A few weeks ago I was interviewed by Fox2 News . Not for anything having to do with cardiology but because I randomly stumbled upon the City of St. Louis taking down a street sign.
This was no ordinary street sign.
It was associated with the small strip of road that runs adjacent to the Confederate Memorial that sits in Forest Park (America’s #1 Urban Park!)
The Forest Park Confederate Memorial became part of a national discussion after long-time St. Louis Mayor, Francis Slay, writing in his blog in 2015, proposed a a committee for reappraisal of the statue:
Their charge would be to recommend whether, with the benefit of a longer view of history, the monument is appropriately situated in Forest Park – the place where the World was asked to meet and experience St. Louis at its best and most sublime — or whether it should be relocated to a more appropriate setting.
They also should address whether the monument represents a peculiar memorial to what euphemistically was referred to in the American South as a “peculiar institution” – slavery-and wherever ultimately situated, whether the monument should be accompanied by a description of the reality and brutality of slavery, over which the war was waged, including in this city, and the bitter badges of slavery, Jim Crow and de facto discrimination and segregation, that are its continuing legacy.
I would ask the commission, also, to reappraise the name “Confederate Drive,” the Forest Park thoroughfare on which the monument is situated. They might consider whether “Freedom” or “Justice” would be more fitting.
It looks like the committee delivered their report in December , 2015 and it can be found here. They indicate their charge was to assess how best to get rid of the statue, not really to “reappraise” it.
They asked for proposals from various museums/historic organizations for moving the statue and received no satisfactory proposals. . The cost of moving the statue to another site was estimated at 268,000$ and moving it to storage at 122,000$.
A new mayor of St. Louis, Lydia Krewson, was elected last November and she has vowed to move the statue.
Apparently, it’s a lot easier and cheaper to remove the street sign than the statue.
Don’t expect any brilliant insights into this controversy from my interview with Fox2 News. Before I’m ready to make any public pronouncement on an issue I require hours and hours of research and clearly I have no expertise or background that would qualify me to pontificate on the fate of this statue.
Since then, I’ve thought about it and read more and hope to share some observations down the line.
Since the interview aired it seems to have gone viral around St. Luke’s hospital with many marveling at my odd “beekeeper’s” hat and others impressed by my handling of a random cyclist’s yelled comments.
Since determining that running would lower my cardiovascular risk and that it was actually good for my wonky knees (running is associated with a lower risk of ostearthritis or hip replacement, see here), I’ve been trying to do it regularly.
I’ve even contemplated running 5 kilometers, although not as part of any formal exhibition: just a personal , private goal. To this end I have for the first time recently run 4 kilometers.
Listening to music during these longer runs greatly helps the time pass and sometimes I am able to find songs which fit my running cadence, albeit not through any systematic analysis but through mere serendipity. I let my entire musical collection (nicely streamed by Apple music) be my running playlist and this ranges from the Talking Heads to Thelonius Monk to Bach.
This morning’s run (the second time I reached 4K) I was aided by two songs: one by the king of surf guitar, the other by the kings of psychedelic jam rock.
Dick Dale and Miserlou
Although, Dick Dale was huge in the early sixties, he did not register on my musical radar until I watched Pulp Fiction and in its dazzling opening scene and was jolted by Dale’s staccato machine gun guitar riffs alternating with his plaintive trumpet solo on “Miserlou“.
I immediately strapped on my Strat and began trying to emulate his unique playing style.
Here’s Dick and the Del-Tones performing their version for the movie “A Swinging’ Affair”
This version contains none of the rhythmic power and electrifying guitar attack of the single and the band appears to be on tranquilizers. To make matters worse, Dick doesn’t play that magical melodic moaning trumpet solo which contrasts so brilliantly with the pile-driving reverb-drenched guitar riffs on the original version.
You can see some of the power of the left-handed Dale in this live performance of Miserlou from 1995 but alas, no trumpet solo.
Dick Dale, remarkably, is still touring and playing well at age 80.
As fortune would have it the beats per
minute of this song is 173 which fits my preferred running speed stride cadence perfectly.
The Other One (Not Cryptical Envelopment)
The next song to aid me on my run was a live performance from the Grateful Dead’s 1972 European Tour which is 36 minutes long.
I was slow to revere the Dead but when I first listened to their live album Europe ’72 I was hooked. Instead of studying in college, I spent way too many hours playing Sugar Magnolia (and Blue Sky, et al..) thereafter.
The Other One highlights their free and wild improvisational style. While running I could focus on what Keith Godchaux was doing on the piano and that takes me to a psychic place in which I feel no pain.
Please excuse my hubris but I am convinced that I could have done a good job as the Dead keyboardist. It’s probably a good thing I never got that gig, however, as it carries a very high mortality rate (not to mention that I’m a much better cardiologist than keyboardist.)
As Billboard pointed out in its obituary on the last keyboardist, Vince Welnick (who committed suicide by slitting his throat at age 55 in 2006):
Welnick was the last in a long line of Grateful Dead keyboardists, several of whom died prematurely, leading some of the group’s fans to conclude that the position came with a curse.
Welnick had replaced Brent Mydland, who died of a drug overdose in 1990. Mydland succeeded Keith Godchaux, who died in a car crash shortly after leaving the band. And Godchaux had replaced the band’s original keyboard player, Ron “Pigpen” McKernan, who died at 27 in 1973.
Last week a very good Grateful Dead documentary (Long Strange Trip) was released on Netflix. I’ve been somewhat mesmerized by what I’ve watched so far. For example, at one point, Phil Lesh reveals that Jerry Garcia asked him to join the band as their bassist even though he had never played the instrument. (If only he had asked me!)
N.B. Miserlou is a very old folk song with a scale that sounds exotic to Western ears: the double harmonic scale
The song’s oriental melody has been so popular for so long that many people, from Morocco to Iraq, claim it to be a folk song from their own country. In fact, in the realm of Middle Eastern music, the song is a very simplistic one, since it is little more than going up and down the Hijaz Kar or double harmonic scale (E-F-G#-A-B-C-D#). It still remains a well known Greek, Klezmer, and Arab folk song.
In an earlier post the skeptical cardiologist introduced Geo, a 61 year old male with no risk factors for heart attack or stroke other than a high cholesterol. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.
His doctor had recommended that he take a statin drug but Geo balked at taking one due to concerns about side effects and requested my input. My first steps were to gather more information.
-I calculated his 10 year risk of stroke or heart attack at 8.4% (treatment with statin typically felt to benefit individuals with 10 year risk >7.5%) and as I have previously noted, this is not unusual for a man over age 60.
-I assessed him for any hidden or subclinical atherosclerosis and found
The vascular ultrasound showed below normal carotid thickness and no plaque and his coronary calcium score was 18, putting him at the 63rd percentile. This is slightly higher than average white men his age.
So Geo definitely has atherosclerotic plaque in his coronary arteries. This puts him at risk for heart attack and stroke but not a lot higher risk than most men his age.
Strictly speaking, since he hasn’t already had a heart attack or stroke, treating him with a statin is a form of primary prevention. However, we know that atherosclerotic plaque has already developed in his arteries and at some point, perhaps years from now it will have consequences.
What is the best approach to reduce Geo’s risk?
It’s essential to look closely at lifestyle changes in everyone to reduce cardiac risk.
The lifestyle components that influence risk are
Cigarette Smoking (by far the strongest)
Obesity (Obviously related to #1 and #2)
Patients who try to change to what they perceive as a heart healthy diet by switching to non-fat dairy and eliminating all red meat will not substantially lower risk (see here.) Even if you are possess the rock-hard discipline to stay on a radically low fat diet like the Esselstyn diet or the Pritikin diet there are no good data supporting their efficacy in preventing cardiac disease.
Geo was not far from theMediterranean diet I recommend but would probably benefit from increased veggie and nut consumption. He was not overweight and he doesn’t smoke. I encouraged him to engage in 150 minutes of moderate exercise weekly.
Low Dose, Intermittent Rosuvastatin
I engaged in shared decision-making with Geo. Informing him, as best I could, of the potential side effects and benefits of statin therapy.
After a long discussion we decided to try a compromise between no therapy and the guideline recommended moderate intensive dose statin therapy.
This approach utilizes a low dose of rosuvastatin taken intermittently with the goal of minimizing any statin side effect but obtaining some of the benefits of statin drugs on cardiovascular risk reduction.
I have many patients who have been unable to tolerate other statin drugs in any dosage due to statin related muscle aches but who tolerate this particular treatment and I see substantial reductions in the LDL (bad) cholesterol with this approach.
Studies have shown that rosuvastatin 5–10 mg or atorvastatin 10–20 mg given every other day produce LDL-C reduction of 20–40 %
Studies have also shown that In patients with previous statin intolerance, rosuvastatin administered once or twice weekly (at a mean dose of 10 mg per week) achieved an LDL-C reduction of 23–29% and was well tolerated by 74–80 % of patients.
In a recent report from a specialized lipid clinic, 90 % of patients referred for intolerance to multiple statins were actually able to tolerate statin therapy, although the majority was at a reduced dose and less-than-daily dosing.
Results in Geo
After several months of taking 5 mg rosuvastatin twice weekly Geo felt fine with no discernible side effects. He obtained repeat cholesterol levels:
His LDL had dropped 52% from 140 to 92.
Hopefully, this LDL reduction plus the non-cholesterol lowering beneficial properties of statins (see here) will substantially lower Geo’s risk of heart attack and stroke.
We need randomized studies testing long-term outcomes using this approach to make it evidence-based. But in medicine we frequently don’t have studies that apply to specific patient situations. In these cases shared decision-making in order to find solutions that fit the individual patient’s concerns and experience becomes paramount.
The skeptical cardiologist has a question for all patients who have elevated blood pressure: has your doctor ever taken your BP in both the right and left arms?
Have you ever noted a difference in the systolic BP between arms (interarm difference or IAD) when you do home recordings?
Although UK and USA national hypertension guidelines recommend measuring BP in both arms on a first visit and most PCPs are aware of the recommendation, only 30% agree with it and few actually adhere to it. (2007) Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence. Br J Gen Pract 57(545):948–952.
It’s important to measure the difference between right and left arm BP at least once because:
An IAD >10 mm Hg often indicates peripheral artery disease (such as a blocked subclavian artery to the arm with the lower BP) and is associated with higher cardiovascular disease risk.(Clark, et al (2006) Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review. J Hum Hypertens 20(12):923–931)
A blocked subclavian artery can cause neurological symptoms, dizziness or loss of
A consistently lower BP in the left arm compared to the right arm can be a sign of a serious and correctable congenital heart disease called coarctation of the aorta.
The true BP (i.e. the one we should be treating) is the higher of the two. Thus, if you do have a consistent IAD, you should only measure the higher one for monitoring BP.
In 2009, Parker and Glasziou noted that whereas 13 of 15 national hypertension guidelines recommend measuring BP in both arms:
“only seven guidelines gave some justification, with only one quantifying the prevalence of substantial arm differences and only one providing a reference to the evidence. No guideline provided a description of appropriate techniques for reliably measuring blood pressure in both arms. “
they speculated that if PCPs were given better justification and precise details on how to reliably measured the IAD they would be more likely to do it.
I’ve mentioned the “why” for measuring IAD above.
The “why” is so compelling that if you have hypertension or pre-hypertension (SBP 120-140) and you’ve never had the BP compared in both arms you should do it yourself.
The “how” of IAD is more complicated.
In a subsequent post I will give my recommendations on how to reliably measure IAD and I will tell the story of a 75 year old competitive ice hockey player with a totally blocked subclavian artery to his right arm.
Originally known as quackery, the modalities now being “integrated” with medicine then became “complementary and alternative medicine” (CAM), a term that is still often used. But that wasn’t enough. The word “complementary” implies a subordinate position, in which the CAM is not the “real” medicine, the necessary medicine, but is just there as “icing on the cake.” The term “integrative medicine” eliminates that problem and facilitates a narrative in which integrative medicine is the “best of both worlds” (from the perspective of CAM practitioners and advocates). Integrative medicine has become a brand, a marketing term, disguised as a bogus specialty.
Much of this quackery being integrated is easy to recognize:
A lot of it is based on prescientific ideas of how the human body and disease work (e.g., traditional Chinese medicine, especially acupuncture, for instance, which is based on a belief system that very much resembles the four humors in ancient “Western” or European medicine); on nonexistent body structures or functions (e.g., chiropractic and subluxations, reflexology and a link between areas on the palms of the hands and soles of the feet that “map” to organs; craniosacral therapy and “craniosacral rhythms”); or vitalism (e.g., homeopathy, “energy medicine,” such as reiki, therapeutic touch, and the like). Often there are completely pseudoscientific ideas whose quackiness is easy to explain to an educated layperson, like homeopathy.
Functional Medicine addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership. It is an evolution in the practice of medicine that better addresses the healthcare needs of the 21st century. By shifting the traditional disease-centered focus of medical practice to a more patient-centered approach, Functional Medicine addresses the whole person, not just an isolated set of symptoms.
Dr. Gorski notes that functional medicine has been integrated into well-respected academic programs:
“there are modalities being “integrated” into medicine whose quackiness is not so easy to explain. Perhaps the most popular and famous of these is a specialty known as “functional medicine” (FM) whose foremost practitioner and advocate (in the US, at least) is Mark Hyman, MD, a man whose fame has led him to become a trusted medical advisor to Bill and Hillary Clinton. Perhaps Hyman’s greatest coup came in 2014, when the Cleveland Clinic Foundation hired him to create an institute dedicated to FM, an effort that has apparently been wildly successful in terms of patient growth. Never mind that around the same time Dr. Hyman teamed up with rabid antivaccine activist Robert F. Kennedy, Jr. to write a book blaming mercury in the thimerosal preservative that used to be in vaccines for causing autism, an idea that was shown long ago to have no scientific merit.
To fully understand the bogusness of functional medicine I highly recommend you take time to read Dr. Gorski’s excellent and detailed article at science-based medicine . It’s entitled
Functional medicine: The ultimate misnomer in the world of integrative medicine
The skeptical cardiologist has finally prepared Dr. P’s Heart Nuts for distribution. The major stumbling block in preparing them was finding almonds which were raw (see here), but not gassed with proplyene oxide (see here), and which did not contain potentially toxic levels of cyanide (see here).
During this search I learned a lot about almonds and cyanide toxicity, and ended up using raw organic almonds from nuts.com, which come from Spain.
I’ll be giving out these packets (containing 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts) to my patients because there is really good scientific evidence that consuming 1/2 packet of these per day will reduce their risk of dying from heart attacks, strokes, and cancer.
The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (PREDIMED, in which participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30g of mixed nuts per day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) at no cost, and those in the control group received small nonfood gifts).
After 5 years, those on the Mediterranean diet had about a 30% lower rate of heart attack, stroke or cardiovascular death than the control group.
It’s fantastic to have a randomized trial (the strongest form of scientific evidence) supporting nuts, as it buttresses consistent (weaker, but easier to obtain), observational data.
I applied for a trademark for my Heart Nuts, not because I plan to market them, but because I thought it would be interesting to possess a trademark of some kind.
The response from a lawyer at the federal trademark and patent office is hilariously full of mind-numbing and needlessly complicated legalese.
Heres one example:
Applicant must disclaim the wording “NUTS” because it merely describes an ingredient of applicant’s goods, and thus is an unregistrable component of the mark. See 15 U.S.C. §§1052(e)(1), 1056(a); DuoProSS Meditech Corp. v. Inviro Med. Devices, Ltd., 695 F.3d 1247, 1251, 103 USPQ2d 1753, 1755 (Fed. Cir. 2012) (quoting In re Oppedahl & Larson LLP, 373 F.3d 1171, 1173, 71 USPQ2d 1370, 1371 (Fed. Cir. 2004)); TMEP §§1213, 1213.03(a).
The attached evidence from The American Heritage Dictionary of the English Language shows this wording means “[a]n indehiscent fruit having a single seed enclosed in a hard shell, such as an acorn or hazelnut”, or “[a]ny of various other usually edible seeds enclosed in a hard covering such as a seed coat or the stone of a drupe, as in a pine nut, peanut, almond, or walnut.” Therefore, the wording merely describes applicant’s goods, in that they consist exclusively of nuts identified as hazelnuts, almonds, and walnuts.
An applicant may not claim exclusive rights to terms that others may need to use to describe their goods and/or services in the marketplace. See Dena Corp. v. Belvedere Int’l, Inc., 950 F.2d 1555, 1560, 21 USPQ2d 1047, 1051 (Fed. Cir. 1991); In re Aug. Storck KG, 218 USPQ 823, 825 (TTAB 1983). A disclaimer of unregistrable matter does not affect the appearance of the mark; that is, a disclaimer does not physically remove the disclaimed matter from the mark. See Schwarzkopf v. John H. Breck, Inc., 340 F.2d 978, 978, 144 USPQ 433, 433 (C.C.P.A. 1965); TMEP §1213.
If applicant does not provide the required disclaimer, the USPTO may refuse to register the entire mark. SeeIn re Stereotaxis Inc., 429 F.3d 1039, 1040-41, 77 USPQ2d 1087, 1088-89 (Fed. Cir. 2005); TMEP §1213.01(b).
Applicant should submit a disclaimer in the following standardized format:
No claim is made to the exclusive right to use “NUTS” apart from the mark as shown."
I’ve gotten dozens of emails from trademark attorneys offering to help me respond to the denial of my trademark request. Is this a conspiracy amongst lawyers to gin up business?
Nuts Reduce Mortality From Lots of Different Diseases
The most recent examination of observational data performed a meta-analysis of 20 prospective studies of nut consumption and risk of cardiovascular disease, total cancer, and all-cause and cause-specific mortality in adult populations published up to July 19, 2016.
It found that for every 28 grams/day increase in nut intake, risk was reduced by:
29% for coronary heart disease
7% for stroke (not significant)
21% for cardiovascular disease
15% for cancer
22% for all-cause mortality
Surprisingly, death from diseases, other than heart disease or cancer, were also significantly reduced:
52% for respiratory disease
35% for neurodenerative disease
75% for infectious disease
74% for kidney disease
The authors concluded:
If the associations are causal, an estimated 4.4 million premature deaths in the America, Europe, Southeast Asia, and Western Pacific would be attributable to a nut intake below 20 grams per day in 2013.
If everybody consumed Dr. P’s Heart Nuts, we could save 4.4 million lives!
If you’re curious about why nuts are so healthy, check out this recent meta-analysis, a discussion of possible mechanisms of the health benefits of nuts complete with references:
Nuts are good sources of unsaturated fatty acids, protein, fiber, vitamin E, potassium, magnesium, and phytochemicals. Intervention studies have shown that nut consumption reduces total cholesterol, low-density lipoprotein cholesterol, and the ratio of low- to high-density lipoprotein cholesterol, and ratio of total to high-density lipoprotein cholesterol, apolipoprotein B, and triglyceride levels in a dose–response manner [4, 65]. In addition, studies have shown reduced endothelial dysfunction , lipid peroxidation , and insulin resistance [6, 66] with a higher intake of nuts. Oxidative damage and insulin resistance are important pathogenic drivers of cancer [67, 68] and a number of specific causes of death . Nuts and seeds and particularly walnuts, pecans, and sunflower seeds have a high antioxidant content , and could prevent cancer by reducing oxidative DNA damage , cell proliferation [71, 72], inflammation [73, 74], and circulating insulin-like growth factor 1 concentrations  and by inducing apoptosis , suppressing angiogenesis , and altering the gut microbiota . Although nuts are high in total fat, they have been associated with lower weight gain [78, 79, 80] and lower risk of overweight and obesity  in observational studies and some randomized controlled trials .
The skeptical cardiologist was intrigued and disappointed to hear FBI director James Comey state that “It makes me mildly nauseous to think we might have had some impact on the election.”
Somewhere in my medical training it was drummed into my head that nauseated rather than nauseous is the word he should have used.
I was taught that nauseated means feeling nausea whereas nauseous means causing nausea.
Thus, if the smell of rotting fish makes me sick to my stomach I am nauseated by it but the smell itself is nauseous or nauseating.
On CNN Erin Burnett interviewed Senator Cory Booker regarding Comey’s comments and I noticed that Booker always used the term nauseating rather than nauseous. Clearly, he had learned the proper way of using the terms.
As a consequence, I have passed this rigid distinction on to my children and loved ones including my eternal fiancee’. (Another grammatical error I frequently try to correct in those around me is the use of “off of.” When off is a preposition off of canalmost always be shortened to just off and writers who value concision can avoid it.)
Alas, it appears that acceptable usage of these words has changed over the years and the vast majority of my patients say they felt nauseous before they vomited . I try to stop myself from correcting them because I’m fighting a losing battle.
As WritingExplained.org notes:
Garner’s Modern American Usage says that using nauseous when nauseated is meant (Example: I feel nauseous) is becoming so common that to call it an error is to exaggerate. Still, The Chicago Manual of Style calls this slip-up poor usage.
Clearly the tides are shifting on the usage of these words. There is even some evidence to show that nauseating is now the preferred word for causing nausea, e.g., a nauseating ride, a nauseating smell, a nauseating odor, etc.
It’s entirely possible that 20 years from now my patients will have completely substituted nauseous for nauseated and nauseating for nauseous. Wouldn’t that be ironic?
Perhaps you find this a nauseatingly trivial post with nauseous concepts that nauseate you. If so, please get off my cloud.
The skeptical cardiologist stopped wearing his initial wearable piece of technology (a Garmin device that constantly prompted him to move, described here), within 6 months of purchasing it; it just wasn’t worth the effort of charging and putting on the the wrist.
I am not alone in finding FitBit type devices not worth wearing after awhile. ConscienHealth points out that sales and stock price of FitBit are down significantly. Part of this is competition, part saturation of the market, but part must be due to individuals going through a process similar to mine.
The great promise that wearable fitness/sleep/activity tracking devices would make us healthier has not been fulfilled.
A recent study showed that among obese young adults, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months.
Taking the Apple Watch Plunge
However, knowing I was a fan of all things Apple, the eternal fiancee bought me a Series 1 Apple Watch, which I have come to love. This love has little to do with how the device tracks my steps or my sleep or my pulse or my movement.
Let me count the ways I do love my Apple Watch…
I can answer my phone without touching my phone or
having it near me or even knowing where my phone is.
Since I’m constantly misplacing the damn thing, this is a surprisingly helpful feature. There is also the really cool aspect of walking around and having a telephone conversation using my watch.
During a busy day of seeing patients in the office I typically will receive multiple calls from the ER or other doctors I have to talk to immediately. Now, I can rapidly screen my calls with a tilt of my wrist and excuse myself to take the call. If I’ve been trying to get ahold of Dr. X to discuss a mutual patient, and he calls while I’m doing a transesophageal echocardiogram, I can have someone touch my watch instead of reaching into my pants for my iPhone, or searching in my office for it, or missing the call altogether.
I’m missing much less important calls these days.
And although previously I would take calls while driving, the watch makes this process much simpler and therefore much safer.
2. Receiving and responding to text messages does not require accessing my iPhone.
This doesn’t seem like that big of a deal, but again, the ability to rapidly scan incoming texts with just a tilt of the wrist greatly facilitates expeditious screening and processing.
The Apple Watch allows response via either audio recording (translated seamlessly and quickly to text) or pre-set standard responses or emojis.
3. “Hey Siri” function simplifies and makes hands-free and iPhone-free many useful tasks. For example:
To set a timer for my (heart-healthy) boiled eggs, I say “Hey Siri, set timer for 11 minutes.” Normally in this situation I avoid setting the timer because I’m too busy to grab my phone, open it, and find the timer app (I know I could use Siri on my phone, but that requires more effort).
If I suddenly remember I need to call someone while driving, the “Hey Siri” function allows making the call without taking my hands off the steering wheel.
If a brilliant idea for a blog post occurs to me while driving or walking through the hospital corridors, “Hey Siri” can take a note with ease.
4. Checking the time is a lot easier (I know, all watches do this, but I’ve haven’t worn a watch for about 20 years).
5. If I misplace my iPhone (this happens roughly once per hour when I am at home), I can “ping” it by pushing a button on my Apple Watch: follow the ping and “voila!” I have found my iPhone. Most of the time it is lying under a piece of paper or article of clothing within a few feet of where I’m working, but sometimes it is in an obscure corner for obscure reasons.
Here’s a true story which illustrates my tremendous absent-mindeness and the value of the “ping.”
I left my office Friday evening and after stepping outside I realized I did not have my iPhone in its usual location, the left front pocket of my pants. I searched the pockets in my pants and in the jacket I was wearing to no avail. I began heading back to my office believing that I had left it on my desk but then realized that I might have put it in my satchel. Not in my satchel. A bright idea then occurred to me: ping the iPhone to see if it was in the satchel, but hidden.
Sure enough I heard the iPhone ping. But it was not in the satchel; it was (for obscure reasons) in my shirt pocket (a place that apparently makes it undetectable to me).
6. Information on local weather is immediately available. I have configured my watch “dial” to show me the local temperature. Right now with a flick of my wrist I can see that it’s 17 degrees outside and I’m going to have to dress warmly. I’ve also configured my watch dial to tell me when sunrise/sunset is and what my heart rate is.
These last two things, although immensely interesting, are not that helpful.
Oh, excuse me, my watch timer is telling me my eggs are done.
P.S. I’m still in the process of evaluating the work-out/sleep/move/mindfulness features of Apple Watch and hope to write about it in the near future.
Feel free to share the things you love or hate about your Apple Watch below.
As I sit here writing, I perceive a scintillating band of zig-zags in the shape of a reverse C on the left side of my visual field. I sense the scintillating reverse C with either, or both eyes closed, and I first noted it when the letters in the New Yorker article I was reading became obscured by the C. Attempts to focus on the crescent are futile: it moves as I move my eyes or head. Within its body are vague browns, blacks and whites, and overall it is reminiscent of an Egyptian or Art Deco piece of art.
I have a friend in Brooklyn, a flaneur, and one in Florida, a raconteur; I have now become a migraineur: one who suffers from migraine headaches or, in my case, the visual or tactile hallucinations known as migraine aura that precede the headaches.
I go to my bookshelf and find Oliver Sacks’ book “Migraine: Understanding a Common Disorder, which I purchased long ago when I was not a migraineur (primarily to complete my collection of Sacks’ unique and brilliant writing). On page 62, figure 2b, I find a drawing which closely approximates what I’m “seeing.”
I had asked Siri to start the timer on my Apple watch when I first noticed the visual disturbance, and now note that at 16 minutes 32 seconds, my vision was back to normal. At 25 minutes 16 seconds, I experienced a very subtle ache in my left frontal region which persisted for 5 minutes.
I have observed patients with severe migraine headaches: suffering from nausea, intense pain, photosensitivity and requiring dark and sleep and powerful analgesics to cause remission. I am fortunate because my after-aura headaches, if any, are minimal and brief.
The first time I experienced the visual hallucination was five years ago. I was not blogging then, but made a detailed note of the experience, complete with paranoid rumination on brain testing and side effects of MRIs. What follows is the transcript with the comments of the present day skeptical cardiologist in green or red.
“I had a crazy day Thursday. I gave a talk to the echo lab from 7 to 8 AM and then rushed over to the hospital to see the most urgent of the 9 inpatients I had. I had seen 4 patients by the time I got paged to see my first patient in the office. I headed over there and saw 6 patients . Then I hurried back to the hospital to grab the EKGs I was supposed to read that day. I was a little stressed because I needed to read these and try to see more of my inpatients before heading over to the outpatient testing facility which I had to be at by 1230 to supervise stress testing. I sat down in my hospital office and started reading the EKGs. After I had read a few, I became aware of a defect on the left side of my vision. It felt like when you have looked at a bright light and it leaves a residual on your retina.
At first I thought it was due to the fact that i was reading the EKGs with only the desk lamp on my left on. I turned on the overhead light and it didn’t help. I then realized that I had a hockey puck shaped defect in my left visual field in both eyes. When the defect covered key portions of the EKG, I couldn’t read it. It was filled with a jagged, prism like filling. Otherwise I felt fine. My first thought was that I was having a scintillating scotoma and that this was a migraine aura. Other things seemed much less likely-TIA for example. I called Dr S, my favorite neurologist, on his cell phone and told him what was going on. He suggested I visit him in his office right then. His office was in 400 East which would necessitate a right turn from my office. Instead, I took a left turn down to the West office building, took the elevator up to the fourth floor and finally realized my mistake when all I could find were office numbers that ended in W. (At the time young Dr. P felt this disorientation was related to the aura but perhaps it was due to distraction) By the time I reached his office twenty minutes after the visual symptoms started, they had resolved.
Dr. S did a neuro exam and history, and concluded that I most likely had a migraine aura but thought that I should get an MRI to be certain there was no structural brain disease. After I left his office I began feeling slightly nauseated with a slight headache. Over the next two hours the headache became a moderate frontal headache associated with a sense of fatigue.
I got the MRI yesterday and Dr. S thinks it is normal, although the radiologist read it as showing small subcortical defects which could be consistent with “chronic migraine, small vessel disease, or demyelinating process.”
I almost didn’t get the MRI. This is one of the classic situations in medicine where the history and physical alone makes the diagnosis with near certainty (young Dr. P is correct, see what Choosing Wisely says here), but because a very small number of cases might have something more serious (a brain tumor or vascular lesion in this case ), (perhaps also fueled by medical legal concerns and patient’s love of fancy tests) an expensive imaging test is ordered.
If you took 1000 people with my symptoms and the normal neuro exam with low atherosclerotic risk factors, and did brain MRIs on them, the vast majority of findings would be incidental, probably false positives (I believe young Dr. P made up this statistic but the national migraine center in the UK says :
“The main problem with MRI scans is ‘looking for a shilling and finding a sixpence,’ in finding abnormalities that are unrelated to headache, entirely by chance. The risk of a minor abnormality of no medical significance is 1 in 4. The risk of a chance abnormality that might need treatment is about 1 in 40. Once these ‘incidentalomas’ have been found, the patient may then find it difficult to obtain insurance (for example travel) and there is often a temptation to repeat the scan time and time again to check that the ‘incidentaloma’ is not changing..)
False positives lead to unnecessary anxiety in patients and in some cases unnecessary testing (Dr. S told me that he sees tons of patients who have had normal MRIs with readings similar to mine who are convinced they have MS) (MS=multiple sclerosis, a demyelinating process. Although my MRI was read as having abnormalities possibly due to a “demyelinating process” I must not have had one because 6 years later I have had no other symptoms)) and in some cases unnecessary additional testing.
As I was lying in the MRI gantry listening to the “ratatat “of the scanner, I wondered if we really know the consequences of rearranging the molecules of brain tissue with giant magnetic fields.
Dr. S had ordered the MRI with gadolinium. I recalled seeing adds from law firms seeking “victims” of MRI scans (one man was awarded 5 million dollars after developing nephrogenic systemic fibrosis after one dose of gadolinium (NSF). I knew that gadolinium had been linked to some really serious disorders. The tech had said nothing to me about adverse effects of the “dye” she would be using. My nose began itching like crazy, then my left eyelid. I couldn’t scratch until I emerged from the scanner. After the initial images were done and I was brought out of the scanner, I scratched my face like crazy and asked the tech if there were any side effects from gadolinium.
“Why yes, she said, you can have severe allergic reactions,” but we’ve only had a couple.” Also, she said, there is some disorder… she couldn’t remember the name or what it did but knew that it was only a problem if you had kidney failure or had diabetes and were over the age of 60.
As I was lying in the scanner after receiving the gadolinium, I began trying to estimate what risk I would be willing to assume in this situation. The disease you can get if you have severely impaired kidney function and receive gadolinium is nephrogenic systemic fibrosis.
Would I accept a 1 in 1/1000 chance of NSF in exchange for diagnosing something other than migraine 1/1000 times? I couldn’t and can’t easily and logically make that call. I have no idea how patients can make these decisions.
Migraine experiences have served as a major source of artistic inspiration in both past and contemporary painters, sculptors, film-makers and other visual artists. Check some of their work out at migraine aura foundation.
In a previous post, the skeptical cardiologist pontificated on the causes and evaluation of the most common cause of palpitations: premature ventricular contractions or PVCs.
The vast majority of these common extra beats turn out to be benign (meaning not causing death, heart attack or stroke), and most patients with sufficient reassurance of this benignity (often accompanied by significant caffeine reduction), do well. These people usually continue to notice the beats either randomly, or with stress, but they recognize exactly what is going on and are able to say to themselves “there go my benign PVCs again,” and aren’t worried or bothered.
A small percentage of patients that I diagnose with palpitations due to benign PVCs continue to have symptoms.
Part of my initial evaluation involves checking potassium, magnesium, kidney function, and thyroid levels.
Potassium Supplementation For PVCs
Low potassium levels (hypookalemia) have been clearly associated with an increase in ventricular ectopy. Patients who take diuretics like hydrochlorothiazide (HCTZ, often used for high blood pressure) or furosemide (Lasix, often used for leg swelling or heart failure), are at high risk for hypokalemia with potassium levels less than 3.5 meQ/L.
Hypokalemia can also develop if you are vomiting, having diarrhea, or sweating excessively. There are lots of other infrequent causes including excess licorice consumption. The body regulates potassium levels closely, due to its importance in the electrical activities involved in cardiac, muscular and neurological function.
The normal range of potassium (K) is considered to be 3.5 to 5 meq/L , however, I have found that PVCs are more frequent when the potassium is less than 4.
Most of my symptomatic PVC patients with potassium less than 4 find significant improvement with potassium supplementation. I usually give them a prescription for potassium chloride (KCl) 10-20 meq daily to accomplish raising the level to >4.
An alternative to potassium supplements is ramping up how much potassium you consume in your diet. Most patients I talk to about low K immediately assume they should eat more bananas, but lots of fresh fruit and vegetables contain as much or more K than bananas.
The charts to the right show that a medium tomato contains as much K as a medium banana with a third of the calories. Avocados are a great source of K and contain lots of healthy fat. Yogurt (and I recommend full fat yogurt, of course) is a great source as well.
If you have kidney disease you are much more likely to develop hyperkalemia, or high K, and you want to avoid these high K foods. Potassium infusions are used as part of a “lethal injection” in executions because extreme hyperkalemia causes the heart to stop beating. (In fact, Arkansas is hurrying to execute 8 men between April 17 and 27 utilizing KCl. According to deathpenaltyinformation.org: “The hurried schedule appears to be an attempt to use the state’s current supply of eight doses of midazolam, which will expire at the end of April. Arkansas does not currently have a supply of potassium chloride, the killing drug specified in its execution protocol, but believes it can obtain supplies of that drug prior to the scheduled execution dates”)
Lifestyle, Stress and PVCs
It’s probably time I revealed that I have PVCs. I feel them as a sense that something has shifted inside my chest briefly, like my breath has been interrupted, like my heart has hiccoughed. If I didn’t know about PVCs and hadn’t made the diagnosis very quickly by hooking myself up to an ECG monitor in my office, I know I would have become very anxious about it.
I know exactly what causes them: stress and anxiety. And this is the case for many patients. Stress activates our sympathetic nervous system, causing the release of hormones from the adrenal gland that prepare us for “fight or flight.” These hormones stimulate the heart to beat faster and harder and often trigger PVCs.
I rarely get PVCs these days, as the major source of stress in my personal life has gone away. This is also a typical story my patient’s relate: troubling palpitations seem to melt away when they retire or change to less stressful occupations, or as they recover from depression/anxiety/grief related to death of loved ones, divorce or illness.
You can’t always control external stresses, but several factors in your lifestyle are key to managing how those stresses activate your sympathetic nervous system and trigger troubling PVCs.
Dr. Mandrola lists as Steps 5-8 (Steps 1-4 are reassurance) for PVC treatment his “four legs of the table of health”:
: good food, good exercise, good sleep and good attitude. Cutting back on caffeine and alcohol, looking critically at the dose of exercise, going to bed on time, and smiling are all great strategies for PVCs.
Of these four table legs, I consider regular aerobic exercise the most important, and modifiable factor for PVC reduction. Aerobic exercise improves mood and increases the parasympathetic (the calming component of the autonomic nervous system) activity, while lowering the output of the sympathetic nervous system.
The three factors that I find essential to handling the demanding and stressful job of being a cardiologist: restful sleep, regular, aerobic exercise and lots of love from my eternal fiancee (who also has occasional PVCs!)
Beyond sleep and exercise there is a plethora of techniques that purport to help individuals deal with stress: yoga, meditation, and progressive muscular relaxation, among them.
Apps touting methods for relaxation abound these days. My new Apple Watch is constantly advising me to engage in a breathing exercise for a minute at a time. I don’t find any of these techniques helpful for me (I haven’t found a good way to shut my brain down without falling asleep), but they may work for you.
Magnesium, Snake Oil and PVCs
Patients will find that the internet is rife with stories of how this supplement or vitamin or herb dramatically cures PVCs. You can be assured that a sales pitch accompanies these claims and that the snake oil being promoted has not been proven effective or safe. Because symptomatic PVCs like most benign, common and troubling conditions (lower back pain, fatigue, and nonspecific GI troubles come to mind), are closely related to mood and wax and wain spontaneously; the placebo effect proves powerful. In such conditions, snake oil and charlatans thrive.
Magnesium is enthusiastically hyped on the internet for all manner of cardiovascular problems including PVCs. Even Dr. Mandrola, who I respect quite a lot as an EP doc who promotes lifestyle change and who is definitely not a quack, lists his step 10 for PVCs (apologetically) as follows:
Step 10 (a): Please don’t beat me up on this one. Some patients report benefit from magnesium supplementation. I have found it helpful in my case of atrial premature beats. Let me repeat, I am not promoting supplements. Healthy patients with benign arrhythmia might try taking magnesium, especially at night. Don’t take magnesium if you have kidney disease. And if you take too much, watch out for diarrhea.
Most of the internet’s top quacks, however, greedily market and glowingly swear by magnesium. A Google search for magnesium cardiovascular disease yields 833,000 entries and the first page is a Who’s Who of quackery, including Dr Mercola (strong candidate for America’s greatest quack), Dr. Sinatra (see here, currently in the semifinals for America’s greatest quack cardiologist), NaturalNews and Life Extension (see here). This totally unsupported and dangerous blather from the Weston Price Foundation is often repeated and is typical:
(magnesium) Deficiency is related to atherosclerosis, hypertension, strokes and heart attacks. Deficiency symptoms include insomnia, muscle cramps, kidney stones, osteoporosis, fear, anxiety, and confusion. Low magnesium levels are found in more than 25 percent of people with diabetes. But magnesium shines brightest in cardiovascular health. It alone can fulfill the role of many common cardiac medications: magnesium inhibits blood clots (like aspirin), thins the blood (like Coumadin), blocks calcium uptake (like calcium channel-blocking durgs such as Procardia) and relaxes blood vessels (like ACE inhibitors such as Vasotec) (Pelton, 2001).
Magnesium levels are very important to monitor in hospitalized and critically ill patients, especially those receiving diuretics and medications that can effect cardiac electrical activity.
However, for individuals with normal diets and palpitations due to PVCs, there is scant evidence that it plays a significant role in cardiovascular health.
The MAGICA study looked at supplementation with both magnesium and potassium (in the active treatment group, daily oral dosing consisted of 2 mg of magnesium-dl-hydrogenaspartate (6 mmol magnesium) and 2 mg of potassium-dl-hydrogenaspartate (12 mmol potassium) daily. The dose was chosen to increase the recommended minimal daily dietary intake of magnesium (12 to 15 mmol) and potassium (20 to 30 mmol) by ∼50% in addition to usual diet ) in 307 patients with more than 720 PVCs per hour and normal baseline K and Mg levels.
The patients receiving magnesium/potassium supplements showed a decrease of 17% in frequency of PVCs but no improvement in symptoms.
A 2012 study in a Brazilian journal evaluated magnesium pidolate (MgP) in 60 patients with both PVCs and premature atrial contractions (PACs). The dose of MgP was 3.0 g/day for 30 days, equivalent to 260 mg of Mg elemental.
93% of patients receiving MgP experienced improved symptoms compared to only 13% of patients recieiving placebo. Both PVC and PAC frequency was reduced in those receiving MGP, whereas they increased by 50% in those receiving placebo.
This small study has never been reproduced, and the main results table makes little sense. It would not have been published in a reputable American cardiology journal and cannot be relied on to support magnesium for most patients with benign PVCs or PACs.
Drug or Ablation Treatment of PVCs: Usually Not Needed
A small percentage of my patients require treatment with beta-blockers which reduces the effects of the sympathetic nervous system on the heart. Very rarely, I will use anti-arrhythmic drugs. And every once in a while, very frequent PVCs resulting in cardiomyopathy require an ablation.
However, the vast majority of patients with benign PVCs, in my experience, feel drastically better with a simple non-pharmacological approach consisting of 4 factors:
Reassurance that the PVCS are benign
Caffeine (or other stimulant) reduction
Lifestyle adjustment with regular aerobic exercise