70-year-old with probable glioblastoma receives DES—delays diagnosis for weeks!

Uninsured smoker receives Cypher: SAT 3 weeks later—SURVIVES!

Patient with multiple myeloma requiring quarterly bone marrow biopsy receives DES: ONCOLOGIST SCREAMING!

80-year-old on warfarin receives DES: Bleeds buckets!

Although these were real events that occurred in my practice in the first few years following the advent of drug-eluting-stent (DES) implantation and interventionalists are doing a better job overall with stent selection, our efforts as cardiologists in general are still lacking. This blog was inspired by actual statements made in our THO forum on the topic. Issues affecting stent selection are as important to the medical-legal aspects of performing a procedure as the pericath risks we've all recited thousands of times. Admittedly, trials like Berne-Rotterdam that studied the Xience and Promus stents demonstrated a lower 1.4% risk of subacute thrombosis (SAT) when thienopyridines were discontinued, but we still can't rest on our laurels. There are scores of patients who face a real and unnecessary risk of bleeding from poor stent selection because we never had the "stent-selection" conversation.

In my 20-year history of performing cath work, my usual cath paragraph recitation went something like this: "There is a 2% risk of stroke, heart attack, death, allergic reaction, kidney failure, bleeding, blood vessel injury, and rhythm disturbance." When one of my patients got a moderate-sized groin hematoma and had to go to the OR for an uncomplicated and successful debridement due to skin necrosis, I realized my consent form was inadequate. The groin tissue was culture negative, but I added to my laundry list of possible complications the words "and infection" in my consent spiel nearly 12 years into my life as an invasive cardiologist. When bare-metal stents came on the market, I morphed it to include, "If you receive a stent, it will require extra blood thinner to be given for several months or indefinitely, depending upon your course and the findings at cath". When primary PCI without surgery on-site came to our facility, I morphed it yet again to include the words, "Off-site surgical backup is at Jewish Hospital in Louisville, KY, and if you were to experience a life- threatening complication, transport to that facility would be required."

After the above headliners actually occurred in my patient population as a result of poor stent selection, I added this final caveat to my routine consent talk: "Is there any surgery planned for you, or do you have a history of bleeding that might influence our stent selection?" So many times, the answer is yes. I've heard everything from "I have a face-lift planned next month" to "getting my knee fixed in June, doc" to "I can't afford clopidogrel, I have no insurance" and even things like "just had a unit of blood for aplastic anemia last month," with no mention of any of these plans or maladies on the intake history at the hospital admission or as a new patient to my office practice. My routine conversation with patients about cardiac cath, surgery, or intervention now includes a paragraph about stent selection. Furthermore, I suggest the following paragraph be included in every written consent form:

"I understand that I may require a heart artery stent that requires blood thinners, which help protect stents from clotting but can also increase the risk of bleeding. I understand it is my responsibility to inform my physician of my bleeding risks or any planned noncardiac surgery."

In addition, we need to add the "Do you have a risk of bleeding?" question to all intake or "get-to-know-you" conversations. The excuse that "patients are sedated and can't help us make a decision" no longer flies. Their family members aren't sedated, (well, not usually) and though we are always in a hurry to beat the 60 to 90 minute clock with STs up, the patients weren't sedated when they got into the ambulance or when they came flying through our emergency-department door. At every point of care, the potential cath patient deserves this conversation. It is an essential and most basic part of any history-taking process that is often neglected. With very little effort we can most certainly beef up our consent forms for stent implant and no doubt will avoid future headlines like these in our communities:

Cardiologist neglects to have stent selection conversation—Patient bleeds unnecessarily!

and whether we really want to admit it or not, one of the scariest headlines of all:

DOCTOR SUED!

Starting a real "consent-the-stent" campaign will help prevent both.

Today's visit was different, as I could tell he was deeply troubled. Our discussion quickly turned away from his health queries to the topic of an extreme injustice he recently witnessed. Embarrassingly, it was not the result of callous banking practices or armed robbery. It was at the hands of medical administrative professionals, more accurately described as "highway robbery" instead.

My patient's story began with the death of a poorly educated gentleman from a rural area 14 years ago. He suffered from multiple medical problems, including heart disease, and at the end of his battle incurred a hospital bill of around $17 000. When his land sold recently, his children stood to take home around $88 000 US. My patient, as an excellent banker and decent human being, was proud for this meager family, who, it seemed, would finally profit from their father's initial investment. "Do you know how much that family recovered from that deal?" he asked. "I have no idea," I replied. "ZERO," he said, holding up his thumb and his index finger into a circle. "They never saw one penny of it." "Why?" I asked. "The hospital charged a 14% interest rate for over a decade," he said, shaking his head in disbelief. "They received nothing. That is criminal," he lamented as he stepped from the exam table and reached for his tie. "Someone should do something about that. Someone should go to the newspaper in that town, but they won't do anything about it. The hospital in that city funds most of the newspaper's advertising revenue. It's a shame, because that kind of practice should be exposed," he said. "So much for objective journalism," I thought when he walked toward the checkout desk.

This isn't the first time a hospital has been accused of nefarious debt-collecting practices. In January of 2009 the Wall Street Journal's health blog by Jacob Goldstein reported that Minnesota's Attorney General sued Allina's Twin Cities hospitals and clinics for charging excessive interest on unpaid bills. They denied any wrongdoing but quickly lowered their interest rate to 8%. "Allina has dug a deeper financial hole for patients facing tough economic times by charging usurious interest rates of up to 18% on medical bills," Attorney General Lori Swanson said in a statement. The legal debate centered on whether or not the hospital's rate would qualify under the state's "open-ended credit plan," under which interest rates of up to 18% are allowed. They countered that because they cared for the uninsured, they should be able to charge higher interest rates to make up for it.

My question is this: If hospitals receive government funding to pay for the under- or noninsured, should they be allowed to charge such exorbitant rates under their state's "open-ended" credit plan? My secretary contacted a hospital today in a neighboring town that charges a 0% interest rate and if the debt is not collected at six months, "we work with the patient," they told her. In my book, that's a far more humane approach. Just today, a patient told me he dealt with the legal counsel for his local hospital by going the bank to borrow $3500 dollars, because he was able to obtain a loan for a far lower interest rate. Obviously, folks without good credit are forced to continue the debtor's-prison approach formerly practiced by the Twin Cities hospitals and currently followed by many institutions today.

Patients with few resources figured out the hospital debt legacy scam long before providers. Around 15 years ago, a 50-year-old gentleman refused a cardiac cath and rarely allowed me to admit him despite frequent exacerbations of angina and heart failure. I thought he was a bit strange and certainly a difficult man, leaving against medical advice frequently. Before he died, he refused to consider formal embalming because of the debt his family would incur, so from dust he came, to dust he returned, with no help from the local funeral parlors. Another gentleman died in our ER from an acute MI. He would not allow EMS to be contacted although he and his family knew he was experiencing a heart attack. When he fibrillated and lost consciousness, they called 911. He arrived pulseless after more than 40 minutes in the field, a goodly portion of which was without CPR. We could never establish a pulse and quite frankly were afraid we might. He'd been down too long. The family knew there was a good chance they would be left with only a vegetative patient instead of the person they knew and loved. They also had extreme guilt about pursuing a prolonged hospital and rehab admission that was obviously against his wishes. More aggressive measures would definitely have run counter to his phobia about incurring medical debt,

These two cases taught me that the fear of debt for some actually takes precedence over the love of life. Unfortunately, the fear of medical debt is not just some irrational psychiatric diagnosis. It is becoming a common concern.

How can a hospital that advertises itself as a "not for profit" position itself to profit from an unsophisticated, uneducated sick human being with a meager income? And if the practice is legal, is it necessarily moral? I liken it to someone who picks their nose in public. It's legal, but it's distasteful . . . repulsive really, not unlike what happened to this man's legacy. It is a trespass on the same level as the Old Testament example of the family who had one beloved lamb they kept as a family pet. It was slaughtered for the king's dinner party, when in fact the King had thousands of sheep from which to choose. Similarly, it was neither moral nor ethical to inflate the posthumous debt left for this family who suffered the premature death of their loved one and the loss of their primary wage earner. Religious zealots as well as unbelievers will likely agree that judgment in this world should be harsh for such practices. I believe that in the hereafter, the punishment should and will be far worse indeed.

Dr Ornish ran rapid-fire through a series of slides that in strong pictorial fashion drove his points home. He is a man in a hurry because there is a lot to tell and a lot to change in a short amount of time. Among his first slides is that of a sink running over with water feverishly attended by minions mopping in futility. He means to send the subliminal message that we spend inordinate amounts of time "mopping up the floor but we don't turn off the faucet." This was no subtle hint at his belief that the futilities of modern medical therapy fail in comparison to the benefits of sweeping lifestyle change. He demonstrated improvements in myocardial perfusion and regional wall motion after dietary changes and exercise were implemented. There were more benefits shown with cardiac PET studies. "Even modest improvements in stenosis can significantly improve perfusion." I drank the Kool-Aid with enthusiasm, though it was sweetened only with stevia or honey, I'm sure.

The dynamic Ornish presentation was chock-full of illustrations as well as statistics. There was the impressive testimonial of one of the success stories of an average everyday American male, who says, "I am no longer using a cane or a wheelchair. In November of 2001, I had to ride one of those scooters through Wal-Mart . . . and I didn't like it. Now, I no longer take my diabetic medications. My total number of meds has now been reduced by 75%. I could not go to the mailbox without chest pain. Now I am walking at least two miles per day, and I ride a stationary bike 10 miles per day." As his testimonial comes to an end, Dr Ornish interjects, "This is not a best-case scenario, it's the average-case scenario."

Next there were data from 93 patients with prostate cancer who implemented his program and demonstrated a positive impact on PSA, LNCaP levels, and MRA studies, all of which suggested a reduction in tumor activity at one year. "What are some of the mechanisms?" he asked. "Gene expression," he answers. "We know there are over 500 genes that can be affected. We know there are oncogenes that promote breast cancer and prostate cancer. You can do a lot." He laments that so many individuals indicate they are powerless because they believe "it's all in the genes," but Dr Ornish knows better. He's seen "telomerase levels increase by as much as 30% in three months," insisting that "our genes are not our fate."

Dr Ornish then covered the potential for neuron growth stimulation. "Remember how as med students you were taught if you went on a weekend binge, you lost neurons and those neurons were not replaceable?" he asked. "Well, you can actually grow neurons, and your brain can actually get bigger. Walking for three hours per week for just three months causes neurogenesis," he said. "Chocolate, tea, blueberries, frequent sex, alcohol in moderation, and stress management" can also grow neurons. He quipped that these successes to date were demonstrated mostly in mice, "because humans weren't interested in studies that required the cohorts to be celibate and then sacrificed along with the controls at the end of the study." Another giddy chuckle rose from the audience.

The next slide is that of a gorgeous man, coal-black hair, strong square-set jaw, and the epitome of virility dressed in a cowboy hat and a leather vest. "Half of men who smoke have erectile dysfunction," he said, and indeed this cowboy was smoking a flaccid cigarette, as wilted as a Dali clock dangling from his lips. The next slide is that of a crusty old fortuneteller with the caption, "I give smokers a discount because there isn't as much to tell." The audience laughed again.

 "If you go on a diet, you are likely to go off a diet," Dr. Ornish went on. "Our plan is radically simple. . . . It begins with you. You decide how much to change. You keep track of your own progress. The more you change your way of eating and living, the better you get, and the more things you change, the better you feel and then the healthier you are. You get the idea," he said encouragingly.

"So what is the optimal way of eating?" I asked Dr. Ornish in an interview after the program, "and how does your diet vary from the Mediterranean diet?" I confessed to him, tongue in cheek that I had always thought of Ornish followers as emaciated unhappy folks, wobbling from one place to the other, weak, pale, and hungry. He smiled and politely let me get me get away with it. "Well, I recommend less animal protein. Perhaps a cup per day of nonfat yogurt or nonfat milk instead," he replied.

The Ornish diet is similar to the Mediterranean diet in several ways. He recommends mostly plants, fruits, legumes, whole grains, and soy, but he directs 4 g per day of fish oil or its equivalent. "Always count calories, remember that organic is better, and choose quality over quantity" he urged in today's talk. "Reduce the total intake of fat, sugar, and refined carbs. Remember, refined carbs accelerate conversion of calories to fat and produce inflammation, which plays a role in the development of so many chronic diseases. High-protein low-carb diets lower the number of endothelial progenitor cells and double the level of nonesterified fatty acids," he added.

The diet and life style guru then projects a gloomy future, quoting what many of us already know; more than half of Americans will have diabetes or be prediabetic in the next eight years at a cost of $8 billion to the US. He also pointed out that in trials, "metformin did not do as well as lifestyle changes in diabetic management, so the trick is to cure it," and cure it as well as prevent it, we can. One study he quoted included 23 000 patients who by exercising 3.5 hour per week, avoiding smoking, eating healthily, and maintaining a normal weight prevented the development of diabetes in 93% of its cohorts.

Dr Ornish wants to be all things to all people in the wellness world, so he ventured into the world of carbon footprints and green living. "Our food choices affect the energy crisis," he says. "Of the fossil fuels we burn, 20% go to produce processed food. It takes 10 times more energy to eat higher on the food chain." Quarter-pounders apparently require 26 oz of petroleum and 17 pounds of coal per burger to produce. "I went to McDonald's and got them to put salads on the menu, but unfortunately, the price of the food does not reflect the cost to society. Just look at the cost of a $7 salad and compare that with a 99-cent hamburger," he said.

The next slide depicted a large elderly person listening to his doctor. The doctor says, "We can operate or you can go on a strict diet." The patient replies, "You better operate, doctor, my insurance doesn't cover a strict diet." Continuing the rapid-fire delivery required by time constraints, he stated that of 4000 men and women from 24 sites studied, adherence to his diet was still at 85% to 90% at one year. "That's powerful," he concludes. He contributes his success to support groups, which meet "an unmet need for connection." "Humans are touchy-feely," he points out.

Dr Ornish seems to have a lot to brag about. He claims that 96% of his patients with coronary disease report improvement in angina severity. Improvements in depression scores best those of SSRIs. Hostility scores substantially drop and overall quality of life indicators improve. No longer do his patients ask the question, "Am I going to live longer, or is it just going to seem longer?" he quips.

And it's not just the lay public that is paying attention to Dr Ornish. Besides his impact on the fast-food industry with the McDonald's menu improvements, Medicare began covering his program for reversing heart disease under intensive cardiac rehab with a team approach. "Physicians like it because it's not just reimbursable, it sustainable," he said. He assisted the St Vincent de Paul homeless shelters, which "no longer have to depend so much upon third-party payers to care for that high-risk population. The real epidemic there is loneliness, depression, and isolation, all of which increase mortality by three to seven times," he said.
Dr Ornish thinks the things that work best to make us all happier are altruism, forgiveness, compassion, and love. "I am most interested in transformation. Those things make relationships better and are essential sources of peace, joy, and well-being," he concluded.

"Behold I will rain bread from heaven for you; let the people go forth and gather what is sufficient for every day."  —Exodus 16:4

Manna.

Dr Warber began by defining integrative medicine as a practice that "reaffirms the relationship between the practitioner and the patient [and] is informed by evidence and makes use of all appropriate therapeutic approaches to achieve optimal health and healing . . . encompassing spirit, heart, mind, and body—the relational and emotional heart," she further explained.

Dr Warber presented an interesting case report of a 57-year-old female smoker with dyslipidemia, hypertension, and a family history of stroke and heart attack. She was referred by her primary-care physician because she declined mainstream medications to approach her risk-factor profile. Her diet was excellent, and although she claimed to exercise regularly, "she only exercised one day per week." Her BMI was 26—"that's a little over weight" she explained—"and her cholesterol was 260, HDL 45, and LDL 190. So, what to do with this patient?" Dr Warber asked, before venturing into some positive benefits of alternative therapies.

Making the point that smoking cessation delivers the biggest bang for the buck in the world of risk reduction, she always discusses the options of counseling, nicotine replacement, acupuncture, hypnosis, autogenic training, and even the mainstream option of antidepressants. "48% of patients prefer physician-directed counseling for smoking cessation and 35% prefer nicotine replacement; the remainder prefers acupuncture, hypnosis, or autogenic training, otherwise referred to as biofeedback." With regard to alternative options for blood-pressure control, she compared the 12- to 16-mm-Hg drop with pharmaceuticals with biofeedback, which can garner a 14/9 systolic/diastolic drop in blood pressure. Biofeedback requires the utilization of a device that directs controlled breathing at a rate of 10 breaths per minute or less. It "plays a little melody that helps to synchronize breathing," she said. "Micronutrients such as calcium supplementation in randomized controlled trials garner a 2.2-mm Hg drop in systolic BP. Magnesium, although [it has no impact] on systolic blood pressure, effects a 2.2-mm-Hg drop in diastolic numbers," she explained. Arginine, which she deems a "semiessential" amino, is a precursor to nitrous oxide, and at doses of 18 to 20 g per day in divided doses "has been associated with a 5.29/2.6-mm-Hg drop in systolic/diastolic pressure in a meta-analyses," Dr Warber explained." Co-Q 10 appears to reduce peripheral vascular resistance at a dose of 100 to 120 mg/day or 60 mg bid" and in a randomized controlled trial was associated with systolic reductions of up to 11 mm Hg. Although there are no adverse effects of Co-Q 10 reported in trials," there are negative interactions with warfarin" as alluded to in Dr Cooper-DeHoff's presentation, with significant reductions in INR. Fish-oil utilization at a dose of 3 g per day garners an up to 4.5-mm-Hg reduction in systolic pressure. "Adverse side effects such as belching, bad breath, a fishy aftertaste, and abdominal pain" are some of the downsides, points out Dr Warber. She also adds a specific red flag for warfarin users due to the known antiplatelet effects of fish oil. 

Dr Warber then ventured into the world of lipids, stating that although statins are proven to be beneficial in secondary prevention, "Their role is not so clear for primary prevention." She alluded to stanols, which are "highly saturated derivatives of sterols that do not have to be taken with a meal." Two- to three-gram doses per day have been associated with an 11% reduction in cholesterol vs a 2.3% reduction seen with placebo. "My patients love Benecol chews," Dr Warber stated, a product that contains stanols at a cost of around $28 for 120 chews, with a recommended dose by product instruction of two to four chews per day. "Policosanol at a dose of 5 to 40 mg per day garners a 23% reduction in LDL cholesterol," she adds, "but studies conducted outside of Cuba demonstrated no effect at all." I felt a strong surge of caution here, because we have learned a hard lesson in mainstream medicine—that just because we are able to slide the cholesterol numbers into the normal range, with some entities like niacin and ezetimibe, their benefit remains to be proven, and in some realms, there are concerns about the possibility of harm with ezetimibe.

So, what did Dr. Warber do for her patient? She encouraged spiritual engagement, the exploration of her life's purpose, encouraged activities that promote good self-esteem, and suggested journaling for emotional expression. She encouraged healthy relationships, engaging in yoga or tai chi for 30 to 60 minutes per day, a diet of eight to 10 servings of fruits and veggies per day, fish oil or cold-water fish, and soy nuts. She counseled regarding smoking cessation, instructed relaxation techniques for BP lowering, and directed her to consider arginine, Co-Q 10, and plant stanols. It remains to be seen as to how these treatments affect the patient's blood pressure and lipid numbers, but the point is that a patient who was otherwise unwilling to consider mainstream medicine can still receive huge benefit from exercise and smoking cessation. It removed the barrier that stood between patient and physician and fostered an environment of consideration and possibilities.

One audience participant was not so convinced. "This isn't primary prevention as far as I'm concerned, this is secondary prevention," he said. "She could benefit from cholesterol-lowering medications and you might consider a calcium score." But he missed the point that she isn't willing to consider those things. Although we have pharmaceuticals that are known to reduce her risk of death, stroke, and heart attack, physicians are still bound to offer help to those who are unwilling to use them. We must somehow try to muster some understanding for patients who are okay with the most lethal of all entities in the world of cardiovascular risk—smoking and sedentary lifestyle—and who are afraid, no matter how illogical or ridiculous their ideas may seem to us, of mainstream solutions. We must try to find a common ground from which to start a conversation. Skeptical patients take more work, require more time, and can be very frustrating to deal with, but they deserve our time and our efforts; after all, as healers, we must never forget that mainstream-medicine haters, as our brothers and our sisters, are people too.

Dr Dean Ornish stepped to the microphone next.
 
 
 
 

Patients utilize alternative meds for various reasons. In a 2006 survey, 66% of individuals indicated they used supplements to treat a specific health condition, 65% intended them to enhance overall wellness, and 42% aimed to prevent illness. Love them or hate them, supplements are here to stay . . . but Dr Cooper- DeHoff pointed out there have been significant shifts in trends. 
In 2002, echinacea reigned king, and ginseng, garlic, and St John's wort were exceedingly popular. Five years later, fish oil, of which there is at least some evidence of benefit, is now a dominant choice, followed closely by glucosamine and chondroitin. "Physicians are now recommending more physical activity, which means more joint pain," Dr Cooper- DeHoff reasoned. Echinacea is decreasing in popularity, flaxseed oil is emerging, and we now see very little St John's wort. Interestingly, Co-Q 10 is becoming a major player.

Dr Cooper-DeHoff pointed out that as Americans utilize green tea and caffeine for weight loss and as an energy source, they garner the side effects of anxiety and tachycardia. In my office setting, I see tons of folks every year who suffer from caffeine intolerance and although caffeine in normal amounts won't kill you, (unless you have a long QT), it can certainly make you think you're dying and generates scores of unnecessary office visits and testing. Energy drinks that are typically sugar laden can contain up to 360 mg caffeine, or the amount found in three to four cups coffee. This excessive amount of caffeine is a structural analog of adenosine that generates side effects of nausea, palpitations, protracted vomiting, rhythm issues, and seizures. Even more confounding is the fact that caffeine intoxication is not detected on blood screening.

Dr Cooper-DeHoff pointed out that side effects of other supplements could also be serious and even devastating. A brand known as Total Body has been associated with a 10 000-fold increase in selenium levels, producing significant liver toxicity, pulmonary edema, and even death. She then described a common issue with red-yeast rice, used as a condiment in Asia with the active ingredient shared by the cholesterol-lowering drug lovastatin called monacolin K. "The difficulty is the variability in concentration," she points out, "which varies lot to lot and bottle to bottle, and there are even significant variations from manufacturer to manufacturer." For instance, some brands suggest two capsules twice per day. "This means that if the patient switches brands, they could actively change their dose of lovastatin from 4 mg per day to up to 40 mg per day unknowingly," she warned. A most horrifying fact about red-yeast rice is that the supplements routinely contain arsenic and citrinin. Citrinin is a known nephrotoxin. With regard to arsenic, I found it interesting that the Dr Oz–generated warning about apple juice containing miniscule amounts of arsenic a few months back caused a full-fledged panic nationwide, yet the arsenic issue with red-yeast rice was no more than a blip on the screen.  "I note while walking up and down the aisles of places like Wal-Mart that the compounds or byproducts are not listed on the label," Dr Cooper-DeHoff pointed out. She then went on to add that even relatively safe entities like Co-Q 10 are not without problems. Advertised as a "miracle antioxidant" for hypertension, Alzheimer's, and statin-induced myopathy, few understand that Co-Q 10 is structurally similar to vitamin K and can decrease the INR in warfarin users, a result that can be devastating for patients with heart-valve problems, prior stroke, or atrial fibrillation.

Although we as practitioners may loathe supplements, it is our responsibility to be educated so that we can help our patients navigate their risks. The results of a 2006 AARP survey revealed that 77% of patients did not share their supplementation use with their doctors: 12% felt their healthcare providers would be dismissive or would tell them not to utilize them anymore; 30% didn't think it was important for their doctors to know what they were taking; but most damning for us as a profession is the fact that 50% of patients surveyed said their physicians never even asked if they were taking supplements.

Patients think that "natural is safe," said Dr Cooper-DeHoff when she rolled her next slide of devastating complications with supplement use. More adverse effects included heart-transplant rejection with St John's wort, seizures with ginkgo, rhabdomyolysis with Commiphora mukul, interactions of fish oil and gingko with warfarin, diabetes insipidus with Solanum indicum, and exacerbations of hemochromatosis with milk thistle. She cited both pharmacodynamic augmentation as well as impacts on the pharmacokinetic issues of absorption, distribution, metabolism, and elimination of several major drug groups with alternatives.

"Herbal supplements need to suggest some benefit or some efficacy in order to sell," said Dr Cooper-DeHoff, and sell they do, to a tune of 363 million annually in the weight-loss arena. In October of 2011, supplements by the names of Advanced Slim, Botanical Slimming, Magic Slim Tea, Pai You Guo, Slender Slim 11, A-slim, Lose Weight coffee, and p57 Hoodie were found to contain sibutramine, a compound pulled from the US market in 2010. Increases in BP, stroke, and heart attack were reported side effects. Many were obtained over the internet, so no one has any idea what else might be in them.

If energy and vitality or illness prevention won't sell, sexual enhancement always will. The FDA warned about 12 products containing sildenafil, including Magic Power Coffee, Man King, Via-Xtreme, Black Ant, Hard Ten Days, and Man Up, all of which actually contained compounds that could be fatal with the heart medications that contain nitroglycerin.

"Bath salts" are also not benign. The white-powder crystals contain elements of the khat plant or cathinones, a synthetic derivative that can increase HR and BP and cause sweating and agitation. Unfortunately, the symptoms can be confusing to practitioners. Like caffeine, cathinones will also not appear on a standard drug screen, so it's important to ask the patient or significant others about their supplementation histories.

Driving the point home about how prevalent alternative supplementation has become, Dr. Cooper-DeHoff snapped a picture with her cell phone of an innocent-appearing piece of chocolate placed on her pillow this week at the Hyatt McCormick. On the label was the wording "sleep" and "good night," which upon closer inspection contain valerian extract. "What if someone waited until in the morning to eat their chocolate? They would wonder why they were so sleepy all day," she quipped.

I tell my patients that anything that is processed isn't natural. Earthquakes, tornados, and appendicitis are all natural but aren't desirable. A pair of sneakers, the Mediterranean diet, and yoga are more effective and tons cheaper in the long run than anything the supplement industry offers. When it comes down to it, there is nothing natural about selling nature in a bottle, period.

Dr Michos, in a very objective fashion, then outlined the pros and cons of vitamin-D supplementation. She referred to the observational NHANES publication in the 2007 Archives of Internal Medicine in which levels of less than 15 were linked with hypertension. Wild-mice studies indeed demonstrate vitamin D to be a negative inhibitor of the RAS system. "Hmm  . . . wonder if I should take a little vitamin D? After all, I'm the last person standing in my family that's not on antihypertensives. Maybe a little bit wouldn't hurt."

There were slides of macrophages in a milieu of oxidized LDL that did not produce foam cells if exposed to vitamin D. "That was intriguing," I thought. Although I've never given a rat's butt about a rat's aorta, by golly, I was impressed by images of teensy-tiny aortas that were as clean as whistles compared with their little vitamin-D–deficient mice friends. Then there was the thought-provoking Framingham offspring study, in which there was a 16% decrease in risk of CV events with adequate D levels. Other studies were cited with up to 18% lower all-cause mortality with adequate levels. But, just as I was getting comfortable with the thought of recommending vitamin D supplementation, the troubling truth reemerged.

In the WHI, 36 282 postmenopausal women took 400 IU/day of vitamin D with no mortality benefit, but Dr Michos pointed out that the placebo-arm cohorts were allowed to take their own supplements and the dose was too low. The PRIMO randomized controlled trial was also troubling because there was no improvement in LV mass with supplementation, but the dose again was too low, genetic responses assumed to be highly variable, and there was no control for BMI. The VITAL trial, currently enrolling, seems doomed from the beginning, with 20 000 healthy cohorts who will be delivered 2000 IU of vitamin D per day. Dr Michos seems pessimistic that it will answer any of our questions, since being vitamin-D deficient was not part of the enrollment criteria. "Currently, the evidence is inconclusive for vitamin-D supplementation," she said. "It's a risk factor, but whether it is causal or confounding remains to be seen. We need large randomized clinical trials, since the saga of hormone therapy, antioxidants, folate, and vitamin B did not match our enthusiasm."

Although I'm definitely not, as of yet, enthusiastic about vitamin-D supplementation, I was mesmerized by thought of the lack of foam cells, clean mouse aortas, and an "association with" a lower mortality with adequate D levels. Like Hamlet, I lamented at the end of the presentation, "To D or not to D?" 'Tis indeed still the question, and though it remains unanswered, I'm at least much less hostile and certainly better informed. At least that's something. 

When I first joined Dr Jim Whiteside's practice in Glasgow, KY in the early 1990s, I encountered many patients who had been treated by the "Amish doctor," a local iridologist who looked in their eyes and prescribed hundreds of dollars' worth of herbs and supplements. His fame spread far and wide for such amazing and complex diagnoses as GERD, prostatism, and constipation. It was amusing at first, but then it turned serious when a patient stopped by one day with a small glass bottle of "ground-up squirrel thyroid" and asked if it was safe. He had known supraventricular tachycardia that must have been missed on that very thorough iridology exam he had received early that day. I threw it in the trash. The "doctor" told another patient he was dying of heart trouble and after a normal stress test, numerous office and hospital visits due to extreme cardiac anxiety, a normal cath was required to put the patient's mind at ease. Another patient was prescribed "the cleansing." She had an extreme catharsis, and I suspect her sudden cardiac death was due to a warfarin-cathartic interaction or catecholamine surge from the stress of it. A young 25-year-old came to my check-in desk one afternoon in a full-fledged panic, although I'd never seen her as a patient, begging to be seen. She, too was told she was suffering from severe heart trouble. I threw her on a treadmill that afternoon and after she ran for over 10 minutes, nothing happened, and she went on her way with a new lease on life. Finally, another patient who had visited this diagnostic wizard had a V-fib arrest at home using a device the "Amish Doctor" had sold him to try to return his liver to the correct orientation, since it had mysteriously "turned upside down." When I heard of the small child whose snakebite was treated by being instructed to lie down beside a severed chicken's head, I could stand it no more.

I contacted the Kentucky state attorney general, who sent a special investigator with a clean bill of health to see the "Amish doctor." Like all other patients, he received a laundry list of diagnoses and an offer to purchase around $300 worth of medication. Since the "doctor" knew it was illegal for him to charge for a visit, he asked for a "love offering." Furthermore, he treated a bipolar patient whose parents had traveled from Arkansas to be healed by his amazing feats. The trick was that they had left their daughter at home, and not only was he fabulous enough to treat her, but he didn't even require the usual "eye exam" to do it. Of course, he garnered several hundred dollars' worth of herbs and supplements for his time. After collecting as much information as possible, we thought we had plenty of examples of impersonation, practicing without a license, etc, but we were wrong. Furthermore, some victims refused to testify "because he was so nice," or because they were "ashamed to admit" they had been so gullible.

Our Kentucky Attorney General Ben Chandler decided that our case was not "winnable," because the practice of medicine from a legal standpoint in the state of Kentucky is poorly defined. "Your mom could be prosecuted for suggesting her neighbor take Imodium AD for diarrhea," the special investigator said. "Under the current law, if we won this fight it would be problematic." I never really understood why we ducked out on this very important issue, but I'm certain it had to do with being short-handed, short of change, or my exclusion from the "good ole boy" network that reigns king throughout so much of our rural areas of the US. Fortunately, for reasons I'll never understand, the popularity of the "doctor" has waned, though I hear of an occasional burp (or other reciprocating gastric explosion) of adoration on occasion.

Knowing the back story, you can now imagine what I must have been feeling today on my way to room S100c in McCormick place for the 10:30 am session. A bull running toward a thousand red flags would have had far less adrenalin. Chaired by Dr Lynne Braun of Chicago and Dr Elizabeth Jackson of Ann Arbor, this session was refreshing. I have hardly spent a more valuable 90 minutes in my career of learning. We heard from Dr Erin Michos of Baltimore on vitamin-D metabolism, Dr Rhonda Cooper of Gainesville on dietary supplements, Dr Sara Warber of Ann Arbor on integrative medicine, and Dr Dean Ornish of Sausalito on lifestyle management. Each session was jam-packed with practical information that our patients deserve to know, but furthermore, we should be required to possess.

Without further ado, I will start the series on "Vitamins and supplements in cardiovascular disease prevention" with information on the mysteries of vitamin D. 

I read every page of the healthcare reform bill and posted on that issue a few years ago. I lamented that the word "cardiologist," the gatekeeper of the our country's most expensive DRGs, congestive heart failure the most damning, was never mentioned one single time in the entire diatribe. Congestive heart failure was never mentioned as an entity, period. Although trauma networks were addressed, PCI networking, a smoke-free America, and effective strategies for heart-failure prevention and readmissions were never mentioned. Behind what door were we all sleeping? Or more precisely, who was holding the door shut?

Dr Kavita Patel, an internist currently at the Brookings Institution, a nonprofit public-policy organization based in Washington, DC, said, "I'm pretty pissed about how I worked in the White House and at how bad a job we did in talking about healthcare reform. I'm trying to understand how we took something so amazing and frittered away an opportunity. I find myself constantly being amazed how little anyone understands where the faults lie and why we did not do a good enough job in reaching out to leaders like Jack [Lewin]. We did not reach out enough to talk about leadership. How can we communicate more effectively?" She then added, "Nothing is happening. We won't know what will happen until closer to November. There is uncertainty about the role of physicians." She then said, "My impassioned plea is that we must translate policy into sense. There is a dysfunction," and then pointed out that "in DC, we go after the vulnerable and the impression is that since they don't know what they want. . . . Let's go after them and impose policy. There is certainty, however. There will be payment reform. The deficit will not go away. The demographics of our country are changing, but as long as we keep Medicare age at 65, we are going to see a dramatic change in how we are going to think about it."

Then it was Dr Richard Anderson's turn, the owner of the Doctor's Company, "the nation's largest insurer of physician and surgeon medical liability," who asked rhetorically, "What is and what isn't in the bill? The standards of care, bending the cost curve, and defensive medicine," he answered. "It is impossible to mend the cost curve if we don't amend defensive medicine." Then he asked, "What's missing? Everything! In this 2500-page bill, there are only one or two mentions of professional-liability reform. Section 10608 extends federal malpractice protections to nonmedical personnel at free clinics. That's nice," he said, "but the real question is, 'Why aren't we all protected by the Tort Claims Act?' He then affirmed that "100% of medical care in America is defensive. The standards of care are standards passed down from the courts; 91% believe malpractice concerns result in defensive medicine, 93% report engaging in various forms of defensive medicine. Greater than 90% of med students and residents see defensive medicine as necessary. The cost?" he asked: "150–$200 billion per annum in defensive medicine alone." He then added, "Physicians are never going to escape accountability, but more decisions will lead to accountability without authority."

Dr Anderson then went on to address the "best practices that aren't." He said that "guidelines are often wrong" and pointed to a study of patients with CHF that showed that quality measures prescribed by federal government had no effect on outcomes. He then pointed to the recommended practice of instituting antibiotics for pneumonia implemented within four hours, which actually worsened outcomes. "The mammogram controversy," he said, "shows we cannot agree on the guidelines and the costs are enormous. $70 of the cost of each screening mammogram goes toward litigation."

Then there is the current electronic medical records (EMR) debacle. Dr Anderson believes "EMR is a holy grail." He thinks, "It's a once-in-a-lifetime $40 billion–plus opportunity, but it's working out incredibly poorly. The payment system, if used effectively, has a potential return of 15 to 1, but may be a net negative unless fully integrated." He then said, "Billing verification trumps clinical utility. The tower of Babel can be a moral hazard, newly minted, and if put into physician offices can be a flytrap for more litigation. Irrelevant information for documentation is added for reimbursement purposes. A lot of it is now 100% 'unreadable.' We have a long way to go before we harvest any of the value of what should be a major step forward."

There were some pieces of advice among those who delivered on a fantastic gripe session. "We need to put the poisonous politics aside, and we need to get to a better place in healthcare delivery" said Dr Anderson. "Here is an optimistic alternative view: Better coordinated care, the practice of evidence-based medicine, improved medical records, and a reduced need to sue for costs of care." Yep, I thought, and there is about as much chance of that happening as my winning the Lotto tonight, but I am resigned that we must try.

A female heart-failure physician from the audience put another salient point forward by adding, "No one hears us when we say patients must be held accountable. Just last week, on our heart-failure ward, a young woman was eating Kentucky Fried Chicken and French fries." I even lamented in the question-and-answer session that the ACC needed to drive harder on issues of mapping America for a timely PCI, smoke-free agendas, and uniformity in heart-failure management strategies. "We are on every single smoke-free legislation," said Dr Lewin. Dr Jerry Kennett added, "That is all a part of our Million Hearts campaign." Well, it might be, but it's not trickling down to our population, I thought. Nor is it rising up to the level of the White House.

The message was clear today that physicians are failing as a group because we aren't organized. We can't even decide if we want to be called "a group" of doctors or "individual groups" with our own special agendas. Abe Lincoln said it best, "A house divided cannot stand," but today I bet he would add something like, "A door cannot open with someone's foot barring the way" or "A door latch will not open by itself." We need to remove the feet, the hands, the lies, and the hidden agendas that prevent us from standing together as healthcare providers. President Obama needs to plan a weeks- long summit with the leaders of our country's largest healthcare organizations. He needs to make a few phone calls to the physicians on the forefronts of the fight against our most expensive diseases as well. He needs to hear how Dr Harlan Krumholz's group of physicians reduced 30- day heart-failure admits. He needs to hear how Dr Aversano's C-PORT trial proved we can promote safe and timely PCIs throughout our nation, and he needs to understand how a successful smoke-free America campaign can stop many of the drivers of our most expensive DRGs like cancer, stroke, heart disease, and COPD. He needs to examine the 17 most expensive medical diagnoses and summon physicians who work in those trenches to his side immediately for an urgent, long overdue and intense discussion. Finally, our president needs to remove his "lawyer's mantle" and understand that tort reform is a lifesaving chemotherapy for one of the most malignant cancers that's actually not just threatening but killing our healthcare system.

Dr Jack Lewin said it best; "There is a deafening silence in DC as to what we think." Well, I don't mind telling them what I think. We need a president that is "tripartisan," uniting both Democrats and Republicans on the side of humanity, because putting the humanity back in healthcare is the only thing that will ever work. Otherwise, any amount of effort never will. 

See also:

HF update from ACC: Tackling readmission rates, galectin-3; chronic lung disease comorbidity

We began with Dr Larry Allen and Colleen Rohrer RN from the University of Colorado. "The admit diagnosis is often inaccurate and the claims codes delayed," said Dr Allen. They simplified things by identifying patients with a BNP >100 or who received an IV loop diuretic. They excluded patients with ESRD, cirrhosis, or cancer. They tried to determine the readmit risk by utilizing the LACE model at first, but it didn't work for their point of assessment early in the admission rather than at discharge. They found the UT Southwestern model published in Medical Care in 2010 worked well, employing its 27 variables extracted from the electronic medical records. Nurse Rohrer receives "an email at 4:00 am every morning of patients ranked by risk score." It took them long 1.5 years to generate the email and get the risk scores generated, but it was worth it. "None of this is cheap or free, but it has been good for our institution," added Dr Allen.

Next we heard from Dr Adrian Hernandez from Duke University and Dr John Heitzer from the NY Methodist Hospital. Dr Hernandez began by saying, "At Duke, we think we are number one in everything, and when readmit rates started 'getting out' in MI and heart failure . . . we were worse than average. The administration," he joked, "went through five stages of grief: denial—'It's not possible,' followed by anger—'Why are people doing this to us?' Then on to bargaining by thinking, 'Maybe we can have some special consideration; after all it's the fault of all the people who are sent here who are very complex'; then depression—'Yes, this is really a problem,' and finally, acceptance—'Yes, it's a problem, and it will not go away.' " He then rhetorically asked, "Will it mean something? Will it actually change the patient's journey?"

Dr Heitzer discussed "The utility of volunteers to reduce hospital CHF readmission" program. They targeted two areas by acknowledging that 50% of readmits are due to pharmacologic and dietary noncompliance and admitted the inability of doctors to spend the time needed for discharge. Their innovation utilized premed students, who contacted CHF patients on the day of discharge and at 24 to 48 hours postdischarge with education on their disease process, a med review, and emphasis on daily weights and fluid restriction. They also encouraged regular follow-up. The volunteers were trained with a one-hour course on CHF info and given an educational handout. Of the 137 patients, 70 were in the intervention group. At 30 days, the readmit rates for a population with an average EF of 35% was nearly 50% lower in the intervention arm.

Next Dr Ileana Piña and Dr Vivek Bhati from Montefiore Medical Center in New York presented their "Brown-bag-clinic" approach. Dr Piña stated, "Before you do anything, you start looking first. Where are the patients coming from? Are ACOs sending people in? Don't believe all the administrative data you get. Out of 50 charts, 30 had no evidence of heart failure anywhere." She noted that skilled nursing facilities "had readmit rates as high as 40%."

Dr Bhati then outlined her "brown-bag-clinic" approach, which requires each patient "to bring in every med in their cabinet." Nurses and pharmacists counseled their patients on side effects and utilization. "If you do low-hanging fruit first, it doesn't take long to produce results. At the VA hospital, they reduced hospital readmits to 8%", said Dr Piña. Dr Bhati quipped, "One brown bag, 50 cents. Saving heart-failure admits, $17 billion."

Last, we heard from Dr Mary Walsh and Mary Fischer MSN, from St Vincent Hospital, in Indianapolis Indiana. They discovered that at the skilled nursing facilities, "there was a culture of not wanting patients to lose weight. Skilled nursing facilities are monitored on patient satisfaction, so they were concerned about providing a lower-sodium diet," said Nurse Fischer. They even invited nursing assistants to participate in their ANEWLEAF program, where they reported:

A—acute agitation or anxiety.
N—nighttime shortness of breath or increased nighttime urination.
E—edema.
W—weight gain.
L—lightheadedness.
E—extreme shortness of breath lying down.
A—abdominal symptoms, nausea, pain, decreased appetite, distention.
F—fatigue.

They recently worked with a Jewish skilled nursing facility that is required to serve kosher food but committed to providing a 2-g sodium option. Another "high-end skilled nursing facility is now engaged in complying with our CHF protocols," said Nurse Fischer.

Few presentations at major meetings are as "real" as this one this morning. One could almost feel the cool clammy skin, hear the rales . . . and see the panic in the faces of drowning and failing hearts begging to be saved. Dr Krumholz put it best: "Really, the success is about not hitting home runs. It's about small ball; inexpensive, thoughtful interventions that involve better communication and take into account what it feels like to be a patient. These things can effect change everywhere."

Indeed it can. . . . So when and how do the rest of us start? Check out the ACC's H2H program to learn more.

Could swear I smelled popcorn

As I reach the foot of the Cinderella castle, it is about that time that I smell hot buttery popcorn and when I begin to try to persuade our younger one to skip the Magic Kingdom and do Epcot first. Epcot remains my favorite theme park throughout my 16-year history of many park visits. It is one of the few places where one gets a strong visual of ancient history while planted firmly in the present and at the same time a marvelous bird's-eye view of projections for the future in health and general science. Dr Braunwald, as the grandest of all tour guides, this morning first paid homage to Dr Simon Dack (1909–1994), one of the founding fathers of the ACC. He then followed with the interesting caveat that 2012 is the "centenary" year of the publication of the first information on myocardial infarction. In 1912, Dr James Herrick (1861–1954) of Chicago published in JAMA "Clinical features of sudden obstruction of the coronary arteries." In that article, he stated, "The importance of absolute rest in bed for several days is clear" postinfarction. Unfortunately, "a few days became six weeks," Dr Braunwald observed, with a 30% in-patient mortality for acute myocardial infarction in his time of training. "On early-morning rounds to draw bloods, I'd find that some of our patients had slipped away quietly in the night in some of the rooms off to the side," he lamented. The birth of the coronary care unit in 1961 by Dr Desmond Julian then cut AMI mortality by 50%. "The remainder of the AMI deaths would then be from pump failure rather than ventricular fibrillation," he added.

The Universe of Energy," dinosaurs, and such

My favorite of all the Epcot attractions is housed in a dark cool structure at the Universe of Energy, where dinosaurs munch on fresh greens as we glide along on the still waters of ancient marshes. Orchestral strains swell to deafening heights as the narrator continues his tour. Evolutionists take heart as prehistoric humans are depicted in their delight at the discovery of fire and later the impact of the first wheel. Similarly, in the history of AMI therapy, Dr Braunwald and his colleagues added a most important link to the chain of events that would improve AMI mortality with the publication of "Factors influencing infarct size following experimental coronary artery occlusion" in Circulation in 1971. This "animal-studies only" publication was "our first real hope that medical therapy might reduce the size of an MI," he said. Then in 1976, Dr Evgeny Chazov, "a brilliant Soviet physician," extended this thinking to humans. The audience was then treated to ancient pre– and post–intra-coronary lytic angiograms that demonstrated that, despite the successful lytic therapy of an acute infarction, significant residual obstruction lingers. "Rapidly, IV fibrinolysis replaced the intracoronary approach," Dr Braunwald pointed out. "Then in 1988, TIMI-1 demonstrated the impact of a 90-minute reperfusion strategy on mortality. Over a 25-year period . . . IV streptokinase was followed by the addition of aspirin. Later, streptokinase was replaced with tPA. Soon thereafter, primary PCI was born and then was rapidly married to scaffolds, a practice we have come to know in this era as "stenting."

On to Spaceship Earth

Despite all of these new advances in our 100-year anniversary of recognizing that arteries that suddenly become blocked cause myocardial death and then very often the death of the organism that experiences it, "we still expect 610 0000 new myocardial infarctions this year." Dr Braunwald stated. "Is myocardial reperfusion a double-edged sword?" he rhetorically asked. "The calcium paradox, in which reperfusion raises intracellular calcium, and then the O₂ paradox, where an increase in toxic oxygen radicals open the mitochondrial permeability transition pore causes mitochondrial damage, then myocyte death," he said. But current and future studies will address such entities as ischemic preconditioning with cyclic ischemia and reflow maneuvers. Remote ischemic preconditioning by utilizing the lower limbs in early studies seems to be affecting STEMI outcomes. Studies with cyclosporine infused prior to PCI in STEMI decreased creatine phosphokinase (CPK) release significantly at 72 hours, and finally, the latest addition to the ACS cocktail, rivaroxaban at a dose of 2.5 mg po bid plus ASA and a thienopyridine in ATLAS 2 TIMI 51 decreased death rates from 4.1% with placebo to 2.2%. Although there was increased bleeding, "there was no increase in fatal bleeding," he pointed out.

Finally, Mission Space

REPAIR AMI, published in 2010, reported that two years' post-MI, the intracoronary delivery of bone-marrow–derived progenitor cells produced more myocardial thickening and a better EF. Dr Roberto Bolli's smalll SCIPIO trial, funded by Jewish Hospital of Louisville, KY, demonstrated that 16 patients who received right atrial (RA) appendage–derived cardiac progenitor cells delivered an astounding and earth-shattering 13% improvement in LVEF. The CADUCEUS study, published in the Lancet this year, demonstrated a reduction in infarct size and an increase in viable myocardium, and the BAMI trial will enroll in the second quarter of this year to explore further arenas of stem-cell therapy. No doubt, vocabulary words that are common vernacular in the world of stem-cell research like "cardiospheres" and "cardiac progenitor cells" or "colony-forming cells" with such descriptors like CD34 or CD133 will creep into the language of everyday cardiologists like myself.

The future as projected by Dr Braunwald is bright for patients who suffer from profound myocardial damage, and the future of stem-cell therapy has never been so palpably close or the steady heartbeat of progress in the arena of heart failure therapy so clearly heard. Like all good Epcot rides, the Braunwald tour of past and future therapies in myocardial ischemia came to an end, leaving its participants with a strong sense of satisfaction but an even more optimistic yearning to draw the future more closely to us; a future fueled with the knowledge of gatekeepers who were present today, like Drs Braunwald, Bolli, Perin, Simari, Moye, and others, the elite among the experimental prototype community of tomorrow and experts in the repair of myocardial damage who walk among us today.

You may now exit to your left. Watch your step . . . 

We live in a fickle political environment that tolerates tolerance for a season and then elects an ultraconservative at the next cycle. We retaliate against the "Reagans" by electing "Clintons" and can often find no middle ground. Our voting public's thirst for change is never quenched and therefore, expectantly, neither is that of our own government. Over the past decade, hospitals purchased scores of talented internists who astutely managed critically ill patients and set them in offices to treat sore throats and colds. Hospitalists whose greatest goal is a timely discharge took their places. Private cardiologists who resisted acquisition ran to their offices to hunker down and see as many patients as they could fit into a daily schedule to withstand the onslaught of change threatened by reimbursement trends. Now, this new legislation starts the subtle unraveling of the very financial structure that engineered that series of gross missteps in the hospital acquisition of private practitioners. No matter how you slice it, it has not been good for patients, at least not on the local fronts of small communities.

The planned Medicare pay cut to the private sector in the next 10 months was previously slated at $18 billion. With the new legislation, lawmakers will essentially "rob hospital-acquired Dr Peter" to" pay "private practitioner Dr Paul." According to Robert Lowe's piece, federal payment cuts to hospitals over the next 11 years will amount to $7 billion less in Medicare funds that "make up for unpaid deductibles and copayments owed by patients." Adding further insult to injury, hospitals like the one in my community that serve "a disproportionate number of low-income patients also would receive $4.1 billion less in Medicaid payments." Rightly so, the American Hospital Association fears it has been mortally wounded. They followed the earlier reimbursement signal to load their ranks with tons of freshly acquired private doctors to run their sweatshops and are reeling at this governmentally directed homicidal/suicidal ideation for their now nearly fully implemented plan.

The projected 11-year plan toward sweeping change in reimbursement will be another tough course to navigate for those who began private practice in the golden era of medicine and then chose a life of what for some has amounted to an indebted servitude to hospital institutions. Although hospital acquisition was a welcome respite for some, a forced move for others, and a safety net for new physicians, this new legislation signals a new downside. I am lucky to have practiced during the 1990s and early 2000s. It was a wonderful era of self-direction, hard work, and adequate pay. Although "physician greed" is often blamed for our debacle, it's a miniscule portion of what has driven us to the brink. Insurance companies give their CEOs ridiculous annual incomes of up to $4 million per year, thus driving down reimbursement to physicians for those sectors. America's aversion to early detection, our abhorrence of a diet that actually nourishes our bodies, and the choice to run away from an adequate fitness program as our only form of exercise have placed us in a precarious position. Add to this our unfathomable resistance to providing a timely PCI for all Americans and the dragging of our feet toward a smoke-free society, and the result has been a workable formula for governmental bankruptcy. We are suffering for our couch-potato mentality and our obsession with "procedures and pill fixes." We reward sloth. We abhor prevention. We have convinced ourselves that "big is beautiful" when we should embrace the attitude that "big is lethal." Free love has certainly not been "free," with scores of single-parent families resulting from that movement who now struggle to make ends meet. Our focus should have been on the coordination, not the division, of healthcare efforts on the behalf of providers and their hospitals as well as the education of our public. Hospital acquisition as the fix for this mess will be labeled a predictable failure because nothing is going to work until we change the way we behave ourselves as individuals and become a team again. To place us as physicians on different pages with different agendas made for a haphazard and confusing "bad read" of a novel. Predictably, when patient care is billed as the focus when truthfully it's really the "business of medicine" and bonusing CEOs for profit, our true mission fails.

The newly projected reversal in reimbursement trends will have taken only about seven years to cycle into our routines. That's pretty quick in the world of medicine but not quick enough for those who have suffered the greatest lack of consortium and absence of camaraderie of our careers, when our brothers and sisters in private practice were ripped from our midst. It resulted in an era of lesser patient care. The crevasse created by the axe of hospital acquisition has once again started to experience a shift of the tectonic plates, but unbelievably it is being pushed by the very government who fostered the first destructive series of earthquakes to begin with. I just hope we don't all fall in it and disappear before a real workable plan can come to fruition, and then at that, we won't have too long to get comfortable before it starts all over again. 
 
See also:

Ten-month Medicare "doc fix" passes Congress, heads for White House"

Patient B: Tom has a 90% LAD lesion, 50% circ, and a 50% RCA. He initially saw a cardiologist because he can't play tennis without moderate substernal chest pain but has very good exercise tolerance, completing 10 minutes on a Bruce protocol and a "less-than-hyperdynamic response in the anterior wall." He opts to undergo a PCI to the LAD. Three weeks later, he comes back and says, "I'm having no chest pain, but I'm short of breath a little when I play tennis, and I'm having some difficulty with fatigue." The cardiologist looks at his medication regimen and says, "You know, you had no demonstrable ischemia in anything but the LAD distribution, you are having no angina, so let's taper off your beta blocker and see how you feel. Be sure to stay on your aspirin, statin, and carry some nitro. By the way, let's go over the Mediterranean diet and then see me in a few weeks." A month later, he reports he won his tennis match yesterday, he and his wife are scheduled for a cruise in eight weeks, and he's never felt better. Five years later, he's cardiac-event free and feels great. 

Point 1: Patients don't just see cardiologists because they don't want to die. They actually see us because they want to "live" and live well. Medication side effects, the cost of medications, the ability to do activities without having to consider a stopping point that may produce chest pain are all part of the formula of what it takes to be a "heart patient." Whether or not a PCI is the appropriate course of action for our patient will have to be decided in the exam room on a case-by-case basis. It cannot and will not ever be legislated. As for reimbursement, we are obligated to do what is right for the patient, no matter the reimbursement issues that we may face. We swore an oath to do that despite any economic reimbursement or medical-legal issue. When the issues of patient comfort and safety are our first consideration, there is no other argument that counts.

Point 2: What exactly is "stable" angina? It is generally defined as predictable cardiovascular symptoms of shortness of breath or discomfort located somewhere between the belly button and the ear lobes, chest, arms, or upper back when one exerts oneself. Despite this fairly classic definition, the diagnoses of stable angina and, more concerning, the diagnosis of unstable angina are often missed. How is one to approach large territories of silent ischemia? What about those patients who have their gallbladder out for severe rest pain only to discover they had a 90% LAD lesion now completely relieved with a PCI? What about the young patient I saw once with excellent exercise tolerance who had an esophagogastroduodenoscopy with a diagnosis of an ulcer but called me one night after we accidentally met at a meeting. He just wanted to talk to me about his ongoing pain of six months' duration. When I cathed him, his LAD was hanging on by a hair with haziness and what appeared to be an ulcerated plaque. He was obese, and his glucose challenge in the hospital registered a blood sugar of around 300. He had no clue that he was literally a ticking time bomb, and neither did the other two physicians that saw him. You couldn't hold a gun to my head and make me say he had a stable situation. His symptoms were moderate, but in nondiabetics, the same pain might have been severe enough to warrant the "acceptable label" of "unstable," which would have generated a referral for cath a few months earlier.

Randomized prospective trials, adequately powered have given us great insight into the question "to cath or not to cath," but when it comes down to it, the variables in our patients are so highly complex, so thoroughly affected by genetics, environment, diet, undiagnosed diabetes, first- or secondhand smoke exposure, activity levels, and job expectations that every patient should be labeled as "guilty" of having progressive angina until proven otherwise. Add to this the great danger that lies in the patient's interpretation of their symptoms and then their physician's interpretation of their symptom complex, it is no wonder that patients can still get into trouble. Despite all the data, we can still rely only upon common sense and a high index of suspicion to help us navigate a course for our patients. Whether we discuss old news, new news, or no news, and whether or not our actions lower our patient's mortality, isn't all we owe them in the long run.

Living well is important, not just living.

See also:

No mortality or MI benefit in stable CAD patients treated with PCI: New meta-analysis

Mistake 1: Allowing our patients to take on water like the Titanic. When ankles are nothing more than weeping pegs of "peau d'orange" and patients pant for air like a marathon runner crossing the finish line, direct them to restrict their volume intake. A goal of 1700 cc in a 24-hour period should help. (That's milk, water, colas, tea, anything liquid!) Ask them to remember the saying, "The more I drink, the more I drown" in order to avoid ramming themselves headlong into that iceberg just ahead.

Mistake 2: Allowing patients to congregate daily at the "salt lick"—ie, their kitchen table. As a child, I often saw my father pack a large, glistening-white, 15-pound salt block to the cow lot for dietary supplementation. He placed it under a large shady oak tree with gnarly roots. The cattle would come running to it and would lick it like a kid with a giant ice cream cone. I confess I sneaked out there once and licked it, too (don't tell mom). Many CHF patients love salt that much. If they confess to having a shaker on the table, instruct them to never—and I mean never—touch it. Teach them to read labels and restrict sodium to less than 2400 mg in 24 hours. Teach the salt mantra: "Treat a salt shaker like a cobra." 

Mistake 3: Assuming that anyone will ever fill a prescription, much less take it. ACE inhibitors, ARBs, carvedilol, metoprolol, spironolactone, and bisoprolol all work well in outpatients, but only if they are swallowed. Patients at best have a 50% compliance rate, so trust no one. Teach your patients the compliance mantra: "Bring all bottles of medication to each visit," and check the fill dates. Encourage compliance by prescribing a comfortable regimen. Only give Lasix at night to those patients you don't like (kidding), because ruining sleep patterns in the elderly is double punishment. Also, don't just grab Lasix as a therapy; actually prescribe therapy that gets at the basic pathophysiology of the specific driver of their heart failure.

Mistake 4: Failing to understand the implication of findings on cardiac ultrasound. If the EF is "normal" and if there is no significant valvular pathology and none of the other masqueraders of heart failure listed in this piece are present, assume possible diastolic dysfunction. Weight loss, beta blockers, sleep apnea, volume restriction, sodium restriction, blood-pressure control, and other medical therapies for systolic dysfunction can provide benefit. Do the mitral and/or aortic valves leak moderately? Is the LV size large? Is the EF impaired? Is there evidence of ischemia, stunned or hibernating myocardium (ie, an opportunity for pump-function improvement)? A referral to a cardiologist for fine-tuning of medications and serial echos to discuss whether surgery for valve leak (MV or AV) or revascularization is appropriate. They will also decide if the tricuspid valve gets a "me-too" approach. Timing of valve repair or replacement is an ongoing debate in the literature and in conference rooms across the world, but an optimal plan can usually be formulated.

Mistake 5: Being LVAD/BiV phobic. If heart failure is resistant after meds are maximized, please refer for a discussion of device therapy. These devices improve quality of life dramatically and decrease mortality. A BiV can shrink an MR jet and an LVAD can transform a life into something worth living, so don't resist throwing out the lifeline to your drowning patient.

Mistake 6: Failing to look in the mirror and repeat these words over and over until you hear this statement in your sleep: "I hate Actos. I hate Actos. I HATE ACTOS!" Banish it and loathe it in heart-failure patients. Make like Curly of Three Stooges fame; put your head down, twist your butt, slap the top of your head twice, then do a little dance and butt heads with Actos every single time. Giving pioglitazone to someone with big legs or shortness of breath is no different than tying a concrete block to your patient and pitching them in the river . . . except you won't go to jail for prescribing Actos in heart failure . . . at least not yet. "Nyuk, nyuk, nyuk"—geesh!

Mistake 7: Ignoring calcium-channel blockers on the medication list in those with peripheral edema. I often wonder just how many millions of gallons of fluid are sloshing around in our heart-failure patients' legs the world over. Turning them into camels isn't fair, and not recognizing we are responsible is worse. Just like bikinis, not everyone can rock them (calcium-channel blockers), so tailor your medical therapy to fit your patients' physiology and stop those calcium-channel blockers if there is any way possible.

Mistake 8: Always blaming the LV for peripheral edema. Survey for nephrotic syndrome. I find a bunch of sneaky massive protein spillers every year with a 24-hour urine. Sleep apnea, caval obstruction, or offending medications could also be the culprit, and consider lymph edema or venous drainage issues. Cirrhosis is another sneaky one. Finally, constrictive physiology can be at play, so a right heart cath performed by an experienced interpreter of right heart pressures may be necessary.

Mistake 9: Calling it CHF when it's asthma or COPD. A CHF patient once told me, "Dr Melissa, I'm not trying to play doctor, and I know I have heart trouble, but this doesn't feel like fluid, it feels like the asthma I had when I was a child." Even if the BNP is a little elevated, make certain pulmonary issues aren't at play. That patient's PFT and the addition of good asthma meds changed his life.

Mistake 10: Hanging our hats on data derived from "heart-failure trials" when the left ventricular end diastolic pressure or PCWP have not been measured as a prerequisite to enrollment. Shortness of air does not necessarily equal heart failure, so results are often skewed.

Other than Lasix and maybe some captopril, there was really nothing I could do for CHF patients in the late 1980s. I approached each consult back then with fear and loathing. Now, I literally skip to the patient's room with life-changing and lifesaving help in hand! If we as providers slow down, take time, ask questions, and give some very basic direction, whether we are generalists or cardiologists, all of us can still help save a broken heart. Who knows? With stem-cell therapy coming down the pike, we might even be able to mend one!

The plot thickens
 

Ty was forced to stop competitive sports

Jeff's other daughter, Stacy, moved from Park City, KY to Kansas City, MO last year. They consulted a pediatrician for their daughter Ty for anxieties created by the newness of relocation. Ty's QTc interval was around 500 ms. At that very moment, we would begin to understand fully how 40 extra ms, a length on a heart tracing no greater than several hairs laid side by side, could change so many lives forever. Her brother Tanner was then tested, and his QTc was 490 ms. Gracie, the youngest, had a normal QTc. Ty and Tanner were placed on beta blockers. They were taken out of competitive sports, and alarm clocks were removed from their bedrooms. Caffeine was forbidden.

Their pediatric electrophysiologist, Dr Lana Tisma-Dupanovic at Children's Mercy Hospital in Kansas City, told them that the death rate for long QT syndrome "can be significantly reduced"  if the patients are placed on beta blockers.  She alluded to data  (Priori/Napolitano)  published in Circulation in 2008 in which beta-blocker therapy was demonstrated to decrease all events and cardiac arrest differently in different LQTSy types. For example, in LQTSy 1 they have been shown to decrease all events rate from 39% to 10% and cardiac arrest from 2% to 1%. In LQTSy type 2, beta blockers decreased all events rate from 58% to 32% and cardiac arrest from 8% to 6%. In LQTSy type 3  events were decreased from 57% to 32% and cardiac arrest from 18% to 14% only. "This is why I have recommended automated external defibrillator [AEDs] to be given for Ty and Tanner," she said. 

Decision making is even more difficult in patients with a "borderline" QTc, syncope, and palpitations, many of whom  will have a normal genetic test. "That is where it becomes difficult," Dr Tisma-Dupanovic said. Holters, stress testing, and the clinical presentation will guide therapy. "It has become more common to find the long QTc in children now that it is standard of care to perform an ECG anytime a pediatrician is contemplating pharmacologic therapy for [attention-deficit/hyperactivity disorder] ADHD and other emotional issues," Dr Tisma-Dupanovic added. Everyone who knows and loves this family is grateful someone was looking for it.

More twists of fate, yet
 
Amanda, with the normal ECG, was later found to have a completely different missense mutation in the SCN5A gene, a less lethal situation than her sister Stacy's mutation at the KCNH2 location. It is amazingly rotten "luck" to have not one but two QT-modifying genetic mutations in one family. Add this to our odd cystic-fibrosis gene (only 17 reported cases worldwide) and pheochromocytoma (my brother's recently confirmed mutation), and you see how unique we are as a cluster of individuals. We agreed, half-jokingly, "It is a wonder we don't all have gills," referring to the famed mutant Waterworld movie characters. If Jeff, the grandfather of Ty and Tanner, does not test positive for both of these genes, Sonya (our blood relative) will be placed under suspicion for a QT-modifying gene as well. 
 
Genetic testing has come light-years in a decade
 

Genetic testing can avert tragedy

I dealt with a horrendous tragedy in our community over a decade ago. A nine-year-old boy collapsed on the sidewalk on his way to say good-bye to his 17-year-old brother, who had suffered brain death after an anoxic injury from a motor-vehicle accident. The family buried both of their boys on the same day. The mother had "seizures" at the funeral.  A single daughter survived. At that point, the only QT genetic test available, according to the long-QT registry, was somewhere in Texas. They accepted genetic material from the deceased as a free service for research purposes. I was told sharply, "Do not call us back. We will call you. We are backlogged forever. It might be seven years." I called every other year but, as projected, it was around seven years when they finally pronounced the tests "inconclusive." I plan to contact them and redirect them unless they've already found their way to adequate testing.
 
"Will Ty and Tanner receive defibrillators at some point?" I asked their doctor. "They may, depending on their clinical course," said Dr Tisma-Dupanovic. "The size of the device can be problematic." In some extreme cases, she added, "Children as young as three months have received a device, but it is rare because it can take up a large portion of the abdomen, and there are other difficulties such as 'T-wave' oversensing in younger population that leads to inappropriate shocks, lead fracture, infections, and need change of leads as child grows."  With regard to  AEDs,  an update is required  when the patient's weight increases to greater than 10 kg. Because of the lack of implantable cardioverter defibrillator therapy in most children, she directs some aggressive changes in family dynamics. In some instances she recommends they purchase an AED and train all family members of a responsible age in cardiopulmonary resuscitation.  Tanner now plays golf instead of baseball. Ty is pursuing art and writing.  Their first-degree relatives are all being tested. "It is amazing how well they implemented the changes and dealt with the diagnosis," Dr Tisma-Dupanovic said. "Some families have a very tough time going through the phases of grieving when the diagnosis is made, with anger and denial," she said. "It is a pleasure to provide care for this family," she added.

How legislation can save lives

I asked Dr Tisma-Dupanovic what we could do now to help. "Some coaches are great about pulse checks and referring to a school nurse," she said. "I'd also like to push for the need for AEDs at all schools. They need education regarding the specifics of device utilization and how to maintain it," she said. "It needs a new battery every six months."

I recounted my failed efforts at that very legislation a few years ago when I traveled to Frankfort with the now-incarcerated KY State Representative Steven Nunn (who pleaded guilty to murder), begging for legislation for AEDs in each school, and even after a mother brought a picture of her deceased son, a baseball player, they turned us down flatly. They wouldn't legislate it because they couldn't fund it. Ty and Tanner's mom, Stacy, said, "Our insurance paid for an AED for each of the kids. We have Blue Cross/Blue Shield. They didn't even know how to go about getting us an AED and kept trying to get us a heart monitor to wear. I stressed 'portable' AED, and finally someone understood. I was amazed at the lack of knowledge, but they claimed no one had ever asked them about it. I think most people assume their insurance would not pay for an 'at-home' AED. But I persevered and asked three different people the same questions five different ways to get the answers. We had to go out of network for equipment, but I think they cost $1300 each." Stacy and Scott, according to Dr Tisma-Dupanovic, have been amazing parents in dealing with the long-QT issue, exhibiting both courage and persistence.

Affordability of testing
 
I contacted the managing director of Gene-Dx, Dr Sherri Bale, in Gaithersburg, MD and told her I had reviewed an amazingly detailed report on Amanda's testing. I was impressed with the 3.5 pages of family history and explanation, complete with a family tree. "For patients with no coverage, there is a $2500 out-of-pocket cost," said Sherri, "but we work with the insured to keep their personal cost to a minimum." Medicaid apparently doesn't participate in coverage for testing, and Medicare coverage is limited because most of those have other insurance. "For very specific genetic tests, the cost can be as low as $350," she added.

So, now you know the "rest of the story" as it unfolded in this beautiful young family, beginning with the day where everything changed for them, forever. A simple piece of paper and a tiny drop of ink have saved their children and their children's children for generations to come. An affordable 8x11-in electrocardiogram, painless and inexpensive, performed in less than 60 seconds by a caring pediatrician is all it required to identify this prolific serial killer. We are grateful that the "stranger beside us" who waited patiently, undetected and poised to take its prey, now threatens far less and can hide from this family no more.

 See also:

Genealogies yield clues to mutation-specific arrhythmias

(Story updated with corrections 2/11/12 6:15 am CST)

Many patients fall into the current doughnut hole of VAD implant criteria and drown in a watery grave while we stand on the shore, life preserver in hand, waiting and waiting until their heads no longer bob on the surface. The new implant criteria should acknowledge that it is wholly unfair to ask that the heart be completely incapacitated but pompously insist that renal function be "adequate" in order to proceed with a VAD. This new conclusion can now be drawn, thanks to the body of literature and experience now available with VAD therapy. It would be unfair, however, to proceed without acknowledging that it is also a delicate balance to decide who is too sick for a biventricular pacing device but too well for an LVAD. There will be gray areas, but those questions represent the interface of medicine as both art and science and therefore will require careful consideration from an individualized perspective. 

In prior blogs, I've referred to several patients who have had fantastic success with an LVAD. One of my patients, however, has now passed away. He was the youngest of all the patients and failed two bypass surgeries from diabetes and continued smoking until very late in his disease process. He succumbed to a drive-line infection but lived almost two years with good quality of life provided by God and his device. His youngest children will remember him well. (I confess I have not been able to bring myself to contact his minister, where a posthumous message awaits me.) Another patient, several years out, is still flying high, doesn't want a heart transplant, and hardly has time to keep her appointments because she is too busy. I saw our practice's most recent VAD patient at a play. He had to jump the hurdles of gut bleeding from RV hypertension, angiodysplasia, renal insufficiency, and insulin-requiring diabetes to grab one. In the year following his implant, he drove to my house, stepping out of his truck beaming like he'd just dove "a perfect 10" off a cliff. He's out at the local restaurants. He spent part of the summer on a houseboat. His family had a great Christmas holiday. He's 100 pounds lighter and off insulin. It's nothing short of a miracle and he's having the time of his life because he "has a life." Plugging up at night and unplugging in the morning is a small price to pay from his perspective.

So the optimal approach to the questions regarding timing of LVAD implant is to plow through the morbidity/mortality data for both medical management and device therapy, consider the cost of the implant, the insurance coverage, and then weigh all these things against the cost of repeat hospital admissions for heart failure and pharmaceuticals for our patients and their impact on quality of life. We should then discuss every aspect of both management options with the patient and family, and finally ask ourselves that all-time-favorite-patient-generated question: "Doctor, what would you do if it were you?"

Then, without hesitation and by all means, do it!

See also:

3B or not 3B? Should patients get an LVAD before reaching end-stage HF?

I admit it feels really good to get that off my chest.

I owe my heretic philosophy to a lecture by Dr P Gabriel Steg that I stumbled upon quite by accident many years ago while in Barcelona, waiting for that year's European Society of Cardiology lectures to begin. I heard a voice echoing down the hall of what I thought was an empty convention center while waiting for another lecture to begin. I followed the sound as I had 30 minutes to kill. I opened the door to a gigantic auditorium where probably a thousand attendees sat listening to information on the now-defunct rimonabant compound. Dr Steg had an amazing PowerPoint that explained the finite mechanism of hormone production of the abdominal fat pad and the horrible metabolic derangements produced by it. I recall understanding for the first time how being "fat" kills a person, how the inflammatory response causes plaque rupture, fluid retention, hypertension, stroke, clot, blockage, and even lends itself to vascular spasm. Gabriel might not agree with this extreme interpretation of his presentation, although I don't know for certain. We've discussed many other things, but I've never had an in-depth discussion on his views of sugar metabolism. I assure you, however, that hundreds of patients in Glasgow, KY have been changed forever by his lecture. I am truly grateful to him.

Heretic statement #2: "More people die of 'borderline diabetes' than true diabetes because it is not given the respect it deserves." Melissa Walton-Shirley

I do not believe in the term "borderline" diabetes. It makes about as much sense as saying one is "borderline" pregnant. You either "are" diabetic or you "aren't." You either have blood glucose of less than 140 after 75 g of glucose or you don't. If you eat a slice of pie and your blood sugar hits 160, you are a type 2 diabetic. Perhaps all you need to do is lose weight, push back the plate, exercise, and reverse it, or you might be one of the unfortunate who need four insulin shots per day. I submit it is the same disease process, just different extremes of insulin resistance. Both versions can spell blindness, diabetes, heart attack, and dialysis.

For laypersons that follow my blog, there is a distinct difference between unfortunate "true" type 1 diabetics who have had the misfortune to suffer the death of their insulin-producing islet cells. They have a completely different disease process. Unless they undergo an islet-cell or pancreas transplant, they will always be a type 1 diabetic and will require insulin supplementation. Contrast this to the typical type 2 diabetic. About 95% of those in my practice are overweight, don't eat properly, and rarely exercise until they receive "the diagnosis." It is amazing to me that about 95% of them have no clue that they are completely "curable." It is a matter of lifestyle change. With rare exception, I've hardly met a true type 2 diabetic who could not get off insulin after losing about 50 pounds. Nothing is more frustrating to me than someone who relates to me, "Well, I'm terribly sick with diabetes, doctor. I've had to go on insulin," while folding their hands in resignation, accepting a fate of dialysis, amputation, blindness, heart disease, and stroke. I really want to shake them out of their complacency.

I do have about 10 normal-weight individuals in my practice who have impaired glucose metabolism and are not type 1. I'll leave it to the endocrinologists to explain it. I don't know if it is production of an imperfect insulin molecule or if there is severe genetic resistance, but they do exist. In Glasgow, KY, they are an extreme minority.

Heretic statement #3: "There is an inherent prejudice in the medical community against the use of the term diabetes even after an impaired glucose-tolerance test is completed." Melissa Walton-Shirley

You have no idea the number of times I have opened the door to a patient who is positively beaming with the fantastic news: "My doctor told me I'm really not diabetic like we initially thought! I'm just borderline!" Yippee! I think as I close the chart over a postprandial blood sugar of 240. I want to then beat my head against the wall until I am unconscious. It would be the only true escape from such indifference to the obvious ability to save lives, legs, vision, and healthcare dollars (in concert with making America smoke-free, of course!). The last patient who argued with me regarding this issue had a postprandial blood sugar of 420 (no exaggeration) who seemed "borderline," convinced at first of his diagnosis.

The new guidelines published on assessment of hemoglobin A_1c, although most welcome, in my less-than-humble opinion are a fantastic first step in detection of the disease that kills so many human beings on a daily basis but fall just short of what will actually "make" the diagnosis of so many diabetics. I order a nonfasting two-hour glucose challenge with 75 g of glucola on most patients who present for hospital admission from whatever cause if they have some weight to lose or if they have a single abnormal blood sugar on the chart. I am amazed at the heights to which those glucose levels soar, but it is required that I show it to the patient in black and white before most are motivated to do anything about it. 

Heretic statement #4: "If your physician tells you that you are just a 'borderline diabetic,' don't believe it." Melissa Walton-Shirley

Run screaming to the nearest gym, fresh produce aisle, and a good nutritionist.

I'm willing to bet that you are sweeter than you think.

See also:

New guidelines suggest blood glucose testing for all inpatients

Cocoa Beach, FL is our favorite respite, where time melts like Salvador Dali's clocks, draping itself over palms and boardwalks. It spreads itself over gritty powder-white sand and lingers on comfortable worn flip-flops. The ocean, blue as the sky, gives up mounds of shells and is my constant companion on long morning walks and nighttime excursions. I love this beach. I long for it at times, but there has been no other time that I have been needier of this refuge than the last two years of my practice.

Like an old sea captain who reflects backward on his career, I took inventory this weekend of my time on the high seas of private practice. Although challenging, the first two decades of my career were smooth sailing and most rewarding, but there is truth in the saying "there is nothing more deceptive than the calm before the storm." An able and wise cocaptain stood beside me through rough waters and celebrated victory upon victory. He still stands beside me today. We still rise to every challenge but are both a bit battle-worn, not from physical demands so much as from the politics and change in our local medical climate.

We have learned much from two years of turmoil. We have toughened up with assaults from our own government, which has locked in private practitioners at the other end of the spyglass, cannons at the ready, to dismantle old practices that have served the multitudes. Private practitioners are scapegoats, with threats to decrease our reimbursement by one-quarter, a misguided attempt to correct the sins of mismanagement and waste, and for that portion of the population who drink, smoke, and eat us into financial oblivion, individuals who are always expecting the treasure chest of government funding to be ever at the ready. They have no thought of the efforts and sacrifices required to fill it. Our income and those in our employ who have also entrusted their future to us are ever vulnerable. Add to this the pain of loss of consortium of our former colleagues who have fallen victim to the more attractive cousin of socialized medicine, hospital acquisition, and the sting of abandonment by the very institutions we have helped to build and sustain. With the weight of disappointment of the immediate past and the reality of the consequences of the temporary definition of legal collusion, another year of disappointment of last year's magnitude is at first difficult to contemplate.

Despite my clothing heavy from the water coming into our ship, I am miraculously now more optimistic. In part, I owe it to the lessons I have learned from nature on how best to cope with the adversities of a hostile practice environment. I have learned that sharks do not adapt to their environment but rather adapt all that is around them to theirs. I either must steer clear or outsmart their tiny brains, which understand only pain and hungry greed. I will sustain by being as reliable as the ocean tides and as truthful as the promise of a rising moon. I will give up the dead yearnings of yesteryear much like the sea spits out its dead each morning on every shoreline that edges its mother earth. I will accept the need to endure occasional raging winds but will still enjoy the warmth and comfort of calm waters. I will be a survivor and will hang onto whatever driftwood, plank, or passing ship that might lend itself in times when there is need of rescue, as long as it is a vessel with honorable intention. If the intentions are ever otherwise, I would rather let go and sink slowly to where the waters become murky and dark. For a brief moment, interrupted only by the sounds of sea birds, I once again, and hopefully for the last time, allow myself to sink, free falling into that small corner of my imagination to that unthinkable place. My toes first sense the cool depths of resignation, then my legs and my face, immersed and though hungry and panicking for air, a comfort compared to a life of piracy chosen by a few and a life fully mapped with few choices for others. I see in the distance other ships passing above me and contemplate their offers of assistance but stay submerged until that dreadful chapter of my imagination is finished.

I open my eyes and step back into reality. I feel the sand beneath my feet, the sounds of children playing in the waves. I stand to walk back toward home accompanied by a hint of dread at the thought of the beginning of another year. It will be a year of strategy, some certain disappointments, surviving . . . but then I abandon those negative feelings for a ship that passes with flags flying, sails full of wind, the ocean spray peeling off the bow as it parts whatever waters that lay before it. I am the proud captain of my ship. I author the manifest, the ports of call, and with the help of God, the destination. I realize that I have a beautiful family, a warm home, and a great life partner that welcome me at the end of every day's journey. I have tens of thousands of patients who are treading those murky waters of uncertainty who view me as their life preserver, their anchor, and their guide. They are adrift in a far more unsettling sea than what we as medical professionals will ever perceive.

As I reach my destination, I realize the sun that so gently caressed my skin this last hour, while now setting on a crimson horizon with the fingers of night dangling toward earth will rise over a glorious first new day of 2012. The subconscious scales that weighed my future are now tipped toward the positive. I have willed myself in the space of this hour to believe with every fiber of my being that right will triumph over might. I am resolved that I will be productive and happy. I will approach the year with a clear focus on each patient and each decision before me. My calm resolve perceived as weakness by some will be my navigation tool and my greatest strength.

My New Year's wish for all of you is that 2012 will bring you prosperity, happiness, health, and, most of all, peace in a future that often times is what we make it. May you always be your own captain. 

The human beings I champion in the political and medical trenches are people like my mother's only sibling, who arrived at my ER door in the mid-1990s with an inferior MI who suffered an IC bleed after I delivered tPA. I sat by Uncle Gordon's bedside for four days watching Cheyne-Stokes respirations and sweat roll down the forehead of a man who reached his hands out to me in the ER and said, "There's my Missie. Come here old sweet. She will help me." This man I loved like a father, who had no children and loved my brother and me as his own died at the hands of lytic therapy with my prints on the weapon. I sob as I write this piece and wished for a year that it had been me who had died instead. This horrible pill to swallow is made even more bitter by the fact that if he had arrived at a door in Marysville, TN, just an hour south of us, which had performed PCI without surgery on-site for years prior, he would have likely gone home in a couple of days. He could have farmed the land he loved for another 15 years before he would die a more timely death. Combine this story with the scores of others who fail lytic therapy, like my partner's patient, who is a single parent and lives with sudden death looming large over her life on a daily basis because she was trapped here in our ER due to weather that turned us into a no-fly and no-drive zone during her MI. We had a cath lab upstairs, for Pete's sake, but could not have performed a PCI back then even if we'd had an interventionalist on-site, due to state regulations. What about the gentleman I treated who had knee surgery who was not a candidate for lytic and required transport, but by the time he arrived at a PCI center, had lost 15 years of good-quality life? The medical team rejoiced at that save, but a lost opportunity for more good-quality life was forgotten at his funeral that happened a decade and a half too early. It took us six years, three governors, scores of battles at Kentucky Hospital Association meetings, multiple empty promises, and navigating around unholy alliances until we were able to expand PCI without surgery on-site. Why in the world should saving lives and money be so difficult?

The shortsightedness of our complacency for myocardial rescue is unforgiveable in this country. When we first started the push in Kentucky to become the 38th state to allow PCI without surgery on-site, I was astonished by the answers given to me by our much more practical European counterparts. They would often reply, "What do you mean by the term without surgical backup on-site. I've never had it." One physician, annoyed by my question, said, "It's a ridiculous question. The patient requires a lifesaving procedure. Why would you even consider such an issue as requiring a transport? Doesn't happen in my country. You do what is necessary." Another said, "I've been performing this procedure for 30 years in downtown Paris and I've never required an emergency surgical procedure."

Indeed, we don't approach acute-MI therapy in the manner in which it is approached in many other countries. I once interviewed a physician from Poland who worked in a government subsidized AMI station. "My door-to-balloon times are 12 minutes," he stated. He explained there are no elevators; just a drive-through-window type approach where the pants were pulled down, some Betadine doused on the site, and in 12 minutes the heart attack is over and a huge hunk of myocardium is saved. After the lifesaving business has been attended to, there is time for introductions and social graces later. For those lucky individuals who receive a timely PCI in that fashion, there are bound to be a gazillion fewer automatic implantable cardioverter-defibrillators (ICDs) or admissions for patients drowning in their own fluid from pump failure. By looking at these extreme models for primary PCI, we know that we can and should do better for our ACS patients in the US. We should bury our heads in shame if we have been any part of what helps to grind down the necessary machinery to expand access to primary PCI without surgery on-site.

As staunchly supportive as I am of primary PCI without surgery on-site, I am even more staunchly supportive of regulation, monitoring, and reporting. Crooks should be prosecuted, but patients who are in dire need of this service should not be denied access because of the sins of the few. We should no longer choke at the gnat of the complication rate of <0.05% of PCI without surgery on-site while we hungrily gobble the camel of the 40% of patients who fail lytics or are not lytic eligible or the 4% who die of IC bleeding like my uncle. We need to educate our tertiary centers that just because we have "prehospital ECGs" it does not guarantee arrival at a PCI-capable site. Furthermore, let's not forget those who begin their infarct in a non-PCI hospital or those who arrive by private car. Let's remind our colleagues that even if you are sharing the same piece of geography across the street from a PCI-capable center, just packaging the patient and unpackaging the patient and running across the street with them burns precious myocardium. Studies have clearly shown that for every minute wasted the LVEF declines. Why not let the interventionalist do the driving to wherever the infarcting patient arrives if it is so close? Vanquish the smoke screen of mystery surrounding this procedure. I've stated before that we should treat the need to open an artery with the same respect that we treat the need to open an airway. Just because the funeral is five years later, an untimely death from preventable pump failure is no less a tragedy. Our guidelines writers, who are good and decent men and women, are beginning to understand the need for updating our guidelines but, for reasons I cannot understand, require much encouragement on the behalf of cardiologists who serve the underserved before they will jump-start the much-needed process that will lead to better acute cardiology care in America. Any of you with influence should open a dialogue today that insists on monitoring and expansion of access to these services simultaneously. Join me in condemning the lackluster presentations on this issue that I heard on the NCDR data delivered at a major meeting, with just enough negative slant to take the wind out of sails that were beginning to fill with hope for necessary change.

It is time we take a page from the history books of other countries like the Czech Republic, which mapped its country and found a route so short to a timely PCI that those off-site arrivals fare as well as on-site arrivals for outcomes. It is time we write a new page in the history book of this country, which embraced the much-needed mapping for trauma patients but failed to even utter the words "cardiology," "heart attack," or "heart failure" in a healthcare reform bill that will reform nothing in the realm of ACS. It is time we champion those who number among the half million patients who suffer the same fate on an annual basis at the hands of ST-segment elevation MI but are denied access due to the unfounded fears that surround the issue of expansion of access to a timely PCI. It is time we checked unfounded fear and the unforgivable darkness of greed that taints this issue. Those in tertiary centers who are fat and happy with PCI labs bursting at the seams need to be far more concerned with the scores of ICDs of the noninsured required at the end of their annual fiscal budgets than the rare complications that occur from a PCI. I submit that if we diffuse the lifesaving technology of primary PCI to the masses and preoccupy ourselves with the benefits, instead of hiding behind the unfounded fears of excessive risks and monetary losses, we will save lives and create more grandparents who can lead more productive lives. 

I hate to admit that the US is behind on any issue, but folks, we are dreadfully behind in promoting a timely PCI for all patients in our country. In the wake of our complacency we leave a growing population of cardiac cripples who pant for air as they sleep, walk to the mailbox, or just sit in their chairs waiting for life to be over. As their personal lives are devastated by our failure, they are breaking our medical banks from recurrent admissions for primary pump failure, device needs, and a laundry list of medications that compete for the monies necessary for personal basic necessities. We can do better and we should do better. Some of us forget that we even took an oath to do better. For all the "Uncle Gordons" of the world, my conscience insists that none of us should rest well until we really do better for all patients who suffer from an acute MI in America.

See also:

Survey says: Most cardiologists support elective PCI sans on-site CABG . . . with caveats

Cardiologists get it on both ends now. Blue Cross Blue Shield (BCBS), which pays just one of its state CEOs a salary of $4.6 million per year, tells me daily I can't get a stress exam on someone with risk factors because they aren't having chest pain. "But she's not going to be 60 years old for a few weeks," one BCBS physician told me, despite the fact that her ovaries had been missing in action for 25 years. Another day, I could not get a stress exam on an asymptomatic gentleman a year after he had a silent MI. He was still infarcting and recovered his LV function after a quick PCI. They wanted me to wait another year before I could get a follow–up stress exam because he wasn't "having typical symptoms" (duh). Now the CMS is telling me that the new trend in medical fashion will be "If you miss the diagnosis, you won't get paid for the workup." Will you also stop reimbursing normal head CTs after a loss of consciousness for an MVA? Will you embed FBI agents in every pathology department in the country to radio the White House that Ms Jones, with RUQ pain and a negative GB ultrasound, who had visited every ER in the district, had no gallstones? How about a negative colonoscopy for rectal bleeding? It is a sure bet that this political snowball will pick up a lot of testing and workup while rolling out of control downhill toward hell.

The opportunities to save money in all walks of medicine are as abundant as eggs on the White House lawn on Easter weekend. They are free. All you have to do is to bend over and pick them up. For the love of all things sacred in medicine, CMS--who in the world are you talking to? Do you ever ask anyone who is actively engaged in a full-time practice what they think will work to rein in cost? I've said it until I'm blue in the face. When you are looking at a budget and need to cut costs, the very first thing you do is examine the most expensive items on your expenditures, and I submit to you with absolute confidence that that is NOT CROOKED MEDICINE!

If you don't believe me, call Suze Orman, Dave Ramsey, even Donald Trump. They would open the books on medicine and point to congestive heart failure as the big-ticket item. Then they would ask, "What drives the cost of this item upward?" We as drones in the medical world would say, "Mr Trump, it's undetected and undertreated hypertension. It's rampant glucose intolerance that most overweight Americans have at this very moment who are being patted on the back and told it's just 'borderline diabetes.' Ms Orman, it's lack of exercise and improper diet. Mr Ramsey, it's greater than 50% medical noncompliance. It's America's love of smoking and the pathological paranoia that if you have to step outside to smoke, you'll wind up in a prison camp somewhere. It's the glaring omission of the need to map America and get every ST-elevation MI a primary PCI in a timely fashion and the need to make PCI stations as abundant as Wal-Marts. It's time to treat PCI without surgery on-site with the same respect as the need for intubation in respiratory arrest. It's time to emphasize the need for changes in the "healthcare reform plan," that diatribe that made War and Peace look like a comic strip, the one where trauma, family medicine, and obstetrics were mentioned, but NOT ONE TIME was the word "cardiology" uttered or the need to reduce heart-muscle damage by doing a better job at treating heart attacks. It's our convoluted thinking that you should be able to sue your doctor for a million dollars, your doctor who was trying to help you, had a good track record, and had a poor outcome, despite the fact that most Americans who bring those suits had never exercised regularly, ate right, or made much effort on their own to maintain good health. We have to stop the mentality that it's okay to drive 120 mph, but if you hit a tree and get a wound infection, you get a million dollars annually for life (or more correctly, your malpractice lawyer gets a million dollars to spend for life).

Furthermore, we cardiologists, who employ a substantial work force to fill out your forms and do your billing inquiries and kill trees and wreck carpal tunnels from all the necessary keystrokes, do not deserve to have our salaries reduced on a whim. Every year, it's a new threat of a 20% or 30% reimbursement cut when there is an opportunity to save billions by just having a conversation with the White House. Insist on driving real campaigns that target compliance, make all public buildings in the US smoke-free, and map America for timely primary PCI. Quit just talking about malpractice reform and DO it! Offer incentives for hypertension screening, dietary instruction, and access to and utilization of exercise facilities for every business in America. Do not engage in a pathetic witch hunt, but go ahead and lay a trap for the crooks that are few and far between in cardiology.

If you are running for public office, especially the highest level of office in our country—specifically I am addressing you, President Obama, and you, Mr Romney or Mr Gingrich—you owe it to us to sit down with a physician who is actively engaged in full-time private practice to understand the most important issues we face in our country. Instead of just being reactive, let's become proactive and at the same time react wisely and logically. Go ahead. Be bold. Focus on detection and prevention. Don't be afraid to drive up the immediate cost of healthcare by looking for renal-cell carcinoma or triple As or carotid disease. It will save in the long run by preventing two years' worth of chemo, radiation, and hospice care. Save billions of dollars in nursing-home stays for stroke. Drive the utilization of calcium scoring to detect asymptomatic coronary artery disease. Incentivize easy access to blood-pressure screening. Teach America how to check their pulses and screen for undetected afib. Make PE and health curricula in grades 1 through 12 just as important as math and science. After all, if we can't teach kids how to live longer, healthier, and more productive lives, we have taught them nothing of value.

A great first step, and about the only thing the CMS has done that makes any sense whatsoever, was to make a feeble attempt at obesity screening and counseling. Someone must have had a TIA up there to have actually tried to address a real issue. I applaud that, but it was a drop in the bucket. Politicians cannot micromanage what goes on in a cardiologist's office, but you can help us by laying the groundwork for success by just convening for a week on cardiovascular issues alone. If you don't know what to do, instead of just picking some crazy scheme, for the sake of the future of American cardiology, why not pick up the phone and ask someone who is actually practicing it? CMS, by putting all the drivers of our most expensive DRG under the political microscope in cooperation with the scientists who actually fight in the trenches of cardiovascular disease every day, you can be successful in putting American medicine on the right track. It is only through the utilization of this formula that we can successfully improve healthcare spending. Otherwise, you will fail, and so will we. 

See also:

Stents, ICDs, inappropriate? Then, under new audit program, CMS won't pay

I saw a funny silent Marty Feldman clip once. The hilarious bug-eyed comedian was an undertaker in a small town competing with a mortician who also ran a funeral parlor just across the street. Each morning, they greeted each other warmly as they passed on the busy main street flanked by restaurants and dry-goods stores. Swathed in long black coats and top hats, the two crept about the town oddly with shovels, ropes, and whatever tools necessary to promote their business. Apparently, times were hard, so occasionally, one would knock the other unconscious, slip him into a wooden box and hastily start the funeral only to discover the box was empty. Suddenly, a shovel would crack the other's head and down he would go into another waiting wooden box! The cat-and-mouse game automatically started again until one could catch the other off guard. That same dogged determination driven by stiff competition is pervasive in all walks of American industry, and unfortunately, on occasion it creeps into the practice of cardiology. The greatest majority of us act honorably and courteously, but this piece is for those who occasionally do not.

Case in point: An acquaintance recently evaluated his patient for noncardiac surgery and explained that the surgery was risky, but he was well medicated and his stress nuclear demonstrated minimal ischemia in a small segment. Unfortunately, the patient suffered cardiac complications perioperatively at another facility but was discharged home in stable condition. Instead of the original attending cardiologist being informed of the need to pursue a workup or that complications had even occurred, he found out only when records were requested and the patent's care was transferred to the cardiologist who attended the patient in the other town. Fortunately, the original attending took the initiative to contact the patient, who was very relieved to hear from him. The original cardiologist remarked that if that same patient had gone to one of the larger hospitals in a true tertiary center, there would never have been any issues with referral back into his practice. Hunger, however, can motivate strange behavior. I insist it is no excuse to ignore the four Cs of competition.

The first two Cs stand for: Continuity of Care: I can't stress enough the worth of 20 to 30 years of knowledge of a patient's habits, intolerances, personality traits, and strengths. It's sometimes difficult to translate those subtleties like preferences, quirks, or psychosocial issues that are often not reflected in the medical record. On the other hand, the implication of a lapse in continuity of care issues can be more blatant. A patient was on her way to the cath lab for chest pain one morning when her usual attending cardiologist stopped the nurse and said, "Wait a minute, that's my patient. Does the angiographer know she's been spiking fevers to 103 at home over the last week and has lung cancer and a recent normal stress nuclear that addressed her chest pain? To which the nurse replied, "Uh . . . I don't think so . . . I'll call." Needless to say, the cath was quickly canceled and she was referred back to her surgical oncologist for treatment.

The next two Cs stand for Common Courtesy: Bob Harrington's interview with Clyde Yancy on civility was excellent. Although it may be difficult to remain civil in extreme instances, every effort should be made to respect a long-term doctor-patient relationship. I've always made great effort to get patients referred to our facility back to their original cardiology-care providers. I believe that if one is too lazy to build one's practice by reputation and hard work, with all probability, one is too lazy to take care of the patients they catch in their net. Even when patients come for a second opinion, we should call the other physician, if the patient will allow it, to discuss the case. It's a bit uncomfortable at times, but it keeps the lines of communication open and it fosters good karma. On almost every occasion, I learn something that helps with patient care.

In this tough economic medical environment where things may heat up over time, if we mind the four Cs of competition, the focus of our work, our patients, will be served best. Continuity of Care and Common Courtesy together make good practice and are the essential of the most important C of all, one that is most essential to fulfilling our duties as a cardiac healthcare provider: Character.