July 27, 2012 | 2:15 pm

CT Scans Not Very Helpful in Diagnosing Heart Attacks

Posted by Albert Fuchs, M.D.

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CT scanner
Photo credit: Wikimedia
Commons

Obstetrician 1: Get the EEG, the BP monitor, and the AVV.
Obstetrician 2: And get the machine that goes ‘ping!’.
Obstetrician 1: And get the most expensive machine - in case the administrator comes.
—From Monty Python’s movie “The Meaning of Life”

Heart attacks remain the number one cause of death for men and women in the U.S. Heart attacks typically feel like squeezing or pressure in the center of the chest that lasts longer than a few minutes. So if you ever have such symptoms, call 911 immediately. Over 6 million people go to emergency departments because of chest pain, and they present an important medical challenge. A very small fraction of them, less than 1%, are having heart attacks. They should be identified and treated (ideally with angioplasty) as quickly as possible since the time between the onset of pain and treatment is critical to the chance of survival and recovery. But the vast majority of patients have chest pain that is due to something not nearly as dangerous, like acid reflux, muscle spasm, anxiety, or gallstones. They can frequently be treated as outpatients after a heart attack has been ruled out.

The standard of care for excluding a heart attack is an immediate EKG in the emergency department and a blood test called troponin. For the troponin result to be definitive it must be drawn several hours after the onset of chest pain, so many patients are admitted for observation and to await the definitive second troponin test.

Wouldn’t it be nice if we had a way to exclude heart attacks immediately, so that the many patients without a heart attack could be spared the unnecessary hours in the hospital? That was the thought of the investigators of a study in this week’s New England Journal of Medicine. They conducted a study in which patients presenting to emergency departments with chest pain and whose initial EKG and troponin was normal were randomized to either usual care or an immediate CT scan of their coronary arteries.

The results were meh. The group which received the CT scans went home 7.6 hours earlier on average, but they received a dose of radiation and they were exposed to intravenous contrast, which can cause side effects. The overall cost of care was higher in the group receiving the CT. And in the outcome that really matters – catching every person with a heart attack – both groups did equally well.

An accompanying editorial makes the point that exposing millions of people to CT scans with intravenous contrast when most of them are very unlikely to be having heart attacks is likely to do more harm than good. And the only benefit the study showed – earlier discharge by a few hours – is likely to help hospitals much more than patients.

So if you’re hospitalized for acute chest pain, be patient. You may have to spend the night waiting for that second troponin. Rent a Monty Python movie, and try to relax. There’s no reason to demand the machine that goes ‘ping’.

Learn more:
CT for chest pain in ER gets patients home sooner (Los Angeles Times)
Study questions CT scans to rule out heart attacks (Associated Press)
Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain (New England Journal of Medicine article)
Coronary CT Angiography for Acute Chest Pain (New England Journal of Medicine editorial)
In Event of a Heart Attack Let the Paramedics Come to You (My post in 2008 about what to do in case of a heart attack)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

July 20, 2012 | 11:14 am

Many with Prostate Cancer Do Not Benefit From Surgery

Posted by Albert Fuchs, M.D.

Surgeons not doing
prostate surgery
Photo credit:
Wikimedia commons

My regular readers know that prostate cancer has been a controversial topic recently. The controversy centers around our ignorance of whether treating early prostate cancer helps patients, and by extension, whether early diagnosis is helpful. In May I wrote about the US Preventive Services Task Force’s new recommendation against screening men for prostate cancer with PSA blood testing, finding that the benefits of such screening are small or non-existent while the harms are large.

Nevertheless, for patients already diagnosed with prostate cancer choosing a treatment plan is fraught with anxiety but very little data. I wrote in 2006 that for some patient with newly diagnosed prostate cancer, electing to forego any treatment may be a reasonable choice. Still, a patient who has just been diagnosed with cancer is frequently unreceptive to the notion that he need not do anything. A study in this week’s New England Journal of Medicine attempted to clarify if surgery done to remove the prostate in patients diagnosed with prostate cancer improves their survival.

The study enrolled 731 men with newly diagnosed cancer that had not yet spread outside the prostate. These men were randomized to have surgery (radical prostatectomy) or to receive no treatment other than regular follow up and monitoring. They were followed for an average of 10 years.

The results were interesting but not definitive. The group that underwent surgery did not live longer than the group without treatment, nor did they have fewer deaths due to prostate cancer. Not surprisingly, the group that underwent surgery also had significantly more complications from surgery, primarily difficulty with erections and urinary incontinence. This would seem to suggest that surgery had no benefit despite significant harms. Given the huge number of men who undergo prostatectomy every year, the study has received much media attention. (See links below.)

But the conclusions from the study are not so clear. As an accompanying editorial in the New England Journal of Medicine points out, the study enrolled far fewer than the 2,000 patients it initially hoped to attract. The study therefore was not statistically able to detect small mortality benefits of surgery that may have appeared had more patients been followed for more years. Moreover, fewer men in the group that underwent surgery had their prostate cancer spread to their bones, a complication that can be painful and debilitating. Though less compelling than a mortality benefit, the prevention of bone metastases is a finding favoring surgery.

There was one additional important finding that favored surgery. Among the subset of men with tumors judged to be at high risk of spreading because of a PSA higher than 10 or because the cancer cells looked very abnormal microscopically, the men who underwent surgery lived longer than those who did not.

So the conclusion of this study is mixed. Men who have prostate cancer that is likely to be aggressive are likely to live longer if they have surgery. But men who have less than 10 years of life expectancy or whose prostate cancer is more indolent (by PSA and microscopic appearance) are very unlikely to benefit from surgery, while still suffering all the surgical complications.

The important but difficult lesson is not to panic after the diagnosis. There is plenty of time to collect opinions and choose the right course. And sometimes the right course is doing nothing.

Learn more:

Surgery unneeded for most early-stage prostate cancer, study says (Los Angeles Times)
Questioning Surgery for Early Prostate Cancer (Well, New York Times health blog)
Radical Prostatectomy versus Observation for Localized Prostate Cancer (New England Journal of Medicine article)
Prostate Cancer — Uncertainty and a Way Forward (New England Journal of Medicine editorial)
Why I Won’t Have a PSA Test When I Turn 50 (My post in May about prostate cancer screening)
Fighting Prostate Cancer by Doing Nothing (My post in 2006 about the option of not treating prostate cancer)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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July 13, 2012 | 11:11 am

Are You Obese?

Posted by Albert Fuchs, M.D.

Photo credit:
Wikimedia Commons

Americans are getting heavier and have been doing so for decades. One in three adults in the US is obese. Overweight and obese people are more likely to develop diabetes, high blood pressure, heart disease, and other serious health problems. What can be done?

Last month the US Preventive Services Task Force (USPSTF) released a new recommendation that all primary care doctors screen their patients for obesity. To do that, a doctor measures the patient’s weight and height and uses it to calculate the patient’s body mass index (BMI). Do you know your BMI? If not, use this handy BMI calculator to figure it out.

The BMI is a somewhat imprecise measure of healthy weight since it doesn’t take into account body fat percentage, but it’s easy to determine and therefore widely used. Normal weight for adults is from a BMI of about 20 to about 25. A BMI over 25 is considered overweight. Over 30 is obese.

The USPSTF recommends referring everyone with a BMI greater than 30 to an intensive behavioral intervention program that focuses on increasing exercise, controlling food portions, and self-monitoring progress towards weight-loss goals. Of course, eating better and exercising is notoriously difficult, and on average the long term weight-loss is only modest. But in obese people a loss of even 5% of weight is likely to lead to some health benefits. In any case, increasing physical activity and eating better is likely to lead to health benefits even if weight loss is not achieved, or if the weight is regained later.

The medications currently available for weight loss are only minimally effective and have some side effects, so the USPSTF did not recommend medication use. The current recommendations also did not evaluate surgery for weight loss, which has been gaining supporting evidence in the last few years.

So know your BMI. If it’s too high, that’s a good sign you should be eating less and moving more.

Learn more:

Obesity screenings for all American adults? Not so fast, some say (Booster Shots, the Los Angeles Times health blog)
Doctors Hesitant To Deal With Patients’ Weight Problems (Shots, NPR’s health blog)
BMI calculator (Centers for Disease Control and Prevention)
About BMI for Adults (Centers for Disease Control and Prevention)
Screening for and Management of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement (Annals of Internal Medicine)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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