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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The Approaching Medical Maelstrom

The AHA 2014 Scientific Sessions are over and I have already written twice about IMPROVE IT but I feel compelled to write again. Although the media has been oddly silent about the trial (why is that I wonder???), I predict its fallout will greatly impact the disciplines of Cardiovascular Disease Prevention, Clinical Lipidology, and even the essence of clinical practice. The reasons are manifold. First, the trial proved two critical theories: a lower LDL cholesterol level is better, and statins are not the only way to achieve a clinically relevant LDL reduction. Additional key considerations from IMPROVE IT include:

  •  Lower LDL in properly chosen patients (and probably almost everyone) yields lower rates of stroke and heart attack, the two most formidable foes of modern man. For example, in the trial, an LDL of 53 was significantly better than an LDL of 70. Should we doctors then aim for 40, or perhaps even 25?
  • In our high-risk patients should we consistently and continuously add medications to statins in order to drive cholesterol levels lower and lower? For example, in a patient with a prior heart attack is it now fair to accept 70 for an LDL when we know that 53 would decrease our patient’s chance of having a recurrent and potentially life-threatening event?
  • What do we do with the hotly debated 2013 ACC/AHA Cholesterol Guidelines? They eliminated LDL goals and allowed for the use of Zetia only with individualized – and typically time-prohibitive – clinician/patient discourse, but they did NOT encourage driving LDL lower than 70. The Guidelines advocated for an LDL response to therapy of > 50%. So where does that leave our heart patients who start with LDLs of 180, for example. If they achieve the intended LDL reduction of 50% and thereby remain with an LDL of 90 mg/dL the guidelines surely say all is well – job well done. They state there is no indication to go further. Well now there is an indication. Now we can say with certainty that an LDL of 53 is a far better goal than 90. Having an LDL of 90 leaves significant and now manageable residual risk. So then how can a health care provider in good conscience advocate keeping such a patient at an LDL that clearly conveys greater risk?
  • The Guidelines also strongly advocate our utilization of maximum statin doses prior to adding an agent like Zetia. Knowing that higher dose statins produce more side effects while yielding a diminishing return on cholesterol lowering, wouldn’t it now be more prudent for doctors to prescribe low dose statins in combination with Zetia? This would limit side effects while yielding lower LDL levels than would the Guideline recommended approach. More food for thought.
  • How will insurance providers respond to Improve-It’s results? After the ACC/AHA Guidelines’ release, with lightening speed they downgraded access to add-on therapies such as Zetia. Of course that saved them money. So what now? Will they respond in kind, follow the science, and quickly allow patients access to these medications? We shall see but I have my doubts. Profits it seems oftentimes take precedence over science and health.
  • One more crack at the Guidelines for now: It is true that we do not know what represents the optimal LDL cholesterol level in human beings. Based upon our ever-expanding understanding of lipids including our body’s limited need for extraneous cholesterol however, it is safe to say that that level is probably quite low, perhaps even as low as 25 or 30 mg/dL. And, given the fact that many of us are goal-oriented, wouldn’t it now make sense to join our friends across the pond as well as our very learned friends here at home in the National Lipid Association and simply reinstate LDL goals?
  • As I sit at my desk tapping these keys I am clearly frustrated by the politics and economics woven inextricably into the fabric of medical practice. But I am also comforted and encouraged by the knowledge that many of us have already spent the last decade and beyond practicing the way we felt the science dictated. And by so doing, in the matter of LDL-lowering with Zetia, for every 120 patients we’ve treated in an Improve-It style, we’ve saved 3 from enduring a stroke or heart attack. This fact renders all our struggles worthwhile.

On a final note let us not forget that doctors have NO financial incentive to prescribe these medications. Our only “dog in the fight” is protecting our patients from harm. Insurance providers often do have a financial incentive to preclude doctors from prescribing some medicines (typically those that cost them more money). So whom do you, the patients, want to be in control of your medication regimen – the more highly educated and clearly non-conflicted physicians, or the less knowledgeable and often-conflicted insurance carriers? The answer to me seems pretty clear.

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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An Update From the 2014 American Society for Preventive Cardiology (ASPC) Annual Meetings

Two weeks ago was the ASPC’s Annual meeting in Boca Raton, FL. The event was superb. Internationally recognized experts in a variety of disciplines convened in Boca Raton for the three–day-event. Nearly 200 healthcare practitioners from around the country came to listen to Professors from Northwestern, Harvard, NYU, The Mayo, Columbia University, The Miami Miller School of Medicine, Emory, Ohio State, UCLA…  Topics such as the somewhat controversial 2013 ACC/AHA Cholesterol and Obesity Guidelines, the enormously under-recognized disorder Familial Hypercholesterolemia, and the vast sex differences in CVD presentation and treatment were discussed.

My lecture was entitled, “The Omega-3 Fatty Acids DHA and EPA: Caution when interpreting the Trials. It’s time to get back to the basics.”  The talk highlighted enormous limitations inherent in recent omega-3 studies. It is not only clinicians and laypeople who must understand such issues, but the press as well. Too many reporters – and even physicians in the news – misinterpret clinical studies, oftentimes sending not just misleading messages to the pubic, but potentially damaging ones as well.

DHA and EPA are the essential fatty acids found in fish, NOT flax, Chia, or olive/canola oil. These fatty acids have been studied in a variety of disorders ranging from heart attacks to dementias, ADHD, eye disease, inflammatory bowel disorders, and Rheumatologic ailments. The list is actually even more extensive than this. Their benefits are legion – anti-inflammatory, anti-oxidant, anti-arrhythmic, and anti-thrombotic to name a few. Scientists across the globe are spending their entire careers evaluating the myriad biological effects of these fatty acids. Although we still do not know precisely how DHA and EPA will fit into our medicinal armamentarium, we do know that they have an important role to play. More studies and clinical trials are needed. One thing is clear however. DHA and EPA are here to stay. They represent a component in our diets that should be emphasized, not neglected. Nearly daily fatty fish or fish oils should be a part of most people’s dietary habits.

Beyond the value of DHA and EPA is an even more important message though. The media, in their unbridled attempt to produce quick and enticing stories, often critically misses the mark. Consequently we all must be very careful about how we interpret what we read or hear. We must always be vigilant when drawing conclusions about our health as well as other consequential matters.

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 Glory of Gum – A Smoker’s Tale

Recently, on a medical sojourn, I was met at the airport by a garrulous woman driver. She was a young-appearing fifty year old who as it turns out had recently sustained a TIA, or “mini-stroke.” Although my first thought was atrial fibrillation, she actually had developed a near occlusion of her left carotid artery. Her right carotid artery, she informed me, had a mere 40% stenosis. Our discussion continued and I gleaned that she had a very strong family history of early onset vascular disease, several close relatives even dying quite young from their events. So my next thought was Familial Hypercholesterolemia. But no, her LDL was apparently normal. Then she fessed up. She had been – and continued to be – a smoker. Just like everyone else in her family! Shocking.

To smoke cigarettes nowadays is something I simply cannot wrap my head around. Cancer, stroke, heart disease, lung disease, wrinkles… Tobacco is devoid of any redeeming quality. It’s just plain bad. So why would anyone smoke in the first place? But, once an individual has experienced a near death event that is a direct consequence of tobacco, how in the world could she continue to smoke. My 40-minute drive took on a mission. I was going to get her to quit. I asked about her children and even grandchildren. We spoke about loss of limbs, dependence upon an oxygen tank, facial cancers and their attendant disfigurement, another stroke – the next one of course placing her in a wheel chair, unable to speak or care for herself. Then she dropped me at my destination. She was to pick me up several hours later. Before stepping out of the car I told her with stern authority that a cigarette should never again cross her lips. Chew gum I said. Gain weight if you must, but please don’t ever come near another cigarette. (I must confess; my tone was intentionally severe and perhaps even paternal. The impact I hoped would justify my behavior.)

I went through my day, completed my tasks, and eagerly awaited her return. Upon her arrival she stepped from the car and proudly and loudly through a mouthful of gum intoned that she had done it. She quit smoking. I am not certain whether her resolution will last an hour or a lifetime. For that moment though she was no longer a smoker. A gum chewer yes, but not a smoker.

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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Response to “A New Gender Issue: Statins” an Article by Roni Caryn Rabin

There appears to be an endless supply of medically related stories in the lay press that serve nothing more than to create mass misunderstanding of science and medicine. Surely their provocative messages sell papers and airtime. But they have an often-ignored downside as well. Tuesday we saw another such article. In the New York Times’ Rabin piece, a prevalent fear of medications is fueled, and the integrity of a prominent physician is impugned. (Full disclosure – I too unabashedly receive compensation from pharmaceutical companies for consulting and educational purposes.) Statistics are cited; the quintessential anti-statin doctor is quoted; and fabricated conclusions are rendered. The science of statin therapy is much too complex for a single cursory article to do it justice. In fact, entire conferences are devoted to the subject matter. And yet a sweeping conclusion – with potentially devastating ramifications – has again been made. Women reading this article will do what one would expect, either discontinue their statins on their own, or hopefully discuss such an action with their doctors prior to doing so. The article is meant to be terrifying, citing exceedingly rare muscle complications and referring to an unproved complication of statins, memory loss. So much is left unconsidered. For starters, the ACC/AHA risk scoring system cited by Ms. Rabin likely underestimates, not overestimates, CVD risk in women. And, as the leading cause of death in US women is cardiovascular disease, we do not want to make the mistake of under-evaluating and under-treating this segment of the population.

Today in the office I saw a young woman who suffers from premature heart disease that would not have been detected or appropriately treated had the guidelines been followed to a tee. Yet her coronaries have been non-invasively imaged; significant disease was detected; and yes, statins are being utilized. As a result, her life may very well have been saved. Doctors must be able to think and act with fluidity, moving both within and beyond the guidelines, in order to render the best care we can. Articles such as Ms. Rabin’s serve solely to diminish our ability to do so.

To demonstrate more clearly why we need to drastically broaden – not shrink – our efforts to identify and treat cardiovascular disease in women here are a few chilling and sobering statistics:

  • Women are 15 times more likely than men to die within the year following a heart attack.
  • Women with angina have twice the morbidity and mortality as men with angina, even in the absence of obstructive coronary artery disease.
  • 64% of women dying suddenly from heart disease had no prior symptoms.
  • Women under 50 are three times as likely as men under 50 to die after a bypass operation.
  • Marriage decreases cardiovascular risk in men, yet increases it in women (a frightening statistic, yet one that provides fodder for some excellent jokes).

Other similar statistics abound. The point is that we unambiguously understand that women are at great risk for heart disease. Sadly though, we currently have inadequate clinical trials assessing their risk. The appropriate answer is to fight even harder to identify and treat women at risk. It is not to dismiss our vast and growing understanding of the salient role cholesterol plays in the genesis of cardiovascular disease. It is not, as this article implies, to withhold a medication that has done more to thwart heart disease than any other therapy in the last century. I entreat all in the press to be more circumspect and responsible in your reporting. You have a great influence on your readers. Please wield it with caution.

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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ConsumerLab Approval: A Brief Boast about VitalOils1000

couple bike riding

I make it my practice not to blog about VitalRemedyMD or any of its products, but this week demands a self-promoting shout-out. VitalRemedyMD is a company I started over ten years ago. It is now owned and operated by my wife (Laura Baum – also an MD). VitalOils1000 was created about six years back as the first and only enteric-coated fish oil pill to contain a full 1,000 mg of combined DHA and EPA. Thus, VitalOils1000 was the first omega-3 fish oil to meet the American Heart Association recommendation for individuals with cardiovascular disease in just one pill. This fact holds true even when considering prescription fish oil.

Yesterday we made the grade again. On April 6th ConsumerLab.com, the preeminent watchdog of the nutritional supplement world, released their every-other-year study of omega-3 fish oil products. Once again VitalOils1000 was “approved.” This year, in addition to “proving” our purification, concentration, and quality of enteric coating, we were also tested for PCBs and Dioxins. We were one of only two products tested in this comprehensive fashion, and we “passed” this important criterion as well. Our purification process of supercritical fluid technology enables us to achieve these exceptionally high standards for safety and purity.  There is so much confusion about omega-3 products that I felt compelled to write about our continued success with VitalOils1000. Needless to say, I am very proud. Thank you for permitting me a moment to boast.

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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Mayo Clinic Cardiovascular Disease Prevention Conference – a Testament to the Dedication of Healthcare Practitioners

Okay. You read the title and immediately imagined a bunch of doctors and scientists lounging on the spectacular Mexican beaches while you – if you live pretty much anywhere in the US – dig yourself out from yet another snowfall. It is true that the beach is pristine. And yes, the weather is unbeatable. But, truth be told, every speaker and attendee spent days and evenings continually holed up in a windowless conference room discussing issues ranging from exercise and diet, to Familial Hypercholesterolemia (FH), to even the impact of COPD on CVD. The meeting was excellent. Great discussions, proposals for future collaborations, some colleagues reuniting while others being introduced to a new group of associates. The ACC/AHA Cholesterol and Risk Assessment Guidelines as well as the new BP Guidelines were hotly debated.

In all, it was a wonderful weekend that enabled us to exchange ideas, consider alternate approaches to our patients, and simply grow as doctors, nutritionists, and scientists. So while American Medicine continues to be a target of mostly criticism, rest assured there are many who continue to do their part to ensure the viability and continuation of truly top-notch healthcare and research.

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Fight Heart Disease in Women – Celebrate National Wear Red Day February 7th

Heart disease is the number one killer of women in the United States, causing more deaths than all forms of cancer combined. Join the American Heart Association and Go Red For Women by celebrating National Wear Red Day; wear a red outfit on February 7th, 2014 to increase awareness of the battle against heart disease in women. Solidarity and awareness are often needed to eradicate a foe. And make no mistake about it, heart disease and stroke represent terrible adversaries for women, even more so than for men. A few alarming statistics:

  • Women are 15 times more likely than men to die in the year following a heart attack.
  • 64% of women who die suddenly from heart disease had NO prior symptoms.
  • Women under 50 are 3 times as likely as men to die after a heart attack or bypass surgery.
  • A startling reality – marriage decreases cardiovascular disease risk in men but increases it in women!
  • Congestive heart failure in the setting of a normal pump function is much more common in women than men… and we don’t know how to effectively treat this.
  • “Traditional” risk factors and risk factor scoring can fail to adequately identify women with Cardiovascular Disease.
  • And to make matters even worse, diagnostic testing for heart disease is less accurate in women than in men.

Go Red for WomenMany women are unaware of the symptoms of a heart attack, or may attribute their symptoms as due to other causes. If you’re experiencing pain in your chest, jaw, neck or back, don’t assume it‘s just from the gym or a little extra stress. These could be symptoms of a heart attack – see a doctor.

Given this grave threat to women’s heart health we believe that it’s important for us all – men and women – to band together on February 7th and show support for the fight against heart disease in women by simply wearing Red.

photo credits: Go Red for Women

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

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February is Heart Month

woman jogging at sunrise

Dear Readers,
Tomorrow, February 1, marks the start of yet another Heart Month. For some reason, heart disease and stroke don’t seem to invoke the same attention and concern as other far less common and threatening disorders. Perhaps it is its dramatically high prevalence that is the culprit, desensitizing us to the gargantuan toll cardiovascular disease (CVD) takes on Americans of all ages. Whatever the reason, we must wake up and attack the underlying causes of CVD head on. Now possessing effective preventive and therapeutic strategies to drop CVD from its long held spot as the top-killer in our Western World, we must band together in an effort to educate health care practitioners and laypeople alike and concomitantly implement such stratagems. For my part, I have decided to focus attention on Familial Hypercholesterolemia (FH) a common and typically unrecognized genetic cholesterol disorder that kills young men, women, and even children in the prime of their life.

Here are some sobering statistics about FH: one in about 300 Americans has it; yet less than 1% have been diagnosed. 20% of all heart attacks in people under the age of 45 are a consequence of FH. 5% of all heart attacks in people under the age of 60 are from FH. FH increases the risk of CVD 20 fold. Most important of all, when FH is diagnosed and treated early in life, patients can live normal life spans. That is correct – they can live out their lives freely without fear of dying young and without the even more terrible fear that their children will die young. The problem of course lies in the fact that most healthcare practitioners and laypeople remain unaware of the disorder. Being unaware renders us impotent, incapable of rendering appropriate preventive therapies. It is only through the elevation of awareness that we will lower the threat of FH. My plea to you therefore is to help spread the word. You can easily let people know about FH through the FH Foundation, http://thefhfoundation.org  A grassroots effort is required here. Please participate. When I say the life you may be saving could be your own or that of someone you love, I am not being melodramatic. During many of my talks on FH, members of the audience (even healthcare practitioners) have discovered that they carry the genetic disease. Spread the word and see for yourself. Thank you in advance for your support.

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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