PROMISEs, Promises: Stress Test or CT Angio for Patients With Stable Chest Pain

I posted the following comments for SERMO, a social network for over 300,000 physicians yesterday.. I would encourage any physician readers to join SERMO and engage in the medical discussions going on there.

As physicians, we have to decide on a daily basis how to evaluate the patient who has chest pain. Most chest pain is not cardiac, but if we miss the patient whose chest pain is a sign of coronary ischemia or impending infarct, the results can be catastrophic.
The standard approach across the US for patients presenting with stable chest pain is to do some sort of stress test. Usually, treadmill or chemical ECG stress tests are combined with an associated imaging technique (nuclear or echocardiography). These kinds of tests are considered  “functional” or “physiologic.”
Coronary CT angiography (CTA), on the other hand, is a visualization of the actual anatomy of the coronary arteries, and has been proposed by many as a more useful starting point for evaluation of chest pain.

Prior to this study, there were no randomized comparisons of these two approaches on health outcomes in patients with stable chest pain. In patients with acute chest pain, presenting to the ER, two randomized controlled trials have shown superiority of CT angiography.

This morning at the American College of Cardiology meetings in San Diego, the results of the PROMISE (the PROspective Multicenter Imaging Study for Evaluation of Chest Pain) were presented.  Simultaneously with the presentation, the full paper was published here.

As a noninvasive cardiologist board-certified in both echocardiography and nuclear cardiology, and as a reader of coronary CT angiography,  I was particularly interested in hearing and reading these results.

The study was a well-done, realistic comparison of these two techniques. Over ten thousand patients presenting with stable chest pain were randomized to CTA versus stress testing at multiple different sites.

The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure.

All tests were interpreted locally and the site clinical team made all subsequent care decisions. Stress MPI (nuclear) were ordered in 67%, stress echo in 23% and stress ECG in 10%. Pharmacologic stress was utiilized in 29%. The median follow up was 25 months.
The major finding was that there was no difference in occurrence of the primary end-point between the anatomic strategy (CTA, 3.0% at 25 months) and the functional strategy (stress testing, 3.3%).

My Take Home Points From the PROMISE Study

1. In the stable chest pain patient (even with significant risk factors) the prognosis is good.
2. We now have two roughly equivalent options for evaluating such patients, CTA or stress testing.
3. CTA is less likely to result in a cath with totally normal coronary arteries and it is useful for identifying early atherosclerosis. The patients in the CTA arm received more statins and aspirin due to this.
4. Currently, there are insurance companies which will not approve CTA for any indication other than congenital coronary artery anomaly. It is highly likely that this study will move CTA from a IIA indication to a I indication in guidelines and allow wider acceptance by insurance companies.

Skeptically Yours,

ACP.

Reporting From the American College of Cardiology Meetings 2015: Let the Science and Marketing Begin!

As part of his relentless pursuit of cardiologic knowledge, the skeptical cardiologist is in San Diego preparing to report on the 64th annual Scientific Sessions of the American College of Cardiology.

At last year’s meetings in Washington, DC, there were over ten thousand physicians attending, about two-thirds of whom were in clinical practice and one-third primarily involved in research.

These cardiologists will be listening to the latest presentations on scientific findings in cardiology and reviewing the best practice and guidelines in clinical cardiology.

They will also be interacting with almost three-hundred exhibitors. The exhibitors consist of companies that want to sell their wares to cardiologists.

Here is an interactive map of all the exhibitors in the “expo.”

If you move your cursor over the largest rectangle in the map you see that this 7800 square foot space belongs to Astra Zeneca, a British multinational pharmaceutical and biologics company. Astra Zeneca sells drugs in a lot of areas but I know that their major focus here at the ACC meeting will be on their new anti platelet drug known as Brilinta (ticagrelor).

They have been aggressively promoting this to cardiologists at my hospital through a combination of company sponsored dinner talks and pharmaceutical rep office lunch visits. When I began using the app for the ACC2015 meetings one of the first things to pop up was a stealth advertisement for this drug.

I moved my cursor over one of the smallest boxes I could find and up popped United Biologics, Inc. who have 100 square feet. Apparently they are “engaged in designing and manufacturing silicone replications of human vasculature, including common pathologies.”

I will be posting about the science and the marketing that goes on here over the next few days.

I’ll focus on the areas I am an expert in, including echocardiography and imaging, along with the new developments in fields like atrial fibrillation, valvular heart disease, prevention of coronary disease and heart failure that can help my patients.

If any of my readers have a particular topic you would like me to report on, let me know.

Yours in skepticism, ACP

Addendum: I have been to lots of ACC meetings in cities like Dallas, Atlanta and Orlando. The convention centers are usually located in very boring parts of the downtown area and are not particularly aesthetically pleasing. The San Diego convention center on the other hand is wonderful.IMG_3406

It is immediately adjacent to Embarcadero Marine Park, a very nice section of the harbor with boats and walking trails and exotic vegetation.

IMG_3396

The building itself it a joy to behold, an architectural gem with features suggesting sails and spires from the nautical world. I can’t wait to get inside and start learning.

Cardiology Marketing: A Plea For Honesty and Scientific Accuracy

In the last few years the skeptical cardiologist finds himself inundated and sickened by slick promotional material from various hospitals across the country. These pamphlets typically tout the cutting edge research being done or the latest surgical and catheter-based techniques that the cardiologists at their facilities are doing.

Obviously, a lot of marketing energy and money is being expended by hospitals in an effort to lure patients away from their normal referral hospitals to come to these hospitals located in cities like Cleveland, Baltimore, Los Angeles and New York.

It is my sense that the doctors who are featured in these print infomercials either don’t proofread the advertising copy or they are shamelessly engaging in overhyping procedures that are, at best, marginally better than those available in the community.

Robots For Heart Surgery

Let’s take the latest example I pulled from my office mail which is the “Cardiovascular Report” from Johns Hopkins Heart and Vascular Institute.

Each article in the four page glossy pamphlet, comes replete with a large color picture of a photogenic doctor who looks incredibly earnest and dedicated.

Each article begins with an anecdote which has become a staple, it seems, for all medical reporting. We learn of a specific patient who had a particular cardiology problem. After bungling by the local doctors, the patient is very fortunate to have been referred to Johns Hopkins where cutting edge knowledge, elite cardiologists, and often a new surgical or catheter-based procedure dramatically effected their outcome.

Although the story of one patient makes for dramatic reading and human interest, patients should never make decisions on what procedures to do based on such anecdotes.

The story entitled “An Ideal Candidate for Robotic-Assisted Mitral Valve Repair” begins with an anecdote about Jim Watkins of Overland Park, Kansas who knew he had a heart murmur and was diagnosed with “benign mitral valve prolapse” and told by his cardiologist “not to worry about it but to have a follow-up every three years or so.”

The article implies that such a conservative approach was foolish, but the vast majority of mitral prolapse patients with less than severe leakage from their mitral valves are best managed this way. One of the major criticisms of cardiologists is that we perform too many tests too frequently.

A routine echocardiogram (heart ultrasound) revealed “moderate-to-severe mitral valve leakage and marked leaflet regurgitation.”  This phrase could not have been proofread by a competent doctor because mitral leakage and regurgitation are describing the same thing. The story quotes the patient as saying that “they wanted me to have open-heart surgery before Christmas.”

Assuming that Mr. Watkins was free of symptoms at this point, and that the function of his left ventricle was normal, there would be no reason to rush into surgery for moderately-severe mitral regurgitation.

The patient began exploring options and “learned that minimally invasive robotic repair was an option that offered faster recovery and minimal scarring.”

I’m pretty certain he learned all the positives of the technique from a website like that of Johns Hopkins, Cleveland Clinic or Mayo Clinic, who specialize culling the best mitral repair candidates from the population across the United States.

The articles then states “The Midwest hospitals that could do it, however, had months-long waits.” I find this statement totally unbelievable. I know that the longest wait I have ever noted for such surgery in St. Louis is about a week.

The article goes on to say that “the patient found, by expanding his geographic search, Dr. Kaushik Mandal at Hopkins. Within 5 minutes Mandal returned the call” (in all of these medical anecdotes, the doctors are incredibly responsive and compassionate in addition to promulgating the latest, most expensive techniques in cardiology).

He flew to Baltimore and had the mitral valve surgery and was discharged a week later with “no restrictions.” The reader could not have been in any doubt about the outcome for Mr. Watkins, as this one case was selected from the entire experience of the hospital to highlight a good outcome.

One has to question, however, that the patient was discharged with “no restrictions.” Really? The doctors were fine with activities such as driving a car and lifting heavy boxes one week after a thoracotomy?

A more significant criticism of this promotional puff piece and similar marketing material is the total lack of an objective, balanced approach to the risks and benefits of the procedure compared to standard approaches.

Is there any evidence that robotic assisted mitral valve repair provides superior outcomes to non-robotic assisted minimally invasive repair? No.

Dr. Alfredo Trento, a proponent of the robotic mitral repair system approach writes

A consensus statement of the International Society of Minimally Invasive Cardiac Surgery (ISMICS) 2010 on minimally invasive vs open mitral valve surgery concluded, on the basis of review of retrospective studies, that, in patients with mitral valve disease, minimally invasive surgery either robotically or through a right minithoracotomy may be an alternative to conventional mitral valve surgery, given the similar short and long-term mortality and also the reduced sternum complications, transfusion requirements, and hospital stay. However, the risk of stroke was higher with minimally invasive surgery than with conventional approaches (2.1% vs 1.2%) as was the risk of aortic dissection, phrenic nerve palsy, and groin complications; additionally, cross clamp times and cardiopulmonary bypass time were increased.

Far too often in medicine, hospitals adopt the latest and greatest expensive technology or procedure before it has been proven superior to existing approaches.

One of the major driving forces behind this reckless spending is marketing the hospital and it’s “cutting-edge” approach to disease management.

As patients and physicians, we need to resist this kind of marketing and insist on an honest and balanced approach to evaluating newer technologies and surgical approaches.

Cardiologists and cardiac surgeons working in the centers that produce this kind of misleading marketing material should take responsibility for what is written and insist on an accurate description of the advantages and disadvantages of their techniques.

Dairy and the Paleo Delusion

The Paleo diet (primal/evolutionary) has become very popular in the last few years. Followers believe they are eating the way our stone age, or paleolithic, ancestors ate. Since our genes have not had time to evolve to match the drastic change in diet that occurred with the agricultural revolution, they argue, modern diets are making us sick and contributing to most of our chronic Western disease like atherosclerosis, diabetes and dementia.

True experts in evolutionary science have questioned most of the theoretical underpinnings of the Paleo movement. Marlene Zuk, an evolutionary biologist, has written an excellent critique in her recently published book “Paleofantasies: What Evolution Really Tells Us About Sex, Diet and How We Live.”

Dr. Zuk points out that there likely was no one single hunter-gatherer diet and that we have a very limited understanding of exactly what that diet consisted of. She also makes the point that this concept that at some point in the past, humans were perfectly adapted to their environment, is not true.

The Milk Paleofantasy

Although the Paleo movement is not monolithic on the topic, some of its leading figures are vehemently opposed to milk consumption.

For example, Loren Cordain (whose web site states that he is “widely acknowledged as one of the world’s leading experts on the natural human diet of our Stone Age ancestors”), has nothing but bad things to say about dairy and milk consumption. Cordain has a Ph.D in “health” and is quite a prolific author, having written “The Paleo Cure For Acne” (spoiler alert: the cure involves not drinking milk).

One major problem with the paleo concept of diet is the assumption that our genetic makeup has not changed or evolved over the last 10000 years.

It turns out that we are not stuck with the same genome of our caveman ancestors and that our ability to tolerate milk confirms this.

The Evolution of Lactose Tolerance

The main sugar in milk from all mammals is lactose. The ability to digest lactose depends on having the enzyme lactase present in the lining of the intestinal tract. All mammals at birth have lactase, but as they age, lactase production is reduced by around 90%. This loss of lactase leads to lactose intolerance.

Lactose that is not digested ends up being fermented by bacteria in the large intestines. This fermentation produces methane, hydrogen gases and other by-products, resulting in bloating, abdominal pain, and diarrhea.

Around 10-20,000 years ago, a mutation in the gene that controls production of lactase resulted in lactase persistence. Some of our paleolithic ancestors began noticing that they were lactose tolerant and could drink the milk of cattle that they had domesticated.

As Zuk writes:

Beginning about 7000 years ago, DNA studies of ancient bones reveal that there was a progressive increase in the frequency of lactase persistence. Increase in a genes frequency tends to correspond with a survival advantage suggesting that the ability to consume dairy prolonged lives.

Lactase persistence is present only in about 35% of the world’s population. It is common in Scandinavia and parts of Africa and the Middle East and about 90% of Americans have it.

The rapid increase in the dominant gene for lactase persistence in humans suggests that the Paleo concept of a genome stuck in the stone age is incorrect.

Stumbling onto a heart-healthy diet using Paleofantasies

Despite the lack of scientific support for the basic theories underpinning the movement, I do think the Paleo diet has some good points. For the most part, this is going to be a low-carb diet. Other areas I can agree with them on are:

-Avoid processed foods, added sugar, refined starches

-Eat lots of minimally processed vegetables

-Grass-fed beef is fine

-Wild game consumption is great (but wild game is hard to find)

But ultimately, the Paleos, as students of evolutionary biology, should be embracing the evolutionary changes humans underwent that allowed the consumption of dairy as adults.

From the Skeptical Cardiologist’s Cookbook: Darwin Dali-ghts ©

Food preparation is not the forte’ of the skeptical cardiologist.

However, a “heart-healthy” snack he created yesterday is generating such a buzz in the Pearson kitchen that he felt compelled to share it.

Ingredients

IMG_3344One head of cauliflower, raw, uncooked and broken up into florets . Mine was organic from Whole Foods. Peanut butter. Mine was ground from peanuts a week earlier at Whole Foods.

Preparation

It takes about 2 minutes to convert a head of cauliflower into bite size pieces. Be sure to leave the stems intact because they can be used as “handles”, if you will, to dip the cauliflower pieces into the peanut butter.

Response

IMG_3348
My friend Charles had his doubts initially but became a huge fan after  having a few bites. His skepticism evolved into a passionate belief in the snacks.

 

 

 

 

 

IMG_3349
Salvador was entranced and made vertiginous by the phantasmagoria of colors, textures  and shapes that emerged from the combination of cauliflower and peanut butter.

 

 

 

 

 

 

 

 

 

Nutritional Content

This snack, which I have dubbed  a Darwin Dali-ght ©, combines two heart healthy ingredients.

 cauliflower nutritionA head of uncooked cauliflower contains 146 calories. It is chock full of things we cardiologists think are good for you including:

  • 12 grams of fiber
  • 11 grams of protein.
  • 472% of the recommended daily allowance of Vitamin C.
  • 12% of the daily calcium allowance

 

It has negligible amounts of cholesterol and fat (but we are no longer concerned about these) and 11 grams of sugar (it is not added sugar so this is OK).

Some authors (such as the ubiquitous quack Mercola) have proclaimed it a superfood, going on and on about various antioxidants and obscure chemicals found in it that may have anti-inflammatory or anti-cancer properties but this is all speculation.

A whole head of cauliflower contains  about 1800 mg of potassium which is 50% of the daily allowance. Depending on what source you consult you will see it listed as both low in potassium and high in potassium. Given that a 100 gram serving of cauliflower contains about 300 mg of potassium,  I will be recommending it to my patients with low potassium and telling my patients with high potassium to stay away from it.

Two tablespoons of peanut butter contain 3.3 grams of saturated fat and 12.3 grams of unsaturated fat. We don’t have to worry about these fats, they  don’t contribute to obesity or heart disease (see here).  The fat in the peanut butter adds to the satisfaction and feeling of fullness created by the Darwin Dali-ght ©. Peanut butter is also full of great antioxidants and potassium.

The bandmates of the skeptical cardiologist (including the son and youngest daughter of the skeptical cardiologist) dug into some Darwin Dali-ghts after yesterday’s jam session and were pleasantly surprised at how tasty and satisfying these heart-healthy concoctions are.

Nota Bene: I have discovered today how to make the © sign on a Mac keyboard (alt g).  Also, please note, that I have not heavily researched whether this combination of foods has been created or copyrighted previously.

-ACP;)

 

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

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

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

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

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

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

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

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

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

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

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

Evidence Strongly Supports Statins in Secondary Prevention 

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

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

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

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

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

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

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

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

Evidence Strongly Supports Atherogenic Cholesterol is Related to Coronary Heart Disease

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

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

Conflating the Diet-Heart Hypothesis and the Cholesterol Hypothesis

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

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

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

The Great Cholesterol Truths

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

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

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

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

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

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

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

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

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

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

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

These authors concluded

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

How Might Calcium Supplements Increase Cardiovascular Risks?

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

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

Higher calcium levels may also promote clot formation.

Bone Fracture versus Heart Attack

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

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

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

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

Preventing Fractures and Heart Attacks

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

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

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

Eggs and Heart Disease

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

The Skeptical Cardiologist

The Wonderful Egg and Your Heart

photoI think eggs are wonderful. They are little balls of nutrition that can be prepared in numerous fascinating ways to make breakfast interesting and delicious. I particularly like omelets.  Alas, when I was training as a medical student the medical establishment had embraced the diet-heart hypothesis. It was felt that dietary cholesterol and fat (subsequently modified to saturated fat) by increasing levels of cholesterol in the blood (subsequently modified to raising levels of bad or LDL cholesterol) were responsible for the increasing rate of coronary heart disease that was being observed.

This certainly made sense at the time: If you eat too much cholesterol, of course it’s going to raise your blood cholesterol levels and contribute to the buildup of those nasty cholesterol plaques that would clog your arteries and give you heart attacks and strokes.

Since egg yolks contain 210 mg of cholesterol…

View original post 1,713 more words

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

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

The AHA sponsored http://www.goredforwomen.org site proclaims

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

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

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

Heart Sisters

by Carolyn Thomas    @HeartSisters

“I was asleep and my symptoms woke me up. I had several simultaneous symptoms, but the first one seemed to be central chest pain. It wasn’t sharp or crushing or burning, more like a dull pressure. The pain radiated down my left arm and up into my neck and jaw. I had cold sweats, and I felt nauseated.”

Laura Haywood-Cory, age 41, heart attack, six stents

Researchers tell us that over 90% of us already know that chest pain like Laura’s could be a symptom of what doctors call Acute Myocardial Infarction(AMI – or heart attack) or Acute Coronary Syndrome(any condition brought on by sudden reduced blood flow to the heart muscle).  So it may not surprise you to learn that chest pain is the main reason that over 6 million people rush to the Emergency Departments of North American hospitals…

View original post 2,175 more words

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

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

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

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

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

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

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

%d bloggers like this: