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A really beautiful presentation of our best medicine…

Here is a doc who has it going on…

Dr Mike Evans hits it out of the park.

(Stent-ers, listen with caution at 7:20)

I am now a follower of Dr Mike Evens (@docmikeevans)

Good job, Doc.

JMM

Related posts:

  1. My new AF presentation is up
  2. Work-life balance in Medicine–Maybe the young are on to something?
  3. My most recent AF presentation at Norton Stroke Sympsoium
  4. Benefits of the “Fury of American Medicine.”

11 replies on “A really beautiful presentation of our best medicine…”

This is too funny! I logged in here to post this same ‘visual talk’ knowing it would be right in line with Dr. John’s wonderful ‘anti-inflammatory’ take on all aspects of daily life! Share this with kids too……..real-time illustrating is mesmerizing and will help the info ‘stick’.

As a 2-stenter fit young female by 41…because doctors wouldn’t do any cardiac testing of any kind because I was a GIRL….and my profession being high energy particle accelerator science illustrating…I found this both fun and (personally only), beyond ironic. It was my fitness level that probably helped me survive years of misdiagnosed heart attacks, 37-41. Swimming became my miracle after extensive heart damage was discovered during acute MI. Fabulous for respiratory-cardio workout when the heart is no longer able to fight vertical gravity for long. It was 2 stents that opened lesion blockages that had been allowed to kill off a lot of heart muscle. Water laps helped me push the stent restenosis from 75% to a mere 30%. The Big One hit (ironically again) not long after I finished the nightly after work looooooong walk with my neighbor’s dog Franky! Some of us do everything right and still take a lot of unnecessary hits.

Dr. M, could you expand on your “stenters listen with caution” comment? Not quite sure I follow the “caution” comment.

Verted, I can offer my take on ‘stenters listen with caution’ comment as Dr M hasn’t replied here.(I read many of his posts which are excellent teaching instruments). My experience, as a young fit female, is that there is a medical culture of blame projected at heart patients with arterial blockages and Systemic denial of treatement to young women in cardiac duress because they ‘don’t fit the profile-diagnositc tree’ profile (young males are sped straight into cardiac testing). I posit that every human is somewhere on the arterial damage contiuum from our first breath, but, unlike cancer patients, heart patients are met with a bizarre implication or direct ‘what could you have done differently? How can you correct your ‘lifestyle’? There may be plenty a particular patient could do to enhance heart health…or there may be nothing beyond responsibly and swiftly seeking medical help to intervene. This is where the patient control ends….and medical culture actions will be impacting patient survival/quality of life. Looking forward to the future (not long now) when ‘a human body’ in cardiac distress is automatically scanned asap, regardless of age and gender. Correctly. At the molecular level. Science will soon exclipse defunct medical oral traditions so that the beauty of medical practice can truly slip into ‘do no harm’. There is nothing mysterious about systemic denial of aggressive cardiac treatment for women at this time, nor are there large long term US clinical studies (not questionnaires) of young women proving they are all automatically at low heart attack risk. I have no problem pushing back on comments like ‘stenters listen with caution’. Because, at this time, there is no clear scientific understanding of all the external/internal mechanisms and hormonal-enzyme flux factors that play into individual coronary blockage, regardless of gender. The average age of women having heart attacks in US is 44, posting in on-line forums. My cardiac cath nurse with 30 years experience also declared ’44’.

JM,

Thanks for the thoughtful comment.

First, the gender issue:

My opinion about gender ‘issues’ in heart disease have changed. I used to feel that women’s heart disease–under the hood if you will–wasn’t any different. But with age and experience my views have changed. Take AF for instance: after looking back at our experience in the real world, we found that women were under-represented in AF ablation, more difficult to ablate and had lower success rates. The reason for the difference is unknown. Similar findings have been shown for females with coronary disease. I agree that clinical trials need to enroll higher numbers of women and doctors should be cognizant of gender-issues–namely that women may present with atypical symptoms. Point taken. Thanks.

Second, the stent issue.

As a cardiac fellow many years ago, one of the first lessons that I was taught was that squishing a blockage may relieve angina but did not reduce the risk of heart attack or death. This seemingly paradoxical idea holds true for stents too. There are two reasons: one is that heart attacks most often arise from ‘younger’ more irritable, but less obstructive partial blockages. The second reason stems from the fact that a stent adds another disease to the inside of the blood vessel. The implanted metal acts as a nidus for clots to form, thus requiring extended use of blood-thinning drugs. Now we know that stents placed for non-symptom-causing partial blockages are no better than medical treatment (not just pills, but exercise and lifestyle modifications) for preventing heart attacks and death. That this lesson has held for two decades intrigues me.

Cynics like to over-simplify the overuse of stents by pointing to the few outliers who practice predatory medicine. This is wrong-minded and counter-productive. I’ll tell you why I think stents get overused: stents get placed in high-grade blockages because they make the blockage look so much better. It’s hard for a heart doctor to walk away from a 90% blockage. Maybe wrongly, but it is still true that high-grade blockages scare most doctors (and patients) more than the ‘mild’ 20% ‘irregularity.’ And I also believe the majority of heart doctors would want a stent if it was their 90% blockage.

Heart doctors read the data, they understand the data, but they also see a blockage and want to fix it. Not because of compensation but because we are taught–from day one–that heart disease stems from coronary blockages. It will take time to educate all the stake-holders.

And I’ll leave with you this scenario: try explaining to a conference room filled with concerned family members that Dad has a severe blockage but we aren’t going to ‘fix it.’ Rather we are going to treat Dad by telling him to exercise, eat right and perhaps, take a statin.

Hope this helps.

By Post Author

Dr John,
I’m in total agreement with you that most stenting is palliative at best. My FIRST encounter with cardiac treatment was during full on STEMI, acute MI, 41, enduring 5 hours of intermittent non-stop hypoxia from ambulance to first successful bare metal stent deployment in 99% blocked RCA from large lesion flapping around. LAD was also 99% blocked but had to leave that one until 9 weeks later. I had no idea what a stent even was. Lucked up getting the Duke Univ. cardio who co-engineered angios and stenting techniques that night. He found ‘this has been going on a long time because there is a lot of preexisting dead heart muscle in there’. Mine wasn’t elective. It was 100 percent life saving. Cardio’s comments were ‘We have no idea why you had such severe lesions because you don’t fit any profiles. No evidence of HD anywhere else.’ Then began an extreme learning curve on my part. When a year a half out a cath showed 75% blockage in both stents and new cardio told me ‘restenosis had probably occurred within first 6 months and it was best to just pull out, continue on drug therapies while we waited for more advanced/safer treatment for female arteries’, I was in complete agreement with him. But only because I had pushed hard to learn these subjects in an organically expansive fashion.

Cardiology is enormously complex and few patients will ever really get your most salient points…which are valid. Unfortunately…at this time…the reality for younger women is repeated dismissals during lesser cardiac events so that by the time we reach your theater we may be badly damaged, clueless and under pretty extreme duress. We are legion and have no control over non-cardiology practices referring us to your world…so we end up in ERs a big mess and no idea what is going on. Yes, drug therapies are critical in reducing progression of heart disease. But how do women get access to this in time to prevent life changing events? Even a statin was never mentioned or prescribed for my HDL of 28. I was having ‘man symptoms’ yet never referred for caridac testing.

Thank you for your explanations from the medical side. I am working from the heart attack survivor side, which is deeply isolating in terms of tracking down the mysteries of ‘new normal’ and decyphering non transparent treatment narratives. Few patients are told their heart cannot regenerate new heart muscle cells ( I wasn’t) and don’t understand why they just cannot feel better, that the brain may be permanently effected by oxygen deprivation during heart attack. It seems a humane practice to explain even a few profoundly important facts to heart patients.

Respectfully looking forward to your upcoming blog posts. Jaynie

Dear John
Your AF presentation for the primary care doctor was excellent
Would you be able to post it as a Power Point? Best – RS

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