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Heart of Health - do you have one?

Title for the show: Treating Cardiovascular Disease - Conventional Approaches Not Working.

What is Cardiovascular Disease? ‘Cardio’ for heart. ‘Vascular’ for vessel. Cardiovascular disease generally means the obstruction of arteries - the vessels that deliver oxygen and other nutrients to all of our cells and tissues. This includes obstruction of the arteries to the heart: the coronary arteries; arteries to the brain: the carotid arteries; arteries to the legs: the peripheral arteries. In fact every single artery in the body can become obstructed as a result of atherosclerosis (‘hardening of the arteries’).

Medical Economics of Cardiology and Cardiovascular Surgery Trumps Evidence-Based Medicine: According to current scientific evidence, surgical intervention with bypass surgery or angioplasty does not improve the health outcomes of patients with stable coronary artery disease.

A. Case Against CABG.
The scientific evidence generally does not support the use of ‘bypass surgery’ (coronary artery bypass grafting, CABG) for the treatment of patients with stable angina: a pattern of recurring chest discomfort, that is not worsening in frequency, duration, quality, location, severity, etc. This is in contrast to unstable angina.

Studies:
1. Eleven Year Survival in the Veterans Administration Randomized Trial of Coronary Bypass Surgery for Stable Angina, The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group: Eleven (11) year study done at 13 different veterans hospitals showed that patients who undergo bypass surgery have the same survival rates as patients who have only medical management, without surgery. New England Journal of Medicine 1977; 311:1333-1339.

2. European Coronary Artery Surgery Study Group, Long-Term Results  of a Prospective Randomized Study of Coronary Artery Bypass Surgery in  Stable Angina Pectoris: This study found a slight, statistically insignificant increase in survival rate in bypass surgery patients. Lancet 1982; Nov.27, pp 1173-1180.

3. Ten-Year Follow-up of Survival and Myocardial Infarction in the Randomized Coronary Artery Surgery Study: Results were similar to those of the Veterans study (#1 above). Circulation 1990; 82:1629-1646.

B. Case Against Angioplasty: COURAGE Trial.
This study of 2,300 patients with stable coronary disease (stable angina) shows that angioplasty and stents do not prolong life, or even prevent heart attacks in most of these cases. This was discovered by comparing the outcomes of patients with stable angina who had angioplasty, with the outcomes of the patients who had only medical therapy (no surgical intervention). New England Journal of Medicine 2007, March 26.

Conclusion: despite the widespread belief that angioplasty and stenting cuts down on heart attacks and death, it’s never been shown to do that in patients with stable coronary disease.

Important note of caution: For patients having heart attacks – myocardial infarction – or unstable angina, the angioplasty procedure or bypass surgery may be life saving in those cases. It is thought that about 50% of all deaths from heart attacks occur within 1 hour of the start of symptoms, often before the patient gets to the hospital. If you experience chest pain that is new, worsening or not lessening in severity, call 911 immediately.

To Intervene or Not to Intervene: How do the world’s doctors treat stable angina (stable coronary artery disease)? In this 2007 New England Journal of Medicine survey of over 7600 doctors, essentially 60% (57%) of them recommended surgical intervention: angioplasty or bypass surgery. The other 40% (43%) recommended the more conservative approach: medical management alone, thus ‘bypassing bypass’ and ‘avoiding angioplasty.’ Australia and Oceania win as the most conservative areas globally, with essentially 55% of the surveyed doctors recommending the ‘medicine-only’ approach, compared to the rest of world at around 45% with the same recommendation. Click here to view the excellent Clinical Decisions Interactive by Drs. Susan Cheng and John Jarcho.

Belief System and Mantra Sometimes Necessary in Conventional, Allopathic Medicine: “The benefits outweigh the risks and costs; The benefits outweigh the risks and costs!” - even if the evidence may not support that belief.

Consequences of Ignoring or Regarding Evidence-based Medicine, Evidence-based Cardiology:

A. Ignoring: “…an ‘industry’ is being built around this operation - coronary bypass surgery: the creation of facilities for open heart operations in community hospitals…and proliferation of catheterization and angiography suites…the expansion and development of training opportunities in clinical cardiology, cardiovascular surgery and cardiovascular radiology. This rapidly growing enterprise is developing a momentum and constituency of its own, and as time passes, it will be progressively more difficult and costly to curtail it materially…. The financial implications of CABG are profound…. The enormous funds already being devoted to this procedure divert support available for other, perhaps more necessary, aspects of medical care.” Eugene Braunwald, M.D., Professor Emeritus of Medicine and Cardiology at Harvard Medical School. New England Journal of Medicine 1977; 297(12):661-663.

B. Regarding: The COURAGE trial and the studies on bypass surgery cited above should lead us to improve the way we treat all patients with stable coronary artery disease. Now that would be good medicine. But will we regard and act upon the scientific evidence, or continue to largely ignore it?

Next Week: Intravenous EDTA chelation therapy for the treatment of cardiovascular disease. The conclusion in the New England Journal of Medicine survey above said many of the doctors surveyed from around the world expressed how important it is for doctors to discuss with their patients all treatment options and their possible outcomes. But are all the treatment options being discussed? If not, why not? Let’s look at and regard the scientific evidence for one option some doctors think is part of a good ‘Integrative Medicine’ approach to treating cardiovascular disease: EDTA chelation therapy.

Good Medicine Word Of The Week: Angioplasty – the process of mechanically opening a partially or completely obstructed artery by inflating a balloon to squash the obstructing material (the ‘atherosclerotic plaque’).

 

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…The Real History of Medicine.

Title for this installment: Experiences in Empiricism - Past and Present.

Introduction: “The beautiful rests on the foundations of the necessary,” Ralph Waldo Emerson. Thanks for being part of the early TGM experience as we continue to lay the necessary foundation for what we think is beautiful, good medicine. Empirically minded doctors throughout history have had the mindset that evidence from experience – if the evidence has born the test of time – is just as valuable as evidence supported by rigorous scientific research. The practitioners who are more rationalist-minded tend to believe – rationalize – that we shouldn’t offer any therapy unless: A) it’s undergone the gamut of scientific studies to ‘prove’ that it’s safe and effective; and B) unless we’ve fully defined the therapy’s mechanism of action. This is neither practical nor realistic for the advancement of good medicine.

Empiricism at Work Historically: The Homeopaths Introduced Nitroglycerin to Medicine.
Nitroglycerin is a perfect case in point for our discussion today, because back in the 1800s, before the FDA even existed, it was introduced into medicine empirically, not based on controlled scientific studies. And we need to credit and thank the Homeopaths – the chief empiricists of that time – for the fact that the good medicine has been grandfathered into our modern-day ‘standard of care.’

If the Homeopaths Introduced Nitroglycerin into Medicine Today:
The current ‘FDA-Approval-Based’ health care model (the approval of drugs, ‘space alien molecules’) largely controls our health care and it fosters and epitomizes the rationalist mindset. It’s possible that if nitroglycerin were discovered today that we’d never get the medication through the FDA approval process and included in our therapeutic armamentarium.

EDTA Chelation: Contemporary Example of Empirically-Based Therapy.
The NIH Trial to Assess Chelation Therapy (TACT) for the treatment of cardiovascular did not come about as a result of a pharmaceutical company wanting to get approval for a promising cardiovascular drug, since Abbot lab’s patent on EDTA expired a long time ago. Instead, the NIH trial was initiated largely as a result of public pressure on the NIH – pressure by innovative, contemporary, empirically-minded doctors and their satisfied patients – to get approval for a non-patentable, and thus non-prevailing therapy that empirically really works (based on the historical experiences of doctors and their patients).

Modern-Day Medical Mavericks and Chelation Therapy:
Even to get to the point of now having the NIH trial, a lot of good doctors, empirically-minded practitioners - history’s recent medical heretics – have fought really hard to be able to offer EDTA chelation to their patients.

Insights From Informal Polling of Contemporary Empiricists at ACAM Meetings:
If the vast majority of doctors offering intravenous EDTA chelation to their cardiovascular disease patients (with chest pain and claudication) indicate during a ’straw pole’ that they see – experience – dramatic improvements in their patients, does this really mean anything? To the empirically minded doctor, probably: yes. To the rationalist minded doctor: probably not. The different frames of reference and perceptions regarding the value of empirical evidence illustrate the tension between the empiricists and the rationalists throughout medical history.

Echoes From the Wilds of Good Medicine: Thank you Steve from Arizona for feedback and insights.

Good Medicine Word of the Week: Empiricism - the frame of thought, the mindset for medicine, that experience-based evidence throughout medical history - not necessarily just controlled clinical trials - are really important and valid aspects of good, evidence-based medicine.

Next week’s show: The 3rd installment of History of Healing–History of Killing, with more necessary insights to lay the foundation for TGM.

Good medicine is a beautiful thing. Thanks for being part of it with us!

Send TGM #5 to a friend: click here.