There’s an iconic image from legendary medical illustrator Frank Netter, M.D. that I will never forget from my medical school days. It’s a picture of a man clutching his chest as he exits a restaurant to trudge into the snowy night. The artwork was originally published in 1969 as part of the CIBA Collection of Medical Illustrations that serves as the benchmark for anatomic art in the last half century. I’d venture that there is not a doctor on the planet who is not familiar with the artistic footprint of Dr. Netter.

This particular picture accompanies the section of the atlas pertaining to “angina pectoris,” the chest pain that arises when the heart muscle is not getting an adequate supply of blood and oxygen. While the symptoms can be variable, angina is most often described as a squeezing pressure in the chest. As is typical of Dr. Netter’s style, his illustration captures many of the subtleties of the subject described. The man is middle-aged and mildly overweight and one can clearly see the burning ember of a cigarette butt he’s dropped into the snow. He is coming out of a restaurant and lumbering up a couple of steps into the driving winter wind. His right hand claws at his chest (see Levine sign) as his left hand loses its grip on his brief case.

In this illustration, Dr. Netter has made sure all the elements are there for a classic case of angina.

Risk factors? Check.

Exertion? Check.

Recent culinary indiscretion at a local pub? Check.

Driving snow and winter wind? Now it’s getting personal.

Those of us in the Midwest have had our share of arctic conditions over the last month as our temperatures hover well below freezing for what seems like an eternity and snow blankets our region to a degree that’s not been seen in years. The deep drifts have brought with them the familiar early morning buzz of snow blowers being reluctantly fired up for action, and, with that, come the admissions to the hospital of patients with heart attacks and chest pain.

While this is something I can’t quantify with any reliable objective data, my feeling is that I have seen more patients this year with heart conditions exacerbated by the elements than I’ve seen in years past. Is this just my imagination—my mind, being driven mad by the numbness of the arctic chill—or is there evidence linking a miserable winter to a rise in heart disease?

Indeed, solid research confirms the link between a bad winter and a rise in the rate of cardiac events. In one study, published in the British Journal of Medicine in 2004, researchers tracked temperature and climate data from 24 different countries in an attempt to establish a link between lousy weather and heart attacks. They discovered that a strong relationship exists between low temperature and the population’s rate of heart attacks and stroke. Their conclusions were so robust that they were able to provide an algorithm for determining what sort of rise in problems we can expect with cold air: “On average, a 5°C reduction in mean air temperature was associated with a 7% and 12% increase in the expected hospitalization rates of stroke and AMI (heart attack), respectively.” (How would it be if we added that to our evening weather broadcast? “And for tomorrow we can expect a high of 5 degrees, winds out of the north at 15 mph, and scattered heart attacks throughout the metro area.”)

Another study, published in the journal Circulation the same year, showed that the risk of cardiac-related death is at its absolute highest in the period between Christmas and New Years Day. The authors are careful to point out that it’s not clear whether the increased prevalence of heart attacks is due to the cold weather or the abundance of stale fruitcakes and spiked eggnog.

What, exactly, are the possible factors that lead to winter heart attacks in susceptible individuals? Here are some possibilities:

1. The body shunts more blood to the skin when the air is cold to maintain body temperature. To do this the heart needs to work harder to cycle the blood volume more quickly.
2. Depression, long linked to the cold darkness of winter, is known to be a risk factor for cardiovascular disease.
3. Flu and cold viruses can trigger inflammatory responses in the coronary arteries that can disrupt the delicate balance of coronary cholesterol plaques.
4. People generally exercise less when the weather is bad and slip into worse physical condition. Just this week Circulation published a study linking risk of cardiac death to the number of hours a person sits glued to American Idol.
5. People tend to eat more, smoke more, and gain more weight during the holiday season.

At the precise moment a person with occult coronary disease is at his deconditioned, flabbiest worst, he decides it’s time to man up and get out in the subzero temperature to perform his own stress test behind a 75-lb snow blower. It’s no surprise the night ends up with a trip to the cath lab.

I suppose the best way to avoid a January visit to the coronary care unit is to keep yourself in good shape during the rest of the year so that snow removal season isn’t such an extraordinary departure from your usual physical activity. Stay warm, get your flu shots, and watch your diet and your weight.

If there’s any question about your physical capability to shovel snow or rake ice off your roof, check with your doctor—it may be better to first try the conventional office-based stress test before you attempt the do-it-yourself-in-the-driveway method. I don’t think Dr. Netter needs any more modeling subjects for his medical atlases.

Imagine, for a minute, you’re a surgeon performing a routine operation when your scalpel slips, severing a critical blood vessel, and the patient nearly bleeds to death while you frantically try to save him.

Or, suppose you’re a pathologist scanning through a tissue specimen from a patient with suspected cancer. Instead of correctly identifying the malignant cells you skip over the pertinent findings and declare the patient free of cancer, only to learn later that your erroneous diagnosis led to a dangerous delay in treatment.

What if you are a primary doctor who ignores a radiologist’s report on a routine chest x-ray that identifies a suspicious spot on the lung?  The patient goes on, blissfully ignorant, until she begins coughing up blood and gets diagnosed with incurable cancer.

In each of these situations I imagine you’d experience a type of regret and remorse that would be difficult to describe.  While I’ve never caused a patient to bleed to death or failed to identify a cancer (to my knowledge) I have had my share of less deadly complications.  Each has been painful for me even if it may not have led to any problematic outcome for the patient.

Now consider a different scenario.  A patient comes to you for some new ache or pain and, instead of applying the diagnostic skills you’ve practiced since medical school, you simply order up one of our seductively beautiful medical imaging exams.  The test satisfies your medical curiosity with its detailed digital vivisection and the patient leaves the hospital feeling good about the thoroughness of his doctor.

But do you ever stop to realize you’ve just performed a test that has the potential to damage the patient’s health as much as any of the hypothetical situations described above?  Add to that the catch that neither you nor the patient can know immediately whether or not he will be one of the unfortunate patients to suffer the complication.

This is what went through my mind as I listened to a news story a last month.  Patients receiving computed tomography (CT, or “CAT”) scans at Cedars-Sinai Medical Center in Los Angeles were exposed to several times the usual dose of radiation than is needed for the scans they received.

“Beginning in February 2008, each time a patient at Cedars-Sinai Medical Center received a CT brain perfusion scan -- a state-of-the-art procedure used to diagnose strokes -- the dose displayed would have been eight times higher than normal. No standard medical imaging procedure would use so much radiation, which one expert said is on par with the levels used to blast tumors.

“Somebody should have noticed. But nobody did -- everybody trusted the machines.

“Late last week, the U.S. Food and Drug Administration and Cedars-Sinai revealed that 206 stroke patients who received scans at the prestigious Los Angeles hospital were overdosed with radiation. Now doctors and safety experts around the country face a troubling question: In an era of supposedly fail-safe medical technology, how did the problem go undetected for 18 months?”

This story broke about the same time two studies were published in the Archives of Internal Medicine regarding the risk of cancer from radiation associated with routine CT scans.  In the first paper the researchers determined that approximately 29,000 future cancers (half of which will be fatal) will arise in the United States from the radiation used in conjunction with CT scans done over the course of only one year.  This is based on an assessment of the number of CT scans done during 2007 and was calculated using the theoretically established estimate of one death per 2000 scans performed.  The second publication was a survey of CT scanning at four prominent California medical centers that found a remarkable 13-fold difference in the amount of radiation delivered by similar scans at these facilities.  One site routinely deluged its patients with over 50 mSv of x-rays (see below to put this amount in perspective).

Some of you may be aware of these estimates, but I for one was not and found them both surprising and disturbing.  I have been ordering CT scans on patients ever since I was an intern rotating through the emergency room and, while I’ve acknowledged the theoretic risk associated with the radiation from these studies, I’ve never really thought about it in such starkly objective terms.

Let’s back up a minute and review some basics about radiation dose in medical imaging.  For us to understand the metrics of radiation dose let’s use as our baseline the amount of radiation you would receive from a standard chest x-ray, a simple and common study that exposes you to about 0.1 millisieverts (mSv) of ionizing radiation.

Now consider the CT scan.  In order to produce its dazzling images of the inside of your body it must flood you with anywhere from 1.5 mSv (for a typical head CT) to 10 mSv (chest, abdomen and pelvis) of x-rays.  That translates to the equivalent dose of radiation you would receive from undergoing a hundred chest x-rays.  It has been said that the radiation exposure from a full-body CT scan (something that no radiologist I know would recommend, but a study that is nonetheless not infrequently requested by patients) is the same as standing a mile and a half away from the WWII atomic blasts in Japan.

Whether you like it or not you already receive a fairly hefty dose of unavoidable radiation on a daily basis coming at you from ordinary sources such as the sun and naturally occurring radioactive isotopes in the soil.  It is estimated that each person is exposed to an average of 2.4 mSv of ionizing background radiation per year (equaling 24 chest x-rays).  By undergoing a CT scan you are at least doubling your yearly dose of radioactive exposure.

Why am I telling you all this?  Simply to remind you that our wonderful imaging technology is not free—it comes at a cost that is significant to at least some patients.  My more frequent readers will recall a recent piece I wrote extolling the virtues of coronary CT angiography.  At present this study constitutes one of the most radiation-intensive scans we can perform, zapping you with up to 13 mSv for one set of images.  Based on the calculations from one of the papers I cited above, one in every 270 forty-year-old women undergoing a CT coronary angiogram will develop cancer from the procedure.  This doesn’t mean we shouldn’t use this valuable tool—we just have to be very careful to apply it only to those patients who really need it.

It was December 22nd, 1895 when Wilhelm Roentgen introduced radiation-based medical imaging to the world and in the years since then this marvelous technology, for all its risk, has saved exponentially more lives than it has put in jeopardy.  But for this equation to work in our favor we need to reserve the use of CT scans for only those who would truly profit from the information they provide.

The message to you as a patient is to not expect to be treated to the most technologically advanced imaging study when good old-fashioned clinical reasoning could suffice.  In the end it may not be in your best interest to pester your doctor into ordering a CT scan when your clinical scenario doesn’t justify it.

And the message to us doctors is to think twice before we casually request such comprehensive radiology imaging.  While killing a patient by ordering an unnecessary CT scan may not stir as much soul searching on the part of the doctor as inadvertently severing a critical artery during the course of a botched surgery, the outcome for the patient is nonetheless the same.

Earlier this evening I made a trip to the intensive care unit of one of our area hospitals.  As I walked down the hall to the patient’s room I had to pass by several waiting rooms filled with family members.  The units were especially busy and the waiting rooms were filled to capacity.

Years ago, when I was in residency, I used to go to great lengths to avoid the ICU waiting rooms.  My job, when on call with the internal medicine service, was to admit all patients who presented to the hospital over a 24-hour period, launch their evaluation and initiate therapy, and dismiss those patients whose condition became stable for them to leave the hospital.  Going through this process for 10 or 20 patients invariably eats up every one of the 1440 minutes of the day  (most of the routine work didn’t get done until midnight, and the rest of the night was spent solving problems and “putting out fires”).

One sure way to fall hopelessly behind was to get trapped by a family with an endless list of questions and demands for their ill relative, and the best way to become thus ensnared was to casually wander by the waiting room.  One senior resident counseled me to stride past the waiting room at such a fast clip that it always looked like I was rushing off to resuscitate a coding patient.  “Leave the family interactions to the attending physician.  That’s why he gets the big bucks.”

During one particularly sleep-deprived stretch of internship I even envisioned writing a video game based on the experience of a resident on call.  The goal of the game would be to manage the utter chaos of a call night while avoiding pitfalls that suck up your time, such as the interminable attending rounds and dreaded ER call for the impacted nursing home patient.  Getting snagged outside the ICU waiting room would be a penalty akin to having your car towed in Grand Theft Auto.

I hesitate to admit such things since it makes me come across as a callous and uncaring individual, but you have to understand that during internship my goal was much the same as my patients’: survival.

Now that I am the attending physician I see it as my duty to spend whatever time is needed to communicate with the family and friends of my patients.  I no longer speed past the waiting room trying to look too occupied to stop and answer questions, and this evening in particular I paused to take in the scene.

There’s no question that the ICU waiting room can be a sad, dreary place, but what I saw tonight was something quite different.  Families were gathered around talking and laughing, sharing stories, playing games and putting together puzzles.  No one was watching TV, working on their computers or doing homework or chores. 

It’s helpful these days that the hospitals accommodate the atmosphere needed in the ICU waiting room.  They offer plenty of chairs and tables, food for late night snacking, and games that foster communication rather than competition—the scrabble boards and jigsaw puzzles were particularly popular tonight.

It made me think back to my own experience when my father was in the hospital for the last few days of his life.  My five siblings and I came in from near and far to gather outside the ICU waiting for the doctors to deliver their final verdicts.  For us it was a terribly difficult time, but it was also a reunion of sorts and allowed us to catch up with one another and share childhood stories about our father. 

As I watched the families tonight I was struck with a nostalgic wistfulness. I found that I look back on the events surrounding my father’s passing not so much with sorrow but with fondness.  What else could bring a disparate family of grown, independent siblings together, dropping everything at a moment’s notice, than the critical illness of a family member?  What could better bolster the bonds of family than standing by each other in times of shared grief?  I was fortunate to have brothers and sisters to shoulder the burden of my father’s loss and tonight I found myself missing their company more than ever.

We will all die at some point, and for many of us this will involve a stay in one of our intensive care units.  For all the tragedy that surrounds the family gathering in the ICU waiting room I’m glad to see the good in it.  It is somehow reassuring to me as a doctor—and a future patient—to be able to watch family members revel in the company of the living as they support the suffering of the nearly departed.

Happy Holidays one and all.

‘Tis the season when nearly everyone entertains the idea of New Year's resolutions. I have no stats on this but I suspect that sales of gym memberships, diet and self-help books, and nicotine patches go through the roof around this time of year. Every purveyor of exercise equipment targets those of us with good intentions but a record of poor follow-through with promises of renewed health, youthful energy, and the ability to slide into those skinny jeans for the first time in years. We all graze our way through the holidays and promise ourselves redemption through an ascetic lifestyle of assiduous exercise and vice-free nutrition. Ten pounds gained through the holidays, five pounds lost in January. You do the math and it’s no surprise we’re all 50 pounds heavier than ten years ago.

Sadly, we break our New Year's resolutions more reliably than politicians back out on campaign pledges. More reliably than a promising Husker season turning into another “rebuilding year.” More reliably than being delayed in a layover in Denver (which is the situation I find myself in as I write this). More reliably than . . . well, you get the picture. I am of course no exception to this, having never seen Presidents Day with my resolutions intact. One website I consulted contradicts my anecdotal experience, suggesting that a whopping 46% of all resolutions are still in force by the 4th of July. My suspicion is that this website is secretly funded by the makers of the “Abdomen-izera™” (as seen on TV).

The problem, as I see it, is that we simply set our sights too high. It’s not infrequent for me to see patients tipping the scale at 300 pounds who ask me how much weight I think they need to lose. I tell them that if they can get below 280 their blood pressure, diabetes, sleep apnea, and energy level might see a big improvement. They look at me a little surprised and tell me they were thinking more along the lines of getting under 200 pounds. I see them a year later and they are ten pounds heavier. Losing twenty is manageable. Losing a hundred for most people (unless they happened to be a contestant on a reality television show) is as likely as sunny, warm winter day in Omaha.

Here’s what I propose: Let’s all think of resolutions that are simple, sustainable, and make sense. Try these:

1. Take every opportunity you can to increase you daily level of activity. Park farther away, make an extra loop around the office every hour, take the stairs instead of the elevator, treat your dog to an extra quarter mile on your daily walk, etc. Be creative, but pick things that are easy to incorporate into your daily habits.

2. If you’re a smoker, resolve to ask your doctor what he or she thinks you should be doing to quit. Despite the fact that it is our jobs as doctors to get to you quit smoking, we bring the subject up far less than we should. We really can’t be blamed, though. Bringing up the issue over and over is a little like being the school nerd who keeps asking the cheerleaders to homecoming. After a while the repeated rejection makes you want to drop the subject all together. That’s why you should decide to initiate the conversation and then think hard about following the advice you get.

3. Plan to get your routine health screening done this year. No one likes needles or colonoscopy probes (at least no one I know) but there’s a good reason to stay up to date with your routine maintenance. There are plenty of websites that will supply you with the checklist of tests, scans, and studies you might need and your primary doctor will be happy to guide you based on your personal health history.

4. Become compliant with your medications. Consider these stats:
   
   • 14-21% of patients never fill their original prescription
   • 60% cannot identify own medications
   • 30-50% ignore instructions associated with their drugs
   • 20% take other people’s medications
   • 125,000 people with treatable ailments die each year because they take their medication improperly
   • Annual hospital costs due to noncompliance in this country amount to $8.5 billion

5. Treat yourself to one big, juicy, greasy, cholesterol-laden meal a week (or whatever your culinary vice may be). Now, you’re thinking, that’s one resolution I can live with. But in return, tighten your diet down for the remaining 20 meals you ingest each week. Cut back on sugars, fats, fried foods, starches, and (most of all) sheer volume. Reward yourself once a week for a job well done.

6. Find ways to simplify your life so that you have time to exercise. If you want to get more fit you need only 30 minutes a day. What can you give up for a half hour a day?

7. Compile a list of your medications and health problems and research each so you know what you’ve got and why you take each drug. Enlist a family member or friend if needed. Ask your doctor or nurse to help clarify the ones you have questions about. Carry the list with you whenever you go out and update it as often as needed.

8. Pick someone close to you and together decide on a health goal that you both need to meet. Plan activities around your shared interest and support each other when the going gets tough (which, for me, comes well before Groundhog Day).

9. If you’re overweight plan to lose enough pounds over the next 12 months to get back to where you were two years ago. Do that for a few years in a row and it’ll be like turning back time.

10. Share this cardiology website with two friends and challenge each to pass it on to two more people and so on and so on. By the end of the year envelopes filled with cash will be pouring into your mailbox. At least that’s my resolution . . . and you know what that’s worth.

A month or so ago one of our readers commented on the need for more information on atrial fibrillation, and, since I’m always happy to comply with requests to blather on about anything in this blog, I’ll gladly accommodate.

To understand atrial fibrillation (AF) you must first understand how normal electric activity in the heart works.  Once every second an area of cells known as the sinus node produces a spontaneous electrical impulse—a minute shock—that spreads throughout the muscle of the top chambers of the heart (the right and left atria).  The atria are responsible for pushing blood down into the ventricles, the muscular bottom chambers of the heart that pump blood out to the body and the lungs.  The electrical stimulus first causes contraction of the atria and then a split second later (one-fifth of a second to be more precise) makes its way down into the ventricles to cause contraction there.  The result is that the atria contract first followed by the ventricles.  Lub-dub.

Let me use an example to better illustrate the electrical rhythm of a heart beat.  Think of a big band orchestra (a la Tommy Dorsey or Count Basie) with a conductor leading the music, the musicians playing the music, and a room full of dancers.  Think of the sinus node as the conductor—constantly tapping out a rhythm, telling the heart to go slower or faster as needed.  The musicians represent the atrial muscle and follow the conductor impeccably.  Now pretend that the dancers, who in this scenario represent the ventricular muscle, move with the beat of the music.  Under normal circumstances the three parts—conductor, musicians, dancers—perform in perfect synchrony.

Now let’s pretend that a clarinetist decides to spin off into an allegretto while the rest of the orchestra is in the middle of an andante.  He plays fast and furious, and so loud that the neighboring instruments get confused and start their own solos.  This behavior makes its way through the orchestra until all musicians are playing their own tunes, to their own beat.  Nothing that the conductor can do will matter since he has lost control of the musicians.  The dancers, in turn, hear the cacophony and dance faster and faster, trying their best to keep up with the flood of rhythms they perceive.

This is what happens with AF.  The top atrial chambers descend into a chaotic dervish and the ventricles do their best to follow, but tend to beat so fast and irregularly that the person starts to have symptoms of palpitations, shortness of breath, and lightheadedness. 

To add to this, since the atria are no longer contracting in a coordinated fashion, the blood that normally courses smoothly through the atria with each squeeze begins to coagulate along the corrugated walls of the chambers.  In the left atrium this represents a particular problem since any clot that forms there and breaks free will migrate through the left ventricle and out the heart, coming to rest only when it lodges in a small artery in the brain (causing a stroke) or elsewhere in the body.

Therapy for AF really needs to focus on two areas:

1. Decreasing risk of stroke
2. Slowing the heart rate

To decrease the risk of clot to the brain we generally employ the age-old drugs warfarin and aspirin.

Slowing the heart rate is a little more complicated.  We generally adopt one of two strategies:

1. Promote normal rhythm.  The most common way to do this is to add a medication that pushes the heart toward normal rhythm and decreases the likelihood of AF.  For this we frequently use propafenone (Rythmol), amiodarone (Pacerone), sotalol (Betapace), flecainide (Tambocor), and a few others.  Adding one of these drugs is like hiring the club’s bouncer to stand over the shoulder of the wayward clarinetist and whack him every time he falls out of tempo.

A second way to keep the patient out of atrial fibrillation is to do an invasive procedure called pulmonary vein isolation (also referred to as AF ablation).  In many patients we know where the AF starts (at the inlet of the 4 pulmonary veins) before it expands to involve the whole upper half of the heart.  If we encircle the pulmonary veins with a scar line we can insulate the rest of the heart from the abnormal electrical activity of this small area.  It’s like taking the troublesome clarinet player and moving him to another room where he can’t bother anyone.

This procedure is done either through the veins (by an electrophysiologist) or through a small hole in the chest wall (by a heart surgeon).  Our group offers both approaches.

2.   Allow AF to continue but control heart rate.  We do this mostly with medications like beta-blockers, calcium blockers, and digoxin.  This therapy is akin to allowing the band to play as chaotically as they want but limiting how fast the dancers move. 

Most older patients and those with valve problems have hearts that are so stubbornly stuck in AF that we can’t get them back into normal rhythm despite our best efforts.  Allowing the AF to continue and simply controlling the rate doesn’t seem as glamorous an approach as rhythm control, but in reality patients can live long and healthy lives with ongoing AF as long the ventricular rate is in a comfortable range (heart rate between 50 and 80 at rest and up to 120 or 130 with activity) and the patient is on some type of anti-clotting medication (aspirin or warfarin).  A couple of large research studies suggest that this approach may actually be safer in many people.

Atrial fibrillation is a very complicated issue that we often take for granted because we see it so frequently.  With the right medications AF should be no more than a nuisance issue for the patients who suffer from it and they should be able to continue with full physical activity—even if that includes dancing and clarinet playing.