Prevention magazine pushes high-tech non-evidence based heart screening more than basic prevention

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The February issue of Prevention magazine has an article, “Surprising Faces of Heart Attack” profiling “three women (who) didn’t think they were at high risk. Their stories are proof that you could be in danger without even knowing it.”

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No, their stories are not proof of that.

The story is about three women in their 40s. The story varyingly states that the three should have had the following screening tests:

* advanced cholesterol test, carotid intimal medial thickness test ( CIMT)
* advanced cholesterol test & stress echocardiography
* cardiac calcium scoring and CIMT

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There’s an accompanying piece, “7 Tests You’re Not Having That Could Save Your Life.”

7 Tests.jpg

Harry Demonaco photo.jpgI asked one of our medical editors, Harold Demonaco, director of the Innovation Support Center at the Massachusetts General Hospital, to review the two pieces. As his job title on his day job suggests, he deals all the time with review of the evidence for new and emerging health care technologies.

He wrote:

The section, “7 Tests you are not having that could save your life” states: “If you have not had these cutting edge screenings, put this magazine down and call your doctor. Now”


While much of the information is correct, it is the context that is disturbing. Suggesting that these tests are essential in everyone is a bit over the top. Some of the information provided for each test is basically correct. However in some cases the recommendations go well beyond national guidelines.

The major issue here is the tacit assumption that tests are infallible, without any downsides and are always a good thing. That is simply not the case. So who should get these tests? Here’s what national guidelines suggest:

1. Cardiac calcium scoring-

The most recent recommendations in 2007 states:

“….it may be reasonable to consider the use of Coronary Artery Calcium scoring measurement in asymptomatic patients with intermediate coronary heart disease…” Intermediate risk implies a 10-20% risk of a coronary event in the next 10 years.

“The committee does not recommend use of Coronary Artery Calcium measurement in people with low risk (below a 10% risk of a coronary event in the next 10 years. This patient group is similar to the “population screening” scenario and the committee does not recommend screening of the general population using CAC measurement.

A far cry from what is being suggested in the article.

2. Carotid intimal medial thickness
The article suggest the test is needed if you are over age 40 or if you are under 40 and a close relative had a heart attack or stroke before age 55. Here’s what the US Preventive Services Task Force said in 2009:

“Carotid intima-media thickness (CIMT) measurement is a noninvasive test that serves as a surrogate marker for coronary atherosclerosis. There is a correlation between CIMT and traditional coronary risk factors. The clinical utility of measuring IMT for the purpose of predicting risk of coronary or cerebral events has not been established. It is not evident from the literature that CIMT is able to improve on risk prediction above what is provided by utilization of traditional risk factors or the effect of these measurements on patient outcomes.”

3. Advanced lipid profile and lipoprotein test

The article notes: “Get Them If: You have a family history of heart disease”
But, the 2010 guidelines from the American College of Cardiology and the American Heart Association suggests that lipid parameters beyond standard fasting lipid profile are not recommended in asymptomatic adults.

4. DNA detection

Anyone over age 40 should have genetic testing according to the article. A published meta analysis from the Journal of the American College of Cardiology found, “ significant relationship between development of clinical coronary artery disease and the gene variant…” Hardly an endorsement for use of the test in anyone over the age of 40.

The article is basically within standard guidelines with regard to testing with A1C and stress echocardiography.

Surprising faces of heart attack

Each of the women’s stories represents a teaching moment that is lost. The histories are incomplete and little can be said other than generalities. Having said that, each story is interesting in what is said. One woman is said to have hypersomnia requiring her to have 10-12 hours sleep each night. Hypersomnia is a condition that results in excessive sleepiness during the day. There is also a suggestion that 5 hours of sleep nightly increases risk of a cardiac event. That is perhaps true if the person is sleep deprived. It is probably not true if, like many people, 5 hours sleep is sufficient. Suggesting that all of us need 10-12 hours sleep is not supported by any literature.

Another woman is described as a 47 year old woman who at the time of her heart attack was morbidly obese (her height of 5 ft 4 inches and a weight of 245 pounds gives her a body mass index of 42, well into a range defined as morbidly obese. This single element in her history places her in a high risk category. Ms. Younger had borderline obesity when she had her heart attack. Perhaps the tests suggested are appropriate but other more mainstream tests should be done prior to these high tech options according to standards of care. Rather than focusing on high tech and in some case rather controversial tests as being necessary, where is the recommendation on primary care, an annual physical and most importantly on lifestyle modification?

For a magazine named “Prevention” there seems to be a good deal of emphasis on high tech testing and not on preventive medicine.

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Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Michael Kirsch, M.D.

January 22, 2011 at 6:39 am

Let’s not forget about the Total Body ‘Scam’!

Susan Fitzgerald

January 24, 2011 at 1:17 pm

Thank you, Gary, for getting your resident expert’s take on this. Great example of the kind of needless procedures that help rack up the country’s medical tab, while scaring everybody into the bargain.

Lisa Collier Cool

July 13, 2011 at 9:33 pm

Hi Gary,
While you’re entitled to take any view you like about my work and that other health journalists, I have several points about your post re my articles in Prevention, starting with your failure to disclose that I interviewed you last year for an article in American College of Obstetricians and Gynecologists’ Pause magazine, during which you indicated that you were strongly opposed to ACOG’s recommendations on frequency of mammograms for women in their 40s. I believe that this should have been mentioned so your readers can judge whether you might have any bias about my work, since I didn’t end up quoting your views about mammograms, given that you’re not a healthcare provider.
Next, your post doesn’t mention that the special report actually consists of 21 pages and several articles, not just the 2 you discussed, all of which were rigorously fact-checked with sources including studies in peer-reviewed medical journals, more than 30 interviews with leading cardiologists, reports from the American Heart Association, which provided the 6 women interviewed for the article. As a result, I was able to avoid such errors as the potentially dangerously inaccurate claim by the medical editor you quoted saying that sleeping five hours a night is just fine for people who feel they don’t need much sleep, given a recent cross-sectional study of 30,397 participants in the 2005 National Health Interview Survey found that sleeping this little is associated with with an odds ratio of 2.20 for cardiovascular disease, compared to participants who slept 7 hours. What’s more, there are a number of other studies with similar findings, including increased risk in people who average 6 hours.
I also wonder why you had my article reviewed by someone who not only isn’t a cardiologist, but isn’t even a MD. According to an online bio, Mr. DeMonaco holds a MS degree, so seems like an odd choice to review a portion of my special report on heart disease prevention or offer medical advice to your readers about sleep. Certainly I would never have interviewed someone with these credentials for any article I wrote on healthcare, since I talk to highly credentialed physicians in the field I’m covering.
Mr. DeMonaco is correct in saying that some of the screening recommendations in the special report, which is focused on state-of-the-art heart disease prevention, does indeed go beyond national guidelines in some cases, based on how a number of nationally renowned CVD prevention specialists treat their own patients, with far greater success at preventing heart attacks and strokes than that the standard of care that results in one on 3 heart attacks and one in 4 strokes being a recurrence in someone who has already survived one or more CVD events and in CVD remaining the leading killer of Americans, causing about one in 2 deaths in this country. There is substantial evidence that the standard of care may be adequate to protect doctors from lawsuits, but not to protect patients from heart attacks and strokes through early detection and optimal care.
Neither you nor Mr. DeMonaco point out how little medical evidence there is in support on those guidelines and how rarely they are updated (some are a decade or more old). Many are just based on expert opinion. Although many people consider guidelines to be the epitome of medical evidence, a troubling 2009 study published in JAMA reported the following regard the current practice guidelines of the American Heart Association and American College of Cardiology:
>Considering the 16 current guidelines reporting levels of evidence, only 314 recommendations of 2711 total are classified as level of evidence A (median, 11%), whereas 1246 (median, 48%) are level of evidence C. Level of evidence significantly varies across categories of guidelines (disease, intervention, or diagnostic) and across individual guidelines….Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing. These findings highlight the need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived.
This would actually be a very interesting topic to cover in your blog to provide balance for the many posts that only present the case in favor of adhering to guidelines, even those that are out of date, based on weak evidence or mere expert opinion, or aren’t effectively addressing the #1 killer of Americans.

Lisa Collier Cool

July 13, 2011 at 11:29 pm

To add to my earlier comments re this review of a portion of my special report in Prevention by a non-doctor with a MS degree, Mr. Demonaco is also incorrect in stating that the portion of the report he read contains any recommendation that “all of us need 10=12 hours of sleep per night.” This statement is false and seriously misrepresents the content of that article. This particular patient, due to her rare sleep disorder, stated in the article that she personally needs that amount of sleep to feel “normal,” but that most nights she was getting fewer than 5 hours, which has been linked to more than double the risk of cardiovascular disease, as per the study I cited in my previous comments, contrary to Mr, Demonaco’s medically unsound assertion that sleeping that amount is just fine.
Finally, regarding genetic testing, it appears that as a non-cardiologist and non-doctor, Mr Demonaco is unaware that many leading hospitals are using these tests to check for heart disease risk, including Vanderbilt Heart and Vascular Institute, Johns Hopkins, Jefferson University Hospital, and University of Pennsylvania. For the first time, the American Heart Association included a chapter on family history and genetics in its 2011 Heart Disease and Stroke Statistics update, published in Circulation in December, in which Veronique Roger, MD, MPH, lead author of the report, states that the trend in cardiology calls for not only tracking disease, but also taking a closer look at risk factors and what it takes to stay healthy: “it’s going to be important to continue to track how genetics can influence the burden of CVD,” she notes. Daniel Rader, MD, director of Penn’s Preventive Cardiology and Lipid Clinic, recently reported that genetic testing for heart disease risk is a superior technique to asking patients about their family history, which often misses people at high risk.
I think that the responsible way to look at the facts in that portion of the report would have been to seek the opinions of nationally renowned cardiologists (I spoke to several of them, multiple times during my research) for a truly expert opinion instead getting the views of someone with a MS degree who has no particular expertise in heart disease prevention. Somewhat ironically, while he apparently doesn’t think much of Prevention magazine, its high editorial standards would not have permitted me to use him as an expert in the article that he’s commenting on your blog.

Gary Schwitzer

July 14, 2011 at 5:12 am

It doesn’t require a cardiologist or a physician to evaluate evidence.
Here’s a brief biosketch of Harry DeMonaco, whose expertise you question:
He is the Director of the Innovation Support Center at the Massachusetts General Hospital. A graduate of the Massachusetts College of Pharmacy and Allied Health Sciences he holds a bachelors degree in pharmacy and a masters degree in therapeutics. He formerly served a Director of Drug Therapy Management and the Director of Pharmacy as well as Chair of the Human Research Committee at the MGH. He has a keen interest in the innovation process in medicine and organizational behavior related to change. He is the author of two dozen articles and book chapters and routinely conducts manuscript reviews for medical journals. He formerly served as a core editor at Harvard Health Publication and is a member of the editorial advisory board for Proto Magazine and Biologic Therapies in Psychiatry.
We stand by our post. Much of the piece smacked of fear-mongering.

Gary Schwitzer

July 14, 2011 at 5:40 am

I also want to respond to your comment about your “interview” with me last year about mammography.
Let me be clear: I don’t believe in “journalism” that gives health care advice. That’s one of the problems I had with the heart piece in question above. So I don’t give advice to anyone about screening tests except that it is wise to be fully informed with unbiased, balanced information. That’s the only bias I have. I wouldn’t tell anyone not to be screened or to be screened. But I do have a bias strongly opposing news that doesn’t report both the potential benefits AND harms.
I recall our phone “interview” and, since we’re matching recollections, I recall a biased line of questioning on your part, closed-minded to the potential harms of screening.
Remember: you asked me for the interview, not the other way around. And, after a lengthy phone call, if you chose not to use any of it, that’s up to you. It apparently didn’t suit the piece you already had in mind.

Harold DeMonaco

July 14, 2011 at 8:42 am

I would like to thank Ms. Cool for her comments. Her opinions are commonly held and have support among many. She notes that I am “not even a physician.” I plead guilty as charged. There is an implicit understanding in her comment that one must be a physician to understand the value of medical technologies. To that point I would strenuously disagree. I have co-chaired a committee that evaluates new technologies at a well respected Harvard affiliateds institution and have done so for 10 years. Apparently others would disagree with her as well.
There has been a growing tendency for the media to view medical diagnostics as only beneficial. The general public, in large measure, assumes this as well. The furor over the US Preventive Services Task Force recommendations on breast cancer screening is perhaps the most notable example. The reality is that this is not the case. There are in fact downsides to any test, especially when misapplied to a population of patients who are at low risk for the disorder in question. The most recent report from the National Lung Screening Program once again highlights the risks even in a patient population at high risk.
The value of a diagnostic test is a balance of the sensitivity of that test (the proportion of people with the disease who are correctly identified) and specificity (the proportion of people who do not have the disease and are correctly identified). Implicit in the use of a test in the person’s (or patient’s) likelihood of having the disease in question (also know as the prior probability). People with a low likelihood of the disease are more likely to have a false positive even with diagnostic tests with high sensitivity and specificity. Mis-applying diagnostic tests is not only wasteful, it exposes the patient to risks associated with more invasive follow up procedures. The vast majority of diagnostic tests are invaluable to physicians and their patients when applied in a selective patient population.
Ms. Cool would appear to suggest that the guidelines associated with cardiac diagnostic tests are flawed. Indeed they are. They are the opinions of a group of notable experts in the field and their recommendations based on the literature available at the time. Most guidelines also rate the relative validity of the recommendations based on the literature as well. While Ms. Cool is certainly entitled to believe that the opinions of a small number of experts is more valuable than the collective wisdom of a nationally selected group, I do not share her opinion.
This discussion should not be about personalities or who said what and when. This discussion should be about the ability of the media to provide valuable and unbiased information to the public that truly informs.

Lisa Collier Cool

July 14, 2011 at 6:25 pm

Thank you for posting my comments and the details of Mr. Demonaco’s bio. While I am sure that he is good at his job, perhaps even outstanding, were I ever unfortunate enough to develop heart disease, or should I be determined to have risk factors for developing it, I would indeed seek the opinions of leading cardiologists of the ilk interviewed for the article rather than consult a non-doctor who evaluates technologies about the preferred tests to evaluate my heart health. I would seek a doctor who is able to deliver more than the standard of care that is resulting in one in 2 Americans dying of CVD, one who uses the latest study findings from peer-reviewed journals and randomized clinical trials to provide optimal care rather than blindly adhere to guidelines that may be based solely on so-called expert opinion of a decade ago.
I am currently collaborating on a book about prevention of heart disease, stroke and type 2 diabetes through a type of optimum care that my coauthors, a MD and nurse practitioner who specialized in CVD prevention, have successfully used with more than 2,000 patients at high risk for heart attack and stroke (including survivors of previous heart attacks and strokes, patients weighing as much as 400 pounds, those with various other risk factors such as high cholesterol, diabetes, and high blood pressure, etc.) with the result than only 2 had had subsequent events, one of whom had halted his treatment prior to the heart attack.
Leading doctors will tell you that almost all heart attacks and strokes are preventable, yet standard care isn’t doing a good enough job. Many top cardiologists have told me that over the years. So I stand by the article, which is being nominated for several awards, and also my belief that when writing about journalism that one should disclose interactions with the person one is writing about, to help readers judge if there might be any bias. I’m not taking a position on whether or not you do harbor bias against me due to your mammogram views not being quoted in my previous article, although you snippy comments re the line of questioning do make me wonder. My point is that this interaction should have been mentioned in your blog post, as per normal journalistic practice.
The topic of this interview, as you may recall, was a discussion of the quality of media coverage of the USPSTF’s updated mammogram guidelines and the controversy they provoked, not your opinions as to the merits of any medical group’s guidelines, which you offered spontaneously and were not relevant to the article, given that you are not a doctor and commenting on medical guidelines is beyond your area of expertise, as I’m sure you’d agreed.

Lisa Collier Cool

July 14, 2011 at 8:02 pm

Thank you, Mr DeMonaco. Your qualifications sound extremely impressive in your field, though with all due respect, I would have expected Gary to have consulted a physician or researcher who specifically focuses on cardiology.
I am in agreement that the guidelines are flawed and with some of your other points. However, I notice that you didn’t remark on the 2 errors I identified in your review, one of which presents me in a false light as an inaccurate journalist by erroneously stating that the article claimed that everybody needs 10 to 12 hours of sleep, when I never made any such assertion and strongly disagree with this notion. I hope you will correct this misrepresentation of the article’s content, which I’m sure was inadvertent on your part.
Additionally, I hope you will also correct the mistaken claim in your review that averaging 5 hours of sleep a night is NOT associated with increased risk for cardiovascular events, when multiple studies in peer-reviewed journals demonstrate a strong association with averaging less than 6 hours and a significant increase in CVD risk in large study populations, reported at more than doubling risk in the study cited in the article, since I think we’d both agree that it’s extremely important to be accurate in discussing health matters and recommendations, even if we disagree about the merits of some of the screening tests discussed in the article. Again, thanks for taking the time to weigh in.

Gary Schwitzer

July 14, 2011 at 9:07 pm

I’m happy to post another round of your comments, but will not continue this ad infinitum, since we seem to be covering the same ground over and over. I don’t have unlimited time to respond to the same comments over and over.
Let me reiterate: You refer to my “mammogram views.” My “mammogram views” are about imbalanced journalism about mammography. Period. I don’t give health care advice. I work every single day to improve health care journalism. My work in this area is well known. After all, it must be what drove you to call me for a lengthy interview about news coverage of mammography, none of which you chose to use.
Maybe you need to hear it from someone else.
I often quote John Crewdson, who spent 37 years as an editor and correspondent for the Chicago Tribune and The New York Times, where he won a Pulitzer Prize for National Reporting:
“There are multiple reasons women are ill-informed about breast cancer. The fault lies primarily with their physicians, the cancer establishment, and the news media — especially the news media. Until coverage of breast cancer rises above the level of scary warnings mixed with heartwarming stories of cancer survivors, women are likely to go on being perplexed.”
A recent analysis published in the American Journal of Preventive Medicine was entitled, “The Public’s Response to the U.S. Preventive Services Task Force’s 2009 Recommendations on Mammography Screening.”
It concluded:
“Of the 233 newspaper articles, blog posts, and tweets coded, 52% were unsupportive, and only 18% were supportive…. These results are consistent with previous studies that suggest a media bias in favor of mammography screening.”
So there you have it from another veteran journalist and from an academic analysis if you don’t want to take my news analysis into account: mammography news coverage was often biased.
Bias in screening stories exists when journalist discuss only benefits and downplay or totally ignore potential harms. That is what we discussed about much of the coverage of the US Preventive Services Task Force’s recommendations – and what you chose not to use.
I will also reiterate that it does not require a physician with a subspecialty in cardiology to evaluate evidence. I know many people with an MS, MPH, PhD or other non-MD degree who can evaluate evidence better than many MDs. I am currently attending the terrific NIH Medicine in the Media workshop training journalists in how to evaluate evidence. Indeed, journalists can be trained to evaluate evidence rigorously and completely. About 60 journalists are benefiting from such training this very week. You may wish to avail yourself of this wonderful training yourself some day. I was also asked to write a guide for the Association of Health Care Journalists on how to evaluate evidence. As a member, you have free access to this guide. You may wish to access it yourself.

Harold DeMonaco

July 15, 2011 at 8:16 am

Ms. Cool:
I must admit that I find this discussion to be rather pointless at this juncture. So, my impression in reading your article was that you suggested that we needed 10-12 hours sleep. Since I cannot go back and relive the moment and I don’t have access to the source document, perhaps my impression was incorrect.
A valid discussion about sleep duration and cardiovascular events is well beyond this medium. I stand by my comments about the sleep duration. Normal sleep has a Gaussian distribution down to and including as little as 5-6 hours. Cardiac risk appears to be bimodal with too little sleep (deprivation) associated with increased risk and now evidence that too much sleep (albeit poorly defined) also increases risk.