All posts by Dr. AnthonyP

Cardiologist, blogger, musician

Black Friday Sales Even A Skeptic Can Embrace

The skeptical cardiologist refuses to buy anything on Black Friday.  I don’t want to be manipulated into buying something just because it is cheaper for a while.

However, I have noticed that many of the cardiovascular products I recommend or have written about are substantially discounted today.

I present them in no particular order.

The QardioArm BP cuff which I have called the iPhone of BP devices is marked down from $99 to $69$ for a “limited time.”

While it is portable, stylish and accurate it is not, as Qardio ludicrously claims, “four times more effective at lower blood pressure.”

Omron, whose blue-tooth enabled BP devices connect to an online dashboard your doctor can visualize is offering 30% off through 12/31/2019 on all devices on their website.

I presume this includes the delightful Omron Evolv.

It may include the Omron Heart Guide, a wrist-based watch which measures BP. I’ll be writing my review of this device soon.

I’ve written a lot about the value of AliveCor’s Kardia Mobile ECG and the single lead device is marked down from $99 to $ 84 for Black Friday.

Finally, one of my favorite gadgets (see here), the Keyto ketone breath sensor sent me this email this morning.

I can’t vouch for the Keyto chocolate shake or the basil pesto that they are now including with Black Friday sales but I love the Keyto.

By the way, it wasn’t clear to me when I first got the Keyto device what kind of diet Keyto promotes. They favor a plant-based keto (with fish) diet which they consider “heart healthy.”  More on this down the line.

Appositely Yours,

-ACP

The Distortion of The Death of Dr. Robert Atkins Continues

Three years ago I carefully researched the details of the death of Robert Atkins and wrote about it on this blog. I was motivated by the grossly inaccurate portrayal of him promulgated on vegan and plant-based websites. Elsewhere on this website I have described in detail the death of Nathan Pritikin whose ultra-low fat diet stands in stark contrast to Atkins’ ultra-low carb diet.

The most important point I hoped to make was that we should not judge the benefits of any diet based on how the founder of that diet dies. There is far too much randomness in death and far too much genetic influence over our health to base dietary decisions on one man ( or woman’s) mode of departing existence.

Atkins suffered a completely random event slipping and falling on ice and suffering an epidural hematoma. Pritikin developed leukemia and died after committing suicide.

Unfortunately my article did not end the misinformation rampant on the internet about Atkins so I’m reposting it today for all of you who may be feeling guilty about eating too much on Thanksgiving yesterday.

One of the characters in my story, Michael Bloomberg, has recently announced that he is running for President.


In the spring of 2003 at the age of 72 years, Robert Atkins, the cardiologist and  controversial promoter of high fat diets for weight loss, fell  on the sidewalk in front of his Atkins Center for Complementary Medicine in Manhattan.  He lost his footing on a patch of ice, slipped and banged his head on the pavement.  At the time of his fall his book ”Dr. Atkins’ New Diet Revolution” lead the NY times paper-back best seller list.

He was taken to nearby Cornell Medical Center where a clot was evacuated from his brain. Thereafter he lapsed into a coma and he spent 9 days in the ICU, expiring on April 17, 2003.

screen-shot-2016-11-27-at-8-44-55-amThe cause of death was determined by the New York Medical Examiner to be “blunt injury of head with epidural hematoma.”

An epidural hematoma is a collection of blood between the skull and the tough outer lining of the brain (the dura) which can occur with blunt trauma to the head which results in laceration of the arteries in this area. It is a not  uncommon cause of death in trauma . Actress Natasha Richardson (skiing, see below)  died from this. Nothing about the manner in which Robert Atkins died would suggest that he was a victim of his own diet any more than  Natasha Richardson was.

However, within the year a campaign of misinformation and deception spear-headed by  evangelistic vegans would try to paint the picture that Atkins died as a direct result of what they perceived as a horribly dangerous diet.

Michael Bloomberg, then New York major,  was quoted as saying

“I don’t believe that bullshit that [Atkins] dropped dead slipping on the sidewalk.”

According to the Smoking Gun:

“The 61-year-old billionaire added that Atkins was “fat” and served “inedible” food at his Hamptons home when Bloomberg visited. The mayor’s inference, of course, was that Atkins was actually felled by his meat-heavy diet, that his arteries were clogged with beef drippings. “

Enter The Vegans

Richard Fleming, a physician promoting prevention of cardiovascular disease through vegetarianism and with close ties to an organization  called Physicians Committe for Responsible Medicine (PCRM) sent a letter to the NY Medical Examiner requesting a copy of the full medical examination of Atkins. The NYME office  should have only issued copies of this report to physicians involved in the care of Atkins or next of kin but mistakenly complied with this request.  Fleming, who would subsequently publish his own low fat diet book, conveniently gave the report to PCRM which is directed by animal rights and vegan physicians.

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From the front page of pcrm.org. The two major concerns of the group are converting everyone to veganism and animal rights.

Neal Barnard, the President of PCRM, in an incredibly unethical move sent the letter to the Wall Street Journal with the hope that the information would destroy the popularity of the Atkins diet, a diet he clearly despises..  Barnard said the group decided to publicize the report because Atkins’ “health history was used to promote his terribly unhealthy eating plan..” The WSJ subsequently published an article summarizing the findings.

To this day, advocates of vegetarianism and low fat diets, distort the findings of Atkins’ Medical Examination in order to depict high fat diets like his as dangerous and portray Atkins as a victim of his own diet.

To scientists and thoughtful, unbiased physicians it is manifestly apparent that you cannot base decisions on what diet plan is healthy or effective for weight loss on the outcome of one patient. It doesn’t matter how famous that one person is or whether he/she originated and meticulously followed the diet. It is a ludicrous concept.

Would you base your decision to engage in running  based on the death of Jim Fixx?  Fixx  did much to popularize the sport of running and the concept of jogging as a source of health benefit and weight loss. He died while jogging, in fact. An autopsy concluded that he died of a massive heart attack and found advanced atherosclerosis (blockage) of the arteries to his heart.

Fixx inherited his predisposition to heart disease and couldn’t run himself out of it. Multiple studies over the years have documented the benefit of regular aerobic exercise like running on longevity and cardiovascular risk.

Would you based your decision to engage in  a very low fat diet based on how Nathan Pritikin died?  Pritikin authored an extremely popular book emphasizing eliminating fat from the diet but developed leukemia and slashed his wrists,  committing suicide at the age of 69 years. Would vegetarians accept the premise that their preferred diet results in leukemia or suicidal depression based on Pritikin’s death?

The Distortion of Atkins Death

The NYME report lists Atkins weight at autopsy as 258 pounds. Low-fat zealots seized on this fact as indicating that Atkins was screen-shot-2016-12-17-at-5-32-56-ammorbidly obese throughout his life.  For example, a  you-tube video of an audio interview of Atkinas online posted by “plant-based coach”  has this obviously photoshopped head of Atkins put on the body of a morbidly obese man. Atkins actually weight around 200 pounds through most of his life and a hospital note on admission showed him weighing 195 pounds. A substantial weight gain of 63 pounds occurred in the 9 days after his admission due to the accumulation of fluid volume and swelling which is not uncommon in the critically ill.

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No autopsy was performed on Atkins but the NYME wrote on the document that he had “h/o of MI, CHF, HTN.”

MI is the acronym for a myocardial infarction or heart attack. As far as we can tell without access to full medical records, Atkins never had an MI. He did have a cardiac arrest in 2002. While most cardiac arrests are due to a cardiac arrhythmia secondary to an MI they can also occur in patients who have a cardiomyopathy or weakness in the heart muscle from causes other than MI.

In fact, USA Today reported that Stuart Trager, MD,  chairman of the Atkins Physicians Council in New York, indicated that Atkins was diagnosed with a cardiomyopathy at the time of his cardiac arrest and that it was not felt to be due to blocked coronary arteries/MI. Cardiomyopathy can be caused by viral infections or nonspecific inflammation of the heart muscle and would have nothing to do with diet.

Trager also stated that Atkins, as a result of the cardiomyopathy, had developed heart failure (CHF) and the pumping ability of his heart (ejection fraction) had dropped to 15% to 20%. While CHF can be due to heart attacks causing heart weakness in Atkins case it appears it was unrelated to fatty blockage of the coronary arteries causing MI and therefore likely not related  to his diet.

What Does Atkins Death Tell Us About His Diet 

The information about Atkins death tells us nothing about the effectiveness or dangers of his diet.  In one individual it is entirely likely that a genetic predisposition to cancer or heart disease overwhelms whatever beneficial effects the individual’s lifestyle may have had. Thus, we should never rely on the appearance or the longevity of  the primary promoter of a diet for the diet’s effectiveness.

The evangelists of low-fat, vegan or vegetarian diets like PCRM have shamelessly promoted misinformation about Atkins death to dismiss high fat diets and promote their own agenda. If their diets are truly superior it should be possible to utilize facts and science to promote them rather than a sensationalistic, distorted focus on the body of one man who slipped on the ice and fell to his death.

Epidurally Yours

-ACP

ISCHEMIA Shows Medical Therapy Outcomes As Good As Coronary Stents or Bypass For Most CAD Patients

The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical And Invasive Approaches) study presented at the AHA meeting this week provides further evidence that a conservative approach utilizing optimal medical therapy is an acceptable strategy for most patients with stable coronary disease (CAD).

Cardiologists have known for a decade (since the landmark COURAGE study) that outside the setting of an acute heart attack (acute coronary syndrome or ACS), coronary stents don’t save lives and that they don’t prevent heart attacks.

Current guidelines reflect this knowledge, and indicate that stents in stable patients with coronary artery disease should be placed only after a failure of  “guideline-directed medical therapy.”  Despite these recommendations, published in 2012, half of the thousands of stents implanted annually in the US continued to be employed in patients with either no symptoms or an inadequate trial of medical therapy.

Yes, lots of stents are placed in asymptomatic patients.  And lots of patients who have stents placed outside the setting of ACS are convinced that their stents saved their lives, prevented future heart attacks and “fixed” their coronary artery disease. It is very easy to make the case to the uneducated patient that a dramatic intervention to “cure” a blocked artery is going to be more beneficial than merely giving medications that stabilize atherosclerotic plaque, dilate the coronary artery or slow the heart’s pumping action to reduce myocardial oxygen demands.

Stent procedures are costly  in the US (average charge around $30,000, range $11,000 to $40,000) and there are significant risks including death, stroke and heart attack. After placement, patients must take powerful antiplatelet drugs which increase their risk of bleeding. There should be compelling reasons to place stents if we are not saving lives.

What Did ISCHEMIA Prove?

ISCHEMIA (paper unpublished but slides available here) showed that an invasive strategy (employing cardiac catheterization with resulting stenting or coronary bypass surgery (CABG)) offered no benefit over optimal medical therapy in preventing cardiovascular events in patients with moderate to severe CAD.

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Rates of all-cause death were nearly superimposable over the years studied, reaching 6.5% and 6.4% at 4 years for the invasive and conservative groups,

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Inclusions and exclusion criteria are listed below. Patients with unnaceptable angina despite optimal medical therapy were not included. These patients clearly benefit symptomatically from revascularization (as long as their chest pain is actually angina and not from another cause.)

All patients had stress imaging studies demonstrating moderate to severe amounts of ischemia. Such patients with very abnormal stress tests in the past have typically been sent immediately to the cath lab.

Based on ISCHEMIA we now know in these patients there is no need to do anything urgently other than institute OMT.

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These patients were on good medical therapy which likely explains the very good outcomes in both conservative and invasive arms. The “high level of medical therapy optimization” is what cardiologists should be shooting for with LDL<70, on a statin with systolic blood pressure <140 mm Hg, on an antiplatelet drugg and not smoking.

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Interestingly coronary CT angiography (CCTA) was utilized prior to patients receiving catheterization. I’ve been  utilizing this noninvasive method for visualizing the coronary arteries increasingly prior to committing to an invasive approach.

Quality Of Life 

Finally, in a separate presentation the ISCHEMIA trial showed that the invasive strategy did improve symptoms and quality of life modestly. It did not improve quality of life in those without angina symptoms.

The ORBITA study (which I wrote about here) showed that a large amount of the symptomatic improvement in patients following stenting may be a placebo effect.

Importance Of ISCHEMIA

Hopefully the results of ISCHEMIA will cut down on the number of unnecessary catheterizations, stents and bypass operations performed. This, in turn, will save our health system millions of dollars and prevent unnecessary complications.

Outside the setting of an acute heart attack the best approach to patients with blocked coronary arteries is a calm, thoughtful, and measured one which allows ample time for shared decision-making between informed patients and knowledgeable physicians. Such decisions should carefully consider the ISCHEMIA, COURAGE and ORBITA results.

Nonischemically Yours,

-ACP

N.B. Ischemia is a fantastic acronym for this study. Doctors use it a lot to describe the absence of sufficient blood flow to tissues.

N.B.2 Although I deplore the number of unnecessary caths and stents performed in the US, especially in patients without symptoms and those with noncardiac chest pain, I still utilize them in my patients with flow-limiting coronary stenoses and unacceptable anginal chest pain with symptoms despite optimal medical therapy and have noticed outstanding results. This angiogram shows a tight, eccentric LAD blockage in such a patient who now, post stent, has had complete resolution of the chest pain that limited him from even short walks.

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

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

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

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

What Is Heart Rate Recovery?

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

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

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

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

Heart Rate Recovery As A Predictor Of Mortality

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

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

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

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

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

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

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

m_joc00680f2

 

 

 

 

 

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

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

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

Apple Watch and Heart Rate Recovery

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

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

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

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

 

IMG_2A2C306430A7-1

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

 

 

 

 

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

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

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

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

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

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

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

Autonomously Yours,

-ACP

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

When should you take your once daily BP meds?

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

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

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

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

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

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

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

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

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

Chronotherapically Yours,

-ACP

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

 

 

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

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

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

What To Monitor and How To Measure

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

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

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

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

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

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

• Remain still:

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

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

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

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

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

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

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

• Record all readings accurately:

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

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

What Should The BP Goal Be?

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

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

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

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

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

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

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

Home Blood Pressure Monitoring Devices

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

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

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

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

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

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

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

Sphygmomanometrically Yours,

-ACP

Should You Choose The High-Dose Flu Vaccine?

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

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

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

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

Influenza More Deadly In Elderly But Vaccine Less Effective

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

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

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

Fluzone HD: High Dose Antigen Which Increases Antibody Reponse

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

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

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

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

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

The CDC summarizes it as follows

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

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

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

Should You Choose Fluzone?

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

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

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

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

Skeptically Yours,

-ACP

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

Flublok is a quadrivalent recombinant vaccine of standard dosage.

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

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

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

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

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

 

You Should Stop Taking Zantac (Ranitidine) Now

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

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

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

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

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

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

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

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

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

Famotidine , according to this review:

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

Skeptically Yours,

-ACP

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

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

Valisure is a unique pharmacy which per its website:

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

 

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

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

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

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

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

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

A Tasteless Quinine Chill Tonic

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

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

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

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

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

A Delightful Book Exchange And Champagne Bar

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

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

Cool Random Art

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

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

Elsewhere we encountered a giant iron.

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

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

Musical Jams At Jack of the Wood

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

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

Excellent Beer, Booze, Farm To Table Food

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

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

Gorgeous Blue Ridge Mountains and Trails

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

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

Moog Factory Tour

A highlight of Asheville for me was the Moog factory tour

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

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

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

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

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

The Unseen Biltmore Estate

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

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

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

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

Serendipitously Yours,

-ACP

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

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

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

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

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


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

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

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

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

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

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

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

(See my post on cardioversion here.)

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

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

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

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

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

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

To Ablate Or Not To Ablate

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

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

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

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

Importance Of Quality Of Life

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

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

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

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

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


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

Skeptically Yours,

-ACP

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