Calling for Field-Tested Evidence-Based Guidelines

Brian Klepper

Yesterday a nice comment arrived from Robert Gleeson MD, a new visitor to C&C, in response to the CV and lipid protocols developed by Bill Bestermann MD and David Carmouche MD.

Dr. Gleeson said,

“Outstanding. Clearly written and easily understood, evidence based, practical, applicable, designed to improve outcomes and lower costs. We need to find a way to more broadly disseminate these.

And Brian needs to find a way to get more people to submit similar protocols in similar format.”

I’m certainly game, but I’m only in the position to post these guidelines, not identify or evaluate them. So that leaves the task up to the clinicians that visit here. If you know of someone who does superlative work in an area and is willing to memorialize the protocol, by all means, please ask them to submit and, after review and validation, I’ll post for common access.

Thanks so much for the suggestion.

Women Heart – Leading the Charge in Health System Reform: A Call to Action

William Bestermann

In all of American medicine, there is no better example of the disconnection between what we know and what we do than in the case of women with coronary artery disease.  While the different symptom patterns in women with abnormal heart arteries are receiving more attention, even women who properly engage the system very often receive medical care that is not appropriate and leaves them in great danger while adding layers of needless cost.  The woman who is seen in the emergency room for chest pain or other symptoms suggestive of coronary disease will be evaluated under an outdated scientific paradigm aimed at finding blocked arteries.  She will have a stress test done and /or a cardiac catheterization.  If these tests are normal, the patient will be told that the symptoms are not related to her heart.  Every other week, I see a woman who has had symptoms of coronary artery disease and has been told that the problem is her esophagus or worse depression.  She is told in effect: “Go home, take your Valium and Prozac, you will be fine!”  What she has been told is wrong-too often dead wrong!

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Kudos to Dr. Bestermann!

My good friend Bill Bestermann, MD, a preventive vascularist at the Holston Medical Group in Kingsport, TN, has published an important article in CardioRenal Medicine. This paper, a long time coming, is not research but a highly informed thought piece that explains a new, previously unappreciated potential mechanism for the diabetes drug Metformin. It has far reaching implications for the management of many chronic diseases.

Bill first introduced this concept here on C&C in a piece called Metformin, Asymmetric Dimethylarginine and Cancer: The Keys to the Kingdom or a Tool to Pick the Lock?. He began to think seriously about some of these issues a year and a half ago after learning that my wife Elaine had been diagnosed with primary peritoneal (ovarian) cancer. It goes without saying that I am deeply, personally grateful for this contribution.

What’s most important about this most recent paper is that it was rigorously reviewed for CardioRenal Medicine, and so has at least the initial imprimatur of scientific credibility. I hope it now gets the additional attention I believe it deserves.

I’d urge all my clinician colleagues to review it carefully. I believe you’ll be appropriately inspired by both its elegance and its profound clinical ramifications.

Women and Heart Disease

Bill Bestermann

Download this presentation: Women and Heart Disease 22611

The second floor conference room was filled to capacity for my talk this Tuesday.  Most of those present were women.  They listened very attentively for the entire 45 minute presentation, and there was a lot of head-nodding in affirmation and generally positive signals of an engaged audience.  Then they stayed for 45 minutes to ask questions,  The questions showed that they had “gotten it.”  They were there for an hour and a half.

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Insulin and Increased Cancer Risk


“Traditional wisdom can be long on tradition and short on wisdom”

Warren Buffet

My colleagues have asked me about an article in Diabetes Care that shows roughly a 40% reduction in cancer risk in patients who are on insulin and treated concurrently with metformin.  The reduction in cancer risk was attributed to beneficial effects of metformin. This information is not surprising. We have already gone into the metformin and cancer story in this space.

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An Approach to Lipid Management in Patients with Cardiometabolic Risk


Note by Bill Bestermann, MD. Dr. David Carmouche works at the Baton Rouge Clinic in Baton Rouge, Louisiana.  He runs a Center for Cardiovascular Disease Prevention within the clinic and works full time in clinical practice producing optimal medical therapy in high risk patients.  Dr. Carmouche is certified in lipid management by the National Lipid Association, and is recognized by his peers as an expert in lipid management.

He is actively involved in multiple leadership roles that are characterized by the common theme of more effectively treating cardiovascular disease with lifestyle and medical interventions. A group of about 20 academic and community cardiovascular risk experts asked him to lead the development of the cholesterol treatment section of a program describing optimal medical therapy for metabolic syndrome patients.

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Protocol Approach for IOM Priority Vascular Conditions

Brian’s Note: In the post below, Dr. Bestermann, a highly regarded vascular physician, has developed and posted a field-tested protocol for the treatment of vascular conditions deemed high priority by the Institute of Medicine.

This is a work in progress that is likely to undergo significant change as new data emerges. But it is here and available in hopes that clinicians will make use of it, patients will benefit from it, and that by sharing important information we can provide better care for lower cost.

Protocol Approach for:

Type 2 diabetes, prediabetes, hyperlipidemia, hypertension, CAD, cerebrovascular disease, PAD, congestive heart failure


This protocol is field tested, weight-centric and has been used in my personal practice for ten years[1] with ongoing adjustment to reflect newer knowledge[2] and products[3], [4].   Consistently applied, the protocol accomplishes risk factor control levels consistent with optimal medical therapy while facilitating weight loss and renal function improvement in most patients.

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