Interventional Prevention – Taking Cardiovascular Disease Prevention to a New Level

In the November 27, 2013 JAMA issue, my letter, “The Pitfalls of Population-based Prevention was published with a very favorable response from Dr. Harvey Fineberg, the head of the Institute of Medicine (IOM). I was elated to see not only the letter’s publication and my introduction of the term, “Interventional Prevention” – a modern-era approach to risk reduction – but Dr. Fineberg’s forward-thinking reply as well. Interventional Prevention is after all a departure from “standard” prevention practices. We typically think of prevention in two facets, primary and secondary.

Primary prevention entails thwarting events before they have occurred while secondary prevention is the system wherein doctors utilize strategies to stop adverse events from occurring AFTER a first event has taken place. For example, hypertension and tobacco abuse are both well-established risks for heart attack and stroke. Our goal as health care practitioners is to lower blood pressure and help patients stop smoking in order to prevent heart attacks and strokes. In patients who have already had one of these events, this is termed secondary prevention; while it is primary prevention in those who have never suffered such an outcome. This describes the established approach to prevention.

Interventional Prevention is a much more proactive process. In this construct, doctors use cutting-edge predictors of risk such as biological markers in our blood and urine and imaging of different vascular beds (carotid and coronary arteries for example) to diagnose “hidden” disease or biologic perturbations and motivate patients to make significant lifestyle and medication changes in order to reduce their risk. Then we can evaluate these same markers and actually see improvements. We can do this in patients who have never had heart attacks and strokes, ostensibly decreasing their risk of ever experiencing such an adverse outcome. In Interventional Prevention, doctors identify and expose novel risks, make changes in patients’ regimens, and then facilitate improvement in what would otherwise have been “hidden” risk factors. Essentially we illuminate the invisible thereby affording patients and doctors the opportunity to heal aspects of our bodies before these perturbations cause irreparable harm. For example, with appropriate interventions we can demonstrate improvement in inflammatory blood enzymes such as LpPLA2. High levels of LpPLA2 predict both heart attacks and strokes while low levels predict the opposite. Through proper interventions we can witness the normalization of this and many other blood and urine biomarkers, clearly demonstrating on an individual basis the improvement in health and concomitant diminution of risk. This is truly patient-centric medicine. The medicine of the future has already arrived.

Learn more about comprehensive preventive cardiology at preventivecardiologyinc.com

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New AHA / ACC Cholesterol Guidelines – Controversial but not to be Feared

Last week four guidelines were released by the AHA and ACC. A tremendous amount of controversy surrounded the Cholesterol Guidelines as they deviated in fundamental ways from prior standards. The writers of the guidelines took a strict Evidence Based Medicine (EBM) slant, limiting extrapolation and thereby altering the traditional approach to cholesterol management. For example the format of all prior clinical trials did not specifically address cholesterol goals. Thus they were excluded from the guidelines. That does not, however, mean that it is wrong to continue to try to “get our patients to goal”. It simply means that in the strictest view of EBM, there is insufficient evidence to do so. The American Society for Preventive Cardiology (ASPC, of which I am Treasurer) and several other organizations endorsed the document. The National Lipid Association (NLA) did not. It is critical for practitioners to understand two things when trying to utilize this document as effectively as possible. First, the guideline was meant to be a living work, one that will be updated at regular intervals. Second, and perhaps far more consequential, it is essential that practitioners ardently adhere to a single paragraph from the guidelines which follows:

“Guidelines attempt to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate.”

In sum, we most always remember that guidelines are just tools to help practitioners understand the most recent evidence in medicine. They are not laws. Clinical judgment must always reign supreme.

Please read more about preventive cardiology at www.preventivecardiologyinc.com.

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Learn to Read the Label: What to Look for When Choosing an Omega-3 Fish Oil Supplement

Omega-3 fish oil supplement labels can be very deceiving. This video explains how to choose the appropriate fish oil supplement.

Get more info on the world’s most potent omega-3 fish oil supplement at vitalremedymd.com

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Sugar: Our Unrequited Love

It has become common knowledge that sugar is bad for us. Interestingly, human beings require both fat and protein for optimal health and even survival, but we needn’t consume even a grain of sugar to live full and robust lives. Our love of sugar is unrequited; sugar in many ways is our enemy. It is quite probable that you’ve been to your doctor who, in reviewing blood tests, has informed you of your Hemoglobin A1c (HgA1c) level. He or she might have told you that HgA1c is a measure of your blood sugar level over the past three months. I’ve said that on many occasions to my own patients. Recently I recognized a lost opportunity in conveying the aforementioned message. Therefore, I am writing this brief note to clear the air.

Although it’s true that HgA1c tells us whether or not one’s blood sugar has been too high over the previous three months, it actually tells a far more important story. Hemoglobin (the Hg part of HgA1c) is an iron-containing protein. Proteins, and fats, are susceptible to permanent damage by high blood levels of sugar. HgA1c is actually the amount of damaged hemoglobin in our blood. It is not alone however. All proteins and fats can be victims of sugar-induced damage and the process whereby sugars permanently injure proteins and fats is termed glycation. Thus, when one has a high HgA1c he or she should understand that hemoglobin is not the only molecule in the body bearing the brunt of high sugar levels; it’s simply an easy one for us to test. Other fats and proteins such as those in our arteries, brains, nerves, kidneys, and eyes are also being marred by sugar. And when these proteins are hurt, the organs within which they reside are also damaged. Thus we experience heart disease, brain injury, peripheral neuropathies, kidney failure, and even blindness from high sugar levels.

So the message when it comes to elevated HgA1c is not simply, “you have high sugar”, it’s really, “your high sugar levels are taking a terrible toll on the many proteins and fats that support your body’s normal functioning.” So please be mindful when it comes to sugar. Sugar may be sweet, but sugar is not your friend.

Learn more about how the finest quality vitamins, minerals, and omega-3’s, can improve and maintain your health. vitalremedymd.com

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High Cholesterol Levels – Time is Plaque

In the initial days of thrombolytic therapy (potent blood thinners used to treat heart attack patients) we had a saying that, “Time is Muscle”. The intent was of course to get our patients treated as quickly as possible, understanding that the longer their arteries remained closed, the more heart muscle would be lost. More damage meant worse outcomes. And so we got faster and faster, ultimately treating our patients within minutes of their initial evaluation. This need for speed has been brought into the era of acute interventions, the stents. Now we speak of door to balloon times and all hospitals boasts of their superior swiftness. The faster we get our patients to the cardiac catheterization lab for definitive treatment to stop their heart attacks, the better they do.

Analogous to the situation with heart attack patients, individuals with extremely high LDL cholesterol are now known to develop plaques in their arteries in accord with the duration that they experience their high lipid levels. Some children have such high cholesterol levels starting even from when they’re in utero; they develop heart attacks before the age of five. This of course is quite rare, but it does illustrate the importance of both cholesterol levels and time in plaque formation. For proper prevention we need to adopt a greater sense of urgency, one that embodies our understanding that the longer one has high cholesterol levels, the more likely he or she is to develop vascular disease. In short, we ought to start declaring, “Time is plaque!”

Please read more about treating high cholesterol at www.preventivecardiologyinc.com.

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TCT, a Great Interventional Cardiology Meeting, but Just One More Thing…

Today’s blog post will be brief. The TCT meetings just ended but an essential fact was omitted and should be shared with doctors and laypeople alike. 25% of patients who experience heart attacks before the age of 45 have a common genetic disorder called Familial Hypercholesterolemia (FH). 25% is actually quite a substantial number so it’s important for us to identify and treat these patients appropriately. As the disorder is genetically transmitted, 50% of first degree relatives will also have this disease. That means there’s a 1 in 2 chance that each child, sibling, and parent of patients with FH will also harbor this disorder, a genetic mishap that increases the risk of premature heart attacks by up to 20 fold! The sooner such patients are identified and treated, the less likely they are to ever have a heart attack. So please know your risk!

Please read more about FH at www.preventivecardiologyinc.com.

Related: more blog articles on the topic of Familial Hypercholesterolemia (FH)

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