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The Cardiometabolic Risk Working Group: Another Coven Practising Drug-Induced Magical Thinking

Posted by Colin Rose on April 14, 2011

The latest issue of the Canadian Journal of Cardiology, published by the Canadian Cardiovascular Society (CCS), both of which are largely funded by the drug industry has shamelessly published a “Position Statement by the Cardiometabolic Risk Working Group” (see highlights below). We have previously blogged about the American “Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults” and the Canadian “Working Group on Hypercholesterolemia and Other Dyslipidemias”. Now that the ability of “cholesterol” to induce terror in doctors and patients has become a little worn and less profitable, drug dealers have invented a new disease, “cardiometabolic risk” with which to terrorize asymptomatic people into demanding even more drugs and doctors into prescribing them. Many of the members of the previous covens have migrated to the new one.

These medical covens take it upon themselves to dictate to the rest of the medical profession what drugs should be prescribed to prevent diseases of lifestyle in the otherwise “normal” population, so-called primary prevention. How are these covens assembled and what gives them the authority to establish norms for other doctors? This paper reveals in stunning clarity the answers to these questions. As we can see from the Acknowledgements and Disclosures sections, most of the authors of this Position Statement have many long-term financial relations with many drug dealers. Of the ten members of the executive committee of the Cardiometabolic Risk Working Group, nine have multiple financial relations with drug dealers and of the whole Working Group 19 out of 21 have similar relations. Clearly, drug dealers have distributed tens, if not hundreds, of millions of dollars to these doctors, justified under various guises, to facilitate a culture of drug dependency. Drug dealers choose members of  the Working Group, pay them to be “authors”, pay a medical writer to compose the Position Statement and get it published in a journal which would not exist without the financial support of the same drug dealers. Why am I not impressed and why would any other doctor follow the advice of this coven? But most family physicians and many cardiologists treat this sort of statement, endorsed by presumably unassailable organizations like the CCS, as revealed truth by a mysterious higher authority in possession of occult knowledge that must be accepted or suffer ostracism by one’s colleagues. Of course it doesn’t hurt that a 30-second drug prescription for numerical symptoms of junk food addiction is much easier that spending many unpaid hours reducing the addiction, the only real way to prevent its consequences.

Here is an example of the occult numerological incantations of the Working Group. Compare this with the occult number philosophy of Agrippa based on the pentacle below.

Optimize lipid levels. In patients with cardiometabolic risk with a moderate or high Framingham Risk Score, treatment should be initiated with a statin to reduce low-density lipoprotein cholesterol (LDL-C) by at least 50% and to 2.0 mmol/L. Apo B levels are a better measurement of lipid-related risk in these patients, and the target level for treatment is 0.8 g/L in high-risk and moderate-risk individuals. There is a large residual risk for patients at high risk for CVD, despite LDL-C reduction with high-dose statins. Many patients with cardio- metabolic risk may also have an acquired combined hyperlipidemia, associated with increased triglycerides (TGs), a modest increase in LDL-C, and low high-density lipoprotein cholesterol (HDL-C). LDL particle numbers are increased, as reflected by the increased levels of apo B100. Beyond LDL-C lowering, strategies that might reduce the residual risk include reducing the total cholesterol (TC) to HDL-C ratio, high-sensitivity C-reactive protein, and TG, although there are no clinical trial data to date to support such strategies. In the patient with diabetes, glycemic control optimization and health behaviour modification should be attempted prior to the addition of another agent, such as a fibrate. In the Action to Control Cardiovascular Risk in Diabetes trial the addition of fenofibrate to simvastatin in patients with type 2 diabetes failed to show any reduction of CV events, although there may have been benefit in the subset of individuals with high TG/low HDL-C.

The deliberations of the Cardiometabolic Risk Working Group have much in common with pagan covens with occult rituals and symbols like the pentacle which when worn will drive out evil numbers such as “cholesterol”. Expensive statins for “cholesterol” and ARBs for high blood pressure are the new pentacle. The significance of the pentacle, as described by Heinrich Cornelius Agrippa in his Three Books of Occult Philosophy, makes as much sense as the Position Statement of the Working Group.  “A Pentangle also, as with the vertue of the number five hath a very great command over evil spirits, so by its lineature, by which it hath within five obtuse angles, and without five acutes, five double triangles by which it is surrounded. The interior pentangle containes in it great mysteries, which also is so to be enquired after, and understood; of the other figures, viz. triangle, quadrangle, sexangle, septangle, octangle, and the rest, of which many, as they are made of many and divers intersections…

When one manages to decode the occult numerology of the Statement one can see that the goal of the Working Group is to have every overweight junk-food addict in Canada, the typical “high-risk” patient, on some combination of pills for “high” blood pressure and “high” cholesterol. The “targets” for blood pressure and cholesterol are set low and arbitrarily to guarantee that most of the Canadian population would be on some drug. The drug dealers can be assured that doctors will prescribe the newest, most expensive patented drug rather than a cheaper generic alternative because they have already spend hundreds of millions of dollars in advertising the advantages of the patented drugs. This is called clever marketing but it has nothing to do with the health of the population. The consequences of self-destructive lifestyles will not be lessened by any number of drugs which will have the unintended consequence of worsening those lifestyles when people are convinced they can continue those lifestyles with impunity under the “protection” of drugs that make the numerical symptoms of those lifestyles look better. While the Position Statement gives lip service to the necessity of “health behaviour interventions” it insists also on the necessity of “vascular protective measures”, code for expensive drug prescription.

Canada is currently in the middle of a federal election campaign in which the most important issue for voters is “health care”. All parties are promising to increase “health care” spending by 6% a year indefinitely. With an inflation rate of only 2%, a PhD in mathematics is not required to see that in the not too distant future “health care” will consume the entire tax revenue of federal and provincial governments. The increase in “health care” spending is driven by the sort of activities represented by this Position Statement but no candidate dares to mention drug-induced magical thinking in their campaign speeches or platforms. The electorate loves its addictions and demands infinite “health care” to provide the mirage of protection from the consequences of those addictions and any candidate who points out the obvious absurdity of this belief is dead electoral meat.

How can we exorcise the myths promoted by these venal covens? There at two excellent drug review publications written by authors with absolutely no connection to drug dealers that should be required reading for every doctor: Prescrire, a French publication available in English, which is expensive but is the gold standard in independent thinking about drugs and the Drug and Therapeutics Bulletin of Navarre, a Spanish publication, available in English, which is free but covers a limited range of drugs. A recent excellent article from the latter, “Magical numbers in pharmacological prevention of cardiovascular disease and fractures: a critical appraisal“, analyzed in detail the occult numerology of the drug-funded covens’ pontifications on “primary prevention” and concludes,

A considerable part of the pharmacological recommendations to prevent cardiovascular events and fractures in healthy persons lack any solid justification. No clear efficacy, nor the size of the effect of these agents or a clear balance between risk and benefit make the intervention clinically and socially worthwhile. The “therapeutic targets” and the “operative definition” of disease or risk factor that include instruments or tables to calculate risk are new gateways to unnecessary medicalization. In the context of modern medicine, immersed in conflicts of interest, the physician is obliged to interpret the results of trials and the recommendations from guidelines and consensus at a critical distance, and to place emphasis on the development of clinical prudence as a desired skill.

In other words a truly professional doctor will ignore any advice from the drug dealer funded covens and use his or her own best judgement.

Lawrence A. Leiter, David H. Fitchett, Richard E. Gilbert, Milan Gupta, G. B. John Mancini, Philip A. McFarlane, Robert Ross, Hwee Teoh, Subodh Verma,  Sonia Anand, Kathryn Camelon, Chi-Ming Chow, Jafna L. Cox, Jean-Pierre Després, Jacques Genest, Stewart B. Harris, David C. W. Lau, Richard Lewanczuk, Peter P. Liu, Eva M. Lonn, MD, Ruth McPherson, Paul Poirier, Shafiq Qaadri, Rémi Rabasa-Lhoret, Simon W. Rabkin, Arya M. Sharma, Andrew W. Steele, James A. Stone, Jean-Claude Tardif, Sheldon Tobe, Ehud Ur

Posted in Canada, cardiology, cholesterol, cme, continuing medical education, diabetes, diabetes, Type 2, diet, drug marketing, drugs, election, ethics, health care, junk food, medical terrorism, obesity, professionalism, statins | 5 Comments »

“Low risk” nurse with normal cholesterol but self-destructive lifestyle ends up with heart transplant after CCTA

Posted by Colin Rose on December 20, 2010

Here in a nutshell is a demonstration of the problem with expecting technology to substitute for good clinical medicine and save us from our self-destructive addictions. If anyone is puzzled about the dichotomy between the exorbitant cost of the US medical system and its relative lack of effect on any measure of health here is the reason.

Below is a story from theheart.org followed by the actual paper in the Archives of Internal Medicine minus the references.

In the absence of any symptoms attributable to coronary artery disease there was no reason to do any more testing but the temptation to use high tech tools without good indication is irresistible to many doctors. CCTA is the latest expensive test to detect coronary atherosclerosis. Patients think that they will never have a heart attack and live longer if the disease is detected and some surgical procedure, like an angioplasty or bypass is done and doctors making $millions from doing them are not about to discourage them and point out the total lack of evidence for any significant benefit from angiography or the surgical procedures in patients with chronic coronary disease.

The authors have labelled this patient “low risk” because her “cholesterol” was normal but clearly she was at high risk based on her obesity and hypertension, both indices generally of  junk food addiction, in spite of her being a nurse.  When she started new exercises she probably got muscle pain from weight lifting. With an obvious self-destructive lifestyle, she should not have been “simply reassured” as recommended by the editors. But instead of encouraging her to make meaningful lifestyle change her doctors ordered tests with no clinical indication.

Framingham scores, lipid profiles and CRPs can be very deceptive because they do not assess LDL modification in the arterial wall, essential to the formation of atherosclerotic plaque. In spite of having “normal” numbers for all the usual “risk factors” she had advanced atherosclerosis in her coronary arteries. Apparently no dietary history was taken and no attempt was made to encourage her to change her lifestyle, an example of gross diagnostic and therapeutic incompetence, all too common in an era of absolute faith in the power of technology to protect us from our self-destructive addictions. Doctors abdicate professionalism by ordering tests instead of dealing with the real problems, like junk food addiction, which take much time for which they are not compensated and risk alienating patients who demand a high-tech fix or reassurance so that they can continue their risky behaviour.

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Case study shows how “just-in-case” CCTA in a low-risk patient may spectacularly backfire

DECEMBER 17, 2010 | Reed Miller

San Francisco, CA – Coronary computed tomographic angiography (CCTA) in patients with a low pretest risk of coronary disease wastes resources and can even lead to horrendous outcomes, a case study published December 13, 2010 in the Archives of Internal Medicine shows. The report tells the story of a 52-year-old white female who initially presented with chest pain and had a CCTA; this was followed by an unfortunate chain of events in which she suffered an aortic dissection during cardiac catheterization and that culminated in her having a heart transplant.

Part of its ongoing “Less is More” series begun last April, the latest case, reviewed by Dr Matthew Becker (St Vincent’s Heart and Vascular Institute, Erie, PA), Dr John Galla (Providence Hospital, Mobile, AL), and Dr Steven Nissen (Cleveland Clinic, OH), describes how the well-meaning attempt to reassure a patient with a low risk of coronary disease backfired spectacularly.

“Perhaps the most important point to be learned from the case described by Becker and colleagues is that there are safer ways to reassure patients,” say journal editors Drs Rita RedbergMitchell Katz, and Deborah Grady (University of California, San Francisco) in an accompanying editorial. “Patients value our advice. Talking with our patients should be our first choice for reassurance.” They add that “applying the ‘less-is-more’ principles prospectively could have avoided this unfortunate case.”

From diagnostic uncertainty to disaster
The 52-year-old nurse had hypertension and mild obesity and had recently begun an exercise and diet regimen to control her weight and blood pressure. She presented to her primary physician with chest pain, but no other symptoms: she had a normal ECG with a normal lipid profile and normal C-reactive-protein level. Her doctor attributed the chest pain to a musculoskeletal cause but performed a CCTA to reassure her that she was not at risk for a coronary event.

The CCTA showed discrete, noncalcified, nonobstructive plaque in the mid and distal segments of the left circumflex and dominant right coronary arteries and diffuse, complex calcification in the proximal left anterior descending (LAD) coronary artery. Because that calcification was difficult to quantify, the physician recommended that she undergo cardiac catheterization to get a clearer look at the LAD.

This exam, performed at the local community hospital, revealed only a mild irregularity in the LAD, but during the procedure, the patient complained of chest pressure, which prompted an aortogram that revealed an aortic root dissection that was compromising the left main coronary artery.

So the patient underwent urgent coronary artery bypass graft (CABG) surgery and stayed in the hospital for two weeks with a residual left ventricular ejection fraction of 35%. The bypass graft soon failed and was treated with multiple drug-eluting stents, but despite her compliance with dual antiplatelet medical therapy, a stent in the vein graft supplying the circumflex artery developed a thrombosis, causing an ST-segment-elevation MI complicated by cardiogenic shock. The thrombosis was successfully treated, but the patient remained in refractory cardiogenic shock and ultimately underwent orthotopic heart transplantation.

Unnecessary testing happening every day
“With few cardiac risk factors and an atypical chest pain presentation, this patient had a low pretest probability for coronary artery disease and should have been reassured and not undergone any further risk stratification,” say the authors. “Lacking randomized data suggesting improvement in clinical outcomes and with clear risks, including contrast load, radiation exposure, and suboptimal diagnostic specificity, CCTA should have a very limited role in the evaluation of patients who present with chest pain.”

They acknowledge the risk of complications associated with cardiac catheterization is low, but catastrophic events are always a possibility. They believe the physicians in this case overestimated the stenosis in this patient’s coronaries because they did not fully appreciate the CCTA’s potential for false-positive findings. Complete visualization of all segments of the coronary tree with CCTA is often hindered by cardiac motion, which can lead to the appearance of “blooming artifacts” of coronary calcification that may cause the observer to overestimate the extent of stenosis.

Becker et al point out that previous studies comparing CCTA with conventional coronary angiography in diverse patient populations show CCTA’s sensitivity is between 79% and 100% for the detection of obstructive coronary disease, but its specificity is only 64% to 85%, corresponding to “an unacceptably high false-positive rate” of up to 81% in some populations.

As reported by heartwire, the recently released professional guidelines on Appropriate Use Criteria for Cardiac Computed Tomography list CCTA as “inappropriate” for detection of CAD patients with a low risk of heart disease, ability to exercise, nonacute symptoms that may be an “ischemic equivalent,” and an interpretable ECG.

Patient could have been simply reassured
“If a test is not sufficiently accurate to change clinical management in a particular setting, it should not be done,” but according to Redberg et al, often these tests are done anyway—sometimes even before the patient sees a physician—because nobody has assessed the patient’s pretest probability of the disease or properly considered how the test result will change the clinical management of the patient.

“There are cases where [the test presents] more risks than benefits, and you really need to consider the risks and benefits and not [assume that] just because you can do the test, you should do the test. And this case highlights that,” Redberg told heartwire.

Cases like this where an inappropriate test leads to many complications and near catastrophe are rare, “but to have a CT or another test that was just done for reassurance, when you could have just told the patient ‘You’re fine,’—I think that’s done every day lots of times.

“You don’t know which [tests] are going to lead to that kind of problem, but you do know which of those is not going to give you any benefit, so if there is no benefit, it’s better not to be taking any risk, even a small one.”

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Left Main Trunk Coronary Artery Dissection as a Consequence of Inaccurate Coronary Computed Tomographic Angiography

Matthew C. Becker, MD; John M. Galla, MD; Steven E. Nissen, MD

Arch Intern Med. Published online December 13, 2010. doi:10.1001/archinternmed.2010.464

ABSTRACT


A 52-year-old woman presented to a community hospital with atypical chest pain. Her low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels were not elevated. She underwent cardiac computed tomography angiography, which showed both calcified and noncalcified coronary plaques in several locations. Her physicians subsequently performed coronary angiography, which was complicated by dissection of the left main coronary artery, requiring emergency coronary artery bypass graft surgery. Her subsequent clinical course was complicated, but eventually she required orthotropic heart transplantation for refractory heart failure. This case illustrates the hazards of the inappropriate use of cardiac computed tomography angiography in low-risk patients and emphasizes the need for restraint in applying this new technology to the evaluation of patients with atypical chest pain.

REPORT OF A CASE

A 52-year-old white female nurse with a medical history that was notable for hypertension and mild obesity presented to her local primary care physician with the recent onset of chest pain. Further investigation revealed that in an effort to lose weight and assist in the control of her hypertension, she had adopted a new diet and exercise program several weeks earlier. At her initial presentation, she described 48 hours of nonexertional, sharp chest pain that was aggravated by elevation of her right arm and deep inspiration. She denied associated symptoms of shortness of breath, nausea, vomiting, or diaphoresis, and her office electrocardiogram showed no abnormalities.Other than mild hypertension (blood pressure, 142/85 mm Hg), the results of her physical examination were unremarkable except that elevation of her right arm and palpation of the right chest wall reproduced the symptoms with which she presented. With a normal lipid profile and an ultrasensitive C-reactive protein level, she was diagnosed as having atypical chest pain most likely of musculoskeletal origin. Hydrochlorothiazide was used to treat her hypertension, and cardiac computed tomography angiography (CCTA) was performed to exclude the possibility of coronary artery stenosis and to reassure her. Interpretation of the CCTA findings suggested that both the left circumflex and the dominant right coronary arteries had discrete areas of mild, noncalcified, nonobstructive plaque in their mid and distal segments. The large-caliber left anterior descending coronary artery (LAD) was reported to have diffuse and complex calcification of the proximal segment, which made accurate quantification of the luminal stenosis challenging.

Subsequently, the patient’s physician recommended cardiac catheterization to enable more precise assessment of the LAD luminal stenosis. Selective coronary angiography was performed at the local community hospital and revealed only a mild luminal irregularity of the LAD. Shortly after the second injection of contrast, the patient complained of intense chest pressure and was noted to be hypotensive and tachycardic (blood pressure, 78/45 mm Hg; heart rate, 110/min). Mild “staining” of contrast was noted in the left coronary cusp of the aorta, and an ascending aortogram revealed a dissection of the aortic root extending into, and resulting in compromise of, the left main coronary artery. An intra-aortic balloon pump was placed, and the patient underwent urgent coronary arterybypass with saphenous vein grafting of both the LAD and the left circumflex coronary artery.

Following a prolonged, 14-day hospital course and a residual left ventricular ejection fraction of 35%, the patient was discharged home with intensive cardiac rehabilitation. Unfortunately, within 6 months of the bypass, she presented again with escalating chest pain and was noted have premature graft failure that was treated with percutaneous coronary intervention with multiple drug-eluting coronary stents. Despite her compliance with dual antiplatelet medical therapy (aspirin and clopidogrel daily), she presented 8 weeks later with an ST-segment elevation myocardial infarction complicated by cardiogenic shock. Emergent catheterization revealed thrombosis of the stent in the vein graft supplying the circumflex artery that was successfully treated with a catheter-based intervention. However, the patient remained in refractory cardiogenic shock and ultimately required urgent orthotopic heart transplantation.

COMMENT


Emergency department visits for chest pain syndromes represent a large and growing health care burden. Because patients with chest pain require urgent triage and timely management, there are great incentives for developing a new generation of novel, complementary diagnostic strategies. A recent addition to the diagnostic armamentarium, multidetector CCTA, can noninvasively generate reconstructed images of the coronary circulation. However, the brisk expansion and rapid adoption of CCTA over the past decade has outpaced supportive clinical data and has led to the referral of a much larger, and often lower-risk, segment of the population for coronary artery catheterization. We believe that in this case the unwarranted use of advanced diagnostic imaging (false-positive CCTA findings) directly contributed to unnecessary cardiac catheterization that resulted in a tragic complication and significant morbidity.Advanced diagnostic imaging technologies or the latest biomarker cannot, and should not, replace a thorough history and physical examination with subsequent decision making guided by the bestevidence-based practice. The need for testing in patients with chest pain is based on the clinician’s estimation of the pretest probability of coronary disease. In a patient with a low pretest probability (<10%) of having significant coronary disease, the preferred course is to reassure the individual and to focus the treatment plan on primary or secondary prevention strategies. Additional diagnostic testing rarely garners useful information and exposes the patient to unnecessary risk—both from the diagnostic test itself and from subsequent invasive testing because of false-positive results. While the risk of complications associated with cardiac catheterization is low, catastrophic events can occur. As opposed to CCTA, in appropriately selected patients coronary angiography allows the presence, location, and, most importantly, the functional significance (eg, fractional flow reserve, intravascular ultrasonography) of lesions to be determined. Because there is often discordance between luminal stenosis and the physiologic significance of lesions, functional testing has assumed critical importance in the assessment of patients with a moderate pretest probability (10%-90%) of coronary disease.

Therefore, given the possible adverse consequences of the overuse of diagnostic imaging in a broad and uncensored population of patients with chest pain, recent joint professional guidelines emphasize that ” . . . an appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication. . . . “Furthermore, because of differences in body habitus, coronary physiology, exercise physiology, symptom presentation, and disease prevalence, the diagnostic accuracy of stress testing may be affected by the female sex. In addition to having a markedly different ST-segment response to exercise from a young age, data suggest that ST-segment depression tends to be less sensitive and specific for coronary artery disease in women. With normal electrocardiographic findings, negative cardiac biomarkers, and a classically atypical presentation, our patient had an age-specific risk level that was below average. She had a low pretest probability of coronary disease (<10% risk of myocardial infarction or death per 10 year interval), making further testing inappropriate and the chance of false-positive study results unacceptably high. However, in an era of rapid advancement in diagnostic imaging strategies, the savvy clinician must not forget the basic tenets of data-driven medicine, patient selection, and risk tolerance and ultimately realize when less may be more. Such is precisely the case with CCTA.

Because CCTA is rapid and noninvasive and has wide availability, it has increasingly been used to detect coronary atherosclerosis in a broad array of patient populations. However, the lack of randomized data suggesting clinical benefit, as well as technical and anatomical limitations, restricts its application in many patients. Studies comparing CCTA with conventional coronary angiography in diverse patient populations suggest that CCTA is highly sensitive (79%-100%) for the detection of obstructive coronary disease, with a positive predictive value ranging from 86% to 91%. However, these same studies report suboptimal specificity (64%-85%) and negative predictive values of 83% to 90% that correspond to an unacceptably high false-positive rate of up to 81% in selected subpopulations. Further limiting the diagnostic accuracy of CCTA is the fact that complete visualization of all segments of the coronary tree is hindered by cardiac motion (heart rate, >70/min), smaller vessel caliber (<2 mm), and tortuousity that may result in portions of a vessel moving in and out of an imaging plane. Furthermore, given its high attenuation coefficient, the presence of coronary calcification commonly produces a “blooming artifact” that makes accurate assessment of adjacent arterial luminal challenging and may result in overestimation of the degree of luminal stenosis, which is likely the case in the patient described herein. Therefore, CCTA often overestimates the presence and severity of coronary atherosclerosis to a degree that is dependent on the study population, the equipment used, and the experience of the interpreting physician, which may lead to unnecessary, higher-risk, and costly invasive procedures.

Nevertheless, the use of CCTA has increased dramatically over the past decade, with some estimates suggesting up to 26% per year. In an era in which comparative efficacy of therapies has assumed critical importance, the unchecked growth of CCTA seems not only unfounded but also irresponsible and unsustainable. Aside from its cost implications, CCTA also exposes the patient to substantial amounts of ionizing radiation. It is estimated that the collective dose received from medical radiation increased by more than 700% between 1980 and 2006, with increases in computed tomography accounting for more than 50%. Furthermore, 64-slice CCTA (without tube current modulation) exposes the patient to an average effective dose of 15 mSv of radiation compared with only 7 mSv for diagnostic coronary angiography. With recent data suggesting that 1.5% to 2.0% of all reported cancers in the United States may be linked to ionizing radiation from computed tomography, there is reason for pause.

In conclusion, our patient suffered a rare but devastating complication from an cardiac catheterization that was the direct result of unnecessary CCTA and false-positive findings. With few cardiac risk factors and an atypical chest pain presentation, this patient had a low pretest probability for coronary artery disease and should have been reassured and not undergone any further risk stratification. Lacking randomized data suggesting improvement in clinical outcomes and with clear risks including contrast load, radiation exposure, and suboptimal diagnostic specificity, CCTA should have a very limited role in the evaluation of patients who present with chest pain.

Posted in atherosclerosis, cardiology, CCTA, cholesterol, coronary artery disease, coronary computed tomographic angiography, diet, ethics, heart transplant, junk food, lifestyle, obesity, professionalism, surgery, technology, waist circumference | 1 Comment »

MUHC Endorses Pfizer’s Products

Posted by Colin Rose on April 9, 2010

Lipitor.ca

This is a back lit box on the first floor of the Montreal General Hospital, the “mountain campus” of the MUHC. This is how the McGill University Health Centre is caring for your health. Obviously Pfizer expects that the “professionels de la santé” at the MUHC would highly recommend Pfizer’s products and obviously the MUHC administration expects that they would. How many $millions is Pfizer paying the MUHC for this priceless endorsement of its products which directly benefit those “professionels de la santé?” What would happen to any of the “professionels de la santé” who gave “précieux conseils” that Lipitor was useless in the vast majority of people for whom it is prescribed as described in our blog page on statins? Do true professionals associate with organizations that take money from the profits of companies selling the products they recommend? In Quebec our taxes are about to increase dramatically to pay for a “health contribution” a lot of which will go to paying for expensive, mostly useless drugs like Lipitor. That’s good business if you are running a hospital but not if you are really caring for health. If you would like to protest this highly unprofessional behaviour  phone Rebecca Burns (MUHC media) at (514) 934-1934 Ext. 71443 or  email Dr. Arthur Porter, CEO of the MUHC.

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Update, April 16, 2010

It seems the MUHC administration felt some heat. One week after posting this blog, the Pfizer ad had been removed. They reacted so fast that they had no replacement and had to leave only an embarrassing blank light box.

Thanks to all those who took the time to register their opinion of this example of grossly unprofessional behaviour.

One hopes that in the future McGill and the MUHC will think twice about prostituting themselves to the drug dealers.

MGH-Box

Posted in cholesterol, drug marketing, drugs, ethics, professionalism, statins | Tagged: , , , | 2 Comments »

“When diet doesn’t work”

Posted by Colin Rose on September 21, 2009

Here is a graphic illustration of the concept of moral hazard as applied to the drug treatment of lifestyle diseases.

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Reprinted from AdWatch

LescolItaly2008-04

Many studies confirm that doctors’ behaviour can be influenced by drug advertising, but many of them are unaware of this.
Not only the advertising text, but also the images play an important part.
For example, see the above image in the Lescol advertisement published in the April 2008 issue of Rivista SIMG (Journal of the Italian Society of General Practitioners).

Lescol (fluvastatin sodium) is one of the statin class of drugs used to treat of high cholesterol when diet and other lifestyle changes don’t work.
The Summary of Product Characteristics states “for best results in lowering cholesterol, it is important that you closely follow the diet suggested by your doctor”.

What kind of advice could the doctor have given the two people on the beach?

They seem to be really happy and relaxed. The pastel colours, the calm sea and the blue sky in the background convey the impression that all is going well and no changes are needed.

The designer must have been influenced by the Colombian painter Fernando Botero, famous for his fat men and women, who generally emanate a sense of calmness and satisfaction.

What I can understand, as a doctor, after looking at this image?
“It doesn’t matter what I advise my patients to eat; it isn’t worth them trying to change their lifestyle behaviours.
Only the pill can make the difference!”

Posted in atherosclerosis, cardiology, cholesterol, diet, drug marketing, drugs, food, junk food, moral hazard, statins | Tagged: , , | Leave a Comment »

Yves Bolduc – Minister of Health and Drug Salesman

Posted by Colin Rose on April 27, 2009

On learning that Quebec spends much more per capita on drugs than the Canadian average, Yves Bolduc, Quebec’s Minister of Health and Social Services, proclaimed that he wanted everyone to know that this was GOOD NEWS and that he was happy to see that Quebec was ahead of the other provinces. He added that in Quebec people take the drugs they need for their diseases while in the other provinces they don’t take the drugs they need and as a result their high blood pressure and cholesterol problem aren’t treated. He also thinks that spending more on drugs is economic because more drugs mean less is spent in other treatments.

Lets examine the Minister’s logic.

If Quebec is ahead of other provinces, in what respect is it ahead? Quebec has the same life expectancy as Ontario but less than British Columbia who spend much less on drugs. Nova Scotia which spends the most on drugs has one of the lowest life expectancies in Canada. So, there is no correlation between drug consumption and the best measure of overall health, life expectancy.

statcan-lifeexpectancyBolduc says that drugs are needed to treat high blood pressure and cholesterol. Not true. Lifestyle change is far more efficient and cheaper than drugs for treating these “diseases” that are in most cases just symptoms of self-destructive lifestyles. He wouldn’t dare say that all weaned citizens of Quebec should follow a low-fat Mediterranean type diet, eat no junk food and have a waist circumference less than half their height before even considering drugs for lifestyle diseases, like hypertension, diabetes and atherosclerosis. Political disaster. If he did so, the highways of Quebec would be instantly blockaded by pig and dairy farmers. All fast food franchise owners, restaurant owners, junk food producers, their employees and their families would never vote Liberal.

There is not  a shred of evidence that spending more on drugs for the diseases of lifestyle to which he refers translates into less spending on other treatment for these diseases.

So why does the Minister like more drug sales in Quebec and everywhere else? Maybe it’s because drug marketing is the largest industry on the west half of the island of Montreal where there are innumerable drug marketing agencies employing thousands of people funded by profits from Big Pharma. If you run a gigantic bureaucracy like the Ministry of Health and Social Services you need a lot of money and all that tax revenue from drug profits helps your Ministry to get bigger and bigger and gives you more power. So buying more drugs is a form of hidden taxation with no significant benefits in most cases. The Minister wouldn’t dare say that most of the expensive drugs are unnecessary and lifestyle change is essential. He would be reducing his own power and making a lot of voters on the West Island, a stronghold of Liberal power, very unhappy.

ledevoir-pic-bolduc-quote1

Posted in cholesterol, death, drugs, statins | Tagged: , , , , | Leave a Comment »

Harvard Medical School in Ethics Quandary

Posted by Colin Rose on March 3, 2009

March 3, 2009

BOSTON — In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.

Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.

“I felt really violated,” Mr. Zerden, now a fourth-year student, recently recalled. “Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.”

Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes.

They say they are concerned that the same money that helped build the school’s world-class status may in fact be hurting its reputation and affecting its teaching.

The students argue, for example, that Harvard should be embarrassed by the F grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money.

Harvard Medical School’s peers received much higher grades, ranging from the A for the University of Pennsylvania, to B’s received by Stanford, Columbia and New York University, to the C for Yale.

Harvard has fallen behind, some faculty and administrators say, because its teaching hospitals are not owned by the university, complicating reform; because the dean is fairly new and his predecessor was such an industry booster that he served on a pharmaceutical company board; and because a crackdown, simply put, could cost it money or faculty.

Further, the potential embarrassments — a Senate investigation of several medical professors, the F grade, a new state law effective July 1 requiring Massachusetts doctors to disclose corporate gifts over $50 — are only now adding to pressure for change.

The dean, Dr. Jeffrey S. Flier, who says he wants Harvard to catch up with the best practices at other leading medical schools, recently announced a 19-member committee to re-examine his school’s conflict-of-interest policies. The group, which includes three students, is to meet in private on Thursday.

Advising the group will be Dr. David Korn, a former dean of the Stanford Medical School who started work at Harvard about four months ago as vice provost for research. Last year he helped the Association of American Medical Colleges draft a model conflict-of-interest policy for medical schools.

The Harvard students have already secured a requirement that all professors and lecturers disclose their industry ties in class — a blanket policy that has been adopted by no other leading medical school. (One Harvard professor’s disclosure in class listed 47 company affiliations.)

“Harvard needs to live up to its name,” said Kirsten Austad, 24, a first-year Harvard Medical student who is one of the movement’s leaders. “We are really being indoctrinated into a field of medicine that is becoming more and more commercialized.”

David Tian, 24, a first-year Harvard Medical student, said: “Before coming here, I had no idea how much influence companies had on medical education. And it’s something that’s purposely meant to be under the table, providing information under the guise of education when that information is also presented for marketing purposes.”

The students say they worry that pharmaceutical industry scandals in recent years — including some criminal convictions, billions of dollars in fines, proof of bias in research and publishing and false marketing claims — have cast a bad light on the medical profession. And they criticize Harvard as being less vigilant than other leading medical schools in monitoring potential financial conflicts by faculty members.

Dr. Flier says that the Harvard Medical faculty may lead the nation in receiving money from industry, as well as government and charities, and he does not want to tighten the spigot. “One entirely appropriate source, if done properly, is industrial funds,” Dr. Flier said in an interview.

And school officials see corporate support for their faculty as all the more crucial, as the university endowment has lost 22 percent of its value since last July and the recession has caused philanthropic contributors to retrench. The school said it was unable to provide annual measures of the money flow to its faculty, beyond the $8.6 million that pharmaceutical companies contributed last year for basic science research and the $3 million for continuing education classes on campus. Most of the money goes to professors at the Harvard-affiliated teaching hospitals, and the dean’s office does not keep track of the total.

But no one disputes that many individual Harvard Medical faculty members receive tens or even hundreds of thousands of dollars a year through industry consulting and speaking fees. Under the school’s disclosure rules, about 1,600 of 8,900 professors and lecturers have reported to the dean that they or a family member had a financial interest in a business related to their teaching, research or clinical care. The reports show 149 with financial ties to Pfizer and 130 with Merck.

The rules, though, do not require them to report specific amounts received for speaking or consulting, other than broad indications like “more than $30,000.” Some faculty who conduct research have limits of $30,000 in stock and $20,000 a year in fees. But there are no limits on companies’ making outright gifts to faculty — free meals, tickets, trips or the like.

Other blandishments include industry-endowed chairs like the three Harvard created with $8 million from sleep research companies; faculty prizes like the $50,000 award named after Bristol-Myers Squibb, and sponsorships like Pfizer’s $1 million annual subsidy for 20 new M.D.’s in a two-year program to learn clinical investigation and pursue Harvard Master of Medical Science degrees, including classes taught by Pfizer scientists.

Dr. Flier, who became dean 17 months ago, previously received a $500,000 research grant from Bristol-Myers Squibb. He also consulted for three Cambridge biotechnology companies, but says that those relationships have ended and that he has accepted no new industry affiliations.

That is in contrast to his predecessor as dean, Dr. Joseph B. Martin. Harvard’s rules allowed Dr. Martin to sit on the board of the medical products company Baxter International for 5 of the 10 years he led the medical school, supplementing his university salary with up to $197,000 a year from Baxter, according to company filings.

Dr. Martin is still on the medical faculty and is founder and co-chairman of the Harvard NeuroDiscovery Center, which researches degenerative diseases, and actively solicits industry money to do so. Dr. Martin declined any comment.

A smaller rival faction among Harvard’s 750 medical students has circulated a petition signed by about 100 people that calls for “continued interaction between medicine and industry at Harvard Medical School.”

A leader of the group, Vijay Yanamadala, 22, said, “To say that because these industry sources are inherently biased, physicians should never listen to them, is wrong.”

Encouraging them is Dr. Thomas P. Stossel, a Harvard Medical professor who has served on advisory boards for Merck, Biogen Idec and Dyax, and has written widely on academic-industry ties. “I think if you look at it with intellectual honesty, you see industry interaction has produced far more good than harm,” Dr. Stossel said. “Harvard absolutely could get more from industry but I think they’re very skittish. There’s a huge opportunity we ought to mine.”

Brian Fuchs, 26, a second-year student from Queens, credited drug companies with great medical discoveries. “It’s not a problem,” he said, pointing out a classroom window to a 12-story building nearby. “In fact, Merck is right there.”

Merck built a corporate research center in 2004 across the street from Harvard’s own big new medical research and class building. And Merck underwrites plenty of work on the Harvard campus, including the immunology lab run by Dr. Laurie H. Glimcher — a professor who also sits on the board of the drug maker Bristol-Myers Squibb, which paid her nearly $270,000 in 2007.

Dr. Glimcher says industry money is not only appropriate but necessary. “Without the support of the private sector, we would not have been able to develop what I call our ‘bone team’ in our lab,” she said at a recent student and faculty forum to discuss industry relationships. Merck is counting on her team to help come up with a successor to Fosamax, the formerly $3 billion-a-year bone drug that went generic last year. But Dr. Marcia Angell, a faculty member and former editor in chief of The New England Journal of Medicine, is among the professors who argue that industry profit motives do not correspond to the scientific aims of academic medicine and that much of the financing needs to be not only disclosed, but banned. Too many medical schools, she says, have struck a “Faustian bargain” with pharmaceutical companies.

“If a school like Harvard can’t behave itself,” Dr. Angell said, “who can?”

Posted in cholesterol, drugs, professionalism, statins | Tagged: , , , , , | 1 Comment »

‘The Heart Truth’ for both men and women

Posted by Colin Rose on February 26, 2009

Unilever, the maker of Becel margarine, would like us to believe that Becel is a health food; the more you eat the better. To that end Unilever contributes $millions to various cardiovascular and dietetic organization who reciprocate by putting the Becel logo on their literature and web sites.

There is no such thing as a healthy refined fat. Both margarine and butter are junk food, naked calories. Besides, pure fat is tasteless. The taste in butter and margarine comes only from their salt content. Obesity is the major nutritional problem and refined fats (butter, margarine or oil)are the most concentrated form of calories and should have no place in a healthy diet.


The Heart Truth’ for both men and women
Margaret McKellar, brand manager, Becel.
National Post
26 Feb 2009

Re: Barbara Kay, Apparently Men No Longer Have Heart Disease Or Strokes: That’s The Message From Becel Margarine And The Heart And Stroke Foundation, Feb. 16. I have had personal experience in dealing with loss due to heart disease and stroke. My…read more…

 

 

Posted in atherosclerosis, cholesterol, diet, junk food, lifestyle, obesity | Tagged: , , , | Leave a Comment »

The Atherogenic Football Diet

Posted by Colin Rose on February 1, 2009

Who are the coaches and “nutritionists” that advise football players to eat atherogenic, obesogenic , diabetogenic, hypertensogenic diets just so they can trample the opposing team? They should be banned from the game.
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By Madison Park
CNN

(CNN) — Football players guzzle protein shakes, down steaks and lift weights. They train and gain weight, hoping to build mass under the careful eye of the team’s coaches, nutritionists and gurus.

“It was a scripted lifestyle where they tell you how to eat, how to take care of yourself, how much body fat you should have,” said Chuck Smith, a former defensive end for the Atlanta Falcons and the Carolina Panthers.

But once their glory days are over, they have the same problem as millions of other Americans: They’re fat.

footballobesity

Football Team

“When I trained, they told us to eat all you can eat,” said Smith, who played in Super Bowl XXXIII with the Falcons. “Drink beer, eat peanut butter to gain weight. All those eating habits were great for football. But when I got done, no question I had to make adjustments.”

Without scheduled practices, meals, and games on Sunday, it became tougher to keep in shape.

When players were younger, they had the opposite problem.

Many tried to gain weight, believing that bigger is better. But as they age and retire from football, many are seeing that “big” is causing problems.

Smith, who weighed 274 pounds during his professional days, often had four plates of food in one sitting “to keep my weight up.” After retirement, Smith had to unlearn those habits.

“I had to retrain my thinking,” he said. “I don’t need to be full. I don’t have to stuff myself to feel comfortable. That took a long time. You stuff yourself to gain weight, then you get out of shape.”

Smith learned he had high cholesterol (he had to take Lipitor), and his blood pressure was climbing, too.

“I had to take the bon-bons out of my mouth,” said Smith, 39. “I had to empower myself. Strength coaches, nutritionists aren’t going to take care of me. Guys have to empower themselves to take care of themselves.”

Smith is now a fitness trainer at Defensive Line Incorporated, where he works with football players. Through healthy foods and workouts, he trimmed his body fat, lowered his cholesterol and shed 50 pounds.

Some players understand the risks, said Dr. Archie Roberts, a former National Football League quarterback and retired cardiac surgeon.

“They understand that if they stay 250, 300, 350 pounds as they age, that’s going to shorten their life span and cause them more health problems,” he said. “Others don’t get it and they’re unable — for whatever reason — to lose the weight, and they will suffer the consequences, just like anybody else in the general population carrying too much weight.”

Diabetes, hypertension and high cholesterol are all cardiovascular risks associated with obesity.

Roberts heads the Living Heart Foundation, a nonprofit promoting health for former football players. For five years, he has conducted research to determine whether former football players are at added risk for heart problems (they’re not).

After left tackle Bob Whitfield retired from the New York Giants in 2007, he gained 20 pounds. The 37-year-old Pro-Bowler is trying to lose 40 pounds, which would bring him to 290 pounds, the lowest he has weighed since ninth grade.

“You don’t want to be the person at the buffet and people look at you crazy,” Whitfield said. “Overall, you want to have a healthier lifestyle. It doesn’t mean you want to be muscled up. … I don’t want to be the biggest man in the room anymore.”

Looking back at his career, Whitfield doesn’t think his size made him a better player.

“When that mass gets too heavy, you decline, you can’t accelerate, you don’t have as much force,” he said. “I never felt that being bigger gives you a competitive advantage. I put it on flexibility, the explosive nature of your movements.”

Several decades ago, 300-pound players were a rarity; now, the league has more than 500, Roberts said.

Decades ago, the Washington Redskins’ offensive line was known for its size and dominance.

“They had the largest line in the NFL, called the Hogs, 20 years ago,” said Dr. Ben Levine, director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital in Dallas, and professor of medicine. “If you go back and look at their size, they’re about the size of the running backs today. The impression was these guys were massive, huge. They couldn’t play in the NFL today. They’re too small.”

Smith said he wasn’t forced to gain weight, but perceptions exist on how a player should look based on his position. That “needs to change in the NFL,” he said.

Being faster, stronger and more aggressive is more important than size, Smith said. He drew an analogy to airline stewardesses: “We want her to be tall and slim so she can walk down the aisles. Now is there really a difference between a 135-pound woman and a 150? Well, maybe a little bit different in the hips, but the same effectiveness happens when she does her job.”

He added, “I’m a classic example that size doesn’t matter.”

But that’s not what young, aspiring players think.

Jackie Buell, director of sports nutrition at Ohio State University, said she encounters players who seek to gain as much as 30 pounds by next season and seldom care whether it’s fat or muscle.

Buell’s research examined 70 college linemen and found that nearly half have metabolic syndrome, meaning that the players have at least three of the five risk factors of developing diabetes and heart disease. Her next project is to explore whether junior high and high school football players are developing metabolic syndrome.

“My fear is, these young men have this metabolic profile, what happens when they stop working out intensively?” Buell said. 

Posted in atherosclerosis, athlete, cholesterol, diabetes, Type 2, diet, drugs, football, junk food, lifestyle, obesity, statins, waist circumference | Tagged: , , , | Leave a Comment »

Drug Marketing by “Study”

Posted by Colin Rose on December 13, 2008

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Posted in atherosclerosis, cardiology, cholesterol, drug marketing, professionalism, statins | Tagged: , , , , , , , , , , | Leave a Comment »

Men, not women, out of work

Posted by Colin Rose on December 10, 2008

The real issue here is the proliferation of moral rot in American society which will inevitably spread to all capitalist economies, Canada included. At present the only growing American industries are junk food and “health care”, industries that employ mostly women. Obese, junk-food addicted Americans are obsessed with the mirage that diseases caused by self-destructive habits can be prevented and death can be delayed indefinitely if they take enough pills for “cholesterol”, hypertension and diabetes and have enough operations, like gastric and coronary bypasses. Such societies cannot compete against less self-indulgent economies eventually implode and are unable to defend themselves. Unless there is a major change in US society the terrorists just have to wait until it self destructs and they can walk in and create a totalitarian Islamist state. As long as Americans can get their BK Quad Stackers and Lipitor they will not resist.

BK Quad Stacker

 Medical terrorism

 


Men out of work
BY ROBERT GAVIN
National Post
10 Dec 2008

The careers of Neal Boyle and Scott Hacker couldn?t be more different. Boyle, whose education ended with high school, worked 20 years crushing rocks at the U.S. Gypsum plant in Charlestown, Mass. Mr. Hacker, who holds an MBA, changed firms several…read more…

 

 

 

 

Posted in addiction, angioplasty, cholesterol, death, diabetes, Type 2, diet, junk food, statins, surgery | Tagged: , , , , , | Leave a Comment »