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Lee Kirksey, MD  
Male
Cleveland , OH

Specialties: Peripheral Arterial Disease, PAD

Interests: vascular, specialist, treatment options
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Tim Russert's unfortunate death underscores important Fact

Jul 03, 2008 - 12 comments
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tim russert

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Heart Disease

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heart scan

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Stroke

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heart specialist

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Cardiac catheterization

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specialist

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The untimely and unfortunate death of NBC Meet The Press moderator and political analyst revealed an important fact.
Our ability to predict fatal heart attacks is at best an "evolving science". While the US is widely believed to be at the forefront of technology for developed countries, much room for improvement exists.

The problem is that even the current gold standard of cardiac catheterization falls short of identifying everyone who subsequently progresses to have a heart attack. Thats because of plaque rupture. Plaques, caused by cholesterol buildup, may lie dormant and not cause a problem until the previously stable plaque becomes unstable and ruptures.

What causes a plaque to become unstable is not completely understood. Furthermore, our ability to predict and identify the unstable plaques are limited. Take for instance, angiography or cardiac cath which demonstrates the degree of narrowing within the coronary artery. Unfortunately, this degree of narrowing does not necessarily correlate with the chance of plaque rupture. In fact, a mild narrowing can rupture and cause immediate inadequacy of the oxygen to the heart muscle.

Take a look at the NY times article below. It really provides the sobering picture of a man who battled with high blood pressure and cholesterol elevation. Despite having apparently the best physicians and medicine that we can hope to provide, he succumbed to heart disease.

Science still has a way to go to identify the vulnerable plaque. There are ways of predicting unstable plaque in the carotid vessel which causes stroke. Perhaps someday, this technology will be improved and applied to the heart which is more difficult to image deep within the chest an in motion

For right now, I think the most reliable method of individual prevention is on the front end with what you eat, how you exercise, eliminating stress and other behavioral strategies to decrease your risk of getting heart disease

The article also raises the question of the role of the heart scan, CT angiogram or calcium scoring. Ill talk about this topic again in a later blog



To learn more about Russert's pre existing medical condition including autopsy findings, click and paste
http://www.nytimes.com/2008/06/17/health/17russert.html?ex=1371873600&en=976afc1dc9246bb0&ei=5124&partner=permalink&exprod=permalink

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by PlateletGal, Jul 03, 2008

Thank you for the link, Dr. Kirksey.

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by Momto3, Jul 04, 2008
Thanks!!  I'll be sure to check that out.

When you have a spare few minutes (if you ever do...lol), can you comment or share with our members the differences in the types of cholesterol testing.  I've just learned about a detailed lipid panel (the one that shows the breakdown or smaller particles) and how it can be used for cholesterol management.  

I'm not very familiar with the tests, but it is my understanding that doctors are unable to determine a patient's actual LDL, but rather it is deduced on the basis of the other scores (TC and HDL).  However, there are tests that can determine the makeup of the LDL (in very minute particles).  If I understood correctly, a person with a good TC, can still have very small particles that are more prone to attaching to the arterial walls.  I hope that makes sense....

As always, thanks so much for all of your work to help the members of the MedHelp forums!!

connie

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by newgirl2708, Jul 04, 2008
Thank you Dr. Kirskey. I always appriciate your articles and input. You have a way of making it easy for us 'non' Dr's. to understand our bodies. ;)
I look forward to your future blogs.
Sincerly,
Newgirl

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by keyzersoce, Jul 04, 2008
I believe momto3 is referring to the lipoprotein subfraction test, which measure the size of the "bad" cholesterol. The theory is, that even if your cholesterol count is good, your "bad" cholesterol, or ldl, may be really small and dense and able to slip more easily into your arteries and cause a heart attack.

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by mareke, Jul 04, 2008
An interesting hypothetical posthumous interview of Tim Russert can be found at the following address:

http://www.drmcdougall.com:80/misc/2008nl/jun/russert.htm

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by Momto3, Jul 04, 2008
Thank keyzersoce!!  That's it!!  I'd really like to know more about those tests....so interesting.

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by Texheart, Jul 04, 2008
Hi Momto3.  I think we talked 3-4 years ago.  Didn't you go to Cleveland Clinic?  I am picking up bits and pieces on Medhelp again.  You mentioned LVOT and Mitral Valve.  I have LVOT due to SAM with only a mild Mitral valve problem but I do have a loud murmer that they hear in the upper part of the chest.  I have paps coming out of the kazoob.  Drives me nutts.  I have 4 heart stents and one of the stents (Taxus) had closed up 50-60% and 2 months ago the doctor did a ballooning to open this up.  Aortic valve is also mildly-moderately stenosed.  I am so tired of this mess.  It is good to see familiar names again.

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by Texheart, Jul 04, 2008
Oh...there was a name that was helpful to so many on Medhelp.  he was a young man in his late twenties and I cannot remember his name. He was on for years...Now, I do not find him anywhere.  I hope nothing happened to him. He lived in Pennsylvania.

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by Momto3, Jul 04, 2008
Hi Texheart!!

Sent you a private message.....



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by toby45, Jul 06, 2008
Dr. Kirksey,

Thanks for posting the article, for it brings to light the wide spectrum of opinion on what should be fairly clear cut. I personally had an Acute MI resulting from a 100% blockage of the LAD, and lucky to survive and talk about it. I'm 45 yo, very fit, weight and height proportionate (5'10", 160 lbs, w/no family history of cardiac/BP probs - up 3 generations to my great grand parents and their brothers and sisters)

For 3 years, I was in the "danger zone" with normal TC (165), elevated Tri's (225-260), high LDL (70's) and low HDL (started at 45 dropping over 3 years to 25 at the time of the MI) - and no one did anything about it...I was put on NO meds or monitored whatsoever. Nor was I told I was in a high risk category.

What is frustrating is that the so called "conservative" opinions on invasive procedures are also underpinned by the pressure of Ins. companies hand-cuffing cardiologists from performing them. I was for instance given Stress test after stress test, and came out with flying colors. Stress Tests are cheap, 64 slice CCTA's are not!

Stress Tests are well known to be inaccurate in 50% of the cases w/single anterior blockages and increase to 80% accuracy IF there are multiple anterior blockages. This is not meteorology - this is supposed to be medical science. There are lives at stake.

But the dirty little secret is that the imperatives are financial...not medical. Sadly no cardio will ever go on record to say this. Insurance companies know that some will be missed and patients will die or as in my case they will have to pony up $250K to remedy the situation. But for the majority of patients, their coronary time bomb has a longer fuse - the stats prove it and so does their risk analysis to determine opportunity costs.

Instead of branding a doctor as being conservative by NOT doing an invasive procedure, we should be labeling a cardio as a risk taker if he DOES NOT follow through if any of the parameters are out for more than 6 mts.

Tim Russert did have access to the best Cardios that money could buy, but was unable to find a "conservative" cardiologist who should have gone in and  looked for himself.

For the rest of us, I have learned "offline" from my cardio's that I must learn to cry "heart attack" at least once a year so I'm put through the full battery of tests that include nuke mri's and  CCTA's!

Keen on getting your feedback doc!
Toby

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by JSGeare, Jul 06, 2008
Thak you, Toby: And another thing:

While we're munching one of those delightful Philly Cheese steak subs around the corner on Market Street, Doc, tell me exactly what is the data that supports the contention of "front end" prevention? Was there a large population of lazy, cheese eating, martini drinking, TV-watching, couch potatoes that was compared to a similar size and age group of fiber-consuming gym rats with no stress, or what? If you're not very good at predicting when my plaque will calve off a hunk of Elmer's Glue-all to knock out the lights in my chandelier, by actually LOOKING at the stuff, then how do figure that the food intake and exercise is a predictor? I mean, really, HOW?

It makes sense to me, in a basic kind of way, that "you are what you eat," but I've seen too many cases of foods being bad for you, then OK, then good for you to really trust what anyone says about this.

Now here's an intellectual stumbling block for me. You said: "Plaques, caused by cholesterol buildup, may lie dormant and not cause a problem until the previously stable plaque becomes unstable and ruptures. What causes a plaque to become unstable is not completely understood. Furthermore, our ability to predict and identify the unstable plaques are limited."

OK, I'll buy that and I appreciate your honesty. So, how is it then, that you then say: "There are ways of predicting unstable plaque in the carotid vessel which causes stroke. Perhaps someday, this technology will be improved and applied to the heart which is more difficult to image deep within the chest an in motion." So which is it? If you don't completely understand it" then how much DO you understand it? 80%? 50%? What? And then again, if you don't understand it, what are the "...ways of predicting unstable plaque in the carotid vessel"? I really want to know.

After all is done and said, a lot of the basis of predicting cardio-related events is going to be statistical, I should think, same as any other guesstimate of what's going to hurt or kill us. I have no problem with that, assuming the test methods, study populations and variables have all been properly accounted for. But there are statistics -and the probabilities which flow from them- and then there are the individuals, like Toby, who ultimately pay the price -one way or the other- for someone's not always flawless interpretation of the stats. The only thing I've ever been able to do when confronted with this situation is to look the doc straight in the face and say: "Suppose you were me, or suppose I was your spouse or your kid. Knowing all you know -what would YOU do? Don't put me in the shoes of the thousands of statistics walking around (or rotting underground) out there. Put yourself in MY shoes. Now, what?

Not that you haven't actually HAD that situation. You very well may BE in medicine because of it. All I'm saying is, never forget it. Thank you for your service.

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by sadie1246, Jul 07, 2008
You know I don't agree with either of you, I am sixty one going on eighty one and I have a 1298 count on the triglycerides and 450 on the cholesterol.  my lipase is 752 and I have no immune system.  I have heart disease, MD and Ms and I tired as hell of doctors tellling me it is my fault.  I am a size six and don't look bad, matter of fact everyone tells me I look great but the doctors tell me I could die at any time.  

My diet is not that bad I do go on a food binge once in awhile as I am on steroids and numerous other drugs (prescribed of course).  I had a cardiac cath and the damn doctor almost killed me i had a pseudo anurism and my blood pressure was almost nill.  i went by squad to the hospital and he sent me back home telling my husband and son I was crazy, my other doctor among many sent me to his friend by squad again and he immediately operated and saved my life, I couldn't even be put to sleep my potassium was 2.

What about that???????????????????????????????????????????

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