All posts by Dr. AnthonyP

Cardiologist, blogger, musician

Since Dietary Cholesterol Isn’t Important Can I Stop Taking My Cholesterol Drug

A year ago one of my patients began experiencing  chest pain when he walked up hills. Subsequent evaluation revealed that atherosclerotic plaque (95% narrowing of a major coronary artery ) was severely reducing the blood flow to his heart muscle and was the cause of his chest pain. When this blockage was opened up with a stent he no longer had the pain.

Along with other medications (aspirin and plavix to keep his stent open) I had him start atorvastatin, the generic version of Lipitor, a powerful statin drug that has been shown to prevent progression of atherosclerotic plaque and thereby reduce subsequent heart attacks, strokes and death in patients like him

I saw him in the office the other day in follow up and he was feeling great . He asked me “Doc I read  your post yesterday.s Since you say that cholesterol in the diet doesn’t matter anymore, does that mean I don’t have to take my cholesterol drug anymore.?”

His question gets at the heart of the  “diet-heart hypothesis”. The concept that dietary modification, with reduction of cholesterol and fat consumption can reduce coronary heart disease.

The science supporting this hypothesis has never been strong but the concept was foisted on the American public and was widely believed. It was accepted I would  say because it has a beautiful simplicity which can be summarized as follows:

“If you eat cholesterol and fat it  will enter  your blood stream and raise cholesterol levels. This excess cholesterol will then  deposit in your arteries, creating fatty plaque , clogging them and leading to a heart attack.”

This concept was really easy to grasp and simplified the public health recommendations.

However, cholesterol blood levels are determined more by cholesterol synthesized in the liver and predicting  how dietary modifications will effect these levels is not easy.

Since the public has had the diet-heart hypothesis fed to them for decades and given its beautiful simplicity it is hard to reverse this dogma. My patient’s question reflects a natural concern that if science/doctors got this crucial question so wrong, is everything we know about cholesterol treatment and heart disease wrong?

In other words, are doctors promoting a great cholesterol hoax?

Evidence Strongly Supports Statins in Secondary Prevention 

For my patient the science supporting taking a  cholesterol-lowering statin drug is very solid. There are multiple excellent studies showing that in patients with established coronary artery disease taking a statin drug substantially reduces their risk of heart attack and dying.

These studies are the kind that provide the most robust proof: randomized, prospective and blinded.

level of evidenceWhen cardiologists rate the strength of evidence for a certain treatment (as done for lifestyle intervention here) we use  a system that categorizes the evidence as Level A, B, or C quality.

LeveleA quality (or strong) evidence consists of multiple,large, well-done, randomized trials such as exist for statins in patients with coronary heart disease.

Level B Evidence comes from a single randomized trial or nonrandomized studies.

Level C evidence is the weakest and comes from “consensus opinion of experts, case studies or standard of care.”

When treatment recommendations are based on Level C evidence they are often reversed as more solid data is obtained. Level A recommendations almost always hold up over time.

The level of evidence supporting restricting dietary cholesterol and fat to reduce heart attacks and strokes has always been at or below Level C and now it is clear that it is insufficient and should be taken out of guideline recommendations.

Evidence Strongly Supports Atherogenic Cholesterol is Related to Coronary Heart Disease

There are other lines of evidence that strongly support  the concept that  LDL cholesterol (bad cholesterol) or an atherogenic form of LDL cholesterol is strongly related to the development of atherosclerosis. If you are born with really high levels you are at very high risk for coronary heart disease, conversely if you are born with mutations that cause extremely low levels you are highly unlikely to get coronary heart disease.

Thus, the cholesterol hypothesis as it relates to heart disease is very much till intact although the diet-heart hypothesis is not.

Conflating the Diet-Heart Hypothesis and the Cholesterol Hypothesis

There is an abundance of misinformation on the internet that tries to conflate these two concepts. Sites with titles like “The Great Cholesterol Lie” , “The”  Cholesterol Hoax”, The Cholesterol Scam”  abound .

These sites proclaim that cholesterol is a vital component of cell membranes (it is) and that any attempt by diet or drugs to lower levels will result in severe side effects with no benefit

Doctors, according to these types of sites, in collusion with Big Pharma, have inflated the benefits of statin drugs and overlooked the side effects in the name of profit. Often, a “natural” alternative to statins is promoted.  In all cases a book is promoted.

The Great Cholesterol Truths

It’s unfortunate that nutritional guidelines have promoted restriction of cholesterol and fat for so long. These guidelines (like most of nutritional science)  were based on flawed observational studies. They should not have been made public policy without more consensus from the scientific community.  The good news is that ultimately the truth prevails when enough good scientific studies are done.

It is right to question the flimsy foundation of nutritional recommendations on diet and heart disease but the evidence for statin benefits in patients with established coronary heart disease is rock solid.

Hopefully, the less long-winded explanation I provided my patient in the office will persuade him to keep on taking his atorvastatin pills while simultaneously allowing him to eat eggs, shrimp and full fat dairy without guilt.

Calcium Supplements: Would You Rather Have a Hip Fracture or a Heart Attack?

ct_calcium
Does taking extra calcium pills contribute to the deposition of calcium into the coronary arteries that we see in CT scans like this?

Since I’ve been utilizing coronary calcium CT scans to detect early atherosclerotic plaque (see here) in my patients, I have frequently been asked about the relationship between calcium supplements and heart attack risk.

For example, Mrs. Jones has just found out that she has a very high calcium score and that it reflects the amount of atherosclerotic plaque lining and potentially clogging the coronary arteries to her heart. She has also been taking calcium and Vitamin D supplements recommended to her to prevent bone thinning and fractures in the future.

Did all that extra calcium she was consuming end up depositing in her coronary arteries, thus increasing her risk of heart disease?

This is a complex and not fully settled issue, however, there is enough evidence to suggest that we be cautious about calcium supplements.

A recent meta-analysis (Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691) of cardiovascular events in randomized, placebo controlled trials of calcium supplements (without vitamin D co-administration) showed that calcium supplements significantly increased the risk of myocardial infarction by 31% in five trials involving 8151 participants.

A recent meta-analysis of trials involving calcium and Vitamin D supplements found a similar increased risk of cardiovascular disease in the subjects randomized to taking calcium and Vitamin D.

These authors concluded

“in our analysis, treating 1000 patients with calcium or calcium and vitamin D for five years would cause an additional six myocardial infarctions or strokes (number needed to harm of 178) and prevent only three fractures (number needed to treat of 302”

How Might Calcium Supplements Increase Cardiovascular Risks?

Calcium supplements acutely and chronically  increase serum calcium concentration. Higher calcium levels are associated with more carotid artery plaque, aortic calcification, and  a higher incidence of heart attack and death.

Just like atherosclerosis, the process of calcium deposition into the arteries is very complex. Higher calcium levels could alter certain regulators of the process, such as fetuin A, pyrophosphate and bone morphogenic protein-7 or bind to calcium receptors on vascular smooth muscle cells lining the arteries

Higher calcium levels may also promote clot formation.

Bone Fracture versus Heart Attack

The informed doctor would have to tell Mrs. Jones that her calcium supplements may have contributed to her advanced coronary calcium and raised her risk of heart attack and stroke.

As with all medications, she and her doctor are going to have to discuss the relative risks and benefits.

If she has great concerns about fractures and has very low bone mineral bone density (osteoporosis) along with no family history of premature heart disease then the calcium supplementation may be appropriate.

Conversely, if she has high risk factors for coronary heart disease and/or a strong family history of premature coronary heart disease and only slightly low bone mineral density, avoiding the calcium supplements would be appropriate.

Preventing Fractures and Heart Attacks

It’s best to get calcium from the foods we eat rather than a sudden concentrated load of a supplement. Full fat dairy products like yogurt and cheese are heart healthy (see here and here) and they are an excellent source of calcium.

Weight-bearing exercise (such as running/jogging/hiking) and strength-building exercise (lifting weights, resistance machines, etc.) are also important for strengthening bones.

Thus, eating full fat dairy and aerobic exercise will help prevent both a fracture and a heart attack.

Eggs and Heart Disease

The skeptical cardiologist has been telling his patients for several years not to worry about the amount of cholesterol in the food that they eat. Despite recommendations from the AHA and the USDA’s 2010 Dietary Guidelines for America which suggest limiting daily cholesterol for all to 300 mg and for those with heart disease to 200 mg there has never been any convincing evidence that cholesterol consumption increases an individual’s risk of heart attack or stroke.
I am really happy to discover that the Committee which makes recommendations for the US government published 2015 Dietary Guidelines for America has written that cholesterol is “not a nutrient of concern.”(http://www.health.gov/dietaryguidelines/2015.asp#qanda).
In celebration of this sea change in guideline recommendations I am reblogging one of my earliest posts from two years ago on eggs, cholesterol and heart disease

85% of hospital admissions for chest pain are NOT heart attack

The skeptical cardiologist notes that today has been proclaimed “Go Red For Women” day. I’m not sure what wearing red on the second Friday of each February accomplishes but I do think it is important that women recognize that they are at risk for heart disease and stroke.

The AHA sponsored www.goredforwomen.org site proclaims

“each year, 1 in 3 women die of heart disease and stroke”

That is pretty alarming! After three years of this there will be very few women left.

A much better source of information than the AHA or go red for women sites in my opinion is the blog of Carolyn Thomas entitled Heart Sisters.
Carolyn suffered a heart attack and her site is a wealth of information on women and heart disease. Her posts are well researched and informative.
She recently wrote about the fact that 85% of hospital admissions for chest pain are not for Heart Attack. With her permission, I am re blogging this important post which reviews the symptoms of heart attack that differ between men and women and the misdiagnosis of heart attack that is more common in women.

The Ultimate Reason to Stop Taking Worthless Dietary Supplements: They Don’t Even Contain What They Claim to Contain

The skeptical cardiologist has written multiple rants about the worthlessness of taking dietary supplements, herbs, vitamins and minerals.

Today the New York Times is reporting a “cease and desist” letter the New York State  Attorney General has sent to GNC, Target, Walgreens and Walmart regarding their sale of “adulterated and/or mislabeled dietary herbal supplements.”

It turns out that 5 out of 6  of these supplements when tested by analytic DNA technology  were “either unrecognizable or a substance other than what they claimed to be.”

If the lack of evidence supporting efficacy and safety of these herbal supplements wasn’t sufficient to stop you from buying these products, perhaps the fact that the bottles you purchase don’t contain what they are supposed to contain will.

Hopefully, this will begin the downfall  of the multibillion dollar worthless and unregulated dietary supplement industry.

What Cold Medications Are Safe For My Heart?

It’s the cold and flu season here in St. Louis. That means the beds in my hospital are filling up with people who have upper respiratory infections of one kind or another and have developed complications. Not uncommonly,  the skeptical cardiologist is asked to consult on one of his  heart patients who has developed worsening heart failure or atrial fibrillation as a consequence of the pulmonary issues.

In the office it seems like every other patient has recently had a flu-like illness and is still dealing with lingering symptoms, most commonly a persistent cough.

At this time of year I get a lot of questions  from patients which come down to  “What over the counter medication can I take for my cold/flu/cough symptoms that is safe for my heart?”

My answer prior to writing this post  has always been  “Take anything that does not contain pseudoephedrine.”

Pseudoephedrine  (brand name Sudafed)is a decongestant, so often OTC cold meds that contain it will add a D to the title.

It is a sympathomimetic drug meaning that it stimulates the part of the autonomic nervous system that is responsible for “flight and fight” activation. This system kicks in the heart rate goes up, the blood pressure goes up and the heart beats stronger. Blood vessels constrict to nasal passages, thereby reducing fluid build up and resulting in the decongestant properties of the drug.

You won’t find it on the shelves in your local pharmacy because methamphetamine can be produced from it. Laws vary from state to state but at a minimum you will  have to present your driver’s license and you will be allowed to purchase a limited amount from the pharmacist.

A related drug, phenylpropanolamine,(which was used in OTC cold remedies and for weight loss)  was removed from the market in 2000 after the FDA warned of an increased risk of hemorrhagic stroke in young women

I use the little red 30 mg Sudafed pills when my nose is really running badly (think 30 tissue/ hour) and I’m sneezing frequently and it dries me up pretty effectively.  After I take it I feel like I’ve consumed a really highly caffeinated (think Starbucks) cup of coffee for about 4 hours. For this reason, I don’t take it within 6 hours of going to bed.

Sudafed is often combined with other cold , sinus and flu OTC remedies with names like:

Allegra-D, Alka-Seltzer Plus Cold Medicine Liqui-Gels, Aleve Cold and Sinus Caplets, Benadryl Allergy and Sinus Tablets, Claritin-D Non-Drowsy 24 Hour Tablets, Contac Non-Drowsy 12 Hour Cold Caplets, Robitussin Cold Severe Congestion Capsules, Sudafed  24 Hour Tablets, Triaminic Cold and Cough Liquid, Thera-Flu Cold and Cough Hot Liquid, Tylenol Sinus Severe Congestion Caplets, and Vicks 44M Cough, Cold and Flu Relief.

Adverse Effects of Pseudoephedrine: Stroke, Blood Pressure, Heart Rate

A 2003 paper from Mexico identified 22 cases of stroke (out of 2500 stroke cases at their center) that were associated with taking agents like pseudoephedrine within 24 hours. The majority were with phenylpropanolamine but there were 4 cases associated with pseudoephedrine. Given how often pseudoephedrine is taken and how few strokes were reported, it is difficult  to draw any conclusions that  pseudoephedrine causes stroke

In 2005, a review of all studies looking at oral pseudoephedrine concluded

This analysis demonstrates that pseudoephedrine causes a small but significant mean (1–mm Hg) increase in SBP, with no significant effect on DBP and a slight increase in HR (3 beats/min)

On average, these are very minor changes in blood pressure and heart rate and would be unlikely to cause any problems in the vast majority of patients with significant heart disease or hypertension.

The study found NO increased rate of adverse effects (such as heart attacks or strokes) in the patients taking pseudoephedrine.

Coridicin Hbp, A Typical Mixture Of OTC Ingredients

One of my patients pulled from her purse an OTC cold remedy that appeared to have the American Heart Association seal of approval.

IMG_3315

The HBP refers to high blood pressure and the blurb on the front claims this is cold relief for people with High Blood Pressure.

This is really just marketing hype to get patients to buy a more expensive combination of otherwise cheap ingredients.

Let us look closely at the benefits and side effects of this typical and common OTC cold/sinus/flu remedy

Typical “Multi-symptom” OTC Cold/Flu/Sinus/Cough Ingredients

-Acetaminophen (tylenol)- helps with aches, pain, headache and fever.

-Dextromethorphan (look for DXM or DM) is commonly found  in these kinds of multi-ingredient brand name products and is promoted as reducing cough (as an antitussive). However, there is very little evidence to support its efficacy.  This study found 30 mg dextromethorphan no better than placebo at reducing cough. The Cochran Database  Review in 2012 concluded :

There is no good evidence for or against the effectiveness of OTC medicines in acute cough.

In addition to lacking evidence for efficacy, dextromethorphan is used as a recreational drug due to its side effect as a  dissociative hallucinogen in very high doses. Per Wikipedia:

It may produce distortions of the visual field – feelings of dissociation, distorted bodily perception, and excitement, as well as a loss of sense of time. Some users report stimulant-like euphoria, particularly in response to music

-Chlorpheniramine is an antihistamine. It’s one of the oldest antihistamines and as such is “sedating”. This means it almost certainly is going to make you drowsy. I remember trying to function on medical wards 30 years ago when it was the only antihistamine available and it turned me into a zombie for 24 hours.

. Since newer non-sedating antihistamines (like loratadine which is available OTC and generic) have become available I cannot fathom how something like Coricidin has survived.

What is the antihistamine in this hodgepodge of drugs doing for your cold symptoms? Nothing, other than making you drowsy. Antihistamines are useful for allergically related runny nose or sneezing.

What Are the Downsides of Multiple Medication Cold Remedies

I think you are much better off avoiding these brand name mixtures of different active ingredients.

Instead, you should take what you need for a specific symptom in the appropriate dosage and time interval.

Thus, if you have pain, take  the minimal dose of tylenol that relieves it and repeat when it comes back.

If you have a cough, recognize that the OTC ingredients are no better than placebo and are being abused as recreational drugs. Most coughs go away shortly but if one is particularly troublesome and persistent get a cough suppressing drug from your physician.

If you have a really runny nose with a lot of sneezing it is probably OK to take pseudoephedrine even if you are a heart patient or have high blood pressure. Take it as I described above. Start with 30 mg of the little red Sudafed pills , wait an hour to see how you feel. Take a second if it has not been effective.  Repeat at 4-6 hour intervals as needed. Take your blood pressure at least once after starting it.

Don’t buy the multi-symptom multiple ingredient combinations which are simply a marketing tool to get you to spend more money on something from which you won’t benefit.

The second and third items are Coricidin bottles which had been used as slides
Various guitar slides. Includes two original Coricidin bottles from the 1970s–the favorite of many slide guitar players, including Duane Allman.. from king nate/Flickr user”johnny from space 1

I see no reason to ever take coricidin. In the late 1960s, however, legend has it that Duane Allman  had a cold on his birthday.  His brother Greg gave him two gifts: a glass bottle of coricidin pills and Taj Mahl’s debut album. From this he learned how to play slide guitar by listening to Statesboro Blues.

And the rest is history.

I “Ain’t Wastin’ Time no More” on OTC Cold Meds…. Super Bowl is approaching.

ACP

 

 

Life Extension Foundation for Longer Life: Would you like some snake oil with your redundancy?

Recently one of my patients presented me with a print out of the information contained in the “Life Extension magazine” July 2007 issue entitled

“Reversing Atherosclerosis Naturally”

She asked me to read this because I had recommended statin (cholesterol lowering) medical therapy to her and she did not want to take statins but preferred a “natural” way to address her problem of advanced atherosclerosis.

My first reaction  was to ask what the site was selling. At first she told me that she had not purchased anything from the site but it turns out she had purchased some of the snake oil that the site promoted in a very slick faux scientific way.

After looking at the document she presented me I concluded that Life Extension’s only goal is to convince naive searchers for “natural” methods of treating or preventing heart disease and aging that they should be taking something called glissading

The “article” begins with the following exciting pronouncement:

“Scientists have discovered a natural ingredient derived from a species of melon that has been shown to reverse signs of atherosclerosis in aging blood vessel walls. This nutritional supplement is able to boost levels of the body’s most powerful antioxidant defense enzyme, superoxide dismutase (SOD)”

The first sentence should be the tip-off for the reader that this is a site selling useless, unregulated yet expensive “nutraceuticals.” I could spend a thousand words (and minutes) convincing you that this supplement is useless but it is only one of hundreds of similar preparations, so my time would be wasted. Instead, let’s look at the problem in general.

The Allure of “Natural” Treatments

What attracts patients to use substances that are sold over the internet without any guarantee that they are effective, safe or that they even contain the “active” ingredients the promoters claim?

I really like Anthony Almdada’s description in his chapter in Nutraceutical And Functional Food Regulations In The US.

“The quest for “natural,” the drive to engage in “self-care” and the almost free and boundless access to the virtual, omniscient libraries called the Internet and social media messaging are forging a new breed of companies and consumers. Armed and dangerous with a modicum of evidence of simply a sugar-coated science tale, bioactives are birthed, brands are born, products are launched.”

Steven Novella (Science-Based Medicine) has written eloquently about the “plant vs pharmaceutical false dichotomy” here. He quotes the (Dr Oz featured) “Medicine Hunter,” Chris Kilham, as saying:

“my goal is to have more people using safe, effective, proven, healthful herbs, and fewer people using toxic, overly expensive, marginally effective, potentially lethal pharmaceutical drugs”

Kilham has created a forced choice or false dichotomy which would lead one to choose herbs over pharmaceuticals. In reality, the pharmaceutical drugs are the substances which have been proven safe and effective (having undergone rigorous trials in humans and an intense review process by the FDA) despite being manufactured by man. Herbs and nutraceuticals, despite coming from nature, are not proven to be either safe or effective.

Novella writes:

“First and foremost, herbs and plants that are used for medicinal purposes are drugs – they are as much drugs as any manufactured pharmaceutical. A drug is any chemical or combination of chemicals that has biological activity within the body above and beyond their purely nutritional value. Herbs have little to no nutritional value, but they do contain various chemicals, some with biological activity. Herbs are drugs. The distinction between herbs and pharmaceuticals is therefore a false dichotomy.”

What Happens to a Plant-derived Substance That Proves Safe and Effective for a Medical Condition?

The simple answer is that it moves from the unregulated, over the counter, internet-marketed realm into the realm of being regulated by the FDA and prescribed by doctors.

A really great example of a botanical that became a useful pharmaceutical is digoxin.

Two hundred and fifty years ago, doctors had no FDA to help them choose safe and effective medications. They tried various, presumably medicinal, botanical preparations on their patients to see what worked.

Sometimes the patient got better, sometimes not.

Sometimes the patient got violently ill and died.

Since the doctors were only working on one patient at a time and did not have the luxury of large randomized trials to guide them, they could only guess whether the substance they had given their patient helped or hurt.

Through the wonders of the internet, you can download for free and read for yourself the experiences of one such doctor, William Withering, who was experimenting on his patients with a preparation made from the leaves of a plant with the Latin name of digitalis purpurea, more commonly known as foxglove.

He tried different ways of preparing it, sometimes using an infusion, sometimes a powder, and he tried different amounts on his patients. He recognized that the concentration of the active ingredient in the plant was different depending on the time of year, the growing conditions, and the part of the plant he utilized. There was no standardization of concentration available to him.

The only way he knew that he had given too much was when the patient’s pulse slowed too much or the patient vomited.

Over time, chemists and physiologists were able to identify the active chemical in foxglove, now called digitalis or digoxin, and produce it in a form that was pure and consistent.

According to GlaxoSmithKline, farmers in the Netherlands grow fields of woolly foxglove, which is a member of the snapdragon family. Bales of dried foxglove leaves are shipped to the U.S. Here, processing facilities macerate the leaves and extract digitalis using an aqueous-alcohol solvent. Further treatment and processing yields powdered digoxin, which is compounded into tablets, injectable solutions, elixirs, and capsules. It takes about 1,000 kg of dried foxglove leaves to make 1 kg of pure digoxin, the company adds.

Cardiologists are still using digoxin, primarily to slow the heart rate in patients with atrial fibrillation and to a lesser extent, to help patients with congestive heart failure.

We use less of it than we did 50 years ago because of the development of synthetic drugs, which are more effective for these conditions.

In addition, digoxin has what we term a narrow therapeutic window; even when we use precisely formulated pills, we can sometimes run into the problems from side effects that William Withering saw 250 years ago using foxglove leaves: slow pulse, vomiting and life-threatening abnormal heart rhythms.

To my patients who are attracted to internet-marketed, non FDA-regulated “natural” cures for aging and atherosclerosis I say: Take these substances at your own risk, they have been proven neither safe nor effective.

Although it is wise to be cynical and skeptical of drugs that are researched and heavily marketed by big pharmaceutical companies, at least we have the reassurance that they have all gone through a rigorous process of testing for both safety and efficacy, and that the pills we put in our mouths contain a precise amount of the active ingredient without any contaminants or unknown ingredients.

St. John
The SC and his youngest, Gwyneth, engaging in life extension activities on recent trip to St. John.

HealthTap: Telemedicine or Terrible Medicine?

The skeptical cardiologist  is evaluating an online medical service called HealthTap. I first started getting inundated with emails from Dr. Geoffrey Rutledge, Chief Medical Officer of HealthTap in 2013. They started off saying:

“I’m delighted to personally invite you to be featured for free as a Top Doctor on HealthTap, where you will be recognized for your experience, expertise, and compassion. All you have to do is sign up.”

Health Tap allows patients to submit questions online which are answered by some of the thousands of doctors signed up. In addition, patients can get a “virtual consult” for 99$. James Hamblin in the Atlantic has written a nice piece describing the experience of the virtual consult with HealthTap from the patient’s perspective.

Beginning in November, 2014, Dr. Rutledge told me via email

“You still have time to achieve Top Doctor Awards, but the deadline for participation is now just a few days away! Sign up for free today, and you can be recognized in just 4 days with prestigious Top Doctor, Top General Internist, Most Influential Doctor, and Thought Leader Awards in the Fall 2014 Top Doctor Competition. You are eligible for each of these awards at the national, state, and regional levels.”

How could I resist competing for one of these meaningless but prestigious awards? After all, as Dr. Rutledge told me

Winners of Top Doctor Awards will be featured on HealthTap+ to 64,000 U.S.-licensed doctors and many millions of patients who visit HealthTap+ each month. As an awardee at the state or national level, you will receive a certificate to display in your office that highlights your achievement to your patients, a prominent badge for display on your online profile, and a virtual plaque that you can post on your blog or website.

Over the Thankgiving break I signed up to become a HealthTap doctor. I’ve been evaluating it since then and have found it to be an extremely annoying and tiresome program which utilizes high pressure marketing schemes and motivational techniques that are reminiscent of a video game.

The first thing i did after signing up was to look at the questions that patients were posting on the website. I answered two questions that were cardiology related. On one of the questions the information I gave was incorrect. I had two doctors “agree” with my answer and got two thank you  clicks from patients.

I then went trough a training session via video with a person from healthTap on the use of the Virtual Concierge app. I have yet to utilize this to actually interface with a real patient.

docscorehealthtap trophiesAs a result of my actions my DocScore on HealthTap  has skyrocketed from 50 to 85!

I unlocked “The Catalyst Trophy”and “The Chain Reaction Trophy”!

According to HealthTap I have helped 3080 patients and my patient satisfaction score is 5.0!

Spending two minutes answering 2 questions online, one incorrectly, sure pays off in the world of virtual medicine! This is a lot easier than seeing real patients.

 

I usually get a couple of emails from HealthTap per day saying meaningless marketing things like :

This is a time of year for helping others, showing your gratitude, and taking on new personal initiatives for growth. HealthTap+can help you accomplish your goals. With the exciting launch this year of HealthTap Concierge, we’ve demonstrated a simple, yet powerful way you can benefit from the latest state-of-the-art technology to boost your income and enjoy the flexibility of practicing from anywhere, at anytime, with no cost, hassle or overhead. With HealthTap Concierge, you can grow your practice, or relieve the load on your already too-busy practice.

HealthTap really wants to me sign up my own patients and show them the “magic of virtual care.”  :

In celebration of the holidays, we are thrilled to partner with you to help your patients. From now until December 26th, we’ll waive all charges for initial Virtual Consults that you give to your patients if you’d like to share this gift.

Giving the gift of a free consult is a great way to welcome your patients to your new Virtual Practice and show them the magic of virtual care.  

Tell your patients they can see you for a free virtual consult if they visit your Virtual Practice and schedule a consult with you by December 26. All they have to do is enter this special gift promo code when they make their appointment: 
firstfree-c9txs

Since I can’t imagine how this will help my patients I haven’t solicited any virtual patients. I’m pretty sure, however, that, I could improve my DocScore and unlock a few more trophies if I did.

I could really improve my standing if I started handing out kudos to other doctors who in turn would give me votes for various things like my bedside manner or my skill in “eat healthier.”

healty eaterThis doctor is first in the St. Louis Region for “being inspiring” and 4th nationally for varicose veins based on 155 doctor votes. I wonder how many of those votes were from doctors that know anything about him. There is no way to know unfortunately.

This is reminiscent of liking somebody on Facebook . A lot of the attempts by HealthTap to motivate me to do stuff on their site reminds me of social media and/or video games.

When I play Rock Band it is always satisfying to unlock trophies and get higher point scores and on Facebook I’m pleased when a lot of people “like” my posts.

I don’t think such meaningless trophies and likes and high point scores translate to any meaningful guarantee of quality, expertise or knowledge in the world of medicine. It seems to me that those doctors who participate a lot in HealthTap must have a lot of time on their hands (perhaps because they have no real patients to see) and/or they are seeking to merge their need to play and succeed at video games with their medical training.

I’m sticking to my real practice of cardiology where I can touch and see my patients, listen to their heart and lungs, follow up on the recommendations I’ve made and get to know them over time. I find this to be very satisfying and fulfilling .

This particular style of telemedicine to me is terrible medicine.

If HealthTap is the future of medicine, count me out.

Healthy Skepticism and Bias in Cardiology : Let’s Eliminate Drug Ads from Scientific Publications

The skeptical cardiologist has been asked by a number of his patients  “Why are you the skeptical cardiologist?”  In essence, I think they are either asking what does “skeptical” mean or what makes you skeptical and why should I care?

In the About section of this blog I wrote “All of these experiences have taught me to cultivate a healthy skepticism for information that has potential bias.”

Whereas skepticism initially was an approach that doubted the veracity of everything and questioned our ability to know anything, healthy skepticism accepts the veracity of information only after it has been evaluated by a scientific or evidence-based approach.

John Byrne, MD, has a wonderful website, skeptical medicine, which describes in detail the skeptical doctors approach.

The modern skeptic is a scientific skeptic. We use proper science and basic ethics to inform our decisions. We withhold acceptance of claims until proper evidence is presented. We use axioms such as ‘Occam’s Razor’, ‘Extraordinary Claims Require Extraordinary Evidence ‘, and ‘Correlation is Not Necessarily Causation’ to evaluate claims. The skeptic recognizes that humans are prone to biases. We recognize that people defend their biases with logical fallacies. Skeptics understand that we are all prone to such biases and fallacies, even skeptics.  To overcome these tendencies, we must learn about biases and fallacies in order to spot and correct them, especially in our own thinking.

Thus, as a skeptical cardiologist, I am doing my best to use scientific approaches to evaluate recommendations for lifestyle, testing and treatment in the world of cardiology. I do not accept recommendations in these areas from cardiology authorities (American Heart Association, American College of Cardiology guidelines, scientific conferences), media, or the government, without carefully examining the scientific studies supporting them. I seek to eliminate biases that can undermine such studies and recommendations.

The Influence of Drug Money on Doctors

Identifying bias in medical recommendations is essential. Just as our politicians are heavily influenced by campaign contributions from special interests, physicians can also be heavily influenced by special interest spending.

I have tried to eliminate any possibility of pharmaceutical company marketing from influencing my medical decisions. I used to believe that I could accept meals and honoraria from drug companies and not be biased by them. However, several years ago, I realized that any time I spent listening to a heavily biased pharmaceutical representative promoting their product was replacing and/or competing in my brain with information about medications and diseases from unbiased sources. In subtle ways, even to the most ethical doctors, this has been shown to effect prescribing practice. If it didn’t, these companies would not be spending billions promoting their drugs directly to doctors.

The American College of Cardiology and Drug Advertisements

The major professional organization for cardiologists is the ACC or American College of Cardiologists. I get lots of emails from the ACC offering educational opportunities and information on the activities of the college. The ACC also mails me, weekly, the Journal of the American College of Cardiology, the major publication for scientific studies on cardiology in the wIMG_3297orld. Once a week or so, they send me “Cardiology World News,” which is a summary of relevant articles and developments in cardiology. All of these sources of information from the ACC are riddled with advertisements for drugs. The newer and more expensive the drug, and (it appears) the less the benefit, the larger the advertisements. Accompanying the latest Cardiology World News this last week was the large multipage pamphlet pictured below, touting the fact that Brilinta is “preferred over clopidogrel” for NSTEMI in the updated AHA/ACC guidelines. The skeptical approach is to question the validity of these guideline recommendations by reviewing the studies that they were based on, as well as the possible conflicts of interest of the authors (how many are paid honoraria or have research funded by Astra-Zeneca, the company promoting Brilinta)?

IMG_3299Within the pages of Cardiology World News were several multipage advertisements for drugs, especially for newer oral anticoagulant drugs, such as Xarelto. Even the prestigious Journal of the ACC is stuffed with these annoying advertisements. The emails I get from the ACC often contain banner ads for similar over-priced and over-marketed brand name drugs; the websites of ACC and Medscape are littered with banner ads for drugs. Since I am the skeptical cardiologist, I’ve reviewed the studies that resulted in these drugs being approved, and then make my own conclusions about how to prescribe them to my patients.  Such ads are not useful in my decision making.

When I read journals, studies, editorials or reviews of cardiology information,  I simply want unbiased information. I don’t want my mind cluttered by biased presentations from drug companies.

Why is my professional organization helping to promote these biases?  Obviously, it is for the money.

To the American College of Cardiology I say: “let’s eliminate drug ads from your publications.” With that simple step, we can help reduce the control that pharmaceutical companies have over physicians and move toward ensuring that all of our drug and device recommendations to patients are in their best interest.

 

 

The Skeptical Cardiologist’s Year in Review

Hopefully in 2014 the skeptical cardiologist crushed a few myths about cardiology. Here are what I consider the most important topics I covered last year:

1. Eating Fat Doesn’t Make You Fat or Cause Heart Disease.

It has taken decades to overcome the damage done by nutritional guidelines that advocated substituting carbohydrates for fat. Slowly but surely it appears that nutritional authorities are recognizing that:

-You can lose weight on high fat diets

-There is no good evidence that lowering fat or saturated fat in the diet reduces cardiovascular disease

2. Added Sugar is the Major Toxin in Our Diets

Decades of flawed nutritional advice convinced the public that they could eat whatever they wanted as long as it was low in fat.

This resulted in “heart-healthy” products loaded with high fructose corn syrup and other added sugars.

Eliminating these added sugars from your diet is the single best dietary move you can make.

3. Supplements/ Vitamins/Fish Oil do not prevent heart disease

Americans spend billions of dollars on useless “natural” supplements, vitamins, minerals, herbs, nutraceuticals and fish oil.

No vitamin or mineral  has been shown to reduce heart disease (see here)

There is no benefit to taking multivitamins ( see here and here)

Taking a fish oil supplement does not prevent heart disease (or dementia, bad skin, or arthritis for that matter)

4. Routine cardiovascular screening tests like ECGS and echocardiograms can cause more harm than good

5. Direct screening for atherosclerosis can help identify those at higher or lower risk for heart attack, stroke or sudden death

Consider having a carotid ultrasound (to identify early atherosclerotic plaque) or a coronary calcium score done if you have a strong family history of premature cardiovascular disease

6. Dietary cholesterol does not need to be restricted to prevent heart disease.

Eat all the shellfish and cioppino you want

Enjoy your eggs, yolks and all.

7. Dairy fat is good for your heart.

This is the topic that launched this blog and the one I have written most extensively about.

It started when I tried to convince the significant other of the skeptical cardiologist (SOSC) that she should not put butter on her croissant. I was not able to find scientific evidence to support my recommendation to avoid full fat dairy.

Instead I found that

Two years after starting the blog I am now happily putting butter on croissants and consuming them without guilt along with the (now) fiancé of the skeptical cardiologist (F0SC).

IMG_0768Next week she and I will be back in St. John doing further research on the cardiac effects of snorkeling and rum-based drinks.

My very best wishes for all of you in 2015!

-TSC