Food sources of vitamin K2

27. December 2007 William Davis (46)


Vitamin K2 is emerging as an exciting player in the control and possible regression of coronary atherosclerotic plaque. Only about 10% of dietary vitamin K intake is in the K2 form, the other 90% being the more common K1.

The ideal source of K2 is natto, the unpalatable, gooey, slimy mass of fermented soybeans that Japanese eat and has been held responsible for substantial decreases in osteoporosis and bone fractures of aging. Natto has an ammonia-like bouquet, in addition to its phlegmy consistency that makes it virtually inedible to anyone but native Japanese.

I say that the conversation on vitamin K2 is emerging because of a number of uncertainties: What form of vitamin K2 is best (so-called MK-4 vs. MK7 vs. MK-9, all of which vary in structure and duration of action in human blood)? What dose is required for bone benefits vs. other benefits outside of bone health? Why would humans have developed a need for a nutrient that is created through fermentation with only small quantities in meats and other non-fermented foods?

Much of the developing research on vit K2 is coming from the laboratories of Drs. Vermeer, Geleijnse, and Schurgers at the University of Maastricht in the Netherlands, along with several laboratories in Japan, the champions of K2.

MK-7 and MK-8,9,10 come from bacterial fermentation, whether in natto, cheese, or in your intestinal tract; MK-4 is naturally synthesized by animals from vitamin K1. While natto is the richest source of the MK-7 form, egg yolks and fermented cheeses are the richest sources of the MK-4 form.

Chicken contains about 8 mcg MK-4 per 3 1/2 oz serving; beef contains about 1 mcg. Egg yolks contain 31 mcg MK-4 per 3 1/2 oz serving (app. 6 raw yolks). Hard cheeses contain about 5 mcg MK-4 per 3 1/2 oz serving, about 70 mcg of MK-8,9; soft cheeses contain about 30% less. Natto contains about 1000 mcg of MK-7, 84 mcg MK-8, and no MK-4 per 3 1/2 oz serving.











Feta cheese

Thanks to the research efforts of the Dutch and Japanese groups, several phenomena surrounding vitamin K2 are clear, even well-established fact:

--Vitamin K2 supplementation (via frequent natto consumption or pharmaceutical doses of K2) substantially improves bone health. While K2 by itself exerts significant bone density/strength increasing properties in dozens of studies, when combined with other bone health-promoting agents (e.g., vitamin D3, prescription drugs like Fosamax and calcitonin), an exaggerated synergy of bone health-promoting effects develop.



--The MK-4 form of vitamin K2 is short-lived, lasting only 3-4 hours in the body. The MK-7 form, in contrast, the form in natto, lasts several days. MK-7 and MK-8-10 are extremely well absorbed, virtually complete.

--Bone health benefits have been shown for both the MK-7 and MK-4 forms.

--Coumadin (warfarin) blocks all forms of vitamin K.





Interestingly, farm-raised meats and eggs do not differ from factory farm-raised foods in K2 content. (But please do not regard this as an endorsement of factory farm foods.)

Another interesting fact: Since mammals synthesize a small quantity of Vit K2 forms from vitamin K1, then eating lots of green vegetables should provide substrate for some quantity of K2 conversion. However, work by Schurgers et al have shown that K1 absorption is poor, no more than 10%, but increases significantly when vegetables are eaten in the presence of oils. (Thus arguing that oils are meant to be part of the human diet. Does your olive oil or oil-based salad dressing represent fulfillment of some subconscious biologic imperative?)

If we believe the data of the Rotterdam Heart Study, then a threshold of 32.7 micrograms of K2 from cheese yields the reduction in cardiovascular events and aortic calcification.

It's all very, very interesting. My prediction is that abnormal (pathologic) calcium deposition will prove to be a basic process that parallels atherosclerotic plaque growth, and that manipulation of phenomena that impact on calcium depostion also impact on atherosclerotic plaque growth. Vitamins D3 and K2 provide potential potent means of at least partially normalizing these processes.

As the data matures, I am going to enjoy my gouda, Emmenthaler, Gruyere, and feta cheeses, along with a few egg yolks. I'm going to be certain to include healthy oils like olive and canola with my vegetables.


All images courtesy Wikipedia.

Copyright 2007 William Davis, MD
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Comments (46) -

  • MAC

    12/28/2007 5:58:00 PM |

    Is not magnesium also a regulator of calcium?

    NIH link on magnesium: http://www.ods.od.nih.gov/factsheets/magnesium.asp
    though they really don't spell out magnesium's role in regulating calcium, just that it "keeps bones strong".

    Dr. Eades blog on magnesium and it's deficiency and role in inflammation: http://www.proteinpower.com/drmike/uncategorized/magnesium-and-inflammation/

    BTW Dr. Davis, Dr. Eades recently posted a comment on your TYP book as the best source regarding CT heart scans.

  • Anonymous

    12/28/2007 7:05:00 PM |

    Fascinating! Perhaps K2 is one factor that contributes to the so-called French paradox. It might make sense to eat imported cheeses produced by traditional methods in European countries that have the lowest rates of CHD -- France, Portugal, Italy, Spain, and Switzerland.

    In addition to vitamin K, many other fat-soluble nutrients (lycopenes, carotenoids, etc.) in plant foods simply aren't absorbed unless accompanied by fat, which, ironically, renders those "healthy" fat free salad spritzes downright hazardous to health.

  • Anonymous

    12/28/2007 7:33:00 PM |

    Great blog, enjoyed reading about vitamin K2.  

    With recent findings on the importance of bone strengthening supplements and drugs for heart health, would weight lifting be helpful at bringing about plaque regression?

  • Carl H

    12/28/2007 8:14:00 PM |

    What about Miso?  Another fermented soy product.  Not bad + not natto.

  • Dr. Davis

    12/28/2007 11:06:00 PM |

    Hi, Mac--

    Yes, magnesium is among the three nutrients that I fuss about for bone and arterial health, along with K2 and D3.

    Thanks for the heads up on Dr. Eades blog. I've only recently stumbled across his Blog and found it wonderful, full of unique and refreshingly candid comments.

  • Dr. Davis

    12/28/2007 11:07:00 PM |

    No, not specifically. K2 improves bone health and possibly arterial health. Weight lifting improves bone health. But that's as far as the intersection goes.

  • Dr. Davis

    12/28/2007 11:08:00 PM |

    I love miso and was raised on it. But to my knowledge it is not a significant source of K2.

  • Cindy Moore

    12/29/2007 8:29:00 AM |

    "--Coumadin (warfarin) blocks all forms of vitamin K."

    Do you know if there is any evidence that long term (20 yrs+) warfarin use may increase risk?

  • Anonymous

    12/29/2007 8:58:00 AM |

    My research shows that CoQ10 has a structure very similiar to vitamin K.  Perhaps supplementation with CoQ10 may help provide Vitamin K2.

  • Dr. Davis

    12/29/2007 1:21:00 PM |

    Yes. Unfortunately, now several studies have shown that there is greater heart valve and artery calcification with prolonged Coumadin usage. Although the data are very preliminary, there may be benefit to K1 and K2 supplementation, though your doctor's cooperation is required to do this.

  • Harry35

    12/30/2007 1:38:00 AM |

    Here's a list of fermented and unfermented cheeses that I compiled by googling around. Not sure how to tell which of the fermented cheeses have the most K2, though.

    Fermented:

    Aged goat cheese
    Bleu Cheese
    Brie
    Cambozola
    Camebert
    Cantal
    Cheddar
    Cheshire
    Cultured dry cottage cheese
    Edam
    Emmenthal
    Feta
    Gorgonzola
    Gouda
    Gruyere
    Muenster
    Parmesan
    Port du Salut
    Roquefort
    Romano
    Stilton

    Unfermented

    Farmer cheese
    Mescarpone
    Most cottage cheese
    Mozzarella
    Pot cheese
    Processed cheese
    Provolone
    Provatura
    Quark
    Ricotta
    Scamorza

  • Dr. Davis

    12/30/2007 2:07:00 PM |

    Wow! Thanks, Harry.

    I didn't realize that provolone and ricotta were unfermented.

  • chickadeenorth

    12/30/2007 4:37:00 PM |

    Wow great info and timely article...thnx.
    I eat those fermented cheeses that  and have eggs, I use only olive oil though. I read somewhere that any oil that gets sticky on outside of the jug gets sticky inside the body and since canola is one of those I quit using it, wish I could find that article, ( Eades maybe?)what do you folks think.
    So having some oil on veg and salad is great, I don't use those low fat or spritz things are they seem too processed and full of chemicals.

    Thnx Dr D for the excellent info as always.

    So do you eat those slimy soybeans, are they pretty icky or do you think a person could get used to them. Lots of my Japanese guests ( from Japan not North America) bring some of their own food and I have seen these before. Looks kind of like eatin the foods off Fear Factor....j/k.

  • MAC

    12/30/2007 4:48:00 PM |

    Seem to remember reading somewhere recently that if the cheese has the word "culture" in the ingredient list then it is a fermented product. This could mean yogurt and kefir may have K2. Web sources seem to indicate this but didn't find any I consider reliable.

  • Dr. Davis

    12/30/2007 10:54:00 PM |

    I don't think that there's anything wrong with actually eating natto. It's just that it is quite difficult to stomach. I had it several times as a kid and found it thoroughly unappetizing, despite having tried some really exotic stuff like raw octopus and seaweed. Natto was the one thing I simply could not eat.

    The stick oil thing has me stumped. Our bodies digest foods like oil before they make it into the blood stream. Why its behavior in a bottle would have any bearing on its behavior in the body is beyond me.

  • Cindy Moore

    12/31/2007 12:08:00 AM |

    Mary Enig is an excellent source of information about oils. Her general belief is that processed oils (like corn, cannola and soy) are heat treated during the processing and this heat damages the fat molecules, so these fats are essentially spoiled when they are bottled. These oils are also polyunsaturates, which are the least stable of oils, so they should be stored properly and protected from heat, light, etc. (Flax and fish oils are "good" polys, but care should be used to keep these fresh and prevent oxidation)

    I only use virgin olive oil, virgin cocount oil and butter, and I rarely (if ever) use olive for cooking. (I want to try the nut oils, but haven't given them a shot yet).

  • chickadeenorth

    12/31/2007 8:20:00 AM |

    Cindy why don't you use olive oil to cook in at low heat,curious, I thought that was ok if it didnt get too hot. I just got some walnut and almond oil and have to try them.I also use coconut oil to cook in and grapeseed for salads.

    I cannot get vit k 2 in Ca and have a friend going to Florida in 2 days who will buy me some, what is a good name brand and dose,  also a good name brand and dose for DHEA thanks for feedback.

  • Cindy Moore

    12/31/2007 5:51:00 PM |

    chickadeenorth, I don't often us olive in cooking because I've read (Enig I believe) that if it smokes it shouldn't be eaten....and I've had too many instances of the heat getting ahead of me and the oil ending up burned. I just find it easier to use coconut....and then I add butter and/or olive oil at the end to give it flavor, if needed. Mostly I just use the coconut oil.

    I use Source Naturals K, but am also interested in hearing some recommendations. I bought this because I'm told Source Naturals is a good company.

  • Dr. Davis

    12/31/2007 6:10:00 PM |

    We've used Source Naturals, Life Extension, and Jarrow. All seem like the real thing.

  • chickadeenorth

    12/31/2007 8:40:00 PM |

    ..thnx...is this in dry tablet form, what dose of tablet should I get her to pick up, what about DHEA?? name brand and dose.

    Ya I cook with natural gas so keep flame very low and don't over heat anything,I don't use allot as have good pots, maybe should use coconut more often, its adds a nice flavor especially to chicken and pork.

    I think some guests from Japan bought some of those soybeans once in a can, is that how they come, they ate something that looked familiar to your picture.

  • g

    1/1/2008 6:35:00 AM |

    Apparently the ADA have new guidelines coming soon!  AND guess what they advise now!  LOW CARB diets!!

    This is funny...
    http://thefitnessinsider.menshealth.com/2007/12/apparently-hell.html

  • chickadeenorth

    1/1/2008 5:13:00 PM |

    Hmm wonder what pushed their buttons, the powers at be in USA are also supposedly going to recommend a higher dose of Vit D too.
    http://articles.mercola.com/sites/articles/archive/2008/1/1/experts-starting-to-agree-more-vitamin-d-is-better.aspx

  • brassman

    1/1/2008 6:04:00 PM |

    Vitamin K is fat soluble. Will a tablet be absorbed well or do I need a soft gel as with vitamin d?

  • chickadeenorth

    1/1/2008 9:06:00 PM |

    Is this the right DHEA I am looking for, if so I found a source in Canada but still no Vit k 2.Sorry I can't log onto the forum.Smile

    http://www.nutrichem.com/Phosphatidyl-Serine-Complex-23.html

  • Dr. Davis

    1/2/2008 12:10:00 PM |

    The label and info says phosphatidylserine, not DHEA.

  • Dr. Davis

    1/2/2008 12:11:00 PM |

    The data would suggest that, unlike vitamin D, even tablets of K2 are well absorbed.

  • Anonymous

    1/31/2008 1:02:00 AM |

    Hello Dr. Davis,
    Thank you for this great post. We've recently learned that K2 was probably what Weston Price had  called Activator-X, since he had not been in contact with other researchers who were learning about vitamin K at the time.

    Anyway, I can help with the "sticky oil" comment. Oils that oxidize easily become sticky (basically like varnish drying) when exposed to oxygen. This means that canola oil and other less-saturated fatty acids can oxidize (producing free radicals) in the bottle (and MAYBE in the blood - there is oxygen in the blood, but I'm not an expert in blood chemistry). We don't know how long the oil was exposed to air before it was bottled. X-virgin olive oil, on the other hand, has a lot of anti-oxidants built in (and numerous phyto-nutrients), so probably has a longer shelf life. Most Canola oil is a highly processed modern hybrid. The Mediterranean people never lived on Canola oil. The fact that both are monounsaturated is largely irrelevant.  -David

  • Dr. Davis

    1/31/2008 1:33:00 PM |

    Thanks for the help, David.

  • donny

    7/1/2008 6:23:00 PM |

    I hate to comment on an article this old, but I've been reading a lot of stuff online about vitamin k lately. I found this article recently. Really, it looks like an attempt to denigrate food sources of vitamin k in comparison to supplementation.
    First they compared spinach consumption to a vitamin k supplement called konakion, and showed that konakion raised serum levels of k1 maybe seven to eight times as much as 227 grams of boiled spinach with butter. Then, they did a bait and switch, comparing the spinach and butter to a milligram of k2 mixed with 5 grams of butter, and they have a chart with that showing that the k2 with butter raised serum levels of k2 twice as much as the spinach with twenty five grams of butter.
    I'm just wondering if green vegetables, with butter, might be a good way to raise k2 levels after all?

    http://journals.cambridge.org/download.php?file=%2FBJN%2FBJN76_02%2FS0007114596001304a.pdf&code=2e2d0ca6a4129581d36eebf438633b36

  • Anonymous

    12/2/2008 3:05:00 PM |

    "Why would humans have developed a need for a nutrient that is created through fermentation with only small quantities in meats and other non-fermented foods?"

    Perhaps this is an example of how our "sterile" environment is killing us.  Before refrigeration, I am sure humans were subject to much more fermented food.

  • Dane Miller

    4/20/2009 5:58:00 PM |

    I , too hate commenting on an article so old.  Great stuff but canola as a healthy oil?  I think not.  Canola is terrible for you.  Or should I said rapeseed oil.

  • jpatti

    5/25/2009 1:05:39 AM |

    I understand there's a good bit of K2 in unpasteurized milk.  Apparently, grass-fed animals do produce a lot of A, D and K2, but much is destroyed through pasteurization.

    I've recently added raw milk to my diet.  Decided it was worth taking extra insulin for the health benefits.  Can't get raw butter or cream in my state, but am getting it from the same dairy, so it's grass-fed if not raw.

    My bp has dropped about 30/30 without the Lisinopril I was on before.  As hubby says, if it's placebo, it's one worth sticking to.  ;)

    Besides raw milk, I've also about tripled my intake of butter and eggs.  

    And btw, fermenting raw milk yourself is wicked easy.  Take a quart of milk, heat it to around 100-110 degrees (I do this with a quart jar in my crockpot in an inch of water with the lid off).  Remove about a half cup of warmed milk and stir in about 1/4 cup yogurt.  Pour this back into the main container, turn off the crockpot (so it doesn't overheat and kill the culture), and cover with a blanket or such to insulate it.  

    I do this while fixing dinner, in the morning I have yogurt - fermented raw milk, yummy stuff, chockful of K2.  It's not thick like store-bought, more like a drink.  I add blueberries to it most often.

    The point is, with a source of raw milk it takes about 5-10 minutes of "work" to make your own fermented dairy.  You need a quart sized jar, a source of heat, a thermometer, some insulation and some culture (store-bought plain yogurt works fine) - fermented dairy just happens overnight.

  • robbyn

    9/27/2009 9:44:19 AM |

    I know that sauerkraut contains vit k2, but do not know how much per 100g. Has anyone been able to find the figures?

  • Anonymous

    1/5/2010 5:13:32 PM |

    Dear Dr. Davis
    Hello
    Is there a special food diet for patients with aortic valve calcification. How many milligrams
    of vitamin CaLaughing:K2:K:Mg, are recommended for patients.
    Thanks
    Lev

  • Sharon

    2/17/2010 6:56:22 AM |

    Serious question Dr.Davis:    Fibrinogen can create calcification, K2 reduces calcification, natto reduces fibrinogen but is there any clottin risk and conflict in using both agents for a patient with the two dysfunctions?

    Thank you Sharon

  • Anonymous

    3/15/2010 8:46:14 PM |

    Recently had a CT.  After the CT, got up off table and had no pain for 2 weeks.  In constant pain due to significant cervical and lumbar radiculopathy, fibromyalgia, osteoarthritis, etc.  Has anyone ever had a CT with contrast who was in pain and pain gone after the contrast CT?  My doctor told me to blog to see if could find others who drank a liquid and had an IV during the CT.  Was wonderful to have no pain for 2 weeks, and interesting it happened immediately upon rising from the table where the CT was performed.  Anyone exeriencing this, please blog

  • ea

    3/25/2010 1:35:56 AM |

    In http://www.westonaprice.org/On-the-Trail-of-the-Elusive-X-Factor-A-Sixty-Two-Year-Old-Mystery-Finally-Solved.html it says:
    Since the amount of vitamin K1 in typical diets is ten times greater than that of vitamin K2, researchers have tended to dismiss the contribution of K2 to nutritional status as insignificant. Yet over the last few years, a growing body of research is demonstrating that these two substances are not simply different forms of the same vitamin, but are better seen as two different vitamins: whereas K1 is preferentially used by the liver to activate blood clotting proteins, K2 is preferentially used by the other tissues to place calcium where it belongs, in the bones and teeth, and keep it out of where it does not belong, in the soft tissues.
    In other words, to properly use the Calcium in your diet, you need vitamin K2 (as well as A & D) ~ and, since K2 is fat soluble, also fat so that you can absorb the K2.  With K2 the Calcium will be used to strengthen bones and teeth. Without K2 the Calcium will be deposited in joints leading to osteoarthritis, in blood vessels leading to heart attacks and strokes, in eyes leading to cataracts, and in other soft tissues.

    In http://www.westonaprice.org/On-the-Trail-of-the-Elusive-X-Factor-A-Sixty-Two-Year-Old-Mystery-Finally-Solved.html there is also a table of K2 content of various foods.

  • bed frame

    7/6/2010 7:09:17 AM |

    Before I don't know what is vitamin K2 is. But after reading and analyzing your post. Now I know that it is important. I thank you for sharing this very helpful post.

  • Yogi Sinzapatos

    7/29/2010 3:50:33 PM |

    Mixing jpatti's home made raw milk yogurt with flaxseed oil = Dr. Johanna Budwig's cure for cancer (and many other diseases).

  • dermatology laser

    9/30/2010 3:23:32 AM |

    Vitamin K2 might be, for instance more relevant in the form of a supplement or in low-fat dairy.

  • Chuck

    10/21/2010 3:38:37 AM |

    As far as Warfarin blocking the absorption of vitamin K, I am not a big fan of people taking rat poison. Warfarin is the active ingredient in rat poison.

    It is worse than the urine of a pregnant horse. Premarin-- pregnant mare urine. I am American and natto does not taste that bad. Of course it is better to add it to something else. For example no one eats sugar by itself.

    Now raw garlic by itself is painful to eat. But I add it to other foods and it is OK. Raw ginger by itself is also painful to eat.

  • buy jeans

    11/3/2010 4:53:24 PM |

    MK-7 and MK-8,9,10 come from bacterial fermentation, whether in natto, cheese, or in your intestinal tract; MK-4 is naturally synthesized by animals from vitamin K1. While natto is the richest source of the MK-7 form, egg yolks and fermented cheeses are the richest sources of the MK-4 form.

  • Heidi

    11/11/2010 5:34:36 PM |

    Earlier in the thread there was mention made on canola oil. Here's a link that explains the dangers:
    http://www.westonaprice.org/know-your-fats/559-the-great-con-ola.html

  • Jack C

    11/18/2010 3:03:20 AM |

    Somewhere in my files there is a study, from Japan I believe, that found that serum concentrations of MK4 increased after consumption of natto, which contains no MK4. It therefore appears that MK7, 8 and 9 will convert, to some degree, to MK4. Conclusion (mine): Aged cheese can provide all of the vitamin K2 needed. Aged raw milk cheese has most of the benefits of raw milk but is as pathogen free as pasteurized milk due to destruction of pathogens by low pH during aging.  

    While I can not quickly lay my hands on that study, I have found a couple of other related studies of interest.

    Vitamin K is required for activation of osteocalcin. Vitamin K deficiency is associated with low bone mineral density due to increased levels of uncarboxylated (unactivated) osteocalcin(ucOC). The plasma vitamin K2 concentrations required to minimize ucOC increases with age (PMID 16469998). Conclusion: (mine) Eat more aged raw milk cheese as you age to protect you bones.

    Rats readily convert vitamin K1 to K2 but humans do not.

    "Vascular calcification may be species specific to humans. As laboratory animals, such as the rat, grow old, they suffer from only mild arterial calcification" (PMID 18772323): Conclusion (mine): K2 is the answer: Eat more raw milk aged cheese as you get older to prevent calcification of arteries.

    Jack C.

  • Gillian

    1/17/2011 5:13:44 PM |

    Hi, Dr Davis
    I´ve read in some earlier comment of yours, that natto is not really a reliable source for K2, is that so and if, then why?
    I also wonder why I sometimes feel pain in my legs when eating cream.
    I have seen the famous photographer from Sweden that have filmed arteries and showed that cream supposedly block the arteries..
    What is your opinion??

  • Lobster bake

    2/18/2011 9:17:08 AM |

    Thanks, very well written post, found it through a random Google search and I shared it on my Facebook. This Vitamin K foods are very helpful to keep our body healthy and young.

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Bait and switch

23. March 2008 William Davis (5)
“When banks compete, you win.”

The TV ad opens with a 60-something man sitting in his living room, talking to a three-piece suit-clad, 30-something banker. The older man is explaining to the dismayed younger man why he’s going to use Lending Tree loan service for a home loan.

“But Dad, I’m you’re son!” the younger whines.

Many of Lending Tree’s clients have collaborated in filing a multi-million dollar class action suit against the company, claiming “bait and switch” tactics. They claim that home buyers are lured by low interest rates or low closing costs on a home loan. Once the buyer concludes the hassle of filling out numerous forms, the suit accuses Lending Tree of making a switch to a costlier loan.

Bait and switch is among the oldest con games around. If you’ve ever bought a car from a car dealer, chances are you’ve had your own little brush with this deception. The ad promises the SUV you’ve wanted for only $299 per month. Only, once you get there, the salesman informs you that only a limited number of special deals were available and they’ve run out. But he’s still got a really good deal right over here!

Most of us recognize that we’ve been hookwinked. Yet we still go along and buy a car from the dealer.

What if it’s not a sleazy salesman behind the pitch, but a physician. If it’s hard to resist the sales pitch at the car dealership, it can be near impossible to ignore the advice of your doctor. But the truth is often loud and clear: in many instances, it is a genuine, bona fide, and fully-certified scam.

Among the most common bait-and-switch heart scams: Your cholesterol is high. The sequence of subsequent testing is well-rehearsed. “Gee, Bob, I’m worried about your risk for heart disease. Let’s schedule you for a nuclear stress test.” The stress test, like 20% or more of them, is “falsely positive,” meaning abnormal even though there’s nothing wrong with you. Another 30% are equivocal, not clearly abnormal but also not clearly normal. Now up to 50% of people tested “need” a heart catheterization in the hospital to clarify this frightening uncertainty. You might end up with a stent or two, even bypass surgery. Your simple $20 cholesterol panel has metamorphosed into $100,000 in hospital procedures. That familiar sequence is followed thousands of times, seven days a week, 365 days a year.

There are times when these heart tests are valuable and provide meaningful answers. Then there's the other half of the time when they provide murky information that can be used for a practitioner's economic advantage.


Copyright 2008 William Davis, MD

A fictional tale of medical economics in heart disease

23. March 2008 William Davis (2)
Dr. Robert Connors is the hospital’s most prized cardiologist.

Practically a fixture in the cath lab, he generates more revenues for the hospital than any of his colleagues. Last year alone, he performed over 1500 procedures, bringing in $18 million dollars to the cath lab, $27 million to the hospital. Dr. Connors is very good at what he does: 55-years old, he has been involved in high-tech heart care since the “early days,” 25 years ago, when hospital procedures really began to take off.

Over his career, he has personally performed over 25,000 heart procedures and has built a reputation as a skilled operator of complex coronary procedures. Because of his skills, he enjoys a vigorous flow of referrals for procedures from dozens of primary care physicians. His skill has also earned him referrals from cardiologist colleagues who seek his abilities for difficult cases.

On any day, Dr. Connors typically schedules up to 12 procedures. His entire day is spent in the cath lab, usually from 7 am until 6 pm. He meets many patients for the first time on the catheterization laboratory table as staff shave their groin, preparing for the procedure. Much of the procedure itself is not even performed by Dr. Connors, but by one or another cardiologists-in-training, a “fellow,” or member of the fellowship the hospital proudly maintains as a clinical teaching institution. Nor will Dr. Connors talk to most patients at the close of the procedure. He leaves that to either the fellow or a nurse. Dr. Connors views himself as a procedural specialist, not someone who has to take care of patients. He gave up seeing patients in his office over 10 years ago.

Dr. Connors’ procedural enthusiasm gained him the attention of drug and medical device manufacturers. Because Dr. Connors lectures widely and advises colleagues, his comments can dramatically alter perceptions of the value of a technology. He has, on many occasions, catapulted an unpopular device to most-asked-for among colleagues, bringing millions of dollars in revenues to the manufacturer. One particularly lucrative arrangement he made around 10 years ago involved a “closure” device, a $400 single-use plug used to close the access site made during heart catheterizations. By swaying his colleagues at _______ Hospital, 50 orders per day (one per procedure) tallied $20,000 every day, $7.1 million dollars per year for the manufacturer. Although he’d used other devices on the market, the 5,000 shares of stock he was offered encouraged him to issue glowing comments to colleagues on the superiority of this specific brand of closure device. Now over 90% of all catheterizations at _______ Hospital conclude with the device manufactured by the company in which Dr. Connors maintains partial ownership.

Negative comments, on the other hand, topple other products when Dr. Connors sees fit to pan them. For this reason, device and drug manufacturers run straight to Dr. Connors to gain his good graces as soon as possible after a product is released into the market. Because the competition is just as likely to do the same, it has often come down to a bidding war, the company providing the most lucrative arrangement most likely to win.

Thus, Dr. Connors proudly boasts of how many times he has flown to Hawaii, Europe, and other exotic locations at industry expense. He also boasts of how, for $100,000 paid to him for a “consulting fee,” he can overturn the choice of products lining hospital shelves. As the hospital’s annual budget for coronary devices will top $84,000,000 this year, device manufacturers regard the sum paid Connors as a profitable investment.

Despite his lofty status in the hospital, Dr. Connors has long expressed a love-hate relationship with ________ Hospital. While he enjoys his work and has made a more than comfortable income, he has long felt that the hospital administration didn’t truly appreciate his contributions. Five years ago, he therefore demanded that he be made “Director of Research.” After all, he had hired a nurse to help him coordinate enrollment of patients into several device trials brought to him by medical device manufacturers. When he encountered an initial lukewarm response from hospital administrators, he threatened to take his “business” elsewhere to a competing hospital. Hospital administrators gave in. They provided him with the title he wanted, along with $100,000 annual “stipend.”

Just fiction? Make no bones about it: Cardiac care is business, big business. And there's money to be made, lots of it.


Copyright 2008 William Davis, MD

Disease engineering

21. March 2008 William Davis (10)
Imagine you catch pneumonia.

You have a fever of 103, you’re coughing up thick, yellow sputum. Breathing is getting difficult. You hobble to the doctor, who then fails to prescribe you antibiotics. You get some kind of explanation about unnecessary exposure to antibiotics to avoid creating resistant organisms, yadda yadda. So you make do with some Tylenol®, cough syrup, and resign yourself to a few lousy days of suffering.

Five days into your illness, you’ve not shown up for work, you’re having trouble breathing, and you’re getting delirious. An emergency trip to the hospital follows, where a bronchoscopy is performed (an imaging scope threaded down your airway) and organisms recovered for diagnosis. You’re put on a ventilator through a tube in your throat to support your breathing and treated with intravenous antibiotics. Delayed treatment permits infection to escape into the fluid around your lungs, creating an “empyema,” an extension of the infection that requires insertion of a tube into your chest through an incision to drain the infection. You require feeding through a tube in your nose, since the ventilator prevents you from eating through your mouth. After 10 days, several healing incisions, and a hospital bill totaling $75,000, you’re discharged only to be face eights weeks of rehabilitation because of the extreme toll your illness extracted. Your doctor also advises you that, given the damage incurred to your lungs and airways, you will be prone to more lung infections in the future, and similar situations could recur whenever a cold or virus comes long.

A disease treatable by taking a 10-day, $20 course of oral antibiotics at home was converted into a lengthy hospital stay that generated extravagant professional fees, testing, and costly supportive care. You’ve lost several weeks of income. You’re weak and demoralized, frightened that the next flu or virus could mean another trip to the hospital. You are susceptible to repeated bouts of such episodes in future.

Such a scenario would be unimaginable with a common infection like pneumonia, or it would be grounds for filing a malpractice lawsuit. But, as horrific as it sounds in another sphere of health care, it is, in effect, analogous to how heart disease is managed in current medical practice.

First, you’re permitted to develop the condition. It may require years of ignoring telltale signs, it may require your unwitting participation in unhealthy lifestyle practices, like low-fat diets, "eat more whole grains," and "know your numbers."

It then eventuates in some catastrophe like heart attack or similar unstable heart situation, at which point you no longer have a choice but to submit to major heart procedures. That’s when you receive your heart catheterization, coronary stents, bypass, defibrillators, etc.

Of course, none of these procedural treatments cures the disease, no more than a Band Aid® heals the gash in your leg. The conditions that were present that created heart disease continue, allowing a progressive disease to worsen. At some point, you will need to return to the hospital for yet more procedures when trouble recurs, which it inevitably does.

A coronary bypass operation costs, on average $67,823. That includes the cost for the heart catheterization performed by a cardiologist to provide the surgical roadmap of your coronary arteries, the surgeon’s fees, the hospital charges. If there are any complications of your procedure, then your hospital bill may total a substantially higher figure.

$67,823 is just the upfront financial pay-off. Over the long run, your life is actually worth far more to the cardiovascular health care system because no heart procedure yields a permanent fix. In fact, repeated reliance on the system is the rule.

In fact, over 90% of people who enter the American cardiovascular health care system do so through a revolving door of multiple procedures over several years. It is truly a rare person, for instance, who undergoes a coronary bypass operation, never to be seen again the wards of the hospital because he remains healthy and free of catastrophe. A much more familiar scenario is the man or woman who undergoes two or three heart catheterizations, receives 3,4, or 6 stents, followed a few years later by a heart bypass, pacemaker, defibrillator, as well as the tests performed for catastrophe management, such as nuclear stress test, echocardiogram, laboratory blood analysis, and consultation with several specialists. The total revenue opportunity is many-fold higher than the initial 60-some thousand dollars, but instead totals hundreds of thousands of dollars per person.

A heart attack alone is a $100,000 revenue opportunity (Agency for Healthcare Research and Quality, 2004).

Of all coronary bypass procedures performed, 25% are “re-do’s”, or bypasses in people who’ve had a previous one, two, or three bypass procedures.

Perhaps it's excessively cynical to label it "disease engineering." But, whether from benign neglect or purposeful failure to diagnose, the fact remains: Heart disease is, all too often by the standard path, undiagnosed and neglected for years until the procedural payoff strikes.


Copyright 2008 William Davis, MD

Free checking, auto shows, low-cost hotel rooms, and bypass surgery

20. March 2008 William Davis (3)
Of the three major highways that lace the city of Milwaukee, there are at least five, and sometimes as many as ten, billboards that prominently feature one hospital heart program or another.

The passing of former First Lady, Ladybird Johnson in July, 2007, reminds us that, just 30 years ago, billboards were a far more common feature (many called them eyesores), proliferating like a dense forest of trees competing for a sliver of sunlight. Ladybird Johnson played a pivotal role in helping to dramatically reduce the number of billboards permissible on the nation’s highways. Of the relative few that remain today, a premium must be paid to post an advertisement. It costs several thousands dollars every month to maintain these highway commercials. But it’s not just an expense; it’s an investment.

The tens of thousands of eyes that view these billboards every day are potential customers, insured Milwaukeeans who carry health insurance and represent a major heart procedure just waiting to happen. They “need” to be directed to the right place. The billboards don’t feature health and wellness, heart disease prevention, or nutritional advice. They feature surgeons proudly wearing scrubs and masks, nurses, and declarations of the advantages of each hospital program. In effect, they invite you to have your heart attack, heart catheterization, bypass surgery, or other major heart procedure at their hospital. High-tech, high-ticket hospital heart care has become the subject of mainstream marketing, the stuff of flyers, brochures, and billboards.

The excesses of “big heart disease” have created a system that makes procedural heart disease “repair” far more profitable than heart disease prevention. Unfortunately, “repair” has disastrous financial, physical, and emotional consequences for everyone save the “repairman.”

While great good has been achieved by the American health care system, this gargantuan and inefficient system has also cultivated a culture of excess that has made many of its participants—physicians, hospitals, drug and device manufacturers—rich. And at our expense.

This approach was, to a degree, justifiable at a time when nothing better was available. But that's no longer true.


Copyright 2008 William Davis, MD

No-flush niacin kills

20. March 2008 William Davis (18)
Gwen was miserable and defeated.

No wonder. After a bypass operation failed just 12 months earlier with closure of 3 out of 4 bypass grafts, she has since undergone 9 heart catheterization procedures and received umpteen stents. She presented to me for an opinion on why she had such aggressive coronary disease (despite Lipitor).

No surprise, several new causes of heart disease were identified, including a very severe small LDL pattern: 100% of LDL particles were small.

Given her stormy procedural history, I urged Gwen to immediately drop all processed carbohydrates from her diet, including any food made from wheat or corn starch. (She and her husband were shocked by this, by the way, since she'd been urged repeatedly to increase her whole grains by the hospital dietitians.) I also urged her to begin to lose the 30 lbs of weight that she'd gained following the hospital dietitians' advice. She also added fish oil at a higher-than-usual dose.

I asked her to add niacin, among our most effective agents for reduction of small LDL particles, not to mention reduction of the likelihood of future cardiovascular events.

Although I instructed Gwen on where and how to obtain niacin, she went to a health food store and bought "no-flush niacin," or inositol hexaniacinate. She was curious why she experienced none of the hot flush I told her about.

When she came back to the office some weeks later to review her treatment program, she told me that chest pains had returned. On questioning her about what she had changed specifically, the problem became clear: She'd been taking no-flush niacin, rather than the Slo-Niacin I had recommended.

What is no-flush niacin? It is inositol hexaniacinate, a molecule that indeed carries six niacin molecules attached to an inositol backbone. Unfortunately, it exerts virtually no effect in humans. It is a scam. Though I love nutritional supplements in general, it pains me to know that supplement distributors and health food stores persist in selling this outright scam product that not only fails to exert any of the benefits of real niacin, it also puts people like Gwen in real danger because of its failure to provide the effects she needed.

So, if niacin saves lives, no-flush niacin in effect could kill you. Avoid this scam like the plague.

No-flush niacin does not work. Period.


Disclosure: I have no financial or other relationship with Upsher Smith, the manufacturer of Slo-Niacin.


Copyright 2008 William Davis, MD

Breakfast comments

19. March 2008 William Davis (7)
I received some wonderful comments to the What's for breakfast blog post.

Even though comments are viewable by clicking on them, I wanted to be sure these were readily visible, since they were so helpful and augmented the few suggestions I made. I'm impressed with the variety of foods people are willing to introduce into breakfast, particularly foods not traditionally thought to be part of standard American breakfast choices.




I normally eat a handful of almonds, some raw cashews, and occasionally an orange for breakfast. I used to eat cheese with breakfast also, but found once I began eating cheese it was hard for me to stop at one or two pieces.

Anonymous



My favorite breakfast is often left over Thai curry. I omit the rice. I also like making a thai omelet which is simply 2 eggs and some fish sauce and water and serving it with Sirachi sauce or Thai peanut sauce. It is street vendor food in Thailand I hear. Here's a recipe.

I find left over dinners are quite wonderful for breakfast. You just have to get past this notion that you have to eat certain foods at certain times in the day. Where'd that idea come from anyway?

Zute



I’ve tried eating oatmeal throughout my life, really wanting to like it. Until now the mere taste or smell of it made my stomach queasy. The key for me was toasting the oatmeal. Here’s what I generally do:

For Steel-cut oatmeal with the taste and texture of rice pudding-

In a frypan:
Toss 1 TBS of butter or so into a hot pan.
Add 1 cup of steel-cut oatmeal until toasted.
--few minutes
In a saucepan:
Boil 2-1/2 cups water
Add 1 cinnamon stick (or equivalent)
Add toasted Steel-cut oatmeal and cook for 15-20 minutes or so

Add 1-1/2 cups of low-fat milk, yogurt, or some combination, etc…
-Optional- Wisk an egg yolk into the milk.
-Optional- Add ¼ tsp salt.
-Optional- 2 TBS honey or Brown sugar. I use one 1 TBS of each.
Add some lemon or orange zest

Return to a boil for 10-15 minutes and then chill before eating. The oatmeal will congeal, resembling rice pudding.
Sprinkle more cinnamon/sugar on top
Add what you like: raisins, nuts, etc...

Use the cinnamon stick if you can, it really makes the difference. I’m constantly refining this recipe.

Anonymous



Once I decided to give up my (former) love affair with breakfast cereals, I was in a quandary about what to do for breakfast. I don't have much time in the morning to get creative and don't have the inclination at that time of the day to do so either.

I've settled on a routine of 2 hard-boiled (organic free-range) eggs (I boil them up a week in advance and leave them, shells-on, in the fridge), and a home-made protein-berry smoothie (frozen organic unsweetened berries, water-based).

This 8 am combo is easy, fast and tasty (I vary the berries and sometimes add natural flavour extracts for variety). It keeps my blood sugar flat and me full until my 1pm lunchtime. And I don't miss the cereals one bit!

Anonymous



I met an out-of-town friend for breakfast the other morning at a French-style bakery cafe. I ordered the goat cheese and herb omelet, but said I didn't want the potatoes or bread with it. They offered extra fruit or a salad instead. I chose the salad, with olive oil and vinegar. My friend wondered how I could eat a salad so early. Why not?

At home I usually eat 2 or 3 eggs over easy cooked in butter for breakfast most mornings and I am comfortably hungry for lunch about 3-4 hours later. But after my nicely filling cheese omelet and generous romaine salad (with a tiny bit of fruit - I ate the berries/melon and left the super-sweet pineapple), I wasn't hungry again until very late in the afternoon so had a small snack (cheese and half an apple) to hold me off and ate my next meal at dinner time. And it was a slow-developing comfortable hunger, not the powerful, "gotta eat something, anything" hunger that follows carb-heavy food.

Breakfast food, indeed!

Anna



You are absolutely right - breakfast is the most difficult meal to change. When I gave up wheat, I started using brown rice or potatoes mixed with anything interesting - nuts or meat or veges. I have now learned that these carbs make my blood glucose skyrocket. I have dropped the rice and potatoes and my BG has dropped nicely.

My favorite breakfast is sauteed veggies with some leftover meat or even an omelette. Soups are great in the AM. Nuts are for the days I am in a hurry.

Would be a little easier if I were not dairy intolerant.

Anne



Here in South India,it is 'Idli' - steam-cooked Lentil-rice (predominantly lentil) droppings, and 'Dosa' - lentil-rice pancakes. We have altered it a bit by increasing lentil ratio and dropping the rice to a minimum. Tastes good and fills you nice, for 4-5 hours.

Neelesh



I have two or three eggs, usually scrambled, but sunny-side-up and over-easy get thrown in for variety. I cook them using butter made from grass-fed cows. I also make my scrambled eggs using whipping cream instead of the more typical water or milk. I'll put a spoonful of fresh-made salsa over the top for some zing, some sliced cheese on the side and a cup of whole, organic milk to drink.

I'm completely sold on the "high-fat, moderate-protein, low-carb" diet and especially the admonition to start the day with a strong breakfast. My overall energy levels are fantastic, running performance is as good as high-school, and my belly hasn't looked this tight in decades.

Ross

What's for breakfast?

16. March 2008 William Davis (106)
Breakfast, for some reason, seems to be the toughest meal of the day for many people.

I think it's because the quest for sweet has dominated the American breakfast for so long, with its half-century legacy of cartoon character-festooned breakfast cereals; baked flour products like pancakes, waffles, and English muffins; more recently, "healthy" alternatives like bran muffins and oat waffles.

This breakfast lifestyle has also contributed to the obesity and diabetes ("diabesity") epidemic. Breakfasts of wheat- or corn-based cereals, even those labeled "heart healthy," fruit, and whole grain breads are guaranteed paths to low HDL cholesterol, high triglycerides, flagrant small LDL, increased inflammatory responses, high blood pressure, and higher blood sugar. Such foods also make you tired, make your abdominal fat grow (wheat belly), and increase appetite so that you want more.

So what can you eat for breakfast that doesn't provoke these patterns?

I will never pretend to be terribly clever in creating meal menus, but I can tell you what has worked for me and many of my patients. Be warned: It may require you to suspend your previous notions of what "should" be included in a list of breakfast foods.

Here are some examples that you may find helpful:

--Raw nuts--one or several handfuls of raw almonds, walnuts, pecans, pistachios
--Cheeses--the real, traditional sorts like gouda, goat, Swiss, edam, etc. (not Velveeta, Cheez Whiz, etc.)
--Eggs, Egg Beaters--and "spice" them up with sun-dried tomatoes, salsa, olives, tapenades, olive oil, onions, green peppers, etc.
--Yogurt (real, of course), cottage cheese
--Ground flaxseed, oat bran--as hot cereals or added to yogurt, cottage, or other foods. Esp. helpful for reducing both total LDL and the proportion of small LDL.
--Oatmeal--slow-cooked, not the instant nonsense.
--Soups--great for winter.
--Dinner foods--chicken, beef, fish, green beans, asparagus, tomatoes, etc., most easily added by saving left-overs from dinner. You'll be surprised how filling dinner foods eaten at breakfast can be.

It's really not that tough. It just means selecting from an entirely different list of foods than you might be accustomed to.


Copyright 2008 William Davis, MD

The first lawsuit?

16. March 2008 William Davis (1)

The closing arguments in actor John Ritter's wrongful death lawsuit are over and the two doctors charged with negligence cleared, five years after his death from a dissection (tear of the inner lining) of the thoracic aorta. The family sought $67 million in damages, claiming that the aortic dissection was misdiagnosed as a heart attack and that the enlarged aorta should have been reported to Mr. Ritter two years earlier during a full body scan.

The AP story can be viewed at http://ap.google.com/article/ALeqM5gmv6HnJJPBee2gWgEYResT5m6YkAD8VDF9CO0


Well, perhaps this is the start of a trend. Up until now, it has been commonplace for doctors to ignore many of the important findings on heart scans, full body scans, and similar direct-to-the-public imaging services. For instance, similar to John Ritter's case, enlarged thoracic aortas are commonly ignored. I'd even say that as a rule they are ignored. I have seen many patients in consultation who have had large aortas identified on heart scans, yet nothing--not a thing--was done about it. While the doctors escaped a lawsuit this time, it might not happen a second time.

I truly hope that Mr. Ritter's unfortunate experience and the consequent lawsuit do not trigger the usual defensive medicine response of resorting to major procedural "solutions."

A better response would be to 1) identify the problem--enlarged aorta in this case, 2) identify the causes, then 3) correct the causes. It does not necessarily mean that a major procedure like replacing the aorta (a horrendous surgery, by the way) needs to be pursued each and every time.

It is possible that Mr. Ritter's lawsuit is just the first. Over the next several years, it could trigger an avalanche of lawsuits for all the neglected findings on tests like heart scans, body scans, and other imaging methods that are gaining expanded direct-to-consumer access.


Images courtesy Wikipedia.

The origins of heart catheterization: Part II

13. March 2008 William Davis (0)
On the afternoon of October 30th, 1958, nearly 30 years after Werner Forssmann’s fumbling attempts, Dr. Mason Sones, a 5 foot 5 inch, plain-talking, cuss-every-few-words, cigarette-wielding radiologist at the Cleveland Clinic, was performing a routine angiogram of a patient’s aorta (the large vessel emerging from the heart) in a dark basement laboratory. (In Sones’ day, imaging methods remained primitive, disease diagnosis relying more than anything else on the physician’s powers of observation and crude diagnostic procedures. Abdominal pain was assessed with exploratory laparotomy, headaches with air injected into the brain and nervous system (“pneumoencephalography”), an excruciatingly painful ordeal. Being able to track the course of x-ray dye injected into specific internal organs, whether liver, biliary tree, aorta, lungs, or coronary arteries, represented a huge advance in diagnostic tools for human disease.)

In 1958, no one had yet injected dye directly into the coronary artery of a living human.


Just as the dye injector was triggered, Dr. Sones’ eyes widened in horror when the black and white monitor showed that the catheter had inadvertently jumped into the right coronary artery. The injection pump, already triggered to release its load, proceeded to pump 30 cc of X-ray dye straight into the artery. (Modern techniques usually require only 5–10 cc of dye.) Dr. Sones recounts the incident:

“It was late in the day and we were tired. I hit the switch to rev up the x-ray generator so I could see. As the picture came on, I could see that the damn catheter was in the guy’s right coronary artery. And there I was, down in the hole [a recess to shield him from radiation]. I yelled, “Pull it out! Pull it out!”*? By that time, about 30 cc of the dye had gone into the coronary artery. I climbed out of the hole and I grabbed a knife. I thought that his heart would fibrillate and I would have to open his chest and shock his heart. [In Sones’ day, modern CPR hadn’t yet been developed as a method of resuscitation.] But he didn’t fibrillate—his heart stopped. I demanded he cough. He coughed three times and his heart began to beat again. I knew at once that if the heart could tolerate 30 cc of dye, we would be able to safely inject small amounts directly into the coronary artery. I knew that night that we would have a tool to define the anatomic nature of coronary disease.”


*An observer, Dr. Julio Sosa, reported that Dr. Sones, in his shock, also blurted, “We’ve killed him!” After all, conventional wisdom of that era, based on observations from dye injections into the coronary arteries of dogs, was that injecting x-ray dye into human coronary arteries would result in immediate death from the electrical imbalance provoked in heart muscle momentarily deprived of oxygen-carrying blood.

Thus it was established that it was indeed possible to directly inject x-ray dye into human coronary arteries and reveal its internal contours. That’s not to say that the x-ray dyes of 1958 were innocuous. Far from it. In addition to briefly interrupting heart rhythm, as happened with Sones’ first accidental attempt, the dyes used then typically caused dizziness and the sudden urge to vomit. During the first 30 years of direct coronary catheterizations, it was common for hospital staff to run to the patient’s side, bucket in hand to catch the inevitable vomit, once the heart was jump-started by coughing.

Not surprisingly, Dr. Sones’ discovery set off both an avalanche of criticism and bold predictions of how the new technique might change the course of diagnosis in heart disease.

Over the subsequent weeks and months, Dr. Sones proceeded to purposefully insert catheters into coronary arteries and create angiograms that revealed the extent of coronary atherosclerosis. He learned how to fashion new catheter shapes to facilitate access to the arteries. Sones developed an impressive experience in the new technique. For the first time, clear images of the coronary arteries were routinely obtainable for the confident diagnosis of coronary atherosclerosis before death. Dr. Sones became an unlikely celebrity in Cleveland, entertaining physicians from around the world eager to learn about his methods, politicians and celebrities, even Middle Eastern nobility complete with bodyguards and food testers.

Dr. Sones continued to work in Cleveland, furthering the techniques of heart catheterization after his fortuitous error. He died of lung cancer in 1985, 17 years after his discovery.

Thus was born the modern age of heart catheterization.

Today, over 10,000 heart procedures are performed in the U.S. every day, 365 days a year, the vast majority of which involve heart catheterization or begin with a heart catheterization. Dr. Sones' fortuitous blunder was followed by 30 years of productive refinement and development before the blatant excesses of this technique really began to be exploited.


Copyright 2008 William Davis, MD

The origins of heart catheterization: Part I

12. March 2008 William Davis (2)
The modern era of heart disease care was born from an accident, quirky personalities, and even a little daring.

The notion of heart catheterization to visualize the human heart began rather ignominiously in 1929 at the Auguste-Viktoria Hospital in Eberswalde, Germany, a technological backwater of the day. Inspired by descriptions of a French physician who inserted a tube into the jugular vein of a horse and felt transmitted heart impulses outside the body, Dr. Werner Forssmann, an eager 25-year old physician-in-training, was intent on proving that access to the human heart could be safely gained through a surface blood vessel. No one knew if passing a catheter into the human heart would be safe, or whether it would become tangled in the heart’s chambers and cause it to stop beating. On voicing his intentions, Forssmann was ordered by superiors not to proceed. But he was determined to settle the question, especially since his ambitions captured the interest of nurse Gerda Ditzen, who willingly even offered to become the first human subject of his little experiment.

Secretly gathering the necessary supplies, he made his first attempt in private. After applying a local anesthetic, he used a scalpel to make an incision in his left elbow. He then inserted a hollow tube, a catheter intended for the bladder, into the vein exposed under the skin. After passing the catheter 14 inches into his arm, however, he experienced cold feet and pulled it out.

One week later, Forssman regained his resolve and repeated the process. Nurse Ditzen begged to be the subject, but Forssmann, in order to allow himself to be the first subject, tricked her into being strapped down and proceeded to work on himself while she helplessly watched. After stanching the oozing blood from the wound, he threaded the catheter slowly and painfully into the cephalic vein, up through the bicep, past the shoulder and subclavian vein, then down towards the heart. He knew that simply nudging the rubber catheter forward would be sufficient to direct it to the heart, since all veins of the body lead there. With the catheter buried 25 inches into his body, Forssmann untied the fuming Ditzen. Both then ran to the hospital’s basement x-ray department and injected x-ray dye into the catheter, yielding an image of the right side of his heart, the first made in a living human.



Thus, the very first catheterization of the heart was performed.



An x-ray image was made to document the accomplishment. Upon hearing of the experiment, Forssmann was promptly fired by superiors for his brazen act of self-experimentation. Deflated, Forssmann abandoned his experimentation and went on to practice urology. He became a member of the Nazi party in World War II Germany and served in the German army. Though condemned as crazy by some, physicians in Europe and the U.S., after hearing of his experience, furthered the effort and continued to explore the potential of the technique. Forssmann himself was never invited to speak of his experiences outside of Germany, as he had been labeled a Nazi.

Many years after his furtive experiments, the once intrepid Dr. Forssmann was living a quiet life practicing small town medicine. He received an unexpected phone call informing him that he was one of three physicians chosen to receive the 1956 Nobel Prize for Medicine for his pioneering work performing the world’s first heart catheterization, along with Drs. André Cournand and Dickinson W. Richards, both of whom had furthered Forssmann’s early work. Forssmann remarked to a reporter that he felt like a village pastor who was made a cardinal.

Strange, but true.


Copyright 2008 William Davis, MD