An angel returns to heaven: Goodbye Farrah----1947-2009

[Bill Glasheen]

You got to wonder how someone becomes a TV pitchman for junk that doesn't work.

Per Jim's comment, I use OxiClean as an additive for all my wash. Because I was on the edge of civilization when they started my development, I have a septic tank. I can't put chlorine bleach in the laundry, unless I want to kill all the good bacteria in the septic tank. But a peroxide-based bleach works just fine since it degrades to oxygen and water. Furthermore, it won't burn holes in the clothes or leave spots if you accidentally spill it, and it doesn't give you an asthma attack if you smell it.

Not all products with famous pitchmen are good for the septic tank. Mr. Whipple's Charmin can really clog a septic system up, and sometimes will clog your plumbing as well.

There is product, and then there is marketing. Ideally good products find good marketing.

- Bill

[IJ]

Medicine very easily fails to help people with coronary artery disease, especially the silent kind. The way people die suddenly is from an arrhythmia that occurs when heart muscle is starved of oxygen and behaves erratically. Those sudden heart attacks are WORSE when they occur in arteries that are largely wide open. Someone has a 20-30% blockage which causes no symptoms, then BAM it tears open, a clot occludes the artery, and they're gone. If the blockage had been 90%, the amount of flow still going through wouldn't be missed that much and there probably would have been collaterals (detours) that developed in response to the chronic lack of blood flow.

When someone has those ready to pop partial blockages, stress tests will show nothing--they can get enough blood to their heart muscle at rest and at stress UNTIL it suddenly pops. Even if they had cardiac cath, the doctors wouldn't stent open the lesion. They can't know which lesions will pop and doing all the 20% ones would cause much more harm than good.

Your only avoidance options are good genes, and good lifestyle, and medicines (which you may not be on if no one knows about your heart disease). You may have some risk factors--or you may not. Risk factors increase your chances but the overlap in heart attack patients between those with and without risk factors (or combinations thereof) is substantial. And don't ignore symptoms of a heart attack--call 911 (don't drive, lest you arrest en route with no help around at 60mph). If your first symptom of heart disease is sudden death, well, hope OTHERS don't ignore that symptoms, and hope they have an defibrillator or at least some top notch CPR (it's almost always done wrong).

[JimHawkins]

What makes it suddenly pop?

With large deposits of cholesterol is there no way to detect this?

His heart was enlarged--no way to detect this?

Is there no way to attack those deposits?

I mean this is a huge killer of folks and it's hard to believe there is no way to detect and attack these problems in the 21st century?

[mhosea]

You can detect an enlarged heart with an MRI or CAT scan. I don't know anything about angiograms, but I assume they can tell you a lot about blood flow around the heart. You may have these tests if you have some worrisome symptom, but who orders these as routine preventive care? Now, as to reasonable preventive care, I wonder if a simple (hs)CRP test would have raised any red flags.

[JimHawkins]

I dunno, as a one time corporate manager I am a can do kind of guy... Too many folks in business are ready to tell you why something can't be done, too risky, too difficult, they just can't wrap their brain around simplicity, or perhaps there is a tendency to make things as complicated and as expensive as possible? I'll bet their cousins are in medicine.... I bet we can do way better with existing resources and technology..

I used to watch Pet Medic on Animal Planet all the time. I love animals and I took a pre-med curriculum in college so I found PM fascinating.. Anyway, on that show, which took place at one of the best animal hospitals in the country they had one guy who's only job was using their sonogram machine, and this guy was good.. Any time they needed info on something internal, bang, they would bring the animal to this guy and he would look around with his scanner.. This guy could tell all kinds of things from his vast experience using this device and they used him extensively, since the time and cost of doing so was scant...

So.... what about using this kind of scanner on people? I mean if this guy could tell so much internally by doing a quick sonic scan why is this not done with people? Or is it? I never hear anything like this being used for the variety of applications it found in that animal hospital, and I know they could tell if a heart was enlarged...

Is it possible that principles like KISS and various creative problem solving techniques used in this area are being overlooked or ignored when people are involved? I mean clearly there needs to be cheaper and simpler ways of scanning the internals of patients and hey in that show they did that among many other innovative works... Can we learn something from these folks?

[JimHawkins]

Just listening to the news... A Cardiologist was saying that there is yet no way of removing the the plaque from inside the arteries, etc.... Blows my mind... She also said that it's coming soon, possibly in pill form but will be VERY expensive... What a shock...

I thought that some modern drugs reduced the buildup so I am still confused.. I also think there are some natural elements that are thought to reduce the amount of plaque... But this seems to be quite a problem..

No micro organisms that would like to feast on the deposits? Make some...

Where are the nanites and the retro viruses?

[Bill Glasheen]

Lots of questions and comments here. Given that I was on the research faculty in the division of cardiology of a major medical institution, I have some inside info (pun intended) on much of this. So here goes.

• An MRI or CAT scan is not the way to look at a heart, unless you want to spend a lot of money. One of the biggest problems is that the heart moves. Unless you get involved in some pretty extensive sampling with ensemble averaging over time (to reproduce a single cardiac cycle), you're wasting your time. That kind of technology has been developed, but is far more expensive that lots of "good enough" technology.
• Yes, sonograms are the way to go to image a heart. I did lots of research in the "echo" lab where we studied heart motion during heart attacks, and injected contrast agents to see blood perfusion in the heart muscle in real time. My mentor ran the echo lab in the hospital. He had an amazing ability to diagnose from these fuzzy but real time moving images.
  
  However... You are only going to see certain kinds of cardiac abnormalities with an echo. You WILL very easily see an enlarged heart. That's a no-brainer. But if a blood vessel isn't stenosed enough to limit flow in a region during rest, then you won't see the consequence of it like the case of the fellow who feels fine at rest but has a heart attack shoveling snow.
• A simple physical exam - a lost art with many MDs - will flag lots of people who need further testing. The typical pathway from there would be angiograms (injecting dye in the coronary arteries) and cardiac stress tests (imaging the heart perfusion during exercise with radioisotpes).
• Ian got lots of things right about the fellow who has a slowly generating stenosis (which the body compensates for via collateral circulation) vs. the sudden blockage (which the body has no reserve for). However I don't like his use of the word "pop." Things don't really pop, unless you're talking aneurysm - a very different scenario. Instead they get clogged like the plumbing in your house. Sudden, unexpected heart attacks can happen when a piece of plaque breaks off and clogs a coronary artery.
• The problem with getting rid of plaque in coronary arteries is this - if you have it in one place, chances are extremely high that you have it in lots of places. Going around trying to clean out your arteries via mechanical methods is like playing whack-a-mole. You can re-route (CABG) or open up (angioplasty with stent) partially or fully-narrowed coronary arteries, but that's just to keep the heart going. The underlying cardiovascular disease is still there - throughout your body.
  
  However Dean Ornish has shown that extreme diets with exercise can reverse cardiovascular disease to some extent. I mean super low fat diets, vegetarian diets, etc.
  
  The bottom line is that it's easier to slow down or prevent cardiovascular disease with lifestyle changes than it is to reverse it with modern medicine. Relying on modern medicine instead of lifestyle management (personal responsibility) is the biggest reason why our health care financing system is broken today. With enough money thrown at a problem, you CAN make things better. But when health care inflation grows much faster than the GDP, then we have a problem.

A final thought... An enlarged heart - if that was the problem - isn't necessarily a lifestyle problem. There can be other issues which would have caused that - including genetic. However if this guy was supposed to be getting a hip transplant, then he should already have had a cardiac screening before surgery. They should have caught his cardiac problem(s), and addressed those first.

- Bill

[IJ]

I second Bill's comments. As to the issue of "popping," I was not referring to a rupture of an artery, but rather the rupture of a plaque. When we eat junk and extra calories and don't exercise, starting in tweeners, we begin to lay down fats in the walls of arteries. A fatty streak develops into a blob of plaque in which fat is no longer normally stored inside cells, but instead oxidized and damaged fats and cholesterols have ruptured cells and exist in a soup of thrombogenic stuff and reactive cells. These plaques have very thin linings separating them from the flowing blood. When these linings, coated with cells whose job is to allow blood flow and not provoke the blood into misbehaving, are disrupted, then all that crud comes into contact with blood it was never meant to. The blood interprets its contact with this material as if you were cut and bleeding, and does its job--a cascade occurs activating the clotting proteins and liquid blood turns into clot. The clot occludes the artery, blood flow ceases to the muscle beyond the clot (barring the presence of collaterals), and those muscle cells can cause an arryhthmia and sudden death, or just die and leave a weakened heart. The whole process is called acute coronary syndrome or ACS, and the outcomes if intervention isn't immediate are either unstable angina (a threatened heart attack), or heart attack (aka myocardial infarction).

Few additional comments: an enlarged heart can sometimes be detected by exam, but if you add up all the stuff we are supposed to do in a preventive visit, it takes FAR longer than the whole visit slot nevermind the patient's sore knee and their insurance form and the ten minutes to get them in the room and me writing my note. This is the kind of stuff that makes "working to rule" an effective strike alternative. Anyhoo, we rarely pick it up on exam. You can see it on chest x ray as well, or ultrasound (cheaper than CT or MRI), but what data is there that this kind of screening would benefit us, rather than expose us to xrays and cost? None I've heard of. So it's not done.

I somewhat doubt Bill's claim that more efficient physical diagnosis would help. As mentioned before, the killer plaques are not just sometimes but *usually* nonobstructive. Thus, you can't hear them, you can't see them, you can't detect their effect on arteries or the heart externally. You might find evidence of diffuse vascular disease, like a funny sound in the neck arteries or diminished pulses in the legs. THAT would scare me--bad vessel one place = bad vessel other place. But what to do about it? Turns out that while aspirin helps people with coronary artery disease (CAD), and we assume everyone with peripheral vascular disease and diabetes has CAD too, aspirinating the PVD / diabetes group doesn't help. Should they all get cardiac cath? No. It's hugely expensive, invasive, may cause bleeding or heart attack, can damage the kidneys, and you should NOT stent arteries that are <70% blocked or permit adequate flow; doing so is unhelpful or can make things worse and requires months to years of additional medicine to keep the stent open. Cath is ONLY indicated in people who 1) have a heart attack, right then and 2) have angina that can't otherwise be relieved. (However, you and I pay to do it much, much more often than it's indicated).

Well, what about the hip surgery? Shouldn't he have had a medical evaluation? Sure! I work in such a clinic. It's almost useless. We used to think that betablockers prevented perioperative heart attack. And they do, but unfortunately they also cause bradycardia, hypotension, and stroke, such that the final result is a wash and the only people who now should get them have waaay advanced heart disease or are already taking them. Stress testing before surgery? It may characterize your risk but won't reduce it. That is known from a study of stress or not preop; no benefit. We also know it because of large, well done studies in people with really bad CAD. They were randomized to either bypass or stent (as indicated) or NOTHING before surgery and the final death rates were the SAME. The extra work only added cost and delayed the primary surgery. And hurt.

What can we do? Anyone with symptoms of CAD needs a workup. Anything that could be a heart attack is very serious and therapy then has been shown to save lives and improve health. Otherwise, we can reduce the risk factors. Treat, or out-diet and cure, your diabetes. Don't bleeping smoke! Keep your blood pressure controlled: <120/<80 is ideal. Have healthier parents and don't be old, or male. Eat a low salt diet and eat healthy foods and fats instead of junk. Know your cholesterol and manage it with diet, exercise, and meds. *Consider* an aspirin if your heart risk outweighs your bleeding risk--matters more to men, I think aspirin largely prevents stroke instead in women. *Consider* additional testing like CRP, but know the limits. A risk factor may double your chance of something, but if your risk is 1/1000, for individual patients, that means almost nothing. You have to know before testing: what is the chance I'll have it? What can be done about it? How well does that work? What are the downsides of treatment? Then calculate a number needed to treat: how many people like me would have to go through all this to save a life? Trust me, every little thing we do adds relatively little; you may not want to know.

And don't expect magic. We're flawed bits of biology, not the airline industry, and right now we don't have the ability to make the guarantees that air travel can, nor can our preventive exams offer the safety margin their inspections can. Yet.

Few other thoughts:

Sonogram on heart with CAD that will be lethal tomorrow but has not yet damaged the muscle = normal.

Screening sonograms (echo)? No evidence for that. Partly because of the above.

Reversal of CAD? Yup. Aggressive meds and lifestyle change DO make it regress. Most Americans can handle that regimen like they can lose weight, unfortunately.

[Bill Glasheen]

And then there is Jim Fixx.

Who is he? His dad died of a heart attack at age 42. Jim was overweight and out of shape, and headed in that direction. So Jim ate right, ran, lost 60 pounds, and wrote a book about exercise and dieting (The Complete Book of Running). He is credited with helping start the modern fitness revolution, and popularizing running. As an aside, he was a member of MENSA and wrote a number of puzzle books for the super smart.

And what happened to Jim Fixx? He died of a heart attack - at age 52. An autopsy showed major blockage in 3 coronary arteries.

Moral of the story - choose your parents wisely, and don't be male.

- Bill

[chef]

Hmmm...choose your parents wisely??? Hah hah on that.

I'm destined for death then.


A sad Vicki

[Bill Glasheen]

I'm destined for death then.

We all are. We're born full of life and movement, and spend the rest of our finite years fighting rigor mortis.

- Bill

[Van Canna]

Bill, Ian....

Have you heard of the K factor?

http://www.amazon.com/K-Factor-Richard- ... 0671639838

[Bill Glasheen]

Van

Everyone has to have their special label... It sounds sexy, and it sells books I guess.

K would be the elemental symbol for potassium, and "the K factor" is about having the right sodium/potassium balance.

My thoughts? Low sodium diets - for the sodium sensitive - can lower blood pressure. And we all need the right amount of potassium. Off the top of my head, bananas are a good source of potassium.

Don't consume too much potassium though. I used to use KCl injections (after a good bolus of pentobarbitol) to euthanize my dogs after a cardiology research experiment. It stops the heart in systole (contraction mode).

I would include two more minerals in that list - minerals that are more likely to be lacking in your diet. That would be calcium and magnesium. You can get Ca plus Mg supplements (sometimes with vitamin D) at any health food store. It's good for your bones. And it serendipitously will lower your blood pressure a few mm of mercury. Some people put Ca, Mg, and Zn (zinc) together. It both helps the bones and it helps with your hormone production. Bodybuilders sometimes call the zinc/magnesium combination "ZMA fuel." (They usually throw in a little B6 for good measure.)

Moral of the story - diet is important. But you aren't going to do it with a single magic pill. And it's worth mentioning that exercise and weight management are probably just as important - if not more so.

- Bill

[JimHawkins]

I have heard that K bonds with salt or something like that.. That the K negates the salt to some degree.. I also noticed that many multivitamins have very little K in them.. I realize you don't want to OD on K but too little and it appears we are missing out on its benefits.. So how much is the right amount??

I started taking K along with more Mg, D and Ca along with my regular MV plus some other goodies and my BP is down...

[IJ]

Other Jim Fixx morals:

1) If you lead an unhealthy life, and later decide to reverse course, it may be too late.
2) So train your children well and get started now.
3) And when you have chest pain when you run, for Dawkin's sake, don't keep going out for runs until you die of a heart attack and end up the source of morals on the Dojo Roundtable. Fixx ignored warning signs.

K Factor:

I'm not aware of any major evidence that the ratio of K to Na is important beyond the major point that you want to minimize your sodium intake to about where it hurts. Americans eat 4, 6 and more grams of Na a day; the advice? 2 grams. To get there, you need to exclude almost anything that adds salt to nature's products, which means the salt shaker is gone, salt in recipes is gone, processed and fast and restaurant and most Asian food is mostly gone. America thinks salt is flavor; it's not, it's saltiness, but to improve "flavor" its crammed into everything. Learn to use other seasonings. I'll try to get the meat from this article for the forum later:

JAMA -- The Urgent Need to Reduce Sodium Consumption, September 26 ...
The Urgent Need to Reduce Sodium Consumption. Stephen Havas, MD, MPH, MS; Barry D. Dickinson, phd; Modena Wilson, MD, MPH. JAMA. 2007;298:1439-1441.

As for potassium, sure, it's helpful. A high K low Na diet does correlate with lower BP. The effect on individuals is small, however. It's usually just a few points which means that all my patients who come in at 160/94 can get to 156/92 with diet! Awesome, right! High K foods also include orange juice, potatoes, avocado, prunes, figs, and milk:

http://www.essortment.com/all/potassiumfoodh_rkyn.htm

Know your specific situation; people with kidney disease can get into serious trouble with K, people on diuretics may need more; people on certain medications like digoxin, sotalol, amiodarone, and other heart medicines are more sensitive to electrolyte disturbances. Eating a high K diet by favoring fruits and milk won't hurt you if you have relatively normal health. Dietary K has a minimal effect on serum potassium because it is absorbed gradually, and is easily buffered in cells (where almost all the K is found) until excess K can be peed out. It's K in serum that affects the heart's electrical system, so when Bill (or Texas and California) kill animals and inmates with K, they give it IV all at once. During my residency, a nurse misprogrammed an IV pump and executed a healthy patient with a dose of K equivalent to about 4-5 bananas--the patient was dead 30-40 minutes but came back without brain damage due to immediate recognition and care.

Thus: no IV bananas.

As for specific effects on preventing and treating hypertension, try this:

http://www.cmaj.ca/cgi/content/abstract/160/9/s35

Going overboard and especially Calcium and Mag aren't going to help.