data.

Despite the statistical flaws PREDIMED is still an important study demonstrating the benefits of nuts.  PREDIMED was the best randomized trial data we had for nuts but there are tons of observational data which are very consistent and show a strong association between increased nut consumption and reduced mortality..

Consequently, I made up a new batch of Dr. P’s Heart Nuts in honor of the survival of PREDIMED and will be distributing them to patients today.

Meditativeterraneanly Yours,

-ACP

And You May Ask Yourself: Why is David Byrne So Awesome?

The skeptical cardiologist was a second year medical student when the Talking Heads released their debut album, Talking Heads 77. Along with Elvis Costello and The Clash, the Talking Heads kept my spirit alive between crushing sessions of memorizing microbiologic, biochemical and anatomic minutiae.

The band went on to a very successful and highly influential career. I followed them closely through 1985’s commercially successful album, Little Creatures, which features two of my favorite songs from the mid to late 1980s “And She Was” and “Road To Nowhere.”

 

David Byrne, the idiosyncratic songwriter and frontman for the
Talking Heads, is currently on a concert tour in support of his solo album American Utopia  

We caught his performance in St. Louis at the Peabody Opera House Friday night and I have one word to describe it: awesome!

Daniel Durcholz’s review for the St. Louis Post-Dispatch did a much better job of summing it up than I could. He wrote:

I’m impressed with the back strength of the keyboard player (upper right). To dance/walk with (I’m guessing) a 61 key synthesizer and play at the same time seems quite difficult.

an eye-popping, mind-blowing concert that was achieved without the aid of props, video screens, or even a conventional stage set. Byrne’s 11-piece band — each of them clad in a gray suit and barefoot, like Byrne himself — carried their instruments like members of a marching band, allowing them to dance and assemble in various formations.

Beaded curtains lined the sides and back of the stage, forming a boxlike space that the musicians could perform within, effortlessly exiting and entering as needed.

Several songs featured a bright light source mysteriously moving around the stage, casting gigantic, fascinating shadows. That is Byrne front and center with guitar. Sitting in the balcony gave good views of the three-dimensional movement and positioning of the players

The overall look and feel of the show was hyper-theatrical, yet utterly human at its core. There were no backing tracks, Byrne emphasized at one point. “Everything you hear is being played by these incredible musicians,” he said.

No stranger to innovation, Byrne reinvented the concert experience in the Talking Heads’ 1984 film “Stop Making Sense.” This current outing is, if anything, even more radical and engaging.

Stop Making Sense is considered by many to be the greatest concert film of all time ((although I’m sure the eternal fiancee’ would place The Last Waltz above SMS) )but I think a Jonathan Demme or Martin Scorcese film of David Byrne’s current concerts might claim that honor.

Until such film is released this performance of “Everybody’s Coming to My House” (arguably the best song on his new album) by Byrne and his band on The Late Show With Stephen Colbert will have to suffice.

The information available through the internet never ceases to amaze me. You can click here to see exactly what Byrne played Friday night complete with links to the songs and/or videos of the songs.

If you click on the 9th song on the setlist you will be taken to this iconic existential video:

So, if you ever liked the Talking Heads or just love good music try to catch David Byrne’s show..

You might find yourself singing along with him as the audience did last Friday night the following words:

And you may find yourself
Living in a shotgun shack
And you may find yourself
In another part of the world
And you may find yourself
Behind the wheel of a large automobile
And you may find yourself in a beautiful house
With a beautiful wife
And you may ask yourself, well
How did I get here?

And you may find yourself asking “Why is David Byrne so Awesome?”

Letting the days go By,

-ACP

h/t Lauren at http://www.allezgourmet.com for alerting me to Byrne’s St. Louis concert.

Which Exercise Is Best For Heart Health: Swimming or Walking?

Reader Pat asked the skeptical cardiologist the following question:

Which would be the better heart healthy choice? Walking briskly 3 x week or swimming for 45 minutes 2-3 x a week?

Swimming is an attractive alternative to walking or running for many of my patients with arthritis because it is a lot easier on the load-bearing joints of the lower extremities.

To my surprise there is at least one study (from Australia) comparing swimming and walking that was published in the journal Metabolism in 2010.

The investigators randomly assigned 116 sedentary women aged 50-70 years to swimming or walking. Participants completed 3 sessions per week of moderate-intensity exercise under supervision for 6 months then unsupervised for 6 months.

Compared with walking, swimming improved body weight, body fat distribution and insulin resistance in the short term (6 months).

At 12 months swimmers had lost 1.1 kg more than walkers and had lower bad cholesterol levels.

It should be noted that these differences barely reached significance .

Types of Activities And The Intensity of Exercise

My general recommendations on exercise (see here) give examples of different aerobic physical activities and intensities.

These activities are considered Moderate Intensity

  • Walking briskly (3 miles per hour or faster, but not race-walking)
  • Water aerobics
  • Bicycling slower than 10 miles per hour
  • Tennis (doubles)
  • Ballroom dancing
  • General gardening Vigorous Intensity

These types of exercise are considered Vigorous Exercise

  • Racewalking, jogging, or running
  • Swimming laps
  • Tennis (singles)
  • Aerobic dancing
  • Bicycling 10 miles per hour or faster
  • Jumping rope
  • Heavy gardening (continuous digging or hoeing, with heart rate increases)
  • Hiking uphill or with a heavy backpack

As a rule of thumb, consider 1 minute of vigorous exercise equivalent to 2 minutes of moderate exercise and shoot for 150 minutes per week of moderate exercise or 75 minutes of vigorous exercise.

Of course one can swim laps at peak intensity or at a very slow, leisurely pace so swimming laps doesn’t always qualify as “vigorous” exercise. Likewise one can play singles tennis languorously and be at a moderate or lower intensity of exercise.

It is entirely possible that the swimmers were working at a higher intensity during their sessions than the walkers and that could be the explanation for the differences seen between the two groups.

Ultimately, the best type of  exercise for heart health is the one you can do and  (hopefully) enjoy on a regular basis.

Antilanguorously Yours,

-ACP

N.B. Speaking of swimming. A year ago I wrote about longevity and featured Eugene, a 98 year old who could swim the length of a swimming pool underwater. Eugene turns 100 in 2 days.

Mitigating Sarcopenia In The Elderly: Resistance Training Is A Powerful Potion

While researching afib-detection apps recently, the skeptical cardiologist stumbled across an article with the title “Resistance training – an underutilized drug available in everybody’s medicine cabinet”

This brief post from the British Journal of Sports Medicine blog nicely presents the rationale for using strength training to improve the overall health of the elderly. I have reblogged it below.

Americans spend billions on useless supplements and vitamins in their search for better health but exercise is a superior drug, being free  and without drug-related side effects

I’ve spent a lot of time on this blog emphasizing the importance of aerobic exercise for cardiovascular health but I also am a believer in strength and flexibility training for overall health and longevity.

As we age we suffer more and more from sarcopenia-a gradual decrease in muscle mass.

Scientific reviews note that loss of muscle mass and muscle strengh is quite common in individuals over age 65 and is associated with increased dependence, frailty and mortality

Specific information on progressive resistance training for the elderly is sparse but I found this amusing and helpful video on a Canadian site that provides some guidance for beginners.

 

And below is the referenced blog post:

Resistance training – an underutilised drug available in everybody’s medicine cabinet

By Dr Yorgi Mavros @dryorgimavros

As we get older we begin to lose muscle mass, approximately 1% every year. But more importantly, the decline in muscle strength declines at a rate 3-times greater [1]. The consequences of this decline in strength are significant, with lower muscle strength being associated with an increased risk dementia[2], needing care, and mortality[3]. But should we accept this as our fate, or is there anything we can do prevent, reverse or at least slow this age-related decline?

In 1990, a type of exercise called progressive resistance training, commonly known as strength training, was introduced to 9 nonagenerians living in a nursing home, specifically to treat the loss of muscle mass and strength, and the functional consequences of disability [4]. After just 8 weeks, these older adults saw average strength gains of 174%, with 2 individuals no longer needing a cane to walk. In addition, one out of the three individuals who could not stand from a chair, was now able to stand up independently. Just take a moment to think about the results of that study. If I told you there was a medicine that you or a loved one could take, and it could make either of you strong enough to now get out of a chair, would you take it?

What if you or a loved one had a hip fracture, and I told you that same medicine could help reduce the risk of mortality by 81%, and the risk of going in to a nursing home by 84%, as was shown in this study [5]. Currently, the only way to take this medicine is by lifting weights, or pushing against resistance.

A recent study from Britain, [6] showed an association between adults who participated in 2 days per week of strength training and a 20% reduction in mortality from any cause, and a 43% reduction in cancer mortality. Data from the Women’s Health Study in the US published at a similar time were very similar, with women reporting up to 145 minutes per week of strength training having a 19-27% reduced risk of mortality  from any cause [7].

So where does the benefit of strength training come from? First and foremost, it is anabolic in nature (meaning that it can stimulate muscle growth) making it the only type of exercise that can address the age-associated decline in muscle mass and strength. Within our laboratory at the University of Sydney, we have shown that we can use this type of exercise to improve cognitive function in adults who have subjective complaints about their memory [8]. What’s important though, is that there was a direct relationship between strength gains and improvements in cognition, and so maximizing strength gains should be a key focus if you want to maximize your benefit [9]. This type of exercise has even been taken into hospitals and used in adults with kidney failure undergoing haemodialysis, where it was shown to reduce inflammation, and improve muscle strength and body composition [10].

Other laboratories around the world have also used strength training to increase bone strength in postmenopausal women [11], help manage blood sugar levels in adults with type 2 diabetes [12], as well as to counteract the catabolic side effects of androgen-deprivation therapy for men with prostate cancer [13]. Not to mention its benefits to sleep [14], depression  [15] and recovery from a heart attack  [16].

So it is no surprise to see that the  Australian [17] and UK [18] public health guidelines for physical activity recommend we take part in activities such as strength training 2-to-3 days per week. Unfortunately however, these recommendations lack detail and guidance on intensity and frequency.

A key theme in all the randomized controlled studies discussed above, is that not only were exercises performed at least 2 days per week, but they were fully supervised, used machine and/or free weights, and were done at a high intensity, which is commonly set to 80% of an individual’s peak strength. It is for this reason I like to focus on the guidelines put forward by The American College of Sports Medicine (ACSM) [19]. The ACSM advises that everyone, including older adults do at least 2 days of progressive resistance training, which is to be performed at a moderate (5 – 6) to high/hard (7 – 8) intensity on a scale of 0 to 10, involving the major muscle groups of the body. So if you are looking to maximise the benefit from your time in the gym, or looking to make a positive change to your lifestyle, remember that there is medicine you can take; Try lifting some weights or doing other forms of strength training, 3 days a week, and importantly, make sure it feels moderate to hard. Not only will it add years to your life, but life to your years.


Since college I have regularly done weight training 3 times per week As I get  dangerously close to age 65 and joining the ranks of the “elderly” I have ramped up the intensity of my workouts, working hard to forestall the sarcopenia that will ultimately be my fate.

Antisarcopenically Yours,

-ACP

***************************

Video credit: Produced for the University of British Columbia’s (UBC) Department of Physical Therapy, the Aging, Mobility, and Cognitive Neuroscience Laboratory, the Centre for Hip Health and Mobility and the Brain Research Centre at Vancouver Coastal Health and UBC
hiphealth.ca/news/preventing-dementia

 

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

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