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(Narrator)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an association of independent, locally owned and community based Blue Cross/Blue Shield plans committed to better knowledge for healthier lives.
(Clock ticking)
(Heart beat)
(Music)
(Dr. Peter Salgo)
Welcome to Second Opinion where each week we solve a real medical mystery. When we close this file a half an hour from now you'll not only know the outcome of this week's case but you'll be better able to take charge of your own health care. I'm your host Dr. Peter Salgo and you've already met our special guests. They're joining our cast of regulars, primary care physician, Dr. Lisa Harris and communication expert, Dr. Laurel Milberg. Now, no one on this team knows the case. It's in here. Let's get right to work. Let me tell you about Joyce. Joyce is forty-eight years old. She's married. She has two teenage children. She's in her primary care physician's office.
(Dr. Lisa Harris)
As always.
(Peter)
As always, for her routine annual exam. Now, the only actively treated health problems that she reports to her PCP are that she has seasonal asthma and she treats that with an inhaler and occasional reflux symptoms which are treated with an over the counter H2 blocker. It does not say in the chart which one. She's large breasted and her doctor has noticed an increase in her shoulder and neck bending forward. Joyce mentions in passing, just by the way, doc, I've got some twinges of pain lasting for just an instant in my left breast and she also complains of getting more tired now than she has been in the past. She's in your office, Lisa, what do you want to do right now?
(Lisa)
Well, you've now opened Pandora's Box. There's about forty different things here -
(Peter)
It's here in the chart. I didn't open Pandora's Box.
(Lisa)
running through my head. So, first of all, this is a forty-eight year old woman. We don't know her family history unless you happen to have that in the chart.
(Peter)
Both grandfathers died of heart attacks in their late sixties.
(Lisa)
So there's some potential risk for coronary disease. You said she's large breasted but we don't know her weight or her height.
(Peter)
She's five foot five inches tall says the chart. She weighs a hundred fifty pounds. She's heavy but she's not really morbidly obese.
(Lisa)
She's not morbidly obese.
(Peter)
It looks like she's also peri-menopausal.
(Lisa)
What is her blood pressure?
(Dr. Peter Salgo)
Her blood pressure is normal.
(Dr. Lisa Harris)
I'm sorry, you know I don't accept normal particularly. I don't know what clinicians mean by that. Some people think 150/100 is normal.
(Peter)
Normal is written right here in her chart as N-O-R-M-A-L.
(Lisa)
So I'm going to take that as 130/70 or less.
(Peter)
Take it for what it's worth. I can also tell you that she did have a lipid profile. Her LDL is 135, low density lipo proteins. Her HDL is 40. In addition, she never smoked and she is not diabetic by the chart and there's no family history of diabetes. Would you like to know some more about the quality of pain?
(Lisa)
Yes.
(Peter)
Absolutely. How did I know you would? It's not related to exercise. She's not had it long enough to seek treatment in the past. It's unrelated to her meals. It's more likely to happen when she's standing up than when she's lying down. No jaw pain, no sweating, no nausea. She's noticed no changes in her breasts. What are you worried about?
(Lisa)
This is a forty-eight year old woman who has asthma, who has some acid reflux symptomatology, who's borderline obese, has an elevated LDL and is now having new onset left sided chest pain. In my head as she's sitting in my office the first thing I want to do is a 12-lead EKG and then she's going for a stress test.
(Peter)
Is she pulling a trigger on this? C'mon.
(Dr. Laura Milberg)
Well, maybe the important thing to think about is that this woman actually said that in the by the way position in the office visit and so I would guess that she's concerned about -
(Dr. William Blanchet) I find decreased exercise tolerance - patients come and say I couldn't climb the mountain as fast as I climbed it yesterday. It really concerns me and correlation of coronary disease better than chest pain.
(Dr. Nanette Wenger)
What we have to realize is that the chest pain syndrome is the most common presentation of coronary disease for women. This is in contrast to heart attack for men, so worry about any discomfort from here to here in the woman and this is where we have to ask the questions, the details. I'm not sure that what's in that chart may be all of what or any of us might want to know.
(Peter)
You want to send her for a cardiogram.
(Lisa)
Yes, I do.
(Dr. Peter Salgo)
You want to get a cardiogram?
(William)
I want to get a cardiogram as functions of baseline.
(Peter)
You want to get one?
(Dr. Arthur Moss)
Oh, yes. In her age group if it hasn't been obtained before I think a baseline, electrocardiogram, could be very helpful. It's a cheap, inexpensive test with a great deal of information so I would have no problem and I would, in fact, encourage it.
(Peter)
Do you want to know what the cardiogram showed? She got one in the office. It looked basically normal so it says in the chart, but here there's a -
(Nanette)
Basically, normal is not normal.
(Peter)
I'm about to give you the look. Cardiologists, you're always over these things and you should be because it says here that she's got "slight" and I don't know if it's one millimeter or two millimeters - just slight ST elevation in the anterior leads. The limb leads are normal. What do you make of that?
(Nanette)
That could be a normal variance
(Peter)
Oh great.
(Nanette)
So I really would like to look at the lateral precordial leads to say is there any depression and is this reciprocal.
(Peter)
I've got a funny feeling here because I know where we're going and we're going to be starting to talk about something called Framingham. Somebody help me out and tell me, tell our viewers, what is Framingham? What does it mean and how do you do a Framingham asset?
(Arthur)
So, the Framingham study originally back in 1953-54 identified cigarette smoking, high blood pressure and cholesterol as risk factors.
(Dr. Peter Salgo)
Let me stop you right there. The Framingham Study looked at what put you at risk for heart disease. Did it tell you that you had heart disease?
(Arthur)
No, it told you the risk for the likelihood of heart disease and it was exclusively on males and several year s later, like two decades later, they developed a Framingham risk score which predicted in males the likelihood of a coronary event in the next ten years, a probability.
(Dr. Nanette Wenger)
Frankly, I'm not sure she's interested only in her risk factor over the next ten years. She's interested in a lifetime risk and of course that's one of the weaknesses of Framingham and if you look at the new American Heart Association Women's Prevention Guidelines for this woman they are looking at lifetime risk and really do something very simple, much simpler than the computations dividing women into high risk if they have defined disease or diabetes or chronic kidney disease or women who are at risk if they have any of these factors. It makes it much easier in the office. You don't have to do these complicated calculations.
(Lisa)
Framingham was done in a very closed population of Caucasian men in northeast America.
(Peter)
In Framingham, Massachusetts.
(Dr. Lisa Harris)
Yes, so I always take a large grain of salt with that when you're generalizing that to other populations.
(Peter)
You've been sitting here like the voice of our conscience. You haven't said much. You're fifty-three now?
(Nic)
Yes.
(Peter)
And when you were thirty-eight what happened to you?
(Nic)
I had my first heart attack then and I hope my only heart attack. I was shoveling snow and I thought I pulled a muscle in my left arm and several days later I went to the doctor. The PA looked at me and said have you ever had an EKG and I said no. She said well, we should get one and after she got the results they told me that I either am now having or have recently had a heart attack.
(Peter)
Did you know that you had any risk factors?
(Nic)
Not consciously.
(Peter)
What does that mean, not consciously?
(Nic)
Well, I had the beginning of elevated blood pressure apparently and enough that my doctor was interested in getting a cholesterol test and on later reflection I discovered I had family history that I had never thought about.
(Dr. Peter Salgo)
What family history is that?
(Nic)
Both of my grandfathers died of heart attacks and at this point I have four first cousins that have had heart attacks before fifty and three of them have died.
(Peter)
If you were listening to Nic in your office and you were extracting this history from him even before his heart attack what Framingham category would he have fit in?
(Nanette)
Probably low risk.
(Peter)
Even though he has a family history?
(Nanette)
Age is such a distracting factor in the Framingham risk score that young people are not perceived to be at risk.
(Peter)
Given what you know - I'm going to force you to deal with the real politic here - how would you classify Joyce's heart attack risk?
(Nanette)
I think from the numbers that we have she, by Framingham, is at low risk and yet we know that very many middle aged women do - and she's peri-menopausal - do find themselves at risk and having a heart attack. Now, remember her cholesterol is borderline so I have some concern with that.
(Peter)
Let's just look at the numbers. Heart disease is the leading killer of women in America. Does that mean that we're doing a really poor job of assessing their risk? Framingham is not the tool we want. That we could do better for them.
(William)
We are doing an abysmal job of assessing their risk.
(Peter)
But we have fifty years of Framingham behind us.
(William)
We do and when we look at women who have heart attacks, when we look at young men and women and by young I mean a man less than fifty-five and a woman less than sixty-five. If we look at a study - people who come into the hospital with their heart attacks, what percent of them would have qualified for some other preventive therapy before their heart attack, the answer is twenty-five percent.
(Dr. Peter Salgo)
Nic, your case is significantly different than Joyce's because you really were hypercholesterolemic - too many cholesterol in your blood. That's a vast difference.
(Dr. Nanette Wenger)
What we've seen in virtually every report is that women tend to be under evaluated and under tested and we are now teaching women to ask their primary care providers what are my risk factors?
(Peter)
We talk about age. We say that younger women don't get heart attacks. We used to say that.
(Nanette)
Younger women do get heart attacks.
(Peter)
They do, but there's a magic number I keep seeing in the literature about seventy years old, over seventy, under seventy. Where did that number come from? What does it mean?
(Nanette)
I just hope they're defining young women as women under seventy.
(Laughter)
(Nanette)
That would be delightful. I think that this is really the age where you see the peak of the heart attacks, but we've seen many young women and as a matter of fact, in the hospital when I have a woman under fifty who has a heart attack or a woman under fifty who comes to bypass surgery, she is at high risk. The young woman is really relative to the man much more at risk.
(Peter)
Lisa and Bill, you were prepared to ship this woman off for a stress test. At this point, are you prepared to send her to a cardiologist?
(Dr. William Blanchet)
I think we have to find out why she doesn't have the same exercise tolerance she had before, so, yes, I would have her undergo a stress test.
(Peter)
Lisa?
(Lisa) Yep.
(Peter)
With that I want to pause for just a minute and sum up where we've been. The impact of cardiac risk factors for women under the age of seventy are not as well understood as for risk factors in men and women over seventy, but no matter your age or your gender, you should work with your doctor to understand your own personal risk factors. All right, according to the guidelines available we can say that Joyce is at low risk. Even though she's at low risk, do what William and Lisa want to do and ship her out for further workup? What do you want to do? Arthur?
(Arthur)
I wouldn't use the term ship her out. That's rather dysfunctional. I think an exercise tolerance test would be reasonable and would get a lot of information.
(Dr. Peter Salgo) Joyce does go not only for a stress test but a stress echo and this is where thy put her on a treadmill and ask her to work a certain amount with a cardiogram attached and they look at her heart with an echo machine to give them a picture of her heart. The report here is negative. That's all they say - it's negative. Can we rule out heart disease now?
(William)
Absolutely not.
(Peter)
Why not?
(William)
Absolutely not because as it turns out over eighty percent of heart attacks occur in people without obstruction disease.
(Peter)
Obstructive disease means obstruction in the arteries.
(William)
Cholesterol plaque is obstructing enough to the blood flow that the heart muscle doesn't get adequate blood during exercise.
(Peter)
Let me just stop you here. Arthur, eighty percent of people who have heart attacks he says occur in people without obstructive disease. What are you doing a stress test for looking for obstruction? You're going to miss eighty percent.
(Dr. Arthur Moss)
Well, now you're getting at the fundamental of risk screening and intervention. Her likelihood of having a coronary event in the next ten years is very small. Now, there are a lot of other things that one can do.
(Peter)
What would those be diagnostically, for example?
(Arthur)
What is prominent now is the use of CAT scans to look at coronary calcium, however, I would be interested in Bill's comments first.
(Dr. William Blanchet)
When you look at people who have died from heart attacks and you look inside their blood vessels in the heart, virtually all of them have calcium within their coronary vessels and so the theory is if we can identify who has calcium within their vessels we can identify who is at risk for heart attacks. Coronary calcium imagery is a CAT scan that can take a picture fast enough to image the moving heart as though it were still looking for calcium. Here's a test that costs about one-third to one-fifth the cost of your exercise echo stress test which will predict much, much more accurately this woman's risk for a future coronary attack.
(Peter)
There are 64-slice Scanner, CT scans, right? There's MRIs, there's PET scans, calcium scoring, which you talked about, thallium testing. All of these things look for different things in the heart. Are all of them better than that stress test that she just had as reported out as normal?
(William)
All of them are different than the stress test and all of them are looking for different things. You can do this with a 64-slice Scanner, you can do this with an electron beam scanner and there are differences between the two scanners. You simply look at the presence of calcium. It's an inexpensive test I think qualifies as a screening test.
(Dr. Peter Salgo)
Are you going to send her for one of these tests?
(William)
I certainly will.
(Peter)
You will. You won't?
(Arthur)
No, I would not. From my knowledge of a CAT scan for coronary calcium you can pick up some calcium in the vessel wall and it gives you some various very rough measure of atherosclerosis, however, the CAT scans are are traditionally negative, very low yield in the under fifty age woman and in fact the standards it'd be very rare.
(Peter)
But you want to send her for one. Is he wrong?
(Lisa)
What I need to ask you - are you talking about just getting a calcium scoring or are you talking about calcium scoring plus a CTN geography?
(William)
I'm talking about just getting calcium scoring.
(Lisa)
I'm with Art.
(Nic)
What's the difference between those two things?
(Dr. William Blanchet)
The difference is with calcium scoring you take a patient without injecting dye into them doing an imaging of the coronary vessels looking for the presence of calcium. CT angiography, you inject dye into a vein and you scan the vessels and you get a picture of the lumina of the vessels. There's absolutely no data on CT angiography as far as predicting future events. There's mountains of data regarding CT calcium imaging, particularly electron beam calcium imaging as far as predicting future events. There's studies that show that it's three times more powerful than all three (inaudible) risk factors combined.
(Dr. Nanette Wenger)
Let's go back to this test that was called normal. I really want to know to call it normal how intense was the exercise. Did she exercise to an adequate intensity? What was the baseline echocardiogram that we looked at? Did she have a thick ventricle?
(Peter)
The chart says normal. That's all I can tell you.
(Nanette)
Well, you know, I wouldn't send a patient back to someone who has sent me a repot that just said normal.
(Lisa)
She's sitting in my office. I am going to do some intensive lifestyle changes with her. We always act like that's not something that you can do. That's not achievable for patients, but it is and you put the power back in her hands. She is obese. She has reduced exercise tolerance and that may be because she has gained some weight. She has some minor risk factors. She has a borderline cholesterol, her blood pressure is normal. I would really hound on her about making some major lifestyle changes as far as diet and exercise and she'd come back in thirty days.
(Peter)
You're sitting there, Nic. You've been silent again. Thirty-eight years old, you have your heart attack, right? You didn't have any of these studies.
(Nic)
No.
(Peter)
What happened, by the way, after your heart attack? What did they do about it?
(Nic)
Well, they did an angiogram to see if they can do angioplasty and decided that wasn't possible so I had a double bypass.
(Dr. Peter Salgo)
Sixteen years ago.
(Nic)
Right.
(Peter)
If sixteen years before you had your heart attack someone had said to you, Nic, you are a walking cardiac time bomb and you hear the ticking in your head, would you have believed it, first of all, at thirty-eight and would you have done something to change lifestyle factors that Lisa would ask you to do to have decreased your risk?
(Nic)
Yeah, I think I would have changed lifestyle to some degree but probably not to the degree that I did after the heart attack. That's a real wakeup call.
(Peter)
Well, I'll tell you about Joyce. She mentioned the twinges because she thought she had breast pain, but now she's worried about her heart. She wants answers. Her stress test didn't satisfy her, her cardiogram didn't satisfy her, so she has her doctor send her for a 64-slice CT scan and guess what they find William?
(William)
Did they do a CT angiogram or did they do a calcium -
(Peter)
It's a 64-slice CT scan, period. That's all it says.
(William)
This is so reflective of the paramount ignorance regarding the difference between a CT angiography in calcium score.
(Peter)
Your head's beginning to hurt, isn't it?
(William)
Angiogram is not a screening test and she should not have had an angiogram as a screening test. It's a tremendous amount of radiation. There's risk to the diaload (?) and in the subset of patients who are most likely to benefit from revascularization the amount of calcium vessels makes a 64-slice angiogram relatively useless.
(Peter)
I could tell you the result if you'd like to know.
(Dr. William Blanchet)
I would love the result.
(Dr. Peter Salgo)
And I'll bet you can tell me which study she had based on this result. She has her test and it shows that she has a forty percent narrowing - does that tell you what test she had - she had an angiogram - in two of her arteries. Forty percent narrowing. What does that mean to you? I was going to ask Arthur what it means to him.
(William)
Well, obviously, she has advanced coronary disease for someone her age. Someone her age should not have any narrowings. She has two (inaudible) narrowings. She has advanced cardio disease.
(Peter)
Arthur, what does it mean to you?
(Arthur)
Well, she has some narrowing and it's a clear indication for prophylactic preventive therapy, there's no question. Even more reason to lower her cholesterol, to adjust her lifestyle, etc., so I would agree that in her age group she shouldn't have any narrowing and the fact that she does have some narrowing with this information I think the only thing one could do would be to add these lipid lowering statin drugs and we would have done this to begin with on the base of the critical office before we got through the exercise test and the coronary calcification -
(Nanette)
Well, let's put her on something simple like an aspirin first because we documented that she has coronary disease. You see, the issue is significant obstructive disease and it is unusual that a forty percent narrowing will give you enough functional limitation of blood flow to produce symptoms.
(Peter)
So you're saying she has forty percent narrowing and that's not what's causing her twinge.
(Dr. Laura Milberg)
Well, that's what I would want to know if I were this patient - not the twinge, the inability to finish my golf game. Is that why I couldn't do that?
(Peter)
You had experience with a broad variety of patients. They had forty percent of structure in the arteries that are feeding your heart. What did they hear?
(Laura)
I think I'm halfway to bypass surgery.
(Nanette)
Yeah, but again, I think that is our job and what I would say to this patient is you have coronary disease and our job is to see that that forty percent doesn't become any worse.
(Peter)
Let's stop for just a minute. The test that you get, the diagnose of heart disease are based on who who are and your risk factors. When getting tests it's important to know that sometimes the technology according to some people, at least, has outpaced our ability to know what to do with the results. You need to ask, you, the patient, is this test going to make a difference in how you treat me and is it going to be useful to me as a patient? Very, very important.
(Dr. Nanette Wenger)
Well, remember, most of those were not available when you had your heart attack.
(Nic)
Absolutely.
(Nanette)
So, a lot of what was done ten years ago or even five years ago is very different than today.
(Laura)
If I'm Joyce and you're sending me for all these things I'm already having a heart attack just because I'm being sent for all these - I need some explanation along the way. I think the tendency is to give the whole bucket of therapy at once regardless of anyone's readiness. You could be in shock for a while. I don't know how you felt right afterwards, but it's like say it isn't so. There is a dosing of the information and a dosing of the readiness.
(Peter)
Let me tell you what her doctor tells Joyce. Joyce has gotten all these results it says here in the chart. She's concerned about her arteries even though her doctor says forty percent is not significant. He assures her that she can live with this obstruction. She's got to change some things, but she's heard that heart disease is the number one killer of women in the United States. Should Joyce be worried?
(Nanette)
Joyce is worried when she came to the office and my job is to say that we are going to do the best we can to see that this doesn't progress and it is a partnership between the patient and physician in terms of lifestyle and medication.
(Dr. Peter Salgo)
Joyce's doctor tells her that the painful twinges were, in fact, due to the weight of her breasts. Her doctor says that she should use fish oil, folic acid and a baby aspirin every day.
(William)
No statins, no -
(Peter)
She does not recommend a statin. This is what she recommends.
(William)
What are the lifestyle -
(Peter)
That's all that we have in the chart.
(Nanette)
And there's good evidence that folic acid does not produce benefit and that if it's combined with some B vitamins may even produce risk.
(Peter)
Well great.
(Dr. Nanette Wenger)
So, I really don't like that preventive advice.
(Peter)
You're one of the co-authors of the 2007 guidelines for preventing cardiovascular disease, so can you bring us up to speed? What do the new guidelines say? What does the update reflect? What would she have been told if she were your patient?
(Nanette)
Well, again, the first approach is lifestyle, lifestyle and lifestyle. She's good because she's not smoking. Her blood pressure is fine so I would have her on a heart healthy diet. I'd put her on an exercise regimen. Get her to an idea body weight and because she has documented obstruction in the arteries she is a high risk woman now, so that she would be on a statin and she would be on an aspirin.
(Peter)
Give me some more on this. The antioxidants, what did your report recommend?
(Nanette)
To date, in women and in men all of the studies of antioxidants have shown no benefit and potential risk.
(Dr. Peter Salgo)
What about folic acid?
(Nanette)
As a cardiovascular preventive study neither for women nor for men has there been benefits and actually in patients after a heart attack in Norway if they combined the folic acid with the B vitamins that combination gave a worse outcome than nothing.
(Peter)
And with that we're going to pause for just a moment and sum up what we've been discussing. Heart disease is the number one killer in the United States. If you don't know if you're at risk of heart disease you've got to work with your doctor to find out. There are dietary, pharmacologic and lifestyle actions that you can take to help prevent a heart attack. Let me tell you a little bit more about what's going on with Joyce. She went into prevention mode. She continues to golf. She feels good but she still worries about her arteries. I can't let you go, Nic, without finding out how you're doing.
(Nic)
I'm doing great. I've had probably two dozen stress echo tests in the last fifteen years.
(Peter)
Are you living in fear of the next heart attack?
(Nic)
No, not at all, but I'm taking as good care if I can. My wife helps me take care of the diet part so that's a big help for me and I see the doctor all the time. I see my cardiologist twice a year and my internist three times a year, so lots of doctor calls.
(Peter)
I want to thank all of you for being here. This has been a terrific discussion. We covered a lot of ground here today. Let's sum up some of the key things to remember. The impact of cardiac risk factors for women under the age of seventy are simply not as well understood as risk factors in men and women over seventy, but no matter your age or gender you should work with your doctor to understand your own risk factors. You are a patient of one. The tests that you get to diagnose heart disease are based on who you are and what your risk factors are. When getting tests I think it's really important for you to realize that sometimes our technology can outpace our ability to know what to do with the results, so you need to ask your doctor if the tests that your doctor is recommending is going to make a difference in your outcome or in your treatment. Heart disease is the number one killer in the United States. If you don't know whether or not you're at risk of heart disease or what your risk is you need to work with your doctor to find out. There are dietary, pharmacologic and lifestyle actions that you can take to help prevent having a heart attack. This is a new era. And of course our final message is this - taking charge of your health means being informed and having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.
(Narrator) Search for health information and learn more about doctor/patient communication on the Second Opinion Web site. The address is pbs.org.
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(Music)
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