Dr. Bill Blanchet: A ray of sunshine

Another heated discussion is ongoing at The Heart.org, this one about Tim Russert's untimely death: Media mulls Russert's death as cardiologists weigh in

Although I posted a couple of brief comments there, I quickly lost patience with the tone of many of the other respondents. Should you choose to read the comments, you will see that many still cling to old notions like heart attack is inevitable, defibrillators should be more widely available, "vulnerable" plaques cannot be identified before heart attacks, etc.

I quickly lose patience with this sort of outdated rhetoric. However, our good friend, Dr. Bill Blanchet of Boulder, Colorado, has a far stronger stomach for this than I do.

Here, a sample of his wonderfully persuasive comments:

Heart disease cannot be stopped but we can certainly do better!

Goals we must achieve if we hope to solve the Rube Goldberg of coronary disease:

1. Find something more reliable than Framingham risk factors to determine who is at risk. Framingham risk factors are wrong more often than they are right. If you are comfortable treating 40% of the patients destined to have heart attacks, continue to rely on “traditional” risk factors only.

2. Treat to new standards beyond NCEP/ATP-III. These accepted standards prevent at best 40% of heart attacks in patients treated. This is unacceptable, and arguably why Tim is dead today! Why prevention protocols emphasize LDL and more or less ignore HDL, triglycerides and underemphasize blood pressure eludes me.

3. Motivate patients to participate in coronary prevention. Saying “you need to get exercise and lose weight” is not adequate motivation, it hasn't worked to date and probably won't work tomorrow. If you are satisfied saying it is "the patient's fault for not listening to me" so be it, that excuse doesn't work for me!

Currently “good results” consist of being able to convince 50% of patients at risk by traditional risk factors to participate in prevention and hopefully 30% will be treated to goal. Of those treated to goal, 60% of the heart attacks will still happen anyway. Mathematically we can hope to prevent <10% of heart attacks with this approach!

I have personally found a solution to this dilemma. It goes like this:

1. EBT-CAC [electron-beam tomography coronary artery calcium] is the most reliable predictor of coronary events period, the end! Anyone who disagrees has not objectively read the literature. The only test more predictive than the initial calcium score is the follow up score 12 to 36 months later. EBT predicted Tim Russert’s event 10 years before it happened; passing his stress test gave him inappropriate reassurance 2 months before he died. If only Tim had the benefit of a second EBT sometime over the last 10 years he and his doctor would have known that what they were doing was insufficient and improvements could have been made.

2. I treat to the standard of stable calcified plaque by EBT (<15% annualized progression, preferably <1% annualized progression). This correlates with a very low incidence of coronary events. Even the ACC/AHA 2007 position paper agrees with this. This is accomplished with aspirin, omega-3 fatty acids, diet, exercise, weight control, smoking cessation, treatment of sleep apnea, stress reduction, control of HDL, triglycerides and LDL cholesterol and excellent control of BP and insulin resistance plus the recent addition of vit D-3. Meeting an LDL goal of 70 is easy but prevents only a minority of events, treating to the goal of stable CAC by EBT is a challenge but when achieved, the reward is near elimination of heart attacks and ischemic strokes. This has indeed been my personal experience!

3. A picture of plaque in the coronary artery is a monumental motivator for patients to get on board to make things better. The demonstration of progression of that plaque despite our initial therapies gets all but a few suicidal patients interested in doing a better job. I think that similar motivational results can be had with carotid imaging; the difference is that CAC by EBT is clinically validated as being a much stronger predictor of events with progression and non-events with stability than any ultrasound test including IVUS.

Wow! I couldn't have said it better.

Sadly, I doubt even Dr. Blanchet's persuasive words will do much to convince my colleagues on this forum. And the cardiologists on this forum are likely among the more inquisitive and open-minded. The ones stuck in the cath lab day and night, or implanting defibrillators, are even less inclined to entertain such conversations.

While I admire Dr. Blanchet's energy for continuing to argue with my colleagues, the lesson I take is: Take charge of health yourself. If you wait for your doctor to do it for you, you could be in the same situation as poor Tim Russert. This is an age when your physician should facilitate your success, not prevent it or leave you wallowing in ignorance.

Comments (4) -

  • Anne

    6/27/2008 7:40:00 AM |

    Being from over the pond I had never seen or heard Tim Russert, but over the past few weeks I seem to hear nothing but discussion and speculation about his death on the US forums I'm on. When I first saw a picture of Mr Russert in the first wave of reports after his death I thought to myself "That man is overweight, no wonder he died early. Why is everyone surprised ?"

    My mother died of an early heart attack because she smoked. At least five years before her death her cardiologist told her that her arteries were clogging because of her smoking. Yet she continued to smoke. She didn't even try to cut down.

    Why are people so surprised when smokers and overweight people die from heart attacks ?  I personally get very angry about it. My mother's untimely death had a terrible impact and caused a lot of problems for my family and it was her own stupid fault. Is there a Mrs Russert and Russert children/grandchildren ? Mr Russert's early death will have had a monumentally awful impact on them. I read he was a very intelligent interviewer....well he wasn't so intelligent because he must have known that his overweight was bad for him but he didn't lose it. Stupid. You don't need to be a cardiologist to know that overweight causes heart disease.

    Millions of pounds and dollars are spent on treating the symptoms these people have yet no one spells it out that they should just stop smoking, lose weight (stop taking drugs, stop drinking, whatever) FIRST ! It's pointless pouring medications into these people when they just carry on injuring themselves.

    I may still be very angry at my mother for killing herself with smoking and so may be 'over' ranting about this, but I make no apologies because these people know what they are doing. Their deaths are no mystery, require no endless discussions about causes. Their deaths are first and foremost their own faults and not their doctors. Sure they need help to stop smoking, to lose weight, stop drinking, stop taking drugs etc but they are responsible for carrying that through.


  • Anonymous

    6/27/2008 4:01:00 PM |

    I found the most interesting part of the Dr."s comments were that while he would like less than 1% progression of calcium, he seems to be happy with "just" less than 15%. Although this is pretty close to what Dr. Agaston shoots for. He says in his South Beach heart Book than 10% or less means you've pretty much eliminated future risk and he STILL says there is no such thing as "regression".

  • Anonymous

    7/8/2008 6:06:00 PM |

    I volunteered for a study 10yrs ago and the heart ct gave me a calcium score that said 80% of my age group was better than I. It didnt change how I lived the next 10years. It took high blood sugar, reduced vision, wt loss, and frequest urination to prod me into action. By adding oatmeal and increasing fats yet drastically cutting carbs overall I inadvertently did amazing things to lower cholesterol without meds or exercise. I want another scan to see if fixing your floating cholesterol problem has a regression effect on your plaque or if it truly is too late once the plague is there.

  • buy jeans

    11/3/2010 10:04:59 PM |

    Sadly, I doubt even Dr. Blanchet's persuasive words will do much to convince my colleagues on this forum. And the cardiologists on this forum are likely among the more inquisitive and open-minded. The ones stuck in the cath lab day and night, or implanting defibrillators, are even less inclined to entertain such conversations.