The heart risk factor no one knows about

Most readers of these columns, I assume, are aware of the relation between elevated cholesterol and coronary heart disease, and of the benefit of reducing high cholesterol with diet and medication. The statins have saved many lives, and newer agents have come to market for those who cannot take statins.

I do hope you are not among the third of Americans who do not know their cholesterol.

What I would like to discuss here is another heart risk factor, which has been prominently discussed recently in the cardiology community but has not received much attention more widely. This is lipoprotein(a), commonly referred to as Lp(a) and verbalized as “L p little a.”

Lp(a) is an LDL (low density lipoprotein) molecule with an apo(a) protein attached. It can be trapped in the arterial wall, causing atherosclerosis (“hardening of the arteries”) and it increases clotting.

We know a lot about Lp(a). It is genetically-determined; there is very little effect of diet on levels. This means that you don’t need to measure it on a regular basis – if it is high, it will stay high, and if it is low, it will stay low.

It is a major factor in causing coronary disease, independent of standard cholesterol values.

As of now, there are no medications available to lower it, but new medicines are on the horizon.

If we cannot treat it, you may ask, why measure it?

First, if it is elevated, your doctor can put you on cholesterol-lowering medication even if your standard cholesterol levels are normal and would not be treated. No one risk factor works alone, and even if we cannot yet lower a high Lp(a), we can still reduce your risk of heart attack by treating other risk factors.

Second, there is recent evidence that low-dose daily aspirin, which is now considered not appropriate for the general population, will cut in half the heart attack and stroke risk in people with Lp(a) over 50.

So, at your next visit, ask your doctor if they have ever measured your Lp(a), and request they do so if it has never been done.

Knowledge is power.


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Private Equity in Health Care

Those of you in the metro Boston news market have been regaled with the saga of the failing Stewart Health Care System, owner of nine hospitals in eastern Massachusetts. One eye-catching story described the $40 million yacht purchased by Stewart’s CEO, Dr. Ralph de la Torre, while Stewart hospitals were having equipment repossessed because of failure to pay their bills.

While a 190-foot yacht catches attention, it is only a symptom of a deeper problem.

Private equity (PE) firms’ business model is to buy companies as cheaply as possible, pull as much cash as they can from the company and then either resell it or declare bankruptcy. To be able to sell the business, they have to jack up profits by cutting costs and/or raising prices.

Private equity investment in healthcare is a recent phenomenon but one which is rapidly growing. These firms focus on specialties where lucrative procedures can be done and/or where patients have little choice. Many emergency medicine groups, pathologists and anesthesiologists now work for entities controlled by private equity. These groups were responsible for most of the “surprise” out-of-network bills that made headlines in the last few years. Knowing that patients rarely if ever have the option to select a physician in these fields, they would pull out of insurance contracts and then bill whatever they wanted.

Quality is secondary to the acquiring PE firm; profits come first. They can increase revenue by raising fees and/or encouraging their employed physicians to do as many well-paid procedures (such as catheterizations and endoscopies) as can be justified, even if not all are truly needed. They can cut costs by skimping on equipment and supplies that are not “revenue-producing,” even if they improve quality care. They can also substitute less-qualified, lower-paid personnel, such as aides in place of nurses.

Steward offers a textbook example. Cerberus Capital bought the troubled Massachusetts-based Caritas Christi hospital system, promising to turn it around. Soon after, they sold the land and buildings of its own hospitals to a real estate trust, pulling out $1.2 billion and saddling the hospitals with hundreds of millions in annual rent. That transaction allowed Cerberus to quadruple its investment and to pay its investors a $100 million dividend. They bought hospitals around the country, including Texas, Florida and Ohio. Many of these have since been closed, doubtless after the PE investors had pulled as much money out as possible.

So, Stewart’s CEO has a very expensive yacht and communities around the country are dreading the closure of what is often their only nearby hospital.

Tell your state legislators that private equity has no place in health care, certainly not without very strict guidelines and oversight.





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Do you want to live to be 100?

In 1521 Ponce de Leon arrived in Florida in search of the mythical fountain of youth; those who drank from it or bathed in it were said to be returned to their youth. Some 500 years later, the New York Times ran a lengthy article on a longevity guru whose disciples wear T-shirts emblazoned Don’t Die and who buy supposedly rejuvenating vitamins and supplements from him by the bushel.

What is real in our search for longevity? I assume that most of you, like me, are interested in healthy longevity – I would rather be well and active into my 90’s than live into my 100’s in a frail dependent state.

The maximum lifespan of any species, including our own, seems to be fixed. The longest documented human lifespan was 122 years, and the next oldest were 119. About 120 would seem to be as much as we can hope for.

In the famous Blue Zones, 5 scattered sites in Italy, Japan, Greece, Costa Rica and California, many people live healthy and active well into their 90’s, and much of what we know about healthy longevity came first from studying these populations, backed up by many other studies.

While heredity clearly plays a role – the best single predictor of a long life is having long-lived parents - only some 30% of your chance for a long healthy life comes from choosing the right parents. Much is under our control.

Diet is a critical factor. If longevity is very important to you, prepare to be hungry. There is incontrovertible evidence in mice and considerable data in humans that calorie restriction lengthens lifespan.

What you eat is important. Contributing to a long and healthy life is eating a plant-based diet, heavy in fruits and vegetables with little or no red meat. Get your protein from fish and nuts, and use olive oil in place of butter. This type of diet leads to less heart disease and less cancer.

Move. Regular exercise both leads to less premature death and better quality of life. While any amount of exercise is much better than none, more is better. Even walking 30 minutes a day will pay dividends, but exercising more and longer is even better. Do not forget strength. Aerobic exercise will do the most to extend life, but strength training prevents falls and injuries and strengthens the bones.

Don’t smoke. If you do, quitting now will do more to improve your health than anything else you can do.

Minimize your alcohol intake. There is soft evidence that moderate drinking may reduce heart disease, but it increases a variety of other disorders. One drink a day is probably a wash, but more is clearly bad.

Get enough sleep. Sleep is when we rejuvenate, and try for at least 8 hours a night.

Socialize. Spending time with friends and family and participating in group activities is very common in the Blue Zones and has been shown to be associated with less depression and better physical health.

See your doctor once in a while. Many chronic diseases that shorten life, including hypertension, high cholesterol and diabetes, have simple treatments that prevent premature death and worse diseases. A few preventive measures such as colonoscopy and immunizations have good data supporting their use.

Pills? Not many. As I wrote a while back, there is now data supporting the use of a daily multivitamin to stave off dementia. Softer evidence favors the amino acid taurine and the diabetes pill metformin; both are in early stages of testing and I do not take either. Most other supplements enrich their sellers but do not help you.

There are no quick fixes to let you live longer and better, but there are many things you can do.



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COVID - forgotten but not gone

Understandably, most of us have developed “Covid fatigue.” After what seems like years of warnings and behavior changes, we want to put it all behind us. Unfortunately, while we are tired of the virus, the virus is not tired of us.

The latest variant to appear, JN.1, is much more transmissible that its predecessor even though it has only a minor genetic change. It has rapidly become the dominant strain hitting the U.S. and much of the world. Fortunately, the last vaccine, aimed at an earlier variant, seems to be very protective against severe illness and death, even if not that good at preventing infection.

While not nearly as dramatic as the situation of 2-3 years ago, both case counts and deaths have been trending up. For the last period for which we have complete data, some 1500 Americans are dying of Covid every week – most, but not all, older and/or with severe underlying illnesses, and most not up to date on their vaccines.

Only 19% of adults 18 and older and 8% of children have received the current vaccine. Of those 65 and older, at highest risk of severe disease, only 38% have been fully vaccinated.

What should we do?

First and most important, get your booster! Vaccines only work when you get them.

Second, wear a well-fitted mask when you are indoors with lots of people. Think concerts, bridge games, indoor sporting events. While not a panacea, masks do cut down transmission of both Covid and other respiratory viruses such as colds and flu.

Finally, if you are sick, stay home. You do not want to be the one who recovers but finds out that you gave the virus to your elderly aunt who died. There will always be another event.

For those who do get sick, treatments are available that help. Paxlovid is under-used. In the older population, it cuts hospitalization and death by more than half. If you are very high risk, IV antibody treatments are even more effective.

We do not want or need to go back to the days of school closures and shuttered restaurants, but we can and should do these simple things that protect us all.



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Is the FDA protecting us adequately?

The high point of the FDA (Food and Drug Administration) showing its worth came in 1960, when Dr. Frances Kelsey refused to let thalidomide be marketed in the U.S. She prevented the U.S. from experiencing the epidemic of babies born with deformed limbs to mothers who were prescribed the drug for morning sickness in Europe.

Do we still have similar guardians? Recent years have seen a raft of drugs and devices of dubious value approved by the FDA.

Example: Zurzuvae was approved in August 2023 to treat postpartum depression. This is a major depressive disorder that begins during pregnancy or within 4 weeks after delivery. Standard recommended care is psychotherapy or the well-studied group of antidepressants called SSRIs (selective serotonin reuptake inhibitors). Zurzuvae works on the same brain receptors as benzodiazepines (think Valium, Xanax) and barbiturates, and so not surprisingly causes sedation, sleepiness and dizziness, and most people who take it for over a week suffer withdrawal symptoms when they stop.

Two studies of Z were done in women with severe postpartum depression, and in both it was compared to placebo, not SSRIs. It was superior, but the placebo group saw about 75% of the improvement seen in active drug users. The real test would have been comparison with a safer SSRI, not a placebo.

Moreover, even though only patients with severe depression were studied, the drug was approved for all patients with the disorder. I’d avoid it.

Example: In Dec 2019, the FDA approved the oral drug Olaparib for treatment of pancreatic cancer. This drug is priced at $12,000 PER MONTH. The study leading to approval showed a very modest improvement in survival: 18.9 months vs. 18.4, with no quality-of-life benefit. Statistically significant perhaps, but clinically? I’d also question using placebo rather than existing approved drugs as the comparison.

In addition to drugs, I could describe many devices of dubious value, but will only mention one in the interest of brevity.

In 2023 the FDA approved two devices that destroy nerves to the kidney to treat high blood pressure without medication. Two studies have been done. One showed no benefit and one showed statistical lowering, but by an average of 3 mm – less than the usual variation I would see between two measurements in the same visit. Is that worth the estimated $6000 that using the device will cost? Do we have data showing long-term benefit? (No!)

We should require that the pharmaceutical and medical device industries fund studies that clearly define which patients will benefit from new drugs and devices. We should then also require our regulators to protect the public by forcing new innovations to pass a proper bar before being allowed on the market. “Might help some people,” at high cost and with potential side effects is not a high-enough bar, not when lives are at stake.

Let the FDA know they need more Dr. Kelseys and fewer rubber stamps.



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Who makes the decisions about your health care?

If you have commercial health insurance or are one of the over half of Medicare enrollees who have a “Medicare Advantage” plan, decisions about your health care are not decided solely by you and your doctor(s). There is a third party in the room: your insurer, whose interests are financial rather than health.

As medicine became more complex and much more expensive, one response of health insurance companies was to try to decrease the use of expensive tests and treatments. They developed lists of tests, medications and procedures that could in some cases be substituted by older cheaper tests and treatments. When a doctor wished to order an expensive new approach, they had to justify why this was necessary.

If done properly, this was fair and reasonable. Every expensive new drug is not always better than a cheap old one. Every patient with back pain does not need a CT scan or MRI. The problem is that insurers went overboard.

The process works like this: your doctor sends a prescription to your pharmacy or asks their staff to schedule you for an imaging test. They then hear from the pharmacy or the radiology department that your insurance company requires “prior authorization.” The cost will not be paid until the insurance company agrees it is needed. The doctor’s office calls the insurer and are questioned by a clerk with no medical background using a checklist. Sometimes miracles happen, every box is checked and you get approval.

More often, your doctor is told that the request does not meet their criteria for necessity and will not be paid. There are now three choices: do it anyway and have you, the patient, pay the bill; forget about it and try a different approach; request an appeal of the decision.

For all but the very wealthy, paying out of pocket is very difficult. If there indeed is a good cheaper alternative the system has worked as intended. Most of the time the request is necessary for the best outcome and the doctor must appeal.

A survey found that the average doctor’s office devoted 14 person-hours a week to prior authorizations – time that costs the doctor money and takes away resources that could be better spent on care. Clearly the insurers hope that if they deny needed care, the doctor may sometimes decide it is not worth the time and effort to appeal.

Recent investigations by ProPublica and others have found that many insurance companies rely on biased algorithms to deny needed care. They have also documented that insurance company medical directors review 10,000 cases/year or more, and often make decisions without even looking at the patients’ charts. Moreover, many companies employ as medical directors doctors who have been driven out of practice by disciplinary action or numerous malpractice suits.

If your doctor’s suggestion is denied by your insurance company, what can you do? If you and your doctor agree that the denied service is truly best for you, insist on appealing. While the doctor’s office has to take the lead, you can add your voice to the process. Get the HR office at work to intercede on your behalf. Threaten to – and do if necessary – contact the state office of consumer affairs.

It is their money – but it is your life and health.



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All Fall Down

As children, we played Ring Around the Rosie, ending with “ashes, ashes, we all fall down.”

When small children fall down, it is fun. When older adults fall down, it is anything but fun. Over the course of my career, I saw many frail but independent elders fall, breaking a hip, and ending up in nursing homes for the rest of their lives.

The leading cause of injury and injury deaths among adults 65 and older is falls. At the last census, 14 million older adults – 28% of those 65 and older – reported falling during the prior year. In 2021, 38,742 older adults died due to falls.

How can you avoid adding to these dismal statistics? There are many things you can and should do!

You can do things to your body. Work on balance. An excellent way to do this is to sign up at the Y or your local Senior Center for Tai Chi – an exercise program focused on balance. At home you can do simple exercises on your own, such as standing on one leg – just Google “balance exercises.”

Increase your muscle strength with resistance exercises, including squats. This will both improve your leg strength, which reduces falls, and strengthen your bones, so you are less likely to sustain a fracture if you do fall.

Speaking of bones, do you know your T-score? Women in particular, but older men as well, should be checked for osteoporosis at least once. If your bones are very thin, your fracture risk is higher and you can discuss options with your doctor for improving this.

Beware of medication! Some medications can make you unsteady either by lowering your blood pressure too much or by directly impacting your brain. Sleeping pills and sedatives are a major culprit. A “med review” to look for any that can be stopped should be a regular event with your doctor.

Many simple things can reduce your risk of falls. When going up or down stairs, hold on to the banisters. Have adequate lighting, particularly at the bottom of stairs. If your vision is less than perfect, put bright tape on the last step so you do not miss it.

Be sure that any small rugs have non-skid bottoms or a non-skid pad under them.

Be cautious with ladders. Do not climb any higher than you would feel safe falling. DO use small ladders rather than chairs to get something down from a high shelf – ladders are designed to stay upright when you stand on them; chairs are not. Keep things used often on lower shelves.

Add grab bars to the shower. Closing your eyes to keep soap out of them can make you unsteady.

Both at home and in hotels, have a night light to help you safely navigate from bed to bathroom.

Be proactive! Do not be a statistic!



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