Choose Wisely: An EKG?

Should an EKG (electrocardiogram- the heart tracing) be a ROUTINE part of your annual physical? NO- not unless you have risk factors that suggest otherwise! I am blogging this month about the American Academy of Family Physician's recommendations for tests and procedures that patients and doctors should question. The Choosing Wisely campaign is focusing attention across specialties to look at evidence-based recommendations that should be discussed to help make better decisions for patient health & health dollars.

So what about the heart tracing? Well, it turns out that there is little evidence that pure screening EKGs in healthy, low-risk people will pick up silent coronary heart disease and subsequently prevent heart attacks. Instead, what we see is a moderate number of false-positive tests that lead to additional unnecessary and often invasive procedures.

Who SHOULD get EKG's? Risk factors for coronary disease include high blood pressure, high "bad" (LDL) cholesterol or low "good" (HDL) cholesterol, smoking, family history of heart disease, diabetes, males over age 45 & women over 55, and obesity. The more risk factors you have, the higher your risk, and the more likely it is that your doctor will indeed recommend an EKG at your office visit.

Check out the other AAFP Recommendations: Bone Density Test, Sinus Infection treatment, and Back X-rays

BOTTOM LINE: ROUTINE EKGs in healthy, low risk patients are unnecessary and possibly harmful- skip this test unless you & your doctor determine you are at risk for heart disease!

Simvistatin (Zocor) Warning!

Are you one of over 2 MILLION Americans who are taking Simvistatin (Zocor) 80mg to lower your cholesterol? The FDA has issued a safety announcement regarding the highest recommended dose of simvistatin, trade name Zocor. The bottom line is that the 80mg dose, has been found to have an unacceptable rate of muscle damage, especially in the first year of use. The FDA no longer recommends STARTING patients on this high dose, even those patients who are tolerating the next highest dose (40mg) but need still better improvement in their cholesterol panel. If you have been on simvistatin for more than a year and you are doing well- low "bad" cholesterol numbers and no unexplained muscle aches- then you are exempt from this rule, and may continue taking the drug at this dose (but I'd suggest you have a conversation with your doctor at your next check up.)

In the last several years, we have switched many patients to simvistatin, because frankly, it became generic and was much less expensive than its name-brand counterparts. Doses are not equal among statins- they are apples and oranges. When you switch, for example, from Rosuvastatin (Crestor) to simvistatin (whether it's name brand Zocor or generic), you will need a much higher dose of simvistatin to achieve the same effects.

The cardiology gurus push us to get those cholesterol levels lower and lower to optimally reduce risk of heart attacks and strokes. In response, we push the dose of our cholesterol lowering medications higher and higher, which obviously increases the rates of side effects. In the case of statins, the most serious side effect comes when there is muscle breakdown (myopathy) so severe that it effectively clogs up the kidneys and can throw them into frank kidney failure. This potentially fatal process is called rhabdomyolysis, "rhabdomyo" meaning skeletal muscle, and "lysis" meaning breakdown. Rhabdomyolysis is a rare dangerous side effect of ALL statins- roughly 4-5 people out of 100,000 on these drugs will be hospitalized from this problem. Unfortunately, the 80mg dose of simvistatin carries the highest risk.

Statins help reduce heart attacks and strokes, but make sure you have optimized your diet and exercise so you can be on the lowest dose that your genetics allow. My pet peeve is seeing people blame medications for bad outcomes, when behavior modification might have prevented that person from ever NEEDING the drug to begin with!

BOTTOM LINE: If you are on a statin, especially simvistatin (ZOCOR), be aware of the warning signs of dangerous side effects (unexplained tender muscles), and take ownership of your part of the cardiovascular risks of high cholesterol by eating MORE fruits and vegetables and exercising daily!

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Let's GO! Rap with tha Hip Hop Doc & Get Healthy!

Last week I was blogging on heart disease in women, and the American Heart Association's new guidelines calling awareness to the NUMBER ONE KILLER of women here in the United States. Today, I'm excited to bring you a HEART-PUMPING song that will stick in your brain and keep you moving and dancing all day!

Meet the Hip Hop Doc- Dr. Rani Whitfield- a very cool FAMILY PHYSICIAN who has found a unique way to reach his patients. His Youtube video "Let's Go!" speaks directly to us women, telling us to "Wait-FREEZE- Don't eat that! Fatty foods cause heart attacks!" (Click on LET"S GO to see the video!)I love it! Our whole house is now dancing and singing these words as we open the fridge and scout around.

Dr. Whitfield didn't stop with just the video, though. Check out his website, www.h2doc and you'll be amazed with all his efforts. From his six month campaign of heart runs and walks to raise awareness about heart disease, to his innovative new comic book and the Legion of Health- super-sized super heroes with names like Suga Free, Six Pack, and of course, h2d (that's Hip Hop Doc, if you're not following closely...)- his message engages everyone, with a special appeal to youth and those young at heart.

BOTTOM LINE: Check out tha Hip Hop Doc, and come on everyone, Let's GO!

To Statin, or Not to Statin- That is the Question!

Okay, in this day and age of fixing everything with pills, we are often faced with whether or not to start a patient on a cholesterol lowering drug (a statin.) How can we decide if the benefits outweigh the risks? How much improvement can we expect from a medication?

Often, simply educating the patient about a high fiber diet will do the trick, especially if it is his or her triglycerides (the smallest breakdown product of fat) that are really high. Eating a diet with more than 25g of fiber per day will often lower lipid levels to our goal range. How do we do that? At the risk of beating a dead horse, it's MORE fruits and vegetables, plus some extra sources of high fiber such as beans, nuts, more berries, or high fiber cereals such as Fiber One or Bran Buds.

What is HIGH? Total cholesterol >200, triglycerides > 150, LDL (bad cholesterol) > 130 [or >100 if other heart risk factors such as diabetes, high blood pressure or smoking], or LOW HDL (the good cholesterol that takes away plaques) which is <40 in men and <50 in women. If you have more than one number above normal, it's time to consider either serious dietary modification or perhaps medications.

Luckily, we have a tool that can help us decide whether or not to start medications. The Framingham Risk Score looks at your lipid levels and calculates your risk of an adverse cardiac event in the next decade. You can plug in "improved" numbers (that you would get with a drug like Lipitor, Zocor, or Crestor) and see how much, if any , it lowers your risk.


BOTTOM LINE: If you are deciding whether or not to start (or continue) a statin medication, consult with your doctor and discuss your Framingham risk score!