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The greatest killer we have in America today, (over 900,000 deaths each year making up approximately 42% of all deaths) is cardiovascular disease, which involves the process of atherosclerosis or "hardening of the arteries." As our vessels degenerate, it just depends on which part of our body is affected the most. If the coronary arteries are primarily involved the risk for a heart attack increases. When the cerebral vessels are affected, one is at risk for a stroke. Peripheral vessels may also be involved putting the limbs at risk as well as the possibility of an aneurysm. Over 60 million people in the United States have cardiovascular disease affecting some part of their body.
There are over 1,500,000 heart attacks each year from which 500,000 people die. Most devastating perhaps is the fact that 250,000 of these deaths occur within one hour of the heart attack. Forty-five percent of all heart attacks occur in people who are under the age of 65 with the first sign of heart disease in over 30% being sudden death. When a person is fortunate enough to have a warning sign, the symptoms are subtle and easily passed off as minor indigestion.
Symptoms are usually characterized as substernal chest discomfort that comes on with exertion or stress and is relieved within a few minutes with rest or relaxation. There may be some referral of the pain into the shoulder, back, or down either arm and is sometimes associated with sweating or shortness of breath. The final event leading to a heart attack is the actual rupture of an atheromatous plaque (usually a smaller, less mature plaque) within the artery immediately followed by a thrombosis (blood clot) totally blocking the artery.
Cardiovascular Disease-An Inflammatory Disease
Heart disease, stroke, and peripheral vascular disease are diseases of inflammation of the arteries and NOT a disease of too much cholesterol in the blood. In fact, over half of the patients who suffer a heart attack actually have normal cholesterol levels. In a review article that appeared in the January 14, 1999 issue of the New England Journal of Medicine the cause of hardening of the arteries is clearly attributed to inflammation of the arteries.
Excessive free radicals created by high blood pressure, diabetes, cigarette smoke, fatty meals, elevated insulin levels with oxidized LDL cholesterol, elevated homocysteine, and possibly some infectious agents have the capability to cause inflammation of the surface lining of the arteries called the endothelium. This either causes an actual tear of the endothelium or causes the endothelium to function abnormally.
LDL cholesterol is then allowed to enter into the subendothelial space (area just under the lining of the artery) where it becomes oxidized and starts to build a plaque. The cholesterol actually comes along as a band-aid trying to repair the damage to the artery caused by inflammation. This is what creates hardening of the arteries.
The medical literature, as well as lay media , is finally acknowledging the fact that "hardening of the arteries" is the result of this low-grade inflammation. However, they still are not revealing the actual underlying cause of the inflammation. Instead, they are simply stating you need to be taking a "statin" drug that will not only lower your cholesterol but also reduce inflammation.
As a clinician, I desire to decrease or eliminate the actual causes of this inflammation so the process doesn't start in the first place. Few know this can be accomplished by healthy lifestyles and nutritional supplementation.
Did you know that elevated cholesterol in the blood has not always been considered a risk factor for coronary artery disease and stroke? When I first began practicing medicine in 1972, we considered any cholesterol level less than 320 normal. Now everyone is aware of the dangers of elevated cholesterol and we "know" to be especially concerned about LDL cholesterol (bad cholesterol).
In 1989, however, Dr. Daniel Steinberg reported in the New England Journal of Medicine (NEJM) that native LDL cholesterol is not bad. Claims Steinberg, it only becomes "bad" when LDL cholesterol is oxidized or modified by excessive "free radicals". When a person has enough antioxidants on board, LDL cholesterol does not become oxidized or "bad".
Since this landmark review article, several clinical trials have substantiated the fact that individuals who have the highest levels of antioxidants (vitamin C, vitamin E, beta-carotene, etc.) do have the lowest level of heart disease. Now the medical literature is further indicating that individuals who take supplemental antioxidants have a significantly lower incidence of vascular disease.
In the August 7, 1997 issue of the NEJM, Marco Diaz, M.D. wrote a review article on the use of antioxidants and heart disease. It seems that antioxidants not only decrease the risk of developing heart disease, but even in patients with advanced coronary artery disease antioxidants offer a significant benefit. The Cambridge Heart Antioxidant Study showed individuals with advanced coronary artery disease who consumed at least 400 I.U. of vitamin E had 77% fewer nonfatal heart attacks over those who took a placebo. Dr. Diaz concluded that antioxidants stabilize the atheromatous plaque by reducing the inflammation of the artery, thus decreasing the risk of plaque rupture. This means that even those patients who have advanced coronary artery disease would benefit by the use of the recommendations found on this website.
In the past few years we are seeing study after study, indicating homocysteine as an independent risk factor for vascular disease (hardening of the arteries). Elevated homocysteine levels in our blood causes tremendous inflammation to our arteries. In a 1995 issue of JAMA, Boushey reviewed 27 previous clinical trials, which all showed even mildly elevated levels of homocysteine significantly increased the risk of vascular disease. He concluded that between 10 and 15% of every heart attack and stroke in this country was directly related to elevated homocysteine levels. In other words 150,000 to 225,000 heart attacks each and every year are solely related to elevated homocysteine levels.
WHAT IS HOMOCYSTEINE?
Homocysteine is a sulfur-containing amino acid that is involved in the metabolism of methionine, an essential amino acid. Methionine is an essential protein found most commonly in meats, eggs, and dairy products.
During normal metabolism within the body, methionine is broken down into homocysteine which in turn is broken down into cysteine (which is harmless), or sometimes actually turned back into methionine again. But in order to be turned back into methionine, an enzyme is needed requiring vitamin B12 as a cofactor and folic acid as a substrate. Homocysteine may also be broken down into cysteine, but this enzymatic reaction requires vitamin B6.
This may seem confusing to you but the important thing to remember is the simple fact that in order for homocysteine levels to remain in a safe range, you must have adequate levels of folic acid, vitamin B6, and vitamin B12. Elevated homocysteine levels in our blood are primarily the result of a nutritional deficiency of folic acid, vitamin B12, and vitamin B6. When these nutrients are given in supplementation for just pennies a day, our homocysteine levels will fall back into a safe range the majority of the time.
Other Causes of Inflammation
Other causes of inflammation in the arteries are brought about by excessive free radicals produced by high blood pressure, diabetes, cigarette smoke, hyperinsulinemia (elevated insulin levels in the blood), fatty meals, and possibly some infectious agents (usually bacteria from gum disease). All of these conditions can either be eliminated or significantly reduced through lifestyle changes and nutritional supplements.
My clinical approach to protecting patients who either already have cardiovascular disease or for those wanting to prevent this disease is the same-the goal is to reduce or eliminate all causes of inflammation in the arteries. Initially an evaluation must be made all of my patients, males over 35 years of age and females over 40 years of age, for risk factors (see below).
Evaluation for the Risk of Cardiovascular Disease
- Complete history and physical
- Chemistry profile, which should include a general screen for diabetes, kidney, liver, and thyroid function, along with a lipid profile
- Other lab work should include a highly-sensitive CRP (hs C-Reactive Protein, which measures the inflammation in the arteries), homocysteine level (ideally this level should remain below 7), and fibrinogen level.
- An exercise stress test with echocardiogram is recommended for those patients who are already having concerns about chest discomfort (seek medical advice from the attending physician about whether this test is indicated or not)
- Cardiac calcification score-(ultra-fast CT imaging of the heart) this is a test that can determine how much micro-calcification is present in the coronary arteries. This provides an indirect indication of the amount of plaque already present in one's coronary arteries. Because the first sign of heart disease over one-third of the time is sudden death, I like to find out whether my patients who may have some risk factors for heart disease actually have some evidence of plaque in the arteries already.
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