Stephen W. Parcell, ND
Despite the fact that heart attack is the #1 cause of death for Americans many people still do not understand how to prevent having one or how to work with their doctors to identify coronary artery disease or atherosclerosis early in life before it becomes dangerous. Atherosclerosis is an inflammatory condition of the artery wall. It affects the arteries of heart. We call this his coronary artery disease (CAD). If one of these coronary artery plaques breaks apart or ruptures a blood clot may ensue blocking blood flow to the heart muscle. High cholesterol is not the main cause of heart attacks. Just treating cholesterol prevents at best 30-40% of heart attacks. This is why it’s very important to know more about risk factors and what you can do to stop plaque building or even reverse it.
Most Americans think that if they don’t have symptoms they are fine. People typically say they went through their yearly physical and got a clean bill of health. They may have had an EKG or exercise treadmill test and since they passed that they think they are good to go. This is a problem because an EKG only shows electrical abnormalities in heart and may indicate a past heart attack, changes in heart size or arrhythmia but cannot tell the doctor anything about the level of plaque in the arteries of the heart. Its plaque the causes heart attacks most of the time. A person can have advanced atherosclerosis and have a normal EKG. Even worse, an exercise treadmill test can give a false sense of security.
If a person fails the treadmill test obstructive coronary artery disease is likely present. This may lead to surgical procedure which could very well say this person’s life. On the other hand if a person passes it they’re told that everything is fine. This may not be true in and I’ll tell you why. Often during the process of atherosclerosis the outside diameter of an artery will enlarge to accommodate the increased amount of plaque within its muscle layers leaving the inside diameter where the blood flows largely unchanged. So, the point is that the heart muscle will still get plenty of blood during the exercise treadmill test leading to a normal EKG and a lack of chest pain during exercise.
Another reason why someone may pass the exercise treadmill test is that if they have a long history have a long history of cardiovascular fitness (runners, swimmers, cyclists, rowers) the arteries of the heart may form what’s called collateral circulation or collateral branches. This is an adaptive change the heart makes to gain the blood supply it needs in the face of compromised blood flow.
Most of us have heard that hypertension is a silent killer. It’s called that because a person can be completely unaware they have it until it gets really bad. Usually, when hypertension is severe symptoms such as headaches or ringing in the ears will result. Well, there is one more silent killer. It’s atherosclerosis. Often a person will have absolutely no symptoms until their first major heart attack. This is why I am a big fan of 2 particular screening tests. The heart scan and the carotid intima media thickness test. Ideally these tests should be done together. The first checks for plaque in the heart the second checks for plaque in the major arteries of the neck. It’s important to note that not everyone is a candidate these tests. People at extremely low risk for heart disease don’t need to run out and get a heart scan and people with many risk factors also do not necessarily need one because the test will almost always show plaque.
I’ll give an example. A 33-year-old female runner with a total cholesterol of 180, triglycerides of 80 an LDL of 101 and HDL of 65 with no history of smoking or first tier relative dying of a heart attack before age 50. A heart scan in a patient like this we just expose her to on the radiation and but almost always illness score of zero plaque anyway.
Another example: A 58-year-old man with a 30 pack year history of smoking, moderate abdominal obesity, rheumatoid arthritis, triglycerides of 168, LDL of 150 and HDL of 35. Additional risk factor analysis and aggressive treatment would be indicated immediately regardless of heart scan results. A heart scan and carotid artery test could be used however to monitor effectiveness of treatment. I might send someone like this to a cardiologist for an exercise treadmill right away because it would be concerned there could be narrowing of an artery. Another issue is hormones. The estrogen present in a premenopausal woman appears to have a cardioprotective effects and this is one reason why premenopausal women aren’t a lower risk of heart attack. After menopause women catch up fairly quickly to men with plaque buildup and are more likely to die from a heart attack. Even though men have more heart attacks women are more likely to actually die from one.Another protective factor for women might be the loss of iron during menstruation during premenopausal years. Iron is pro-oxidative and is linked with inflammation in the arterial wall. Since men don’t lose iron every month through blood loss they typically have much higher iron stores and women.
Additionally, low testosterone (also known as hypogonadism) may be experienced in men as they get older. A natural decrease in testosterone as a man gets older age is called andropause. Not all men experience this at the same degree. Typically I recommend getting a baseline testosterone level at age 40 and checking it every year if it’s borderline low. Low testosterone levels are associated with increased risk of heart attack as well as atherosclerosis, high triglycerides, metabolic syndrome and abdominal obesity.
Regarding cholesterol, there are different risk levels associated with the size and number of the cholesterol particles themselves. This is why I sometimes say “it’s lipoproteins that need to be watched not cholesterol.” This is because the lipoprotein is what carries the cholesterol. Lipoproteins are the little balls (particles) cholesterol travels in. If these balls are small they can get into the arterial wall and increase inflammatory atherosclerosis and heart attack risk. HDL, the good cholesterol, also travels in little balls and bigger HDL particles indicate improved cholesterol transport away from the artery wall to the liver for reprocessing.
So to summarize, people should be doing a lot more to assess their heart attack risk in this country. The standard of care, as it is called, is really not adequate to prevent heart attacks currently. Detailed personal and family history and assessment of traditional heart attack risk factors in addition to advanced testing and possibly a heart scan and carotid intima media thickness test is indicated in everyone 40 years or older. Men may want to look at these things at age 30. A female with a first degree relative who experienced a heart attack before age 50 may also want to consider a preventive cardiology visit earlier than age 40.
For more information on how to change your risk of a heart attack reverse coronary atherosclerosis read my book “Dare to Live”.