OT: there goes the conventional wisdom re: our hearts

Oh well, here we go again. I know plenty of us are concerned about our heart health even more than we are about our PC. It appears that the treatment some of us have received might not have been required after all, and might have even put us at some additional short term risk( I'd also like to see the figures on all cause mortality):

Somebody said...

There might even be harm: To doctors' surprise, study participants who had a procedure were more likely to suffer a heart problem or die over the next year than those treated with medicines alone.

Hochman co-led the study and gave results Saturday at an American Heart Association conference in Philadelphia.

"This study clearly goes against what has been the common wisdom for the last 30, 40 years" and may lead to less testing and invasive treatment for such patients in the future, said Dr. Glenn Levine, a Baylor College of Medicine cardiologist with no role in the research. Some doctors still may quibble with the study, but it was very well done "and I think the results are extremely believable," he said..................................
After one year, 7% in the invasively treated group had one of those events versus 5% of those on medicines alone. At four years, the trend reversed — 13% of the procedures group and 15% of the medicines group had suffered a problem. Averaged across the entire study period, the rates were similar regardless of treatment.

If stents and bypasses did not carry risks of their own, "I think the results would have shown an overall benefit" from them, said another study leader, Dr. David Maron of Stanford University. "But that's not what we found. We found an early harm and later benefit, and they canceled each other out."

https://www.nbcsandiego.com/news/health/big-study-casts-doubt-need-heart-procedures-565042972.html

I saw this this morning on cbs news although the cardiologist on the show summed it up as there was no difference in mortality between the cabg/stent group versus the medication/changed lifestyle group although the quality of life was reported to be better in the cabg/stent group because of less angina. Maybe insurance will start denying coverage for these surgeries, interesting anyway...

TJ123 said...
This sounds like another one of those "PSA tests don't matter" studies. Without a PSA test I would've been clueless I had PC at age 57. Being a pT3a without the RALP chances are high it would've metastasized.

I had a 4x CABG 13 years ago. Major blockages w/o symptoms. Abnormal EKG started the process. I was walking through a mine field without knowing it. No doubt in my mind that without that CABG I'd be taking a dirt nap about now.

They refuse to fix the overspent healthcare system administratively so I guess the plan now is to deny surgery to those with blocked cardiac arteries to save money.

The article struck me the same way too, and insurance companies denying life-saving surgery would not surprise me whatsoever.

This news has been around for a while, it’s long been thought by many that stents don’t extend life in patients with stable angina. The difference here is tat I think it was a much larger study.
In fact, from the article linked it says...

Somebody said...
Twelve years ago, a big study found that angioplasty was no better than medicines for preventing heart attacks and deaths in non-emergency heart patients, but many doctors balked at the results and quarreled with the methods.

This will make a lot of doctors unhappy. I have no idea if these treatments are warranted, but as with many procedures, they are probably run like mills.

clocknut said...

.....Studies are great, but a good cardiologist will look at each case individually and use his or her best judgment to advise a course of treatment.

Very interesting post, clocknut. Happy that you're doing well. Fascinating discussion.

We see Google MD's around here, who have the answers without beginning to realize the infinite variables for both the individual patient (even themselves) and the condition. They offer advise, but many times do more harm than good, IMHO.

Andrew, above, said it well, Sometimes I think we tend towards over treatment and often don't really do a good job of balancing risks and rewards.

JNF said...
Dean Ornish book "Program for Reversing Heart Disease" is a read I would suggest for all.

Me too....it is an excellent book!

As an aside, here is another one of those 'infamous' studies. This one confirms that Omega 3 protects against heart disease, WITHOUT adding to PCa risks. For what it's worth.

https://intermountainhealthcare.org/news/2019/11/omega-3-continues-to-show-protection-against-heart-disease-related-death-without-prostate-cancer-risk/

If they use this study as rationale to cut back on heart procedures it will be interesting to watch the direction of the death rate associated with heart disease. My guess is that it will rise markedly - just like the death rate and incidence of metastasis rose re: PCa when PSA testing was rationed. Currently healthcare costs accounts for about 20% of GDP. That's quite high compared to most other industrialized nations. There's pressure within the industry to bring costs down. Once I was in a doctor's office and inquired with the office manager how much a certain office procedure would cost. She replied "What do you care? Your insurance will pay for it." That's the problem....right there.....that nobody cares to address in this country. Where else would you go to buy something without knowing the price in advance?

And speaking of underlying conditions: note my other most recent thread dealing with pre-diabetes, diabetes and obesity. You might recall that one of the conclusions of that study was that docs are very often not really on top of diagnosing prediabetes. And that 25% of those that do get diagnosed with pre-D actualy already have diabetes. In addition, if even if diagnosed with either, many docs were not on top of getting folks trained in lifestyle changes. Now consider that diabetes is a major, major contributor to many diseases, with heart disease being about at the top of the list of illnesses that it contributes to.

So, imagine some one tooling along for 20+ years with undiagnosed prediabetes( and that is a whole bunch of us), just shy of setting off the alarms that would grab his docs attention for an actual diabetes diagnosis, leading to treatment for diabetes. So there he is, for untold years, building up plaque in the coronary and carotid arteries, very much helped along by the high insulin and almost too high blood sugars, until finally an artery narrows enough so that chest pain develops, hopefully before a major heart attack. So a stent, or even a drug(hopefully bypass surgery is not needed yet) and he now has good circulation again. And assuming he escapes major SEs from the treatment, he feels much better and can function again, just as well as he did a few years before. But has the underlying condition, the one that led to the blockage in the first place, and which may have already started other arteries well on their way to blockage, been dealt with? In most cases, not one iota.

And then there is the debate about diet. For the last 50 years, during which diabetes has increased by roughly 8 times, docs and most nutritional authorities have been recommending lower fat(especially saturated) and that has usually also meant higher carb diets. And without the extreme calorie and oils(all types) restriction associated with Ornish. So, even when docs have recommended certain diets, and even when that unpleasant advice has been followed, has it helped? Or has it actually made it worse, by increasing the rates of diabetes? Food for thought, I guess.

But here is what I think(just personal opinion): If it wasn't for bypass surgery, stents and maybe certain drugs which have also appeared during this 50 years, the number of folks dead from heart disease(or at least debilitated because of it) would have increased at a similar rate to diabetes.

The article said "All were given lifestyle advice and medicines that improve heart health.". I wonder what the lifestyle advice was?

Post Edited (BillyBob@388) : 11/19/2019 4:13:10 PM (GMT-7)

Considering that diabetes is epidemic, and I bet prediabetes is even more common, maybe worries about whether stents and bypass surgery are really superior for stable heart disease is not the most important thing we should be looking at. The article said "People with severe but stable heart disease from clogged arteries may have less chest pain if they get a procedure to improve blood flow rather than just giving medicines a chance to help, but it won't cut their risk of having a heart attack or dying over the following few years, a big federally funded study found............................................After one year, 7% in the invasively treated group had one of those events versus 5% of those on medicines alone. At four years, the trend reversed — 13% of the procedures group and 15% of the medicines group had suffered a problem. Averaged across the entire study period, the rates were similar regardless of treatment......".

But consider:
https://www.heart.org/en/health-topics/diabetes/why-diabetes-matters/cardiovascular-disease--diabetes

Somebody said...

Cardiovascular Disease and Diabetes

The following statistics speak loud and clear that there is a strong correlation between cardiovascular disease (CVD) and diabetes.

At least 68 percent of people age 65 or older with diabetes die from some form of heart disease; and 16% die of stroke.
Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes.
The American Heart Association considers diabetes to be one of the seven major controllable risk factors for cardiovascular disease.

Why are people with diabetes at increased risk for CVD?

Diabetes is treatable, but even when glucose levels are under control it greatly increases the risk of heart disease and stroke. That's because people with diabetes, particularly type 2 diabetes, may have the following conditions that contribute to their risk for developing cardiovascular disease.

High blood pressure (hypertension)
High blood pressure has long been recognized as a major risk factor for cardiovascular disease. Studies report a positive association between hypertension and insulin resistance. When patients have both hypertension and diabetes, which is a common combination, their risk for cardiovascular disease doubles.

Abnormal cholesterol and high triglycerides
Patients with diabetes often have unhealthy cholesterol levels including high LDL ("bad") cholesterol, low HDL ("good") cholesterol, and high triglycerides. This triad of poor lipid counts often occurs in patients with premature coronary heart disease. It is also characteristic of a lipid disorder associated with insulin resistance called atherogenic dyslipidemia, or diabetic dyslipidemia in those patients with diabetes. Learn more about cholesterol abnormalities as they relate to diabetes.

Obesity
Obesity is a major risk factor for cardiovascular disease and has been strongly associated with insulin resistance. Weight loss can improve cardiovascular risk, decrease insulin concentration and increase insulin sensitivity. Obesity and insulin resistance also have been associated with other risk factors, including high blood pressure.

Lack of physical activity
Physical inactivity is another modifiable major risk factor for insulin resistance and cardiovascular disease. Exercising and losing weight can prevent or delay the onset of type 2 diabetes, reduce blood pressure and help reduce the risk for heart attack and stroke.

.......................................................................................................................................................................................

So, we can clearly strongly alter our risk of all of this crap by just assuming(unless we definitely know otherwise of course) we are at least probably prediabetic and making the changes that would back risk of diabetes up a good bit. Because doing so is extremely unlikely to result in harm even if we are not pre-diabetic. Even if we are genetically more prone to heart disease, we can run those odds through the roof by eating in a way that leads to chronically higher blood insulin because it rises in an attempt to keep our blood sugar in the normal range, even when we eat too much sugar/carbs.

Few of our doctors will measure blood insulin, unfortunately. As a prediabetic, you can have a pretty good blood sugar of 99, but a very high blood insulin. However, I have been reading that triglycerides can be a stand in for blood insulin. If those ar higher, insulin is higher, frequently. And one way to knock triglycerides in the dirt is by lowering carbs. Which doing so in clinical trials invariably lowers insulin, which lowers risk for diabetes and need for diabetes drugs, which should greatly help our hearts. IMO, at least.

Post Edited (BillyBob@388) : 11/19/2019 6:06:01 PM (GMT-7)

Good points, Mattam!

From the OP, which seems to be a fairly news worthy report:
“After one year, 7% in the invasively treated group had one of those events versus 5% of those on medicines alone. At four years, the trend reversed — 13% of the procedures group and 15% of the medicines group had suffered a problem. Averaged across the entire study period, the rates were similar regardless of treatment.”.


From the previous link I supplied re: diabetes and heart disease: “Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes.
The American Heart Association considers diabetes to be one of the seven major controllable risk factors for cardiovascular disease………………….Abnormal cholesterol and high triglycerides
Patients with diabetes often have unhealthy cholesterol levels including high LDL ("bad") cholesterol, low HDL ("good") cholesterol, and high triglycerides. This triad of poor lipid counts often occurs in patients with premature coronary heart disease. It is also characteristic of a lipid disorder associated with insulin resistance called atherogenic dyslipidemia, or diabetic dyslipidemia ……………………..”.

So, the “bad” group from my OP, that had invasive procedures, had a 7% rate of bad cardiac/stroke events, and the “good” group had only 5%, leaving the bad group with a 40% worse rate of events during the 1st year, but that trend reversed after 4 years, with the medicine only group running 15% more bad events than the treatment group. IOW, a wash, or almost. The difference is not big, but I guess what is news worthy is that looking at large numbers, there is no big advantage as far as bad events to having the riskier procedure.

However, in the link on diabetes vs heart disease, the diabetics are 200 to 400% more at risk to die from heart disease than the non diabetics. And there is also this: “Diabetes is treatable, but even when glucose levels are under control it greatly increases the risk of heart disease and stroke. That's because people with diabetes, particularly type 2 diabetes, may have the following conditions that contribute to their risk”. IOW, it is not enough to simply get the blood sugar under control using treatment via drugs. Why? Because the insulin remains just as high or higher(you might even be injecting more insulin!)

It does no good- or not enough good- to simply end up with a better looking sugar # by attacking it with drugs. The damage behind the scenes is still going on. Just as “curing” pain with a stent might not be good enough, because in both cases the underlying problem should be addressed before it causes more problems.

And it is quite likely that the underlying problem is the same in both cases whether prediabetis, diabetes or the heart disease they appear to cause: to much sugar/carb input, leading to too much blood insulin.

The “bad” treatment might have 40% more bad events in the first year than meds only, only to end up a winner by a small amount at 5 years. The diabetes characterized by high blood insulins has 200-400% more bad events, and can be controlled by diet, maybe leading to no need for the procedures in the first place. Which one should we be most concerned about? Especially as so many of us(about 1 in 3 adults prediabetic) are on our way to diabetes? And, oh yes, almost forgot: there is that pesky relationship of these same underlying causes with cancer.

Post Edited (BillyBob@388) : 11/19/2019 8:13:12 PM (GMT-7)

I would not hang my hat on Dean Ornish; see the following:

"Dean Ornish, MD earned his reputation with his work on the management of atherosclerosis with extremely low fat vegetarian diets. But like predecessor Nathan Pritikin, Ornish's recommendations are not suitable for most people. The few small studies claimed to prove the worth of his work have also been questioned on scientific grounds. Dr. Richard Pasternak, director of preventive cardiology at the Massachusetts General Hospital in Boston, has said that 'There's virtually no science' in them [117]. Dr. Robert Eckel, Professor of Medicine at the University of Colorado Health Sciences Center in Denver and chairman of the nutrition committee of the American Heart Association also expressed serious doubts, as did Dr. Frank Sacks, a nutrition professor at Harvard Medical School and the Harvard School of Public Health. Dr. Sacks, in trying to replicate Dr. Ornish's results with a grant from the NIH, found that it was difficult to recruit patients and few could stick with the program [118]. Fortunately, Ornish's program has been superseded by more effective forms of managing elevated blood cholesterol and the discovery of other treatable risk factors.

"Like Dr. Gordon, Dr. Ornish began as a devotee of an Indian guru, Sri Swami Satchidananda. He became involved with the Swami after dropping out of Rice University in 1972 in a state of suicidal depression. It was apparently during this time that he formed his beliefs about the importance of a vegetarian diet with no added salt, sugar or fat and no caffeine combined with meditation, yoga and exercise.

"Dr. Ornish has enthusiastically endorsed many irresponsible unscientific works by others including Larry Dossey's Healing Words [119], and psychic Judith Orloff's Second Sight [120]. Dr. Gordon's own Center for Mind-Body Medicine features an endorsement by Ornish as well [121]."

https://www.quackwatch.org/01quackeryrelatedtopics/hearing/gorski2.html