Lown Forum

Shmuel Ravid, MD, MPH

T HE

2009

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LOWN CARDIOVASCULAR RESEARCH FOUNDATION

Atrial brillation: The importance of individualized treatment

Atrial brillation (AF), an irregular pulse originating in the upper chambers of the heart (the atria), is the most common sustained heart rhythm abnormality (arrhythmia). Increasingly prevalent, AF is a signicant health issue, currently aecting 2.5 million adults in the US at an estimated cost of $6.65 billion annually. About 20% of strokes are due to AF. Most patients with AF can be treated eectively with medications. In recent years, however, invasive procedures for treating AF have been heavily marketed by specialized AF centers and related industries. The Lown Cardiovascular Center has been a pioneer in researching and treating patients with AF since Dr. Lowns historic introduction, in the early 1960s, of direct current electrical cardioversion, which remains a primary intervention to restore normal rhythm in AF patients. The physicians at the Lown Center have managed thousands of patients with AF. With more than 40 years of experience, we have developed a unique approach to this condition, emphasizing medical therapy tailored to the individual patient, which produces excellent outcomes and good quality of life in the majority of patients with AF.

Individualized treatment
We dont treat AF, but the patient with AF. An eective AF management plan takes into consideration many factors unique to each patient, including underlying heart disease, severity of symptoms, degree of physical activity, emotional state, compliance with medications and possible side eects, and, importantly, each patients preferences. For example, patients with infrequent AF episodes may require only intermittent treatment. By providing therapy on an as-needed basis, we avoid unnecessarily exposing them to potential side eects.

MYTHS & FACTS ABOUT AF

MYTH: Patients with AF generally have poor quality of life and bad prognosis. FACT: AF is a common condition, especially in older people. It is a generally benign and manageable clinical problem. MYTH: Onset of AF poses a medical emergency requiring hospital admission. FACT: Most AF episodes and the vast majority of AF patients can be treated safely and eectively as outpatients. MYTH: AF is generally life threatening. FACT: Proper anticoagulation (blood thinning) is eective for stroke prevention, and control of heart rate alleviates symptoms and prevents potential complications. MYTH: Procedures such as ablation are frequently necessary. FACT: AF ablation may benet carefully selected patients but in our experience this is infrequently necessary.

Education and reassurance

Being diagnosed with a cardiac condition can be alarming and stressful. We take time to help our patients understand their heart health, reassure them that AF is generally a benign and manageable condition, and arm that most people with AF are able to lead full and normal lives.

Maximize non-invasive therapies

Through careful listening and examination, we identify and address issues that may co-exist with a person's AF, such as other medical conditions that can inuence its course. A core principle of the Lown Center's model of cardiac care is to utilize invasive procedures, such as ablation, only as a last resort and only in symptomatic patients for whom other medical alternatives have failed or are not feasible. In our extensive experience, this is infrequently necessary.
Read the Lown Center patient guide: Atrial brillation on page 4.

INSIDE

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Foundation news President's message Heart Hero Award: Uganda Guide to atrial brillation Patient prole: Living with AF

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LCRF anxiety research Question from a patient Lown Center News b eat Donors celebrate a Lown Center Golden Anniversary Consumer beware: Mobile vascular screenings

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FOUNDATION NEWS New Lown Center home care project

The Lown Cardiovascular Center is embarking on a new demonstration project in which a small group of patients will be able to communicate with us from their homes via videoconferencing over the internet. The project's purpose is to explore how communication technology might enhance our model of care. Potential benets of participation may include receiving quick answers to simple questions, engaging in face-to-face consultations without coming into the oce, and increasing patients' peace of mind. We will be recruiting a limited number of patients for this project. If you are interested and wish to learn more, contact Jessica Gottsegen at 617-732-1318 x3805 or jgottsegen@partners.org.

Presidents message
Vikas Saini, MD, President, Lown Cardiovascular Research Foundation
During a recent presentation in Tokyo, I made the case that the key to cost containment is reimbursement of physicians for spending more time talking with patients, thus reducing premature ordering of multiple procedures. This approach is the core of the Lown Centers practice style and key to its eectiveness. We have completed a rst-phase statistical analysis of our coronary artery disease project. Results show a mean follow-up time of 13.2 years for enrolled patients, and an annualized mortality of 3.7%. For those under 80 years, the rate was 3.2%. Many among this cohort of people originally came to the Lown Center for a second opinion. As reported previously (1), our cardiologists determined that most of them did not require surgery. Our results compare favorably with people who undergo bypass surgery: recent Medicare results indicated that long-term survival after bypass surgery in northern New England was 4.2% in those under 80 years old. We have also found other interesting and important associations. Exercise duration on treadmill testing was an important prognostic indicator, rearming the value of maintaining tness. As discussed by Dr. Blatt on page 4, initial anxiety levels were a signicant variable in outcomes, reinforcing our interest in exploring ways to inuence nontraditional risk factors. Our next goal is to develop statistical techniques that will allow comparison of our outcomes to those of the general population of patients. This is part of a broad area of emerging research called comparative eectiveness, which has understandably drawn keen interest from policy makers in Washington as everyone struggles to delivery quality at aordable cost. Stay tuned.
(1) Long-Term Outcomes of Optimized Medical Management of Outpatients With Stable Coronary Artery Disease (Am J Cardiol 2004;93:294299). Read it on the LCRF website: http://www.lowncenter.org/articles/CAD.pdf

LCRF welcomes Jessica Gottsegen

The Lown Foundation welcomed Jessica Gottsegen as our new Foundation assistant in May 2009. Jessica is a 2009 graduate of Brandeis University, where she received Bachelor of Arts degrees in Psychology and in Health: Science, Society, and Policy. At Brandeis, she dedicated a great deal of time to the Waltham Group, the universitys community service program, and was responsible for managing 16 volunteer programs with over 400 student volunteers. In 2007 she interned in the Stop TB department of the World Health Organization in Geneva, Switzerland. She also interned with the American Cancer Society and volunteered for ve years at Camp Sunshine, a camp for children with life-threatening illnesses. Jessica works closely with other LCRF sta to support Foundation activities. Her role includes assisting with development and fundraising and providing general administrative support. She is thrilled to be part of the Lown Foundation team and looks forward to working with Foundation supporters locally and globally. Please join us in welcoming Jessica, and feel free to contact her at 617-732-1318 x3805 or jgottsegen@partners.org.

Receive your Lown Forum by email

Members of the Lown Foundation community can now receive our quarterly Lown Forum newsletter by email. If you'd like to receive a PDF of the Forum rather than a print copy, please send your name and preferred email address to info@lownfoundation.org or call Jessica Gottsegen at 617-732-1318 x3805.

Newpatientappointmentsavailable Patients of the Lown Cardiovascular Center frequently ask whether--and how--they can refer friends or relatives to the Center. New patient appointments are currently available. Individuals who would like to make an appointment with one of the Lown Center cardiologists should contact Maura Emery, Appointment Coordinator, 617-732-1318 x3315.

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Be Alive With Your Heart Uganda receives ProCor's 2009 Louise Lown Heart Hero Award
A few years ago, nutritionist Edward Buzigi and other health care providers at Uganda Medical Center noticed a striking increase in the number of patients with heart disease, obesity, and hypertension. Data from the District Health Oce conrmed that chronic diseases were rapidly increasing: nearly half of Wakiso District's population was hypertensive and nearly 20% were obese.

hand--her mother's obesity and hypertension were eectively managed, at no cost, through the program. Edward reports that the $2000 award funding will help the program install internet services, buy a secondhand computer to increase their capacity for data management, and expand services to other parts of the district. He also hopes that the award's visibility will help attract further funding.

The Wakiso District is the second most densely populated district in Uganda. At the time of the last census, in 2002, more than Education on the benets of fruits and vegetables is provided by ProCor's award review program sta and nutrition students from the local university. half the population of about 1 committee chose the 2009 million was under 18 years old and 17% of its residents were winner from 20 applications from 15 countries, including orphans. Having lost much of one generation to HIV/AIDS, Canada, Ghana, Guatemala, India, Iran, Iraq, Jamaica, the hospital's board and sta decided to develop a program Kenya, Mauritius, Nepal, Philippines, Russia, Saudi Arabia, to prevent the new health threat posed by cardiovascular Thailand, Uganda, and the US. Special thanks to LCRF disease and its risk factors. Board member Janet Johnson Bullard and International Be Alive With Your Heart encourages a heart-healthy Advisory Council member Ruth Bonita for joining the review lifestyle from childhood through old age. Project sta and committee this year. volunteer nutrition students from Kyambogo University Read more about the Heart Hero at www.procor.org. provide education on nutrition and physical activity in schools, homes, public gathering places, and worksites. 2008 Award recipient featured in They also oer screenings for risk factors like hypertension, leading medical journal diabetes, and obesity. "Making visible what otherwise would "This is a wonderful example of how a small group of go unnoticed" is, according to Dr. motivated people, with scarce resources, can have a Bernard Lown, the goal of the Louise dramatic and sustainable impact on reducing cardiovascular Lown Heart Hero Award. A prole of disease," commented Dr. Brian Bilchik, ProCor's director. last year's recipient, Dr. Toakase Fakakovikaetau, was published in The To address the trend toward fast foods, which Edward Lancet, a leading international explains is "due to modernization and time saving," the medical journal, in June 2009. The program encourages schools and households to plant prole came about after a Lancet backyard gardens and farms. Produce that grows well in the editor read about ProCor's award, and demonstrates district--beans, bananas, tomatoes, avocados, carrots, the award's success in achieving its goal. cabbage, and green leafy vegetables--is now consumed at home, at school, and is also made available to others. "Toakase Fakakovikaetau: pioneering paediatrician in Tonga" describes Dr. Toa's eorts to screen Tongan As a result of the project's eorts, more than 40 schools schoolchildren for rheumatic heart disease and provide have planted vegetable and fruit gardens in the last two early treatment so they can grow up healthy. With 1.8 years, and nearly 200 households in the district have million registered web users and 30,000 print established backyard vegetable farms. subscribers, the Lancet's visibility will help attract The program's sole source of funding is Alex Wambi, who much-needed attention to a health challenge that is was raised in the district and now lives in the UK. She began under-recognized and under-addressed. supporting the program after observing the benets rstRead the article online: www.thelancet.com

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Lown Center patient guide: Atrial brillation

Shmuel Ravid, MD, MPH Understanding atrial brillation
Atrial brillation (AF), an abnormal atrial rhythm, is frequently associated with rapid pulse but may present with a slow heart rate as well. In some patients, both varieties are present. AF might be present intermittently (paroxysmal) or permanently (persistent or chronic AF). Either type of AF might be present without an obvious cause (lone AF). AF may manifest with palpitations, breathlessness, fatigue, lightheadedness or fainting spells, congestion, and reduced exercise tolerance. Many AF patients have no symptoms; their AF may be discovered incidentally during a routine physical exam or EKG test. Even symptomatic patients with paroxysmal AF experience many asymptomatic (silent) episodes. condition, if treated properly with blood thinners and either restoring normal rhythm (rhythm control) or slowing the heart rate response to AF (rate control). Intensive treatment of all coexisting cardiac conditions and risk factors (high blood pressure, heart failure, diabetes, etc.) is necessary to reduce recurrence and complications of AF. Treatment with Coumadin (warfarin) for patients at high risk for stroke, especially the elderly and those with heart failure and/or high blood pressure, eectively lowers the annual risk of stroke from 3-5% to about 1%. Coumadin therapy is inconvenient, requiring frequent blood testing and patient compliance. Patients younger than 75 years without overt heart disease or high blood pressure may be safely treated with 325 mg aspirin. Both drugs increase the risk of bleeding complications, but the benet of blood thinning in AF patients is well documented and outweighs the risks. Meticulous heart rate control with medications like beta blockers, calcium channel blockers, or digoxin is a mainstay for alleviating AF symptoms. Intermittent antiarrhythmic drug therapy is eective in restoring normal rhythm in some patients with infrequent episodes of AF (cocktail therapy), or as long-term treatment for maintaining normal rhythm in others. However, such drugs should be used cautiously because of potentially signicant side eects. Electrical cardioversion remains the procedure of choice to restore normal (sinus) rhythm for persistent AF. Performed under short-term anesthesia, this outpatient procedure is eective and safe, and is generally attempted in most AF patients at least once.

Causes of AF
AF may coexist with, be aected by, or contribute to underlying cardiovascular diseases. The majority of AF patients are older than 70 and frequently have a history of hypertension, coronary heart disease, diseases of the heart valves or muscle, diabetes, or heart failure; some are lone brillators without an identiable cause. Incidence of AF increases with age. Fewer than 0.5% of adults younger than 55 experience AF, but it aects about 7% of adults in their 70s and more than 10% of people in their 80s. AF is hereditary in a minority of patients. Other causes of AF, some of which are preventable, include hyperactive thyroid, sleep disorders, alcohol consumption (even moderate amounts in sensitive patients), and ingestion of various stimulants. AF is occasionally triggered by emotional or physical stress in susceptible individuals.

Adverse outcomes of AF
The most serious complication of AF is stroke, which is caused by blood clots that originate in the atria and travel through the circulatory system to the brain (arterial embolism). Infrequently, embolism from AF blocks other arteries, potentially causing a heart attack, intestinal ischemia, or kidney malfunction. Annual incidence of stroke is about 3-5% in patients older than 70. Weakening of the heart muscle (cardiomyopathy) and heart failure due to rapid AF for extended periods of time may occur. Occasionally, fainting spells result due to slow AF.

Non-medical interventions
Over the past two decades, various techniques for a "quick x" of AF have been developed and promoted by the industrial medical complex. Radiofrequency ablation of AF is currently the most popular invasive intervention. While a viable option for a select minority of AF patients, especially younger patients with symptomatic paroxysmal AF, we prefer to use it only as last resort. The procedure is imperfect, and neither innocuous (about a 1-2% serious complication rate) nor inexpensive, and in our experience, is frequently unnecessary.
This Lown Center patient guide summarizes the latest medical information and the Lown Center's unique approach to key cardiovascular issues. We encourage you to contact your cardiologist if you have any questions or concerns.

Treatments
Treatment goals for AF are to prevent serious complications, minimize symptoms, and improve quality of life. Treatment should be individualized and determined by medical considerations as well as patients preferences and expectations. Although complications occasionally occur, AF is generally a benign, non-life threatening

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PATIENT PROFILE Getting my life back with AF

Karen W. was in the middle of preparing for the holidays in December 2004 when she realized something was wrong. I was so tired I could barely get through the shopping," she recalls. "I went to the local walk-in clinic one evening; my problem was diagnosed as stress and I was given a prescription for Valium. But on Christmas Day, she had diculty preparing dinner. "I couldnt lean over to take the food out of the oven. I was short of breath and coughing. My family was worried, so I went back to the clinic. They told me I had atrial brillation and to see a cardiologist 'right away.'" "This was one of the darkest moments in my life," Karen acknowledges. She has been in the real estate business for more than 40 years. Now I couldnt climb stairs imagine a realtor who cant climb stairs!" A friend suggested she call the Lown Center. The day I met Dr. Ravid was one of the most fortunate days of my life. He gave me my life back, she says. "It took a while to get everything under control, but I could see that he was condent he was going to get me through this, and I

had complete condence in him. He started me on several medications and kept adjusting them. He did a cardioversion in March 2005 but it only lasted two days. He performed another cardioversion the following June, and all of my other miserable symptoms began to disappear. I was able to climb stairs again and since then I have been doing well." Karen encourages other AF patients to follow their physicians recommendations. When Dr. Ravid speaks, I listen. When he told me to lose 20 pounds, I thought, Okay' and I did it. I just put food portions I normally would eat on the plate, and then took half of it o again. I lost the 20 pounds. She wishes to impress upon other patients that when a physician prescribes medications, diagnostic testing, or lifestyle changes, the advice is for your benet and well being. By following Dr. Ravids advice, I have been able to resume my career." During busy periods, it is not unusual for Karen to work more than 60 hours a week, most of which are spent on her feet. Younger associates envy her energy. "Now when I am showing a property and reach the top of a ight or two of stairs without being short of breath," she concludes, I silently thank Dr. Ravid.

LCRF data oers insight into eects of anxiety on the heart

Charles M. Blatt, MD
Seventeen years after we started work on a major research study called "The Coronary Artery Disease (CAD) Project," new results oering further insight into the impact of the psychological state on the the prognosis of patients with CAD have emerged. this nature is full of pitfalls, and attempts by other institutions to create a cost-eective study design have not been fruitful. The Lown Foundation, however, continues to explore the biology that links a patient's psychological state, and the health of that patient's coronary arteries. We know that depression, for example, is associated with inammation that may give rise to coronary blockage,

As clinicians, every day we see the impact of Anxiety may be as powerful as high blood anxiety on how a patient will fare. Now we have solid data to show that the psychological pressure, high cholesterol, or even smoking. state of anxiety may be as powerful as high blood pressure, high cholesterol, or even smoking on the angina, and heart attack. We now also note an association outcome of patients with CAD. between inammation, the psychological state, and the Of course, the question that begs to be answered is: Will treatment of anxiety with medication, therapy, or both at some point during the progression of the coronary artery disease (or, perhaps best, before CAD becomes evident) alter the course of the disease process--perhaps preventing a heart attack or slowing the progression of the disease so bypass surgery, stroke, or even death are avoided? One might ask, "Why has this study not been done?" The simple answer is : It is not as easy as it sounds. A study of propensity to develop atrial brillation (AF). Indeed, the more we learn, the more complex, interactive, and mysterious the human biology underlying heart disease appears to be.

The long-term nature of our study provides a uniquely valuable perspective. Although the importance of the emotional state to good cardiac health is obvious on the surface, we will continue to explore beneath the surface in an eort to nd more eective means of caring for patients wth heart disease.

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Question from a patient

Vikas Saini, MD Should I take sh oil capsules?
The evidence suggests that omega 3 fatty acids are good for heart health. In prehistoric times, we consumed many times more of these essential fats than we do now. Since researchers rst noticed the seeming benets of omega-3 fatty acids in studies of diet and heart disease in large populations, the evidence has grown enormously. Omega-3s are a distinct group of dietary fats which are part of the larger class of polyunsaturated fatty acids (PUFAs). Omega-3s are found in sh in the form of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), and in vegetable sources in the form of alphalinolenic acid (ALA). If your diet is rich in omega-3s, you probably dont need to take supplements. It is well-known that sh contains these oils--but not all sh. The best sh sources are cold-water sh, such as sardines, mackerel, salmon, and tuna. Cod and haddock have much less, while tilapia has very little. There are vegetarian sources as well. The highest content is in ax oil. Cooking with canola, soy, peanut, or mustard oil will also contribute. Walnuts and pumpkin seeds are good snack sources of omega-3s. How does this translate into real life? Use canola oil for cooking as much as possible. Try to eat 2-3 servings of the sh mentioned above each week, and two or more servings per week of a vegetable source like walnuts, pumpkin seeds, or crushed ax seeds. If your diet doesnt contain enough omega-3, then taking supplements is a good idea. Fishoil: 1200 mg /day of the combination of EPA and DHA is a reasonable dose. Some preparations have a slightly shy odor. Others, especially "pharmaceutical grade," have been processed to remove the smell and are even available with lemon or orange avorings. Flaxoil: 5-7 gms (1-2 tablespoons) should be enough. However, unlike sh oil, the benet of ax oil can be blocked if you are eating too much other fat, even if it is a healthy fat like saower or corn oil.
Send your suggestions for the Lown Forum's "Question from a patient" column to Catherine Coleman, Editor, at 617-732-1318 x3332 or ccoleman5@partners.org.

LOWN CARDIOVASCULAR CENTER

NewsBeat
Drs.BrianBilchikand VikasSaini are co-authors of Madurai Area Physicians Cardiovascular Health Evaluation Survey (MAPCHES)--an alarming status, published in the Canadian Journal of Cardiology (Vol 25, No 5, May 2009). The study demonstrated an alarmingly high incidence of CVD risk factors and stroke among a cohort of 4000 physicians in southern Tamilnadu, India. Dr.BernardLown delivered the commencement address and received an honorary degree at the University of New England College of Osteopathic Medicine's graduation on June 6, 2009 in Portland, Maine. Dr.FredMamuya co-authored SCCT guidelines for performance of coronary computed tomographic angiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee, published in the Journal of Cardiovascular Computed Tomography (2009; 3:190-24). He also chaired two sessions at the Annual Scientic Meeting of the Society of Cardiovascular Computed Tomography in Florida on July 16-17, 2009. Dr.TomGraboys, President Emeritus of the Lown Foundation, and his wife, Vicki, discussed his memoir, Life in the Balance, for an audience of nearly 500 physicians, medical students, and the public at the Semel Institute for Neuroscience and Human Behavior at UCLA on June 2, 2009....Dr. Graboys spoke about his personal journey from cardiologist to patient with Lewy body dementia with Parkinson's disease on WRNI in May 2009. The interview is available online: http://www.wrni.org/content/doctor-becomes-patient Dr.BrianBilchik was appointed to the Chronic and Cardiovascular Diseases Working Group of Harvard Institute of Global Health (HIGH), which organized a conference, "Cardiovascular Disease in Developing Countries--Moving Forward," on July 22, 2009. Dr.VikasSaini participated in the 7th Teikyo-Harvard Symposium in Tokyo, Japan from June 26-28,2009. His presentation, "Hospitals, workers, and communities: time for a new paradigm," focused on the relevance of the Lown Center's recent research ndings to health care system reform, particularly costs of overtreatment and the role of the doctor-patient relationship in creating viable solutions.

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Foundation donors celebrate their Lown Center "Golden Anniversary"

Fifty years ago, James Bickman was unable to nd a cardiologist who could diagnose and treat his heart condition, so he consulted the "up and coming" Dr. Bernard Lown. Since then, "Through all these years, through thick and thin, from here to the other end of the earth, the Lown Center's physicians have been there for us," notes his wife, Ada. "We call this our Golden Anniversary with the Lown Center."

"In an ever-changing healthcare system that is in desperate need of reform, I will forever value the philosophy of the Lown Center to treat each patient holistically as an individual, taking into equal account a patients expectations, environment, and goals of care. During a recent hospital rotation, I often thought of my training experience at the Lown Center and asked myself how a diagnostic test or procedure would change a patient's care and management. I witnessed rst-hand the ways in which the side eects of too many, often gratuitous, interventions adversely aected patient outcomes. A more thorough history taking could readily have eliminated the need for many of those tests. Thank you!" Fatima Akrouh, 4th year Harvard Medical School student
TheLownCardiovascularResearchFoundation promotesahumaneandcost-effectivemodelof cardiaccarethatadvocatespreventionover costly,invasivetreatmentsandrestoresthe relationshipbetweendoctorandpatient.
BoardofDirectors Nassib Chamoun Chairman of the Board Vikas Saini, MD President Bernard Lown, MD Chairman Emeritus Thomas B. Graboys, MD President Emeritus Patricia Aslanis Charles M. Blatt, MD Joseph Brain, SD Janet Johnson Bullard Carole Anne McLeod C. Bruce Metzler Barbara H. Roberts, MD Ronald Shaich Robert F. Weis AdvisoryBoard Martha Crowninshield Herbert Engelhardt Edward Finkelstein William E. Ford Renee Gelman, MD George Graboys Barbara Greenberg Milton Lown John R. Monsky Jeffrey I. Sussman David L. Weltman CONTACTUS

"We support the idea of passing along to young physicians the importance of listening to patients," say James and Ada Bickman, longstanding supporters of the Lown Foundation.
Mr. and Mrs. Bickman are among the Lown Cardiovascular Research Foundation's longest-standing supporters. "The Foundation's research is constantly looking for new ways to help people with cardiovascular disease," Mrs. Bickman explains. Mr. Bickman is committed to supporting the style of cardiac care that is the cornerstone of the Lown Center. "These days, everything is measured by seconds and minutes. But life isn't that measurable," he notes. "We support the idea of passing along to young physicians the importance of listening to patients, asking a lot of good questions, taking time, and making patients feel at home. It will do younger doctors a lot of good to learn these methods. I wish the Lown Center's approach would expand across the health care industry."
Gifts to the Lown Foundation are vital in order to continue our cardiovascular research, patient care, medical education, and global outreach. Donations may be made online at www.lownfoundation.org or may be mailed to Lown Foundation, 21 Longwood Avenue, Brookline MA 02446.

LownCardiovascular ResearchFoundation
21 Longwood Avenue Brookline MA 02446 (617) 732-1318 info@lownfoundation.org www.lownfoundation.org www.procor.org LownCardiovascularCenter Brian Z. Bilchik, MD Charles M. Blatt, MD Wilfred Mamuya, MD, PhD Shmuel Ravid, MD, MPH Vikas Saini, MD Craig S. Vinch, MD LownForum Editor Catherine Coleman Editorialsupport Claudia Kenney Jessica Gottsegen
c2009 Lown Foundation Printed on recycled paper with soybased ink.

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Health consumer beware: Mobile vascular screenings--scan or scam?

Q&A with Dr. Fred Mamuya
Shopping in a mall last winter, Elizabeth M. spotted a big sign: "Beware of silent killer diseases like stroke." The sign advertised three screenings for $75. The price seemed reasonable for peace of mind. After signing a waiver, her neck, legs, and abdomen were scanned with portable ultrasound equipment. A few weeks later, she was notied that she had signicant carotid disease and should contact her doctor. "We spoke on the phone at great length. She was devastated and ready to y back to Boston to see me," recalls Dr. Brian Bilchik. "I had seen her recently, and assured her that there was no need for urgent action." When she eventually returned to Boston, Dr. Bilchik repeated the test in the Lown Center's vascular lab and conrmed that no intervention was required. "But despite my continued reassurance, she remained very anxious for a very long time," he said. According to Dr. Fred Mamuya, Director of the Lown Center's vascular lab, "These mobile screenings are abbreviated tests which do not tell the full story. The studies are incomplete, so results are not sucient or useful from a diagnostic or management standpoint." In addition to not being useful, the tests are often harmful for patients---producing either a false sense of security, unnecessary alarm and stress, or inaccurate results that can lead to repeat testing, unnecessary medications, or interventions. According to the US Preventive Services Task Force (USPSTF), an independent panel of experts, the potential harm outweighs the benets of these tests.

Director, Lown Cardiovascular Center Vascular Lab

When is vascular scanning appropriate? Routine screening for carotid artery and peripheral arterial disease is not recommended in patients who do not have any symptoms. The only recommended screening is abdominal ultrasound to exclude aortic aneurysm in men between 65 and 75 years old with a prior history of smoking; or men and women over 65 years old with a family history of abdominal aortic aneurysms. Moreover, any vascular scanning should be performed in an accredited facility with credentialed technologists and a high level of quality assurance. You should tell your physician if you have symptoms such as leg pain while walking, transitory neurological symptoms that appear without any warning (transient ischemic attack), or abdominal pain following a meal. Sudden diculty in controlling your blood pressure may also suggest the need for a vascular examination. Moreover, your physician is able to discern potential problems following a complete physical examination. I see ads for screenings everywhere. Why are they popular? Companies that do screenings make a lot of money, then move on to the next church or senior center. One of my patients described it as "a traveling circus." The tests are marketed to capitalize on people's fears about their health. My friends are having these tests and say I should too... Discuss your questions or concerns with your cardiologist. Become familiar with the facts and don't give in to peer pressure. If it's a topic of dinner conversation, you might want to share what you know with others.

Lown Cardiovascular Research Foundation 21 Longwood Avenue Brookline, Massachusetts 02446-5239

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