How Important Is Cholesterol, Really?

January 24th, 2008 by DrRich

In addition to being the Rabble-Rouser-In-Chief for this fine blog and its groundbreaking parent website, DrRich for several years has also been the cardiology expert at About.com. (About.com is a New York Times company, but since his association with About.com predates that of the NYT, DrRich sincerely hopes that his more conservative readers will not hold this against him.) In this capacity, DrRich routinely tries to clarify for his readers (who are mainly patients with heart disease and their loved ones), controversial topics in heart disease. Because cardiologists (like all theologians) never tire of arguing over how many angels can dance on the distal pole of a defibrillation lead, and because the popular media delights in reducing these arcane arguments to breathless (and commonly misleading) headlines, there is a never-ending cascade of material upon which DrRich can draw.

Most recently, the results of a clinical study called ENHANCE has had many in the popular media (in response to new concerns voiced by medical experts), questioning the deeply-entrenched cholesterol paradigm - that is, the idea that LDL cholesterol (the bad kind of cholesterol) is indeed bad, and that anything we can do to lower it is good. Questioning the cholesterol paradigm - a belief system we’ve all been taught since we were babes in arms - is deeply disturbing, confusing and troublesome to many American patients (judging, at least, from the response DrRich has received from readers of his heart disease site).

These patients have been told for years to arrange their lives around the reduction of their cholesterol levels. And while the proportion of people who actually do so does not exceed the proportion who, in earlier times and under a different paradigm, actually arranged their lives so as to further their odds of spending eternity in paradise (modern sinners often preferring instead to rely on today’s equivalent of the deathbed conversion - the stent), the sudden notion that the cholesterol god is dead leaves these patients unbalanced, uncentered and oddly empty. They are also beginning to believe that their doctors, who (some appear to be saying) have been preaching a false doctrine at them for many decades, are even more full of cr*p than previously thought.

In response to this existential crisis, and so as to fulfill his duties to About.com and its parent company, DrRich has posted an article that purports to place all this in perspective, and more importantly, to give patients some guidance as to how to proceed in regard to their cholesterol therapy NOW (i.e., during the next 10 years or so, while the experts debate the issue, and argue over whether the current guidelines - the following of which doctors will continue to be paid-to-perform - actually make sense.)

Normally, DrRich would not trouble readers of the Covert Rationing Blog with topics pertaining to his other duties. But this recent cholesterol controversy has already attracted the attention of other medical bloggers he admires, some of whom have offered (for instance, here and here) very level-headed opinions on the matter. Frankly, while DrRich is clearly very comfortable pontificating on matters related to healthcare reform (and most other topics), he gets nervous touching on theology or its close relative, cholesterology. So DrRich will be very interested to know from readers of this blog if his advice - which, again, is aimed at American patients - seems sufficiently clear, and most of all, reasonable. The posting can be found here.

Thank you for your indulgence.

Posted in Cardiology Topics | 3 Comments »

Sudden Death Is Still the Healthcare System’s Friend

January 3rd, 2008 by DrRich

In an article published in the January 3 issue of the New England Journal of Medicine, researchers report that hospitalized patients who have cardiac arrest (sudden loss of cardiac function due to the onset of a heart arrhythmia known as ventricular fibrillation) are often not receiving defibrillation (an electrical shock delivered to the chest) within the recommended 2-minute window of opportunity. Further, patients whose defibrillation is delayed beyond the 2-minute window have a substantially reduced chance of surviving the cardiac arrest. The researchers recommend that hospitals take steps to administer defibrillation more quickly to patients with cardiac arrest, in order to improve patient outcomes.

An accompanying editorial (written by Dr. Leslie Saxon, an old friend of DrRich) points out that in public areas where Automatic External Defibrillators (AEDs) are available, such as casinos, the odds of surviving a cardiac arrest is over 50%. In contrast, the odds of surviving cardiac arrest in a hospital, according to this new study, is only 34%.

Dr. Saxon goes on to suggest that hospitals ought to employ readily available technology (technology ubiquitously found in AEDs and implantable defibrillators) to improve their survival statistics - presumably, to nearly the levels achieved in casinos and shopping malls.

DrRich finds this study enlightening, and the recommendations made by Dr. Saxon admirable.

But, unfortunately, there is a big and fundamental difference between the business interests of hospitals, and those of other institutions in which cardiac arrest is relatively likely to occur (i.e., institutions that tend to attract persons of a certain age and body habitus, who are likely to enjoy sedentary forms of excitement, and who do not particularly mind tobacco smoke).

Which is to say that in a casino, saving the life of a customer is good for business. Aside from the favorable publicity you might get on a slow news day, the saved person and his/her family and friends are likely to think favorably of your establishment for years (and scores of Social Security checks) to come.

The healthcare system, on the other hand, thinks differently about people who are prone to cardiac arrest. These are typically individuals with chronic and expensive medical problems - most often they have coronary artery disease, diabetes, or heart failure - and (as DrRich has pointed out before) their sudden death today will save the system countless dollars tomorrow. While nobody ever talks about this, one simply needs to look at behaviors to see the truth of it.

Hospitals ought to be embarrassed by these latest statistics. But, DrRich suspects, their principle reaction more likely will be one of concern, a concern that will take this form: Will this new study generate the kind of publicity that might force us to actually do some of what Dr. Saxon suggests?

We can expect hospital administrators to lie low and watch the media. If this study creates a ripple, expect a few press releases here and there about how they’re studying various process improvements, coupled with mild disclaimers about how sick these patients really are, being hospitalized and all, so one musn’t expect miracles.

In the meantime, if you’re one of the millions of Americans who are at increased risk for cardiac arrest, then unless you’re also one of the fortunate few whose doctors see fit to offer you an implantable defibrillator, you’re probably better off spending as much time as you can in front of the slot machines than in your local healthcare institution.

References:
Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008; 358:9-17.
Saxon, LA. Survival after Tachyarrhythmic Arrest — What Are We Waiting For? N Engl J Med 2008; 358:77-79.

Posted in General Rationing Issues | 7 Comments »