Which Diet Works Best For Weight Loss?

In the ongoing nutritional war between adherents of low-fat and low-carb diets, the skeptical cardiologist has generally weighed in on the side of lower carbs for weight loss and cardiovascular health.

I’ve questioned the vilification of saturated fat and emphasized the dangers of added sugar  and I consider myself a keto-friendly cardiologist.

Recently I stumbled across a good review on the scientific evidence of various popular diets for weight loss. Obesity and its health consequences are clearly increasing and impacting the cardiovascular health of millions. As such, as a cardiologist it would be great to have a one true diet that is best for weight loss for my patients.

Unfortunately, as I discussed in my analysis of the DIETFITS study there isn’t a one size fits all dietary silver bullet. This recent review does a good job of analyzing the data and has some nice graphics.

Here’s the first graphic which summarizes the food groups allowed for 7 of the most popular diets

Is there any food group we can all agree on?

Yes, the non-starchy vegetables!

Dr. P’s Heart Nuts come in a close second (outlier Ornish recommends “moderation”. Extreme outlier Esselsytn who eschews all oils forbids nuts.)

Interestingly, the only one of these diets that bans red meat, chicken, seafood and eggs is the Ornish diet which is basically a vegetarian diet (see here for the lack of science behind this diet.)

Is there any food group that we all agree should be avoided? If we exclude the outlier Ornish  then there is unanimity that we should be avoiding added sugar and refined grains.

My recommended version of the Mediterranean diet says that high fat dairy is perfectly fine and actually preferred over processed skim or low fat dairy. Yogurt and cheese are encouraged.

Do Macronutrients Matter?

The second graphic nicely summarizes the macronutrient composition of these diets. The Atkins diet and ketogenic diets recommend less than 10% carbs whereas Ornish the outlier recommends less than 10% fat.

My recommended variation on the Mediterranean diet would lower the carb % to around 20% by avoiding starchy vegetables, most added sugar and most refined grains. I try to avoid ultra-processed foods completely. With this diet I am in some degree of ketosis (as measured by the fantastic Keyto device) most of the time although I’m not strictly following keto guidelines.

For example last night I had this delicious steak and smoked portabello quesadilla from Three Kings Pub. The tortilla alone contains about 40 grams of carbs, double the recommended amount for keto diets. I add elements of Three Kings Middle Eastern Sampler (Red pepper hummus, grilled eggplant relish, tzatziki, roasted head of garlic and dolmas. Served with grilled flatbread and an assortment of veggies) to get some of those universally acclaimed nonstarchy vegetables . I don’t utilize the balsamic reduction that is typically drizzled on the quesadilla because it tastes like pure sugar to me (sure enough it contains 11 grams of carbs)and I mostly avoid the grilled flatbread.

 Manipulation Of Diet Timing For Weight Loss

Breakfast is not the most important meal of the day and I only break my overnight fast when I get hungry which is typically around noon.

Variations on this type of intermittent fasting (periodic fasting or 5:2 diet, alternate-day fasting, time-restricted feeding, and religious fasting) have become popular. The review summarizes the science in this area as follows:

“There is growing evidence demonstrating the metabolic health benefits of IF. In rodents, these appear quite profound, whereas in humans they are sparse and need further investigation, especially in long-term studies. It has been suggested that IF does not produce superior weight loss in comparison with continuous calorie restriction plans [130], and there are limited data regarding other clinical outcomes such as diabetes, CVD, and cancer. IF diets seem safe and tolerable for adults…”

In other words, rats live longer with IF but we don’t know if humans do. If you find intermittent fasting helps you consume less calories through out the day and lose weight, go for it. For me fasting from 9 PM to late morning (typically 14-16 hours) give me greater energy and focus throughout the day and makes weight management simpler.

Conclusions: What Is The Best Diet For Weight Loss?

Both low carb and low fat fanatics will be disappointed in the conclusions of the review but I think it is reasonable:

There is no one most effective diet to promote weight loss. In the short term, high-protein, low-carbohydrate diets and intermittent fasting are suggested to promote greater weight loss and could be adopted as a jumpstart. However, owing to adverse effects, caution is required. In the long term, current evidence indicates that different diets promoted similar weight loss and adherence to diets will predict their success. Finally, it is fundamental to adopt a diet that creates a negative energy balance and focuses on good food quality to promote health.

I would

And here is the summary graphic

Dietetically Yours,

-ACP

N.B. With regard to the starchy vegetables, check out my “Potato Theory of Obesity.”

Source for images: Scientific evidence of diets for weight loss: Different macronutrient composition, intermittent fasting, and popular diets – ScienceDirect

And finally  (from  the  DietDoctor.com website) a graphic that illustrates the amount of healthy (nonstarchy!) vegetables that you would need to consume to reach 20 grams of carbs.

How Common Are Inaccurate Coronary Artery Calcium Scans?

One reason the  skeptical cardiologist has been so enthusiastic about coronary calcium (CAC) scans is that I have found them to be highly reproducible and highly accurate.

Unlike most  imaging tests in cardiology if we perform a CAC on the same individual in the CT scanner of hospital A and then repeat it within a few days in the CT scanner of hospital B we expect the scores to be nearly identical.

Also, unlike most other imaging tests we don’t expect false negatives or false positives. If the CAC score is zero there is no coronary calcification-high sensitivity. If the score is nonzero there is definitively calcium and therefore atherosclerotic plaque in the coronaries-high specificity.

This is  because calcium as defined in the Agatson score is literally black and white-a pixel is either above or below the cut-off. Computer software automatically identifies on the scan. A reasonably trained CT tech should be able to identify the calcium that is residing in the coronary arteries based on his or her knowledge of the coronary anatomy as registered on CT slices. Using software the total Agatson score is calculated.

A physician reader (either cardiologist or radiologist) (who should have a very good understanding of the cardiac and coronary anatomy ) should review the CT techs work and verify accuracy.

A recent case report, however, has demonstrated that the above  assumptions are not always true.

Franz Messerli, a pre-eminent researcher in hypertension and a cardiologist describes in fascinating detail a false-positive CAC scan he underwent in 2013.  He was told he had a score of 804 putting him in a high risk category consistent with extensive plaque formation.

After consulting with cardiologist friends and colleagues he decided to put himself on a statin and aspirin despite having an excellent lipid profile.

Messerli assumed that the CAC score was not a false positive (although later in his article he indicates he had questioned the reading) writing:

“although one can always quibble with ST segments or wall motion abnormalities, on the CAC the evidence is rock-hard, you actually with your own eyes can see the white calcium specks! ‘Individuals with very high Agatston scores (over 1000) have a 20% chance of suffering a myocardial infarction or cardiac death within a year’—although I did not quite classify, this patient information coming from esteemed Harvard cardiology colleagues3 was hardly reassuring.

(His reference 3 for the 20% risk of MI or cardiac death in a year for CAC score >1000 is suspect. It is a 2003 “patient page” on coronary calcium in Circulation which does not have a reference for that statistic.)

A more recent study found patients with extensive CAC (CAC≥1000) represent a unique, very high-risk phenotype with CVD mortality outcomes (0.80%/yr) commensurate with high-risk secondary prevention patients (0.77%/yr) from the FOURIER trial)

Six years after the diagnosis Messerli was at a Picasso exhibition, “leisurely ambling between his Blue and Pink Period “when he developed chest pain.

To further evaluate the chest pain he underwent a coronary CT angiogram and this demonstrated pristine and normal coronary arteries, totally devoid of calcium.

He did have a lot of mitral annular calcification (MAC). The CCTA images below show how close the MAC is to the left circumflex coronary artery (LCX).


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The slice above shows how the MAC would appear on the CT scan designed to assess coronary calcium.  It’s position is very close to that of the circumflex but an experienced reader/tech  should have known this was not coronary calcification.

MAC is a very common finding on echocardiograms, especially in the elderly and it is likely that this error is not an isolated one.

Dr. Messerli writes

After relating these findings to the cardiologist who did the initial CAC, he indicated that most likely someone mistook mitral annular calcification as left circumflex calcium. This was hardly reassuring, since I specifically had asked that obvious question after receiving the initial CAC

Around the time I read Messerli’s case report I encountered a similar, albeit not as drastic case. A CAC scan showed a significant area of calcification near the left circumflex coronary artery which was scored as circumflex coronary calcification.

image001

The  pattern of this calcification is not consistent with the known path of the circumflex coronary in this case. When it was eliminated from the scoring the patient had a zero score. The difference between a nonzero score and a zero score is hugely significant but for patients with scores >100 such errors are less critical.

I have also encountered cases where extracardiac calcium mimics right coronary calcification.

There are some important take-home points from my and Dr. Messerli’s experience.

  1. False positive CAC scans do occur. We don’t know the frequency. If the scans are not overread by a competent cardiologist or radiologist with extensive experience in cardiac CT these mistakes will be more common

When I asked Dr. Messerli about this problem he responded

I am afraid you are correct in that CAC scores are generated by techs and radiologists and cardiologist simply sign the report without verifying the data. Little doubt that MAC is most often missed.
     2. Like other cardiac imaging tests (such as echocardiography) having an expert/experienced/meticulous  tech and reader matters.
    3. Dr. Messerli and I agree that a research project should be done to ascertain how often this happens and to evaluate the process of reading and reporting CAC.
4. Patients should look at the breakdown of the calcium in the CAC by coronary artery. Whereas it is not uncommon to see most of the calcium in the LAD it is rare to see a huge discrepancy in which the circumflex coronary artery score is very high and the LAD score zero. Such a finding should warrant a review of the scan to see if MAC was included in error.
Skeptically Yours
-ACP
N.B. Dr. Messerli’s report can be read for free and makes for entertaining reading.
I was very intrigued by two comments he made at the end:
  1. “Had my CHD been diagnosed a decade earlier, guidelines might well have condemned me to taking beta-blockers for the reminder of my days.6 This, as Philip Roth taught us in ‘The Counterlife’, might have had rather unpleasant repercussions.7

Until recently I had never read anything by Philip Roth but when he died last year I read his Pulitzer Prize winning  1987 novel American Pastoral and liked it. Given this Roth reference involving beta-blockers I felt compelled to get my hands on “The Counterlife.” The book is a good read (much better IMHO than American Pastoral) and one of the main plot points relates to the side effects (see my post on feeling logy) a character suffers from a beta-blocker. Stimulated by a desire to be able to perform sexually if taken of the medication, the character undergoes coronary bypass surgery and dies.

2. “As stated by Mandrola and true in the present case, ‘given the (lucrative) downstream testing that often occurs when coronary calcium is found in asymptomatic people, the biggest winners from CAC screening may be the testers rather than the tested’.”

I feel the CAC in the right hands should not lead to (lucrative or inappropriate) downstream testing in the asymptomatic (see my discussion on this topic here.)

 

 

Which Ambulatory ECG Monitor For Which Patient?

The skeptical cardiologist still feels that KardiaPro has  eliminated  use of long term monitoring devices for most of his afib patients

However not all my afib patients are willing and able to self-monitor their atrial fibrillation using the Alivecor Mobile ECG device. For the Kardia unwilling and  many patients who don’t have afib we are still utilizing lots of long term monitors.

The ambulatory ECG monitoring world is very confusing and ever-changing but I recently came across a nice review of the area in the Cleveland Clinic Journal of Medicine which can be read in its entirety for free here.

This Table summarizes the various options available. I particularly like that they included relative cost. .

The traditional ambulatory ECG device is the “Holter” monitor which is named after its inventor and is relatively inexpensive and worn for 24 to 48 hours.

The variety of available devices are depicted in this nice graphic:

For the last few years we have predominantly been using the two week “patch” type devices in most of our patients who warrant a long term monitor. The Zio is the prototype for this but we are also using the BioTelemetry patch increasingly.

The more expensive mobile cardiac outpatient telemetry (MCOT) devices like the one below from BioTel look a lot like the patches now. The major difference to the patient is that the monitor has to be taken out and recharged every 5 days. In addition, as BioTel techs are reviewing the signal from the device they can notify the patient if the ECG from the patch is inadequate and have them switch to an included lanyard/electrode set-up.

The advantage of the patch monitors is that they are ultraportable, relatively unobtrusive and they monitor continuously with full disclosure.

The patch is applied to the left chest and usually stays there for two weeks (and yes, patients do get to shower during that time) at which time it is mailed back to the company for analysis.

Continuously Monitoring,

-ACP

A Review Of SonoHealth’s EKGraph Portable ECG Monitor: Comparison To Apple Watch ECG And AliveCor’s Kardia ECG

The skeptical cardiologist keeps his eyes open for new, potentially improved ways of personal mobile ECG monitoring and when I saw the following comments on an afib forum I was intrigued:

I recently started using a SonoHealth product that I find MUCH MUCH superior to Kardia..

Really? MUCH MUCH superior? The more someone utilizes all caps
to emphasize theirs points the less I tend to believe them. But, as I am on a mission to discover the truth in all things cardiologic I went to the SonoHealth website and encountered this:

The EKGraph would indeed appear to be MUCH MUCH superior to Kardia mobile ECG if the website marketing can be believed.

Like the Kardia the EKGraph offers a personal ECG monitor obtained using the fingertips and syncing to an app on your smartphone.

The EKGraph claims to have 3 lead capability, something it emphasizes in its marketing but it is only capable of displaying one lead at a time and ,  similar to Kardia one can obtain lead II and precordial ECG leads by putting one electrode on the leg or chest.

Also similar to Kardia, the EKGraph promises “rhythm detection.” As we shall learn, however, rhythm detection by the EKGraph cannot be trusted whereas Kardia has a wealth of published data supporting its accuracy.

Unlike the Kardia, the EKGraph does have a “bright LCD screen” which displays the ECG wave pattern and heart rate along with the heart rhythm diagnosis.

I emailed SonoHealth and they were  kind enough to send me one of their ECG devices to demo. After spending some time with it I can say unequivocally that it should not be purchased or utilized by any patient who wants reliable personal mobile ECG monitoring with accurate diagnoses.

A few days later a package arrived containing the EKGraph in an Applesque box which also contiained a USB charging cable. In addition they included a carrying case and a tube of ECG gel.

 

 

Working With The SonoHealth APP

To make a recording one puts the metal strip on the left side of the device on hand, arm or leg and the other metal strip on the right side of the device on an opposing limb or the chest.

This very happy model gives you a feel for the size of the device and the method of making a Lead I recording.

 

 

 

 

 

 

 

 

It is possible to made a decent single lead ECG tracing with this device and view the tracing on the associated smartphone app. However, the recordings are typically very noisy and full of artifact making it hard to discern the rhythm. The software appears to lack appropriate filtering.

The SonoHealth app is free but getting it registered was a problem. On the company website support area several readers have complained of the same problem over the last few months:

 I am having trouble registering on the phone because when I hit the red button to register, I see the email and username fields at the top of the form, but when I click on email, the info fields jump to name, and I can’t scroll up to access those two fields. I then get a notification that those two fields are required to register. Any suggestions?

There is no response to this issue posted 3 months ago from the company.

Syncing with the app via Blutooth is straightforward. Pressing the sync button transfers all new tracings to the app where they can be reviewed.

Tracings can be emailed or printed.

Rhythm Detection

The major problem with the EKGraph  is that its  ability to diagnose  rhythm  is  very limited. This device has no published data verifying the accuracy of its rhythm diagnoses whereas the Apple Watch 4 and Kardia ECG devices do.  It it is not approved by the FDA.

I used the device on my self and despite identical rhythms the EKGraph called one “tachycardia” and the other “bradycardia.”

I tried using the SonoHealth on patients in my office who were in normal sinus rhythm and received wild, seemingly random diagnoses.

Whatever algorithm the device is using to diagnose rhythm is clearly not making allowances for poor quality recordings.

This patient is in NSR but the EKGraph calls it “tachycardia, VPB bigeminy” mistaking the artifact between the normal QRS beats and ventricular ectopic beats.

Multiple Sketchy Companies Utilizing Similar Hardware

I have noted other mobile ECG device with a remarkably similar appearance to the EKGraph.  A search on Amazon yields AliveCor’s devices and  the SonoHealth Ekgraph . The Amazon comparison page shows 3 additional  EKGraph identical-appearing devices seemingly from 3 different sketchy companies all priced at $79.

A consumer asked SonoHealth about the identical external appearance of SonoHealth’s and EMAY’s devices  and the company’s response was::

As a small new company making a new design for the outside shell didn’t seem viable. A mold from scratch costs anywhere from $65,000-$85,000. So our manufacturer allowed us to use their current mold to make the EKGraph.

So even though the outside is similar the software side is totally different. We have new and improved software. There’s also our own SonoHealth app that we developed from scratch.

SonoHealth is a USA company that provides excellent customer support.

I would disagree with SonoHealth’s assessment-there is nothing to suggest their software is either new or improved or even accurate.

The app that they developed from scratch is clunky and difficult to use.

Ratings and Online Presence of SonoHealth

SonoHealth posts on its website alleged reviews of EKGraph. They are uniformly positive. It’s hard to find anything that isn’t 5/5 stars. Apparently, all the problems I found with the product are unique to me.

However, these reviews should be taken with a grain of salt. A few weeks after acquiring my SonoHealth EKGraph I received an email from the company offering a gift card if I followed their precise instructions in writing a review:

TERMS: In order to receive the $10 giftcard reward you MUST write both a Company and a Product review. We will send each reviewer the egiftcard to the email that they provided when leaving the review. (For verification purposes, the email you enter when leaving the review must match the email associated with your order.)

This manipulation of the review process is shady and calls into question the validity of any review on the company website or Amazon.

Let The (Mobile ECG) Buyer Beware

The SonoHealth EKGraph is capable of making a reasonable quality single lead ECG. Presumably all the other devices utilizing the same hardware will work as well.

However, the utility of these devices for consumers and patients lies in the ability of the software algorithms to provide accurate diagnoses of the cardiac rhythm.

Apple Watch 4 and AliveCor’s Kardia mobile ECG do a very good job of sorting out atrial fibrillation from normal rhythm but the SonoHealth EKGraph does a horrible job and should not be relied on for this purpose.

The companies making and selling the EKGraph and similar devices have not done the due diligence Apple and AliveCor have done in making sure their mobile ECG devices are accurate.  As far as I can tell this is just an attempt to fool naive patients and consumers by a combination of marketing misinformation and manipulation.

I cannot recommend SonoHealth’s EKGraph or any of the other copycat mobile ECG devices. For a few dollars more consumers can have a proven, reliable mobile ECG device with a solid algorithm for rhythm diagnosis. The monthly subscription fee that AliveCor offers as an option allows permanent storage in the cloud along with the capability to connect via KardiaPro with a physician and is well worth the dollars spent.

Skeptically Yours,

-ACP

A Patient’s Confusing Journey Into The Quagmire Of Cardiac Imaging: A Cautionary Tale

Mary-Ann, a reader from the north,  provides today’s post. Her story illustrates how easily medical care can veer off the rails while it is simultaneously railroading patients.  It is a cautionary tale with wisdom that can help most patients.

In this post I’ll just present Mary-Ann’s perspective and solicit responses.  Down the line I’ll provide some perspective on the processes, the problems and the solutions.


It started innocently enough. I showed up for a regular visit with my cardiac provider, a mid-level professional. She noted I was flushed and had a high pulse — about 100. 

Starbucks, I explained, and I flush easily — always have. She looked skeptical.

That is how I went from a half-caf Americano to a 48-hour holter monitor.

I went back for results — the usual ectopic beats but nothing scary or new. But again, she noted I had a fast heart rate and I was flushed.

And once again I explained: Starbucks — it is right down the street and okay, I might have a problem.

That is the short — but highly accurate — version of how I wound up getting a stress echo. 

I showed up for the results of the echo and that is where the runaway train started down the tracks.

“…possible inferoapical wall hypokinesis with lack of augmentation of systolic function, which are abnormal findings and may be indicative of ischemia due to underlying coronary artery disease. EF was 56% at rest and 40-50% at stress.” 

Wait — what?!

I was marched down the hall and scheduled for a cardiac angiography — and told not to run any marathons in the intervening two days. 

Marathon?! I was terrified I was going to drop dead at any moment. I contemplated just sitting the waiting room for 48 hours — just to be safe.

Then I started reading the professional literature and things were not adding up. An EF at stress of 40 – 50% is not good — in fact, it can be heading into heart failure land.

But I was active and fine — it did not make any sense.

I called the office; my provider was not available. I explained that I was worried there was a mistake. Oh no, I was assured, they are very careful to not make mistakes.

I wrote my will. I cried a lot. 

And when the person called to remind me of the procedure (like I could forget!?) I once again explained that I was worried there had been a mistake, and once again — reassurance. No mistake.

Nevertheless, she (aka me) persisted!

I sat on the hospital bed in nothing but a gown and handed the nurse my two-page letter; it started like this:

“I am reminded that what is normal and ordinary for a professional is never that for a patient. I am terrified.

First, I want to be really sure that there is not any chance of a mix-up in the stress echo test results. This is not simple denial or wishful thinking…” 

And that nurse paid attention, which is how I wound up not having a cardiac angiography. 

The cardiologist scheduled to do the procedure — we shall call him Doc #2 — wrote: 

“She has some concerns regarding the results of the stress echo study … I reviewed the most recent stress echo and it appears to me that the results for the resting versus the stress echo ejection fractions have been transposed…”

Translation: A Typo.

I was elated! Jubilant! We went to Starbucks to celebrate.

The giddy joy quickly turned to something along the lines of WTH just happened here? I read the original echo report written by Doc #1 — that lit the tinder. There were two different values for EF at stress documented in the report, and another sentence that was repeated. 

The professorial side of me was deeply affronted — in a subsequent meeting with hospital administrators I confess to saying that someone who is making hundreds of thousands of dollars a year doesn’t get to write such a sloppy ass report — and about someone’s heart, no less! 

But the best part of that meeting was learning that Doc #1 denied there was a typo — he stood by his findings. 

Oh dear.

And Doc #2 stood by his findings as well. And Doc #3 got involved somewhere along the way and he agreed with Doc #2. And the mid-level Provider also agreed with Doc #2.

The majority rule seems like an odd way to make health care decisions — wouldn’t you think all those smart people could talk among themselves and agree?

Apparently not.

That first meeting with the hospital folks included all manner of solicitous apologies and an attitude of collaboration. Of course, they said, we can send the echo to an outside cardiologist — at our expense — and get an answer.

And then I made the unthinkable mistake — and I blame the Skeptical Cardiologist for this — of asking informed questions.

“Are the cardiologists involved in reading my echo Level III echo specialists?”

“I understand that there can be variance in estimated EF between cardiologists — what level of variance is considered acceptable?”

The hospital team responded to my questions by calling a meeting — and the tone had changed considerably (Thanks a lot, Corporate Legal).

The offer to pay for an outside opinion was off the table — after all, they said, you would not have a patient-provider relationship with the cardiologist reading the echo. Ahem, I noted — I have zero relationship with the first cardiologist who read the echo and would not know him if I bumped into him at Starbucks. And you all did offer to pay for that outside opinion…

Oh never mind those minor details. No outside opinion on their dime. They would do a Lexiscan at their expense as a tie breaker. Final Offer.

Tiebreaker — really?! Is this a soccer game?

And seriously — should I have to have an invasive test to settle THEIR disagreement?! [Note: If it involves needles, it is invasive.]

Because there were not enough cardiologists involved already, I saw yet another one — from a different practice. He offered that the EF at stress looked more like 55%, placing his bet smack in the middle, and recommending a CT Angiography Coronary Arteries with Contrast as the tiebreaker.

Tiebreaker. That word implies both sides are equivalent or equal. However, my heart is not actually a game and the two teams cannot both be right — there is no equivalency in play here. What we are really trying to do involves accuracy — not breaking a tie score.

But I digress.

It doesn’t seem like you should have to make a chart to keep track of what cardiologists say about the same echo but in this case, it seemed necessary.

 And in the meantime, yet another cardiologist weighed in that the quality of the echo was poor — and no wonder they could not agree.

Deep breaths.

And so, for the past four months I have tried to navigate all this, and to understand what this actually means about cardiology and medicine and so many things. My confidence and my mind have been blown. Resources – and time – have been wasted. 

Ectopic heartbeats are typically benign in a structurally normal heart — I thought I was safe. But I have not felt safe since that day when I learned that Doc #1 and Docs #2, 3, and so on had decided to have a stand-off at the OK Corral that is my heart.

Except, I do not know if it is okay. And that is the problem. 


Unfortunately, Mary-Anne’s tale is not uncommon. It touches on many of the areas that patient’s should be aware of including

-Undergoing diagnostic imaging testing when you are free of symptoms

-Inadequate quality control in diagnostic imaging and how that leads to false positive results

-Variance in imaging performance and interpretation-how the same test can be read as normal by one doctor and markedly abnormal by another.

-The tendency of some cardiologists to recommend invasive testing when it is inappropriate and likely to cause more harm than good

-The importance of second opinions, especially if invasive testing is recommended

-The importance of patient’s doing their own research and asking good questions based on that research.

Transparently Yours,

-ACP

AliveCor’s KardiaBand Will No Longer Be Sold And Smart Rhythm Is No More

The skeptical cardiologist was quite enthusiastic about AliveCor’s Kardia Band for Apple Watch upon its release late in 2017.

I was able to easily make high fidelity, medical grade ECG recordings with it and its AI  algorithm was highly accurate at identifying atrial fibrillation  (see here). This accuracy was subsequently confirmed by research.

Many skepcard readers spent $200 dollars for the Kardia Band and had found it to be very helpful in the management of their atrial fibrillation.

However, in December of 2018 Apple added ECG recording to its Apple Watch 4, essentially building into the AW4  the features that Kardia Band had offered as an add on to earlier Apple Watch versions.

In my evaluation of the Apple Watch I found it to be “an amazingly easy, convenient and straightforward method for recording a single channel ECG” but its algorithm in comparison to AliveCor’s yielded more uncertain diagnoses.

Given it size, prominence and vast resources, Apple’s very publicized move into this area seemed likely to threaten the viability of AliveCor’s Kardia Band.

But then-interim CEO (and current COO)  Ira Bahr later told MobiHealthNews that his company’s broader business wasn’t threatened by its new direct competitor.

“We’re not convinced that Apple’s excellent, engaging product is a competitor yet,” he said in February. “We believe that from a price perspective, this product is least accessible to the people who need it most. If you’re not an Apple user, you’ve got to buy an Apple Watch, you’ve got to buy an iPhone to make the system work. So their technology is excellent, but we think the platform is both complicated and expensive and certainly not, from a marketing perspective, targeting the patient populations we target.”

Indeed, AliveCor’s Mobile ECG device and its recently released 6 lead ECG are doing very well but the threat to the viability of KardiaBand was real and MobiHealth News announced Aug. 19 that AliveCor had officially ended sales of the Kardia Band.

An AliveCor representative told MobiHealthNews that the company “plans to continue supporting KardiaBand indefinitely” for those who have already purchased the device. The company’s decision was first highlighted by former MobiHealthNews Editor Brian Dolan in an Exits and Outcomes report.

Mr. Bahr has confirmed to me that AliveCor does plan to continue supporting KardiaBand indefinitely. This includes replacement of KardiaBand parts.

Did Apple Kill Smart Rhythm?

The informed reader who notified me of AliveCor’s decision also notes:

The official reason is that they could not keep up with the Apple Watch updates and therefore the Smart Rhythm feature did not work properly.

I think many of us knew from the beginning that smart rhythm was not very accurate But in spite of that the Kardia band provided a valuable convenience over their other products.

It does appear that Smart Rhythm is no more.

AliveCor’s website was updated 6 days ago to state that Smart Rhythm was discontinued:

” due to changes beyond our control in the Apple Watch operating system, which caused SmartRhythm to perform below our quality standards”

Likely, as my reader was told, the frequent  AW4 updates plus the lack of a large KardiaBand user base made it unprofitable for AliveCor to continue to support Smart Rhythm.

Smart Rhythm, of course was AliveCor’s method for watch-based detection of atrial fibrillation. It clearly had limitations, including false positives but given AliveCor’s track record of dedication to high quality and accuracy I assumed it would improve over time..

Apple, on December 6, 2018  with the release of its watchOS 5.1.2 for AW4 announced its own version of Smart Rhythm at the same time it activated the ECG capability of AW4.

Apple called this feature “the irregular rhythm notification feature” and cited support for its accuracy from the widely ballyhooed Apple Heart Study (which I critiqued here.)

The irregular rhythm notification feature (TIRNF)was recently studied in the Apple Heart Study. With over 400,000 participants, the Apple Heart Study was the largest screening study on atrial fibrillation ever conducted, also making it one of the largest cardiovascular trials to date. A subset of the data from the Apple Heart Study was submitted to the FDA to support clearance of the irregular rhythm notification feature. In that sub-study, of the participants that received an irregular rhythm notification on their Apple Watch while simultaneously wearing an ECG patch, 80 percent showed AFib on the ECG patch and 98 percent showed AFib or other clinically relevant arrhythmias.

Despite widely publicized reports of lives being saved by TIRNF we still don’t know whether its benefits outweigh its harms. It is not clear what its sensitivity is for detecting atrial fibrillation and I have reported one patient who was in atrial fibrillation for 3 hours without her AW4 alerting her to its presence.

For AW4 users, absence of an alert should not provide reassurance that your rhythm is normal.

Thus is does appear that the Goliath Apple hath smote the David AliveCor in the watch-based afib battle. This does not bode well for consumers and patients as I think as competition in this area would make for better products and more accountability.

Philorhythmically Yours,

-ACP

N.B.

Per AliveCor the KardiaBand currently works with all all Apple Watches except the original one.

The Apple TIRNF per Apple:

is available for Apple Watch Series 1 and later and requires iPhone 5s or later on iOS 12.1.1 in the US, Puerto Rico, Guam and US Virgin Islands. The irregular rhythm notification feature does not detect a heart attack, blood clots, a stroke or other heart-related conditions including high blood pressure, congestive heart failure, high cholesterol or other forms of arrhythmia.

What Is A Cardiologist?

The skeptical cardiologist recently received a cease and desist letter from a lawyer representing Dr. Steven Gundry who felt I was defaming the goop doctor and supplement peddler by saying he was not a cardiologist.

The lawyer’s letter reminded me that many patients do not understand exactly what a cardiologist is and mistake us for cardiothoracic surgeons.

Here’s how the American College of Cardiology defines a cardiologist:

A cardiologist is a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels.

And here is part of my response to the lawyer which further clarifies the differences:

I understand your confusion with respect to the terminology of cardiologist versus cardiac or cardiothoracic surgeon. A surprising number of patients and readers think that I as a cardiologist perform “heart surgery.” Of course, actual surgery on the heart requiring “cracking open the chest” (which is what most laypeople consider “open heart surgery”) is always done by a cardiac surgeon not a cardiologist.

Like all other board-certified cardiologists I have gone through accredited training programs in internal medicine followed by a formal cardiology training program. There is no evidence that Dr. Gundry has done this.

Cardiologists, being extremely bright, entrepreneurial  and energetic, have expanded the toolkit they have for diagnosing and treating heart disease without having to engage in surgery. Thus,
cardiologists can insert  stents to open blocked coronary arteries, implant pacemakers and even replace valves all by accessing the cardiovascular system via its arteries and veins.

We don’t call this surgery because we aren’t surgeons and didn’t go through surgical training. We call these procedures. These are invasive procedures, to be fair, as we have invaded the vasculature and the interior of the heart and from these arterial and venous incursions complications may ensue.

A typical invasive procedure that cardiologists do looks like this:

This is a cardiologist  gaining access to the arterial system by inserting a catheter into the radial artery.

 

 

A typical open heart surgery performed by a cardiothoracic surgeon requires large incisions with direct visualization of the heart and looks like this:

 

 

 

 

 

Cardiologists And Cardiac Surgeons Undergo Totally Different Training

I began my response to Gundry’s lawyer by indicating my surprise that the lawyer felt Gundry was a cardiologist:

This comes as quite a surprise to me as my detailed research into Dr. Gundry’s background, training and credentials revealed absolutely no evidence that he is or ever was a cardiologist as we in the medical community define cardiologist. In fact, as you can see in his listing on CTSnet (which is a network of cardiothoracic surgeons) his post medical school training consisted of the following

University of Michigan Hospitals Surgery Internship (1977-78)
National Institutes of Health, Clinical Associate in Cardiac Surgery (1978-80)
University of Michigan Hospitals Surgery Residency (1980-83)
University of Michigan Hospitals Cardiothoracic Surgery Residency (1983-85)

He is trained as a cardiothoracic surgeon. Cardiothoracic surgeons go through surgical training programs which are completely different from the medical training programs that cardiologists like myself go through.

My description of him in this regards reads as follows:

“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)”

As you can see, my statement is perfectly accurate.

As far as him being a being elected a “Fellow of the American College of Cardiology” I can find no documentation of this and he is not currently listed as a member of the American College of Cardiology. But even if he was this does not make him a cardiologist because many cardiothoracic surgeons are members of the ACC.

Might I suggest you ask Dr. Gundry if he thinks he is a cardiologist. I’m pretty sure he would answer no.

What Is A Quack?

The lawyer then went on to accuse me of suggesting that Gundry is a quack because:

A “quack” is defined in common parlance as a lay person pretending to be a licensed physician. In other words, a fake doctor. The term “quack” connotes dishonesty, deception, fraudulent behavior, etc. Dr. Gundry has been a licensed physician and surgeon since at least 1989 (see Exhibit B attached), performed thousands of heart surgeries, and developed patented, life- saving medical technology. Your statements are not only factually incorrect, but are also irresponsible and intentionally misleading, resulting in harm to Dr. Gundry’s reputation and income.

To which I responded:

There seems to be an attempt here to suggest that by saying he is not a cardiologist I am calling him a quack. But as my previous information should have convinced you he is not a cardiologist but a cardiothoracic surgeon. He has done very good work as a cardiothoracic surgeon and I am happy to attest to that. I will be happy to add that information to his description in my up and coming posts on him.

At no point do I call him a quack in my posts. Clearly if I’m calling him a cardiothoracic surgeon I am acknowledging that he is a licensed physician and not, clearly, a fake doctor.

I have to admit my definition of quack has not been the common dictionary definition of “fake medical doctor.”  I have always considered those who engage in quackery to be quacks.

Quackery is defined at Quackwatch (the definitive website on the topic) as the promotion of unsubstantiated methods that lack a scientifically plausible rationale. 

And one can have a perfectly legitimate training as a medical doctor and engage in what most would consider quackery.

Even board-certified cardiologists like myself can engage in quackery.

Clearly there is a disconnect between the common definition of quack and that of quackery and in a  subsequent post I will delve further into the miasma of quackery, quacks and quacking,

Anatinely Yours,

-ACP

N.B. While researching this post I came across a fantastic article on Gwyneth Paltrow’s goop Doctors from David Gorski at Science-Based medicine. I highly recommend reading the entire piece (gwyneth-paltrow-and-goop-another-triumph-of-celebrity-pseudoscience-and-quackery) for your edification and pleasure.

Gorski’s paragraph on Gundry begins

  • Dr. Steven Gundry, a cardiothoracic surgeon very much like Dr. Mehmet Oz who, as he took incredible pains to lecture Dr. Gunter in his section of Goop’s hit piece on her, who once was a very respectable academic surgeon and, even better than Dr. Oz, served as Chairman of Cardiothoracic Surgery at Loma Linda University for a number of years, before leaving academia to undertake his private practice. (No wonder he and Dr. Oz seem to have an affinity for each other!) These days, he devotes his time to his practice, writing books, giving talks, and selling expensive supplements like Vital Reds (a bargain at $69.95 for per jar, discounted to $377.73 if you buy six jars) and Lectin Shield (a slightly more expensive bargain at $79.95 a jar, $419.70 for six), while bragging (as he did in his response to Dr. Gunter) about how so very, very hard he works and even—gasp!—accepts Medicare and Medicaid patients. His most recent book is The Plant Paradox: The Hidden Dangers in “Healthy Foods” That Cause Disease and Weight Gain. (Spoiler: That “hidden danger” is lectins.)

 

Featured image Photo by Ravi Singh on Unsplash

Does One Need A Doctorate To Analyse Science? And Does Bias Smell?

The skeptical cardiologist reserves the exclusive and unimpeachable right to censor reader comments he deems inappropriate, nasty or unhelpful.

There’s a good chance if you attack me personally, I won’t post your comment. On the other hand,  if I find your attack particularly amusing there is a good chance I’ll include it in a blog post.

Here’s an ad hominem attack I really enjoyed:

You may be an MD, but you are no doctor. That requires a doctorate, which I have, and I can smell the bias from the other side of the Earth. Your “skepticism” is a front for your cynicism, and you yourself are the very thing you hate when denigrating people like Esselstyn as “evangelists”. Get a doctorate degree and learn science before attempting to analyse it.

There is so much to unpack and ponder in this paragraph! I love it.

The reader says that I am “no doctor.” This, it appears, requires a doctorate (which, coincidentally my reader has). The reader advises me to “get a doctorate degree” before attempting to analyse science.

The Cambridge English dictionary defines doctorate as “the highest degree from a university” whereas Merriam-Webster defines it as “the degree, title, or rank of a doctor”

If we assume the reader is going by the Cambridge English definition, and my title of doctor of medicine doesn’t count as a doctorate, let’s see what does.

Wikipedia lists a ton of different types of doctorates. My reader didn’t specify what kind. Would a Doctor of Music qualify me to analyse science? If so, sign me up for the coursework.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

My newly-minted mother-in-law has a doctorate in English, is she more qualified than me to analyse science?

The reader left his comment on my post about the death of Robert Atkins, so I’m not even sure what bias I am accused of, but I love this sentence:

“I can smell the bias from the other side of the earth”.

In my defense it should be pointed out that the entire Robert Atkins post is a precise  analysis of his medical history and doesn’t really touch on science. Perhaps the bias my reader smells from so far away is my bias to seek the truth.

Finally, I have to say the killer sentence in my reader’s comment  is the most brilliant ad hominem attack I have ever encountered:

Your “skepticism” is a front for your cynicism, and you yourself are the very thing you hate when denigrating people like Esselstyn as “evangelists”.

It is so deep and piercing that I am incapable of defense and I can only say “mea culpa” and I yield to your doctoral brilliance.

By the way, this whole PhD versus MD debate brings up the burning question of who one should be referring to as doctor. Should I address my mother-in-law as Dr. Perkins since she has a Ph. D. in English Literature?  And, by the way, although she is my go-to person for questions about D.H. Lawrence, Hemingway and Shakespeare, I don’t think her scientific analytic skills are up to mine even with her doctorate.

Doctorally Yours,

-ACP

Photo by Adrien Converse on Unsplash

N.B. I have deduced my reader is from Australia based on his use of analyse and his smelling my bias on the other side of the earth.

(Also, his email address ends in au)

frequency of usage of analyse versus analyze in England
frequency of usage of analyse versus analyze in England .
frequency of analyse versus analyze in America

 

 

Graphic Cigarette Package Warnings May Soon Be Coming To Our Country

Two years ago I asked (and answered) the question Why Doesn’t The USA Have Graphic Warning Labels On Cigarette Packs Like The Netherlands?

Big tobacco had successfully blocked such labels but yesterday the FDA announced a proposed rule which would post new graphic health warnings on cigarette packages if approved:

The 13 proposed warnings, which feature text statements accompanied by photo-realistic color images depicting some of the lesser-known health risks of cigarette smoking, stand to represent the most significant change to cigarette labels in 35 years.

Here are some of the proposed graphics which aren’t quite as attention-grabbing as the ones I saw in Europe.

 

 

Cigarette smoking is by far the worse thing my patients do to compromise their health and I’m in favor of hammering home the horrible complications smokers face.

Do you want feet like this?

 

 

 

 

Or Lungs like these?

 

 

 

 

Or a scar on your chest from open heart surgery?

 

 

 

 

 

All this and more can be yours if you keep smoking!

I’ve reposted below my initial blog on the topic.


While strolling the delightful (and typically debris-free) streets of Haarlem in The Netherlands the skeptical cardiologist espied an unusual cigarette pack on the ground.

In comparison to the typical American cigarette pack I noted a very prominent and disgusting picture of a leg which had been ravaged by peripheral artery disease.

The large print translates “smoking clogs your arteries.”

This is one of many potential warnings on Dutch cigarette packs. My favorite is

Roken kan leiden tot een langzame, pijnlijke dood

(Smoking can lead to a slow, painful death)

Perhaps, if such warning had been on American cigarette packs in the 1990s my mother would have been able to walk without severe pain in her legs (claudication) from the severe blockages caused by her decades of cigarette smoking.

When cigarette smoking patients tell me that “you have to die from something” I tell them that although they are greatly increasing their chance of dying from lung and cardiac disease, the smoking may not kill them but  leave them miserable and unable to walk or breath.

Experts on tobacco control note that these large, graphic and direct warnings are much more effective than the first small boxed warnings:

After the implementation of the first warning labels in 1966, the FTC’s 1981 report concluded that the original warning labels were not novel, overexposed and too abstract to remember and be personally relevant.46 Warning labels, like advertisements, wear out over time.47 Written warning labels wear out faster than graphic ones.48,49 In response, Congress passed a law mandating four rotating warnings. Studies on them began appearing in the late 1980s, demonstrating that several years after the implementation, those written labels on cigarette packs were also not noticed and not remembered by smokers and adolescents.5053 Since then, the diffusion and evolution of tobacco warning labels have been propelled by observational and experimental studies showing the effectiveness of large graphic warning labels in informing consumers about the health harms of smoking and reducing their smoking behavior.45,54

Here’s how Australia’s warnings have evolved

autralia-cigarette.jpg

 

 

 

 

 

 

 

In 2011 the US Congress passed legislation moving America towards such effective graphic warnings:

However, the law was challenged by Big Tobacco and has never been enacted. From the FDA site:

The Family Smoking Prevention and Tobacco Control Act requires the FDA to include new warning labels on cigarette packages and in cigarette advertisements. On June 22, 2011, the FDA published a final rule requiring color graphics depicting the negative health consequences of smoking to accompany the nine new textual warning statements. However, the final rule was challenged in court by several tobacco companies, and on Aug. 24, 2012, the United States Court of Appeals for the District of Columbia Circuit vacated the rule on First Amendment grounds and remanded the matter to the agency.[1] On Dec. 5, 2012, the Court denied the government’s petition for panel rehearing and rehearing en banc. In 2013, the government decided not to seek further review of the court’s ruling.

The FDA has been undertaking research related to graphic health warnings since that time.

[1] R.J. Reynolds Tobacco Co., et al., v. Food & Drug Administration, et al., 696 F.3d 1205 (D.C. Cir. 2012)

What Other Countries Are Doing

According to a Canadian Cancer Society report from late 2016,

More than 100 countries/jurisdictions worldwide have now required pictorial warnings, with fully 105 countries/jurisdictions having done so. This represents a landmark global public health achievement.

Increasingly, the United States stands alone, because of a constitutional doctrine privileging commercial speech above public health.

Here are the countries requiring pictorial warnings courtesy of that Canadian Cancer Society report.

And some of their warning pictures:

And this a picture that FDA would have required:

 

Skeptically Yours,

-AcP

Neil Young’s Harvest Moon Gathering Should Be Awesome

For multiple reasons Neil Young is the skeptical cardiologist’s favorite musician. I love everything he has done from work with Buffalo Springfield to CSNY  to Crazy Horse. His solo work is simply amazing.

I last saw him at the Fabulous Fox Theatre here in St. Louis last summer and at the age of 72 he was still mesmerizing as he ambled from grand piano to acoustic or electric guitar singing in his inimitable and still powerful voice and telling stories behind his brilliant iconic songs like Ohio.

He continues to create relevant and beautiful work to this day. On top of all this he handles his musical catalogue with tremendous integrity. You will not find a Neil Young song in a Bud, Chevy or Uber commercial.

Therefore, when I heard about the benefit concert he was putting on in September I bought tickets even though it was going to be just outside of LA.

I am sadly unable to attend as I could not get out of my hospital  on-call obligations for that weekend .

If any readers are interested in purchasing my two tickets let me know.
Here’s the description:

Neil Young and Norah Jones top the lineup for the inaugural Harvest Moon A Gathering. The benefit concert will be held at the Painted Turtle in Lake Hughes, California on Saturday, September 14.

Father John Misty and Masanga round out the lineup for the 2019 Harvest Moon A Gathering. The daytime concert will feature performances on a grassy hillside with views of the performers, mountains and Lake Hughes at the site, which is nestled near Los Angeles National Forest. Proceeds from the event will benefit both The Painted Turtle, a non-profit providing children living with serious medical conditions a traditional camp experience free of charge, and The Bridge School, which provides free education to children with severe speech and physical impediments.

Each ticket will include an all-star celebrity chef picnic cooked and served by SoCal’s top chefs as well as a beer and wine tasting from select California Breweries and Wineries.

Price is for two tickets. Face value. Concert is sold out.

For many years Neil and Pegi Young put on The Bridge Concert which was an annual benefit for the Bridge School. This was an absolutely awesome outdoor event in Mountain View, CA but the concerts ended after Neil and Pegi divorced.

I was fortunate enough to catch the last one in 2016 and I consider it one of the best concerts I’ve ever been to. Here are the artists and their setlists.

The crowd at The Bridge School Concert 2016. A wonderfully chill, friendly and happy group. Expect the same at Harvest Moon.
With any luck, the Harvest Moon will be equally exciting.
Skeptically Yours,
-ACP
Update. It appears I have a buyer.

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

%d bloggers like this: