All posts by Dr. AnthonyP

Cardiologist, blogger, musician

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

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

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

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

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

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

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

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

-that a true Heimlich was applied

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

-that the outcome was positive.

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

Heimlich and Koop: “Back Blows Are Lethal”

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

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

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

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

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

Complications Of The Maneuver

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

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

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

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

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

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

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

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

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

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

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

A 3 year old boy developed pancreatitis and a pseudocyst

An 88 year old man suffered a laceration of the liver

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

Severe Injuries To The Aorta

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

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

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

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

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

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

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

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

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

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

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

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

The Elderly: High Risk For Both Choking And HM Complications

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

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

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

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

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

The authors of the 2018 case report described above concluded:

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

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

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

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

the ANZOR guidelines recommend starting with back blows

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

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

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

Heimlich Maneuver: Time For A Reconsideration 

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

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

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

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

Skeptically Yours,

-ACP

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

 

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

 

 

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

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

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

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

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

Its conclusions:

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

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

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

Big Heart Attack Or Little Heart Attack?

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

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

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

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

Stunned or Hibernating Myocardium?

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

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

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

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

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

Skeptically Yours,

-ACP

Behold The Korg Triton and Marilyn Monroe’s Posthumous Starring Role

The skeptical cardiologist has started taking Tuesdays off more or less. Whereas I used to spend this day deep in the bowels of the hospital in a darkened room viewing all manner of echocardiograms and EKGS and occasionally venturing into the special procedure room to perform cardioversions and transesophageal echocardiograms, I now “work” from my home.

Cutting back my work hours enables two things:1) It makes for a sustainable work situation-one where I can enjoy patient care and interaction more (the most fulfilling part of the job) and interact with computer screens less thus  allowing me to keep working for another 10 years and 2) It allows me to do all the other things I love doing but which I never seem to find enough time for. These other things are mostly music creation, research and writing for this blog, reading, and taking care of my health.

In the realm of music creation I’ve been doing a lot more straight improvisation on my acoustic grand. I just sit at the keys and start playing whatever my brain tells my hands to do. It’s quit exhilarating but I fear that too much of it may drive the wife formerly known as the eternal fiancee’ bananas.

In order to avoid a bananas wife and to allow playing of the grand piano at any time of the night or day, I have ordered a Yamaha CP4 digital piano. This, according to all reports, plays very much like an acoustic grand and has sounds which are hard to tell from a Steinway.  In anticipation of its arrival I dug up from the basement my old synthesizer workstation a Korg Triton Studio. It was upon this 76 key electronic marvel that yours truly did most of the music production for my first album “Atherosclerosis Is My Psychosis” under the pseudonym Dr. P And The Atherosclerotics.

Emboldened by the interest readers displayed in my Neil Young tickets, I am hereby offering up for sale my beloved Korg Triton Studio 76 to readers of my blog who will provide a nurturing home for the instrument.  The wife just put this up plus its Korg gig bag on something called “Facebook MarketPlace” for $800 but I am willing to sell it for much less to any reader who says nice things about my blog.

What, you may ask, does all this have to do with Marilyn Monroe? Well, quite a bit (not much actually, its just clickbait.)  Using my extra time off this morning I ran 2 miles in the neighborhood and while listening on my airpods the following (reasonably obscure) Monty Python sketch (cowritten by Graham Chapman and Douglas Adams)  from   The Album of the Soundtrack of the Trailer of the Film of Monty Python and the Holy Grail   came up.

In it Michael Palin interviews film director Carl French (Graham Chapman) who has just released his latest movie which features the deceased and cremated  Marilyn Monroe in every scene.

Fans of MP will enjoy but those who are easily offended by nasty words or off-kilter humour should avoid.

 

Pythonically Yours,

-ACP

Recent Papers Support The Cardiometabolic Health Benefits Of Full Fat Yogurt

A recent  Marion Nestle post,  Industry-funded studies of the week: Yogurt highlights three papers which strongly support the health benefits of consuming full fat dairy-in particular yogurt.

Nestle does a great job of highlighting food industry ties to nutritional research and publications on her excellent website Food Politics and in her books including “Unsavory Truth: How Food Companies Skew the Science of What We Eat.”

She notes that publication of these yogurt papers was paid for by a big player in the yogurt industry:

These three papers were part of a supplement to Advances in Nutrition published in September 2019: Supplement—6th Yogurt in Nutrition Initiative (YINI) Summit / More than the Sum of Its Parts, sponsored by Danone Institutes International. Publication costs for this supplement were defrayed in part by the payment of page charges.

Yes, these three papers were published in a supplement sponsored by the yogurt industry and therefore must be taken with a grain of salt.

However, a totally unbiased look at the data on yogurt and cardiovascular disease which I have provided here and here comes to the same conclusion. Misguided attempts to make full fat yogurt healthier by eliminating dairy fat have created artificial sugar-laden monstrosities which are actually stealth desserts.

It’s interesting that the dairy industry has been complicit in promoting the idea that low fat dairy is healthier because (as I pointed out here) it allows them to double dip the milk cash cow-skimming off the healthy fat and selling the separated fat and the residual skim milk separately.

The second paper ( Dairy Foods, Obesity, and Metabolic Health: The Role of the Food Matrix Compared with Single Nutrients) was based on a talk that Dariush Mozaffarian gave at the American Society of Nutrition 2018 Congress. I’ve been following Mozaffarian’s work since 2012 and I consider him to be an excellent researcher, writer and thinker who can be trusted to present unbiased information. The content of that talk presented by him at a national scientific congress in front of his academic colleagues is unlikely to be biased.

Here is what he concludes:

The present evidence suggests that whole-fat dairy foods do not cause weight gain, that overall dairy consumption increases lean body mass and reduces body fat, that yogurt consumption and probiotics reduce weight gain, that fermented dairy consumption including cheese is linked to lower CVD risk, and that yogurt, cheese, and even dairy fat may protect against type 2 diabetes. Based on the current science, dairy consumption is part of a healthy diet, without strong evidence to favor reduced-fat products; while intakes of probiotic-containing unsweetened and fermented dairy products such as yogurt and cheese appear especially beneficial.”

It’s important to look at the disclosures for any scientific paper and Mozzafarian has a lot of industry ties to disclose:

DM received an honorarium from the American Society of Nutrition for the preparation of this manuscript. A freelance science writer, Denise Webb, was supported by Danone Institute International to prepare an initial draft of this manuscript for DM based on a recording of his talk and slides at the American Society of Nutrition 2018 Congress. The final manuscript was edited in detail and approved by DM. The funders had no role in the design, analysis, interpretation, review, or final approval of the manuscript for publication…DM reports research funding from the NIH and the Gates Foundation; personal fees from GOED, Nutrition Impact, Pollock Communications, Bunge, Indigo Agriculture, Amarin, Acasti Pharma, Cleveland Clinic Foundation, and America’s Test Kitchen; scientific advisory board, Elysium Health (with stock options), Omada Health, and DayTwo; and chapter royalties from UpToDate; all outside the submitted work.”

The lead author of the third paper Nestle’ highlights ( Effects of Full-Fat and Fermented Dairy Products on Cardiometabolic Disease: Food Is More Than the Sum of Its Parts.)  is Arne Astrup another nutritional writer/researcher who I have a ton of respect for. He’s written extensively on the topic of saturated fat and dairy in multiple publications which were not tied to the dairy industry in any way.

Astrup concludes:

 “Although more research is warranted to adjust for possible confounding factors and to better understand the mechanisms of action of dairy products on health outcomes, it becomes increasingly clear that the recommendation to restrict dietary saturated fat to reduce risk of cardiometabolic disease is getting outdated. Therefore, the suggestion to restrict or eliminate full-fat dairy from the diet may not be the optimal strategy for reducing cardiometabolic disease risk and should be re-evaluated in light of recent evidence.”

His disclosures are extensive but they reveal how wide-ranging his interests are and how dedicated he is to optimizing diet.

AA is a member of advisory boards/consultant for BioCare Copenhagen, Denmark; Dutch Beer Institute, Netherlands; Gelesis, United States; Groupe Éthique et Santé, France; McCain Foods Limited, United States; Novo Nordisk, Denmark; Pfizer, United States; Saniona, Denmark; and Weight Watchers, United States. AA has received travel grants and honoraria as a speaker for a wide range of Danish and international consortia. AA is co-owner and member of the board of the consultancy company Dentacom Aps, Denmark; cofounder and co-owner of UCPH spin-outs Mobile Fitness A/S, Flaxslim ApS, and Personalized Weight Management Research Consortium ApS (Gluco-diet.dk). He is coinventor of a number of patents owned by the University of Copenhagen, in accordance with Danish law. He is coauthor of a number of diet and cookery books, including books on personalized diet approaches. AA is not an advocate or activist for specific diets and is not strongly committed to any specific diet.”

I love what he says at the end of his disclosure statement

“AA is not an advocate or activist for specific diets and is not strongly committed to any specific diet.”

Hooray! That is exactly what we need in the world of dietary recommendations.

I am particularly heartened by the conclusions of these two illustrious international nutritional authorities who have managed to cut through the long-standing nutritional dogma that all saturated fat is bad. As one who has no ties to any food or medical industry group and who is not an advocate or activitist for specific diets I concluded as they have that

  1.  Based on the current science, dairy consumption is part of a healthy diet, without strong evidence to favor reduced-fat products; while intakes of probiotic-containing unsweetened and fermented dairy products such as yogurt and cheese appear especially beneficial.”
  2. It becomes increasingly clear that the recommendation to restrict dietary saturated fat to reduce risk of cardiometabolic disease is getting outdated. Therefore, the suggestion to restrict or eliminate full-fat dairy from the diet may not be the optimal strategy for reducing cardiometabolic disease risk and should be re-evaluated in light of recent evidence.”

As I wrote in my letter to the FDA and in a recent critique of the AHA I would change the verbiage to “the suggestion to restrict or eliminate full-fat dairy from the diet is not a proven strategy for reducing the risk of cardiovascular disease, obesity or diabetes and should be eliminated from current dietary guidelines.”

Two key points that these papers help emphasize:

  1. Eating fat doesn’t make you fat
  2. All saturated fat is not bad for your heart

It is important to look at industry influence on research and publications (along with other biases)  but it is hard to find an expert in these areas who hasn’t had some industry ties. Part of these ties develop because researchers who have concluded a particular food is healthy based on their independent review of the literature will be sought after as a speaker at conferences organized by the support groups for that food.

Fortunately, my evaluations remain unsullied by any food industry ties and, like Dr. Astrup, I am not an advocate or activist for specific diets and I am not not strongly committed to any specific diet.

Skeptically Yours,

-ACP

N.B. Trader’s Point Creamery Yogurt no longer distributes their wonderful products. I’ve started consuming Maple Hill 100% grass fed full fat yogurt and it is quite good.

N.B. #2.Arne Astrup’s bio.

Prof. Arne Astrup is Head of the Department of Nutrition, Exercise and Sports at the University of Copenhagen, and Senior Consultant at Clinical Research Unit, Herlev-Gentofte University Hospital. Astrup attained his medical degree from UCPH in 1982 and a Doctorate in Medical Science in 1986. He was Appointed Professor of Nutrition and Head of the Research Department of Human Nutrition at The Royal Veterinary and Agricultural University, Denmark, in 1990, he led the department throughout its development ever since.

His researches focus on the physiology and pathophysiology of energy and substrate metabolism and appetite regulation, with special emphasis on the etiology and treatment of obesity, including the role of diet composition and of specific  nutrients, lifestyle modification, very-low-calorie diets, exercise, and medication. Major research collaborations include participation in the EU multicenter studies.
He led research that showed that GLP-1 is a satiety hormone in humans, and was instrumental in Denmark being the first country to ban industrial trans-fat in 2014. He is author/co-author of over 600 original, review and editorial scientific papers and more than 1000 other academic publications such as abstracts, textbook chapters and scientific correspondence. He has supervised 32 PhD students to date.

Darius Mozzafarian’s bio (Wikipedia)

Dariush Mozaffarian (born August 19, 1969) is an American cardiologist, Dean and Jean Mayer Professor at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University, and Professor of Medicine at Tufts University School of Medicine.

Mozaffarian is the author of nearly 400 scientific publications and has served as an adviser for the US and Canadian governments, American Heart Association, World Health Organization, and the United Nations.

The New Guidelines On Meat Are Exposing The Fault Lines In Nutrition Advice

The skeptical cardiologist this morning was greeted by headlines announcing that an international panel of 14 unbiased researchers had concluded that it was OK for humans to continue eating red meat and processed meat at current levels.

The startling news was  a reversal of what the Dietary Guidelines for Americans, the AHA and the American Cancer Society have been telling us for years and threw the nutritional world into a tizzy. The bottom line recommendation, written in language suggesting a lack of certainty in the evidence and lack of confidence in the advice reads as follows:

The panel suggests that adults continue current unprocessed red meat consumption (weak recommendation, low-certainty evidence). Similarly, the panel suggests adults continue current processed meat consumption (weak recommendation, low-certainty evidence).

The guidelines were accompanied by five systematic reviews, and appeared Monday in the Annals of Internal Medicine, as part of the “Clinical Guidelines” section of Annals which is published by the American College of Physicians.

Much has been written on this event and I’ve read lots of scathing commentary. In fact a group of prominent nutrition experts tried to suppress the publication.

I think the best summary comes from Julia Volluz at Vox  (Beef and bacon healthy? A fight raging in nutrition science, explained. – Vox)

Volluz does her typically excellent job of explaining the science in a balanced way and includes some of the prominent voices who are outraged by the publication.

As I’ve pointed out (here and here and here) the science behind most nutritional recommendations is weak and often public health authorities make sweeping dietary recommendations that aren’t justified.

We are making gradual progress in rolling back bans on some healthy food, like eggs but unjustified bans on other healthy foods like full-fat yogurt and coconut oil persist.

When it comes to red meat consumption the systematic analyses reveal mild associations with poor health outcomes but these associations don’t prove causality and could easily be due to confounding factors or poor input data.

Thus, if you want to cut back your red meat consumption on the chance that these associations are truly reflective of causation go ahead. Especially if you have ethical or environmental concerns about production of red meat.

Just keep in mind that the calories you cut from less meat consumption should be replaced by more healthy nutrient-dense foods like non-starchy vegetables, nuts, dairy fat, avocado and olive oil and not by low quality carbs and ultra-processed food or you may be doing more harm than good.

Skeptically Yours,

-ACP

It’s National Coffee Day-Let’s Celebrate The Health Benefits Of Java!

The skeptical cardiologist admits to being a coffee snob and addict. For the last 10 years I’ve been using the Chemex system to brew my morning cup of Java. Once I consistently partook of Chemex pour-over coffee made from freshly ground, recently roasted quality coffee beans it was hard for me to enjoy any other kind. I find Starbucks coffee particularly loathsome.

Although numerous studies have established that coffee consumption is safe (assuming you are not adding  titanium dioxide to your cup), the belief that it is bad for you persists in the majority of patients that I see.

Since today is National Coffee Day let me take this opportunity to reassure my patients and readers who consume the good brew that they are not harming their hearts.

While it is possible to adulterate coffee into an unhealthy concotion (see my post on “How Starbucks Is Making Heart Healthy Coffee Into a Stealth Dessert”) overall coffee is heart-healthy.

In fact a recent study (Coffee Consumption and Coronary Artery Calcium Score: Cross‐Sectional Results of ELSA‐Brasil (Brazilian Longitudinal Study of Adult Health)) showed that coffee consumption is associated with less subclinical atherosclerosis as measured by coronary artery calcification (CAC).

The intro to this paper summarizes information known about coffee and cardiovascular disease (CVD). Although early observational studies suggested coffee could increase risks:

More recent meta‐analysis of prospective studies showed that moderate coffee consumption was associated with decreased CVD risk, all‐cause mortality, and mortality attributed to CVD and neurologic disease in the overall population. High coffee consumption (>5 cups/d) was neither related to CVD risk nor to risk of mortality.12, To corroborate this evidence, the 2015–2020 Dietary Guidelines for Americans show that consumption of 3 to 5 cups/d of coffee is associated with reduced risk of type 2 diabetes mellitus and CVD in adults. Consequently, moderate coffee consumption can be incorporated into a healthy dietary pattern, along with other healthful behaviors. Although coffee consumption has been studied in relation to various risk factors of CVD, only 4 studies have investigated the association between coffee intake and subclinical atherosclerosis, and the data available were limited and inconsistent.

Coffee is rich in phenolic compounds which have demonstrated anti-inflammatory, antioxidant and antithrombotic properties which could lower cardiovascular risks. However, unfiltered coffee is rich in cholesterol‐raising compounds (diterpenes, kahweol, and cafestol) that can  increase total cholesterol, low‐density lipoprotein cholesterol, and triglycerides.which could worsen cardiovascular risk.

Consumption of filtered coffee however does not effect lipid levels adversely- presumably those nasty diterpenes are retained by my Chemex filter.

The Brazilian Longitudinal study looked at 4426 residents of Sao Paulo, Brazil who underwent a CAC measurement.  Information on coffee consumption was obtained from a food frequency questionnairre.

Those who reported high coffee consumption (>3 cups per day) had one-third the chance of a CAC>100 than nondrinkers. More coffee=less plaque build up in the coronary arteries. Less atherosclerotic plaque should = less heart attacks and strokes.

Scientific Consensus On The Healthiness of Coffee Consumption

In contrast to what the public believes, the scientific evidence very consistently suggests that drinking coffee is associated with living longer and having less heart attacks and strokes. Multiple publications in major cardiology journals in the last few  years have confirmed this.

You can read the details here and here. The bottom line is that higher levels of coffee consumption (>1 cup per day in the US and >2 cups per day in Europe) are NOT associated with:

  • Hypertension (if you are a habitual consumer)
  • Higher total or bad cholesterol  (unless you consume unfiltered coffee like Turkish, Greek or French Press types, which allow a fair amount of the cholesterol-raising diterpenesinto the brew)
  • Increase in dangerous (atrial fibrillation/ventricular tachycardia) or benign (premature ventricular or supra-ventricular contractions) irregularities in heart rhythm

Higher levels of coffee consumption compared to no or lower levels IS associated with:

  • lower risk of Type 2 Diabetes
  • lower risk of dying, more specifically lower mortality from cardiovascular disease
  • Lower risk of stroke

So, if you like coffee and it makes you feel good, drink it without guilt, there is nothing to suggest it is hurting your cardiovascular health. It’s a real food. These tend to be good for you.

Nonpoikilothermically Yours,

-ACP

N.B. The Chemex Coffeemaker was invented in 1941 by Dr. Peter Schlumbohm PhD. Made simply from non-porous, borosilicate glass and fastened with a wood collar and tie, it brews coffee without imparting any flavors of its own. On permanent display at MOMA NY and other fine museums, it is truly a work of art.

Despite Kaldi’s gastronomic abomination I’m still predominantly using their coffee beans.

The Brailian coffee study has numerous flaws like all observational dietary studies.

The caffeine in coffee can bring on palpitations. If you feel palpitations or other symptoms after consuming coffee you should lower the caffeine content or amount until you no longer experience troubling symptoms. Be guided by how you feel.

Enlightened Medical Management of Atrial Fibrillation, Part II: The Pill In The Pocket Approach

It has been estimated that patients with paroxysmal atrial fibrillation (PAF) have health care costs 5 times those without  afib. More than 50% of those costs are attributed to ER visits and acute care hospitalizations. The pill in the pocket (PIP)  approach can substantially reduce those hospital visits.

PIP addresses the complimentary patient priorities of minimizing daily drug burden and empowering patients to self-manage their episodes of sustained PAF thereby reducing the need to visit the ER or be hospitalized.

How Doth The Pill In Pocket Work?

With this approach, the patient upon experiencing a symptomatic episode of atrial fib takes (or as we doctors like to say “self-administers”) a single bolus of oral flecainide or propafenone (two so-called antiarrhythmic drugs or AADs.)

It is not necessary that the pill be in the pocket of the patient, indeed the pill might be in the pocket of the pastor of the patient or perhaps in the purse of the paramour of the patient. Indeed, the pill only need be near enough that the patient can pop it into his or her pie hole within a reasonable time period after the AF begins.

In properly selected patients, generally within 3 hours, the rhythm will suddenly pop back to normal

Prior to popping the AAD pill it is wise to have the patient pop a pill that slows the heart rate such as a beta blocker or cardizem or verapamil.

After popping the pill it wise to have the patient assume a supine position or at least a sitting position for a few hours or until the heart pops back to normal.

One Man And One Woman’s PIP Experience

I first saw Pete in 2017 on the day after his 60th birthday.  He awoke in the middle of the night feeling his heart fluttering. He was weak  and very light headed and came to our ER where he was noted to be in rapid atrial fibrillation.

He was given intravenous  cardizem which slowed his heart rate and made him feel better but did not convert him back to normal rhythm. We started him on the newer oral anticoagulant, Eliquis, to reduce his stroke risk.

The next day I performed a cardioversion on him after excluding the presence of left atrial thrombus with a transesophageal echocardiogram.

He did well for some time without recurrent afib but two years later he was again awoken from sleep around 1130 PM with a feeling of his heart fluttering and shortness of breath.

In the ER afib with rapid ventricular response was again noted and this time the ER doctor suggested that an electrical cardioversion be performed right away. Pete was told  there were “slight risks” to the procedure but he was nervous about doing it without me being on the case. His heart rate  was 106 and he was given an intravenous beta-blocker,  metoprolol to slow the heart rate.

The next morning we discussed options with him and decided to try the PIP approach to convert him back to normal rhythm. He received 300 mg flecainide orally at 11 AM and 1.5 hours later he converted to the normal rhythm.. The monitor strips recorded below captured the transition nicely.

pill in pocket flecainide

A 72 year old woman whom we shall call Miss Mystery X  presented with a sensation of weakness and dizziness beginning at noon. She had a history of paroxysmal afib. We had her come into office and ECG demonstrated atrial fibrillation at a rate of 100 BPM.

She was admitted to telemetry and given 300 mg flecainide and 45 minutes later the telemetry ECG strip below indicated conversion to normal sinus rhythm without any pauses, symptoms or hypotension. We discharged her later that day.

cooks-pip.png

For both of these patients we have carefully documented that they have a structurally normal heart by echocardiography and stress testing which is essential when utilizing flecainide. In addition, we carefully assess for stroke risk and anticoagulate them accordingly.

They now have available as outpatients a method for converting from afib to SR which is proven safe and effective for them.

I recently saw Miss X in the office after her hospital visit. She had just returned from a trip to Peru and Bolivia. Among other fascinating adventures she had flown over the Nazca Lines.

Aerial view of the “Heron”, one of the geoglyphs of the Nazca Lines, which are located in the Nazca Desert, near the city of Nazca, in southern Peru. The geoglyphs of this UNESCO World Heritage Site (since 1994) are spread over a 80 km (50 mi) plateau between the towns of Nazca and Palpa and are, according to some studies, between 500 B.C. and 500 A.D. old. Courtesy Wikimedia Commons.

Fortunately, she had no episodes of afib but should she have started fibrillating she knew that she had a safe and effective treatment that could convert her back to normal without the need of engaging foreign doctors and hospitals.

One of these two patients has acquired  the AliveCor Kardia Mobile ECG and will have the capability of transmitting to me his ECG via KardiaPro should his device alert him to the presence of atrial fibrillation. This capability further enhances the control that patient’s can have over the diagnosis and treatment of their afib episodes

The Science Behind The PIP Approach

The seminal article on the PIP approach was published in the New England Journal of Medicine in 2004 by Alboni, et al.

The paper reported on 268 patients with PAF presenting to the ER who had a structurally normal heart and were without disabling symptoms or low BP who were given larges oral doses of oral flecainide or propafenone. Overall, 210 patients converted to normal rhythm and were felt appropriate for out patient treatment.

This approach was quite successful:

During a mean follow-up of 15±5 months, 165 patients (79 percent) had a total of 618 episodes of arrhythmia; of those episodes, 569 (92 percent) were treated 36±93 minutes after the onset of symptoms. Treatment was successful in 534 episodes (94 percent); the time to resolution of symptoms was 113±84 minutes.

ER visits and hospitalizations for PAF were markedly reduced.

I tracked down Dr. Alboni through the scientific research social media site ResearchGate.net and asked him if he was still utilizing this approach and if he had any new data.

He responded.

the follow-up was terminated as reported in the paper. However, I have then observed that in patients > 75 years there are many side effects (unpublished data) and I do not utilize anymore the pill-in-the-pocket approach in these patients. I am still using flecainide and propafenone according to the doses and the methods described in the paper.

His 2004 paper enrolled patients 18 to 75 years of age and I have tended to restrict the PIP approach to my patients under age 76 due to concerns about more conduction disease and occult CAD in older patients.

When I pressed Dr. Alboni for more data or info on this he responded:

  • I observed a high incidence of side effects in patients > 75 years in the daily clinical practice, but I did not carry out a research because, after a concentration of side effects in a few patients, I did not prescribe anymore this treatment to old patients

PIP Current Practice

There is a nice paper on recent experience with the PIP approach which was published in 2018 by Josh Andrade who runs a multidisciplinary AF clinic in Vancouver, Canada

Consecutive patients aged 18-75 years of age attending the Vancouver multidisciplinary AF clinic and receiving PIP treatment were studied over a 3 year period. Entry criteria included, sustained symptomatic episode lasting >2 hours, frequency <1/month, absence of severe or disabling symptoms with AF episode

Patients with significant structural heart disease (LVEF<50%, “active ischemic heart disease”, severe LVH) were excluded along with those with the following features:

-Abnormal conduction (QRS>120ms, pr>200 ms, pre excitation)

-Clinical or ECG evidence of sinus node dysfunction/bradycardia or AV block

-hypotension with systolic blood pressure <100 mm Hg

Participating patients received their first PIP treatment while being monitored on telemetry in either an ER or hospital telemetry.  They were given the instructions below to give to the doctors in the ER.

Vancouver PIP sheet1

And they were provided with these instructions:

PIP vancouver 2

As the graph below shows, the PIP  approach resulted in a substantial reduction in ER visits, as well as a substantial reduction in the need for electrical or IV pharmacologic cardioversions

Adverse events (mostly low blood pressure but also 2 cases of conversion of  rhythm to a more rapid atrial flutter requiring cardio version) were noted in 16% of the initial PIP-AAD administrations and 19% failed to convert to NSR.

The Andrade PIP approach has patients receive a single dose of a rate-slowing drug 30 minutes prior to giving the AAD. This was done to prevent 1:1 conduction of atypical flutter. It’s not clear if this is beneficial and it could potentially contribute to episodes of bradycardia or hypotension.

In my practice I utilize flecainide over propafenone exclusively for both PIP therapy and chronic maintenance therapy. The generic version of flecainide for chronic therapy is twice daily versus thrice daily for propafenone and therefore preferred.  Dr. Andrade told me that when using the PIP approach:

In our clinic it’s probably 60:40 Propafenone to Flecainide.

Pill In The Pocket: Another Tool in The Toolkit For Enlightened Medical Management of Atrial Fibrillation

For the patient with PAF and relatively infrequent episodes of symptomatic afib the PIP approach can be very useful. Once established as safe and effective it allows the patient to avoid ER and hospital visits related to the PAF.

The ideal patient is less than 76 years of age and has a structurally normal heart.

PIP works really well for patients who are armed (pun intended) with a way to monitor their rhythm such as Apple Watch 4 or AliveCor’s Kardia Mobile ECG. Use of personal ECG monitoring in conjunction with a cardiologist practicing Enlightened Medical Management of afib is the optimal approach.

ProPIPically Yours,

-ACP

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