Category Archives: Cardiac Tests

Most Echocardiograms Done In the UK Are Free But Not Read By Cardiologists

In the course of researching a previous post on the cost of an echocardiogram, the skeptical cardiologist discovered a website in the UK ((HeartScan)) that offered a “private” echo at a cost of around $400.

Subsequently,  Antoinette Kenny, the creator of HeartScan, was kind enough to answer some questions I had about echocardiography in the UK.

 

From the HeartScan website. I presume this is Dr. Kenny, herself, performing an echocardiogram on a patient.

 

First she provided me with some background on her career. (Green text below from Dr. Kenny)

As you will know from HeartScan’s website (redesign of which is almost complete and will be launched next month) I am a cardiologist in the UK. I am still a fulltime NHS (UK’s public health service) cardiologist at one of the leading heart centres in the UK, the Freeman Hospital, Newcastle upon Tyne. I am Head of the Regional Echocardiography Department there providing TTE, TEE, stress echo, 3D etc. My career has also been heavily involved with the British Society of Echocardiography (BSE) which is affiliated with British Cardiovascular Society and promotes standards of practice for echocardiography in the UK including accreditation programmes for individuals and departments/private services.

Dr. Kenny is clearly well-trained and dedicated to providing high quality echocardiography.

And according to  HeartScan’s FAQs

At HeartScan you are secure in the knowledge that your Echo will be performed to the highest standards laid down by the British Society of Echocardiography. HeartScan is to date the only private provider in the UK to be awarded British Society of Echocardiography Departmental Advanced Accreditation.

Are Echos Free In The Uk?

You are correct, echocardiograms are free of charge through the NHS in the UK. However, there are waiting times involved for elective referrals and typically patients may have to wait for 6-12 weeks or longer in some geographical areas.  So some patients will chose to have their echocardiogram privately and self-fund.  Other patients are covered by health care insurance and will have their echo reimbursed by their health insurance provider

It would be unusual for someone to wait for more than 1-2 weeks for an echocardiogram in the US. I suspect the longer UK waiting time does not cause worse outcomes.

Hopefully, patients presenting with some conditions (acute heart failure  comes to mind)  are moved up in the queue.

How Does Dr. Kenny Determine What To Charge For Her Private Echocardiograms?

My services are very competitively priced and I chose this price point to be competitive with other private echo services but also add value to the patient in that the echo is reported by a cardiologist who is an echo specialist.  Other local private hospitals provide an echo privately at a higher cost (approx. £380-480 for a sonographer reported echo).

So £295 is the cost of what I believe is a very high quality echo with a high quality  report.  I guess I have tried to make private echo reported by an echocardiologist as available as I can.  Whilst we are a small clinic I do get patients who travel great distances for an echo as they tell me they trust the service (as they know it’s reported by a specialist) and find the pricing better than they can attain locally.

A Marked Difference In The Practice of Echocardiography Between In The US Compared To The UK

One of the main differences between the UK and US I think is that imaging cardiologists are very much in the minority here so that in a smaller hospital there may be no cardiologist who has echo expertise.  Therefore the Echo service is almost completely physiologist delivered.  In larger teaching hospitals over the last decade or so there has been an increased awareness of the importance of imaging and thus an increased training and appointment of imaging cardiologists.  However numbers are small in relation to the service load. For instance in my unit we perform almost 18,000 TTEs annually but there are only 1.5 Echo consultants (and we both do general cardiology also).  So the TTE service is physiologist reported with myself and my colleague running ongoing education and  QA programmes for the physiologists.  We only report a small percentage of TTE cases that are flagged up by the physiologists but we perform the TOE (TEE!) and DSE’s etc. Echo is a relatively small sub-specialty in the UK so echo cardiologists tend to know each other and lecture on each other’s teaching courses etc. But there are many hospitals with no cardiologist echo expertise.

I was amazed by this. In the US, sonographers record the examination and make measurements. In some (typically academic) centers the sonographers create a preliminary reports, however, an echo trained physician signs off on all reports.

I was curious what training and reimbursement these physiologists receive  as they doing, in essence,  what a cardiologist does in the US.

Salary and Training of Physiologists in UK

Yes, our cardiac physiologists have considerable responsibility!

Their training is changing with a programme of ” modernising scientific careers” that’s underway but I will send you on info regarding their training. In essence the previous model was to complete a university course and then train in the hospital in various disciplines. For those in cardiology they train in the cath lab, cardiac rhythm management and Echo so have a very broad base before then specialising in Echo ( or cardiac rhythm etc).

Salaries depend on experience and seniority but the salary for a cardiac physiologist who has attained BSE accreditation and reports independently is up to £42,000 a year.

I’m fascinated by this fundamental difference in the way echocardiography happens in the US versus the UK. I wonder how it impacts either clinical outcomes or the cost of medical care in the two countries.

I’ll be posting information on the training that UK physiologists go through in the near future.

I welcome comments from any UK readers on their experience with private or NHS echocardiograms, either good or bad.

I remain Anglophilically yours,

-ACP

 

N.B.  For your further edification, I’ve copied Dr. Kenny’s About Page from the HeartScan web page.

Perhaps Dr. Kenny can tell us what all those initials after her name mean.

About Dr Kenny

Dr. Antoinette Kenny, Director of HeartScan Ltd.
MB BCh BAO MD FRCP FRCPI

Dr. Antoinette Kenny is a full time Consultant Cardiologist and Specialist in Echocardiography (ultrasound heart scans) at the Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  She is also an expert in cardiac screening for individuals involved in sport.

Dr. Kenny qualified in medicine in Dublin in 1983 and trained in clinical cardiology at St. James’s Hospital Dublin and Papworth Hospital Cambridge. She was awarded the Grimshaw-Parkinson  Fellowship from Cambridge University for her research towards an MD thesis in echocardiography at Papworth Hospital. She was made a Fellow of the Royal College of Physicians, London, in 1998 and of the Royal College of Physicians, Ireland, in 1999.

Following her clinical cardiology training and MD thesis she was appointed Fellow in Echocardiography at the Oregon Health Sciences University, Portland, Oregon, USA.  There she undertook training in advanced echocardiography, including three-dimensional echo techniques, with Professor David Sahn the internationally renowned specialist in echocardiography. In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.  (Source Royal College of Physicians Census).

Echo experience:
As Clinical Head of Echocardiography at Freeman Hospital for over 20 years, Dr. Kenny has gained a vast experience in assessing patients with heart failure, valve disorders and inherited cardiomyopathies.  Her expertise includes evaluation and selection of patients for advanced valve replacement techniques such as TAVI (transcutaneous aortic valve implantation) and minimally invasive surgery.  She is a member of the Specialist Heart Valve Team at Freeman Hospital providing specialist echocardiographic expertise for the selection of patients for valve surgery.

Sports Cardiology experience:
Dr. Kenny is also a cardiology adviser to the Football Association (FA) and a member of the FA cardiology consensus panel producing guidelines for cardiac screening.  She has performed cardiac screening for the Football Association since this programme was introduced for young footballers in 1996.

Dr Kenny has also been involved with investigation and heart screening in premiership football players for the last decade and provides heart screening for Newcastle United FC, Sunderland AFC and Middlesbrough FC, including their first team players. Dr. Kenny has particular expertise in distinguishing between the normal changes produced by athletic training (athlete’s heart) that could be misinterpreted as abnormalities and abnormal cardiac conditions that can pose a serious health risk.

Achievements:
Dr Kenny holds full accreditation with the British Society of Echocardiography, the national benchmark of quality in performing and interpreting Echo scans.  As an elected council member of the British Society of Echocardiography she has been involved with standards and quality in delivery of national Echo services.  She also held the post of Chairman of the Scientific and Research Committee of the British Society of Echocardiography with responsibility for organisation of the annual meeting and educational sessions.

She is co-author of a well received textbook of echocardiography which has been translated into other languages. Dr. Kenny is also a leader in education in echocardiography, co-directing a national Echo course and invited to lecture at both national and international Echo conferences.

Dr. Kenny has developed and led research studies in advanced applications of echocardiography over the last two decades and has published widely in peer reviews journals.

How Much Does or Should An Echocardiogram Cost?

One might assume the skeptical cardiologist has a quick and accurate answer to this question given that he has spent a very large amount of his career either researching, teaching or interpreting echocardiograms.

Surprisingly, however, it turns out to be extremely difficult to come up with a good response.

An echocardiogram is an ultrasound test that tells us very precisely what is going on with the heart muscle and valves. I’ve written previously here and here on how important they are in cardiology, and how they can be botched.

As in the  example of a severely leaking aortic valve  below, we get information on the structure of the heart (in grey scale) and   on  blood flow (color Doppler). This type of information is invaluable in assessing cardiac patients.

In the last week I’ve had 2 patients call the office indicating that even with insurance coverage, their out of pocket costs for an echocardiogram were unacceptably high – almost a thousand dollars.

Wide Variations In Equipment, Recording and Interpretation Expertise For Echocardiograms

A small, handheld ultrasound machine that performs the basics of echocardiography can now be purchased for 5 to 10K. More sophisticated systems with more elaborate capabilities cost up to 200K. In my echo lab the machines are typically replaced about every 5 years, but in smaller, more cost sensitive labs they can be used for decades.

An echo test typically takes up to an hour, and a sonographer performs up to 8-10 tests per day. At facilities trying to maximize profit, tests are shortened and sonographers might perform 20 per day.

In the U.S., echos are performed by sonographers who have trained for several years (specifically in the field of ultrasound evaluation of the heart) and earn on average around 30$ per hour, however, Medicare and third party payors usually don’t require any sonographer certification for echo reimbursement.

Physicians who read echocardiograms vary from having rudimentary training to having spent years of extra training in echocardiography, and gaining board certification documenting their expertise.

Interpretation of a normal echocardiogram takes less than 10 minutes, whereas a complicated valvular or congenital examination requiring comparison to previous studies, review of clinical records and other imaging modalities, could take more than an hour.

Given these wide parameters, estimating what one should charge for the technical or physician portions of the average echo is challenging.

Wildly Differing Charges For Echocardiograms

Elizabeth Rosental wrote an excellent piece for the NY Times in 2014 in which she described the striking discrepancy between 2 echos a man underwent at 2 different locations:

Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. “Why would that be?” Mr. Charlap asked. “It really bothered me.”

Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups”

This graph shows the marked variation across the US in price of an echo.  In all the examples, however, what the hospitals were paid was around 400$ which is the amount that CMS pays for the complete echo CPT code 93306.

Costs Outside the US

At the Primus Super Specialty Hospital in New Delhi, India, apparently you can get an echocardiogram for $50.

This site looks at prices for private echos across the UK. The cheapest is in Bridgend in Wales (where suicide is rampant) at 175 pounds. You can get an echo for 300 pounds at the Orwell clinic (where their motto is “War is peace. Freedom is slavery. Ignorance is strength.”)

At one private  UK clinic, you can have your echo read by Dr. Antoinette Kenny, who appears extremely well qualified  for the task.

“In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.”

Whereas I would not be interested in getting an echo done in India or Mexico, I would definitely have one done in Dr. Kenny’s center if I lived nearby.

Self Pay Cost

My hospital, like most, will write off the costs of an echo for indigent patients. I will read the tests on such patients pro bono (although doctors never use that term because we feel it makes us sound to lawyeresque).

The hospital also has a price it charges for those patients who are not indigent, but who have excessively high deductibles or co-pays with their insurance. In some cases this “self-pay” charge is significantly less than what the patient would pay with their insurance.

Paying out of the pocket for the echocardiogram may also make sense if the patient and/or physician really thinks the test is warranted, but the patient’s insurance deems it unncessary.

If you find yourself in a situation where a needed echocardiogram performed at your ordering doctor’s preferred facility is prohibitively high, it makes sense to look around for a more affordable option.

However, I must advise readers to be very cautious. In the NY Times example, the hospital charges for Mr. Charlap seemed inversely proportional to the quality of the echo he received.

This is not necessarily the case for a self pay echo. It is more likely that a cheap upfront out-of-pocket cost quote in a doctor’s office or a screening company reflects cheap equipment with minimal commitment to quality and brevity of exam and interpretation time.

I have encountered numerous examples of this in my own practice.

One of my patients who has undergone surgical repair of her mitral valve decided to get an echocardiogram as part of a LifeLine screening (see here and here for all the downsides of such screenings).

The report failed to note that my patient had a bicuspid aortic valve and an enlarged thoracic aorta.  These are extremely significant findings with potentially life threatening implications if missed.

If a high quality echo recording and interpretation is indicated for you make sure that the equipment, technician and physician reader involved in your case are up to the task.

Ultrasonically Yours,

-ACP

What Is the Significance Of A Spot On The Lung? The Three-eyed Radiologist On Incidental Pulmonary Nodules

The Three-eyed Radiologist (TR) has been asked by The Skeptical Cardiologist (SC) to discuss the epidemic of incidental pulmonary nodules that are found on routine cardiac diagnostic studies including coronary calcium CTs, coronary CTAs, and myocardial perfusion scans (using CT for attenuation correction), not to mention a whole host of other CT (computed tomography or “CAT”) scans and x-ray exams performed for many reasons that have nothing to do with inspecting lungs for pulmonary nodules. The TR will herein anticipate and answer common questions that might be asked by the SC audience.

  1. What is a pulmonary nodule (and why should I care)?

A pulmonary nodule is a nonspecific “spot” or lesion or density seen in the lung (1). It could be nothing. It could indicate lung cancer, and that is why you should care. Larger nodules, say 8 mm or larger (bigger than one-third of an inch), are of greater concern than smaller ones, but size alone is not an indicator of malignancy or benignity.

An incidental pulmonary nodule (inside red circle) discovered on a CT scan of the chest which was done in conjunction with a nuclear stress test.

A nodule may initially appear to be benign but upon further investigation be malignant—or vice versa. It could be a scar. It could indicate an old infection of no consequence. It could indicate an active infection or inflammation.

Again, it is a nonspecific finding that requires further thought, analysis and maybe additional testing.

2. Okay, you scared me by mentioning cancer. What should I do about a pulmonary nodule?

In many instances, the nodule can be dismissed if it has characteristic imaging features of a granuloma (calcium) or hamartome (fat) or if it can be shown to be stable over time (at least two years in many typical nodules). In most other cases, the nodule will require a follow up scan or two, and occasionally a PET scan and or a consultation with a lung doctor (a pulmonologist). Less frequently, the nodule will need a biopsy or to be removed, especially if it is likely or proven to represent cancer.

3. How common are pulmonary nodules?

Very common. In fact, last week the TR’s own 85 year old father texted him to tell him about the incidental pulmonary nodule discovered in the right lung when he was having a CT scan of the kidneys for blood in the urine.

The TR spends a good deal of his work day following pulmonary nodules with serial chest CT scans and discovers them regularly, too. The American Thoracic Society estimates that as many as one half of all people getting an x-ray or CT scan that includes part of the lungs has a pulmonary nodule (1). The TR’s experience is that the number is quite a bit lower in actual practice.

4. I have a pulmonary nodule. What should I do about it?

First, do not panic. Much of the time, this amounts to very little.

There are evidence-based consensus recommendations called, The Fleischner Society Guidelines (2), created with input from leading chest radiologists, pulmonologists, and chest surgeons, to advise the doctor and patient to manage these incidental lung nodules. It was updated in early 2017, and the new guidelines represent the state-of-the-art for handling this medically common scenario.

Based on the size and appearance, there are standardized work up and follow up protocols. The TR was positively pleased to see that the new recommendations are much less aggressive than the early version, previously requiring more frequent workup and monitoring for minuscule nodules that never seemed to amount for much. As the TR ages, his visual acuity for small things is naturally declining, and he is thrilled that the tiniest nodules can now usually be ignored.

5. While I have you here, TR, what’s the deal with lung cancer screening?

Lung cancer screening is a newer test, using low dose CT scans, for the early detection of lung cancer in a subset of people with a history of smoking (3). It was graded “B”, by the USPSTF, for its life saving potential (for comparison, screening mammography gets a “C” grade) and is offered to Medicare and commercial insurance patients who qualify, based mostly on age and smoking history. The CT scans are used to detect and follow the same nodules discussed above. If you are a smoker or former smoker, consider a discussion with your doctor as to whether or not lung cancer screening might benefit you.

6. Thank you, TR. What can I do to repay you for this useful information?

Do not tell the SC, but the TR loves salted caramel gelato and will accept gelato donations.

1) https://www.thoracic.org/patients/patient-resources/resources/lung-nodules-online.pdf

2) http://pubs.rsna.org/doi/pdf/10.1148/radiol.2017161659

3)https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening

N.B. The Three-eyed Radiologist is Robert Kanterman, MD, a radiology colleague at St. Luke’s Hospital in Chesterfield, MO. He can be followed on Twitter @3EyeRadiologist

 

What Is The Cause of Low Voltage (Unreadable or Unclassified) AliveCor/Kardia Mobile ECG Recordings?

The skeptical cardiologist has had several of his readers submit stories and tracings of AliveCor Mobile ECG recordings which yield unclassified or unreadable recordings. In some cases this is due to excess noise but a lot of these tracings suffer from low voltage: the height of the tracing is very small.

John, a skepcard reader, is typical.

Recently, he noted his heart was racing and made an AliveCor recording which came back interpreted by the app as normal

EKG-3
First tracing. Note the QRS complex (the large regular spikes) are 2 boxes high. Right in front of them is a little bump, the p wave indicating normal sinus rhythm

 

Three hours later he made a second recording which has drastically lower voltage: the only deflections visible are tiny QRS complexes, the p waves have disappeared. I think this is also normal sinus rhythm but because p waves can’t be seen this came back uninterpretable and if there were any irregularity AliveCor would have called it atrial fibrillation:

EKG-4
Second tracing. Note the QRS spikes now are less than half of a box tall. There are no consistent p waves visible (unless one has a good imagination). The bumps after QRS spikes are T waves.

John has a theory on the cause of some of his low voltage recordings which I shall reveal in a subsequent post after testing it.

In the meantime, if any readers have suggestions as to causes of low voltage recordings or have noted similar issues please comment below or send recordings and observations to DRP@theskepticalcardiologist.com.

Voltagophilistically Yours,

-ACP

 

 

 

 

Donald Trump Has Moderate Plaque Buildup In His Coronary Arteries and his Risk For A Cardiac Event Is Seven Times Hilary Clinton’s Risk

Donald Trump recently appeared on the Dr. Oz show and handed a letter to the celebrity medical charlatan and TV host, Mehmet Oz.

The letter was written by his personal physician , Dr. Harold Bornstein,  screen-shot-2016-10-04-at-3-21-11-pm
and summarized various  laboratory and test  results which led Bornstein to conclude  that Mr. Trump is in excellent health (Bornstein did not repeat his earlier, bizarre statement that “If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency.”)

From a cardiovascular standpoint the following sentence stood out:

“His calcium score in 2013 was 98.”

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.

What Does Donald’s Trump’s Calcium Score Tell Us About His Risk Of A Major Cardiac Event?

We know that, on average, even if you take a statin drug (Trump is taking rosuvastatin or Crestor), the calcium score goes up at least 10% per year which means that 3 years after that 98 score we would predict Trump’s calcium score to be around 120.

Based on large, observational studies of asymptomatic patients, Calcium scores of 101 to 400 put a patient in the moderately high risk category for cardiovascular events.

When I read a calcium score of 101-400, I make the following statements (based on the most widely utilized reference from Rumberger

This patient has:

-Definite, at least moderate atherosclerotic plaque burden

-Non-obstructive CAD (coronary artery disease) highly likely, although obstructive disease possible

-Implications for cardiovascular risk: Moderately High

Patients in this category have a 7-fold risk of major  cardiac events (heart attack or death from coronary heart disease) compared to an individual with a zero calcium scorescreen-shot-2016-10-04-at-3-16-25-pm

 

 

Clinton versus Trump: Zero is Better

Since we know that Hillary Clinton recently had a calcium scan with a score of zero, we can estimate that Trump’s risk of having a heart attack or dying from a cardiac event is markedly  higher than Clinton’s.

Clinton, born October 26, 1947 is 68 years old and we can enter her calcium score into the MESA calcium calculator to see how she compares to other women her age. A  coronary calcium score of 6 is at the 50th percentile for this group.

Interestingly, Trump’s score of 98 at age 67 years was exactly at the 50th percentile. In other words half of all white men age 67 years are below 98 and half are above 98, creeping into the moderately high risk  category.

(This should not be surprising, I touched on the high estimated cardiovascular risk of all aging men in my post entitled “Should all men over age sixty take a statin drug?”)

So, based on his coronary calcium score from 2013, Donald Trump has a  moderate build up of atherosclerotic plaque in his coronary arteries and is at a seven-fold higher risk of a cardiac event compared to Hilary Clinton.

Let the law suits and tweets begin!

Electorally Yours,

-ACP

 

 

 

 

Getting To The Heart Of Father’s Day

The skeptical cardiologist received an email from the folks at AliveCor a few days ago with the subject line:

Dad’s heart matters – Kardia Mobile for Dad will give you peace of mind and make Dad happy

The email contains this image of an older well-dressed man (withScreen Shot 2016-06-18 at 9.03.26 AM lots of bling) standing in a beautiful meadow near the ocean. The man has decided to turn his back on the ocean and check his heart rhythm using the AliveCor/Kardia (AliveCor has changed the name of its ECG devices to Kardia) mobile ECG. This man is a happy dad! (Unless his heart rhythm is interpreted as atrial fibrillation. Then the beach walk is ruined.)

The email asks the question “What if Dad’s heart really was an open book?”

Uhh, he’d be dead? Clearly books don’t function well at pumping 5 or 6 liters of blood through the cardiovascular system every minute whether they are open or closed. Perhaps  the question is using either  the heart or an open book as a metaphor?

The advertisement goes on to suggest that I get my dad an AliveCor device for father’s day  “So you always know what his heart is thinking.”

I believe this is the marketing person’s attempt to extend the metaphor of the open book, i.e., you know exactly what dad’s brain is thinking, now you can extend this knowledge to his heart.  The metaphor of the heart “thinking” is quite poor but poor metaphors are the norm today.

Bad metaphors and bad writing abound on father’s day because 90 million greeting cards are purchased and given as (according to the Greeting Card Association)  “a meaningful expression of personal affection for another person.” Despite the increasing use of Facebook and its ilk to transmit emotions, the Greeting Card Association assures us that “The tradition of giving greeting cards … is still being deeply ingrained in today’s youth, and this tradition will likely continue as they become adults and become responsible for managing their own important relationships.

Mobile Ecg Monitor As A Father’s Day Gift

I have to say that despite the horror of the writing in this email advertisement it got me thinking about getting my father a Kardia device. I’ve suggested  previously that  an AliveCor device would make a good gift for Christmas for a loved one who has intermittent unexplained palpitations or atrial fibrillation but had not considered this for my dad.

For one thing he does not possess a smart phone which is required to  make the Kardia device functional. For another, he doesn’t have atrial fibrillation (that we know of. Perhaps if I knew what his heart was thinking we would find out that it likes to fibrillate late at night,)

Perhaps it’s time to upgrade my Dad to an iPhone I began thinking.

But wait! He has an iPad mini (that he seems to only use for FaceTime conversations.)

Further research reveals that Kardia is not only compatible with iPhone and Android smartphones but apparently iPads and IPod Touch.Screen Shot 2016-06-19 at 8.04.27 AM

Taking Care of Dad’s Heart

What about the rest of the slick advertising copy in my email?

And now you can know the way to help take care of it. Kardia gives Dad a medical-grade EKG in only 30 seconds. It even gives him expert analysis and tracking, with reports getting shared directly with his physician

This part is pretty clear and correct. I use Kardia daily in my office to record patient’s heart rhythm and I have a dozen patients now who make recordings outside of the office. They can have their recordings read by a random cardiologist for a fee or establish a link with me as their provider and I can review them through my account for free.

 Is It The First Father’s Day Gift That Leads To More Father’s Days?

The ad ends with the remarkably brazen statement that “It’s the first Father’s Day gift that leads to more Father’s Days.”

While I find the device more helpful in many instances than current expensive and intrusive long term monitoring devices for detecting and monitoring atrial fibrillation and other abnormal heart rhythms, it is a huge leap to suggest that this translates somehow into a longer life span.

To AliveCor’s credit, despite such ridiculous marketing drivel , studies presented at the recent Heart Rhythm Society Scientific Meetings suggest:

  • Kardia Mobile Superior to Conventional Monitoring: Researchers at the Leeds General Infirmary found that the AliveCor monitor is superior to conventional Holter monitoring in patients with palpitations, providing a higher diagnostic yield, more detected arrhythmias, with a similar workload.

  • Kardia Mobile Leads to Improved Patient Compliance:Researchers at the University of Buffalo found that AliveCor provides a diagnostic yield comparable to a 30-day ambulatory looping event monitor and that the smartphone-based ECG monitor can be used as a first approach for the diagnosis of palpitations.

  • Kardia Mobile provided more information resulting in changes in arrhythmia patient management than traditional external event recorders in a study from researchers at the University of Miami.

  • AliveCor’s AF algorithm was reported to be superior by researchers at Arizona State University to the patient’s own ability to detect AF via symptoms.

    But even if these studies make it to publication they don’t suggest the device provides any improved longevity. In fact, such data, do not exist for any monitoring device.

Happy Father’s Day, Dad! Don’t be surprised when we FaceTime later today that I’ve found another use for your iPad.

Paternally Yours,

-ACP

N.B. Clearly I receive no consulting, speaking or P.R. writing fees of any kind from AliveCor. Nor do they provide me with any free devices. What’s more, when I lose one of their devices they don’t replace it.  I am totally free of any conflict of interest.

 

AliveCor Is Now Kardia and It Works Well At Identifying Atrial Fibrillation At Home And In Office

I’ve been using the AliveCor Mobile ECG App/Device to record my patients’ heart rhythm in my office for about 6 months now.

It has for the most part taken the place of the more elaborate, but cumbersome and time-consuming, 12-lead ECG in patients where heart rhythm is my only concern.

I’ve also convinced about a dozen of my patients who have intermitent atrial fibrillation to obtain the device and they are actively using it to monitor at home their heart rhythm. Through the AliveCor website, I can view their recordings and see what their heart rhythm is doing when they have symptoms.

Last week, a patient of mine (I’ll call her Suzy) who has had significant prolonged episodes of atrial fibrillation associated with heart failure (but cannot tell when she is in or out of rhythm) notified me that her device was interpreting her rhythm as atrial fibrillation. She had not had any symptoms, but was making  daily recordings for surveillance.

Suzy called our office and we brought her in the next day and confirmed with a 12-lead ECG that she was indeed in atrial fibrillation with a heart rate of 120 beats per minute.

It’s pretty amazing that this little, inexpensive device can now replace expensive and elaborate long term cardiac monitors for many of my patients.

AliveCor Rebrands Itself to Kardia


Screen Shot 2016-03-28 at 5.38.34 AM
I’ve noticed that AliveCor has rebranded itself as Kardia. If you go to http://www.alivecor.com now you see the fourth generation device along with promotion of a “Kardia band” which apparently works with an Apple Watch to record your ECG.

The Kardia band is not available for purchase at this time but if and when I can get one, it might motivate me to purchase an Apple watch.

When I purchased my AliveCor device in June, 2015 it cost $74.99 from Amazon.com. The newer version is priced at $99 at both AliveCor and Amazon websites. I’m told by Dr. David Albert of AliveCor that this “fourth generation” version is more accurate, so I have purchased it to see if it reduces the problem of occasional bad recordings.

Screen Shot 2016-03-28 at 5.38.10 AM

You can see in this picture from the website that the formerly flat metal electrodes now have bumps. Dr. Albert says these result in more surface area for better contact with skin. We will see.

The Value of Early Detection Of Atrial Fibrillation

Meanwhile, I will be doing an electrical cardioversion (shocking or resetting the heart) on Suzy to get her back to normal sinus rhythm.  If we had not detected the asymptomatic onset of her rapid atrial fibrillation using the AliveCor/Kardia device, chances are we wouldn’t have known about it until her heart muscle weakened again and she became short of breath from heart failure.

I have Suzy on blood thinners to lower her risk of stroke associated with her Afib but for my patients who are not on blood thinners, detection of silent or asymptomatic AFib is even more important.

-Affibly yours,

-ACP

p.s. The skeptician in me feels this post borders on infomercialese.

Let me make it clear that I have no connection with the company formerly known as AliveCor and have received nothing from them (not even free test devices or Apple Watch Kardia Bands!) but I’m just really excited about the device and how it can help my patients (oh, please excuse me, this really sounds like marketing) “empower” themselves to take control of their heart rhythm.

In the course of writing this, I’ve discovered an academic paper evaluating 13 ECG smart phone type ECG devices so there are other devices you could try. I haven’t had the time or resources to evaluate them.

Are SSM and HealthFair Cardiovascular Screenings Promoting Wellness or Unwellness?

IMG_5657My patients and I continue to receive mailings from SSM Health Care (here in St. Louis), informing us that they have “partnered with HealthFair to deliver ultrasound tests of the heart and arteries” in our neighborhood.

If you are considering getting these, I recommend reading my  previous post on them (Shoddy Cardiovascular Screenings are more likely to cause harm than good). Also, I recommend this summary (which points out in well-referenced detail that these are not recommended by major preventive organizations) from a blogger who writes eloquently on the lack of benefit of wellness programs.

HealthFair’s financial model involves partnering with hospitals like SSM to promote these unnecessary screenings performed in mobile vans that travel to settings like Walgreen’s out in the community. The hospital system pays HealthFair (typically an “undisclosed amount”) to put the SSM name on their promotional flyers.  SSM does not provide any review of the quality of the studies performed.

SSM benefits by having its “brand” spread around and when abnormalities are detected on the exams, these patients are then provided with the names of SSM physicians.

Both SSM and HealthFair benefit in this relationship by identifying as many abnormalities as possible. It doesn’t really matter to either if the abnormalities detected are real or important. The bottom line is getting more patients into the SSM system, getting down stream referrals and testing and adding to the SSM bottom line.

Steven Weinberger, MD executive vice president and chief executive of the American College of Physicians. and two co-authors wrote in the Annals of Internal Medicine journal,  calling hospital involvement without disclosing potential downsides “unethical.”

“Because of a lack of counseling by these companies about the potential risks of an “abnormal” test result, the consumer is initially unaware that this may open a Pandora’s box of referrals and additional testing to monitor or treat these abnormal findings. Our medical system and society bear the cost of poor coordination of care and additional testing and treatment to follow up on unnecessary “abnormal” screening test results (10). That most of these tests are not medically indicated in the first place is left undisclosed to the consumer, nor is there a discussion of potential adverse consequences or additional costs.”

The Particular Dangers of Screening Echocardiography

In my previous post I warned in particular of the dangers of getting a screening echocardiogram, a test which I have spent my professional lifetime studying, writing on, teaching and interpreting.

I’ve also discussed in detail how easy it is to botch an echocardiogram and what to look for to guarantee that you are getting an accurate study.

Let me provide another example of how a poorly performed and/or interpreted echocardiogram can lead to a lifetime of unnecessary anxiety and inappropriate testing.

I saw a patient in my office recently who was changing cardiologists because of dissatisfaction with communication. Reviewing records from the prior cardiologists, I saw that an echocardiogram was performed in 2012 and read as showing enlargement of the aortic root and pulmonary hypertension.

A greatly enlarged aorta or aortic aneurysm can rupture or tear resulting in sudden death. It’s a very serious condition, consequently once enlargement of the aorta is identified, we counsel patients on appropriate activities, screening of relatives, and follow them lifelong with tests to monitor the size of the aorta.

I reviewed the echocardiogram which was performed in the cardiologists’ office and it was clear that an older echocardiographic technique called M-mode had been utilized, and that the measurement was invalid. When I repeated the echocardiogram in my hospital’s echocardiography laboratory, it was normal (we have a very rigorous quality assurance program and review on a regular basis with the sonographers and physicians best practice for recording and measuring the aorta by two-dimensional recordings).

Pulmonary hypertension (elevation of the pressures on the right side of the heart) can also be a sign of very severe and life threatening cardiac or pulmonary problems. If diagnosed, it typically requires extensive testing with associated risks. Like aortic root enlargement, it must be followed carefully, lifelong.

Pulmonary hypertension can be measured reasonably accurately by a well done echocardiogram utilizing a combination of Doppler flow measurements and imaging of the inferior vena cava.  Because of the critical importance of getting these measurements right, I have devoted numerous educational conferences to reviewing them with our sonographers and reading physicians.

In the case of my patient (and I presume, numerous patients undergoing less rigorously performed screening echocardiograms) the initial echocardiogram did not truly show pulmonary hypertension and the echocardiogram I did confirmed this.

The Profit Factor

Ultimately, these types of screenings done in the name of promoting wellness, are being done for money.

HealthFair is strictly in it for profit; they want to get as many patients as possible paying for these screenings. Their bottom line is not enhanced by spending time and money on guaranteeing that good equipment, trained sonographers and experienced physician readers are involved.

SSM is only interested in getting more patients funneled into their system. They are paying HealthFair to identify abnormalities and therefore, abnormalities will be found. SSM in this relationship is going against good medical practice and recommendations of national medical organizations in order to make money.

A program that on the surface is promoting wellness, therefore, in the final analysis may be promoting unwellness.

If you have had one of these echocardiographic screenings and had an abnormality detected, I would be happy to review the initial recordings and provide my opinion on their accuracy.  I would do this gratis as the skeptical cardiologist in the interest of research and knowledge, not to accumulate patients or revenue.

-ACP

 

Mysterious AliveCor Mobile ECG artifact noted at Commander’s Palace

The skeptical cardiologist was in New Orleans last  weekend. There is no breaking low carb news to report but I did make it to Commander’s Palace for lunch.

Screen Shot 2015-10-29 at 3.18.45 PMThere the eternal fiancée of the skeptical cardiologist (EFOSC)  and I enjoyed delicious food, delightful company (Dave and Barb, who I wrote about last year when they dramatically improved their longevity by tying the knot in The Big Easy) and several oddly colored $0.25  martinis.

barbalivecor
Full disclosure. This was taken during brunch at Broussard’s and is a recreation of the aliveCor recording session at Commander’s Palace. Note the jazz trio in the background who later came by our table and played the St. Louis Blues.

During a lull in the activities I pulled out my iPhone and was asked by the lovely Barb what the funny looking thing stuck on the case was. This necessitated demonstrating my Alivecor mobile ECG device and recording her electrocardiogram.

CPalivecor annotated
The red arrows point to a regular artifact occurring at 200 beats per minute. Toward the end of the recording the artifact goes away and the normal QRS complexes (blue arrows) can be seen clearly.

Strangely enough, the recording was full of an odd artifact.

There was much discussion on the source of the artifact and we repeated the recording having her use her third and fourth fingers on the electrodes instead of the second and third fingers she used the first time.  Same result.

Barb speculated that it was due to the absence of husband Dave who had left the table to use the facilities.

When Dave returned we recorded his ECG and there was no artifact whatsoever.

Screen Shot 2015-10-29 at 3.15.04 PMI repeated the recording on Barb and lo and behold it was now free of artifact.

What was the source of this mysterious ECG artifact noted after an outstanding lunch and multiple 25 cent oddly colored martinis?

High blood alcohol level?

Strange electrical devices being utilized intermittently at Commander’s Palace?

Or perhaps I was recording the actual adverse electrical signals created by the absence of Barb’s devoted spouse, something heretofore not reported.

Further studies are clearly needed to fully define and characterize these waves which I have decided to call Commander’s electromagnetic marriage disruption waves or CEMDW’s.

martinily yours

-ACP

 

 

 

Should You Get a Stress Test After Your Stent or Bypass Operation If You Feel Fine?

If you’ve had a coronary stent implanted or undergone bypass surgery, it is common to wonder about the status of the stent or the bypass grafts or the coronary arteries that maybe had a 50 or 60% blockage and were left alone.

This is especially likely if there was little or no warning that you had really severely blocked coronary arteries.

After all, you are thinking: “doesn’t it make sense to monitor these things and stay on top of them; be proactive?”

It certainly seems reasonable on the surface, and for many years, routine stress testing of patients without symptoms on an annual basis, was the norm.

However, this practice is much more likely to cause harm than to benefit patients and is recognized by the American College of Cardiology as one of 5 things that patients and physicians should question as part of the “Choosing Wisely” campaign (see here).

“Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes.”

Studies have shown that stress testing less than two years after a coronary stent, very rarely change management.

The American College of Cardiology, American Society of Echocardiography and the American Society of Nuclear Medicine are all in agreement that stress testing less than two years after a coronary procedure is “inappropriate,” and more than two years after the procedure is “uncertain.”

Why Do Cardiologists Order These Tests If They Are Inappropriate?

There are 3 reasons, and they are representative of the major factors driving all over-testing in medicine.

  1. Financial. Cardiologists frequently benefit from stress tests they order in multiple ways. First, they may own the nuclear camera used in the test and the more stress tests performed in their office, the more money they will make from the technical remuneration for the procedure. The cardiologist also frequently interprets the test results and receives a professional fee for both supervising and interpreting the nuclear images. Finally, if the test is abnormal, the cardiologist may then recommend additional testing, which he may perform (cardiac catheterization, stent) or interpret (coronary CT angiogram).
  2. Defensive medicine. It is not uncommon for cardiologists to be sued for NOT performing a test or procedure when the patient’s outcome is bad. On the other hand, I have never heard of a cardiologist being sued for DOING an inappropriate stress test.
  3. Keeping the customer happy. Too often patients feel that if their doctor is performing frequent tests on them, he is being vigilant, proactive and “staying on top of things.” They don’t realize the down sides to the extra testing and the lack of benefit.

Not uncommonly, patients switching to me from another cardiologist indicate that they have been getting an annual stress test and are disappointed to hear that I am not recommending one.

They may think that I’m lazy or not up on the latest techniques in cardiology. Usually in this situation I have to spend a fair amount of time trying to teach them about the possible downsides of over-testing.

In the case of stress nuclear testing, harm comes from two sources:

  1. Radiation. Stress nuclear tests typically utilize the radio tracer Technetium-99 and result in a radiation dose of around 15 mSv. This is about 10 times the radiation from a typical coronary calcium scan. A chest x-ray gives 0.02 mSV and the annual background radiation in the US is 3 mSv.
  2. False positives. Nuclear imaging is very susceptible to images which appear to show abnormalities of blood flow, which in reality are just due to soft tissue (breast, diaphragm, fat) interposed between the heart and the camera. These can be interpreted as due to a heart attack or blocked coronary artery when everything is actually fine with the artery.  False positives then lead to additional testing such as a cardiac catheterization, which carries risks of bleeding, heart attack, stroke and death.

One important point to remember is that coronary stenting has not been shown to reduce heart attacks or prolong survival outside the setting of an acute heart attack. Therefore , if you’ve already had a cardiac catheterization that either resulted in bypass surgery or a stent of one artery, it is highly unlikely that a subsequent catheterization/further procedures will lower your heart attack or dying risk.

Certainly, if you have a change in symptoms that suggest that your coronary artery disease has progressed, this is an appropriate reason to consider stress testing. Such symptoms include shortness of breath on exertion and chest discomfort, especially if it occurs during activity. Diabetics often don’t have symptoms that warn them of a problem, therefore, we should consider stress testing more frequently and at a lower threshold for them.

For most people, however, more is not always better when it comes to cardiac testing and, in many circumstances, can be worse.

Here’s to choosing wisely,

-ACP