Menopause unleashes lipoprotein(a)

Faye was clearly frustrated.

At age 52, she was having chest pains every day. A CT heart scan showed a score of zero. A CT coronary angiogram showed no plaque whatsoever.

"Everything went downhill when my menopause started. I gained weight, I started to have chest pains, my blood pressure went up, my cholesterol shot up."

She saw three physicians, none of whom shed much light on the situation. They ran through the predictable sequence of (horse, not human) estrogens, anti-depressants, suggestions for psychological counseling.

But we checked Faye for lipoprotein(a), which she proved to have at a high level of 182 nmol/l. This explained a lot.

A curious and predictable set of phenomenon occur to females with Lp(a) proceeding through the menopause. As estrogen recedes:

--Lp(a) levels rise dramatically.

--Blood pressure goes up, sometimes creating severe hypertension by mid- to late-50s.

--Chest pain can develop, presumably due to "endothelial dysfunction" or "microvascular angina", both representing abnormal coronary artery constriction facilitated by worsening expression of Lp(a).

All too often, these phenomena get dismissed as simply part of the menopausal package, when they are, in fact, important facets of this very important genetic pattern that confers high risk for heart disease.

If any of this rings familiar for you or a loved one, think Lp(a). Though Faye hadn't yet developed any measurable coronary plaque by her CT heart scan score, it was likely on its way, given the surge in Lp(a) expression as menopause unfolded--unless its recognized and appropriate preventive action taken.
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Heroin, Oxycontin, and a whole wheat bagel

Heroin, Oxycontin, and a whole wheat bagel

For a substantial proportion of people who remove wheat from their diet, there is a distinct and unpleasant withdrawal syndrome. Here are the comments of Heart Scan Blog reader, Scott, from Texas:

Hello Dr. Davis,

I've been experimenting with diet, converging upon a Paleo type diet, but I keep running into problems. I have isolated the problem to cutting out wheat.

Sugar, rice, fruit, corn, potatoes, etc. are relatively ok to add or remove from the diet, but cutting out wheat in particular brings on a moderate headache with heavy fatigue all day long. This resembles the wheat withdrawal symptoms I found on your blog. As I write this, I'm on day 8 of wheat-free. I consume a fair variety of meat and veggies each day with a moderate amount of white rice for carbs. Perhaps a bowl of corn flakes with milk and half a bar of dark chocolate a day. I've learned from experience over the past 5 months or so that none of these foods affect the withdrawal. It's purely wheat.

My question is, what is the range of times for withdrawal symptoms that you've heard from different people? Has there been anyone who never recovered from the wheat withdrawal symptoms even after many months?

It's very tough to get work done like this, and even though my body and head feel much healthier in general, my sinuses have cleared, don't have to take a big nap after I eat, etc., I don't want to go down a path where this is the way things are going to be forever. 



People who have never experienced wheat withdrawal pooh-pooh the effect. But, for about 30% of people, wheat withdrawal is a real, palpable, and sometimes incapacitating experience.

Beyond removing an exceptionally digestible carbohydrate that yields blood sugar rises higher than nearly any other known food (due to the unique amylopectin structure of wheat-derived carbohydrate), wheat withdrawal is a form of opiate withdrawal, somewhat like stopping heroin, Oxycontin, and other opiates. Stop eating whole wheat toast for breakfast, whole grain sandwiches for lunch, or whole grain pasta for dinner, and the flow of exorphins, i.e., exogenous morphine-like compounds, stops. You experience dysphoria (sadness, unhappiness), mental "fog," inability to concentrate, fatigue, and decreased capacity to exercise. It is milder than withdrawal from prescription opiates. Unlike withdrawal from more powerful opiates like heroine, there are, thankfully, no seizures or hallucinations. There are also no deaths.

In my experience, most people get through with wheat withdrawal in about 5 days. An occasional person will struggle for as long as 4 weeks. Thankfully for Scott, I've never seen it last longer than 4 weeks. (Interestingly, people who survive the withdrawal syndrome are often prone to a peculiar re-exposure phenomenon that I will discuss in future, i.e., they get sick upon re-exposure.)

The modern dwarf mutant variant of Triticum aestivum (that our USDA urges us to eat more of) contains greater proportions of gluten proteins compared to wheat pre-1970; glutens are the source of wheat-derived exorphins.

Incidentally, a drug company should be releasing a drug in the next year that will contain naltrexone, an oral opiate blocking drug, for a weight loss indication. They claim it is a blocker of the "mesolimbic reward system." I say it's a blocker of wheat exorphins.

Comments (27) -

  • Tree

    1/25/2011 1:50:08 PM |

    Celiac disease is often noticed by people who go off wheat for health reasons, then when they try to eat it again, it makes them sick.  

    For the record, Corn Flakes contain barley malt which has the same protein, gliadin, as wheat.  I have celiac and the "formula" is no wheat, barley or rye because they are so closely related and have the same "gluten" protein.

  • Martin Levac

    1/25/2011 1:55:45 PM |

    Isn't it interesting. They treat obesity by fixing the "mesolimbic reward system" because they believe eating too much "food" makes us fat. But then you say wheat isn't food, it's a drug.

    Are we really eating too much "food"?

  • Emily Deans, M.D.

    1/25/2011 2:15:16 PM |

    A heroine is a very different concept than "heroin."  And withdrawal from oxycontin or heroin is unlikely to cause hallucinations or seizures (Trainspotting babies on the ceiling notwithstanding) - though it is exceedingly unpleasant, it is not typically medically dangerous.  Perhaps you are thinking withdrawal from alcohol, barbituates, or benzodiazepines, all of which can cause hallucination, seizures, or death if done without medical supervision.

  • Anonymous

    1/25/2011 2:35:18 PM |

    I have celiac and had similar problems when I first went off gluten.  It took me about a month to stop reacting.  I get quite ill whenever I accidentally am exposed to gluten, say at a restaurant.  My symptoms are migraine and flue like aching in my joints, plus severe fatigue.  None of my doctors thought I might have celiac by the way, because I am slightly overweight (BMI 25) and didn't have severe digestive symptoms, but there is recent research showing that many patients present with migraine as their only celiac symptom.

  • Dr. William Davis

    1/25/2011 2:47:15 PM |

    Oohh. Thanks for catching the typo, Dr. Deans. Fixed.

    By the way, I've seen plenty of hallucinations and seizures with opiate withdrawal, as well as benzodiazepine withdrawal. Or, perhaps it was combination addictions that were at fault.

    That, however, was not the point.

  • Emily Deans, M.D.

    1/25/2011 3:11:53 PM |

    I think the point was well-made - just didn't want anyone to fear that wheat withdrawal was medically dangerous (quite the opposite).  I've had a few cases where I was able to stop night (carb - typically bread) binging with (off-label) use of naltrexone - pretty telling, I would say.

  • Dr. William Davis

    1/25/2011 10:21:46 PM |

    Dr. Deans--

    I am VERY impressed you knew of this effect.

    I have tried this, too, in people who are, despite their best effort, unable to resist temptation to consume this drug-disguised-as-food called wheat.

  • Anonymous

    1/26/2011 12:24:48 AM |

    My health improved dramatically after I stopped eating wheat, grains, and other carbs, I even had a cataract disappear.  But it required nine months before I could adjust to the low carb way of eating. It's worth all the trouble, no more high blood pressure or diabetes medicine.  Most of my arthritic pain is gone, I am able think more clearly. Lost 30 pounds. No more allergies or indigestion.
    Thank you for writing this blog!

  • DK

    1/26/2011 4:08:13 AM |

    I was able to stop night (carb - typically bread) binging with (off-label) use of naltrexone - pretty telling, I would say.

    Nothing at all particularly telling I would say. Other than telling that opioid receptors are part of the reward circuit. Which is obvious and not disputed by anyone. Naltrexone main use is in treatment of alcohol dependence. Using your logic ethanol is an agonist of opioid receptors. Which is self-evidently not true. The effects are indirect.

  • Might-o'chondri-AL

    1/26/2011 5:30:17 PM |

    Question here:

    Is the "craving" for wheat due to psychoactive tri-peptides derived from wheat protein ?  If that is the molecule that "dopes" our opiod receptors then decreasing levels of tri-peptides as the day progresses will make some look for their wheat "fix".

    Naltrexone @50mg was FDA approved (1984) in 1984 opiod addition; to block receptors. I think the doctors here are referring to single evening doses of 3 to 4.5 mg.
    for screened patients.

  • BWR

    1/27/2011 3:08:46 AM |

    Here's what I don't understand: Why is it that entire countries of people who eat bread by the basket, like Spain, have exceptionally low levels of heart disease? This is a sincere question. I want to do what's right for my heart, but it seems to me that a naturally occurring sample size of several million people is pretty compelling. What am I missing?

  • Anonymous

    1/27/2011 8:25:08 AM |

    Jack LaLane on sugar:

    http://www.youtube.com/watch?v=LJVEPB_l8FU

  • Jonathan Byron

    1/27/2011 1:56:02 PM |

    Milk and dairy products are also a source of endorphin-like chemicals. Would it make sense to try to kick a wheat habit by temporarily drinking more milk?

  • Anonymous

    1/27/2011 3:42:20 PM |

    BWR

    It is possible that Spanish bread is made from a much healthier wheat variety.

    The devil is on the details.
    From a HSB comment May 24, 2010
    Here in France, Einhorn( Triticum monococcum) has been cultivated since the 9 th millennium BC in a small area of Haute Provence. It is called petit epeautre and it is truly delicious! It has very little gluten.
    There is much regulation in the cultivation in order to protect the genetic purity of this ancient grain. Like wines it has a AOC (appelation d'origine controlee

    Please note: Higher Mg and Lysine in einkorn

    Modern wheat has had much of the Mg bred out
    http://petitepeautre.com/nutritiona.html

    Scandinavian Journal of Gastroenterology
    http://www.einkorn.com/toxicity-of-einkorn-gluten/

    Same for casein in milk where A1 milk can be a serious problem and the casein is similar to gluten
    http://www.guernsey.net/~wgcf/PageMill_Resources/Acres_Woodford.pdf

  • Dr. William Davis

    1/27/2011 4:37:27 PM |

    Hi, BWR--

    There are some unanswered questions with this thing called wheat. As the anonymous commenter pointed out, there may be differences in strains grown worldwide. While 99% of all wheat grown today are dwarf variants of Triticum aestivum, there are pockets of agricultural adherence to older cultivars.

  • revelo

    1/27/2011 8:41:02 PM |

    I am perfectly willing to believe than many people cannot tolerate wheat. But this obsession with villifying wheat discredits Dr Davis's very valuable promotion of regular heart scans and other diagnostics, as well as D3, Iodine and other supplements.

    It isn't just the Spaniards. My own ancestors are a mix of French, German and English, and I don't seem to have any problems with wheat, rye, barley, to speak nothing of oats. Furthermore, I believe a heavy grain diet is precisely why I am able to keep my weight down and my test results good. I experimented with going to a somewhat more paleo diet recently and the result was to DECREASE my insulin sensitivity when I went back to eating oats. Now that I'm back to eating mostly oats, my insulin sensitivity has returned to normal. Worse, the paleo diet caused a surge in uncontrollable hunger. One particularly bad day, I ran through a dozen eggs, a pound of meat, another pound of nuts and all sorts of other food before my appetite finally settled down. I never had these uncontrollable appetite problems with my usual mostly oats diet, nor did I have problems when I used to eat mostly pasta (though I was younger then and had higher metabolism than now).

    Appetite is the key. If a food sends appetite soaring, then it doesn't matter how healthy that food is by itself--it will make you fat and thereby reduce insulin sensitivity and thus destroy you in the end. Conversely, if a food depresses appetite, then assuming it isn't absolute poison (like arsenic), eating that food will allow you stay lean, and by staying lean you stay insulin-sensitive (assuming you also do some daily exercise), and that is the ultimate key to avoiding most health problems, from what I understand. For some people, wheat and oats may very well be the keys to appetite suppression, and it is thus a disservice to condemn these foods for everyone.

  • Anonymous

    1/27/2011 10:47:13 PM |

    what do you make of this new study citing adverse effects of a high fat diet?

    http://www.ajcn.org/content/early/2011/01/26/ajcn.110.002758.abstract

  • Onschedule

    1/28/2011 1:21:46 AM |

    @revelo,

    In his practice of Cardiology, Dr. Davis has apparently observed great results with a good number of his patients that choose to avoid wheat. Apparently, an impressive enough effect, in his opinion, to make the statements that he does. These observations, and the recommendations he makes based upon them, hardly "discredit" his professional advice.

    It may be true, as you suggest, that not every single person will have a problem eating wheat, but a person's weight (or appetite) is not the only indicator of potential heart-health related issues. While wheat might not make everyone fat, it may still provoke immune response, inflammation, surge in blood glucose and triglycerides, etc.

    Anecdotally, thanks to Dr. Davis' advice regarding wheat, my 68 year-old mother lost 15% of her bodyweight in four months, without exercise, and without any other change in her diet except to replace the pastas and breads with eggs, vegetables, and meats. She had always taken great pride in the "healthy" foods she ate, but over the past twenty years had very slowly gained weight and a bloated appearance. She started crying during our last visit because she is so happy to "recognize" herself again in the mirror, and is wearing clothes that haven't fit in over a decade. I stopped eating wheat one year ago. Since then, I've dropped from size 34 to 28 pants and get compliments weekly concerning how young I look; I feel great and lab results (blood tests, radiology) are unbelievably improved.

    Wheat avoidance may not indeed be necessary for everyone; but, it's done wonders for *all* of those around me that have given it a good chance.

  • reikime

    1/28/2011 3:53:27 AM |

    Jonathan,
    Subbing milk for the wheat wold NOT work as milk produces a morphine- like substance called caseomorph and wheat produces gliadimorphs. Two different types of exogenous morphines.

    This is one of the rationales for the gluten free- casein free diet that seems to greatly help some children on the autistic spectrum.  Sorry to be a spoilsport!

  • reikime

    1/28/2011 3:55:31 AM |

    oops!  typo alert ...sorry
    Subbing milk for the wheat would NOT work as milk...

  • Might-o'chondri-AL

    1/28/2011 7:55:05 AM |

    reikime,
    thanks for the answer.

  • reikime

    1/30/2011 12:39:45 AM |

    You're welcome Might-.

  • Olive Kaiser

    1/30/2011 3:13:16 AM |

    Check out www.theglutensyndrome.net

    I get folks who contact me from my site who have strange neurological symptoms when they either withdraw from gluten/wheat the first time or  flip flop on and off too much. I have a page on temporary adverse effects from going gluten free.

    Our 23 year old nursing student daughter experienced a very strange neurological effect from a 6 week gluten challenge after being strictly gluten free for 6 months.  Ischemia/reperfusion injury is a possibility, and gluteomorphin withdrawal also.  Her story is on the site.  For sure she is very strictly gluten free now, and doing fine 6 years after the experience. http://glutensensitivity.net/cases.htm#ztop

    In the book, "Mendel in the Kitchen, Nina Federoff, a strong proponent of GMO technology, relates how wheat was genetically altered by the 1950's by both x ray irradiation and chemical mutation, and the gluten levels were raised far above older varieties. The wheat today is not the same as our ancestors, at least not here in the States.

    FYI, a new lab (www.Cyrexlabs.com)  has just opened 2 weeks ago with much more complete gluten syndrome testing.  They are testing many more antibodies than previous standard panels, and expected to turn up many more folks with gluten syndrome.  They also teach that gluten can damage multitudes of tissues by molecular mimicry between gluten related antibodies and look alike innocent tissues all over the body.  The villi, which have been the gold standard target tissue in the celiac community, are turning out to be just one of many possible sites of damage.  

    Many folks have gluten/wheat related antibodies, but their main target of autoimmune tissue damage is in places other than the villi, such as the heart, nerves, organs, joint lining, etc.  Villi as the target tissue is found in relatively a few folks, and that is the tissue damage that has gotten most of the attention.

    Dr. Aristo Vojdani, PhD, Immunology, and others have accumulated a lot of research to support these theories, and they fit the gluten syndrome community like a glove.

  • Jonathan Byron

    1/30/2011 3:39:54 AM |

    >> "Subbing milk for the wheat wold NOT work as milk produces a morphine- like substance called caseomorph and wheat produces gliadimorphs. Two different types of exogenous morphines."

    Right, but is the fundamental problem generally the morphine-like effect, or is it some other antigen specific to gliadins? My wife has hashimoto's thyroiditis, and the smallest trace of wheat, barley, or other gliadin grains quickly makes her miserable... she can feel her thyroid swell, she gets cold, she has other problems. Dairy does not have this effect. Since cutting out gluten from grains, her T3, T4, and TSH levels have returned to normal, while her anti-thyroid antibody level has dropped to very near normal.

    I am willing to consider that with some conditions (like autism), both gluten and milk can be a problem. It is not clear to me that if gluten is a problem then milk must also always be a problem. If the casomorph proteins allows some people to quit wheat with fewer withdraw symptoms due to the substitution of endorphin-like molecules, that could be a good thing.

  • reikime

    1/30/2011 10:37:28 PM |

    Jonathan,

    The issues your wife has with gliadin really dont seem related to the morphine like responses some people have with gluten and /or dairy.

    Sure some people that have a wheat/gluten intolerance can ingest dairy just fine...that said, if the microvilli are damaged from wheat and not healed yet, you are much more likely to have a problem with dairy.
    The tips of the villi are where lactase is produced.
    Also, if one is subject to the effects of gliadiamorphins, IMHO one would likely be sensitive to caseomorphins, because the unhealed intesine is permeable.. ie leaky gut syndrome. This allows proteins into the bloodstream that would normally not be there. (and to wreak havoc)

    Willing to say I may be wrong, though. Anyone?

    I spend alot of time on celiac  research issues, so naturally this is where my brain goes!  lol

  • Dr Charles Parker

    3/22/2011 1:02:56 PM |

    Great to see that others have identified gluten as a potential pathogen/allergen that can significantly contribute to both mind and body deterioration through compromised immune dysfunction. I know you, Dr Davis, often think of the heart as the canary in the coal mine, and I see the brain as a canary partner showing first signs of impending acute deterioration.

    This link will take you to a series of interviews I did with Dr Peter Osborne on similar issues as discussed in this posting:

    http://www.youtube.com/watch?v=dJCZmNzkRNA&playnext=1&list=PLD61FCED98A4A5C66

    Hope this helps encourage more discussion and awareness, and thanks for your excellent work!
    cp

  • Carb Flu « The Paleo Spot

    9/16/2012 4:53:03 PM |

    [...] The first couple of weeks without grains and sugars were not pleasant.  In the beginning, I had a headache nearly every single day.  By body was detoxing and coming off the caffeine, carbs and sugars.  I was crazy tired.  For several days, I was so ravenous I wanted to gnaw my arm right off my body (would somebody please pass the sea salt…?)  If this lifestyle is sooo healthy, why have I been feeling like I’ve been run over twice by a dinosaur?  The answer is simple and thanks to in-depth research before starting my journey, it is something that I anticipated would happen – I have been experiencing the classic symptoms of Low Carb Flu. [...]

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Be smarter than your cardiologist

Be smarter than your cardiologist

“Do you need a stent?”

Sad to say, but that sentence condenses the wisdom of over 90% of practicing cardiologists.

Prevention of heart disease means take Lipitor or some other statin and cutting the saturated fat in your diet. That’s it. Maybe throw in exercise.

Regression of coronary plaque? That phrase has only entered the conversation since the AstraZeneca-supported trial of Crestor succeeded in achieving 8% regression of plaque (Track Your Plaque Members: See News) as demonstrated by intracoronary ultrasound.



In other words, in the minds of my colleagues, it can’t be true until a drug company tells them it’s true. It’s beyond me why this brainwashing of otherwise intelligent people has occurred, but it is blatantly evident in practice.

Fish oil is another example. The spectacular benefits of fish oil have been known for 20 years. But only recently has it become a “mainstream” practice to recommend fish oil, largely because a drug manufacturer has put a preparation through the rigors of FDA approval (Omacor) and is now marketing directly to physicians. All of a sudden, fish oil is a good thing? No, it’s just achieved legitimacy in the eyes of practitioners because it graces marketing literature.

If you’re reading this, you’re likely interested in coronary plaque regression using the only tool available for you to measure, track, and regress coronary plaque: CT heart scans. Intracoronary ultrasound will achieve the same goal, but it is an invasive procedure performed at heart catheterization, involves threading a wire and imaging probe all the way down the artery, involves real risk of tearing the inner lining of the artery, and is costly (around $14,000-$20,000 for the entire package). Do it every year? That’d be nuts.

If you’re thinking about coronary plaque regression, using fish oil, concerned about patterns like low HDL and small LDL, aware of the vitamin D deficiency issue as a coronary risk factor, etc., you are far more aware than the vast majority of practicing cardiologists. They are interested in what new brand of anti-coagulant to use during their heart catheterization (because the product representative gushes about the new agent—only $1200 a dose!). Or, they are interested in gaining the procedural skills to put in a new device like a biventricular pacemaker. Regress/reverse coronary plaque? What for?

You already know that a conversation about coronary plaque reversal will not be obtained in your cardiologist’s office. Your family practice doctor or internist? Fat chance! Knee arthritis, pap smears, pneumovax inoculations, sore throats, gout, back pain—they’re spread far too thin to know anything more than the most superficial amount about coronary plaque control. Most know nothing.

That’s where we come in. That’s our mission: Educate people about the extraordinary tools that you have available to you, all in the cause of control or reversal of coronary plaque.
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Rosiglitazone not so rosy?

Rosiglitazone not so rosy?

Dr. Steve Nissen of the Cleveland Clinic published a study that suggests that the pre-diabetes and diabetes drug, rosiglitazone, may increase likelihood of heart attack by 43%.

I say "suggests" because the analysis was something called a "meta-analysis", a re-examination of data obtained by pooling unrelated studies and reanalyzing the data. Strengths of this sort of analysis: Sometimes trends that are not evident in smaller studies finally become evident in the larger numbers of participants obtained through pooling of data. Downside: Any statistician will tell you that a meta-analysis can only suggest an association, it cannot prove it.

Nonetheless, we are talking about people's lives. As they say, if you are taking this drug, also known by the brand name, Avandia, then talk to your doctor. I think that this is sound advice, as there are a number of factors to weigh in decision making. For instance, how far along the diabetic path are you? Have you had negative experiences with other agents?

It will, unfortunately, be months to years before confirmatory evidence on this question become available. In the meantime, Nissen will accuse the drug industry of pushing drugs through the FDA approval process without full safety data. GlaxoSmithKline, the manufacturer of Avandia, will counter with claims of weak data, the existing trials not confirming Nissen's findings, etc. We've seen it before.

My take on this is to step back and look at the broad picture. Do we need yet another reason to say that it's far better to maintain normal body weight, dramatically reduce reliance on processed carbohydrates and wheat, exercise, and following other insulin-sensitizing strategies, rather than rely on insulin-sensitizing drugs? (That's what rosiglitazone is supposed to do.) Metabolic syndrome, also known as pre-diabetes, or diabetes is present to various degrees in two thirds of all adults I meet. Nearly all of it is self-inflicted. Nearly all of it is curable with the above lifestyle strategies if undertaken early enough in the process.

A 190 lb, 5 foot 2 inch woman, or a 220 lb, 5 foot 10 inch man, both of whom are surprised that they have pre-diabetes really need to get a grip on reality and health. To me, it's no surprise that drugs do not reverse all the nasty manifestations of lifestyle gone berserk. It should also come as no surprise that the complex, chaotic physiologic mess created by metabolic syndrome and pre-diabetes is not perfectly managed by adding one drug.

Comments (3) -

  • Mike

    5/23/2007 8:39:00 PM |

    The FDA should have fully analyzed the data before granting approval to Rosiglitazone. It is my opinion that all drug test data should be public domain on all approved drugs or medical equipment (stents, pace makers, etc.). That is the only way that a patient can truly give informed consent to using them.

  • Nancy

    5/23/2007 10:50:00 PM |

    Yeah, probably most of the time it is self-inflicted except when you look at the nutritional recommendations and grain heavy diet being pushed by the US government, and even the ADA (!) the whole idea that grains are so darned healthy is probably responsibile for a lot of the diabetes in our society.

  • Anne

    5/24/2007 11:04:00 AM |

    Rosiglitazone has also been associated with macular edema. This improves when people discontinue the drug. It is also thought to increase the risk of bone fracture.

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"Make big money fast with CT scans"

"Make big money fast with CT scans"

Rather than the headline New Study Could Change Heart Disease Diagnosis And Treatment being run in Utah TV and newspapers, instead it should read:


Make big money fast with CT scans!

Is your bottom line shrinking? Have you fallen on hard economic times? Is competition from other hospitals and providers threatening your financial health?

Then we have a solution: Do a CT coronary angiogram on everybody! Look for disease in people with no symptoms, scare the heck out of them, and voila! Instant need for bypass surgery!

Ka-ching!! That'll be $100,000, please.

Do it again, and again, and again, and your hospital will be quickly in the black in no time!

And, for the savvy marketer, tell the newspapers that you're going to conduct a study to see if this approach works--even before the study gets started! Even if the study pans, you'll come out a winner because you did it in the name of "research"!




Apparently a group of cardiologists at the Intermountain Medical Center and LDS Hospital in Salt Lake City, with the financial assistance of Siemens, a manufacturer of CT scanners, is funding a 1000-patient study of diabetics, all without symptoms of heart disease, half of whom will undergo "screening" CT coronary angiograms (not heart scans) followed by bypass surgery, if "needed". The other half will receive conventional, "aggressive" medical therapy. "Aggressive" means cholesterol treatment, blood pressure control, and blood sugar control (no kidding).

The outcomes of the two groups will be compared after two years.

To understand the absurdity of this study, note that they are proposing what amounts to "prophylactic" bypass surgery, since the participants are without symptoms. Since there are no stress tests, a measurement of flow or functional capacity (exercise tolerance) cannot be factored in. Decisions will be made on the basis of severity of "blockages" in asymptomatic people, a hazardous notion that has never been shown to provide benefit. No doubt: Some diabetics with extensive disease may obtain benefit from screening, but many more will undergo what amounts to unnecessary bypass that provides no benefit. We already know from studies dating back over 20 years to the days of the original CASS (Coronary Artery Surgery Study) that putting asymptomatic people through bypass surgery willy-nilly does not reduce mortality.

Of course, the "aggressive" preventive treatment they propose is more like the least common denominator level of treatment. In fact, I would characterize the "aggressive" preventive treatment as ridiculous. Doing less would be malpractice. Much more could be done, but doing a lot more would pose a real challenge to the bypass arm of the trial.

But the smell of money drives such efforts: More CT angiograms, more hospitalization for bypass surgery. The payoff to the hospitals from this effort is likely to exceed $5 to $10 million, all money that they might not have otherwise seen. The ill-informed people in the local media gush with enthusiasm, the hospital acts like they are at the cutting edge of medical technology, the doctors pose as saviors.

All this time, real preventive efforts go unmentioned. No fish oil (28% reduction in heart attack, 45% reduction in sudden death from heart attack), no genuine diet efforts (i.e., not the diabetes-promoting American Diabetes Association diet), no effort to identify sources of coronary risk beyond LDL cholesterol (low HDL,small LDL,and postprandial or after-eating abnormalities, for instance, are prominent sources of risk in diabetics), no vitamin D. In my view, the preventive arm of the study amounts to doing virtually nothing beyond prescribing statin drugs.

Don't fall for it.

Comments (6) -

  • Anonymous

    5/31/2008 2:02:00 PM |

    Good timing for my father on this blog post.  It isn't heart disease but next week my father is driving to Chicago to have his head examined with an MRI to learn the potential of having an aneurysm. (I think I said that right, aneurysm)  I asked him why and he told me the exam is "free".  I don't much about how hospitals are run but from my experience every time I've been to one nothing was free.  If anything everything bought was 10 times normal price.  I've warned my father not to fall for scams - nothing is free dad.  My guess is this is a way for the hospital to drum up $100,000 business from the unsuspecting sucker.

  • Jenny

    5/31/2008 2:14:00 PM |

    Even more important is the danger from the high levels of radioactivity exposure caused by those scans. There was a study published that looked at the CT scan exposure of ER patients and found that the cumulative level was far over the level known to cause cancer.

    Science News report.

    CT scans should be used only when justified by a very real and present danger. And even then often X-rays would be a better choice.

  • Anonymous

    5/31/2008 3:41:00 PM |

    Just when I thought the profession could not sink lower!  This seems to be another example of the current philosophy - "sick until proven healthy."  Unfortunately, this type of doctor doesn't recognize anyone as healthy. Oy....

  • Jessica

    5/31/2008 4:53:00 PM |

    Great analysis.

    We hosted a health care forum on 14 May and during the Forum, one of the doctors said, "we're wasting money trying to prove that healthy people are healthy."

    So true.

    Asymptomatic and they're being entered into a study which includes invasive "bypass" as a clinical intervention?

    Brain dead.

  • PJ

    5/31/2008 11:36:00 PM |

    You know, that's actually terrifying.

  • jpatti

    6/4/2008 3:40:00 PM |

    I really can't *imagine* anyone signing up for this study.

    After a week of heartburn, I spent the night screaming and vomiting before an unsuccessful emergency angio.  And after all that, while on narcotics and IV heparin, I had to be "talked into" a bypass.

    I can't imagine doing it for the sake of science.

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