Beat the odds: uncovering the hidden signs of heart disease

By Amber Ackerson, Nov, 2002

Tom, a 56-year-old private contractor in East Quogue, New York, woke up one Tuesday morning feeling out of sorts. He hadn't been feeling well for several days, but now he felt worse. On his way to work, Tom's chest pain began.

He'd been to the emergency room twice in the past week, but the doctor assured him that he just had stomach problems. The antacids, however, weren't helping, and the chest pain was getting worse. Tom started to feel lightheaded and weak. Something was very wrong.

By the time he reached the job site, he could barely talk. "Get me to a hospital," he said, "I'm having a heart attack." His friend Paul jumped into the truck as Tom moved over to the passenger side. The pain had become unbearable, and as they pulled up to the hospital, Tom started to lose consciousness.

Holding onto Paul on his way to the emergency room entrance, Tom fell to the ground. His heart stopped. Clinically, he was dead.

Fortunately, help was close at hand. The medical team got Tom's heart going again and put him on life support. Tom learned later that he'd suffered a massive heart attack. "I flatlined, I actually died," he says. "A nurse even asked me if I'd seen the white light. Well, I hadn't. I wasn't wearing my glasses." To the great relief of his family, Tom survived--and so had his sense of humor.

An angiogram showed that two of Tom's major arteries were almost entirely blocked with fatty deposits--a condition commonly known as atherosclerosis. Tom was able to avoid major surgery, but he required two stents--small devices put inside clogged arteries to keep them open.

"With today's high-tech methods, they didn't even have to open up my chest," he says. "The stents were inserted through an artery in my leg."

Recovery from a heart attack is slow-going. "I have to deal with the low energy, the fear that it could happen again and the adjustment of taking all these medications for the rest of my life," says Tom. "It's been really hard on my family too. I hate to see my 10-year-old daughter look so worried. My wife had a panic attack and had to go to the emergency room herself. And, of course, my contracting business went on the back burner, which, in the height of work season, is a big problem."

Tom has had to make some major lifestyle adjustments and to deal with the depression and anxiety that often occur after a heart attack. He occasionally still has chest pains, and he's had to go back to the emergency room twice when it seemed his heartbeat wouldn't settle down.

Despite the emotional upheaval, Tom's recovery is progressing well. His heart shows all the important signs of healing, and the medications are working.

But the experience has left Tom with some very good questions--questions that everyone needs to know the answers to. "Weren't there any tests that could have shown earlier on that I was developing atherosclerosis?" he says. "Tests that could tell me why, after bringing my cholesterol down, I still got atherosclerosis? And what about those risk factors they talk about? I didn't have any of those."

standard cholesterol tests

Heart disease develops when there are too many fats or lipids in the blood, and doctors check for this by testing total cholesterol level. Tom's doctors gave him a standard cholesterol test, which reports the levels of total cholesterol (TC), high-density lipoproteins (HDLs), low-density lipoproteins (LDLs) and triglycerides (TG) present in the body (see "HDL and LDL explained", p. 44).

The National Cholesterol Education Program (NCEP) places the desirable TC level at 200 or below. TC levels between 200 and 240 are considered borderline high, and anything at or above 240 is considered a high risk for heart disease. According to NCEP guidelines, cholesterol-reducing drugs are recommended for borderline levels only if the patient has two or more additional major risk factors such as smoking or high blood pressure.

According to his doctor, Tom didn't fall into the high-risk category for a heart attack. He didn't have any major risk factors other than borderline high cholesterol.

But while Tom's cholesterol had been 270 at one point, he'd been able to bring it down to 220 with a regimen of diet, exercise and supplements.

"My doctor wasn't worried, and neither was I," says Tom. "I started exercising regularly and was careful about my diet. I took supplements and herbs, and my cholesterol came down. I had my family pretty late in life, and I want to be around for awhile, so I'm really good about going for check-ups. I had a stress test done three or four years ago, and the doctor said my heart would last until I was 95. They checked my carotid arteries with ultrasound. Everything read normal. No one ever told me I was in a high-risk category."

early warning

Tom's case isn't unique. According to John Furlong, ND, of Great Smokies Diagnostic Laboratory in Asheville, NC, nearly half of all heart attacks strike people who don't know they're at risk--people without the typical risk factors such as high cholesterol, hypertension, diabetes or smoking.

The problem, says Tom, is that patients who don't fall into the high-risk category don't receive all the preventative care they may need. "People like me slip through the cracks. We're not typical candidates for heart attacks, so our doctors don't do a full work-up of tests. If there's one message I want to get out there, it's that people need more comprehensive screenings at a younger age."

Now there's a way to test for these risks so that treatment can start early--before heart disease develops. "To get a more complete picture, we now test for what are known as cholesterol subclasses and independent risk markers," says Furlong. And these tests, outlined below, can go a long way toward preventing heart attacks for low-risk people such as Tom.

identifying the problem

According to Furlong, two important new tests--screenings for cholesterol subclasses and independent risk markers--can help identify potential heart problems in people who don't have standard risk factors for heart disease.

Fractionation is a laboratory method that identifies lipoprotein subclasses specifically related to heart disease. These subclasses include low-density lipoprotein (LDL), high density lipoprotein (HDL), intermediate density lipoprotein (IDL-C) and very low-density lipoprotein (VLDL).

LDL subclasses. LDL particles vary in size, density and cardiovascular risk potential. The LDL subclasses are composed of LDLs 1 through 4. High levels of LDL 3 and 4 confer a greater risk of heart disease, even for people with normal total LDL levels.

Conversely, LDL subclasses 1 and 2 are beneficial, so that, contrary to popular interpretation, LDL levels that are elevated due to increased 1 and 2 subclasses actually represent a reduced risk of heart disease. Elevations of LDL 3 and 4 may be attributable to inherited factors, the use of certain medications such as beta-blockers and conditions such as diabetes mellitus.

HDL subclasses. The HDL subclasses consist of HDL 2 and HDL 3. HDLs as a group are known as "good" cholesterol, and subclass HDL 2 is the most beneficial.

IDL subclasses. According to Furlong, IDL levels may be an extremely important means of monitoring people with atherosclerosis because IDL levels have been shown to correlate with the severity of atherosclerosis.

VLDL subclasses. VLDL subclasses consist of VLDLs 1 though 3. Furlong says that VLDL 3, also known as remnant lipoprotein or RLP-cholesterol, directly correlates with atherosclerosis and plays an important role in detecting the disease in people otherwise considered low risk. According to a May 1998 study published in The Journal of American Medicine, men with normal blood cholesterol levels and heart disease had increased levels of RLP-cholesterol that had not been detected with conventional cholesterol screening.

independent risk markers

homocysteine. Homocysteine acts as an abrasive to the inner lining of arterial walls, which leads to the development of atherosclerosis. High levels of homocysteine can occur as the result of inherited enzyme deficiencies, nutritional deficiencies of folio acid or vitamins [B.sub.12] or [B.sub.6], the use of tobacco and certain medications including methotrexate, nitrous oxide, phenytoin, carbamazepine, nicotinic acid, colestipol and thiazide diuretics.

Homocysteine levels increase with age, and men are more prone to elevated homocysteine than women. According to a 1998 study reported in the Archives of Internal Medicine, the most effective way to reduce homocysteine levels is to supplement 400 micrograms per day of folic acid--whether or not you have a known deficiency--and to supplement vitamins [B.sub.6] and [B.sub.12] if you have a deficiency.

c-rective protein (CRP). In March 2000, scientists at Harvard University announced that they had found that CRP levels are a powerful predictor of future heart attacks and strokes.

CRP levels rise in response to inflammation caused by organisms such as Epstein-Barr virus or chlamydia pneumonia. That's why aspirin, with its anti-inflammatory action, can provide protection.

lipoprotein(a) (Lp(a)). This risk marker has been cited as the best predictor of the severity of heart disease and is strongly influenced by heredity. People with elevated Lp(a) levels are at risk of heart disease even in the absence of conventional risk factors.

fibrogen. Fibrinogen is involved in blood clotting, and high levels are associated with both heart disease and stroke. Inflammation, use of oral contraceptives, smoking, stress, obesity and aging can all cause elevated fibrinogen levels.

ounce of prevention

The new tests for cholesterol subclasses and independent risk markers can go a long way toward preventing heart attacks in traditionally "low-risk" individuals. And that's more important than ever, according to heart attack survivor Tom.

"With all of us baby boomers now in our 50s," he says, "what happened to me is going to happen to a lot of families. People need to talk to their doctors about that. And doctors need to understand that just because someone doesn't have typical risk factors, he or she may still have a relatively good chance of developing heart disease."

As the new tests gain wider acceptance in the medical community, "low-risk" people like Tom should be able to detect the problem early enough to avoid potential heart attacks.

HDL and LDL explained

Cholesterol doesn't circulate freely in the blood; rather it is transported by lipoproteins.

High-density lipoproteins (HDLs), or "good" cholesterol, have a higher protein content and are denser than low-density lipoproteins (LDLs), or "bad" cholesterol, which are higher in fat. Furthermore, in the case of atherosclerosis, LDLs transport fat to the artery walls.

In contrast, HDLs move cholesterol from these areas to the liver, which breaks them down and eliminates them. The health benefits of HDLs are thought to be due in part to this reverse cholesterol transport.

People with an HDL level of 30, for instance, have twice the risk of heart disease as people with an HDL of 60.

heart-healthy lifestyles

Despite the fact that some risk factors seem to be hereditary, for many of us, atherosclerosis can be prevented or reduced by eating well and getting plenty of exercise. Nutritional and botanical supplements can also help promote and maintain heart health.

The key tips for avoiding high cholesterol and atherosclerosis include:

diet

* High-fiber foods including oats, oat bran, oat milk, beta glucan, psyllium seed, fruits, flaxseed, sunflower seed, vegetables, beans and whole grains

* Non-fat acidophilus products: yogurt, kefir and milk

* Fish and unprocessed, unsalted nuts, particularly walnuts and almonds

* At least 48 ounces of water per day

* Fresh garlic

* Olive oil

* Light alcohol consumption: 1 glass of red wine per day for women, 1 or 2 for men

* Soy, tofu, tempeh and miso

* Brewers' yeast

* Red yeast rice

foods to avoid * Eggs

* Margarine

* Beef, pork, veal and poultry--dark meat and skin

* Animal fat and hydrogenated oils

* All processed foods and fast foods

* Both full- and low-fat dairy products

* Added salt

* Refined carbohydrates, including white bread, white rice and sugar

* Coffee (regular and decaf)

lifestyle

* Quit smoking

* Get regular aerobic exercise

* Achieve ideal body weight

* Eat frequent, small meals in place of large meals

* Take medications regularly

* Get counseling for stress management. Key stressors include marital discord and Type "A" behavior, which is generally defined as hostility, overly time-conscious, aggressive, impatient, angry and distrustful.

supplements

* Calcium: 800-1,000 milligrams (mg) daily

* Chromium: 200 micrograms (meg) daily

* Vitamin C: 1,000 mg daily

* Vitamin E: 400-800 IU daily

* Co-Q10: 100 mg daily

* Flaxseed oil, a source of omega-3 fatty acids: 1 tablespoon daily

* Inositol hexaniacinate, a non-flushing, non-toxic form of niacin: 500 mg three times daily

* Folio acid: 400 mcg daily

Other supplements--including vitamins [B.sub.5] (pantethine form), [B.sub.6], [B.sub.12], L-Carnitine, Guggul, lycopene and Beta sitosterol--play important roles in reducing the chance of heart disease and other ailments in certain individuals.

To achieve the best results, ask your physician or naturopath to recommend what supplements you should take. Your doctor can tailor a supplement regimen to suit your specific needs. For more information about reducing your risk of heart attack, visit the American Heart Association's Web site at americanheart.org.

assess heart health

The standard method for cardiac risk assessment used by most physicians is based on the National Cholesterol Education Program (NCEP) guidelines, which are summarized below.

It's important to note that while a number of additional risk factors have been established, they aren't used in standard risk calculation.

primary risk factors

* Cigarette smoking

* High blood pressure (hypertension)

* High serum cholesterol and various cholesterol fractions (GET)

* Low HDL levels

* Diabetes mellitus

* Family history of heart disease

* Advancing age, defined as older than 45 for men and older than 55 for women

According to Bastyr University's Joseph Pizzomo, ND, and Michael Murray, ND, in A Textbook of Natural Medicine, the following heart-disease risk factors ,have been shown in some cases to be even more significant than standard major risk factors such as smoking, hypertension and family history of heart disease.

secondary risk factors

* Low antioxidant status

* Low levels of essential fatty acids

* Low levels of magnesium and potassium

* Increased platelet aggregation in the blood

* Elevated homocysteine

* Type "A" personality

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