Thursday, April 8, 2010

Medical Numbers and Medical Arts

Here I am, approaching five months of living with a stent.

Because there's no peeking back inside my heart, everything is measured with, at best, a secondary view.  Often it's not even that close.  And I think the path from a lot of those measurements back to the health of my heart is filled with a lot of forks, branches of which are chosen for reasons that aren't always based in any sort of firm science.

Recent numbers are along these lines:

  Bad cholesterol: 54 - that's a nice low number, yay for Lipitor
  Good cholesterol: 43 - that's a nice high number, yay for exercise and moderate alcohol consumption
  Fitness as measured by VO2 Max: 56 ml/kg/min - that's also a nice high number
  Calories consumed per day: 1700-ish - this is a low number, but I'm still supposed to be losing weight
  Cholesterol consumed per day: 180mg-ish - this is about 100mg/day less than the recommended allowance

All of that, I'm told, bodes well for heart health, mortality, and other things we're all supposed to want.

And this is where the art of medicine comes in.  Like any art, it's subject to the skill, desires, and motivations of the artist and left open to interpretation by whatever audience the artist can muster to look at her art.

What makes 54 a good or bad number for LDL cholesterol?  Some guidelines say under 100 are good.  My hospital seems to think the people who think that are pikers, and that under 70 is better.  But there is no published science just yet that supports that.  So we're rapidly away from numbers and squarely in the realm of art.

What makes 43 a good or bad number for HDL cholesterol?  As far as anyone has told me, nothing makes it good.  In fact, it seems to matter so little that there isn't even a drug to raise it (and if the drug companies can't find a way to promote it and make a profit, that's surely an indicator of something).  HDL apparently "clears out" LDL cholesterol, so there is no upper bound on how much of that you should have.  Yet.  (Also, I have this mental picture of little fatty blobs wearing white hats racing around my blood stream rousting out other little fatty blobs wearing black hats and sending them away to my gut where they are expelled ignominiously and sent to perish in the waste water treatment plant, where I'm sure they are ganging up and plotting against me, one day to come to my house while I'm sleeping and clot every artery in my body all at once the night before something good was going to happen.)  Anyhow, stories aside, alcohol raises HDL, but don't have too much.  One to two drinks a day is good for me, so that's 8oz of wine, two cans of beer, a few shots of liquor.  The American Heart Association tells me to drink 14 drinks a week.  Family Doctor says that if I drink more than 14 drinks per week, I'm at risk for alcoholism.  Apparently it's a fine line between being heart healthy to being a drunk.  Choices, choices.  If only we had some science to help us... alas, we're still in the realm of art.

I think the calories and fitness are "real" numbers, because they are so distant from my heart health that they stand alone.  Eat fewer calories, lose weight.  That actually is sort of like science, or its big brother, math.  Weight loss seems to be a third or fourth order measure of heart health - carrying less weight makes your heart work less.   But so does Atenolol, evidently; being in shape keeps your heart rate low (which no one can say is good or bad, so there's that), but so does Atenolol.  So fitness is nice, and raises your HDL levels, but it seems like no one can attribute longevity to either of those things directly, so big whoop.  Speaking of the, in my mind dubious value of Atenolol,  cardiologists love beta blockers.  My pharmacist once said "If cardiologists had their way, there would be low-dose beta blockers and loop diuretics in the tap water."  I've mentioned that to a few doctors, and they all generally agreed that it does, indeed, seem like a thing cardiologists would do.

My favorite art, though, is the art of proscribing diets.  I am on a reduced cholesterol diet - not much cheese, easy on the eggs, most of what I get comes from meat.  With the help of LoseIt I can tell you roughly how much cholesterol I ingest, which is right about where I'm supposed to be.   However, recent studies and articles in the popular press suggest that dietary cholesterol doesn't affect blood cholesterol, at least not as much as what the guidelines were based on.  I asked a nutritionist about this, and she said that's pretty true, and some eggs and cheese probably wouldn't kill me on the spot (although the saturated fats in the cheese probably would).  So I asked why I was on a reduced cholesterol diet.  She said "we put all heart patients on a diet like that".  But it doesn't seem to matter.  Art.  And in this case, it sounds sort of like amateur art.

Next time you feel bad and go to the doctor, don't expect an answer.  Get over it, there is no answer.  And almost no amount of numbers or data or statistics or measurements are going to help.  It's art.  With luck, you'll get a good artist.  Another MRI isn't going to help the artist any more than a digital camera would have helped Ansel Adams.  The tools are useful and necessary, but the interpretive art is what you're going to get.  Like all art, it takes time and adjustment.  It doesn't take the greatest new tools, but good application of reasonable tools.  So stop expecting an answer firmly based in science, and hope for a pretty picture.  It will reduce your stress, which is good for your heart, or so they say.

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