Deja vu all over again?

10. January 2009 William Davis (8)
HeartHawk brought a report and debate on The Heart.Org website to my attention:

Screening for risk factors or detecting disease? Debate divides the CV community. After landing on theheart.org, paste this onto your URL address:article/883239.do. (Full address: http://www.theheart.org/article/883239.do. I don't know why, but I couldn't go there directly.)

Some interesting comments:

Dr. Jay Cohn (University of Minnesota):

"They're saying that we can't identify disease very effectively so let's just stick with risk factors, which we know are very poorly predictive and nonspecific. It boggles my mind as to why they won't open up their minds to the importance of moving forward in finding better strategies to identify the disease that we are treating. It's very strange. They criticize these disease markers because they are not predictive of events, but they are looking at very short-term outcomes. We're interested in lifetime risk. We're screening people in their 40s who are concerned about morbid events in their 60s and 70s, and no trials are going to track them that long."

"You have to accept the pathophysiologic reality that heart attacks don't occur in the absence of coronary disease, and coronary disease doesn't occur in the absence of endothelial dysfunction and vascular disease, all of which now can be identified."

". . . Can we as a society and as a profession accept the idea that there is a link between the vascular abnormalities and the events? "And that that linkage is tight enough that it should allow us to accept slowing of progression of the vascular abnormalities as an adequate marker for slowing disease progression, without waiting for events to occur? As soon as you use the word surrogate, people jump up and say we have all these markers that we know don't work well—things like premature ventricular contractions [PVCs] on the electrocardiogram, LDL, HDL—but those are not the markers we're talking about. We're talking about structural and functional changes in the blood vessel and in the heart."


Wow. The idea may be starting to catch on.

As an interesting aside, Cohn et al use a 10-test panel to screen for vascular disease:

"Named for the center's benefactor, the Rasmussen score includes tests for large and small artery elasticity (compliance), resting blood pressure, blood-pressure response to moderate treadmill exercise, optic fundus photography, carotid intimal-media thickness (IMT), microalbuminuria, electrocardiography, left ventricular (LV) ultrasonography for LV volume and mass, and brain natriuretic peptide (BNP). Each test result is scored out of 10 for low, intermediate, or high risk, and the combined results yields a score that Cohn et al believe is more predictive than any of the existing standalone tests."


The counterarguments in this debate were provided by Dr. Philip Greenland (Northwestern University), who repeated his oft-used argument that, while he accepts that vascular disease can be identified, no one has proven that measuring it improves outcomes:

"We do have that evidence for risk-factor screening. Even though people criticize risk-factor assessment because it is not sensitive enough or not accurate enough, the interesting and curious thing is that we actually have evidence that if you go to the trouble of screening for risk factors and treating them, patients have better outcomes. We do not have that evidence for any of these other tests."


An interesting debate ensues that includes Track Your Plaque friend, Dr. William Blanchet, who characteristically argues persuasively in favor of broad screening for coronary disease with coronary calcium scoring:

"If we were doing our jobs in primary prevention, we would not need to look at improved intervention and secondary prevention to reduce coronary death."


Here's a shock: Dr. Melissa Shirley-Walton, the cardiologist who previously preached the "cath lab on every corner" argument seems to have undergone a change of heart:

"What if I walked up to a gentleman and said, "you are at risk for CAD, take a statin", to which he replies, "I'm afraid of those meds". BUT if he sees his calcium score........he is then convinced to be pro-active. What is so wrong with that? What is so wrong with allowing him to spend 250.00 US out of pocket in order to save the US 150,000.00 US later on?

No hard endpoints you say with intensive therapy for primary prevention? What about extrapolating from trials for secondary prevention like HATS? ARBITER2? And what exactly is the true definition of secondary prevention? Is it truly primary prevention if we already have intima thickness abnormalities, or fatty streaks? That would more likely fall under secondary prevention by today's new standards.

So, I'm all for any visual aid that will encourage compliance with life style change, necessary medical therapy and followup. If the patient is willing to spend 250.00$ to get a calcium score, so be it. Better yet, why not lower the price so everyone can have the option if they are motivated enough to seize an opportunity?"


I have to admit that I thought that Dr. Blanchet was wasting his time trying to persuade Shirley-Walton et al, but perhaps he is having an impact, though having hammered away at them for the last year or so.

These arguments, for me, eerily echo many previous debates I've heard. But I am encouraged by the more favorable treatment the notion of atherosclerosis screening is receiving. Just 5 years ago, all coronary calcium scoring would have received from the conventionalists is "more clinical studies are needed."

So perhaps the cardiology and medical worlds are inching slowly towards broad acceptance of screening for coronary and vascular disease.

BUT, screening is not sufficient. What do you do with the information?

Here is where the conventional-thinkers stop. The question that seems to occupy them: Perhaps we should screen people for hidden coronary and vascular atherosclerosis so we can better decide who needs a statin drug or a procedure.

I would pose a different challenge: We should screen people for hidden coronary and vascular atherosclerosis so we can better decide who needs to engage in an intensive program of disease reversal using natural means and as little medication and procedures as possible.

Well, perhaps in time.
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Comments (8) -

  • Jenny

    1/10/2009 3:17:00 PM |

    I've been mulling over that Veterans study published in NEJM that found lowering blood sugar had no impact on CVD in older veterans with diabetes. The conclusion from this seems to be that people shouldn't bother lowering blood sugar.

    That conclusion seemed to me to be just like saying, "Water does not put out fire" based on a study where a single pail of water was not able to make any difference in a raging house fire.

    Obviously some damage is irreversible and if you wait until someone is 65 and has had diabetes for a decade (many years of which the diabetes was undiagnosed) you are not going to be able to fix it in a year or two of doing even the correct things.

    This is probably true with all the other factors.

    OTOH, as I keep being reminded every time I visit the nursing home, there are times when a swift and fatal heart attack is a whole lot better than the alternatives. Without heart disease your old age likely to with years of cancer, COPD, or dementia.

  • JD

    1/10/2009 5:39:00 PM |

    http://www.sciencedaily.com/releases/2009/01/090106181731.htm

    More reasons not to take statins due to risk factors.

    "Results showed that 21% of the patients who were thought to need statin drugs before the scan (because of the Framingham and NCEP assessment tools) did not require them; “26% of the patients who were already taking statins (because of the risk factor assessment tools) had no detectable plaque at all,” said Kevin M. Johnson, MD, lead author of the study."

  • steve

    1/10/2009 6:46:00 PM |

    excellent post.  I fail to see why a calcium score is necessary if sub fraction testing of lipids is done.  Why isn't it enough to see that if you have tons of small LDL particles and little large fluffy ones, as well as low HDL then you need to take some lifestyle corrective action?

  • Anonymous

    1/10/2009 10:53:00 PM |

    Good blog Dr.D.

    FYI..In Torrance, they are doing a two for one calcium score test. So we are going for it. Costs a total of $400.00 for 2. Its the location on your website TYP.

    So thanks for sharing the testing locations.

    Stevie

  • pomeropd

    1/11/2009 12:57:00 PM |

    Good to hear someelse is attempting to develop a monitoring/early detection approach.

    BUT, the cost mentioned on their website $1800 is far more costly than a CT calcium score.

  • mark

    1/11/2009 11:28:00 PM |

    Dr. Davis, I did an archive search for Vitamin A and came to this entry:

    http://heartscanblog.blogspot.com/2008/06/vitamin-d-newsletter-autism-and-vitamin.html

    You wrote: "5) Vitamin A--Is vitamin A with vitamin D good or bad? This one I do not have an answer to. Reading the literature Dr. Cannell cites didn't help much. (Dr. BG--Any comments? Dr. BG is a vitamin A advocate.)"

    Chris Masterjohn wrote an article for the Weston Price Foundation on Vitamin D, and a sizeable segment deals with the relationship of intakes of  vitamin D AND A.  He provides some references, which will hopefully provide an answer to the question.

    The article is here:
    http://westonaprice.org/basicnutrition/vitamin-d-safety.html

    Mark.

  • Scott W

    1/12/2009 12:17:00 AM |

    One of my favorite quotes - Leo Tolstoy wrote:

    "I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives."

    It's about ego and losing face. Facts that disagree with their belief system are either incorrect or irrelevant.

    Scott W

  • Thomas

    1/12/2009 8:03:00 PM |

    Two points: science is about trying to improve our explanations, not searching for correlations (or 'risk factors', or 'links'). The role of experiment is to select between explanations.

    So we ought to be conjecturing and criticising/testing theories of heart disease.

    Treatment is a separate, medical, problem.

    On a philosophical level, I think we need to look at the individual: well-being and motives.

    It's probably correct to say that people need to cut back on carbs and alcohol, however, we need ask *why* people go after those things, and other addictions generally.

    If cutting carbs comes at the cost of self-coercion and misery, then we may have fixed somebody's CVS but we haven't solved the deeper problem. Which is a longterm recipe for relapse.

    Or are we afraid to venture near the intellectuals quagmires of subjectivity and spirituality?

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