Articles
Your Health Alert
Week 12
Tuesday, January 6, 2009
Daily Camera, Boulder, CO
Standard Care for Cardiovascular Disease Will Get You Killed!
An old friend recently called to tell me that he had a balloon angioplasty and a stent in his coronary artery. He had been on low dose statins (Zocor then Lipitor) and an aspirin for 3 or 4 years. When I asked him what he is doing differently since getting the stent he said, “Nothing.” Does anyone else see the problem with that answer?
Keep doing the same things, and you will keep getting the same results. The treatment that allowed his first obstruction will certainly allow another.
So what do we do differently at Heart Attack Prevention Strategies? When I find the systemic disease atherosclerosis (Plaque) anywhere in a patient the treatment gets dramatically more aggressive. I’ve discussed how we find disease in previous articles, but this article is about treatment. I use four paths of treatment, that I call cornerstone therapy.
The first cornerstone of my therapy is Lifestyle. I do not have any medicine as important as a healthy lifestyle. However, the definition of a healthy lifestyle can vary depending on your genotype and specific blood tests (please refer to week 8 about using genetics testing to help prevent heart attacks).
The first part of lifestyle is getting regular exercise. Some of the pleiotropic effects of exercise include increase in insulin sensitivity, myocardial oxygen supply and contraction, mental health, increased HDL (good cholesterol) and endothelial function. Exercise also decreases LDL (bad cholesterol), triglycerides, blood pressure, and blood coagulation. However, exercise is more beneficial for some blood types than for others.
The next part of lifestyle is a healthy diet. This should include the avoidance of all trans fat, and keeping saturated fats to a minimum. The Mediterranean Diet will benefit most people, except for those with genotype Apo E 4. And in general, dark leafy vegetables will be very helpful.
Other important issues for lifestyle are the avoidance of stress, anxiety and depression. In the Interheart study, sponsored by NIH, psychosocial issues were the third leading predictor of heart attacks. Along these lines, it is important to get at least six and preferably seven or eight hours of sleep each night. There have even been recent studies to suggest that good dental hygiene is very important in preventing atherosclerosis. And smoking will certainly increase your risk.
The second cornerstone for patients with plaque is anti-platelet, meaning 162 mg of aspirin a day for most. But then I test the patient for aspirin resistance because 27% of the population has it. For them, if the dose is not properly corrected the risk of an event is twice as high.
An Angiotensin Converting Enzyme (ACE) Inhibitor is the third cornerstone. Usually used for treating blood pressure these drugs stabilize endothelium (anti-inflammatory) in at least eight ways totally independent of lowering the blood pressure. The drug Ramipril worked the best of all the ACE’s lowering heart attacks 20% and strokes 32%. Sometimes if the heart hormone Pro BNP-nt is elevated (above 64) I will use the Angiotensin Receptor Blocker (ARB) Telmisartan instead of Ramipril. And sometimes I will add the new renin inhibitor Aliskiren if needed.
I am sure there is only one word in Boulder dirtier than Statins. But the fourth cornerstone of therapy is usually a statin, and Rosuvastatin (Crestor) and Simvastatin (Zocor) are my favorites. For years we have known that statins will lower LDL cholesterol about 30% with a corresponding decrease in cardiovascular events. Statins have many additional effects besides lowering cholesterol. They regulate nitrous oxide for endothelial function, inhibit LDL oxidation, lower circulating inflammatory markers, inhibit platelets, reduce leukocyte adhesiveness, favorably affect circulatory clotting factors and stabilize plaque by decreasing the lipid content, reducing inflammatory infiltrate (macrocytes and T lymphocytes), effecting vascular smooth muscle growth and decreasing the inflammation at the fibrous cap. And statins are remarkably safe in spite of what you hear at the local coffee shop. Do I prescribe statins for patients who do not have evidence of plaque in their arteries? You bet I do! --If they have dyslipidemia and/or other risk factors which cannot be corrected otherwise. I would rather prevent plaque than treat plaque. In the recent JUPITER trial there were 17,000 participants who had never had a cardiovascular event. They all had normal cholesterol. But they all had an elevated c-CRP (cardio marker of inflammation) of 2.0 or greater. They gave half of them 20 mg of Crestor and half of them a placebo. The group that took Crestor had about half as many heart attacks, strokes and deaths as the placebo group.
Most patients that I see that need treatment have problems that are not adequately addressed with just the cornerstones. In these cases we employ additional strategies. For instance a low HDL will benefit from Niaspan, fenofibrate or pioglitazone. Someone with elevated Lp(a) needs Niaspan and perhaps estrogen or testosterone. Elevated fibrinogen responds to Niaspan, fenofibrate, raloxifene and lifestyle changes. For Insulin Resistance there are lifestyle changes, pioglitazone, Ramipril, Carvedilol, Magnesium and Chromium. Pioglitazone has been shown to cut the number of recurrent strokes in half. EPA and DHA in fish oil or in Rx Lovaza work well for treating the Triglyceride/HDL axis disorder. Some recent studies suggest a benefit from Vitamin D in preventing heart attacks. Other things that favorably affect cholesterol and glucose include cranberry juice, fiber, almonds, coffee, ginseng, sweet potato root, cinnamon, chromium, magnesium, plant stanols and low alcohol consumption (for some).
There are many other unique problems which we treat with unique solutions. No two patients are alike and it takes addressing all risk factors to beat this disease. And I say that every adult American is at risk until proven otherwise. But atherosclerosis can be detected and it can be stopped. As one patient put it, “If you can prevent it, then just prevent it!”
Next week I will write the Conclusion of this 13 week series. Previous columns with explanations of many of the terms used today can be found on the Heart Attack Prevention articles page.
Joe Turnbow, M.D.
Copyright 2008, Heart Attack Prevention Strategies P.C. All rights reserved.