Risk Factors:
Age
Ethnicity
Sleep Apnea
Bad sleep/<6 hours of sleep
Low Vitamin D
Atrial fibrillation / history of irregular heartbeats
Oral infections, including Periodontitis and Endodontic, periapical abscesses, infected Root canals
Systemic Infections
Gut dysbiosis
9P21 gene
Haptoglobin 2-2 gene
Apo E4 genotype; diet depends on genotype
Familial Hypercholesterolemia
Xanthomas
High Lp(a)
KIF6 genotype, makes atorvastatin (Lipitor) and pravastatin (Pravachol) protect only 60% of people
Atorvastatin is less effective on women, and even less with insulin resistance. Better to use rosuvastatin (Crestor)
Atorvastatin more effective in male heart patients with a certain KIF6 genetic variant
4q25 gene – 140% higher risk of Atrial fibrillation, Quintuples the risk for strokes and doubles it for heart attacks or dementia
Smoking
Substance abuse
Asthma
Taking corticosteroids
Mental disorders
Migraines
Stress/Working long hours
Women divorce
Sedentarism
Insulin Resistance
Metabolic Syndrome
Triglycerides/HDL ratio
>3.5 (white);
>3.0 (Hispanic);
>2.0 (Black)
High LDL/ High ApoB
Blood pressure >120 mmHg
Autoimmune disease,
Lupus
Psoriasis
Rheumatoid Arthritis
A ring around the colored part of your eye (Cholesterol and triglycerides deposit).
Earlobe with a diagonal crease called Frank’s sign (Nobody knows why, but they are at x3 risk for Coronary Artery Disease and “better predictor of risk for severe CAD, heart attacks, and peripheral artery disease”).
Male pattern baldness
Erectile Dysfunction
Prematurely gray hair or wrinkles on Women
Miscarriages
Premature births
On Hormone Replacement Therapy [
They are not fond of it]
Antibiotic Azithromycin dangerous in high risk patients
Antibiotic Septra and Bactrim, don't combine with antihypertensive medications (RAAS inhibitors) because it can raise your potassium dangerously high
High inflammation markers:
F2-Isoprotane/Creatinine Ratio: > 0.86 ng/mg
Fibrinogen >370 mg/dL
hs-CRP >1
Microalbumin/Creatinine Urine Ratio (MACR) -
Men, >4 mg/L
Women, >7.5 mg/L
Lp-LPA2 - high in oral infections. >200 nmol/min/mL
Myeloperoxidase (MPO) - ‘the worst of them all’, high in oral infections, otherwise appears to be genetically influenced. >420 pmol/L]
NT-proBNP >125 pg/mL
Their optimal medical therapy:
“Dr. Serruys and his team define OMT [Optimal Medical Therapy] as receiving four types of heart medications: an antiplatelet drug, a statin, a renin-angiotensin system inhibitor, and a beta-blocker”
]
Excerpts:
About one in four heart attacks and strokes are repeat events, according to the Centers for Disease Control and Prevention (CDC).1
BaleDoneen Method rapidly shrinks and stabilizes arterial plaque in the first year of treatment, helping people avoid heart attacks and strokes.
It was also proven that our method eradicated lipid-rich arterial plaque (the most dangerous kind) in 100 percent of cases.
[...]
he’d needed emergency quadruple coronary bypass surgery at forty-two to treat severely clogged arteries that were putting him at high risk for a heart attack. “It was the worst thing I’d ever gone through,” he told us. “They split me open like a clam and after the operation, I was in so much pain I had to go on short-term disability. I told my wife I’d rather die than go
Over the next ten years, he underwent an additional sixteen stenting procedures to reopen clogged arteries all over his body, including those in his heart, legs, kidneys, and gut.
However, we assured her that we’ve successfully treated many patients who were even sicker than he was, including two of the patients you’ll meet later in this book: Joe, who was in such poor cardiovascular health when he plugged into our method that he’d been told he needed a heart transplant; and Camille, who told us that after suffering a near-fatal heart attack at forty, she was so terrified she’d have another one that she dreaded going to sleep at night, fearing she wouldn’t wake up in the morning.
[..]
Moreover, a major study done nearly thirty years ago found that 86 percent of heart attacks occur in patients whose coronary arteries are less than 70 percent blocked, and 68 percent happen when the major arteries supplying the heart are less than 50 percent obstructed. A number of other studies have similar findings.
[#Sleep Apnea]
Like about 22 million other Americans, he had
obstructive sleep apnea (OSA), a disorder marked by brief, repeated episodes in which the person stops breathing during sleep. Characterized by such
symptoms as loud snoring, daytime drowsiness, and a dry mouth or sore throat upon awakening, OSA frequently goes undiagnosed. If untreated, this sleep disorder
doubles the risk for heart attack, stroke, high blood pressure, heart failure, atrial fibrillation, diabetes, and other cardiovascular problems. Recent studies, however, have shown that treatment of OSA eliminates this excess risk and helps improve blood pressure control.26 Neal’s case bears this out: After he started using a CPAP (continuous positive airway pressure) machine to keep his airways open at night, his blood pressure improved dramatically.
[#blood pressure]
Therefore, we recommend that patients whose blood pressure is even slightly above normal (which is a level below 120/80) be evaluated to see if they need treatment.
We also believe in setting individual—not aggressive—treatment goals. Certain patients, including those with type 2 diabetes, can be harmed if their blood pressure is reduced to a level below 120/80.
[#genes]
example, like about 50 percent of Americans, Neal is a carrier of the
9P21 gene, which is often called “the heart attack gene,” because it is an independent predictor of risk for these events, even when such factors as family history, high blood pressure, diabetes, obesity, and elevated levels of the inflammatory marker C-reactive protein are taken into account. A recent study, however, found that when carriers of the 9P21 and other high-risk genes
stay physically fit, they can reduce their risk for CVD by up to 50 percent, highlighting the amazing power of an optimal lifestyle to keep your heart healthy,
no matter what is written in your DNA. Like about 25 percent of Americans, Neal is also a carrier of another high-risk gene called
Apo E4. This genotype not only dramatically raises risk for CVD, but it also puts people who carry it at up to twenty times higher risk for developing Alzheimer’s disease. In chapter eleven, we will look at these and other high-risk genes more closely and also discuss the best genetically guided strategies people who carry them can use to protect themselves, including a diet and exercise plan based on your Apo E genotype.
[#medical history]
For each family member, record as much of the following data as possible:
Date of birth
Sex
Ethnicity
Medical conditions, including the age at which they occurred
Dental disorders, such as gum disease, oral infections, and tooth loss
Pregnancy complications, such as gestational diabetes, preeclampsia (high blood pressure and protein in the urine), miscarriages, and stillbirths
Mental health conditions
Red flags for heart attack, stroke, and dementia, such as those listed in chapter three
Lifestyle, including smoking, substance abuse, and diet and exercise habits
For deceased relatives, list the age at death and the cause
[#insulin resistance]
We recommend that everyone with known arterial disease get the OGTT [Oral Glucose Tolerance Test], regardless of their weight or BMI. Here’s why: If you have atherosclerosis, there is a 70 percent risk that you also have IR or diabetes.
[..]
For example, Camille did need a statin, but the one that was prescribed after her heart attack wasn’t an effective therapy for people with her genotype.
[#Erectile Dysfunction]
Although a variety of conditions can interfere with a man’s sexual performance—including stress, sleep disorders, diabetes, alcohol consumption, smoking, anxiety, depression, and the use of certain medications—
CVD is the leading culprit. A 2019 analysis pooling the results of studies of more than 150,000
men found that those with ED were 59 percent more likely to have CVD,
[#Migraines]
Migraine headaches, particularly those preceded by sensory symptoms known as an aura (such as seeing flashing lights or zigzag lines, or a disturbed sense of smell, taste, or touch),
are strongly linked to increased risk for stroke, particularly in women.
[#Periodontitis]
Other research has shown that people with gum disease are at 70 percent higher risk for Alzheimer’s disease than those with healthy gums, and among those who already have the memory-robbing
Oral pathogens have also been linked to an increased threat of many other chronic conditions, including diabetes, rheumatoid arthritis, and even colon cancer.15 A 2021 study of more than five hundred patients with COVID-19 reported that those with gum disease were 3.5 times more likely to need ICU care, 4.5 times more likely to be put on a ventilator, and nearly nine times more likely to die, compared to those without gum disease.
[#autoimmune]
Other research suggests that people with lupus—an autoimmune disorder best known for causing a butterfly-shaped rash across the nose and cheeks—
are particularly vulnerable to heart disease. A 2018 study found that young women with this disease are fifty times more likely to die from a heart attack than young women without lupus. Researchers believe that immune system cells called neutrophils may be the culprits: A recent study found that in lupus patients, these normally protective cells go rogue
, leading to stiff, inflamed, and plaque-filled arteries.
[...]
[#sleep apnea]
Loud snoring or frequently waking up in the night for no apparent reason are both common symptoms of OSA. As you learned in chapter two, this often-undiagnosed sleep disorder is one of the most common root causes of high blood pressure that doesn’t respond to prescribed medications, as turned out to be the case with both Neal and J.P. If you fit this scenario, talk to your medical provider about having a sleep study, even if you don’t think you snore, since many people with OSA are unaware of their symptoms. Several studies have also shown that having OSA doubles risk for heart attacks, strokes, and other CV events. The good news is that if this sleep disorder is treated, the excess risk can be eliminated.
[..]
[#gout]
Three years before his heart attack, he was diagnosed with gout, an inflammatory form of arthritis that occurs when uric acid builds up in the body, leading to joint pain and swelling, especially in the big toes.
Although gout and diabetes are different diseases, people who have one are more likely to get the other. If you have gout even occasionally, we recommend having your blood sugar checked with the OGTT, since discovering and treating this very common condition is a key component of our prevention plan. When we tested J.P. after his heart attack, he turned out to be prediabetic.
[...]
[#stress]
Working long hours Not only is clocking long hours on the job stressful, but it can take a toll on your cardiovascular health. In a recent analysis of studies that included more than 600,000 initially healthy men and women,
those who worked fifty-five or more hours a week had a 13 percent higher rate of heart attacks and 33 percent higher rate of strokes, compared to those who worked thirty-five to forty hours a week.25 The participants were tracked for seven to eight years. Working long hours has also been linked to increased likelihood of weight gain, smoking, and excessive drinking.26
[#Asthma ]
Having persistent asthma symptoms can double your risk for a cardiovascular event, such as a heart attack, stroke, or related complication of arterial disease, a recent study found.27
Another study found that taking daily medication (such as oral or inhaled corticosteroids) for chronic asthma boosts risk for such events by 60 percent over a ten-year period, as compared to having intermittent asthma that doesn’t require controller medications.28 What’s the link between asthma—a respiratory disease that affects about 25 million Americans—and heart risk? Inflammation plays a key role in both conditions, as do genes.
In fact, children are up to five times more likely to develop it if their mother has asthma and up to twice as likely if their father does.29 In the study of users and non-users of asthma control medications,
those with persistent symptoms requiring daily treatment had much higher levels of systemic inflammation than those with intermittent symptoms. The findings align with a large body of research tying other inflammatory
[#divorce]
For example, a 2015 study found that one
divorce raises women’s heart attack risk by 30 percent—and two divorces doubles their risk! The same study found that men must be divorced at least twice to have any increased heart attack risk.
[#optimism]
Optimism. People with an upbeat outlook have a 35 percent lower risk for heart attacks, strokes, angina, and death from CV causes, according to a 2019 analysis of studies that included nearly 130,000 men and women who were tracked for about fourteen years.32
[#Earlobe #Red flags]
For example, when we teach healthcare providers about cardiovascular red flags in our continuing medical education (CME) course, we show them a photo of coauthor Brad Bale’s earlobe, which has a diagonal crease called Frank’s sign.
People with this tiny wrinkle or fold, which looks like the backslash on your computer, are at more than three times higher risk for CAD than those without it, according to a recent study.33 Another study concluded that Frank’s sign is a better predictor of risk for severe CAD, heart attacks, and peripheral artery disease than such well-known risk factors as smoking, high blood pressure, and high cholesterol.
[#men #baldness]
Male pattern baldness
A 2014 study linked this form of
hair loss, which affects the front and top of the scalp, to a 40 percent rise in heart attack risk, as compared to that of men the same age with a full head of hair.36 And the earlier this pattern of hair loss begins, the stronger its impact on cardiovascular risk, the researchers reported. Although scientists don’t yet know the reason for this link, other studies have reported similar findings. For example, a 2017 study of two thousand men found that in those under forty,
male pattern baldness was a bigger risk factor for developing CAD than obesity is.37 That’s why even young men with male pattern baldness should get a comprehensive cardiovascular evaluation with the tests recommended in this book. Such a workup would have identified Neal, who started to go bald in his early thirties, as being at very high risk—long before his arterial disease grew so severe that he needed emergency bypass surgery.
[#gray hair #wrinkles #women]
Prematurely gray hair or wrinkles
The researchers also reported that
young men with heart disease were more likely to have prematurely gray hair than their healthy counterparts, suggesting that accelerated aging may play a role. Going gray at a young age, or excessive wrinkling in sun-protected areas is also linked to elevated heart risk in women.
[#familial hypercholesterolemia #red flags]
A ring around the colored part of your eye
Primarily found in people with an inherited form of extremely high cholesterol (familial hypercholesterolemia, or FH),
this condition creates a deposit of cholesterol and triglycerides in an arc on either the top or bottom of the iris (the colored portion of your eye), inside the cornea.38 Because people with FH are at extremely high risk for heart attacks and strokes, early detection and treatment can be lifesaving.
If untreated, people with FH are twenty times more likely to develop CAD than those without FH—and are up to 50 percent more likely to suffer a fatal or nonfatal heart attack by fifty.39
[#xanthomas]
Yellowish, waxy skin growths
Known as xanthoma, these fatty growths can be a sign of high cholesterol.
They can be as small as a pinhead or as big as a grape and can occur in many areas, including the corners of your eyes, your hands, and the back of your legs. In one large, long-term study, people who had them were at a 48 percent higher risk for heart attacks.
[#genes]
Moreover, he had a variant of the
haptoglobin gene called Hp 2-2 that raises lifetime risk for arterial disease as much as smoking does, and also increases the likelihood of developing autoimmune diseases and cancer.5 Not only is this gene probably related to Casey’s psoriasis—an autoimmune disease that is known to increase heart attack and stroke risk—but, more significant,
people with his genotype do best if they follow a gluten-free diet. He also got some genetic good news from our tests: He carries a copy of the heart-protective Apo E2 gene, which may counteract
[#Lp(a) #genes]
The researchers report that patients with
one copy of the gene responsible for elevated Lp(a) levels are 58 percent more likely to develop coronary heart disease (CHD) while taking a statin for prevention than those without the gene, while risk for CHD is more than doubled in statin users with two copies of the Lp(a) gene!
[#LDL #ApoB]
public enemy number one by the medical profession.
Yet none of the hundreds of cholesterol studies performed to date has ever shown that LDL causes heart attacks. This unscientific belief has become so ingrained in medical thinking—as well as cardiology guidelines—that it’s been termed “
the great cholesterol hoax.” Indeed, a large body of research suggests that your level of LDL is the worst lipoprotein predictor of your heart attack risk.11 Instead, the most predictive measurement is apolipoprotein B-100 (ApoB),
[#triglycerides]
Conversely, the standard cholesterol test only measures the amount of cargo, such as LDL cholesterol, that the fleet of submarines is carrying. Why does this distinction matter? In a recent study called JUPITER,
there was no correlation between the 11,186 participants’ initial blood levels of LDL (as measured by the standard test) and their subsequent rate of heart attacks, strokes, and other cardiovascular (CV) events over the next two to five years, while their baseline numbers for ApoB and triglycerides (TG) strongly predicted future CV risk.13
[ #antibiotic #azithromycin]
In fact, as she soon found out, it was her second heart attack: She’d been misdiagnosed during her first visit to the ER five days earlier. The antibiotic that was mistakenly prescribed, azithromycin, is extremely dangerous for someone in the throes of a heart attack. A 2020 study of nearly 3 million people found that
those treated with this antibiotic had nearly twice the risk of dying from cardiovascular or other causes in the next five days, as compared with people treated with amoxicillin, an antibiotic not associated with CV events.
have reported increased risk for cardiovascular deaths, serious heart arrythmias, or heart attacks in patients who received azithromycin.2 While deaths linked to this widely prescribed antibiotic are rare, the highest rates were seen in patients with cardiovascular disease.
[#genes #statin]
For example, like about
40 percent of Americans, Juli has a KIF6 genotype that makes the statin her doctors had prescribed after her second heart attack, Lipitor (atorvastatin), ineffective when taken as a sole therapy.12 That meant she was getting zero protection against heart attacks, strokes, and other complications of arterial disease. Other research suggests that this medication
doesn’t work as well in women as in men, and is also less effective for people with insulin resistance. Because many doctors are unaware of these individual differences in statin response, Lipitor is so widely prescribed to patients of both sexes that it’s the world’s bestselling drug.13 A key reason for its popularity: In clinical trials that mostly included men, Lipitor was spectacularly successful at saving lives—in male heart patients with a certain KIF6 genetic variant.14
[#Heart attack #symptoms on #women]
Women’s symptoms can be much more varied and subtle than those in men and may not involve the chest at all. Although such symptoms are often labeled as atypical, they are extremely common in 51 percent of the population: women.
A study of more than 1.1 million heart attack patients found that almost 15 percent of the women died in the hospital after a heart attack, compared to 10 percent of the men, largely due to misdiagnosis and delays in getting care.20 Younger women with atypical symptoms were at 20 percent higher risk for death after a heart attack than their male counterparts.
If there is any suspicion a person may be having a heart attack (see the ten warning signs listed below), it is best to be cautious and call 911 immediately, because every second counts. Patients who arrive by ambulance usually get faster care—and treatment can start on the way to the hospital. Tell medical providers that you think it’s a heart attack and don’t let them brush off the symptoms as anxiety, heartburn, or other noncardiac causes without doing tests. EKGs frequently have normal or inconclusive findings in heart attack patients, particularly in women, so you should insist on having your levels of cardiac enzymes measured, using a blood test called high-sensitivity troponin, which checks for elevated levels of proteins that are released when muscle cells in the heart are damaged, as occurs during a heart attack.22
Pain in areas of the upper body, including the jaw, neck, back, shoulders, or arms Fullness, squeezing, or pressure in the chest or a choking sensation that may feel like heartburn
Dizziness or feeling light-headed
Nausea with or without vomiting
Shortness of breath
Abnormally heavy sweating or breaking out in a cold sweat that may feel stress-related Unusual fatigue, extreme weakness or anxiety, or a sense of impending doom
Rapid, irregular, pounding, or fluttering heartbeats
Sudden confusion
Abdominal pain that may feel like indigestion or severe abdominal pressure that may feel like an elephant is sitting on your stomach
[..]
[#PCOS #women]
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, affecting up to 19 percent of women during their childbearing years. Its name describes the hallmark of this disease: numerous small cysts (fluid-filled sacs) in the ovaries. Although the exact cause of PCOS is unknown, in women who have it, the ovaries produce abnormally high levels of male sex hormones called androgens, which can lead to excessive amount of facial and body hair, male pattern baldness or thinning hair, and weight gain, especially around the belly. Other symptoms include infrequent or irregular periods, infertility, acne or oily skin, and dark skin patches under the breasts, in the armpits, and on the back of the neck.
Women with PCOS are at increased risk for chronic diseases, including diabetes, obesity, high blood pressure, and CVD. The disorder is also strongly associated with insulin resistance, and many women who have it also meet medical criteria for metabolic syndrome, a gang of five cardiovascular bullies that we’ll look at more closely in part two. These include high blood pressure, high cholesterol, high triglycerides, and a large waistline—and when they attack in tandem, risk for heart attacks and diabetes soars.23 Not only does having PCOS greatly magnify a woman’s risk for cardiometabolic disorders, but their first-degree relatives (mothers, fathers, sisters, and brothers) are at a similarly high risk for the same clusters of abnormalities, according to a recent analysis of fourteen earlier studies.24 Indeed, some researchers have reported that the brothers of women with PCOS are at just as high risk for insulin resistance and metabolic syndrome as the women themselves!
[#Red flags #miscarriages #premature]
In Juli’s case, we detected a previously overlooked red flag for cardiovascular peril: Long before her heart attack, she’d suffered two miscarriages. In a 2015 study of more than sixty thousand women,
those who had experienced at least two pregnancy losses were at 75 percent higher risk for heart disease as compared to women with no miscarriages, even when other health factors were taken into account.25
Researchers have also linked delivering a premature baby or having two or more pregnancies to increased risk for CVD.
[#Hormone Replacement Therapy #HRT #women]
There has been intense scientific controversy about the cardiovascular effects of HRT, fueled by wildly conflicting studies. In the early 2000s, millions of women were scared away from HRT by frightening media reports about the potential dangers of its most common form: combination therapy, which combines doses of two hormones that regulate women’s menstrual cycles—estrogen and progesterone. This type of HRT is the only option for women who have not had a hysterectomy, since the other form of HRT, which
only contains estrogen, raises risk for uterine cancer. The addition of progesterone prevents this problem. In 2002, data from the Women’s Health Initiative (WHI), a large, U.S. government–run clinical trial, triggered an avalanche of alarm by reporting large increases in heart attacks, strokes, blood clots, heart disease, and breast cancer in women who received HRT that contained the hormones estrogen and progesterone, compared to women who had received a placebo.
.” It holds that there is a critical “window of opportunity” after menopause during which HRT helps ward off CVD in recently menopausal women who are under sixty, while not providing the same benefits in older women.
The trial, which sought to find out if HRT helped prevent heart disease and other chronic illnesses, even included first-time HRT users as old as seventy-eight.
The researchers then compared rates of fatal and nonfatal cardiovascular events in women under sixty with those in women over sixty. They found that both younger and older HRT users were at increased risk for stroke, mini-stroke (transient ischemic attack), and blood clots, compared to women the same age who didn’t use HRT, and that risk for these events rose with age among women who take hormones. However, younger HRT users were not at increased risk for fatal or nonfatal heart problems, including heart attacks.
We recommend that if you do decide to take HRT, after weighing the risks and benefits discussed in this chapter and consulting your medical provider,
that treatment should start soon after menopause, at the lowest possible dose for symptom relief, taken for the shortest time possible.
#stroke
After weeks of being poked, prodded, and scanned by various specialists, she was told that her healthcare team considered her case a medical mystery. “
One of the doctors said that 25 percent of the time, they can’t pinpoint what happened,”
Of those who survive, only 10 percent make a full recovery and 25 percent recover with minor impairments, according to the American Stroke Association.
The rest experience moderate to severe impairments, with about 10 percent of stroke survivors requiring care in a nursing home or other long-term care facility.
#ultrasound #tests
carotid duplex can’t detect plaque inside the arterial wall, even if it’s highly inflamed (the kind that sparks heart attacks and strokes). Therefore, the lack of blockages in Melinda and Nikki’s arteries was not proof that they were free of atherosclerosis. What most patients—and many doctors—
don’t know is that 99 percent of plaque—including areas of highly inflamed plaque—does not block blood flow at all, according to a startling 2004 study by Dr. Steven Nissen of the Cleveland Clinic.7 These findings suggest that tests that only check for blockages, such as carotid duplex and treadmill stress tests, may miss up to 99 percent of people at risk for heart attacks and strokes. Melinda and Nikki are cases in point. When they were checked with the cIMT test discussed more fully in the next chapter, this fifteen-minute ultrasound scan detected plaque in their neck arteries, solving the mystery of why they’d had strokes.
Lifesaving Lesson No. 4: Even Small Plaques Can Be Potentially Lethal, If Untreated.
In Nikki’s case, we also checked a part of the head that most doctors ignore: her mouth. A dental evaluation revealed that she had previously undiagnosed periodontal (gum) disease.
About 50 percent of Americans over thirty have this chronic oral infection, which has also been linked in very recent studies to increased risk for developing memory impairment and loss. Like many of these patients, Nikki, who has a beautiful smile, was unaware that she had high levels of periodontal bacteria circulating in her bloodstream until she had a simple oral-swab DNA test that will be discussed in chapter ten.
As we’ll explain more fully in chapter fourteen,
statin therapy is one of the cornerstones of our evidence-based disease reversal plan for patients who have arterial plaque.
#Lp(a) #LDL
There’s also some evidence that keeping levels of LDL (bad) cholesterol as low as possible helps people with elevated Lp(a) avoid cardiovascular events.
#Root Canal #abscess
She’d also undergone gallbladder removal surgery, ten root canals to treat endodontic disease (infection of the tooth’s pulp), and
five emergency extractions of severely infected teeth after their root canals had failed.
#Periodontitis #particle size #LDL
People with infected gums have up to twice as much small, dense LDL cholesterol (the most dangerous kind) in their blood as those with healthy gums, according to a recent study. The size of cholesterol particles matters: Some are big and buoyant, so they tend to bound off arterial walls, and others are small and dense, making it easier for them to penetrate the arterial lining and form plaque. Think of the difference between beach balls and bullets. In addition, people with high levels are at up to eight times higher risk for developing metabolic syndrome, even when other risk factors, such as obesity and inflammation, are taken into account, a 2019 study reported.
#Ultrasound #Tests #CIMT #fIMT
The walls of the carotid arteries can be examined directly with the cIMT test, the coronary arteries can be checked for calcified plaque with CACS, and the aorta can be checked for abdominal aortic aneurysm (a weak, ballooning area in the body’s largest artery).
similar, but much less widely available, test called femoral artery intima-media thickness (fIMT) can be used to measure the IMT of the femoral artery, one of the major vessels that supplies the legs with oxygenated blood.
Due to its calcium content, echogenic plaque can be associated with arterial stiffness (hardening of the arteries).7 It’s also possible to have plaque deposits that contain a mix of soft and hard plaque: This is called heterogenous plaque. The higher the lipid content of these areas, the greater the risk of plaque rupture and associated events.
#AAA #Abdominal Aortic Aneurysm #gene #Aneurysm
Although AAA is often stereotyped as a disease of older male smokers, nearly half of the people who develop it are women, nonsmokers, or people under sixty-five, the study cited above reported. While the exact cause is still under investigation, it shares many of the same risk factors as CVD, including smoking, obesity, diabetes, high cholesterol, high blood pressure, and genetics. A 2020 study and earlier investigations have identified twenty-four genes that play a role.15 Carriers of the 9P21 gene are at up to a 75 percent higher risk for AAA than noncarriers. Not only can the AAA scan reliably detect an aneurysm, but it can also identify calcification (atherosclerosis) in the artery wall that signals increased risk for a heart attack or stroke.
#gene #peripheral artery disease #Abdominal aortic aneurysm #PAD #AAA #Aneurysm
the 9P21 gene also boosts the threat of PAD and AAA.
#Aneurysm
Aneurysms measuring less than 1.6 inches in diameter are classified as small. Medium aneurysms measure 1.6 to 2.2 inches, and large ones exceed 2.2 inches. Surgery generally isn’t advised for small aneurysms, since the risks of the procedure outweigh those of rupture.
#Peripheral Artery Disease #PAD
Ankle-Brachial Index (ABI) What It Checks: This rapid test is used to diagnose peripheral artery disease (PAD), the circulatory problem that caused Neal to be unable to walk more than twenty-five feet before excruciating leg pain forced him to stop. This disorder occurs when plaque buildup narrows arteries, reducing blood flow to your extremities (usually the legs).
If you have heart disease, there is a 42 percent probability that you also have PAD.18 Smokers are up to six times more likely to develop PAD.19 Smoking ten cigarettes a day can magnify your risk for developing PAD by as much as 50 percent.20 About 90 percent of the people who develop this debilitating disorder are current or former smokers.21 People with the 9P21 gene and those with a family history of PAD are also at increased risk.
The classic symptom is leg pain or cramps when you’re walking that improve with rest. However, up to 40 percent of people with PAD—a serious, but treatable condition—have no symptoms, so the disorder often goes undiagnosed. That’s dangerous, since having PAD, particularly if it goes untreated, more than doubles heart attack and stroke danger.22
#Ankle Brachial Index #test #PAD #ABI
The Procedure: Ankle-brachial index is a simple, painless exam that compares the blood pressure in your lower legs to that in your arms. After you’ve been resting on your back for ten minutes, a healthcare provider measures the pressure in your arms, using a standard blood pressure cuff, then measures the pressure in arteries near your ankles using a blood pressure cuff and an ultrasound probe (or stethoscope). Blood pressure readings may be taken while you’re at rest and again after you’ve walked on a treadmill. The test takes about fifteen minutes.
We recommend ABI if you are fifty or older, even if you have no symptoms, or at any age if you do. We also recommend starting screening for PAD at forty if you have any of these risk factors: diabetes, high blood pressure, high cholesterol, atherosclerosis, abdominal aortic aneurysm, a family history of CVD, or if you are a carrier of the 9P21 gene.
Some older adults, or those with a history of kidney disease or diabetes, may develop stiff blood vessels that don’t compress easily with a blood pressure cuff. Consequentially, their ABI results may be inaccurate. For these patients, a similar test called toe-brachial index (TBI) is sometimes used instead of the ABI, since the toe’s blood vessels rarely become rigid.
Any number lower than 0.9 indicates some degree of compromised blood flow to the feet, signaling that you have PAD, while a measurement above 1.4 indicates stiff arteries (often due to buildup of calcified plaque, a condition known as calcified atherosclerosis). If you have PAD, it can often be treated with lifestyle changes, including quitting smoking, exercising more, and eating a healthy diet. You may also need medication, such as anti-clotting drugs. These include low-dose aspirin or clopidogrel bisulfate (Plavix). For severe blockages, such as those that affected Neal, treatment may also include balloon angioplasty and/or stents to reopen the obstructed arteries.
#Test
imaging tests, such as carotid duplex and the treadmill stress test discussed below, look for indirect evidence of disease (reduced blood flow to the brain or heart).
#Stress test
If you think you don’t need cIMT or CACS because you’ve already been screened with a treadmill stress test, here’s some news that may make your heart skip a beat: when used for screening, this test is so unreliable that it misdiagnoses up to 40 percent of patients, with the highest error rate in women.24 Like the carotid duplex test, the stress test checks for arterial blockages.
A number of studies indicate that the stress test is a highly inaccurate vascular screening tool, prompting the US Preventive Services Task Force to recommend against using it to check the heart health of low-risk people who lack symptoms.
The downside is that stress tests have a high rate of false positives (healthy people being told they have disease), leading to anxiety, fear, and unnecessary additional tests, as well as false negatives (missing disease).
This occurred with one of our patients, who was extremely physically fit and always passed his annual stress test with flying colors despite having 100 percent blockage in one area of his coronary arteries, and 70 percent blockage in another! Overall, the stress test misdiagnoses up to 40 percent of patients, with the highest error rate in women.
#CAC score
One way the body tries to repair the damage from plaque is by removing the lipid (cholesterol) and replacing it with collagen and calcium. These substances are denser than lipid, so as the plaque “heals,” it shrinks and becomes calcified. In fact, calcium can comprise up to 20 percent of the volume of some plaque deposits.30 Calcium is what creates the hardness in hardening of the arteries.
CAC score screening
Evidence-based guidelines developed by the Society for Heart Attack Prevention and Eradication (SHAPE) task force advise vascular screening with either CACS or cIMT for almost all men forty-five or older and almost all women fifty-five or older.34 The only exception is men or women in these age groups who are at extremely low risk for heart attack or stroke because they meet all of the following criteria: they don’t smoke, have total cholesterol below 200 and blood pressure below 120/80, don’t have diabetes, and have no family history of CVD.
#inflammation #heart attacks #LDL
In a medical version of physics’ “unified field” theory, some scientists have even theorized that chronic systemic inflammation—driven by such factors as obesity, a large waistline, insulin resistance, lack of exercise and periodontal disease—may be at the root of all chronic diseases.
Yet studies have shown that only about 50 percent of heart attacks happen to people with elevated levels of bad cholesterol, creating a scientific conundrum: If high LDL is the instigator of these life-threatening events, why do the other 50 percent occur in people with normal or even “optimal” levels of bad cholesterol?5 A rapidly growing body of scientific evidence has zeroed in on another culprit.
The latest evidence has revealed an amazing fact that most physicians still don’t know: In people with healthy arteries, cholesterol particles, which are extremely tiny, routinely flow through the tennis court and all three layers of the artery wall—the intima, the media, and the adventia—without causing disease, even in people who have high cholesterol.7 This surprising discovery explains why some people with extremely high cholesterol never develop plaque,enabling them to avoid heart attacks and strokes, despite having one of the leading risk factors for these events. Conversely, even low levels of LDL can spell trouble in people with an unhealthy lifestyle, the primary driver of chronic inflammation.
Here’s what happens in people with healthy arteries: After passing through the arterial layers, cholesterol particles normally exit on the advential side, where they are picked up by the veins and lymph vessels. After that, these waxy particles are recirculated throughout the body, where they perform many essential functions, from waterproofing cell membranes to helping produce vitamin D, bile acids that help you digest fat, and many types of hormones, including the sex hormones testosterone, estrogen, and progesterone. It also helps form synapses, the wiring that lets nerve cells communicate with one another. In fact, without cholesterol, you couldn’t survive!
is now recognized that arterial disease results from a triple whammy called the atherogenic triad. Inflammation, driven by such factors as obesity, insulin resistance, a poor diet, lack of exercise, a high stress level, sleep deprivation, and gum disease, is the key culprit in each step of the disease process, which begins when contractile smooth muscle cells in the media undergo a genetic transformation that turns them into migratory smooth muscle cells. These cells move to the deep layer of the intima and produce a Velcro-like substance that latches on to apolipoprotein B-100 molecules (ApoB), a major component of all the dangerous cholesterols we discussed in chapter four, including LDL and lipoprotein (a).
When ApoB gets stuck in the intima, it becomes oxidized, which in turn sparks a fire in the arteries by activating the immune system. The tennis court releases proteins that trap white blood cells and allows them to pass through to the intima, where these Pac-Man-like compounds try to clean up the mess by gobbling them up. If the inflammatory triggers for the genetic transformation persist, more and more ApoB gets trapped, oxidized, and engulfed by the white blood cells. Eventually, they get so engorged with cholesterol that they become foam cells that form fatty streaks and evolve into the cats in the gutter.
In 2012, two groundbreaking genetic studies were the first to prove that atherosclerosis is an inflammatory illness. In one of the studies, researchers analyzed 82 previous studies that included more than 200,000 people and demonstrated a cause-and-effect relationship between an inflammatory biomarker called interleukin 6 (IL-6) and the creation of the cat in the gutter.
Chronic inflammation harms, rather than heals, because the immune system attack never stops. Think of it as similar to being shot by “friendly fire” during a never-ending war raging inside the body, ignited by the disorders discussed earlier in this chapter. In people with the IL-6 variant, however, the malignant effects of arterial fire are dampened because these men and women have relatively few IL-6 receptors, which act as molecular switches to turn on the inflammatory cascade.
As a result, people with this variant have significantly lower rates of arterial disease and associated events, as compared to people without this variant, even when numerous risk factors are taken into account. In other words, their genes act as natural firefighters.
The second 2012 study found that people with two copies of the IL-6 variant get twice the reduction in CVD risk as those with one copy (a 10 percent drop, as compared to a 5 percent drop).9
The team tracked the participants’ health for nearly four years and reported in 2020 that those who received canakinumab were 15 percent less likely to suffer cardiovascular events—including fatal or nonfatal heart attacks and strokes—or need invasive procedures, such as bypass surgery or angioplasty to reopen blocked arteries.12
The drug reduced their risk by lowering their levels of hs-CRP, without reducing cholesterol at all. The canakinumab group also had a nearly 50 percent lower rate of cancer death, but a slightly higher rate of fatal infections, as compared to the placebo group.
In October 2018, however, the drug maker announced that its application had been declined because the FDA didn’t consider the CANTOS data sufficient to support this proposed use. Sold at a staggering list price of $200,000 a year, it’s a monoclonal antibody—a type of drug that acts like a smart bomb—that selectively targets an inflammatory substance called interleukin-1 beta (IL-1B). As we’ll discuss more fully in chapter eleven, some people carry IL-1A or IL-1B genes that heighten their response to inflammation, greatly raising their risk for CVD.
#blood test #aging
How fast is your body aging? The test that can tell: F2 Isoprostanes What the Test Checks for:
We’ve dubbed this blood test the Lifestyle Lie Detector because it can reveal whether our patients are practicing heart-healthy habits.
A normal F2 isoprostanes level is less than 0.86 ng/L, while an optimal result is less than 0.25 ng/L. Although abnormal levels typically signal an unhealthy lifestyle that could cause premature aging, as was true in Catherine’s case, an important caveat is that some professional athletes or very dedicated amateur fitness buffs may also have increased oxidation, due to the extreme stress they’re putting on their bodies.
#inflammation markers #Fibrinogen #CRP #MACR
Fibrinogen, high-sensitivity C-reactive protein, and microalbumin/creatinine urine ratio are biomarkers of endothelial (tennis court) inflammation. [Missing Lp-LPA2, Myeloperoxidase]
In a meta-analysis that pooled results of thirty-one studies that included more than 154,000 patients, risk for heart disease and stroke rose by 82 percent for each 100 mg/dL increase in fibrinogen levels above 250 mg/dL, even when the results were adjusted for the participants’ ages, genders, and numerous major cardiovascular risk factors, including smoking, diabetes, high blood pressure, high cholesterol, and obesity.21
Another large study called the EUROSTROKE project reported that “fibrinogen is a powerful predictor of stroke,” including both fatal and nonfatal strokes, as well as first-time strokes, ischemic strokes, and hemorrhagic strokes (those caused by a torn or ruptured blood vessel).
The researchers found that people with the highest fibrinogen levels were nearly seven times more likely to suffer a hemorrhagic stroke than those with the lowest levels, and had double the risk of a fatal stroke. The study also found that high blood pressure plus high fibrinogen packed a double whammy, magnifying risk even more than high fibrinogen alone. That’s probably because fibrinogen and its by-products, such as fibrin, contribute to vascular disease by damaging the blood vessel lining, while high blood pressure further increases wear and tear that makes it easier for plaque to burrow inside. Plaque often contains large amounts of fibrin. High fibrinogen has also been linked to other diseases, including diabetes, cancer, and high blood pressure, and is frequently elevated in people with insulin-resistant conditions, such as metabolic syndrome, which will be discussed in depth in the next chapter.
And for people with coronary artery disease, elevated fibrinogen increases the risk that a clot will form if plaque ruptures or erodes, setting the stage for a heart attack.
What the Results Mean: The normal value is less than 370 mg/dL. In one study, having a fibrinogen level of 600 mg/dL was associated with a 200 percent increase in the risk for cardiovascular events, compared to people whose fibrinogen level was normal.
#CRP
thousand women,
results of the hs-CRP test were more accurate than cholesterol levels in predicting risk for cardiovascular events. The researchers reported that women with the highest levels of CRP were 4.4 times more likely to suffer a heart attack or stroke than were women with lowest levels.
A score of under 1.0 mg/L is normal, while a score of 0.5 is optimal, indicating that short-term risk for cardiovascular events is very low. However, it’s important to have the test repeated periodically since even a slight elevation could be an early warning sign of increased heart attack or stroke risk.
#Fibrinogen #CRP #MACR
If MACR is normal and hs-CRP and/or fibrinogen are high, this is most likely due to some other health issue, such as insulin resistance, diabetes, an infectious illness, or an inflammatory disorder, such as arthritis.
#MACR
Microalbumin/Creatinine Urine Ratio
What the Test Checks for: This test detects small amounts of albumin, a blood protein, in the urine. The term “microalbumin” refers to amounts of albumin that are too small to detect in the urine dipstick test used for routine urinalysis during annual physicals.
Therefore, an abnormal UACR is an important warning sign of cardiovascular danger, even if your hs-CRP and fibrinogen levels are normal. The researchers found that people with an elevated UACR had 20 percent higher rate of CV events, even when other risk factors were taken into account.27 Another insight from research is that MACR is more accurate than the conventional albumin urine test often used in routine annual physicals because MACR considers how much water the patient has consumed and calculates the concentration of albumin in the urine accordingly.
women whose MACR was above 7.5 and men with a ratio above 4 had nearly triple the risk for heart attacks, strokes, and other cardiovascular events during six years of follow-up in that study.28 Therefore, ratios of 7.5 or lower for women and 4 or lower for men are optimal, rather than the much higher numbers that are still considered normal by standard care.29
#Lp-PLA2
A biomarker of risk serves only as a warning that arterial disease may be in progress. However, treatments that reduce levels of that biomarker have no effect on the end disease. For example, if your car’s “check engine” light went on, removing the light bulb wouldn’t solve the mechanical problem.
Large studies have also shown that people with elevated Lp-PLA2 levels are up to twice as likely to suffer heart-related events as those with normal levels and that this biomarker independently predicts CV risk as accurately as a person’s blood pressure or cholesterol levels.
Research has also revealed that people with periodontal disease (PD) are nearly twice as likely to have elevated Lp-PLA2 levels than those with healthy gums.31 The good news, however, is that treating this chronic oral infection significantly decreases Lp-PLA2 levels—and helps patients avoid tooth loss and other complications of PD.32
Lp-PLA2 values of less than 200 ng/mL are considered normal. In the Mayo Heart Study, 95 percent of patients with scores under this threshold did not have a heart attack or stroke in the next four years, even though they had coronary artery disease (CAD).35
The researchers also found that the higher Lp-PLA2 levels, the greater the risk for a first attack, stroke, or major CV event. Compared to patients with normal levels, those with scores of 200 to 266 ng/mL had a 70 percent higher risk of these events over the next four years, while a level of 267 or above more than doubled risk.
#MPO #Myeloperoxidase
Are you in imminent danger of a heart attack or stroke? The test that can tell: Myeloperoxidase (MPO) What the Test Checks for:
This FDA-approved blood test measures myeloperoxidase, a white blood cell–derived inflammatory enzyme that the immune system uses to fight infection. Normally, MPO is only found at elevated levels at the site of an infection.
In our patients, we find that elevated MPO frequently occurs in tandem with dental infections, a topic we will discuss more fully in chapter ten.
We call MPO the joker because if it’s elevated throughout the body—as occurs in about two in fifty people, a similar distribution to the jokers in a deck of cards—all bets are off.
Of all the inflammatory biomarkers, it’s the worst: If this wild card, which appears to be genetically influenced, gets played, without the right treatment your game of life might be over.
One reason that this malevolent joker is so dangerous is that it produces numerous oxidants that make all cholesterol compounds more inflammatory. This includes HDL, the good cholesterol that normally helps clean the arteries, protecting against plaque buildup. If your blood levels of MPO are high, HDL goes rogue and joins the gang of inflammatory bullies. The joker also interacts with hydrogen peroxide in the bloodstream to produce hypochlorous acid (the active ingredient in bleach).
The joker contributes to creating vulnerable plaque in two ways: It can make the normally protective fibrous cap that covers plaque more prone to rupturing explosively or it can eat holes in the tennis court, leading to plaque erosion and a subsequent CV event. On average, serum levels of MPO are higher in people who suffer erosive events, a 2018 study found.38
The normal value is less than 480 pmol/L. Unlike hs-CRP, levels of MPO in the blood are not likely to be elevated due to infections or illness: This enzyme is a specific biomarker of blood vessel inflammation and vulnerable plaque (the dangerous kind that can lead to heart attacks and strokes).
Elevated MPO predicts future risk for coronary artery disease and cardiovascular events, including fatal heart attacks and strokes. In a recent study, people with high levels of the joker were 2.4 times more likely to die from heart disease over the next thirteen years.
One of the most common culprits for a spike in MPO is dental infections. If untreated, these can trigger heart attacks or strokes in people with vulnerable plaque. For example, as you read in chapter six, shortly after Melinda’s seemingly inexplicable stroke, she was treated for a severely infected tooth, which required extraction. If you have elevated MPO, ask your dental provider to check you for tooth and gum infections, both of which are highly treatable, using the therapies in chapter ten. If you’re being treated for atherosclerosis, elevated MPO can be a warning that your current therapies are not doing enough to cool and stabilize your disease.
#meditation #exercise
We recommend devoting ten minutes a day to mindful meditation. Sit in a relaxed position, close your eyes, and focus on your breathing and the present moment as you let stressful or upsetting thoughts float away. Prayer is another great way to soothe the mind and spirit, enhancing cardiovascular wellness.
Step up physical activity. Why does regular exercise greatly reduce heart attack and stroke risk? While you might guess that physical activity keeps the heart healthy by lowering cholesterol, blood pressure, and body weight—all of which help protect against cardiovascular (CV) events—the well-known Women’s Health
Study found that the number one cardiovascular benefit of regular exercise is reducing inflammation.42 Aim for at least thirty minutes of aerobic exercise, such as brisk walking, jogging, or biking, daily. Check with your healthcare provider before starting a new fitness regimen to make sure it’s right for you.
#Fiber
What’s more, people who eat a diet that is high in fiber (found in most produce) are nearly 60 percent less likely to die from CV causes, according to a study of nearly 400,000 people ages fifty and older.
#soda
Ditch swee
t drinks.
Consuming just one or two sugar-sweetened beverages daily—such as energy drinks, fruit drinks, soda, or coffee drinks—raises risk for a heart attack or dying from CVD by 35 percent, diabetes risk by 26 percent, and stroke risk by 16 percent, according to a 2015 study in the Journal of the American College of Cardiology.
#Metabolic syndrome
Among the many perils they face, according to other recent studies, are atherosclerosis, strokes, fatty liver (fat buildup in the liver), obstructive sleep apnea (OSA), polycystic ovary syndrome, gallstones, diabetes, cancers of the liver, colon, bladder, breast, uterus and pancreas, heart attacks, and Alzheimer’s disease, which is twelve times more likely to strike people with the syndrome as those without it.6
#hypertension #sleep apnea #exercise
We also made adjustments in his medications and
advised him to use a CPAP machine at night to treat his OSA, both of which, along with an improved lifestyle, helped get his hypertension under control. Regular exercise helps treat or prevent more than forty diseases, including diabetes, cancer, CVD, obesity, Alzheimer’s disease, and arthritis—with effects comparable or even superior to medication, according to a 2018 American Heart Association scientific statement.
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. I am always available to tell my testimony in greater detail. Blessings to all
