In my last post I wrote about a fracas going on over at a forum site for doctors.
I’ve had to toss my blog content calendar out the window because of what I’ve been reading over at the Club webMD’s TheHeart.org forum.
Drs. William Blanchet and William Davis have been explaining to other cardiologists there how cardiac events have been “reduced by 90%” and “essentially eliminated” among their medical practice patients.
What’s really amazing is the fact that they hadn’t really been aware of each other much before this last week. Dr. Blanchet was vaguely aware of the Track Your Plaque program but hadn’t seen or heard of Dr. Davis’ HeartScan blog (which I think is a must read). Dr. Davis hadn’t heard of Dr. Blanchet and when he first read one of his posts he joked about maybe he had written it himself.
They’re playing the game with their patients lives in the same way.
Following this thread has been incredibly encouraging because what’s clear is that these two doctors, who are more positive about what can be done about coronary artery disease than anyone else, are clearly the masters of the literature and have the most empathy for the risks and plight of their patients.
The best metaphor for the thread content I can think of is the kind of basketball game that the Harlem Globetrotters play. You’ve seen the Harlem Globetrotters right? The team of superior basketball players playing against a team composed of mediocre players. You have to see it to believe it.
(post images courtesy of 24sec.net)
For example, when asked to describe his program of CAD treatment, Billy “TheEventEliminator” Davis wrote as follows:
The approach is relatively simple:
1) Target LDL (Friedewald) 60 mg/dl; target HDL 60 mg/dl; target triglycerides 60 mg/dl: 60-60-60.
2) Correction of lipoprotein abnormalities, including intermediate-density lipoprotein, lipoprotein(a). (I rely a lot on NMR for lipoprotein analysis.) LDL particle number of <700 nmol/l and/or apoprotein B 60 mg/dl is also targeted.
3) Correction of all phenomena of insulin resistance, including blood glucose.
4) Correction of blood pressure both at rest and with exercise.
5) Correction of serum 25-OH- vitamin D3 levels to 50 ng/ml.
This approach does not guarantee presumed coronary plaque regression using a CT coronary calcium score surrogate, but does weigh the odds heavily in favor of doing so. Also, events are essentially eliminated.
Well, Billy “TheSuddenDeathReducer” Blanchet has been determined for a while not to be outplayed in his patient care by, well, a bunch of FACCers. You see, he’s not a FACC. He’s a doctor of Internal Medicine. And in that forum thread he wasn’t going to sit back and be told he ought to let some of his patients die of heart attack while awaiting even more studies showing the benefit of Calcium Score Heart Scans.
Thank goodness for the upcoming MESA study. That said, there are about 100 EBT calcium studies in the peer review literature already. How can we feel comfortable letting 150,000 Americans die from their first unheralded symptom of heart disease each year while we await yet another study which is still 2 years off?
I understand how difficult it is to think objectively about a technology we were all taught to despise. I made the transition about 6 years ago and my patients have monumentally benefited. I suggest you give it a try for the sake of your patients and especially their spouses and children.
I think it’s fair to say that, between the two of them, Blanchet and Davis have managed to cause a few of their professional peers to think twice about their own cardiac patient care practice.
But even if it didn’t, no matter. What that thread does is to make the point that these two doctors are at the forefront of revolutionary changes in care for their cardiac patients.
The discussion did get a bit messy at one point. There isn’t space here to go into all the gory details. Let me just say here that what happened was this: The Forum Moderator, Dr. Mellisa Walton-Shirley, had the unfortunate experience of having her head explode right there on the court on account of inattention and incoherence.
It happened this way…
Billy “TheSuddenDeathReducer” Blanchet had, earlier in the forum thread, explained a few things I thought all FACCers ought to know, namely, that :
Although CT angiography shows great promise to reduce unnecessary conventional angiography and is helpful in emergency room chest pain evaluation, I do not see CT angiography as a screening study in asymptomatic individuals. 10 times more radiation than EBT calcium imaging plus the risk of IV dye exposure makes CT angiography inconsistent with the principles of a screening test. Taken in the context of a primary care physician’s evaluation of heart attack risk, EBT calcium imaging has great value.
and
there are a number of studies that show a dramatic increase in risk of MI in individuals with an annualized increase in calcified plaque burden of >14%. I consider this to be a valuable measure of inadequacy of medical management. A stress test does not become positive until we have catastrophically failed in medical management. Consequently, even in the patient with “high risk” stratification, one can justify a calcium score to establish a baseline to measure adequacy of primary prevention.
Meanwhile, Billy “TheEventEliminator” Davis has written elsewhere that he believes there is a need for invasive techniques for patients in critical situations and Blanchet had also stated earlier in the thread that:
I have not abandoned revascularization altogether however I try to resreve it for those patients with over 10% of their myocardium ischemic on stress imaging
But, inexplicably, later in the thread, Dr. Walton-Shirley wrote:
I fear that some of you good “pro calcium score folks” have a good point but in your haste to convince the masses of our sinful invasive nature, you are becoming extremists that exclude the opportunity for finding even more patient characteristics that can lower morbidity and mortality.
I think all of you would be more convincing if your distaste and utter hatred for intervention were tempered a bit by admitting that intervention has its place just as Calcium scoring probably does, though with the advent and progress ongoing in the world of MSCT, where will that leave Calcium scoring?
“Distaste” and “utter hatred?” Where did those phrases come from? And even if both Davis and Blanchet have been clear that intervention procedures have their place, Walton-Shirley accuses them of denying it. Think about it. Is that the kind of physician you want to entrust your life to?
And does Walton-Shirley really not know about the meaning of the Calcium Score statistics and how CT Angiography is not a replacement technology for measuring the statistical significance of a coronary plaque burden? And yet she presumes to tell others how useful they are?
Sheesh! I’ve been reading about this for less than 3 months now and I “get it.”
As for the question in the last paragraph about the status of Calcium scoring technology in light of advances in CT angiography: Does Dr. Walton-Shirley even read the posts of others in the forums she’s supposed to moderate? Dr. Blanchet had a completely adequate answer to the question earlier in the thread.
In watching these two all star players describe their approach to playing with their patients lives, I have come to one very simple conclusion.
I’m going to be much more selective in the kind of team that I let play for me. I want the Harlem Globetrotters. Not the Washington Generals.
How about you?
November 27th, 2007 at 1:06 pm
[…] I see that the good Doc Davis over at Track Your Plaque is going to publish a Special Report which consists of an interview with Dr. Billy “TheSuddenDeathReducer” Blanchet that I wrote about last week. […]