ACC/AHA Guidelines: Not a Replacement for Clinical Contemplation

On May 19th the Journal of the American College of Cardiology published an illuminating paper by Pant et al. examining the impact of a dramatic change in one of the Cardiac Guidelines. The paper was entitled “Trends in Infective Endocarditis Incidence, Microbiology, and Valve Replacement in the United States from 2000 to 2011”. In 2007 the ACC/AHA Guidelines were radically shifted, advocating an enormous reduction in sub-acute bacterial endocarditis prophylaxis (SBEP) precautions. The rationale for the dramatic shift from an aggressive to a conservative stance emanated from two findings: a lack of RCT evidence for the need for SBEP precautions under most circumstances, and the growing problem of antibiotic resistance. Without claiming prescience or any other such miraculous gift, I will tell you that at the time I predicted a significant future rise in endocarditis. My belief was that the guidelines overshot their intentions. Some individuals, I surmised, have valvular heart disease that predisposes them to developing SBE yet fails to be “significant” enough to make them candidates for the revised SBEP recommendations.

For several years I bucked the system and continued my aggressive prophylaxis. Then I buckled. I followed the guidelines to a tee. Though none of my patients has developed SBE, I now question my decision to cave under the pressure of the guidelines. I have always been one to try to think through issues, to treat patients outside any preordained box and beyond an overly simplified algorithmic construct. But in this case I felt perhaps I should just go with the flow. In truth, it was just easier to do so. My liability was lessened and my decision-making efforts were simplified. Yet, in retrospect, seeing the predictable rise in streptococcal SBE, I have been forced to re-examine my decision. In doing so, once again I am confronted with our current fixation on RCTs as proof positive “evidence,” with all other levels of understanding being “non-evidence”.

The absence of RCTs in this construct is tantamount to a lack of evidence. This paradigm is of course false. Many levels of valid evidence exist and oversimplification, though appealing, is inherently flawed and theoretically dangerous. We see this now in eight years of follow up after the change in ACC/AHA SBEP Guidelines. We also see this in many other aspects of everyday practice. Though I chose an easier and perhaps idler path in this circumstance, I will now reverse my position and once again give greater thought to each SBEP recommendation I render. It will take longer to do so; more complex doctor-patient discussions will be required; and larger liability will fall upon my shoulders. But these are the elements required to be a better physician. I owe it to my patients, and equally importantly to myself, to do so. Having said this, pragmatic issues remain. How do we practice medicine in an efficient, cost-effective, economically sound, intellectually stimulating, personalized, high-level fashion, while adhering to the mounting pressure of regulatory changes and requirements? This is the question that requires our most focused attention yet typically receives short shrift. For modern American Medicine to enjoy the future we all believe it deserves, this question, along with its counterparts, deserves our full and undivided attention.

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

For more information about the supplements and vitamins critical to your everyday health visit www.vitalremedymd.com.

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Fish Oil: It Conveys Much More Than Cardiovascular Health

woman jogging at sunrise
Numerous studies have evaluated the effects of the omega-3 fatty acids, DHA and EPA, on cardiovascular health. Overwhelmingly, scientists and clinicians involved in such research believe that omega-3 fatty acids play various beneficial roles in preserving optimal vascular and cardiac health: Anti-Inflammatory, Anti-Thrombotic, Anti-Arrhythmic, and TG-Lowering effects are considered to be the most relevant. Recently, Smith et al. published a fascinating and novel clinical trial looking at a non-cardiovascular yet widespread adverse aspect of aging: muscle mass decline. They published their findings in the American Journal of Clinical Nutrition: Fish oil–derived n–3 PUFA therapy increases muscle mass and function in healthy older adults. All parameters evaluated improved with the administration of 3,200 mg of daily DHA+EPA. Thigh muscle volume, handgrip strength, one-repetition maximum (1-RM) lower- and upper-body strength, and average power during isokinetic leg exercises all demonstrated statistically significant improvement. Improving muscle strength as we age can have far-reaching beneficial consequences that could reduce both morbidity and mortality. Thus, these findings need to be further studied in larger and even more consequential trials. But what additional meaning can we garner from their trial?

I believe that beyond their fascinating and clinically pertinent findings there actually lies a far more evocative message. It is simply that we should be extraordinarily cautious about abandoning the evaluation of therapies (even dietary) when they make biological and physiological sense. Fish oil consumption is woefully low in the US when compared to the far more healthy Japanese population. Our life expectancies are far shorter and various cancers occur more frequently in the US. It is scientifically quite plausible that our deficiency in omega-3 fatty acids plays a significant role in our relatively diminished health. But, after the publication of a few clinical trials failed to demonstrate the cardiovascular benefit of fish and fish oil in select patient populations, some physicians truly abandoned their prior admonitions for patients to augment fish consumption. They were derailed by the controversial results of just a few trials (that many exceptional researchers consider to be flawed in the first place). This type of knee jerk reaction has no place in medicine. It is dangerous and counterproductive. To protect our patients and maintain our scientific integrity, we must always practice with open and attentive minds. Once again I implore my scientific colleagues as well as the oftentimes superficially inquisitive media to follow the science, not the hype.

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

For more information about the supplements and vitamins critical to your everyday health visit www.vitalremedymd.com.

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Contemplations on Amsterdam and the ISA

Reflecting on the meetings I stare out the window of the restaurant and watch and recall:

The Anne Frank House with its images of a single family destroyed for the crime of being Jewish,
Nazis gathering Jews in the streets
Raping women
Killing children and old men,
Shopkeepers, bankers, doctors, lawyers, street cleaners, teachers;
None was immune.
I stare from the window watching the dog-walkers, bike riders, bustling streets brimming with energy, life, and carelessness.
The same streets just a moment ago were heavy with German tanks and soldiers herding Jews to their death;
For being Jewish.
Dog walkers and bike riders ride carelessly now, oblivious to the history of their streets;
Unaware that they ride and walk over the dried blood of fallen innocents.
The Amsterdam tulips have just finished their showing.
The city drips with life.
And but a few hours from this place are men and women and children being slaughtered today in fashion similar to what took place a short dream ago.
Over and over it goes.
How to stop this merry-go-round is unfathomable.
People who love their children cry when they hurt; they bleed when they are injured; pray to some god for whatever they pray; hope for their better day. Yet they still tear apart the lives of others. Still break the boundaries of peace and liberty, and freedom of thought and belief.
I ride the elevator to John Legend’s song from Selma, “One day, when the glory comes; it will be ours, it will be ours.”
The meetings were wonderful but they are a distraction, a diversion from the ineluctable.
Still, without them we would have only despair as our companion.
How do we disentangle this man-made, endless, seemingly insoluble dilemma?

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

For more information about the supplements and vitamins critical to your everyday health visit www.vitalremedymd.com.

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The American Society for Preventive Cardiology 30 Years and Counting

ASPC CVD PREVENTION

July 30, 2015 marks the start of the ASPC’s Annual meeting, taking place once again at the spectacular Boca Raton Resort. This year, in addition to our world-class faculty, new elements will be added to the meeting – poster presentations to be published in Clinical Cardiology as well as a Level 1 Expert’s Course in Preventive Cardiology. Over the next three months I will certainly write more about the conference and I hope many of you will avail yourselves of its offerings. (For more complete information please visit www.aspconline.org).

Today however, on the heels of the Dallas Cardio-Metabolic Health Congress (CMHC) I am compelled to write this brief note about the ASPC. The reason is simple. As I sat in the speaker’s row with my friends and colleagues Drs. Jamie Underberg, Amit Khera, and Michael Miller it became clear that the thirty-year-old organization is now firmly entrenched in mainstream education. You see, Dr. Underberg sits on the ASPC’s Board of Directors while Dr. Khera is the Secretary; I am the President Elect, and Dr. Miller is a Past President. It was truly heartwarming to have us all gathered together for the sole purpose of helping to educate our colleagues about issues such as Familial Hypercholesterolemia (FH), Hypertriglyceridemia, Lipid and Cholesterol Guidelines, and the future of HDL research and therapies.  The ASPC is growing at a gratifyingly rapid rate, as more and more physicians, ARNPs, and other healthcare practitioners embrace the doctrine that cardiovascular disease prevention must preempt intervention in order for our nation and the world at large to be able to truly enjoy optimal health. If you are not already a member of the ASPC, please consider becoming one. Also, I encourage everyone interested in prevention to join us in July. I promise you will not be disappointed.

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

For more information about the supplements and vitamins critical to your everyday health visit www.vitalremedymd.com.

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Homocysteine and Folic Acid Supplementation: Another Medical “About Face”

On March 15, 2015 JAMA published on line the results of a superbly designed and potentially practice changing trial. The China Stroke Primary Prevention Trial (CSPPT), tested whether or not the addition of folic acid to anti-hypertension medication could reduce the occurrence of a first stroke. As three quarters of all strokes are “first strokes” and as strokes are a leading cause of death and disability worldwide, the question posed by this trial had far reaching implications. The trial met its endpoint so quickly and incontrovertibly that for ethical reasons it was prematurely terminated. Folic acid can reduce the risk of stroke. Those of us who have open-mindedly interpreted prior studies expected this finding; many others found the results to be shocking.

Important homocysteine related trials like HOPE 2 and others had already demonstrated either statistically significant reductions in stroke with folic acid supplementation or at least signals toward such an outcome. Yet many of the most “vocal” researchers, physicians, and reporters proclaimed that since heart attacks were not reduced with folic acid, “the homocysteine hypothesis was dead.” This perspective always bothered me. We had observational and even interventional trial data supporting the use of folic acid in certain settings. And stroke, the disorder we could impact with a simple vitamin, is horrific. Strokes are terrifying, disabling, and deadly. They are also extraordinarily common. So why would these doctors, scientists, and media members snub data supporting a simple and safe vitamin treatment to potentially reduce such events? It would be helpful to know the reason, as the same phenomenon is currently occurring in relation to omega-3 fish oils.

Plenty of data support fish oil supplementation yet a few trials do not. And as with homocysteine, it seems that the media and many scientists/doctors have chosen to focus their attention on the limited neutral – and oftentimes overtly flawed – data rather than supportive experimental, biologic, physiologic, clinical trial, and common sense evidence. Interestingly, one of the vital lessons gleaned from CSPPT is that those individuals with either specific genetic mutations or very low levels of folic acid received the greatest benefit (reduction of stroke) from taking folic acid. In parallel fashion, one of the key trial limitations of fish oil studies has been the persistent failure to measure blood levels of the omega-3 fatty acids DHA and EPA. It certainly stands to reason that those with lower levels of these critical fats will also gain the greatest advantage from their supplementation. So why not simply measure them? Well, in clinical practice, some of us do. And some of us even advise correcting abnormally low levels with simple and safe fish and fish oil pill consumption.

I am at once elated and disturbed by the CSPPT findings. They prove the efficacy of a simple therapy; yet, they broadcast the hubris of many in my field. Time and again we have had to make an about face in our opinions and recommendations. I see nothing inherently wrong in changing our position as more data emerge. What I struggle with is the egg on our face, the about face that occurs far too late, long after adequate data have told us what to do. Perhaps we will learn though. Maybe as more trials like CSPPT emerge, as more scientists and doctors with the conviction and devotion to finding a greater truth push tirelessly along their paths we will finally learn to be more open minded and accepting of ideas and findings even when they go against our grain.

For more information about the supplements and vitamins critical to your everyday health visit www.vitalremedymd.com.

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

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Hot Off the Press

In medical school we learned about a life threatening form of polydipsia. A subset of patients with schizophrenia consume so much water their sodium can fall to levels unable to sustain life. Twenty liters per day often leads to not just severe illness, but death. How could this be? Water is life’s elixir, and therefore more must be better; correct? Well, simply put, the answer is no. Our kidneys can only handle a water intake of less than one liter per hour. When people exceed this limit, blood becomes diluted; sodium levels fall; and cells swell. As our brain is encased in bone, it has nowhere to go when it swells. Consequently swollen brain cells can lead to permanent damage and even death. It’s not just the unfortunate schizophrenic patients who succumb to such a fate; others do as well. One woman died after drinking six liters in just three hours during a “water drinking competition.” Others have died similarly during college hazing. The point is that a rapid, excessive and unnatural intake of our most vital ingredient for life can kill us in a matter of hours. More is definitely not always better. Aristotle was correct in his dictum of moderation. So where am I going with this you might ask. Let’s consider the most recent “negative” fish oil study by Dr. Voest that was published in a most reputable journal. (For my take on other similar articles please see prior blog posts).

Based upon the fact that some cancer cells can produce long chain fatty acids, Dr. Voest hypothesized that the omega-3 fatty acids in fish could blunt the effect of chemotherapy (such a thought process itself lacks strong scientific validity). Testing his hypothesis he administered 100 microliters of fish oil to 20 gm mice. He was right; fish oil did blunt the effects of chemotherapy. And so his findings were published in the prestigious JAMA Oncology. But let’s look at his study in proper perspective. Ignore the fact that mice are not the optimal animals to study here. Also, ignore the fact that tumor cells produce many substances that have nothing to do with their “desire” to counteract chemotherapy.  Simply examine the administered dose. One hundred microliters of fish oil for a 20 gm mouse is equivalent to 400 ml of fish oil for an 80 kg (175 pound) man. Can you imagine guzzling nearly a half-liter of fish oil? The very thought is life threatening! That’s also tantamount to swallowing around 400 fish oil capsules. Who in his right mind would do that? I’d guess no one. The study therefore has no clinical relevance. The author’s conclusion that patients should avoid fish the day prior to receiving chemotherapy has no basis in science. Yet, the study is on the news; patients are concerned that fish causes cancer; doctors who don’t fully understand this area of medicine will become as alarmed as the patients; doctors’ offices will once again be flooded with unnecessary and distracting queries born of inappropriate trial conclusions; and some people who desperately need to consume fish will place themselves in harm’s way by eschewing vital nutrients. The fallout is, and will continue to be, monumental.

Why such studies are done, and why they are published in top-notch journals eludes me. I understand why the media exploits them; they are fodder for ratings. Still, I will continue to proclaim that such studies must be quelled, and the media must become more cautious. It is fine to conjecture, study, and test hypotheses no matter how outlandish they may seem. What is not acceptable however is perpetuating false conclusions as though they are hardened facts. Such a practice – which is prevalent today – leads both doctors and patients astray and pulls us from important issues, those that can truly save lives and help humanity. Let’s get back on track and re-emphasize honesty in medicine as our prime agenda. Honesty should always trump a good story.

For more information about the supplements and vitamins critical to your everyday health visit www.vitalremedymd.com.

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

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Science: A Playground for the Perpetual Child

Yesterday I read a hardcore Genetics textbook. As I thumbed the pages, simultaneously struggling to appreciate the concepts behind the words and reveling in the wonder of our being, I was struck by the fact that I love to learn. Both friends and self would have flagellated me had I stated that fact (or even felt it) as a young man or child.  Studying and learning were fancies of the nerds. Now I reflect on childhood, mine as well as that of our children. I recall mostly the experiences of our three infants and toddlers. They perpetually tested their environment. The distance of a jump, height of a tree climb, method of a toss, or speed of a swing: Everything was under scrutiny because everything was to be improved. They’d try different methods to accomplish their latest feat and after failure upon failure they’d find a way to succeed. Sometimes they’d later revise their techniques, using the wisdom of age and experience as their guide. In essence they were continuously studying and experimenting on themselves and their environs. They not only loved to study; they lived to study.

Today I find myself in a similar place. No longer able to accomplish past physical achievements, I am relegated to handsprings of the mind. I think and learn voraciously. What I learn, I teach. Though I miss the physical challenges and conquests of youth, this phase of life has plenty to offer. Often I communicate with similarly minded colleagues to discuss the latest and greatest ideas and discoveries. What fascinates us most though, and lures us in more than anything else, is our perpetual amazement by the bottomless well of knowledge from which we draw. It is not intimidating; it is invigorating. Our understanding takes us back in time, to the adventures of childhood. Science is an endless quest for very old children; a fearsome ride one never wants to leave. The adage, “the more you know, the more you realize how much you don’t know” is not only true, it’s tantalizing. It embodies the glory that keeps us steadfast in the game while we are fortunate enough to remain above ground.

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

For more information more about essential vitamins and supplements visit www.vitalremedymd.com.

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Save the Date: It’s the American Society for Preventive Cardiology’s 40th Anniversary – The July 2015 Conference is Shaping up to be Extraordinary

That’s a long title for this week’s blog, but it’s tough to shorten. Planning a conference is quite a challenge: The venue is chosen; topics are selected; speakers are invited; and the word is disseminated. Many people’s hands are in the mix – in the case of the ASPC, our management company as well as members of the planning and executive committees work tirelessly to create a conference that will meet and exceed its intent. This year’s ASPC meetings, again at the beautiful Boca Raton Resort, will bring together attendees from across the country (and likely outside the US as well) in order to learn from some of our nation’s most renowned experts in genetics, vascular disease, hypertension, diabetes, women’s heart health, inflammation, thrombosis, CVD risk reduction strategies, familial hypercholesterolemia, lipids and lipoproteins, novel medications…

Our goal is to highlight the most cutting edge as well as tried and true approaches for ASCVD prevention so clinicians eager to improve their strategies to combat and prevent the toll of vascular disease among their patients can more effectively do so. Conference attendees are among the most dedicated of our country’s healthcare practitioners – cardiologists, internists, obstetricians, family practitioners, nurse practitioners, physicians’ assistants, pharmacists, dietitians, and many others. The Boca Raton Regional Hospital supports the program and offers its physicians the opportunity to attend this one-of-a-kind meeting. Groups such as WomenHeart, and chapters of the ACC and AHA (and others) typically endorse the meetings as well. This year, in honor of the ASPC’s 40th Anniversary, the meetings will offer its attendees two new opportunities. First, abstracts from trainees across the globe will be evaluated for presentation. Second, we will offer the inaugural Expert’s Course in ASCVD Prevention. Diplomas will be awarded to those who successfully complete the course. So who are our speakers – professors and experts in their disciplines from Harvard, Hopkins, Emory, The Mayo, Columbia, UCSD, Tulane, Minnesota, NYU, and other outstanding institutions. And when is the meeting – July 31 through August 2nd. Put it on your calendar – you and your patients will be very happy you did. See you in July!

For more event information visit: aspconline.org

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

For more information more about essential vitamins and supplements visit www.vitalremedymd.com.

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The 2015 Dietary Guidelines: Defining a Healthful Diet

The 2015 Dietary Guidelines have been released, and some supposedly significant changes, advised. Cholesterol intake is no longer limited. Saturated fat is to represent < 10% of daily caloric intake. Sustainability considerations are now to be considered. Simple sugars are anathema and caffeine is okay. Vegetables and fruits remain highly emphasized. Has much changed? Not really. Most of us in Cardiology and Lipidology dropped the cholesterol ban a decade ago. We typically emphasize fresh fruits and vegetables, low fat meat that is organic and devoid of antibiotics, and a limitation of simple sugar. Most of us don’t consider sustainability issues when advising our individual patients. Many of us believe that world issues – including economics – should stay out of the exam room and remain in the courtroom. (I am a member of that camp). But what is the layperson to do with these Guidelines? Does he or she have to make dramatic changes in his or her diet? The answer of course depends upon the individual patient’s status. Is weight loss necessary; does the patient have cardiovascular disease or very high LDL cholesterol, for instance? Let’s first look at the history of man, briefly examine the state of dietary literature, and then make some generalizations.

Anthropology unequivocally demonstrates that human beings are omnivores. In fact, all of our primate relatives also rely upon meat in the wild. They even need it in captivity. When the Washington DC Zoo attempted to breed the Amazon Golden Marmoset monkey, they failed miserably. It was not until meat was added to their diet that the monkeys begin to thrive and reproduce. Since the beginning of our tour on earth we have also eaten meat. In fact, for the first 4 million years of our existence, meat was our main source of nourishment. About 10,000 years ago we introduced farming and animal husbandry. Most farming was done to feed our animals as they represented our most desirable food source. Recently we have fallen prey to our own impact on nourishment – we have started processing, and ruining, our food. Sugar has been added; nutrients have been stripped from grains; grains are squeezed (instead of eaten whole) to produce oils; and animals have been raised in pens, limiting their ability to develop lean muscle mass, and also often requiring the introduction of antibiotics. We have created a food supply that is most likely killing us.

In response to our understanding of the role cholesterol plays in heart disease – and it does play a significant one – we have introduced guidelines to try to reduce cholesterol. Saturated fat eaten to excess does raise LDL (not a good thing), but cholesterol consumption has little impact on our LDL levels. Therefore the current Guidelines did what was appropriate and removed restrictions on cholesterol consumption while maintaining limitations on saturated fat. They also appropriately implore us to eschew sugar. No one will argue against the latter recommendation (except perhaps the sugar industry). But are there studies to support such advice? Unfortunately, beyond PrediMed (which demonstrated the cardiovascular advantage of a Mediterranean diet) no high level studies have been performed. Many observational studies exist, but doing a solid dietary trial is actually immensely difficult. Thus we are left to rely upon our understanding of basic science, animal experiments, pathophysiology, and anthropology. The conclusion for most of us I believe follows Aristotle’s ancient tenet of moderation. We should consume natural foods whenever possible, avoid processed foods, eat copious quantities of vegetables, consume ample fruit, and don’t worry so much about consuming lean meat, fatty fish, and some chicken as well. We should do this in the context of seeing our physicians, discussing our own personal issues, and modifying our diets to adjust to individual needs when indicated. Eating has become a complex endeavor, yet it ought to be much more straightforward. What we need though is access to the aforementioned natural food, the type of food that has been unscathed by human hands. And therein, unfortunately, lies the rub.

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

For more information more about essential vitamins and supplements visit www.vitalremedymd.com.

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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.

For more information more about essential vitamins and supplements visit www.vitalremedymd.com.

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