Heart disease is the leading cause of death in America. About 50% of people dying from heart disease have normal cholesterol. About 50% of people presenting with heart disease have zero or only one of the four main risk factors established by the American Heart Association, which include high cholesterol, high blood pressure, high blood sugar, or smoking. A heart attack is the first warning sign for about 66% of men and 50% of women that have heart disease.
Statistics like these are embarrassing and pathetic. We can, and should, do much better at screening for heart disease. The standard risk factors are worthy, but as the statistics show, not nearly good enough.
Coronary heart disease (CHD) is the result of decreased blood flow through the coronary arteries that supply blood to the heart muscle. Cholesterol makes up the bulk of the material in the plaque that accumulates in the artery wall. But cholesterol is just the raw material for plaque – much like wood is raw material for a fire. And just like a fire a cholesterol plaque needs more than raw material to form.
How Plaque Forms
Cholesterol is made up of fats and as such does not mix with the watery bloodstream so it is packaged with a special wrap that has a water loving outer layer and a fat loving inner layer – thus the cholesterol is packaged inside for transport. The particular type of wrapping determines where this packaged cholesterol goes and how it behaves. Much like a hood ornament on a car, certain proteins are embedded in the cholesterol wrapper to distinguish its “make and model”.
Low density lipoproteins (LDL) have a protein called apoB100 embedded in the wrapper. High density lipoproteins (HDL) have the apoA protein in the wrapper. These proteins control the destiny of the packaged cholesterol. Cholesterol is essential for life being the precursor to our steroid hormones, being found in the cell wall of every cell in the body, and an important component of brain tissue. It is normal for cholesterol to move about through the body and through artery walls and it is normal for LDL cholesterol to be found in the artery walls.
Trouble starts when the other conditions for plaque formation are present. First, LDL must become oxidized. Because we live on planet earth, and rely on oxygen for energy, oxidation is a normal byproduct of life. Just like iron rusts, so our bodies oxidize at all cellular levels. Only when LDL is oxidized does it then start to cause inflammation, attract white blood cells from the immune system, turn on enzymes that break down tissue, and start forming an inflamed plaque just beneath the inner layer of the arteries.
The Heart Attack
Many years may go by with inflamed plaque just “simmering” beneath the surface. With no warning the plaque may suddenly break open, or rupture, and the material inside is released into the bloodstream causing a sudden clotting of the blood in the immediate area. Thus, the heart attack out of nowhere…
Most plaque ruptures before it has caused even a 50% narrowing of an artery. That is why there is seldom an early warning. An artery needs to become about 70% clogged or more before the restriction in blood flow causes obvious symptoms, such as chest pain or shortness of breath with walking.
Stress testing involves testing the heart under stressful conditions, such as walking, or drug induced stress, and monitoring the heart for restrictions in blood flow. Stress tests are useful when someone has a symptom such as chest pain with exertion. But stress testing is not a good screening test since it only detects people with advanced artery plaque causing significant narrowing. Remember, most plaque ruptures long before it ever causes enough narrowing to restrict blood flow.
Looking for plaque in the early stages is the first step to screening. If you are over age 50 I recommend imaging studies that look for plaque such as the carotid ultrasound which detects plaque activity and thickness, or the cardiac CT scan which shows calcium in the coronary arteries and correlates to plaque.
More than just Cholesterol
When we find artery plaque the next step is to assess why plaque is forming. If 50% of people with heart disease have fairly normal cholesterol, then what gives? The other factors that give rise to artery plaque are found in better blood testing.
First, I recommend a cholesterol test called the VAP (vertical aligned profile). It is a more accurate test since it directly measures LDL cholesterol. There are a few “hidden” features of LDL that the VAP uncovers. One subfraction of LDL called the “heart attack marker” is Lp(a). Elevated Lp(a) is associated with 3x the risk of heart disease. The size of LDL particles is another key element, with either small dense or large buoyant particles. The small dense particles are prone to stick, oxidize and cause inflammation – as such they are associated with another 3x risk for heart disease. The VAP also gives the HDL-2 measure which is the only true “good” fraction of the HDL cholesterol.
Other independent risk markers for artery plaque include PLAC (measure of oxidized LDL), apoB100 (number of LDL particles), triglycerides (also cause plaque), glucose and insulin, fibrinogen (marker for clotting), cardiac CRP and homocysteine (inflammatory markers), magnesium and iron. Low hormones such as estrogen and testosterone are very important independent risk factors. We are learning that Vitamin D and K both play key roles in heart disease and most of us are deficient in these key vitamins. Low levels of the omega-3 fatty acids EPA and DHA increase risk of heart disease.
Nitric oxide (NO) is the essence that arteries rely on to stay healthy and control blood pressure. Made by the endothelial cells that line the arteries, NO production is a key marker of artery health. I recommend products such as N1O1 that support nitric oxide production.
There you have it, count ‘em – 22 risk factors for heart disease. When I find patients with no traditional risk factors, yet screening tests show plaque, these better blood tests always uncover the missing risk factors. A simple blood test and a few screening tests can put you “in the know” when it comes to heart disease.
Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call (970) 245-6911 for an appointment or more information.