American Heart Association Recommends Hands-Only CPR

Despite many encouraging advances in the prevention, diagnosis and treatment of heart disease, heart attacks remain the largest cause of death in the US.  Many of those heart attacks happen suddenly and cause a life-threatening abnormal heart rhythm called ventricular fibrillation.  Patients frequently suddenly collapse, and without prompt restoration of a normal heart rhythm, survival is unlikely.

There are two critical factors that determine whether the patient will survive without serious brain injury.  The first is the time from collapse to restoration of normal heart rhythm, which usually happens through the use of an electrical defibrillator.  The second factor is whether the patient receives CPR during that time.

This is a very difficult subject to study since obviously patients can’t be randomized to different groups.  (Who would sign up for placebo CPR?)  The recommendations also have to be simple enough to be taught to the general public and then remembered and executed during a very stressful time.  Despite these limitations, the recommended CPR procedure has undergone many revisions since I first learned CPR.

This week, the American Heart Association took another step in making CPR something that anyone can do.  They removed the mouth-to-mouth breathing from the algorithm and just left the chest compressions.  The reason is that in sudden collapse due to a heart attack the lungs are already inflated with air, and the blood is already oxygenated.  So artificial respiration isn’t needed, just artificial circulation.  These new recommendations also remove the potential for transmission of infection from mouth-to-mouth contact.

The new recommendations are incredibly simple.  If you see someone collapse:

  • Call 911
  • Push hard and fast in the center of the chest

Learn more:
FOXNews article about the new CPR recommendations
New CPR recommendations on the American Heart Association website
Statistical trends from the Centers for Disease Control on the 5 leading causes of death in the US

Tangential Miscellany:

This week, the popular media all decided to debunk the myth that drinking 8 glasses of water a day has any health benefits, as you can read in these articles from Reuters, Chicago Tribune and Slate.  My regular readers learned that last year.

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In Event of a Heart Attack Let the Paramedics Come to You

Yesterday’s LA Times health section had an important article about what to do in the event of a heart attack.  In the last decade our understanding and treatment of heart attacks has improved dramatically.  The best treatment for a heart attack is immediate angioplasty, a procedure that inserts a tiny balloon in the closed artery, opens it and leaves a metal stent to keep the vessel open.  Studies have shown that this immediate intervention saves lives compared to the previous standard of care.  Studies also show that the time between onset of symptoms and the angioplasty is critical to a good outcome.

This is when a wrong decision can cost a life.  Many medical centers can not maintain the staff and facilities required to provide emergency angioplasties 24/7 to any heart attack patient in the emergency department.  Those medical centers give the next best therapy — intravenous clot-dissolving medicine.  So if you decide to have a relative drive you to a nearby ER when you think you’re having a heart attack you are risking two very dangerous hurdles.  First, you’ll be triaged with all the other patients who come into the ER.  Ideally, the triage nurse should give heart attack patients immediate priority, but human systems don’t always work ideally.  Second, you may find yourself at a hospital without facilities for immediate angioplasty.

So always call 911 if you think you’re having a heart attack.  Paramedics have EKGs that can help them determine the likelihood of a heart attack, and they automatically take potential heart attack patients to medical centers that treat heart attacks with immediate angioplasty (like UCLA and Cedars-Sinai).  And when the paramedics bring you to the ER, you won’t wait with everyone else in the waiting room.

How do you know if you’re having a heart attack?  This WebMD article has a good review of the typical symptoms, the most common one being a squeezing or pressure in the center of the chest that lasts longer than a few minutes.

Tangential Miscellany:

Another problem that deserves emergency department attention is transient ischemic attacks (TIAs) or mini-strokes, about which I wrote two years ago.

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Human Growth Hormone is Unproven to Improve Strength

Human growth hormone (HGH) has been receiving a lot of media attention recently because of the controversy of performance-enhancing drugs in baseball.  This made some researchers curious about how much evidence existed that HGH actually improves athletic performance.  They reviewed the scientific studies on HGH in an analysis published in the Annals of Internal Medicine.  The study received a lot of coverage in the lay press, including this Wall Street Journal article.

The authors conclude that the scientific literature does not support that HGH improves physical performance, and that it may actually have some side effects like fatigue.

Earlier this week (before I had heard of this new study) a patient of mine who is a voracious reader asked me about HGH, and when I expressed skepticism about it, asked “Then why is everyone taking it?” That’s a great question.  I’m not certain of the answer though I suspect it has to do with desperation to try anything that may help, and the (mistaken) belief that so many people can’t be doing something without benefit.  In other words, everyone is taking it because each one of them is impressed that everyone else is taking it.

The broader point is that people will do lots of things because of fads, rumor, marketing and a myriad other reasons.  This might be a terrific way to pick a brand of jeans, but I wouldn’t trust my health to what “everybody else” is doing.  I would want to see a good study in the scientific literature.  Smoking was unhealthy in the fifties even when “everybody” was doing it, and cardiovascular exercise would still be good for us even if it became uncool.

Or, as your mother used to say, “If everyone else jumped off a bridge, would you do it too?”

Tangential Miscellany:

My wife Janet and I wish all of you who are celebrating a happy Easter and a happy Purim.

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Even a Little Exercise is Better Than None

I am constantly encouraging patients to exercise.  Usually, the motivation is physical health — the patient’s weight, or blood pressure, or cholesterol, or sugar is too high and exercise is the healthiest way to normalize it.  But I’m increasingly impressed by the ability of exercise to improve mental health.  Patients tell me all the time that their mood is better, their anxiety lower, and their thinking sharper when they exercise than when they don’t.

A recent study adds evidence to that belief.  A study presented this week at an American Heart Association meeting and covered in this USA Today article examined the effects of exercise on quality of life.  The study involved over 400 sedentary overweight women who were randomized into four groups.  One group did no exercise.  Another group was instructed to do about 73 minutes of physical activity per week.  The third group did 135 minutes of exercise per week, and the fourth did 193 minutes.  They were closely supervised with heart rate monitors and pedometers to make sure they were compliant with their instructions.

The women filled out questionnaires that assessed different aspects of quality of life, from emotional health to participating in social activities.  One questionnaire was completed before the beginning of the study and another after the women had been exercising for 6 months.  Not surprisingly, the women who exercised most showed the greatest benefit in quality of life.  What was surprising, however, was that even the women in the group that exercised the least did better that those who didn’t exercise at all.  Even a little exercise improved their quality of life.  The other surprise was that this improvement was independent of weight loss.  The women who exercised felt better whether or not they lost weight.

So take a walk this weekend.  You’ll feel better.  And let me know if you want a pedometer.

Tangential Miscellany:

If you use a web service that gathers headlines from various sources for you, like an iGoogle personalized page or some other news reader, you can automatically get the headlines of my weekly posts with the rest of your news.  Just use the RSS link on the left column of my web page, or ask me for help.

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More Options for Colon Cancer Screening

Colon cancer is a leading cause of cancer death in the US, second only to lung cancer.  Fortunately, there are effective tests that can diagnose colon cancer early, or even prevent colon cancer while it is still a pre-cancerous polyp.  Given that this is one of the few cancers for which effective screening exists, I have been very enthusiastic about recommending colon cancer screening to all my patients over 50.

The options for screening thus far have been colonoscopy, sigmoidoscopy, fecal occult blood testing, and barium enema.  Each of these tests has some benefits and drawbacks, and none have been directly compared to each other in any large studies.  Of these tests, colonoscopy has become the standard of care in our community, largely because it examines the entire colon and allows for the removal of polyps during the examination.

This week, the American Cancer Society released new recommendations for colon cancer screening.  This generated much coverage in the general media, including this NY Times article.  The major change in these new recommendations is the addition of two new testing options for colon cancer screening: CT colonography (also called virtual colonoscopy), and a stool DNA test.

Though these new options may be helpful for the occasional patient that has specific problems that preclude conventional colonoscopy, I think for most patients the new options will not be helpful.  First, there have still been no studies that directly compare the accuracy of any of these screening tests.  Second, CT colonography while less invasive than colonoscopy, still involves the most uncomfortable part of colonoscopy: the preparation the night before that evacuates the colon.  CT colonography also can’t remove any polyps.  So if any polyps are detected with CT colonography, a conventional colonoscopy is then needed to remove the polyp.  Finally, the stool DNA test is too new and impractical.  It is difficult to administer (don’t ask) and its accuracy is not yet well understood.

Many of my patients are squeamish and quite reluctant when I recommend colonoscopy for colon cancer screening.  After the test almost all of them tell me it wasn’t nearly as bad as they feared.  I try to reassure my patients by promising them that on my fiftieth birthday I’ll get a colonoscopy too.  That promise still stands despite the new recommendations.

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The Flu, Part Two

I’m sorry to write about the same topic on two consecutive weeks, but this really deserves the attention.  Last week I wrote about how we’re still not past the peak of this flu season and how the flu shot this year has been less effective, and I linked to a few authoritative web sites that I thought would be useful.

This week, allow me some personal observations.

This year’s flu is hellish.  I’ve had young healthy patients who’ve been in bed for two weeks with it.  The important thing to know for those of you who don’t have it (yet) is that there is an antiviral medicine, Tamiflu, which shortens the duration of the flu if it’s started in the first 48 hours of symptoms.  So if you develop a high fever, aches, and a cough call your doctor that day.  I’ve seen several people who had already been ill for a week, and didn’t call sooner because they were sure they were about to improve.  I had nothing to offer them but medicines for their symptoms and sympathy.  This isn’t the year to postpone getting attention for the flu.

Next week, I promise to educate you about something else.

Tangential Miscellany:

If you know someone with some experience with website design, preferably with the WordPress publishing platform, please ask her to contact me.  I have a little project with which I need help.  Thank you.

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Still In the Middle of the Flu Season

The recent news about this flu season has all been bad.  As reported in this Reuters article, the match between the strains in this year’s flu vaccine and the strains that are actually making people sick in North America are not as close as in previous years, meaning the flu vaccine this year is giving patients less protection than it has in the past.  There are documented cases of vaccinated patients still coming down with confirmed flu infections.  Still, experts think that the vaccine may decrease the severity of the illness.

To make matters worse, it looks like we’re not nearly done with the flu season yet.  According to the weekly flu surveillance by the Centers for Disease Control and the California Department of Health Services incidence of flu both nationally and in California is still on the rise.

So where does that leave us?  Well, if you’re in a high risk group (pregnant women, people with chronic health conditions like asthma, diabetes or heart disease, and people 65 and older) getting the vaccine still makes sense.  It’s also a good time to reinforce good general germ-avoidance habits like frequent hand-washing and avoiding people who are sick.

Finally, since there is an antiviral medicine that shortens the duration of the flu but that only works if it’s taken within 48 hours of symptom onset, please take the time to read about the symptoms of flu and call your doctor promptly if you get sick.

Like the interminable primaries and the rainy weather, I hope this is over soon.

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How Much Good Do Cholesterol Drugs Do?

Last month BusinessWeek had a fascinating article about cholesterol-lowering medications.  The article also teaches us how we should calculate a specific medication’s benefit and harm, and how pharmaceutical companies manipulate our opinions by reporting benefits in percentages but side effects in absolute numbers.  If you want an interesting lesson in evidence-based medicine, or just in cholesterol treatment, take the time to read it.  (My only major objection to the article is the headline, “Do Cholesterol Drugs Do Any Good?”  Of course they do, and the article doesn’t even argue that they don’t.  A more accurate headline would have been “How Much Good Do Cholesterol Drugs Do?”)

Here are the take-home points.

  • Statins definitely prevent strokes and heart attacks in people at high risk for strokes and heart attacks.
  • Statins also lower cholesterol, but no one knows if that’s how they prevent strokes and heart attacks, or if they prevent strokes and heart attacks through some other mechanism.
  • The greater a patient’s risk for stroke and heart attacks, the greater the benefit she derives from a statin.
  • Patients who have no heart disease and no risk factors for heart disease (these are non-smoking men under 45 or women under 55 without high blood pressure, diabetes, or first-degree relatives with heart disease) are at such low risk from heart disease (regardless of their cholesterol) that their benefit from taking a statin is likely to be very small, and only realized after taking a statin for many years.  At that point the side effects of a statin, even if mild and rare, may actually be more significant than the tiny benefits.

(Thanks to Harriet E. for pointing me to the BusinessWeek article.)

Tangential Miscellany:

At the risk of horrible immodesty, I just have to brag for a second about electronic medical records (EMR).  After my post a few weeks ago about the bad news about Zetia and Vytorin I wanted to review all of my patients who were taking the medications to make sure that they were on it for appropriate reasons.  With our EMR I was able to generate a list of every patient on Zetia or Vitorin in a few minutes.  Try that with paper charts.

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What We Don’t Know About Diabetes

This week we learned something very important about diabetes.  We learned that we don’t know something we thought we knew.  (Regular readers will note that this keeps happening in medicine.  For a generation everyone assumes something.  Then we check and discover it isn’t so.)

We’ve always assumed that in type 2 diabetes, the closer to normal that blood sugar is lowered the fewer complications of diabetes patients would have.  Why?  Because diabetes is known to be a major cause of kidney disease, blindness, strokes and heart attacks, and we always assumed these complications are caused by the abnormally high blood sugars in diabetes.

We also have good studies in type 1 diabetes which prove that keeping sugar levels close to normal prevents complications.  So we assumed that this also applied to type 2 diabetes, even though type 1 and type 2 are completely different diseases.

With me so far?  We had lots of good reasons to assume that better sugar control in type 2 diabetes leads to fewer complications, and this assumption has guided diabetes management.  Finally a trial was undertaken to test this belief.  The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial enrolled over 10,000 people with type 2 diabetes who either already had cardiovascular disease or were at high risk for it.  The patients were randomized to one group which received conventional treatment which lowered sugars but not to normal levels, and another group which received intensive treatment which reduced blood sugars to non-diabetic levels.

This week the ACCORD trial was stopped early because of excess deaths in one group.  What stunned experts and will confuse diabetes management for some time is that the group with excess deaths was the group receiving intensive treatment.  This received a lot of media attention, including this NY Times article and this LA Times article.

So intensive lowering of sugars in type 2 diabetes is worse than more lax control of sugars, at least in patients with multiple risk factors for cardiovascular disease.  The burning questions now are:  What should our goal for blood sugars be?  How low is too low?  Do medicines that lower blood sugar in type 2 diabetes do any good?  No one knows.

For now the experts are calming the public by urging them not to change any of their medicines before discussing it with their doctor, but this reassurance simply covers up the ignorance in which we find ourselves mired.  The scary truth is that as of this week, and until more studies help us, we’re not really sure how we should be treating diabetes.

(I am grateful to Judy F. and Victoria W. for pointing me to the articles.)

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Laparoscopic Gastric Banding Can Cure Diabetes in Obese Patients

The scientific evidence for treatment of obesity is trending in a very interesting direction.  For years a safe and effective medication for weight loss has been sought, with only modest results.  (I wrote about orlistat, the medication in Xenical and Alli, a year ago.)  Surprisingly, for obese patients evidence is increasingly mounting in favor of surgery for weight loss, rather than medications or even diet and exercise.

In 2006 a randomized study demonstrated that patients with mild to moderate obesity lost more weight and had a better quality of life than patients randomized to diet, exercise and weight loss medications.  Last week, the evidence got even better.  A study published in the Journal of the American Medical Association examined the effect of laparoscopic gastric banding on obese patients with diabetes.  The study randomized patients with recently diagnosed type II diabetes with body mass indexes between 30 and 40 (20 to 25 is normal) into two groups.  Both groups received conventional diabetes care with medications, but only one group underwent laparoscopic gastric banding.  The difference between the groups was very impressive.  73% of the surgical group had their diabetes entirely resolve, compared to 13% in the conventional therapy group.  The surgical group lost an average of 20% of their body weight, compared to 1.7% in the conventional therapy group.  Importantly, there were no serious complications in either group.  The study generated a lot of media coverage, including this article in the LA Times.

So if you have diabetes and are very overweight, surgery is no longer the most radical option.  It’s becoming the most conservative evidence-based option.  If this trend continues, diet and exercise for obesity will be considered the radical fringe option.

(I’m grateful to Jay F. for pointing me to the LA Times article.)

Tangential Miscellany:

My 15 minutes of fame is extended slightly by this article on concierge medicine.

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