Category Archives: Uncategorized

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

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

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

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

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

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

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

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

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

 

Pythonically Yours,

-ACP

Which Ambulatory ECG Monitor For Which Patient?

The skeptical cardiologist still feels that KardiaPro has  eliminated  use of long term monitoring devices for most of his afib patients

However not all my afib patients are willing and able to self-monitor their atrial fibrillation using the Alivecor Mobile ECG device. For the Kardia unwilling and  many patients who don’t have afib we are still utilizing lots of long term monitors.

The ambulatory ECG monitoring world is very confusing and ever-changing but I recently came across a nice review of the area in the Cleveland Clinic Journal of Medicine which can be read in its entirety for free here.

This Table summarizes the various options available. I particularly like that they included relative cost. .

The traditional ambulatory ECG device is the “Holter” monitor which is named after its inventor and is relatively inexpensive and worn for 24 to 48 hours.

The variety of available devices are depicted in this nice graphic:

For the last few years we have predominantly been using the two week “patch” type devices in most of our patients who warrant a long term monitor. The Zio is the prototype for this but we are also using the BioTelemetry patch increasingly.

The more expensive mobile cardiac outpatient telemetry (MCOT) devices like the one below from BioTel look a lot like the patches now. The major difference to the patient is that the monitor has to be taken out and recharged every 5 days. In addition, as BioTel techs are reviewing the signal from the device they can notify the patient if the ECG from the patch is inadequate and have them switch to an included lanyard/electrode set-up.

The advantage of the patch monitors is that they are ultraportable, relatively unobtrusive and they monitor continuously with full disclosure.

The patch is applied to the left chest and usually stays there for two weeks (and yes, patients do get to shower during that time) at which time it is mailed back to the company for analysis.

Continuously Monitoring,

-ACP

A Patient’s Confusing Journey Into The Quagmire Of Cardiac Imaging: A Cautionary Tale

Mary-Ann, a reader from the north,  provides today’s post. Her story illustrates how easily medical care can veer off the rails while it is simultaneously railroading patients.  It is a cautionary tale with wisdom that can help most patients.

In this post I’ll just present Mary-Ann’s perspective and solicit responses.  Down the line I’ll provide some perspective on the processes, the problems and the solutions.


It started innocently enough. I showed up for a regular visit with my cardiac provider, a mid-level professional. She noted I was flushed and had a high pulse — about 100. 

Starbucks, I explained, and I flush easily — always have. She looked skeptical.

That is how I went from a half-caf Americano to a 48-hour holter monitor.

I went back for results — the usual ectopic beats but nothing scary or new. But again, she noted I had a fast heart rate and I was flushed.

And once again I explained: Starbucks — it is right down the street and okay, I might have a problem.

That is the short — but highly accurate — version of how I wound up getting a stress echo. 

I showed up for the results of the echo and that is where the runaway train started down the tracks.

“…possible inferoapical wall hypokinesis with lack of augmentation of systolic function, which are abnormal findings and may be indicative of ischemia due to underlying coronary artery disease. EF was 56% at rest and 40-50% at stress.” 

Wait — what?!

I was marched down the hall and scheduled for a cardiac angiography — and told not to run any marathons in the intervening two days. 

Marathon?! I was terrified I was going to drop dead at any moment. I contemplated just sitting the waiting room for 48 hours — just to be safe.

Then I started reading the professional literature and things were not adding up. An EF at stress of 40 – 50% is not good — in fact, it can be heading into heart failure land.

But I was active and fine — it did not make any sense.

I called the office; my provider was not available. I explained that I was worried there was a mistake. Oh no, I was assured, they are very careful to not make mistakes.

I wrote my will. I cried a lot. 

And when the person called to remind me of the procedure (like I could forget!?) I once again explained that I was worried there had been a mistake, and once again — reassurance. No mistake.

Nevertheless, she (aka me) persisted!

I sat on the hospital bed in nothing but a gown and handed the nurse my two-page letter; it started like this:

“I am reminded that what is normal and ordinary for a professional is never that for a patient. I am terrified.

First, I want to be really sure that there is not any chance of a mix-up in the stress echo test results. This is not simple denial or wishful thinking…” 

And that nurse paid attention, which is how I wound up not having a cardiac angiography. 

The cardiologist scheduled to do the procedure — we shall call him Doc #2 — wrote: 

“She has some concerns regarding the results of the stress echo study … I reviewed the most recent stress echo and it appears to me that the results for the resting versus the stress echo ejection fractions have been transposed…”

Translation: A Typo.

I was elated! Jubilant! We went to Starbucks to celebrate.

The giddy joy quickly turned to something along the lines of WTH just happened here? I read the original echo report written by Doc #1 — that lit the tinder. There were two different values for EF at stress documented in the report, and another sentence that was repeated. 

The professorial side of me was deeply affronted — in a subsequent meeting with hospital administrators I confess to saying that someone who is making hundreds of thousands of dollars a year doesn’t get to write such a sloppy ass report — and about someone’s heart, no less! 

But the best part of that meeting was learning that Doc #1 denied there was a typo — he stood by his findings. 

Oh dear.

And Doc #2 stood by his findings as well. And Doc #3 got involved somewhere along the way and he agreed with Doc #2. And the mid-level Provider also agreed with Doc #2.

The majority rule seems like an odd way to make health care decisions — wouldn’t you think all those smart people could talk among themselves and agree?

Apparently not.

That first meeting with the hospital folks included all manner of solicitous apologies and an attitude of collaboration. Of course, they said, we can send the echo to an outside cardiologist — at our expense — and get an answer.

And then I made the unthinkable mistake — and I blame the Skeptical Cardiologist for this — of asking informed questions.

“Are the cardiologists involved in reading my echo Level III echo specialists?”

“I understand that there can be variance in estimated EF between cardiologists — what level of variance is considered acceptable?”

The hospital team responded to my questions by calling a meeting — and the tone had changed considerably (Thanks a lot, Corporate Legal).

The offer to pay for an outside opinion was off the table — after all, they said, you would not have a patient-provider relationship with the cardiologist reading the echo. Ahem, I noted — I have zero relationship with the first cardiologist who read the echo and would not know him if I bumped into him at Starbucks. And you all did offer to pay for that outside opinion…

Oh never mind those minor details. No outside opinion on their dime. They would do a Lexiscan at their expense as a tie breaker. Final Offer.

Tiebreaker — really?! Is this a soccer game?

And seriously — should I have to have an invasive test to settle THEIR disagreement?! [Note: If it involves needles, it is invasive.]

Because there were not enough cardiologists involved already, I saw yet another one — from a different practice. He offered that the EF at stress looked more like 55%, placing his bet smack in the middle, and recommending a CT Angiography Coronary Arteries with Contrast as the tiebreaker.

Tiebreaker. That word implies both sides are equivalent or equal. However, my heart is not actually a game and the two teams cannot both be right — there is no equivalency in play here. What we are really trying to do involves accuracy — not breaking a tie score.

But I digress.

It doesn’t seem like you should have to make a chart to keep track of what cardiologists say about the same echo but in this case, it seemed necessary.

 And in the meantime, yet another cardiologist weighed in that the quality of the echo was poor — and no wonder they could not agree.

Deep breaths.

And so, for the past four months I have tried to navigate all this, and to understand what this actually means about cardiology and medicine and so many things. My confidence and my mind have been blown. Resources – and time – have been wasted. 

Ectopic heartbeats are typically benign in a structurally normal heart — I thought I was safe. But I have not felt safe since that day when I learned that Doc #1 and Docs #2, 3, and so on had decided to have a stand-off at the OK Corral that is my heart.

Except, I do not know if it is okay. And that is the problem. 


Unfortunately, Mary-Anne’s tale is not uncommon. It touches on many of the areas that patient’s should be aware of including

-Undergoing diagnostic imaging testing when you are free of symptoms

-Inadequate quality control in diagnostic imaging and how that leads to false positive results

-Variance in imaging performance and interpretation-how the same test can be read as normal by one doctor and markedly abnormal by another.

-The tendency of some cardiologists to recommend invasive testing when it is inappropriate and likely to cause more harm than good

-The importance of second opinions, especially if invasive testing is recommended

-The importance of patient’s doing their own research and asking good questions based on that research.

Transparently Yours,

-ACP

AliveCor’s KardiaBand Will No Longer Be Sold And Smart Rhythm Is No More

The skeptical cardiologist was quite enthusiastic about AliveCor’s Kardia Band for Apple Watch upon its release late in 2017.

I was able to easily make high fidelity, medical grade ECG recordings with it and its AI  algorithm was highly accurate at identifying atrial fibrillation  (see here). This accuracy was subsequently confirmed by research.

Many skepcard readers spent $200 dollars for the Kardia Band and had found it to be very helpful in the management of their atrial fibrillation.

However, in December of 2018 Apple added ECG recording to its Apple Watch 4, essentially building into the AW4  the features that Kardia Band had offered as an add on to earlier Apple Watch versions.

In my evaluation of the Apple Watch I found it to be “an amazingly easy, convenient and straightforward method for recording a single channel ECG” but its algorithm in comparison to AliveCor’s yielded more uncertain diagnoses.

Given it size, prominence and vast resources, Apple’s very publicized move into this area seemed likely to threaten the viability of AliveCor’s Kardia Band.

But then-interim CEO (and current COO)  Ira Bahr later told MobiHealthNews that his company’s broader business wasn’t threatened by its new direct competitor.

“We’re not convinced that Apple’s excellent, engaging product is a competitor yet,” he said in February. “We believe that from a price perspective, this product is least accessible to the people who need it most. If you’re not an Apple user, you’ve got to buy an Apple Watch, you’ve got to buy an iPhone to make the system work. So their technology is excellent, but we think the platform is both complicated and expensive and certainly not, from a marketing perspective, targeting the patient populations we target.”

Indeed, AliveCor’s Mobile ECG device and its recently released 6 lead ECG are doing very well but the threat to the viability of KardiaBand was real and MobiHealth News announced Aug. 19 that AliveCor had officially ended sales of the Kardia Band.

An AliveCor representative told MobiHealthNews that the company “plans to continue supporting KardiaBand indefinitely” for those who have already purchased the device. The company’s decision was first highlighted by former MobiHealthNews Editor Brian Dolan in an Exits and Outcomes report.

Mr. Bahr has confirmed to me that AliveCor does plan to continue supporting KardiaBand indefinitely. This includes replacement of KardiaBand parts.

Did Apple Kill Smart Rhythm?

The informed reader who notified me of AliveCor’s decision also notes:

The official reason is that they could not keep up with the Apple Watch updates and therefore the Smart Rhythm feature did not work properly.

I think many of us knew from the beginning that smart rhythm was not very accurate But in spite of that the Kardia band provided a valuable convenience over their other products.

It does appear that Smart Rhythm is no more.

AliveCor’s website was updated 6 days ago to state that Smart Rhythm was discontinued:

” due to changes beyond our control in the Apple Watch operating system, which caused SmartRhythm to perform below our quality standards”

Likely, as my reader was told, the frequent  AW4 updates plus the lack of a large KardiaBand user base made it unprofitable for AliveCor to continue to support Smart Rhythm.

Smart Rhythm, of course was AliveCor’s method for watch-based detection of atrial fibrillation. It clearly had limitations, including false positives but given AliveCor’s track record of dedication to high quality and accuracy I assumed it would improve over time..

Apple, on December 6, 2018  with the release of its watchOS 5.1.2 for AW4 announced its own version of Smart Rhythm at the same time it activated the ECG capability of AW4.

Apple called this feature “the irregular rhythm notification feature” and cited support for its accuracy from the widely ballyhooed Apple Heart Study (which I critiqued here.)

The irregular rhythm notification feature (TIRNF)was recently studied in the Apple Heart Study. With over 400,000 participants, the Apple Heart Study was the largest screening study on atrial fibrillation ever conducted, also making it one of the largest cardiovascular trials to date. A subset of the data from the Apple Heart Study was submitted to the FDA to support clearance of the irregular rhythm notification feature. In that sub-study, of the participants that received an irregular rhythm notification on their Apple Watch while simultaneously wearing an ECG patch, 80 percent showed AFib on the ECG patch and 98 percent showed AFib or other clinically relevant arrhythmias.

Despite widely publicized reports of lives being saved by TIRNF we still don’t know whether its benefits outweigh its harms. It is not clear what its sensitivity is for detecting atrial fibrillation and I have reported one patient who was in atrial fibrillation for 3 hours without her AW4 alerting her to its presence.

For AW4 users, absence of an alert should not provide reassurance that your rhythm is normal.

Thus is does appear that the Goliath Apple hath smote the David AliveCor in the watch-based afib battle. This does not bode well for consumers and patients as I think as competition in this area would make for better products and more accountability.

Philorhythmically Yours,

-ACP

N.B.

Per AliveCor the KardiaBand currently works with all all Apple Watches except the original one.

The Apple TIRNF per Apple:

is available for Apple Watch Series 1 and later and requires iPhone 5s or later on iOS 12.1.1 in the US, Puerto Rico, Guam and US Virgin Islands. The irregular rhythm notification feature does not detect a heart attack, blood clots, a stroke or other heart-related conditions including high blood pressure, congestive heart failure, high cholesterol or other forms of arrhythmia.

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.