Let’s stop the unnecessary treatment of heart disease

There are many reasons doctors suffer from burnout and compassion fatigue. One of the least-mentioned of these reasons is that much of what we do is so damn unnecessary. In the US, the land of excess everything, caregivers, especially cardiologists, spend most of our time treating human beings that didn’t need to have disease.

Let’s be clear and honest: Lifestyle-related disease is largely unnecessary.

These days, there is so much unnecessary disease that caregivers, especially cardiologists, rarely see it. We look past the obesity right to the cholesterol number and ECG. And then we pull out the prescription pad for the guideline-directed pills. Just typing that causes me angst.

A man gets referred for AF ablation for symptomatic AF. Indeed he has many AF episodes. But he also drinks alcohol excessively, weighs 300 pounds, and refuses to wear his sleep apnea mask. You refuse to do a $100,000 procedure and soon the reputation arrives: you are too conservative an ablationist. Mandrola won’t do procedures.

My interventional cardiology colleagues have it much worse. They are roused from sleep and family time to rush in and save people from mostly unnecessary heart attacks (MIs). One way to see the chorus of emergency PCI (percutaneous coronary intervention) treatment of acute MI is with awe. Another is with utter frustration–because in most cases it was unnecessary.

The study:

A recent population-based prospective study of Swedish men suggested almost four of five MIs in men could be preventable. (That’s not a typo.) Researchers from the Institute of Environmental Medicine in Stockholm Sweden followed 20, 721 men from 1997-2009. They specifically asked about five modifiable lifestyle behaviors: a healthy diet, moderate alcohol consumption, no smoking, being physically active and having no abdominal fat (waist circumference.) There were 1,361 cases of MI in the 11-year follow-up period.

Heartwire journalist Michael O’Riordan recaps the details of the study here on Medscape|Cardiology. The short story was that each of the five low-risk behaviors independently reduced the chance of having a heart attack. Not smoking was the strongest risk reducer. Men who combined all five behaviors were 86% less likely than those who had zero behaviors to have a heart attack.

The wake-up call:

I realize everyone knows lifestyle is important to prevent heart disease. It’s so obvious that we (patients and doctors) have grown numb to it. But pause for a moment and think about the finding that four of five heart attacks could be prevented with simple achievable lifestyle behaviors. That is something.

My electrophysiology colleague Dr. Prash Sanders (Adelaide Australia) stands in front of audiences of doctors and says risk factor modifications, such as weight loss and blood pressure control, are easy. The key word, he says, is motivation.

The challenge for caregivers, especially us cardiologists, is to stop suppressing the idea that heart disease can’t be prevented—that people won’t do it. The first definition of the noun motivation is the reason or reasons one has for acting or behaving in a particular way. That’s our job as caregivers.

My experience in the AF clinic in the past few years of lifestyle-enlightenment is that people can change. I’ve posted the lifestyle studies in the exam room. I discuss the biology of how lifestyle disease relates to the atria. I make the case that AF is (largely) unnecessary. I talk about atrial stretch and fibrosis, rotors and inflammation.

We can do the same with vascular disease and diabetes and high blood pressure. Being active, eating well, not smoking, and carrying less body fat work because they favorably affect oxidative stress, inflammation, endothelial function, insulin sensitivity and blood pressure. These are the reasons why people should eat less, move more and reduce their belt size. Reasons and expectations equal motivation.

The low-hanging fruit is right there. I say we reach up and grab it. Just thinking about doing fewer unnecessary things for unnecessary disease is soothing.

JMM

10 comments

  1. But you must address what is certainly the prime driver in the current status quo of the practice of medicine—corporate profits.

    The incentive for docs to make even the slightest effort to provide information and support to patients to motivate them to shape up and exercise is just not there.

    There is no time for productive encounters with patients when your medical corporation requires that you see 30 patients/day.

    However, the incentive to keep patients fat, inert and dependent on pills, procedures and doctors for their day to day survival is undeniable–$$$$.

    During the past few years I have spent no more than 5-10 minutes per appointment with any of my doctors: internist, cardiologist, electrophysiologist, sleep doctor; and many times they were preoccupied typing into a computer, without even looking at me.

    After casting around on the web for a “solution” to afib, I have eliminated triggers like msg and aspartame, and begun walking 2-3 miles per day, which my heart seems to find soothing, and have been able to reduce the number of afib bouts substantially. But no doctor has ever said a word to me about cause or prevention; only that I should take scary, potentially dangerous anti arrhythmic drugs and/or have a scary, potentially dangerous ablation.

    1. Truer words have never been spoken. Last year, after an initial bout of afib, my cardiologist told me I could “try” lifestyle changes but they “most likely won’t work” Granted, i’m of mormal weight, non-smoker, rarely drink, but my stress level, both physiological and emotional, was off the charts at the time (stress depletes magnesium stores and other key nutrients essential to NSR) . I would much rather reduce stress and inflammation than have my heart shocked, burned, or zapped. I wont’t even “go there” with meds because I’m sensitive to most meds.

      I think that patients, especially in fhe wake of 5-minute visits, need to become a student of their condition. As a science and nutrition junkie, I have no problem tearing into scientific papers to get some answers. The challenge is finding studies whose outcome was not funded by the pharm. or medical device industries. I pray I never have to go the ED again with this. One round of fearful, indifferent doctors and heavy-hitting medications was enough for me.

      Very doubtful I will ever find an EP who understands the need for serious lifestyle changes. We have to take charge. It’s a lonely path, but I’m determined.

  2. @ Joan – THANK YOU for your comment – which illustrates how tremendously helpful it is when patients take the initiative toward incorporating healthy lifestyle changes into their routine.

    As one who for many years taught family medicine residents and medical students, as well as lecturing nationally to primary care audiences on various cardiology-related topics – I think it is less due to “incentive to keep patients fat, inert and dependent on pills, procedures and doctors” – but instead more a result of all-too-many clinicians simply being unaware themselves of how important good lifestyle habits are to staying healthy. All-too-many clinicians do not themselves practice healthy lifestyle habits. That said – among those that do (Dr. John being optimal role model) – there is a tendency at trying to motivate patients.

    When the clinician is aware and does try – then whether or not healthy lifestyle habits are attempted will depend on the patient. But when the clinician is unaware/uniformed/uninterested – then there will be more tests, procedures and pills with resultant minimal (to negligible) emphasis on lifestyle change …

    THANK YOU John for making us aware of this Swedish study on cardiovascular benefits of healthy lifestyle changes.

  3. You keep up this talk and people might start brushing and flossing their teeth–and then where would I be? (maybe climbing the Ventoux!)
    BTW, I haven’t found motivating patients to be at all easy in most cases!

  4. Loved your article doc. And so glad to see that words such as preventive care, motivation and lifestyle changes are ahead of the game than drugs and pills in your article. As a dietitian I often come across patients, young patients on a low dose statin. Why I ask? And I’m told by PCPs that’s the recommendation for ‘preventive heart disease’. Better to be on a statin because a patient has diabetes? That surprises me! If only the other MI- (motivational interviewing) would be used more often than drugs n pills at a doctors visit, patients would be successful in healthy lifestyle changes.

  5. Thanks for sharing. Learning how to effectively treat (and even prevent) diseases through preventative lifestyle measures is an untapped and often undiscussed aspect of medical care, and heart disease is arguably the most prominent example.

  6. Hi Dr.

    I just turned 50, diagnosed with afib and soon after found to have a 90% blocked LAD(which had to be stented). I am 5-11, 185lbs and exercise about 1 hour a day 6 days a week. I eat a mostly healthy diet, do not smoke or drink. I originally came to your site for relief but now I only feel as if I am being criticized for something I have done. I have tried to live a good life. Although I agree many could use lifestyle changes, I am not sure what else I or others could do. I am concerned that you are becoming jaded as we are not all 250 -300lbs, smoke and eat junk everyday. With all due respect, maybe you need time away from your profession. It appears as if burnout is approaching. I appreciate your thoughts, but we all on occasion become jaded with good intent.
    Good luck with that.
    Paul

  7. Hi Dr.

    Thank you for the comments and direction to the newest post. It is appreciated. I think I was getting frustrated as every doctor I see has been telling my case is unusual to have the blockage with my lifestyle (afib included). Then to read your post it just upset me. I have been stented and ablated. All is working well at the moment. I just was tired of feeling guilty for no reason. As a side note, my father passed at age 52 due to heart disease. In my case, Afib saved my life….how is that for irony.
    Paul

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