Notes from the Heart…

Having just returned from the American College of Cardiology Sessions in Chicago, my mind is swimming in the latest and greatest in cardiac care and treatment.  I arrive at my place of work armed and ready to apply these principles to caring for my patients.  What I learned, however, surprised even me.

As an interventional cardiologist, I firmly believe in the power of simple interventions, such as balloons and stents which I use routinely, to impact the length and quality of life.  But, in the end, everyone knows that these therapies close the barn doors after the horses have left.  They are helpful, but if you need them, then in many ways you have waited too long.

What impressed me most was the emphasis in the cardiology community on prevention, and some of the new and impressive research that is looking at non-medical interventions.  Here are some of the latest and greatest news, in layman’s terms:

  • Meat is Murder? Much has been made of the recent paper in Archives of Internal Medicine on red meat consumption being linked to early mortality.  While impressive, it still remains one article.  At the ACC however, a host of supportive data was presented which bolsters this paper, and transforms it from an interesting single study to a major cog in a big wheel of diet modification.  While I am most definitely NOT ready to advocate a vegan lifestyle, I think a universal recommendation opting for greater incorporation  of plant products into our diets with fewer meats is absolutely appropriate at this point.  I was impressed not just with the breadth of research, but of the quality and scientific rigor which went into many recent studies in this field–something that had previously been sorely lacking.
  • Size Does Matter.  A major boost for obesity surgery at this meeting was the study looking at its effects on diabetes.  While it was well known that bariatric surgery (particularly the gastric bypass) could improve the state of control of cardiac risk factors, this study compared it to medications, and it came out better.  This is no surprise, really.  By treating the underlying cause (truncal obesity) of insulin resistance, you will achieve better results than by masking or compensating for the insulin resistance that causes Type II diabetes.
  • Blood pressure drugs got you down? Not to worry, for too much longer anyway.  A simple, catheter based treatment called “renal denervation” which affects the various complex neural pathway causing hypertension has shown very promising results at treating hypertension with minimal side effects.  Its use as a routine treatment is still years off, but look for a fast-track approval process for patients with very severe high blood pressure beginning sometime in 2013.
  • Stents are not the work of the devil.  Over the past five years, oversimplified analysis of the COURAGE trial had led many to feel that coronary stenting had no role in the management of blocked coronary arteries causing chest pain.  A recent major study (FAME II) was stopped early, however, because stents showed so much benefit.  The difference? In the second study, the operator had to objectively prove a stent was necessary first.
  • Neither are surgeons.  As interventional cardiologists such as myself take over everything from clogged arteries to aortic valve replacement, many prematurely mourned the death of the field of cardiac surgery.  Not so.  Recent registry data showed that in many patients good old bypass surgery led to better outcomes than even the newest stents.  In addition, newer questions have been raised about the outcomes from minimally invasive (catheter based) aortic valve replacement.  These need to be answered before rapid, widespread adoption of this procedure.
  • Don’t believe the hype: I have received countless phone calls already this week asking for the newest cholesterol medication which promises to be a “wonder drug.”  This is truly shocking to me, because usually when I want to start cholesterol medication, I am met with a lot of resistance.  To top it off, the newest drug is an injectable medication studied in only a small fraction of the patients that the other therapies have been studied in.  This medication may indeed have an eventual role in management of severely high cholesterol, but its rapid demand reeks of pharmaceutical company influence in everything from clinical trial design and presentation, to the timing and tone of press releases.  High cholesterol is a big money industry, and let’s get something straight: these companies are only interested in selling you their product.  If you happen to get better while using it, well that’s OK too.

Medicine continues to change on an almost daily basis, and cardiology changes faster than most other fields.  These are but a few of the new and exciting perspectives that I gained at the annual American College Conference.  And I’m sure by next year, they’ll all be wrong again.

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Good Grief

Moslem Tov?

Recently, I had the opportunity to attend a bar mitzvah ceremony at a conservative temple here in Los Angeles.  I am well known to many in the congregation due to my profession and I was greeted with warmth and acceptance, despite my Muslim faith.  Although this was not my first temple service, it was the first I attended that fell on Shabbat.  As such, it was the first time I participated in the full religious ritual.  The result was a transformative experience in many ways.

The similarities were eerie, almost like practicing Islam in another dimension.  The sermon was basically about a favorite Muslim topic–tawhid (but as it related to Moses and Aaron, a different subject for a different time).  The head coverings, the segregation of men and women (though not as strict), and the bowing during prayer all evoked images of Muslim services.  Since we share a common heritage, it will come as no surprise to those versed in history or theology that our services have so much in common.

At first, one thing I found a little surprising was the emphasis on holocaust remembrance.  While I am reasonably familiar with the inhuman atrocities committed during the holocaust, I was initially taken aback by the emphasis placed on the holocaust during the services.  After all, my thoughts went, this happened seventy years ago in a far away land, and most of the younger people in the room had never actually met a victim.  Did they really need to perseverate on it so much?

Three words  from my wife caused perspective to crash down upon me, however, as she whispered to me “It’s their Karbala”.

Karbala, of course, refers to the infamous massacre at Karbala, Iraq perpetrated 1400 years ago on Husain ibn Ali, grandson of the Prophet Mohammed (SA).  It is commemorated regularly to this day by Shi’as (such as myself), especially during the Islamic month of Muharram.  It is mentioned at almost every Shi’a service, and often evokes almost uncontrollable expressions of grief, even today.

The power of grief to unite and galvanize a community is second to none.  The massacre of Karbala and the holocaust share this trait in common.  Both are grotesque acts of violence, willfully perpetrated on innocents.  Both of these events are used to unite, and indeed define, their respective communities.  Most historians consider the massacre at Karbala to be the coalescent moment of the Shia movement, which had actually begun a generation earlier.  Similarly, while the modern Zionist movement was in existence long before World War II, the holocaust served to coalesce the movement into a definable and concrete entity.  Even the events of 9/11 can be understood in a similar fashion, as they served to unite the country like very few times in our history. Unfortunately, along with the patriotism, they also awoke the xenophobia which long lived under the surface of the American psyche.

Grief is the ultimate expression of love.  Without love, there can be no grief.  And thus expressions of grief help us to realize the love we harbor inside ourselves.  The grief that we feel serves a true barometer of our internal value for the lost, a barometer immune even from self-delusion.  In this way, grief serves as a true reflection of our soul.  To grieve with someone is thus to share a special bond with them, a bond between the souls.  In this way, shared grief can unite a community like no other single experience.

The holocaust is a trauma on the Jewish experience which will never, and should never, heal.  Much like the effect of Karbala on the Shi’as, the holocaust unites the Jewish people, and even defines them in a very real sense.  Thus, it will very likely be remembered and commemorated 1400 years hence, much as Karbala is today.  The critical observer will find many differences between these events, however.  They would be correct in doing so.  But I would endeavour to focus on the similarities instead, as collective grief is one of the common bonds of humanity which unite us.  With my wife’s simple but profound sentence at that moment, I was privileged to share in that grief; and at least for a moment I became one with my Abrahamic brothers.

 


Calling a Spade a Spade

Recently, a US soldier in Afghanistan left his base at about 3 AM.  He walked about half a mile to a nearby village, entered three different homes, and shot dead at least 16 Afghani civilians (at least twelve of whom were women and children).  In the first home, where eleven of the victims were located, he gathered the bodies to burn them.  He then returned to base and turned himself in to authorities.  At the current time, his motives are unclear.  Much information about the killings and the killer has not yet been released.  What is known is that many of the victims were asleep at the time of the killings.

The US Government has issued a necessary but predictable statement of remorse, assuring that an investigation will soon be undertaken, and appropriate legal actions will be pursued (US soldiers in Afghanistan fall under US legal jurisdiction).  The question remains, exactly what crime was committed here?  Was this act part of the “fog of war” and thus representative of collateral damage?  Perhaps the shooter is not guilty by reason of insanity, due to PTSD and a possible history of previous brain trauma?  The killing may represent first degree murder (based on the premeditation inherent in walking a mile to the nearest town).  But, intriguingly, the news media has yet to use the word “terrorism”.

The first two, more lenient, possibilities also seem the least likely to be successful.  The shooter clearly had not been engaged actively by an enemy at the time of the shooting, and collateral damage can only be claimed if he had targeted a real or perceived enemy.  The insanity defense is very likely to be used and is already being used in the media, where all sorts of excuses (ranging from stress to alcohol to a bad marriage) are being floated for his actions.  It is interesting that these same excuses would be considered absolutely inadequate if the killings had occurred against an American town on American soil.  However, this strategy is unlikely to succeed legally and politically, as the shooter clearly knew what he did was wrong (he immediately turned himself over to authorities), and because the government will want to show swift and severe judgment in order to avoid unrest and backlash.

The question then becomes, is this  US soldier a terrorist?  Here is a person who has targeted innocent civilians and killed them in cold blood.  If his motivations were motivated by pure psychopathy then he is nothing more than a deranged cold blooded mass-murderer.   If, however, his motivations included any element of religious or political ideology, then his actions must be considered an act of terrorism.

When Major Nidal Hasan (also a member of the US Military) opened fire at Fort Hood, he was immediately branded a terrorist.  He had, after all, murdered innocents (sort of–members of the military industrial complex are considered reasonable targets by the Geneva Convention) and was motivated by political ideology.  But, when Joseph Stack flew his plane into the IRS building (sound familiar?), clearly motivated by a political ideology, he was branded a deranged anti-government crusader and some Americans even considered him a hero.  In fact, in an official statement “government officials were quick to rule out any involvement of terrorism in the incident.”

Let us hope that we have not devolved so much as a society as to believe that the definition of terrorism is inherently related to one’s own religion, or the nationality of the victims.  While this seems clearly to be the case with the news media,  the FBI official definition of terrorism includes no such reference:

“the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (28 C.F.R. Section 0.85)

While it is a major tenet of US law that the accused is innocent until proven guilty, it is a painful fact that if in fact our soldier was motivated by any religious or political objective then he has committed an act of terrorism.  If we are to maintain consistency with our rule of law, not to mention any semblance of credibility in the global community, then we must have the strength to call a spade a spade.

RELATED: The Daily Beast editorial board had a very interesting internal discussion on what they should call terrorism, related to the Joseph Stack incident.  They also had the courage to post it online in its entirety.  It is worth a read.

Be Careful What You Wish For

Rick Santorum has shown incredible perseverance so far in this GOP primary season.  Initially considered as a bit player, he has rocketed to national prominence on the strength of some strong primary and caucus wins, and now deserves at least legitimate discussion as a GOP nominee.  Anyone (including Mr. Santorum) who claims to have predicted his degree of relevancy this late in the race should seriously have their honesty questioned.  And yet, here he is.

It is true that Mr. Romney, his main rival and the current frontrunner, is a deeply flawed candidate.  His shifting stances on hot-button issues such as abortion and universal health care are well documented.  His wealth leads to a potentially very accurate and thus lethal charge of being “out of touch”.  And his recent campaign strategy of “vote for me, I’m inevitable anyway” reeks of defensiveness and pushiness at the same time.

Mr. Santorum, however, is arguably no better–and perhaps worse off.  He is a staunch conservative, but his views on most social issues steer far right of the majority of the American populace.  His economic credentials are questionable, as is his foreign policy experience.  His last foray into politics ended in an 18 point shellacking in his home state.

Perhaps a reason for his surprising success can be found in the contests so far.  I have neither the time nor the expertise of great political (and baseball statistician) Nate Silvers, but some trends are too clear to miss.  If one evaluates the states that hold primaries (as opposed to caucuses) and separates them according to open (anyone can vote) v. closed (only registered republicans can vote) primaries, we have the following results:

Date State Type of Primary State Results Santorum v. Romney National Polls Santorum v. Romney

10-Jan

New Hampshire Closed

-30

-9

21-Jan

South Carolina Open

-11

-16

31-Jan

Florida Closed

-33

-13

7-Feb

Missouri Open

30

-17

28-Feb

Arizona Closed

-20

2

28-Feb

Michigan Open

-3

2

6-Mar

Ohio Open

-1

-10

6-Mar

Oklahoma Closed

6

-10

6-Mar

Tennessee Open

9

-10

6-Mar

Vermont Open

-16

-10

(For the sake of simplicity, I have only compared Santorum and Romney and removed states where one or the other was not on the ballot, or that any major candidate claims as their home state.  National polls are from RCP polling data (average of polls) on the date of the primary).

In states with open primaries Santorum tends to outperform his national polling data significantly–in fact, by an average of 11.5 points.  In states with closed primaries, he tends to underperform compared to national polling by an average of 11.75 points.  That is over a 23 point swing!

Although this is not a complete analysis (accounting for regional differences, etc), the magnitude of the difference is clearly significant.  The difference in the type of primaries is entirely comprised of the ability of Democrats and Independents to vote.  It is not a stretch to surmise that Mr. Santorum and his extreme right wing views on social issues, his vitriol towards President Obama, and his radical  religious rhetoric does not embody significant crossover appeal.

It thus stands to consideration that the Democrats (and perhaps independents) are using the open primaries to help nominate Mr. Santorum.  In their eyes, this is a win-win situation–they either succeed in propping up a “straw-man”, who (at least in their estimation) is an easier candidate for Mr. Obama to beat in November, or they help deplete Mr. Romney’s war chest by using Mr. Santorum as a surrogate with which to attack the front runner.

A similar strategy was espoused by Rush Limbaugh in 2008 and dubbed “Operation Chaos” as he urged his listeners to participate in open primaries to drag out the Democratic nominating process, and it has been reborn this year by the Daily Kos, and dubbed “Operation Hilarity.”  The scary thing is, such tactics may actually work.

The Democrats who are doing this are playing a dangerous game.  By swinging for the fences, they are hoping for a home run–ie, President Obama walking to re-election against who they see is an inferior candidate.  But if they succeed in influencing the nomination, they will have helped nominate an extreme social conservative and religious radical, and given him the confidence that no race is out of reach.  At that point, all it would take is one damning picture or quote released at the right time to help create… President Santorum.  And then, perhaps, President Romney wouldn’t look so bad to these Democrats.