Tag Archives: medicine

How To Be A Victorian Doctor: The Importance of Portent

For some time the skeptical cardiologist has been seeking information about the practice of medicine and cardiology during the Victorian era.

Why the Victorian era? Because my favorite writer, Charles Dickens, consistently portrays doctors of that era as incompetent.

And, sadly to say, as I have explored what doctors had to offer in the real world of the nineteenth century it was, in point of fact, very little.

From time to time as I gather this information on my medical forebears I will share it with my gentle readers:

To begin with, however, I present to you one of my favorite examples which is taken  from The Old Curiosity Shop.

“The doctor, who was a red-nosed gentleman with a great bunch of seals dangling below a waistcoat of ribbed black satin, arrived with all speed, and taking his seat by the bedside of poor Nell, drew out his watch, and felt her pulse. Then he looked at her tongue, then he felt her pulse again, and while he did so, he eyed the half-emptied wine-glass as if in profound abstraction.

‘I should give her,’ said the doctor at length, ‘a tea-spoonful, every now and then, of hot brandy and water.’

‘Why, that’s exactly what we’ve done, sir!’ said the delighted landlady.

‘I should also,’ observed the doctor, who had passed the foot-bath on the stairs, ‘I should also,’ said the doctor, in the voice of an oracle, ‘put her feet in hot water, and wrap them up in flannel. I should likewise,’ said the doctor with increased solemnity, ‘give her something light for supper—the wing of a roasted fowl now—’

‘Why, goodness gracious me, sir, it’s cooking at the kitchen fire this instant!’ cried the landlady. And so indeed it was, for the schoolmaster had ordered it to be put down, and it was getting on so well that the doctor might have smelt it if he had tried; perhaps he did.

‘You may then,’ said the doctor, rising gravely, ‘give her a glass of hot mulled port wine, if she likes wine—’

‘And a toast, Sir?’ suggested the landlady. ‘Ay,’ said the doctor, in the tone of a man who makes a dignified concession. ‘And a toast—of bread. But be very particular to make it of bread, if you please, ma’am.’

With which parting injunction, slowly and portentously delivered, the doctor departed, leaving the whole house in admiration of that wisdom which tallied so closely with their own. Everybody said he was a very shrewd doctor indeed, and knew perfectly what people’s constitutions were; which there appears some reason to suppose he did.”

Since reading this I have endeavored to make all my medical pronouncements with solemnity and gravity and as slowly and portentously as possible.

Portentously Yours,

-ACP

N.B. The Old Curiosity Shop was the fourth novel of Charles Dickens.  The novel was published in installments in the periodical Master Humphrey’s Clock.  The first installment was printed in April of 1840 and the last was printed in February of 1841.

 

 

Should I Take Aspirin To Prevent Stroke or Heart Attack?

 

Aspirin is a unique drug, the prototypical  two-edged sword of pharmaceuticals.  It has the capability of stopping platelets, the sticky elements in our blood, from forming clots that cause strokes and heart attacks when arterial plaques rupture, but it increases the risk of serious bleeding into the brain or from the GI tract. Despite these powerful properties, aspirin is available over the counter and is very cheap, thus anyone can take it in any dosage they want. 

Who Should Take Aspirin?

For the last five years I’ve been advising my patients who have no evidence of atherosclerotic vascular disease against taking aspirin to prevent heart attack and stroke. Several comprehensive reviews of all the randomized trials of aspirin had concluded by 2011 that

The current totality of evidence provides only modest support for a benefit of aspirin in patients without clinical cardiovascular disease, which is offset by its risk. For every 1,000 subjects treated with aspirin over a 5-year period, aspirin would prevent 2.9 MCE and cause 2.8 major bleeds.

(MCE=major cardiovascular events, e.g. stroke, heart attack, death from cardiovascular disease)

Dr. Oz, on the other hand, came to St. Louis in 2011 to have  lunch with five hundred women and advised them all to take a baby aspirin daily (and fish oil, which is not indicated for primary prevention as I have discussed here). When I saw these women subsequently in my office I had to spend a fair amount of our visit explaining why they didn’t need to take aspirin and fish oil.

After reviewing available data, the FDA this week issued a statement recommending against aspirin use for the prevention of a first heart attack or stroke in patients with no history of cardiovascular disease (i.e. for primary prevention). The FDA pointed out that aspirin use is associated with “serious risks,” including increased risk of bleeding in the stomach and brain. As for secondary prevention for people with cardiovascular disease or those who have had a previous heart attack or stroke (secondary prevention), the available evidence continues to support aspirin use.

Subclinical Atherosclerosis and Aspirin usage

As I’ve discussed previously, however, many individuals who have not had a stroke or heart attack are walking around with a substantial burden of atherosclerosis in their arteries. Fatty plaques can become quite advanced in the arteries to the brain and heart before they obstruct blood flow and cause symptoms. In such individuals with subclinical atherosclerosis aspirin is going to be much more beneficial.

 

Guided Use of Aspirin

zerilloplaque
Large, complex atherosclerotic plaque in the carotid artery found by vascular screening in an individual with no history of stroke, heart attack, or vascular disease. This patient will definitely benefit from daily aspirin to prevent stroke or heart attack
We have the tools available to look for atherosclerotic plaques before they rupture and cause heart attacks or stroke. Ultrasound screening of the carotid artery, as I discussed here, is one such tool: vascular screening is an accurate, harmless and painless way to assess for subclinical atherosclerosis.

In my practice, the answer to the question of who should or should not take aspirin is based on whether my patient has or does not have significant atherosclerosis. If they have had a clinical event due to atherosclerotic cardiovascular disease (stroke, heart attack, coronary stent, coronary bypass surgery, documented blocked arteries to the legs) I recommend they take one 81 milligram (baby) uncoated aspirin daily. If they have not had a clinical event but I have documented by either

  • vascular screening (significant carotid plaque)
  • coronary calcium score (high score (cut-off is debatable, more on this in a subsequent post)
  • Incidentally discovered plaque in the aorta or peripheral arteries (found by CT or ultrasound done for other reasons)

then I recommend a daily baby aspirin (assuming no high risk of bleeding).

There are no randomized trials testing this approach but in the next few years several large aspirin trials will be completed and hopefully we will get a better understanding of who benefits most from aspirin for primary prevention.

Until then remember that aspirin is a powerful drug with potential for good and bad effects on your body. Only take it if you and your health care provider have decided the benefits outweigh the risks after careful consideration of your particular situation.

Should I Take A Statin Drug? Risks, Benefits and the New Guidelines

StatinsThe skeptical cardiologist just returned from Washington, DC where he attended the American College of Cardiology (ACC) annual conference and visited Ford’s Theatre. I was hoping to gather more information on diet and cardiovascular disease but most of the discussions on prevention of heart disease centered around the new ACC/AHA guidelines for treating cholesterol.

A recently published analysis of the impact of these guidelines found that

As compared with the ATP-III guidelines, the new guidelines would increase the number of U.S. adults receiving or eligible for statin therapy from 43.2 million (37.5%) to 56.0 million (48.6%). Most of this increase in numbers (10.4 million of 12.8 million) would occur among adults without cardiovascular disease.

If you are a man over the age of 59 (which I just became), even without any cardiovascular disease or diabetes, there is an 87% chance the guidelines would suggest you take a statin drug.

This is a startling increase and consequently there has been a lot of criticism and questioning of the validity of these recommendations.

More importantly, for an individual patient, should you take a statin drug if your doctor recommends it? This is an especially good question if you have no evidence of any atherosclerotic cardiovascular disease (so-called primary prevention). At a minimum, you should have a very detailed discussion with your doctor about the risk and benefits of taking the medication in your particular situation.

What are statin drugs?

Statins are the most powerful, safe and effective drugs available for lowering LDL or bad cholesterol levels. They inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, involved in cholesterol biosynthesis. Low density lipoprotein (LDL) cholesterol concentration is lowered by reducing its production in the liver and increasing removal from the circulation. Statins also have anti-inflammatory effects, improve endothelial function, and reduce thrombus formation.

Common examples of statin drugs are Lipitor which is now available as a generic called Atorvastatin , Pravastatin, and Crestor (Rosuvastatin), which is only available in brand name form.

What are the risks of statin drugs?

When large scale randomized trials of statin drug therapy are analyzed, rates of adverse events (17%) or stopping treatment due to adverse events (12%) are similar in the statin compared to placebo/control groups.

The incidence of cancers, liver enzyme elevations, kidney dysfunction or arthritis was the same in the two groups.

There are only two side effects from taking statins I consider significant and mention to my patients:
1. There does appear to be a 9% increase in the risk of developing diabetes. Most of the patients who develop diabetes on statins were at high risk for this to begin with and the overall benefits of lowering CV disease outweighs the development of diabetes in patients who take statins.
2. Statins definitely can cause muscle aches (myalgias) and this seems to happen in about 10% of patients over time. If these develop, we stop the statin and the myalgias go away if they are due to the drug. There are no reliable studies showing any long term residual muscle weakness or ache. A very, very small number of patients develop rhabdomyolysis, in which there is severe muscle damage. These patients are almost always taking multiple medications which interact with the statins and often have kidney failure to begin with.

Some things you don’t need to be concerned with while on statins:

1. That the drug will give you Alzheimer’s or make you stupid. There is much anecdotal misinformation on the web about this, but no solid evidence of any adverse effect on cognition.
2. That the drug will destroy your liver. A small percentage of patients will develop elevations of their liver enzymes (AST or ALT) but this does not lead to liver damage and is considered so insignificant now that the FDA now longer advises checking liver enzymes in patients on statin drugs.

What are the benefits of statins in people without known heart disease?

They lower all-cause mortality by 14%, combined fatal and nonfatal cardiovascular disease by 25%, and stroke by 22%. They lower the chances that you would need a stent or bypass surgery by 38%.
Another way of looking at the benefits of a treatment is the number needed to treat (NNT).
To save one life, you would need to treat 138 patients for 5 years with statin drugs. This means that 137 patients would have done fine without taking the drug.

The higher your risk of developing atherosclerotic cardiovascular disease  (ASCVD (all the disease that occurs as a result of fatty plaque build up in the body, including heart attack and stroke)), the more likely you will benefit from taking a statin drug.
Thus, the new guidelines utilize a risk estimator that takes into account your total and good cholesterol values, your systolic blood pressure, age and whether you smoke, have diabetes or treated hypertension to calculate your risk of developing clinical ASCVD over the next ten years.

If this ten year risk is over 7.5%, statin therapy should be considered.

I’ve looked over the guidelines carefully, read a lot of the original studies and listened to the discussion and I think this is a reasonable approach. I try to present each patient with the risks and benefits and let them make the decision as to whether they want to take the drug.
Each individual has a different perspective, perhaps heavily influenced by their father having died of a heart attack in his fifties or by a close friend who feels that statins ruined his life.

Two important new concepts from the new guidelines

The new guidelines no longer look at the LDL or bad cholesterol level as a goal or as a level for initiating treatment (unless it is super high, above 190). Thus, the only reason to be checking follow up cholesterol panels on patients who are taking good levels of statin drugs is to verify compliance and an effective reduction in LDL from baseline. I will not try to get your LDL below 100 or 70 and you will not have to worry that it is not at that level.

The new guidelines rightly emphasize statin drugs as the only drug therapy that has good outcomes data (meaning they have been show to reduce heart attacks and strokes) supporting their use in primary prevention.
Ezitimibe (Zetia) is a commonly prescribed drug which lowers LDL cholesterol but is expensive and has never been shown to lower heart attack or stroke risk and, in my opinion, should not be prescribed.

Our goal should be prevention of heart disease, not lowering LDL levels or triglyceride levels.

I believe that we can fine tune which patients will and will not benefit from statin therapy by looking for evidence of what is called “subclinical atherosclerosis.” I plan to review this in a future post.
For now, I leave you with the humorous line from the play “Our American Cousin” that caused the distracting laughter during which John Wilkes Booth shot Lincoln in Ford’s Theatre (which is not far from the Washington Convention Center and well worth visiting!)

“Don’t know the manners of good society, eh? Well, I guess I know enough to turn you inside out, old gal — you sockdologizing old man-trap.”

Tell your cardiologist you will sockdologize him if he doesn’t give you a good discussion of the risks and benefits of the statin drug he is recommending.

Does Eating High-Fat Dairy Cause Heart Disease or Obesity

Dietary guidelines recommend the consumption of milk and dairy products as an important part of a healthy, well-balanced diet The 2010 USDA Guidelines state:
“Milk and milk products contribute many nutrients, such as calcium, vitamin D (for products fortified with vita- min D), and potassium, to the diet. Moderate evidence shows that intake of milk and milk products is linked to improved bone health, especially in children and adolescents. Moderate evidence also indicates that intake of milk and milk products is associated with a reduced risk of cardiovascular disease and type 2 diabetes and with lower blood pressure in adults.”

However, dairy fat has been portrayed as the unhealthy component of milk and dairy products, largely because it is energy dense and a rich source of saturated fatty acids . Therefore, typical dietary advice recommends fat-reduced milk and dairy products.

Shockingly, and despite expert and government-backed recommendations, the advice to change to fat-reduced or skim milk and dairy products is not supported by any prospective scientific studies.

The main reason cited for the recommendations is that the consumption of saturated fatty acids is related to an increase in total cholesterol which in turn has been related to increased coronary heart disease-the major cause of heart attacks. As we discuss this topic more, we will discover that this logic is flawed because 1) saturated fats are a diverse family of compounds with varying effects on the cholesterol profile and 2) the cholesterol profile itself is incredibly complex and simple measurements of “bad” (HDL) and “good” (LDL) cholesterol alone probably don’t tell us enough about the risk of heart disease .

Partially as a result of these guidelines, the pattern of dairy fat intake has changed considerably in the last 40 years, a time frame during which the modern obesity epidemic has developed in the United States Butter consumption has dropped considerably and low fat milk has supplanted full fat milk as the preferred product. In parallel, dairy fat consumption from other, possibly less healthy sources such as prepared foods, pizza, industrially produced margarine.

When epidemiologists have scientifically reviewed the relationship between high fat dairy consumption and heart disease or obesity, almost invariably they have found an inverse relationship. That is, the more dairy consumed, the lower the risk of heart disease and the less obesity.

In subsequent posts we’ll look in more detail at the evidence supporting dairy consumption in reducing heart disease and obesity.