Empowered Patient: Top tips for 2010

Here's an excellent article to get you started towards empowering yourself for the new year:

The top ways to empower yourself and take your health care into your hands this year

http://rss.cnn.com/~r/rss/cnn_health/~3/uSyw4UWdILY/index.html
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Mortality Impact of Obesity Said To Be Underestimated

Obesity may have an even greater impact on mortality than anticipated, according to a new method of adjusting for confounding.

http://www.medpagetoday.com/PrimaryCare/Obesity/17690

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5 tips for getting what you need from your doctor

This is a great article. Doctors definitely need to learn how to be better communicators.

I tell all my patients to bring with them a list of all the medicines they take. I tell them to please write down questions prior to our visit. I give them paper to takes notes during our visit. I try and provide them with a list of websites I have visited that I think provides good quality info (see my blog for a list of these sites).

Here's the article:

"Doctors are often rushed, so patients must come to appointments prepared. Learn five steps to having a successful doctor appointment."

http://rss.cnn.com/~r/rss/cnn_health/~3/J655gMaI74M/index.html

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Strongest evidence yet that Lp(a) causes heart disease

Please do not forget that there is a overwhelming amount of data supporting lowering LDL as the most important marker for primary and secondary prevention of cardiac disease.

Research on sub-lipid particles, like LP(a), will be useful to measure to help reduce patients "residual risk", once LDL is < 70mg/dL.

"A novel genetic study provides the strongest evidence to date that Lp(a) is a causative factor for coronary disease; the results suggest that medications targeting Lp(a) could lower the risk of..."

For complete story visit theheart.org.

http://feedproxy.google.com/~r/Theheartorg/~3/hUUOufRwL5U/1036877.do
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How medication mistakes happen in the hospital

What a great idea -- give patients a list of their medications not only at discharge but everyday while in the hospital!

Originally published in MedPage Today

by Katrina Woznicki, MedPage Today Contributing Writer

Hospitalized patients were often clueless when asked about their medications, with almost all of them unable to name all their medications and many leaving out as many as a half-dozen drugs they have been prescribed, according to a small survey of patients in a Colorado hospital.

Ninety-six percent of the 50 patients surveyed left out at least one drug when they were asked to list their medications, and, on average, patients omitted 6.8 medications, Ethan Cumbler, MD, of the University of Denver, and colleagues reported in the Dec. 10 issue of Journal of Hospital Medicine.

Moreover, 44% of the patients thought they were taking a medication that had not been prescribed.

The researchers conducted the patient survey as part of a larger project examining a potential role for patients in reducing medication errors and improving patient safety.

"This study is a first for raising the questions How involved should patients be in their hospital medication safety?' and How do you involve them?'" Cumbler told MedPage Today.

"We don't live in a perfect healthcare system and errors do occur. If you have a patient who wants to be involved in their medication safety, you have to let him or her know what they're taking and to let them be an active participant."

Among scheduled medications, patients commonly omitted several important therapeutics, including antibiotics, cardiovascular drugs, and antithrombotics.

When asked about PRN medications, patients were most likely to omit analgesics and gastrointestinal medications.

"The patient, as the last link in the medication administration chain, represents the final individual capable of preventing an incorrect medication administration," Cumbler et al wrote in the journal article.

But if the survey reflects the average hospital patient, this is a weak link.

The majority of the participants, 81%, said seeing a hospital medication list would improve their satisfaction with the care they received; however, only 28% reported that they saw such a list.

A total of 50 participants answered questions about their outpatient and inpatient medications and described their attitudes about hospital medications and level of interest in patient involvement in hospital safety.

The findings, Cumbler added, only provide a snapshot of one small group of inpatients at one hospital.

The average age of participants was 54, 46% were men, and 74% were non-Hispanic white.

Patients were on an average of 5.3 outpatient prescription medications, 2.2 over-the-counter medications, and 0.2 herbal remedies.

Age did prove to be a factor in patients' ability to accurately identify their hospital medications. Patients age 65 and younger omitted 60% of their PRN medications, whereas patients 65 and older failed to report 88% (P=0.01).

Hospital organizational culture and the complexity of medicine itself pose challenges for inpatients to keep track of their medications, said Ruth S. Day, PhD, Director of the Medical Cognition Laboratory and Associate Professor of Psychology and Neuroscience at Duke University, who was not involved in the study.

"People have trouble perceiving, pronouncing, and remembering medication names even under the best of circumstances," Day said in an interview.

Protocols for outpatient medication monitoring have garnered a lot of attention, added Derung Mimi Tarn, MD, PhD, Assistant Professor of Family Medicine at the University of California at Los Angeles Medical Center, who was not a part of the study.

However, there has been very little focus on the inpatient setting, and it is not routine to give patients medication lists in the hospital. The issue, Tarn said in an interview, warrants further investigation.

Moreover, whether patients could even be effective at reducing hospital medication errors is uncertain.

Patients with dementia or delirium or those in the ICU may not prove helpful in ensuring hospital medication safety, said Tang. "However, there are definitely patients in the hospital who could serve as a valuable stopgap for example, obstetrics patients and parents of pediatric patients," she said. "The level of patient participation would need to be individually based."

Cumbler agreed that "one solution will not work for all," and that approaches to inform inpatients may have to be customized depending on factors such as condition and age.

The study, he added, was only designed to assess whether patients were informed about their hospital medications and whether they were interested and prepared to be more active participants in their care.

Visit MedPageToday.com for more hospital news.

Posted at KevinMD.com. Stay updated and subscribe, follow me on Twitter, or connect on Facebook.
Related Posts
Medication reconciliation
Is the hospital July phenomenon a myth?
On medication lists
A doctor posts bail to give an inmate his medication
Are patients refusing doctors who no longer do hospital work?

http://www.kevinmd.com/blog/2009/12/medication-mistakes-happen-hospital.html

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Letter to me From Senator Dodd

Dear Friend, Thank you for contacting my office. My staff and I are reviewing your e-mail and will get back to you shortly. In the meantime, please sign up for the Dodd Digest, my e-newsletter. I'll be e-mailing these updates to let you know about the work I'm doing on behalf of our state and our nation. Please go to my website, Dodd.Senate.Gov, to sign up. You'll be hearing from me soon. Chris- Please note, due to the high volume of mail I receive, I am only able to respond to residents of Connecticut.

Letter to me from Senator Lieberman

Dear Dr. Portnay:

Thank you for contacting me regarding your concerns about decreased Medicare payments to physicians and other providers of Medicare services. I, too, am very concerned about a viable long-term solution to the payment formula and have taken numerous actions in the Senate to achieve this. Fair payments to physicians and other health care providers are critical to preserving access for more than 44 million American senior citizens who depend on the Medicare program for their essential health services.

I understand and share your views that the rising costs attributable to physicians' services must be taken into consideration when determining Medicare reimbursement. As you know, Medicare law specifies a formula for calculating the annual update in payments for physicians' services. Many Members of Congress, myself included, continue to be concerned about the potential impact of payment reductions on patients' access to services. During my time in the Senate, I supported a number of efforts to examine Medicare updates for payments under the physician fee schedule, as well as legislation designed to undo any impending Medicare cuts to physicians, hospitals, nursing homes, home health care agencies, and other health care providers; and I will continue to do so.

While legislative interventions have prevented payment reductions from occurring in the past, Congress has not addressed the underlying issue of the payment formula accurately reflecting practice costs. Because of my continued concerns about ensuring sufficient payments to physicians, last Congress I sent letters to the Administrator of the Centers for Medicare and Medicaid Services in support of a viable solution to the Medicare physician reimbursement formula and asked congressional leadership to bring legislation to the floor to stop impending cuts and find a long-term solution to the issue. I understand these cuts in physician payments for Medicare services are unsustainable, especially given the rising costs of health care services; and I made my concerns known to those who serve on the Senate Finance Committee as they worked to craft physician payment legislation. In addition, I was supportive of legislative efforts to pass a two-year payment fix so that Congress would not have to repeat this process every year and physicians would have stability in payments beyond one calendar year.

Medicare payment policies and potential changes to these policies are of continuing interest to Congress. The Medicare program has been a major focus of deficit reduction legislation since 1980. With certain exceptions, reductions in program spending have been achieved largely through regulating payments to providers, primarily hospitals and physicians.

Although the task confronting Congress in rectifying the Medicare physician payment formula is formidable, it is one to which I remain committed to finding a more lasting solution. Any actions the Administration can take to more accurately account for the realities of spending on practitioner services under this formula, both as to actual spending and target spending, will help facilitate Congress' efforts and enhance access to the high-quality care that Medicare patients need and deserve.

Please be assured that I remain firmly committed to restoring adequate funding to Medicare physician and patient services during this 111th Congress and beyond. As we debate comprehensive health care reform policy, this issue is critical toward ensuring the ability of providers to deliver high-quality care and services and for Medicare beneficiaries to continue to access essential health care services.

Thank you again for sharing your views and concerns with me. I hope you will continue to visit my website at http://lieberman.senate.gov <http://lieberman.senate.gov/> for updated news about my work on behalf of Connecticut and the nation. Please contact me if you have any additional questions or comments about our work in Congress.

Sincerely,

Joseph I. Lieberman
UNITED STATES SENATOR
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The Lewin Report | Our Bill Was Introduced

This us huge. This bill will stop the proposed Medicare cuts to the
field of Cardiology and will insure patients continue to have the
access they deserve.

Please contact you Congressmen to ask them to support this very
important bill.

http://lewinreport.acc.org/post/Our-Bill-Was-Introduced.aspx

AHA: Focus on cardiovascular health, not disease

This is terrific news. As many of you know, I'm a huge believer that the key to our health is prevention of disease by promotion of healthy living, not the treatment of disease.

" AHA is, this year, trying to focus minds on cardiovascular health, rather than cardiovascular disease, as it unveils its latest statistics. Understanding the numbers that underlie cardiovascular...

For complete story visit theheart.org."

http://feedproxy.google.com/~r/Theheartorg/~3/dJpOphZ4doQ/1036145.do

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Heart Disease and Stroke Statistics--2010 Update. A Report From the American Heart Association

I look forward to this report every year. I contastantly refer to itas I talk to colleagues and patients.

Here's some interesting data from this 2010 report:

Prevalence:
- An estimated 81 100 000 American adults (more than 1 in 3) have 1 or more types of CVD.
- Of these, 38 100 000 are estimated to be > 60 years of age.

Incidence:
- The average annual rates of first cardiovascular (CVD) events rise from 3 per 1000 men at 35 to 44 years of age
to 74 per 1000 men at 85 to 94 years of age.
- For women, comparable rates occur 10 years later in life.


Mortality:
- Mortality data show that CVD as the underlying cause of death (including congenital cardiovascular defects) accounted for 34.3% (831 272) of all 2 426 264 deaths in 2006, or 1 of every 2.9 deaths in the United States.
- Nearly 2300 Americans die of CVD each day, an average of 1 death every 38 seconds. CVD claims more lives each year than cancer, CLRD, and accidents combined.
- A recent study of the decrease in US deaths due to CHD from 1980 to 2000 suggests that approximately 47% of the decrease was attributable to evidence-based medical therapies and 44% to changes in risk factors in the population due to lifestyle and environmental changes.

Out of Hospital Cardiac Arrest:
- The median survival rate to hospital discharge after EMS-treated out-of-hospital cardiac arrest with any first recorded rhythm is 7.9%




http://circ.ahajournals.org/cgi/content/short/CIRCULATIONAHA.109.192667v1?rss=1

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FDA advisory panel votes in favor of broadened rosuvastatin indication

The Food and Drug Administration (FDA) Endocrinologic and Metabolic Drugs Advisory Committee voted 12 to 4 today, with one abstention, in favor of broadening the indication for rosuvastatin (Crestor, AstraZeneca) to include patients with normal LDL-cholesterol levels but who are at low to moderate risk for cardiovascular disease based on other risk factors, most notably elevated levels of high-sensitivity C-reactive protein (hs-CRP).

Specifically, the advisory panel felt there was sufficient evidence of benefit to justify the risks of prescribing rosuvastatin in men >50 years old and women >60 years old who had fasting LDL-cholesterol levels <130 mg/dL, hs-CRP >2.0 mg/dL, triglycerides <500 mg/dL, and no prior

http://feedproxy.google.com/~r/Theheartorg/~3/O0tKRhDBo5E/1035155.do

Stay slim, active, smoke-free: Live long and free of CVD

Everyone agrees: smoking, physical inactivity, and abdominal obesity increase the risks of coronary heart disease (CHD), but just how much are risks reduced in those who can claim "none of the above"?

Men with all three "low-risk factors" had a 59% lower risk of CHD events and a 77% lower risk of dying of cardiovascular disease than did men who smoked, were inactive, and had larger waist circumferences.

http://www.theheart.org/article/1034683.do

The Mediterranean Diet: Alcohol

http://blog.drgourmet.com/the-mediterranean-diet-alcohol/

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Stop Smoking, Or At Least Try

A new study reveals that quitting smoking after a heart attack significantly reduces the risk of death.  But even reducing the number of cigarettes smoked yields some benefit.

http://cardiosmart.com/News/Default.aspx?id=3186

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The Best New Exercises

There's a popular saying among fitness experts: "The best exercise is the one you're not doing." The take-home message? To achieve the best results, you need to regularly challenge your body in new ways. So while classic movements like the pushup, lunge, and squat are the staples of any good workout plan, varying the way you perform these exercises every 4 weeks can help you avoid plateaus, beat boredom, and speed fat loss.

http://www.womenshealthmag.com/node/17904

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LDL Rises Around Time of Menopause

Blood levels of LDL "bad" cholesterol increase dramatically in women around the time of menopause, and the rise is not related to aging, new research confirms.

http://www.webmd.com/menopause/news/20091211/ldl-rises-around-time-of-menopause?src=RSS_PUBLIC

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Extending Intensive LDL-Lowering Boosts Benefits

NEW YORK (MedPage Today) -- For those who might have lingering doubts, post-hoc analyses of two landmark statin trials -- PROVE-IT and IDEAL -- affirm the value of an intensive versus moderate approach to lipid-lowering, researchers here reported.

http://www.medpagetoday.com/Cardiology/Atherosclerosis/17456

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Menopause Itself Appears to Increase CVD Risk Factors (CME/CE)

NEW YORK (MedPage Today) -- Women's cardiovascular risk increases through the menopausal transition, with contributions from both menopause itself and chronological aging, researchers found.

http://www.medpagetoday.com/OBGYN/Menopause/17450

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Why You May Soon Hear a Lot More About CRP Testing

AstraZeneca wants to sell its cholesterol drug Crestor to certain people with normal cholesterol levels. A panel of FDA advisers is meeting next week to consider the proposition, and the agency just put out a hefty pre-meeting memo that summarizes the risks and benefits. (If you don't want to read the whole memo, Dow Jones Newswires story hits the high points.)

AstraZeneca's request is based on a big study called Jupiter, which found the drug reduced the risk of serious heart problems in patients with normal cholesterol but high levels of something called C-reactive protein, or CRP. The company wants FDA approval to use the drug to treat patients like those in the study.

But CRP has yet to join stalwarts like cholesterol and blood pressure as a common measure of cardiovascular risk. "I don't feel we currently evidence for the routine use of [CRP and other new biomarkers] in screening people for risk of heart disease," Thomas Wang, a Mass. General doc, told the Health Blog this summer.

Still, the CRP test might be useful in cases where docs are on the fence about a patient's risk. Indeed, some doctors may already be prescribing Crestor to borderline patients with high CRP levels. And if AstraZeneca gets the new indication it's seeking, don't be surprised if you see a big marketing push aimed at driving up the number of patients who get a CRP test.

Photo by CarbonNYC via Flickr

http://feedproxy.google.com/~r/wsj/health/feed/~3/WPSNTEqtUtA/

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Patients Often Lack Knowledge of Their Own Medications

"Patients routinely under-report, or even over-report, their outpatient and inpatient medications, and
should be included in hospital medication management to improve safety, according to a study published online Dec. 10 in the Journal of Hospital Medicine."


http://www.modernmedicine.com/modernmedicine/Managed+Care/Patients-Often-Lack-Knowledge-of-Their-Own-Medicat/ArticleNewsFeed/Article/detail/647847?contextCategoryId=40126&ref=25

I've been very frustrated with how we educate patients and document what medicine they were taking prior to admission to the hospital and what medications they should be taking on hospital discharge. To do this, many hospitals use a "Medicine Reconciliation Form." I have yet to see this "tool" implemented well at any hospital. One problem is, as mentioned above, patients often so not know what medicines they are taking. Another problem is that many different individuals can fill out this form, on admission or discharge. I can't begin to tell you how often I see a patient 1-2 weeks after discharge and they have NO idea what Rx they are taking (let alone why!).

All patients on my Post-PCI service have their "Med Rec Form" meticulously filled out by my physician extenders. I also have all my patients care around a "Medication Card" in their wallet or purse. On this card, we list all the patients Rx including name of drug, dose of pill, how many pills taken at one time, how many times a day the pill is taken. Unfortunately, as a "consultant", I have no control over medications prescribed by the patient's other MD's.

Until the medical profesion finds a way to solve this problem, there will still be thousands of patients injured every year from improper medication use.
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Can a typo be blamed?

I just finished reading a great piece on theheart.org regarding the " Mounting debate over aspirin use in primary prevention."

In this piece, there is an interview with ATT investigator Dr Colin Baigent (Oxford University, UK) who was a coauthor on both manuscripts regarding the use of aspirin for primary prevention.

Here's the most amazing part of that interview:

"Can a typo be blamed?

Baigent offers one possible explanation for why aspirin for primary prevention was so heartily embraced when the 2002 BMJ paper came out: a critical typo in the original paper. While the online HTML and PDF versions are now correct, in the original print edition of the BMJ paper, the final sentence reads: "For most healthy individuals, however, for whom the risk of a vascular event is likely to be substantially less than 1% a year, daily aspirin may well be appropriate." A correction swiftly issued by the BMJ noted that final word should, in fact, be inappropriate.

Baigent says he received "a profuse apology from the BMJ editor at the time." Still, it's possible the misprint helped disseminate a flawed message about aspirin in primary prevention. It was never the ATT investigators intention to emphasize that daily aspirin in low-risk patients was a good idea, he says."

NPR.org » Surgeon: Health Care Debate Can Learn From Farmers

I think Atul Gawande is amazingly bright and thought provoking.

Last week I finished listening to his book "Complications"

His writings on the health care debate have been seminal (and he has the ear of Obama)

http://m.npr.org/news/playlist/121229972

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Well: Firm Body, No Workout Required?

Muscle-activating shoes claim to tone legs and buttocks while you walk. But do they bring results you can see?



http://feeds.nytimes.com/click.phdo?i=ed0034e91f1a35878523119e5d904a20

Report: Cancer Deaths Declining Since 1990s

December 8, 2009

A report by the American Cancer Society says cancer deaths overall in the United States have been dropping since the 1990s. Researchers say that the decades-long effort to improve diets and reduce bad habits, like smoking, have begun to pay off.

Copyright © 2009 National Public Radio®. For personal, noncommercial use only. See Terms of Use. For other uses, prior permission required.

RENEE MONTAGNE, host:

New cancer cases and the death rate from the disease have both dropped significantly over the last five years. Researchers say one reason is that decades of pushing to improve diets and reduce bad habits has begun to pay off. NPR's Patti Neighmond reports on the findings published in the journal Cancer.

PATTI NEIGHMOND: In order to understand what the slow but steady decline in cancer death means, look at it this way, says oncologist Otis Brawley, chief medical officer for the American Cancer Society. Compare the risk in 2006 to 15 years earlier, in 1991.

Dr. OTIS BRAWLEY (American Cancer Society): All told, the population as a whole has a 16 percent lower risk of dying from cancer in 2006 versus 1991.

NEIGHMOND: Men are still more likely to get cancer, but they did see the greatest reduction in risk. 2006 is the most recent year data's available. These findings confirm earlier evidence that cancer rates are down. One huge reason: People are quitting smoking and fewer are starting.

Dr. BRAWLEY: The population went from about 50 percent of people smoking, or men smoking especially, in the 1960s, to now about 25 percent smoking. And that's driven down lung cancer.

NEIGHMOND: The biggest cancer killer. Lung cancer cases are down. So are cases of the second biggest cancer killer - colon cancer. Brawley says people are changing their diets to include more colon-friendly food like fruits, fiber and vegetables. People are exercising more, which also helps. But overwhelmingly, he says, the biggest change is in screening for the disease. Epidemiologist and study researcher Elizabeth Ward with the American Cancer Society says the most effective screening method is colonoscopy.

Dr. ELIZABETH WARD (American Cancer Society): Colonoscopies is in many ways the gold standard of colorectal screening tests, because it allows for examination of the entire colon. The physician can actually visualize polyps or early cancers and in some cases remove them during the exam itself.

NEIGHMOND: Ward says the cancer declines are remarkable but adds quickly it could be better. For example, with colon cancer only about half the people who should be screened are. Many of those who aren't screened are African-American and Hispanic.

Dr. WARD: Both African-American and Hispanic populations still have lower rates of private health insurance and either lack health insurance or are covered by some public programs that don't have access to the full range of colorectal cancer screening tests and may not even be able to readily see a physician when they note signs and symptoms of colorectal cancers such as blood in the stool.

NEIGHMOND: In the meantime, health experts like Brawley worry that the obesity epidemic could undo many of these recent cancer gains.

Dr. BRAWLEY: The increasing obesity epidemic in the United States could very well cause a tsunami of cancer in the next 20 to 30 years. Already we have increases in esophageal cancer, increases in pancreas cancer, that are all related to obesity.

NEIGHMOND: Obesity is also linked to breast, prostrate, uterine, colon, liver and kidney cancer.

Patti Neighmond, NPR News.

Major push under way across US to cut rehospitalizations

From ACC Newsletter:

The AP (12/8, Neergaard) reports that "a major push is under way around the country to cut rehospitalizations, in part by arming patients with simple steps to keep their recovery on track -- like getting past harried receptionists for quicker follow-up doctor visits, and reducing medication confusion." Dr. Harlan Krumholz, of Yale University, "helped the American College of Cardiology begin a 'Hospital to Home' program this fall, signing up hundreds of hospitals to share solutions with the goal of cutting heart patients' readmissions by 20 percent within three years." Dr. Krumholz said, "Somehow this idea of one in four people landing back in the hospital in a month is treated as business as usual, that it's part of being sick in America. It doesn't have to be that way."
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Knowing What’s Worth Paying for in Vitamins

From The New York Times:

Vitamin sales in the United States are expected to grow 8 percent this year to $9.2 billion, according to Nutrition Business Journal.

http://s.nyt.com/u/iY2

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Unstable Angina

Unstable angina - angina that occurs at rest and apparently for no reason - is a strong warning that one of the coronary arteries has become critically unstable, and that without rapid treatment a full-blown heart attack may ensue. Read about what causes unstable angina, how to recognize it, and how to make sure you are getting the appropriate care, here.

Unstable Angina originally appeared on About.com Heart Disease on Friday, December 4th, 2009 at 07:16:51.

http://heartdisease.about.com/b/2009/12/04/unstable-angina.htm

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From fat to gym rat, woman loses 200 pounds

GO BECKY GO

These days, Becky Griggs starts her morning well before the sun comes up, in time to meet her clients at the gym at 5:30. It's a big change from six years ago, when she was 352 pounds and, as she calls it, engaged in a "slow form of suicide."

http://rss.cnn.com/~r/rss/cnn_health/~3/b6mhkBv0oy4/index.html

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Chances Of Surviving A Cardiac Arrest At Home Or Work Unchanged In 30 Years

This is fascinating yet not surprising. Bystander CPR and automated defibrillators in homes and public places are the key to improving these stats.

Article to follow:

The chance of surviving an out-of-hospital cardiac arrest has not improved since the 1950s, according to a report by the University of Michigan Health System. The analysis shows only 7.6 percent of victims survive an out-of-hospital cardiac arrest, a number that has not changed significantly in almost 30 years...

http://www.medicalnewstoday.com/articles/172809.php

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Hospitals providing faster care for heart attack patients

We are making great strides to treat heart attack patients as quickly as possible

 

In 2005, only about 50% of patients arriving at the hospital with an acute heart attack had their artery opened by angioplasty in less than 90 minutes.

 

In 2006, the ACC founded the Door-2-Balloon Alliance. This natioanl D2B alliance specific aim was to help improve hospitals performance. I'm proud to have been a part of this seminal work, under the leadership of Dr Harlan Krumholz at Yale. The alliance provided hospitals with tools and suggestions to improve its performance.

 

In a recent article in JACC, researchers found that "by spring of 2008, 76 percent of patients" received treatment within the recommended time.

 

Meanwhile, "more recent data shows continued improvement. Nearly 82 percent of eligible patients had a 90-minute or less door-to-balloon time in those hospitals by last summer."

 

This is amazing and should begin to lower MI mortality even lower.

Fwd: 10 surprising facts about cholesterol

Great article I found on cnn.com:

Elevated blood cholesterol is bad news. Thirty-four million Americans
have levels that can increase their risk of all sorts of health
problems. But if you think you've heard everything you need to know
about this waxy fat, there may be a few surprises in store.

http://rss.cnn.com/~r/rss/cnn_health/~3/8dWwALL5w3Y/index.html

LDL cholesterol

Here is some information about LDL cholesterol:

• If too much is circulating in the blood, it can begin to build up on
the walls of blood vessels

• Buildup of cholesterol contributes to the development of plaque in
the blood vessels

• Plaque makes blood vessels narrower and less flexible and increase
the risk for heart attack and stroke

Foods high in omega-3's

Foods found with Omega-3's (other than fish) include olive oil, canola
oil, fish oils, flaxseeds, avocados, and walnuts. Depending on your
eating habits, you may or may not need a Omega-3 supplement.

Sudden cardiac arrest in women less like to be structural

Sudden cardiac arrest in women less like to be structural

Women with sudden cardiac arrest are significantly less likely than men to be previously diagnosed with structural heart disease, according to a prospective study.

Vitamin D: A potential role in cardiovascular disease prevention

As those of you who frequently read thsi blog know, I am intrigued by the possible relationship between Vit D and CV disease.

 

I was going to summerize myself the finding that were presented at the American Heart Association meeting a few weeks ago but I found this excellent article writeen by Lisa Nainggolan and published on theheart.org's website.

 

I hope you find this an intriguing as I do. While we await the results of randomized clinical trials, those of us living in the Northern Hemisphere (speciafically in the winter months) would probably benefit from Vit D supplementaion and a diet rich in food with high levels of Vit D.

 

Here's the article:

Inadequate levels of vitamin D are associated with an increase in the risk of cardiovascular disease and death, a new observational study has found. Dr Tami L Bair (Intermountain Medical Center, Murray, UT) reported the findings here at the American Heart Association 2009 Scientific Sessions.

Bair and colleagues followed more than 27 000 people 50 years or older with no history of cardiovascular disease for just over a year and found that those with very low levels of vitamin D (<15 ng/mL) were 77% more likely to die, 45% more likely to develop coronary artery disease, and 78% more likely to have a stroke than those with normal levels (>30 ng/mL). Those deficient in vitamin D were also twice as likely to develop heart failure as those with normal levels.

"We concluded that even a moderate deficiency of vitamin D was associated with developing coronary artery disease, heart failure, stroke, and death," said coauthor Dr Heidi May (Intermountain Medical Center). However, "it is not known whether this is a cause and effect relationship," she told heartwire. Because this study was observational, more research is needed "to better establish the association between vitamin D deficiency and cardiovascular disease," she noted.

Evidence so far suggestive of benefit of vitamin D

Vitamin D was the subject of much discussion in a general session on vitamins at the AHA scientific sessions. Although the evidence supporting the benefits of vitamin D in cardiovascular disease is probably stronger than for any other vitamin, there have been only a few randomized clinical trials, and previous observational studies "show no robust effects," said Dr Harald Dobnig (Medical University of Graz, Austria). The latter suffer from limitations, such as doses of vitamin D supplementation that are too low, low compliance rates, and short study duration, he noted.

There are some large randomized trials underway looking at outcomes with vitamin D; it is hoped that they will provide definitive answers in five to seven years, Dr Eric Rimm (Harvard School of Public Health, Boston, MA) explained.

"I think there's promise for vitamin D. We know that most people have insufficient vitamin D levels in their blood," Rimm told heartwire. "So although it will take five years until some of the trials that are adequately powered to look at cardiovascular disease with vitamin D will report, the epidemiology right now is suggestive that people should have 1000 or 2000 IU of vitamin D a day," he said.

Vitamin D: How do we get it, and how much is enough?

Rimm discussed vitamin D at length, explaining that there are two sources: sunlight in the form of UVB rays, and diet (foods and supplementation). "Many tissue types and cells in the body have vitamin D receptors, and the active form of vitamin D is modulated by calcium and parathyroid hormone," he explained, with potential downstream effects on a number of bodily systems—inflammatory markers and the renin angiotensin system to name just two—he said.

People at highest risk of vitamin D deficiency include those with darker skin, those living at high altitudes, the elderly (because there is less of the precursor for vitamin D in the blood as people age and older people tend to spend less time outside), the obese, those who avoid the sun or cover the skin in the sun, those who are the immobilized or institutionalized, and pregnant and breast-feeding women.

Deficiency in vitamin D is generally agreed to be a blood level of <20 ng/mL, he said, with 20-29 ng/mL indicating insufficient vitamin D, 30-60 ng/mL indicating adequate vitamin D, and >150 ng/mL indicating excessive vitamin D.

Data suggest that many people are likely getting inadequate vitamin D, he said, with studies showing that black Americans have blood levels ranging from 6-18 ng/mL and that white Americans have levels ranging from 16-25 ng/mL.

In general, a supplement of 100 IU of vitamin D per day will increase blood levels of vitamin D by 1 ng/mL, Rimm said. Those taking 1000 IU per day should have blood levels in the range of 25-32 ng/mL and those taking 4000 IU should have levels of 40-50 ng/mL.

Diet and sunshine good sources of vitamin D

However, Rimm stressed that vitamin D need not just come from supplements. "I think for vitamin D, it's a shame just to count on supplementation because, during the right times of year, five to 10 minutes a day of sunlight is sufficient is to make enough vitamin D. I do hear the concerns about skin cancer and I think people should wear suntan lotion, but it's probably better to put it on 10 minutes after you've been in the sun."

He cautioned that "in northern climes, even if you go out in the sun in January, you're not going to make much vitamin D, so there you would need supplementation to get adequate levels."

One of the best dietary sources of vitamin D is fish.

People should remember that diet is an important source of vitamin D, too, he noted. "One of the best dietary sources of vitamin D is fish. We already suggest people eat a couple of servings a week, but having three or four servings a week of fish can get you a fair bit of vitamin D, and would represent an additional 300 to 500 IU of vitamin D. This still might not be sufficient so you might need a little bit of sunlight or to take a vitamin D supplement. It's really a combination of things, that's probably the best approach."

Both Rimm and Dobnig said it is nearly impossible for anyone to suffer adverse effects from too much vitamin D. Those who spend whole days in the sun, such as lifeguards, have vitamin D levels ranging from 45 to 65 ng/mL, said Rimm. "Vitamin D is safe. Hypercalcemia is not a problem, with the rare exception of granulomatous disease," said Dobnig. He added that because vitamin D is a fat-soluble vitamin, it can be given weekly, or even monthly.

Results of two large randomized trials eagerly awaited

Rimm said he hopes ongoing research will inform the vitamin D debate. Data are needed on intermediate end points, such as inflammatory markers and parathyroid hormone, and on "hard" end points, such as coronary artery disease, sudden death, and heart failure, both in primary prevention and in high-risk populations, including those with chronic kidney disease and heart failure.

The results of two large randomized trials are eagerly awaited, he said, including the National Institutes of Health-sponsored VITAL study looking at whether 2000 IU vitamin D and/or 1 g of fish oil (omega-3 fatty-acid supplementation) can reduce the risk of developing heart disease, stroke, or cancer in 20 000 men and women, which is slated to begin in January 2010.

The Thiazolidinedione Intervention with Vitamin D Evaluation (TIDE) study is being coordinated by researchers at McMaster University, Hamilton, ON. This trial is looking at rosiglitazone versus pioglitazone in people with type 2 diabetes at risk of heart disease, but also has a vitamin D versus placebo arm. The primary outcome for the vitamin D arm will be cancer, but there are a number of secondary cardiovascular end points, said Dobnig.

Right now, I think the evidence for vitamin D probably is stronger than the evidence for other vitamins.

"The evidence for vitamins is not great," Rimm said. "The best thing we can say now is to stop smoking, eat a good diet, and don't be overweight. I think people sometimes lose touch with the most important message of prevention, and jump right to the vitamins thinking that's going to sustain them, so doing what we know first and best is probably the best place to start."

"After that, right now, I think the evidence for vitamin D probably is stronger than the evidence for other vitamins," he concluded.

Happy Thanksgiving

May we all have a healthy and happy year
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Avoiding conflict at work may be linked to increased heart risks

From the ACC:

Bloombergg News (11/24, Cortez) reports that "men who suppress their anger about unfair treatment at work are...more likely to suffer a heart attack or die from heart disease than those who quickly vent their frustration," according to a study published in the Journal of Epidemiology and Community Health. Researchers "enrolled healthy Swedish men with an average age of 41 in the study from 1992 through 1995, then tracked them for a decade to compare a range of work and health factors."       

MedPage Today (11/23, Smith) reported that the researchers found that "those who used 'covert coping' techniques when they felt they had been unfairly treated were more likely to have an MI or die of ischemic heart disease." This "finding extends earlier research that showed that covert coping -- walking away from a conflict and dealing with the anger 'indirectly and introvertly' -- increases cardiovascular risk factors." The UK's Press Association (11/24), BBC News (11/24), The UK's Daily Mail (11/24, Martin), Reuters (11/24), WebMD (11/23, Hendrick), and HealthDay (11/23, Edelson) also covered the story
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CPAP machines: Tips for avoiding 10 common problems

CPAP is an important treatment for sleep apnea, but it's not without its frustrations. Learn how to avoid uncomfortable masks and other common CPAP problems.

 

 http://www.mayoclinic.com/health/sleep-apnea/DS00148

Researchers say selenium may increase cholesterol levels

From ACC newsletter:

The UK's Daily Mail (11/13, Hope) reports "that a high level in the blood of selenium -- a trace mineral found naturally in Brazil nuts, grain, fish and meat -- increases cholesterol levels," according to a study published in the Journal of Nutrition.       

The UK's Telegraph (11/13) reports that "scientists at the University of Warwick studied data on 1,042 individuals aged 19 to 64 who took part in the UK National Diet and Nutrition Survey between 2000 and 2001." The researchers "found that in people with blood selenium concentrations higher than 1.20 micromols per litre, levels of total cholesterol were raised by an average of 8%." Meanwhile, "levels of the harmful type of cholesterol associated with heart disease were increased by 10%." The UK's Press Association (11/12) also covered the story
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New technique helps breastbone heal after open-heart surgery

From ACC Newsletter:

The Canadian Press (11/13, Ubelacker) reports that "Canadian researchers have pioneered a new way to mend a patient's breastbone after open-heart surgery, using a Superman-strength glue that cuts healing time and reduces pain." The procedure "uses a state-of-the-art adhesive called Kryptonite that rapidly bonds to bone and accelerates the recovery process, says Dr. Paul Fedak, a cardiac surgeon and scientist at the University of Calgary." Dr Fedak "is set to head an international trial using the technique, which will involve 500 patients over the next year or two." Reuters (11/12) also covered the story.
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Fwd: Can you teach bedside manner?

So sad that this needs to be done but I know so many physicians with terrible bed side manners --- 

Doctors' training is changing to make sure they all have a good bedside manner, says the General Medical Council's Ros Levenson.

http://news.bbc.co.uk/go/rss/-/1/hi/health/8340560.stm

Fwd: How to shave 10 years off your life: Have high cholesterol, be hypertensive, and smoke

Smoking, together with high cholesterol and blood pressure, can knock 10 years off life expectancy in middle-aged men, new UK research shows. If excessive weight and glucose intolerance are added in, the difference can be as much as 15 years, they add.

http://www.theheart.org/article/1004611.do

NHLBI Publishes New Heart Healthy Cookbook

The health of your heart has a lot to do with the foods you eat. To help busy people and families shop for, prepare, and serve healthy meals, the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health created and published Keep the Beat Recipes: Deliciously Healthy Dinners. The new cookbook features 75 simple and delicious recipes influenced by Asian, Latino, Mediterranean, and American cuisine that are good for your heart and taste great too.

http://www.medicalnewstoday.com/articles/170648.php

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What double-decker buses taught us about heart attacks

Wonderful article/obituary from the WSJ --

In the middle of the 20th century, the number of people dying of heart attacks was rising sharply in the developed world, but nobody knew why. Jeremy Morris, a doctor who died the week before last, figured it out.

Morris thought there might be some link between occupation and heart-attack risk. And when he looked at the men who worked on London's double-decker buses, he found a striking result: The conductors who went up and down the stairs on the bus all day long were half as likely to die of heart attacks as the drivers, who sat at the wheel all day.

He was admirably cautious about interpreting the results, trying to poke holes in his hypothesis that exercise lowered heart-attack risk. "We set about destroying this observation," he told the FT, which ran a profile of Morris earlier this year.

But the data held up; among postal workers, Morris found, those who delivered mail by bike or on foot were far less likely to die of heart attacks than those who sat behind the counter at the post office. He published his findings in the Lancet in 1953, under the title "Coronary Heart-Disease and Physical Activity of Work."

Morris, who would have turned 100 next year, died of pneumonia and kidney failure, the New York Times said in its obit. He swam, rode an exercise bike or walked for at least half an hour on most days until he was well into his 90s. And in recent years, he often walked up and down the stairs of the London School of the London School of Hygiene and Tropical Health, where he was an emeritus professor.

"I'm constantly being asked: 'Your long life, what would you advise?' and so forth," Morris told the FT. "To start telling other people what to do – I'm very reluctant. Except on exercise, where to a large extent I feel it's what I've done myself that's contributed to longevity."

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Plavix appears to work about as well in women as it does in men

From ACC Newsletter

MedPage Today (11/9, Phend) reported, "Unlike aspirin, clopidogrel (Plavix) appears to work about as well in women as it does in men," according to a meta-analysis appearing in the Journal of the American College of Cardiology. In fact, "clopidogrel reduced cardiovascular events by 7% in women and 16% in men compared with placebo, with only a 'weak' trend for a difference between genders." The researchers found that "major bleeding risk was elevated 43% in women and 22% in men compared with placebo, again without a significant difference." HealthDay (11/9, Edelson) and Reuters (11/10, Steenhuysen) also covered the study
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Stay Alert for Angina

If plaque has built up in your coronary arteries, you may experience a feeling called angina.

This is a sign that your heart muscle is not getting enough oxygen.

Angina is often referred to as "chest pain" but this can be misleading. It's not always painful and it's not always in the chest.

Angina typically occurs when you are doing something active, such as lifting a laundry basket or climbing stairs. 

The feeling usually goes away after a few minutes of rest. 

Some of the other symptoms of angina:

- discomfort, aching, tightness or pressure that comes and goes - this can be in the back, abdomen, arm, shoulder or jaw and the chest

- feeling more tired than usual

- feeling breathless while doing something easy

- heartburn, nausea or a burning sensation unrelated to eating

What should you do?

- see a cardiologist if any of the above has stated to occur

- if any of these symptoms last for more than a few minutes, you could be having a heart attack, CALL 911.

FDA commissioner announces initiative to reduce medication errors

Given all the amazing uses of technology that exist in this world, its amazing how often patients receive and take the wrong medication and dosages. The FDA is trying to do something about it.

From the ACC News Letter:

The Washington Post (11/5, Layton) reports that the Food and Drug Administration has announced a new "Safe Use" program in an effort to reduce the misuse of medications, which it claims could prevent "at least 50,000 hospitalizations a year." FDA commissioner Margaret A. Hamburg said she was "stunned at the scope of the problem," and that her agency "intends to work with physicians, pharmacists, insurers, drug companies, patients and parents to develop a list of specific problems, a strategy for addressing them, and ways to measure success." Hamburg indicated that while some of the new measures would require voluntary action on the part of the drug industry and medical community, others "may require new FDA regulations."

        

On their website, CNN (11/5, Young) reports, that commissioner Hamburg also touted a new "drug dosage guidance document" and claimed that better measuring devices "will help patients, parents and other caregivers use the right amount of these medications -- the safest and most effective dose -- especially for children." She also said the agency was currently "working with the Centers for Disease Control and Prevention on estimates for the number of people who die from avoidable medication errors."

        

The Los Angeles Times (11/5, Zajac) reports that the agency also said they will begin to "scrutinize the information provided to patients, such as package inserts, labels and instructions that pharmacists give when dispensing prescriptions." The AP (11/5, Perrone) also covers the story.

Heart attack symptoms im women

In a recent study that got a lot of press -- leading to headlines like this "Contrary to common belief, women feel same heart-attack symptoms as men" reseachers clain that men and women actually have the same symptoms. 

This is actually a distortion of the trial results. Despite the fact that women and men were equally likely to report chest discomfort or other "typical" symptoms of acute coronary syndrome, women were significantly more likely to report nonchest discomfort such as pain in the neck, jaw, and throat. 

It has been known for some time now that some women feel "typical heart pain" but some women do not. More often than men, women having a hreat attack present with throat, stomach, or back symptoms. 

My conclusion:- men and women need to be educated on the "typical" symptoms of a heart attack- women need to be educated on the "atypical" symptoms of a heart attack

Coronary Spasm

Coronary Spasm = Coronary Vasospasm = Variant angina = Prinzmetal's angina

Coronary Spasm is a rare yet established cause of chest pain.

It is characterized by spontaneous episodes of angina (chest pain) in association with ECG changes that mimik an acute heart attack. 

It is caused by a  transient, abrupt, marked reduction in the luminal diameter of an epicardial coronary artery leads to myocardial ischemia (decreased blood flow).

Spasm occurs can occur in either normal or diseased vessels. The reduction in diameter is focal and usually at a single site, although spasm in more than one site and diffuse spasm have been described. Spasm typically occurs within 1 cm of an atherosclerotic plaque in a diseased vessel. This process can usually be reversed by nitroglycerin or a calcium channel blocker. 

In addition to spasm of large epicardial vessels, a functional abnormality of microvessels may contribute to myocardial ischemia. This occurs predominantly women who had a history of prolonged (>30 min) chest pain.

CLINICAL CHARACTERISTICS

The clinical presentation and profile of the patient with variant angina are generally different from that of the patient with unstable or chronic stable angina:

• Patients with variant angina are younger and do not exhibit classic cardiovascular risk factors (except for cigarette smoking).

• Variant angina may be associated with other vasospastic disorders, such as Raynaud phenomenon and migraine headache or its treatment.

• Substance abuse (such as cocaine) is an important risk factor; among cocaine users, spasm may be the cause of myocardial infarction in the absence of angiographically documented coronary disease.

• Exercise and hyperventilation can precipitate attacks of vasospastic angina. The majority of patients, however, have normal exercise tolerance.

• There is a circadian variation with an increased prevalence of angina attacks from midnight to early morning.

Although the pathogenesis of coronary vasospastic angina is not well understood, several contributing factors (other than cocaine abuse) have been identified. These include the autonomic nervous system (particularly alpha-adrenergic receptors), endothelial dysfunction, and adhesion molecules.

A variety of factors may contribute to endothelial dysfunction in patients with variant angina, one of these being inflammation.

DIAGNOSIS:

The key finding for the diagnosis of variant angina is the detection of ST segment elevation during chest discomfort with return of the ST segment to baseline upon resolution of symptoms.

Exercise testing — Exercise treadmill testing is of limited value in variant angina since exercise tolerance is usually well preserved. 

Coronary angiography — Coronary angiography may demonstrate an apparently normal vessel, or proximal fixed obstruction of varying severity in one or more of the coronary arteries. 

Povocative tests — ergonovine and hyperventilation — can be performed in the catheterization laboratory and have been useful in making the diagnosis of suspected variant angina. These tests are done only when the diagnosis of variant angina is suspected, but not firmly established. At present, provocative testing is less frequently performed.

TREATMENT:

MEDICAL THERAPY:

Medical management of variant angina includes risk factor modification, such as cessation of smoking and lipid lowering, and pharmacologic therapy, which begins with the administration of calcium channel blockers (nifedipine, amlodipine, diltiazem, and verapamil) or nitrates. Both classes of drugs are effective in preventing vasoconstriction and promoting vasodilation in the coronary vasculature.

Statins — Endothelial dysfunction is thought to play a role in the development of variant angina and statins can improve endothelial function.

Estrogen therapy has been recommended in postmenopausal women with variant angina because of its beneficial effects on endothelial function. However, the American Heart Association now recommends against the use of hormone replacement therapy because of the findings from the Women's Health Initiative (WHI) and the Heart and Estrogen/Progestin Replacement Study-II (HERS-II), which suggested that estrogen-progestin therapy might cause harm when used for either primary or secondary prevention of cardiovascular disease.

PROGNOSIS:

Patients with variant angina alone (ie, no obstructive coronary disease) generally have a good prognosis

Patients with variant angina who also have obstructive coronary artery disease have a worse prognosis that is, in part, determined by the severity of the underlying disease. T

Research suggests rosuvastatin may benefit certain heart failure patient

From ACC Newsletter

HeartWire (11/3, Stiles) reported, "In a post hoc analysis of the first major trial to have found no statin protective effect overall in patients with chronic heart failure, the efficacy of rosuvastatin...was inversely related to levels of amino-terminal pro-brain natriuretic peptide (NT-proBNP), such that the drug apparently did cut the risk of cardiovascular events in those with less severe disease as gauged by the biomarker." Researchers from the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA) said that "patients with lower plasma concentrations of NT-proBNP had a lower event rate, but seemed to obtain greater benefit from rosuvastatin." The research was published in the Journal of the American College of Cardiology
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Study suggests statins may increase risk of fatigue, shortness of breath in certain heart failure patients

From ACc newletter:

HealthDay (11/3, Dotinga) reported that "statins may boost the risk of fatigue and shortness of breath in some patients with heart failure," according to a study presented at the American College of Chest Physicians meeting. Investigators "looked at the medical records of 136 patients with heart failure." The researchers found that individuals "who had diastolic heart failure and took a cholesterol drug had almost half as much exercise tolerance as those with the condition who didn't take the drugs.
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Aspirin 'only for heart patients'

Given recent studies showing marginal if any benefit of using aspirin to prevent heart attacks, many are advocating a major change in practice patterns. 

"Using aspirin to ward off heart attacks and strokes in those not suffering cardiovascular disease should stop, research says."

http://news.bbc.co.uk/go/rss/-/1/hi/health/8338763.stm

This doe not apply to patients with known heart or vascular disease where there is a significant body of evidence to support the use of aspirin to help prevent a second event. 

Another reason to measure cardioCRP

As recent study published in Circulation reveals the elevated CRP levels (marker of inflammation) were significantly associated with increased risks of stent thrombosis, death, and MI in patients receiving drug-eluting stents.

Since stent thrombosis is a rare yet terrible event - having a marker to help predict patients at higher risk is important. 

More importantly, the next important piece of information will be to test whether lowering the CRP leads to reduced risk of stent thrombosis

New Concept tested: Plaque Sealing

For years -- there has been great interest in the concept of prophylactic stenting. That is, using a stent to treat or "seal" as apparent unstable looking lesion that is not significant yet. Currently, we only stent significant stenoses. 

The concept of plaque sealing was finally tested and the results just published in Circulation. 

The results: "Stenting moderate nonsignificant lesions in old SVGs (bypass grafts) with PES (a drug eluting stent) was associated with a lower rate of SVG (bypass graft) disease progression and a trend toward a lower incidence of major adverse cardiac events at 1-year follow-up compared with medical treatment alone, despite very low low-density lipoprotein cholesterol values.

This study represent what I hope is the first of many studies looking at this novel concept. 

Final Rule Includes Phased In Cuts for Cardiology

From the ACC - News for Cardiologist and their patients

The Centers for Medicare and Medicaid Services (CMS) today released its 2010 Medicare Physician Fee Schedule final rule, which includes policy proposals that will significantly reduce payments for cardiovascular-related services. While CMS has attempted to mitigate the impacts of the cuts by spreading them out over a four-year period, the impact of the cuts is still enormous both for 2010 and beyond. Cuts of this magnitude—whether enacted this year or spread over four—cannot be absorbed and we will continue to fight the implementation of this data until a rigorous review is conducted.

The ACC understands the very real impacts these cuts will have on your practices, your staff and your patients. The College is exploring all options and staff and leaders are working together to help you understand all of your options. Below is a high-level summary of the policy changes finalized in the rule. In addition, we've also provided links to the tools and resources available to you now.

More information over the coming weeks will be provided in Cardiology magazine, ACC News and The ACC Advocate. Please also plan to join ACC CEO Jack Lewin and President Alfred Bove, M.D., F.A.C.C., for an all-member call on Nov. 12 from 4:00 to 5:30 p.m. (EST) to discuss the 2010 rule. To RSVP for the call, click here.

RULE HIGHLIGHTS:

Practice Expense: Despite the hundreds of calls and letters from you, members of Congress and patients, CMS has chosen to incorporate the results of the American Medical Association's Physician Practice Information Survey into its formula for calculating practice expense relative value units (RVUs). In a slight change from the proposed rule, the agency has said the cuts will be phased in over a four-year period versus all at once. With the exception of evaluation and management services, nearly all services that cardiologists perform will see cuts ranging from 10 percent to more than 40 percent for individual services phased in over 4 years. A few key examples for 2010 alone:

• SPECT Myocardial Perfusion Imaging (78452) – 36 percent cut -- NUCLEAR STRESS TESTING
• Transthoracic echo with spectral and color flow Doppler (93306)--10 percent cut
• Coronary Stent (92980) - 4 percent cut
• EKG (93000 )-- 5 percent cut
• Level 4 established patient office visit (99214) -- 7 percent increase

As mentioned above, the ACC is exploring several options for stopping the implementation of these cuts. CMS' decision to phase-in the cuts, while not what we would have hoped, is due in large part to your tremendous efforts over the last few months. Your actions clearly had an impact and we strongly encourage you to continue to email your congressional representatives and CMS detailing the ramifications of these cuts as we move into the next phase of challenging these cuts.

Bundled codes for myocardial perfusion/SPECT imaging
CMS's continued pressure to bundled together imaging services reported with multiple codes has now hit myocardial perfusion imaging. In 2010 myocardial perfusion imaging/SPECT studies including wall motion and ejection fraction will now be reported with a single code. CMS decided to substantially reduce the payment for myocardial perfusion imaging as part of this rule by reducing both the physician work value and the practice expense value. To make matters worse, because there is a new code for the service, CMS apparently is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value. The result is a 36% cut in payment for 2010. This change alone accounts for more than one-third of the projected payment cut to cardiology. ACC will begin immediately to pursue strategies to mitigate this cut. Specifics on the new codes and tips on how to work with health plans to transition to the new codes will be emailed to you next week and also included in the November issue of Cardiology magazine.

Consultations: Payments for consultations provided in office and hospital settings are eliminated under the final rule. The RVUs assigned to these codes will be redistributed to office and hospital visits and services now billed as consultations will be billed as hospital or office visits. This will reduce payments to varying degrees for consultation services.

Malpractice: CMS has chosen to update the malpractice RVUs with data from a new survey of specialty-level malpractice premiums. In addition, CMS has proposed a new method for determining malpractice RVUs for technical component services. The proposed new malpractice RVUs would reduce cardiology payments by 1 percent. However, the impact will vary depending on the mix of services provided.

Equipment utilization: CMS has finalized its proposal to change the agency's formula for calculating the per-procedure cost of diagnostic medical equipment worth more than $1 million. The proposal would assume that all diagnostic equipment with an acquisition cost greater than $1 million is used 90 percent of the time an office is open, thus driving down the practice expense RVUs for services using that equipment. Within cardiology, cardiac MR and cardiac CT services will be subject to payments set based on this utilization assumption. CMS did agree not to apply this cut to equipment for non-hospital cardiac catheterization services.

SGR: As required by current law, the final rule includes a 21.5 percent reduction in Medicare Physician Payment as of Jan. 1, 2010. This cut is in addition to the payment reductions that result from the proposed policy changes described above. In short, there could be as high as a 30 percent cut in Medicare payments for cardiology. However, as in previous years, Congress is expected to pass a one to two year fix this fall. CMS did finalize its proposal to remove physician-administered drugs from the accumulated SGR debt, which makes a fix to SGR less expensive.

A Heart-Healthy Diet and Medication Cut His Heart Disease Ris

As printed on "www.health.com" -- Great story

Though he knew he had high cholesterol, Paul Tasner, 62, of Greenbrae, Calif., didn't realize it was high enough to put him at risk for a heart attack until he got a thorough checkup from his doctor. Unable to lower his cholesterol level through diet and exercise alone, Tasner decided to take the statin Lipitor—and he's glad he did

"I want to live a long and active life, so I followed my doctor's advice."

(PAUL TASNER)

A few years ago, I changed primary care physicians. The new doctor requested a series of lab tests, including a cholesterol panel. We learned my total cholesterol was as high as 298! My doctor told me that I was at risk for heart disease. Not lowering it could lead to heart attack, death, and other bad stuff. 

I've always had high cholesterol, and I tried to get it down with diet and exercise. But as I've gotten older, I've put on weight. I travel a lot for work, and what I really dislike about business travel is that it disrupts my life. Not every hotel has an exercise room, and unless you're very fortunate, you're not in a place where healthy food is plentiful. Sometimes a family-style chain restaurant is the best place to eat, and you can't find anything healthy on the menu there unless you eat salad every day. 

I think the quality of food is important for your health. My wife is pretty focused on healthy eating. We don't eat a lot of fried foods. We try to buy organic fruits and vegetables, though that's something that's not available to everybody. But I hope I don't sabotage that entirely with some of my unhealthy food practices. I'm kind of a chocoholic and I love bread and baked goods. I love the street pretzels in San Francisco. 

My doctor said that if I could lower my cholesterol naturally, great. But if not, he recommended Lipitor for my particular profile. I gave it a try, but I couldn't budge the number, quite honestly. I never like to take drugs, I've always resisted, feeling like 10 years from now they might find out that it's bad for you. Nonetheless I started taking Lipitor, and I'm glad I did because two weeks later my cholesterol was slashed in half. I've been taking it for several years now and haven't seen any side effects. The worst reported side effect is liver damage, but I get physicals regularly with tests for liver functions and I seem to be doing fine. 

I want to live a long and active life. My father lived to be 73; that's not old anymore. I believe his father, my grandfather, was in his 60s when he died. They both died of heart disease. Being severely compromised by a stroke or something equally debilitating really scares me. I don't want to be crippled. I don't want to not be able to move around and travel and live my life. I like working, visiting my family, and seeing my grandchildren. I don't want that taken away from me. 

As told to: Shuka Kalantari

http://www.health.com/health/condition-article/print/0,,20205460_2,00.html

In Hand Washing, Technique More Important Than Technology

10/29/09 - Good Morning America did a segment of handwashing

They actually rubbed their hands with E Coli and used either soap or hand sanitizer to see which worked better

Results:

"The first thing we noticed is that alcohol-based hand sanitizer clearly works the best. In fact, the CDC says you should use a hand sanitizer containing at least 60 percent alcohol. " The most popular product on the market is Purell, which has 62% alcohol.

"As for soap, the antibacterial soap worked only slightly better than the regular soap."

"The Food and Drug Administration recommends using only regular soap because of worries that germs will develop resistance, and people will develop laziness from high-tech soap. Based on the results that we got, it's really not necessary to use antimicrobials in the products. You can see some difference, but it's really not significant"

PLEASE WASH YOUR HANDS!!!!!

Sleep Apnea Treatment Helps Your Golf Game

Men and women who undergo treatment for sleep apnea not only can improve their general health, but their golf games as well, new research indicates.

http://www.webmd.com/sleep-disorders/sleep-apnea/news/20091102/sleep-apnea-treatment-helps-your-golf-game?src=RSS_PUBLIC

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CMS announces physician payment cuts

As written in the ACC Newsletter:

The Wall Street Journal (10/31, Favole, subscription required) reported that the Center for Medicare and Medicaid Services announced new rules to cut payments for physicians who use expensive medical-imaging equipment. Under the rules, the use of equipment for MRIs and CT scans to screen for diseases will result in cuts of up to 38 percent for physicians who are paid under the Medicare Physician Fee Schedule.       

Bloomberg News (10/31, Nussbaum) reported that CMS also announced a "21.5 percent cut for all physicians" with "lower reimbursements for specialists." The "reductions will be made over four years rather than imposed at once in 2010." According to Allen S. Lichter, chief executive officer of the American Society of Clinical Oncology, "cancer-care doctors will see a six percent reduction over four years." Meanwhile, Jack Lewin, chief executive officer American College of Cardiology, noted that "the phase-in means 'a slow death' for heart doctors."       

Lewin noted that "the rule puts into effect policy proposals that will unacceptably reduce payments for cardiovascular-related services," CQ HealthBeat (10/31, Reichard, subscription required) reported.
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Know Your Numbers!!!!!!!!!!!!!!!!!!

You must know these numbers to ensure that you do everything possible reduce your risk of heart attack, stroke and vascular disease.

PLEASE MAKE SURE YOU ASK YOUR HEALTH CARE PROVIDER TO PROVIDE YOU WITH YOUR DATA

Total Cholesterol (fasting): 

- Desirable: less than 200 mg/dL

- Borderline High: 200-239 mg/dL

- High: > 240 mg/dL

HDL Cholesterol (fasting):

- <40 mg/dL for men and <50mg/dL is a major risk factor for cardivascular disease

LDL Cholesterol (fasting):

- optimal: <100mg/dL

- near optimal: 100-129 mg/dL

- High: > 130 mg/dL

Blood Glucose (fasting):

- Normal: 99 mg/dL and below

- Prediabetes: 100-125 mg/dL

- Diabetes: >125 mg/dL

Blood Pressure:

- Normal: < 120/80 mm/Hg

- Prehypertension: 120/80 - 139/89

- Hypertension: > 140/90

Ankle-Brachial Index (ABI): A test that compares the blood pressure readings in your arms and ankles to help determine whether you have PAD

- Normal: 1.0-1.3

- Possible PAD: 0.91-0.99 or > 1.3

- PAD: < 0.90