AHSF Blog/Videos

A stress echocardiogram test, or “stress echo” for short, serves he same general purpose as a standard cardiac stress test. By observing how the heart behaves during exercise, the doctor performing or reading the test can get some clues about the kinds of problem that a person may or may not have.

The difference is that echocardiographic (ultrasound) images of the heart are obtained both at rest, before the exercise protocol begins, and immediately after exercise.  This gives additional information that can minimize some of the shortcomings of the standard stress test.

How is a stress echo conducted?

If you come for a stress echo, you will be asked to walk on a treadmill while connected to an ECG monitor.

The standard exercise protocol is the “Bruce protocol” which proceeds through stages, very easy at first, and gradually becoming more difficult. The initial stage is a low walk at a 10% incline.  With each successive stage the incline increases and the speed also increases gradually.  This allows you to warm up, to get used to the equipment and to relax before the effort gets more intense.  It also gives a chance to the doctor and the technician to observe the heart response more deliberately. Because the stress test starts off nice and easy, it provides a good opportunity to chat, exchange jokes, and get to know one another!

Once an adequate effort level is achieved, you will be asked to lie down on the examination table where images will be obtained while the heart is still pumping fast.  Any abnormal motion of the heart or abnormal pressure is noted at that point.  You can then rest for a few minutes while the ECG machine continues to record your heartbeat.

A few weeks ago, the Center for Medicare and Medicaid Services (CMS) passed a ruling demanding that healthcare institutions post the fees that they charge for various services on their websites.

“It’s about time!” was the general reaction.  In what other industry in the world do you obtain services and have no clue how much things are going to cost?

Unfortunately, as many have pointed out already, the new law will probably not do much to foster transparency. 

For one thing, the prices posted by hospitals are the “list prices” for various services.  List prices are prices that have nothing to do with reality.  They are highly inflated and unrealistic numbers that hospitals and medical groups use to start a price negotiation with health insurance plans.

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I had the pleasure of joining Anthony Diaz on The #PopHealth Show podcast. We had a wide-ranging conversation regarding my prior experiences, my views about health, and what currently excites me in healthcare. We discussed ideas that are dear to my heart. I hope you find the conversation informative and enjoy it as much as I did. You can listen to the episode here (~ 24 minutes)

–Dr. Accad

A few weeks ago, a decision by a federal district court judge stunned the healthcare community when he ruled the Affordable Care Act to be unconstitutional. 

The ruling is being appealed and will not be affecting the status of the law until it is reviewed the Supreme Court. But it was interesting to observe the reaction of various parties…

The American Medical Association (AMA), which claims to speak for all doctors, tweeted that the ruling would “strip health care from tens of millions of Americans and sow chaos into the healthcare system.”

Similarly, the American Hospital Association issued a press release saying that the ruling “puts health coverage at risk for tens of millions of Americans.”

Now, I can understand a reaction of shock among patients who are dependent on health insurance subsidies without which they would be unable to afford the exorbitantly expensive care currently being provided in most healthcare venues.

But doesn’t it seem a bit disingenuous for the most powerful physician and hospital lobbying groups to lament the financial harm that the ACA rollback could have on patients? Isn’t it their institutions that are not only setting the prices for healthcare at stratospheric levels, but also obscuring them so that no one can know with any real certainty how much the care is going to cost?

UPDATE March 20, 2019:  The results of the “Apple Heart Study” were just released at the annual meeting of the American College of Cardiology.  Read my comment at the end of this post for an update.

Today, Apple released its ECG app and irregular heart rhythm notification feature.

The announcement about the technology was made with great fanfare a couple of months ago, when Apple also revealed that the device had received approval by the FDA.  This raised some eyebrows because—according to some—the technology was being approved and released to the public without evidence of effectiveness or harm.

What is so unique and novel about the product is that it claims to be able to detect atrial fibrillation, or “a.fib,” which is a common irregularity of the heart rhythm.  A.fib is not usually fatal but it can be a problem for two reasons.

First, the arrhythmia causes and irregularity and rapidity of the pulse that can provoke palpitations and also impair the pumping capacity of the heart.  This typically causes symptoms, so that people who develop a.fib typically become aware of the problem and seek medical attention relatively promptly.

But not everybody is necessarily aware that they have a.fib.Read more

As readers of the blog may know, I have been a very strong proponent of the coronary calcium scan for many years.  The scan is a great tool to help determine vascular health and make a decision regarding the treatment of high cholesterol.

I have argued in previous blog posts and videos that patients with a coronary calcium score of zero may be able to avoid medications to lower cholesterol.  In the last couple weeks, 2 news items from the cardiology community have bolstered my opinion.Read more

The blood pressure is fickle

We typically think of the blood pressure as a pair of numbers that are measured in the doctor’s office once in a while.  If the numbers are persistently too high, you have “high blood pressure” (also known as hypertension) and that’s a concern for the future.  If untreated, hypertension can lead to serious complications, including heart, kidney and brain damage.

But we know that people can get a little nervous when they’re at the doctor’s office, so the blood pressure may be high there but be normal the rest of the time.  That is called “white coat hypertension,” because the stress of seeing a doctor in a white coat is enough to raise the blood pressure!

And we also know that the opposite can occur: the blood pressure may be deceptively low at he doctor’s office, but much higher during the day when the stress of work or of taking care of the household is in full force.  That is called “masked hypertension,” because the doctor only sees normal blood pressure numbers in the clinic and is unaware that the numbers are actually higher most of the time.

The blood pressure changes all the time, so it’s quite challenging to make a determination about hypertension on a few sets of numbers taken here and there.

A new way to measure BP

A few years ago, medical device manufacturers developed ambulatory blood pressure monitors (ABPMs), which are simple blood pressure machines, the size of a WalkMan tape player (does anyone remember those?!).

The device can be worn over a period of 24 to 48 hours and which automatically obtain a large number of measurements while you’re out and about during the day, and even at night when you sleep!Read more

A gym in our neighborhood has a big sign that challenges the passerby to “Make your body your machine.”  Another one a few blocks away entices potential customers with a poster that says “We don’t use machines.  We build them.”

These are clever and funny points.  There is certainly a sense in which bodies are like machines, with parts that work on each other to accomplish things.  And, for all practical purposes, those parts can be described the same as engine parts:  There is a fuel system (digestion and metabolism), a plumbing system with a pump (the heart and blood vessels), an electrical system (the nerves), a system of pulleys and joints (the muscular system), etc.

But the metaphor can go a little too far.Read more

I had the pleasure of giving a talk at UCSF last week.  The talk was part of the “Cycling to Health” series, which is one of the UCSF Osher Mini Medical School programs offered to the general public.

The talk was videotaped and will be uploaded on the UCTV network in a few months, but I thought I would summarize here for you the main points that I addressed.

In the first part of the talk, I described the normal cardiac adaptions to high intensity cycling, and I made some comments to distinguish cycling from other sports and other endurance sports.

Cycling is considered a sport with high dynamic as well as high static stress.  This causes the cardiovascular system of cyclists to adapt in some major ways.  In fact, there is some data to show that cyclists have the biggest hearts among all athletes!Read more

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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