heart attack

Could Statins Actually Help Prevent Heart Disease?

January 21, 2014 by James Bogash

Ok, so maybe I’ve been too hard on statins. Just because they suck at preventing a first heart attack is no reason to throw the baby out with the bath water.

The list of side effects continues to grow, with diabetes being the most concerning (unless of course, it is you personally who happens to die from a fatal rhabdomyolosis, in which case you’re probably less worried about diabetes….), because for every 11 heart attacks avoided 8 new cases of diabetes will be created.

I have argued less against the use of statins in secondary prevention (those who have already had a heart attack and are now trying to prevent a second heart attack) because the data is a little stronger. In general, though, statins will do very little to protect against a first heart attack. The only real benefit is seen in those who have a greater risk. In other words, the otherwise healthy, lean body weight, low blood pressure 45-year-old male with an isolated, elevated cholesterol will have ZERO benefit from taking a statin. This doesn’t stop him from getting prescribed a statin by some overzealous primary care doctor who just got back from a conference sponsored by Pfizer, however.

As I have mentioned before, only 1 out of every 100 people will see a benefit from taking a statin. My point has always been that lifestyle changes will blow the effectiveness of statins out of the water every single time with lower cost and no side effects.

But what if we could identify a (very) small subset of patients who have not had a heart attack and yet would most likely be that ONE person out of 100 that benefits from taking a statin? Turns out we may be closer to this answer with this particular study.

I have, for a long time, been a vocal advocate for the “heart test,” or calcium artery scoring (CAC) using an ultra fast CT scan. Overall, the studies and subsequent data on the use of the EBCT (electron-beam CT) continues to improve and radiation doses have continued to drop to the point where the radiation exposure can be less than a dental X-ray (as opposed to standard CT scans, which we hand out like candy in the ER, which have a much higher radiation dose and have been linked to some 29,000 cancers per YEAR).

In the study, researchers looked at the benefits of statins through the lens of those having high calcium scores, indicating a higher likelihood of having a blockage in the coronary arteries. Specifically, they looked at the relationship between the CAC, statin use and outcomes (heart attack, chest pain leading to stents being put in, resuscitated cardiac arrest, stroke, cardiovascular death). Here’s the specifics:

Researchers looked for those with Ultra fast CT scores over 100 (21% of participants with CAC 100 or higher).
They then looked at those with abnormal cholesterol levels: LDL > 130 mg/dL, HDL < 40 mg/dL for men (50 mg/dL for women) and triglycerides > 150 mg/dL.

With these two factors in mind, here’s how the study data played out:

More than half of events (55%) occurred in the 21% of participants with CAC ≥100 (the CT scan group bore the brunt of the heart events).
Conversely, 65% of events occurred in participants with 0 or 1 lipid abnormality (in other words, heart events are happening to those with normal cholesterol)
In those with CAC ≥100, event rates were as high as 29.5 per 1000 person-years, regardless of lipid / cholesterol numbers.
On the other hand, when the CAC was a big fat zero, cardiac event rates were 5 times lower at 5.9 per 1000 person-years regardless of lipid / cholesterol numbers.

To summarize, those with higher CAC scores were at a much greater risk of a cardiac event, regardless of where his or her lipid numbers were at. Medicine has been locked into using the blinders of cholesterol (sounds like some D & D special armor…) despite the fact that it just wasn’t making sense when we looked at current research. While there has been some move away from cholesterol, it hasn’t been with a logical head. The most recent guidelines on statin use have indeed thrown cholesterol levels out the window, but instead of replacing them with something smarter like the CAC, the blanket recommendation was just to give everyone a statin.

The smarter approach, based on this study, would be to use treatment for those at the highest risk based on CAC scores, NOT on cholesterol levels. Let me point out though, that nothing in this study actually looked at whether or not statins could lower cardiac events in those with higher CAC scores, although this is an excellent question to ask.

Maybe, just maybe, one of these decades medicine will actually catch up to the research.

Cholesterol Lowering Drugs and HDL—Do They Work?

October 28, 2013 by James Bogash

It’s pretty well established that, despite drug companies mounting a massive push and “educational” effort for years, total cholesterol by itself has little to do with heart disease rates.

However, I still have to educate people in the community and my practice on this little tidbit. The focus away from total cholesterol was made quietly, most likely as an effort to save face by those who had been pushing cholesterol levels as THE answer to heart disease.

The research on HDL (the “good” cholesterol), LDL (the “bad” cholesterol), VLDL (the “worst of the worst”) and triglycerides, however, is stronger.

In my opinion, the HDL:triglyceride ratio is the most valuable, but overall it’s the entire picture painted by all the lipids that give us the best picture. This viewpoint, however, is not what drug research and use is about. Since drugs can usually only affect one blood value at a time (i.e. statins will lower LDL but won’t have a big impact on triglycerides), researchers have to push hard to find a relationship between a value and a disease (such as total cholesterol and heart disease) and then find a drug that affects that value.

Miraculously, despite all my Rantings on cholesterol lowering drugs as well as an eBook on cholesterol lowering drugs, I still have patients come in who think that the drugs they’re on will actually protect them from heart disease and stroke. Needless to say, I’m not a fan of cholesterol lowering medication and will not hesitate to point out the research related to cholesterol.

Which leads me into this particular study. In it, researchers looked at two types of lipids, HDL cholesterol and apoA-1. Most know that HDL is generally considered the “good” cholesterol and lifestyles that promote higher levels will be strongly protective against heart disease and stroke. ApoA-1, however, is less well-known. Apolipoprotein A-1 is one of the major proteins that makes up the HDL molecule and helps to shuttle cholesterol around the bloodstream. Having higher levels is more protective to the heart.

This study looked at the effect that HDL and ApoA-1 levels had on heart disease. Then, they looked at what effect statins had on these relationships. Here’s the specifics:

HDL lowered the risk of a major cardiovascular event by 17%,
ApoA-I level lowered risk 21%.
In those patients taking statins whose LDL cholesterol levels were lowered to at least 50 mg/dL, an increase of HDL-C did not lower heart disease risk.
However, in the statin responders, a rise in apoA-I did lower the risk of heart disease by 7%.

So what does this mean? Higher levels of HDL and ApoA-1 are good for your heart. But when those levels are artificially raised by a cholesterol lowering drug, it either didn’t help at all or the benefit was far less than higher levels occurring naturally.

When we find, from observational studies, that some lab value protects against some disease, it is LIFESTYLE that gives the benefit. Cheating by using drugs to lower the value, if it works and doesn’t kill you from the side effects, will never produce the same benefit.

Your Heart and Blood Vessels on Soy: 5 Things to Know

August 21, 2013 by James Bogash

A simple Google search will leave you confused about whether eating soy is good for your heart and blood vessels or as evil as Twinkies.

Ok…so nothing could be as evil as Twinkies.

But what IS the deal with soy? Is it good for us, or does it vaporizes the thyroid, cause breast cancer and stimulate teenage boys to grow Dolly Parton-esque boobs?

As someone who reads through hordes of medical literature, I can tell you that the evidence overwhelmingly points to soy as being very protective for our health. I don’t even recall coming across any negative studies on soy, and this is a topic I always keep my radar screen open for. Interestingly enough, all of the articles and blog posts on the Internet demonizing soy seem to point out the evils and then, in fine print, begrudgingly note that soy might be ok if it’s not processed and non-GMO.

When pressed, the naysayers agree that soy is part of a healthy lifestyle once those two factors are addressed. So why not address these two requirements right out of the gate? I can’t figure that one out myself. Regardless of other opinions, I continue to promote soy as part of a healthy lifestyle. And, as noted, this means no processed soy (as in veggie burgers, veggie dogs, textured vegetable protein, etc..) and non-GMO.

Also important to note is that soy contains protective compounds referred to an isoflavones, specifically daidzein and genistein. By themselves, these compounds have protective effects. Beyond this, if someone has the right blend of bacteria in his or her gut (like Asians raised on soy) these bacteria in the gut convert another class of compounds (lignans) into an even more potent compound called enterolactone. This benefit may be destroyed by antibiotics.

You can see that it’s not all that simple. The take home message is that soy is, in almost all circumstances, very good for you, so long as the above 2 criteria are met. And you’re not allergic (not really all that common unless you were inundated with soy over a long period of time), and in some susceptible people it might cause some thyroid problems.

All of this brings me to this particular study looking at the effects of genistein on certain cardiovascular markers. Participants to 54 mg/day (just under a cup’s worth of tofu) for 6 months, along with a Mediterranean-style diet. Here’s what they found:

Blood flow (as measured by flow mediated dilation at 50 seconds and peak FMD) improved.
Decreases in total cholesterol, triglycerides and homocysteine.
Descreases in visfatin (a hormone produced by fat cells that drive diabetes and inflammation).
Adiponectin (another fat-derived hormone, but one that protects against diabetes and inflammation) levels were increased.
The participants on the genistein experienced no more side effects nor discontinued the study.

Overall, this was a very positive effect on the health of the blood vessels. Contrast this with the negative health effects of poor quality, abused, commercially grown beef. Complete opposite ends of the vascular health spectrum.

Think You’re Doing Everything to Protect Your Heart? Even THIS?

August 20, 2013 by James Bogash

heart disase sleep — Enough sleep needed to protect the heart

Despite societal beliefs, heart disease is NOT genetic. It is almost entirely environmental. Lifestyle factors to lower your risk are very well established.

Most of you can probably name off the top few easily: Exercise, not smoking, plant based diet, don’t stress, avoid animal based saturated fats, more omega-3 fatty acids, etc… But some are a little more elusive and less well known. But usually these risk factors may play a smaller (but no less important) role, such as BPA in plastic water, dark chocolate, nuts and lycopene in tomatoes. But what if there was a very important risk factor that had a large impact on your risk of a heart attack or dying of a heart attack that you were not aware of?

Enter this large study out of the Netherlands. Luckily, the Dutch are a generally healthy people, so these researchers were actually able to find some healthy people to study (as opposed to the US, where researchers have to peek into dark corners and seedy vegan restaurants to find the healthy residents). Basically, they looked at 17,887 men and women and how their health behaviors were linked to the later risk of heart attacks or cardiac deaths.

Here’s the behaviors and the amount they lowered the risk individually:

Sufficient physical activity (≥3.5 h/week cycling or sports–52% of study participants) led to 26% lower risk.
Healthy diet (Mediterranean Diet Score ≥5–37% of participants) led to 12% lower risk.
Moderate alcohol consumption (≥1 beverage/month–91% men, 78% of women participants).
Non-smoking (65% of participants) led to 43% lower risk.

Overall, when all 4 of these healthy lifestyles were done together, there was an overall 57% lower risk of heart disease and 67% lower risk of fatal heart attack. Sadly, even in this healthier country, only 12% of the study participants adhered to all the factors studied. And like many of the studies on heart disease, these guidelines are pretty basic and very easy to achieve. More specific lifestyle changes would likely lead to much greater reductions.

There was one more behavior they look at:

Sufficient sleep duration of at least 7 hours per night.

Man, I better hit the hiking trail drinking red wine and eating raw nuts dipped in pure cacao.

In the study, 80% of men and 86% of women obtained sufficient sleep. Pretty sure we wouldn’t see these numbers here in the US with salaried employees with kids (or 5 blog / week health related blog authors…). Overall, getting sufficient sleep lowered the risk of heart disease by 22% and fatal heart attack by 46%. These are some pretty strong numbers.

But when added to the 4 factors listed about, the protection jumped, lowering risk of heart disease by 65% and fatal heart attack by 83%. These are some pretty serious numbers.

Overall, this really should not come as too big of a surprise because we know that sleep is incredibly important and, conversely, not sleeping well is unhealthy. Study after study have linked poor or too little sleep to increased inflammation, obesity and diabetes.

Lest you think that you’re ok because you load up on Ambien and Lunesta with your valium, there are some pretty scary associations between the use of these types of drugs and death (arguably something we want to avoid…).

And stress kills sleep quality and duration, which likely feeds into this entire picture of preventing heart disease and fatal heart attacks.

With that said, I’m off to bed to lower my risk of a heart attack..

Reactive Oxygen Species in Skeletal Muscles From Heart Failure – (07-12-01)

July 21, 2013 by James Bogash

Reactive Oxygen Species in Skeletal Muscles From Heart Failure

This article looks at the dysfunction in skeletal muscle following a heart attack in mice. This dysfunction is believed to come from free radical damage. This leads to a very wide variety of new approaches to heart attacks. Research already shows strong benefits to magnesium application to reduce infarct size; now it may be possible to prevent damage to skeletal muscle with an antioxidant cocktail–possibly Vit C, Vit E and CoQ10 just to name a few. Although prevention is always the best approach, this is evidence piling up on how to potentially reduce the damage to the heart and the rest of the body during a heart attack.

Circulation — Abstracts: Tsutsui et al. 104 (2): 134

Read entire article here

Energy Drinks, Red Meat, the Gut and the Heart: My Take

June 4, 2013 by James Bogash

By now, you’ve probably heard the news about two recent research studies strongly linking a compound called TMAO to heart disease and stroke. After all, Dr. Oz covered it, so it’s got to be big news.

Here’s the basics:

Two dietary compounds L-carnitine and phosphatidylcholine (we’ll cover diet sources later) get converted by bacteria in the gut to TMA.
TMA heads to the liver where it is further converted by an enzyme called FMO3 to TMAO.
TMAO has been strongly linked to heart disease and stroke irrespective of other, more widely known, risk factors.

L-carnitine comes from a few notorious sources. Red meat. Energy drinks boasting high levels of L-carnitine. Bodybuilding supplements.

Phoshotidylcholine is founds in eggs and beef liver (just in case you eat this on a regular basis…).

While some articles are blowing off the results of this study, I think that we need to look at this data as real, and try to figure out why and how it may occur. Overall, the results in these two particular studies (New England Journal of Medicine, Nature Medicine) should raise some eyebrows. Here’s what they found:

Those with the highest levels of TMAO had a 254% overall increased risk of having a heart attack, stroke or dying.
The risk of dying in the highest TMAO group was an impressive 337% higher.
This risk was present even after accounting for traditional risk factors as well as in those patients who were considered low-risk.

Now here’s where the story gets a little more interesting…

In one of the studies, participants were given antibiotics. The antibiotics almost completely shut down the production of TMAO.
Once the antibiotics were stopped, the TMAO levels increased again.
In vegetarians and vegans, the levels of TMAO remained low despite increased intake of phosphatidylcholine or L-carnitine.

Clearly, the bacterial flora in the gut had an incredibly strong role in whether or not these dietary components caused problems or not.

Gee…have we heard this somewhere before?

Have you maybe heard someone say that destruction of the normal flora in the human body is a potentially devastating event, especially in a child? Like…maybe me??

There is a well accepted concept that the bacterial flora in the gut adapts to a particular lifestyle. Women in Asian countries with higher intakes of soy have higher equol-producing bacteria in their gut and thus, derive greater benefits from eating soy than do their American-born, non-soy-eating counterparts. Could this be yet another example of how the bacterial flora in vegetarians adapt to that lifestyle, lowering the risk of disease?

Further, could our country’s love of antibiotics for minor sniffles be destroying the delicate balance of the bacteria in our gut, leading to chronic disease? Multiple lines of research suggest this is a solid answer.

So what is the bottom line? Of course, avoiding energy drinks and limiting red meat intake was already on your list. While these studies did not identify specific bacteria that were responsible for the conversion, they generally fall under the category of methylotrophic bacteria. These are NOT generally the types of bacteria found in probiotic supplements. It would seem likely that the use of probiotics would lead to less of the bacteria that leads to the conversion of these dietary compounds to TMA.

Is Your Cardiologist a Hypocrite? 80% Chance the Answer is Yes

May 17, 2013 by James Bogash

Respect. Without this one factor, the advice your doctor gives you will go in one ear and out the other. There are a variety of factors that contribute to the level of respect you have for your physician.

High on the list is whether or not your physician practices what he or she preaches. Does he or she reek of cigarette smoke, and yet expects you to quit? Does he or she have a belly that stick way too far past the waistline and yet expects you to lose weight to manage your diabetes? Does your doctor tell you that you need to ramp up the exercise, but wouldn’t know what to do with a jump rope if he or she tripped over it?

These situations make it hard to follow your doctor’s advice. Unfortunately, it does not seem to be an isolated experience.

This particular study looked at a large population of 1770 cardiologists in Italy and questioned them on their heart-healthy behaviors. (Keep in mind that Europeans, in general, are healthier than us Americans) One group of questions asked about 5 classic heart disease risk factors. This simple list included:

High blood pressure
High cholesterol
Smoking
Diabetes
Previous vascular events

Pretty simple list of things to avoid that are almost entirely lifestyle dependent. So what did the researchers find?

More than 49% of the participants had at least 1 risk factor.
More than 28% had 2 to 5 risk factors.
A mere 22.1% had none of these factors.
Despite the reported risk factors, >90% of cardiologists considered themselves at mild risk of a cardiac event.
Furthermore, overweight and obesity, physical inactivity, and stress at work or at home were commonly reported.
Very interestingly, cardiologists self reported only a limited use of cardiovascular drugs, such as statins or aspirin.

How can society expect to stem the tsunami of chronic disease if the stewards of health are themselves, not healthy? “Do as I say, not as I do.” It won’t work.

The bottom line is that your health and the responsibility for your health lies with you. NEVER rely on any physician to teach you more about staying healthy then you can learn yourself (except maybe me, of course….). According the this study, the odds are that even your cardiologist doesn’t know what’s good for his or her heart.

Heart Attack Statistics: Dental Invader Found in Heart Plaques

April 16, 2013 by James Bogash

Heart attack statistics stem from multiple factors; the famous one cause : one cure model that dominates medicine just doesn’t fit here.

It would be wonderful, though, if this were true. That means that treating everyone with a statin to lower his or her cholesterol would actually work. Or lowering everyone’s high blood pressure with a beta blocker, ACE-inhibitor or calcium channel blocker would yield amazing outcomes. Or the identification of a single genetic factor that caused heart disease would yield the biggest blockbuster drug ever.

Alas, heart disease is multifactorial and requires a comprehensive lifestyle approach to avoid or manage it (you can read my recommendations by downloading my free ebook here).

But this does not mean that there are not certain factors that play major roles in the development of sickened blood vessels that ultimately lead to a heart disease or fatal myocardial infarction.

And it’s not cholesterol.

Chronic inflammation is arguably one of the key factors that contribute to heart disease. Chronic inflammation comes from many sources, including poor dietary choices, stress and sedentary lifestyles. Chronic infections are on the list.

Key among these is the oral cavity and the gut. Which brings us to this particular study.

Researchers looked for the presence of bacteria within the plaques (thrombi) from patients who suffered a heart attack and compared the levels of certain bacteria to those found floating around in the bloodstream. Here’s what they found:

The total amount of bacterial DNA in the thrombi was 16 times higher than in the blood.
Viridans streptococci (a bacteria typically associated with dental infections), was found in 78.2% of thrombi.
Bacteria associated with periodontal disease were found in 34.7% of the plaques.
Bacteria-like structures were detected by in a subgroup of 30 patients with a heart attack that were examined by a specialized CAT scan, those with a periapical abscesses were 13.2 TIMES more likely to have viridans streptococci DNA found in his or her plaque (Tweet this).

The bottom line is that, although our country’s disturbing heart attack statistics are the result of many different things going wrong in the body, it is very clear that good oral health needs to play a role in a heart-healthy lifestyle.

We all know that this includes brushing, flossing and regular dental visits, but how many of you out there use a tongue scraper as well?