Heart Disease and Lifestyle: Why Are Doctors in Denial?

John Mandrola


January 12, 2015

I think and write a lot about the role of lifestyle choices as a treatment strategy. As an endurance athlete, I know that exercise, diet, sleep, and finding balance in life are the key components of success. It is the same in cardiology.

In a randomized controlled trial of primary prevention, no cardiologist would want to be compared against a good physical trainer or nutritionist. We would get trounced. Our calcium scores, biomarkers, pills, and procedures would not stand a chance. The study would be terminated early due to obvious superiority of lifestyle coaching over doctoring—which would blunt the true treatment effect and make us look less bad. (Wink to my epidemiology friends.)

But this is a dreadfully tired message. It is, as Dr Bryan Vartabedian writes in his book The Public Physician , another pool-safety post:

E  very summer, pediatricians and children's hospitals write posts about keeping kids safe around pools. We don't need another pool-safety post.

Doctor V, as he is known on social media, warns us that dry, empty writing on less-than-unique health topics does not stand a chance of being heard over the noise.

He suggests overcoming this problem by coming at it with a new angle, viewpoint, or voice. I am not so sure about that.

I write a post about new oral anticoagulant drugs or statins or AF ablation, and people pay attention. You see it in the traffic. It's the same story at medical meetings: sessions on drugs and procedures draw the crowds. Late-breaking studies rarely involve the role of exercise or eating well. Exercise, diet, and going to bed on time have no corporate backing. The task of drawing attention to the basics is getting harder, not easier.

And this is our problem. I believe the collective denial of lifestyle disease is the reason cardiology is in an innovation rut. This denial is not active or overt. It is indolent and apathetic. Bulging waistlines, thick necks, sagging muscles, and waddling gaits have begun to look like normal. During the electronic medical record (EMR) click-fest after seeing a patient, I rarely click on "normal" physical exam. The general appearance is abnormal—either overweight or obese.

In mathematics, an asymptote is a line that approaches a given curve but does not meet it at a finite distance. This is how I see modern cardiology. Our tricks can no longer overcome eating too much and moving too little. We approach health but never get there. If you waddle, snore at night, and cannot see your toes while standing, how much will a statin or ACE inhibitor or even LCZ696 help?

In fact, a reasonable person could make an argument that our pills and procedures might be making patients sicker. The treatment of the elderly comes immediately to mind. A week doesn't pass when I do not see a frail patient with late-stage malignancy (or other life-limiting disease) who is still taking a statin. Although the statin drug did not cause the demise—biology did—this is an utter failure of basic doctoring, a total apathy to the obvious.

When I started electrophysiology, I mostly treated people with fluky problems. My ablation procedures were on people with supraventricular tachycardia (SVT) due to aberrant pathways. My devices were mostly pacemakers in the elderly—a disease due to aging. These sorts of problems are (mostly) independent of how many sugar-sweetened beverages one drinks.

Now it is different. My practice is dominated by atrial arrhythmia—a disease now recognized as being due (in large part) to excesses of life, such as obesity, high blood pressure, sleep disorders, and overindulgence in alcohol. In other words: unnecessary. I make hundreds of dollars putting a hundred burns in a left atrium for a disease that a poorly paid physical trainer might prevent or treat. This has become cardiology writ large.

But the thing I cannot get over is that I am doctor, not a proceduralist. I am tasked with helping people be well. I fail in that task if I ignore the most effective and safest treatment option. I fail if I take the easy path. The prescription pad is easy. The EP lab is easy. The truth is hard.

I also fail as a health writer if I give up trying to make the euphemistic pool-safety post sticky enough to make a difference. New anticoagulant drugs are easy. Ablation technology is easy. Statins are even easier. The truth—nutrition, exercise, balance in life—is hard.

Cardiology and electrophysiology need to step back and take a hard look at how to make the pool-safety post interesting.

When we do this, progress will come. Our patients will be healthier, society will be healthier—and there will still be plenty of procedures to do. Even transcatheter aortic-valve replacements.



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