The battle for asymptomatic disease

The heart disease revenue pie is shrinking. So is the "serving size" being shared by competing hospitals.

In other words, as more hospitals open heart programs, there is more competition for the same heart patient. Throw into the mix the drop in "acute" presentations of disease, probably due to the now widespread prescribing of statin drugs. When I first started cardiology practice 15 years ago, for instance, days and nights spent taking care of heart attacks coming through the emergency room was a common event. It still happens, but far less frequently. (I don't mean to suggest that the actual prevalence of coronary heart disease has decreased, just the acute, catastrophic version of it.)

Throw into this mix the results of the COURAGE Trial that has put a damper on the value of stents and angioplasty vs. "optimal" medical therapy in people with stable anginal symptoms, since there was little advantage of procedures. Though it has not stopped the practice, it has reduced the enthusiasm for procedures. Though data are hard to come by, I've heard talk of 10% or greater drops in total procedural volume over the past year.

It's not uncommon for hospitals to have overbuilt heart facilities in anticipation of continued growth of this--until recently--growth industry called heart disease. However, factors are converging that may provide a new profit opportunity for hospitals.

One such opportunity is CT coronary angiography. The usual scenario: Man or woman without symptoms is persuaded somehow--an ad, primary care physician, next door neighbor with a scary event, Dr. Mehmet Oz gushing about this sexy new technology on yet another Oprah episode--to undergo a CT coronary angiogram. A "severe" blockage is found, despite the lack of symptoms, and voila! A stent patient or bypass patient is created out of nothing! Do this repeatedly and systematically, and a hospital can regain its former high-procedural volume glory.

Heart scans, though I believe deeply in them and they are the basis for the Track Your Plaque prevention and reversal program, can also be used and abused this way. Asymptomatic person has a score 150. Concerned, they go to their physician who orders a nuclear stress test. An "inferior perfusion defect" is seen, presumably representing poor flow through the right coronary artery (but often just means that the diaphragm overlaps the heart muscle and yields this apparition, a "false positive" or misleading result). "But--wink--we've got to find out if there's a severe blockage, don't we? You don't want to end up in an early grave!"

Thus, the battle for new patients with asymptomatic disease is getting underway in earnest. The scramble for cardiologists to learn how to use CT coronary angiograms is proceeding at breakneck speed, with new training courses being offered nationwide several times and places every month. CT coronary angiography is a useful test, but it is also subject to enormous abuse. It also provides the ticket for the unscrupulous physician and the revenue-hungry hospital eager to expand its patient volume.

Many people believe that this cannot happen commonly in 2007, given scrutiny of practices, litigiousness, and the expectation of a moral sense in medicine. However, I've witnessed such incidents several times this month alone. If you need graphic proof of just how far this can go before action is taken, read Coronary, Stephen Klaidman's chilling tale of a cardiologist and cardiothoracic surgeon in small-town northern California who built an enormous heart center based on fabricated heart disease diagnoses. You'll also find their story in Shannon Brownlee's recently released Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.

Of course, the Track Your Plaque program is meant principally for people without symptoms, also. But we are advocating that asymptomatic disease is a reason for prevention, not procedures. There's a difference.

By the way, the two practitioners who engineered the escapade detailed in these books, cardiologist Chae Hyun Moon and cardiac surgeon Fidel Realyvasquez, walked away with a monetary fine and suspension of their California medical licenses. It is likely that many people died because of their abusive practices, but the state struggled to make a sufficiently persuasive case for reasons that I still don't understand.

Comments (10) -

  • G

    11/2/2007 6:36:00 AM |

    Poor Oprah, she's on the yellow brick road and doesn't even know it! I hope your results validating CT scans and dramatic primary CAD reduction bring on a revolution. It could not be soon enough. Personally, I find it so hard to teach my diabetes patients about wheat-elimination with the goal to improve their diabetes, reduce insulin doses and lose weight. (Not to mention, of course, other benefits like reducing early death -- esp the silent fatal heart attack kind) It's like trying to treat an obese child -- you look at the parents -- then realize you need to treat the parents first. To save lives from heart disease (which is increased five-fold in people with diabetes), I think the whole Western society needs to be educated and exposed to the TYP program!  i greatly think Oprah needs your help (at least get her out of the hands of M&M, you know, that sugar-coated pair Mehmet and Mike)  *ha haaa haa*  What a great help she would be if she was also convinced, and moved the TYP plan to the forefront?  PBS is good, but n-o-t-h-i-n-g is as good as Oprah ;)

    Your writings are mandatory reading for all my patients! Keep up the strong work!

  • Dr. Davis

    11/2/2007 10:41:00 AM |

    Thanks, G.

    Love your analogy of the obese and child and parents.

    I agree. It's a long uphill climb and one that runs against the winds of what the hospitals and powers that be tell us. Imagine how slow the climb would be without the information disseminating powers of the internet!

  • G

    11/2/2007 11:17:00 PM |

    Dr. D

    Thank God for the powers of the Internet!  I was researching estrogen (for a talk at a pharmacy school I teach at) and came across your blog under Sue Shellenbergers Wallstreet J article in March. What a fluke!! I went through all the archives almost as fast as I was hooked and addicted to watching Lord of the Rings.  You are undoubtedly the BEST health resource that I have come across -- including primary literature and cardiolgy texts.  I love your ex-interventionalist rhetoric and rants. You approach the whole body including mental health (LOVE the 'be happy' blog!) and emphasize heart prudent OPTIMAL nutrition.  Because I've lived it and I've seen health improvements with the basic low carb TYP rx on my DM patients (you know the 1-2% that actually aren't nonadherent), I know with 200% certainty IT works. Your explanations and references are always great in illustrating who they work for the heart and vasculature.

    I have faith that you will demonstrate compelling outcomes and data on how all these components work together (D replacement, nuts, vegetarianism, low GI foods, oat bran, fish oil, etc).  Without a doubht that seminal cardiology publication when it finally hits the stands will change e-v-e-r-y-t-h-i-n-g. (at least it will stir the establishment up a bit *what entertainment value THAT will have!!!* the suspense...)

    OK, i know you don't do individual consults, but I have a patient that I need help on...  his cardiologists have given up -- he's had multiple surgical interventions (s/p stents about 1-2 mos ago). I've implored him to read and study the TYP book and blog (he better be reading this).  Diffuse CAD still cause DOE and SOB. Within DAYS after the last stents were put in, the symptoms returned again. (drug-coated no less *YECK*)  He's doing the whole aggressive medical management thing (with me). he's eliminating all refined processed carbs (he misses his biscotti), we've added B3 (still titrating), D3 4000 Iu/d (baseline=37 ng/ml) and 3400mg EPA+DHA, oat bran and raw nuts. he's on Vytorin 10/80 for the heck of it. I hope to obtain 60/60/60/60 in 3-6mos. his a1c is almost < 6.5% (from 8.5%).

    My question for you is -- will he ever get off of the short or long acting nitrates? (at this point it's not apparently helping anyway) will the DOE always be there?!  what dramatic reversal in CAD have you seen?  he's a fit avid soccer player, but can't play at all right now.

    When you use Slo-niacin, can you get them to therapeutic doses faster? he's on short acting right now.  I am so grateful for your generosity in sharing your compelling and honest insights. You are totally making a difference...  

    Thank you in advance for your feedback.  Take care! G

  • Dr. Davis

    11/3/2007 1:24:00 AM |

    Hi, G--

    Thank you kindly!

    Interestingly, simply articulating the concept or philosophy of obtaining reversal, of at least setting that as a goal, can truly turn someone's view of themselves and their disease completely around.

    Some thoughts for the patient you discuss:

    1) Time is crucial. It may simply require several months.

    2) Consider using therapeutic fasting for the fastest means to resolution of symptoms. There is a report on this approach on the website, or see Joel Fuhrman's book,
    Fasting and Eating for Health. (Ignore the low-fat eating comments in the book, however.)

    3) Consider l-arginine to accelerate anti-inflammatory and endothelial-normalizing effects.

    4) Unfortunately, I never use immediate release niacin, but I imagine that a 500 mg increase every two weeks could be tried, similar to the accelerated course we sometimes use with SloNiacin or Niaspan.

    5) Consider doxycycline for its matrix metalloproteinase-suppressing activity. See the associated report on the website, also.

    Nitrates in my view are just Band Aids that provide little genuine therapeutic benefit beyond temporary symptom relief.

  • G

    11/3/2007 4:17:00 AM |

    No matter what the results are, I'm eternally grateful (and he will be too). I'm going to approach his doc on Monday... THANK YOU VERY VERY VERY MUCH! G

  • Anonymous

    11/3/2007 1:38:00 PM |

    Boy G you are the first dietitian I know who promos low carb for diabetes, goodonya, do you read Dr Bernsteins Diabetic Solution. His book and webcasts and TYP are my bibles.

    Is Oprah's weight gain due to following Dr Oz.

    Here;s a story for you that is scary for a pateint with undiagnsoed chest pain:

    I had undiagnosed chest pain for several months, quit Actos ( it started around time I went on Actos)but it remained after quitting for 6 weeks actually, and they did a stress test and said nada but I know from your book I need another calcium score done so am pushing for that.

    In the meantime this Dr who is new to town told me I must stay on Actos no matter what the side effects are and sometimes you just have to take risks to stay on drugs!!  

    I actually only asked for Actos to try get my A1C to a 4.5 from a 5.4 as Dr Bernstein recommends that diabetics have the same rights to normal bg as non diabetics, so then I didn't see him again and saw his wife. They are both new Dr from South Africa.

    She put me on nitro spray, didn't even see me, called me out of the blue and said maybe I should use it,would aid in her diagnosis if it worked!! yet they won't give me a repeat Rx for metphormin which I have been on for 15 yr (over the phone)!!!!

    I didn't want to use it but the pain scares me as it is harsh, bends me over and I live out of town and fear if I am having a MI I am at higher risk, so the next time  I had the chest pain, I tried the nitro once and my bp dropped to 84/58 and I almost went into shock, so I dumped her and have a new young doc who tries to practise cardiology along with her caseload.

    My Dr of 21 yr moved so its been awful living rural in small town and not enough Dr, she seems intelligent, listens and I think I can bend her ear towards TYP.

    I am going to push for advanced lipid profile again,and another EBCT, my pain is lessening as my high stress job finished, I can't believe that crippling pain was due to stress and fear the Actos set me up for something.

    I am the therapist that got the referrals for those appearing in emerg thinking they are having a heart attack and they wern't, it was anxiety induced. I tried all the relaxation techniques I taught and it didn't help my chest pain so I was scared so used the nitro much against my better judgment and won't ever again.

    The stress test showed nothing wrong, good recovery, the ecg showed no heart attack.

    I had a Pulse Wave analysis test done at a conference I went to on menopause. This conference follows the programs of Dr John Lee who also thought outside the box like you do Dr D and he had good results and not the side effects from hormone trtment like oral drugs has.

    He suggests bio identical creams only so if you search out Jackie Harvey and the workshops she does called Heart to Heart for women and the medical profession, you will learn about menopause help that is also non traditional.

    This new doc I found supports her ideas, will support the saliva test and prescribe bio identical progesterone cream if your test suggests you need it as you have estrogen dominance, and it does seem to help.

    Tell me if you think this Pulse wave analysis is right on, they recommend a liquid L arginine as say it absorbs better but boy is it pricey.

    BTW I don't have a goggle acct and don't really know how to set one up so come under anonymous so it makes a few of us, sorry.

    Thank you for this siteSmile

  • Dr. Davis

    11/3/2007 7:06:00 PM |

    Reluctantly Anonymous via Google--

    Actually, what you are describing--chest pains around the menopausal years with some gauge of "endothelial dysfunction," i.e., abnormal coronary artery constriction--is how I first came to appreciate the power of l-arginine about 15 years ago.

    Back then, research from the NIH uncovered a poorly-named entity in perimenopausal women called "microvascular angina." It is wonderfully responsive to l-arginine. That's the situation in which I also learned that arginine only works when taken on an empty stomach.

  • gc

    11/3/2007 11:42:00 PM |

    Wow thank you for that info, Smile

  • Anonymous

    11/11/2007 2:31:00 AM |

    Thank you Dr. Davis for posting about the book "Coronary," which I ordered after reading about it on your website.

    It is one of the most chilling books I have read.  One would like to think that the unnecessary angioplasties and heart bypasses that the book described were anomalies, limited to two amoral out-of-control doctors in a small Northern California town.  But you write that you have seen it in your city in the Midwest.

    It makes me cynical about the entire medical profession.  By the way, I have seen the same amoral greediness from many so-called "alternative medicine" doctors in Los Angeles.  It may not be on the same scale as Drs. Moon and Realyvasquez, since these so-called anti-aging gurus are only pushing unnecessary supplements (which they sell at great markup in their offices) and unnecessary blood work and saliva tests (I have no doubt whatsoever that they are getting illegal kickbacks from the labs), not surgery and invasive procedures.  I guess it's the difference between a little shoplifting and armed bank robbery, but still it does make one cynical about the whole medical profession.

    Thank goodness for your blog, which at least helps laypeople have a fighting chance.

  • Dr. Davis

    11/11/2007 2:51:00 AM |

    I like your analogy: shoplifting vs. armed bank robbery.

    Legislating against such excesses is an impossible task. In my view, the solution is education.

    An informed, educated consumer is one who can make his/her own choice, whether it's to pursue acupuncture, chiropractic, take hawthorne, undergo coronary angioplasty, or some other path.