Heart Month 2015: We’ve come a long way but still have “miles to go before we sleep”

So many strides have been made in the management of ASCVD (atherosclerotic cardiovascular disease): our understanding of its pathophysiology, our ability to thwart an erupting heart attack, our techniques to destroy brain threatening strokes, and methods to correct valves and aneurysms through tiny holes in the body have all blossomed over the last few decades. Still many questions remain. What’s the optimal diet? Is it low fat, high fat, high protein, high complex carbs, no fat, only omega-3 fats…? How much exercise do we really need? And what’s the best form of exercise? What’s the optimal role for cardiac imaging? Who should get a bypass and who, a stent? How long should dual antiplatelet therapy continue after a drug eluting stent? What’s the optimal blood pressure? Why do men and women have such divergent responses to CVD and its therapeutic interventions? How low should we drive cholesterol levels?  When is the best time to start driving these levels down? Why do we continue to have such a high residual risk of a CVD event even after seemingly doing everything right? Why is peripheral arterial disease (PAD) such a fearsome predictor of future stroke and heart attack? The list is interminable. That’s not hyperbole. And the infinite list of remaining questions is at the same time both frustrating and invigorating. Though we’d like to have all the answers and all the solutions to our woes, this never-ending list humbles us and reinforces the miracle of our being. We are truly the most fascinating and remarkable living “machines”.  For today though, and this Heart month, let’s focus a moment on familial hypercholesterolemia (FH), another source of both recent advances as well as remaining controversies.

FH is a potentially devastating form of genetic high cholesterol. Its victims possess important genetic mutations that beget likely premature heart disease and lifelong angst. Parents pass the disease to their children, concomitantly bearing the crosses of guilt and fear. Many questions involving FH remain: How many undiagnosed patients are there with FH? How do we precisely distinguish HoFH from HeFH? How do we increase patients’ access to therapies such as lipoprotein apheresis, lomitapide and mipomersen when indicated? How do we choose these therapies for a given patient? After all, all patients, as all people, are different. Fortunately many are laboring to find answers to the FH questions. Leading the charge is Katherine Wilemon and the FH Foundation (FHF). Growing at an unprecedented rate and having the support of the world’s brightest FH scientific and medical minds as well as generous pharmaceutical sponsors, the foundation is spearheading programs to find those with FH so they can be properly treated. Through its website, the FHF is bringing patients together so they can find common solace. The group is also cataloguing patients with FH so scientists can better study the disease and in so doing defeat it. The list goes on.

Perhaps the best way to understand all that the foundation is doing and plans to do is for you to join us for an FH Foundation tweetathon at 8PM Thursday February 19th. Just go to #KnowFH and join the thousands of others who will be discussing what’s old, what’s new, and what’s in store for the future of those with FH. Speak to you Thursday!

Learn more about preventive cardiology at www.preventivecardiologyinc.com.

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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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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.

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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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National Cholesterol Education Month – check your cholesterol levels

couple bike riding

Today September – National Cholesterol Education Month – comes to a close.

Two weeks ago I participated in the First International Familial Hypercholesterolemia (FH) Summit, hosted by the FH Foundation and attended by 120 cholesterol experts from around the world. It was an inspiring event. Katherine Wilemon, a young heart attack survivor and bearer of the not-so-uncommon and far-too-frequently deadly genetic cholesterol disorder FH, led the charge for FH awareness and concomitant therapy. We all left the meeting brimming with optimism.

Last week I had the privilege of delivering Grand Rounds at UCI, again on the subject of FH. The message was well received; if doctors fail to consider FH we will of course fail to identify it. Absent its identification, treatment cannot be rendered. Translation – we must put FH on our radar screen.

While many of us are working tirelessly to “spread the word”, naysayers blather uncensored on the internet and in the popular press about the dangers of cholesterol lowering drugs and the fallacy of the “cholesterol hypothesis”. Never before has medical science so clearly identified a culprit for heart disease and never before have we had such wonderful ways to mitigate the threat. Yet the gains we make are eroded daily by these adversaries. What are we to do? Somehow less knowledgeable but more vociferous folks have usurped our podium. Somehow the public has lost faith in medical science, instead choosing to believe oftentimes fork-tongued purveyors of “anti-science” spreading the paranoid perspective that drug companies and doctors conspire solely for their own advancement. How do we fight and win this battle? I believe that victory rests in patients once again understanding why it is that doctors deliberately choose their arduous path. Doctors don’t whimsically decide to devote ten or more years of their post-college lives to incomparably hard work and abysmal pay. The decision to become a physician is always well-considered. It is also a choice that can be made by only the brightest and hardest working young men and women. So what is the common denominator that drives these people to enter an exhausting and oftentimes unappreciated profession? Simply put, it is to help others. Doctors become doctors because they care. This I can promise you to be true. So when your doctor offers advice about cholesterol (or other issues for that matter) please consider from whence the advice originates. Contrast that to the recommendations you may see or hear on the internet, through the media, or even from an ostensibly well-meaning friend.  Doctors have their patients’ best interests at heart. The same is not so clear about the naysayers.

So at the close of National Cholesterol Education Month, do yourself and your loved ones a favor. Check your cholesterol levels. Then speak with your doctor. Be sure you’re being treated as well as we can treat you. It really could save your life.

Learn more about comprehensive preventive cardiology at preventivecardiologyinc.com

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Cholesterol-Lowering Foods

Just as a diet rich in cholesterol-boosting foods and saturated fats may have given you high cholesterol, one rich in cholesterol-lowering foods may help you lower your “bad” cholesterol levels.

woman holding flower in fieldTransitioning to a “dietary portfolio” that combines a variety of cholesterol-lowering foods can be an effective way to lower your “bad” cholesterol levels and improve your overall health.

A study conducted by Dr. David A. Jenkins of St. Michael’s Hospital in Toronto found that combining foods with recognized cholesterol-lowering properties proved very effective in lowering serum cholesterol under metabolically controlled conditions.
The study concluded that use of a cholesterol-lowering dietary portfolio resulted in greater LDL-C lowering during 6 months of follow-up.

Foods that can lower cholesterol

  • Fatty fish: eating two servings of fatty fish (good fat) like salmon, tuna, mackerel or bluefish per week will not only increase your intake of cholesterol-cutting omega-3s, but potentially reduce consumption of meats and protein sources containing LDL-boosting saturated fats (bad fats).
  • Nuts: whole almonds, walnuts and peanuts (unsalted of course) have been shown to slightly lower LDL cholesterol levels.
  • Beans: including navy, lentils, garbanzo, and kidney.
  • Vegetables: garlic, okra, spinach, eggplant and other veggies rich in soluble fiber.
  • Fruit: including avocado, apples, strawberries, grapes and citrus.
  • Grains: oats, barley, psyllium and other whole grains.
  • Liquid vegetable oils: canola, sunflower, safflower, and others and margarine enriched with plant sterols in place of butter, lard, or shortening when cooking or as condiments.
  • Soy products and tofu: products made from soybeans can have a modest impact on lowering cholesterol and can have the added bonus of replacing some animal protein in your diet.


Don’t eat:

  • Fatty meats.
  • Fat-rich dairy products like whole milk and cheeses.
  • Processed foods loaded with trans fats, saturated fats, salt and chemicals.

Do eat:

  • Foods high in omega-3s, including fatty fishes.
  • Foods high in soluble fiber.
  • Whole grains.
  • Low-fat dairy products.
  • Lean meats and poultry.

Exercise regularly: Excess weight boosts harmful LDL levels.

Note: Genetics play a major role in our cholesterol levels and overall heart-health. Have your cholesterol levels tested regularly and heed your doctor’s advice on cholesterol-lowering medications, statins and daily dietary supplementation.

Additional sources:

The Harvard Heart Letter 

Mayo Clinic

Related: more articles on heart health featured on the FPIM blog

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Vitamin D – an Important Daily Vitamin

Hands and Sunset

I’ve felt for quite some time that vitamin D — and D3 in particular — should be an important component of a healthy individual’s daily vitamin intake, often in the form of supplementation.

As we learn more and more about the promising role of vitamin D, additional patients with D deficiencies are being identified. Unfortunately, vitamin D is not found naturally in many foods, so most of our vitamin D is produced in our bodies by the action of sunlight on the skin.

Aging decreases our synthesis of vitamin D
Most vitamin D is produced in our bodies when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. As humans age, however, we often lose the ability to manufacture adequate amounts of vitamin D.  Research indicates that vitamin D is important not only for proper absorption of calcium and the maintenance of bone health, but also for maintaining healthy joints, a healthy cardiovascular system and healthy moods. In addition, vitamin D plays an important role in regulating cell division and differentiation and supports immune system function through its effects on macrophages, natural killer cells (NK), and T cells. Scientific data indicate that vitamin D also has a role in helping to maintain breast, prostate, colon, and kidney health. In other words, its impact in our bodies is far-reaching.

Vitamin D3 more effective than D2
A recent study published in The American Journal of Clinical Nutrition* further supports my evidence-based belief that vitamin D3 is more effective than D2 (it can raise blood levels of vitamin D up to 70% better than D2). AJCN’s first-ever systematic review and meta-analysis comparing the effectiveness of the vitamin D forms supports the findings of many other researchers and studies.  (Note: vitamin D is found in two forms D3 or Cholecalciferol and D2, or Ergocalciferol. In contrast to Cholecalciferol, Ergocalciferol is not natural; it is a byproduct of irradiated fungi).

Check your vitamin D level
Ask your doctor to do a simple blood test for 25-hydroxyvitamin D [25(OH)D] that will provide the best measure of your vitamin D status. A 25(OH)D level of 40-50 ng/ml is currently thought to be optimal. If necessary, supplement with a daily multivitamin with adequate levels of vitamin D3 and then additional vitamin D3 as needed. A general rule of thumb is that your vitamin D level will rise 10 points for every 1,000 IU D3 taken daily.

Read that label
Look for the terms vitamin D3 or cholecalciferol on supplement labels. The D2 form of the vitamin (ergocalciferol) though widely used in fortification and supplements, is less potent and artificially derived.

*Study: “Comparison of vitamin D2 and vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis1–3” — Laura Tripkovic, Helen Lambert, Kathryn Hart, Colin P Smith, Giselda Bucca, Simon Penson, Gemma Chope, Elina Hyppo ̈nen, Jacqueline Berry, Reinhold Vieth, and Susan Lanham-New

Learn more about the highest quality vitamins, minerals, and omega-3’s – created by a leading preventive cardiologist. vitalremedymd.com

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