Tag Archives: American College of Cardiology

Marketing Medicine, Changing Practice, And Groping Watchmen at the American College of Cardiology Meetings

In March, the skeptical cardiologist attended the annual Scientific Sessions of his professional organization, the American College of Cardiology. This year’s meeting was held in Orlando, a city which, for me, holds little allure beyond milder March temperatures than St. Louis.

The meetings are termed Scientific Sessions because lots of science is presented and discussed. The results of the latest, most important and “practice-changing” studies on cardiovascular drugs, devices, and diseases are released to much ballyhoo.

They take place in massive soul and leg muscle-sucking convention centers, where one typically has to hike several thousand meters to get from one presentation to another.

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The Orange County Convention Center-the second largest in the U.S., offering 7,000,000 sq. ft. of space, wifi everywhere, and the opportunity to garner 10,000 steps going from one room to another.

Medical science is best when not adulterated by commercial interest, but the ACC meeting is blanketed by advertisements for the latest (consequentially most expensive) and greatest (hopefully) life-saving drugs and devices.

A feature of these meetings is the draping of the escalators with drug marketing material. Look! Repatha now approved for a new indication!

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I used an app provided by the ACC to find sessions I was interested in, plan my itinerary and to interact with presenters. Quite irritatingly, every time I opened the app, I was presented with a commercial for, you guessed it, Repatha, one of two new (and really expensive) PCSK9 inhibitors.img_1022

I was so irritated by this advertising intrusion into my app use that I totally failed to find out what the new indication for Repatha was. (It was to prevent heart attacks and strokes, something the FDA decided in December, 2017, after reviewing the outcomes data from the FOURIER trial presented at the ACC last year (I listed this as #3 of my top cardiology stories of 2017).

Booth 1807 was in the sprawling “Expo” area of the conference, where drugmakers and device makers compete for the attention of cardiologists by offering espresso-based beverages, free nitrogen ice cream, made to order cannolis (the definite favorite of the Eternal Fiancee’, herself working the Expo for Scimage) and occasional kitsch, like rubber bouncy balls that light up when they hit a hard surface.

Typically, I avoid the cannoli and cappuccino but seek out the oddest opportunity to be seduced by the dark side.

One day I ventured into the Expo area to explore how companies were promoting their products in 2018 and before I knew it I was inside a heart,  grasping a left atrial appendage occluder.

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The skeptical cardiologist standing on the interventricular septum while occluding the left atrial appendage. This is how I ACC!

The Watchman device I was grasping has been approved for preventing stroke in patients with atrial fibrillation who are at high risk and can’t, or won’t, take blood thinners. Boston Scientific has been flying cardiologists to various cities for the last year to wine and dine them and fill them full of reasons to send their patients for the device. Thus far I have avoided going on such a boondoggle. (Read John Mandrola’s skeptical take on Watchman here).

If you didn’t get the message about Repatha from the app or the escalators, there were frequent presentations from investigators at various sites in the Expo floor.

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A lipid expert explaining why cardiologists should be prescribing cholesterol lowering PCSK9 inhibitors. Note the towering graphic “High LDL. Prior CV Event? Time to Act!”

The presenters are typically experts in the field, but are handsomely compensated for their time. Consequently, one cannot rely on this being unbiased information, so I avoid these like the plague. To the ACC’s credit, such presentations do not qualify for CME credit, and are labeled as industry-sponsored.

Despite my irritation with constant marketing and advertisements, and the bias these things introduce into cardiology practice, I get a lot out of attending the ACC sessions.

Full participation allows me to accumulate 34 hours of continuing medical education (CME), hours which I need to maintain certification in the various fields I specialize in, such as echocardiography, nuclear cardiology, vascular imaging, and coronary CT angiography.

I usually find several presentations which advance my knowledge base or change my viewpoint, and how I practice cardiology. This is ultimately good for my patients. I wrote about three of these for Medpage Today here. Consider reading the article, if only to experience the wonder that is the new and large photo of the skeptical cardiologist.

I’ll share some other thoughts from the meetings as time allows. Until then I remain

Skeptically Yours,

-ACP

 

 

 

Why Is The American College of Cardiology Distorting The 2015 Dietary Guidelines for Americans?

The 2015-2020 Dietary Guidelines for Americans (DGA) have finally been released and I’m sure that most of you could care less what they say. You may think that they can’t be trusted because you believe the original science-based recommendations have been altered by political, food and agribusiness forces.  Perhaps you don’t trust science to guide us in food choices. Perhaps, like the skeptical cardiologist, you realize that the DGA has created, in the past, more problems than they have corrected.

This time, the skeptical cardiologist believes they have made a few strides forward, but suffer from an ongoing need to continue to vilify all saturated fats.

As such, the DGA no longer lists a recommended limit on daily cholesterol consumption (step forward) but persists in a recommendation to switch from full fat to non fat or low fat dairy products, which is totally unsubstantiated by science, (see my multiple posts on this topic here).

By now you should have gotten the message that a healthy diet consists of lots of fruits, vegetables, nuts, legumes, fish, olive oil and whole grains. The DGA emphasizes this.

There is general consensus that processed foods and added sugar should be limited.

Most of the controversy is about what to limit and how much to limit foods that are considered unhealthy.

Red meat and processed meat remain in the crosshairs of the DGA (although not stated explicitly), but eggs and cholesterol have gotten a pass, something which represents a significant change for the DGA and which I have strongly advocated (here and here).

But hold on, my professional organization, the American College of Cardiology says otherwise.

Misleading Information From the American College of Cardiology

The American College of Cardiology sent me an email and posted on their website the following horribly misleading title:

“2015 Dietary Guidelines Recommend Limited Cholesterol Intake”

The first paragraph of the ACC post reads as follows:

“Physiological and structural functions of the body do not require additional intake of dietary cholesterol according to the 2015 Dietary Guidelines released on Jan. 7 by the U.S. Departments of Health and Human Services (HHS) and of Agriculture (USDA). As such, people should practice healthy eating patterns consuming as little dietary cholesterol as possible. – ”

While technically these statements can be found in the document (by digging way down) the executive summary (infographic below) says nothing about limiting cholesterol.

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The “Key Recommendations” list eggs as included under a “healthy eating pattern” along with other protein foods.

 

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In addition, there is no mention of cholesterol under what a healthy pattern limits.

 

 

In the same section on cholesterol that the ACC inexplicably has chosen to emphasize, is this sentence:

“More research is needed regarding the dose-response relationship between dietary cholesterol and blood cholesterol levels. Adequate evidence is not available for a quantitative limit for dietary cholesterol specific to the Dietary Guidelines.”

So the DGA recommends no specific limit on dietary cholesterol.

This is consistent with what the DG advisory committee recommended when they wrote “dietary cholesterol is no longer a nutrient of concern.”

The DGA goes on to state:

“A few foods, notably egg yolks and some shellfish, are higher in dietary cholesterol but not saturated fats. Eggs and shellfish can be consumed along with a variety of other choices within and across the subgroup recommendations of the protein foods group.”

The Vegan Agenda

I have a theory on why the ACC went so wildly astray in reporting this information: they are led by a vegan.

The current president of the ACC, Kim Williams, is an evangelical vegan, unrepentant, as this NY times article points out. Apparently, he tries to convert all his patients to the “plant-based diet.”

He is quoted extensively in the ACC blurb on the DGA and is clearly attempting to put a bizarre vegan spin on the new guidelines, ignoring the evidence and the progressive shift from the 2010 guidelines.

Can any information from the ACC be trusted if such basic and important science reporting was so heavily distorted by its President?

No wonder Americans tune out dietary advice: it can so easily be manipulated by those with an agenda.

-May the forks and knives be with you

-ACP

 

 

 

 

Healthy Skepticism and Bias in Cardiology : Let’s Eliminate Drug Ads from Scientific Publications

The skeptical cardiologist has been asked by a number of his patients  “Why are you the skeptical cardiologist?”  In essence, I think they are either asking what does “skeptical” mean or what makes you skeptical and why should I care?

In the About section of this blog I wrote “All of these experiences have taught me to cultivate a healthy skepticism for information that has potential bias.”

Whereas skepticism initially was an approach that doubted the veracity of everything and questioned our ability to know anything, healthy skepticism accepts the veracity of information only after it has been evaluated by a scientific or evidence-based approach.

John Byrne, MD, has a wonderful website, skeptical medicine, which describes in detail the skeptical doctors approach.

The modern skeptic is a scientific skeptic. We use proper science and basic ethics to inform our decisions. We withhold acceptance of claims until proper evidence is presented. We use axioms such as ‘Occam’s Razor’, ‘Extraordinary Claims Require Extraordinary Evidence ‘, and ‘Correlation is Not Necessarily Causation’ to evaluate claims. The skeptic recognizes that humans are prone to biases. We recognize that people defend their biases with logical fallacies. Skeptics understand that we are all prone to such biases and fallacies, even skeptics.  To overcome these tendencies, we must learn about biases and fallacies in order to spot and correct them, especially in our own thinking.

Thus, as a skeptical cardiologist, I am doing my best to use scientific approaches to evaluate recommendations for lifestyle, testing and treatment in the world of cardiology. I do not accept recommendations in these areas from cardiology authorities (American Heart Association, American College of Cardiology guidelines, scientific conferences), media, or the government, without carefully examining the scientific studies supporting them. I seek to eliminate biases that can undermine such studies and recommendations.

The Influence of Drug Money on Doctors

Identifying bias in medical recommendations is essential. Just as our politicians are heavily influenced by campaign contributions from special interests, physicians can also be heavily influenced by special interest spending.

I have tried to eliminate any possibility of pharmaceutical company marketing from influencing my medical decisions. I used to believe that I could accept meals and honoraria from drug companies and not be biased by them. However, several years ago, I realized that any time I spent listening to a heavily biased pharmaceutical representative promoting their product was replacing and/or competing in my brain with information about medications and diseases from unbiased sources. In subtle ways, even to the most ethical doctors, this has been shown to effect prescribing practice. If it didn’t, these companies would not be spending billions promoting their drugs directly to doctors.

The American College of Cardiology and Drug Advertisements

The major professional organization for cardiologists is the ACC or American College of Cardiologists. I get lots of emails from the ACC offering educational opportunities and information on the activities of the college. The ACC also mails me, weekly, the Journal of the American College of Cardiology, the major publication for scientific studies on cardiology in the wIMG_3297orld. Once a week or so, they send me “Cardiology World News,” which is a summary of relevant articles and developments in cardiology. All of these sources of information from the ACC are riddled with advertisements for drugs. The newer and more expensive the drug, and (it appears) the less the benefit, the larger the advertisements. Accompanying the latest Cardiology World News this last week was the large multipage pamphlet pictured below, touting the fact that Brilinta is “preferred over clopidogrel” for NSTEMI in the updated AHA/ACC guidelines. The skeptical approach is to question the validity of these guideline recommendations by reviewing the studies that they were based on, as well as the possible conflicts of interest of the authors (how many are paid honoraria or have research funded by Astra-Zeneca, the company promoting Brilinta)?

IMG_3299Within the pages of Cardiology World News were several multipage advertisements for drugs, especially for newer oral anticoagulant drugs, such as Xarelto. Even the prestigious Journal of the ACC is stuffed with these annoying advertisements. The emails I get from the ACC often contain banner ads for similar over-priced and over-marketed brand name drugs; the websites of ACC and Medscape are littered with banner ads for drugs. Since I am the skeptical cardiologist, I’ve reviewed the studies that resulted in these drugs being approved, and then make my own conclusions about how to prescribe them to my patients.  Such ads are not useful in my decision making.

When I read journals, studies, editorials or reviews of cardiology information,  I simply want unbiased information. I don’t want my mind cluttered by biased presentations from drug companies.

Why is my professional organization helping to promote these biases?  Obviously, it is for the money.

To the American College of Cardiology I say: “let’s eliminate drug ads from your publications.” With that simple step, we can help reduce the control that pharmaceutical companies have over physicians and move toward ensuring that all of our drug and device recommendations to patients are in their best interest.