Heart stent unnecessary? Maybe

More news coming out of the American College of Cardiology meeting in New Orleans. Too bad Dr. Wes is not there to give us the inside scoop (he he, just kidding).

The theory with heart stents is pretty easy to explain to patients. The paradigm has been that symptoms of angina, or chest pain, are caused by a slight blockage in the tiny heart vessles (see above - image from here). So, why not open the vessel up with a heart stent and relieve the chest pain. Simple, right?

In this Associated Press article, researchers have found that in people with stable angina, medication treatment (meaning pills) is just as good as having an angioplasty procedure and having a heart stent placed.

It involved 2,287 patients throughout the U.S. and Canada who had substantial blockages, typically in two arteries, but were medically stable. They had an average of 10 chest pain episodes a week — moderately severe. About 40 percent had a prior heart attack.

All were treated with medicines that improve chest pain and heart and artery health such as aspirin, cholesterol-lowering statins, nitrates, ACE inhibitors, beta-blockers and calcium channel blockers. All also were counseled on healthy lifestyles — diet, exercise and smoking cessation. Half of the participants also were assigned to get angioplasty.

After an average of 4 1/2 years, the groups had similar rates of death and heart attack: 211 in the angioplasty group and 202 in the medication group — about 19 percent of each.

After five years, 74 percent of the angioplasty group and 72 percent of the medication group were free of chest pain - "no significant difference," [one of the researchers] said.

The results of this study will be published in the New England Journal of Medicine and will send shockwaves through the world of cardiology. This will be a huge paradigm shift in what is the current thinking.

This will set up a philosophical and academic war between the interventional cardiologist (those that make a lot of their living doing angioplasties and stents) and the cardiologist who do few or no angioplasties. It will also be a business war between the drug makers and the stent makers.

It will come down to this question: When a patient has chest pain, what is the better treatment? Drugs AND stent or Drugs WITHOUT stent? We'll have to see how this plays out....

Now, something I am concerned about is what the press report really passed over very quickly. (Surprised that I'm upset at the press again?) What should be emphasized is that this study relates to patients who are medically stable. Medically stable means not actively having a heart attack or actively having worsening chest pain symptoms right in front of you.

I can see a heart attack patient in the ER tomorrow saying, "I just heard this report saying that an angioplasty and stent are not needed. Plus, there have been a lot of bad press lately about stents anyway. I don't want one."

I want to emphazise that in the emergency situation (meaning heart attack and/or worsening chest pain symptoms) -- Angioplasty and stent placement are not only the mainstay of treatment, they have been shown to save lives. So, interpret these study findings how they were presented -- in medically stable patients -- and don't interpret this as a generalization on angioplasty and stents in general.

Dark chocolate saves lives

Well, not necessarily. But, that made a great title for a post, huh? Anyone that knows me knows that I have a weakness for chocolate - M&M's in particular. And, dark chocolate? Well, in moderation, this is the best chocolate of all.

And, now, I have the data to prove it. There was actually a study presented at the American College of Cardiology scientific meeting in New Orleans. In a six week trial, some study subjects were given dark chocolate and some were given placebo. (Reuters).

"In this sample of healthy adults, dark chocolate ingestion over a short period of time was shown to significantly improve (blood vessel) function," said Dr. Valentine Yanchou Njike of Yale Prevention Research Center, a co-investigator of the study.

"While the findings from this study do not suggest that people should start eating more chocolate as part of their daily routine, it does suggest that we pay more attention to how dark chocolate and other flavonoid-rich foods might offer cardiovascular benefits," Njike said.

First of all, where can I sign up for a study like this? (Call me!). And, second, I can finally feel a little less guilty when grabbing for those dark chocolate M&M's. I'm improving my blood vessel function, you know...

Flu Shot Rant: Part Deux

For those of you who have been following this blog since last fall, you know how the issue of flu shots just irks me. For part one of this story, read the first flu shot rant. Now, as the flu season is coming to an end, this post is part two.

In this Associated Press story from March 21, it talks about how 10 million flu shots will need to be destroyed because of the expiration date of June 30th.

Wasted vaccine means lost money for drug companies and one stopped making flu shots because of it — setting the stage for a flu shot shortage in 2004.

Wait a minute. Since when does the press care about drug companies making money? There's this UPI story describing a JAMA study talking about drug companies spending millions of dollars on evil doctors. Don't get me wrong, I myself am not a fan of big pharma, just pointing out the hypocrisy.

Getting back to flu shots, I'm having a difficulty understanding why the June 30th expiration date is chosen for annual flu shots. I thought that it was because of the shelf life, but apparently, chemically, these doses are still good. So, it's not a chemical expiration date. It's a business expiration date.

The June 30 date is mostly to ensure that all old vaccine is gone before new doses come out. "There is some benefit to a system where unused vaccine is discarded even if it hasn't really lost that much potency," said Dr. John Treanor, a vaccine expert at the University of Rochester in New York.

Old vaccine could be a tough sell if one of the strains is not well-matched to what's expected to circulate. "You'd have to tell people next year that the vaccine they got could be inferior," said Dr. Walter Orenstein, a vaccine expert at Emory University.

One more argument for the current system: Straying from a set expiration date for an entire season's vaccine would probably cause a huge headache for those trying to manage vaccine supplies, and for manufacturers trying to calculate the following season's demand, added Dr. Carolyn Bridges of the federal Centers for Disease Control and Prevention.

Ok, I'm not an epidemiologist nor an infectious disease specialist, but aren't flu shots manufactured guessing what the flu strains could be? So, if I had some expired flu vaccine on hand that I could give out during the annual initial flu shot shortage, wouldn't a potentially "inferior" vaccine be better than no vaccine at all?

Stockpiling leftover vaccine until new vaccine is available "doesn't sound like an unreasonable thing to be doing," said another vaccine scientist, Dr. Robert Belshe at St. Louis University. After all, usually only one of the three vaccine strains changes — often, only slightly. Twice in the last decade, the recipe didn't change at all, said Alexander Klimov, a CDC flu strain expert.

And three times in the last decade, the vaccine strains recommended for the United States in one winter were identical to what was recommended for the Southern hemisphere the following summer, he said.

Also, several recent studies showed that even poorly matched vaccine can still be highly effective — something to consider amid worries about bird flu and efforts to stockpile vaccine to protect in a pandemic.

Here's just a friendly suggestion for the Food and Drug Administration. Why not do away with the June 30th expiration date for the flu vaccine? We can definitely stop the annual cycle of madness in which people get angry in the fall for not having their flu shot on demand, and the press in the spring bring up the fact that millions of flu shots are wasted.

But, this is the government we're talking about - meaning bureaucracy and the status quo. So, nothing will be done. This means that come this fall, we'll talk about this cycle starting again. And, I'll be here to rant about it.

Grand Rounds

Grand Rounds 3.26 is now up an running at Blog, MD with my blog friend and colleague Sam Blackman, MD. He's a pediatric hematologist-oncologist which, to me, has to be a tough job. I tip my hat to you and your work. Thanks to Dr. Sam for including my post this week...

Dr. Anonymous, apparently more concerned with staying awake than going to sleep, reports on the news that the “pick me up” people feel when drinking that first cup of coffee in the morning may have more to do with stopping withdrawal symptoms than with the stimulant effects of caffeine.

If you don't know what Grand Rounds is, it is a weekly compilation of the best posts from the medical blogosphere that moves to different sites each week. And, who doesn't like reading about medicine and science? Next week, GR moves to Medviews.

Don't forget Pediatric Grand Rounds. Submit to Dr. Rob at Musings of a Distractible Mind. He has a grand total of five submissions as of this posting. So, show Dr. Rob some love and send him your pediatric post today!

Finally, I've been kind of laying low as far as the Grand Rounds thing and blog carnival thing over the past few weeks. I apologize to those hosts I snubbed with my lack of submissions. It wasn't anything personal against the hosts, I felt I wasn't writing anything really worthy of sharing, until recently.

Being posted on Grand Rounds is not a right, it's a privilege. So, I may not submit something every single week. If I think something I write is "grand rounds worthy," I'll submit for consideration. If I'm not happy with my writing (which is what's been happening the past few weeks), I won't submit. There are too many great writers out there in blogland for me to submit utter drivel. Anyway, that's a long explanation.

Macho men heal faster

Remember this song from The Village People? Well, according to a study by the University of Missouri-Columbia, "men who fit the classic Hollywood tough-guy mould may be able to heal more quickly." (inthenews.uk)

In the study of occupations typically associated with masculinity such as the armed forces, the researchers found there was a correlation between their machismo and their ability to recover from serious injury.

Writing in the American Psychological Association's journal Psychology of Men and Masculinity, Professor Glen Good of the MU college of education said there were some interesting conclusions.

"It has long been assumed that men are not as concerned and don't take as good of care of their health," he said, "but what we're seeing here is that the same ideas that led to their injuries may actually encourage their recovery."

What does this mean for me? Well, I guess I should really protect against a potentially fatal wound, like a paper cut. Or, I could achieve my manliness and become someone like The Black Knight. HA!

Thinking Blogger Award

I've been tagged by It's Me, T.J. from the dogcatskidslife blog. As TJ remarks, it's being tagged with an award - the one above. I have to also give credit to the original post from The Thinking Blog. What a great idea!

The participation rules are simple:
1. If, and only if, you get tagged, write a post with links to 5 blogs that make you think,

2. Link to this post so that people can easily find the exact origin of the meme,

3. Optional: Proudly display the 'Thinking Blogger Award' with a link to the post that you wrote (here is an alternative silver version if gold doesn't fit your blog).

Here is my list of the blogs that make me think (and you're subsequently tagged to continue the meme):

1. My Three Shrinks

2. The Curmudgeon

3. May

4. Dr. Wes

5. Mimi

I wish I could list more, but people would probably get after me for tagging more than five. I bestow to the five blogs above the Thinking Blogger Award. Congratulations and I'm wondering who will be named next.

Skip the Kiss of Life

The term "kiss of life" is taken from a BBC News article I talk about below. For those in the United States, it is better known as mouth-to-mouth resuscitation. I put the Trump/Rosie picture up there so that you could probably make up a funnier line than I could. HA!

Anyway, according to the American Heart Association, in their Adult Basic Life Support course, the first step is always to assess the airway and breathing. If the person is not found to be breathing, this is what you're supposed to do:

Give 2 rescue breaths, each over 1 second, with enough volume to produce visible chest rise. This recommended 1-second duration to make the chest rise applies to all forms of ventilation during CPR, including mouth-to-mouth and bag-mask ventilation and ventilation through an advanced airway, with and without supplementary oxygen (Class IIa recommendation).

During CPR the purpose of ventilation is to maintain adequate oxygenation, but the optimal tidal volume, respiratory rate, and inspired oxygen concentration to achieve this are not known. The following general recommendations can be made:

1. During the first minutes of VF [ventricular fibrillation] SCA [sudden cardiac arrest], rescue breaths are probably not as important as chest compressions because the oxygen level in the blood remains high for the first several minutes after cardiac arrest. In early cardiac arrest, myocardial and cerebral oxygen delivery is limited more by the diminished blood flow (cardiac output) than a lack of oxygen in the blood. During CPR blood flow is provided by chest compressions. Rescuers must be sure to provide effective chest compressions and minimize any interruption of chest compressions.

2. Both ventilations and compressions are important for victims of prolonged VF SCA, when oxygen in the blood is utilized. Ventilations and compressions are also important for victims of asphyxial arrest, such as children and drowning victims who are hypoxemic at the time of cardiac arrest.

3. During CPR blood flow to the lungs is substantially reduced, so an adequate ventilation-perfusion ratio can be maintained with lower tidal volumes and respiratory rates than normal. Rescuers should not provide hyperventilation (too many breaths or too large a volume). Excessive ventilation is unnecessary and is harmful because it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival.

4. Avoid delivering breaths that are too large or too forceful. Such breaths are not needed and may cause gastric inflation and its resultant complications.

Now, Japanese researchers published in The Lancet showed that chest-compression-only resuscitation is adequate without mouth-to-mouth resuscitation. (BBC news)

Dr Ken Nagao and colleagues at the Surugadai Nihon University Hospital in Tokyo say in these circumstances it would be better for all parties to stick to giving chest compressions alone, which they called cardiac-only resuscitation. They checked their theory by looking at the outcomes of more than 4,000 adult patients who had been helped by bystanders.

They found chest-compression-only resuscitation was the clear winner compared with conventional CPR (cardiopulmonary resuscitation, or mouth-to-mouth breathing together with chest compressions).

The Resuscitation Council in the United Kingdom agrees with this statement and has made these changes in their Adult Basic Life Support guidelines:

To aid teaching and learning, the sequence of actions has been simplified. In
some cases, simplification has been based on recently published evidence; in
others there was no evidence that the previous, more complicated, sequence had
any beneficial effect on survival.

There are other changes in the guidelines. In particular, allowance has been
made for the rescuer who is unable or unwilling to perform rescue breathing. It is
well recorded that reluctance to perform mouth-to-mouth ventilation, in spite of
the lack of evidence of risk, inhibits many would-be rescuers from attempting any
form of resuscitation. These guidelines encourage chest compression alone in
such circumstances.

Who's right and who's wrong here? Does it really matter? Is there a "right" way to administer CPR? In this age of evidence based medicine, I'm sure that there will be more studies done to bolster the case of both sides.

I do agree that people these days are less inclinced to perform mouth-to-mouth. I mean, there are some who would rather perform mouth-to-muzzle rescue breathing (just kidding).

If anything else, a news story like this puts CPR in the spotlight. So, whatever you think about mouth-to-mouth resuscitation, if you've never been taught the concepts of Basic Life Support, get out there and learn about CPR! You may save a friend or family or even a complete stranger one of these days.

The Secret to Quit Smoking

Yeah, I know what you're thinking. Some of you out there believe I'm going to tout the latest prescription drug on the market. Others of you are probably thinking I'm going to talk about alternative medicine choices for smoking cessation. (Image credit)

Well, you're both wrong. The secret to stop smoking is simple -- Take A Walk! It's simple. It's natural, and has no side effects. What? Do you think I'm kidding? Do you think I'm out of my mind? (this is possible, ha) But here, I tell the truth.

Described in this Associated Press story, researchers at the University of Exter have found that as little as five minutes of exercise can help smokers quit. The research is published in the medical journal called Addiction.

[Dr. Adrian] Taylor and [his] colleagues reviewed 12 papers looking at the connection between exercise and nicotine deprivation. They focused on exercises that could be done outside a gym, such as walking and isometrics, or the flexing and tensing of muscles. According to their research, just five-minutes of exercise was often enough to help smokers overcome their immediate need for a nicotine fix.

"What's surprising is the strength of the effect," said Dr. Robert West, professor of health psychology at University College London. West was not involved in the review. "They found that the acute effects of exercise were as effective as a nicotine patch," he said.

Who would have thunk this? Exercise conquers nicotine cravings? That's an interesting idea. I wonder if it works for food cravings as well. I'll have to try this out myself. Maybe I can put my tennis shoes next to the potato chips to remind myself. Hmmmmm.....

Heat Wave

For the first time in what seems a long time, the temperature has reached close to 70 degrees around here. Yay! I guess it's finally time to wash all that salt off my car from the wintertime.

I guess I have the guy above to thank for this heat wave. I mean it is global warming that is causing this today, isn't it. Yeah right! I mean, the guy did invent the internet after all. (Sorry, these funny jabs are just satire, you know.)

Anyway, looking ahead at the weather forecast, it's supposed to get back down in the 20's with snow showers by the weekend. So, today is the day to enjoy! Maybe I can even sneak out to the muddy golf course later. We'll see.

Finally, in the ongoing saga of my sitemeter (like anyone cares), here is the latest post from the The Sitemeter Weblog:

We’ve discovered as have many of you that not all the stats categories have updated since March 3rd. We have our tech team digging into the problem. When we have the problem identified and fixed we’ll post a notice here.

s25 is still lagging heavily [that's me]. This is also being addressed.

As always, we’re doing everything we can as quickly as we can. We understand the importance of timely stats, which is why we are also working on the development of a load balanced server system. Until we complete the new backend server configuration and can migrate everyone over we are faced with the reality of trying to manage individual server problems, traffic surges, and other unforeseen issues as they develop. We appreciate your patience and understanding.

Even this message does not bother me today. Maybe I can even try to cut out of work early to enjoy what's left of the day. Pshaw! Like that'll happen. A guy can dream, can't he?

Don't forget to check out a relatively new section of the Doctor Anonymous blog: Dr. A's Video of the Day. Currently, it's at the top of my sidebar. I may change this video a few times a day, depending on what I find. But, "video of the moment" didn't sound as cool. Oh well...

The March Madness Meme

Yes, that's right, boys and girls - It's March Madness time again. Don't know what this is about? Well, it's a marketing ploy, that actually works. This refers to the annual national college basketball tournament in the USA. And, I admit that even I get caught up in the hype.

I remember back in college (Oh no! Not another college reference!). The first full day of the tournament (Thursday) is usually a national holiday on college campuses across the country. It's college basketball on TV almost from dawn to dusk (depending in which time zone you live).

Of course, you want to win the entire thing. But, for those who don't know, the last four teams in the tournament, are proud to call themselves, "The Final Four." Ah, memories. Anyway, where's the meme part, you ask? Well in re-living these memories, I thought of a meme that I think wil be interesting....

You can call this, "The March Madness Meme," or, "The Final Four Meme." Here it is: Name four colleges/universities. That's it! Isn't that simple?

It can be your Final Four teams. It can be a college or university that you went to or are going to. It can be a school you would have wanted to attend and why. This meme is pretty flexible. Without further ado, here's my list:

THE Ohio State University: My parents told me that I would flunk of school and never get into medical school if I went here. And, they were probably right. I would have loved to go there, though.

University of Notre Dame: I know Ms. Emergiblog likes this choice! I took a tour of the campus during football season there -- what a great atmosphere! What can I say, I had twelve years of Catholic school education, and I had a lot of friends going there. Oh well, I guess, was not meant to be.

University of Santo Tomas (Philippines): I don't know how good their basketball team is but this is where my father went to school. Now, that would have been interesting to see my father as a college student.

Georgetown University: I dunno why this choice. I think I just wanted to be in the movie St. Elmo's Fire. Yes, a closet Brat Pack fan. All those movies were classic 80's movies - Breakfast Club, Sixteen Candles, Pretty in Pink, etc.

That's the meme. Have fun with it. I'm wondering how many schools around the world people will name. I'm not tagging anyone. If you feel like taking up this challenge, that's great. If not, that's fine, too. Finally, GO BUCKS!