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There is a LOT of misinformation regarding doctor's letters in lieu of the ones @BernieSanders released, in no small part because the modern journalist has no idea how to report on science/medicine, so I thought I'd take it upon myself as a physician to break it down
#NotMeUs 1/?
Let's start w/some basics. Doctors are accustomed to writing health summaries and letters for clearance and take the task very seriously. What this should stress for you is that every statement is deliberate. An errant word can cost someone their livelihood so stakes are high 2/?
The opening statement in the first letter is meant to establish credibility in what Dr Monahan is sure to realize will be a very high profile statement. Those certifications are under threat if he screws this up 3/?
Additionally, he establishes how long he's treated Sanders because that gives him a frame of reference for the senator's health over time and where his baseline usually resides 4/?
Next are Bernie's vitals and labs. At 6', 174lbs, his BMI is 23.6. BMI is a very flawed measure for obesity but more so at the extreme. This BMI puts Bernie in the 20th percentile for his age. He's leaner than most in his cohort without being in danger of being underweight 5/?
Being underweight in your late 70s is a major marker for rapidly declining health. That Bernie is a good weight should not be taken lightly. His pressure is also fantastic at 102/56. The American Heart Association goal BP is under 120/80, target resting heart rate is 60-100 6/?
Labs showed a normal blood count, vit D, and thyroid hormone level. This means no anemia and likely good iron stores. Vit D doesn't mean much outside of other health issues but thyroid is important as it helps regulate mood, metabolism, energy and concentration 7/?
A fasting glucose of 84 is fantastic. Goal is under 100 with repeat values above 126 indicating diabetes so no worries here. Total cholesterol of 117, goal is under 200. Most surprising is his LDL at 58!! LDL is "bad" cholesterol that is most closely linked to heart disease 8/?
Goal LDL for healthy adults is under 100 but the PROVE-IT study found outcome improvements in adults after a heart attack with LDL levels as low as 60. So Bernie's level is outstanding and, to be honest, VERY difficult for people to hit even among much younger patients 9/?
The only quibble here is his HDL ("good") cholesterol. Goal is above 40, ideally above 45. HDL is notoriously difficult to bring up however as medications are either ineffective or poorly tolerated. Best way to raise HDL is cardio exercise. Get that heart pumping, Bernie! 10/?
An ECG in sinus rhythm doesn't really tell us much tbh. I wish we could see it to see if there's any abnormalities at all. At the very least, it tells us there hasn't been enough damage or heart enlargement to cause conduction problems but those are ruled out further down 11/?
Ok, time for medical history. Gout is often diet or kidney related but he's not on any prophylactic medications for gout which means he has gout attacks sparingly. He's being treated effectively for hypercholesterolemia with Atorvastatin and low thyroid with Levothyroxine 12/?
The laryngitis secondary to reflux means he has heartburn issues but he's not on any acid reducing meds which means it's likely mild. Chronic uncontrolled reflux does increase the risk of throat cancer, but no acid meds means he's likely never had an ulcer so risk is low 13/?
His daily meds include Atorvastatin for cholesterol, aspirin and clopidogrel to prevent his recent heart stent from clotting, levothyroxine for low thyroid function, and lisinopril for blood pressure. Overall a fairly light regimen 14/?
Ok, time to talk about the heart attack. There's some great info here. Cardiac markers are usually the first thing used to screen for an MI(heart attack) apart from an ECG. That they ordered an echocardiogram before sending him to the cath lab means his ECG was likely normal 15/?
Echocardiograms help measure how well your heart pumps blood and how the heart walls and valves move. It's basically an ultrasound for your heart. A normal ECG during a heart attack is known as an NSTEMI which is slightly milder than a STEMI, though outcomes are similar 16/?
Greatest mortality predictors following an MI are age and heart failure. Can't do much about his age and it's definitely a pertinent prognosticator but a lack of heart failure medications means Bernie's heart is at least pumping adequately 17/?
Another important piece gleamed from this paragraph is the fact that this was single vessel disease and only one artery was treated. All vessels are evaluated during a cath. Single vessel disease decreases his likelihood of repeat MI and eventual need for bypass surgery 18/?
A 3 day hospitalization also reinforces the sense that this was a mild heart attack and is typical for 1st time stent recipients without complications. 19/?
One thing many pundits failed to realize is that a heart attack diagnosis IS NOT ALWAYS CLEAR CUT. If Bernie really did have a normal ECG, a heart attack can't be confirmed until AFTER his cath lab. So a short delay in reporting before confirmation is not at all surprising 20/?
Next is follow up discussion. Bernie initially took a beta blocker but it was stopped, likely because there was no sign of heart failure or abnormal rhythm and he has a friggin resting heart rate of 62. Serial normal echocardiograms rules out chronic heart failure 21/?
Normal heart wall motion and normal repeat 24hr heart monitoring also means there was very little permanent damage done to the actual heart muscle. This is further reinforced by a treadmill test that Bernie passed with flying colors 22/?
A heart rate 92% of target heart rate for age means his heart rate got as high as 130-150 without discomfort or signs of low blood flow. That's FANTASTIC. Pundits mocked the favorable comparison to his age cohort but that's both medically relevant AND 100% accurate 23/?
Ok, that's 20+ tweets breaking down the most in depth of the letters he released. I hope this clarifies their contents. If this was beneficial, I'd be happy to do the same for the other 2 letters and even compare it to Trump's. Let me know 😁
I discuss the remaining letters here:
I discuss Biden's health summary letter here:
I discuss Warren's health summary letter here:
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