Category Archives: Uncategorized

What Is A Cardiologist?

The skeptical cardiologist recently received a cease and desist letter from a lawyer representing Dr. Steven Gundry who felt I was defaming the goop doctor and supplement peddler by saying he was not a cardiologist.

The lawyer’s letter reminded me that many patients do not understand exactly what a cardiologist is and mistake us for cardiothoracic surgeons.

Here’s how the American College of Cardiology defines a cardiologist:

A cardiologist is a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels.

And here is part of my response to the lawyer which further clarifies the differences:

I understand your confusion with respect to the terminology of cardiologist versus cardiac or cardiothoracic surgeon. A surprising number of patients and readers think that I as a cardiologist perform “heart surgery.” Of course, actual surgery on the heart requiring “cracking open the chest” (which is what most laypeople consider “open heart surgery”) is always done by a cardiac surgeon not a cardiologist.

Like all other board-certified cardiologists I have gone through accredited training programs in internal medicine followed by a formal cardiology training program. There is no evidence that Dr. Gundry has done this.

Cardiologists, being extremely bright, entrepreneurial  and energetic, have expanded the toolkit they have for diagnosing and treating heart disease without having to engage in surgery. Thus,
cardiologists can insert  stents to open blocked coronary arteries, implant pacemakers and even replace valves all by accessing the cardiovascular system via its arteries and veins.

We don’t call this surgery because we aren’t surgeons and didn’t go through surgical training. We call these procedures. These are invasive procedures, to be fair, as we have invaded the vasculature and the interior of the heart and from these arterial and venous incursions complications may ensue.

A typical invasive procedure that cardiologists do looks like this:

This is a cardiologist  gaining access to the arterial system by inserting a catheter into the radial artery.

 

 

A typical open heart surgery performed by a cardiothoracic surgeon requires large incisions with direct visualization of the heart and looks like this:

 

 

 

 

 

Cardiologists And Cardiac Surgeons Undergo Totally Different Training

I began my response to Gundry’s lawyer by indicating my surprise that the lawyer felt Gundry was a cardiologist:

This comes as quite a surprise to me as my detailed research into Dr. Gundry’s background, training and credentials revealed absolutely no evidence that he is or ever was a cardiologist as we in the medical community define cardiologist. In fact, as you can see in his listing on CTSnet (which is a network of cardiothoracic surgeons) his post medical school training consisted of the following

University of Michigan Hospitals Surgery Internship (1977-78)
National Institutes of Health, Clinical Associate in Cardiac Surgery (1978-80)
University of Michigan Hospitals Surgery Residency (1980-83)
University of Michigan Hospitals Cardiothoracic Surgery Residency (1983-85)

He is trained as a cardiothoracic surgeon. Cardiothoracic surgeons go through surgical training programs which are completely different from the medical training programs that cardiologists like myself go through.

My description of him in this regards reads as follows:

“He is also widely described as a cardiologist but he is not, He is (or was) a cardiac surgeon (like, strangely enough, the celebrity prince of quackery, Dr. Oz)”

As you can see, my statement is perfectly accurate.

As far as him being a being elected a “Fellow of the American College of Cardiology” I can find no documentation of this and he is not currently listed as a member of the American College of Cardiology. But even if he was this does not make him a cardiologist because many cardiothoracic surgeons are members of the ACC.

Might I suggest you ask Dr. Gundry if he thinks he is a cardiologist. I’m pretty sure he would answer no.

What Is A Quack?

The lawyer then went on to accuse me of suggesting that Gundry is a quack because:

A “quack” is defined in common parlance as a lay person pretending to be a licensed physician. In other words, a fake doctor. The term “quack” connotes dishonesty, deception, fraudulent behavior, etc. Dr. Gundry has been a licensed physician and surgeon since at least 1989 (see Exhibit B attached), performed thousands of heart surgeries, and developed patented, life- saving medical technology. Your statements are not only factually incorrect, but are also irresponsible and intentionally misleading, resulting in harm to Dr. Gundry’s reputation and income.

To which I responded:

There seems to be an attempt here to suggest that by saying he is not a cardiologist I am calling him a quack. But as my previous information should have convinced you he is not a cardiologist but a cardiothoracic surgeon. He has done very good work as a cardiothoracic surgeon and I am happy to attest to that. I will be happy to add that information to his description in my up and coming posts on him.

At no point do I call him a quack in my posts. Clearly if I’m calling him a cardiothoracic surgeon I am acknowledging that he is a licensed physician and not, clearly, a fake doctor.

I have to admit my definition of quack has not been the common dictionary definition of “fake medical doctor.”  I have always considered those who engage in quackery to be quacks.

Quackery is defined at Quackwatch (the definitive website on the topic) as the promotion of unsubstantiated methods that lack a scientifically plausible rationale. 

And one can have a perfectly legitimate training as a medical doctor and engage in what most would consider quackery.

Even board-certified cardiologists like myself can engage in quackery.

Clearly there is a disconnect between the common definition of quack and that of quackery and in a  subsequent post I will delve further into the miasma of quackery, quacks and quacking,

Anatinely Yours,

-ACP

N.B. While researching this post I came across a fantastic article on Gwyneth Paltrow’s goop Doctors from David Gorski at Science-Based medicine. I highly recommend reading the entire piece (gwyneth-paltrow-and-goop-another-triumph-of-celebrity-pseudoscience-and-quackery) for your edification and pleasure.

Gorski’s paragraph on Gundry begins

  • Dr. Steven Gundry, a cardiothoracic surgeon very much like Dr. Mehmet Oz who, as he took incredible pains to lecture Dr. Gunter in his section of Goop’s hit piece on her, who once was a very respectable academic surgeon and, even better than Dr. Oz, served as Chairman of Cardiothoracic Surgery at Loma Linda University for a number of years, before leaving academia to undertake his private practice. (No wonder he and Dr. Oz seem to have an affinity for each other!) These days, he devotes his time to his practice, writing books, giving talks, and selling expensive supplements like Vital Reds (a bargain at $69.95 for per jar, discounted to $377.73 if you buy six jars) and Lectin Shield (a slightly more expensive bargain at $79.95 a jar, $419.70 for six), while bragging (as he did in his response to Dr. Gunter) about how so very, very hard he works and even—gasp!—accepts Medicare and Medicaid patients. His most recent book is The Plant Paradox: The Hidden Dangers in “Healthy Foods” That Cause Disease and Weight Gain. (Spoiler: That “hidden danger” is lectins.)

 

Featured image Photo by Ravi Singh on Unsplash

Does One Need A Doctorate To Analyse Science? And Does Bias Smell?

The skeptical cardiologist reserves the exclusive and unimpeachable right to censor reader comments he deems inappropriate, nasty or unhelpful.

There’s a good chance if you attack me personally, I won’t post your comment. On the other hand,  if I find your attack particularly amusing there is a good chance I’ll include it in a blog post.

Here’s an ad hominem attack I really enjoyed:

You may be an MD, but you are no doctor. That requires a doctorate, which I have, and I can smell the bias from the other side of the Earth. Your “skepticism” is a front for your cynicism, and you yourself are the very thing you hate when denigrating people like Esselstyn as “evangelists”. Get a doctorate degree and learn science before attempting to analyse it.

There is so much to unpack and ponder in this paragraph! I love it.

The reader says that I am “no doctor.” This, it appears, requires a doctorate (which, coincidentally my reader has). The reader advises me to “get a doctorate degree” before attempting to analyse science.

The Cambridge English dictionary defines doctorate as “the highest degree from a university” whereas Merriam-Webster defines it as “the degree, title, or rank of a doctor”

If we assume the reader is going by the Cambridge English definition, and my title of doctor of medicine doesn’t count as a doctorate, let’s see what does.

Wikipedia lists a ton of different types of doctorates. My reader didn’t specify what kind. Would a Doctor of Music qualify me to analyse science? If so, sign me up for the coursework.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

My newly-minted mother-in-law has a doctorate in English, is she more qualified than me to analyse science?

The reader left his comment on my post about the death of Robert Atkins, so I’m not even sure what bias I am accused of, but I love this sentence:

“I can smell the bias from the other side of the earth”.

In my defense it should be pointed out that the entire Robert Atkins post is a precise  analysis of his medical history and doesn’t really touch on science. Perhaps the bias my reader smells from so far away is my bias to seek the truth.

Finally, I have to say the killer sentence in my reader’s comment  is the most brilliant ad hominem attack I have ever encountered:

Your “skepticism” is a front for your cynicism, and you yourself are the very thing you hate when denigrating people like Esselstyn as “evangelists”.

It is so deep and piercing that I am incapable of defense and I can only say “mea culpa” and I yield to your doctoral brilliance.

By the way, this whole PhD versus MD debate brings up the burning question of who one should be referring to as doctor. Should I address my mother-in-law as Dr. Perkins since she has a Ph. D. in English Literature?  And, by the way, although she is my go-to person for questions about D.H. Lawrence, Hemingway and Shakespeare, I don’t think her scientific analytic skills are up to mine even with her doctorate.

Doctorally Yours,

-ACP

Photo by Adrien Converse on Unsplash

N.B. I have deduced my reader is from Australia based on his use of analyse and his smelling my bias on the other side of the earth.

(Also, his email address ends in au)

frequency of usage of analyse versus analyze in England
frequency of usage of analyse versus analyze in England .
frequency of analyse versus analyze in America

 

 

I Am A Keto-Friendly Cardiologist And I Love Keyto

The skeptical cardiologist has become more selective with regard to who he will accept as a new patient.  In practical terms this means I now call patients who want to see me and discuss with them why they want to see me, how they were referred or heard about me, and what their expectations are.

This might seem a little odd but turns out to be an excellent way for me to meet and smooth entrance for these newbies into my practice and gather important records and recordings prior to the first visit.

Recently, when I asked one of these potential patients why they had sought me as their cardiologist, the wife told me that through her internet research she had gleaned that I was a “Keto-friendly Cardiologist.”

Given that I have challenged conventional dogma on the dangers of dietary saturated fat and cholesterol and have written about ketosis (see here and here) a few times on this blog and defended Dr. Atkins I do actually consider myself “keto-friendly”.   However my prospective patient’s wife was not aware of the skeptical cardiologist as a blog writer.

How or why I was identified as Keto-friendly cardiologist was not clear.

I realized I needed to make it perfectly clear. It is now time to come out of the keto closet.

I am a “Keto-friendly cardiologist”!

I have dozens of patients who have been very successful using very low carb/high fat diets to help them lose weight and gain control of their diabetes and hypertension.

I don’t poo poo low carb high fat diets and I think they are vey compatible with a heart-healthy existence.

(I also advocate my version of a “plant-based diet“.)

In fact, lately I’ve gone back to dabbling with a Keto Diet myself.

To aid me in the dabbling I have found a device called Keyto to be the key to success and understanding of my ketosis.

Keyto: Breath Sensor for Ketosis and Weight Loss

When I went back to dabbling with ketosis in early 2019 I was using the Keto-Mojo finger prick device to measure my blood levels of beta hydroxybutyrate. I liked the precision this offered  compared to urine dip sticks but grew to dislike the need to prick my finger and create blood loss.

About a month ago I ordered I discovered the keto breath sensor KEYTO and have found since then that  it wonderfully simplifies  the process of being on a keto diet.

Keyto costs $99 and comes in a box the size of a video cassette  case.

In the box is the sensor device, four blowing mouthpieces, a very simple user manual, a AAA battery and a cute little bag for carrying the device

Ethan Weiss, MD, a highly respected preventative cardiologist and founder of Keyto includes a welcoming message for users which summarizes the mission of Keyto:

We designed the Keyto program to help you over-achieve your weight loss and health goals. With the Keyto Breath Sensor in this box, and the Keyto App on your phone, you have the key to unlocking success. You’ll be eating delicious foods, losing weight, and many  users even report an increase in energy and focus

Using Keyto Is Simple and Convenient

Getting started with Keyto is very easy: download the Keyto smartphone app, log in and follow the straightforward directions for pairing the breath sensor with the app.

Once paired via Bluetooth making measurements is easy. It’s important to understand the breathing technique needed and to facilitate this I strongly recommend watching the brief explanatory video Weiss has provided. Basically, you want to use a normal breath and blow for 10 seconds so that you are near the end of expiration when the device makes its recording.

To initiate a measurement you push the plus sign on the main “Journey” screen in the app then push the on button on the sensor.

Usually, if the sensor has been turned on and the app is activated the app immediately connects to the sensor, occasionally I have had to turn the sensor off and on again to initiated the connection.

At this point the sensor begins  warming up, reaching a temperature of 400 degrees Fahrenheit over a period of about 80 seconds.

The app displays the progress and offers you the option of answering some questions about how you are feeling and doing on the keto diet.

I often take my BP while this is going on. Sometimes I read the New Yorker. Frequently I listen to Radiohead (Climbing Up The Walls). It takes a while. Pay attention, though. You don’t want to miss your blowing window and have to repeat the process.

 

The app will give you a warning about 10 seconds prior to the time you need to blow. The graph to the right appears when it is time to blow and you can view the sensors output as it tracks the acetone it is seeing over the 10 seconds that you blow.

At the end of the blow you wait a few seconds, eagerly awaiting your score. Will you be in Ketosis?

 

Finally, your score is revealed. In this case I was congratulated for being in light ketosis with a fat burn of “medium high.” The highest score is an 8.

You can add notes to the record of your score

If you blow a 6 the app tells you that your fat burn is high and that you are in ketosis: “metabolizing fat like a champion.”

Accuracy of Keyto

When I first began using Keyto I checked the Keyto numbers versus the beta hydroxybutyrate (BOHB)  numbers I was simultaneously getting from my Keto-Mojo meter.

I found a Keyto 3 corresponded to 0.8 BOHB, a Keyto 4 to 0.9 BOHB, and a 5 to 1.0 BOHB.  That was enough to convince me that the device was accurate and useful in measuring my level of ketosis.

Given that it is so convenient compared to a finger stick I have stopped using the Keto-Mojo completely.

My observations confirm what Weiss and Ray Wu, MD, the cofounders of Keyto describe in very lucid prose here.

In extensive user testing, Keyto is directionally consistent with the more accurate commercially available blood meter. Keyto and blood β-hydroxybutyrate trend directionally the same in the majority of cases. Both go up and down in similar magnitude at different ranges of ketosis. There are some differences which are likely due to biology – the kinetics of clearance of acetone and β-hydroxybutyrate are not identical.

Some of the differences are also likely due to how we designed the Keyto program. Our primary goal was to develop a system that would give users the information they need to know i.e. if they are in ketosis, which would ultimately help promote healthy behavior change. Therefore, we chose not to report acetone concentrations in PPM or to attempt to convert PPM to blood β-hydroxybutyrate (mmol/L). The Keyto Level system was simply more effective, motivating, and fun without adding complexity and false precision.

I can make multiple measurements throughout the day without worrying about the cost or the discomfort of a finger stick. The ability to make multiple measurements means that I am getting very rapid and frequent feed back on how my dietary and lifestyle choices are effecting my level of ketosis.

Warning! Because the device is so convenient-literally you can have it with you at all times-you may find yourself blowing into it excessively. This may irritate your friends and loved ones, especially those that aren’t on a keto diet.

Keyto is Legitimate

The Keyto website has an excellent introduction to the keto diet (keto 101) and has numerous other very helpful resources for those who seek to lose weight using the diet.

In general I get a good feeling of integrity and legitimacy from every aspect of the Keyto operation.

I have a tremendous professional respect for Ethan Weiss, the cardiologist behind Keyto. He’s very active on Twitter and is typically spot on with his comments. He’s done a podcast with Peter Attia which serves as an excellent summary of atherosclerosis and coronary artery disease. He does really good basic science research involving growth hormone.

Weiss is now doing his own podcast called Best Known Method by Keyto which I highly recommend. It is not, surprisingly, focused on the keto diet or the keyto brand but interviews thought leaders in cardiology like Ron Krauss and Lisa Rosenbaum.

If you want to read more about how the Keyto breath sensor works see here. This is a very clear and concise description of the science behind the device and it is complete with references.

Ultimately, although I consider myself a keto-friendly cardiologist, I’m most interested in the diet that helps my patients achieve  and sustain their goals of weight loss and better health. For many this is the keto diet.

And for those who find the keto diet is optimal for their health I will be advising them to acquire a Keyto breath sensor and check out the programs Keyto offers to support their health goals.

Acetonely Yours,

-ACP

Thank You, America, From A Non-Refugee Immigrant

This being July 4,  the skeptical cardiologist is reminded of how much he owes the United States for allowing him to become a legal citizen and resident. I asked my sister, Vickie, who emigrated with me from England in 1959 what she was thankful for in the United States and she texted back:

The opportunities this country gives so many refugees. I am friends with so many that love the USA for the freedom we have and wonderful people who have supported them! Thanks for asking!

The US  has been kind to refugees in the past, especially around the time my family immigrated to the US in the late 1950s.

In 1956,  President Eisenhower used “parole powers” to let in Hungarian refugees fleeing Soviet retribution after their failed revolt. By 1960 there were more than 200,000 Hungarian refugees in the US.

In January of 1959, Fidel Castro overthrew Batista in Cuba and, thousands of Cubans were  admitted to the US as political refugees. Eventually, all these Cubans were made US citizens.

The United States eventually enacted the 1966 Cuban Adjustment Act to allow permanent resident status to Cuban refugees who arrivee after 1959. About one million Cubans emigratee to the United States between 1959 and 1990.

Immigration Policy in 1959

Given recent turmoil surrounding immigrants and immigration I felt compelled to look back on what the immigration process looked like when I entered the US.

The process of my gaining citizenship began in 1959 when my dad and mom decided to emigrate from England and come to the United States.

The Immigration and Nationality Act of 1952 made it easy for us to come here because  it  “(1) reaffirmed the national origins quota system, (2) limited immigration from the Eastern Hemisphere while leaving the Western Hemisphere unrestricted, (3) established preferences for skilled workers and relatives of U.S. citizens and permanent resident aliens; and (4) tightened security and screening standards and procedures.”

Decisions on who to allow into the country it seems have long been a source of controversy as this summary of post-world war II US immigration policy makes clear. The 1952 Immigration Act under which we entered  ended policies dating from the 1890s that excluded Asian immigrants. However, only 100 immigrants from each country in Asia were allowed.

The bill upheld the ethnicity-based quota system for new immigrants that favored white Europeans, revising limitations to admit one-sixth of 1 percent of each group already in the United States.

Under the 1952 act my family was welcomed into the US. When my dad visited the American consulate in Liverpool he was told he was a shoe-in since he was a white European who was trained as a chemist. In addition, my mother’s sister resided in the U.S.A. (Coffeyville, Kansas to be exact).

I Become A Citizen

In 1968, after 9 years in America, my parents were sworn in as United States Citizens.

It was at that time that I became naturalized under section 341 of that 1952 Immigration Act which allowed children under the age of 18 to become citizens when their parents had passed all the citizenship requirements and were sworn in.

What Is This Immigrant Thankful For?

There is so much that I take for granted in the US. I feel like  even the poorest Americans are better off  than 99.9% of the people who have ever lived. The framers of the US constitution were really brave, insightful men and that first amendment is something I am profoundly grateful for.

Amendment I. Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.

I won’t bore you with a long list of other great things about the US (like free public bathrooms and high doctor salaries) but will end with a paean to the great National Park System which has preserved the beauty and the wildness of vast swaths of unique areas across the continent.

I have taken my family hiking in as many of these wonders as time allowed: Zion, Rocky Mountain, Bryce, Yosemite, Great Smoky Mountains, Grand Canyon, Yellowstone, Grand Tetons, US Virgin Islands and Saguaro.  

My first paean to the national park system was at the end of my Saguaro post:

Since my kids became old enough to appreciate hiking and nature I have tried to focus family vacations on visits to National parks. I can’t think of any more valuable experience for them than hiking in some of the most beautiful places on earth and experiencing diverse and fascinating flora and fauna.  And all of this comes at a ridiculously low price for the user.

For example, because I’m 62 years old I qualify for a Lifetime senior pass to all National parks and monuments. Cost? 10$!!!! I’m finally seeing the perquisites of becoming a senior citizen.

Since the National Park Service was created in 1916 it has grown to protect 88 million acres, 43,000 miles of shoreline, 85,000 miles of rivers and streams, 12,000 miles of trail and 8,500 miles of road in more than 400 national parks, sites and monuments.

I sure hope the vision of prior Presidents, Congressman and ardent conservationists (all praise be to Teddy Roosevelt!) who established the federal system that protects these national treasures continues.

Happy Birthday America, my adopted countryland!

Pyrotechnically Yours,

-ACP

The Ultimate Guide To The Coronary Artery Calcium Scan (Score) Circa 2019

The skeptical cardiologist’s first post on coronary artery calcium (CAC) scan was posted in 2014 and had the wordy title “Searching for Subclinical Atherosclerosis: Coronary Calcium Score-How Old Is My Heart?”

This post still serves as a good introduction to the test (rationale, procedure, risks) but in the 5 years since it was published there has been a substantial body of data published on CAC and in 2018 it was embraced by major organizations.

Overall, I’ve written 20 posts in which CAC plays a predominant role since then and I feels it’s time to put the most important changes and concepts  in one spot.


Detection Of Subclinical Atherosclerosis: What’s Your Risk of Dropping Dead?

First, the rationale for using CAC (also known as a coronary calcium score or heart scan) is detection of “subclinical atherosclerosis”, a non-catchy but hugely important process which I describe in an early post on who should take aspirin to prevent heart attack or stroke:

We have the tools available to look for atherosclerotic plaques before they rupture and cause heart attacks or stroke. Ultrasound screening of the carotid artery, as I discussed here, is one such tool: vascular screening is an accurate, harmless and painless way to assess for subclinical atherosclerosis.

In my practice, the answer to the question of who should or should not take aspirin is based on whether my patient has or does not have significant atherosclerosis. If they have had a clinical event due to atherosclerotic cardiovascular disease (stroke, heart attack, coronary stent, coronary bypass surgery, documented blocked arteries to the legs) I recommend they take one 81 milligram (baby) uncoated aspirin daily. If they have not had a clinical event but I have documented by either

  • vascular screening (significant carotid plaque)
  • coronary calcium score (high score (cut-off is debatable, more on this in a subsequent post)
  • Incidentally discovered plaque in the aorta or peripheral arteries (found by CT or ultrasound done for other reasons)

then I recommend a daily baby aspirin (assuming no high risk of bleeding).


Help In Deciding Who Needs Aggressive Treatment

Second, CAC is an outstanding tool for further refining risk of heart attack and stroke and helping better determine who needs to take statins or undergo aggressive lifestyle reduction, something I described in detail in my post “Should All Men Over Sixty Take a Statin Drug”.

The updated AHA/ACC Cardiovascular Prevention Guidelines came out in 2013.

After working with them for 9 months and using the iPhone app to calculate my patients’ 10 year risk of atherosclerotic cardiovascular disease (ASCVD, primarily heart attacks and strokes) it has become clear to me that the new guidelines will recommend statin therapy to almost all males over the age of 60 and females over the age of 70.

As critics have pointed out, this immediately adds about 10 million individuals to the 40 million or so who are currently taking statins.

By identifying subclinical atherosclerosis, CAC scoring identifies those who do or don’t need statins.


This is particularly important for patients who have many reservations about statins or who are “on the fence” about taking them when standard risk factor calculations suggest they would benefit.


The Widowmaker

In 2015 I wrote about a documentary entitled “The Widowmaker” (see here and here) which is about the treatment and prevention  of coronary artery disease and what we can do about the large number of people who drop dead from heart attacks, some 4 million in the last 30 years:

The documentary, as all medical documentaries tend to do, simplifies, dumbs down and hyperbolizes a very important medical condition. Despite that it makes some really important points and I’m going to recommend it to all my patients.

At the very least it gets people thinking about their risk of dying from heart disease which remains the #1 killer of men and women in the United States.

Perhaps it will have more patients question the value of stents outside the setting of an acute heart attack. This is a good thing.

Perhaps it will stimulate individuals to be more proactive about their risk of heart attack. This is a good thing.

Although CAC has some similarities to mammography (both utilize low dose radiation, 0.5 mSV) I concluded that CAC was not “the mammography of the heart” as the documentary proclaims.

What We Can Learn From Donald Trump’s CAC?

In 2018 I noted that “Donald Trump Has Moderate Coronary Plaque: This Is Normal For His Age And We Already Knew It.”

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

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

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

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

What is most notable about the Trump CAC incident is that Trump, like all recent presidents and all astronauts underwent the screening. If the test is routine for presidents why is it not routine for Mr and Mrs Joe Q Public?

At a mininum we should consider what is recommended for aircrew to the general public:

A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation.

The 2018 guidelines Take A Giant Step Forward

In late 2018 I noted that CAC had been embraced by major guidelines:

I was very pleased to read that the newly updated AHA/ACC lipid guidelines (full PDF available here) emphasize the use of CAC for decision-making in intermediate risk patients.

 

 

 

For those patients aged 40-75 without known ASCVD whose 10 year risk of stroke and heart attack is between 7.5% and 20% (intermediate, see here on using risk estimator) the guidelines recommend “consider measuring CAC”.

If the score is zero, for most consider no statin. If score >100 and/or >75th percentile, statin therapy should be started.

A Few Final Points On CAC

First, it’s never too early to start thinking about your risk of cardiovascular disease. I have been using CAC more frequently in the last few years in  individuals <40 years with a strong family of early sudden death or heart attack and often we find very abnormal values (see here for my discussion on CAC in the youngish.)

coronary calcium scan with post-processing on a 45 year old white male with very strong history of premature heart attacks in mother and father. The pink indicates the bony structures of the spine (bottom) and the sternum (top). Extensive calcium in the LAD coronary artery is highlighted in yellow and in the circumflex coronary artery in ?teal. His score was 201, higher than 99% of white male his age.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If heart disease runs in your family or you have any of the “risk-enhancing” factors listed above, consider a CAC, nontraditional lipid/biomarkers, or vascular screening to better determine were you stand and what you can do about it.

Included in my discussions with my patients with premature ASCVD is a strong recommendation to encourage their brothers, sisters and children to undergo a thoughtful assessment for ASCVD risk. With these new studies and the new ACC/AHA guideline recommendations if they are age 40-75 years there is ample support for making CAC a part of such assessment.

Hopefully very soon, CMS and the health insurance companies will begin reimbursement for CAC. As it currently stands, however, the 125$ you will spend for the test at my hospital is money well spent.

The Importance of Proactivity

In “The MESA App-Estimating Your Risk of Cardiovascular Disease With And Without Coronary Calcium Score” I recently wrote that:

If you want to be proactive about the cardiovascular health of yourself or a loved one, download the MESA app and evaluate your risk.  Ask your doctor if a CACS will help refine that risk further.

There are many other questions to answer with regard to CAC-should they be repeated?, how do statins influence the score?, is there information in the scan beyond just the score that is important? Is a scan helpful after a normal stress test?

I’ve touched on some of these in the past, including the really tough  question “Should All Patients With A High Coronary Calcium Score Undergo Stress Testing?

Like most things in cardiology we have a lot to learn about CAC. There are many more studies to perform. Many questions yet to be answered.

A study showing improved outcomes using CAC guided therapy versus non CAC guided therapy would be nice. However, due to the long time and thousands of patients necessary it is unlikely we will have results within a decade.

I don’t want to wait a decade to start aggressively identifying who of my patients is at high risk for sudden death. You only get one chance to stop a death.

Apothanasically Yours,

-ACP


 

How To Be A Victorian Doctor: The Importance of Portent

For some time the skeptical cardiologist has been seeking information about the practice of medicine and cardiology during the Victorian era.

Why the Victorian era? Because my favorite writer, Charles Dickens, consistently portrays doctors of that era as incompetent.

And, sadly to say, as I have explored what doctors had to offer in the real world of the nineteenth century it was, in point of fact, very little.

From time to time as I gather this information on my medical forebears I will share it with my gentle readers:

To begin with, however, I present to you one of my favorite examples which is taken  from The Old Curiosity Shop.

“The doctor, who was a red-nosed gentleman with a great bunch of seals dangling below a waistcoat of ribbed black satin, arrived with all speed, and taking his seat by the bedside of poor Nell, drew out his watch, and felt her pulse. Then he looked at her tongue, then he felt her pulse again, and while he did so, he eyed the half-emptied wine-glass as if in profound abstraction.

‘I should give her,’ said the doctor at length, ‘a tea-spoonful, every now and then, of hot brandy and water.’

‘Why, that’s exactly what we’ve done, sir!’ said the delighted landlady.

‘I should also,’ observed the doctor, who had passed the foot-bath on the stairs, ‘I should also,’ said the doctor, in the voice of an oracle, ‘put her feet in hot water, and wrap them up in flannel. I should likewise,’ said the doctor with increased solemnity, ‘give her something light for supper—the wing of a roasted fowl now—’

‘Why, goodness gracious me, sir, it’s cooking at the kitchen fire this instant!’ cried the landlady. And so indeed it was, for the schoolmaster had ordered it to be put down, and it was getting on so well that the doctor might have smelt it if he had tried; perhaps he did.

‘You may then,’ said the doctor, rising gravely, ‘give her a glass of hot mulled port wine, if she likes wine—’

‘And a toast, Sir?’ suggested the landlady. ‘Ay,’ said the doctor, in the tone of a man who makes a dignified concession. ‘And a toast—of bread. But be very particular to make it of bread, if you please, ma’am.’

With which parting injunction, slowly and portentously delivered, the doctor departed, leaving the whole house in admiration of that wisdom which tallied so closely with their own. Everybody said he was a very shrewd doctor indeed, and knew perfectly what people’s constitutions were; which there appears some reason to suppose he did.”

Since reading this I have endeavored to make all my medical pronouncements with solemnity and gravity and as slowly and portentously as possible.

Portentously Yours,

-ACP

N.B. The Old Curiosity Shop was the fourth novel of Charles Dickens.  The novel was published in installments in the periodical Master Humphrey’s Clock.  The first installment was printed in April of 1840 and the last was printed in February of 1841.

 

 

Is Dean Ornish’s Lifestyle Program “Scientifically Proven To Undo (Reverse) Heart Disease?”

Supporters of vegetarian/ultra low fat diets like to claim that there is solid scientific evidence of the cardiovascular benefits of their chosen diets.

To buttress these claims they will cite the studies of Esseslystn, Pritikin and Ornish.

I’ve previously discussed the bad science underlying the programs of Esselsystn and Pritikin but have only briefly touched on the inadequacy of Dean Ornish’s studies.

The Ornish website proclaims that their program is the first program “scientifically proven to undo (reverse) heart disease.” That’s a huge claim. If it were true, wouldn’t the Dietary Guidelines for Americans, the American Heart Association, and most cardiologists and nutrition experts be recommending it?

Who Is Dean Ornish?

Dean Ornish has an MD degree from Baylor University and trained in internal medicine but has no formal cardiology or nutrition training (although many internet sites including Wikipedia describe him as a cardiologist.)

Ornish, according to the Encyclopedia of World Biographies became depressed and suicidal in college and underwent psychotherapy “but it was only when he met the man who had helped his older sister overcome her debilitating migraine headaches that his own outlook vastly improved. Under the watch of his new mentor, Swami Satchidananda, Ornish began yoga, meditation, and a vegetarian diet, and even spent time at the Swami’s Virginia center.”

Can Ornish’s Program Reverse Heart Disease?

After his medical training Ornish founded the Preventive Medicine Research Institute and has has widely promoted his Ornish Lifestyle Program.  the website of which claims:

Dr. Ornish’s Program for Reversing Heart Disease® is the first program scientifically proven to “undo” (reverse) heart disease by making comprehensive lifestyle changes.

The Ornish claims are based on a study he performed between 1986 and 1992 which originally had 28 patients with coronary artery disease in an experimental arm and 20 in a control group. You can read the details of the one year results here.and the five year results here.

There are  so many limitations to this study that the mind boggles that it was published in a reputable journal.

-Recruitment of patients. 

193 patients with significant coronary lesions from coronary angiography were “identified” but only 93 “remained eligible.” These were “randomly” assigned to the experimental or control groups. Somehow , this randomization process assigned 53 to the experimental group and 40 to the usual-care control group.

If this were truly a 1:1 randomization the numbers would be equal and the baseline characteristics equal.

Only 23 of the 53 assigned to the experimental group agreed to participate and only 20 of the control group.

The control group was older, less likely to be employed and less educated.

“The primary reason for refusal in the experimental group was not wanting to undergo intensive lifestyle changes and/or not wanting a second coronary angiogram; control patients refused primarily because they did not want to undergo a second angiogram.”

In other words, all of the slackers were weeded out of the experimental group and all of the patients who were intensely motivated to change their lifestyle were weeded out of the control group. Gee, I wonder which group will do better?

-The Intervention.

The experimental patients received “intensive lifestyle changes (<10% fat whole foods vegetarian diet, aerobic exercise, stress management training, smoking cessation, group psychosocial support).
The control group had none of the above.

Needless to say this was not blinded and the researchers definitely knew which patients were in which group.

Control-group patients were “not asked to make lifestyle changes, although they were free to do so.”

There is very little known about the 20 slackers in the control group. I can’t find basic information about them-crucial things like how many smoked or quit smoking or how many were on statin drugs.

-The Measurement

Progression or regression of coronary artery lesions was assessed in both groups by quantitative coronary angiography (QCA) at baseline and after about a year.

QCA as a test for assessing coronary artery disease has a number of limitations and as a result is no longer utilized for this purpose in clinical trials. When investigators  want to know if an intervention is improving CAD they use techniques such as intravascular ultraound or coronary CT angiography (see here) which allow measurement of total atherosclerotic plaque burden.

Rather than burden the reader  with the details at this point I’ve included a discussion of this as an addendum.

-The Outcome

Ornish has widely promoted  this heavily flawed study as showing “reversal of heart disease” because at one year the average percent coronary artery stenosis by angiogram had dropped from 40% to 37.8% in the intensive lifestyle group and increased from 42.7% to 46.1% in the control patients.

The minimal diameter (meaning the tightest stenosis) changed from 1.64 mm at baseline in the experimental to 1.65 at one year. At 5 years the minimal diameter had increased another whopping .001 mm to 1.651. 

 

 

In other words even if we overlook the huge methodologic flaws in the study the  so-called  “reversal” was minuscule.


Utlimately, dropping coronary artery blockages by <5 % doesn’t really matter unless that is also helping to prevent heart attacks or death or strokes or some outcome that really matters.

There were no significant differences between the groups at 5 years in hard events such as heart attack or death.
In fact 2 of the experimental group died versus 1 of the control group by 5 years.

There were less stents and bypasses performed in the Ornish group but the decision to proceed to stent or bypass is notoriously capricious when performed outside the setting of acute MI. The patients in the experimental group under the guidance of Ornish and their Ornish counselors would be strongly motivated to do everything possible to avoid intervention.

I’ve gotten a lot of flack for humorously suggesting that Nathan Pritikin killed himself as a result of the austere no fat diet he consumed but the bottom line on any lifestyle change is both quality and quantity of life.

If you are miserable most days due to your rigid diet you might consider that life is no longer worth living

Ornish’s Lifestyle Intervention Is Not A Trial Of Diet …And Other Points

 

Although often cited as justification of ultralow fat diet, the Ornish Lifestyle trial doesn’t test diet alone.

It is a trial of multiple different interventions with frequent counseling and meetings to reinforce and guide patients.

The interventions included things that we know are really important for long term health-regular exercise, smoking cessation, and weight management. These factors alone could account for any differences in the outcome but they are easily adopted without becoming a vegetarian.

The patients who agreed to the experimental arm were a clearly highly motivated bunch who agreed to this really strict regimen. Even in this population there was a 25% drop out rate.

Since investigators clearly knew who the “experimental patients” were and they were clearly interested in good outcomes in these patients there is a high possibility of bias in reporting outcomes and referring for interventions.

Despite all the limitations the study does raise an interesting hypothesis. Should we all be eating vegan diets?

 if Ornish really wanted to scientifically prove his approach he should have repeated it with much better methodology and much larger numbers.

Finally, this tiny study has never been reproduced at any other center.

Because of the small numbers, lack of true blinding, lack of hard outcomes and use of multiple modalities for lifestyle intervention, this study cannot be used to support the Ornish/Esselstyn/Pritikin dietary approach.

It most certainly doesn’t show that the Ornish Lifestyle Program “reverses heart disease.” Consequently, you will not find any evidence-based source of nutritional information or guideline (unless it has a vegan/vegetarian philosophy or is being funded by the Ornish/Pritikin lifestyle money-making machines) recommending these diets.

Skeptically Yours,

-ACP

N.B.1 A recent paper on noninvasive assessment of atherosclerotic plaque has a great infographic which shows how coronary artery disease progresses and how and when in the progression various imaging modalities are able to detect plaque:

I’ve inserted a vertical red arrow which shows how IVUS detects very early atheroma whereas angiography (ICA, green line) only detects later plaque when it has started protruding into the lumen of the artery.

The paper notes that “Intravascular ultrasound (IVUS)  constitutes the current gold standard for plaque quantification. Multiple studies using IVUS and other techniques have revealed a robust relation between statin therapy and plaque regression. In the ASTEROID trial coronary atheroma volume regressed by 6.8% during 24 months of high-intensity lipid therapy. A meta-analysis of IVUS trials including 7864 patients showed an association between plaque regression and decreased cardiovascular events.”

While I believe Ornish started off as a legitimate scientist several authors have pointed out that he has joined the ranks of pseudoscientific practiioners.

Here’s one analysis from Science Blogs :

In the end, the problem is that Dr. Ornish has yoked his science to advocates of pseudoscience, such as Deepak Chopra and Rustum Roy. Why he’s done this, I don’t know. The reason could be common philosophy. It could be expedience. It could be any number of things. By doing so, however, Dr. Ornish has made a Faustian deal with the devil that may give him short-term notoriety now but virtually guarantees serious problems with his ultimately being taken seriously scientifically, as he is tainted by this association. Let me yet again reemphasize that this relabeling of diet, exercise, and lifestyle as somehow being “alternative” is nothing more than a Trojan Horse. Inside the horse is a whole lot of woo, pseudoscience and quackery such as homepathy, reiki, Hoxsey therapy, acid-base pseudoscience, Hulda Clark’s “zapper,” and many others,

I Want To Tell You About A Chord That George Harrison Did Not Invent

The skeptical cardiologist has of late been obsessed with a Beatles song. It is the fifth song on the second side of the four mop tops seventh studio album and the third George Harrison contribution to Revolver, arguably the best record album of all time.

With a subscription to Apple Music I can listen to the entire Beatles catalogue now and one day I Want To Tell You (IWTTY) began playing. I hadn’t closely listened to this song before but at 25 seconds in someone begins playing very loudly two notes on a piano and keeps playing them for 8 seconds. The effect is strikingly dissonant but mesmerizing.

It turns out much has been written about this section of I Want To Tell you (along with anything else remotely related  to The Fab Four.)

The two notes are F and E and they are being played by Paul McCartney emphasizing the flattened ninth (and highly dissonant) portion of the chord E 7 b9.

Tim Riley in his Beatles song by song analysis, “Tell Me Why” writes of IWTTY:

The guitar line is central, the backbone for the esoteric lyrics, and the piano’s annoying dissonant figure at the end of each verse disrupts its stability.

The piano conveys the frustration of the singer, and its single-note solo is the peace he wants to attain

I’ve also seen this section described as “creating a frustrated bitonal disonance ( G sharp 7 diminished against E7 or E7 flat 9)

Apparently Harrison:

Lacking formal music training, apart from in his sitar studies…later described the harsh-sounding E79 as, variously, “an E and an F at the same time”  and “an E7th with an F on top, played on the piano”.

The Wikipedia entry on IWTTY spends considerable time on the significance of the E7flat9.

Writing in Rolling Stone’s Harrison commemorative issue, in January 2002, Mikal Gilmore recognised his incorporation of dissonance on “I Want to Tell You” as having been “revolutionary in popular music” in 1966. Gilmore considered this innovation to be “perhaps more originally creative” than the avant-garde styling that Lennon and McCartney took from Karlheinz Stockhausen, Luciano Berio, Edgar Varese and Igor Stravinsky and incorporated into the Beatles’ work over the same period.

The Wikipedia entry goes on to say that the chord “became one of the most legendary in the entire Beatles catalogue.”

Harrison was deliberately using the chord’s dissonance to create an emotion.”The musical and emotional dissonance is then heightened by the use of E79, a chord that Harrison said he happened upon while striving for a sound that adequately conveyed a sense of frustration.”

“speaking in 2001, Harrison said: “I’m really proud of that as I literally invented that chord.”

 I thought it highly unlikely that George Harrison “invented” (literally or figuratively) the seventh flattened ninth chord but had no way of checking the accuracy of the Wikipedia quote (from Guitar World magazine.) or the context. Was Harrison that musically naive, was he joking or did he mean something else?

Later that day I sat at my Kawai baby grand piano and began playing songs from The Encylopedia of Jazz.

One of my favorites from this book  is Satin Doll (written in 1953 by Duke Ellington and Billy Strayhorn) and as I was playing it I realized that it was loaded with  flattened ninths. There’s a D7flat9 when the word Satin is sung. These chords make the song more complex and memorable.

Next I played my favorite song in this Jazz book i “Lullaby of Birdland” (music written by George Shearing in 1952) which features two 7flat9 chords (F# and B7) in the second measure (played with the words “that’s what I.”)  Later on in the song we are treated to 7flat 9 in D and the chord that George Harrison claimed to have literally invented E7b9.

Here’s Ella Fitzgerald singing it with Duke Ellington

So a cursory review reveals that the chord was being utilized a lot in 1953 (and that I have a special attraction to its complexity.)

Perhaps Harrison can claim he was the first to appropriate the chord in rock and roll music? Alas, we know that an F#7b9 is prominent in the Beach Boys’ Caroline, No which was released in March, 1966, 3 months before the Beatles released IWTTY.

He may not have invented the chord or even been the first to use it in rock and roll but his use in IWTTY coupled with McCartney’s hammering on the F and E have made me forever cognizant of that song’s beauty. 

For that plus his brilliant guitar work and songwriting during and after The Beatles I will be eternally grateful.

Nondissonantly Yours,

-ACP

N.B. Dear Readers. If any of you have access to the Guitar World interview of 2001 (from Wikipedia-Garbarini, Vic (January 2001). “When We Was Fab”. Guitar World. p. 200) wherein Harrison is alleged to claim he invented the magical 7b9 please share it with me. 

Also, please note there is a new button on my website which allows you to sign up for my weekly emal newsletter (which i promise will be mostly related to cardiology and not esoteric musical chords.)

My Top Four Practice-Changing Presentations From the ACC 2019 Meeting: From Alcohol To Aspirin

The ACC meetings in New Orleans have wrapped up and I must stop letting the good times roll.

In the areas I paid attention to I found these four presentations the most important:

1. After the historic back to back presentations of the Partner 3 and Evolut trials it is clear that catheter-based aortic valve replacement (TAVR) should be the preferred approach to most patients with severe symptomatic aortic stenosis.

Both TAVR valves (the baloon-expanded Edwards and the self-expanding Medtronic) proved superior to surgical AVR in terms of one year clinical outcomes.

2. The Alcohol-AF Trial. It is well known that binge alcohol consumption (holiday heart) can trigger atrial fibrillation (AF) and that observational studies show a higher incident of AF with higher amounts of alcohol consumption.

This trial was the first ever randomized controlled trial of alcohol abstinence in moderate drinkers with paroxysmal AF (minimum 2 episodes in the last 6 months) or persistent AF requiring cardioversion.

Participants consumed >/= 10 standard drinks per week and were randomized to abstinence or usual consumption.

They underwent comprehensive rhythm monitoring with implantable loop recorders or existing pacemakers and twice daily AliveCor monitoring for 6 months.

Abstinence prolonged AF-free survival by 37% (118 vs 86 days) and lowered the AF burden from 8.2% to 5.6%

AF related hospitalizations occurred in 9% of abstinence patients versus 20% of controls

Those in the abstinence arm also experienced improved symptom severity, weight loss and BP control.

This trial gives me precise numbers to present to my AF patients to show them how important eliminating alcohol consumption is if they want to have less AF episodes.

It further emphasizes the point that lifestyle changes (including weight loss, exercise and stress-reduction) can dramatically reduce the incidence of atrial fibrillation.

3. AUGUSTUS. This trial looked at two hugely important questions in patients who have both AF and recent acute coronary syndrome or PCI/stent. The trial was simultaneously published in the New England Journal of Medicine. The questions were:

Apixaban (Eliquis, one of the four newer oral anticoagulants (NOAC)) versus warfarin for patients with AF: which is safer for prevention of stroke related to AF?

Triple therapy with  low dose aspirin and clopidogrel plus warfarin/NOAC versus clopidogrel plus warfarin/NOAC: which is safer in preventing stent thrombosis without causing excess bleeding in patients with AF and recent stent?

Briefly, they found:

The NOAC apixaban patients compared to warfarin had a 31% reduction in bleeding and hospitalization. No difference in ischemic events.

Adding aspirin  increased bleeding by 89%. There was no difference in  ischemic events. (Major or clinically relevant nonmajor bleeding was noted in 10.5% of the patients receiving apixaban, as compared with 14.7% of those receiving a vitamin K antagonist (hazard ratio, 0.69; 95% confidence interval [CI], 0.58 to 0.81; P<0.001 for both noninferiority and superiority), and in 16.1% of the patients receiving aspirin, as compared with 9.0% of those receiving placebo (hazard ratio, 1.89; 95% CI, 1.59 to 2.24; P<0.001).)

This means that the dreaded “triple therapy”  after PCI in patients with AF with its huge bleeding risks no longer is needed.

It also further emphasizes that NOACs should be preferred over warfarin in most patients with AF.

The combination of choice now should be a NOAC like apixaban plus clopidogrel.

4. REDUCE-IT provided further evidence that icosapent ethyl (Vascepa) significantly reduces major cardiovascular events in patients with establshed CV disease on maximally tolerated statin therapy.

The results of the pirmary end point from the REDUCE-IT were presented at the AHA meeting last year and they were very persuasive. At the ACC, Deepak Bhatt presented data on reduction of total ischemic events from the study and they were equally impressive. Adding the pharmaceutical grade esterified form of EPA at 2 grams BID reduced first, second, third and fourth ischemic events in this high risk population.

The benefit was noted on all terciles of baseline triglyceride levels. Thus, the lowest tercile of 81 to 190 mg/dl benefitted as well as the highest tercile (250 to 1401).

Although I dread the costs, it’s time to start discussing adding Vascepa on to statin therapy in high risk ASCVD patients who have trigs>100 .

As I wrote previously I didn’t learn anything from the much ballyhooed and highly anticipated Apple Heart Study . It’s entirely possible more participants were harmed than helped by this study.

Philomathically Yours,

-ACP

A Set Of Peculiar Security Questions

The skeptical cardiologist has gotten used to answering security questions when establishing online accounts.

My answers to these questions are typically pretty obvious (to me) and easy to retrieve from my overwhelmed brain.

However, recently I was establishing an online account and encountered the following questions:

I was baffled by almost all of these and gave up.

For question #3 I might answer “to discourage online account activation.”

Unquestioningly Yours,

-ACP

N.B. Some of these questions are worthy of addition to the Proust Questionnaire