Anti-inflammatory Colchicine Exhibits Major Benefits After a Heart Attack

Jean-Claude Tardif, M.D., of the Montreal Heart Institute in Canada presented a paper at the Scientific Session of the American Heart Association last week demonstrating the benefits of using colchicine to reduce inflammation after patients have a heart attack.  In a study called COLCOT, performed at 167 different health centers in multiple countries, almost 5000 patients were double-blinded and either given 0.5 mg of colchicine a day or a placebo.

All of these patients received standard post heart attack cardiac care including cholesterol lowering medicine, anti-platelet agents and blood pressure medicines in addition to the study drugs.  The patients were on average 60 years old, 80 % were overweight men with 93% having undergone angioplasty as a treatment of their cardiac disease.  Ninety-nine percent were taking aspirin, 98% were taking an additional anti-platelet agent, 99% were on a statin to control cholesterol and 89% on a beta-blocker.

The doctors conducting the study recognized that acute heart attack patients are demonstrating a high degree of inflammation at that time and are at increased risk for another heart attack, stroke or acute rehospitalization for an ischemic event.  The addition of colchicine reduced this risk by 34% when used with all the currently recommended post heart attack medications.  A new study, COLCOT 2, is being planned to see the effect of colchicine in preventing coronary ischemic events in diabetics who are at increased risk.

Colchicine is an anti-inflammatory drug originally used to treat gout and inflammation of the sack around the heart known as pericarditis.  It originally was not patented and sold for pennies.  The drug was purchased by a Wall Street investment firm, patented, and now a 30-day supply sells for more than $250.

Patient Hand-Offs and Communication

document businesspeople 1I was finishing tying my shoes as I got dressed to take my lovely wife out to dinner for our 41st wedding anniversary. It was 7:30 p.m. after a hectic day at work and we had a wonderful dinner planned at a local restaurant.

The telephone rang with the caller ID identifying a call on my office work line. “Hello this is the Emergency Department, please hold on for Dr S.” Before I could get in a word edgewise I was put on hold. Five minutes later Dr S. got on the line. “Steve this is Pete. “Dr. Rheumatology” saw your mutual patient Mrs. T this afternoon and she was complaining of shortness of breath beginning three weeks ago. She complains of overwhelming fatigue. He sent her here for evaluation. Her exam is negative. At rest she doesn’t look short of breath. Her EKG doesn’t show any acute changes but I do not have an old one to compare it to. Her chest x ray is negative and her oxygen saturation on room air is 97 % (normal is greater than 90%). She has lupus and multiple autoimmune problems and is on many immune modulators. Maybe she has a constrictive cardiomyopathy or restrictive lung disease. I called Dr. Rheumatology and he said this isn’t his department to call the PCP (primary care physician) to admit the patient and you are the PCP. “I told the ER physician I had not seen the patient in over six months or heard from her but I would be right in to see her”.

I explained to my wife that duty calls and there was a sick patient in the ER. She was extremely understanding. On the drive to the ER I called the Rheumatologist to ask him his clinical impression because he had been seeing her every two weeks and had examined her just that afternoon. He returned my call and we discussed the clinical aspects of the situation and his thoughts. Then I told him that I thought he should have called me when he sent the patient to the ER if he expected me to assume care. If he did not call then he most certainly should have called me when the ED doctor called him to report on the findings and he said call the PCP. Hand-offs should be direct especially in an acute situation and especially if you sent the patient to the ER and do not intend to take ownership of the situation you sent the patient to the ER for.

He told me that in 30 years of practice no one had ever criticized him for this and he does it all the time. He told me he had been working long hours and did not have time to call referring physicians. I told him that was no excuse and if he was working that late maybe he needed to restrict his patient volume so he could communicate in a professional manner.

I arrived at the ER 20 minutes later and learned that the patient had been there for three and half hours already. She had been in the ER while I had been at the hospital earlier that afternoon checking on another patient. Had I known she was there I could have easily seen her, cared for her and still made my anniversary dinner.

A review of her old EKG and comparing it to the new one, plus taking a thorough history and exam, revealed the problem. She was having a heart attack. Her bouts of shortness of breath with activity with overwhelming fatigue were her equivalent of crushing chest pain.

Getting called to the hospital during “off” hours is part of a physician’s way of life. Having a colleague take your role and time for granted at the expense of the patient is disturbing and unprofessional.

All too often today physicians, both specialists and primary care, don’t take the time to communicate directly and clearly with their colleagues about patient care.  When this happens, clearly the patient is negatively impacted.

ACO’s and the Patient Centered Medical Home will not cure this. Only courtesy, respect and putting the patient first will change things.

The Heat Index

The heat index tells you how hot it feels outside in the shade. It is not the same as the outside ambient temperature. It combines the humidity with the temperature.  When you are standing in the open and full sunshine the heat index is even higher. A heat index of 90 or greater is considered dangerous.

Sunburn, Sunscreen and How to Avoid Damaging Ultraviolet (UV ) Light

Summer has arrived and individuals are outside trying to obtain the perfect tan.  Exposing yourself to the sun allows your skin to be exposed to ultraviolet light. We are most concerned about ultraviolet light in UV-A spectrum (320-400 nm) and the UV-B spectrum (290-320).  UV-A rays penetrate deeply and cause skin damage including photoaging of the skin, immunosuppression both locally on the skin and systemically and increased risk of cancer and infection. It is the UVB radiation that causes tanning.  The delayed tanning that occurs 3 days after exposure is due primarily to UV-B radiation and is due to a redistribution of melanocytes and new melanin synthesis and formation. This delayed tanning is at best mildly protective against sunburn SPF 2-3 but has no effect on protecting against cancer or photoaging.

Sunscreens can help reduce your risk of developing skin damage and cancer.  Sunscreens are either inorganic containing products that physically shield and block the effects of ultraviolet rays or organic compounds that physically absorb the ultraviolet rays. You should be looking for a sunscreen that is “broad spectrum” protecting against UV-A and UV-B rays.  You want a sunscreen that is substantive.  “Water resistant” products protect up to 40 minutes after water immersion.  “Very water resistant” products protect up to 80 minutes after water immersion.  Data and research shows that a broad spectrum sunscreen with SPF 17 or greater will provide protection against squamous cell carcinomas and photoaging but are less effective in preventing basal cell cancers and melanomas.

It is recommended that we use sunscreen daily on all sun exposed skin. The clouds only scatter UV-B Rays so on cloudy days you are being bombarded with UV-A rays despite it appearing to be overcast.  It will require about a shot glass worth of sunscreen to protect the most sun exposed areas (two tablespoons) which are the face, ears, hands, arms and lips. You should be using an SPF of at least 30 which should be applied 15-30 minutes BEFORE sun exposure.  It should be reapplied every two hours and after swimming or heavy perspiration.

  • Remember that the sun’s rays are strongest between 10 a.m. and 4:00 p.m.
  • Water, sand and, in the winter, even snow reflect UV radiation so be extra careful in those environments.
  • Wear protective clothing such as closely woven, natural fiber, long sleeve shirts and pants, sunglasses and wide brimmed hats.
  • Do not use tanning beds.
  • Do not expect sunscreens to allow you to spend more time in the sun. Long exposure to the sun’s damaging UV rays increases your risk of skin cancer and photoaging.

Summer means longer days and more time spent outside. Be prepared and protect your skin from damage and injury.

Heat Related Illness

It is summer time and the heat and humidity are higher than at any other time of the year.   We spend more time in the outdoors so we must learn to protect ourselves against the unique illnesses caused by this increased exposure.  Heat related illness occurs when your body cannot keep itself cool. As the air temperature rises, your body cools off by sweating.  Sweating occurs when liquid on your skin surface evaporates. On hot humid days, the evaporation of moisture is slowed down by the increased moisture in the air. When sweating cannot cool you down your body temperature rises and you may become ill.

Some people are at greater risk to develop heat related illness than others. This includes infants and young children, people 65 years of age or older, people with mental illness taking medications, the physically ill; especially those with heart disease, high blood pressure and lung disease.  Individuals who have suffered from heat exhaustion or heat stroke in the past have an increased risk of developing recurrent heat illnesses.

When your body overheats due to very hot weather and or exercise in the heat, you are susceptible to heat exhaustion. Patients experience heavy sweating, non-specific weakness and or confusion, dizziness, nausea, headache, rapid heartbeat and dark very concentrated urine.

If you experience these symptoms in the heat you need to get out of the heat quickly. Find an air conditioned building and rest in it. If you cannot find an air conditioned building then get into the shade and out of the sun. Start drinking cool liquids (avoid caffeine and alcohol which exacerbate fluid loss and heat related disease). Take a cool shower or bath or apply cool water to your skin. Remove any tight constricting clothing.  If you do not feel better within 30 minutes you must contact your physician or seek emergency help.

Untreated or inadequately treated heat exhaustion can progress to heatstroke. Heatstroke occurs when the internal body temperature rises to 104 degrees Fahrenheit or higher. Heatstroke is far more serious than heat exhaustion it can cause damage to your internal organs and brain and it can kill you.  Patients with heatstroke are running a fever of 104 degree F or higher. They complain of severe headaches with a dizzy or light headed feeling. Their skin is flushed or red in appearance and they are NOT sweating.  Many will be experiencing severe and painful muscle cramps accompanied by nausea and vomiting. Their heartbeats are rapid, their blood pressure low. They are often extremely agitated, anxious and disoriented with some experiencing tonic clinic epileptic type seizures.

Heatstroke is a medical emergency and you must call 911 immediately. While you are waiting for help to arrive remove their clothing after taking the patient to an air conditioned or shady place. Wet the skin with water and fan the skin if possible. If you have access to ice or ice packs place them on the patient’s neck, back, groin and armpits while waiting for help.

Heat illness is preventable. When the heat index is over 90 and you must go outside wear lightweight, light-colored, loose fitting clothing. Wear a hat or use an umbrella.  Apply sunscreen SPF 30 or greater 15-20 minutes BEFORE going outside. Drink plenty of water before you go out and 2-4 glasses of cool water each hour you are outside working in the heat. Avoid alcohol and caffeine including soda with caffeine.  Take frequent breaks every 20 minutes and drink water or sports drink even if you do not feel thirsty. Try to schedule your outside work for before 10 a.m. or after 6 p.m. to avoid peak sun exposure.

If you are being treated for chronic medical conditions ask your doctor how to prevent heat illness.  Patients taking antihistamines, some blood pressure medications (beta-blockers and vasoconstrictors), diet pills, anti depressants and antipsychotics impair your ability to control your internal body temperature. Water pills to prevent excessive fluid lead to dehydration. Anti-epilepsy and anti-seizure medicines impair your body’s ability to regulate internal temperatures as well.

Heat illness is preventable if you take the precautions outlined above.