All posts by Dr. AnthonyP

Cardiologist, blogger, musician

What Can America Learn Now From Australian Gun Laws?

I wrote a post in December of 2016 which asked “What Can America Learn From Australian Gun Laws?”

Since then we’ve had more mass shootings in the US, most recently at least 17 have died in a high school in Florida, shot by a 19 year old with an AR-15 he purchased legally.

After the Las Vegas mass shooting I noticed that there was a call from the editors of most of the medical journals I follow for physicians to advocate for gun control.

These comments from an editorial in the Annals of Internal Medicine are typical:

Here’s a short list of how health care professionals can use our skills and voices to fight the threat that firearms present to health in the United States.
Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don’t wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury.
Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with local, state, and federal governments. Don’t let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press.
Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents.
Don’t be silent. We don’t need more moments of silence to honor the memory of those who have been killed. We need to honor their memory by preventing a need for such moments. As health care professionals, we don’t throw up our hands in defeat because a disease seems to be incurable. We work to incrementally and continuously reduce its burden. That’s our job.

What follows is my original 2016 post.


In April of 1996, a 28-year old man murdered 35 people in Tasmania primarily utilizing a Colt AR-15 rifle (a lightweight, 5.56×45mm, magazine-fed, air-cooled semi-automatic rifle with a rotating bolt and a direct impingement gas-operation system.)

This event led to public outcry in Australia and  bipartisan passage of a comprehensive set of gun regulation laws (the National Firearms Agreement (NFA)).

In the 20 years since the law was put into place (1997-2016), there has not been a single fatal mass shooting in Australia.

In the 17 years prior to the NFA enactment 13 mass fatal shootings (defined as ≥5 victims, not including the perpetrator) occurred in Australia.

An analysis of this process was recently published in JAMA.

Australia’s 1996 NFA mandated:

  • the ban and buy-back of semiautomatic long guns.
  • licensing of all firearm owners and registration of firearms.
  • that  persons seeking firearm licenses  must document a “genuine need,” have no convictions for violent crimes within the past 5 years, have no restraining orders for violence, demonstrate good moral character, and pass a gun safety test.
  •  uniform standards for securing firearms to prevent theft or misuse, record-keeping for fire arms transfers, purchase permits, and minimum waiting periods of 28 days.
 I agree with the comments in an accompanying editorial written by Daniel Webster of the John Hopkins School of Public Health, Center for Gun Policy and Research(:gun-regulation.)

Research evidence should inform the way forward to advance the most effective policies to reduce violence. However, research alone will not be enough. Australian citizens, professional organizations, and academic researchers all played productive roles in developing and promoting evidence-informed policies and demanding that their lawmakers adopt measures to prevent the loss of life and terror of gun violence. Citizens in the United States should follow their lead.

-ACP

N.B. Of the 46 mass shooting since 2004, 14 featured assault rifles, including Newtown, Aurora, Orlando and San Bernardino. Apparently there are 10 million AR-15 type rifles in private hands in the USA and as Vox has pointed out

“the AR-15 is caught in a cycle. The more it’s used in high-profile mass shooting cases, the more people want to ban it. The more people want to ban it, the more AR-15s are sold. And the more AR-15s are sold, the harder it becomes to create a ban that would be able to stop the next tragedy.”

For more on assault-style rifles you can view this Washington Post video created after the Orlando shootings.
//www.washingtonpost.com/video/c/embed/28d02e8e-3118-11e6-ab9d-1da2b0f24f93

Sincerely,

-ACP

Tom Brady Lost The Super Bowl: Can We Now Dismiss His Ridiculous, Pseudoscientific “Alkaline” Diet?

I think Tom Brady is the best professional quarterback of all time (IMBO Baker Mayfield of the Oklahoma Sooners is the best all-time college QB).

However, I think he has succeeded despite, not due to, the silly diet he follows as outlined in his best selling book, TB12.

Although he set a Super Bowl record for passing a few days ago his team lost and I’m really hoping that this will tamp down the unjustified enthusiasm in his lifestyle.

Tom Brady being “strip-sacked”. by Philly defensive end Brandon Graham. Clearly Brady’s diet is responsible for this and should be abandoned by all adherents.

Brady, according to reports, attempts to follow a diet that is 80% alkaline and 20% acidic. As Business Insider points out:

His extreme diet is a key part of what he refers to as the TB12 Method, an approach consisting of 12 fitness principles that Brady outlines in his book, called “The TB12 Method: How to Achieve a Lifetime of Sustained Peak Performance”. He also sells a selection of rather expensive products and supplements designed to help adherents live according to his fitness gospel.

For an outstanding take down of the nonsensical pH balancing diet (free of any TB references strangely enough) please read Harriet Hall’s typically outstanding article at skeptic.com entitled “PH Mythology: Separating pHacts from pHiction.”

She concludes correctly that:

“systematic analyses of all the published scientific studies have determined that the evidence does not support the acid/alkaline theory of disease, so it should be dismissed as pseudoscience.”

Although  Brady eats a lot of fresh, organic vegetables he avoids those in the nightshade family because Brady  and his wife, Gisele Bündchen’s personal chef, Allen Campbell, believes they cause inflammation (according to a 2016 The Boston Globe’interview, )

The nightshade family includes vegetables which nutritionists believe are very good for you like tomatoes, peppers, mushrooms, and  eggplants.  In fact there are more putative anti-inflammatory chemicals in these plants than inflammatory.

You should no more base your diet on Tom Brady’s success than  you should on the manner in which Nathan Pritikin or Robert Atkins died.

If Tom Brady is diagnosed with pancreatic cancer tomorrow will you conclude that it was due to the absence of the health-promoting phytochemical, lycopene, from his diet due to avoiding tomatoes?

Following the latest trends in diet or exercise based on anecdotes from celebrities is a fool’s game. Those celebrities that cash in on their good fortune to promote pseudoscientific quackery like Brady and Gwyneth Paltrow (aka GOOP) should be ashamed that they are contributing to this idiocy.

Nightshadily Yours,

-ACP

N.B. Perhaps Phlly fans should start following some of the “sci-fi” training tools that Brandon Graham’s trainer utilizes:

  • When the workout is finished, Graham is fitted with something called an ECP (External Counterpulsation), a medical device that’s used for cardiac patients. They lay him down, put the ECP on his legs and hook him up to an EKG machine to monitor his heart. When his heart is in the relaxation phase, the device will compress, which apparently “enhances oxygenated blood flow through the coronary arteries to the heart muscle” and, according to Barwis, promotes quicker healing.

 

Thoughts On Physician Assisted Suicide

A beloved patient of the skeptical cardiologist committed suicide two years ago.

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Although 90 years in chronological age, Phyllis appeared and behaved as one much younger. She was full of life, energy and happiness when she came to my office for treatment of her atrial fibrillation and heart failure.

 

Her daughter and I discussed what happened and how it could have been prevented.  Her perspective follows:

My mother, Phyllis, was a complicated woman.  She was intelligent, charming, beautiful, spirited and fun with an inquisitive mind and many interests.  She could play competitive Bridge and win, even in her 90’s. She drove a little red convertible and had the top down whenever possible. She liked to dress stylishly and had excellent taste.  She had a lifelong habit of health and always exercised and ate carefully…except for chocolate.  She had a legendary addiction to chocolate and I think she will be remembered in our family for many generations to come by all of the wonderful chocolate stories. She was always working to improve herself and to that end almost never read fiction, preferring biography or autobiography. In her 40’s she took up synchronized swimming and water ballet.  She was very single minded in her goal to improve her skills, participated in the Sr. Olympics in Denmark in 1989 and won a silver medal!  At the age of 50 she decided to take up skiing and although she gave it up at 65, she did get good enough to ski the black slopes.  She was very happily married to my father, Jack, until his death at 69.  A few years later she married Earl and they had a solid union until his death.

She made the decision to end her life very soberly with much deliberation.  This had been on her mind for years before she actually accomplished it.  The prior Spring she had set a date and only due to much family intervention, involving lots of fun, did she cancel it.  She felt the odds of something happening to her, which would keep her bed or wheelchair bound or would take away her mental facilities, became greater and greater with each passing year. In her final year she could see differences with each passing month.  She never wanted to be dependent on anyone or anything. She was not depressed.  She had several falls in the last few months, nothing serious, just cuts or bruises, but she could see it was just a matter of time before a bad fall could take her out.  She no longer could eat chocolate or drink coffee or wine, all of which had been a great comfort to her. She had developed a heart problem, which she knew would only get worse as she aged. And she was very scared that her lifelong habit of heath would backfire on her.  That she would go on and on and on trapped in a bed or left with no mind.

She had discussed suicide with all her family at great length in the years leading up to her death. She didn’t like the idea anymore that we did but she was afraid that something would happen to her and she would no longer have the ability to make this decision if she felt it was necessary.

So in the early hours of February 19, 2016 she put a gun in her mouth and pulled the trigger.

How unfair that she had to do this gruesome and scary thing all by herself. She would still be alive if she knew that when the time came in which she no longer felt she had an acceptable quality of life she could have taken a pill or be given a shot and then died gently surrounded by all who loved her.

I think everyone needs to look at their own life and ask themselves – what do I want the final years of my life to look like?  Medical science has given us the ability to live much longer healthier lives.  But that comes at a cost.  Many people live on and on in nursing homes, just shells of humans because medical science can keep them alive almost indefinitely.  Is this what the average person wants?  Do most people think to themselves – I’m really looking forward to those years when I’m fed, bathroomed and bathed by strangers?

I think Physician Assisted Suicide can be a good answer for those people who do not want to live in this manner and have made their intentions very clear to family and doctors.

I miss my mom.  I miss our long talks and walks.  I miss lunches out with her. I even miss our disagreements.  And I know that if Physician Assisted Suicide had been legalized in Missouri, she would still be here, playing Bridge, laughing, talking about good books, enjoying family visits, shopping for pretty clothes and getting ready for all the parties of the Holiday season.

 

Physician-Assisted Suicide

Since this happened I have become an advocate of state laws allowing physician-assisted suicide (PAS).  These laws are intended  for patients with terminal disease, but I think if Phyllis had lived in a state where these existed she would not have felt compelled to do what she did.

Physicians are divided on the topic of PAS with 55-65% in state medical society surveys favoring allowing such laws.

Despite this, the American College of Physicians recently published a position paper stating its opposition to PAS:

It is problematic given the nature of the patient–physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession’s role in society. Furthermore, the principles at stake in this debate also underlie medicine’s responsibilities regarding other issues and the physician’s duties to provide care based on clinical judgment, evidence, and ethics. Society’s focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care.

Stat news has two physician-authored pieces on this topic which are well worth reading. In the first article, Ira Byock, M.D., a palliative care physician, writes that “there are some things doctors must not do. Intentionally ending patients’ lives is chief among them.” He decries excessive pain and suffering at the end of life but thinks that “so much of that kind of suffering could have been avoided with good care.”

The second article was written by Roger Kligler a physician in his sixties who is dying of metastatic prostate cancer. He writes:

When my suffering becomes intolerable, I hope my doctors will permit me the option to end it peacefully with medical aid in dying — something I have been working to get explicitly authorized in Massachusetts, where I live. Medical aid in dying gives mentally capable, terminally ill adults with six months or less to live the option to request a prescription medication they can choose to take in order to end unbearable suffering by gently dying in their sleep.

For more information on this topic I recommend the website of Death with Dignity, the organization which authored the Oregon statute governing the prescribing of life-ending medications to eligible terminally ill people. About 100 patients a year have taken advantage of the Oregon Death With Dignity Statute. The website notes that “Overall, 1,545 patients obtained a lethal prescription from 1998 through 2015. On average, 64 percent took the drugs.  Almost all died but six people woke up and died later of natural causes.”

-ACP

 

 

 

Medical Emergencies On Airplanes: Should Doctors “Heed The Call”?

In a recent episode of Larry David’s hilarious HBO series,  Curb Your Enthusiasm, (“Accidental Text on Purpose”), Larry, (after giving up his aisle seat to a woman with a supposedly overactive bladder) finds himself sitting next to Dr. Nathan Winocour. When a call for medical assistance for a stricken airplane passenger is issued, Larry is perturbed that the doctor fails to “heed the call.”

Winocour justifies his inaction with two comments:

“Give it a minute. He’s gonna be fine.” and

“Have you ever been part of an emergency landing? Is that what you want, Larry? To spend the night in Lubbock, Texas, at a Days Inn with a $15 voucher from Cinnabon? Think about it.”

He’s correct that the vast majority of medical “emergencies” resolve without any specific intervention.

And if he had attended on a patient with a serious non-transient medical problem he would suddenly find himself having to make an incredibly difficult and life-deciding decision on whether or not to  divert the plane or make an emergency landing with insufficient diagnostic tools and inadequate information.

Dr. Winocour is not alone in this failure to heed the call. Many physicians are conflicted about identifying themselves as a physician in medical emergencies-on planes or elsewhere.

Last year, a British physician was described in an article as having assisted in 3 medical emergencies while on American Airlines flights in the previous year. This man is so eager to assist in in-flight emergencies that he “pre-identifies” himself as a physician as he boards the plane.

I wondered how many physicians enthusiastically pre-identify themselves as ready to heed the call, so I posted a poll in 2017 on the physician social media site, SERMO.

Most Physicians Don’t Want To Assist In Medical Emergencies In Flight

A majority of physicians indicated that they were not interested in assisting in medical emergencies in flight.

Screen Shot 2018-02-01 at 8.14.01 AM

Only 3% would pre-identify (with another 2% agreeing to pre-identify if they were upgraded to first class). Another 19% would not pre-identify but would respond it there was a call for a physician.

Medical Liability Issues

In 1998 Congress passed the Aviation Medical Assistance Act, which tries to protect medical Good Samaritans who heed an airplane call. The act protects physicians, nurses, physician assistants, state-qualified EMTs and paramedics:

“An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”

Despite this apparent protection, many physicians left comments like the one below on SERMO indicating they would not heed the call due to concerns about medical liability:

Yes, I am aware of good samaritan docs trying to come to the rescue but were sued anyway. The standard of care still applies to doctors rendering care, whether they are acting as a good samaritan or not- thus we are held to a much higher standard of care than any bystander would be rendering aid. Good samaritan laws in several states note that doctors remain bound to the physician standard of care whether charging the patient or not. Even if it is a life threatening situation involving a complete stranger, the doctors are held to a higher standard of care that permits the patient or their families to sue you. In Florida, there are no caps on malpractice, therefore you can be held personally liable for all your assets, with the exception of those held in “tenancy in entirety”. Therefore I never identify myself as a doctor when coming on a scene to help anyone outside my office, and never give my name if rendering aid.

Other Factors Limiting Heeding

Other physicians noted the lack of appropriate medical supplies on airplanes and the hassle factor.

I’ve responded several times. The last time was when the plane hit an air pocket and the drink cart came down on a flight attendant’s foot. I needed an Ace bandage. Opened the small kit–lots of stuff but no Ace. Opened the big kit to see the contents list. I could have run a code or taken out a GB–but nothing for a compression dressing. Finally wrapped her foot with her panty hose and put an ice pack on it. Then they insisted I fill out a raft of forms about opening the kits, although nothing had been touched. They had my name and address but didn’t bother to say thanks. I did hear from the flight attendant–her foot was fractured.
Never fill out those damn forms unless they agree to pay you for it. And take your own ace bandage.

One MD expressed concerns that failure to heed the call could lead to legal consequences:

I don’t think the risk is zero (in the US) if no other passenger identifies himself/herself as a physician in the event of a flight emergency. For example, if a passenger dies en route and it was later discovered you were on that flight and that had you intervened you might have saved a life, the family members could come after you.

Hm. Now I have another reason to wear ear plugs and close my eyes when flying; can’t be dinged when I did not hear/see the announcement for a physician.

This urologist’s comments are typical of those who have volunteered, but feel like they didn’t help too much and were inadequately thanked or compensated for their time and effort.

I assisted on a flight from Ireland back to the states. Woman had a vasovagal episode and passed out. Spent about 15 minutes and only thanks I got was asking me for my name and license number “just in case.” It was United Airlines. Will never offer my services again unless someone needs a foley.

Dr. Winocour’s failure to heed the call ended up costing him dearly. When he desperately needed a joke for a speech he was giving,  Larry refused to heed the comedian call.

How do you feel? Should physicians heed the call in the air?

Airobatically Yours,

-ACP

What Is A Plant-Based Diet (And Should I Be On One)?

The phrase “plant-based diet” is being tossed around a lot these days. The skeptical cardiologist never knows what people mean when they use it and so must assume that most of the world is also puzzled by this trendy term.

Is A Plant-Based Diet Code For Veganism?

For some, a “plant-based diet” (PBD) is what vegans eat.

Veganism combines a diet free of animal products, plus a moral philosophy that reject the “commodity status of animals.” Vegans are the strictest of vegetarians, eschewing milk, fish and eggs.

One PBD advocate in the introduction to a Special Issue of the Journal of Geriatric Cardiology,  defines it as follows:

“a plant-based diet consists of all minimally processed fruits, vegetables, whole grains, legumes, nuts and seeds, herbs, and spices and excludes all animal products, including red meat, poultry, fish, eggs, and dairy products.”

You will notice that this cardiologist “excludes all animal products”  and that the qualifying phrase “minimally processed” has crept into the definition.

Forks Over Knives-Whole-food, plant-based diet

The “documentary” Forks Over Knives brought the phrase “whole food, plant-based diet” to national prominence. The movie focused on the diets espoused by Caldwell Esselstyn and T. Colin Campbell. Since its release in 2011 a whole industry based on the Forks Over Knives (FON) brand has been launched. FON uses the following definition:

 “A whole-food, plant-based diet is centered on whole, unrefined, or minimally refined plants. It’s a diet based on fruits, vegetables, tubers, whole grains, and legumes; and it excludes or minimizes meat (including chicken and fish), dairy products, and eggs, as well as highly refined foods like bleached flour, refined sugar, and oil.”

I’ve written detailed posts on the Esselstyn diet here and here. I think it is needlessly restrictive and not supported by scientific evidence. (Esselstyn’s website and book state unequivocally “you may not eat anything with a mother or a face (no meat, poultry, or fish” and “you cannot eat dairy products” which differs from the FON definition.)

The key new terms in the FON approach to note are:

Whole Food. The Oxford English Dictionary (OED) defines whole food as “food  that has been processed or refined as little as possible and is free from additives or other artificial substances.”

Unrefined or minimally refined. The OED defines refined as:

“With impurities or unwanted elements having been removed by processing.”

The FON definition for a PBD then is similar to our first definition-minimally processed vegan-but allows (at least theoretically)  minimal meat, dairy and eggs. The FON Esselstyn/Campbell diets choose to define vegetable oil, including olive oil, as highly refined foods and do not allow any oils.

U.S. News and World Report Definition Of Plant-Based Diets

U.S. News and World Report publishes an annual rating of diets based on the opinion of a panel of nationally recognized experts in diet, nutrition, obesity, food psychology, diabetes and heart disease.

US News defines a plant-based diet as “an approach that emphasizes minimally processed foods from plants, with modest amounts of fish, lean meat and low-fat dairy, and red meat only sparingly.”

This definition is radically different from the first two. Notice now that you can have “modest amounts” of meat and dairy, foods which are anathema to vegans. Also, note that “low-fat dairy” is being recommended, a food which (in my opinion) is highly processed and that lean meat is to be preferred and red meat avoided.

I was happy to see that for the first time, the Mediterranean Diet ranked as  Best Diet Overall, but shocked to find that the Mediterranean diet came out on top of the US News list of “Best Plant-Based Diets.”

Readers will recognize that this is the diet I recommend and follow (with slight modifications). On this diet I regularly consume hamburgers, steak, fish and whole egg omelettes.

The plant-based diet of vegans or of Forks Over Knives is drastically different from the Mediterranean Diet.

For example, olive oil consumption is emphasized in the Mediterranean Diet, whereas the Esselstyn diet featured in FON forbids any oil consumption.

The FON/Esselstyn diets are very low in any fats, typically <10%, whereas the Mediterranean Diet is typically 30-35% fat.

Esselstyn really doesn’t want you to eat nuts and avocados because he thinks the oil in them is bad for you. This is nuts! I’m handing out nuts to my patients just as they were given to the participants in the PREDIMED randomized trial showing the benefits of the Med diet.

Dr. Pearson’s Plant-Based Diet

Since the term “plant-based diet” apparently means whatever a writer would like it to mean, I have come up with my own definition.

With the  Dr. P Plant-Based Diet© your primary focus in meal planning is to make sure that you are regularly consuming a large and diverse amount of healthy foods that come from plants.

If you don’t make it your focus, it is too easy to succumb to all the cookies, donuts, pies, cakes, pretzels, chips, French fries,  breakfast bars and other  calorie-dense but nutrient-light products that are cheap and readily available.

In Dr. P’s Plant-Based Diet© meat, eggs, and full fat dairy are on the table. They are consumed in moderation and they don’t come from plants (i.e. factory farms).

I, like the PBD  definers of yore, have taken the liberty of including many vague terms in my definition. Let me see if I can be more precise:

Regularly = at least daily.

Large amount = 3 to 4 servings daily.

Healthy = a highly contentious term and one, like “plant-based” that one can twist to mean whatever one likes. My take on “healthy” can be seen on this blog. I’m not a fan of plant-based margarines, added sugar, whether from a plant or not, should be avoided, and the best way to avoid added sugar is to avoid ultra-processed foods.

Ultra-processed foods (formulations of several ingredients which, besides salt, sugar, oils and fats, include food substances not used in culinary preparations, in particular, flavours, colours, sweeteners, emulsifiers and other additives used to imitate sensorial qualities of unprocessed or minimally processed foods and their culinary preparations or to disguise undesirable qualities of the final product).

Ultra-processed foods account for 58% of all calories in the US diet, and contribute nearly 90% of all added sugars.

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

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

On Dr. P’s Plant-Based Diet© you can add butter to your leeks and green onions.You can add eggs to your onions, tomatoes and peppersAnd you can eat salads full of lots of cool different plants for lunch.

To answer my titular question-if you are using Dr. P’s definition of a plant-based diet then you definitely should be on one.

Viva La Plant!

-ACP

Which Kind of Baby Aspirin Should I Take To Prevent Heart Attack? Chewable Versus Enteric Coated Versus Regular

The skeptical cardiologist recently asked his Eternal Fiancée to grab a bottle of baby aspirin  while she was at the local Walgreen’s. Aspirin or acetyl salicylic acid (ASA) comes in either a 325 mg dose or in a low dose which can be between 75 to 100 mg and is often called “baby” aspirin.

However, since a link between aspirin use and a potentially lethal disease called Reye’s syndrome was identified in the 1980s, no authorities recommend aspirin in children or babies, and the low dose ASA (LDASA) is primarily marketed and used for prevention of cardiovascular disease.

Although Bayer and Dr. Oz would have us believe that all individuals over the age of 55 should be taking LDASA, as I pointed out here in 2014, the FDA no longer recommends it for prevention of cardiovascular disease.

The US Preventive Services Task Force, on the other hand, recognizes certain individuals without heart disease who benefit from LDASA:

The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.
I’m 63  years old, so the USPTF recommendation for me to take LDASA is a little less enthusiastic:
The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin.
Following my own advice (see here), I have started taking 81mg of aspirin regularly (well, when I remember) in order to prevent stroke and heart attack. I do have subclinical atherosclerosis with a plaque in my LAD, and I think the aspirin will make my platelets less sticky and less likely to form clots if my plaque ruptures, thereby reducing my chances of an acute heart attack.
I am willing to accept the increased risk of bleeding from the gastrointestinal tract and hemorrhagic stroke associated with LDASA use.

Previous to this I had been taking ASA from little sample bottles that Bayer sends to my office. These bottles are quite annoying as they are stuffed with cotton and contain very few pills making extrication of the tiny pills an exercise in futility (I am using this as an excuse for my lack of regularity in taking them).

There’s no reason to pay the premium for Bayer ASA despite the company’s advertising attempts to link inextricably their name with ASA.  Aspirin is aspirin, whether Bayer made it or Walgreens. In Bayer’s defense, their website has reasonable information on heart attacks and they appear to be giving aspirin away to people named Smith.

But what type of aspirin should you get? Enteric-coated, safety-coated, delayed release, chewable?

Chewable Aspirin

I asked the Eternal Fiancée to buy the cheapest baby aspirin possible.

She ended up buying a chewable formulation with orange flavoring, presumably aimed at children:

When I put one of these in my mouth I tasted the sickly sweet taste of an artificial sweetener. The ingredients are listed as: Dextrates, Ethyl Cellulose, FD&C Yellow 6 Aluminum Lake, Orange Flavor, Sodium Saccharin, Starch. Saccharine! Yikes!

The only reason to chew ASA is if you are having an acute heart attack.

In this situation, chew 4 of the LDASA or one regular 325 mg aspirin.  Chewing the aspirin makes the levels rise faster in your blood stream and can help dissolve the clot causing your heart attack more rapidly.

How do you know if you are having a heart attack? This is actually a very difficult question to answer with certainty. See here for a reasonable discussion.

Low Dose Aspirin: Enteric-Coated versus Non-coated

It is very difficult (perhaps impossible) to find low dose, non-chewable ASA that has not been “safety-coated” or “enteric-coated.” These formulations have become popular by promoting the idea that they are less likely to cause stomach pain or bleeding.

The concept is that the coating leads to delaying the aborption of the ASA until it reaches the small intestines where, presumably, it will do less damage. However, there is no good evidence to support lower bleeding risk with enteric-coasted (EC) ASA.

There is, on the other hand, very good evidence that therapeutic levels of aspirin in the bloodstream, and therefore the speed and efficacy of ASA in preventing heart attacks, is reduced by these “safety” formulations.

The most recent study showing this was published in 2017.

Volunteers were given either 325mg regular ASA or 325mg EC ASA and researchers looked at how each formulation effected platelet activity.  The onset of antiplatelet activity was determined by the rate and extent of inhibition of serum thromboxane B2(TXB2) generation.

The EC ASA took longer and was less effective at blocking platelet activity than plain ASA. Presumably, this translates into lower efficacy in preventing heart attacks and strokes.

Therefore,  if you feel like you are having a heart attack, chew ASA which is not enteric or safety-coated. Yes, you can chew a regular 325 mg ASA pill. Or you can chew 4 of the LDASA, preferably uncoated but still helpful if coated.

If it turns out you weren’t having a heart attack there is no down side to having chewed 325 mg ASA.

I just spent a fair amount of time trying to find non EC, non-chewable LDASA online and failed.

For the time being I will be swallowing daily the orange chewable LDASA and I will carry a bottle around in my satchel for emergency use.

Salicylically Yours,

-ACP

N.B. Aspirin is generally recommended in secondary prevention of cardiovascular disease, ie. for those who have had heart attacks, stents or bypass surgery . For a good review of the evidence for this see here.

Donald Trump Has Moderate Coronary Plaque: This Is Normal For His Age And We Already Knew It

In October, 2016 the skeptical cardiologist predicted that Donald Trump’s coronary calcium score, if remeasured, would be >100 .  At that time I pointed out that this score is consistent with moderate coronary plaque build up and implies a moderate risk of heart attack and stroke.

Trumps’ score gave him a seven-fold increase risk of a cardiovascular event in comparison to Hilary Clinton (who had a zero coronary calcium score) .

Yesterday it was revealed by the White House doctor , Ronny Jackson, that Trump’s repeat score  was 133.

I was able to predict this score because we knew that Trump’s coronary calcium was 98 in 2013 and that on average calcium scores increase by about 10% per year.

I pointed out that his previous  score was average for white men his age and his repeat score is also similar to the average white male of 71 years.

Entering Trump’s numbers into the MESA coronary calculator shows us he is at the 46th percentile, meaning that 46% of white men his age have less calcium.We can also calculate Trump’s 10 year risk of heart attack and stroke using the app from the ACC (the ASCVD calculator) and entering in the following information obtained from the White House press briefing:

Total Cholesterol          223

LDL Cholesterol            143

HDL Cholesterol              67

Systolic Blood Pressure 122

Never Smoked Cigarettes

Taking aspirin 81 mg and rosuvastatin (Crestor) 10 mg.

His 10 year risk of heart attack or stroke is 16.7%.

Given that his calcium score is average it doesn’t change his predicted risk and the conclusion is that his risk is identical to the average 71 year old white man-moderate.

We also know that Trump had an exercise stress echocardiogram which was totally normal and therefore can be reasonably certain that the moderate plaque build up in his arteries is not restricting the blood flow to his heart.

Here is what Dr. Jackson said about the stress echo:

He had an exercise stress echocardiogram done, which demonstrated above-average exercise capacity based on age and sex, and a normal heart rate, blood pressure, and cardiac output response to exercise.  He had no evidence of ischemia, and his wall motion was normal in all images. the stress echo:

The New York Times article on this issue, entitled “Trump’s Physical Revealed Serious Heart Concerns, Outside Experts Say”  however, presents a dramatically worrisome and misleading narrative.

It quotes several cardiologists who were very concerned about Trump’s high LDL level, weight and diet.

It’s interesting that some of the experts quoted in the NY Times piece feel that Trump’s Crestor dose should be increased in light of the recent NY  Times piece questioning whether the elderly should take statins at all.

If we have serious concerns about Trump’s heart then we should have the same concerns about every 71 year old white man because he is totally average with regard to cardiac risk. In addition he is on a statin and on aspirin, the appropriate drugs to reduce risk.

In contrast to the average 71 year old male he has had a battery of cardiac tests which show exactly where he stands cardiac wise.

Most of these cardiac tests we would not recommend to an asymptomatic individual of any age. Jackson revealed that Trump had an EKG and an echocardiogram.

His ECG, or commonly EKG, was normal sinus rhythm with a rate of 71, had a normal axis, and no other significant findings.

He had a transthoracic echocardiogram done, which demonstrated normal left ventricular systolic function, an ejected fraction of 60 to 65 percent, normal left ventricular chamber size and wall thickness, no wall motion abnormalities, his right ventricle was normal, his atria were grossly normal, and all valves were normal.

So our President has a normal heart for a 71 year old white male. This automatically puts him at moderate risk for heart attack and stroke over the next 10 years but he is being closely monitored and appropriately treated and should do well.

Nonalarmingly Yours,

-ACP

N.B. I see that Trump’s LDL was reported previously as 93. The current LDL of 143 suggests to me that he has not been taking his Crestor.

N.B. Below is an excerpt from my prior post which explains coronary calcium

Regular readers of the skeptical cardiologist should be familiar with the coronary calcium scan or score (CAC) by now.  I’ve written about it a lot (here, here, and here) and use it frequently in my patients, advocating its use to help better assess certain  patient’s risk of sudden death and heart attacks.

coronary calcium
Image from a patient with a large amount of calcium in the widowmaker or LAD coronary artery (LAD CA).

The CAC scan utilizes computed tomography (CT)  X-rays, without the need for intravenous contrast, to generate a three-dimensional picture of the heart. Because calcium is very apparent on CT scans, and because we can visualize the arteries on the surface of the heart that supply blood to the heart (the coronary arteries), the CAC scan can detect and quantify calcium in the coronary arteries with great accuracy and reproducibility.

Calcium only develops in the coronary arteries when there is atherosclerotic plaque. The more plaque in the arteries, the more calcium. Thus, the more calcium, the more plaque and the greater the risk of heart attack and death from heart attack.

Should You Take A Statin If You Are Over 75?: The Value of DeRisking in The Elderly

The NY Times published an article earlier this month with the provocative title “You’re Over 75, and You’re Healthy. Why Are You Taking a Statin?”

It’s actually a balanced presentation of this difficult question (although it includes the seemingly obligatory anecdote of a patient getting severe muscle aches and weakness on Lipitor) and I agree with the concept that patients should demand a good thoughtful explanation from their PCP if they are on a statin.  Shared  physician and patient decision-making should occur irrespective of age when a statin is prescribed.

Unfortunately, the NY Times piece was triggered by and contains references to a weak observational study that was recently published in the Journal of  the American Geriatric Society..

A much better article on this same topic was published earlier in January in what is arguably the most respected cardiology journal in the world (Journal of the American College of Cardiology).

It contains what I think is a very reasonable discussion of the problem: the elderly at are a substantially higher risk of adverse “statin-associated symptoms” but also at much higher risk of stroke, heart attack and cardiovascular-related death than the young.

Key Points To Consider For Use of Statins In Elderly

Some key points from that article to ponder for those over 75 years

  1. Major European and North Americans national guidelines differ markedly in this area as this graphic illustrates

“At one end of the spectrum, the 2016 ESC/EAS guidelines miss great opportunities for safe, cheap, and evidence-based prevention in elderly individuals 66 to 75 years of age. At the other end of the spectrum, the 2014 NICE guideline provides near-universal treatment recommendations well into the very elderly >75 years of age where RCT evidence is sparse and more uncertain.”

2. Data on from 2 large primary prevention trial (JUPITER and HOPE-3) show that rosuvastatin (Ridker, et al)

reduced the risk of a composite endpoint (nonfatal MI, nonfatal stroke, or cardiovascular death) substantially by 49% (RR: 0.51; 95% CI: 0.38 to 0.69), and the risk was reduced by 26% (RR: 0.74; 95% CI: 0.61 to 0.91) in those ≥70 years of age. The efficacy was similar in individuals ≥70 and <65 years of age, indicating little heterogeneity in treatment effect by age. Today, nearly all apparently healthy elderly individuals have RCT evidence supporting statin efficacy.

3. The elderly compared to the younger are much more likely to have a nonfatal event  which does not reduce their longevity but impacts their quality of life.

Thus, patient preferences are critical important for well-informed shared decision-making. If a patient only values longevity, there are little data to support primary prevention with statins in people >65 years of age. On the other hand, if preventing nonfatal and potentially disabling MI or stroke is of value to the patient, it might be reasonable to initiate statin therapy. From this perspective, it is noteworthy that the relative importance that people assign to avoiding death compared with avoiding nonfatal events appears to be highly age dependent. Although younger individuals <65 years of age weigh avoiding death highest, elderly individuals ≥65 years put a much higher weight on avoiding MI or stroke than death, These differences are compatible with elderly individuals having a greater focus on quality of life and avoiding disability than on extending life.

The Value of Derisking and Deprescribing

In my practice, I do a fair amount of deprescribing statins in the elderly. I have a very low threshold for initiating a trial  of temporary statin cessation if there is any question that a patient’s symptoms could be statin-related (see here.)

The older the patient, the higher the bar for initiating statins and I think in all patients a search for subclinical atherosclerosis (coronary calcium scan or vascular ultrasound) helps inform the decision.

Previously, I had no term for this higher bar but I like the  term  the  JACC paper introduces, derisking:

A promising approach to personalize treatment in elderly people is “derisking” by use of negative risk markers (i.e., absence of coronary artery calcification) to identify those at so low risk that statin therapy may safely be withheld . In the BioImage study of elderly individuals, for example, absence of coronary artery calcification was prevalent (≈1 of 3) and associated with exceptionally low ASCVD event rates

If you are >75 ponder all these factors and have an intense discussion with your doctor about taking a statin.

If you are still on the fence after this discussion consider a compromise approach that I have outlined here.

Deriskingly Yours,

-ACP

Exercise As Medicine: Preventing Age-Related Decline in Cardiac Stiffness

As we age our hearts and arteries become stiffer. This cardiovascular stiffening plays a key role in hypertension, atrial fibrillation, and heart failure in older individuals (1).

Age-related cardiac stiffening is worse in those who are sedentary compared to those who exercise regularly (2).

Recent studies strongly suggest that regular exercise can prevent or minimize these age-related changes, thereby hopefully reducing the high rate of heart failure, hypertension and atrial fibrillation in the elderly.

In my post on fitness as a vital sign I briefly mentioned a fascinating study from 2014 which looked at 102 healthy seniors (age>64 years) and stratified them into 1 of 4 groups based on their lifelong histories of endurance exercise training.

Consider which of these 4 categories you fall into:

Sedentary subject-exercised no more than once per week during the prior 25 years.

Casual exercisers-engaged in 2-3 sessions per week

Committed exercisers-performed 4-5 sessions per week

Competitive “Masters level” athletes-trained 6-7 times per week

Exercise sessions were defined as periods of “dynamic activity lasting at least 30 minutes.”

The participants had sophisticated measures of their exercise capacity (max VO2), the size and mass of their left ventricles (cardiac MRI) and the stiffness of their left ventricles (invasive pressure/volume curves to calculate LV compliance and distensibility.)

This graph shows the key finding of the study: a markedly different pressure/volume curve in the sedentary and casual exercisers (blue and red dots) versus the committed or master exercisers. The two curves on the left correspond to a very stiff heart, similar to curves found in patients with heart failure.

The far right curve of competitive exercisers resembles that of a young heart.

The black triangle curve of the committed exerciser is in between these extremes

F5.large-3

The study concludes:

“low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes”

It would appear we need at least 4-5 30 minute exercise session per week to forestall the age-related stiffening of the heart and lower our chances of getting heart failure, hypertension and atrial fibrillation.

Since this was an observational study there is always a chance that lack of exercise is not the causes of poor cardiac stiffness.  It is conceivable that those of us with stiffer hearts tend to be more sedentary because of the poor cardiac function.

Can You Reverse The Age-Related Changes In Cardiac Stiffness?

If you have already reached middle age there is still hope for you as these same investigators recently published a study showing that cardiac stiffness can be improved with exercise. These findings imply that lack of exercise is the cause of worsening cardiac stiffness with aging.

This study identified 61 sedentary men in their mid-fifties and randomly assigned them to either 2 years of exercise training or attention control (a combination of yoga, balance, and strength training 3 times per week for 2 years) and measured their LV stiffness and max VO2 before and after intervention.

Max VO2 increased by 18% and LV stiffness declined from .072 to .051 in the exercise group but did not change in the control group.

The exercise training arm of this study involved a mixture of continuous moderate-intensity aerobic exercise combined with high intensity training. The high intensity portion of the program involved exercising at 90-95% of HR maximum for 4 minutes followed by a 3 minute active recovery period, repeated 4 times.

Over a period of 6 months under the guidance of exercise physiologists the participants had their exercise levels gradually increased. After 6 months they were training 5-6 hours per week, including 2 of the “high intensity interval” session and 1 long (>/= 1 hour) and one 30-minute base pace session each week.

By the sixth month, participants were training 5 to 6 hours per week, including 2 interval sessions, and 1 long (at least an hour) and one 30-minute base pace session each week.

How Much Exercise Do We Need To Minimize Cardiac Aging?

This chart from recent European guidelines on lifestyle for prevention of disease describes different intensities of aerobic exercise:

 

screen-shot-2016-10-01-at-10-18-34-am

 

 

 

 

 

These guidelines suggest that if you engage in vigorous exercise such as running or jogging, cycling fast or singles tennis, you only need to achieve 75 minutes per week. Moderate exercise such as walking or elliptical work-outs requires at least  150 minutes/week.

Based on these recent studies on exercise and cardiac stiffness and the bulk of scientific literature on the overall health benefits of exercise I would advise for all individuals with or without heart disease

-If you are sedentary, become a committed exerciser.

-Committed exercise means some form of dynamic exercise 4-5 times per week

-If you are already a committed exerciser at moderate intensity levels consider adding to your routine one or two sessions of high intensity interval exercise.

-High intensity exercise will require you to get your heart rate up to 90-95% of your maximum 

-Predicted maximal HR=220 -age.  For a 60 year old this equals 160 BPM. 90% of 160 equals 144 BPM. 

Compliantly Yours,

-ACP

 

 

 

 

Do You Need To Fast Before Your Cholesterol Test?

When the skeptical cardiologist trained in medicine and cardiology in the 1980s the standard protocol for obtaining a lipid profile (LDL and HDL cholesterol plus triglycerides) involved having the patient fast for >8 hours before the blood was drawn.

Beginning in 2009, however, various national organizations began recommending the use of nonfasting lipid profiles. In 2011 the American Heart Association endorsed the fasting lipid profile and shortly thereafter I began telling my patients they did not need to fast for these tests.

Old habits and ideas are hard to kill and to this day most of my patients think that fasting is a requirement. Lab personnel seem to be stuck in the past as well and I typically instruct my patients to lie if they are asked if they have eaten.

A recent JACC article makes powerful arguments for using non fasting lipid profiles.

Rather than go through it in detail I’m going to post the “central illustration” which summarizes the authors points in graphic form.

The nonfasting profile is “evidence-driven” and also is time-efficient, patient, laboratory and physician-friendly.

So to my patients I say “you don’t need to fast before seeing me or prior to any blood work I order on you.”

To other patients whose physicians are still requiring fasting before a lipid profile I recommend challenging your doctor’s rationale.

If that doesn’t work, print out a copy of the above infographic and politely ask them to read the associated paper.

Hungrily  Yours,

-ACP