Repeat After Me: No Heart Attacks in 2019
Are heart attacks preventable?
Can you plan to be heart healthy in 2019?
Can you plan to be free of emergency room visits for heart issues in 2019? Free of an emergency stent? Free of heart bypass surgery? Free of sudden death?
Do you want that for your peace of mind, that of your family, your coworkers or company, your plans for the future?
The concept that heart attacks are preventable is not new. Over 60 years ago a famous Harvard Medical School professor announced that “a heart attack after age 80 is an act of God but a heart attack before age 80 is a preventable event”. Isn’t it time that we make the words spoken by Paul Dudley White, MD, Chief of Cardiology, ring true?
Dr. White was the physician caring for President Eisenhower in 1955 when he suffered a massive heart attack. He was also the first to recognize that “risk factors” can be identified and measured to calculate a person’s risk of heart disease. Since then the science of heart disease detection and heart attack prediction has progressed significantly. I invite you to be part of the “AstroCharm” generation. Please read on for an explanation.
The matter is pressing because over 1,000 people a day in the US alone experience a heart death judged to be preventable by the Center for Disease Control in Atlanta. The onset of a heart attack, stroke or even a sudden death even though the problem, atherosclerosis, was present and undetected for decades. I wrote a book, Dead Execs Don’t Get Bonuses, to lay out the plan to realize the words of Dr. White and my own 30 years of cardiology practice: STAMP OUT HEART ATTACKS, STARTING WITH YOURS, IN 2019. But how?
Step 1: Get a coronary artery calcium scan (CACS)
The paradigm for early heart disease diagnosis needs to change immediately. For example, at age 50 a health care provider says, “we need to schedule your colonoscopy and a mammogram (if female)”. What about the number one cause of death worldwide, atherosclerosis? Why is heart disease not tested for by an examination that directly looks at arteries like other studies look at the colon and the breast tissue? Why did your health care provider bit say to you that “we need to schedule a CACS so we know if you are developing any silent calcified heart arteries” A CACS is a CT scan of the heart that takes under 1 minute, uses no dye or needles, has a very low radiation exposure like a mammogram, and costs about $100. It is the only way to actually see heart arteries in a painless and simple manner. The ideal result in about 50% tested is a CACS score of zero. Even a slight elevation in the CACS raises the risk for heart attack and a multitude of other diseases of aging like dementia and deep evaluation by a preventive cardiologist assessing risks, lifestyle, stress with advanced testing.
Recently the American Heart Association updated its guidelines for the management of cholesterol to insert the CACS exam as pivotal in deciding on therapy. In addition, a large analysis of the predictive power of the CACS exam and the use of cholesterol lowering statin medication was published that makes it clear that getting a CACS is the SINGLE most important step to take in 2019 to avoid a heart attack.
Step 2: Consider a carotid intimal-medial thickness (CIMT) scan
A CACS is an amazing advance in identifying silent aging of heart arteries but it requires calcification to be abnormal, something called hard plaque. There is also a pathology called soft plaque that may threaten health and identify sick arteries. A CIMT is a 20-minute ultrasound of the neck that uses advanced software measurements to examine carotid arteries for bothsoft and hard plaque. The CIMT also measures the thickness of arteries, another sign of aging. The biggest drawback of the CIMT is finding a quality center that offers it. I recently published some examples from my clinic of reversal of plaque detected by serial CIMT, safe to do using ultrasound.
Step 3: Arrange for advanced labs.
In my view, it is unacceptable to have the same lab studies you had for the last 30 years as there have been major advances in laboratory testing. I suggest asking your health care provider for advanced tests although you can order most directly from providers like Wellness FX and Life Extension.
Advanced lipid profile: Rather than giving you a calculated LDL cholesterol level, advanced panels measure LDL particle number and size, which are more predictive of future heart and stroke events. Two people with the same cholesterol levels can have widely different particle and size measurements, making for very different risks.
Hs-CRP: The high sensitivity C-reactive protein is a blood test patented by Harvard Medical School to measure inflammation or the “fire” that results from an irritated immune system. The higher the hs-CRP the greater the risk fo atherosclerosis, heart attack, stroke and even other conditions like cancer and dementia.
Lipoprotein (a): This is a genetic form of cholesterol that’s elevated in about 20% of those tested. It’s rarely drawn even though hundreds of research studies indicate that if it’s high, the risk of heart attack and stroke skyrocket. It runs high in many families that have been decimated by heart disease.
Homocysteine: This amino acid is produced by a process called methylation. It can injure arteries when elevated. It may be due to a genetic defect in the MTHFR gene, which is easily measured. It can be treated with methylated B-complex vitamins.
TMAO: TMAO is a newly described marker of heart and kidney health that’s elevated after eating meat- and egg-heavy diets with an altered gut microbiome. It is a blood test that is available and my clinic has performed more than just about any other clinic in the world. It has been shown to cause heart and kidney damage, and is associated with worsened prognosis.
apoE:This is a genetic marker related to cholesterol metabolism that is measured from a blood sample. For the unlucky few that inherit a pattern called apo E 4/4, the risk of heart disease AND Alzheimer’s Disease is high and may have an onset 20-years earlier than average.
Step 4: Calculate your Astro-CHARM Score.
A major advance in 2018 was the publication of the Astro-CHARM score. This online risk calculator is a collaboration of NASA and the University of Texas Southwestern Medical Center and is the most advanced tool available. It permits entering the CACS, the hs-CRP and more traditional measures (age, smoking status, total cholesterol, HDL-cholesterol, and blood pressure) to predict the 10-year risk of heart attack and stroke.
I have incorporated this into my clinic protocol and it has helped educate patients on what the data obtained may mean. The Astro-CHARM score can also be a tool to help patients make lifestyle changes. For example, when I flip the button from smoker to non-smoker and show a patient that their risk of a bad outcome fell by over half, they often get the message and implement change more readily.
Step 5: Never leave an emergency room (ER) visit without a complete evaluation
If by some misfortune in 2019 you end up in an emergency room with chest discomfort, a black out spell, shortness of breath or racing heart beats take my advice: DON’T GO HOME without a thorough evaluation. Ask for “serial” cardiac enzymes that are repeated two or three times, every four to six hours even if you might stay a few hours more. Ask for repeat electrocardiograms (ECGs) to compare to the one that should have been done on within the first few minutes of arrival. Finally, ask for a definitive test before discharge. This may be a treadmill stress test with echocardiography (no radiation) or nuclear imaging (radiation). Even better is the availability in some ERs of an advanced coronary CT angiogram (CCTA). This is by far the most accurate way to be sure your arteries are clean or clogged before discharge.
Many decades have passed since Dr. Paul White taught that heart attacks are preventable. The current focus on learning CPR or having defibrillators in gyms misses the main point for a successful career and life: it is easy to accurately identify, prevent and reverse the most frequent cause of death in the western world.
Make 2019 the year, right away, to know your score, understand your risk, and prevent and reverse your disease as I have recently outlined.