Author Archives: jpwmd

In a remarkable memoir about a remarkable man (Oblivion, a Memoir), the Colombian writer Hector Abad tells of his father’s passion for sweeping intercessions that would improve the health of the entire population far more than conventional curative medicine.  Hector Abad Gomez was a physician who courageously took up the banner of public health in mid-20th century Colombia with notable success, amid opposition from conventional health care.  He also became a prominent spokesperson for the poor and downtrodden, and this advocacy eventually cost him his life.

Gomez is the father of public health in Colombia and his writings tell the story of a man who probably saved more lives by his unswerving efforts to bring public health measures to a country with a population in woeful need of basic healthcare.

He believed in the power of education and public works to improve hygiene and had much success in generating measures to help all people, not just the rich, who were uniquely able to enjoy the benefits of modern medicine.  He pushed for universal pasteurization of milk (simple boiling), which eliminated a form of tuberculosis.  He said having drinkable water for the entire population saves more lives than sophisticated medical interventions, as so much disease in undeveloped countries is the product of unsafe water and poor sanitation. He highlighted the devastating effects of malnutrition. Anticipating the eradication of smallpox and the elimination of polio in countries with effective public health, he noted the power of vaccines, which have saved the lives of millions (maybe billions) worldwide, 

Public Health in the United States

The public health measures cited above are so common and elementary in the United States that we can forget their power.  But it was not that long ago that we resembled Columbia in the 1950’s.

Congress created the US Public Health Service in 1912, authorizing it to investigate tuberculosis, hookworm, malaria, leprosy, sanitation, water supply, and sewage disposal.  Johns Hopkins University founded the first school of public health in 1916.  Today, the public health establishment includes multiple agencies, including the National Institutes of Health, the Federal Drug Administration, the Center for Disease Control, the Health Resources and Services Administration, and a few more.  

The reach of these agencies is broad, and, with some occasional but important glitches, they have had a profound positive effect on the health of the US population.  One public health official estimated, perhaps somewhat immodestly, that public health added 25 years to the life expectancy of the average American between 1900 and 2000.

This assertion is not hard to believe when some great public health successes are highlighted.  These include a 90 percent reduction in deaths due to motor vehicle travel since 1925, despite a phenomenal increase in vehicular traffic.  Between 1980 and 1995, work-related deaths decreased by 28 percent.  The US enjoys a water supply that is virtually free of microbial contamination.  In 1900, tuberculosis killed 194 people per 100,000 in the US.  In 2020, it was .2 per 100,000.  Malaria does not exist in the US, except in people who contract the disease in other countries and then travel to our country.  HIV/AIDS has gone from a 100 percent fatal disease to a chronic one.  And tobacco!  In the 1960’s, between 40 and 45 percent of adult Americans smoked cigarettes.  Today, that figure is an astounding 13 percent.  It goes on and on.

Comparisons

Countries with developed public health systems like the US enjoy a level of safety that should be a model for so-called third world countries.  Today, 2195 children per day die of infectious diarrhea worldwide, primarily because of contaminated water supplies.  Deaths from diarrhea in the US average about 300 per year. 

In the handling of the Covid-19 epidemic, public health in the US, particularly the CDC, has come under much criticism, a lot of it merited.  On the other hand, successes like the Covid-19 vaccines cannot be ignored.  Based on research that was years in the making, the US produced the world’s best Covid vaccines almost within a year of the identification of the virus.

The Take Home

In the US, we see stupefying advances in medical technology almost weekly.  But none of it approaches the impact on well-being that public health has had.  The United States Public Health Service is the crown jewel of American healthcare.  Dr. Gomez knew what he was talking about.

In 2010, Congress passed the Affordable Care Act (aka, “Obamacare”) and President Obama signed it into law.  One of the main provisions related to Medicaid.  This is a program that provides medical insurance for people with incomes at or below 138% of the poverty line.  It is a joint program between the federal government and each state, with the feds matching state expenditures dollar for dollar.

However, in 2014, the year that Obamacare was implemented, the federal government began to pay 100% of the cost of new Medicaid enrollees in states that accepted the new benefit.  States that embraced the program are “expansion states” and those that did not accept the expanded Medicaid benefit are “nonexpansion states.”

Results

Expansion states that engaged the new Medicaid benefit in 2014 have experienced a 44% reduction in average per capita medical indebtedness compared to nonexpansion states. The regional breakdown was stark: in the Northeast, mean medical debt is now $167, whereas in the South, it is $616. In 2015, across the entire country, 23.8% of the population reported past due medical debts. The figure in 2020 was 17.8%.

Nor are the benefits limited to a reduction in medical debt. In expansion states, access and use of medical care increased.. Food and housing insecurity decreased. Medical outcomes, especially in maternal and fetal health, improved. Racial disparities in medical insurance diminished. And aggravated assaults went down.

A Ways to Go

At the time of implementation of Obamacare, 24 states opted out of the new benefit. To date, 11 states remain nonexpansion states, nine of which are in the South along with Wyoming and Wisconsin. Six states (Maine, Utah, Idaho, Nebraska, Oklahoma, and Missouri) have skirted their recalcitrant state governments and obtained the expansion benefit by means of state referenda.

There is much to be done. In 2020, 66.5% of bankruptcies were directly caused by medical expenses. Although the 8.6 % of medically uninsured Americans is at an all time low, this statistic could be easily reduced. If all of the states that have opted out of Obamacare’s Medicaid expansion were to join in, an additional 3.7 million Americans would gain medical coverage.

k

I recently posted a blog entry (medicalbeat.net: October 13, 2022) about guns based on opinion pieces in a recent issue of the Journal of the American Medical Association (September 27, 2022).  I presented data on gun violence in the United States, but only touched on potential interventions that might ameliorate the problem.  One could make the case that our “problem” is urgent—the US experiences 25 times the death rate from firearms compared to other high income countries.

Interventions with successful track records

I noted that CAP (child access prevention) laws and waiting periods (so-called “cooling off” periods (i.e., a required period of time between purchase and possession of a firearm) have been associated with a decrease in deaths by firearms, especially suicides.  But there are many other interventions that have been linked to a reduction in gun deaths.

– Laws requiring a license-or-permit to purchase handguns are probably effective in diverting guns from use in the commission of violent crimes.

– States with lower level of gun related deaths and injuries have more gun laws: in states with the fewest gun laws, the rate of suicides by firearms was greater than the rate in states with numerous laws.  Idaho has one measure on the books regarding gun safety, while California has 111.  The former experiences a firearm mortality rate that is double the latter.

– Domestic violence restraining orders (DRVOs) are associated with reductions in intimate partner homicides.

– Background checks?  The data to support these are thin, but, combined with permit-to-purchase laws, research suggests that universal background checks may be effective in reducing deaths from firearms.

– Large capacity magazines (LCMs: devices that enable shooters to fire as many as 50 rounds without reloading) and assault weapons were banned by Congress in1994 for 10 years.  When the ban expired, mass shootings increased along with the number of mortalities: these numbers doubled in the years after the ban was lifted.

Judicial and legislative actions: the “anti-interventions”

Some actions, or non-actions, actually abet the gun problem.  

– In the name of the preservation of Second Amendment rights, the Oklahoma legislature has banned waiting periods for the purchase of guns. 

– The US supreme court recently struck down a 109 year-old law requiring “proper cause” (i.e., a special need for self-defense) for obtaining a license to carry a concealed weapon in public.  “Right to carry” laws have been associated with increased violent crime.

– Stand-your-ground laws allow people to use deadly force when they reasonably believe it is necessary to defend against violent crimes.  In a review by the Rand Corporation, research showed that these laws increase homicides.  38 states are currently stand-your-ground jurisdictions.

– Congress did not provide funding to the Center for Disease Control and Prevention (CDC) to study the gun violence epidemic for almost a quarter of a century.  This finally changed In the 2020 federal fiscal budget, but experts in the epidemiology (the scientific study of adverse health conditions, with an eye to identifying effective interventions) of gun violence believe the US lost over 20 years in developing a database that would help researchers find ways to reduce gun deaths. 

– Last summer, Congress passed the bipartisan “Safer Communities Act.”  It mandates background checks for potential gun purchasers under 21 and incentivizes states’ implementation of extreme risk protection orders (ERPOs).  It also provides expansion of access to mental health services.  Why do I include this measure in the “anti-intervention” category?  Because ERPOs are difficult to implement and, it could be argued, background checks should be universal, not limited to minors.  Moreover, the passage of this rather tepid bill may also allow lawmakers to believe much has been accomplished to prevent gun deaths, thereby undercutting more efforts in the near future.  The reality is that much work is to be done.    

Where there is a will, there is a way

When a young man killed 35 people with a semi-automatic rifle in Australia a few years ago, the government swung into action.  Legislation was passed that prohibits the manufacture, import, and possession of these rifles.  The law also provided for a buy back program, which resulted in the surrender of one-third of all privately owned guns.

Path forward

There is a compelling trove of information that points to common sense ways to curb gun violence in the United States.  Instead, in too many jurisdictions, “guns to go” is the way purchases are made.  The will to act is lacking in Congress, though, and clearly something needs to change in politics if we are to make significant progress in controlling our gun epidemic.

The Problem

The September 27, 2022 issue of the Journal of the American Medical Association (V. 328, No. 12) devoted almost half of its pages to “Firearms and Violence,” in the form of well documented opinion pieces. The effort is chockfull of arresting data.

The first article pointed out that mass shootings get the major portion of publicity on gun violence, but that “only” three percent of deaths from guns are attributable to automatic rifles. The real problem lies with hand guns, especially in regard to suicides.

In the period from 2010 to 2020 in the US, of all firearm deaths (45,222 in 2020, for instance), 60 percent were due to suicides. Looked at a different way, among all suicides, over 50 percent were carried out with firearms. In youth aged 10 to 19 who died by suicide, 42 percent used a firearm, almost always one that a family member owned.

71 percent of people who attempt suicide do so within an hour after deciding to do so. Two thirds of survivors of attempted suicide never try again.

Approaches to the problem

One editorialist in the above cited JAMA issue stated that any serious approach to gun regulation must address firearm suicide. There has been a scattering of somewhat modest attempts to legislate gun control, but these vary significantly by state. Legislation called “Red flag” laws is one initiative, but only 19 states have passed such laws.

These laws allow almost anyone (usually a family member, a friend, a therapist, etc.) to petition a court for an order to prevent someone from accessing a gun. Only nine states have such legislation, but such laws are problematic anyway. They generally require burdensome paper work by the concerned individual who fears for the safety of an individual perceived to be at risk for suicide, and a court appearance is part of the petition. Most importantly, initiating such an action can compromise an important relationship with the person thought to be at risk for suicide.

Child access prevention laws (“CAP”s) require gun owners to secure guns in their homes and not provide a minor with a gun. Laws like these have been linked to a decrease in youth suicides, but most are weak and poorly written.

Given the impulsiveness attending many suicide attempts, I have thought that legislating “cooling off” periods make sense. These measures require a time period between purchase of a firearm and possession. States with waiting periods for handgun purchase have experienced a decrease in suicides overall from 11 to 27 percent compared to states without them. Only nine percent of states have such laws on the books, however, and Oklahoma, in the name of protecting Second Amendment rights, has proscribed them.

In general, there is evidence that states with the fewest laws that regulate guns experience the greatest suicide rates, but studies that support this are weak. This is true of most gun control measures. You can’t randomize people to bestowing guns on their children versus no guns.

Implications

Legislation that meaningfully regulates automatic rifles is important, but it is not where the real money is. In fact, I fear that if our society were, for instance, to outlaw ARs, we might erroneously think that the work on gun control is done. But regulating handguns is where the low hanging fruit lies, and commonsense approaches could save thousands of lives each year.

The

I recently found a spot on my arm that worried me. My regular dermatologist was not available for an appointment as fast as I wanted, so I decided to check out a new dermatology clinic in my town. I got an appointment for the next day, but when I looked up the credentials of the practitioner with whom I was scheduled, I found she was a nurse practitioner, not a physician. I cancelled the appointment as I was distrustful of an organization that did not disclose that I was signing up for an appointment with a nurse practitioner. Had I been told I was not seeing a physician, I probably would have kept the appointment. At any rate, the experience prompted me to look into the training and practice of nurse practitioners and physician assistants (now referred to as “physician associates)–something I have been meaning to do for some time.

Training

Nurse practitioners (NPs) are registered nurses who have completed an NP-focused graduate program. To practice, they have to pass a national certifying exam.

Physicians associates (PAs) have a bachelor’s degree and then undergo a three year PA program with heavy emphasis on clinical training. They too must pass a national certifying exam.

In about half the states, NPs can render care independently, with no physician supervision. PAs require a greater degree of physician supervision, although their association is working to gain greater practice autonomy.

Need

The need for primary care clinicians in the US is a big reason that the movement to NPs and PAs has prospered, as experts in the physician workforce predict an ever greater shortage of physicians. The most alarming statistic is that, currently, 95 million Americans lack access to primary care. In 2004, there were 106,000 NPs, whereas there are 355,000 today. In 2010, there were 89,019 PAs; today there are 159,000. In comparison, there are almost one million practicing physicians in the US, about 40 percent of whom are primary care providers.

Quality of Care

As a primary care physician (retired), I have been circumspect about NPs and PAs, as they simply do not have the amount of training physicians undergo. In researching this blog entry, I was ready to call for studies that compared the quality of care rendered by NPs and PAs compared to physicians. In fact, there are many, and many of them are of high quality. In randomized trials, quality control parameters such as glucose control in diabetics and blood pressure control demonstrated no difference between NPs and physicians. Prescribing preventive measures such as vaccines and mammograms also showed no difference. Importantly, patient satisfaction with NPs was no different from physicians’ ratings.

The Future

Given the inability to receive timely care, many patients have begun to accept non-physician care. Wanting to avoid long waits for an appointment with a physician, they often turn to immediate care clinics that are staffed by NPs and/or PAs. Major pharmacy chains are getting into the primary care business too, and given that PAs and NPs earn less than half of primary care practitioners ($115,390 and $111,680 per year, respectively), profit without physicians is greater. And quality does not appear to be compromised.

Given the research data I have cited, I wonder whether I was overtrained. Regardless, it is clear the direction the clinical care workforce is taking–a phenomenon that is being largely driven by patients. And there appears to be no reason to think this trend compromises healthcare.

Most of the information in this post came from the “Medical Economics Journal,” V99, Issue 9, September 2022. It is readily accessible to anyone online.

By the way, my spot was “nothing.”

I think it was Winston Churchill who said that Americans always do the right thing… after trying everything else.

This observation applies in medicine. In a recent blog (see blog entry of February 28, 2022), I detailed the story of drugs and procedures that had leaked into the medical armamentarium without proof of effectiveness, only to eventually fall to the power of well executed studies that demonstrated their uselessness (and possibly their danger). Enter vitamin D.

Vitamin D in its Heyday

About 10 million tests for vitamin D levels are done yearly in the US, and over one-third of US adults over the age of 60 take the supplement. In 2017, consumers spent almost one billion dollars on vitamin D, and Medicare patients incurred a bill of $365 million on testing levels of the vitamin in the blood in 2016.

The leading advocate for vitamin D is Dr. Michael Holick, a Boston University endocrinologist, who, according to a 2018 article by a writer for Kaiser Health News, almost single handedly created the vitamin D sales and testing industry. He has realized significant financial benefit from the drug industry and laboratory testing concerns.

The supplement has enjoyed a remarkable run in recent years, with claims that it prevents cancer, cardiovascular disease, and falls. Among other maladies, it was alleged to improve cognitive function and decrease age-related macular degeneration. Perhaps it most prominent claim to fame was the assertion that it prevents osteoporosis and fractures.

However…

It does none of these things.

Decisive Study on Vitamin D Supplementation

Researchers recently published a state of the art study (prospective, randomized, controlled) in the New England Journal of Medicine (July, 2022) that investigated the usefulness of vitamin D for the prevention of fractures in men over the age of 50 and women over 55. Parts of this study had already examined the effects of vitamin D supplementation on cardiovascular disease and cancer.

25,871 participants were randomized to vitamin D or placebo. Median followup was 5.3 years. Long story short, the placebo group had no different outcomes compared to the vitamin D group, no matter what the level of vitamin D in the blood.

In an editorial that accompanied the above noted research, the writer noted that the trial showed that the “lack of effect for preventing numerous conditions suggests that providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements, and people should stop taking vitamin D supplements to prevent major diseases or extend life.”

I predict strong pushback to this definitive study from the manufacturers of vitamin D. They may want to engage the services of the gifted advertisers of Prevagen, another multibillion dollar medicine that is wholly ineffective (see blog entry on May 28, 2022).

Nota Bene: there are legitimate medical indications for vitamin D supplementation. If you are taking vitamin D, you should not unilaterally stop it on the basis of this blog or the article cited in the New England Journal of Medicine. Consult your doctor.

On August 7, I posted a piece on the high price of insulin. A physician friend pointed out that the figures I quoted would result in about a $90,000 per month cost of an average insulin user. This would exceed even the greatest ambition of the drug companies, Instead of the cost per unit of insulin, I should have written cost per vial of insulin. This correction does not change the import of the posting, to wit, that insulin prices in the United States are eight times higher, or so, than in other developed countries.

Apologies.

37 million people in the United States have diabetes, seven million of whom require insulin.  Insulin* is a hormone that regulates the level of blood sugar in the body and is necessary for life.  The cost of insulin for insured patients ranges from $334 to $1000 per month, and this cost represents a tripling in the last decade.  These prices are the highest in the developed world.  In Canada, for instance, the cost per unit of insulin is $12, whereas the cost in the U.S. is $98.70.  

Early this year, the House of Representatives passed President Biden’s Build Back Better bill, which would cap the cost of insulin at $35 for a 30 day supply.  It stalled in the senate.  A recently negotiated “Inflation Reduction Act” (action pending in Congress as of this writing) promises to cap out-of-pocket drug expenses at $2,000 per year for those enrolled in Medicare drug plans and cap insulin costs at $35 per 30 days (There would be no effect on the cost of insulin in private insurance plans).

I will let an endocrinologist (a physician who specializes in the care of diabetic patients) from Mayo Clinic illustrate the consequences of not being able to afford insulin:

Alec Smith was 23 when he was diagnosed with type 1 diabetes. He worked as a restaurant manager in Minnesota. At age 26, he could no longer stay on his mother’s health care insurance plan and needed to find his own coverage. On June 1, 2017, he was on his own. The insurance available to him came with a $7600 deductible and a monthly premium of approximately $440. Because he could not afford this, Alec decided to temporarily forego insurance coverage and purchase insulin with cash. Unfortunately for him, the cash price of insulin was far beyond his means.  He decided to try and ration the amount of insulin he took till he had enough savings to purchase insurance. Sadly, on June 27, 2017, he was found dead in his apartment of diabetic ketoacidosis

Of course the big question is WHY IS INSULIN SO EXPENSIVE in the United States?

The pharmaceutical industry says that the high cost of developing drugs is the reason for the high prices.  Of course insulin has been in medical use for a hundred years, and the most commonly used preparations currently (“analogs”) have been available for about 20 years.  So I do not understand how recent research has caused the price of insulin to triple in the last decade.

I think a better explanation for the high price of insulin lies in the fact that three companies control 90 percent of the insulin market.  This virtual monopoly “serves” a vulnerable population that  must buy the preparations, regardless of the cost, or risk the fate of Alec Smith.  

Or maybe lobbying has something to do with it (do you think?).  In 2021, $3.77 billion was spent to lobby Congress and federal agencies.  At the top of the list of industries that spent the most on lobbying was the “Pharmaceutical Research and Manufacturers of America,” coming in at $187,414,530 in expenditures.

Consumer Medical Decisions in the Marketplace  

There is nothing illegal about any of this.  The drug companies are simply maximizing profit, an activity on which our market driven economy is based.  The underlying question is whether healthcare should even be subject to the rules of capitalism.  

There are many advocates of making healthcare more market based, that is, confer more decision making power on the consumer.  If people can research washing machines before purchasing one, why not let them, unrestrained by labyrinthine insurance rules, shop for a cardiac surgeon?  

The trouble is that healthcare does not obey the rules of the marketplace.  Insurance policies limit choice, and geographical constraints also restrict alternatives.  And of course, even for the most sophisticated medical consumers, trying to penetrate the fine print in insurance policies is almost impossible.  

But there are even bigger obstacles to informed medical decision making.  If you find yourself in an emergency department with acute appendicitis, how can you be expected to look around for a surgeon you like?  And of course emotion clouds judgment.  How can anyone be expected to make rational decisions for an incapicated loved one with a life threatening illness?

The marketplace mostly works admirably when it comes to buying a car.  For healthcare, the marketplace is an awkward fit at best.

*For the sake of simplicity, I will use the term “insulin” to include its natural form and the analog form, which mimics the action of natural insulin with advantages in absorption, distribution, metabolism, and excretion.

Leading into 1955, there were about 16,000 cases of polio per year in the United States.  Dr. Jonas Salk produced a vaccine against this terrifying public menace, which he tested on himself, his wife, and his three sons.  Soon after, on April 25th, 1954, a trial was instituted with 1.3 million children as subjects.  It was done with the highest clinical research standards (randomized, controlled, and double blind) and the study found the vaccine to be 80 to 90 percent effective in preventing polio.  A day after the results of the study were released, the vaccine was licensed.  Today, polio does not exist in the United States.*

I received the vaccine in 1955 when I was eight years old.  In later years, my mother spoke to me about the agonizing decision she and my father, and all parents, had to make to allow their children to get vaccinated.  There was no question about the immediate effectiveness and short term safety of the vaccine, but what about long term complications?

Recalling this conversation, I have a lot of sympathy for the difficulty parents face today regarding vaccinating their children against Covid-19.  A month after little kids became eligible for the vaccine, only 5.3 percent of Illinois children have received at least one dose.  As with the polio vaccine, there is no question about the short term safety and efficacy of the Covid vaccine.  But there can be legitimate questions about long term side effects.  Supply issues may be part of the problem for the low numbers, but I wonder how much influence vaccine naysayers may be playing a role in the small numbers. 

Dr. Marty Makary is a surgeon with a masters in public health at The Johns Hopkins University School of Medicine.  He is a prominent critic of the government’s response to the Covid epidemic and has frequently appeared on Fox News (where he faces uncritical, simpering interviewers) with messages that question many of the interventions that the government has undertaken to prevent/treat Covid.  

He published a piece in June of this year about “6 things parents need to know” regarding vaccinating children between 6 months and 5 years of age.  He feels the studies on which the CDC (Centers for Disease Control) based its recommendation to vaccinate were too small to make definitive decisions.  And that, at any rate, 75 percent of children between zero and 17 years of age already had the disease, and were therefore already immune. 

I believe many of his points are worthy of debate, but I am struck by the omission of other important considerations that should go into decision making on whether to administer a Covid vaccine to children.  One is the “Multisystem Inflammatory Syndrome” in children (MIS-C). This is a rare condition that appears to be related to Covid infection.  Its manifestations are protean and can be life threatening.  Vaccination against Covid confers a high level of protection against MIS-C.

What about the “long haul” complications of Covid infection in children?  You can find alarming studies that document symptoms like debilitating lassitude that last for over 120 days after infection, even in some children with minimal or no symptoms at the time of infection. Vaccines have only recently been approved in children, so their effect on the incidence of the long term complications is unknown.  But it is something to consider.

And even if Covid infection in children is not very dangerous, does vaccinating children help to safeguard the adult population, especially the elderly?  Probably.  Computer models have shown that vaccinating children can reduce Covid infections by 11 percent in the general population.  Even if unproven, vaccinating children to reduce the possibility of Covid infection in grandma and grandpa seems like a worthy public health measure.

Finally, vaccinating children may be worthwhile even if they have been infected with Covid.  Considerable evidence exists that “double immunity” (immunity that results from “natural” infection and  vaccine induced immunity) is superior to the immunity gained from getting the infection.

In previous posts, I have decried “misinformation by omission.”  Dr. Makary’s “six things” piece is a good example of this.  I do not believe that cherry picked opinion is helpful to parents who are faced with an understandably difficult decision about vaccinating their children.

*At the time of this writing, the first case of polio in the United States in ten years was reported.

The role of stress in the pathogenesis of disease (how diseases start and progress) has long been the subject of medical research.  

Hypertension (elevated blood pressure sustained over time) has been one of the main targets.  There is no dispute that episodic stress can temporarily elevate blood pressure, but researchers have not been able to link stress with actual hypertension.  In other words, stress does not seem to chronically elevate blood pressure to the point of a higher risk for cardiovascular disease such as strokes and heart attacks.

What about cancer?  Again, there is no evidence that stress is implicated in causing cancer.  But there is plenty of research that demonstrates stress can be a major factor in exacerbating established cancer.

So a recent study in the Journal of the American Medical Association caught my attention: “Association of Mental Stress-Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease.”  In other words, does mental stress predict increased risk for future adverse cardiac events?

The exercise treadmill test is the tried and true method for assessing the presence of coronary heart disease (i.e., narrowed arteries that compromise the flow of blood to the heart muscle, causing heart attacks).  Monitored subjects exercise on a treadmill, and electrocardiograms and sophisticated imaging techniques can fairly reliably predict the presence or absence of significant cardiac disease.  It is a very useful method for patients with obscure chest symptoms and/or as a means to follow possible recurrences in patients with established coronary heart disease.  This method induces physical stress.

But what about psychological stress?  Although many studies have found a link between psychological stress and the risk of coronary heart disease,  they are far from definitive—they are small, largely anecdotal, and lacking in ethnic, racial, and gender diversity.  

In contrast, researchers in the study cited above looked at almost 1,000 diverse patients with established coronary heart disease.  They induced mental stress (public speaking challenge) and used sensitive techniques to detect the presence of cardiac ischemia (i.e., decreased blood flow to the coronary arteries).  They then used conventional stress testing (i.e. treadmill exercise) to test for the presence of coronary ischemia in the same population.  All patients were followed for an average of five years and were monitored for subsequent cardiac events.

The results showed mental stress-induced ischemia to be a significant predictor of future heart attacks and deaths.  Patients who displayed conventionally induced ischemia on the treadmill test were also at higher risk of future heart attacks and death, but at only about two-thirds of the rate of patients who displayed mental stress-induced abnormalities.* 

The authors of the study, and an accompanying editorialist, were careful not to make any wild claims about the implications of the work.  Is mental stress ischemia modifiable? Is the test for mental stress reproducible in multiple clinical settings? Should patients with coronary artery disease be screened for mental stress ischemia, and, if so, what interventions might be undertaken?  Should we view stress, along with other known cardiac risk factors such as smoking, obesity, diabetes, hypertension, sedentary lifestyle, and elevated cholesterol, etc., as another factor that should be assessed in the stratification of risk for cardiac disease?

This study is a valuable contribution to answering these questions.  But no one knows for sure what the role of psychological stress is in heart disease.  This issue will be an increasingly important research topic, and much needs to be done.

*Patients who had abnormalities with both physical and mental induced stress had the highest risk.

.