AN INTERVIEW WITH DR. JOEL KAHN
I do not want to burst your bubble, but the medical system is under severe stress and serious mistakes happen daily. Some of these mistakes are lethal and I do not want you to be one of them. The latest report indicates that medical errors are the third leading cause of death in the United States exceeded only by heart disease.
During the week I wear several different hats. One is my medical career where I currently practice an aggressive brand of preventive cardiology and heart disease reversal. Another is that I am asked frequently to review records from other doctors and hospitals where patients have experienced bad outcomes, often death. I serve as an impartial medical expert. Just this week I reviewed a file of a 50-year old male smoker who went to the emergency room with 2 days of new and intermittent chest pain. He had minimal testing and was released in an hour with instructions to see his family doctor in a week. Sadly, he died of a heart attack 3 days later. This is all too common.
While not all deaths can be foreseen and prevented, I have created a list of questions to ask or testing to request from your health care providers in hopes that it will prepare you for dealing with this overtaxed medical complex and protect you from heart damage.
1. I WANT ADVANCED LABS.
In my 30 plus years of training and practice, you are likely to have the same lab tests at an annual physical now as in the 1970s. This is not acceptable as there have been major advances in assessing your physiology by labs. I would suggest you ask for the following tests:
Advanced lipid profile: Rather than a calculated LDL cholesterol level, advanced panels measure LDL particle number and size which are more predictive of future heart and stroke events. Two individuals with a calculated LDL cholesterol level of 150 mg/dl can have widely different particle and size measurements and have very different risks.
Lipoprotein a: This is a genetic form of cholesterol that is elevated in about 20% of those tested. It is rarely drawn even though hundreds of research studies indicate if it is elevated, the risk of heart attack and stroke skyrocket. There is even a foundation dedicated to educating the public of the risk. In my clinic, when lipoprotein a is elevated, I work to make sure all other risks for heart and stroke are managed but I also have a protocol to lower and neutralize the effects on arteries.
Homocysteine: This amino acid is produced by an important process called methylation. It is important for artery and brain health along with decreasing risk of autism and cancer. When elevated, it may be due to a genetic defect in the MTHFR gene which is also easily measured. It can be treated with methylated B complex vitamins and the level will return to normal.
Inflammatory markers: The best known is hs-CRP but there are 5 others I measure in my practice. If there are markers of inflammation in the blood, a hunt is on for infections, food allergies, skin conditions like psoriasis, a diet rich in processed foods, central obesity, gingivitis, and sleep apnea among others. Inflammation can be reduced by addressing these root causes.
TMAO: This is a newly described marker of heart and kidney health and rises both by meat and egg heavy diets and an altered gut microbiome. It has now been conclusively shown to cause heart and kidney damage and is associated with a worsened prognosis. It may give an impetus to transition to more plant based diets.
ECG: Years ago a routine physical included an electrocardiogram (ECG or EKG) but this may be skipped nowadays. I suggest it for one particular reason, the measurement called the QT interval. A segment of the population has a genetic defect that causes the QT interval to be prolonged. Some people are prescribed drugs that prolong the QT interval. A long QT can result in death from a cardiac arrhythmia and a number of medications have been pulled off the market due to this risk. Knowing if you have a prolonged QT interval before you are prescribed antibiotics, antidepressants and other medications is key. More can be learned atwww.sads.org.
Vascular screening: Many hospitals offer a vascular screening program using ultrasounds of the carotid arteries, abdominal aorta and legs. These may cost between $50-$100 although for about twice that similar screenings are done in churches and workplaces. Although they are rarely definitive, they can offer a good value if you are a smoker or have a strong family history of early heart disease or stroke of the status of your arteries. Arteries should have no plaque so the word “mild” plaque should prompt you to have a complete evaluation by a vascular expert.
Coronary artery calcium scan (CACS): A CACS is by far the most accurate way to determine if your heart arteries are silently suffering. The heart gives no warnings until the arteries are badly blocked and the first symptom you have may be the day you die. Do not wait. In my community this 1 minute CT scan costs $80, uses no dye, and takes 1 minute. It is far more accurate for screening your heart than a stress test. My book “Dead Execs Don’t Get Bonuses“ goes into detail on how this test works. Your score should be zero and anything higher should prompt you to see a preventive cardiology expert.
2. DO NOT LEAVE AN ER WITHOUT A COMPLETE EVALUATION.
There is a chance you or a loved one will end up in an emergency room (ER) or urgent care clinic with chest pain symptoms needing evaluation. First, do not go to an urgent care clinic with chest pain, pressure, tightness, squeezing, or compression. Go to an ER. However, the ER has pressure on them to turn over the rooms. I have reviewed dozens of charts with young people sent home with cursory evaluations only to die or be maimed by massive heart attacks within days. Tragic. Do not go home without a thorough evaluation.
Second, ask for “serial” cardiac enzymes that are repeated every 4-6 hours for 2-3 times.
Third, ask for a repeat ECG to compare to the one you presented with.
Fourth, ask for a definitive test before discharge. This may be a treadmill stress test with echocardiography (no radiation) or nuclear imaging (radiation). In some ERs, the CACS or more likely the more advanced coronary CT angiogram may be available. If you are not severely allergic to iodine dye, this is by far the most accurate way to be sure your arteries are clean. If they are not clean, a cardiologist will have to evaluate your status but you will know the score and be alive.
To see tip #3, head over to: Foodbabe.com