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.

More Confirmation Stents Overused

Merrill Goozner

First posted 7/6/11 on GoozNews

Another day, another study showing that invasive cardiologists overuse angioplasty and insert unneeded stents in patients without acute symptoms of coronary artery disease. The latest study, which appeared in today’s Journal of the American Medical Association, deemed 15 percent of the 600,000 angioplasties done every year are either inappropriate or their necessity is uncertain.

Since the COURAGE trial results were released in 2007, cardiologists have known that drug intervention (primarily statins) works just as well or better than angioplasty in patients with stable coronary artery disease (cost: $1,000 a year or less if generics are used compared to $20,000 for the stent operation). A study that came out two months ago showed there had been no change in cariology practice in the wake of the COURAGE trial. This latest study confirms that invasive cardiology is largely an evidence-free zone where the self-interest of the surgeons and the hospitals trumps the needs of patients, who have no clue as to what’s going on. “Thank God the doctor did that operation. I could have died tomorrow.”

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CABG in Decline

Merrill Goozner

First published 5/3/11 on Gooz News

The number of Americans with serious heart disease in need of hospital treatment is on the decline. A new study in today’s Journal of the American Medical Association shows the overall rate of coronary revascularizations — ranging from the coronary artery bypass graft (CABG) surgeries to in-and-out catheter-based procedures like angioplasties and stent insertions — fell from just under 1,500 per million adults a quarter in 2001 to less than 1,250 per million adults a quarter in 2008, a 15 percent decline.

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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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Bending the Health Cost Curve by Spending More on Rx: Adherence Can Lower Costs


Originally published 1/1/11 on Health Populi

For every $1 spent on health care in the U.S., 10 cents goes to prescription drugs, 31 cents goes to hospital care, and 27 cents goes to professionals (doctors, dentists, and other services), based on 2009 health spending reported to the Centers for Medicare and Medicaid Services (CMS).

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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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The New Science of Vascular Disease

This article, published almost two years ago on C&C, we’ll refer to these as Recycled but Relevant – is a perfect opening to our Urgent Science section.

If you agree that this kind of review article can be useful to clinicians, let us know. If you would like to write one like this about another topic, or know someone who would, let us know that as well.


Originally Published on The Health Care Blog, 1/28/09

Vascular disease and the conditions that produce arterial problems consume roughly one- third to one-half of the $2 trillion annual spend in American health care. The science and systems exist today to dramatically improve the quality and cost related to cardio-metabolic conditions but almost nothing has been done to implement these new tools since the Institute of Medicine (IOM) published “Crossing the Quality Chasm” in 2001.

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