Wednesday, May 23, 2007

Cardiologists are embracing integrative approaches to detect and treat heart disease.

In The Past, patients with cardiovascular disease had few options for treatment, other than drugs and surgery. Fortunately, the last 20 years have seen a shift, as many cardiologists explore natural approaches, using stents and bypass surgeries only as last resorts.
Complementary therapies, therefore, have become an important first line of defense in the fight against cardiovascular disease. In addition, new technology and screening methods play a large role in preventing the disease.
Heart Scan
Long before cardiovascular symptoms are clinically evident, atherosclerosis begins disrupting the health and function of specialized cells that line the arteries. These endothelial cells are the key to atherosclerosis. In fact, endothelial dysfunction is the coronary heart disease's central feature. Therefore, identifying endothelial dysfunction before symptoms and a fatal heart attack occur is the new frontier of cardiology.
Clearly, early detection and prevention are invaluable in protecting health and longevity. That's where a CT scan comes in. This scan can help determine a coronary artery score. It's especially useful for the asymptomatic patient with risk factors such as hypertension, hyperlipidemia, smoking, diabetes and positive family history. Many of these patients pass cardiac stress tests, but may still have severe nonobstructive coronary artery disease that requires aggressive management of risk factors.
The coronary calcium score measures calcium deposits in atherosclerotic plaque in the coronary arteries. This heart scan allows us to discover the presence of plaque and atherosclerosis in the endothelium while the patient is still asymptomatic. The calcium score estimates the extent of disease based on the number and density of calcified plaques in the coronary arteries. The EBCT calcification scores match with angiographically significant stenosis findings. A calcification score of 80 has a sensitivity score of 84 percent with specificity of 84 percent. However, cut-points in the calcification scores that would provide 90 percent specificity and sensitivity also have been identified. (See table for further breakdown.)
To reduce risk, we use the coronary calcium score to guide lifestyle modifications and medical therapies. When a patient has a calcium score that indicates disease, we can move more aggressively to make dietary changes and use supplements. If evidence of ischemia exists on stress testing, patients may be referred for coronary artery angioplasty/stenting or surgery.
The coronary calcium score measures hard plaque. Another method scans carotid intimal medial thickness and provides a way to measure soft plaque, using noninvasive carotid ultrasound. Abnormal (higher) carotid IMT is associated with cardiovascular risk factors and can also predict coronary artery disease and heart attacks in adults.1
Lipid Profiles
Another key to promoting heart health is drawing lipid profiles, which provide precise information for future health. But knowing a patient's total cholesterol, high density lipoprotein (HDL) and low-density lipoprotein (LDL) levels is simply not enough. LDL accounts for only 25 percent of the risk of premature cardiovascular disease. The remaining 75 percent represents "residual risk" from other risk factors.2-3
The Vertical Auto Profile (VAP) and the Berkley Heart Lab Advanced Testing methods provide a more complete picture of cardiovascular system health than the routine cholesterol test.
The VAP test directly measures LDL, as well as LDL particle size. This is important because patients with small, dense LDL have four times the risk of developing heart disease. In addition, the VAP test also measures several other important lipoprotein subclasses, including VLDL (very low-density lipoprotein), lipoprotein(a) [Lp(a)], HDL subtypes (HDL2 and HDL3) and IDL (intermediate-density lipoprotein).
These new generation blood tests offer a far more comprehensive and reliable prediction of future cardiovascular risk than the standard cholesterol test. For example, high levels of Lp(a) raise the risk of coronary artery disease by 300 percent, even if all the other standard lipid panel results look good. High levels of Lp(a) are present in one-third of patients with coronary artery disease. For this reason, we aim to bring Lp(a) levels below 15 mg/dl. Niacin is the most effective and commonly used therapy to lower Lp(a).
Other new generation screening blood tests can help as well. For example, measuring apoB provides a much more accurate way of determining the number of LDL particles. In addition, apolipoproteinE measures a protein attached to some lipoprotein particles, which provides information on patients' risk level and how responsive they will be to diet. This more advanced and sensitive testing makes it possible for doctors to identify up to 90 percent of at-risk patients.4
Cholesterol: The Good and Bad
Once we have a baseline lipid profile, treatment becomes a matter of choosing the best and least toxic approach for addressing each of the risks. If LDL is elevated or if HDL is too low, we may suggest an integrative approach using diet and lifestyle modification and the appropriate supplements, rather than statins.
LDL is most often referred to as the "bad" cholesterol whereas HDL is known as the "good" cholesterol. LDL transports cholesterol throughout the body to the cells. LDL is dangerous because it can penetrate the blood vessel wall and create foam cells, which form the core of a plaque deposit. Oxidized LDL cholesterol also initiates inflammation in the blood vessels, which accelerates atherosclerosis.
HDL, on the other hand, prevents the formation of plaque by carrying cholesterol away from the arteries to the liver where it's eventually processed and eliminated.
LDL and HDL have been recognized by the American Heart Association as strong and independent risk factors that can affect heart health. While high levels of LDL are associated with increased risks of cardiovascular disease (potentially leading to heart attack or stroke), high HDL can positively affect heart health, drastically reducing the risk of heart disease.
Physicians can prescribe statins to lower LDL levels, but I have concerns with some potentially dangerous side effects associated with their use. Coenzyme Q10 (CoQ10) deficiency is one adverse effect. Statins may cause liver problems and elevate liver enzymes. They also can heighten the risk of myopathy and rhabdomyolysis, which is characterized by muscle pain, weakness and kidney failure.
As physicians, we have other tools at our disposal, among them:
Pantethine. Patients who have elevated LDL can use supplemental pantethine to reduce it. Pantethine, a form of pantothenic acid (also known as vitamin B5), is found in small amounts in foods such as liver, salmon and yeast. Pantethine lowers cholesterol by blocking its production.
Studies have shown that pantethine safely and effectively inhibits several of the enzymes and coenzymes used for cholesterol production. It blocks the activity of one coenzyme involved in cholesterol synthesis, HMG-CoA, by about 50 percent.5 This significantly lowers cholesterol production. To compensate, the liver pulls additional LDL out of the bloodstream.
Studies have shown that, on average, pantethine can lower total cholesterol levels by 16 percent, LDL cholesterol levels by 14 percent, and serum triglycerides by 38 percent. It also can raise HDL cholesterol by 10 percent.6-8
Plant sterols. Another approach to reduce LDL is using plant sterols, which are the fats of plants. Found in nuts, vegetable oils, corn and rice, plant sterols are structurally similar to cholesterol and can act as a stand-in for cholesterol and block its absorption. Because plant sterols look like cholesterol, they fit perfectly into cholesterol channels. The cholesterol being blocked from absorption remains in the intestines where it is eventually excreted.
If the diet contains adequate amounts of plant sterols, the amount of cholesterol absorbed from the intestinal tract is greatly reduced. Mirroring pantethine's effect on the liver, this cholesterol reduction causes the liver to pull LDL cholesterol out of the blood, reducing total and LDL cholesterol levels.
Flavonoids and tocotrienols. We also can reduce LDL and total cholesterol with Sytrinol taken in a dose of 300 mg daily. Sytrinol is a patented formula made from citrus and palm fruit extracts that contain flavonoids and tocotrienols. In human trials with analysis by ANOVA, this formula has significantly reduced total cholesterol, LDL and triglycerides.
The antioxidant and anti-inflammatory properties of flavonoids and tocotrienols contribute to managing additional cardiovascular disease risk factors. In addition, several supplements combine plant sterols with pantethine to deliver impressive results.
Few drug treatments boost HDL levels. However, multiple nutrients in the medical literature have clinically been shown to alter good cholesterol levels. For example, various vitamins, such as vitamins C, E, B6, and B12, niacin, folic acid, magnesium and selenium, have produced positive results.
In addition, protein-building amino acids and powerful antioxidants, such as CoQ10, alpha lipoic acid (ALA), N-acetyl cysteine (NAC), policosanol and extracts of hawthorn, garlic, grape seed, soy isoflavones, have positively affected heart health.
Lowering Trigylcerides
HDL exists in a careful balance with triglycerides, which are stored fats used as an energy source for metabolism. Triglyceride levels fluctuate easily, especially after meals. Increased levels are almost always a sign of excessive carbohydrate and sugar intake.
High triglycerides are yet another independent risk factor for cardiovascular disease. High triglycerides raise the risk of heart attack or stroke. Lifestyle factors that significantly aggravate elevated triglycerides and low HDL levels are obesity, smoking and sedentary lifestyle. Thus, diet, weight control, exercise and smoking cessation offer a foundation to treat elevated triglyceride and low HDL levels.
Fortunately, integrative medicine has several additional options for lowering triglycerides. Pantethine and plant sterols lower triglycerides safely and effectively. Fish oils also are effective for reducing triglyceride levels. The American Heart Association recommends that patients with elevated triglycerides take a daily dose of 2,000 to 4,000 mg of combined EPA and DHA from cold water fish.
Other Risk Factors
Elevated Lp(a) is arguably the most dangerous sub-fraction of cholesterol. It's an independent clinical risk factor for heart disease and stroke, and increases the risk of premature heart disease by up to 70 percent. Statins do not reduce Lp(a), and beta blockers may actually increase it. However, patients with high Lp(a) can reduce it easily with niacin and fish oils.
I also suggest testing for two other known risk factors: homocysteine and high-sensitivity c-reactive protein (hs-CRP). Inflammation is central to the endothelial dysfunction that underlies coronary artery disease. Measuring levels of c-reactive protein (CRP) is a good way to assess inflammation. Studies have shown that higher levels of CRP increase the risk of stroke, heart attack and peripheral vascular disease.
By using these new generation tests, we can assess a person's cardiovascular picture more comprehensively. An integrative approach further arms us in this war, helping us prevent heart attacks and strokes.
For a list of references, go to and click on the references toolbar.
Dennis Goodman, MD, FACP, FACC, FCCP, is a physician team member of Scripps Center for Integrative Medicine in La Jolla, Calif. Prior to this, Dr. Goodman was chief of cardiology and medical director of the Cardiac Treatment Center at Scripps Memorial Hospital in La Jolla. He is a clinical associate professor at University of California, San Diego.
Disclosure: Dr. Goodman indicates he is on the scientific advisory board of Enzymatic Therapy and is a developer of a comprehensive cardiovascular nutritional supplement, HDL Booster, which incorporates flavonoids and tocotrienols.
In Range
Studies show that raising good cholesterol reduces cardiovascular disease risk more than lowering bad cholesterol alone. As a result, the American Heart Association and the National Cholesterol Education Program have established the following guidelines to keep the heart healthy.
Keep HDL levels above 40 (above 60 is optimal).
Keep LDL levels between 100 and 159 (preferably less than 130).
Keep total cholesterol (HDL and LDL) under 200.

Dennis Goodman, MD, FACP, FACC, FCCP
Vol. 2 •Issue 4 • Page 59
New Frontiers for Heart Health

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