It's STILL About the Plaque, Stupid!

I like About.com. In fact, I use it to keep up on my Spanish. But, just as with Yahoo!, it leaves a lot to be desired in terms of heart health advice. Since I took the time to "go off" on Dr.Margolis at Yahoo! Health, it's only fair I treat the drivel being pushed by Dr. Fogoros at About.com with the same disdain. Such a pity too because he ALMOST got it right.

The good doctor attempts to answer the provocative question, "EBT (Ultrafast CT) Scans - Godsend, or Scam?" in the About.com: Heart Disease section. He actually does a pretty good job explaining everything until he gets to the real meat of the issue; the efficacy of using heart scans to track heart disease. Unfortunately, like many other traditional practitioners, he remains blinded by the hopelessly outdated fixation on OBSTRUCTIVE heart disease.

For many years heart disease theory and practice was centered on treating heart disease like a "plumbing" problem. You simply test the coronary arteries for flow and if it's adequate everything is just fine. If not, you hope you catch it in time and call "roto-rooter." Everything was focused on finding and fixing obstruction to flow. But a not-so-funny phenomenon kept occurring. People would pass their stress test and then die of a heart attack the next day! What the hell?

It is now known that most heart attacks actually occur at sites with no symptomatic or even detectable flow obstruction. Unstable, previously undetectable "silent" plaques rupture exposing their lipid core to blood, a clot forms, and bang, you're dead! The bottom-line is that what you need to know is NOT the amount of obstruction you have but your total PLAQUE burden. A heart scan will tell you this, a stress test or even a catheterization often WILL NOT.

Dr. Fogoros completely misses the point when he laments that a heart scan does not have the power to accurately predict who has an obstruction at any given instant. That is what a stress test is for. It will tell you if you currently have obstructive heart disease and are in imminent danger of dying immediately. However, it will not tell you a thing about what will happen at any point in the future - like tomorrow! A heart scan is the most accurate predictor of your risk for future heart attack.

Here is the bottom-line. Get a freakin' scan heart scan. If your score is zero, throw a party. If it is non-zero find a doc who understands what your risk is, how to determine the root cause of whatever is causing the problem (hint: High LDL cholesterol is not the most common problem), and put together a program to treat your root causes. Get a yearly repeat scan to see if your plaque burden is growing or shrinking. If it has been arrested or starts reversing - again - throw a party. This means your heart attack risk is almost as low as a zero score. If it is growing, you need to be more aggressive in your current program or change it. The key here is that without a follow-up scan you have no idea of what to do next.

So stop worrying about obstructive heart disease (OK, so don't worry quite so much). Focus on plaque burden.

Plaque is Where It's At!


HeartHawk

The Davis/Walton-Shirley Dilemma - What's the Answer?

WOW! The recent comments elicited by my latest blogs on PCI demonstrate a profound concern and understanding about the dilemma of heart attack prevention versus intervention. It does my heart good (pun intended) to realize there are so many people out there who not only give this issue thought but are willing to share those thoughts. Thanks go out to Dr. Walton-Shirley and Dr. Davis for taking time out of what I am certain are very hectic schedules and the legion of commenters like Bix, wccaguy, warren, and the ever-enigmatic "Anonymous."

This issue has many real life similarities. For example, even though my parents, teachers, insurance agent, and Smoky the Bear all extol the virtues of fire prevention, it is still nice to know the fire department is only a call away to bail you out when you do something stupid (like when I went into my backyard to pitch a few golf balls while waiting for a pan of oil to heat up on my oven top). The same could be said for heart disease prevention except for the fact that, unlike fire prevention, figures of authority preaching prevention are few and far between. It leads the conspiracy theorists among us to wonder if this peculiar situation is a matter of incompetence or perhaps planned obsolescence! Remember, it was not that long ago that Detroit purposely designed cars to need expensive repairs after several years.

So what to do? On the one hand preventionists have a hell of a point, the technology to prevent most heart attacks exists today and is simply not being made available on a widespread basis. On the other hand, we have a large segment of society that either blindly follows outdated health practices or are simply to dumb or lazy to take responsibility for their health. What do we do, let them die? (Darwinists might argue that this is a valid option).

I believe the comments made on this blog point the way. Yes, let's continue to develop fast, cost-effective rescue measures for the unlucky few who infarct despite prevention or those too blind to help themselves. But, at the same time, let's DEMAND that the medical establishment educate and discipline itself to practice modern prevention. Let's have the interventionalists actively put pressure on their own colleagues to balance their practice with prevention and throw out the ones who operate "catheterization factories." There is no room in medicine for putting unethical profit and "God complexes" above lives. Remember, even if there were an interventionalist in every "pot" and a cath lab in every "garage" many people would still die needlessly.

So, there's my compromise. Any takers?


HeartHawk

Dr. Melissa Walton-Shirley States Her Case

Back in June I wrote a rather scathing blog that took Dr. Walton-Shirley to task for her position on Primary PCI. She was understandably upset that I would read into her comments something that she claims was either misread or simply not there and wrote this comment to take me to task.

I guess I really cannot blame her for being upset that I used her as the latest scapegoat for the failing medical establishment, but, I felt, and still do, that my position on the medical community as a whole was right on the money. So, in an effort to set the record straight on numerous fronts, let's get down to the nuts and bolts of my position. Then YOU can decide.

1. First, let's all understand something. In any debate there are two sides and both sides must anchor their end of the spectrum. Dr. Walton-Shirley feels the best use of time, talent, and money is to build more cath labs and train more people in how to use them so that IF you have a heart attack, you stand a better chance of being pulled back from the brink of death. Unfortunately, you have to first let people get so sick that they are about to die. My position is to use those same resources to prevent such disasters from happening in the first place. Take your pick. You cannot spend the money twice.

2. My role in this melodrama is to be as aggressive and relentless as the other side. This is not Little League. Like it or not this a "blood-sport" and that is not just a metaphor. People's lives and quality of life are at stake. I am not above spilling a little blood of my own along the way.

3. In my blog I praised Primary PCI as a wonderful tool. I miss my mother, my grandfather, and my uncle and wish a cath lab had been across the street when they were in the throes of their heart attacks. But, I wish, even more, that they had access to enlightened medical care 5-10-20 years before those sudden, life-ending events, care that would have PREVENTED them having a heart attack in the first place.

4. My biggest complaint is the complete lack of self-policing within the traditional medical community. There are ways to effectively prevent and treat heart disease that simply are not being disseminated by the so-called guardians of our health. I have had top-flight, (previously) trusted internists and cardiologists make the following statements to me and my relatives.

- (after a routine cholesterol panel) "I have seen 50 patients today and your LDL cholesterol is lower than all of them. Now stop worrying." (NOTE: My doctor said NOTHING about my abnormally low HDL cholesterol nor, given my family history, do more than a conventional Friedewald lipid panel).

- (after my brother was tested at my urging - not his doctor's - and diagnosed with high lipoprotein(a)) "Here, take this statin. It's magic!" (NOTE: Statins are completely useless for reducing lipoprotein(a))

- (after my first nuclear stress test) "There is no evidence of any obstructive disease. I would not do anything at this point." (NOTE: It has been established that you can have extesive CVD with no detectable obstruction)

-(a conversation after an uncle's triple bypass) "ME: Too bad you didn't have a heart scan. UNCLE: I did, seven years ago. My score was 1200 but my doctor said as long as my stress test was OK to ignore it." (NOTE: 1150 of the 1200 was in his LAD, the only artery receiving - count 'em, not 1, not 2, but 3 bypasses)

- (2 weeks before my mother's fatal heart attack) "Congratulations, you passed your physical. Looks like you escaped your family's curse."

These were not schmucks but the best physicians we could find (and I'm damned good at it). Sorry, but I am not exactly the trusting sort anymore. In fact, I am as mad as hell!

SO WHERE IS THIS ALL GOING?

I do not fault Dr. Walton-Shirley for studying hard, working late, saving lives, and espousing ideas to save even more lives. If her ONLY intent was to make Primary PCI more available my ONLY question is whether this is the best use of resources. However, I am totally frustrated when the medical establishment continues to blindly put the cart before the horse. Dammit, it is just wrong to constantly beat the drum for more heart procedures when the overwhelming majority of them can be avoided. How about a little balance?

So, thanks for all the hard work and please do keep saving lives Dr. Walton-Shirley. As someone whose style is to be aggressive I admire the fact that you cared enough to fire back. Perhaps this will be the start of a wonderful professional relationship. We owe it to everyone to work together and limit "friendly fire." In fact, if I see your next published editorial is about cutting-edge prevention I guarantee I will write an equally effusive blog about a doc who "gets it." God knows we need more of them. But, don't be too surprised if I still get a little irritated when your colleagues fail to speak out about prevention and malpractice within your own ranks. But, I guess that's my job.

Regards,


HeartHawk

I told you so ... you Yahoos!

I hate to gloat (so I lie) but this breaking news just came in.

A few days ago I took Yahoo Health expert Dr. Margolis to task for suggesting in his health quiz that Vitamin D was of no value for fighting heart disease. Guess again! Experts like Dr. William Davis have been extolling the virtues of Vitamin D supplementation for well over a year now. He credits D with remarkable instances of heart scan score reversal when used in conjunction with his Track Your Plaque program (note that honest brokers of heart health information will never promote a single "magic bullet" because there ain't no "one size fits all" answer in this game).

Anyone who still doubts the efficaciousness of Vitamin D should take notice of the study recently released by Drs. Autier and Gandini in the September 10th issue of the Archives of Internal Medicine. They found that doses of Vitamin D ranging from 300IU to 2000IU correlated with decreased risk of ALL CAUSE mortality (that includes heart disease, cancer, etc.) with no toxic effects. The study was a meta-analysis of 18 independent trials involving 57,311 participants.

Of course, this study does not have the power to differentiate effectiveness against any specific disease (say CVD for example) or determine recommended doses. The good doctors leave it to future studies to ferret out that information. But, considering the size of the study, it is a sure 20 to 1 bet (the study used the standard 95% confidence interval) that something phenomenal is going on.

So let me say it for the hundreth time. Traditional medicine is hopeles sly behind the curve when it comes to heart disease prevention and reversal. Unfortunately,they are largely invested in letting you get so sick you have to buy their surgical interventions and drug therapies. You have to dig and dig deep, gleaning information from many sources, in order to to have fighting chance to beat heart disease. Yes, there are quacks looking to snow you. But, if you don't fall hook line and sinker for every gimmick and snake oil salesman, if you do your research and believe in hard data over anecdotal instances, if you find praticitioners and patients with a history of success over years rather than days, if you just use COMMON SENSE, you can, and will, beat heart disease.

Now go take your Vitamin D!


HeartHawk

You Just Might be a Yahoo if . . .

. . . if you get all your heart health info from Yahoo!

Now, don't get me wrong, Yahoo is a fine search engine. Heck, how could I have made the above obervation if I never used it? But, it is yet another example of how hopelessly confused and inadequate traditional, mainstream medicine is.

The latest example can be found at Yahoo Health in a Heart Health nutrition quiz authored by Simeon Margolis, M.D., Ph.D. (although I also must admit that as a basketball junkie I am thoroughly impressed that Dr. Margolis still holds the record for most points scored in a game at his prestigious alma mater, Johns Hopkins). However, in question #5 of the quiz, the good doctor dismisses the heart health value of a long list of supplements - including Vitamin D! There have been numerous reports and studies published in the last year that support the use of Vitamin D supplementation as a preventive measure for heart disease. I am sworn to secrecy but I know of a small clinical study (which won't be available for at least six months) that will validate the latest research about the ability of Vitamin D to actually reverse heart disease. That study is too small to provide conclusive proof but the data is astounding.

The point is that many, if not most, physicians today are hopelessly out of date and out of touch with the fast pace of heart disease detection and prevention. So, at the risk of endless repetition, get your information from as many sources as possible. Relying on the advice of your local physician, or even the celebrity docs on Yahoo!, could be a fatal mistake!

Yippity Yahoo,

HeartHawk

It's the Plaque - Stupid!

I remember when I first met Dr. William Davis and we discussed the book he was writing titled "Track Your Plaque." My first thought was, "What a goofy name!" In retrospect, focusing on plaque and methods to track and reverse it was brilliant.

The latest debate about relative risk ratios and antioxidants reminds me about how traditional medicine relies on all manner of risk factors to determine how to treat heart disease. However, risk deals only with might or could happen. Yes, if you have high LDL cholesterol, low HDL cholesterol, or any number of other risk factors you might have heart disease. But, why live in the world of "maybe" when you could know exactly whether you have heart disease, how serious it is, and whether what you are doing is effective in treating it?! Get a heart scan and you will know for certain. As Homer Simpson would say, "DOH!"

The efficicacy of heart scans is no longer in question. Recent studies, statements by the AHA, the SHAPE guidelines all agree - heart scans are the best predictor of heart attack. I have always been impressed by the powerful statements issued by noted and independent heart disease experts and researchers.

Dr. Steven Nissen, Cleveland Clinic: "We now know that 95% to 99% of the heart disease occurs at sites WITHOUT artery narrowing. Thus, the old tests we perform to detect narrowing and blockages have really misled us. We miss over 95% of the heart disease that causes heart attacks."

Dr. Harvey Hecht, The Heart and Vascular Institute: "plaque imaging is ...not to be confused with risk factors, which merely estimate a probability of developing atherosclerosis. Rather, [plaque imaging] directly measures atherosclerosis, irrespective of the presence or absence of risk factors; it provides the final common denominator and is the most powerful predictor of cardiac events."

Regardless of cholesterol or the supplements you may or may not be taking, settle the question. Get a heart scan and, if you have a non-zero score, repeat it every year to see if you are gaining or losing ground. The plaque that is the root cause of heart disease can be treated - but only if you know how much you have!

Plaque, it's not just for teeth anymore!


HeartHawk

Dr. Cook Weighs in on WACS Antioxidant Study

Given all the commotion over the WACS Antioxidant Study, I contacted Dr. Nancy Cook who served as the lead bio-statistician on the study. She has agreed to let me publish her verbatim replies to a number of questions that are central to the debate. Here they are!

HeartHawk: What was the significance of setting the noncompliance threshold at using 2/3 of supplied study agents?

Dr. Cook: The threshold of 2/3 was pre-specified, but not particularly based on biologic activity. However, I can say that most of the women in the study either took all (or at least 90%) of the study pills or none. We didn't have many at intermediate levels, so the exact choice of cut point would probably not make much difference to the analysis.

HeartHawk: Please comment regarding the significance of the improved risk-ratio for Vitamin-E when noncompliant subjects were censored.

Dr. Cook: It's true that some significant effects emerged in our analyses censoring on noncompliance. This analysis, though, is not intent-to-treat, and can be subject to bias since those who take the study pills are likely to be very different from those who don't. It's also possible that intervening changes in risk factors are related to the lack of compliance, possibly differentially by treatment group (similar to confounding by indication). The outside use of these supplements also needs to be taken into account. The analysis censoring on compliance thus needs to be interpreted with caution. The results among compliers could be due to this self-selection bias, to a true preventive effect in those who keep taking the vitamin E regularly, to a possible early effect that goes away with time, or to a false positive finding due to the multiple comparisons. At this point we can't separate these out. So, while some of the findings for vitamin E are indeed tantalizing, they don't hold up to strict statistical or clinical trial standards. And the body of evidence for anti-oxidant trials in general has largely been disappointing. The most straightforward interpretation is based on our primary result, that there is overall no effect of this particular supplement on the composite endpoint. We cannot trust the secondary analyses to be reliable at this point.

HeartHawk: Any thoughts or comments about what WACS results may intimate about the value of naturally occurring antioxidants in foods as compared to supplements in any dosage or combination.

Dr. Cook: It's true that not everything is known about anti-oxidants, either by type or in combinations. As suggested in the discussion in the paper, some scientists have suggested that other forms of the anti-oxidants (eg. gamma- vs alpha- tocopherol) may be more beneficial. It's also possible that it is a combination of nutrients that has an effect. At this point it seems from a vast array of observational studies that diets high in fruits and vegetables are protective, which has also been supported by intervention studies such as DASH. So perhaps we haven't been studying the right form of anti-oxidant, or maybe a combination is needed, or maybe it is other nutrients in fruits and vegetables that are protective. There is still a lot that is uncertain. The best advice to the public is to eat a diet high in fruits and vegetables as well as to follow other healthy lifestyle habits, such as exercising regularly, rather than relying on supplements.

Thank you for your time and interest Dr. Cook!


HeartHawk

More on Antioxidants and the WACS Controversey

Hey, Hey! Looks like old "Hawky" hit a nerve with my jab at antioxidants! That's great because it's an area that deserves considerable debate given the fact that many of us consume significant amounts of them. Thanks go to "Captnsaj" and "Anonymous" for getting the debate going. Let's see where it goes!

First, let me confirm I am not an antioxidant "hater." Although, I do think Linus Pauling's and Mathias Rath's advice about ingesting mega-doses of Vitamin C is kinda loopy. What I AM saying is that, statistically, the WACS Study says they are not effective at reducing CVD. Lord knows I believe in the value of supplements and have had my share of disagreements with the drug companies. Drug company funding is ALWAYS problematic in any study but WACS was funded by the National Heart, Lung, and Blood Institute.

It seems Mike Adams is taking the lead in attacking the WACS study. So, for the time being, I will play devil's advocate and take the opposite side. Here goes ...

1. Let's start by refuting Mike's claim the study supports the use of antioxidants. In fact, the ONLY conclusion it draws is they are no more effective than placebo. The two exceptions were the findings that Vitamin E reduced risk once non-compliant subjects were removed and was duly noted in the report. However, the study produced dozens of statistical findings and the only one that showed statistical significance (just barely with a P=0.04) was the use of Vitamin E in women with confirmed prior CVD (but not women with risk factors but no confirmed CVD). There was also a "suggestion" Vitamin E in combination with Vitamin C should be looked at for effectiveness as reducing stroke risk as it showed statistical significance (P=0.o3). Frankly, when you generate that many statistics on a sample population, one or two may produce a false positive (in fact, statistics say it is likely). You have to consider the overwhelming body of statistics generated.

2. One needs to understand a little bit more of the math behind statistics. The study said the relative risk ratio (RR) for heart disease related events (heart attack, stoke, revascularization, and death) was not improved by any of the supplements. The key is to look at the confidence intervals (CI) and "P" values for each statistic. When P values exceed the "significance level" (o.o5 in this case) or the CI encompasses the value "1" then statisticians assume the null hypothesis is not rejected. In other words the tested agent did not produce any result that could not be explained by other than random chance. Note that the P values are all far greater than 0.05 in almost every case and the CI's encompass "1". In the few cases where marginal significance was achieved, the P values where only modestly below 0.05. Normally, I like to see these values in the range of 0.001 to 0.01 before I completely reject the null hypothesis. Required reading at this point should be Chapter 3 of Steven Milloy's treatise SCIENCE WITHOUT SENSE: The Risky Business of Public Health Research. There is also a good layman's description of the subject at http://sportsci.org/resource/stats/pvalues.html

3. Mr. Adams claims that non-compliant subjects were used to "dilute" the results. Unfortunately, that is not neccesarily the way statistics work. I put a call in to Dr. Nancy Cook the bio-statistician that oversaw the project. Perhaps she will provide more data. The example Adams gives where 50% of the test subjects did not receive "sandwiches" is a little outrageous and does not correspond at all with the way the WACS Study was run. I might also add that even using his fictitious example, the efficaciousness of "sandwiches" would still be borne out using the WACS statistical methodology.

4. Mr. Adams makes patently ridiculous statements like "If we taught people the truth about nutrition, they wouldn't need prescription drugs!" and "Drugs don't make people healthy." Tell that to all the people who died of infections or lost limbs before the advent of antibiotics (yeah, I know what you are thinking, but ANYTHING can be over-prescribed and misused). These sorts of patently false claims leads me to discount much of his other rhetoric.

5. Most drugs are simply purified and concentrated forms of naturally occurring substances. And just because a supplement is not a prescription agent does not mean it is not a drug. In fact, supplements like L-Carnitine require a prescription in Canada. Also, I doubt the Vitamin C Mr. Adams takes is distilled from oranges. It is likely made in a big chemical plant just like all the drugs he rants about. Finally, he mentions what he feels to be relatively low doses used in the WACS study. Linus Pauling routinely advises doses like 10 grams of Vitamin-C. How is THAT natural?

As always, the truth is somewhere in the middle. That is why I always advise people get their info from multiple sources - even zealots like HeartHawk and Mike Adams!

As for me, what the heck, I say hedge your bet. If you got the time, inclination, and money, a daily dose of 1000mg C and 400IU of E can't hurt. In fact, the WACS study makes a point of saying that it did not find any dangerous effects as were found for Vitamin E in earlier studies. Just don't expect any miracles!

More comments are encouraged!

Regards,


HeartHawk