The following is a guest blog post by Marilyn Mann, a securities lawyer who became interested in medical research while researching treatment options for her teenage daughter, who has heterozygous familial hypercholesterolemia, a genetic disease that causes very high LDL-cholesterol. She blogs at http://marilynmann.wordpress.com/.
“Oh no he didn’t.” That was my first reaction when, a few minutes into CNN’s one-hour special, “The Last Heart Attack,” Sanjay Gupta is shown being wheeled into a CT scanner to undergo a coronary artery calcium scan. I had read a story on the CNN website promoting calcium scans, so I was expecting a certain amount of boosterism for the high tech scans, but it hadn’t occurred to me that Gupta was going to make himself a guinea pig as part of a “mission to never have a heart attack.” Here are my thoughts:
1. The calcium scan exposed Gupta to significant radiation, increasing his risk of developing cancer.
2. A trim, healthy man in his early 40s, Gupta is almost certainly at low risk of a heart attack as estimated by his Framingham Risk Score (i.e., less than 10 percent risk of a heart attack in the next 10 years), and the leading cardiology societies do not recommend calcium scans in low risk patients such as Gupta.
3. The use of high tech tests such as calcium scans, and the carotid ultrasound and advanced lipid testing Dr. Gupta also undergoes on the program, is one of the primary reasons our health care expenditures are spiraling out of control.
4. Calcium scans, when they are positive for calcium in the coronary arteries, often lead to referrals for expensive and potentially risky additional tests.
5. Calcium scans often find “incidentalomas” (i.e., suspicious masses on other organs), often leading to additional tests such as biopsies, even though the vast majority of such masses are harmless.
6. Calcium scans and carotid ultrasounds have only been shown to provide a small amount of incremental risk prediction over screening using traditional risk factors such as age, gender, blood pressure and LDL and HDL cholesterol.
7. Even if a person is found to have atherosclerosis through a calcium scan or carotid ultrasound, the main recommendation would be for the person to start taking a statin or take a higher dose of a statin, if already on one. Statins do not make a person heart attack proof – they only lower risk 25 to 30 percent.
8. The fact that calcium scans are not a magic answer is, oddly enough, demonstrated on the program by the fact that both Bill Clinton and Tom Bare, a heart patient interviewed on the program, had calcium scans several years before their bypass surgeries.
I fear that many middle-aged people – after witnessing Gupta undergoing these tests – will feel the need to request the same tests. But here’s a thought not mentioned by Gupta or Dr. Arthur Agatston, who administered the screening tests to Gupta: screening with calcium scans and carotid ultrasounds has never been shown to improve health outcomes over traditional risk factor screening alone.
If the main result of high tech scans is to put more people on statins, but statins do not make people “heart attack proof,” is there something else that will? The answer presented on the program is strict low fat plant-based diets, as advocated by Dean Ornish and Caldwell Esselstyn, and recently adopted by former president Bill Clinton, who is extensively interviewed on the program. Both Esselstyn and Ornish claim their programs can lead to regression of atherosclerosis, but the evidence for this is thin: a small trial of the Ornish program was published in The Lancet in 1990. The trial involved 28 patients on the Ornish program and 20 controls, and showed some regression of atherosclerosis in the Ornish program group. Esselstyn has published a study of 22 heart patients showing that those who stuck with his diet and also took statins to lower their total cholesterol to 150 or below did well over several years. Both the Ornish program and Esselstyn’s program involve intensive counseling and could never be implemented on a wide scale. Don’t get me wrong, I think plant-based diets are great, and I’m glad Bill Clinton is eating beans, whole grains, vegetables and fruit instead of hamburgers and fries, but I don’t think we’ll see the last heart attack anytime soon.
– by Marilyn Mann
Journalist Larry Husten also reviewed the program on his Cardiobrief blog. Excerpts:
Gupta tells viewers that there are over one million heart attacks each year in the US and that he has the answer:
“I’ve got a secret to share — with what we know right now we could see the last heart attack in America. I’ve been investigating this for over a year. I’ve got lessons to share, things you need to know, things your doctor may not tell you.”
Gupta’s “secret” is basically intense screening with calcium scans, carotid ultrasound, and blood tests for LDL particle size. People at high risk should then follow a radical low-fat diet.
Gupta never mentions the lack of a solid evidence base for this program, and never mentions the cost or other risks of screening programs. Calcium scans get a rave review, but there’s no mention of radiation exposure.
Despite his entire year of research on the topic, Gupta somehow missed the wide divergence of opinion about the utility of these screening tests and widespread concerns about the practical barriers to implementing a radical low-fat diet. He never mentions that by most current guidelines a significant proportion of the population should not receive these screening tests.
Gupta almost never asks hard questions of his sources.
And then there’s the fear-mongering, which once again goes unchallenged:
“Unless you do the imaging and advanced testing, you are really playing Russian roulette with your life.”