Dr. Walton-Shirley,

Well written; almost as if I were there.

I have comments about two issues:

(1) I would have been in the one-third group voting to add a another agent for the goals of greater efficacy, cost efficiency and safety.

Like all treatment tools, the statins, excellent though their track record is, exhibit decreasing efficacy and increasing problems the more they are pushed and their therapeutic index varies rather widely depending on the individual.

Given the complexity of the issues, relying on only one physiologic tool, the statins, is foolish for most. In my limited 32 years of experience within the medical profession, it remains my view that the medical establishment continues to suffer from focusing too much on treating signs and symptoms of advanced disease. I believe it is better to promote both excellence of health and life productivity.

While being an interventionist, one who has long worked to reduce/eliminate a role for invasive interventions, I have personally taken "high dose" (in the eyes of many) statins since 1990 and have aggressively prescribed them for most patients I have seen since 1990. Yet statins only address one of multiple pathways of our destroying our body functions via accumulation of monocyte/macrophage WBCs in the walls of our arteries. While this behavior, along with eventual episodical narrowing of arterial lumens with internal clot patches over plaque ruptures, is a common (i.e. normal) human behavior, it is without any track record of being healthy, promoting quality/length of life or improving productivity.

Because of these issues, I quit performing or promoting stress tests (by any and all technologies, including rubidium-82 PET) in 1995. While third parities continue to pay for such "services", I believe they are extremely costly and very inefficient.

I believe that it is preferable to (a) promote the public to spend their money on strategies that work to protect their health as opposed to (b) evaluate whether their individual health has finally become bad enough to consider doing something effective (changing physiology) or even more expensive and dangerous (invasive interventional tests and treatments).

Trials, such as Jupiter (the results of which I was not surprised by) provide limited guidelines about relative group efficacy and minimal standards. Granted though, such trials are helpful in providing clues and confirming guesses as to wisdom.

(2) Regarding carotid IMT, I have done these for a several years. However, delegating them to be done by technicians or physicians not directly monitored by a physician focused on high degrees of accuracy and reproducibility is a waste and fraught with problems. The increasing pressure we all feel for earning money in less time with more bureaucratic obstacles (supposedly in the name of quality), combined with ever increasing overhead costs, all powerfully work to degrade quality of care for those we see.

However, carotid IMT also offers a great opportunity for tracking actual disease burden, at one location, well before any significant stenosis, and to more carefully individualize one’s approach to the actual status of each individual patient. While I do perform IMT measurements at some pseudo-standardized locations, the real key to IMT is to focus on the location(s) at which the individual patient has the greatest IMT measurements across obvious plaque. Next also include length and circumference of the visualized plaque. Next include printed DICOM images of the plaques (thickness, length and circumferential view) within the written echo report so that the patient, and anyone they show their report to, can see the "hidden" disease.

Especially in the bulb area, carotid plaques are typically quite visible, quantifiable and trackable decade(s) before significant stenosis, much less bruits (essentially always very advanced disease) and/or stokes are clinically detectable.

When people can (a) see a portion of their own disease, (b) understand that help is available and that (c) someone is devoting time and expertise to helping them (a) avoid ever becoming symptomatic, (b) be sent for invasive intervention in the future or (c) become debilitated, I have found carotid IMT to be a great patient motivator and ally inducer for symptomatic disease prevention.

Again, I think this is a better way to spend patient’s money than on advanced disease partial (too little too late) treatment such as carotid surgery, stenting and/or hospitalization.

Conclusions, comments:

Unfortunately choices, such as I have made, markedly pay less well. We are commonly not recognized or paid well for preventing advanced symptomatic disease. Now that is really inefficient and sad. Nonetheless, it is the job I have taken on and work to excel at performing.

I have always given patients copies of all their labs, reports, angiographic images, echo images, etc.; i.e. they see that same data, as much as possible, that I see. They are their own primary decision maker (physician if you will), not us M.D.’s. Thus they should be have the quantitative data in their own hands and maintain their own records.

Those in the medical profession, by long protecting turf and assuming our work is too complex (or not worth the effort) to explain to the public, have also failed to very publicly track and display both the complexity and the results of our efforts. Because the public has difficulty in both (a) seeing the specifics of what we do from every angle imaginable and (b) in helping us improve, their fears and paranoia often drive criticism and attacks, often played upon and promoted by many commercial and political interests.

Approaches which empower patients, though atypical, typically seem to shift patient attitudes; they usually choose to become allies and friends.

Milton Alvis, http://maps.google.com/maps?z=4&q=Milton+Alvis