The study found that more than one-third of patients who underwent elective coronary angiograms did not have coronary artery disease and over 60 percent did not have significant blockages. Data from 663 hospitals enrolled 398,978 patients.  38 percent of patients did have serious disease.

The study concluded, “Better strategies for risk stratification are needed to inform decisions and to increase the diagnostic yield of cardiac catheterization in routine clinical practice.”

Comment:

Well over 1.8 million invasive angiograms are performed each year. 

At Pacific Cardiology, we have long advocated a much better approach to the diagnosis and treatment of heart disease:  Prevention.

Last year, we presented to our local lawmakers and insurance companies and Medicare, our approach to evaluating and treating heart disease in patients who have no symptoms or complaints. 

We recommend for patients with moderate/intermediate risk for heart disease (10 year NCEP risk) who have no symptoms, to have a calcium screening heart scan performed.

• If your calcium score is greater than 400, this indicates the presence of complex and significant heart disease.  Your risk of suffering a heart attack/cardiac death over 3-5 years is dramatically increased.  Nuclear imaging is then required as is intensive risk factor modification. 
• If your calcium score is much less than this, then a routine stress test or stress/echo may be performed (cost effective).  Risk factor modification is still required, but less intensive. 

We believe that ‘Prevention is the Most Important Treatment of Heart Disease’. 

Comment:  Although this study and others do demonstrate a potential benefit of serial calcium scores, our practice does not recommend this. 

If a calcium score is low or zero and risk factor reduction is undertaken, then repeating a calcium score may not be necessary. 

We feel that benefit of the calcium score is in helping stratify patients who are in intermediate risk categories (10 year event risk) into either high or low categories, where treatments differ.

These investigators combined the results (meta analysis) of 13 studies to evaluate a patients prognosis if 0 coronary calcium was detected by a calcium screening heart scan.  Out of 65,000 asymptomatic patients 26000 had 0 coronary calcium.  Only 146 (0.6%) had a cardiac event over the next 51 months

Comment: We agree with these findings.

These findings are not surprising, but calcium screening heart scans should not be used indiscriminately.  It is important to utilize this technology appropriately. In patients who are under the age of 45 (men) or 50 (women), calcium heart scans are not recommended by Pacific Cardiology.

Every 60 seconds, someone will die from a heart attack.

1.4 million Americans suffer a heart attack each year.

• 785,000 heart attacks are first heart attacks.
• 470,000 heart attacks are recurrent.
• 195,000 heart attacks are ‘silent’-discovered incidentally.

Symptoms:  Only 18% of heart attacks are preceded by chest pain. 

• 82%-85% of heart attacks occur in patients who never had any complains.

Consequences:  If you have a heart attack, the chances of dying within ONE YEAR:

• Age 40-49: 18% of men will die within one year of suffering a heart attack.  23% of women will die.
• Age 50-69: 14% of men will die within one year of suffering a heart attack.  12% of women will die.
• Age  70 and older:  27% of men will die within one year of suffering a heart attack.  28% of women will die.

If you suffer  a heart attack, the chances of dying within 5 YEARS:

• Age 40-49: 33% of men will die within 5 years of suffering a heart attack.  43% of women will die
• Age 50-69: 27% of men will die within 5 years of suffering a heart attack.  32% of women will die
• Age  70 and older:  56% of men will die within 5 years of suffering a heart attack.  62% of women will die

Treatment: 1.3 million angioplasties and 448,000 bypass surgeries are performed each year. 

Cost:  2009: $165.4 billion dollars

Comment:

• Most People who suffer a heart attack never experience any warning or chest pain. 
• Waiting for symptoms to develop is far too late.
• We believe that Prevention is the most important treatment of heart disease — not bypass surgery or angioplasty. However, this strategy requires that preventative measures are initiated many years before symptoms develop.

Comment:  This confirms data from other registries that screening evaluations are critical to preventing heart disease.  We recommend calcium screening heart scans for those with risk factors for CAD and/or intermediate risk.

(This column originally appeared in the Feb. 19 edition of AMA eVoice and is used with permission of the American Medical Association).

by AMA President James Rohack, MD.

“As a cardiologist, February has always been dear to my heart since it reflects a national awareness of a disease that I have spent my professional life trying to help patients manage.

In 1963, Congress required the president to proclaim February as American Heart Month to focus on what was, at that time, the No. 1 killer of Americans. In the 47 years since that annual declaration, cardiovascular death rates have decreased, but the disease still remains the top killer of Americans.

As one looks at the risk factors for developing cardiovascular disease, there are many that are influenced by behavior. Risk factors such as diabetes mellitus, hypertension and high LDL cholesterol often can be prevented or better managed by making healthier decisions about eating, tobacco use and physical activity. And as physicians, we can help direct patients by providing the right tools that help patients identify and choose healthier behaviors.

Healthy eating, physical activity and not using tobacco are three key lifestyle behaviors that can help prevent and manage cardiovascular disease.

What is clear from recent studies is the lack of awareness of cardiovascular disease risk for Americans. Thirty-four percent of women between the ages of 25-34 thought breast cancer was the leading cause of death. Twenty-two percent of women over age 65 thought the same thing. And the ethnic disparities are more troubling. Only 43 percent of black women and 44 percent of Hispanic women correctly picked cardiovascular disease as their highest risk for death. In America this year, more women will have heart attacks than men. But the disparities in care are troubling.

What you can do is be aware and make others aware of the real risk for cardiovascular disease—both for men and women—and help your patients help themselves by taking healthier life steps. These can start with children as part of first lady Michelle Obama’s Let’s Move initiative, which deals with childhood obesity. The AMA enthusiastically supports this program and will be enhancing what it can do to help doctors help patients with this effort.

Attacking the No. 1 killer of Americans at an early age is a good thing. That’s why the AMA is actively involved in prevention every month to help you help your patients every day.”

Comment:

• Heart Disease is the #1 killer of men and women.
• Nearly 85% of all patients who suffer a heart attack have no warning until the day of their event. 
• Most women and diabetics do not experience ‘chest pain’.

We believe that health care reform should focus upon a strategy of prevention, rather than waiting for symptoms to develop.  Most people are highly educated regarding the necessity of reducing risk factors through diet and exercise.  

Preventative evaluations such as stress tests, calcium scores, and certain blood tests are, unfortunately, not covered by private insurers or Medicare. 

Each of us must decide the true value of Preventative Evaluations. 

In a review of over 50 studies that examined CRP in 160,000 patients it was found that CRP was associated with increased CV events if other risk factors of CAD were present such as HTN, DM, Hypercholesterolemia, Increased BMI, etc. 

Comment: We agree with these findings.  Although it is uncertain if CPR is an independent marker for underlying CAD, if present in the setting of other traditional risk factors, evaluation for silent CAD, in our opinion, is warranted.

In other words, elevated CRP should raise the concern for underlying CAD if associated with traditional risk factors.

The American College of Cardiology (ACC), a 37,000 member organization has strongly objected to the devastating cuts and predicts that many cardiology practices will limit services or simply close their doors. 

The result of these cuts will be:

1.  Decreased quality of cardiovascular care nationwide.

2.  Higher costs to patients and medicare.  Costs for the identical procedures performed in doctors offices are 2-4x’s higher if performed at the hospital.  In addition, the patient copayments for these procedures will be much higher. 

3.  Decreased access to care.

4.  Longer patient wait times. 

According to ACC President Fred Bove, MD. “Over the past decade there has been a 27 percent reduction in morbidity and mortality in cardiovascular disease in this country, yet these cuts will effectively destroy the very system that achieved that amazing success.”

Comment:

We agree with Dr. Bove and the American College of Cardiology. 

In an international study of 167 patients who had atrial fibrillation that failed antiarrhytmic medications, Atrial fibrillation catheter ablation was superior to medication in:

1.      Preventing recurrence.

2.     Improving Quality of life

Comment: Our experience in patients who have undergone atrial fibrillation ablation has been similar to the findings of this small trial.  In our practice referrals for atrial fibrillation ablation are limited to those who are refractory to medications and/or significantly symptomatic. The success rate for this procedure has increased over time, but is not to the level of other arrhythmia procedures.

Atrial fibrillation ablation is currently not performed in Hawaii.  Our patients are referred to Stanford University Medical Center for Atrial Fibrillation Ablation procedures.

Comment: It is true that non-HDL cholesterol measures are perhaps equally if not more important that measuring LDL cholesterol (either direct or calculated).  This has been known for quite some time and we routinely evaluate/monitor/follow our patients Non-HDL cholesterol levels.  For certain patients, we recommend LDL subfractionation. 

With regards to non-fasting cholesterol assessments, it has been proposed many years ago to be a more realistic assessment of a person’s cholesterol profile.  However, we recommend continuing with the standard fasting cholesterol measures at this time in order to obtain accurate TG and LDL-C levels.