Heartfelt with Dr Melissa Walton-Shirley

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My Valentine to President Clinton: Niacin and a three-hour glucose-tolerance test

Feb 14, 2010 21:52 EST


After Super Bowl Sunday there are always lots of armchair quarterbacks. However, on theheart.org forum, they weren't giving tips on how the Saints could have secured their win more easily. Comments have come fast and furious in an effort to help former President Clinton achieve a normal life expectancy. Some have been critical of the steps that led to his circumflex-artery stenting, yet others have wondered aloud if he's been given every advantage possible from current lipidology and medical-management strategies. I questioned whether or not glucose intolerance might be the secret driving force behind his disease progression. Ultimately, I wonder if our unsolicited advice should even be simpler.

The answer to our former president's healthcare woes is likely rooted in a statement he made in the first chapter of his book My Life. He spoke about the memory of his father, who drowned in a single-vehicle rollover just before he was born. He said it "infused" him "at a younger age than most" with "a sense of mortality. The knowledge that I too could die young drove me both to try to drain the most out of every moment of life and to get on with the next big challenge. Even when I wasn't sure where I was going, I was always in a hurry."

Although there's really nothing wrong with grabbing hold of life with both hands, it can be a problem if there's no time for proper exercise, appropriate diet, regular follow-up, and compliance with medications. Patients often ask me post-CABG if they can continue to work. I always answer that "work is good for all of us, but it's the schedule that can be a killer." I don't want any patient to work long hours to the exclusion of a lifestyle that allows for healthy choices. I strongly recommend the avoidance of night-shift work. I insist on regular exercise at least five days per week. I direct healthy food choices--ie, the Mediterranean diet and plenty of water for normal-EF, normal-GFR individuals. I recommend lower sodium intake and avoidance of trans fats. I direct many of our patients to a secondary-prevention clinic where Berkeley panels often unearth high insulin levels, abnormal HDL sub fractions, and the need for the addition of fish oil and niacin.

It's no secret that former President Clinton continues to burn the candle at both ends, often crisscrossing the globe. He seems to participate in every opportunity imaginable to contribute something to the world. His activities range from hostage negotiation to the oversight of rebuilding earthquake-ravaged Haiti. All of these missions are admirable and quite frankly, exactly what make Bill Clinton, well, Bill Clinton. However, if he's busy to the point that he can't get on his treadmill regularly, get the proper amount of sleep, stay on schedule with meds, make his stress appointments, or get his lipid profiles checked, he's working for the good of the world but to his own detriment. I must insist that he follow his own advice. To borrow a phrase from his 1993 message to the joint sessions of Congress on healthcare reform, he made the point that "we have to change our ways if we really ever want to be healthy." Although he was referring mostly to our US healthcare system in general, there would be no better advice to give someone who has been diagnosed with coronary artery disease. In that speech, he did hint at personal responsibility, and although he may be making a valiant effort, now would be a good time to examine all the issues surrounding his latest episode of unstable angina.

President Clinton, my wish for you is to "be healthy," and since it's February, Heart month, here's my Valentine to you: It's a heart-shaped box containing a three-hour glucose-tolerance test, a bottle of niacin, some fish-oil capsules, fresh nitroglycerin, eight hours of sleep per day, an hour of exercise five days per week, the Mediterranean diet, a quiet dinner with your wife, and a nice long phone call from Chelsea. I'll add a six-month follow-up with your cardiologist, including a lipid profile, BP check, annual echo, and stress cine. Continue on with your statin, your aspirin, your beta blocker, and your brand-new clopidogrel (or prasugrel?) prescription. By all means, carry on with your quest for a better world, but remember, your family and your admirers will always think it will be a better world with you in it.

See also:

President Bill Clinton gets two stents at Columbia





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Your comments
My Valentine to President Clinton: Niacin and a three-hour glucose-tolerance test
# 1 of 17
February 16, 2010 03:09 (EST)
Mehrdad Saririan, MD

According to the guidelines and appropriateness criteria, there is no role for annual echo and stress cine if the patient is well and without symptoms. This is wasteful testing, not to mention the radiation exposure if nuclear stress testing in ordered. And it shouldn't matter that this patient's name happens to be Bill Clinton.

I agree with everything else in your "heart shaped box", for what it's worth. :-)
# 2 of 17
February 16, 2010 07:51 (EST)
melissa

Mehrdad,

I think those recommendations must be individualized.  For instance, a patient with normal EF, no sigificant valvular pathology and good distal targets can probably do just as well with periodic followup, but lower EF individuals with significant valvular issues and poor distal targets might get into trouble that we could avoid by modifying their medication regimen.  Thanks for posting!!!!

Melissa

# 3 of 17
February 17, 2010 10:54 (EST)
Mari

Melissa

Has anybody told you lately not only are you obviously a great cardiologist, but your writing skills are equally impressive.  Really enjoyed reading this.  Funny and smart.

tx
# 4 of 17
February 17, 2010 08:08 (EST)
Sergio Paz

Dear Melissa: a quiet dinner with the Secretary of State????

I think that primary angio keeps you out of the News.

Sorry! I dont want to be offensive.

Sincerely,Dr Paz

 
# 5 of 17
February 18, 2010 12:18 (EST)
Larry Phillips

Why a 3-hour instead of a 2-hour glucose tolerance test? 

Only zero and 2-hour samples are needed for most diagnoses.  The 1-hour value is useful for identification of future risk, but doesn't contribute to present diagnosis, and the 3-hour value need only be include if gestational diabetes is a consideration.
# 6 of 17
February 18, 2010 07:31 (EST)
Ron
Dr Gifford-Jones MD a regular medical columnist has approched this subject with advice to Mr Clinton to use 10,000 mg of Vit C and 6,000 mg of lisine can open up the clogged arteries and alow one to reduce the use of statin drugs.  His site is www.mydoctor.ca/gifford-jones. 
Syndicated Medical Journalist Published by 60 Canadian newspapers, 80 in the United States and the Epoch Times which is published in several countries.
I am interested in comments of his advice as I am recommended for Aortic Valve replacement surgury and triple bypass surgury in the next couple of months.
Thanks
# 7 of 17
February 18, 2010 09:06 (EST)
Melissa

Sergio,

I think a little R and R with your spouse (provided you like them!!!) is just the most lovely idea and probably decreases arterial stiffness!!! HA! 

Larry, 

I'll got for a two hour challenge.  I usually do a nonfasting 2 hour challenge in the hospital setting, but it's out of habit that I order a 3 hour out patient GTT.  Gabriel Stegg got me to thinking about that after he gave a most fabulous metabolic syndrome lecture back when Ramonibant was getting ready to go to market.  It completely changed by practice life by adding the GTT to my daily orders at the hospital.  

 

Mari,

I've had a really tough day and reading your post made me smile.  I can't thank you enough!Hope you have a great weekend! Glad you enjoyed the piece!

Melissa

# 8 of 17
February 19, 2010 09:54 (EST)
Melissa

Ron,

We cannot advise patients individually on the forum but I will make some general observations from your post.  Vit C has thus far been "a bust" for mortality reducing.  I've seen many trials now where the death rates were the same for those taking vit C and those on placebo.  As for lisine, I have no earthly idea but I'd never forsake the proven mortality reduction for some statins in exchange for a "whim" that something in theory should work.  As for your upcoming surgery, I'll defer that to you and your physician for decision making.  I can assure you, however, that to my knowledge, there have been no claims that "vitamins and supplements" can repair valvular heart disease. If your practitioner /friend has suggested that, I'd walk, not run......to the nearest exit.  

Good luck.  I wish you the best of health for the coming year.

Melissa

# 9 of 17
February 23, 2010 03:53 (EST)
D.G. Hackam
Great blog posting, Melissa. I agree with all you've written. I would also suggest screening his Lp(a), TSH, B12, and antiphospholipid antibodies (lupus anticoagulant) - maybe he is prothrombotic?  Most of all, I would urge q6-12 month vascular plaque burden scanning by the modality of your choice. After that, anything that it takes to sizably push his plaque into regression. This might even include a DHPCCB/ACEi in light of ACCOMPLISH.
# 10 of 17
February 23, 2010 07:02 (EST)
golftee

Great suggestions Dan, though I'll bet his issue is more with glucose intolerance than Lupus anticoagulant, but if money were no option, I'd look at every possibility to try to keep myself from progressing my disease.  I thought about the ACE, but I'm still trying to get enthusiastic about normal EF ACE therapy for non hypertensives with CAD.  (I don't really know his EF, though!)

Melissa

# 11 of 17
February 24, 2010 09:38 (EST)
D.G. Hackam MD PhD
I agree with you Melissa. It is hard for me to get worked up about ACEi in normotensive patients, but how normotensive do you think he is with all his travel commitments, speaking engagements, and high profile work in the third world and on the home front? I would love a 24h ambulatory BP monitor for a week. Masked hypertension occurs in 30% of office visits where the BP is normal in clinic and elevated out of clinic. In that case, I think ACE+CCB would be a great option, given its cardioprotective benefits in ASCOT-BPLA, ACCOMPLISH, and for the ACEi in EUROPA (normal EF) and HOPE (normal EF).
# 12 of 17
February 24, 2010 11:05 (EST)
Melissa

Dan,

I think the balance between the benefits of supporting  data and the risks and impact of noncompliance of  polypharmacy are at the heart of every decision on this very topic.  Just the fact that historically, ACE/CCB combination was the last of the  compounds to get the green stamp for cardioprotection after a long line of aspirin, statin,niacin,  beta blockers......it's tough to walk into a patient's room and say , I've got one more thing I'd like to prescribe.  They always look at me and say "yea, right and that's what you said 2 years ago". But, we have no other choice than to weigh all of this information, size it up for our patient and try to make the best fit!

Appreciate the discussion as always.

Melissa 

# 13 of 17
February 24, 2010 11:18 (EST)
Dan

   Melissa, I agree with you.  

   Only his cardiologists really know what therapies are most important. We select those from the evidence-based arsenal (not supplements!) on the basis of individual patient characteristics including EF, history (ACS vs chronic stable angina), and BP/HR.  But I have to say, once a patient is already taking between 3-6 medications a day, adding another one or two is not likely going to make them stop all of them.  The hardest jump is going from zero to some meds.  Going from some meds to one or two more is not so bad for compliance.  I try to stick with once daily medications to reduce pill burden and educate about the benefits of each type, as well as the most likely potential side effects. Have a picture of plaque regressing over time really helps to motivate my patients to stay on their pills. In that way, we are not just treating risk factors but disease biology itself. That might have saved the need for a couple of stents in this case (I'll bet his disease was silently and insidiously progressing over time, like so many cases of atherosclerosis).
# 14 of 17
March 12, 2010 12:48 (EST)
DR SS Iyengar

Dear Dr Melissa,

Well written!

Aren't ACE-inhibitors part of your post-CABG prescriptions?

You think meditation will help, and does he have time for that?

Regards

Dr Iyengar
# 15 of 17
March 12, 2010 07:15 (EST)
Melissa

Dr. Iyengar,

thanks for reading our heartfelt blog series! Glad you enjoyed it.  I have to confess that I don't regularly write for ACE post CABG if they are normotensive with a normal EF.  It's tough enough in our economy to get folks to take an aspirin, a statin, a low dose BB, carry nitro, exercise and follow the mediterranean diet. I'm still waiting to be convinced on that one. 

I'm all for "meditation", but I'm not certain about the definition/duration in order for it to work.  I doubt he takes time, but I think lots of us meditate though we don't call it that.  I awaken sometimes at 4 am and think, pray, plan, even though I think I'm sleeping, it seems I have answers when I get out of the bed.....hm....is that meditation?

Melissa

# 16 of 17
August 21, 2010 02:39 (EDT)
collin

I agree with you Melissa. But why do you gofor a three hour test, mostly two hour glucose tolerance test is sufficient.  I really dont think vitamins and supplements can repair the valvular heart. I think Yoga can help.

 Thanks

Collin paul

Isagenix

 

 

 
# 17 of 17
August 22, 2010 05:26 (EDT)
Melissa

Agree with you Collin....truly I order an in- patient 2 hour test and and out- patient 3 hour test......why?  That's the way the test is offered at our hospital and we have a check box for test ordering.

simple but true.

 As for Yoga......I try  to do it on occasion and I find it difficult because my flexibility is limited........ but maybe with more  practice!

Melissa

 

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About Dr Melissa Walton-Shirley
Dr Walton-Shirley performs invasive cardiology, nuclear cardiology, and stress echocardiography in a private practice in Glasgow, KY.

Her chief medical interests are CHF/hypertrophic obstructive cardiomyopathy and the promotion of primary PCI for acute MI. Recently she played a significant role in helping to launch an ambitious pilot study of primary PCI in Kentucky, the Kentucky Primary Angioplasty Pilot Project. She has also participated in the TIMI 19, Duke-HF, NRMI, and CRUSADE trials and is proud to have been an advocate of the first smoke-free initiative in Kentucky (2011). She champions a smoke-free America.

Dr Walton-Shirley received her undergraduate degree at the University of Kentucky and went to medical school and did her residency and fellowship at the University of Louisville. She is married with two daughters. Her interests include singing, writing poetry and songs, fitness, and, of course, theheart.org.