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James O. Gemmer, MD Chairman of the Board

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MIEC Owned by the policyholders we protect.


In This Issue SAN FRANCISCO MEDICINE March 2011

Volume 84, Number 2 Heart Health FEATURE ARTICLES

10 The State of Heart Health: Heart Health Defined by the American Heart Association Kenneth A. Fox, MD

11 An Ounce of Prevention . . . Prevention of Cardiovascular Disease in Asymptomatic Adults Ezra A. Amsterdam, MD 13 Confronting a Lifestyle Disorder: Healing the Heart with Overall Health Peter Curran, MD 15 Was the Buddha a Preventive Cardiologist? Mindfulness as a Prescription for Cardiovascular Disease Dina Amsterdam

17 The Patient, Stethoscope, and Physician: A Closer Examination of Women’s Cardiac Health Issues Eisha Zaid 19 Finding the Common Heart: Support Groups at Commonweal Create Space for Healing Michael Lerner, PhD

20 Atherosclerotic Plaque Reversal: The Holy Grail of Prevention? Yerem Yeghiazarians, MD 22 Air Pollution and the Heart: Growing Evidence for the Link Gordon Fung, MD, PhD

MONTHLY COLUMNS

4 Membership Matters 5 Classified Ad 7 President’s Message George Fouras, MD

9 Editorial Gordon Fung, MD, PhD 28 Hospital News OF INTEREST

4 Public Health Update: Pertussis Tomás Aragón, MD, MPH 30

Health Policy Perspective Clearing Some Smoke: Medical Cannabis, Fifteen Years Later Steve Heilig, MPH

32 SFMS 2011 Annual Dinner Photos Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

24 The New and Improved CPR: An Outline Gordon Fung, MD, PhD

25 Saving a Heart Attack Patient: A Story of Sudden Death in the Streets of San Francisco Toni Brayer, MD, FACP 26 The Place of Heart in Poetry: Considering Both Science and Metaphor David Watts, MD

www.sfms.org

March 2011 San Francisco Medicine 3


Membership Matters March 2011 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 84, Number 2 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

Editorial Board Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD

Erica Goode, MD, MPH

Toni Brayer, MD

Shieva Khayam-Bashi, MD

Linda Hawes Clever, MD

Arthur Lyons, MD

Peter J. Curran, MD

Stephen Walsh, MD

SFMS Officers President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Director of Administration Posi Lyon Director of Communications Amanda Denz, MA Director of Marketing and Membership Jonathan Kyle Board of Directors Term: Jan 2011-Dec 2013

Lily M. Tan, MD

Jennifer H. Do, MD

Shannon Udovic-

Benjamin C.K. Lau, MD

Constant, MD

Man-Kit Leung, MD

Joseph Woo, MD

Keith E. Loring, MD Terri-Diann Pickering, MD

Term: Jan 2009-Dec 2011

Marc D. Rothman, MD

Jeffrey Beane, MD

Rachel H.C. Shu, MD

Andrew F. Calman, MD Lawrence Cheung, MD

Term: Jan 2010-Dec 2012

Roger Eng, MD

Gary L. Chan, MD

Thomas H. Lee, MD

Donald C. Kitt, MD

Richard A. Podolin, MD

Cynthia A. Point, MD

Rodman S. Rogers, MD

Adam Rosenblatt, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

4 San Francisco Medicine March 2011

Save the Date! Young Physician Mixer Coming Soon On May 19, 2011, we will host another Young Physicians Mixer. Watch for details to follow next month.

CMA’s Legislative Leadership Day Is April 5

Physician advocacy is most effective when doctors meet directly with legislators to share the realities of working on the front lines of health care. Don’t miss the opportunity to participate in the California Medical Association’s 37th Annual Legislative Leadership Conference, which will be held on Tuesday, April 5, at the Sheraton Grand Hotel in Sacramento. Breakfast will start at 8:00 a.m. and the program run from 9:30 a.m. to 1:00 p.m. followed by visits in the Capitol with legislators and constitutional officers. On April 5th, from 4:30 p.m. to 5:30 p.m. we will have light refreshments available (location to be determined in the Capitol) where everybody can stop by after their legislative visits to debrief and fill out evaluation forms. This is voluntary. We have a room block available at the Sheraton Grand Hotel on the night of April 4th that we strongly encourage everybody to use. The rate is $169. Contact Jonathan Kyle for more information, jkyle@sfms. org or (415) 561-0850 extension 240.

SFMS Seminar

Friday, March 25, 2011: Customer Service, Patient Relations and Telephone Techniques: Creating a ‘Director of First Impressions’ This half-day practice management seminar provides valuable training for both front and back office staff to handle patients and tasks both efficiently and professionally using superlative customer service skills. This seminar will provide your staff with the tools necessary for positive patient relations. 9:00 a.m. to 12:00 p.m. (8:40 a.m.

registration/continental breakfast) $95 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for non members Contact Posi Lyon, plyon@sfms.org or (415) 561-0850, extension 260 for more information.

CMA Webinar Calendar

CMA if offering a number of excellent webinars this year that are free to SFMS members. Register at www.cmanet.org/ calendar. • April 6: Coding for Medical Necessity and Quality Care | Mary Jean Sage • 12:15 p.m. to 1:15 p.m. & 6:00p.m. to 7:00 p.m. • April 20: Implementing a Compliance Program | Mary Jean Sage • 12:15 p.m. to 1:15 p.m. & 6:00 p.m. to 7:00 p.m. • May 4: Dealing with Sensitive Personnel Issues | Debra Phairas • 12:15 p.m. to 1:15 p.m. & 6:00 p.m. to 7:00 p.m. • May 18: A Guide to CMA’s Amazing Legal Library | Samantha Pellon, CMA • 12:15 p.m. to 1:15 p.m. • June 1: ICD-10 | Practice Management Institute • 12:15 p.m. to 1:15 p.m. • June 15: Best Practices for Accounts Receivables | Mary Jean Sage • 12:15 p.m. to 1:15 p.m. & 6:00 p.m. to 7:00 p.m.

SFMS Webinars

The SFMS will offer the following webinars in partnership with ACCMA. Visit our website, www.sfms.org/events, for full details or to register. Contact Posi Lyon with any questions, plyon@sfms.org or (415) 561-0850 extension 260. • April 5: Tricky Business: Consent, Confidentiality and Patient Abandonment | 12:30 p.m. to 1:45 p.m. • Billing & Coding Bootcamp: a five-part series • April 29: Live Session: Basic Training | 9:00 a.m. to 4:00 p.m. PST • May 6: Webinar #1: Surgery Coding | 10:00 a.m. to 12:00 p.m. • May 20: Webinar #2: Procedures, www.sfms.org


Services and Modifiers | 10:00 a.m. to 12:00 p.m. • June 3: Webinar #3: Managing & Preventing Claims Denials | 10:00 a.m. to 12:00 p.m. • June 17: Webinar #4: Understanding Insurance Guidelines and Maximizing Payout | 10:00 a.m. to 12:00 p.m. • May 11: It’s Not Magic, It’s Good Management: Tips, Strategies & Legal Issues for Medical Managers |12:30 p.m. to 1:45 p.m. • June 7: Can You Hear Me Now? Physician-Patient Communication to Promote Outcomes and Reduce Liability |12:30 p.m. to 1:45 p.m. • June 22: Managing Your Managers (for Physicians) |12:30 p.m. to 1:45 p.m. • July 13: CalOSHA Training for the Medical Practice |12:30 p.m. to 1:45 p.m.

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Public Health Update: Pertussis in San Francisco Note: With the departure of San Francisco Director of Public Health Mitch Katz, MD, to Los Angeles, longtime Associate Director Barbara Garcia takes the director’s position, and Tomás Aragón, MD, MPH, another veteran SFDPH staff member, becomes health officer. This is the first of Dr. Aragón’s reports for this journal; please join us in welcoming him and congratulating him on his new position.—The Editors

PERTUSSIS IN SAN FRANCISCO Dear Colleagues: In 2010, 8,383 pertussis cases were reported in California— the highest number in fifty-two years. In September, 2010, California Assembly Bill 354 was passed, requiring all the state’s students entering seventh through twelfth grades for the 2011–2012 school year to show proof of a Tdap booster shot before starting school or be denied entry. This law impacts many sectors, including health, education, public health, and families in general. As clinicians in San Francisco,

www.sfms.org

you play essential roles in facilitating the implementation of this new law. An estimated 25,000 students in San Francisco must be immunized before the start of school. To avoid the last minuterush, we must immediately start to immunize all adolescent patients age ten and over (those entering seventh through twelfth grade) with Tdap vaccine. The San Francisco Department of Public Health has ideas to help, which include using reminder/recall systems, automated phone messages, your office’s outgoing message, and any other form of communication to bring patients in for their Tdap shot and well child checkup. Physicians that see adults can also help by communicating to parents of teens and preteens that their children need to come in to their doctors’ offices for a Tdap, or their children face school exclusion. Take advantage of every opportunity to inform and/or vaccinate these patients with Tdap. Whether they come in with a

cold, a sprain, or an acne appointment, vaccinate. Clearly document the patient’s Tdap shot and be sure to provide the patient with a record of receipt. The California Immunization Registry (CAIR) provides rapid, clear, and simple documentation of all immunizations, saving time and effort for the many California providers and schools who use CAIR. If you are interested in using CAIR, please contact the CAIR Help Desk at (800) 578-7889 or www.cairweb.org. Ensure that your office is sufficiently stocked with Tdap and other adolescent vaccines, including meningococcal, varicella dose 2, HPV, and influenza. Please visit www.shotsforschool. org for more information and resources on how you can implement AB 354, and thank you for your efforts in immunizing San Francisco’s students. Thank you for your dedication. Sincerely, Tomás Aragón, MD, MPH Health Officer, SF City and County

March 2011 San Francisco Medicine 5


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President’s Message George Fouras, MD

News from the SFMS

T

he Medical Society held its annual dinner this year on January 27, 2011, for the fourth time at the ConcordiaArgonaut Club in San Francisco. While one primary focus of the evening is the “passing of the gavel” from the outgoing president to the incoming president, the night actually consists of much more. This event is an opportunity for all of us to share a moment of collegiality and to recognize those among us who have participated in our work. Approximately 150 members and friends of the medical society attended the event, which began with a cocktail hour that Senators Mark Leno and Leland Yee and ex-supervisor Bevan Dufty attended. As in past years, Drs. Stephen Walsh and Herb Peterson provided live music for the hour, and I would like to express our thanks for their contribution. The evening culminated with a moving presentation by Mia and Sharon Behrens, along with Mia’s treating psychiatrist, Dr. Lenore Terr. Mia’s story may be read in the January/February issue of San Francisco Medicine, which is now available on our website. It was moving to see and hear how a young lady who was so badly traumatized was able to overcome the psychological and physical damage that was inflicted upon her, becoming the bright and charming young lady she is today. Overall, the evening was a great success.
 On February 9, 2011, we held our first social event for this calendar year, our annual San Francisco Symphony Night. Members gathered prior to the performance for a brief reception in the Davies Symphony Hall green room. On the state level, it is almost certain that a new effort by the trial lawyers to change MICRA will be introduced, and we expect this effort will attempt to raise the current limit on personal damages to $1 million. It is important that we all take this opportunity to remind our state legislators and governor, yet again, why tort reform was required in the first place. Virtually every physician in California, as well as our hospitals and clinics, save large amounts in insurance premiums due to MICRA—comparisons with non-MICRA states show the dramatic difference. For that reason, members who have relevant stories of problems with health care access pre–MICRA are encouraged to contact Jodi Hicks at CMA, jhicks@cmanet.org or (916) 444-5532. The SFMS will continue to advocate with our legislators and provide education to physicians and others on the importance of this issue.

www.sfms.org

The state continues to grapple with the $26.4 billion budget deficit. Governor Brown has proposed a preliminary breakdown of $12.5 billion in cuts, $12 billion in new revenue, and $2 billion in other changes. As part of his package, Brown is proposing another 10-percent provider rate cut in Medi-Cal, for projected savings of $1.7 billion. The previous court case concerning an identical cut proposed by Governor Schwarzenegger is currently before the U.S. Supreme Court. Brown is also proposing instituting further use controls regarding the Medi-Cal program, which include limiting the number of visits, limits on the number of prescriptions, and hard caps on other benefits. For those members who see Medi-Cal patients, this will make it even harder to continue to care for them. In addition, we can expect that more people will need to use the public health safety net, creating even greater use of high-cost emergency room visits for basic health care needs. More information will be coming as the budgeting process continues. Chief among the questions will be whether Brown is successful in getting an extension of temporary taxes on the ballot this summer. As noted by SFMS Treasurer and board member Shannon Udovic-Constant, MD, in a recent letter to the San Francisco Chronicle, “Governor Jerry Brown’s proposed budget for California is poised to cut 100,000 children from health insurance and will decrease access to pediatricians for many more due to provider cuts to Medi-Cal. The budget must not be balanced on the backs of California’s most vulnerable children. The California Legislature must say no to the proposed cuts to Healthy Families and Medi-Cal. If these cuts pass, California will soon be last in the country in delivering health care for children.” And that’s just for kids. Such cuts will impact patients of all ages, as well as clinicians, clinics, and hospitals. The SFMS is joining in a diverse coalition to urge that budget savings be found elsewhere, where they would impact a less vulnerable population. At the other end of the lifespan, we are starting to work to improve palliative and end-of-life care in San Francisco with a grant from the California Health Care Foundation. We are also moving forward with the citywide electronic medical record project, SFHEX. As this busy year gets underway, we thank all SFMS members for their support via participation in our numerous projects and through their memberships. March 2011 San Francisco Medicine 7


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Editorial Gordon Fung, MD, PhD

Heart Health

R

ecently I was asked to give a presentation to UCSF’s first- and second-year medical students about how and why I had decided to go into cardiology. I reflected about what the field of cardiology was like in the late 1970s and early 1980s, when I was making my decision, and the enormous changes that have occurred in my short lifetime in this field. At that time heart disease was (as it still is today) the leading cause of death among adult Americans. This was true for every year of the twentieth century, except in 1918 when the leading cause of death was the flu. Because the heart is a single organ system and any disease of the heart is usually considered catastrophic to human life, much attention has been paid to research on the management of heart disease, as well as its diagnosis and ultimately its prevention. This was the field of medicine that was so engaging and challenging that it drew me to pursue it as my career choice. 2010 was a landmark year for the American Heart Association, for two reasons. The first was the realization that the entire field of cardiology has been primarily focused on the management of, identification of risk factors for, and prevention of heart disease—without a clear-cut definition of good or optimal heart health. With numerous developments in our understanding of the management and prevention of heart disease, the mortality from this devastating disease has been decreasing, so 2010 seemed time to focus our energy on encouraging good heart health. Dr. Kenneth Fox, a member of the San Francisco American Heart Association’s board of directors, agreed to help us understand the meaning of good heart health and how to achieve it. The American Heart Association selected seven parameters that define good heart health, which include such healthy behaviors as regular physical activity and maintaining a healthy weight. Acting in coordination with the Centers for Disease Control, the AHA set as its goal for 2020 to improve the heart health of all Americans by 20 percent as well as to decrease heart disease and stroke mortality and morbidity by an additional 20 percent. The second noteworthy event of 2010 was that the American Heart Association totally revamped the approach to bystander CPR. Based on evidence-based research, the AHA eliminated the breathing steps for all compression CPR and changed the universally recognized mnemonic of ABC (AirwayBreathing-Compressions) to C-A-B (Compressions first, then Airway-Breathing). www.sfms.org

One of the major advances in cardiology over the past three decades has been the recognition of numerous connections between the brain and the heart. The brain has many hormonal as well as direct neurologic connections and signals to the heart and the entire circulatory system, and it is constantly monitoring the heart’s function within its complex environment. Our president-elect Dr. Peter Curran has a special interest in the mind and body approach to heart disease, and he has kindly put together his perspective on a new approach to cardiac disease. Another step forward over the past several years has been the recognition that the heart is well integrated into and interconnected with the entire body. We have come to appreciate that many things that we do for our general health directly affect our heart health. Dina Amsterdam has kindly agreed to provide an up-to-date review of recent studies regarding the benefits of yoga, meditation, and other mindfulness practices. Dr. Ezra Amsterdam, past editor of the journal Preventive Cardiology, provides an overview of the state of that field. Other writers in this issue contribute their knowledge on a variety of factors that influence cardiovascular fitness. Dr. Toni Brayer describes some misconceptions about exercise and heart health. I address the dangers of the environment and air quality to our heart health. Whenever one talks about the heart, heart health, or heart disease, one usually also thinks of Valentine’s Day or the heart in poetry or literature. This month would not be complete without the perspective of Dr. H. David Watts, a UCSF gastroenterology attending, an accomplished author and poet, and a classically trained musician and commentator on NPR’s All Things Considered. He reflects on how the heart is viewed by the general public and the literary world.

March 2011 San Francisco Medicine 9


Heart Health

The State of Heart Health Heart Health Defined by the American Heart Association

Kenneth A. Fox, MD

W

hat is the state of your patients’ cardiovascular health? The American Heart Association/American Stroke Association now has a resource to answer that question. The Association for the first time defined poor, intermediate, and ideal cardiovascular health, using seven key health factors and behaviors that support heart and brain health. We call these “Life’s Simple 7,” and my choice of words in describing them is deliberate. With obesity and unhealthful lifestyles threatening to undo our recent dramatic progress in reducing heart disease and stroke deaths, it is time to broaden the conversation beyond disease states and risk factors to include health behaviors and health factors. The goal is primordial prevention—never allowing acquired cardiovascular diseases a chance to develop. According to the new definition, to be in ideal cardiovascular health an adult must have never smoked or must have quit more than one year ago; have a body mass index of less than 25 kg/m2; engage in physical activity of at least 150 minutes (moderate intensity) or 75 minutes (vigorous intensity) each week; eat four to five of the key components of a healthy diet consistent with current American Heart Association guideline recommendations; and have total cholesterol of less than 200 mg/dL, blood pressure below 120/80 mm Hg, and fasting blood glucose of less than 100 mg/dL. Please see the accompanying charts for definitions of intermediate and poor cardiovascular health, for definitions for children, and for details of the dietary Continued on page 12 . . . 10 San Francisco Medicine March 2011

LIFE’S SIMPLE 7 POOR (Health Factor or HEALTH Behavior)

(Warning)

Adults

Smoker

1. Smoking Status

Children

Improvement)

(Excellent)

Quit for 12 months or less

Never smoked or quit more than 12 months ago

2. Body Mass Index (BMI) (a measure of body fat)

Never tried/smoked a whole cigarette

Adults

25–29.9

18.5–24.9

1–149 minutes/week moderate or 1–74 minutes/week vigorous or 1–149 minutes/week of moderate + vigorous

150+ minutes/week moderate or 75+ minutes/week vigorous or 150+ minutes/week moderate + vigorous

Children

Tried in the last 30 days

INTERMEDIATE HEALTH IDEAL (Needs HEALTH

30 or greater

More than 95th percentile

3. Physical Activity Adults

None

Children

None

Adults

0–1 components of a healthy diet

------

85th–95th percentile

1–59 minutes/day moderate or vigorous

Less than 85th percentile

60 minutes+/day moderate or vigorous

4. Healthy Diet Score (in the context of an overall healthy eating pattern and energy balance); see table on page 12 for details on scoring

Children

Same as adult

5. Total Cholesterol Adults

Children

240 or more mg/dL 200 or more mg/dL

6. Blood Pressure Adults Children

SBP2 of 140 or more, or DBP22 90 mm Hg or more More than 95th percentile

7. Fasting Plasma Glucose Adults

Children

126 mg/dL or more Same as adult

2–3 components of a healthy diet

4–5 components of a healthy diet

200–239 mg/dL or treated to goal

Less than 200 mg/dL untreated

SBP of 120–139 or DBP of 80–89 mm Hg or treated to goal

SBP of less than 120 or DBP of less than 80 mm Hg untreated

100–125 mg/dL or treated to goal

Less than 100 mg/dL

Same as adult

170–199 mg/dL

90th–95th percentile or SBP of 120 or more or DBP of 80 mmHg or more

Same as adult

Same as adult

Less than 170 mg/dL untreated

Less than 90th percentile

Same as adult

American Heart Association/American Stroke Association, January 2010

www.sfms.org


Heart Health

An Ounce of Prevention . . . Prevention of Cardiovascular Disease in Asymptomatic Adults

Ezra A. Amsterdam, MD

S

ince the latter half of the twentieth century, it has been recognized that atherosclerotic cardiovascular disease (CVD) is the leading cause of death in this country, a striking statistic that applies to both men and women. Despite remarkable advances in the management of CVD, this pattern has continued. Within the spectrum of CVD, coronary heart disease (CHD) accounts for most deaths and disability, chiefly through myocardial infarction and its complications. What may not be commonly appreciated is the alarming fact that in a majority of victims, the initial manifestation of the disease is a catastrophe in the form of sudden cardiac death or acute myocardial infarction. However, two characteristics of CHD afford an important opportunity for prevention: First, CHD has a long latent period, entailing decades of incubation prior to its first clinical expression; and second, risk factors for CHD have been identified and implicated in its etiology, suggesting targets for favorable modification and possible prevention.

New Guideline for Assessment of CV Risk

The foregoing concepts provide the basis for the recently published “Guideline of the American College of Cardiology (ACC) and American Heart Association (AHA) for Assessment of Cardiovascular Risk in Asymptomatic Adults” (Circulation, 2010; 122:e584-e636). The purpose of this guideline is to aid the clinician in making informed decisions about safe and effective lifestyle and pharmacologic interventions to reduce the risk of CVD in asymptomatic (apparently healthy) individuals. In accord with prior guidelines, www.sfms.org

this iteration adheres to the concept that the intensity of the intervention should match the hazard of the individual’s risk for CVD. Thus, a systematic approach to measurement of risk is the key to selection of management. Although there has been considerable interest in so-called “novel” risk factors in recent decades, the guideline focuses on those factors that are well established, reproducible, modifiable, and whose alteration can help avert CVD. Basic recommendations of the ACC/ AHA guideline are that all adults, starting at age twenty years, should have assessment by a global CVD risk-prediction score plus family history. This should be performed every five years. The Framingham risk score (FRS), of which there are a number of variants, is the best known of several instruments for determining global risk. The traditional form of the FRS provides a ten-year risk of CHD in asymptomatic persons based on five risk factors: age, systolic blood pressure, smoking status, total cholesterol, and HDL cholesterol. These risk factors are considered as semicontinuous variables with points assigned to each factor based on sex, age, and the level of the risk factor. The total point score provides the tenyear risk for the individual, expressed as the percent likelihood of a cardiac death or myocardial infarction during the following ten-year interval. For example, a ten-year risk of 14 percent indicates that the individual is a member of a population of which 14 percent will have a fatal or nonfatal myocardial infarction within ten years. The FRS divides populations into three risk categories. These are low: <10

percent ten-year risk; intermediate: 1120 percent; and high: >20 percent. The latter is considered a CHD equivalent. These categories provide the basis for determining the intensity of the interventions to favorably modify the individual’s risk factors. Family history, an important risk factor not included in the traditional FRS, should be determined and included in the global risk estimate. A positive family history of CVD is defined as disease in a first-degree male relative at age <55 years or a first-degree female relative at age <65 years. A positive family history is useful for reclassification of persons with intermediate risk to the high-risk category.

Further Considerations Regarding the FRS

Several points should be considered in regard to the FRS. 1) Generalizability: Although concerns have been raised regarding the generalizability of the FRS, it has been documented that it performs well in both men and women as well as in a variety of societies and ethnic groups, although calibration is required in the latter instances. 2) Applicability: It is emphasized that the FRS and the other instruments to measure global risk in asymptomatic populations should not be applied in persons with overt CVD. The latter group has the highest risk and the therapeutic targets for those individuals’ risk factors are provided in guidelines for secondary prevention. 3) Limitations: A limitation of the FRS has been absence of family history of CVD, which is now included in the curContinued on following page . . . March 2011 San Francisco Medicine 11


An Ounce of Prevention . . . Continued from previous page . . . rent guideline. In addition, FRS does not include several factors of the metabolic syndrome (abdominal obesity, elevated triglycerides, and glucose intolerance). Therefore, it is not unreasonable to consider factoring metabolic syndrome into the risk algorithm. 4) Young persons: Because it only affords a ten-year risk prediction, FRS is of limited value for young adults. However, projection of risk can be performed by recalculating ten-year risk for a decade or two; hence in the case of unchanged risk factors to demonstrate risk at the older age. 5) Novel risk factors: As previously noted, the current guideline for risk assessment in asymptomatic persons is based on careful scrutiny of the scientific validation of the risk factors. Thus, many of the novel risk markers that have been undergoing investigation during recent years were not recommended because of failure to meet to these rigorous requirements. The characteristics of a risk factor had to confer independent value beyond that of the FRS (or other global

risk scores). This high bar for inclusion resulted in all but complete absence of the novel risk factors from the guideline, other than limited support (“may be reasonable”) for coronary calcium scoring, high sensitivity C-reactive protein, and measurement of carotid intima-media thickness to reclassify intermediate-risk patients. Some of the novel approaches of recent interest that did not meet the standards for inclusion to assess asymptomatic patients are genetic testing; computed tomography coronary angiography; magnetic resonance imaging to detect vulnerable plaque; and measurement of apolipoproteins, LDL particle size, and natriuretic peptide levels.

The State of Heart Health Continued from page 10 . . . recommendations. These definitions were developed in conjunction with the American Heart Association/American Stroke Association’s 2020 impact goal: to improve the cardiovascular health of all Americans by 20 percent, while reducing deaths from cardiovascular diseases and stroke by 20 percent by 2020. One of our first tasks as physicians is to address a startling knowledge gap in the public. An AHA/ASA survey released in conjunction with the impact goal found that nearly 40 percent of those surveyed rated their own cardiovascular health as ideal. Actually, less than 1 percent were in the ideal category. The survey uncovered an equally startling level of denial. More than half of those surveyed indicated that a health professional had warned them they were at risk, and 70 percent de-

Healthy Diet Score: 4–5 diet goals must be met for “ideal health” category

Summary

This guideline places asymptomatic persons into the three broad categories of low, intermediate, and high risk. Persons in the low-risk category do not require further testing for risk assessment because more intensive diagnostic approaches are not indicated. Those at high risk (established CVD or coronary risk equivalents) are candidates for intensive preventive interventions. For

intermediate-risk patients, the guideline should be useful in the selection of appropriate tests to further define risk status to determine appropriate therapeutic interventions. Ezra A. Amsterdam, MD, is professor of internal medicine and associate chief for academic affairs in the University of California, Davis, School of Medicine. His fellowship in cardiology was at the Peter Bent Brigham Hospital (now Brigham and Women’s) and Harvard Medical School. His has won 23 teaching awards and honors from U.C. Davis and national societies. His publications include more than 550 articles and 7 books, which reflect his scientific interests in the prevention and management of coronary artery disease. A frequent lecturer in this country and abroad, Dr. Amsterdam is a past or present member of the editorial boards of multiple journals and has participated in the development of clinical guidelines of the American College of Cardiology and American Heart Association. Described as “inspirational” by his peers, he says his passion for cardiology is reflected by the adage: “To the man who loves his work, there is no difference between work and play.”

Dietary Goals Fruits and vegetables

>4.5 cups/day

Sodium

<1500 mg/day‡

Fish 3.5-oz servings (preferably oily fish)

>2 servings/week

Sugar-sweetened beverages

Whole grains (1.1g of fiber in 10g of carbohydrates), 1-oz.-equivalent settings

Other Dietary Measures Nuts, legumes, seeds Processed meats Saturated fat

>3 servings/day

>4 servings/week <2 servings/week

<7% of total energy intake (kcal)

American Heart Association/American Stroke Association, January 2010

scribed themselves overweight or obese. Prevention is powerful medicine indeed. Data show that if you are a man and you reach the age of fifty with optimal health factors and ideal health behaviors, you will have less than a 5 percent lifetime chance of having a cardiovascular event, and if you are a woman that percentage is

12 San Francisco Medicine March 2011

<450 kcal (36 oz)/week

8 percent. In fact, that fifty-year-old man or woman in optimum cardiovascular health has a life expectancy of greater than 39 more years—years free of heart diseases and stroke. Of course, not everyone can attain ideal cardiovascular health, but moving Continued on page 14 . . . www.sfms.org


Heart Health

Confronting a Lifestyle Disorder Healing the Heart with Overall Health

Peter Curran, MD “Remember, underachievement isn’t about doing absolutely nothing. It’s about the right effort at the right time, in the right place. And not one bit more.”—Ray Bennett, MD

T

he middle-aged man looked like some of the others that came through the cardiac cath lab in the Central Valley town. Hardworking, sometimes smoked, drank or ate too much with a shape to prove it, and appearing anxious. His heart had the typical scars of atherosclerosis lining the arteries and a pump that was thickened and slightly dilated. Several of the local citizens left the cath lab with metal stents shoved into their diseased vessels. Cardiologists were busy in this town, and there was a feeling of a Civil War surgical outpost where one patient’s leg is quickly amputated to make room for the next. Nobody had time or interest to ask what was driving the demand in cardiac services, or whether there was anything that could be done to reverse the trend. The prevalence and approach to disease contributed to a higher surgical volume in an alarmingly younger population of cardiac patients, and several of these hearts returned for second and third procedures, often within the first year. Cardiac rehabilitation, a structured three-month outpatient program focused on exercise and health education following a cardiac event or surgery, has historically been the Rodney Dangerfield of cardiology practice; its benefits of improved survival and quality of life are well known but underappreciated and underused for reasons that are not entirely known. Poor reimbursement to both hospital www.sfms.org

and physician is one factor, but also patients’ perceptions toward exercise and group therapy are additional potential roadblocks. During fellowship training, cardiac rehab is often assumed or ignored entirely. Cardiology training and practice have been molded by “evidence-based medicine,” a popular catchphrase in the past decade. Findings of large randomized studies direct physicians to prescribe effective but potentially toxic drugs for the rest of their patients’ lives for a small absolute treatment benefit at a substantial financial cost, and promoted by directto-consumer advertising, with practice guidelines written by physicians on payrolls of the pharmaceutical industry. The Honolulu Heart Study challenged the lifestyle approach to health. A relatively large study of male seniors consisted of three groups of walkers: greater than two miles per day, between one and two miles, and less than one mile. They were studied for more than ten years. Participants who walked the farthest had a 50 percent better overall survival compared with the less-active group. Cardiac drugs studied in randomized trials may improve a composite outcome in a strictly defined population by a few percent. The cohort in the Heart Study improved overall survival, the strongest of all clinical research endpoints, by walking. Were we missing the forest for the trees in the treatment of chronic heart disease by promoting procedures and drugs over proven lifestyle changes? The farmer in the Central Valley clinic was not expected to survive. At age seventy-two, he had had quadruplebypass heart surgery for severe coronary disease and left ventricle dysfunction.

He deteriorated following surgery due to premature bypass graft closure and myocardial infarction, manifesting as acute heart failure one month later. Coronary angioplasty was done emergently to improve circulation to the heart. He remained on the ventilator for days and required intravenous drugs to support his blood pressure. When hospital-acquired pneumonia injured his lungs, his family was notified of the poor prognosis. Then, somehow, he stabilized and started to gradually improve. One month later the farmer was discharged to home. He did not immediately tolerate most of the usual cardiac medications because of low blood pressure and other side effects. But he could walk and thrived in cardiac rehab. One year later he completed a three-mile heart walk for the American Heart Association. When asked how his motivation seemed to surpass that of other survivors, he looked incredulous. “They want to live, don’t they?” he asked. Albert Schweitzer once said that happiness is good health and a short memory. The human body has an amazing ability to repair itself and move on in cases of trauma, infectious diseases, and other acute illnesses. The common cold runs its course no matter what is done to relieve the symptoms. But when it comes to chronic illness such as hypertension, heart failure, atherosclerosis, or diabetes, medical treatment strategies become as “permanent” as the disease. Expensive drugs are prescribed with no end point. Cardiac procedures are performed that permanently alter coronary anatomy by rerouting blocked vessels or inserting nonabsorbable metal stents inside Continued on following page . . . March 2011 San Francisco Medicine 13


Confronting a Lifestyle Disorder Continued from previous page . . . the vessels, with occasional benefit but long-term consequences. Cardiac injury sustained during myocardial infarction is usually considered irreversible, but now we know that muscle contractility (or ejection fraction) improves, coronary arteries demonstrate positive remodeling, collateral circulation creates new avenues of blood flow, and myocardial ischemia lessens. In other words, the heart heals itself in the framework of overall health. During the first few weeks of recovery from a cardiovascular event, cardiac rehab patients improve quickly in several objective and subjective measures, including exercise tolerance, risk factor modification, and psychosocial indicators. There is a group psychological benefit in cardiac rehab (and other rehab forums) that is not matched in the individual setting. Blood pressure improves and the patient feels better. Often the original medication list of the patient shortens as drugs are able to be safely tapered or discontinued in a few short weeks, and recurrent procedures are avoided. Any therapy worth its cost should directly result in the recipient feeling better. If the prescribed indication is advertised to prevent a future harm or to delay an inevitable natural death, then some other entity is benefiting from the adherence more than the patient. The traditional patient-physician office setting is a difficult environment for advocating health and lifestyle changes. Short of significant health care reform, office appointments will continue to be too short and problem-focused. It is easier to take a blood pressure and write a prescription for an antihypertensive drug than hear about various life stressors that may impede healthy lifestyle choices. In medical school, physicians are taught that 90 percent of diagnoses are made by taking a good history and physical exam. This medical pearl works for acute illness or injury, but good health is not simply a proper diagnosis in the physician’s office; it is a process continued over a lifetime. “I don’t want to confront my fears; I’m afraid of them!”—SpongeBob SquarePants

A thirty-eight-year-old presented to the emergency room with an acute myocardial infarction. The history obtained stated that he had no “traditional cardiac risk factors” to account for the infarct. However, further questioning revealed that he was homeless with a drug problem and standing in a food line when the chest pain started. The fact that the young man did not have hypertension, diabetes, or familial hypercholesterolemia seems irrelevant to the crisis happening in his personal life. Until all aspects of health are addressed, the treatment of the sick is incomplete. At his recent appointment the farmer’s heart bore the scars of myocardial infarction on echocardiogram. He continues to exercise daily on treadmill and stationary bike and makes a weekly pilgrimage to the produce market to sell his goods. Peter J. Curran, MD, is a private practice cardiology consultant in San Francisco, director of Cardiac Rehabilitation at St. Mary’s Medical Center, and president-elect of the San Francisco Medical Society. He is also on the editorial board for San Francisco Medicine. Correspondence via peter. curran@chw.edu.

References Hakim et al. Honolulu Heart Study: Effects of walking on mortality among nonsmoking retired men. N Engl J Med. 1998; 338:94-99. Wenger NK. Current status of cardiac rehabilitation. J Am Coll Cardiol. 2008; 51:1619-1631.

14 San Francisco Medicine March 2011

The State of Heart Health Continued from page 12 . . . from poor to intermediate health, or making improvements after the age of fifty, also confers benefits. What can we do to guide patients on the path to improved cardiovascular health, within the time constraints of a typical practice? I would like to recommend two free, online resources. The first is My Life Check (heart.org/ MyLifeCheck), a simple and quick health assessment tool that will help patients understand their current level of heart health and create a customized action plan. In just a few minutes, My Life Check walks the patient through the seven health factors and behaviors and delivers a numeric score of 1 to 10. My Life Check can be used on its own, but it is integrated with Heart360 (Heart360.org), an online health management system with both patient and provider portals. Patients can set goals, track health information over time, and sign up for text message prompts to enter data such as blood pressure or weight, and then upload the information directly from their phones. The easy-to-use provider side offers direct access to patient-reported data, patient grouping, alerts, secure messaging, reporting tools, and more. Heart360 is on Microsoft HealthVault. To learn more, visit Heart360.org and take the provider tour. Both My Life Check and Heart360 are available in Spanish as well as English. I challenge you to join me in educating patients about how to attain their own personal best state of cardiovascular health. Kenneth A. Fox, MD, is chief of the Department of Neurology and medical director of the Primary Stroke Center at Kaiser Permanente, San Francisco. He is a member of the board of directors of the San Francisco division of the American Heart Association/American Stroke Association.

www.sfms.org


Heart Health

Was the Buddha a Preventive Cardiologist? Mindfulness as a Prescription for Cardiovascular Disease

Dina Amsterdam

A

s a yoga practitioner and meditator for almost twenty years, I’ve experienced firsthand the extraordinary healing benefits of these inwardly focused practices. Through a diagnosis of Crohn’s disease, celiac sprue, and debilitating lower back pain, I took refuge in the soothing balm of these meditative arts. I knew, in my earliest experiences with yoga and meditation, that something physiological was occurring, as physical pain was markedly reduced and psychological distress significantly altered. As a teacher since 1994, I’ve witnessed amazing personal transformations as well as inexplicable physiological health benefits in a myriad of my clients and students. Most recently I’ve been astounded by the immediate pain-relieving effects that the mindfulness-based approach I use, InnerYoga, has had on patients at San Francisco Functional Restoration Program (SFFRP). SFFRP, a branch of the Bay Area Pain and Wellness Center, is a last-stop pain program for those who suffer with life-debilitating sensations and who haven’t had luck with more conventional methods of pain reduction. Many of the patients I see at SFFRP have suffered with chronic pain for many years without relief. When their pain drops from a level of 8 to 2 during a twenty-minute meditative InnerYoga visualization or breathing practice, they are amazed (as am I). The particular approach I offer, InnerYoga, is, simply put, rooted in awareness, kindness, and breathing. These three pillars are also the basic components of mindfulness—the foundation of any meditative art, whether it is physically based (like yoga and tai chi) or still (like a formal sitting meditation session). Mindfulness is the practice of being present with whatever conditions www.sfms.org

are arising in the here and now (physically, emotionally, mentally, and environmentally), without judgment and with warmth and acceptance. When I was a formal student of science, psychoneuroimmunology to be exact, I was interested in understanding what the psycho-physiological mechanism could be that produced this subjective healing experience, as well as whether this topic had been examined with a rigorous scientific approach. The question loomed, “Was it all just a placebo effect?” I didn’t believe so; however, as I dug into the matter as a young woman, I found that the scientific community had not, thus far, adequately explored the topic. This was about twelve years ago. In the last decade, this area of research has blossomed. There are exciting findings relating to many areas of health and mindfulness practice. Some of the most impressive studies directly address the effects of mindfulness on cardiovascular disease.

“Was the Buddha a Preventive Cardiologist?”

At a cardiology conference this past fall, I gave a lecture entitled, “Was the Buddha a Preventive Cardiologist?” This title was born out of increasingly compelling data indicating that mindfulness (originated and proliferated by the Buddha approximately 2,500 years ago) may be an effective prescription for the prevention and reversal of heart disease. This is exciting news for the cardiologist and the primary care doctor! Until now it’s been obvious that chronic unregulated stress is a major culprit in heart disease, but there hasn’t been a scientifically tested prescription that a doctor could confidently offer his or her patients to help them address it effectively. Just recently (in

2010), the Journal of Clinical Endocrinology & Metabolism published a striking yet fairly unsurprising study showing that chronic unregulated stress is, in fact, deadly. After measuring urine levels of the stress hormone cortisol in 861 seniors ages sixty-five and older, researchers discovered that seniors with high levels of stress hormones “were five times more likely to die within the six-year follow-up period.” Although medical researchers still aren’t sure of the mechanism by which stress impacts the heart, what is clear in the scientific literature of late is that mindfulness seems to decrease stress as well as having a direct and measurable effect on healing the symptoms of cardiovascular disease and reducing the incidence of cardiac events.

Mindfulness as Medicine: The Effects of Meditation on Heart Disease and Chronic Stress

One of the amazing things about the sample of studies below is that all of the subjects are average people. They have no previous experience with meditation, a limited amount of time to dedicate to the practice, and are from a wide socioeconomic range—yet, overwhelmingly, they show both physiological and psychological gains from learning to harness the power of their attention with a nonjudgmental orientation. So, in other words, you don’t have to become a monk, wear an orange robe, and renounce all worldly possessions to learn this approach. You can be stressedout, neurotic, busy . . . and still benefit greatly from a range of proven meditative practices. The results of the following studies—some specifically on mindfulness meditation and others on transcendental Continued on following page . . . March 2011 San Francisco Medicine 15


Was The Buddha a Preventative Cardiologist? Continued from previous page . . . meditation (TM, a similar but slightly different approach to harnessing the power of attention using the repetition of a Sanskrit phrase, or mantra)—are impressive. It is worthwhile to note here that TM, in terms of the Buddha’s teachings, falls under the category of shamata (concentration) practice. Shamata was one of the Buddha’s first and most important offerings, and it is the foundational practice of a Buddhist monk’s lifelong training in meditation and mindfulness.

TM & the Heart

Let’s start with a study that produced a truly jaw-dropping result—an example of a measurable physical reduction of atherosclerosis in hypertensive African Americans engaging in the practice of TM. A randomized controlled study of the subjects (men and women aged over twenty years) showed that the practice of TM over a six- to nine-month period (just twenty minutes twice per day) is associated with reduced carotid atherosclerosis compared with a control group of similar subjects enrolled in health education classes. The TM group had a significant decrease of carotid intima-media thickness compared with an increase in the control group. Published in Stroke (2000; 31:568-573) a decade ago, these findings were groundbreaking in terms of suggesting the tangible influence that our mind can have on disease progression and/or on healing. An equally impressive study was presented at the annual meeting of the American Heart Association in 2009. It was the first randomized controlled trial to show that the long-term practice of TM lowers the incidence of clinical cardiovascular events. The subjects, 201 African American men and women (average age fifty-nine years with coronary artery disease [CAD]) were randomized to a TM group or a control group (health education classes in traditional risk factors, including dietary modification and exercise). The results of the nine-year study showed a 47 percent reduction in the combination of death, heart attacks, and strokes; significant reductions in blood pressure, and a marked decrease

16 San Francisco Medicine March 2011

in psychological stress. Robert Schneider, MD, lead author of this study, and director of the Center for Natural Medicine and Prevention, said that the effect of TM in this trial was like adding a class of newly discovered medications for the prevention of heart disease. “In this case,” he reported, “the new medications are derived from the body’s own internal pharmacy stimulated by TM practice.” These results have spurred significant interest in evaluating the beneficial effects of TM for patients with CAD. Last year the National Institute of Health’s Heart, Lung, and Blood Institute announced that it will be funding a $1 million study at Columbia University Medical Center using the most advanced noninvasive methods, such as positron emission topography, for measuring blood flow to the heart to investigate if TM can help CAD patients prevent cardiac events.

Mindfulness-Based StressReduction Studies

One cannot discuss mindfulness in medicine without acknowledging the noteworthy contributions of Jon KabatZinn. Kabat-Zinn pioneered the approach of Mindfulness-Based Stress Reduction (MBSR), a six- to twelve-week program rooted in the daily practice of mindfulness, currently offered at more than 200 teaching hospitals, medical centers, and health maintenance organizations across the U.S. A meta-analysis of studies evaluating MBSR and health benefits (Journal of Psychosomatic Research, 2004; 57:35-43) found that in studies of six to twelve weeks involving a daily twenty-minute mindfulness practice, the training significantly increased the ability to cope with distress in everyday life. Numerous additional studies in mindfulness practice illustrate significant reductions in the psychological variables that are at play during stress (Journal of Alternative and Complementary Medicine, 2006; 8:817-32; Psychosomatic Medicine, 2000; 62:613-622).

Neuroplasticity

The most astounding current explorations and hypotheses surrounding why mindfulness improves health are in

neuroplasticity. Through neural imaging, scientists are now able to locate specific regions of the brain that are activated as a result of mindfulness, as well as those that are deactivated. One study, recently published in Psychiatry Research: Neuroimaging (January 30, 2011), found that subjects with no previous meditation experience had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, and empathy after meditating just 30 minutes a day for eight weeks. In addition, gray matter in the amygdala, a region associated with anxiety and stress, was reduced. A control group that did not practice meditation showed no such changes.

Conclusion

As a scientifically minded yogi who has benefited greatly from mindfulness practice, the results of the research in this area are very exciting to me. Under rigorous scientific evaluation, the Buddha’s ancient inner technology seems to be an excellent adjunct prescription, not just for cardiovascular disease, but for many stress-related illnesses and, most certainly, for a greater sense of overall well-being. Dina Amsterdam, the founder of InnerYoga, teaches people how to access the inner aspects of the body-mind and cultivate more balanced lives. Featured in numerous publications for her expertise, Amsterdam offers workshops and teacher trainings nationwide and internationally. Off the mat, she lectures and leads InnerYoga programs in stress reduction for doctors and patients at medical conferences and facilities. Amsterdam serves on the Teacher Training faculty at Yoga Tree and maintains a private InnerYoga Therapy practice in San Francisco.

Resources There are a wide range of accessible avenues by which to learn more about mindfulness meditation. Here are some resources: The Mindsight Institute (mindsight.org); Mindfulness Awareness and Research Center (marc.ucla.edu); Center for Culture Brain and Development (cbd. ucla.edu); Spirit Rock Meditation Center (SpiritRock.org); Mindfulness-Based Stress Reduction (umassmed.edu/cfm/). www.sfms.org


Heart Health

The Patient, Stethoscope, and Physician A Closer Examination of Women’s Cardiac Health Issues

Eisha Zaid

O

n a brisk, sunny Monday morning, fifteen white coats hurriedly assembled amid the cacophony of beeping. Jagged lines of EKG tracings were visible in each patient’s room and were matched with the beeps of telemetry echoing throughout the cardiac intensive care unit in UCSF’s Moffitt-Long Hospital. Once the attending physicians arrived for cardiology rounds, small teams splintered off discordantly. When our attending arrived, our smaller team marched away to begin the daily ritual of meeting patients. With her black hair pulled back and her glasses resting in her hair, our attending, Dr. Rajni Rao, addressed her post-call team, consisting of a resident, intern, day float, and pharmacy resident. In the group of tall male residents all wearing scrubs, she stood in gray trousers and a red blouse in the middle of the circle, listening carefully to the new admissions. Dr. Rao had good news for our first patient. Ms. S, an elderly female patient, was lying calmly in her bed. Her face was framed by short, thin brown hair. As she answered questions, her eyes look magnified behind square glasses. She spoke slowly with a thick European accent. After Ms. S recounted how she’d felt dizzy during a Sunday church service, Dr. Rao said, “The good news is that you did not have a heart attack. You can go home after you walk around.” With a history of coronary artery disease and new-onset neurological symptoms, Ms. S was admitted and underwent an extensive workup to rule out cardiac and neurological diseases. The workup was completely negative. www.sfms.org

After we left Ms. S’s room to discuss our next patient, we saw her whiz by us and pace around the nurses station. She was ready to be discharged. “Sometimes we never know the cause, despite the thousands we spend on tests,” Dr. Rao said. ***** When Dr. Rao started medical school at UCSF, she thought she would pursue a career in women’s health, having studied and performed research on women’s health as an undergraduate at Harvard University. Like the medical students she mentors, she changed her mind once she started her clinical rotations. She was drawn to cardiology because it was about three things—“the patient, stethoscope, and the physician.” Like any cardiologist, she was fascinated by the fundamental physiological principles governing the heart. Although seemingly complicated, to Dr. Rao the heart represents a pump governed by pressure and volume relationships. She actively applies these principles every time she listens to a heart, performs a physical exam, reviews vital signs, or views an EKG strip. For Dr. Rao, in cardiology, physiology intersects with medicine, producing a dynamic puzzle embedded in a strong patient-physician relationship. During her residency training, she was once told that she did not have the personality to be a cardiologist. Despite the warning, she pursued her passion and is happy she did. Since completing her cardiology fellowship at UCSF with specialized training in echocardiography, she has joined the faculty and splits her time between clinic, inpatient consult and ward services, and teaching. Her primary

clinical interests include general cardiology, pregnancy and heart disease, and valvular diseases. She has poised herself on a physician-educator track. As a young female cardiologist, she joins a field that has been traditionally populated by men. When she started her fellowship training at UCSF, she recalls that 6 percent of cardiologists nationwide were women. Now, she reports, the number has increased to 20 percent. The face of cardiology is changing, and she credits this movement to her mentors in medical school—the female cardiologists who were pioneers in the field and inspired her to follow her passion despite what others told her. ***** In practice, Dr. Rao sees the spectrum of heart disease affecting both men and women. On a typical clinic day, she will see about 40 percent female patients, most of whom are older women. She finds that her female patients are well informed about cardiac disease. Some of the awareness stems from the increasing publicity generated by the American Heart Association’s (AHA) Go Red for Women’s Health campaign. The AHA classified cardiaovascular disease (CVD) as the number-one killer of women, reporting that CVD claims the life of one woman every minute. In launching the Go Red health campaign, the AHA aims to place a female face on heart disease to raise awareness and confront the misconception that heart disease represents an “old man’s disease.” “Women have seen the billboards,” she says. She appreciates the influence generated by the campaign, but she finds Continued on following page . . . March 2011 San Francisco Medicine 17


The Patient, Stethoscope, and the Physician Continued from previous page . . . that the heightened awareness embodied in red dress pins does not always translate to action for a disease primarily affecting older women. The larger problems confronting women’s cardiac health stem from complicated societal issues and gender disparities embedded in our health care system, resulting in lagging rates of detection, treatment, and female representation in clinical trials. Despite the Go Red campaign and Dr. Rao’s greatest efforts, she routinely has to confront what she considers a “societal problem” that makes it harder for her female patients to implement the necessary lifestyle modifications to reduce their risk of heart disease. “It all goes hand in hand. Working, obesity, poor diet, lack of time, and certainly not putting in any time for yourself—these are the big problems,” she says. Dr. Rao sees this reality in her patients, who have to work fulltime to raise a family. With limited time, her female patients struggle to fit in doctor appointments, cycling through scheduling and rescheduling even the necessary ones. “I think it is hard for women to take the time to come in and see the doctor. Women have to arrange their own coverage for everything.” She can name several patients who are forced to put their health last. In particular, she recalls a younger female patient with uncontrolled coronary disease and asthma. She splits her time between her job and her son, who is developmentally delayed and requires special care. For this patient, health is not the priority; her son is. Such patients are forced to make critical decisions, often placing their families first and their own health last. Her female patients are “taking care of everyone else but themselves.” And in certain ethnic groups, she has observed that women put their bodies last. For her female South Asian, Middle Eastern, and Asian patients, going to the gym is sometimes equated with vanity, especially when there are domestic responsibilities to fulfill. “No one really questions the man who

18 San Francisco Medicine March 2011

wants to work out. But if a woman wants to go to Curves or to the gym during the years she is raising children, I think they often, internally or externally, put that stuff on hold,” she says. Since the heart problems developed at age seventy reflect the habits of age twenty, women are unable to develop heart-healthy habits earlier in their lives and are at higher risk for developing coronary artery disease. The reflection becomes more grim as more women neglect their health. As a mother of two children, Dr. Rao can relate directly to her female patients, who have to forego exercising. “Even for myself,” she says. “If it is a choice of going to home to make dinner for the kids or hitting the gym, I am going to go home and make dinner for my kids. It’s an internal thing we do.” ***** Dr. Rao does not counsel her female patients any differently than her male patients; the risk factors for cardiovascular disease are not gender-specific. However, although the risk factors impact both sexes, women with CVD are not always treated equally. Historically, women have been underrepresented in clinical trials across all fields. She strongly believes genderspecific data is necessary to optimize treatment. And the only way to understand these differences is through conducting clinical trials. “You do need to include women in clinical trials, and you have to go out of your way to do so because things may make sense pathophysiologically, but there is always more to the story,” she says. The results from studies conducted in a male patient population can not always be extrapolated to female patients. Dr. Rao cites the Physician’s Health Study, which demonstrated a benefit of aspirin for primary prevention of myocardial infarction in male patients. However, when the same intervention was studied in women through a randomized trial of low-dose aspirin, the same risk reduction was not observed; aspirin did not affect the risk of myocardial infarction in women. This study represents a reminder that gender

differences exist in medicine, and every treatment must be weighed carefully. Even as physicians narrow the treatment gap in other areas, she finds that we continue to overtreat men and underdiagnose women presenting with the usual symptoms of heart disease. According Dr. Rao, studies have demonstrated that when compared to men, women are disproportionately offered statins, ACEinhibitors, and aggressive treatment for acute coronary syndrome. Although women are placed in the atypical equivalent category, Dr. Rao sees women presenting with the usual symptoms, but she finds that these symptoms may get overlooked during the history or may be associated with some other medical problem. Despite the gender differences in diagnosis and treating CVD in women, Dr. Rao does not think women needed to be treated in a separate clinic, since heart disease is not just a women’s disease. Heart disease affects everyone and should be treated appropriately regardless of gender; equality in screening and treatment is the key. For every patient, cardiac health comes down to personal choices. In addition to facing medical disparities in the backdrop, the future of women’s cardiac health will continue to be riddled by the complex societal issues women confront as they join the workforce, struggle to find childcare, select healthy dietary options, and make time for exercise—the same struggles that Dr. Rao grapples with every day. Eisha Zaid is a fourth-year medical student at UCSF and student member of the SFMS editorial board.

References 1. American Heart Association— Go Red for Women. http://www. goredforwomen.org/. 2. Ridker PM, Cook NR et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. The New England Journal of Medicine. 2005; 352:1293-1304. 3. Physician’s Health Study. http:// phs.bwh.harvard.edu/. www.sfms.org


Heart Health

Finding the Common Heart Support Groups at Commonweal Create Space for Healing

Michael Lerner, PhD

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even years ago I had a heart attack, an experience I described in San Francisco Medicine. I had been walking with friends on June 7, 2003, a beautiful day, in Bolinas, California. When we got back to our house, I began to sweat and to feel faint. My friend called 911. An ambulance took me to a tiny helicopter near the Bolinas Fire Station. We flew up over the San Francisco Bay to an East Bay hospital, and I was taken into the cardiac lab. As two young physicians worked on me, the song on the CD they were playing was Bob Dylan’s “Knock, Knock, Knocking on Heaven’s Door.” I had a “good” heart attack. I plunged into lifestyle recovery programs, combining the programs offered by my two cardiologists, Mark Wexman and Dean Ornish: a low-fat diet, meditation, yoga, deep relaxation, exercise, tai chi, and a support group. But above and beyond the lifestyle work, I experienced the heart attack as a “heart opening,” a truly transformative point in my life. I felt called to surrender my life completely to the Divine, whatever name we give the Oneness that the great mystics have found at the heart of all things. Seven years have passed. I have had various scares, but no recurrence of the heart attack. I have struggled—so far successfully—to stay off heart medications. I tried them right after the heart attack, but I didn’t like the way they made me feel and the one I was on caused liver toxicity. My blood chemistries are not perfect, but they are within “normal risk” range, though obviously I would like them to be better. I have stayed quite rigorously on a low-fat diet, now including some fish and www.sfms.org

olive oil. I have a good exercise program. I meditate and do tai chi. My yoga practice has fallen away, though I am committed to reinvigorating it. But the most powerful part of my healing has been a support group that a dozen of us started at Commonweal seven years ago. We have been meeting for two hours once a month ever since. Commonweal (www.commonweal. org) is the nonprofit center I cofounded thirty-four years ago in Bolinas. We have a dozen major programs. My focus for many years has been on the Cancer Help Program, the Collaborative on Health and the Environment, and the New School at Commonweal. I’ve co-led more than 150 weeklong retreats with cancer patients over the past 26 years. In the Cancer Help Program I do the sessions on choices people face in healing, biomedical therapies, integrative therapies, facing pain and suffering, and facing death and dying. In the Collaborative on Health and Environment, we focus on environmental contributors to cancer, heart disease, and dozens of other epidemic conditions of our time. In the New School, we have initiated a series of end-of-life conversations that explore many different aspects of death and dying—medical, cultural, psychological, spiritual, and experiential. I still fear death. A little walnut-sized tightness in my chest forms whenever I worry (as I do) about whether I will have another heart attack, or a stroke, or something else that might carry me away. Yet my attitude toward death has shifted over the past seven years. When I had the heart attack, I discovered that when I was closest to death, I was not

afraid. And when I am far enough away from death, I am not afraid. But there is a band in the middle ground—when I feel what might be heart symptoms—in which anxiety and fear compound each other. I have come to realize it is not the dying process that I fear, nor is it death itself. Rather, I fear that my hope for many more decades of enjoying the exquisite beauty of life might be taken away from me. I love life with a deep passion. I find life precious beyond words. I fear losing time with work I love, friends I love, family I love, and this beautiful blue-green planet that I love. That is my fear. Back to CommonHeart, the Commonweal heart group: I can’t speak of others, but I have permission from the group to speak for myself. I know from the Cancer Help program how deeply powerful well-designed support groups can be. But I had never before experienced a community-based, long-term support group, one founded by the members. There are, as I said, about a dozen of us. One of our members died some years ago. Two members tried it for a while and then moved on. But a dozen of us have stayed, and the experience is profoundly important to us. We meet without a leader. I led the group for a while until the group decided it would do as well without leadership. I was skeptical, but it worked—and made my experience of the group even better. What has happened is we have gotten older together. Most of what we talk about has little to do with coronary artery disease—although our hearts are what brought us together. We talk about the birth of grandchildren, the decline of Continued on page 21 . . . March 2011 San Francisco Medicine 19


Heart Health

Atherosclerotic Plaque Reversal The Holy Grail of Prevention?

Yerem Yeghiazarians, MD

A

therosclerosis is a diffuse process that starts early in life and remains silent for many years. It is the leading cause of death in developed countries. Atherosclerosis is a pathologic process that appears to begin with endothelial dysfunction leading to the deposition of lipid and inflammatory material within the wall of the artery. Over time, as atherosclerosis progresses, it results in arterial remodeling and eventual narrowing of the blood vessel leading to clinical manifestations by a decrease in blood flow to the end organ. For many patients, the first manifestation of the disease is an acute plaque rupture or erosion leading to myocardial infarction or stroke. Over the past two decades, considerable research has been undertaken to better understand the at-risk patient and the at-risk plaque. This has led to the suggestion that some of the plaques are “vulnerable” whereas some others might be more “stable.” A vulnerable plaque is characterized by a thin fibrous cap, a large lipid core, and more inflammatory cells. A more stable plaque is characterized by a smaller lipid core and a thicker fibrous cap. The signals that lead to plaque rupture or erosion are not clear. It is possible that sheer stress forces play a role in these processes, but research is ongoing to clarify these signals. To better understand the process of atherosclerosis, novel imaging techniques are being developed. Arterial angiography, one of the older ways of imaging plaque, is only a luminogram that can establish the degree of arterial stenosis, but it does not image the arterial wall. A number of newer techniques for imaging plaque and potentially identifying vulnerable plaque

include ultrasound, angioscopy, MRI, high-resolution CT scan, spectroscopy, optical coherence tomography, and thermography. Such imaging techniques are likely to lead to improved characterization of the atherosclerotic plaque in the future and identification of features that are associated with an increased risk of plaque rupture. The question that patients with atherosclerosis are asking today is whether there is anything they can do to reverse plaque. Can this be the “holy grail” for cardiovascular prevention? “Doc, is there a medicine you can give me to dissolve the plaque away?” Well, there is good news and bad news in this regard. The good news is that we have made some progress; the bad news is that we still have a ways to go to achieve this goal. Over the past few years, a number of medications and treatments have been postulated and evaluated for their effects on plaque stabilization and reversal. These include aggressive lipidlowering therapy with statins; increasing high-density cholesterol (HDL) by either medications (i.e., cholesterylester transfer protein inhibitors), infusion of HDL-C infusion in a rabbit model of atherosclerosis, or administration of Apo-A1 Milano in patients; smoking cessation; omega-3 polyunsaturated fatty acids; peroxisome proliferator-activated receptor-γ agonist; and lipoprotein-associated phospholipase A2 inhibitor. The initial human studies evaluating plaque regression used contrast angiography, but this method is not sensitive enough to accurately measure plaque volume. Despite this major limitation with this imaging modality, earlier studies with aggressive statin therapy impres-

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sively reported plaque stabilization and potentially even plaque regression. The ASTEROID trial1 (A Study to Evaluate the Effect of Rosuvastatin on Intravascular Ultrasound-Derived Coronary Atheroma Burden) included more than 500 patients with coronary artery disease treated with rosuvastatin at 40 mg daily for two years to average low-density cholesterol (LDL) of below 70 mg/dL. This therapy resulted in a significant decrease in LDL, increase in HDL, and produced regression of atherosclerosis by improving minimal luminal diameter from 1.65+/-0.36 mm (median, 1.62 mm; range, 0.56 to 2.65 mm) to 1.68+/-0.38 mm (median, 1.67 mm; range, 0.76 to 2.77 mm; P<0.001) and decreasing percent diameter stenosis from 37.3+/-8.4% (median, 35.7%; range, 26% to 73%) to 36.0+/-10.1% (median, 34.5%; range, 8% to 74%; P<0.001) by quantitative coronary angiography. These appear to be small changes, and indeed they are, but the fact that any regression noted is impressive. With the advent of more advanced imaging modalities capable of imaging the arterial wall and even potentially providing information on plaque content and morphology, future studies will provide much more information on the biology of atherosclerosis. The hope is that future therapies can not only regress plaque but potentially “stabilize” the more “vulnerable” ones. Whether this strategy of plaque stabilization will lead to a decrease in clinical events will have to be tested in randomized prospective clinical trials in the future. Unfortunately, no medicine or therapeutic modality to date has “dissolved the plaque away”! So what should a patient and a clinician do today? The best strategy www.sfms.org


is still prevention of disease rather than reversal of disease. Keeping the endothelium healthy is the first and likely one of the most important steps. The endothelial lining acts to protect the blood vessel from the initiation and progression of atherosclerosis. Numerous risk factors can lead to endothelial dysfunction. Some of these risk factors are modifiable, but others are not. The modifiable risk factors include control of blood pressure, lipids, glucose level, avoidance of first- or secondhand smoke, and routine exercise. Unfortunately, there are also some nonmodifiable risk factors such as aging, hemodynamic factors, and genetics that one cannot do much about. The repair of the endothelium was thought to be influenced by its neighboring cells, but more recently it has been suggested that the endothelium can also be repaired and repopulated by circulating endothelial progenitor cells, and the number of these circulating cells has in fact been correlated to clinical cardiovascular outcomes (the higher the number of these cells in the circulation, the better are the clinical outcomes). Since atherosclerosis is a systemic disease, treatment should focus at a systemic level unless acute plaque rupture or high-grade symptomatic lesions are present, which could be considered for more focal treatments. So, for now, we wait and we tell our patient that the “holy grail” of cardiovascular prevention is not plaque reversal but plaque prevention. I also tell them that whoever finds a therapy that becomes the “holy grail” of plaque reversal will become a very rich person, and that might indeed be the one therapy that will push the mean age of survival to triple digits. And whether we want or how we can afford that scenario, my friends, is another article and debatable discussion to be had! Yerem Yeghiazarians, MD, is an associate professor of medicine, the codirector of the Adult Cardiac Catheterization Laboratory, the director of the Peripheral Interventional Cardiology Program, and director of the Translational Cardiac Stem Cell Program at the Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research at the University of California, San Francisco. www.sfms.org

Reference Ballantyne CM, Raichlen JS, Nicholls SJ, Erbel R, Tardif JC, Brener SJ, Cain VA, Nissen SE, ASTEROID Investigators. Effect of rosuvastatin therapy on coronary artery stenoses assessed by quantitative coronary angiography: A study to evaluate the effect of rosuvastatin on intravascular ultrasound-derived coronary atheroma burden. Circulation. 2008; 117(19):245866. Healing the Common Heart Continued from page 19 . . . elderly parents, our own experiences of aging, the trajectories of our work and relationships, whatever health crises we are experiencing, and much more. On the winter solstice, we gather for a long evening at the home of one of our members. We eat together, read poetry, and sing sometimes. But this is just the outer form. What has happened in an interior way is that we have formed a kind of web of profound interconnectedness that touches all of us deeply. We each have our stuff—but we can overlook each other’s stuff, for the most part. We care about each other in a special way. And we can say a good deal that is true to each other. Not everything—there are limits to what you can say in a community-based group. But there is a lot that you can say. I think there are experiences we could take further. There are a variety of symbolic practices that could take us deeper. I’ve mentioned the possibility from time to time. But groups fall into patterns. We have a pattern that is deeply set and comfortable to us all. I don’t feel any urgency to impose “my trip” about these practices on anyone else, and so far no one else has felt any great urgency to change what works so well for all of us. There are three envelopes of longterm experience that hold CommonHeart as a group. The first is our direct experience with each other over the past seven years. The second is the Commonweal community, with which we are all connected in one way or another. And the third is that we all live in West Marin,

and many of us in Bolinas. West Marin is a string of small towns with a powerful sense of shared community, set along the Pacific Coast. Bolinas is a microcosm of West Marin. I remember one day seven years ago, just weeks after my heart attack, when I went to buy groceries at the Bolinas Coop. I was still experiencing deep post-heartattack anxiety and could scarcely stand to interact with other people. A friend I had known for years, though only slightly, came up to me without any words and just put his hand on my heart and held it there. I was moved to tears by his kindness. Bolinas—and West Marin—is that kind of community. I have watched three generations come of age in the thirty-eight years I’ve lived here. I know the children of the children of the friends I made when I moved here. I could talk about the ongoing experiences of spiritual transformation that have continued ever since that transformative moment when I realized that the purpose of this heart opening was to allow a deeper level of surrender to the Divine. But that is a particularistic way of formulating an experience that each of us in CommonHeart has, whether we use spiritual or psychological or some other words to describe our experience. We each try to eat well, exercise, and connect with meaning in our lives. Each of us has a different story about what that looks like. But what we share is that each month for two hours, we enter the Commonweal Library, pull chairs into a circle, light a candle that sits on a plate of sand surrounded by a few stones, and meditate together. Then whoever wants to share something takes a stone and puts it at his or her feet. And then we begin. Michael Lerner is president and cofounder of Commonweal and of Smith Center for Healing and the Arts in Washington, D.C.

March 2011 San Francisco Medicine 21


Heart Health

Air Pollution and the Heart Growing Evidence for the Link

Gordon Fung, MD, PhD

O

n May 10, 2010, the American Heart Association published in Circulation: Journal of the American Heart Association an article entitled “Particulate Matter Air Pollution and Cardiovascular Disease: An Update to the Scientific Statement from the American Heart Association.” We received permission to reprint the article here. However, in view of its length of 47 pages, with 426 references, we opted to print the abstract and focus on the parts of the article pertinent to our readers. Abstract: In 2004, the first American Heart Association scientific statement on “Air Pollution and Cardiovascular Disease” concluded that particulate matter (PM) air pollution contributes to cardiovascular morbidity and mortality. In the interim, numerous studies have expanded our understanding of this association and further elucidated the physiologic and molecular mechanisms involved. The main objective of this updated American Heart Association scientific statement is to provide a comprehensive review of the new evidence linking PM exposure with cardiovascular disease, with a specific focus on highlighting the clinical implications for researchers and health care providers. The writing group also sought to provide expert consensus opinions on many aspects of the current state of science and updated suggestions for areas of future research. On the basis of the findings of this review, several new conclusions were reached, including the following: Exposure to PM <2.5 µm in diameter (PM2.5) over a few hours to weeks can trigger cardiovascular disease-related mortality and nonfatal events; longer exposures (e.g., a few years) increases

the risk for cardiovascular mortality to an even greater extent than exposures over a few days and reduces life expectancy within more highly exposed segments of the population by several months to a few years; reductions in PM levels are associated with decreases in cardiovascular mortality within a time frame as short as a few years; and many credible pathologic mechanisms have been elucidated that lend biological plausibility to these findings. It is the opinion of the writing group that the overall evidence is consistent with a causal relationship between PM2.5 exposure and cardiovascular morbidity and mortality. This body of evidence has grown and been strengthen substantially since the first American Heart Association scientific statement was published. Finally, PM2.5 exposure is deemed a modifiable factor that contributes to cardiovascular morbidity and mortality.1 To give one a better perspective on this topic, most experts agree that the data supporting the increased risk of cardiovascular disease from air pollution are more robust than the data supporting air pollution effects on lung disease. The strength of the data comes from the numerous sources where accurate measurements of air pollution quality can be compared to cardiovascular disease mortality and morbidity outcomes. The data are acquired both locally and worldwide. Laboratory simulations can be created to further research specific mechanisms of disease at the biological and molecular levels. It is important to recognize that there are six types of air pollutants, and particulate matter is only one of those. The others are ozone, carbon monoxide, nitrogen oxide, sulfur dioxide, and lead.

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PM is a term for particles found in the air, including dust, dirt, soot, smoke, and liquid droplets. Particles can be suspended in the air for long periods of time. Some particles are large or dark enough to be seen as soot or smoke. Others are so small that individually they can only be detected with the electron microscope. Many man-made and natural sources emit PM directly or emit other pollutants that react in the atmosphere to form PM. These solid and liquid particles come in a wide range of sizes. Particles less than 10 µm (PM10) pose a health concern because they can be inhaled and can accumulate in the respiratory system. Particles less than 2.5 µm in diameter (PM2.5) are referred to as “fine” particles and are believed to pose the greatest health risk. Because of their small size (approximately 1/30th the average human hair), fine particles can lodge deeply into the lungs. Sources of fine particles include all types of combustion activities (motor vehicles, power plants, wood burnings, etc.) and certain industrial processes. Particles with diameters between 2.5 and 10 µm are referred to as “coarse.” Sources of coarse particles include crushing or grinding operations, and dust from paved or unpaved roads. Other particles may be formed in the air from the chemical change of gases. They are indirectly formed when gases from burning fuels react with sunlight and water vapor. These can result from fuel combustion in motor vehicles, at power plants, and in other industrial processes. Roughly one out of every three people in the United States is at a higher risk of experiencing PM2.5related health effects. One group at high risk is active children, because they often www.sfms.org


spend a lot of time playing outdoors and their bodies are still developing. In addition, oftentimes the elderly population is at risk. People of all ages who are active outdoors are at increased risk because, during physical activity, PM2.5 penetrates deeper into the parts of the lungs that are most vulnerable to injury. Air-quality forecasts in your area are often given with weather forecasts on local television and radio stations and may be found on the weather page of your newspaper. Another way to learn about unhealthy exposures is to check the daily Air Quality Index (AQI) forecasts; visit www.airnow.gov to find the forecasts for your area. The most recent AQI ranking for the San Francisco Bay Area is moderate. This means that air quality is acceptable; however, some pollutants may be a moderate health concern for a very small number of people who are usually sensitive to air pollution. There is a large and growing body of evidence demonstrating both acute effects of air pollution, such as vascular dysfunction, arguing for the existence of pathways that convey signals systemically within hours of PM inhalation, and chronic effects, such as the promotion of atherosclerosis. At the molecular level, evidence supports a role for ROS-dependent pathways and multiple stages, such as in the instigation of pulmonary oxidative stress, systemic proinflammatory responses, vascular dysfunction, and atherosclerosis. More recent studies support the idea that inhalation of PM can instigate extrapulmonary effects of the cardiovascular system by three general “intermediary” pathways. These include pathway 1, the release of proinflammatory mediators (e.g., cytokines, activated immune cells, or platelets) or vasoactive molecules (e.g., ET, possibly histamine, or microparticles) from lungbased cells; pathway 2, perturbations of systemic autonomic system balance or heart rhythm by particle interactions with lung receptors or nerves; and pathway 3, potentially the translocation of PM (i.e., UFPs) or particle constituents (organic compounds, metals) into the systemic circulation. Several precautionary recommendawww.sfms.org

tions can be made for health care providers who interact with patients or individuals at risk for CVDs. A recent observational study found that patient awareness of air-quality indices and media alerts along with health professional advice can significantly affect reported changes in outdoor activity to avoid exposure to air pollution. • Evidence-based appropriate treatment of the traditional cardiovascular risk factors should be emphasized. This may also lessen the susceptibility of patients to air pollution exposures. • All patients with CVD should be educated about the cardiovascular risks posed by air pollution. • Consideration should also be given to educating patients without CVD but who are at high risk (e.g., the elderly, individuals with metabolic syndrome or multiple risk factors, and those with diabetes). • Provide information to at-risk

patients regarding the available sources that provide a daily EPA Air Quality Index (e.g., local and national media, EPA website, etc.). • On the basis of the forecast Air Quality Index, prudent recommendations for reducing exposure and limiting activity should be provided based on the patient’s level of risk. • Practical recommendations to reduce air pollution exposure should be given to at-risk patients. For the medical society and scientists, continued advocacy for cleaner air standards that will improve the health of our communities should be a priority.

References

1. Brook RD et al. Particulate air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Circulation. 2010; 121:2331-2378.

CMA Foundation Announces New Practice-Based Reference Guide and Webinar The California Medical Association (CMA) Foundation is pleased to announce the release of a new practice-based reference guide and a webinar for diabetes and cardiovascular disease care. The new resource is a Web-based version of the Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2009–2010. The PRG first became available in hard-copy format in 2010. It was developed with the support and expertise of thirty-three physicians and health care leaders from a variety of physician associations, medical groups, health plans, and other organizations dedicated to the prevention and management of diabetes and its complications. To access the PRG, please go to: http://www.thecmafoundation.org/projects/ aped/. The Diabetes and Cardiovascular Disease Webinar is a clinical education module that will be led by Dr. Gordon L. Fung, MD, MPH, PHD, director of Cardiology Services at Mt. Zion at UCSF, and San Francisco Medical Society member and Editor. The learning objectives for the module are the following: a) Describe the pathophysiology and potential complications of type II diabetes. b) Articulate the clinical significance of treating type II diabetes as a cardiovascular disease equivalent. c) Describe how you can avoid cardiovascular complications of type II diabetes. d) Manage diabetes to include the use of lipid-lowering medications and aspirin to prevent cardiovascular complications. The event will be held March 25 at 7:30 a.m. To register or get more information, please e-mail Joe Mette, Diabetes Quality Improvement Project Assistant, at jmette@thecmafoundation.org. March 2011 San Francisco Medicine 23


Heart Health

The New and Improved CPR An Outline

Gordon Fung, MD, PhD

O

n October 18, 2010, the American Heart Association released its latest guidelines rearranging the ABCs of cardiopulmonary resuscitation (CPR), in its 2010 “American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” published in Circulation: Journal of the American Heart Association. The most significant change for the general public learning CPR was the new order for CPR. The new guidelines call for chest compressions to be the first step for lay and professional rescuers to revive victims of sudden cardiac death, changing the forty-year-old universal mnemonic of A (Airway)-B (Breathing)C (Compressions) to C-A-B. In previous guidelines, the association recommended looking, listening, and feeling for normal breathing before starting CPR; now, compressions should start immediately on anyone who is unresponsive and not breathing normally. All victims in cardiac arrest need chest compressions. In the first few minutes of a cardiac arrest, victims will have oxygen remaining in their lungs and bloodstream, so starting CPR with chest compressions can pump that blood to the victims’ brain and heart sooner. Research shows that rescuers who started CPR with opening the airway took 30 critical seconds longer to begin chest compressions than rescuers who began CPR with chest compressions. The change in the CPR sequence applies to adults, children, and infants but excludes newborns. Other recommendations, based mainly on research published since the last AHA resuscitation guidelines in 2005, are:

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• During CPR, rescuers should give chest compressions a little faster, at a rate of at least 100 times per minute. • Rescuers should push deeper on the chest, compressing at least 2 inches in adults and 1.5 inches in infants. • Between each compression, rescuers should avoid leaning on the chest to allow it to return to its starting position. • Rescuers should avoid stopping chest compressions and avoid excessive ventilation. • All 9-1-1 centers should assertively provide instructions over the telephone to get chest compressions started when cardiac arrest is suspected. The year 2010 marks the fiftieth anniversary of Kouwenhoven, Jude, and Knickerbocker’s landmark study documenting cardiac arrest survival after chest compressions. The American Heart Association established the first resuscitation guidelines for health care professionals and the general public in 1966. Last year the American Heart Association trained more than 13 million people in CPR worldwide. Research has shown effective bystander CPR provided immediately after sudden cardiac arrest can double or triple a victim’s chance for survival. Unfortunately, less than onethird of out-of-hospital sudden cardiac arrest victims receive bystander CPR. EMS treats nearly 300,000 victims of out-of-hospital cardiac arrest each year in the United States. Less than 8 percent of people who suffer cardiac arrest outside of the hospital survive to make it home from the hospital. Sudden cardiac arrest can happen to anyone at any time. Many victims appear healthy, with no known heart disease or risks factors. Sudden

cardiac death (SCD) is not the same as a heart attack. SCD occurs when electrical impulses in the heart become rapid or chaotic, which causes the heart to suddenly stop beating. A heart attack occurs when the blood supply to part of the heart muscle is blocked. A heart attack may cause SCD. The latest guidelines also have specific recommendations for health care professionals. • Effective teamwork techniques should be learned and practiced regularly. • Professional rescuers should use quantitative waveform capnography— the monitoring and measuring of carbon dioxide output—to confirm intubation and monitor CPR quality. • Therapeutic hypothermia, or cooling, should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest. • Atropine is no longer recommended for routine use in managing and treating pulseless electrical activity (PEA) or asystole. Pediatric advanced life support (PALS) guidelines provide new information about resuscitating infants and children with certain congenital heart diseases and pulmonary hypertension, and they emphasized organizing care around two-minute periods of uninterrupted CPR.

www.sfms.org


Heart Health

Saving a Heart Attack Patient A Story of Sudden Death in the Streets of San Francisco

Toni Brayer, MD, FACP

T

he year was 1989, and it was a beautiful San Francisco day for the annual Bay to Breakers road race. I wasn’t much of a runner, but I knew I would have no problem jogging the 7.46-mile race across San Francisco, for fun. As I came down the Hayes Street Hill and started along the Panhandle, I saw a commotion in the street ahead. A runner was down on the ground and people were starting to gather around. The circle around the downed man was enlarging by the time I arrived. That’s when I stopped being a recreational jogger and kicked into “doctor” mode. The man was already turning a dusky color and a quick assessment showed he wasn’t breathing. Along with my running companion, who was also a physician, we started CPR with chest compressions and breathing. (CPR guidelines have changed considerably since this time.) Because of the crowds and location, it seemed to take the paramedics an inordinately long time to reach us. We continued our attempt at resuscitation without stopping until they arrived and then applied a cardiac external defibrillator and transported him to St. Mary’s Hospital. The rest of the race was easy compared to the adrenaline rush of CPR in the field. After the race, we took a t-shirt that said “I Survived the Bay to Breakers” and visited our runner patient at the hospital. Sitting up in bed, he was younger than he had appeared on the ground. His only complaint was a “sore chest.” He had suffered a myocardial infarction and he was extremely lucky to be alive. I wonder if that patient knew that the success rate of cardiopulmonary resuscitation outside of the hospital was only 1 to 3 percent. This statistic has improved with advances in www.sfms.org

early CPR and the use of automated external defibrillators (AEDs), but even now the chances of a patient surviving and leaving the hospital are still quite small if they have sudden death outside of the hospital. At least 250,000 people die of heart attacks each year before they reach a hospital, and heart attack is still the number-one cause of death in the United States. Fortunately, death from heart disease while participating in a sport is rare. But very strenuous exercise can temporarily increase the risk of death, and every year 0.75 of every 100,000 young male athletes die during their sport. In middle-aged men, the incidence is about 6 per 100,000. Postmortem studies show that something was wrong with a dead athlete’s heart prior to the activity, either coronary artery disease or an anatomical defect related to the left main coronary or hypertrophic cardiomyopathy. Another cause of death seen in athletes is Marfan syndrome. Olympic volleyball star Flo Hyman had Marfan syndrome, as did Florida State basketball player Ronalda Pierce, who died of an aorta rupture. Aberrant coronary circulation in young athletes causes insufficient coronary flow that worsens during exercise, and unfortunately these patients have no preceding symptoms or warnings. Even less common is arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients might have a family history of sudden death or a personal history of syncope or arrhythmia. A sudden cardiac death in a sport is rare enough to make the headlines, and it causes fear and confusion about the safety of sports participation. Athletes are supposed to be the healthiest members of the population. The extent of a preparticipation sports evaluation for young people is a hot

topic, and experts disagree on the value of EKG, exercise stress EKG, or cardiac echo for asymptomatic screening. Because the incidence of abnormalities is so low, the false positive rate is high. The debate goes on about the cost effectiveness of these tools for screening purposes. One aspect of athletic participation screening that is not controversial but is still underused is a complete physical exam. This must include personal history with focus on heart murmur; high blood pressure; chest pain or discomfort with exertion; syncope or presyncope; exercise intolerance; family history of cardiomyopathy, long QT syndrome, Marfan, or abnormal heart rhythms; family history of sudden or cardiac death before age 50; and family history of disability from heart disease before age 50. The exam should focus on stigmata of Marfan syndrome, cardiac auscultation supine and standing, blood pressure, and femoral pulses to exclude aortic coarctation. Despite the press attention an event such as this gets, it is clear that regular exercise protects the heart and that, over the course of a year, regular exercisers will have fewer cardiac events than their sedentary counterparts. We should be encouraging our patients both young and old to be active and to exercise. Participation in organized sports has health benefits that go beyond fitness, especially for kids. I don’t know the background of the man whose heart gave out during the Bay to Breakers Race. He may have had symptoms he ignored. I will never know. I am glad I was behind him that day, and I hope his recovery allowed him to remain active and race again. Toni Brayer, MD, FACP, practices internal medicine in San Francisco. March 2011 San Francisco Medicine 25


Heart Health

The Place of Heart in Poetry Considering Both Science and Metaphor

David Watts, MD

N

ow here’s a challenge: consider the place of heart in poetry. . . . . . . Meaning both the science and the metaphor. At the root of it all will be healing. This connection is not apparent, I know. One might wonder how I got here when considering all of the possibilities before me. I’ll start explaining by asking a few questions: 1) Does poetry have a heart? Valentine’s Day passes. Love poems abound. How do I love thee, let me count the ways. I love you . . . We know this. It is familiar. By now the cliché is ingrained. This is the metaphor of the heart, and it works for us as a society. Poetry continues to console and inspire through the cultivated mechanism of engagement by which it has become part of our culture: We are refreshed. We are reassured. Love is affirmed in our lives. But we can’t stop there. The question goes much deeper. 2) Does poetry have a living, breathing heart? Now we’re pushing the envelope. But here’s a little something to consider: I lead writing workshops all over the country. Many times a poem will show up that begins with grace and confidence. The metaphors are working, there’s music in the flow of the lines, the subject is examined with insight and cleverness, and there are bursts of refreshing language . . . then something happens: Light Falls Light falls to my desk With the graceful intention Of a feather, drifting, resting . . .

I cannot discern Whether it is lilt Or illumination which captures My attention. It reminds me that I, like light Spilled upon my desk, cannot always Undo whatever it is I have just done that Is somehow offensive to someone in Some offhand way, whatever their particular prejudice Might be. It’s painful to read that. Well, I made it up. Made it up to make a point. This poem begins not terribly but then promptly goes to hell in a basket. You can see it on the page. The third stanza looks like somebody sat on it—the line goes kookoo, the stanza spreads like an amoeba, the language goes flat and lifeless. When this happens, it usually means the poet has decided not to go into the center of a hard truth. He has hedged, gone chicken, and the poem doesn’t like it. It says f___ you and goes into cardiac arrest. Only the poet returning to that precise spot and finding, somehow, the courage to follow the pathway the poem wants, no matter the personal embarrassment, or pain, or exposure it causes . . . only that act of determination will resuscitate our victim. This is what it feels like to the poet. The poem refuses to cooperate if the poet does not take seriously his charge to tell the truth no matter what. Faced with a wimp for a creator, the poem simply withdraws its poetic mechanisms. Over centuries of writing, our predecessors in the art, in manner akin to the

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Darwinian survival of the fittest, have, by trial and error, fashioned techniques of craft that work and by the same token, identified those that do not. The good ones have been handed down in the form of poems that we recognize as representative of the art. Music, rhythm, line breaks, rhyme, combinations of accentuated and unaccentuated syllables— the reason these techniques work is not just because they create beauty but because they are tied organically to the truth. They reveal something to us in the careful way the words are assembled. By this time in our generational development, the connection between technique and truth is so tight it has entered the very genome of poetry, so that no matter how brilliant the thinking, if we falter at the altar of truth, the poem will fail. Of course, it is us on the page—our consciousness in all its mysterious forms—it is our own essential selves reflecting back to us through the poem to give it its living, beating heart. Yet this heart doesn’t show itself upon undulating waves of the electrocardiogram. The human experience in a complicated universe is too broad to be reduced to a simple electronic tracing. Even so, we may imagine its systole and diastole in the words that beat upon the page, and if we were to break this heart, the poem, every time, will self-destruct. 3) We can heal the poem with truth. Since the poem is us or perhaps the collective us, does truth heal us as well? Jaime Pennebaker had asthma. He attributed it to the dust that blew in from Oklahoma and New Mexico to contaminate his West Texas homestead. Every time he visited home after leaving for college, he got an attack. It was self-evident. www.sfms.org www.sfms.org


Then he moved to Florida. His parents came to visit and he got asthma. Eureka! It wasn’t the errant dust. It was his parents. The second shock of epiphany was that the exposure of the critical connection between parent and bronchospasm was force enough to keep the asthma from ever reactivating again. He was well aware of the “talking cure” of Breuer, Freud, and the world of psychotherapy. He reasoned that the private realm of writing was perhaps a better place to stumble upon these therapeutic linkages. As professor of psychology, he did experiments. College students wrote for twenty minutes, three times in one week. Some wrote a grocery shopping list. Some wrote about a traumatic event. Some wrote about the emotional response to a traumatic event. Some wrote both the details of the event and the emotional response to it. Only the last group demonstrated a diseaseprevention effect, an immune system enhancement that lasted six months after. The linguistic connection between a traumatic event and the emotional response to that event was the key to health maintenance and disease prevention. Later experiments demonstrated that “expressive writing” improves air flow during asthma attacks, reduces the pain of rheumatiod arthritis, and improves immune markers in AIDS, among other positive effects upon our physical wellbeing—concrete examples of events in the psychological realm having a direct effect upon the physical. Well, that process so distinct to “expressive writing” is what poets have been doing all along, isn’t it? Mining truth and defining its connection to our emotional lives? In a way, Pennebaker demonstrated an important contributor to making the art of poetry into art: its capacity to engage and strengthen the human spirit. Well, that’s how this business of heart and poetry connects to healing. Finding truth turns out to be a healthy experience. How about that? OK, but now I have one more question: 4) What does this mean for us in the practice of medicine? For one thing, get our patients writing. For another, ourselves.

www.sfms.org

Medical school has the distinct ability to annihilate altruism. We’ve all seen it. We enter the hallowed halls full of piss and vinegar, out to save the world and hell-bent to do it, and then by the third year we are arrogant, cold, and distant, or perhaps just distracted and fearful. Not always, surely. But there is more than a grain of truth lurking there. It’s because we’re deluged with science—not the fault of science, I hasten to add; without it we’d all be frauds. It’s the fault of curriculum committees who do not recognize that brain balance is critical to an existence marked by contentment. My guess is that in the same way the London cabbies induce, by the constant bombardment of cartography, PET scan-documented hypertrophy in grey matter regions responsible for geographic knowledge, third-year medical students suffer hypertrophied regions of linear thought and atrophied regions of altruism. Don’t attempt didactic lectures on humanistic subjects to try and correct this problem. They’ll never work. Leave it to the experts. Just a little poetry in the right tea cup might do. Some stories

authentic to the circumstance of medicine. Expressive writing here and there, perhaps. We cannot hope to become humanistic physicians by thinking about the subject, or by analyzing external manifestations. The brain informs, but it is the heart that sets behaviors. To influence behavior we must speak the language of the heart, that which is to be found in poetry and in stories that engage the imagination and model the human personality, with all its quirks and richness of spirit. Such would be true as well of those of us in practice. Regular contact with our interiors, our pasts, our experiences of the day reflected in the tranquility of a quiet moment under the guidance of the truthwriting hand might serve to make us more compassionate in thought and in deed. It is easy enough to lead the unexamined life. Anyone can do that. But the consequence of that deprivation is a tragically missed opportunity for pleasure . . . but also, and importantly, for a lasting state of balance in our lives. David Watts, MD, is a poet and a regular commentator on NPR’s All Things Considered.

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Hospital News CPMC

Kaiser

Michael Rokeach, MD

Robert Mithun, MD

The Heart Failure Care Management Program at Kaiser Permanente San Francisco is a physician-supervised, advanced-practice nurse- and pharmacist-run program designed to provide comprehensive care to patients with heart failure. Physicians directly refer patients to the program from the emergency room and the inpatient and outpatient clinics, which include medicine and cardiology. Patients enrolled in the program learn self-care management skills such as a low-sodium diet, monitoring of daily weight, self-titration of diuretics as instructed, physical activity, and recognition of early warning signs of developing or worsening heart failure. Medication reconciliation, education, and compliance are emphasized, as well as early follow-up posthospitalization and prevention of readmissions. There is also an inpatient care manager who serves to help transition care between inpatient and outpatient as part of our integrated program. We use a designated heart failure unit that facilitates consistent patient education and nurse care pathways while the patient is receiving treatment. Patients enjoy being able to have a direct telephone number to call a care manager and may require daily calls and weekly visits. Other services included are specialty referral for interventions such as interventional procedures, open-heart surgery, device options (which include ICD and BIV), and/or transplant evaluation. Long-term planning includes a review of advanced directives and/or a referral to hospice if indicated. Patients are kept within the program for six months to a year and are discharged if they have stable heart failure with optimal medical management and demonstrate the ability to self-manage their condition. Quarterly monitoring increases the number of patients who receive target medications; more appropriately uses the hospital, emergency department, and primary and specialty care; and improves quality of life for heart failure patients.

For the fifth year in succession, California Pacific Medical Center has been named to the Leapfrog Group’s annual list of top hospitals for patient safety and quality. This year a record 65 hospitals, out of nearly 1,200 surveyed, were named to the prestigious list, but CPMC is one of just 3 hospitals nationwide to make the list 5 years in a row. “Winning this 5 consecutive years is a tribute to every person who works at CPMC,” says Warren Browner, MD, MPH, CEO of California Pacific Medical Center. “It’s a reflection of the commitment, the skill, and the compassion of our staff in caring for our patients and making their health and safety our top priority.” CPMC is pleased to announce that our Internal Medicine Residency program director, Dr. Paul Aronowitz, has been named president of the Association of Program Directors of Internal Medicine (APDIM) for the 2012–2013 academic year. APDIM is the widely recognized educational organization representing all internal medicine residency programs in North America. We congratulate Dr. Aronowitz on this honor and anticipate substantial benefit to our training programs at CPMC as well as to those around the country who will benefit from his insight and leadership. Congratulations to our very own Reverend Carolyn Dyson, who has been named a 2011 Local Hero by KQED for her extraordinary work with the African American Breast Health and Sister to Sister Breast Health programs, as well as other community bridgebuilding activities. Rev. Dyson was honored during a celebration at KQED on Thursday, February 3. In the coming weeks, KQED will feature videos of the 2011 Local Heroes online, so you can learn more about all the honorees and their contributions to our community.

28 San Francisco Medicine March 2011

UCSF

David Eisele, MD

Prevention strategies such as managing cholesterol and high blood pressure have proven highly effective in helping people avoid heart and vascular diseases. Most patients, however, only seek care for acute problems. “We’re always putting out fires instead of preventing them,” says William Grossman, MD, director of the new UCSF Center for Prevention of Heart and Vascular Disease at UCSF’s Mission Bay campus. With numerous different identified risk factors that all interact, preventing cardiac events requires spending enough time with patients to create a prevention program that meets individual needs. Through this approach, coupled with interdisciplinary consultations in a state-of-the-art facility, we are seeking to alter the course of cardiovascular disease, which affects 80 million Americans. Having a full range of interdisciplinary care and research in one location eases the process. In addition, the new facility includes cardiology and vascular practices, all of which are now housed in the same building as the renowned Cardiovascular Research Institute (CVRI). At the CVRI, comprehensive teams of heart experts work with anyone who has had a cardiac event or possesses any of the traditional risk factors. In most instances, during their initial visit, patients can do everything required to create a personalized primary or secondary prevention program. After the initial visit, cardiologists conduct thirtyto forty-minute follow-up visits every three to six months. Patients also can take advantage of biannual educational seminars that complement information on the center’s website and in its newsletters and educational e-mails. The result is a thorough, personalized, up-to-date prevention plan that covers medication, diet, and lifestyle recommendations. Finally, the proximity of CVRI ensures that knowledge emerging from the center can be translated into new preventive measures, enhancing both individual patient care and the management of entire populations of heart patients. www.sfms.org


Hospital News Saint Francis

Patricia Galamba, MD

We have been taking heart health seriously here at Saint Francis. Besides the cardiac care that we provide to all patients, we have made it a priority to improve the heart health of our staff. In April we will roll out our second annual free cholesterol and glucose screening. Last year 10 percent of our employees participated, and we’re shooting for 20 percent this year. The screenings are offered in combination with informational sessions conducted by pathologist Harris Goodman, MD, and cardiologists Peter Teng, MD, and Peter Curran, MD. During Nurse Appreciation Week in May, the staff nurse IIIs and IVs will host a daylong health fair for employees, including BP checks, diabetes screening, BMIs, and lipid panel. We all know how important exercise is for a healthy heart, so the hospital offers employees, volunteers, and physicians a free 24/7 gymnasium, which is bustling with activity. For more than five years, Saint Francis has hosted a Weight Watchers program on site. The participants are offered incentives if they reach their goal (5 percent loss), and if they reach their ideal weight President/CEO Tom Hennessy will reimburse them for the cost of signing up with Weight Watchers. The cafeteria menu includes healthy choices and the Weight Watchers Point System is displayed with most food items. Weekly we host free yoga instruction and mat pilates training. Stair walking is another great activity on site, since we have a twelvestory building in which to train. One of our employees actually competed at last year’s Firefighters’ Pyramid Building Climb and was the first woman to complete the climb. I’d say we’re really getting in shape here at Saint Francis, and heart health is our focus.

www.sfms.org

Veteran’s

St. Mary’s

Frank Charlton, MD

Diana Nicoll, MD, PhD, MPA

This year has already been an exciting one at St. Mary’s. Much is going on, and as the new chief of staff I am encouraged by the renewed energy and spirit on our campus. During my thirty-plus year tenure here, there have been many changes and the outlook for 2011 is bright. In February we opened the CHW Cancer Center at St. Mary’s, offering patients comprehensive cancer care right here on our campus. We have a brand-new radiation therapy department as well as a new infusion unit. We thank the many physicians who played a vital role in bringing the new Center to life. Our cardiology department is known for having performed the first balloon angioplasty (PTCA) in the U.S. in 1978, during my internal medicine residency. Now we are one of the first U.S. cardiology units to offer percutaneous left atrial appendage ligation. Drs. Remo Morelli and Randall Lee treat qualified AFib patients at risk for stroke with this procedure. Dr. Jennifer van Warmerdam, a former San Francisco ortho resident at St. Mary’s, has returned to us to become the new medical director of the Total Joint Center. She recently completed the Harvard Adult Reconstruction Fellowship at Massachusetts General Hospital. St. Mary’s residents continue to excel, and several residents recently won awards at the American College of Physicians’ and the Society of Hospital Medicine’s annual meetings. We also are planning to open a dedicated Vein Center soon. This new Center is a collaborative effort between St. Mary’s and UCSF surgeons and will treat patients who suffer from varicose veins and other venous diseases. Despite these new developments, one thing never changes: At St. Mary’s we continue to maintain our tradition of providing our patients and the people of San Francisco with first-class, compassionate health care.

The San Francisco VA Medical Center (SFVAMC) has developed a unique partnership with City College of San Francisco (CCSF) to provide mental health and outreach services to veterans on campus. CCSF recently opened a newly modernized Veterans Resource Center (VRC), with the mission to serve students who are veterans and to support their transition from military life to civilian careers. San Francisco VAMC mental health and outreach staff are on site five days per week to provide mental health counseling services and enrollment support. The SFVAMC office is next to the veterans’ lounge, a place where veterans can relax with and provide support to one another. CCSF estimates there are nearly 1,000 veteran students currently enrolled. “While other VA’s have had an outreach presence at colleges and universities, none have made the commitment we have,” said Keith Armstrong, LCSW, director of Family Programs at the San Francisco VA Medical Center. “We believe it’s important to take our services to where the veterans are, and a college campus is an excellent place to start.” The creation of the VRC also received significant support from local organizations including the Carpenters Union Local 22 and the International Brotherhood of Electricians Local 6, who were among many organizations and services that donated their time, material, and labor to remodel the VRC. “This is a great opportunity to provide services to veterans in a new and innovative way, and many of our staff played an important role in building this collaboration,” said Armstrong. “We’re proud of the work we’re doing and the excellent partnership we have with City College. We’re looking forward to partnering with other colleges and universities in the future.”

March 2011 San Francisco Medicine 29


Health Policy Perspective Steve Heilig, MPH

Clearing Some Smoke Medical Cannabis, Fifteen Years Later

T

he SFMS was the only medical association to endorse California Proposition 215, which in 1996 effectively legalized physician-authorized use of cannabis for medical conditions. We took a bit of “heat” for that, with a common joke among colleagues from other areas being, “What are you guys smoking?” But as an epicenter of the HIV epidemic, and after consulting with local oncologists, HIV specialists, and others, as well as hearing directly from the federal “drug czar” who visited to urge us to oppose the proposition, the SFMS board strongly to endorse it. The anecdotal evidence and perceived low risk of use, coupled with the values of patient and physician privacy and choice, won the day. That was almost fifteen years ago. Research has continued into the medical use of cannabis, although not as rapidly as it might if the plant were not otherwise illegal. More physicians have become comfortable talking about it, even recommending it (some perhaps too comfortable, but more on that), and an entire industry has grown to provide access to anybody with a “cannabis card.” This latter development arose in great part due to the vague and open language of Prop. 215, and even more due to the profit motive. Last October, California Proposition 19 would have legalized “recreational” use of cannabis in the state, but it failed. It lost in heavy cannabis-growing counties at least in part due to fears of prices dropping, and elsewhere due to both reluctance to legalize another drug and growing skepticism about the shady “medical pot industry.” A minority of physicians have authorized the majority of users (on a recent trip to Los Angeles, I saw miniskirted young women on roller skates wearing signs offering “cheap and fast” medical authorization); cannabis “clubs” or dispensaries have sprung up all over, sometimes with less than savory atmospheres (the San Francisco Bay Guardian recently rated local clubs’ “thug factor”). Quality control is anarchic regarding use of pesticides and other additives that could harm patients; dubious “organic” claims are rampant. And the prices in the clubs, which logically should be much lower than street prices, often are the same or even higher. It all adds up to what I called, in a Proposition 19 postmortem published last October, “a shame, a scam, and a sham.” While that hyperbole did not make me popular with cannabis advocates, some of whom are old friends and colleagues, unfortunately it is not so exaggerated. The medical cannabis “movement” has been consumed by corrupt capitalists, and people are watching, including federal authorities who have never accepted state votes for legal medical use. I am far from the only one who fears a federal backlash.

30 San Francisco Medicine March 2011

In an extensive new collection of articles published as The Pot Book: Its Role in Medicine, Politics, Science, and Culture, edited by New York University psychiatrist Julie Holland, MD, Dr. Holland interviews renowned author and U.C. Berkeley professor Michael Pollan, whose writing on cannabis in his bestselling 2001 book The Botany of Desire is a classic work in this arena. What they agree on here is striking: Holland: So, what do you think of the California medical marijuana situation? Pollan: It’s a mixed bag. It’s wonderful to see it normalized and regularized for a lot of people. I know many people who have their couple of plants, and it’s not a big deal. It gives you a taste of what a sane drug policy might look like. On the other hand, there is incredible abuse. A great number of people are pretending to be medical marijuana growers or sellers when they’re not. And they’re abusing the system in a way that I think may lead to the collapse of this whole regime, and the blame will be on them. It won’t be on the DEA. Holland: I totally agree. I hope that California understands the rest of the country is watching them to see how they do. This is a big experiment, and they’re bushwhacking and leading the way, and I really don’t want them to screw up. Pollan: There’s so much money in this, and the temptation is so great. I just worry that they’re going to ruin this experiment, and California’s failure will be used to keep it from happening anywhere else. ***** Unfortunately, I agree with this assessment and also fear the federal risk these otherwise largely “pro-cannabis” authors worry about. We don’t even have to get into what the percentage of purported medical use truly is, versus how much cannabis is sold under medical cover. But what might be done? The California Medical Association, spurred by a policy proposal supported by the SFMS in the fall, has just appointed a task force to consider that question. SFMS president George Fouras, MD; leading researcher Donald Abrams, MD; and San Francisco Kaiser Chief of Addiction Medicine David Pating, MD, were nominated by us and appointed. This author is a “consultant.” Can further liberalization of laws and perhaps taxation be accomplished? How to implement more evidence-based medical guidelines and systems? Do other states such as New Jersey, which has a much more restrictive law (some say too restrictive, but the medical criteria are fairly in line with those in a 1999 National Academy of Sciences review), set a good precedent? We will see, and do our best. As noted above, many people are watching, and perhaps hoping that some of us in California might be able to clear the smoke. www.sfms.org


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SFMS 2011 Annual Dinner Photos The 2011 San Francisco Medical Society annual dinner was held on January 27, 2011, at the Concordia-Aurgonaut Club in San Francisco. George Fouras, MD, was installed as the 2011 president of the SFMS. The evening began with a cocktail hour where SFMS members mingled while live music played. As dinner began so did the change of command ceremonies. After Dr. Fouras was officially installed as the SFMS president he gave out several awards and recognitions and introduced the keynote speakers. This year Dr. Lenore Terr and Mia and Sharon Behrens delivered a speech detailing their first hand experiences with the foster care system. Dr. Fouras is a child psychiatrist specializing in adolescents in the foster care system.

SFMS 2011 Officers: (Left to right) Peter Curran, MD, President-Elect; Lawrence Cheung, MD, Secretary; Gordon Fung, MD, PhD, Editor; George Fouras, MD, President; Michael Rokeach, MD, Immediate-Past President; Shannon Udovic-Constant, MD, Treasurer

Keynote Speakers Mia and Sharon Behrens with SFMS President George Fouras, MD

32 San Francisco Medicine March 2011

Keynote Speaker Dr. Lenore Terr and her Husband, Abba Terr www.sfms.org


Left: Senator Mark Leno and Shannon Udovic Constant, MD Below: SFMS Board Members Paul Abramson, MD, Jeniffer Do, MD, and Peter Curran, MD

Journalist Dave Perlman starts a cane battle with longtime friend and Perlman Award for Excellence in Journalism Recipient, Al Jonsen, PhD

Roland and Jaqueline Barakett, MD www.sfms.org

Sheila Rokeach and John Brown, MD

Marc and Sisi Rothman, MD, with Richard Wolitz, MD March 2011 San Francisco Medicine 33


Above: Raymond Munn with George Fouras, MD

Above: Immediate-Past President Michael Rokeach, MD, with 2011 President George Fouras, MD Left: Dr. Rokeach receives thank you gift from Dr. Fouras for his service

Right: Fifty Year Member Roland Barakett, MD, with Dr. Fouras Below: Dr. Fouras thanks keynote speakers “The Healing Team” for their moving presentation

Congratulations to Albert Jonsen, PhD, (below, left) for winning the Perlman Award for Excellence in Journalism for his contributions to San Francisco Medicine! This year David Perlman (below, right) was also in attendance to present the award.

Our thanks to the following corporate sponsors who helped make the 2011 SFMS Annual Dinner possible: Brown & Toland Physicians California Pacific Medical Center Chinese Hospital and Chinese Hospital Medical Staff Hill Physicians Medical Group Kaiser Permanente San Francisco Marsh Medical Insurance Exchange of California Saint Francis Memorial Hospital St. Mary’s Medical Center

Special thanks to Saint Francis Memorial Hospital for providing meeting space and parking for the 2011 SFMS board meetings.

34 San Francisco Medicine March 2011

www.sfms.org


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March 2011