A recent report on incidental findings from a cardiac monitoring study bolsters my view that modernity is shredding our health. The paper is a re-analysis of one of the most important cardiac trials of the decade—the LOOP trial. First LOOP, then the new study.
Read drmirkin.com. He has kept me straight for over 40 yrs. At 72, I have had multiple issues, but it always comes down to exercise and diet. But don’t forget the real KEY to health and that is to have close meaningful relationships.
I think you’ve convicted the wrong suspect. You’ve attended to the part of the scientific method where hypotheses are tested. In the cases of anticoagulants for stroke prevention in people with occult atrial fib and pacemakers for asymptomatic bradycardia, we have new evidence that the hypotheses were incorrect. Scientific knowledge increased; we’re better off than we were before. Time for a rethink, time for new theories and new hypotheses. That’s how science should work, these are constructive and healthy phenomena.
I think that what is being called “Scientism” is the guilty party. Our (modern) loving embrace of the new, the technological, the product of years of expensive development, advised by the experts and the commissions and the societies, paid for by our insurance or tantalizingly, horribly expensive. When we adopt too soon without appropriate testing, because, well, with all those smart scientists and all that money behind it, how could it not be good?
Dr Mandrola--great article. I am a medical student who has recently gone deep down the rabbit hole of the big food corporation--big pharm--medicine triangle of profit thanks to the recent pushing of Ozempic. Doctors and pharmaceutical companies are making billions of profit off patients who are living under a structurally violent food ecosystem. You should check out Calley Means and his new start up company True Med, which will allow patients to use HSA dollars to buy healthy foods with a prescription from a Doctor. We fix the food through legislation and public health policy, and modernity will self correct as I see it. Calley’s start up is just that --a start. Would love to see him on a Sensible Medicine podcast episode.
This is a really interesting set of results but why target 75 year Olds? Surely a much more useful group to invest a study of this scope would be the age range 45 to 55 years. Which from my very limited research is known for cardiovascular issues. This group has the potential for losing 25-30 years of life and many years of contributions to society. Myself included here, I had a heart attack aged 47. At the point I had been very active, running 80+ miles per week, eating healthy foods.
I had MRI and angiogram which showed all arteries clear without any blockages or reduction of blood flow. I had low BP and low resting HR low 40s. EF of 30
I had an ICD implanted and on drugs like Warfarin. I maintained a daily run obviously slower and reduced pace.
8 years of stability and then rapid degradation to EF of 12 over about 8 months. Blackout due to vfib HR 245, and shocked back to normal. Ablation surgery improved VT episodes for about 2-3 months until a VT storm took me down and a heart transplant rapidly following ECMO.
Family history is awful for cardiovascular issues.
But groups that includes my age benefits hugely from these studies.
Am I such an outlier or are there many who go undiagnosed and not as fortunate as myself to overcome these issues?
I like screening coronary calcium scans. A recent case gives me pause. Middle aged man with very low calcium score ended up having a coronary stent 2 yrs later. It supports the idea that a CCS needs to be done in the context of all the other risk factors. There is no easy answer here.
But imagine if we started looking for, and Tx, these things in people 10yrs earlier! shouldn't we reduce the age recommended for screening to include pts 10ys younger? for everything? why, you could see pts going up to 10yrs longer before their first Mi! or...whatever. for any item, that we can sell a daily product for.
in fact, implant these in kids at birth! (it may even be worth offering that for free? as a public service! you have to spend money to [EDIT: SAVE LIVES] & ...oh, nah, actually make the Gvt pay for it. at an inflated price. (bc they can afford it! anyone who votes for it get stock options. you know, for their public service?)
seriously, though: ethically, just think of the the "life yrs" sales! i mean saved. no, i meant sales, i did mean sales. fine entry as always. _JC
Why do you blame "modernity", a person I have never met? "Modernity" is a 'systems' perspective, and that perspective just makes it easier for the accountable people involved to skip to a different world-view where they take no blame. (There is nothing wrong with accepting blame, by the way, and doing penance and making amends. We should all try it. It hurts, though). You hint at 'blame' when you describe the errors in this study from the gitgo in setting up the samples. What I think you are pointing out, Doc, is that a "doctor" is just a primate who went to medical school, whether they wanted to or not, whether they should have or not. Ditto the hospital CEO and the members of the board of whatever company makes the Life-Saving-Gizmo du jour: just change the name of the school, the 'socializing institution' itself made up of, well, primates. How do you reach those folks, for folks they are - just like us? How do you engage them in the lives, and even the *contexts* of the lives, of the very people whom they see as their 'raw materials', their 'patients' and 'consumers'? How do you teach them to think clearly rather than measure blindly? How do you teach them the importance of sympathy, and empathy. Otherwise, Doc, you are going to be writing the same blog piece again and again, I'm sorry to say.
Lots of parts to an answer but I think the largest part of it is medical conservatism, based on good evidence. This applies to drugs, devices, procedures and most importantly whether the physician will "stop and think" before acting.
Thanks. What an excellent article. It feels like I fight the overtreatment fight daily. I was unaware of LOOP results. They are still being advised by academic neurologists in my community.
I’ve seen it said that on average people were no better after seeing a doctor up to around 1900. Overall I suspect we continue to progress but lots of missteps along the way.
I think you go too far, Dr M. Cardiovascular mortality rates in the US are 1/3 what they were in my birth year. Anyone who trained in the late ‘80s knows that we have made enormous strides in the treatment of atherosclerosis. Hospitals were packed with patients having ACS and awaiting CABG. Thanks to public health measures, statins, stents, etc, CABG rates are way down. Unstable angina does not clog the in patient wards. “Modernity” has brought great benefits as well as unforeseen costs. I love your analysis of LOOP and your approach to Afib in general, but a major reason we waste so much time on Afib is we are no longer seeing patients with huge infarct scars and intractable heart failure.
“Another example: instead of preventing heart disease with good food and a culture of exercise, modern medical doctors order coronary calcium scans. There exists not a shred of evidence that the scans lead to lower rates of heart disease in the scanned”
Could there be a subset of patients that would benefit from screening? Can they be determined from any of the data? New procedures or therapies usually start with a specific population in mind but once they are shall I say let out in the wild they do not perform as well as expected due to them being used on inappropriate candidates.
Timely post...for me. Diagnosed with A-fib 5 years ago, quite dramatic and alarming presentation, initiation of expensive drugs. My resting heart rate was, and is 60 bpm. Recently developed unsettling palpitations with missed beats. I have badgered the cardiology office into ordering a Holter monitor. I mistakenly (I was told) thought the rhythm should be stabilized and regular with Coreg. Not so. This article was helpful to me in getting in front of perhaps unnecessary and dangerous interventions. Since I’m not passing out due to bradycardia, then I’ll just be steady as we go.
Read drmirkin.com. He has kept me straight for over 40 yrs. At 72, I have had multiple issues, but it always comes down to exercise and diet. But don’t forget the real KEY to health and that is to have close meaningful relationships.
LOOP was for 75 Year olds. Only applies to those around that age.
I think you’ve convicted the wrong suspect. You’ve attended to the part of the scientific method where hypotheses are tested. In the cases of anticoagulants for stroke prevention in people with occult atrial fib and pacemakers for asymptomatic bradycardia, we have new evidence that the hypotheses were incorrect. Scientific knowledge increased; we’re better off than we were before. Time for a rethink, time for new theories and new hypotheses. That’s how science should work, these are constructive and healthy phenomena.
I think that what is being called “Scientism” is the guilty party. Our (modern) loving embrace of the new, the technological, the product of years of expensive development, advised by the experts and the commissions and the societies, paid for by our insurance or tantalizingly, horribly expensive. When we adopt too soon without appropriate testing, because, well, with all those smart scientists and all that money behind it, how could it not be good?
Love your writing, John. Stay strong.
Dr Mandrola--great article. I am a medical student who has recently gone deep down the rabbit hole of the big food corporation--big pharm--medicine triangle of profit thanks to the recent pushing of Ozempic. Doctors and pharmaceutical companies are making billions of profit off patients who are living under a structurally violent food ecosystem. You should check out Calley Means and his new start up company True Med, which will allow patients to use HSA dollars to buy healthy foods with a prescription from a Doctor. We fix the food through legislation and public health policy, and modernity will self correct as I see it. Calley’s start up is just that --a start. Would love to see him on a Sensible Medicine podcast episode.
This is a really interesting set of results but why target 75 year Olds? Surely a much more useful group to invest a study of this scope would be the age range 45 to 55 years. Which from my very limited research is known for cardiovascular issues. This group has the potential for losing 25-30 years of life and many years of contributions to society. Myself included here, I had a heart attack aged 47. At the point I had been very active, running 80+ miles per week, eating healthy foods.
I had MRI and angiogram which showed all arteries clear without any blockages or reduction of blood flow. I had low BP and low resting HR low 40s. EF of 30
I had an ICD implanted and on drugs like Warfarin. I maintained a daily run obviously slower and reduced pace.
8 years of stability and then rapid degradation to EF of 12 over about 8 months. Blackout due to vfib HR 245, and shocked back to normal. Ablation surgery improved VT episodes for about 2-3 months until a VT storm took me down and a heart transplant rapidly following ECMO.
Family history is awful for cardiovascular issues.
But groups that includes my age benefits hugely from these studies.
Am I such an outlier or are there many who go undiagnosed and not as fortunate as myself to overcome these issues?
I like screening coronary calcium scans. A recent case gives me pause. Middle aged man with very low calcium score ended up having a coronary stent 2 yrs later. It supports the idea that a CCS needs to be done in the context of all the other risk factors. There is no easy answer here.
But imagine if we started looking for, and Tx, these things in people 10yrs earlier! shouldn't we reduce the age recommended for screening to include pts 10ys younger? for everything? why, you could see pts going up to 10yrs longer before their first Mi! or...whatever. for any item, that we can sell a daily product for.
in fact, implant these in kids at birth! (it may even be worth offering that for free? as a public service! you have to spend money to [EDIT: SAVE LIVES] & ...oh, nah, actually make the Gvt pay for it. at an inflated price. (bc they can afford it! anyone who votes for it get stock options. you know, for their public service?)
seriously, though: ethically, just think of the the "life yrs" sales! i mean saved. no, i meant sales, i did mean sales. fine entry as always. _JC
Why do you blame "modernity", a person I have never met? "Modernity" is a 'systems' perspective, and that perspective just makes it easier for the accountable people involved to skip to a different world-view where they take no blame. (There is nothing wrong with accepting blame, by the way, and doing penance and making amends. We should all try it. It hurts, though). You hint at 'blame' when you describe the errors in this study from the gitgo in setting up the samples. What I think you are pointing out, Doc, is that a "doctor" is just a primate who went to medical school, whether they wanted to or not, whether they should have or not. Ditto the hospital CEO and the members of the board of whatever company makes the Life-Saving-Gizmo du jour: just change the name of the school, the 'socializing institution' itself made up of, well, primates. How do you reach those folks, for folks they are - just like us? How do you engage them in the lives, and even the *contexts* of the lives, of the very people whom they see as their 'raw materials', their 'patients' and 'consumers'? How do you teach them to think clearly rather than measure blindly? How do you teach them the importance of sympathy, and empathy. Otherwise, Doc, you are going to be writing the same blog piece again and again, I'm sorry to say.
Lots of parts to an answer but I think the largest part of it is medical conservatism, based on good evidence. This applies to drugs, devices, procedures and most importantly whether the physician will "stop and think" before acting.
Thanks. What an excellent article. It feels like I fight the overtreatment fight daily. I was unaware of LOOP results. They are still being advised by academic neurologists in my community.
I’ve seen it said that on average people were no better after seeing a doctor up to around 1900. Overall I suspect we continue to progress but lots of missteps along the way.
I think you go too far, Dr M. Cardiovascular mortality rates in the US are 1/3 what they were in my birth year. Anyone who trained in the late ‘80s knows that we have made enormous strides in the treatment of atherosclerosis. Hospitals were packed with patients having ACS and awaiting CABG. Thanks to public health measures, statins, stents, etc, CABG rates are way down. Unstable angina does not clog the in patient wards. “Modernity” has brought great benefits as well as unforeseen costs. I love your analysis of LOOP and your approach to Afib in general, but a major reason we waste so much time on Afib is we are no longer seeing patients with huge infarct scars and intractable heart failure.
Brilliant. Do we need a Switzerland approach for behavior change? This article by Vitaliy is interesting look and ponders question of applying to health. https://contrarianedge.com/hidden-costs-of-living-in-switzerland/
Great article, thank you. We are curious as to your thoughts on POTS? Is it more of an autonomic nervous system issue vs a cardiac issue?
“Another example: instead of preventing heart disease with good food and a culture of exercise, modern medical doctors order coronary calcium scans. There exists not a shred of evidence that the scans lead to lower rates of heart disease in the scanned”
Duh
Right in this great little article!
Thx Doc!!!
Could there be a subset of patients that would benefit from screening? Can they be determined from any of the data? New procedures or therapies usually start with a specific population in mind but once they are shall I say let out in the wild they do not perform as well as expected due to them being used on inappropriate candidates.
Timely post...for me. Diagnosed with A-fib 5 years ago, quite dramatic and alarming presentation, initiation of expensive drugs. My resting heart rate was, and is 60 bpm. Recently developed unsettling palpitations with missed beats. I have badgered the cardiology office into ordering a Holter monitor. I mistakenly (I was told) thought the rhythm should be stabilized and regular with Coreg. Not so. This article was helpful to me in getting in front of perhaps unnecessary and dangerous interventions. Since I’m not passing out due to bradycardia, then I’ll just be steady as we go.