Getting intimate with the carotid intima


We are pleased to announce the addition of the “carotid intima-media thickness” test (CIMT) to the array of non-invasive diagnostic tools available at Athletic Heart SF.

The idea behind the CIMT is simple: an ultrasound image of the carotid artery can provide information about the health of the artery itself and, more generally, about the overall health of the cardiovascular system.

The ultrasound image can identify two conditions.  First, the ultrasound can detect if there is actual plaque build-up which, if advanced, can block the flow of blood and contribute to the risk of stroke.  Fortunately, advanced plaque build-up is relatively rare.

Second, even in the absence of plaque build-up, the thickness of the vessel wall (CIMT) can give a broad indication of cardiovascular health.  The intima is the name of the inner lining of a vessel wall, and the media is the middle layer.  Both are seen in the image below as the bright thin line and the thin darker band behind it.

Ultrasound image of a carotid artery. The thin intima-media layer is indicated by the arrow.

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Triathlon safety: What you need to know


Dr. Larry Creswell recently wrote a blog post summarizing the excellent research work that he and his colleagues have conducted to better understand the causes and conditions of death during triathlon events.

They have identified all triathlon fatalities that occurred during a 31-year period (1985-2016) and analyzed as many of the relevant factors as possible.  Their work was published in the journal Annals of Internal Medicine.

They observed the following:

  • Average age was 47 with a wide range, but the risk of death increases dramatically with age.
  • Most victims were male (85%).  This is also the case among marathon fatalities, as we saw previously.
  • About 40% of victims were fist time participants, and none of them were elite triathletes.
  • Almost 75% of fatalities occurred during the swim event, frequently within the first few minutes.  No specific swimming condition (e.g., water temperature) could be identified.
  • Many of the biking segment deaths were traumatic in nature.

In many cases of non-traumatic death, preexisting heart or vascular disease was discovered at autopsy.  The article notes that:

A surprising and important observation of this investigation, on the basis of autopsy reports, was the high frequency of clinically silent cardiac abnormalities (present in about 50% of the cases with an autopsy report available) that may have caused or contributed to sudden cardiac death.”

Dr. Creswell recommends that athletes should consider their heart health before participating.  Middle-aged men in particular should consider undergoing cardiovascular screening ahead of the event.  Read his excellent blog here.

Your blood pressure is 125/82. Is this too high?


As some of you may know, a new definition of hypertension (high blood pressure) was recently proposed by the American Heart Association, the American College of Cardiology, and 9 other sponsoring organizations.

According to the new definition, if one’s resting blood pressure (measured properly) is more than 120/80, it should be considered “elevated.”  And if one’s BP is more than 130/80, then the person with that blood pressure should receive a diagnosis of hypertension.

Needless to say, the proposed definition has generated a lot of controversy.  If all doctors adopted the new definition, that would create millions of new patients overnight, and a third of American adults would be considered to have a chronic disease!

What’s more, anyone with a blood pressure over 120/80 would be advised to have close medical follow-ups: repeat visits every 3-6 months, according to the new guidelines.Read more

When endurance athletes have “hearts of stone”


I have just returned from attending a course on the “Prevention of Sudden Cardiac Death in Athletes,” hosted by the University of Washington medical school in Seattle.  It was a terrific conference at which academic leaders in the field gave updates on the latest research.

Dr. Aaron Baggish, from the Massachusetts General Hospital in Boston, summarized two recent studies that have persuasively shown that coronary calcifications are more common in long-term endurance athletes compared to more sedentary controls.

When the studies were published this past summer, Dr. Baggish was asked to write an editorial commentary to share his perspective.  That editorial was provocatively subtitled “Hearts of Stone.”  The phrase refers to the appearance on CT scans of hearts with heavily calcified arteries as shown in this image:

Calcium in coronary artery detected by CT scan.
Image attribution: Wikimedia Commons


In the last several years, a few reports were published suggesting that endurance athletes may be more prone to having build-up of plaque and calcium in their coronary arteries.  Those reports presented a paradox, because we also know beyond any doubt that regular, moderate level exercise promotes cardiovascular health and longevity.  The studies raised the concern that exercise could be harmful after a certain point.Read more

I refuse to tell you what to eat


A recent tweet from JAMA, the journal of the American Medical Association, urged me and other doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk.  I will not do it.  I simply will not.  I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!”  I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted?  After all, the recommendations themselves seem sensible enough:  Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables.  What’s not to like?

Unhealthy guidelines

I don’t know.  Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid.  But what have they got to show for?  The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.Read more

Am I a “statin denialist”?


As you may recall, in a previous video I addressed the topic of statin drugs, and whether these drugs are over-prescribed.  In that video, I criticized the approach of treating people’s cholesterol without any regard to the patient’s cardiovascular health or to other considerations.

Recently, Dr. Steve Nissen, chairman of cardiovascular medicine at the famed Cleveland Clinic and a very vocal proponent of statins, wrote an editorial in which he rebukes those who question the use of statins as “an internet-driven cult with deadly consequences,” a cult he calls “statin denial.”

Those are pretty strong words.  In fact, I think these are smearing words, meant to stifle any debate.

Am I a statin-denialist?  I’m not sure.  Dr. Nissen defines the problem as he sees it in 2 ways:  1) statin denial is “the proposition that cholesterol is not related to heart disease” and 2) statin fear is the notion that lowering serum cholesterol levels will cause serious adverse effects, such as muscle or hepatic toxicity—or even worse, dementia.”

Now, it’s true that some people hold an extreme position regarding statin drugs and, in my opinion, exaggerate their risk.  But it is undeniable that thousands, if not millions of healthy people are prescribed statin drugs—and therefore turned into patients, who need to worry and undergo constant monitoring.  The risk of being healthy yet turned into a patient is, in my opinion, very serious.Read more

Direct care: The option that saves time and money

Your Heart Health in a Heartbeat – Episode 7

* You can either read the transcript or watch the video at the bottom *

The direct care experience

Recently, a young man called my office wanting to be seen.  I spoke with him for a few minutes to better understand his concerns and plan for his visit.  It turned out that his girlfriend had been hearing a pulsating, “wooshing” sound whenever she would lean her head on his chest: woosh, woosh, woosh…Obviously, there was a concern that this had to do with his heart.  He was otherwise feeling well and was able to exercise without any difficulty.Read more

Cardiac arrest in marathons and triathlons

Your Heart Health in a Heartbeat – Episode 6


Cardiac arrest during marathons: 10 facts to consider.

Study of triathlon deaths concludes more screening is needed.

Interesting research studies from the American College of Cardiology 2016 meeting.


Hello everyone,

There has been bad news coming from the marathon and triathlon communities regarding cardiac deaths during these events.  At the London marathon, a middle aged man suffered a cardiac arrest, and in Canada, a few days ago, a middle-aged woman also had a cardiac arrest and died during the swim portion of a triathlon.

So I thought I would take a few minutes today to go over what we know about cardiac arrest at these endurance events, and then go over some new recommendations for screening that were proposed at a recent meeting of the American College of Cardiology.Read more

Blood pressure and exercise

Your Heart Health in a Heartbeat – Episode 5

Document mentioned: 

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hypertension


Hello everyone and thank you for joining me.

I’m Dr. Accad, medical director of Athletic Heart of San Francisco, and today I would like to talk about high blood pressure in relationship to exercise.  I am doing this in light of a document recently published jointly by the American College of Cardiology and American Heart Association that makes some recommendations for competitive athletes who have blood pressure concerns.Read more

535 kids screened!

Again, Athletic Heart SF is delighted to have participated in a screening event for school kids age 12-18 that took place on January 26, 2016, at Sacred Heart High School in Menlo Park.  The event was organized by Via Heart Project, and the kids also received instructions in basic CPR.

A total of 535 kids were screened, a 3 were found to have conditions that put them at risk of serious cardiac complications.  Others were also found to have some structural anomalies of the heart or aorta that would need further follow-up.

If you think your school district could benefit from a screening and would like to get involved, I encourage you to contact the non-profit Via Heart Project organization.  Also, don’t forget that the availability of AED is essential to increase survival rates in case of cardiac arrest.  If your local school is not properly equipped, Via Heart also helps with that.