More On Calcium Scores

My last blog concerned the use of calcium scores to determine whether a patient did or did not have coronary artery disease.  An article has been published that I would like to share with you because it compares the Framingham risk calculator and the use of calcium scoring to determine which is better in defining patient illness.

This article titled “The detection of any coronary calcium outperforms Framingham risk score as a first step in screening for coronary atherosclerosis” was published in the Am J Roentgenol 2010: 194:1235-1243.  The study details that 1416 men and 707 women were included.  The mean age of the men equaled 51.4 years, and the mean age of the women equaled 56.9 years.

In those patients who had a presence of a segment plague score of 4 or higher, any calcium was 98% sensitive in men and 97% sensitive in women.  In the same population if you had a Framingham risk score of 10% or higher, it correlated with the findings only 74% of the time in men and 36% of the time in women.

If your plague segment score was 3 or higher, the presence of calcium was 97% sensitive in men and 92% sensitive in women.  In contrast, the Framingham score of 10% or greater was found in 88% of men and 35% in women.

This is not really surprising as I explained before that the presence of any calcium infers that the patient has the illness and needs to be treated.  It does not mean that they have symptomatic disease but the data can be used to propel the patient to “make the right decision” and stop smoking, control their blood pressure and take statins.  In much the same way the Framingham calculator does that because you input the blood pressure, the smoking status and the LDL level as some of the information to achieve a score.  By “manipulating” the data, one can point out that lowering numbers or stopping smoking reduces risk considerably.

Why the disparity in women and men scores is so great, I do not know.  It is widely understood that the diagnosis of coronary disease in women lags behind men, although equal numbers of men and women die each year.  Perhaps women should have scoring and men the Framingham test and then the numbers would be more reflective of need. 

Technology may help us lead the way to better patient care in both men and women.

Tags: blood pressure, calcium scoring, coronary atherosclerosis, Framingham Risk Calculator
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The Opportunity We Lost

Healthy People 2010 was launched in 2000.  The aim of this project was to reduce the number of cardiovascular deaths by 20%. This is certainly a worthy project.  The results were published in the Bulletin of the World Health Organization in February.

I’m sure you can guess but we didn’t make it.  400,000 deaths in the U.S. from cardiovascular disease are projected to occur this year.  I want to put this into perspective.  416,000 servicemen and women died during World War II.  Each year, we lose that many people to heart disease.  You would think there would be uproar.  The only sound I hear is snacking.

What exactly seems to be the problem?  We have had a reduction in improved total cholesterol and in lower blood pressure in men.  We have also increased physical activity and decreased smoking.  However, this is almost totally offset by an increase in obesity and diabetes.

We must rethink the balance of government and personal responsibility.  The government does not make us eat more or make us fat.  The government can limit the salt in food and demand that soft drinks be removed from schools.  We can develop all sorts of medications, but it seems to come down to what will you do for yourself and most of it seems to revolve around how much you eat.  Most diabetes is related to simply being overweight.  This is a personal responsibly and until we grasp this future progress may not be made.

The most recent National Health and Nutrition Examination Survey found that most Americans are overweight and one-third are obese.  Obesity has overtaken smoking as a major health burden in the United States.  This is very apparent if you travel anywhere outside the United States and compare average body size.  Don’t go to Disney World, it is truly disheartening.

Let’s all pledge to lose 10 or 15 pounds.  We went to the moon. We can understand this problem and solve it.  It won’t be solved by drugs, it must be solved by education and the simple understanding that we eat too much.  Put down the remote and do something.

Tags: blood pressure, cardiovascular disease, Cholesterol, diabetes, Healthy People 2010, Obesity, overweight
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One Down, Two to Go

Let’s start with a surprising and disturbing fact.  As published in the New England Journal of Medicine 1988:339:229-234 and titled Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction, was the conclusion that and I quote “Patients with type 2 diabetes mellitus without a history of myocardial infarction have the same risk of a coronary event as patients without diabetes who do have a history of myocardial infarction.”  In other words, just having diabetes is the equivalent of having coronary disease. 

This well done study became the impetus to attempt to alter this risk.  Surely, a well placed endeavor.  We have seen that very strict control of hemoglobin A1C was harmful.  What about blood pressure control?

The investigators wanted to determine if a blood pressure target of systolic 120 was better than a target of systolic 140.  Presently, the target is systolic 130.  After 4.7 years, there was no significant difference in a composite outcome of nonfatal myocardial infarction, nonfatal stroke or death from cardiovascular causes.  There were more frequent serious adverse events in the intensive therapy group.

So, better glucose control and lower blood pressure causes more harm and no benefit.  Doesn’t look good for the third arm that of lipid control?

In this part of the study, subjects were randomly assigned to simvastatin (Zocor) or simvastatin plus fenofibrate.  Additions of fenofibrate to simvastatin were supposed to lower triglycerides and increase the level of HDL and provide benefit but it did not result in a significant improvement in the composite endpoint.  In fact there was a signal of harm in women subjects.

Well, three for three.  This is how we learn.  This is how we move medicine along.  We will not stop trying to improve the quality of life for patients with diabetes.  It should be pointed out that one of the best ways to prevent the problem is to control your weight and get regular exercise, easily written but hard to do.  As we can see from these studies it is probably still the best advice.

Tags: blood pressure, Myocardial Infarction, simvastatin, simvastatin plus fenofibrate, Type 2 Diabetes
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Maybe Your Mother Was Right

I’m not making this blog up. An article has been published in Circulation, one of our most difficult journals to get published in.  This article in Circulation claims that watching television is killing us.  If you want a copy, e-mail me and I will send you a PDF.  You can also click on the Circulation word, and it will link you to the article.

The article titled Television Viewing Time and Mortality: The Australian Diabetes, Obesity and Lifestyle Study (AusDiab) evaluated the effect of sedentary behavior with mortality risk.  In particular, they examined the relationship of prolonged television viewing and the risk of premature mortality.  8,800 people participated in the study;  3,846 men and 4,954 women.  None of the individuals had a history of any cardiovascular disease.  The participants entered the study during 1999 to 2000.  All participants were examined and had blood tests.  The study ended on November 16, 2006.

Three categories of time where created <2, >2 to<4 and>4h/d and were assessed for a period of a week.  This was a combination of television or video and you had to be watching.  It wasn’t that the television was on but you were doing other things.

Over the 6.6 years, a total of 284 deaths occurred.  87 or 31% were due to cardiovascular disease, 125 or 44% were due to cancer and 72% or 25% were “other”.  Each 1-hour increment was found to be associated with an 11% increase in all cause mortality and an 18% increase in cardiovascular mortality.  Here’s the bottom line, if you watched more than 4 hours a day you had a 46% increased risk of all cause mortality and a whopping 80% risk of cardiovascular mortality, which was independent of the traditional risk factors such as smoking, blood pressure, cholesterol and diet.

Don’t tell NBC, they are having enough trouble figuring out what to do with Jay Leno.

Why this is so? Maybe the association of eating “snacks” when we watch television,  but the data is well done and points out a further reason that we need  to change our habits. Further, television watching is only one sedentary activity we do.  The total time of sedentary work and computer use adds considerably to the problem.

The solution is simple but often ignored.  Get up and do something, anything.

Tags: blood pressure, cardiovascular mortality, Cholesterol, Television Viewing Time and Mortality
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Will Cardiac Diagnostics Work?

We, as physicians, are used to measuring things.  We measure temperature, blood pressure, height and weight.  We measure your blood counts and the level of cholesterol in your blood.  We are used to measuring things and part of this derives from the science of medicine.

In general, we believe that it you can measure something you will understand something better and possibly begin to change it.  With the development of blood glucose monitors,  we are able to be more precise in our control of diabetes.  Those of you who are old enough will remember when glucose control was measured by urine test strips.  Glucose monitors are now an essential part of diabetic care and are approved by Medicare and Insurance companies.  There is some debate as to whether this glucose control does any real good but it is accepted by both physicians and the public.

How do you measure a hearts function.  It is not blood pressure because a normal heart can have a blood pressure of 90/60; a failing heart can have a blood pressure of 200/110.  The physical signs are rapid weight gain and special sounds we hear in the lungs called rales, which is derived from the French word rattle.  A Frenchman Rene Laennec in 1816 developed the first stethoscope, again to measure something.

We measure heart function by measuring the pressure in the heart and lungs.  I do this daily at cardiac cath and we have exquisite knowledge about these dynamics.  We can also measure the pressures non-invasively by echocardiogram.

In the late 1960’s, two physicians at Cedars-Sinai in Los Angeles developed a catheter that could be placed in a vein and threaded into the heart to measure the pressures in the lungs.  Initially known as a Swan-Ganz catheter after its inventors, Jeremy Swan and William Ganz, it eventually became known as a Swan. (Don’t ever be the second name on an invention.)  These catheters saved millions of lives and led to an era of improved intensive care.  The seminal article was published in the New England Journal of Medicine in August 1970.

We now have two ways that I know of to measure the status of the heart on a day to day basis.  The science of these measurements is well understood.  FDA before approval of the devices and the measurements demanded proof that the obtaining of the measurements led to good clinical outcomes such as staying out of the hospital with heart failure.  We at the Jim Moran Heart and Vascular Institute participated in one of the device approval trials.

Next…the devices and why they may help us better care for patients.

Tags: blood glucose, blood pressure, Cholesterol, diabetes
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