By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.
Probably not, says Mark Houston, M.D., a leading expert on hypertension. The fact is that most physicians recognize and treat no more than the five top risk factors for coronary heart disease (also known as atherosclerosis): high blood pressure, cholesterol, diabetes, obesity, and smoking. And that’s not good enough!
Dr. Houston, an esteemed colleague of mine who practices in Nashville and is an associate professor of medicine at Vanderbilt University, is the author of What Your Doctor May Not Tell You About Heart Disease (Grand Central Life & Style), a timely book that focuses on an overlooked healthcare deficiency that could definitely affect you.
“Even within these top risk factors, there are important details that are being missed,” Dr. Houston told me during a conversation about his book. “But that fact aside, there are some 395 other known coronary risk factors that doctors are not even addressing at all and therefore not treating.”
I’ve long felt that many doctors miss the boat in many ways. For one thing, they don’t practice personalized medicine. They will often treat patients the same way, as if each patient is playing with the same deck of genetic cards. Moreover, and directly to Dr. Houston’s theme, they overlook a lot of the published cardiology research that clearly indicates that we’ve reached a limit in our ability to reduce coronary heart disease by treating the way we do with our drugs and narrow understanding of the top five risk factors.
Researchers have made significant advances over the years and now identified some 400 risk factors for cardiovascular disease, the leading medical cause of death around the world. But most doctors in practice haven’t kept up. Far from it, they are lagging far, far behind and that could be a problem for you.
What Your Doctor Isn’t Testing or Telling You About Heart Disease Could be Harmful to Your Heart Health
That’s right. You and other patients may be severely shortchanged. In my years in cardiology practice I repeatedly saw new patients whose regular doctors often weren’t covering the most important heart disease risk factors and instead focusing on just a few of them, including some that I regarded as obsolete.
Dr. Houston’s book puts this dilemma into sharp focus. “The research shows that about 50 percent of patients will still have a heart attack despite optimal treatment of the top five coronary artery risk factors,” Dr. Houston told me.
The missing risks often go right to the core issue of inflammation, the primary underlying cause of arterial disease, and to what’s undermining your critical heart blood vessels on an everyday basis that eventually becomes devastating. They include inflammatory components like small particle LDL cholesterol, homocysteine, C-reactive protein, Lp(a), fibrinogen, heavy metals and environmental toxins, abdominal fat, and excess blood viscosity, just to name a few.
“There’s a huge gap between how patients are actually checked out and how they should be checked out, and because of this they get a very false sense of security,” Dr. Houston says. “People will say that their doctor treated them for two or three risk factors and then told them they shouldn’t have any problem, and then two or three years later they have a heart attack. Half the people who are so-called ‘controlled’ for risk factors in this way are still having heart attacks.”
He points out that many physicians also fail to look beyond the gross numbers that come back from standard lab tests and consider what is going on, and why, inside the critical cardiac arterial system.
“The blood vessels have finite response to an infinite number of insults,” he says. “The three finite responses include inflammation, oxidative stress and vascular immune reactions. The blood vessels respond acutely and correctly to protect themselves from these myriad of insults. However, with chronic insults to the blood vessels’ sensitive endothelial lining, these responses become dysregulated and lead to endothelial dysfunction and cardiovascular disease. Doctors have to ask ‘why’ the patient has endothelial dysfunction or cardiovascular disease and then backtrack to the genesis of the disease to find what the insults are. But the tragedy is that they don’t.”
My Recommendation – and Dr. Houston’s
I have written and lectured about commonly overlooked risk factors many times and frankly I can’t imagine that doctors, including cardiologists, overlook them, yet more often than not they do. By ignoring them a doctor misses key clues that can lead to more effective medical detective work and treatment, and, by the way, reduced medical bills and patient suffering.
Dysfunction of the delicate endothelial lining of blood vessels is the earliest sign of cardiovascular disease and can precede clinical events by decades. Early detection of such dysfunction and inflammation, and then proper treatment of the causes – the things that insult the lining − will prevent cardiovascular disease.
“You have to check the gamut of risk factors and chemical mediators,” he adds. “Then, proper integrative prevention and treatment strategies could be implemented early and aggressively, using scientifically-proven nutraceuticals, antioxidant and, anti-inflammatory agents, anti-immunologic approaches, exercise, stress, weight and body fat management, pharmacologic drugs and other lifestyle modifications.”
Key Missing Heart Disease Risks
Here are a few of the overlooked examples that Dr. Houston covers in his book:
Blood pressure readings – the new way
The typical office or random home readings are dinosaurs. Obsolete. They really provide only snapshots of blood pressure. What missing here is a daily pattern of day and night dips and surges that yield better evidence. There’s a new standard: 24-hour readings, via around-the-clock monitoring devices that doctors lend out to patients.
“When you go to bed at night your blood pressure is supposed to drop about 10 percent from your morning level,” Dr. Houston noted. “If you don’t ‘dip’ you have a higher risk for cardiovascular events. If you dip too much, that’s another risk. And somebody who has an enormous and rapid surge in the morning is creating pronounced stress on the arteries that could potentially generate a hemorrhagic stroke. Marked fluctuations can be dangerous.”
In my practice, I found that 24-hour readings provided a great deal of information on any patient with suspected or documented high blood pressure.
Advanced lipid testing
Standard testing of total levels of cholesterol, LDL, and HDL are basically meaningless for identifying risk and the best treatment options. The only way to handle the cholesterol issue effectively is through the new generation of blood lipid tests. These tests neatly fractionate your cholesterol elements into meaningful particle size and percentages so your doctor can more accurately see whether your cholesterol, no matter what the level, is ominous or not.
You may, for instance, have an overall LDL number that your doctor considers too high and, as a result, unnecessarily prescribes you a cholesterol-lowering statin drug. But the number doesn’t tell you if your LDL is primarily of the small, dense inflammatory type or the large, fluffy basic type that your body produces normally. The same goes for HDL. A pattern of too many small, dense particles – whether LDL or HDL – are the risk factors and there is a specific cut-off point of what is too many.
“As you drop your small, dense number from high to low, then they become less of an issue,” Dr. Houston said. “What is interesting is that the cholesterol-lowering drugs do not change the ratio, only the overall numbers. What we really need to look at in lipid disorders is balance. And that means you want to see a lot of big LDL and HDL particles. The regular tests don’t tell you that. They are obsolete.”
Largely ignored by mainstream doctors is the environmental-genetic-nutrient interaction. We live in a toxic world with toxins, allergens, and offensive agents lurking everywhere in the environment. But not everybody gets sick or has the same adverse response. What you eat, drink, and what you are exposed to, have a uniquely personalized effect on your arteries, and that is where we need to consider genetic susceptibilities.
There are many genetic tests available for cardiovascular disease not being used by doctors that can provide critical clues for susceptibility to heart attack, high blood pressure, and risky levels of Lp(a) and homocysteine. These factors become all the more important for individuals with a family history of early heart attacks.
“One guy can smoke, drink, and have high cholesterol, and he does well, because he has the right genetics,” Dr. Houston said. “The next guy could have one bad gene and does just one thing wrong and he dies at an early age.”
Visceral fat % and total body fat % are also important in the assessment of CHD risk. Excess visceral, or belly fat, produces over 35 chemicals that can contribute to metabolic syndrome and cardiovascular disease.
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