It’s hard for me not to sit amazed at the job medicine has done convincing people we can control heart attacks. One only needs to review the many news stories regarding news journalist Tim Russert's untimely death to see the public fallout of our efforts to "educate" the populace about "screening tests" used to "prevent" the likelihood of having a heart attack. You see, with Mr. Russert's death, those tests have suffered a huge public relations nightmare.
Cholesterol screening and statins: dead in the water.
CT scanning for detection of plague to prevent heart attack: harpooned.
Stress testing to assure you're protected against the Big One: pulverized.
Not one damn thing predicted (or prevented) Mr. Russert's death.
Oh sure, there's plenty of others who want to jump right in to promote the next great lifestyle modification, rather than those damn cholesterol drugs as a way to save your life, provided of course, you buy their book. Or those who promise reduced mortality if everyone just got an ultrasound of their carotid arteries, even though this test still can't predict acute plaque rupture and the onset of a heart attack like Mr. Russert's.
You see, the entire industrial complex of healthcare technology and innovation was shaken, not because Mr. Russert was a nice guy and great journalist, but rather because they will have to explain why their technology isn't worth a damn at predicting heart attacks.
Welcome, my friends, to the world of real-life medicine rather than marketing.
-Wes
21 comments:
Wow, that previous post was a bit evil. Glad it is gone. It is amazing that Russert did not get a cath with that CT 10 years ago and all of the risk factors. But, as I posted on the WSJ blogsite and have you, hard to prevent MIs. I should know. I am 40. First MI at age 27. CABG 4 months later. Stents. Suddent cardiac arrest 6 months ago (aborted) while jogging. St. Jude walkman/iphone/defib/pacer in my chest. I am now 40. All of this thanks to radiation I got at age 15 for Hodgkin's. Oh well. I enjoy your blog.
j craig md-
Glad you're doing so well - you certainly are a poster-child for technology in medicine! Best of luck to you and thanks for your nice comments.
Hi Dr. Wes,
Have you heard of the myogenic theory of heart attacks? I thought this article by Dr. Tom Cowan was very interesting, and may possibly explain the problems with the current theory of cardiovascular disease, and why frequently diagnoses/treatments don't work as expected, as exemplified by Tim Russert's untimely passing.
What Causes Heart Attacks?
Like your blog!
My dad went in for an Angio 10 years ago and the patient lying in the bed next to him in the RR crashed. He was shaken. I told him it was a reality check.
Could it be argued that the statins prolonged his life?
That's what I assume. I truly don't really know.
When it is not known the reason for Tim Russert's untimely death, it make many people question, 'what could have gone wrong'?
Not that there is an answer, but I am convinced that there had to be something that has not been revealed, or symptoms Tim just kept to himself.
I am a believer that all illnesses comes from one of three things; dehydration, malnutrition, or stress.
This is my first time on your blog, and I enjoyed it.
There was an article in the Wall Street Journal today (6/17) on how people feared sudden death from an MI. Folks, you have to die sometime, and die of something... I swear, American marketing has some people thinking that death is somehow optional! The plan of a good diet, exercise, and minimizing stress will make the life you have better and longer, that's all (and that's plenty).
Well said, Dr. Wes.
In this environment of 'blame the victim', it is comforting to see that you have the compassion to see through to the truth, and that is, we can't always dodge the bullet.
It is understandable that people are desperately looking for the 'reason' - they fear for their own mortality, and want to be comforted that it could not happen to them because "they take their ______, do their ______ and never _____"
Sometimes your number comes up. Nobody's fault but fate.
Thank you for your kindness and understanding. I hope his family gets to see your post...
Cap'n Jan
Oh, I forgot to add...
"Wish you were my Doc."
Cheers!
Cap'n Jan
I used to get weirded out about the possibility of dying suddenly with LQTS. Until of course I got cancer and then the possibility of a swift clean death took on a whole new vantage point. I still see my cardiologist, but we now have a different understanding.
vreni-
The microvascular concept has been around quite some time, in this case called "myogenic" theory. In Tim's case, ischemia, whatever the cause, likely resulted in a fatal cardiac arrhythmia. Was it from a partially blocked artery, or a fully blocked one, or maybe a fully blocked one the re-opened? Given the time required to lose consciousness (seconds) and the confounding effects of hypoperfusion on the myocardium at that instant, we'll never really know - yet we so want to know, but sometimes we must accept we'll never know.
geena-
Could it be argued that the statins prolonged his life?
Maybe - you make an interesting counterpoint. I'll look for that spin on the next Lipitor ad...
marco-
Agreed.
Cap'n Jan-
Thanks. At lunch in the doctors' dining room this case came up. One doc commented that people might attend church or temple more often. Somethings, he thought, are just unforeseeable and outside our control despite what the sales personnel would like us to believe.
Well said. I read the transcript of the Larry King show where he interviewed Russert's doctors and over and over again asked "what could he have done to prevent this?" and "do you feel you could have done something better?" All our best treatments do is offer risk reduction, which is not the same thing is removing the risk entirely. Some people will continue to have heart attacks despite proper treatment, just as some people will get lung cancer despite never smoking or having other exposures. The best we do is lower the risk, not remove it.
And Marco, I agree entirely. We do act like death is optional.
If you listen to the trial lawyers, the concepts of odds and risk do not exist - except at the casino and the racetrack.
One wonders how many healthy (low "risk factor") people with "healthy lifestyles" die from sudden heart attacks each year??
Very well said; so many people want to blame others and take no responsibility for their own acts. My best friend had surgery to install stents; she had married a man who had survived three heart attacks, and she managed her weight, carefully policed their fats and cholesterol intake, exercised daily by taking a 2-mile walk, stopped smoking, and she still died of a massive heart attack at the age of 69. (He has since married Wife #3.)
I believe that when it is your time, it is your time. Have I, at age 57, become more conscious of what I eat and my amount of exercise since her passing? Believe it. Do I think I can undo all of my previous poor nutrician and other bad habits? Probably not, but (1) no one lives forever, and (2) I'm doing what I can, one day at a time, so I plan on getting through this day to tomorrow. I do not expect my family (which consists of a great percentage of MDs) to blame test results if I die tomorrow or next week. My self-improvement continues.
Yeah, well, the same exact thing happened to my husband nearly 3 weeks ago as happened to Tim Russert.
My husband did everything he was supposed to do - ate right, exercised, had all the tests, took vitamins, wasn't overweight, no symptoms, no complaints - nothing.
And just like Mr. Russert, he was at work laughing and talking and then one second later he was gone. CPR and an AED were there within 30 seconds of his collapse. Nothing helped.
Science, medicine - it's a bunch of crap. And yes, I am angry because I lost everything when my husband died. He was young. And he had done everything possible to have this not happen and it did anyway.
People die from heart attacks no matter. There's no amount of tests and diets and plans that can make it stop.
Just a question; could taking statins (and perhaps changing his LDL levels too drastically) have contributed?
You would think with all the media attention on Russert's death that we would see some real public education on what coronary disease really is. Nope! I've seen a good number of cardiologists and surgeons come on CNN and Foxnews trying to "educate" people on how to prevent this. CT scans, angiograms, yearly stress tests will save you. See your doctor! Ha! Three months into my cardiology fellowship, it became apparent to me that this "plumbing" approach to cardiovascular disease was being fueled by procedural reimbursements and stupidity. I did over 1000 angiograms over my 3 year fellowship at the Cleveland Clinic. I'm pretty sure that less than 100 of those resulted in any improvement of symptoms or lengthening of quality of life. Maybe after we bankrupt Medicare, we can stop and read what's being publish. Inflammation is everything and finding those markers will be far more prognostic. I haven't heard anyone be honest about Mr. Russert's death. Unfortunately, he was one of the unlucky ones. He developed an unstable plaque in one of the few areas where the heart is not forgiving. A thrombus in the LMT or prox LAD is called a widowmaker for a reason. Thankfully, a vast majority of people present with more tolerable acute coronary syndromes or at least give some symptoms prior to fully developing. Sadly, this will probably result in more unneeded stress tests, CT scans, and angiograms with subsequent stents of vessels that have no business being intervened upon.
I think inflammation is BIG, and in our zeal to stop eating saturated fats, which we have eaten since time began, we have switched to vegetable oils (brand new to the diet from about 1910). Considering heart disease was rare in the early 1900s, this is telling. Vegetable oils by definition are polyunsaturates, meaning they are very unstable, react with oxygen when heated, go rancid and cause free radical damage in the body. Furthermore, omega 6 oils, which most vegetable oils are, follow the inflammatory cox 2 pathway (heard ot cox 2 inhibitors, drugs which decrease inflammation by blocking the cox 2 pathway?) I think the diet advice out there is poor. Low fat diets usually = high sugar diets. It is sugar (which glycate and cause inflammation) and vegetable oils, which also cause inflammation that are the problem, not saturated fat and cholesterol. Anyway, my 2 cents... :)
I thought people were shocked because they were thinking about their own mortality...
I mean he did die quite young, and SO many people have risk factors for heart disease... I wonder if they didn't think about their mortality till that very moment.
I was upset because he was one of the few serious news reporters on tv who didnt yell the news to me and didnt stand down to politicians.
"I know somebody that smoked six packs of butts a day for eighty years and lived to be one hundred years old."
That is the sort of reverse twisted logic many commenters are using here. I do agree that a pharmaceutical solution is a band aid on top of an injury that is already present or maybe even on top of a ticking time bomb. That being said, eating a balanced diet, getting regular exercise, getting enough rest and managing stress will increase the probability of living a longer, healthier life. Will there be exceptions to that rule? Yes, many of them. That doesn't mean you throw in the towel on trying to take care of yourself.
I love this Mark Ripptoe quote:
To a great extent, the health problems experienced by the members of the ridiculous culture in which we live are self-inflicted. They are result of the reluctance of the bulk of the population to do anything that is either physically hard or something that they don’t want to do. People seem to have acquired the idea that they have the inalienable right to stroll through life without having sweated, picked up anything heavy, worked hard, or eaten less than they wanted at every meal. This approach is, of course, wrong. And it has resulted in a lot of expensive, unattractive, and entirely preventable problems amongst people who seem puzzled about why things aren’t going well.
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