Dr John M

cardiac electrophysiologist, cyclist, learner

The Case for Opening (some) Pools In COVID19 Pandemic

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The COVID crisis has decimated water exercise. Can we rethink pool closures?

A significant number of my older patients relied on pools for their fitness. During a pandemic, you can stay active or fit only if you have good legs and joints. Walkers, runners, and cyclists have no problem; they play outside in the Spring weather.

People with bone/joint problems, fitness swimmers, and young children who normally take swim lessons this time of year are out of luck.

Consider the place I swim—the Mary T Meagher Natatorium, named after Mary T, a Louisville native, who won Olympic gold in 1984. The place is an ode to Sparta. The expansive no-frills public facility has tons of space to socially distance. 

Before I tell you my proposal, let’s set out some givens on May 13.

  • Three months into this crisis literally everyone knows the deal: the coronavirus is not going away. It will be as dangerous next year as this year; 
  • Older people are more vulnerable, and they know it;
  • The virus travels via droplets so distance reduces your odds of infection;
  • Other health conditions, such as mental stress, heart disease, obesity, diabetes, immobility and arthritis, do not become less problematic during a pandemic;
  • People differ in their risk tolerance; some people see a 0.5% infection fatality rate as scary as heck, others see a 99.5% chance of survival. 
  • Hand washing reduces transmission. Masks might also reduce transmission.
  • Finally, and this is key, the community-level risk for the virus differs greatly across the US. Policy in New York City or Chicago ought not be the same for rural Kansas or Texas. 

I’ve said before that Americans are not stupid. We can, and we must, rely on people to make good decisions for themselves and their community.

Now to the proposal to open some public pools: 

Start with a big sign in front that says we are open but these are not normal times. 

You place a bunch of hand-sanitizer stations at the entrance.

Tell people to wear a mask and leave it at the poolside. 

Then let them swim, do water aerobics at a distance, and allow teenagers to teach toddlers to swim. 

After the workout, people put their mask on and leave. If they have to use a locker room or shower, that’s fine. I don’t know about women, but in the men’s locker room, social distancing comes naturally whilst being naked.

When schools open in the fall, and they must open, kids should play sports. This includes the swim teams. Teenagers have minimal risk from the virus. If they are mixing in schools, there is no reason not to let them mix on the field and in pools. 

Caveat: I realize that summer scenes of hundreds of children mixed with adults in public pools is more problematic. My proposal applies to opening pools for the purpose of fitness. 

An unintended positive externality: the act of allowing people to exercise in water would be a small step towards making peace with the virus. If people don’t want to risk catching the virus, they can stay away. 

If we let people go to the grocery, walk in crowded parks or shop at gardening stores, we ought to let them enjoy the water. 

JMM 

Conflict of Interest: After fracturing my foot 2 years ago, I rediscovered the joys of swimming. Before the pandemic I often recommended swimming to my patients because there is something soothing about immersion in water.

A short take of the big stories in cardiology in 2015

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Here is my most recent column on theHeart.org | Medscape Cardiology: Mandrola’s Top 10 Cardiology Stories 2015

What follows below is a short-writing summary of my ten picks. The hyperlinks go to earlier columns I wrote on the topic.

1. The FDA approved two new (injectable) cholesterol drugs. The problem with the PCSK9-inhibitors: the study to determine whether or not the $14,500-per-year drugs prevent heart attack or death finishes in 2017. I wished the FDA had waited.

2.  The Sprint Trial studied the effects of lowering BP to 120 versus 140 in high-risk adults. The lower-BP target won. The differences were small, and there were tradeoffs: more pills and more adverse events in the lower-BP group. The challenge will be applying these results to the real world–where patients aren’t as uniform or closely followed as they are during a trial.

3. In 2015 we relearned that coffee, fat and cholesterol are not baddies. Refined sugars are. This made my list because it was a huge reversal; not a single trial backed the 1970s-era advice to cut fat consumption. And, I love coffee.

4. Three discoveries dominated the news in atrial fibrillation. I listed them in the Medscape story.

5. When a researcher presented results of a study of a diabetes drug (one already approved, and in use), he received a round of applause. Why? It was the first time a drug for Type 2 diabetes had been shown to lower death rates. Of course, concerns arose; later in the year, FDA released warnings about adverse effects with this class of drugs.

6. One of the worries with the new oral anticoagulant drugs (NOACs) is a lack of reversal agent. That changed in 2015–at least for dabigatran (Pradaxa). Reversal agents for the other three drugs (Factor-Xa inhibitors) performed well in studies, and will likely be available in 2016.

7. I love pacemakers because they are so pure. Pacemakers don’t treat risk factors; they treat disease. 2015 brought a wireless revolution. Pacemakers without leads performed well in studies. This is the beginning of a new era.

8. Like heart attacks are, strokes are often caused by blood clots that abruptly occlude a blood vessel to the brain. Five studies this year showed that stroke patients did better if they were treated with rapid intervention to open the blocked artery in the brain. This is big because it will require revamping of EMS and hospital systems to treat stroke like heart attacks. E.g–faster.

9. Patients who take clot-preventing drugs (anticoagulants) often require procedures or surgeries. This means stopping the drug for a period of time before and after. In the past, doctors felt it was best to bridge them with IV or subQ anticoagulant drugs. Two big studies in 2015 showed that bridging made matters worse. There were caveats though. I listed them in the column.

10. When you board an airplane and look into the cockpit, you expect that the pilots have been well-trained. Great controversy erupted in 2015 on how best to train doctors. One non-profit organization had enjoyed a monopoly on the lucrative doctor-testing process. Powered by social media and a few vocal activists, a revolt among doctors occurred this year. The monopoly conceded a lot; the question as to how doctors certify in the future remains unknown.

A reminder that you need to register to read Medscape articles. This is free but it requires an email.

JMM

A cautionary note on AF ablation in 2015

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It’s time to write an update on AF ablation. Things have changed.

The major change is that I am doing many fewer ablations for AF.

The reason is we have a better understanding of the disease, or should I say, condition? In the last 2-3 years, good science has changed the way specialists see AF. The old-thinking had AF in its own silo. Your ECG showed AF so you had the disease AF. And if you had a disease, we had a fix–say drugs or ablation.

My partners would say, “John, we are sending you this patient with AF; please fix him.” And by fix, they meant drugs or ablation. Like a blockage–make it go away.

That’s not how AF treatment works. I’m surprised it took this long to figure that out.

The new thinking is that AF (often) occurs as a symptom or sign of something else.

Before I expand on that something else, let’s set out that there exists a small (but very vocal) minority of patients with AF that have no underlying disease or cause. This type of AF, the focal kind coming from an isolated source, usually within or around the pulmonary veins, was the type of AF first described by Dr. Michel Haïssaguerre and colleagues in the NEJM in 1998. If this was the only AF we ablated, AF ablation would be as curative as it is in supraventricular tachycardia.

It is not.

Most AF in developed countries is not a focal or primary problem with the heart. Most AF has a root cause outside the heart.

“Things” outside the heart that lead to AF include obesity, sleep apnea, alcohol, high blood pressure, inflammatory conditions (infections, trauma), excess exercise and probably stress. A blog post can’t explain the biology of how these signals affect the heart, but most experts now agree that each of these conditions, either alone or together, create the milieu in which AF starts and perpetuates.

The overly simplistic explanation goes like this: the above conditions (with inflammation and excess being the common thread) cause atrial chamber dilation, enlargement of individual atrial cells, loss of atria skeleton, change in cell membrane connections and deposition of scar. In total, we call these effects remodeling, and remodeling favors the development and persistence of AF.

We have always known to look for underlying causes of AF before treatment. In the past, though, this search was limited to conditions like high thyroid levels and valve issues.

What’s new now is the evidence linking lifestyle to disease in the atria. Dr. Prash Sanders and his team in Adelaide Australia have demonstrated that attention to risk factor reduction, such as weight loss, gains in fitness, alcohol modulation, and treatment of high blood pressure reduce AF burden–whether or not a patient comes to ablation. That last phrase is key: risk factor management bolsters AF ablation success rates.

When I see a patient with AF, I check for sleep apnea, discuss weight loss, alcohol intake and make sure we’ve got blood pressure under control. I also inquire about stress. A patient frazzled by the transient stressors of life–care-giving for a loved one, grief, or marital problems–will likely get better when the stress passes. What’s so fascinating about athletes with AF is that the excess exercise can have the same effects on the atria as does obesity–oh the irony.

The first step in AF treatment, therefore, is to focus on the root causes of AF. To do this, you first have to spend a fair amount of time removing fear. Patients with AF have to understand AF. They have to know AF is serious but not deadly.

For patients with ongoing symptoms, these long-term treatments must be combined with something now.

In the short-term, I use temporizing measures to relieve AF symptoms: drugs for rate control, anticoagulants for stroke prevention, and maybe even cardioversion with or without anti-arrhythmic drugs. The key is that these treatments are temporary. We aren’t shocking or medicating an AF patient with the idea that this is the fix; we are doing those things to buy time for risk factor management to work. And it does. I’ve seen it work.

Of course, in medicine not all things work perfectly. Risk factor management doesn’t always succeed. Here is where ablation still has a role–later, after we have given time a chance to heal; after we have given risk factor management a chance to heal, and most importantly, once we have gone slowly enough that patients aren’t having ablation out of fear of the disease or the mistaken belief that putting 60-80 ablation lesions in the left atrium is an “easy” fix.

Perhaps the coolest aspect of this new thinking is that even when we end up doing ablation, risk factor management not only improves success rates but it also makes the person healthier overall.

Since embracing this holistic approach to people with AF, I’ve done far fewer ablations and redo ablations.

The take-home message for patients and doctors alike is that AF ablation remains a reasonable option for carefully selected patients. But we should no longer rush to treat a condition caused by scar by creating more scar.

Go slowly; look for causes; treat these causes; give peace a chance. There is almost always a fix for AF. It’s rarely with a catheter alone.

JMM

The cardiac dangers of excess exercise

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Regular exercise is essential for health. I’ve taken to prescribing daily exercise as a drug. I’ve even written it on a prescription pad for effect.

I see exercise as medicine, a safe medicine, an effective medicine.

That means, like all drugs, exercise can be overdosed. The challenge is knowing the upper limit. How much is too much?

Screen Shot 2015-07-30 at 6.26.03 AMRecently, I helped Chris Case, a writer at VeloNews, put together a magazine-length article on the cardiac effects of extreme exercise. He did a great job with an immense topic.

It’s worth a read: Cycling to Extremes

Two other reads:

This February, I wrote a review article on AF and endurance athletes. Athletes and AF: Connecting the Lifestyle Dots

Another review comes from the Lisa Rosenbaum, writing in the New Yorker: Extreme Exercise and the Heart. Lisa is a friend and a talented writer. She is now the national correspondent for the New England Journal of Medicine.

If you are curious, you will be drawn to this paradox. Athletes should not get heart disease. They are fit and lean. They don’t smoke or drink alcohol excessively (usually). They don’t have high blood pressure or diabetes. The only risk factor most athletes with heart disease have is athletics.

JMM

Update: Baltimore, Safety in AF ablation, Podcasts, and some personal notes

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On Baltimore:

Human beings rioting in the streets of an American city forced cancellation of an important cardiology meeting. This is a vivid example that doctors do not practice in a vacuum. We are connected to this world. Here in Louisville, just a few miles north, an HIV crisis runs amok because of IV drug use. Despair. Inequality. These are no small things. What bothers me most about our healthcare system is the waste. We burn money. If we stopped doing that, we would have more to do for the less fortunate. I make a call out to every day physicians to stop burning money. Medicine Can’t Ignore Baltimore and Ferguson.

On a failure of a safety method in AF ablation:

The most devastating complication of AF ablation is damage to the esophagus. Thermal lesions can lead to a connection (a fistula) between the esophagus and the left atrium. This–thankfully rare–event leads to death in the great majority of people. Most doctors take evasive action to protect the esophagus. One maneuver is to monitor temperature in the esophagus. The idea is that if a burn in the heart causes a rise in temp in the nearby esophagus, the operator stops burning and damage is avoided. Sounds good, right? Except a new study from Germany suggests the act of temperature monitoring associated with dramatic increases in thermal lesions. AF Ablation: Esophageal Monitoring Harmful or Helpful?

Podcast for May 1, 2015:

This 12-minute video podcast includes my comments on Baltimore, outcomes in LVADs, gene-therapy for heart failure, statins for all elders, and an FDA alert on hand sanitizers. May 1 Cardiology News Podcast

Podcast for April 24, 2015:

This 11-minute video podcast includes my comments on a consensus statement from AHA on the treatment of adults with congenital heart disease, safety of sports in youngsters with Long QT syndrome, the vital importance of treating sleep apnea in patients with AF, the cardiovascular risk of divorce, and the Dr. Oz controversy. April 24 Cardiology News Podcast

Mention in the Houston Chronicle:

Markian Hawryluk is an accomplished healthcare journalist who contacted me for my thoughts on the Watchman, a device used to occlude the left atrial appendage in patients with AF. It was a long slog through the FDA process but Watchman finally made it. I am worried about where this chapter in cardiology is headed. You can read my quotes here: New device effective in preventing blood clots, but experts fear overuse, high costs. I will surely have more to say about this focal solution for a systemic problem in the months to come. My stance has changed little since I wrote Eight Reasons to Remain Doubtful on Watchman in 2013.

Personal Note:

I am currently on a Mark Twain kick. My recent reads include, The Handmaid’s Tale (Margaret Atwood), Hitch-22, (Christopher Hitchens’ memoir), The Sun Also Rises (E Hemingway), The Human Stain (Philip Roth), Writing Tools and How to Write Short (Roy Peter Clark).

I am back to running and mountain biking. I like both–for lots of reason. One is that they keep my legs sufficiently tired so that I am less likely to succumb to criterium thoughts. It is that season. And crits are so beautiful.

JMM

An update on cycling and writing and video (gulp)

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Hi all,

Things have changed for me. I have taken on a larger role at theheart.org | Medscape Cardiology. This means I have less time for hefty original posts here. (This site is not closing–just changing.)

I write and read a lot more, though. Almost every day. Writing has morphed into what cycling was: a source of contentment. It used to be that if I had a good workout, I felt good during that day. Now I get those same sensations from writing.

I still exercise but its place in my self-esteem bucket is smaller. Except last Tuesday night during the local “ride,” I was dropped out of a break because of an asthma attack. That sucked. But I redeemed myself last night. On the trainer, I made the break with Terpstra and Kristoff in the Tour of Flanders. Grin. Seriously, this is a great way to get a workout: You put on a YouTube video of a race, plug in good music and get yourself in the break. A couple of weeks ago, I was climbing with Contador.

Here are the essays:

Atrial Fibrillation:

My approach to patients with atrial fibrillation has completely and fundamentally changed. We are at a before and after moment in the care of the millions of patients with AF. This has major implications for the cardiology and healthcare community. Read more: Atrial Fibrillation Care: Put the Catheter (and Rx Pad) Down.

Much of the research on lifestyle and atrial fibrillation comes from Adelaide Australia. This team may also have shown us a model as to how to help patients turn towards health: Is This Treatment a Game-Changer for AFib?

Hepatitis C:

The FDA recently released an alert about sudden bradycardia in patients taking the new Hepatitis drug sofosbuvir who were also on amiodarone. Six of these nine cases occurred within 24 hours of taking SOF.  Read more: Could the HCV Drug Sofosbuvir Be Cardiotoxic?

Interviews:

I was honored to sit down with Cutting for Stone author and Stanford professor, Dr. Abraham Verghese immediately after his opening plenary session at ACC2015. Here is the transcript: Abraham Verghese: Hope for Hands-on Medicine in the EMR Era

Palliative Care/ Staci update:

As I noted in my last update, Staci gave an inspiring talk at the ACC meeting. My summary post of it, 15 Things All Cardiologists Should Know About Palliative Care, remained on the most popular list for two weeks. Now Staci has written her own essay on the ACC meeting. She asks the provocative question: Should We Call Death a Bad Outcome?

Video:

Finally, as part of my new role at theheart.org | Medscape Cardiology, I am learning video. This is scary. Here is the first installment of This Week in Cardiology in which I discuss, statins and muscle pain, statins and coronary calcium, the value of exercise in patients with ICDs, the use of meds in patients who have had CRT and the ABIM controversy.

Micro-blogging:

I have embraced the use of Twitter. You can follow me @drjohnm. I usually post a few times each day. Don’t dismiss Twitter. It can be an incredible learning tool.

JMM

Does exercise have to look a certain way? Can Yoga deliver heart health?

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One of my good friends, a guru of sorts, once told me during a ride that things change. He was 50 years-old at the time and the change he was referring to was cycling abilities and priorities. At the time, I was at the peak of my cycling prowess; we were part of strong masters team and things were rolling beautifully. Ah…you are strong, I said. We can keep this up for many more years. He shook his head. “You will see, John.”

Now that I have reached that milestone, I realize the wisdom. Things do change. Bodies change. Priorities change. Pegs on which people hang their self-esteem change.

One thing that remains unchanged, though, is the power of exercise to bring health. Exercise, along with good food choices, sleep hygiene and kindness form the foundation of true health. Wellness.

My views on exercise have always been biased by my own experiences. In the past, I believed that if exercise was to deliver heart health, (drops in blood pressure, change in cholesterol levels, arterial changes) it had to look a certain way. Mostly, it had to be intense and aerobic.

A series of studies on the ancient Indian practice of Yoga challenge such thinking. One study went so far as to study Yoga for the treatment of atrial fibrillation.

I reviewed these studies and wrote some thoughts on the matter. It’s my first post as a writer for the consumer side of WebMD.

The link and title of the story: Yoga for Heart Health? (No registration is required.)

JMM

Will wearables and other gadgets make us healthier?

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Is good health really all that digital?

I am not so sure. I am a skeptic.

I realize this is a risky thing to say these days. It’s hard to bet against Apple. And It was only seconds after Tweeting such doubt that John Nosta, an expert in digital health technology, tweeted back:

Well, yes, surely digital technology is important in the diagnosis and management of diseases. I couldn’t do ablation without engineering and technology. We use digital devices to monitor the heart’s rhythm, and said devices, such as the AliveCor iPhone ECG, herald improvements over clunky wired devices. Diabetes is monitored digitally. Vital signs are too. Dr. Eric Topol wrote recently about the (molecular) stethoscopes of the future. I don’t mean to say digital technology improvements are not improving medical care. They are.

But is the digital revolution correlating with better health? A look around America, call it the “general appearance” part of the exam, would suggest not. The view from my waiting room, my orthopedist’s waiting room, an airport, a mall, anywhere other than fitness enclaves like Boulder Colorado, would lead one to believe the correlation between tech and health is inverse. It seems the more digital, white-screen attached, we become, the fatter and sicker we get.

It’s ironic, perhaps metaphorical, when an obese sedentary smoker asks me about doing a screening ultrasound test to pick up early disease.

That’s how I feel about the fitness and health tracking business. I see the devices as fine tuning when what is most needed is simpler. Far simpler. And obvious.

My experience with bike tech is instructive. When I began cycling competitively, bike computers were in the midst of a revolution–not unlike the present revolution in health gadgets. At first, bike computers were crude; they measured only speed, distance and RPMs. But it was digital. You had data. The numbers enhanced the experience. Then the data got better. It went wireless, and power sensors allowed one to measure performance more truthfully. I got even more excited with the advent of power data. And most recently, GPS and social media apps, like Strava, have further boosted the digital revolution of cycling. Now I can measure and share my cycling performance against my peers.

All along this continuum, I embraced cycling technology. I was an early adopter. I was enthusiastic. I had training logs, spreadsheets and power plots. That was then.

The bikes in my garage today have no devices. I have only my sensations, my belt loops, the tightness of my bike jersey (it doesn’t shrink), and my placings in races.

I jettisoned the digital because I made a discovery: going fast on the bike comes from simpler more qualitative things. I found that eating better food, and less of it, helps. I found alcohol, at any dose, decreases watts. I found going to bed at a good hour increases endurance. And for me, high quality interval training interspersed with adequate rest works like magic.

My cycling health, in other words, did not need digital fine tuning. It needed the basics.

That’s how I feel about health for the masses. Nary does a man with a 38-inch waist need a digital watch. He needs a pair of sneakers, a jacket and a gutsy enough clinician to tell him to carve out time in his day to use them. He needs priorities. And on nutrition and sleep and kindness: it’s the same idea. Almost everyone knows the basics.

If health gadgets helped humans master the obvious, then I would be less skeptical.

JMM

The year in Cardiology 2014 — a top-10 list

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When the editors at Medscape asked me to put together an essay on the Top 10 stories in cardiology in 2014, I thought it would be an easy project. I was wrong. It turns out there was a lot to say about the happenings in cardiology this year.  In the end, the final essay had 37 references–a bunch for a blogger.

The link to the piece is at the end of this post. What follows is a regular-language breakdown of the ten topics. The first five deal with specifics; the second five touch on trends.

Here we go:

1. Renal denervation is the medical name given to a procedure in which a doctor uses a catheter to ablate (burn) nerves in the kidneys. I realize that sounds dubious, nerves are there for a reason, but the procedure had promised to cure high blood pressure. (Grin.)

But then reality struck. A properly done clinical trial showed the procedure did not work. Drinking beetroot juice looked better. This was a big story not just because it surprised experts, but also because it exposed the danger of basing medical therapy on flawed science. (See points 8 and 10.)

2. Congestive heart failure is the name we use when the heart fails to pump enough nutrients to the body. One of the many causes of CHF is a weak heart muscle–which we call systolic dysfunction. There hasn’t been a new drug released for systolic heart failure in more than two decades.

This year, the PARADIGM-HF study showed that CHF patients treated with a new class of drugs, called angiotensin-neprilysin inhibitors (ARNI), fared better than those treated with standard ACE-inhibitors. The absolute differences in outcomes were small but the large numbers of patients enrolled in the study resulted in statistical significance. Novartis has yet to give the drug (LCZ696) a real name. The FDA has yet to hear the details. This story will continue into 2015.

3. Cardiac monitoring can be useful. But like everything in medicine, overuse can lead to a loathsome outcome: the creation of fear, which can transform a well person into a diseased one. Perhaps it is the concerning trends in electrophysiology that lead to my (negative) bias about monitoring of the human body.

Bias aside, cardiac monitoring had a good year. Two clinical trials showed the utility of prolonged rhythm monitoring after stroke. The idea here is to pick up non-symptomatic atrial fibrillation–a treatable cause of a second stroke.

Another group of studies suggested promise for remote wireless monitoring of patients with cardiac devices. These observational trials revealed a strong association between lower mortality and the presence of wireless monitoring.

4. Aspirin therapy is losing its mystique. The old drug is one I often deprescribe. Two studies released this year strengthened the message that aspirin used in combination with anti-coagulant drugs is rarely useful. I’m not sure why so many patients get continued on the combination of these two classes of drugs. I’ve called the combination a dangerous cocktail.

That was not the only bad news for aspirin. Another group of studies questioned the use of aspirin for the prevention of a first cardiac event–which we call primary prevention. The thinking on aspirin for prevention is similar to statins: benefit turns on baseline risk. Low risk patients get little benefit. High risk patients get more benefit. Both groups are exposed to the bleeding risk.

5. Cardioversion of atrial fibrillation is usually a safe procedure. The caveat here is that patients have had adequate anticoagulation (blood thinning) in the month before and after the shock. A dogmatic rule passed down over decades of doctors holds that cardioversion can be done without anticoagulation if the AF is less than 48 hours in onset.

In 2014, findings of a Finnish study questioned the safety of the 48-hour “rule.” The researchers found a small but not insignificant risk of stroke in patients shocked without the protection of anticoagulation. Risk was higher later in the 48-hour window. I wrote about hitting the pause button on cardioversion in August.

5a. Using new oral anticoagulant drugs (NOACs) before and after cardioversion is common. Although these drugs compared favorably to warfarin in clinical trials, doctors wonder whether they provide adequate protection for cardioversion. The concern stems from the fact that, unlike warfarin, NOAC effect cannot be measured. The good news was that two studies released this year reassured doctors that NOACs look to be safe for cardioversion.

****

This is a break point. The next five topics indicate changes in thinking, culture or approaches to care.

6. “Board-certified” was once a term people used without thinking about whom the board was and what certified meant. That changed in 2014. The board is actually the American Board of Internal Medicine, a well-endowed non-profit organization, and being certified now requires complying with onerous and expensive new procedures. I covered the near universal resistance to the new mandates in a previous post. This is a big topic because everyone wants doctors to be well-informed and qualified. How that is accomplished in the future may change.

7. Less-is-more is an old way of thinking about medical care. Numerous studies in 2014 bolstered the idea that less is indeed more when it comes to treating people. Survival in cardiac arrest was better when basic not advanced care was applied. Doing extra testing at the time of ICD implant made no difference in outcomes. Burning in the atria less, rather than more, proved the better strategy in the treatment of advanced AF. Simpler surgery (or no surgery) of the mitral valve also came out ahead.

I can’t stress this concept enough. If I could blog about only one topic, it would be the widespread over-testing and over-treatment of the American public.

8. Expert guideline statements have steadily grown in prominence and influence in the practice of medicine. Documents that were designed to help physicians treat patients in the most evidence-based way have now become shackles of a sort. The irony is that adherence to guidelines, enforced now with a stick rather than a carrot, can actually impair patient-centered decisions. Eg: You will take that (needed) anticoagulant or statin, otherwise, I will be deemed a poor quality doctor.

In 2014, guideline statements lost some of their luster and power. First, numerous researchers made compelling cases that the statistical evidence upon which guidelines are based is less than definitive. Second, a major scandal involving scientific misconduct further exposed the tenuous nature of the evidence. Finally, two studies that delved into the nitty-gritty of guidelines found reasons to suspect the quality and durability of said decrees.

I thought this was a big story because expert guideline statements, and the protocols and quality measures they induce, are running amok. It was a delight to see skepticism reenter mainstream thinking. Don’t you think medical decisions would improve if more patients and doctors were familiar with Dr. John Ioannidis’ 2005 paper in PLoS Medicine, Why Most Published Research Findings Are False?

9. End-of-life treatment in the US remains a national disgrace. I noticed the inhumanity when I started this job in 1996, and I don’t think we have made any progress. Death denial is our default: Death occurs because of a deficit in science or therapy, not because it is the normal end to all life, goes the disordered thinking.

This year, however, three events injected some hope that enlightenment about death is possible. There was Brittany Maynard, who taught us that how we die was a personal choice. There were two literary works from physician writers. Dr. Atul Gawande and Dr. Ezekiel Emanuel both wrote thought-provoking words that stand the chance of jump-starting the conversation.

Oncologists and cardiologists are in the thick of this crisis. And it’s about time we stepped up and provided some needed leadership. Here is a start: If your emaciated patient with metastatic cancer is still on a statin, you fail!

10. Lifestyle choices are health. This equation should be obvious. Yet our situation is stunning. We routinely use expensive and often futile means for treating unnecessary disease. We look right past the value of nutrition, exercise and sleep hygiene, to pills, stents and even surgery.

The good news was that major studies published in 2014 showed us that heart attacks, heart failure and atrial fibrillation are, in great measure, preventable. Eating a healthy diet most of the time, using our bodies on a regular basis, not smoking, drinking alcohol moderately (or not at all), and controlling abdominal girth was the secret sauce.

It’s critical that all doctors start seeing this. For if we don’t; we will be the first generation of caregivers to witness a decline in both the quality and quantity of life of our patients. While we perseverate over statins, or statins-with-ezitimibe, or stents, or AF ablation, our patients are growing fatter, less mobile and more chronically ill. Shame on us.

It’s true that a lot of the obesity mess is out of our hands, but not all of it is. When it comes to health and healthcare, we are the professionals. It’s our job to take the lead.

The link and title to the essay is here:

Cardiology’s Top 10 Stories of 2014: Back-to-Basics Promises Big Advancements

JMM

Sudden death and a common antibiotic

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The longer I practice medicine, the more nervous I get about medications, especially when patients are already on other drugs for chronic diseases. I much prefer deprescribing.

A recent study on the common antibiotic cotrimoxazole, which is a combination of sulfamethoxazole and trimethoprim, and often referred to by its brand name, Bactrim or Septra, lends credence to the notion that combining drugs can be dangerous.

In a case-control study of more than 1.6 million patients over 17 years, researchers from Canada found that cotrimoxazole was associated with a three-fold increased risk of sudden death when used in older patients (age > 66) taking angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).

Steve Stiles covered the research on theHeart.org. Here is a link to the full article in the British Medical Journal. (A side note: The authors wrote the paper in the active voice. It was a pleasure to read.)

The Canadian researchers argued the association was plausible, and that the likely mechanism of sudden death involved high potassium levels (hyperkalemia). Their findings provide important messages to caregivers and patients alike.

Comments:

In a general sense, this study gives me pause because cotrimoxazole carries such a benign reputation. “Go ahead and just cover him with some Bactrim. How can it hurt?” goes the (fast) thinking.

And be honest; did you know trimethoprim blocks the epithelial sodium channel (ENaC) in the distal nephron, thereby impairing potassium elimination? I would guess most caregivers who prescribe cotrimoxazole do not have a working knowledge of epithelial cells in the distal nephron. I did not.

But that’s the thing about drugs: they don’t do just one thing. Trimethoprim is given to kill bacteria but it also acts like amiloride, (a potassium-sparing diuretic) in the kidney. In a young patient with good organ function, this is not significant. Young healthy patients have organ reserve.

Now consider older patients with lifestyle diseases, such as obesity, heart failure, diabetes and high blood pressure, conditions that impair organ function. Many of these patients take (guideline-directed) drugs called angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). ACE inhibitors and ARBs are used a lot. More than 250 million prescriptions are dispensed in the US each year.

These drugs, which act via the kidney, can increase potassium levels in up to 10% of patients. Diabetic patients require special consideration, as many of them are especially prone to high potassium levels.

So now you can see the problem. Cotrimoxazole is also a commonly used antibiotic, with up to 50 million prescriptions written each year. The authors have noted in previous work that cotrimoxazole combined with ACE/ARB drugs associated with a sevenfold increase in the risk of hospital admission for elevated potassium levels. Case reports have also confirmed life-threatening high potassium levels with the combination.

The finding of a threefold increased risk of death with cotrimoxazole over amoxicillin in older patients taking ACE inhibitors or ARBs teaches us to consider other antibiotics in these patients. That’s the easy lesson.

The story here is not just about the specifics of an important drug-drug interaction. It’s about the approach to treating people with diseases. Drugs are used too much. How many of those 250 million ACE/ARB prescriptions could have been avoided if exercise was seen as a medicine, or if elderly patients had been deprescribed? Likewise, how many of the 50 million patients treated with cotrimoxazole had a viral, not bacterial, infection?

The default to pharmacologic treatment needs to change. Drugs have a place. I use them everyday. But they aren’t free. They come with tradeoffs, and, the more drugs we use together in a patient, the more tradeoffs we should expect.

Finally, some would have electronic health records protecting us from prescribing drugs with dangerous interactions. This is magical thinking. Computers are fine. The problem lies with the humans that program the machines. If the goal of the computer is to capture every possible piece of billable data and alert us to every possible bad thing that could happen, the machine becomes part of the patient safety problem.

Be careful out there. Think about tradeoffs. Tradeoffs are truth.

JMM

Public health is on the ballot this Election Day

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The election I am going to watch today is in San Francisco. On the ballot there is Proposition E, an initiative to add a 2-cent tax for every once of sugary beverage. Choose Health SF, a group supporting the tax, estimates it would raise $54 million, which would go towards, get this: “funding active recreation and nutrition programs in San Francisco public schools, parks, and recreation centers; food access initiatives, drinking fountain and water bottle filling stations; and dental health services.”

The other side effect of this tax would be a decrease in consumption of sugary beverages. Some estimates say by up to 31%. That’s a lot fewer calories being ingested, and hence, a lot more public health.

I know taxes are a polarizing topic.

Credit: HighMark Foundation

Credit: High Mark Foundation

But obesity is different. It is serious. Our fatness is killing us, literally.

Some argue such beverage taxes are regressive, eg, they hurt the poor more than the rich. To that I respond, obesity is hurting the poor more than the rich. Obesity in America is regressive.

I don’t get sugary beverages. The massive doses of sugar in these artificially-colored drinks causes spikes in insulin. Insulin then promotes fat storage and arterial disease. The NPR Salt blog recently ran a story about labeling high-calorie drinks by how much exercise it would take to neutralize the sugar. A 110-lb adolescent, for instance, would need to run 50 minutes to burn off a typical 250-calorie soft drink.

I see obese patients every day. I see their heart disease and atrial fibrillation. They tell me about their joint problems, their immobility and often about their complications from diabetes. What fatness does to the human body is nothing less than sad. Do fat men (or boys) actually know their fat cells are churning out estrogen, which has the effect of transforming them into women?

Racing bikes on the weekend provides a striking contrast. Cyclists, especially young ones, are beautiful to watch. I often think to myself: this is how a human body should be. Then I go to work on Monday and see the ravages of excess calories and immobility. Sad.

Of course I realize taxation is politically charged. Millions of dollars are lining up on both sides of the issue. Big corporations are behaving just as you would expect in a capitalist system–they are protecting their self-interest. Soda companies aren’t charged with public health; their job is to make money. This is normal. It’s our system.

We let government set rules about driving, alcohol, car seats and education. We do so for the greater good, to protect the children and the less fortunate.

I write in favor of this tax as a witness from the front lines of public health. It’s really bad here. The people need help.

JMM