I helped a middle aged male patient quit smoking. I offered “smoking cessation medication” to him and he accepted it.  He had no psychiatric history. Within a week, his wife called me to report odd behavior.  He was staying up late, delusional, sexually aggressive, expressed thoughts of suicide. I had to hospitalize him in a psychiatric hospital.  When we stopped “the medication”, he became “normal” and has had no problems since.  Was it due to Varenicline? NO!!!  It was in the mid 1990’s, a full decade before Chantix was marketed in the US.  The drug?  Nicotine replacement patches. 

Mysterious reports of suicide and suicidal ideation NOT SEEN in randomized controlled trials have popped up all over the world.  Much like reports of crop circles and Big Foot, it’s really hard to track them down.  It’s difficult to find a normal person with no history of depression, no life stressors, and no alcohol use who just jumped up and committed suicide on Verenacline. On the other hand and so tragically, it’s very common for patients to commit suicide for a variety of reasons. It’s an entity as old as Judas Iscariot and it isn’t likely something that will go away anytime soon.       

US suicide rates increased for the first time in a decade according to a report in October 2008 from the Johns Hopkins Bloomberg School of Public Health’s Center for Injury Research and Policy.  The increase was noted from 1999-2005 BEFORE VARENICLINE CAME ONTO THE AMERICAN MARKET and primarily due to an increase in suicide among middle aged whites from ages 40-64.  An unusual finding was that rates in women demonstrated the most significant jump, a first -time statistic.  The full report was published in the American Journal of Preventive Medicine in December 2008.

Suicide is the 7^th leading cause of death in the US.  In 1996, 31,000 US citizens committed suicide. According to reports, it’s bad to be from Alaska, Nevada, New Mexico, or Montana all with the highest rates of suicide in the US. (Do they sell more Varenicline in those states?  Wait, that was 1996, no varenicline to blame there),  but it’s good to be from Washington D.C. and the state of  New York with the lowest rates.  It’s bad to be in a bad relationship, to drink alcohol or to be a New York City police officer, all of which are associated with a higher risk of taking ones life. (Maybe we should put a black box warning on bad relationships, alcohol or law enforcement as a profession).  One article sited Veterinarians as having an unusually high rate of suicide. Go figure.  I thought folks who were pet people were relatively well adjusted and happy.  With suicide rate reporting, there must be more to it than meets the eye. Hmmm…………..

The most recently published information on Varenicline was presented in Orlando 3/09 at the ACC demonstrating that of 714 adults randomized to varenicline or placebo NONE OF THEM demonstrated suicidal ideation or suicidal behavior. My personal experience with smoking cessation period is that quitting smoking is tough .  We gleaned this information from the standing whine from unsuccessful quitters that usually goes something like this:  “I had to either start back or kill my husband”. Do you get the idea that quitters get a bit aggressive, even when they go cold turkey?

 There is simply too much good randomized controlled data available to combat this unfounded rumor of suicidal behavior with Varenicline.  Unfortunately, with billions of dollars of blood money to spend, the tobacco industry can fan the flames until we all believe we’ve seen a Big Foot in our back yard.  As prescribing physicians we must continue to rely upon fact and not innuendo. Varenicline is an excellent tool for smoking cessation and with the exception of nausea, headache and stomach upset, it’s relatively benign. We should discuss with our patients the reports of aggressive behavior and suicidality with the FACTS firmly in hand .

   When faced with the option of lung cancer, sudden death, heart attack, stroke or choking to death slowly over a decade, or sinking myself into poverty and illness, or  abandoning my family too early in the name of tobacco addiction,  I’ll take my chances with Big Foot, a crop circle or whatever is in the black box any day.    

The media is buzzing with discussions of Dr Atul Gawande's article in the New Yorker magazine, which looks at the astounding healthcare costs in the town of McAllen, TX. How did this "outlier" capture the attention of the nation and fuel the debate for healthcare reform? Is the debate fair and balanced or rather tainted by journalistic hyperbole?

Drs David Kandzari and Sunil Rao join Dr Philippe Généreux to discuss the reasons for using transradial access and the situations best suited for it. From the fellow just starting out through to the most seasoned interventionalist who is more accustomed to transfemoral access, what are the ways to address the learning curve associated with this procedure, and what does it take to be successful and comfortable with it?

Join this informative discussion and learn helpful "tips and tricks" and valuable data supporting the adoption of transradial access as the default approach for PCI.

Studying for board recertification is a challenging and sometimes laborious process for any busy clinician and one that can provoke a spectrum of emotions from paranoia (will I pass?) to anger (what an incredible burden!) to euphoria (it's over!).

What are your strategies for this daunting process? Do you go it alone or use a study partner? Have you used online resources or are you by-the-book? Beyond practicalities, what are your thoughts on the actual process? Is it possible to fine-tune the system to limit the burden for the practitioner?

See:

The American board of internal medicine website with information on the certification process

2008 Interventional Cardiology Overview and Board Preparatory Course

Recertification in Interventional Cardiology. George D. Dangas, MD, FACC, FSCAI_*, Jeffrey J. Popma, MD, FACC, FSCAI. J Am Coll Cardiol Intv, 2008; 1:332-334.

I grounded a medical helicopter pilot once …….at least I grounded him from flying from MY facility with MY patients………….. and I would do it again. 

Before the days of PCI without surgery on site, I walked with a critically ill patient to the helipad and headed for the office. As I drove from the parking lot, I spied a middle-aged man in an olive green jump -suit peering around the corner of the building. A plume of smoke was billowing from his head.  I promptly got on the phone with his supervisor and demanded that he not fly another patient from my facility, pointing out that he was a smoker with NO co-pilot. The company complied with my request but informed me that the FAA had no restriction with regard to tobacco use. Needless to say, I was shocked. The pilot died a couple of years later of pancreatic cancer but I never knew if he was allowed to fly for other facilities after that fateful day. 

With the untimely death of the Continental Airline pilot last week, retirement age will most certainly become the bone of contention, especially in light of the relaxation of the standard from age 60 to age 65 in 2007.  That would be a huge mistake and a missed opportunity.  "VASCULAR AGE", not numeric age should become the main focus of this discussion and additional risk factors for sudden cardiac death should also be considered including primary and second hand smoke exposure. (yes, second hand smoke really counts).

 HAS THE FAA ACTUALLY REVIEWED ITS MEDICAL REQUIREMENTS SINCE THE 1970’s????  

 Pilots do require a stress ECG, stress echo or stress nuclear assessment. They must achieve at least 85% of MPHR.  They are disqualified if they develop 1mm ST segment depression unless stress echo or stress nuclear is negative for ischemia.  An echo with an EF of < 40% or with a drop by 10% EF compared with a prior study are other grounds for disqualification. The blood pressure must be below an archaic but “acceptable level” of   150/90. It is unbelievable that there is no mention of a BMI cut-off or a calcium score. There is an outdated “substance abuse” clause which states that “Substance dependence means a condition in which a person is dependent on a substance OTHER THAN TOBACCO or ordinary xanthene-containing beverages. ARE YOU KIDDING?  TOBACCO USE DOESN’T COUNT as a risk? 

For Pilots with a diagnosis of “significant CAD, angina and a history  of myocardial infarction”, according to the FAA’s medical certification requirements a “six month recovery period must elapse” and a “six month post- event “ angiogram “ with a negative nuclear perfusion scan” must be performed. .The actual ECG strips must be included for review and the pilot must have discontinued their beta blockers for 48 hours prior to testing. For me and mine, I don’t mind flying with a pilot who is a cardiac patient as long as they have a co pilot.  Even Oprah figured that one out a few years ago when she refused to fly with a single operator.  I’m with her.      

 Personally, I think most cardiologists would rather fly with a pilot that’s completely sobered up after a weekend binge than fly with a guy who just stubbed out a cigarette before boarding. (Rightly so, the FAA is "all over" alcohol use, but severely lacking with regard to cigarette use).  I’d rather have a 70 year old pilot with a low calcium score and a normal BMI in my cockpit than a 50 year old pilot with a calcium score of 1500 or an abnormal 3 hour GTT.  I’d also feel better with a captain who has an annual “clean” holter to rule out intermittent atrial fibrillation that would address a middle aged pilot's  risk of  CVA.  Throw in a normal IMT and I'll really  relax and enjoy the flight,......kind of like that feeling we all get when the pilot turns off the seatbelt sign. Finally, someone at the controls with a normal hsCRP would bring me in for a really smooth landing. 

If the FAA seizes this opportunity to cruise into the 21st century for pilot health assessment, it will have finally earned its wings . A simple invitation to “Fly the friendly skies” just isn’t enough anymore.        

A new meta-analysis questions the use of low-dose aspirin for the prevention of cardiovascular events. Given its current wide use, these findings are important and have far-reaching consequences. What are your thoughts?

See:

Meta-analysis questions use of aspirin in primary prevention

Antithrombotic Trialists' (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373: 1849-1860.

Algra A and Greving JP. Aspirin in primary prevention: sex and baseline risk matter. Lancet 2009; 373: 1821-1822.

Maybe it’s time for a little cross marketing……….between the dentist’s office and the cardiology exam room that is.

When earlier studies linked gingivitis to cardiovascular disease, we as cardiologists began to agree over small talk in doctors’ lounges or medical meetings that the finding was remotely “interesting”.  I’ve even gone so far as to tell a modest number of patients staring at me from behind toothless grins that poor dental habits could be associated with heart disease.   Now with the recent publication from the University of Kiel, Germany suggesting a genetic link between periodontal ills and atherosclerosis, it’s apparent that I should do more than just mention it in casual conversation. 

There is one huge obstacle however.  I don’t think cardiologists know much  about the oropharynx.   About the only time I ever look in someone’s mouth is when I’m forced to fill out that ridiculous ASA criteria prior to a cath (I know just enough to be able to check the box if I can see the Uvula).  Occasionally, I inspect the soft palate for petechia in a patient with a FUO. Other than that, I’m content to listen to the carotids, check for facial asymmetry or JVD, note the thyroid and call it an HEENT exam.   So, I’ve taken a little time to ask folks who are “in the know” about periodontal disease and what exactly we as cardiologists should look for. 

Dr. Phillip Whiteside DMD, graduate of the University of Louisville School of Dentistry in private practice in Glasgow Kentucky (and my personal dentist)  told me that from a dental  perspective “the  gums are inspected for color and texture and a digital exam is performed to check for loose teeth”, a tell tale sign that periodontal disease may be present.  He recommends we ask the patient if “bleeding with flossing” occurs and recommends regular teeth cleaning.  He also explains that “dentists utilize a periodontal probe that measures pocket depth to evaluate for destruction of the periodontal ligament”.  I know I’ll leave the probing to qualified folks like him, but at least I can ask a few questions and make a few recommendations that might motivate the patient toward a formal exam with their dentist.   Dr. Whiteside added “this is not new news for us.  We’ve been telling patients about this link for a long time.  Though we aren’t in the business of practicing medicine, the two areas (of dentistry and medicine) are coming closer together all the time”. 

 Dr. Alan Carr DMD, Department of Dental Specialties and Professor of Dentistry at the Mayo Clinic, Rochester believes the real question is "whether or not a cost effective assay can identify patients with this propensity" and "if we can guide the patient to seek counseling for environmental risk reduction and more frequent surveillance for early disease".  He then added that "the critical need for further study would be toward identifying if the expression of one disase that is untreated makes the other more refractory to treatment".  When I asked his opinion about whether cardiologists should educate patients  regarding dental issues and vice versa he said "yes".  He then added " especially if the above mentioned assay could be developed as a saliva test".  He then stated that "the broader issue here with genetic 'identifiers' is the opporunity to develop cost effective and practical assays that can be used before disease expression" occurrs. This allows a focused approach to patient management.........which can reduce costs of care by treating early stage rather than late stage disease". 

As for the cross marketing approach mentioned above, maybe dentists should place information packets on their waiting room tables informing their patients of the risk factors for coronary disease.  Maybe we should approach our respective national associations about taking a more aggressive stance on campaigns for better periodontal health. It seems imperative that we join together to drive a change in our culture that would cause us to view poor dentition as not something shameful but potentially deadly. No doubt, our current economic downturn in America and the lack of universal coverage for dental insurance will continue to take its toll. Universal coverage for dental health would be another lofty goal.

 From the cardiologist’s perspective, it’s time we tuck something more than just Viagra (or Lipitor) into those much coveted give-away-bags that sometimes  takes so much courage to obtain. Maybe we should surprise our patients with something really practical……….. like a toothbrush, dental  floss and toothpaste as well.       

Please refer to the epublished JUPITER manuscript:  Glynn RJ et al.  A randomized trial of rosuvastatin in the prevention of venous thromboembolism.  N Engl J Med 2009; March 29.

Prescription fulfillment has changed radically over the past years, becoming markedly more complicated since the advent of pharmacy benefits managers (PBMs), which are third-party companies hired by insurance firms to manage the prescription formularies for the members of their plans.

PBM interventions can include notification of generic substitutes, more intrusive suggestions such as the addition of an ACE inhibitor based on guideline recommendations, or even weighing in on evolving fields such as the possible reaction of proton-pump inhibitors and clopidogrel.

What are your thoughts on PBMs? Are they invasive necessities or intrusive annoyances that create fresh levels of bureaucracy without adding value? What is your experience with PBMs?

Where are the opportunities for cardiology fellows considering research in the field of biomarkers of heart failure? In this interview conducted by Dr Rahul Kakkar, Dr Jim Januzzi gives his insight into research that has applicability spanning the full range of the American Heart Association's stages of heart failure.

We can start by learning something from the alcohol industry's advertising approach.  As much as I disagree with the notion that we must “drink responsibly”, (why chance behaving irresponsibly by drinking at all?), I DO appreciate that the industry at least gives lip service to the need to imbibe in a responsible fashion. The food industry has historically NEVER adopted this notion. As a result, Americans harbor a bizarre OBSESSION with food instead of a healthy APPRECIATION of it.  Commercials depicting portly men with “real” meals consisting of a gazillion trans-fat-grams worth of fried chicken (plus two large sides) command our subconscience to scoff at portion control.  Our obsession with overloaded plates of value- meal goodies has lead to an epidemic of diabetes, sleep apnea, hypertension, stroke, heart attack and death while the American medical community as a whole has largely stood by and done nothing. I don't think it is intentional.  I think it's a combination of benign neglect and lack of knowledge. The extent of my medical school education on nutrition consisted of five 1/2 day sessions on food biochemistry presented while we all blinked and yawned and prayed for someone to put us out of our misery.   Now that we have beautiful studies on such entities as the Mediterranean diet, the downside of carbs, the pathology of transfats, we just need to roll up our sleeves and boldly go where few American physicians have gone before.  

Dietary instruction is the golden opportunity to shift our focus from treatment to prevention. When it comes to the end result of poor nutritional habits, we prefer to “put out the fire” instead of practicing “fire prevention”.  We unabashedly admit that we’d rather cath it, stress it, or medicate it than provide instruction on how our patients should properly fuel their bodies. We lament pharmaceutical compliance rates of only 50% but secretly loathe having to encourage even a 50% dietary compliance rate with life saving nutrients.  It’s high time we made the nutrition talk a mandatory part of every office and hospital visit. We should consider the lack of nutrition instruction just as much a part of self described medical malpractice as forgetting to subscribe a beta blocker, statin or aspirin.  We should also insist that America should infiltrate every level of education for our children with information on nutritional choices so our office visits are made more expedient in the future.      

When it comes to food ingestion, we (Americans) do EVERYTHING WRONG.   It’s HOW MUCH we eat, WHAT we eat, HOW WE PREPARE what we eat and even HOW QUICKLY we eat  that's all wrong. Skinny Americans have become extinct among the hoards of obese individuals in our country.  Drive –thru’s are conveyor belts for gluttons who super-size breakfast, lunch and supper and complain that they eat practically nothing but have packed on 100 pounds in a single decade. Mystery abounds in our every day lives, truly clueless as to how we became so obese and even more clueless as to how to correct it.  Beginning with McDonald’s and barreling on into the Kraft OREO era, Americans have been bombarded with images of smiling curmudgeons downing happy meals or unscrewing OREOs and  dunking them into tall crystal glasses of velvety white milk while smiling grandparents look on with approval. To our horror, the smiling curmudgeons of yesterday have become the sickly angina riddled frequent fliers on our cath tables today.  Thanks to slick marketing in the early 1980’s, withholding a happy meal or offering an apple instead of an OREO became grounds for contacting child protective services.   Our consciences have been seared by deep friers and baker’s ovens to the point that the definition of obesity has shifted upward a full 50 pounds from where it was 3 decades ago. 

There is reason to be hopeful however.  The transfat fight in America is taking off.  Places like New York City, Philadelphia and the state of California have finally forged successful legislation to cut the trash out of our foods.  Even Kraft jumped on board only 24 hours after a legal challenge to their recipe for Oreo Cookies outlined that the 7 fat grams in the standard three cookie serving included 160 calories, 1.5 grams of saturated fat and 5.5 grams of “unidentified” fat.  Rapidly and without protest, Kraft changed their 3 cookie serving to a healthier 7 fat grams consisting of 2 grams of saturated fat, 1 gram of polyunsaturated fat, 3 monounsaturated fat grams and only “1 unidentified fat”. If Kraft can do it to an OREO, anyone can morph unhealthy artery damaging chemicals into something beautiful. It was like the first culinary "extreme makeover" in America.   Not only “CAN” it be done, it “SHOULD” be done.

Some Americans have stubbornly fought legislation to make our food preparation healthier.  They protest by siting “governmental interference” and fear the lack of  "freedom to choose” to die by lethal INGESTION.  However, the majority of the public is beginning to demand protection from tainted food substances. Polls prove that up to 69% of the population has started to really care.   In my city of Glasgow, Ky.,  Kentucky Fried Chicken just premiered its new Kentucky Grilled Chicken products to the satisfaction of hundreds of customers. If one of the unhealthiest cities in the world can embrace it, so can anyone. All other restaurants should follow suit. 

I subscribed to Bon Appétit for a couple of years. I guess I liked looking at the glossy pictures of bountiful meals and fantasizing that I could become a marvelous chef in the old European tradition.   My husband laughed. He knew the truth:  He was about as likely to catch me in the smoking hut at my local hospital as he was to catch me in the kitchen. However, I’ve slowly matured into someone that appreciates food more than I’m obsessed with it .That appreciation has spilled over into my every day practice life. I tell my patients that I really don’t care whether they like their diets right away or not. (Gasp)  Food should be viewed as fuel and we should forage for what our bodies require.(double GASP)  I tell them to eat what they NEED, not necessarily what they LIKE and soon, need and preference will become one and the same. (I'm sure I"m viewed by some as a pointy- eared Spock- like, liberal heretic,.... set phasers to stun.)   I laminate copies of the Mediterranean diet and place them in every single exam room.  I mention diet at almost every visit with every single patient. I write a million dietary consults per week for my nutritionist .  Even folks referred merely for stress testing at our hospital do not escape without the iconic Mediterranean Pyramid.  Enough already????........never.

As cardiologists and health care providers, our message to our patients should be clear and ever present:  Treat our diets with as much or an even greater importance than we do our medication regimens.   Like medication, we should take in the food we need daily and consistently.  As physicians, we have a responsibility and a duty to become politically involved in such a way that the culture of American cuisine changes swiftly and certainly. It also helps if we, the advise -givers try to be good examples for our patients and maintain a normal body weight, exercise and make healthy food selections ourselves. ......(and downsize the movie popcorn)

 In an era where advice is liberally thrust onto the American public to drink responsibly, go green,  curb global warming, practice safe sex, recycle,  drive responsibly and  exercise consistently, it’s high time we promote a  new Vulcan like message to our patients. As Mr. Spock would say, "Eat responsibly", then he would punctuate it with a single raised eyebrow ,  head tilted slightly to the left, fingers spread, adding the  infamous words: " Live Long and Prosper."

Now, Take us out Scotty,......at warp speed toward a healthier and more prosperous America.

Clinicians, politicians, policy makers and payers are talking about comparative effectiveness with catch phrases as varied as "focusing on what works," "rationing care," and "limiting choices". But what does "comparative effectiveness" really mean? To help answer this question and unravel the implications for practitioners, cardiovascular research and patient care, Dr Harlan Krumholz joins the show with thoughts and expertise to tackle this controversial and timely issue.

What are your thoughts? Join in by commenting below or calling 1-866-996-5440 to leave an audio response.

In this inaugural episode, Drs Topol and Teirstein focus on SYNTAX. From the basic questions--Does the trial have value? Has it affected clinical practice?--to the problematic issue of randomizing patients to a 20-minute intervention or a weeklong hospitalization, they also ponder what they have learned from revascularization trials and paper cuts as well as the whimsical image of performing PCI on CV surgeons.

Current U.S. Definition of  Reward:  25-30 million dollar contract for one year of play for the Chicago Bulls in 1996  provided by Michael Jordan for his “expert” athleticism.

Current U.S. Definition of Greed:  Dr. X provides endless hours of consultation for device development with SinTronic and brings “expert” new V-fib prevention technology to the US in the year 2100, receiving 3.2 million in personal profit over 5 years.   

Debate:  Michael Jordan doesn’t influence what you put into your body “for profit” whereas the actions of physicians can directly result in increased utilization of devices and compounds for human consumption.

Counterpoint: Image of Michael Jordan guzzling a huge bottle of ice cold Gatorade, smiling and refreshed, beads of enthusiasm dripping from his forehead.  Millions of young athletes subsequently refresh themselves to the tune of a billion dollar profit margin. 

    So is COI disclosure a proclamation of Greed or Reward? Is it the lay public that is more interested in this debate or fellow physicians who are truly concerned about the preservation of honesty and integrity among the members of our sacred society? Are some of the seemingly concerned physicians and scientists  driven by the green-eyed monster or just driven period?  I’d say it’s a little or a lot of all of these issues.    

    Firstly, we have to toss around the term Greed a bit, and don’t get me wrong, I do believe that greed potentially exists in every area of profiting , but I think we should be very careful about how we define it. We also must admit that sometimes we can’t tell the difference between Greed and Reward. Now for the most difficult pill to swallow; sometimes, except in matters of conscience, it really won’t matter what motivates us as long as the results are beneficial to the masses.       

   To further complicate matters, greed is not concrete.  You cannot touch it or see it, but like the wind, it can well up suddenly from no where.  The noise of greed can be as quiet and unnoticed  as the rustling of leaves, or as  deafening  as the sound of a roaring freight train screaming out from the eye of a  tornado. Greed can be as subtle as demanding payment “up- front” from an impoverished but ailing patient with no other options, or it can be as obvious as the physician who takes payment to promote a device that he knows could be harmful but didn’t admit it. Greed unfortunately is not confined to the board room.  It is sometimes found in the exam room, so we must be very careful toward whom we are pointing our finger.  The pay scale may be different, but the motivation is always the same.   

     Since Greed is abstract, we cannot put our arms around it, but still we admit that we  are intrigued at the possibility of being able to harness it for good.   Like the product of giant hillside wind farms where turbines turn slowly, methodically, even eerily capturing what we cannot see but transforming an invisible destructor into enough energy to drive a nation, greed could be put to similar good use. For instance, a “greedy” but brilliant physician has an innovative idea that could save millions of lives and provide unimaginable reduction in suffering over a 100 year period. I don’t think many would argue that he should be paid for the idea.  However, should he hold off on publishing  his idea until it can be sold to the highest bidder while thousands suffer?    Can he speak about it on the lecture circuit?  Can he implement it?  Can he hold stock in its company?

      By the most current and widely accepted definition, it could be said that “greed” has infiltrated the every day practice of medicine, the inner sanctum that previously held only the promise of healing, comfort and longevity. However, thanks to “greed”, the practice of medicine holds the promise of health for those subject to it and wealth for many who enter into it, at least on a relative and materialistic scale.  But is one man’s greed another man’s simple prosperity?  Am I not wealthy if I have three square meals while citizens of 3^rd world countries lay dying of hunger?  Just as wealth is relative, so is the term “greed”. 

     Before any of us  sanctimoniously rend our clothing, declaring our complete immunity from any tendency toward today’s definition of “greediness”, consider this:  Gone are the days when physicians would provide medical care or advice in exchange for a hen, a warm meal or a service.  The culture of care- giving and advice- giving has become a commodity and the change in this culture has been rapid, unimpeded, embraced and even promoted in America. In most instances, viewing medicine as a commodity has not been a bad thing.  The promise of a comfortable life style for our families despite a life of complete and utter chaos on a daily basis attracts highly motivated, intelligent and dedicated individuals to its ranks.  It has produced advances in medicine that would have never occurred if we were still receiving a mere dozen eggs for our innovations. Throughout our culture, humans have died from the lack of innovation and consequently, as scientists, we are now handsomely rewarded for it.  We SHOULD be rewarded but there should be regulations, stipulations, and checks and balances put into place so that some of us don’t go too far and fall prey to the “enough is never enough” mentality.    

     I’ve tried to wrap my head around any meaningful suggestion that might help untangle greed from reward.  I’ve gone back and forth a million times. I’ve even sworn off any remuneration from pharmaceutical companies years ago, but like other physicians, I’ve continued to speak for them because I believe in their products and I like to furnish  and receive assistance from my fellow physicians by sharing what I know and implementing what I learn.  For me, it’s been a personal choice, but it shouldn’t have to be universal.   

    I’ve finally come to the following conclusion: Just as American as apple pie, the idea should hold that the person with the best ideas and the hardest work should be rewarded the most.  We should not stifle creativity and innovation in the name of propriety.    A marriage of the Physician Payment Sunshine Act of 2009 to the Rob Califf idea of a publicized and accessible website where physicians are “outed” with regard to company ties is the ideal.  This marriage demands much needed stipulation and regulation, provides the opportunity for investigation and tracking as well as the much needed requirement of publication of industry ties. 

   Finally, in accepting that greed is an abstract entity ,we also must accept that we cannot legislate it out of existence.  It’s an attitude, a feeling, a desire and for some, a blueprint for our obsessions. Maybe some of us harbor it and some do not, or maybe all of us possess it within the far reaches of our own dark DNA.   Some of us are governed by a moral compass that would never let us profit at the expense of human safety and others become  lost in it forever,  taking blood money and never looking back .

   To most that benefit from the technologies whose birthing places can either be named “Greed” or “Reward”, it will not really matter.  Let progress continue under the watchful eye of government regulators and give all of humanity a front seat to monitor who is doing what, and then in the end, as with all things, let God sort it out.       

  FIVE Nevada legislators  understand the economics of tobacco use and voted against the measure.  They are obviously among the few individuals voting who cared enough to actually study the economics of their state's health care plan at all. Earlier in the day, the New York Times reported that the Nevada State assembly passed legislation ensuring outpatient cancer treatment for indigents.  Democrat Sen. John Lee who supports retaining the ban was incredulous at the turn of events and stated "if you are over 21 , it's oK to go ahead and kill yourself and everyone around you but the other house says 'wait a minute, my gosh.......if they have cancer, we've gotta take care of them'."

  From 1999 to 2007, medicaid expenditures for the state tripled while average expenditures for  the remainder of the country merely doubled.  Nevada spent 1.2 billion medicaid dollars in large part due to heart disease death rates of 242/100,000 as compared with the 211/100,000 for the rest of the country.  The smoking prevalence of 21% is higher than the US average of 19%.  If anyone needs a smoking ban, it's a state who triples its medicaid expenditures over the course of 8 years.  The Nevada FIVE are to be commended but  probably feel a lot like Lot and his family just prior to their infamous city's final firework's display. Having FIVE " righteous"  legislators just  might save them. ( After all, Sodom and Gomorrah only had four.) .... OK, OK,......don't get your Cirque tickets in a twist.....I'm only kidding!

I'm not the brightest bulb on the casino marquee, but I'd suggest that the legislators look at the health benefits reaped by other cities who've passed REAL smoking bans (not fake ones like Tennessee) prior to voting.  Pueblo Colorado's heart attack rate fell by 27% in just 18 months and by 41% by the end of the study period after passing a comprehensive public smoking ban. Surrounding cities who still allowed good clean air to be poisoned by the largely inconsiderate smokers saw no such decrease.    New York City produced a greater than 50% reduction in teen smoking resulting in 24,000 fewer nicotine addicts who WON't have to take the subway to their chemo and radiation therapies in the future.  Lexington, Ky. saw a 24% decrease in ER visits for acute asthma visits following their ban. From my viewpoint, smoking bans aren't much of a gamble.  It's a sure bet for LONG TERM decreases in health care  expenditures that will offset any supposed decrease in revenue from such concerns as losing the Tobacco Plus Expo convention.  (a real "plus" anyway you smoke it in my book).

The finger pointing in Nevada reminds me of a story a patient told me last week.  A very elderly gentleman said to me:   "Yeah,.....I remember when you were a very little girl (about 5 years old I'd say), your mom and dad took you and your brother out to eat.  A saucer was knocked off the end of the table and your dad had to pay for it.  He thought your brother did it, but I saw who really did it", pointing to me.  I vaguely remember eating there at all, much less the rest of the story, but it's the same situation as Nevada. Like my unsuspecting little brother, the Nevada Clean air act  is getting the blame for slumping casino revenues when it fact, the entire country is in a slump period. On the other hand, it's interesting that the increase in lung cancer rates prior to the ban going into effect didn't get  any attention at all from those who are now crying foul over the clean air act.   Not a single casino or bar owner in support of softening the ban seems  the least bit concerned that their patrons, co workers and family members will be  dying at an alarmingly high rate.   Maybe their penchant for rolling the dice extends to gambling with the  health and human life of others as well.

Of course, The solution to the entire mess is obvious.   OUR NATION MUST become a SMOKE FREE nation!!!! (Washington, are you listening??) That way, none of this whining about losing business could be blamed on patrons running to places where they can sniff carcinogens freely and enjoy increasing the cancer rates of their friends and neighbors without pesky bans.  If the entire country were smoke free, we'd be "  healthier and wealthier "  and even "wiser" with all the money we could put toward education instead of toward chemo, radiation, home oxygen and primary PCI's.   

So back to Nevada.  I only hope for the sake of the rest of our country that "What Happens in Vegas Stays in Vegas".  If this state softens its smoking ban, I would hope that the rest of the country would stay OUT of Vegas, at least until someone else gets to deal the cards. If the state legislature votes to protect the public, lessen health care expenditures and prolong quality of life, then Nevada will have really hit the BIG Jack Pot!! 

Melissa

Science, politics, economics, ego, and turf war--all the possible subplots for a spy novel lurk in the background of this timely discussion on access to PCI. Sharing her thoughts on this debate, Dr Melissa Walton-Shirley describes her battle to provide primary PCI at her hospital in rural Kentucky, lagging guidelines, the stark comparison with realities in parts of Europe, and how best to save lives--whether in rural, suburban, or urban locations--throughout the US. This is a passionate episode that you won't want to miss!

What are your thoughts? Join in the discussion by commenting below or calling 1-866-996-5440 to leave an audio response.

Promising results from David Holmes’ PROTECT-AF trial seem to pave the way for a reduced need or possible total eradication of anticoagulation treatment. Are the intra- and peri- procedural events reported in the trial part of a learning curve? With this devise, are we one step closer to replacing the need for warfarin therapy?

See:

PROTECT-AF: Device closure of LAA may provide alternative to warfarin to prevent stroke in AF

ACC 2009: From the eye of the storm in Orlando

Update from PLAATO: Low rate of complications, strokes in 111 patients who underwent left atrial appendage closure

What are the steps to a successful career in clinical research? From broad topics such as personal maturation and focusing on what you enjoy, to practicalities including when to start pursuing research, how to learn the ropes, where to turn for deeper knowledge, and the importance of mentorship, Dr Deepak Bhatt shares his experience in this insightful interview conducted by Dr Arun Thukkani.

In considering how to fit this medication into my daily routine,  my initial impression is that  there will NOT be many indications for it.  Maybe those folks that come into ICU's post op with documented sinus rhythm who have witnessed new  onset of atrial fib would be a good first place to start.  I'd be very comfortable using it there. The idea of going to the bedside, giving a bolus or two of a drug that will convert 50% of patients to sinus in 15 minutes is a  lovely thought and less of a hassle than having to hold the  hands of nervous patients and family members who can't stand the thought of someone being gently electrocuted for sinus rhythm's sake. 

However, I worry that  Vernakalant will be inappropriately utilzed in ERs en masse to facilitate quick patient exits. The temptation will be great to just whip it out willy nilly in this economic environment where "drive through" everything is appealing.   In patients with high CHADS scores, they very well could be discharged without Coumadin and return in a few days with a devastating acute middle cerebral artery occlusion.  Since so many patients are mistaken with regard to the duration of their atrial fibrillation, I'd be very mistrustful of the perception of timing of onset of palpitory awareness.  As a cardiologist, I'd want an echo first.  I'd like to see their last EKG.  In some, I'd want a TEE pre-bolus and if you are going to sedate a patient for a TEE, why not just sedate them a little more and cardiovert them while their enjoying a little extra anesthesia?

This medication also has a strange side effect profile.  We'll have to tell them that 30% of patients have an odd change in taste perception,(but that could work for us.......i.e. instruction to the patient: "you'll think it's a hot fudge sundae but really it's lettuce"?)  11% will experience some form of paresthesias (will I worry they are Tia's?) and 16% will need to keep a box of tissue handy because they have an increase in "sneezing"(no honey, it's not the new cat, it's your cardioversion medication).  Others have transient but what appears to be relatively benign dips in blood pressure.( So do folks with cardizem IV, not usually a big deal).   

So until this medication reaches the US and is put into use, it will be difficult to predict the degree of implementation.  Will it go the way of IV dofetilide or will it become as common as IV cardizem?  Probably the best use of this medication will be a pairing with a heparin drip and p.o. Coumadin with a few days in the hospital post conversion, just to be on the safe side with discharge only after a therapeutic INR is achieved. 

I'm sure we'll figure it out, but if we don't figure it out well, quick trigger fingers for cardioversion in  hopes of a rapid ER discharge order could spell an increase in stroke incidence.  With all the information that cardiologists usually gather before we undertake a cardioversion, I don't think the problems will occur in the "IN- patient" population.  I think it's the "OUT -patients"  who have something to fear and unfortunately, I think it's more than "fear, itself". 

 Fortunately, we may have data that keep us from having to re-invent the wheel, after all, it's already being utilized in other parts of the world.  However, before we start to utilize it ourselves, we need to think about it a bit.......I mean REALLY think about it.

Melissa