Why Every Heart Patient Should Order Pizza

... because the delivery man might just save your life:

Linn's wife says he had just gone into cardiac arrest Friday when the pizza deliveryman knocked on the door of their Colorado home to bring their order. Kami Linn says she opened the door to "some burly-looking dude" and immediately asked for help.

-Wes

Looks Like My Job Will Be Secure

All it takes to assure you will keep your local cardiologist employed is 19 strips of bacon and one egg and you've got yourself one heck of a solid bacon burger:

Having read about the difficulties people making such burgers have had keeping them together, I decided to add one large egg to the food processor along with the 19 slices of bacon. I ground the bacon and the egg together, then, using my hands, pulled the mixture out and used a hamburger press to make a burger. It is possible that my hands have been greasier at some point in my life, but if so I have (fortunately) forgotten it. I was not quite prepared for the raw burger to look like pure fat, and I must admit that it didn’t look very appealing. But it was for science, so I soldiered on!

I put the burger on the rack-Pyrex assembly and slid it under the broiler. Having learned a lesson from last week, I turned the stove exhaust fan to high immediately. I peeked in on it as it cooked, and it seemed to be cooking nicely, with tons of little fat bubbles sizzling on top. After seven minutes or so, I took it out to turn it over, and was pleased how easily it flipped. Five minutes later, it looked done, so I took the temperature of the inside (you need to be careful with pork, of course), and it registered at 160 degrees Fahrenheit, so out it came. Now it looked like food, and smelled delicious.

My family and I thank you, America!

-Wes

Tiny Camera Peeks Inside Coronary Arteries

For a better look inside coronary arteries comes Optical Coherence Tomography (video at link):

Optical Coherence Tomography, or OCT, approved by the FDA in April 2010, forms images by reflecting light inside blood vessels, which allows doctors to see 10 times more detail of an artery than the conventional ultrasound.

Please note that this technology has been around since at least 2002. Is it really new? Or is it really that the company's news of FDA approval is "new?" More importantly, the million dollar question is not if it makes pretty pictures, but rather what does it add to the cost of the procedure and will it improve outcomes?

A brief review of a similar technology, intravascular ultrasound (IVUS), has demonstrated that it's not so easy to demonstrate improved outcomes in most routine cases:

In a systematic literature search (of articles on IVUS), 115 reviews, 10 health technology assessment reports, and 226 relevant primary studies, including 33 economic articles, were identified. 35 clinical and 3 economic studies met the inclusion criteria. In routine intervention with primary stenting, IVUS guidance did not show significant advantages. In specific clinical situations, IVUS information may indicate a change of therapeutic strategy that may benefit patients. Following heart transplantation, IVUS provides additional prognostic value compared to angiography alone. None of the economic analyses included long-term costs or effectiveness. However, after combining cost data with results from the effectiveness meta-analysis, the short-term cost-effectiveness ratio for IVUS-guided intervention was 7700 Euro per prevented major adverse cardiac event (MACE).

Still, the image quality of OCT does appear to be substantially better than IVUS on first glance and it may open another door to our understanding of atherosclerosis.

-Wes

Dick vs. Bill

Bill Clinton gets chest pain, hits the hospital, gets a few stents and, voilà, is back at work. A veritable poster child for stents. No doubt JNJ stock climbed on the news.

On the flip side today: Dick Cheney gets chest pain, hits the hospital, and (I'll bet) he stays a while.

What do you mean, Dr. Wes? Can't cardiologist magically fix everything? Do a cath! Give him a stent! Cardiology is so slam bam thank you ma'am, isn't it? Heck, he's got an ICD! He's the bionic man!

Cardiology is easy until it isn't.

No doubt Mr. Cheney has had impecable cardiovacular care. But despite that care, after three bypasses, a history of atrial fibrillation, deep venous thrombosis, a cardiomyopathy that requires a defibrillator or two, and scores of medications to stabilize the angina - you've suddenly got a tough case. One thing's for sure, a re-do bypass is pretty much out of the question (he probably has limited vascular conduits left to borrow).

For the treating cardiologists hoping for an obvious target to angioplasty, I wouldn't be surprised the "target" vessel will not be so obvious to determine after his angiogram today. Look for a nuclear scan tomorrow to figure which wall of his heart is affected (yes, Congress, he'll get one of those all-too-often ordered i-m-a-g-i-n-g studies!). Then look for either a risky angioplasty atempt to improve his symptoms or a (more appropriate) "tuning" of his medication regimen that will take time.

Bill vs. Dick: it's not about Democrats vs. Republicans. Rather, it's about the multifasceted care required of the same disease in two different patients that demonstrates nicely how health care for the individual will never be adequately managed through cookbook means.

-Wes

Guys: Finally Some News You Can Use

I'm not making this up. From the American Journal of Cardiology:

"In multivariate models adjusted for age, covariates, ED (erectile dysfunction), and the Framingham risk score, a low frequency of sexual activity in men (once a month or less vs ≥2 times weekly) was associated with increased risk of cardiovascular disease (CVD) (hazard ratio 1.45, 95% confidence interval 1.04 to 2.01)."

And yes, the lead author was a woman.

Honey, you readin' this?

-Wes

Nevada Supreme Court Denies Insurance to Smoker

Could this be the start of a trend?

The Nevada Supreme Court on Friday upheld a ruling that a Las Vegas police officer was not entitled to coverage for heart disease.

Under state law, a police officer continuously employed for more than five years is entitled to the presumption that any heart disease is work related. Patricia Guesman, however, was denied coverage by both the hearing officer and a district judge.

The Supreme Court noted coverage is not automatic if “after the police officer's annual medical exam, the examining physician ordered her in writing to correct a predisposing condition that was within her ability to correct and the officer failed to do so.”

The three-justice panel of Ron Parraguirre, Michael Douglas and Kris Pickering pointed out that smoking is a predisposing condition to heart disease. Guesman was warned to stop smoking but failed to do so.

So I guess when the Nevada state's finest develops any form of heart disease (i.e., critical aortic stenosis not typically associated with smoking) and treatment is required, the cost burden will shift from the state to the federal government.

Perfect.

Gee, I wonder why they didn't exclude treatments for oral and bladder cancers, too?

-Wes

PS: All this while Nevada works to ease up on its smoking ban.

Screen Hearts, Not Boobs

The recently-released USPSTF guidelines changed the recommendations to start mammogram screening for breast cancer in women from age 40 to age 50 based on extensive review of the costs, risks and benefits. As a result, when spun as “women’s care under siege,” the recommendation has become a potent political weapon.

Ironically in Texas, a new law was just enacted that requires insurers to pay up to $200 to screen for coronary artery disease based on controversial "entrepreneurial guidelines" proposed by SHAPE, a group of cardiologists that includes the entrepreneurs themselves.

So there you have it: how politics does preventative medicine...

... completely anatomically, of course.

-Wes

h/t: Kevin, MD

Promoting Personal Responsibility

... through the arts.

Nice. (oh, forgive the pun...)

-Wes

Revisiting Cardiac CT Angiograms

The New York Times published an extensive article on the CT angiogram (CTA) for the diagnosis of coronary disease and is a very worthwhile read. In the report, they describe the controversy between cardiologists surrounding these tests. But in their push to provide eye-catching content, they permitted a CT angiogram proponent, Dr. Harvey Hecht of The Lenox Hill Heart and Vascular Institute of New York, to show perfect 3D images of a normal CTA obtained in nice, slow, regular heart rhythm that peels away the rib structures and shows some of the coronary arteries, the inside surface of the heart, and heart valves as he narrates the video. It's like watching something from the "Undersea World of Jacque Cousteau." Yes, they are beautiful pictures and demonstrate the incredible capabilities of this technology. Gosh, who wouldn't want those beautiful pictures of their heart?

Thank you, NYT, for giving Dr. Hecht, and the entire CT proponents all they need to peddle their scans, after all, a picture is worth a thousand words, right?

But if you read the article carefully, those beautiful pictures come at a price: both for the patient and our economically-burdened healthcare system. Not only are they fairly expensive, but the risks of radiation to the patient are real. To the authors' credit, they made this point. But they also failed to explain that for women with generally smaller frames and greater levels of breast tissue, those risks of radiation are amplified. They also didn't show a flawed CTA in their online article sidebar: like one taken in atrial fibrillation (an irregular heart rhythm) or with lots of skipped heart beats - you see, those images aren't quite so clear. Because the heart is a moving organ, collection of the images must be precisely gated to the heart beat. In people with irregular heart rhythms, motion artifact is introduced, degrading the quality of the images obtained.

The authors also failed to show the images of a patient with a heavy coronary calcium score. Those CTA images sometimes don't turn out so well, either. All CT angiograms use iodinated contrast material injected rapidly through an intravenous line placed in the arm. Scanning begins a few seconds later, after the operators think the dye has reached the patient's coronary arteries (the circulation time is estimated). Once the contrast agent reaches the arteries, it causes the blood vessels and chambers of the heart to "stand out" from the surrounding walls of the heart and blood vessels. In the case of someone with too much calcium in the arteries, the native calcium also "stands out" and might shadow the actual ability of the contrast to define the lumen of the blood vessel. Also, things like stents, which are metallic, interfere the same way. Additionally, the contrast agents used might be harmful to a patient if they have compromised kidney function, so most people have a blood test to evaluate their kidney function before the test (yes, more money).

Certainly in complex congenital heart disease, here are few tests better than CTA to define to course of anomalous blood vessels. CTA has also been invaluable to electrophysiologists to image the left atrium and the pulmonary arteries to define the size, number, and orientation of vessels before left atrial catheter ablation procedures. Likewise, there might be a role to perform CTA to exclude coronary artery disease in the chest pain patient who presents to the Emergency Room. But as a screening test for the general population or even our "walking well" in the cardiology clinic, these scans have no role today, despite what others may suggest.

Despite this, the patient testimonial was telling:

Nonetheless, in February, Mr. Franks took a test called a calcium score, which measures the amount of calcified plaque in the arteries. The test, a less extensive form of scanning, revealed a moderate buildup of calcium in his arteries, a potential sign of heart disease.

So he decided to have a nuclear stress test. When that test showed no problem, the cardiologist who conducted it said he did not need more testing.

But Mr. Franks was still not satisfied. “I’m someone who wants to know,” he said.

After doing research on the Internet, he found Dr. Hecht, who recommended a CT angiogram. Dr. Hecht acknowledged that Mr. Franks probably did not have severe heart disease. But he said the scan would be valuable anyway because it might reassure him. And his insurance would cover the cost.

"If it's free, it's for me," right?

Boo rah.

But adding up this patient's cumulative radiation dose (10 mSV for the "Calcium Score" + 27.3 mSv for the thallium study + another 21.4 mSv for the CTA) gives him the equivalent of almost 3000 chest x-rays worth of radiation.

And then his cardiologist (Dr. Hecht) wanted to repeat the test every year "so he could see how quickly the plaque in Mr. Franks’s arteries was thickening" claiming "how do we know that our therapy is effective?"

Boo rah.

For the record, I know of no study demonstrating the safety, cost effectiveness, or the ability of CTA to document CAD progression year to year. Further, Hecht's own paper demonstrated that even with extensive cholesterol lowering, no change to plaque burden was documented. I also have never seen such documentation be able to predict a cardiac event of any type. But Dr. Hecht seems to feel insults to those questioning the utility of CTA are appropriate:

Cardiologists like Dr. Brindis (and Dr. Wes, it seems) hurt their patients by being overly conservative and setting unrealistic standards for the use of new technology, Dr. Hecht said.

“It’s incumbent on the community to dispense with the need for evidence-based medicine,” he said. “Thousands of people are dying unnecessarily.”

Hmmm. Dispense with need for evidenced-based medicine? I wonder what Dr. Hecht will say to his patient when the CTA scan shows a tumor mass one year.

-Wes

References: Nico R. Mollet, Filippo Cademartiri, Carlos A.G. van Mieghem, Giuseppe Runza, Eugène P. McFadden, Timo Baks, Patrick W. Serruys, Gabriel P. Krestin and Pim J. de Feyter. "High-Resolution Spiral Computed Tomography Coronary Arteriography in Patients Referred for Diagnostic Conventional Coronary Angiography." Circulation 2005; 112: 2318-2323.

Abelson R, "Heart Scans Still Covered my Medicare." New York Times 13 March 2008.

Addendum 29Jun2008 @ 1523: - the opposing view over at "The Voice in the Ear".

More Fear-Based Medical Marketing

I'm not sure it gets better than this:

Scanning the heart's arteries for calcium deposits accurately predicts the overall death risk for American adults, a new study suggests.

"So far, this is the best predictor we have of who will have a problem and who will not," said study co-researcher Dr. Matthew Budoff, associate professor of medicine at the Harbor-UCLA Medical Center.

He and his colleagues reported the finding in the July 1 issue of the Journal of the American College of Cardiology.

A calcium scan looks for calcification, a hardening of the arteries caused by high blood fats and calcium deposits that can eventually block blood vessels, causing heart attacks, strokes and other major problems.

I can hear it now:

"Hey Marge, hey lookie here in the Washington Post! I wanna get one of dem der fancy schmancy CT scanner gizmos to find out if I'm gonna DIE sooner than you are! Let's take $600 bucks for that fancy schmancy thing-a-ma-bob out of our retirement fund. It'd be WORTH IT!"

Sometime later, in the doctor's office...

Doctor: "Well, Mr. Jones, I see my this fancy schmancy CT scan that you'd got some calcium in your coronaries. Hmmmm. And you calcium score is 210, just like Tim Russert! So, guess what?"

Mr. Jones: "What?"

Doctor: "Well Mr. Jones, you're at increased risk of DYING!"

Mr. Jones: "Uh, what do you mean, Doctor?"

Doctor: "You heard me: you're at increased risk of DYING with all that calcium in those coronaries - you know - BAM! Just like Tim Russert."

Mr. Jones: "Any idea when, Doctor?"

(Silence)

Mr Jones: "Doctor, did you hear me? When will I die? I mean, won't we all die sometime?"

Doctor: "Heck, Mr. Jones, I don't know! But I can assure you that based on this fine article here in the prestigious Journal of the American College of Cardiology (you know, the same one that's also promoting their new Cardiovascular Imaging journal) that you're gonna die of SOMETHING sooner than some of the other people who don't have that evil calcium in their arteries."

Mr. Jones: "Gosh. So what should I DO about it, Doctor?"

Doctor: "Well, you know, since we're proposing that it's a RISK FACTOR for DYING, you should do the usual stuff: eat right, take tons of statin drugs, don't smoke, take your aspirin, lose weight, eat a low trans fat, high antioxidant, super-radical-consuming diet, do yoga, take mega vitamins, face East, say a few 'Hail Mary's..."

Mr. Jones: "Uh, but I was already doing that stuff..."

Doctor: "Have you had your CRP level and genes tested yet?"

Mr. Jones: "How would that help?"

Doctor: "Well, Mr. Jones, it might mean your risk of DEATH is EVEN GREATER!"

Mr. Jones: "But what can I do about it if it's positive also?"

Doctor: "Well, you know, the usual stuff... like I said... eat right, take tons of..."

Mr. Jones: "That's okay, Doctor. I've had enough. Thanks for all of your help. Hope that $300 bucks comes in handy. Don't mind me: I'll keep doing what I've been doing and get started preparing my Bucket List. Oh, but one more thing..."

Doctor: "What's that Mr. Jones?"

Mr. Jones: "You wouldn't happen to work with General Electric like those two guys who wrote that article you quoted, would you?"

-Wes

Blue Cross Illinois to Permit Reimbursement for CTA

Effective 1 September 2007, Blue Cross/Blue Shield of Illinois will permit reimbursement for CT Angiography for the following conditions:

Computed Tomography (CT) Angiography (CTA), with or without contrast enhancement or media, utilizing 64-slice or greater multi-detector row CT (MDCT) scanner, as an adjunct to other testing may be considered medically necessary for any of the following indications:

A. Detection of coronary artery disease (CAD) in:

Symptomatic individuals (such as, chest pain syndrome as described by the American College of Cardiology [ACC]) who:
Have intermediate pre-test probability of CAD (as identified by the ACC guidelines); AND
Had a non-diagnostic stress electrocardiograph (ECG or EKG) (as defined by the ACC guidelines); AND
Have a contraindication to an exercise stress test or for whom the results are equivocal or suspected to be inaccurate, OR
Symptomatic individuals with unexplained chest pain or anginal equivalent symptoms (as described by the ACC) who:
Have intermediate pre-test probability of CAD (as identified by the ACC guidelines); AND
Had no ECG changes suggestive of ischemia or infarction; AND
Had negative cardiac enzymes and cardiac marker results; AND
Have a contraindication to an exercise stress test or for whom the results are equivocal or suspected to be inaccurate.

B. Evaluation of cardiac structure and function:

To assess complex congenital heart disease, including anomalies of coronary circulation, great vessels, and cardiac chambers and valves; OR
To assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned; OR
To assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from echocardiography, magnetic resonance imaging (MRI), or transesophageal echocardiography (TEE); OR
To assess a pericardial condition (such as, pericardial mass, constrictive pericarditis, or complications of cardiac surgery in patients) with technically limited images from echocardiography, MRI, or TEE; OR
For non-invasive coronary vein mapping prior to placement of a biventricular pacemaker; OR
For non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization; OR
For evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation; OR
To assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.
Note: Refer to the Rationale in this medical policy for guidelines issued by the ACC.

MDCT with less than 64-slice scanner is considered experimental, investigational and unproven.

CTA, using MDCT, to screen asymptomatic individuals for CAD or to evaluate individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing is considered experimental, investigational and unproven.

CTA, using MDCT, for any other indication not listed above is considered experimental, investigational and unproven.

Note: For any other Electron Beam Computed Tomography (EBCT) Technology applications, such as Whole Body Scanning or Imaging for screening, see policy RAD604.006; for CT for Calcium Scoring, see policy RAD604.009.

It's a whole new world...

-Wes

Reference: Blue Cross/Blue Shield Illinois' website.

Genomic Associations and Your Heart

Congratulations! You're the proud owner of chromosome 9p21.3!

What does this mean? It seems it means that you have better-than-even odds you'll get coronary artery disease!

Gee, thanks.

This week's New England Journal of Medicine discusses the use of the inverse solution of sorts that was used to determine which loci on the human genome are likely to be determinants for coronary artery disease. Now I'm no genome nerd, but I guess this is important. But how will John Q. Public apply this information? Will you want to know? It's probably too early to know what this means to the average doctor or patient today.

But there are some interesting potential implications of this new work. The prevelance of coronary artery disease is SO prevelant - millions and millions of dollars are spent on lipid lowering therapies and dietary prevention measures - will your DNA dictate to whom we should guide therapy? What mutations of this gene lead to peripheral versus coronary arterial disease?

Such questions are just the tip of the iceberg. As noted in the accompanying editorial:

The onus now lies on researchers to explain how variation in the function of these genes leads to clinical disease. The results of such genomewide studies tell us that a particular gene is important in the pathogenesis of a given condition, but they do not tell us the mechanism that is responsible. Once we achieve this understanding, which will not be easy, we should have the keys that will lead us to eventual improvements in patient care.

It used to be that we were concerned about issues from the cell to bedside. Now it looks like we'll soon have to understand the implications of one's DNA as it applies to the bedside.

-Wes

Image credit.

Jerry Falwell - Another Victim of Sudden Death

Today, Jerry Falwell was found unconcious in his office and could not be resuscitated, likely from cardiac causes:

The Rev. Jerry Falwell, who founded the Moral Majority and built the religious right into a political force, died Tuesday shortly after being found unconscious in his office at Liberty University, a school executive said. He was 73.

Ron Godwin, the university's executive vice president, said Falwell, 73, was found unresponsive around 10:45 a.m. and taken to Lynchburg General Hospital. "CPR efforts were unsuccessful," he said. Mr. Godwin said he was not sure what caused the collapse, but he said Mr. Falwell "has a history of heart challenges."

"I had breakfast with him, and he was fine at breakfast," Mr. Godwin said. "He went to his office, I went to mine, and they found him unresponsive."

Mr. Falwell had survived two serious health scares in early 2005. He was hospitalized for two weeks with what was described as a viral infection, then was hospitalized again a few weeks later after going into respiratory arrest. Later that year, doctors found a 70% blockage in an artery, which they opened with stents.

You wonder what his ejection fraction was and if an automatic defibrillator might have prevented this...

-Wes

Victims of Our Own Success

This week’s JAMA has confirmed the large drop in death by coronary heart disease in the setting of the acute heart attack. Trumpets have sounded, bands have blared, and patients have benefited. The study of over 44,000 patients proposed that the reasons for these improved outcomes were several:

• Improved adoption of coronary interventions (angioplasty and stenting) as the preferred method of treating an acute heart attack.
• The broad adoption of statin drugs to treat hyperlipidemia (high cholesterol).
• And the broader use of antiplatelet agents (like clopidogrel) in addition to aspirin (aspirin use stayed constant over the study period).

While there is no question that patients are doing better, nationally cardiologists are presently feeling about a 4-6% drop in coronary intervention rates. As such, interventional cardiologists are getting nervous. People are scrambling to explain the drop, since it affects every cardiology group across the country. Is it the statins? Is it the use of CT scans for earlier diagnosis?

Certainly the guidelines on the management of the acute heart attack have helped improve patient outcomes, but perhaps the reason the overall rate of coronary interventions have fallen and fewer patients are dying as a result of their heart attack is something much simpler.

-Wes

No Stent? It'll Take COURAGE.

“Ms. Jones, you know that chest discomfort you get after you pick up your mail and walk up the driveway back to your home?”

“Yes?”

“Well I’ve got good new and bad news.”

“What’s that?”

“First the bad news: your angiogram demonstrated you’ve got 80% blockages in two of your three arteries on your angiogram today.”

“What’s the good news?”

“Well, according to this important trial today I heard about at the American College of Cardiology Meeting, we’ve just got to put you on five medications, and ask you to take it easy for a while, and you’re likely to do fine.”

“But what about those 80% blockages, doctor? Isn’t that pretty close to 100%? And if it gets to 100%, what happens?”

“Well, I suppose you could have a heart attack. But this study I read about today suggested the same thing might happen if you get a stent, too.”

“But doctor, aren’t you going to DO ANYTHING about my blockages?”

“Yes, Ms. Jones, I’m going to put you on all of these pills – they’re good for your heart.”

“But I don’t like taking pills, doc. Isn’t there anything you can do?”

“This is what I’d recommend right now, Ms. Jones.”

“But all of my friends have gotten a stent, and they seem pretty happy.”

“ I understand, Ms. Jones, but our thinking about this is changing rapidly…”

“What would you have done yesterday?”

“Honestly?”

“Yes doctor, honestly.”

“Probably given you the stents.”

“I think I’ll get a second opinion.”

“I understand, Ms. Jones. Don’t forget to get those prescriptions I wrote for you.”


* * *


Potential implications from today’s COURAGE trial?

• Potential lost interventional cardiology revenue, but many more visits for non-invasive cardiologists to assess adequacy of medical therapy and more stress test/nuclear imaging tests over time.


• Increased drug company revenues, especially manufacturers of statin drugs.


• Possibly lower investment in 64-slice CT scans knowing that medication therapy is the preferred first-line of therapy in patients with asymptomatic coronary disease.

But what should be remembered before the doomsday predictions for the stent makers take hold, doctors will have a difficult time always recommending stents for the above reasons – especially when 35,539 patients who were assessed for eligibility in the trial, 32,468 were excluded for a variety of reasons. Remember, patients with severe ventricular dysfunction, clinical instability, or very early ST-segment depression or hypotension on stress testing were excluded from the trial. Certainly in a carefully selected patient population, these results are important, but there are still plenty of patients out there hwo will continue to need the services of an interventional cardiologist.

Will bypass be similarly affected by reduced referrals? Very likely.

What is certain: a seismic tremor was felt in the cardiology community today…

-Wes

References: New England Journal of Medicine COURAGE Trial

NEJM Accompanying Editorial

Coronary Calcium Screening by CT Scan

New guidelines by the American Heart Association and the American College of Cardiology were issued earlier this week supporting the use of coronary calcium scans to assess risk of future heart attack.

Coronary calcium scans, also known as heart scans, provide pictures of the calcium deposits in coronary arteries that might herald the existence of a significant blockage. Depending on the amount of calcium detected, the result of this test is often called a coronary calcium score. Scores range from 0 to over 1000, with the lowest numbers suggesting lower risk and higher numbers suggesting a higher risk of future heart attack. Heart scans and coronary calcium scoring may indicate if someone is at a higher risk of a heart attack or other problems well before they have any outward symptoms of disease.

The new guidelines represent a reversal of the AHA/ACC recommendations from 2000 when there were insufficient data to formalize recommendations regarding coronary artery calcium (CAC) screening to the general public.

But the new recommendations, published online 12 Jan 2007 in the online version of the Journal of the American College of Cardiology, are made with some qualifications. CAC screening is only recommended for patients at moderate risk of developing coronary artery disease while very high and low risk patients are still not recommended to have CAC screening.

So what justifies a moderate-risked individual in whom the CAC screening is recommended?

People referred for CAC screening should not have evidence of other vascular disease or be at high risk of developing such disease (like diabetics or those with known coronary artery disease). If a person has a greater than 10% risk of cardiovascular death in 10 years as determined by having two or more of the following cardiovascular risk factors: cigarette smoking, hypertension exceeding 139/89 or those being treated for hypertension, high cholesterol or low HDL (< 40 mg/dl), a family history of premature coronary heart disease (male first-degree relative < 55 years or a female first-degree relative < 65 years) and age (men >45 and women >55), then they might be candidates for screening.

You can estimate your own risk by using this special calculator from the National Heart, Lung, and Blood Institute.

People with 0 to 1 of the cardiovascular risk factors above should not undergo screening, according to the guidelines.

The controversies and limitations of this test are nicely outlined here. Realize, too, that this report does not cover the appropriateness of newer, 64-slice CT scanners for evaluation of coronary artery disease screening. (Medicare still considers these "experimental").

So look for more CT scanners to come to a mall near you - but only get it if you really need it.

-Wes

Combined Carotid and Coronary Bypass - Safe?

"Dad needs a bypass."

"Are you kidding?"

"No, really, all of the major blood vessels to his heart are critically blocked and the doctors think it's best to proceed with bypass soon."

"So what's the hang up?"

"It seems they found he has a 95% narrowing of his carotid artery on the right, too. They're worried he might have a stroke if the put him of the heart bypass machine."

There aren't too many more complicated issues for recommending a patient with severe coronary disease for bypass when there's a critical narrowing of a carotid artery. It is incredibly harrowing to fight the battle of coronary artery revascularization, only to lose the war when a patient wakes with an expressive aphasia (inability to speak) or the ability to move one side of their body after suffering a major stroke during bypass. This is not minor issue.

So today's article in Neurology with gushing claims from the lay press tries to shed a bit of light on the issue, claiming a 40% increased risk of stroke exists if a carotid endarterectomy is performed in conjunction with a heart bypass procedure, rather than as separate procedures.

But caution must be exercised when interpreting these researchers' findings. There is a clue to the problems with this trial: why was such a "cardiovascularly-related" article found in the journal Neurology? Could it be that the data are suffering from a homonymous hemianopsia?

In evaluating this work, the reader and lay press would be well-advised to review the methodology of this study. It used retrospective chart review of computer-coded data, albeit in large numbers of charts, in an attempt to glean a flicker of data with which to draw a glimmer of a trend - NOT a conclusion. To attempt to make any sweeping treatment recommendations (e.g. there is a higher risk of stroke with combined bypass and endarterecy) without knowing the severity of carotid narrowing, or even if stroke victims had both carotid arteries narrowed as opposed to one, quickly demonstrates the flaws in such a retrospective analysis. Teasing out the validity of data requires "retrospective" analysis that can be subject to bias as well - many of which cannot be anticipated by the reviewer - like coding bias - wich may have been performed to improve reimbursement by the hospital. Another bias might be changes in operators or surgical technique that occurred over the time period studied. Can the authors prove this did NOT happen with their retrospective evaluation? Of course not.

But the most damning of the findings of the study were the admission of the investigators themselves:

"The limitations to the use of administrative data sets include both inaccuracies and inadequacies of available data. Diagnostic coding errors are common, though improving over time. We have tried to eliminate as many miscoded cases as possible by narrowing the data set."

Translation: "We know the data are poor and we fixed them a bit to clean them up and erased some data, but don't worry about that."

What can be said is that there were alot of computer-generated codes flying through a microprocessor and a statistics package that suggested a trend in increased risk might exist. To say much more with this study is meaningless.

A better source is the data from the 2004 ACC/AHA Guidelines for Coronary Artery Bypass Surgery:

Hemodynamically significant carotid stenoses are thought to be responsible for up to 30% of early postoperative strokes. The trend for coronary surgery to be performed in an increasingly elderly population and the increasing prevalence of carotid disease in this same group of patients underscore the importance of this issue. Perioperative stroke risk is thought to be <2% when carotid stenoses are <50%, 10% when stenoses are 50% to 80%, and 11% to 19% in patients with stenoses >80%. Patients with untreated, bilateral, high-grade stenoses and/or occlusions have a 20% chance of stroke. Carotid endarterectomy for patients with high-grade stenosis is generally done preceding or coincident with coronary bypass surgery and, with proper teamwork in high-volume centers, is associated with a low risk for both short- and long-term neurological sequelae. Carotid endarterectomy performed in this fashion carries a low mortality (3.5%) and reduces early postoperative stroke risk to <4%, with a concomitant 5-year freedom from stroke of 88% to 96%.

'nough said.

-Wes

Door-to-Balloon Time: Simple?

You feel heaviness in your chest, throat tightening. You pop and aspirin and have your wife (or husband) take you to the Emergency Room. You've just hit the "door." The story is classic and the ER, fortunately, expedites your evaluation. An electrocardiogram is performed and demonstrates and acute myocardial infarction pattern: a heart attack is in progress. "Guys, call the cath lab," the ER attending pleads.

"Er, sir, it's one in the morning."

"Well, then, call the cardiologist and get them here... yesterday!"

Calls are made. Beepers activated. A cardiologist is roused from sleep, young technicians fumble for their pants and car keys. You hurt like hell, sweat pouring from your brow. Traffic laws are ignored. Red lites make an effective effort to stall. Time is ticking. Faster. Faster!

The cardiologist arrives first, meds are increased, your blood pressure drops. The techs arrive, switches activated. Lites turned on. X-ray system booted. Gown. Hat. Mask. Booties. Scrub. Trays opened. "Call the ER, tell 'em we're ready."

"Okay." The phone is dialed.

"Shit! They have no one to transport the patient! You go!" The tech runs to the lab. IV's hang from every corner of your bed. Doctors look concerned. Minutes. Tick. Hurry. "Get the elevator!" A nurse runs ahead to call the elevator. Tick. Tick. Tick. The door opens. Your bed is pushed into the elevator. You feel and IV yanked from your arm. "Hold it!" the tech screems. His IV pole wheel just got caught in the gap between the floor and the elevator. You feel a warm fluid near your elbow. "Damn it, hold pressure!" The fluid is blood. An IV fell out. Heparin. "We'll get another IV when we get to the lab. Don't worry about it." Go! Go! First floor, second floor. Ding! The elevator door opens. "Easy on the way out of the elevator. Okay, we're clear."

You're hurried to the lab down the hall. Once there, you enter a foreign room, lites blaring. AC/DC's "Hell's Bells" shreaks in the background." You're lifted to the narrowest table ever. Stickers are applied to your shoulders, prongs plugged in your nose, a clip applied to your finger. A big cold jelly-fish-like pad applied to your chest on each side. Pants removed. Warm, wet soap applied to your groins. You hear the scrub sink, with its water running, in the distance. Soon it stops. Another gown worn, another set of gloves applied.

"You're going to feel a little sting down here," the cardiologist says as the anesthetic is applied. Another sting is felt at your forearm."

"Ouch!" The cardiologist pauses. "Did that hurt?"

"Not down there, on my arm!"

"Sorry, I was starting another IV," the tech confesses. The cardiologist continues. The artery entered. A catheter passed to the heart. The coronary artery engaged and contrast administered. "That one's okay," the cardiologist thinks. "JL4 guider." Catheter are exchanged. More die injected, shots taken. The cardiologist turns away, working at the table as quickly as he can. A balloon is prepped, then inserted. "Whisper wire." The lesion is crossed. Your chest is heavier now. The balloon inflated, deflated. Suddenly, the pressure subsides. You relax. "How are you feeling now?"

"Better."

Door-to-balloon time. Simple in theory, yet not so simple in practice. Sweeping changes would have to be implemented in urban areas to achieve this. Techs and cardiologists, likely, would have to reside in-house when on call, or else live very close to their hospital, an impractical option in many cases. And while some recommendations by the American Heart Association and American College of Cardiology seem "simple" to some, their ramifications are significant to all. At least one doctor thinks this is a good idea:

"Thirty-five percent of patients in America have an artery opened in 90 minutes or less. Our goal is 75 percent," said Dr. Steven Nissen, president of the American College of Cardiology.

"Everybody we've asked to do this has said this is the right thing to do. Payers want it. Government wants it. Hospitals want it. Physicians want it."

Really? All physicians want this? All physicians want to live in the hospital waiting for that magic moment when an acute heart attack hits the door? How often does this happen? Five, maybe ten times a month? And how many occur after hours? Do all the techs want to live there waiting, too? Who will pay us for our time sitting, waiting?

While I do not argue that short door-to-balloon times save heart muscle, serious consideration of the costs to all involved, especially those doing the procedures, needs to be carefully examined. Presently we only get paid for doing the job - not waiting. The real people who are pushing this are the payors and hospitals. Why? Because patients do better, certainly, and costs fall. And their wallets swell.

But if "time is muscle," time waiting for a case is also lost money and personal lives to those doing the procedures.

So, who's gonna pay for all that waisted time?

The answer: Doctors.

-Wes