Surgeons
vs. Cardiologists
New technologies and economic demands are creating intense competition between
cardiac surgeons and cardiologists. Cardiac surgeons rely on referrals from cardiologists
for most of their clients; but new technologies, such as angioplasty balloons
and stents that can hold arteries open, let cardiologists treat many patients
themselves instead of referring them for major surgery. Bypass surgeries have
dropped by 20% since the stent's introduction in 1994. Responding to the
drop, Georgetown University Medical Center (Washington, DC) merged its open-heart
surgery program into another Washington hospital center, according to an article
in The Wall Street Journal (10 September 2003). In addition to having fewer patients,
heart surgeons are receiving significantly less money from Medicare and managed
care companies for their services. Heart surgeons received $4,000 from Medicare
for a bypass operation in 1987, but only $1,850 in 2002. Reimbursement cuts have
hurt cardiologists as well. The physician fee for angioplasty has dropped by
over 30% since 1998, yet cardiologists' operating costs continue to rise.
Cardiologists pay almost twice the office overhead (almost 40% of their income)
that heart surgeons do.
The competition for dollars and patients has led to a lawsuit in Towson, Maryland.
Cardiac Surgery Associates, a group of heart surgeons headed by Garth McDonald,
and the cardiology group Midatlantic Cardiovascular Associates had worked well
together until economics pushed the cardiologists to ask the surgeons for some
help with soaring overhead costs. When Cardiac Surgery Associates refused to
contribute, the cardiologists hired their own surgeons and stopped referring
patients to Garth McDonald's group. As a result, the eight heart surgeons
of Cardiac Surgery Associates saw their caseload drop from about 110 surgeries
a month in the late 1990s down to 25 during August 2003. The surgery group filed
a lawsuit against Midatlantic Cardiovascular Associates, accusing them of violating
a state unfair-competition law. Typically, however, multispecialty physician
groups, such as cardiologists and surgeons, are exempt from anti-kickback or
self-referral laws. Kevin Schulman, professor of medicine and business at Duke
University, told The Wall Street Journal, "As technology favors one subspecialty
over another, you get very, very large turf battles…We're going to
see more of these battles where you can literally put some doctors out of business,
and very quickly."
Anand, Geeta & Winslow, Ron. Transformation in Medicine is Putting Specialists
at Odds. The Wall Street Journal 10 September 2003
Hypercholesterolemia & Hormones
Life Extension (September 2003)
published an article by Sergey A. Dzugan, PhD, and R. Arnold Smith,
MD, that proposes that hypercholesterolemia
is the result
of a multi-hormone deficiency. The body uses cholesterol as a basic component
of cell membranes, bile acids, vitamin D3, and as the precursor to steroidal
hormones such as pregnenolone, DHEA, testosterone, progesterone. The authors
propose that the body responds to a deficiency of these hormones by overproducing
cholesterol.
To test their hypothesis, the doctors performed a clinical study from July
1997 to April 2003, involving 41 patients with high cholesterol levels. The
patients,
ages 25 to 81, received combinations of multiple human-identical hormones. "If
even one steroidal hormone is left out, then the body may respond to this deficiency
by synthesizing more steroidal hormonal precursor, (i.e. cholesterol)," the
authors explain. The hormones were given in individualized, physiologic ratios,
designed to produce "youthful physiologic (not ‘normal') serum
levels." The doctors determined each patient's dosage by periodically
measuring serum hormone levels. Dose schedules simulated natural human production
cycles.
All 41 patients responded to the therapy. Mean serum total cholesterol decreased
from a baseline of 254.6 mg/dL to 188.8 mg/dL after treatment, a decrease
of 25.6%. Serum HDL levels (the lipoprotein that scavenges free cholesterol
and
transports it back to the liver) also dropped (19.6%), "but remained much
higher than undesirable levels in all cases." The authors view the decrease
in HDL as a sign that cholesterol levels had normalized and that extra HDL was
unnecessary. The doctors also noticed that the multiple steroid hormone therapy
had improved thyroid function. All patients reported a "significant improvement
in quality of life."
Dzugan, Sergey A., PhD. & Smith, R. Arnold, MD. Treating High Cholesterol
by Replacing Hormones Lost to Aging. Life Extension September
2003
HRT & Heart Disease
When scientists began examining data
from the Women's Health Initiative (a large federal study on hormone
therapy) in July 2002, they were dismayed
to find an unexpected increase in heart disease among women taking Prempro,
a hormone
preparation made by Wyeth. The Women's Health Initiative was the first
randomized controlled study (considered "the gold standard") to involve
thousands of women. Its results closely corresponded to the highly-regarded
Nurses' Health Study, an observational study which derives its data from
thousands of nurses
who periodically report on their health and numerous factors that include
diet, exercise, and use of drugs.
The Women's Health Initiative agreed with the Nurses' Health Study
and other observational studies in several areas. Both types of studies showed
a decreased risk of colorectal cancer among women who take hormones: 63% in
the Women's Health initiative and 66% in the observational studies. Women taking
hormones also had a lower incidence of hip fractures. Both types of studies
found
an increased incidence of breast cancer, stroke, and pulmonary embolism among
hormone users. The observational Nurses' Health Initiative, however, showed
that hormone therapy decreases the risk of having a heart attack by 30%. The
randomized controlled study found that the incidence of heart attacks in women
taking a hormone preparation had actually increased by 40%.
Scientists have been trying to figure out why the two studies gave such different
outcomes in that one area. Is there some important, but unrecognized, difference
between the groups of women involved in the two studies? Did the observational
study miscount hormone therapy users? Gina Kolata, writing for The
New York Times (22 April 2003), explained
that "the nurses' study assesses drug
use every two years. A woman could start taking hormones, have a heart attack
in the next two years, and stop taking them immediately. Later when asked if
she takes hormones, she says, correctly, that she does not. Her heart attack
would be counted as one that occurred in a nonuser." So far, none of these
factors account for the large discrepancy.
Some researchers have also suggested that the negative results of the Women's
Health Initiative may be because of Prempro itself. Women in the observational
studies took a variety of hormone preparations, not just Prempro. Dr. Jacques
Rossouw, an administrator with the Women's Health Initiative, discounts
that idea, saying that randomized controlled studies using other hormone
preparations have also shown increased heart attack risk. Is there an intrinsic
flaw in
either the randomized controlled methodology or the observational study?
The results
of the Women's Health Initiative have scientists questioning research methodology.
Kolata, Gina. Hormone Studies: What Went Wrong? The New York Times 22
April 2003
Low-Dose Coumadin
Coumadin (warfarin) is a blood thinner that doctors have used for 50 years
to prevent blood clots in the legs of patients susceptible to venous thrombosis.
Although it does prevent potentially fatal blood clots, the drug also leads
to
an increased risk of hemorrhagic stroke and other bleeding disorders if taken
long-term. Consequently, doctors usually end full-dose coumadin treatment,
which maintains an anticoagulant range of 2.0 to 3.0 [international normalized
ratio
(INR)], after 3 to 12 months. Once treatment ends, however, venous blood clots
often recur.
Paul M. Ridker, MD, and colleagues decided to study the effectiveness of long-term,
low-dose coumadin treatment. Low-dose coumadin maintains an anticoagulant range
of 1.5 to 2.0 (INR). The four-year study followed 508 patients with a history
of venous blood clots who had previously received full-dose coumadin for a
median of 6 months. Half received low-dose coumadin, the rest were given a
placebo.
Their progress was monitored through office visits every two months. The researchers
reviewed the data at least once a year. After the fourth review the researchers
ended the study earlier than intended because the data showed that low-dose
coumadin prevents venous blood clots without causing major bleeding episodes.
Results were released in February 24, 2003, and published in the New
England Journal of Medicine (10 April 2003). Thirty-seven of the 253 patients
receiving the placebo had recurrent venous blood clots, compared to only
14 of the 255
patients in the low-dose coumadin group. Women receiving coumadin showed
an 80% reduction in risk of recurrent venous blood clots while men showed
a 53%
risk
reduction. The risk of major hemorrhage in those on low-dose coumadin was
very low. Only one confirmed stroke occurred among the low-dose coumadin
group,
compared to two in the placebo group. Overall, four people in the coumadin
group and eight
people in the placebo group died during the four-year study.
Low-Dose Coumadin is Safe and Effective for Long-Term Prevention of Recurrent
Venous Blood Clots. www.coloradohealthsite.org (Note:
This link was not working on 2/20/05.)
Winslow, Ron. Blood Thinner at Low Dose Cuts Risks. The
Wall Street Journal.
25 February 2003
Magnesium & Blood Pressure
Research has shown that blood pressure
is linked to the calcium-activated potassium channels in the
membranes of smooth muscle cells. When
these microscopic ion
channels open, the smooth muscles that control blood vessel diameter relax
and blood pressure decreases. An article in Nature (22 August 2002) reveals
that
magnesium activates calcium-activated potassium channels in cell membranes,
opening the channels. The research, led by Jianmin Cui at Case Western
Reserve University,
helps explain magnesium's beneficial effects on people with heart failure,
stroke, and with high blood pressure.
Case Western Reserve University. Case Western Scientists Reveal How Magnesium
Works on Ion Channels Important for Regulating Blood Pressure. 26 August
2002. www.sciencedaily.com
Policosanol
Policosanol (pronounced polly-KOH-san-all)
is a natural compound, found in sugar-cane wax, that Cuban doctors
have used for decades to prevent
and treat
heart disease.
In Basic Health Publications User's Guide
to Policosanol & Other
Natural Ways to Lower Cholesterol,
Mark Stengler, ND, explains that Policosanol has several advantages over
cholesterol-lowering
statin drugs. Policosanol reduces harmful
LDL cholesterol as effectively as statin drugs, but it also prevents
oxidation of LDL and increases beneficial HDL cholesterol. Policosanol
also affects other
factors believed to contribute to heart disease; it improves circulation,
reduces blood clot formation, reduces inflammation in arterial walls,
and decreases lipoprotein
(a) levels. Lipoprotein (a), according to Dr. Stengler, is a stronger
risk factor for heart disease than LDL cholesterol. "Some studies show that cholesterol
medications such as Mevacor and Zocor may actually increase Lp(a) levels," he
writes. Policosanol provides all these benefits without the negative
side effects that accompany statin drugs.
Statin drugs such as Mevacor, Pravachol, and Zocor inhibit the liver
enzyme HMG CoA reductase. This enzyme helps the liver make cholesterol.
The enzyme
is also
necessary for CoQ10 synthesis. Cells use CoQ10 for energy production,
and it helps strengthen and stabilize the heart's contractions. Unlike
statin
drugs, Policosanol is not toxic to the liver and doesn't seem to interfere
with the liver's ability to metabolize other drugs, including heart medications.
Although studies show a high degree of safety, Dr. Stengler says that
pregnant women and breast-feeding mothers should avoid taking Policosanol
(or any
cholesterol-lowering
drug) because cholesterol and its metabolites are necessary for fetal
and infant development.
User's Guide to Policosanol and Other Natural Ways to Lower Cholesterol contains
excellent descriptions of various cardiovascular conditions for the layperson
and discusses currently-known risk factors. Many of
the risk
markers
for heart disease can be lessened with nutrients and herbs. This little
book makes a fine primer for those interested in more natural ways to
prevent heart
disease.
Stengler, Mark, ND. Basic Health Publications User's
Guide to Policosanol & Other
Natural Ways to Lower Cholesterol. (Basic
Health Publications, Inc., ISBN 1-59120-051-2)
Phenylpropanolamine & Strokes
Drug manufacturers and the FDA
knew, for decades, that phenylpropanolamine (PPA), the active
ingredient
used in over-the-counter decongestants and
diet aids, could
cause hemorrhagic stroke. A 1982 FDA report stated that PPA had "the ability
to cause cardiovascular effects, cerebral hemorrhage and cardiac arrhythmias." A
1984 memo from Sandoz Pharmaceuticals described PPA as "an agent known
to cause hypertension and stroke." Yet, the FDA did not declare PPA unsafe
until November 2000, when it asked drug companies to stop selling it.
The downfall of PPA began with a five-year, $5 million study, sponsored
by the drug industry, called the Yale Hemorrhagic Stroke Project. The study,
which
ended
in October 1999, found a strong link between PPA and hemorrhagic stroke.
The industry, which had approved the protocol and the investigators, attacked
the
methodology and the researchers' integrity when the study produced negative
results. The industry's campaign to discredit the results delayed the final
report upon which the FDA based its withdrawal of PPA products from stores.
The delay gave drug manufacturers time to reformulate their products using
pseudoephedrine.
They had been reluctant to use pseudoephedrine because it costs more than
PPA and because its bitter taste is harder to disguise, decreasing the
medicine's
appeal to children.
PPA stimulates the sympathetic nervous system. It opens nasal passages
by narrowing blood vessels in mucous membranes. PPA's ability to constrict
blood
vessels
and increase the force of heart contractions can cause blood pressure
spikes. When these spikes occur in persons with cerebral aneurysms, arteriovenous
malformations, hypertension or other – often undiagnosed – conditions,
strokes can result. According to an article by Kevin Sack and Alicia
Mundy of the Los Angeles
Times, FDA epidemiologists say that PPA causes
an estimated 200 to 500 hemorrhagic strokes among people, age 18 to 49,
each year.
Sack, Kevin & Mundy, Alicia. How drug linked to strokes remained
on market. The Seattle Times 29 March
2004
Lipid Metabolism & Dioxin
Disturbances in lipid metabolism and stenosis (narrowing) of carotid arteries
are among the disorders caused by occupational exposure to 2,3,7,8-tetrachlordibenzo-p-dioxin
(2,3,7,8-TCDD), according to an abstract presented at the 29th Congress
on Occupational and Environmental Health in the Chemical Industry (3-6
September
2001, Prague,
Czech Republic). Researchers examined 12 Czech workers who were among a
group of about 80 people that became ill after exposure to 2,3,7,8-TCDD
in 1965-68.
TCDD, also known as dioxin, was a contaminant in the herbicide Agent Orange
used to defoliate jungle during the Vietnam War. Internal, neuropsychological,
and
ophthalmological tests, ultrasound examination of the common carotid artery,
and blood cholesterol and triglyceride measurements were performed on the
12 former TCDD workers. Most of them still suffer from psychic disorders,
chloracne,
nervous system lesions, and/or lipid metabolism. Elevated plasma lipid
levels and atherosclerotic plaques in the carotid arteries were statistically
more
frequent in patients with higher TCDD levels.
Although dioxin is not made commercially in the U.S. at this time, TCDD
is produced as a by-product during paper and pulp bleaching, incineration
of municipal
and
hospital waste, and the manufacture of polychlorinated phenols and chlorophenoxy
herbicides. Consequently, its distribution is widespread. The chemical
does not breakdown easily. It persists in the food chain. The general population
is exposed
to dioxin mostly through contaminated food and water. TCDD intake is especially
high among residents of the Great Lakes region who regularly eat local
fish.
Dioxin can cross the placenta and is known to cause birth defects.
2,3,7,8-Tetrachlorodibenzo-p-dioxin. www.standord.edu/group/whitlock/dioxin.html
Pelclová, D. et al. Lipid metabolism and neuropsychological follow-up
study of workers exposed to 2,3,7,8-tetrachlordibenzo-p-dioxin. (abstract) http://link.springer.de/link/service/journals
Tenth Report on Carcinogens. www.ehp.niehs.nih.gov (Note:
This link no longer works, as of 2/20/05.)
Vaccine-Induced Heart Problems
Smallpox vaccinations have been linked to serious heart problems. Seventy-seven
of over 615,000 (1.25%), according to the Pentagon, have developed myopericarditis,
an inflammation of the sac around the heart. The Centers for Disease Control
say that 21 of the 39,500 (5.3%) US medical professionals who received
the vaccination also contracted the illness. When three people enrolled
in clinical
trials to
test a new smallpox vaccine, developed by British biotechnology company
Acambis, also developed myopericarditis, the company ended the trial. Myopericarditis
causes continuous chest pains, fatigue, shortness of breath, and heart
palpitations.
It takes several weeks for a full recovery.
While most people recover from the inflammation, the CDC issued a recommendation
in March 2003, that people with a risk of heart disease avoid the smallpox
vaccine after two health care workers died of heart attacks shortly after
vaccination. Dimitri Cassimatis, a Walter Reed cardiology fellow, hopes
to study 600 to
800
recipients of the vaccine for several weeks in order to "better learn who
is at risk for heart problems and why it occurs after inoculations." In
the meantime, the CDC and Defense Department say that smallpox vaccinations will
continue as needed, asserting that "mass injections can be performed safely
through staff training, patient education, screening out of people with medical
conditions.…"
The anthrax vaccine, which is also linked to heart attacks and strokes,
is being implicated in unexplained blood clot disorders, according to
a report
by United
Press International (6 October 2003). The label on the anthrax vaccine
given to military personnel "warns of infrequent reports of heart attacks or
strokes." Both can be caused by blood clots. Several soldiers and an NBC
news correspondent have suffered – and in some cases died – because
of unexplained blood clots. One previously healthy Army Reserve Captain
developed Deep Vein Thrombosis, chronic fatigue, and a skin reaction
after receiving
three of the required six anthrax shots. Walter Reed physicians blamed
the vaccine
for his condition.
Widespread reports of adverse reactions to these two vaccines have encouraged
soldiers to refuse them. Some 100 active-duty soldiers have been court-martialed, "according
to congressional testimony and documents," and countless others have taken
an other-than-honorable discharge rather than agree to be vaccinated. Soldiers
who say that the anthrax vaccine has ruined their health have filed three federal
lawsuits against the vaccine manufacturer, BioPort, Inc. of Lansing, Michigan.
In March 2004, Sen. Jeff Bingaman (D-NM) sent a letter to Defense Secretary Rumsfeld,
asking that the mandatory vaccine policy be reevaluated: "The apparent
absence of an Iraqi biological warfare capability raises serious questions about
the threat of an anthrax attack against our troops…The use of a
vaccination which appears to have the potential for serious health consequences
for
our troops in an effort to counter a threat that may not exist, seems
to unnecessarily
expose
our troops to risk."
Benjamin, Mark. Mystery blood clots felling U.S. troops. United Press
International. (www.upi.com) 6 October 2003
Schneidmiller, Chris. Military Personnel Suffer More Heart troubles
Than expected After Smallpox Vaccinations, Researcher Says. Global
Security Newswire. 13 May 2004 www.nti.org
Thompson, Marilyn W. Growing Doubts on Vaccine in Military. Washington
Post. 27 March 2004
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