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Can Coronary Artery Disease Be "Thin Sliced"?

In Malcolm Gladwell's best selling book, "blink," the author desrcibes the concept of "thin slicing," that is, using what appear to be seemingly innocuous, superficial characteristics and patterns in people and situations to make astonishing, profound and correct predictions. Can this same principle be applied to medicine and in particular heart disease?

I remember standing at the airport gate waiting for my son to arrive home from college for winter break.
Subconsciously I was keeping score of the people filing past me. Healthy, healthy, borderline, heart attack waiting to happen, healthy, heart attack, etc. I was reasonably sure of my assessments, but how was I able to do this? Do I possess some magical predictive gift unique to mankind? Hardly, as I know that my cardiology colleagues across the country can and do these same assessments every day. I realized I was thin slicing.

What is thin slicing? According to Gladwell, "the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience". The book goes on to describe "the love lab", a laboratory run by psychologist John Gottman in Washington state. What is remarkable about this lab is that Gottman can predict with 95% accuracy whether a couple will still be married fifteen years later simply by analyzing a tape of a husband and wife talking. The accuracy drops to 90% by viewing for fifteen minutes and is still quite impressive with viewing only three minutes of tape. How does he do it?! He focuses on four characteristics common to marriages in trouble he calls the "Four Horsemen": defensiveness, stonewalling,criticism and the granddaddy of them all, contempt.

So what was I seeing that instantly cued me into a person's risk of heart disease and the possibility of sudden cardiac death? Most everyone knows that obesity is a major risk factor for heart disease. It is as recognizable as seeing your loved ones from across the street or a large room like an airport. Obesity can lead to hypertension, hypercholesterolemia and diabetes, other well-known risk factors for heart disease.We also know that BMI, body mass index, calculated by a simple height and weight measurement can give us this same information about risk. But let's face it, obesity defined as BMI>30 kg/m2, is easy to spot.

What is less well-known is the entity known as metabolic syndrome. It involves a pattern of central, abdominal obesity (classic beer gut or "Dunlap's Disease...your belly done lapped over your belt") and is associated with hyperglycemia (insulin resistance), dyslipidemia (high triglcerides, high LDL-bad cholesterol and low HDL-good cholesterol)and hypertension, and is an indepedent significant risk factor for heart disease.

As the departing passengers got closer to me I was able to check out their ears and hair. "Their ears and hair?!", you are asking? What in the world can you see in someone's ears and hair that give you any clue about heart disease? There are two interesting characteristics in ears that correlate with heart disease: one is a diagonal crease in the earlobes (usually middle aged white and black men) and the other is hair in the ear canal (usually white men). No one quite understands this correlation or why heart disease would manifest in this way but studies have confirmed a correlation between the two. The other physical characteristic correlated with heart disease is male pattern baldness.

So like Dr Gottman's love lab in Washington state, we can also develop the Four Horsemen for heart disease:
male pattern baldness, ear changes as described, and the big two, obesity and metabolic syndrome. Obviously these physical characteristics are just the beginning in defining someone's risk. Family history, smoking history, fasting cholesterol profile, blood pressure, sedentary life style, and C-reactive protein level(an indicator of inlammation) are critical determinants in assessing risk. But if we can educate our primary care brethren to pursue this line of questioning when they see physical characteristics of heart disease, we can go a long way toward preventing this disease, by far and away the number one killer in America. More strongly put, if your primary care physician does not pursue this line of questioning he/she is not doing his/her job.

Finally, prevention of heart disease seems a logical path especially in this era of spiraling health care costs. It certainly is cheaper to educate the public regarding their risks and appropriate lifestyle changes than place stents in coronary arteries or perform coronary artery bypass grafting. Unfortunately, there are dynamics on both sides of healthcare, donor and recipient, that keep prevention on the backburner. From the perspective of the primary healthcare provider, physicians are loathe to scold their patients. They risk angering their patients and losing their business. They may feel awkward calling out their patients for being overweight while they have zero compunction in suggesting a skin biopsy for a mole which looks suspicious for skin cancer. It is also time consuming and sometimes frustrating to discuss risk factors and suggest lifestyle changes in patients who may not be compliant.
For cardiologists, reimbursement for placing stents is ten times higher than an office visit to discuss lifestyle changes. In the time it takes to see one office patient they could place stents in two patients. This is cynical perhaps, illustrative certainly, but reality from someone in the trenches.
For patients, it is easier (they think) to have stents placed or surgery performed than face significant lifestyle changes. What usually isn't discussed, however, is that without lifestyle changes, no invasive procedure will fix their problem which will surely recur.

Physicians have a responsibility to use their bully pulpit to encourage their patients to make lifesaving changes. When I look my patients in the eye and tell them, ''my job is to help you live a long time", they understand I am being firm but they also know that I am being an advocate for their health. It's time we all grow up and face this burgeoning problem head-on. Physicians, do the right thing; Patients, understand we are here to help you not criticize you. Insurance companies, up the reimbursement ante for prevention. Only by working and trusting together can we positively impact this disease.

So the next time you see an overweight, bald, middle aged man with ear hair and ear lobe creases in the airport, tell him to go for the apple instead of the bacon double cheese burger. Better yet, tell him to come see me...we need to talk.

By Herbert J Stern MD, FAAP, FACC, FSCAI
Pediatric Cardiology Expert Witness Specializing In Adult And Pediatric Congenital Heart Disease
ABOUT THE AUTHOR: Herbert J Stern MD,FACC,FSCAI; Founder of Stern Cardiology, PC
Herbert J Stern MD, FACC, FSCAI
Dr. Stern is a board certified pediatric cardiologist specializing in congenital heart disease in adults and pediatrics, therapeutic cardiac catheterization with special interests in hybrid (surgical/catheter) procedures; in stroke and migraine patients who have been diagnosed with a patent foramen ovale; congestive heart failure management, patients with single ventricle physiology and pulmonary hypertension. He also enjoys discussing lifestyle changes for those at risk of coronary artery disease.

Copyright Herbert J Stern MD, FAAP, FACC, FSCAI

Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.

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