CAC Score: 96% Accuracy Not Good Enough For Trial Lawyers

Coronary artery calcium scoring, increasingly popular in emergency departments, could misdiagnose four of every 100 patients with significant blockages in their heart arteries, according to the latest research.

Chest pain is one of the most common reasons for an emergency department visit and hospitalization.  It can be life-threatening.  Or it could be a simple chest wall muscle strain.  Much time and money is spent trying to find the cause before it's too late.  Blocked heart arteries is one of the five or six serious, life-threatening causes of chest pain. 

I've written previously about the various tests for blocked arteries in the heart.  Angiography remains the gold standard even though it's riskier than the other tests since it is invasive: needles, catheters, dye injection, etc.  Expensive, too. 

Everyone would like a safer, cheaper, quicker alternative to coronary angiography for chest pain in the emergency department.  One option is determination of heart artery calcium by CT scanning, otherwise known as the CAC score (coronary artery calcium score).  Over time, most blocked heart arteries develop calcium deposits.  But not all heart arteries with significant blockages have the calcium that can be detected by a CT scanner. 

The Multi-Ethnic Study of Atherosclerosis enrolled 6,814 subjects who were free of heart symptoms at baseline.  Over half of these had no CT-detectable calcium in their heart arteries at baseline - a good thing, and generally considered to indicate low risk for future heart disease.  However, over the next 18 months, 175 of the study participants ended up needing coronary angiography. 

In nearly all cases, the extent of heart artery calcification at baseline was directly related to the degree of artery obstruction found at angiography.  But 4% of angiograms showed significant obstruction despite a zero calcium score. 

A four percent misdiagnosis rate might be acceptable to most patients and many physcians, but it won't satisfy a trial lawyer.  He'll be quite happy to sue the ER doctor who gambled and lost on that misdiagnosis rate.  The lawyer is likely to win the case. 

How about avoiding chest pain, ER physicians, and personal injury lawyers altogether?  NutritionData's Heart Health section has some good ideas for you.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Reference:  Rosen, B.D., et al.  Relationship between baseline coronary calcium srore and demonstration of coronary artery stenosis during follow-up.  MESA: Multi-Ethnic Study of Atherosclerosis.  Journal of the American College of Cardiology Imaging, 2 (2009): 1,175-1,183.

That's Just Great: ANOTHER Epidemic to Worry About!

Metabolic Syndrome affects nearly four of every 10 adults in the U.S., yet most people aren't familiar with it.  The syndrome itself is without symptoms.  The problem is that Metabolic Syndrome increases your risk of type 2 diabetes by five-fold, and doubles your risk of developing cardiovascular disease - heart attacks, strokes, poor circulation - over the next five to 10 years.

"How would I know if I have Metabolic Syndrome?" 

Your doctor might tell you, or you can determine it yourself if you know some of your lab values and blood pressure.  The syndrome is defined simply by the presence of at least three of the following five criteria:

1. Waist circumference over 102 cm (40 inches) in men, or over 88 cm (35 inches) in women
2. Serum triglycerides over 150 mg/dl (or already on drug therapy for high triglycerides)
3. HDL cholesterol under 40 mg/dl (men) or under 50 mg/dl (women) (or on already on drug therapy for low HDL)
4. Systolic blood pressure over 130 mmHg and/or diastolic over 85 (systolic is the first or top number) (or already on drug therapy for high blood pressure)
5. Fasting blood glucose level over 100 mg/dl (or already on drug therapy for elevated glucose)

Some physicians argue that there's no reason to label someone as "Metabolic Syndrome."  Others feel that the moniker has helpful therapeutic impact.  The can say, "Look, Mr. Johnson, I care about you and your future health.  Since you have Metabolic Syndrome, over the next decade you have a five-fold increased risk of diabetes and double the risk of heart disease.  Let's talk about how we might reduce that risk before it's too late."

"How can I prevent or even treat Metabolic Syndrome?"

Work with your personal physician, of course.  And consider the following information available at NutritionData:

• Lose excess fat weight
• Start exercising regularly
• Low-glycemic-index eating increases HDL cholesterol, lowers triglycerides and blood sugar, and reduces risk of type 2 diabetes
• The DASH diet lowers blood pressure

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Heart Disease in Women vs Men: Two Different Diseases

Up to 50% of women with heart disease symptoms do not have the typical blocked heart arteries seen in men.  Instead the problem seems to lie in the small arteries of the heart not even seen on traditional angiograms, according to a state-of-the-art paper in a recent Journal of the American College of Cardiology.

Physicians are having to re-think our whole approach to women with heart disease symptoms but no atherosclerotic obstructions in the major heart arteries.  The "plumbing model" serves men fairly well; women, not so well.  Yearly in the U.S., more women than men die from heart disase: 455,000 versus 410,000. 

Are the higher cardiac deaths in women related to their higher average C-reactive protein levels, a marker of inflammation and predictor of heart disease?  We don't know yet.

The authors of the paper speculate that abnormal reactivity in the small heart arteries leads to poor blood flow (ischemia) to the heart muscle.  They propose the term "Ischemic Heart Disease" be applied to this phenomenon, reserving "Coronary Heart Disease" for obstructions in the large arteries.

Lead author Leslee Shaw, Ph.D., discussed the journal article in an interview. 

We have drug therapies that reduce chest pain and improve quality of life associated with small artery ischemia.  We need much more research, especially with regards to prevention of heart failure and death in women.  Recognition of the fact that heart disease in women is not the same as in men should lead to better quality research. 

But you don't have to wait years for research results.  You can start today to reduce your heart disease risk: visit NutritionData's Heart Health section. 

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References: 

Shaw, Leslee, et al.  Women and ischemic heart disease.  Journal of the American Journal of Cardiology.  54 (2009): 1,561-1,575.

Interview with the article's lead author

A Heart Attack Isn't a Death Sentence for Your Sex Life

A heart attack will definitely put a damper on your sex life, but it's only temporary.  Nearly all heart attack patients can return to satisfying sexual activity, with a few precautions.

I recently wrote about the odds of a sex-induced heart attack among the general poplulation.  The risk is higher in those who have already had a heart attack or heart pain called angina.

Problems with sexual functioning after a heart attack occur in at least half of patients.  They worry about triggering another heart attack or even sudden death.  They may be depressed or anxious about the new diagnosis.  Heart drugs may interfere with sexual function.  None of these issues are aphrodesiacs.

Safe resumption of sexual activity after a heart attack depends on medical factors specific to an individual.  Is there ongoing chest pain (angina)?  Is blood pressure controlled?  How out-of-shape is the person?  Are there serious heart rhythm disturbances? 

After a heart attack, reducing the risk of a future sex-induced heart attack boils down to:

• managing or resolving chest pain, high blood pressure, rhythm disturbances, and breathing trouble
• passing an exercise stress test
• drug therapy usually including a beta blocker and aspirin

You'll have to work with your personal physician on these.

Note also that regular exercise also leads to "safer sex."  Your doctor can refer you to a cardiac rehabilitation program or you can get started with Four Weeks to a Fitter You if your doctor approves.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Flu Vaccine Protects Against Heart Attack? What the . . . !

Unless you've been living under a rock recently, you may have noticed a slight push to get vaccinated against the flu.  This will intensify since the Swine flu H1N1 vaccine will be available in next month.  That's why my ears perked up when I read that flu vaccine may protect against heart attacks.  

According to the article in HeartWire from TheHeart.Org from WebMD, a meta-analysis from the UK found two randomized studies examining the protective effect of flu vaccination against death from heart disease, in people with preexisting heart disease.  One study showed a benefit from vaccination, the other was inconclusive. 

That's pretty weak linkage between heart attacks and flu vaccination.

To the extent that heart disease can be aggravated by stress - psychological or physical stress - it makes sense that adding the flu on top of heart disease could be a bad combination.  That's enough reason for heart patients to seriously consider flu vaccination.

As for the Swine flu H1N1 vaccination, you'll have to decide for yourself whether to believe the public health officials' exhortations that the vaccine is reasonably safe.  It will be 3-5 months before we know if dire predictions of a serious Swine flu H1N1 pandemic come true or not.  By then, there may be no more vaccine, or it may be too late to take effect.

Would you like a sure-fire, magic-bullet nutritional approach that prevents all cases of the flu?  Sorry...I don't have one.  I generally follow the kind of food advice Monica Reinagel dispenses in her NutritionData Blog. 

That, and good handwashing technique.  And avoid secretions from sick people when able.

Do you plan on taking the Swine flu H1N1 vaccine?  

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References:

Wood, Shelley.  Flu vaccine may protect against MI.  TheHeart.Org, September 21, 2009.

Warren-Gash, C, et al.  Influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: A systemantic review.  Lancet: Infectious Disease, 9 (2009): 601-610.

ICD: Women, Think Twice Before Accepting This Heart Hardware

Implantable cardioverter-defibrillators (ICDs) are designed to prolong life by shocking the heart out of a life-threatening rhythm disturbance.  Problem is, they don't seem to work in women although three in ten of the devices are surgically implanted in women.

We didn't know this until reported in a September, 2009, issue of Archives of Internal Medicine.  If you're a woman and your cardiologist or heart surgeon suggests one of these devices, be sure he knows about this study. 

Candidates for ICDs typically have heart failure, which predisposes to sudden cardiac death, or, if lucky, aborted sudden cardiac death.  OK, it's better not to have any sort of sudden cardiac death!

It's caused usually by a heart rhythm disturbance, either ventricular fibrillation or ventricular tachycardia.  If not terminated by an electrical shock, they can be fatal.  Have you noticed automatic external defibrillators (AEDs) in the mall yet?  Surgeons can now implant a battery under the skin, with wires leading to the heart that will deliver a shock when needed.  Hence, implantable cardioverter-defibrillator, or ICD.

Click here for information on non-electrical ways to avoid sudden cardiac death.

-Steve Parker, M.D.

Reference:  Ghanbari, Hamid, et al.  Effectiveness of implantable cardioverter-defibrillators for the primary prevention of sudden cardiac death in women with advanced heart failure.  Archives of Internal Medicine, 169 (2009): 1,500-1,506.

Diet-Heart Hypothesis: R.I.P.

Contrary to popular belief, dietary fat - whether saturated or not - is not linked to higher risk of death or illnesss from coronary heart disease, according to a study just published in Annals of Nutrition and Metabolism.  Trans fatty acids are an exception.

This is another nail in the coffin of the Diet-Heart Hypothesis.

Researchers in New Zealand re-examined all the high-quality scientific studies looking at the effect of dietary fats on coronary heart disease, the leading cause of death in Western societies. Atherosclerosis in the heart arteries can cause chest pain (angina), heart attacks, heart failure, death, or the need to overcome a clogged artery with angioplasty or bypass surgery.

Here are the major findings of the meta-analysis:

• total fat intake is not associated with coronary heart disease
• higher trans fatty acid intake is linked to higher heart deaths and events
• saturated fatty acid consumption is not linked to heart deaths or events
• data on heart disease and polyunsaturated fatty acids are "inconsistent and unreliable"
• monunsaturated fatty acid intake was not associated with heart disease
• higher omega-3 fatty acid consumption (from fish oils or actual fish) is linked to lower risk of heart disease, although the data are not quite as strong as the authors would prefer  

With the exception of trans fats and omega-3 fats, the authors write, "The available evidence from cohort and randomized controlled trials is unsatisfactory and unreliable to make judgment about and substantiate the effects of dietary fat on risk of CHD [coronary heart disease]."

But they have made a judgement: Total and saturated fats are not related to heart disease.

In an interesting post-script, the authors mention "Expert Consultation," which sounds like an oversight panel.  This committee seems to have insisted on modifcation to the article to the effect that "replacing saturated fat with polyunsaturated fat reduces CHD risk."  Reading between the lines, I sense the authors had to swallow hard before adding that.

-Steve Parker, M.D.

Reference:  Skeaff, C. Murray and Miller, Jody.  Dietary fat and coronary heart disease: Summary of evidence from prospective cohort and randomised controlled trials.  Annals of Nutrition and Metabolism, 55 (2009): 173-201. Available free online September 15, 2009.

Finally, Some GOOD News: Heart Disease Hospitalizations Down

The U.S. Agency for Healthcare Research and Quality recently reported that hospital stays for coronary heart disease - clogged heart arteries - decreased by 31% between 1997 and 2007, the latest year for which figures are available. No longer the No.1 disease treated in hospitals, heart atherosclerosis now trails both pneumonia and heart failure.

The report includes other "fun facts":

• five circulatory disorders were among the top 10 most frequent principal diagnoses leading to hospitalization
• circulatory disorders were the most frequent cause of hospital stays: 16% of the total
• cardiac catheterization is the second most common procedure among hospitalized men, and the fourth most common in women
• congestive heart failure rates were unchanged between 1997 and 2007
• stays for acute cerebrovascular disease (usually stroke and transient ischemic attack) declined 14% between 1997 and 2007
• admissions for nonspecific chest pain rose 47% between '97 and '07
• admissions for irregular heartbeat were up 28% between '97 and '07

Despite the improvements in hospital admission figures, heart disease and stroke remain the No.1 and No.3 leading causes of death in the U.S., respectively.

I don't have hard figures to back it up, but I bet we can thank the trial lawyers - think "defensive medicine" - for the increase in nonspecific chest pain admissions.

Much of this blog is about coronary heart disease and its prevention.  You can also read about prevention of heart failure.

-Steve Parker, M.D.

Reference: Levit, K., et al.  Statistics on hospital-based care in the United States, 2007 .  Agency for Healthcare Research and Quality, 2009.

You See a Man Collapse at the Mall. What Do You Do?

Over a million Americans have take CPR (cardiopulmonary resuscitation) classes.  Most don't remember the proper ratio of chest compressions to breaths.  A recent study found that it's far more important to give chest compressions than mouth-to-mouth breathing.  In fact, doing chest compressions and not giving any breaths at all is helpful.  Do both if you can, but don't be paralyzed with indecision.

CPR provides some oxygen and blood flow to someone who is not breathing or is without a pulse (no blood flow).  Of course, the victim is unresponsive and not moving.  The underlying cause in adults is often a rhythm disturbance in the heart: ventricular fibrillation or ventricular tachycardia.

During adult CPR, the current recommendation is for 30 chest compressions, then two breaths, then 30 compressions, then two breaths, and repeat the cycle until paramedics arrive and take over. 

Many people, even health professionals, are hesitant to administer mouth-to-mouth breathing to cardiopulmonary arrest victims.  You might have to deal with vomit and germs, etc. 

My point today is that you might save a life if you just give chest compressions without mouth-to-mouth.  

Here's what to do when you see that 60-year-old man suddenly collapse while window shopping outside Victoria's Secret.  You don't have to do it all yourself; enlist bystanders:

• Confirm that he's unresponsive and not moving
• Call 911 (or your local emergency medical service)
• Get an AED (automatic external defibrillator) if available
• Check to see if the victim is breathing. If not, give two quick breaths that make his chest rise.
• Check for a pulse if you know how.  The neck is the easiest place. No pulse? Then start chest compressions, hard and fast (100 per minute, depressing the chest 1.5 to 2 inches).  After 30 compressions, give two breaths.  Then resume compressions (30), then two breaths, etc., until paramedics arrive and take over.

If someone found an AED and you're pretty sure the victim is pulseless, go ahead and try to use the defibrillator.  They're automated; a recorded voice and pictures walk you through it.  By this time, at least a couple minutes have passed and you have nothing to lose.

Don't feel bad if you can't remember this sequence and all the steps. If the victim is unresponsive, breathing ineffectively or not at all, and has no pulse, at least start chest compressions.

With luck, others will be there to help. You and the team may save a life. 

For CPR classes in your area (U.S.), call 877-242-4277.

-Steve Parker, M.D.

References: 

2005 Adult Basic Life Support Guidelines from the American Heart Association

Christenson, Jim, et al.  Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.  Circulation, online September 14, 2009.  DOI: 10.1101/CIRCULATIONAHA.109.85222

World's Oldest Person Dies of Suspected Heart Attack

Gertrude Baines, the world's oldest person, died in her sleep at a convalescent home in Los Angeles yesterday.  Born in 1894, she was 115.  Her physician suspects a heart attack.

Dr. Charles Witt said, "She told me that she owes her longevity to the Lord, that she never did drink, never did smoke, and she never did fool around," according to CNN.com.

From the reports I've read, I gather that she ate quite a bit of bacon, fried chicken, and ice cream!  It's unclear how often and for how long she enjoyed these.  From her published photographs (click the CNN reference below), it looks like her body mass index exceeded the "healthy" range of 18.5 to 24.9.  We learned a few years ago that folks over 65 have better longevity with a body mass index between 25 and 30.

My ears always prick up when I hear these reports of centenarian deaths.  They usually mention factors that the deceased credited with their longevity.  The answers are all over the map.  Few of the oldest old, however, are lifelong daily smokers.  If you want help quitting tobacco, click here.

For us NutritionData afficionados, it makes you wonder exactly how much impact diet and exercise have on health and longevity.  Undoubtedly, many other factors are at play.

Rest in peace, Gertrude.

-Steve Parker, M.D.

References:

Rogers, John.  World's oldest person dies in Los Angeles at 115.  Yahoo!New (Associated Press), September 11, 2009.

Gertrude Baines, world's oldest person, dies at 115.  CNN.com, September 12, 2009.