The People's Perspective on Medicine

Show 1111: What Should You Know About Controversies in Cardiology?

In this broadcast for Feb. 24, 2018, we discuss controversies in cardiology such as the re-definition of hypertension and the proper utilization of stents with two cardiologists.
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What Should You Know About Controversies in Cardiology?

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How should you be keeping your heart healthy? Recent headlines have brought some controversies in cardiology to public attention.

Defining High Blood Pressure:

The American College of Cardiology and the American Heart Association issued guidelines on blood pressure control in 2017 (Hypertension, online Nov. 13, 2017). These cardiology groups recommend that anyone with blood pressure above 130/80 should be considered hypertensive. That means about 46 percent of American adults fall into that category. While not everyone should be prescribed medication to lower their blood pressure into the target range, far more people will be on antihypertensive drugs than previously. What are the pros and cons of this policy?

How Much of a Difference Do Stents Make?

Every year, more than half a million people in North America and Europe get a stent in a coronary artery. Most of these patients expect that a stent will significantly improve their quality of life. But a recent study, called ORBITA (for Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty), calls this assumption into question (The Lancet, Jan. 6, 2018). This study was unusual because it had a control group of people who received sham angioplasty. The actual stent was no more effective than the placebo at improving exercise. The topic of stents is one of the current controversies in cardiology.

A Placebo Group for Surgery?

We discuss the use of placebo in studies of surgical interventions, who will actually benefit from stents, how blood pressure treatment can prevent strokes, and why cardiologists (and other humans) tend to cling to their conceptions of what works and what doesn’t. How can we evaluate such controversies in cardiology?

This Week’s Guests:

Steven Nissen, MD, is chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at the Cleveland Clinic.  He is the co-author, with Mark Gillinov, MD, of Heart 411: The Only Guide to Heart Health You’ll Ever Need.  The photo is of Dr. Nissen. You can listen to previous People’s Pharmacy interviews with Dr. Nissen here, here and here.

Robert DuBroff, MD, is Clinical Professor of Medicine in the Division of Cardiology at the University of New Mexico in Albuquerque, NM. He is board-certified in internal medicine and cardiology and has a specialty in lipidology. His article on confirmation bias was published in QJM, Nov. 2, 2017.

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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I began feeling what could be considered indigestion. I took 2 tums but it persisted. I then began feeling generally “achy” in my upper back and upper arms, with constant chest pains. I had two heart attacks that year. Finally, I was diagnosed with Coronary Artery Disease (CAD). My Cardiologist ordered an angioplasty and discovered a closed artery; Then another cardiologist was called in to place a stent in the artery to open it up. I was hospitalized for a total of 2 weeks. I was prescribed Effient, a blood thinner, and two other medications.

My condition improved but got worse again within a year, so I started on a natural CORONARY ARTERY DISEASE TREATMENT from Rich Herbs Foundation, no attack since treatment. I had a total decline in symptoms. I do lots of walking. Lost some weight, but was never heavy. Eat differently. I feel good overall.

Statins–when overall rate of death is not lowered, there is something else going on. Low levels of cholesterol are associated with increased cancer. Not surprising, as all cells require cholesterol as a building block.

I am in agreement with other writers above. People like us who are in our 70’s and above need higher blood pressure. Too many of our friends are falling, and the reason for some of them is the dizziness associated with blood pressure that is too low.

My husband just had two stents put into a coronary artery. I am not happy with his surgeon for several reasons. He is still practicing 20th century medicine. He refuses to sit down and talk with both of us and answer all of our questions. He put John on plavix, which worries me. The two doctors who wrote this book that you recommend wrote it six years ago, and some things have changed since then. Have they updated the book? They are still saying not to eat anything with natural cholesterol in it. That’s not the way to go. Eggs and olive oil are good, and some butter is not going to harm. Everyone has different ways of metabolizing fats and nutrients. The controversy appears to be between using pharmaceuticals and making lifestyle changes for the most part.

My husband lost his memory and developed neuropathy after being placed on statins by this same doctor years ago. And we still have to fight him off from prescribing statins.

Dr. Nissen does not understand the difference between regression to the mean and the placebo effect. If one selects a group of patients who are at some extreme for headache, blood pressure, etc. and measures them at some point in the future, their values are closer to the average (mean) without any intervention.

Regression to the mean is the tendency of observations that are extreme by chance to move closer to the mean when repeated.

The placebo effect is the nonspecific effect of treatment attributable to factors other than the active drug, including physician attention, patient expectation, changes in behavior, etc.

Benefits from taking a placebo are often attributed to these factors, but regression to the mean can produce such apparent benefits.

Understanding this difference completely changes the way one should interpret the studies Dr. Nissen described.
For more information see: Armitage and Colton, Encyclopedia of Biostatistics

My husband is English. An old doctor, years ago, told him that many English people have high blood pressure and it’s genetic, and told my husband to NOT take any blood pressure pills to lower it. He didn’t, and is doing just fine. Doctors gets free vacations paid for by drug companies if the doctors sell more of their drugs. I am 73 and don’t take ANY pills. I have the attitude that if you leave you body alone, it will take care of itself, within reason. When you take any medication, your body has to change in order to assimilate that medication and it may interact with normal body functions……this is my opinion.

Appropriate blood pressure depends on one’s body, and the trade-off to keep it lower may not be worth the side effects, such as brain fog or fatigue. An individualized approach is absolutely necessary.

I love how you think! I was misdiagnosed with high blood pressure and the meds they had me on triggered a different skin complication. I fully believe it was because of the meds I didn’t even need

Do you have any recommendations on diets for reducing pain caused by excessively high 1635 Serum Ferritin levels which have created extreme arthritis type pain in all joints and muscle tissue. Any direction would be helpful.

re: Heart 411: The Only Guide to Heart Health You’ll Ever Need. This title needs some humility like a subtitle (until what we believe now is proven wrong).

It’s of no surprise to me that Dr Nissen would push the Drug Intervention, as he has reported receiving financial compensation to the tune of $79,366 in years 2013, 2014, 2015 alone.. Not a far cry from what Sen Marco Rubio when he was confronted by the high school student in Fl, when asked if he would NOT TAKE A DIME FROM THE NRA…

At 87 my father fell and suffered a subdural hematoma (from which he thankfully made a full recovery). We had a great neurologist who discovered several of his medications lowered blood pressure as a side effect. His low blood pressure almost certainly contributed to the fall. The neurologist explained that AT HIS AGE he would recommend a higher blood pressure and wouldn’t be concerned with a top number as high as 150! This wonderful doctor also advised a consultation with a GP specializing in senior care and eliminating any medications that did not contribute to daily quality of life. Now dad is 90, walks without assistance and is still among the smartest, sharpest people I know. Just goes to show one size (or number) does not fit all.

I have familial hypercholesterolemia. Can’t take statins due to severe side effects. Tried Zetia, but it doesn’t reduce my numbers and is the likely source of my tinnitus. My doc wants me to go on Repatha, but I’m leery of the side effects since I’m very susceptible to side effects, including rare ones. My carotid and CT scans are clean. My doc says she has other patients with high numbers but no other observable cardiovascular problems. I feel like my situation may qualify as a cardiology controversy. Would appreciate your opinion before I plunge into Repatha.

Everybody, I was disabled on Oct 10, 2002 due to my 3.5 years of taking a statin. I was 34 at the time, a vibrant critical care RN of 12 years, when life as I knew it was abruptly halted. In me they caused Holes in my brain (Neuronal Apoptosis), Mitochondrial DNA mutation most similar to MELAS (Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke Like Episodes), Peripheral Neuropathy, and a 28 day Alzheimer’s like hospital stay, in which I was akin to a 95 year old with end stage Alzheimer’s disease.

Not one of the dozens of neurologists who evaluated me at UW Madison, ever considered a Drug connection, and it wasn’t until Dr Golomb, Principal Investigator in the UCSD Statin Effects Study, told me based on the study, that it was determined that my use of Lipitor was the causal contributor to the Holes in my brain, the Mitochondrial DNA mutations, Neuropathy etc.. And in spite of this brilliant Doctors findings, nearly every doctor id seen since, vehemently refutes the notion that Statins can cause anything short of glorious things (In spite of their Absolute Risk Reductions (ARR) being in the neighborhood of UNDER 2%), hardly what well hear on television and other advertising touting risk reductions in the 30-40% area (THOSE ARE RELATIVE RISK REDUCTIONS) RRR.

My husband was started on Repatha when he was 64. It had a $5 copay. Once he turned 65, Repatha co pay went to $1728.00 a month with his coverage, because the drug company will not offer $5 copay to anyone on medicare. The drug co website said otherwise but they have now corrected it after I argued the point with them. So you may be put on it only to be unable to afford it. He can’t take any of the statins, because they leave him unable to get out of bed due to back and leg pain. With Repatha he still had the back pain but put up with it due to his familial hypercholesterolemia

If you have no signs of heart disease, then why would you treat it??

I have the same issues with the familial hypercholesterolemia as Mary. Would love to hear a solution!!!

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