Surgeons vs. Cardiologists
New technologies and economic demands are creating intense competition between cardiac surgeons and cardiologists. Cardiac surgeons rely on referrals from cardiologists for most of their clients; but new technologies, such as angioplasty balloons and stents that can hold arteries open, let cardiologists treat many patients themselves instead of referring them for major surgery. Bypass surgeries have dropped by 20% since the stent's introduction in 1994. Responding to the drop, Georgetown University Medical Center (Washington, DC) merged its open-heart surgery program into another Washington hospital center, according to an article in The Wall Street Journal (10 September 2003). In addition to having fewer patients, heart surgeons are receiving significantly less money from Medicare and managed care companies for their services. Heart surgeons received $4,000 from Medicare for a bypass operation in 1987, but only $1,850 in 2002. Reimbursement cuts have hurt cardiologists as well. The physician fee for angioplasty has dropped by over 30% since 1998, yet cardiologists' operating costs continue to rise. Cardiologists pay almost twice the office overhead (almost 40% of their income) that heart surgeons do.

The competition for dollars and patients has led to a lawsuit in Towson, Maryland. Cardiac Surgery Associates, a group of heart surgeons headed by Garth McDonald, and the cardiology group Midatlantic Cardiovascular Associates had worked well together until economics pushed the cardiologists to ask the surgeons for some help with soaring overhead costs. When Cardiac Surgery Associates refused to contribute, the cardiologists hired their own surgeons and stopped referring patients to Garth McDonald's group. As a result, the eight heart surgeons of Cardiac Surgery Associates saw their caseload drop from about 110 surgeries a month in the late 1990s down to 25 during August 2003. The surgery group filed a lawsuit against Midatlantic Cardiovascular Associates, accusing them of violating a state unfair-competition law. Typically, however, multispecialty physician groups, such as cardiologists and surgeons, are exempt from anti-kickback or self-referral laws. Kevin Schulman, professor of medicine and business at Duke University, told The Wall Street Journal, "As technology favors one subspecialty over another, you get very, very large turf battles…We're going to see more of these battles where you can literally put some doctors out of business, and very quickly."

Anand, Geeta & Winslow, Ron. Transformation in Medicine is Putting Specialists at Odds. The Wall Street Journal 10 September 2003

Hypercholesterolemia & Hormones
Life Extension (September 2003) published an article by Sergey A. Dzugan, PhD, and R. Arnold Smith, MD, that proposes that hypercholesterolemia is the result of a multi-hormone deficiency. The body uses cholesterol as a basic component of cell membranes, bile acids, vitamin D3, and as the precursor to steroidal hormones such as pregnenolone, DHEA, testosterone, progesterone. The authors propose that the body responds to a deficiency of these hormones by overproducing cholesterol.

To test their hypothesis, the doctors performed a clinical study from July 1997 to April 2003, involving 41 patients with high cholesterol levels. The patients, ages 25 to 81, received combinations of multiple human-identical hormones. "If even one steroidal hormone is left out, then the body may respond to this deficiency by synthesizing more steroidal hormonal precursor, (i.e. cholesterol)," the authors explain. The hormones were given in individualized, physiologic ratios, designed to produce "youthful physiologic (not ‘normal') serum levels." The doctors determined each patient's dosage by periodically measuring serum hormone levels. Dose schedules simulated natural human production cycles.

All 41 patients responded to the therapy. Mean serum total cholesterol decreased from a baseline of 254.6 mg/dL to 188.8 mg/dL after treatment, a decrease of 25.6%. Serum HDL levels (the lipoprotein that scavenges free cholesterol and transports it back to the liver) also dropped (19.6%), "but remained much higher than undesirable levels in all cases." The authors view the decrease in HDL as a sign that cholesterol levels had normalized and that extra HDL was unnecessary. The doctors also noticed that the multiple steroid hormone therapy had improved thyroid function. All patients reported a "significant improvement in quality of life."

Dzugan, Sergey A., PhD. & Smith, R. Arnold, MD. Treating High Cholesterol by Replacing Hormones Lost to Aging. Life Extension September 2003

HRT & Heart Disease
When scientists began examining data from the Women's Health Initiative (a large federal study on hormone therapy) in July 2002, they were dismayed to find an unexpected increase in heart disease among women taking Prempro, a hormone preparation made by Wyeth. The Women's Health Initiative was the first randomized controlled study (considered "the gold standard") to involve thousands of women. Its results closely corresponded to the highly-regarded Nurses' Health Study, an observational study which derives its data from thousands of nurses who periodically report on their health and numerous factors that include diet, exercise, and use of drugs.

The Women's Health Initiative agreed with the Nurses' Health Study and other observational studies in several areas. Both types of studies showed a decreased risk of colorectal cancer among women who take hormones: 63% in the Women's Health initiative and 66% in the observational studies. Women taking hormones also had a lower incidence of hip fractures. Both types of studies found an increased incidence of breast cancer, stroke, and pulmonary embolism among hormone users. The observational Nurses' Health Initiative, however, showed that hormone therapy decreases the risk of having a heart attack by 30%. The randomized controlled study found that the incidence of heart attacks in women taking a hormone preparation had actually increased by 40%.
Scientists have been trying to figure out why the two studies gave such different outcomes in that one area. Is there some important, but unrecognized, difference between the groups of women involved in the two studies? Did the observational study miscount hormone therapy users? Gina Kolata, writing for The New York Times (22 April 2003), explained that "the nurses' study assesses drug use every two years. A woman could start taking hormones, have a heart attack in the next two years, and stop taking them immediately. Later when asked if she takes hormones, she says, correctly, that she does not. Her heart attack would be counted as one that occurred in a nonuser." So far, none of these factors account for the large discrepancy.

Some researchers have also suggested that the negative results of the Women's Health Initiative may be because of Prempro itself. Women in the observational studies took a variety of hormone preparations, not just Prempro. Dr. Jacques Rossouw, an administrator with the Women's Health Initiative, discounts that idea, saying that randomized controlled studies using other hormone preparations have also shown increased heart attack risk. Is there an intrinsic flaw in either the randomized controlled methodology or the observational study? The results of the Women's Health Initiative have scientists questioning research methodology.

Kolata, Gina. Hormone Studies: What Went Wrong? The New York Times 22 April 2003

Low-Dose Coumadin
Coumadin (warfarin) is a blood thinner that doctors have used for 50 years to prevent blood clots in the legs of patients susceptible to venous thrombosis. Although it does prevent potentially fatal blood clots, the drug also leads to an increased risk of hemorrhagic stroke and other bleeding disorders if taken long-term. Consequently, doctors usually end full-dose coumadin treatment, which maintains an anticoagulant range of 2.0 to 3.0 [international normalized ratio (INR)], after 3 to 12 months. Once treatment ends, however, venous blood clots often recur.

Paul M. Ridker, MD, and colleagues decided to study the effectiveness of long-term, low-dose coumadin treatment. Low-dose coumadin maintains an anticoagulant range of 1.5 to 2.0 (INR). The four-year study followed 508 patients with a history of venous blood clots who had previously received full-dose coumadin for a median of 6 months. Half received low-dose coumadin, the rest were given a placebo. Their progress was monitored through office visits every two months. The researchers reviewed the data at least once a year. After the fourth review the researchers ended the study earlier than intended because the data showed that low-dose coumadin prevents venous blood clots without causing major bleeding episodes.

Results were released in February 24, 2003, and published in the New England Journal of Medicine (10 April 2003). Thirty-seven of the 253 patients receiving the placebo had recurrent venous blood clots, compared to only 14 of the 255 patients in the low-dose coumadin group. Women receiving coumadin showed an 80% reduction in risk of recurrent venous blood clots while men showed a 53% risk reduction. The risk of major hemorrhage in those on low-dose coumadin was very low. Only one confirmed stroke occurred among the low-dose coumadin group, compared to two in the placebo group. Overall, four people in the coumadin group and eight people in the placebo group died during the four-year study.

Low-Dose Coumadin is Safe and Effective for Long-Term Prevention of Recurrent Venous Blood Clots. www.coloradohealthsite.org (Note: This link was not working on 2/20/05.)
Winslow, Ron. Blood Thinner at Low Dose Cuts Risks. The Wall Street Journal. 25 February 2003

Magnesium & Blood Pressure
Research has shown that blood pressure is linked to the calcium-activated potassium channels in the membranes of smooth muscle cells. When these microscopic ion channels open, the smooth muscles that control blood vessel diameter relax and blood pressure decreases. An article in Nature (22 August 2002) reveals that magnesium activates calcium-activated potassium channels in cell membranes, opening the channels. The research, led by Jianmin Cui at Case Western Reserve University, helps explain magnesium's beneficial effects on people with heart failure, stroke, and with high blood pressure.

Case Western Reserve University. Case Western Scientists Reveal How Magnesium Works on Ion Channels Important for Regulating Blood Pressure. 26 August 2002. www.sciencedaily.com

Policosanol
Policosanol (pronounced polly-KOH-san-all) is a natural compound, found in sugar-cane wax, that Cuban doctors have used for decades to prevent and treat heart disease. In Basic Health Publications User's Guide to Policosanol & Other Natural Ways to Lower Cholesterol, Mark Stengler, ND, explains that Policosanol has several advantages over cholesterol-lowering statin drugs. Policosanol reduces harmful LDL cholesterol as effectively as statin drugs, but it also prevents oxidation of LDL and increases beneficial HDL cholesterol. Policosanol also affects other factors believed to contribute to heart disease; it improves circulation, reduces blood clot formation, reduces inflammation in arterial walls, and decreases lipoprotein (a) levels. Lipoprotein (a), according to Dr. Stengler, is a stronger risk factor for heart disease than LDL cholesterol. "Some studies show that cholesterol medications such as Mevacor and Zocor may actually increase Lp(a) levels," he writes. Policosanol provides all these benefits without the negative side effects that accompany statin drugs.

Statin drugs such as Mevacor, Pravachol, and Zocor inhibit the liver enzyme HMG CoA reductase. This enzyme helps the liver make cholesterol. The enzyme is also necessary for CoQ10 synthesis. Cells use CoQ10 for energy production, and it helps strengthen and stabilize the heart's contractions. Unlike statin drugs, Policosanol is not toxic to the liver and doesn't seem to interfere with the liver's ability to metabolize other drugs, including heart medications. Although studies show a high degree of safety, Dr. Stengler says that pregnant women and breast-feeding mothers should avoid taking Policosanol (or any cholesterol-lowering drug) because cholesterol and its metabolites are necessary for fetal and infant development.

User's Guide to Policosanol and Other Natural Ways to Lower Cholesterol contains excellent descriptions of various cardiovascular conditions for the layperson and discusses currently-known risk factors. Many of the risk markers for heart disease can be lessened with nutrients and herbs. This little book makes a fine primer for those interested in more natural ways to prevent heart disease.

Stengler, Mark, ND. Basic Health Publications User's Guide to Policosanol & Other Natural Ways to Lower Cholesterol. (Basic Health Publications, Inc., ISBN 1-59120-051-2)

Phenylpropanolamine & Strokes
Drug manufacturers and the FDA knew, for decades, that phenylpropanolamine (PPA), the active ingredient used in over-the-counter decongestants and diet aids, could cause hemorrhagic stroke. A 1982 FDA report stated that PPA had "the ability to cause cardiovascular effects, cerebral hemorrhage and cardiac arrhythmias." A 1984 memo from Sandoz Pharmaceuticals described PPA as "an agent known to cause hypertension and stroke." Yet, the FDA did not declare PPA unsafe until November 2000, when it asked drug companies to stop selling it.

The downfall of PPA began with a five-year, $5 million study, sponsored by the drug industry, called the Yale Hemorrhagic Stroke Project. The study, which ended in October 1999, found a strong link between PPA and hemorrhagic stroke. The industry, which had approved the protocol and the investigators, attacked the methodology and the researchers' integrity when the study produced negative results. The industry's campaign to discredit the results delayed the final report upon which the FDA based its withdrawal of PPA products from stores. The delay gave drug manufacturers time to reformulate their products using pseudoephedrine. They had been reluctant to use pseudoephedrine because it costs more than PPA and because its bitter taste is harder to disguise, decreasing the medicine's appeal to children.

PPA stimulates the sympathetic nervous system. It opens nasal passages by narrowing blood vessels in mucous membranes. PPA's ability to constrict blood vessels and increase the force of heart contractions can cause blood pressure spikes. When these spikes occur in persons with cerebral aneurysms, arteriovenous malformations, hypertension or other – often undiagnosed – conditions, strokes can result. According to an article by Kevin Sack and Alicia Mundy of the Los Angeles Times, FDA epidemiologists say that PPA causes an estimated 200 to 500 hemorrhagic strokes among people, age 18 to 49, each year.

Sack, Kevin & Mundy, Alicia. How drug linked to strokes remained on market. The Seattle Times 29 March 2004

Lipid Metabolism & Dioxin
Disturbances in lipid metabolism and stenosis (narrowing) of carotid arteries are among the disorders caused by occupational exposure to 2,3,7,8-tetrachlordibenzo-p-dioxin (2,3,7,8-TCDD), according to an abstract presented at the 29th Congress on Occupational and Environmental Health in the Chemical Industry (3-6 September 2001, Prague, Czech Republic). Researchers examined 12 Czech workers who were among a group of about 80 people that became ill after exposure to 2,3,7,8-TCDD in 1965-68. TCDD, also known as dioxin, was a contaminant in the herbicide Agent Orange used to defoliate jungle during the Vietnam War. Internal, neuropsychological, and ophthalmological tests, ultrasound examination of the common carotid artery, and blood cholesterol and triglyceride measurements were performed on the 12 former TCDD workers. Most of them still suffer from psychic disorders, chloracne, nervous system lesions, and/or lipid metabolism. Elevated plasma lipid levels and atherosclerotic plaques in the carotid arteries were statistically more frequent in patients with higher TCDD levels.

Although dioxin is not made commercially in the U.S. at this time, TCDD is produced as a by-product during paper and pulp bleaching, incineration of municipal and hospital waste, and the manufacture of polychlorinated phenols and chlorophenoxy herbicides. Consequently, its distribution is widespread. The chemical does not breakdown easily. It persists in the food chain. The general population is exposed to dioxin mostly through contaminated food and water. TCDD intake is especially high among residents of the Great Lakes region who regularly eat local fish. Dioxin can cross the placenta and is known to cause birth defects.

2,3,7,8-Tetrachlorodibenzo-p-dioxin. www.standord.edu/group/whitlock/dioxin.html
Pelclová, D. et al. Lipid metabolism and neuropsychological follow-up study of workers exposed to 2,3,7,8-tetrachlordibenzo-p-dioxin. (abstract) http://link.springer.de/link/service/journals
Tenth Report on Carcinogens. www.ehp.niehs.nih.gov (Note: This link no longer works, as of 2/20/05.)

Benjamin, Mark. Mystery blood clots felling U.S. troops. United Press International. (www.upi.com) 6 October 2003
Schneidmiller, Chris. Military Personnel Suffer More Heart troubles Than expected After Smallpox Vaccinations, Researcher Says. Global Security Newswire. 13 May 2004 www.nti.org
Thompson, Marilyn W. Growing Doubts on Vaccine in Military. Washington Post. 27 March 2004