This guest post reminds me of the time an emergency room doctor sent me home with the advice to take some Advil, only to find out the next day, my appendix was about to burst! I am so thankful for this advice from Dr. Joel Kahn, who serves on my Advisory Council. Dr. Kahn is a practicing interpreventional cardiologist who also writes for Reader’s Digest and has taught dozens of residents and cardiologists. I am thrilled to have him as a contributor here!
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 at www.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.
3. Be wary of drug interactions.
There are so many potential drug interactions and some of them are deadly. Some of them center on the long QT syndrome found on your ECG mentioned above. There are online resources to check your list of medications for interactions, particularly if you are prescribed a new medication. Antibiotics are particularly frequent causes of drug interactions that can be avoided with proper research online.
While I favor natural medicine and therapies emphasizing healthy lifestyle choices, there are genetic and acquired health issues that can be identified and addressed with proper evaluations.
I have focused on heart issues as they are the focus of my quarter century of practice, but these lessons are true of other conditions (e.g. a bad headache not fully evaluated in the ER). Do not be afraid to challenge, ask why, read online, and refuse to go home before proper testing is performed. My hope is that I never am sent a medical chart to review with your name on it. The best way to not be a statistic of the third most frequent cause of death in the U.S is to take excellent care of your health, have proper preventive testing, and stay out of ERs and hospitals unless very ill.
More About Joel Kahn, M.D., FACC, FSCAI
Dr. Kahn is a cardiologist who has launched a campaign to prevent 1 million heart attacks. His brand of cardiology combines the best of Eastern and traditional therapies for total healing. He is known as “America’s Holistic Heart Doc” and graduated Summa cum Laude from the University of Michigan, Ann Arbor. Dr. Kahn has been practicing invasive, interventional and preventive cardiology in Detroit since 1990, and was advanced to full Clinical Professor of Medicine (Cardiology) at Wayne State University School of Medicine and Associate Professor of Medicine at Oakland University Beaumont School of Medicine. He is devoted to his patients who take pride in his passion for teaching and prevention. Reader’s Digest magazine selected Dr. Kahn for their Holistic Heart Doc column and their publishing arm published his book, The Whole Heart Solution, in 2014. His second book, Dead Execs Don’t Get Bonuses, was published in 2015 and both are bestsellers. He appears regularly on Fox TV 2 in Detroit as a health commentator. He has been nominated as a Top Doc in cardiology for most of the past years. In 2013, he received a certification from the University of South Florida in Metabolic Cardiology, and became the first physician to complete the program in the world. To learn more about Dr. Kahn, visit drjoelkahn.com.