Tag Archives: Choosing Wisely

Paranoid Rumination From A Freshly-Minted Migraineur

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.”

An artistic depiction of migraine aura which was similar to mine. Original source is unclear.

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.

Cephalgiacally  Yours

-ACP

Here’s a video of an aura similar to mine (one of many posted at visual migraine animation)

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.

 

 

 

Should You Get a Stress Test After Your Stent or Bypass Operation If You Feel Fine?

If you’ve had a coronary stent implanted or undergone bypass surgery, it is common to wonder about the status of the stent or the bypass grafts or the coronary arteries that maybe had a 50 or 60% blockage and were left alone.

This is especially likely if there was little or no warning that you had really severely blocked coronary arteries.

After all, you are thinking: “doesn’t it make sense to monitor these things and stay on top of them; be proactive?”

It certainly seems reasonable on the surface, and for many years, routine stress testing of patients without symptoms on an annual basis, was the norm.

However, this practice is much more likely to cause harm than to benefit patients and is recognized by the American College of Cardiology as one of 5 things that patients and physicians should question as part of the “Choosing Wisely” campaign (see here).

“Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes.”

Studies have shown that stress testing less than two years after a coronary stent, very rarely change management.

The American College of Cardiology, American Society of Echocardiography and the American Society of Nuclear Medicine are all in agreement that stress testing less than two years after a coronary procedure is “inappropriate,” and more than two years after the procedure is “uncertain.”

Why Do Cardiologists Order These Tests If They Are Inappropriate?

There are 3 reasons, and they are representative of the major factors driving all over-testing in medicine.

  1. Financial. Cardiologists frequently benefit from stress tests they order in multiple ways. First, they may own the nuclear camera used in the test and the more stress tests performed in their office, the more money they will make from the technical remuneration for the procedure. The cardiologist also frequently interprets the test results and receives a professional fee for both supervising and interpreting the nuclear images. Finally, if the test is abnormal, the cardiologist may then recommend additional testing, which he may perform (cardiac catheterization, stent) or interpret (coronary CT angiogram).
  2. Defensive medicine. It is not uncommon for cardiologists to be sued for NOT performing a test or procedure when the patient’s outcome is bad. On the other hand, I have never heard of a cardiologist being sued for DOING an inappropriate stress test.
  3. Keeping the customer happy. Too often patients feel that if their doctor is performing frequent tests on them, he is being vigilant, proactive and “staying on top of things.” They don’t realize the down sides to the extra testing and the lack of benefit.

Not uncommonly, patients switching to me from another cardiologist indicate that they have been getting an annual stress test and are disappointed to hear that I am not recommending one.

They may think that I’m lazy or not up on the latest techniques in cardiology. Usually in this situation I have to spend a fair amount of time trying to teach them about the possible downsides of over-testing.

In the case of stress nuclear testing, harm comes from two sources:

  1. Radiation. Stress nuclear tests typically utilize the radio tracer Technetium-99 and result in a radiation dose of around 15 mSv. This is about 10 times the radiation from a typical coronary calcium scan. A chest x-ray gives 0.02 mSV and the annual background radiation in the US is 3 mSv.
  2. False positives. Nuclear imaging is very susceptible to images which appear to show abnormalities of blood flow, which in reality are just due to soft tissue (breast, diaphragm, fat) interposed between the heart and the camera. These can be interpreted as due to a heart attack or blocked coronary artery when everything is actually fine with the artery.  False positives then lead to additional testing such as a cardiac catheterization, which carries risks of bleeding, heart attack, stroke and death.

One important point to remember is that coronary stenting has not been shown to reduce heart attacks or prolong survival outside the setting of an acute heart attack. Therefore , if you’ve already had a cardiac catheterization that either resulted in bypass surgery or a stent of one artery, it is highly unlikely that a subsequent catheterization/further procedures will lower your heart attack or dying risk.

Certainly, if you have a change in symptoms that suggest that your coronary artery disease has progressed, this is an appropriate reason to consider stress testing. Such symptoms include shortness of breath on exertion and chest discomfort, especially if it occurs during activity. Diabetics often don’t have symptoms that warn them of a problem, therefore, we should consider stress testing more frequently and at a lower threshold for them.

For most people, however, more is not always better when it comes to cardiac testing and, in many circumstances, can be worse.

Here’s to choosing wisely,

-ACP

 

 

Should You Get a Routine Annual Electrocardiogram (ECG)?

Recently, the skeptical cardiologist  was asked by his  old friend and life coach (OFALCSC) whether he was correct to refuse the annual electrocardiogram (ECG) which his primary care doctor had recommended during an annual physical.

ECG showing atrial fibrillation
ECG showing atrial fibrillation

Most of my patients feel that the ECG has the ability to tell me  quite a bit about their heart. The technique utilizes electrodes on the arms, legs and chest region which  record with precision, the depolarization and repolarization of the upper chambers (atria) and lower chamber (ventricles) of the heart.

The ECG is THE tool for assessing the rhythm of the heart.  If performed and interpreted properly (not always a given) it tells us very precisely whether we are in normal (sinus) rhythm, wherein the atria contract synchronously before the ventricles contract, or in an abnormal rhythm. It is also very good at telling us whether you are having a heart attack.

If you are, however, like the OFALSC, and feel fine (meaning without symptoms or asymptomatic), exercise regularly, have never had heart problems,  and have a pulse between 60 and 90, the value of the routine annual ECG is very questionable. In fact, the United States Preventive Services Task Force (USPFTF)

“recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events”

(for asymptomatic adults at intermediate or high risk for CHD they deem the evidence insufficient). The USPSTF feels that that the evidence only supports an annual BP screen along with measurement of weight and a PAP smear.

To many, this seems counter-intuitive: how can a totally benign test that has the potential to detect early heart disease or abnormal rhythms not be beneficial?

There is a growing movement calling for restraint and careful analysis of the value of all testing that is done in medicine. Screening tests, in particular are coming under scrutiny.
Even the annual mammogram, considered by most to be an essential tool in the fight against breast cancer, is now being questioned.

My former cardiology partner, Dr. John Mandrola, who writes the excellent blog at http://www.drjohnm.org, has started an excellent discussion of a recent paper that shows no reduction of mortality with the annual mammogram. He looks at the topic in the context of patient/doctor perception that “doing something” is always better than doing nothing, and the problem of “over-testing.”

In my field of cardiology there is much testing done. It ranges from the (seemingly) benign and (relatively) inexpensive electrocardiogram to the invasive and potentially deadly cardiac catheterization. For the most part, if patients don’t have to pay too much, they won’t question the indication for the tests we cardiologists order. After all, they want to do as much as possible to prevent themselves  from dropping dead from a heart attack and they reason that the more testing that is done, the better, in that regard.

The Problem of False Positives and False Negatives

But all testing has the potential for negative consequences because of the problem of false positives and negatives. To give just one example: ECGs in people with totally normal hearts are regularly interpreted as showing a prior heart attack. This is a false positive. The test is positive (abnormal) but the person does not have the disease. At this point, more testing is likely to be ordered; specifically, a stress test. Stress tests in low risk, asymptomatic individuals often result in false positive results. After a false positive stress test, it is highly likely that a catheterization will be ordered. This test carries potential risks of kidney failure, heart attack, stroke and death. It is bad enough that the cascade of testing initiated by an abnormal, false positive,  screening test results in unnecessary radiation, expense and bother but  in some cases it end up killing patients rather than saving lives.

On the other end of the spectrum is the false negative ECG. Most of my patients believe that if their ECG is normal then their heart is OK. Unfortunately the ECG is very insensitive to cardiac problems that are not related to the rhythm of the heart or an acute heart attack.

Patients who have 90% blockage of all 3 of their major coronary arteries and are at high risk for heart attack often have a totally normal ECG. This is a false negative. The patient has the disease (coronary artery disease), but the test is normal. In this situation the patient may be falsely reassured that everything is fine with their heart. The next day when they start experiencing chest pain from an acute heart attack, they may dismiss it as heart burn instead of going to the ER.

More and more, screening tests like the ECG and the mammogram  are rightfully being questioned by patients and payers. For a more extensive discussion about which tests in medicine are appropriate check out the American Board of Internal Medicine’s http://www.choosingwisely.org.

Keep in mind: not uncommonly,  doing more testing can result in worse outcomes than doing less.