Tag Archives: cardiac testing

Are You Taking A Statin Drug Inappropriately Like Eric Topol Because of the MyGeneRank App?

The skeptical cardiologist was listening to a podcast discussion between Sam Harris and Eric Topol recently and became  flabbergasted.

Topol, the “world-renowned cardiologist” who is seemingly everywhere in media these days was discussing what he considers the overuse of imaging technology during the podcast which Harris’s website describes as follows:

In this episode of the Making Sense podcast, Sam Harris speaks with Eric Topol about the way artificial intelligence can improve medicine. They talk about soaring medical costs and declining health outcomes in the U.S., the problems of too little and too much medicine, the culture of medicine, the travesty of electronic health records, the current status of AI in medicine, the promise of further breakthroughs, possible downsides of relying on AI in medicine, and other topics.

Personally, I have been amazed at the hype and promotion that artificial intelligence (AI) has been getting given the near total absence in cardiology of any tangible benefits from it and I wanted to hear what the man who wrote ” Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again ” had to say about it.

About 28 minutes into the podcast, Harris, who has lately been preoccupied with promoting meditation as a cure for all ills, begins describing a procedure he underwent:

I’ve had a few adventures in cardiology. CT scan, calcium score scan.

Harris, who in neuroscience and philosophy might speak precisely, here is very vague. Did he get a coronary calcium scan (CAC) or a coronary CT angiogram? There is a huge difference and he is conflating the two imaging procedures.

Apparently he is unhappy with having undergone it but:

I might be telling a different story if my life was saved by it.

And his doctor’s rationale  for getting the scan was lacking:

The way this was dispensed to me. We now have this new tool, let’s use it.

Let me just say at this point that if your doctor’s rationale for performing a test is that he has a machine that performs the test just say no. Or demand an explanation of how the results will change your management or prognosis.

Apparently the scan that Harris had didn’t turn out either horrifically worse than expected or remarkably better and didn’t change management:

In my case at the end it didn’t make sense.

Now, I can forgive Sam Harris for being somewhat naive and misguided when it comes to coronary artery scans or coronary CT angiograms but Eric Topol , the world’s leading talking cardiology head should fully understand the value of coronary artery calcium scans.

This is where I first become flabbergasted.

Topol says in response at this point that coronary artery calcium scans are “terribly overused” and that “I’ve never ordered one.”

Eric, you cannot be serious!

Are you telling me that you wouldn’t order one on your 60 year old airline pilot friend whose father dropped dead of a massive MI at age 50 but whose lipids look fine?

Why doesn’t Eric order CACs?

Because “There are so many patients who have been disabled by the results of their calcium score even though they have no symptoms.”

This is where the degree of my flabbergastment increased by an order of magnitude.

Our job as preventive cardiologists is to identify those at high risk and lead them to lifestyle choices and medicine that dramatically lowers that risk.  We educate them that the large build up of subclinical atherosclerosis we identified does not have to result in sudden death, crippling heart attacks or strokes. We reassure them that with the right tools we can help them live a long, productive and happy life.

Eric, what do you tell these people? The calcium score is irrelevant? You’re fine. You shouldn’t have gotten it. Surely not! This would be the preventive cardiology equivalent of sticking one’s head in the sand.

This is not the first time Topol has opined on the dangers of CAC. An excerpt from his book, ‘The Patient Will See You Now: The Future of Medicine Is in Your Hands” posted on Scientific American describes the ills created in a 58 year old man who had a CAC score of 710.

My patient was told that he had a score of 710—a high calcium score—and his physician had told him that he would need to undergo a coronary angiogram, a roadmap movie of the coronary anatomy, as soon as possible. He did that and was found to have several blockages in two of the three arteries serving his heart. His cardiologists in Florida immediately put in five stents (even though no stress-test or other symptoms had suggested they were necessary), and put him on a regimen of Lipitor, a beta-blocker, aspirin and Plavix.

This case is not an example of inappropriate usage of CAC it is an example of really bad doctoring and failure to utilize the CAC information properly.

One should never order a cardiac catheterization/coronary angiogram solely on the basis of a high CAC score. Even ordering a stress test in this situation is debatable as I discuss here.

And Topol’s patients symptoms were most likely related to a beta-blocker that he didn’t need (see here).

My Gene Rank

Later in the podcast I reached maximum flabbergast  levels when Topol announced that as a result of a high score for CAD risk he received using an iPhone app called MyGeneRank he had started taking a statin drug.

He enthusiastically promoted the app which his Scripps Translational Science Institute developed and urged listeners to utilize this approach to better refine the estimate of their risk of heart attack and stroke.

Per the Scripps website:

The MyGeneRank mobile app is built using Apple’s ResearchKit, an open source framework that enables researchers and programmers to build customized mobile apps for research purposes. With user permission, the app connects with the 23andMe application program interface and automatically calculates and returns a genetic risk score for coronary artery disease.

In addition, the app calculates a 10-year absolute risk estimate for an adverse coronary event, such as heart attack, using a combination of genetic and clinical factors. Users are able to adjust behavioral risk factors to see the influence of lifestyle habits on their overall risk.

Elsewhere, Topol, has stated

“We are excited to launch a unique study that combines an iOS app and genomics to help guide important health decisions,” says Eric Topol, MD, Founder and Director of the Scripps Translational Science Institute and Professor of Molecular Medicine at The Scripps Research Institute. “Not only does participating in the study arm individuals with their own data, but it also gives them the opportunity to participate in new type of research – one that is driven by and for patients.”

Curious, I downloaded the MyGeneRank app, answered some questions and gave it permission to access my 23 and Me data. After requiring me to complete a survey on my health it then  yielded  my coronary artery disease risk score.

 

 

 

 

 

 

 

Oh, no! My genetic risk score was at the 81st percentile! In the red zone.  According to Eric Topol I should take a statin like him. Based on these results I probably should be incredibly anxious and crippled by fears of cardiac death.

Fortunately, I have superior information to allay my fears. I’ve had CAC scans in the past which are well below average for men my age. Despite my dad’s history of early CAD, a recent coronary CT angiogram showed minimal plaque. I know exactly where I stand risk-wise.

How many cardiac cripples has Topol’s MyGeneRank inappropriately created?

Is the data that MyGeneRank utilizes superior to that from CAC scans?

For coronary artery calcium scanning there is a wealth of data supporting improved risk prediction and we are looking directly at the atherosclerotic process that eventually causes the diseases we want to prevent.

It’s interesting that a recent study looking at a polygenetic risk score’s ability to predict cardiac events was comparing the risk score’s ability to predict subclinital atherosclerosis:

Each 1-SD increase in the polygenic risk score was associated with 1.32-fold (95% CI, 1.04-1.68) greater likelihood of having coronary artery calcification and 9.7% higher (95% CI, 2.2-17.8) burden of carotid plaque.

In the Scientific American article Topol quotes Mark Twain:, “To a man with a hammer, a lot of things looks like nails that need pounding.”

Topol’s hammer is artificial intelligence. We eagerly await the day he discovers a nail that he can bang on that  significantly advances medical care.

In the meantime I and the vast majority of progressive preventive cardiologists will be utilizing CAC scores intelligently to identify both those patients at high risk for cardiovascular events who need more aggressive treatment and those at low risk who can be reassured and have treatment de-escalated.

Polygenetic CAD risk scores do show promise to improve our predictive powers but more study is needed in this are before we make clinical treatment decisions based on the results.

Astoundingly Yours,

-ACP

Skeptical Thoughts From The Dentist Chair: Part I, The Questions

The Skeptical Cardiologist found himself lying in a  dentist chair one day having his  teeth poked, prodded, scraped, rubbed and polished, when fears of the adverse consequences of these procedures suddenly overwhelmed him.

Previously I had considered routine dental cleaning a necessary annoyance, something that I guiltily avoided, primarily because of the time wasted and discomfort associated with it. But as I lay with my mouth open, a series of questions erupted in my consciousness.

Perhaps this anxious skepticism was related to the writing and thinking that I have done about the downsides of routine annual electrocardiograms or routine stress testing after stents. It has become clear to me that the risk/benefit ratio of any annual medical evaluation should be questioned.

The hygienist introduced herself (we’ll call her Donna), put away her crossword puzzle book, guided me back to the exam room and told me that she was going to do an X-ray.  I wasn’t asked if I wanted an X-ray or explained the purpose of it, but dental radiography now seems to be the norm. Perhaps I am given one every time I visit a dentist because I go infrequently, much less than annually, and dental insurance tends to  pay for an annual X-ray. The dental offices probably assume if it is free, no sane patient will reject it.

More and more, I have become concerned about the radiation from medical radiologic procedures (see my discussion on the radiation from coronary calcium CT scans here). The  hygienists are always careful to put a lead apron over my groin and around my neck, which makes me feel a little better, but I can’t help but wonder…what is the yield of the x-ray in a patient with no symptoms, what is the risk of developing oral cancer from the procedure, if performed every year? And what is the probability that something will be identified that is not really a problem, which may lead to more testing or procedures?

These concerns are similar to ones that we face daily in cardiac testing (and for PSA and mammography), but unlike stress testing and breast cancer screening, there seems to be little scrutiny of the value of the routine annual dental x-ray.

Donna placed a bib around my neck and I noticed that she was wearing medical gloves and that she was preparing a device covered with plastic to stick in my mouth. That’s nice, I thought, good sterile technique! However, adjacent to the part of the device covered in plastic, was metal that was uncovered and I saw her touch that, then manipulate the plastic and put that in my mouth.  I began worrying about transmission of hepatitis or HIV virus from a previous patient which was now being inserted into my mouth.

I began thinking that if one case of hepatitis is created by a routine dental visit, that probably negates the benefits, if any, of the thousand patients that had their teeth cleaned and didn’t get hepatitis.

After irradiating my teeth for unclear reasons, Donna began preparing her pointy metal probes, picks, and claws for the “cleaning.”

As she began picking, clawing and scraping away at my teeth, I began to wonder if this could be more harmful for me than helpful. What if this process was somehow damaging the enamel of my teeth and making it more likely that I would have problems?

I worried about my tongue: what if it I wasn’t positioning it in the right spot? Could it be hit by one of her picking devices, causing me to bleed, which would then cause the multiple bacteria now swarming in my saliva to gain entry into my bloodstream, perhaps landing on a heart valve and causing an infection, endocarditis, that would then result in a need for valve replacement surgery?

Periodically she would squirt a liquid into my mouth and then ask me to close my lips around the plastic sucking device. How well had the sucking device and the squirting tool been cleaned before the last patient and how I could I possibly verify this? I had to put my complete trust in this dental hygienist who I had never met before. I didn’t know what her training was.  I didn’t know what her level of compulsiveness with regard to germ transmission was.

Did I want her to be very aggressive with the cleaning or superficial? Which was better? Previously, I have had both approaches and I’m usually thankful for the brief, superficial variety.

Donna announces that she will be “polishing” my teeth and the dreaded rotary brush, coated with nasty paste is applied. What are the component of the paste? Is it likely to fly off into my lungs and set up a nidus for an inflammatory nodule?  If I swallow it will its toxic contents be absorbed into my blood stream and destroy my liver?

At the very instant that she is done, the dentist enters the room and greets me with a hand shake; he is an affable, fifty-something fellow in  casual dress. I have revisited this dentist a second time because he didn’t find anything amiss the first time I visited him.

I have an intense distrust of dentists, as I have found their “cavity detection rates” differ wildly. (I went to the same dentist in Louisville for 5 straight years and he gave me rave reviews about my teeth. My first visit to a different dentist (highly recommended by a mysophobic ex-wife), resulted in the identification of several (asymptomatic) cavities and subsequent fillings – the first cavities I had had in twenty years. I left her and went back to the guy who never found cavities. (Interestingly, one who studies cavities is termed a cardiologist).

Donna told me that I have some build up of tartar. I ask her to define it and she tells me tartar is plaque on the teeth that has become calcified. I ponder the similarities between the development of calcified plaque in the coronary arteries and the teeth. About ten years ago cardiologists felt there was a connection between ginigivitis and coronary atherosclerosis, possibly mediated by inflammation, but this has mostly been discredited.

I ask Dr. Watley what the significance of tartar and plaque is. He seems a little taken aback and launches into a description of what “some say:” bacteria build up in the plaques around the gums and launch themselves into the blood stream,  landing on heart arteries, pancreas, and spleen.  At first I think he must have forgotten that I am a cardiologist, but then he asks me what I think of his theory;  I tell him there is little scientific support for it. He admits that his other cardiologist patient doesn’t believe it either.

I ask him what the value of a routine cleaning is.  He says “Donna, what do you think? Donna, clearly nervous, talks about preventing bacteria from building up.

I ask “Is there any evidence that annual cleaning is better than another interval?” He says that those who get cleaning every 4-6 months do much better than those who don’t. No doubt!!!

Dentists, like cardiologists, benefit financially from having exams done on a regular basis.  It’s hard to get unbiased information from your dentist or cardiologist, or an organization run by dentists or cardiologists, on the value of routine cleaning or cardiac testing or the frequency at which examinations or testing should be performed.

In Part II of this post, I’ll present the scientific evidence, if any, to answer some of the questions I’ve posed above.

Despite my distrust of dentists, I want to make it very clear that I am not a RABID anti-dentite.