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The following article by Dr. Turnbow was featured in the Peak Asset Management's 2nd Quarter 2009 Newsletter Financial Intelligence. He was asked to write it by John McCorvie, CFA who is a principal in the firm. It clearly shows that what the medical profession is doing in education, early detection and treatment of cardiovascular disease is not good enough.
INVESTING IN YOUR HEART
Fact: Cardiovascular disease (including heart attacks and strokes) kills more people each year than all cancers, infections and accidents combined.
Fact: In men 50% of the time and in women 64% of the time, the first symptom of a heart attack or stroke is sudden death.
Conclusion: The current standard of care for cardiovascular disease could get you killed.
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Now is the time to invest in your heart.
The incidence of initial heart attacks is the only disease condition that has not shown any significant improvement over the past 80 years. We have made great strides in treating people after a coronary event, but essentially no progress has been made in our efforts to prevent the initial event. Would it surprise you to learn that women are ten times more likely to die from heart attacks than from breast cancer? Even after being diagnosed with cardiovascular disease, it is estimated that over 60% of patients still have their initial event (i.e. a heart attack or stroke) at the same time they would have it if they were not receiving any treatment at all. Clearly, as a profession, what we are doing in education, early detection and treatment of cardiovascular disease is not good enough.
My name is Joe Turnbow, MD. I own and practice at Heart Attack Prevention Strategies, PC in Boulder, Colorado. I am a board certified Emergency Physician. Over the past 30 years, I have been the Medical Director of two emergency departments and in 1989 opened my own urgent care center in Boulder, Colorado. Over the course of my career, I have found a passion for preventing heart attacks and strokes. I now devote 100% of my time to saving my patients from America’s number one killer. My intent in this piece is to: 1) create awareness of some of the limitations of “traditional” detection and prevention techniques, 2) introduce some of the advancements in medical thought, technology and treatment in regard to cardiovascular disease, and 3) prompt you to take the steps that could save your life.
Some shortcomings in the current Standard of Care:
- Traditional treadmill/stress tests miss an estimated 86% of significant coronary disease. Treadmill tests measure the flow of blood, not the amount of plaque in the arteries. Most people think that a heart attack occurs when the artery becomes 100% blocked by plaque, which cuts off the blood flow. However, this happens only 11% of the time. So what causes the other 89% of heart attacks? In most arteries when plaque occurs it lives in the wall of the artery causing it to bulge outward. A thin lining forms between the built up plaque in the wall and the opening of the artery, even as the blood is still flowing freely through the artery. When the thin lining ruptures a clot forms and causes a heart attack in 1 – 5 minutes. An artery must be at least 67% blocked for a problem to show up on a treadmill test and 86% percent of heart attacks occur in an artery that is less than 67% blocked.
- Over half of the people having heart attacks have “normal” cholesterol levels. Similarly, a low or mid level risk score on the traditional “Framingham” study does not statistically protect you from a heart attack.
- Aspirin is commonly used as an antiplatelet to help inhibit blood clotting, but a growing body of research suggests that a material percentage (approximately 27%) of the population is asprin “resistant” and therefore requires an appropriate adjustment in dosage to overcome resistance (or the risk of a stroke or other cardio-vascular event is significantly higher).
- Finally, just in terms of common sense, for those who have been identified and treated for cardiovascular disease and subsequently had a heart-attack or a stroke, it is evident to me that treatment was not effective and needs to be reevaluated. Along those lines, I recently received a call from an old friend to tell me that he had a balloon angioplasty and a stent in his coronary artery. He had been on low dose statins and an asprin for three or four years. When I asked him what he was doing differently since getting the stent he said, “Nothing.” (You are your own best advocate!)
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The tools to detect and manage cardiovascular disease exist today.
I believe we need to make a paradigm shift in cardiovascular disease management away from the old curative model of late disease intervention to a new preventive model and early intervention. As I noted above, the tools to detect and manage cardiovascular disease exist today, but it is up to the medical community and individuals to use them. For each of my patients, I perform a comprehensive evaluation of lifestyle factors, advanced diagnostic lab test results and advanced scan results to detect the presence and nature of cardiovascular disease and, if detected, design and implement an aggressive treatment and review program. I say “If you can prevent it, then just prevent it!”
The state of the art tools for detection:
Classical risk factors for cardiovascular disease include family history, high blood pressure, low HDL, high triglycerides, obesity, erectile dysfunction, nicotine use, osteoporosis, gum disease, gout, sleep apnea, migraine headaches, polycystic ovaries, anxiety and depression, lupus, rheumatoid arthritis, psoriasis, previous heart attack or stroke, diabetes, insulin resistance, and age (men over 35 and women over 40). The following is a list of advanced detection tools that should be used to determine if someone is at risk for cardiovascular disease.
- Advanced diagnostic lab testing: including advanced lipid tests and advanced markers of inflammation to help diagnose if the patient is at risk for developing atherosclerosis, or if they already have it (as diagnosed by scanning) why they have it and how to treat it. Specific tests measure: total cholesterol, LDL (measured—100% accurate), HDL, triglycerides, Apolipoprotein B, Apo E genotype, KIF6 gene, aspirin resistance, c-CRP, CBC, CPK, comprehensive metabolic panel with EGFR, fibrinogen, Ferritin, GGTP, 2 hour glucose tolerance, hemoglobin A1C, h. pylori Ab, insulin response to glucose fasting & 2 hour, Lp-PLA2, magnesium, chromium, urine microalbumin/creatinine ratio, myeloperoxidase, Pro BNP-n terminal, PSA & testosterone (men), TSH, uric acid, VAP lipid panel(measures many subclasses of cholesterol that play an important role in heart disease) or the NMR lipid panel which gives us particle numbers, and vitamin D.
- Advanced scanning: there are four advanced scans that you can use to help find the disease (the first three scans are ultrasound scans that are quick, inexpensive, safe and free of radiation):
- The Carotid Intima Media Thickness (CIMT) scan is highly predictive of the development of stroke or heart attack. The American Heart Association says it is valid and reliable. You can follow the thickness of the arterial wall from year to year to assess risk and efficacy of treatment. It can also see soft or hard plaque in the artery.
- An abdominal aorta ultrasound scan looking for aneurysms. As many Americans die each year of ruptured abdominal aortic aneurysms as men die of prostate cancer or women die of breast cancer. The aneurysms are asymptomatic, or display no noticeable symptoms, 90% of the time and the death rate from rupture is 90%.
- The third scan is the ankle/brachial index comparing blood pressure in the arm to the leg. This test is for peripheral arterial disease.
- The fourth scan is the EBCT heartscan. This is an electron beam CAT scan of the heart and is not the same as a 64 slice heartscan. It accurately detects calcium in the coronary arteries which correlates with the amount of plaque 97% of the time. The higher the calcium score, the higher the risk. I also use this scan sequentially to judge the efficacy of treatment.
The tools for treatment and intervention:
Since no two patients are the same, any treatment must be tailored and monitored to meet specific patient needs. There are four cornerstones to a cardiovascular disease treatment:
- Lifestyle. There are no medications as beneficial as a healthy lifestyle. This includes the proper diet, weight (BMI of 22 or less), exercise, avoidance of stress and getting enough sleep and laughter. A healthy lifestyle is important for everyone and, if possible, should start in early childhood.
- An antiplatelet. For most this is 162 mg of aspirin a day, but, as I noted above, the dosage needs to be adjusted to overcome any individual resistance.
- An angiotensin converting enzyme inhibitor (ACE-I). These are commonly used to treat hypertension, but they also induce endothelial stabilization totally independent of what they do for blood pressure. There is also a test to determine if another class of drugs would work better than the ACE-I in a particular patient.
- A statin (like Crestor or sometimes Simvastatin). Statins are good drugs and have many wonderful effects beyond lowering cholesterol. I also use a number of other medications for special situations.
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It is clear to me, based on the facts, that the current standard of care for cardiovascular disease, both in detection and treatment, is just not good enough. Based on my research, education and professional experience in successfully working with hundreds of patients with cardiovascular disease, a better standard of care is available today. From a “Financial Intelligence” perspective, the investment is small and the potential return is your life.
Joe Turnbow, M.D.
Full Listing of Articles by Dr. Joe Turnbow
Week 1 - Introduction to the problem, statistics, and foreshadow of future columns
Week 3 - Treadmill Tests Miss Over 68% of Heart Disease!
Week 4 - Heart Scans Find Plaque in Your Arteries
Week 6 - Lp(a) The Heart Attack Cholesterol
Week 8 - Genetics Testing in Preventive Medicine
Week 9 - Comparing Heart Scans
Week 10 - Heart Scans and Calcium Scores
Week 11 - Your Best Predictor of Strokes
Week 12 - Standard Care for Cardiovascular Disease Will Get You Killed!