Dr John M

cardiac electrophysiologist, cyclist, learner

Let’s stop the unnecessary treatment of heart disease

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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

CW: Athletes teaching heart rhythm doctors?

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What could competitive athletes teach a group of heart rhythm specialists?

Cyclists, runners and yes, even triathletes, know something that we wizards too often forget. I’ll tell you what it is in good time. Keep reading.

I just returned from a giant gathering of heart rhythm doctors. It was, as all national meetings are, an incredible learning experience. You come back motivated and ready for action. (The cycling equivalent would be watching tapes of Paris-Roubaix before a big crit. For tri-peeps, think of the Dave Scott/Mark Allen duel in Kona. Seriously, that was an epic battle of inflammation.)

Sub Q ICD

My Heart Rhythm Society really knows how to put on a show. They recruit wonderful speakers, accept exciting scientific papers and hold too-numerous-to-count practical sessions for us regular docs. And…as an industry-intensive specialty, all the latest innovative technology is available for hands-on exploration. Just walk up to a booth and in seconds you are holding a futuristic ICD—one without leads in blood vessels!

But for all the glitz, I continue to be disappointed in the lack of interest in my passion—the advocacy of healthy living through good choices. Athletes understand this well, but us tech-heavy doctors, not so much.

I found not one abstract, poster or oral presentation on the importance of fitness, healthy lifestyle and what smart people like to call primordial prevention. Heart rhythm doctors crave news about burning, installing and medicating a disease that’s already happened. It’s ironic that much of what I treat day in and day out may have been prevented.

An athlete wouldn’t think about not exercising every day. You punish yourself for eating a cookie. You like sleep because it makes for better muscle recovery. Some athletes even have rules about drinking Coke: I’ve heard nutjob cyclists who allow themselves a cold Coke only when two criteria are met: after a hard-fought bike race or after a three-hour training ride.

Lots of small choices pay big dividends.

I saw this patient recently (a former athlete gone soft with birthdays) who has been introduced to middle age by the new onset of atrial fibrillation. I saw her for consideration of catheter ablation. Really? That fast? Not in my practice. My patients get the lecture before this:

That's a lot of burns!

She has done well managing her disease: she cut down on caffeine and alcohol, improved her sleep hygiene, carved out time for exercise and now focuses on avoiding last-minute cram sessions for projects. Her arrhythmia has improved without medicines and based on these good choices, an invasive procedure was wiped off the table. Granted, it doesn’t always work this nicely. But sometimes it does. This blawger’s opinion is that doctors too often underestimate the value of athletic lifestyle choices. Rather, we do the easy and evidence-based thing: pull out the prescription pad or recommend procedures.

Imagine the effects on public health if young people implemented this patient’s strategy. Remember, the same behaviors that prevent atrial fibrillation also lower blood pressure, control blood sugar, modulate cholesterol, improve cognition, prevent cancer and even help the environment. It’s a tired analogy to invoke auto maintenance; but it’s true. Electrical disorders frequently result from years of poor body maintenance.

Though we heart rhythm doctors bask in technology and worship engineering prowess, we must remember that we are still doctors. We have the capital to influence our patients’ decisions. We aren’t their moms, but we can be their teachers.

Athletes do the little things. They know the benefits of good preparation and long-term maintenance of the only body they will ever have. As an athletic doctor, I want to teach my patients that. I want to write about it. I love technology, and the fury of medicine, but I also love it when I don’t have to use it.

JMM

He proved his point

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“Your health account is your wealth account…Long live living long”

–Jack Lalanne

Though many triathletes try, few succeed in registering higher on the goofiness scale than the satin-skin-suit-clad fitness guru, Jack Lalanne.  I just couldn’t help grinning while I watched tonight’s evening-news recaps of his life; his grin and energy were infectious.  Just looking at his videos seems good for the heart.

The news said he finally died because of complications of pneumonia, but another more plausible explanation was that he finally succumbed to a broken heart.

What from?

From opening his eyes and seeing what is happening to the people.  His physical heart may have been strong enough to tow a boat across San Francisco bay, but his emotional heart may have cracked from the disappointment of bearing witness to our nation’s obesity epidemic.  Perhaps the final straw was seeing that fatness and immobility have even spread to our youth.

Some would let his goofiness trump his message.  Don’t let it.

He pedaled movement, and fruit-juicing, and smiles and mental engagement.  The last I read these tenets are known to prevent many of society’s most common medical problems, like heart disease, cancer, diabetes, arthritis and even dementia.

Mr Schwarznenegger was spot-on when he said that Mr Lalanne left this world a better place than he found it.

And it’s a good bet that Mr Lalanne is already recommending exercise to God.

JMM

Middle-age…

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“It was the best of times, it was the worst of times…”

An intermission, the curtain has closed on youth, but the next act awaits.

Caring for hiccups of the heart, like atrial fibrillation for example, often throws me in front of the mirror, of middle-age that is, and sadly the reflections show imperfections.  Since I am middle-aged myself, there are my own experiences.  But everyday at work, on my job site, I see the effects of these same middle-age experiences on the atrium of my patients.  The results are often profound.  So must be the pressures.

I read this passage in the wee hours of the quiet morning, in the dark, with a flickering book light. It grabbed me.

It is from Elisabeth Strout’s Pulitzer Prize-winning, Olive Kitteridge. Olive is an older women, her husband (Henry) of many years has suffered a stroke and now lives unknowingly of himself or others, in a nursing home. Her only son has moved away with a women who soon after leaves him. She is alone in her cold New England town and she ponders this thought:

“There was beauty to the autumn air, and the sweaty young bodies that had mud on their legs, strong young men who would throw themselves forward to have the ball smack against their foreheads, the cheering when a goal was scored, the goalie sinking to his knees. There were days—she could remember this—when Henry would hold her hand as they walked home, middle-aged people, in their prime. Had they known at these moments to be quietly joyful? Most likely not. People mostly did not know enough when they were living life that they were living it. But she had the memory now, of something healthy and pure. Maybe it was the purest she had, those moments on the soccer field, because she had other memories that were not pure.”

Life moves so fast. The 100 year-old Dr Bing likened life to a rapidly flowing river.

It seems just yesterday, I stood in line at the coaches office waiting to dial the rotary phone to call Mom, or Gramps for a ride home.

Here’s to enjoying the ride while on it.

JMM

h/t to Dr Wes, for the Dr Bing video, and to Staci, who suggested Olive Kitteridge, along with many other good suggestions.

A really bad idea…

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It’s terrible news. Speeding through college to save 10,000 dollars. Seriously?

As a mid-forty year old solidly ensconced in the mini-van era of life, it saddens me to see young people–in an effort to save a few dollars–rushing through the finest of times,  life in college.  Treating college as some sort of right of passage to a greater goal is wildly misguided. Who is advising these youngers?   Are they really in a rush to buy their first sub-zero or Honda Odyssey?

My gosh, I sit here at the MacBook wishing I could construct words like Alice Sebold or Philip Roth; wishing I had taken more than two literature classes; wishing to be a full-time student again.  Here, at Hobart, on the lake…

It is easy to remember the two Biology professors who persistently scolded us pre-med folks for treating college as a vehicle to something else. They wanted us to learn for the sake of enrichment–for the joy of learning itself. At the time, I wrongly considered that they were elitist academics who didn’t like doctors, or doctors-to-be, but I get their point now.  Maybe these middle-aged professors knew that doctors are good at little else, other than doctoring, and so they were helping us in more ways than our youthful minds could comprehend at the time.

Finally, to those who say, money is the issue, I would argue that 10,000 dollars over the course of twenty years is about 73 cents a day.

Some chapters in life should not be shortened.  Obviously.

JMM

No skin in the game..

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Nearly every day an email comes with medical news and it is truly remarkable how many repetitive studies are done, which show adherence to the usual lifestyle factors, diet, exercise and cessation of smoking improve outcomes.

This past week the Go Red for Women Hearts is yet another proclamation, specifically to women, to get with it and live healthy.

This morning the news wires reveal an 18,000 person multi-country study which shows that post-ACS (Acute Coronary Syndrome -medical speak for heart attack or near heart attack), risks of cardiac events were dramatically reduced in patients who adhered to lifestyle modifications.  Go figure…Yet another of the hundreds of studies involving many thousands of patients which all reveal that heart disease remains one of the most preventable and modifiable life-altering diseases.

A quote from an AHA spokesperson hits the highlight,

“This study is consistent with other studies that show improvement in cardiovascular risk profiles with lifestyle counseling. However, the biggest problem is not so much our beliefs in reducing risk for cardiovascular disease though participation in modification of lifestyle, it’s really getting the patients to participate in their care and actively lower their risk factors.”

Some facts…

-Cardiac rehab reimbursement is reduced.
-Physicians consultation fees are reduced.
-“Squishing” or bypassing blockages remains well reimbursed (albeit less so now).
-Patients remain without any incentive to comply, other than old-fashioned motivation, which works in about a third.   The smoker who refuses to quit, pays the same for subsequent heart care than the motivated, and indeed if the deductible is met, future care is “free” later in the year.

Heart disease prevention and the resultant lowering of health care consumption is right there in front of us, and anyone who can see, read and hear knows this.  It is also clear to any master of the obvious, that the present paradigm of “recommending,” smart choices but paying for the treatment of poor choices is not working. 

JMM

A quest for intelligence. A long way off…

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While perusing the aisles in Kroger, to an English professor and dean at a local university, I inquire about a writing course, so as to improve the blog. This author labored to a C in English in high school and despite excelling in the sciences in math, struggled like a muscleman on a cx course in the humanities. The answer from the soft spoken professor, after a pause, read some good books and be a better writer.

So Sunday was the end of bike season and there must be other pursuits which ache much less. Wednesdays are afternoons off -note to my junior colleagues: find a career in which Wednesday afternoons are free – so I made off to the book store. Need to read some good books. On a vision quest to get smarter. Grin.
The day after my chance meeting with the English professor, while waiting in the Walden lobby for Will to finish basketball, a poster catches my eye. It is off the beaten path, around a corner in a nook adjacent to Mr Shell’s office. It is a poster of Walden Pond (go figure) autographed by Don Henley,of Eagles fame. I recognize Don Henley, so I ask Mr Shell and he tells me of their school trips to Walden Pond in Concord Mass. Hmmm, Mr Shell sounds very smart.
Back to the bookstore. It is settled, Henry David Thoreau it is. Do you know that Thoreau’s classic Walden costs 6.95$. My previous read, Krakauer’s latest Where Men Win Glory was 27.95$. Good news, Thoreau’s mentor Ralph Waldo Emerson’s works is only 5.95$.
It is 0500 and 22 degrees outside. Catherine is asleep on the couch and I sit with a blanket at her feet. She unknowingly in her haze snuggles her feet to me and with my book light read to page 70 of HDT’s Walden. It is good, and different than churning circles on the watt machine in the garage. Change.
I will keep you posted on my transition to intelligence. Have already learned that HDT felt it silly to toil on drudgery one’s whole life only to retire old and stiff and unable to enjoy -at least that’s an interpretation.
Read on.
Grin.
JMM

Observations from the Outback…

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November marks the annual American Heart Association (AHA) meeting. This is one of the few major heart meetings each year.

AHA focuses on the newest technologies for the treatment of ongoing cardiac disease. Termed, “secondary prevention,” this year there were studies on implantable devices for heart failure, new blood thinners to assist in the squishing of blockages and new drug and drug combinations to treat high blood pressure and high cholesterol.

Cardiology is famous for their innovation in developing therapies to treat existing disease. Arrhythmia management has exploded in the past decade. The irony is that heart disease remains the most preventable disease known. The most dependent on lifestyle factors.

We fail miserably in our challenge to prevent heart disease (“primary prevention”) in the first place. I fail, my colleagues fail and it is obvious from our observations at dinner last night at the Outback Steakhouse (Indy) that Indianapolis docs are failing as well. There exists no drug, no device or intervention to controls one’s lifestyle.

A vignette:

The main arrhythmia I deal with is atrial fibrillation (AF). In many cases it is highly lifestyle dependent with obesity, body fat composition, sleep, high blood pressure and alcohol consumption all being highly contributory. A very overweight businessman type comes to me for treatment of AF. He does not exercise, sleeps poorly, drinks a few at night and eats too much. Zero time per day invested in his own health. I know that I can transiently correct the arrhythmia with a procedure and drug (add another medicine to his list). I make a deal -a bad idea. He promises a change. “If I could just feel better, I would exercise.” We agree and move forward. Procedure, 3 day hospital stay and a new drug for AF. This is the easy part.

Six weeks later in the office he reports feeling great. Heart rhythm is normal. I ask, “cool, you remember our agreement about exercise and weight loss?” A sad look comes upon him. No, a lifestyle change has proven elusive again. I understand, I am numb to this scenario.

Our challenge is to change this cycle. How? Ideas?

Pretty sure procedures and medicines are not the answer.

JMM