The Heart.org online debate

20. November 2007 William Davis (9)
There's a fascinating and vigorous debate going on at the Heart.org website among Dr. Melissa Shirley-Walton, the recently publicized proponent of "a cath lab on every corner": Dr. William Blanchet, a physician in northern Colorado; and a Track Your Plaque Member who calls himself John Q. Public.

John Q. has been trying to educate the docs about the Track Your Plaque program. Unfortunately, Dr. Shirley-Walton essentially pooh-poohs his comments, preferring to lament her heavy work load. In her last post, when she discovered that John Q. was not a physician, she threatened to block his posts and delete all prior posts.

However, Dr. Blanchet has emerged as a champion of heart scanning, intensive lipid management, and lipoproteins, much similar to our program. In fact, many of Dr. Blanchet's comments were so similar to mine that John Q. asked me if it was really me! (It is definitely not.)


Here's a sampling of some of the discussion going on now:


Dr. Blanchett started out the discussion by saying:

Stent Insanity
I have no trouble agreeing with the argument that we have initiated the widespread use of DES without adequate study regarding outcomes. Shame on us.

That said, we are ingoring the DATA that shows that most heart attacks occur as a result of non-obstructing plaque and all the talk about which stent to use ignors the majority of individuals at risk. In addition, for a decade we have known that stenting does not improve net outcomes anyway.

What ever happened to effective primary prevention? We discarded EBT calcium imaging like moldy cabbage without even looking at the outcomes DATA. With direction provided by EBT calcium imaging and effective primary prevention, I have been able to reduce myocardial infarction by 90% in my very large Internal Medicine practice. Through effectively identifying patients at risk and measuring success or failure of treatment with serial EBT, I have made the argument as to which stent to use moot. No symptomatic angina and rare infracts equals little need for any stent.

Is anybody listening? Certainly not the cardiologists whose wealth and fortunes are based on nuclaer imaging, angiography and stenting.


Dr. Shirley-Walton, skeptical of Dr. Blanchet's claim of >90% reduction of heart attacks using a prevention program starting with a heart scan:

To rely soley upon a calcium score will deprive you of a lot of information that could be otherwise helpful in the management of your patients.

Without seeming sarcastic, I must refute : "of 6,000 patients I've seen 4 heart attacks in 3 years". Although I certainly hope your statistics are accurate, I will suggest the following:

You've not seen all of the heart attacks since up to 30% of all heart attacks are clinically silent. So unless you are echo'ing or nuclear testing all of these patients in close followup, you aren't certain of your stats.

Secondly, in order to attribute this success to your therapy, you would have to have nearly 100% compliance. In the general population, compliance is often less than 50% with any regimen in any given year of treatment. If you can tell us how you've achieved this level of compliance, we could all take a lesson.



Dr. Blanchett, commenting on his use of heart scanning as a primary care physician:

CAC [coronary artery calcium] is an inexpensive and low radiation exam to identify who is at increased risk for heart attacks.

A study of 222 non-diabetic patients admitted with their first MI found 75% of them did not qualify for cholesterol modifying therapy prior to their initial MI (JACC 2003:41 1475-9). In another study of 87,000 men with heart attacks, 62% had 0 or 1 major risk factors (Khot, et al. JAMA. 2003). Almost all individuals with 0 or 1 risk factor are Framingham "Low risk" and therefore will not qualify for cholesterol lowering therapies. (JAMA. 2001;285:2486-2497)

Risk factors alone are not sufficient. In my practice, of the last 4 patients who have died from heart attacks, none qualified for preventive therapies by NCEP guidelines.

Studies have shown that CAC by EBT provides an independent and incremental predictor of heart attack risk. (1. Kondos et al, Circulation 2003;107:2571-2176, 2. Am Heart J 141. 378-382, 2001, 3. St Francis Heart Study Journal of the American College of Cardiology July, 2005) The old saw that CAC simply reflects risk factors and age is just wrong.

Although CT angiography shows great promise to reduce unnecessary conventional angiography and is helpful in emergency room chest pain evaluation, I do not see CT angiography as a screening study in asymptomatic individuals. 10 times more radiation than EBT calcium imaging plus the risk of IV dye exposure makes CT angiography inconsistent with the principles of a screening test. Taken in the context of a primary care physician's evaluation of heart attack risk, EBT calcium imaging has great value.

Coronary calcium changes management by: 1. Identifying those at risk who do not show up with standard risk stratification (St Francis Heart Study: Journal of the American College of Cardiology July, 2005). 2. Motivating patients to be compliant with therapies (Atherosclerosis 2006; 185:394-399). 3. By measuring serial calcium, we can see who is and who is not responding to our initial treatment so that we can further refine our therapeutic goals (Atherosclerosis, 2004;24:1272).

When used in the primary care preventive setting, CAC imaging is indeed of great incremental value. In my practice, in improves my outcomes so greatly that it compels Melissa Walton-Shirley to question my veracity.


Dr. Melissa Walton-Shirley:

Ahhhhhh.......the aroma of profit making, I thought I smelled it. [Accusing Dr. Blanchett of referring patients for heart scans for personal profit.]

I will tell you that I was a little hurt when I was called "a typical cardiologist with a butcher block mentality" after my primary pci piece for med-gen Med was reviewed by the track your placque [sic] folks.

Though, it's clear that they misunderstood and thought I was cathing for dollars, instead my intention was to "push" for primary PCI for AMI, it left me seething until the blessing of a busy schedule and a forgetful post menopausal brain took its toll.
None the less, an honest open discussion is always welcome here but I would appreciate it if everyone would just divulge their affiliations up front so that the context of their opinions could be better understood.

I also insist that the compliance described by you William B. is rather astounding and a bit unbelieveable, however if it's accurate, you are to be congratulated.



Dr. Blanchett, in response to Dr. Shirley-Walton's statement that she relies on stress testing:

I think that the threshold of comfort you get from stress test stratification is different than what I consider acceptable. It is hard for me to tell a bereaved spouse that the departed did everything I suggested and still died from a MI. Coronary calcium imaging provides me the tool that I need.

Are you aware that there are a number of studies that show a dramatic increase in risk of MI in individuals with an annualized increase in calcified plaque burden of >14%? I consider this to be a valuable measure of inadequacy of medical management. A stress test does not become positive until we have catastrophically failed in medical management. Consequently, even in the patient with “high risk” stratification, one can justify a calcium score to establish a baseline to measure adequacy of primary prevention. Calcium scores by EBT cost about 1/5th the cost of a nuclear stress test and subject the patient to 1/10th the radiation of nuclear imaging and provides more precise information.

Regarding John Q, I do not think that non-medical prospective should be excluded from this blog. I think we as physicians benefit from hearing how the non-physician public views medicine. I have become much better at what I do by listening to my patients and learning from them.


Dr. Blanchett continues:

Yes, I have seen a dramatic reduction in coronary events. Of 6,000 active patients, 48% being Medicare age and over, I have seen 4 heart attacks over the last 3+ years. 2 in 85 year old diabetics undergoing cancer surgery, one in a 90 year old with known disease and one in a 69 year old with no risk factors, who was healthy, and had never benefited from a heart scan.

The problem with coronary disease is that we rely on risk factors. Khot et al in JAMA 2003 showed that of 87,000 men with heart attacks, 62% had 0 or 1 major risk factor prior to their MI. According to ATP-III, almost everyone with 0-1 risk facto is low risk and most are do not qualify for preventive treatment. EBT calcium imaging could have identify 98% of these individuals as being at risk before their heart attack and treatment could be initiated to prevent their MI.

Treating to NCEP cholesterol goals prevents 30-40% of heart attacks. Treating to a goal of coronary calcium stability prevents 90% of heart attacks. Where I went to school a 40% was an F. Why are we defending this result instead of striving to improve upon it? I am not making this up, look at Raggi's study in Ateriosclerosis, Thrombosis, and Vascular Biology 2004;24:1272, or Budoff Am J Card

Melissa, I strongly disagree with the assertion that the stress test is a great risk stratifier. Laukkanen et al JACC 2001 studied 1,769 asymptomatic men with stress tests. Although failing the stress test resulted in an increased risk of future heart attack, 83% of the total heart attacks over the next 10 years occurred in those men who passed the stress test.
Falk E, Shah PK, Fuster V Circulation 1995;92:657-671 demonstrated that 86% of heart attacks occur in vessels with less than 70% as the maximum obstruction. A vast majority of patients with less than 70% vessel obstruction will pass thier stress test.

William, regarding your question of owning or referring for EBT imaging, I would be amused if it were not insulting. The mistake that is often made is that EBT imaging is a wildly profitable technology. It is not nearly as profitable as nuclear stress imaging. Indeed there are few EBT centers in the country that are as profitable as any random cardiologists stress lab.

How can we justify not screening asymptomatic patients? Most heart attacks occur in patients with no prior symptoms and according to Steve Nissen, 150,000 Americans die each year from their first symptom of heart disease. My daughter is at this moment visiting with a friend who lost her father a few years ago to his first symptom of heart disease when she was 8 years old. That is not OK! We screen asymptomatic women for breast cancer risk. Women are 8 times more likely to die from heart disease than breast cancer. We do mass screening for colon cancer and we are over 10 times more likely to die from heart attacks than colon cancer. An EBT heart scan costs 1/8th the cost of a colonoscopy.

So what say we drop the sarcasm and look at this technology objectively. Read the literature, not just the editorial comments. This really does provide incredibly valuable information that saves lives.

Yes, a 90% reduction in heart attacks in my patients compared to the care I could provide 5 years ago when I was doing a lot of stress testing and referring for revascularization. Much better statistics than expected national or regional norms. I welcome your scrutiny.


John Q. Public jumps into the fray with:

Fascinating, isn't it, that there appear to be two doctors, William Blanchet in this forum and Dr. William Davis, FACC, of cureality.com that both claim to have dramatically reduced risk of heart attack among their patients and/or actual calcium plaque score regression and BOTH are ardent proponents of CT Calcium Scoring?


Despite Dr. Blanchet's persuasive arguments backed up with numerous scientific citations and John Q.'s support, I sense they had no effect whatsoever on Shirley-Walton's way of thinking.

Such are the deeply-entrenched habits of the cardiology community. It will be many years and impassioned pleas to see things in a different light before the wave of change seizes hold.
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Comments (9) -

  • Anonymous

    11/20/2007 1:32:00 AM |

    I give thanks that the health of my heart does not rely upon the Melissa Shirley-Waltons of the world.

  • Anonymous

    11/20/2007 3:37:00 AM |

    Where exactly is this debate going on? I was unable to find a forum at that site, even though the site index. I did a search for the doctors' names, and came up blank.
    Thanks,
    S

  • Dr. Davis

    11/20/2007 3:45:00 AM |

    Just go to heart.org and the Forum is on the left navigation bar. You will have to sign in, presumably as a media representative.

  • Anonymous

    11/20/2007 1:24:00 PM |

    Looks like this "John Q Public" has emerged from the shadows over at the HeartCipher blog.

    http://www.heartcipher.com/archives/42

  • Anonymous

    11/20/2007 1:27:00 PM |

    The link to the forum in question is:

    http://www.theheart.org/viewForum.do

    The thread title is:

    "DES showdown: Serruys vs Virmani"

  • Paul Kelly - 95.1 WAYV

    11/21/2007 5:23:00 PM |

    Hi Dr. Davis (and everyone!) -

    In talking with my family physician today about CT Heart Scans, she said she doesn't like them because of the level of radiation. She said she just read an article that said even one CT can increase your chances significantly for leukemia, cancer, etc. She's a believer that a comprehensive stress test can tell you what you need to know - i.e. if you have plaque, it's going to affect the results of your stress test and is therefore detectable that way. Is the level of radiation really something to be scared of?

    Paul

  • Rich

    11/21/2007 10:20:00 PM |

    Dr. Davis recently wrote a blog piece titled "Are Cardiologists the Enemy?" that seems particularly relevant here.

    -Rich

  • Anonymous

    11/23/2007 3:48:00 PM |

    Since it seemed like I had read John Q Public's writing style recently, I clicked on this blog's side links, and found JQP was most likely HeartCipher. I read through some of HeartCipher's recent posts and found the link to the forum, at theheart.org -- not heart.org as originally linked.

    Dr. Davis, perhaps the link could be corrected in the blog post?

    Many thanks to the anon commenter for the DIRECT link to the thread (too bad I didn't reread through the comments before sleuthing LOL)! Once I receive my confirmation letter from theheart.org I'll be able to read it.

    S

  • Dr. Davis

    11/23/2007 4:05:00 PM |

    Yes, my mistake, now corrected. Thanks.

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Can you tell the difference?

Can you tell the difference?

12. October 2006 William Davis (0)
Stan is 55 years old. He feels fine, is in moderately good physical condition. His LDL cholesterol is 135 mg/dl, HDL 43 mg/dl, triglycerides 167 mg/dl, total cholesterol 211 mg/dl.

Can you tell me whether Stan has heart disease or not?

How about Charles? Charles has an LDL cholesterol of 127 mg/dl, HDL of 44 mg/dl, triglycerides of 98 mg/dl, and total cholesterol of 191 mg/dl. He is also reasonably fit and feels fine. Can you tell whether Charles has heart disease?

If you can't, don't feel bad. Neither can your doctor. But this is the folly of using cholesterol for risk prediction.

Stan's heart scan score: 0

Charles' heart scan score: 978

Look even more closely at Stan's and Charles' cholesterol numbers. Is there some fine distinction we overlooked? What if we calculated total cholesterol to HDL ratio? Or LDL/HDL ratio?

No matter how you squeeze it, shake it, beat it with a stick, you simply cannot use cholesterol numbers to predict heart disease in specific individuals. Yes, the higher your LDL cholesterol and lower your HDL, the higehr your total cholesterol to HDL ratio, the greater the likelihood of heart disease. But you can simply cannot tell in a specific individual at a specific point in time. If you've seen your doctor puzzle over the numbers, understand that he/she is trying to make sense out of something that doesn't make sense, no matter how hard he/she tries.

You simply need to measure the disease itself: get a CT heart scan, the only measure of atherosclerotic coronary plaque that you have access to.

By the way, if you haven't seen it yet, go to the Track Your Plaque website (www.cureality.com) to see the news piece reporting the American Heart Association's much overdue position statement on CT heart scanning. The AHA has finally released a statement which, in effect, provides their "official" endorsement. Blocked by political shenanigans behind the scenes for several years, the guidelines finally made it to press. The only real difference it makes to me is that my patients may finally get their heart scans paid for by insurance, once the insurance companies realize that it's getting tougher and tougher to dodge their responsibility.
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Wheat withdrawal: How common?

Wheat withdrawal: How common?

5. October 2008 William Davis (11)
In response to the recent Heart Scan Blog poll,

Have you experienced fatigue and mental fogginess with stopping wheat, i.e., "wheat withdrawal"?

the 104 respondents said:


Yes, I have experienced it: 26 (25%)

No, I stopped wheat and did not experience it: 65 (62%)

I'm not sure: 3 (2%)

I haven't tried it but plan to: 7 (6%)

I haven't tried it and don't plan to: 3 (2%)


So 25% of respondents reported experiencing the fatigue and mental fogginess of wheat withdrawal. This is similar to what I observe in my practice.

I counsel many patients to consider the elimination of wheat, as well as cornstarch products, in an effort to regain control over:

--Weight
--Appetite
--Low HDL
--High triglycerides
--Small LDL
--High blood sugar
--High blood pressure

All of these issues respond--often dramatically--to elimination of wheat and cornstarch.

Why would there be undesirable effects of eliminating wheat?

One clear issue is that elimination of wheat and other sugar-equivalents deprives your body of glucose. Your body then needs to resort to fatty acid metabolism to generate energy. Apparently, some people are inefficient at this conversion, having subsisted on carbohydrates for the last few decades of their lives. However, as fatty acid metabolism kicks in, energy generation improves. That is my (over-)simplified way of reasoning it through.

However, are there other explanations behind the mental fogginess, drop in energy, and overwhelming sleepiness? Some readers of this blog have suggested that, since opioid-like sequences (i.e., amino acide sequences that activate opiate receptors) are present in wheat, perhaps withdrawal from wheat represents a lesser form of opiate withdrawal. I find this a fascinating possibility, though I know of no literature devoted to establishing a cause-effect relationship.

Whatever the mechanism, I find it very peculiar that this food widely touted by the USDA, American Heart Association, and other agencies actually triggers a withdrawal syndrome in approximately 25% of people. Spinach does not trigger withdrawal. Nor does flaxseed, olive oil, almonds, and countless other healthy foods.

Then why would whole wheat grains be lumped with other healthy foods?
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Comments (11) -

  • Anonymous

    10/7/2008 12:29:00 AM |

    Eliminate wheat and cornstarch, check.

    What about other grains?

    Is it necessary to eliminate ALL grains to get control of small LDL, etc., etc.?

    What about oats, as oat bran is a mainstay fiber of the TYP program?

    Are cooked oat groats (whole oats) an acceptable grain on TYP?

    So many questions... perhaps better to post these on the TYP members forum.  Smile

    Thanks for this informative blog!

    Terri
    madcook

  • Anonymous

    10/7/2008 2:45:00 AM |

    Well somebody should invite a "Wheat Patch" -
    The withdrawals are very very strong for me and have taken some time to subside.

  • Peter

    10/7/2008 10:57:00 AM |

    Hi Dr Davis,

    Here's an intro

    the peptides

    more on the peptides

    male breast enhancement?

    behavioural effects

    Insulin effects

    I like that last one as it provides a link through exaggerated pancreatic response to carbohydrate, subsequent hyperinsulinaemia leading to reactive hypoglycaemia. Then hunger triggers another bagel, more hyperinsulinaemia and then an anticipatory bagel becomes habitual as hunger is unpleasant and can be avoided. This sets up for chronic hyperinsulinaemia with pathological insulin resistance as a survival tactic for muscles to avoid sugar poisoning. Chronic hyperinsulinaemia equals metabolic syndrome, small dense LDL etc etc...

    Both spinach and haemoglobin contain similar sequences, but wheat is verging on indestructable in its structure, plus it opens the tight junctions between eneterocytes to gain access to the systemic circulation, not a feature of many other foods...

    Peter

    The schizophrenia links would be off topic on a CVD blog...

  • Anonymous

    10/7/2008 1:29:00 PM |

    What implications are there for someone to eliminate wheat if they are not overweight and their triglycerides and LDL particle size are both in a good range?

  • Nancy LC

    10/7/2008 2:11:00 PM |

    I was lucky not to have the brain fog on quitting wheat, but I had it when I was abusing wheat!  

    Truly, it feels like I got my old brain back, the youthful, smart one, when I quit eating wheat and all gluten.  Such brain fog that stuff gave me.

  • Anne

    10/8/2008 12:18:00 AM |

    Not only did I have withdrawal symptoms when I eliminated wheat (and barley and rye), but I become fatigued, irritable, foggy brained and red eyed if I get even the tiniest bit of these grains. I have non-celiac gluten sensitivity. Tests by Enterolab revealed my body makes antibodies against gluten(the carrier proteins in these grains).

    The heart connection? For me, I think wheat contributed to or caused the inflammation that blocked my heart vessel. I cannot prove this other than to say my health has improved dramatically since giving up wheat and other related grains. I have also found I need a diet low in carbs to keep my blood glucose low. That eliminated all the other grains.

    How common is gluten sensitivity? There is a growing number of doctors who believe this affects 10-30% of the population. Add to that, the people who have a wheat allergy(wheat is among the top 8 allergens), and you have a lot of people who should not be eating even a smidgen of wheat.

    Peter, thanks for the links.

  • Margaret P

    10/8/2008 2:45:00 AM |

    I haven't eliminated wheat, but after eliminating corn and its derivatives from my diet, my already painful and increasingly serious sinus infection cleared up.  I also went from needing 11-12 hours of sleep to 9-10.

    I think allergies to corn are very common but almost never recognized.  Corn is in almost every processed food.  I was sick for a decade before a friend suggested avoiding corn and it took only two days to see a dramatic improvement in my health.

  • Anonymous

    10/9/2008 12:53:00 AM |

    I can only speak from my own experience, but after eating wheat (all grains) for 50 years, my immune system is shot. Now if I consume even a couple of items (pasta or muffin or bread), within a day my feet swell up and my left knee is so painful I can barely walk nevermind the pain in my back. Those are just the first warning signs. If I dare continue, I know that within a short time I could possibly die. After a week of no grain and sugar, I'm practically jumping out of bed with no pain whatsoever anywhere. I have tested this several times (stupid me) and no longer experiment.

  • Anonymous

    12/12/2008 9:45:00 PM |

    i have been off wheat and soya for two weeks, for the first week i felt fine, but now i feel half asleep, like i haven't got enough energy for anything and could just fall asleep at any given moment.  i though i was alone! I have also dropeed two dress sizes in the past two weeks and am becoming concerned about how quickly i am losing weight? should this slow down soon? I am a little over weight, but not massively so i don't want to lose too much.

  • Anonymous

    6/5/2009 3:46:15 PM |

    i eliminated wheat from my diet and had the  fogginess and headaches.

    very informative blog, thank you

  • Anonymous

    1/21/2011 7:05:42 PM |

    I'm on day 4 of wheat removal and it's very tough.

    I know from experimentation that potatoes, rice, fruit, corn (corn flakes), and even artificial sugars like a chocolate bar don't affect these withdrawal symptoms.  

    I haven't tried oatmeal or barley out of a fear of gluten, but just to add to the discussion that I'm finding wheat uniquely bad for withdrawal even though I'm getting plenty of carbs from white rice and fruit, also getting plenty of meat and fat and veggies.  Adding in wheat makes the withdrawal symptoms go away, although I feel much worse physically.  Thus, I'm having heavy fatigue and headache constantly despite having a moderate amount of carbs with each meal.  Also, from experience, the rice I eat with each meal gives me very mild negative effects physically, so I'm positive all of this headache and fatigue is from wheat withdrawal.  It's become very consistent by now.  I hope this goes away soon...

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