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Heart and Vascular Risk Factors (Dr. Hazen 10/01/13)

Tuesday, October 1, 2013 – Noon


Cardiovascular disease is the leading cause of death in the United States, killing over 1 million Americans each year. About 81 million Americans are currently living with the disease and most aren't even aware of this reality. It is therefore important for you to become more aware of the disease and both the modifiable and non-modifiable risk factors that are associated with it. Ask Stanley Hazen, MD, PhD, Medical Director of Preventive Cardiology your questions about cardiovascular risk factors and how to control them.

More Information

Coronary Artery Disease and Risk Factors

fairgo: I had an angiogram 10 years ago which showed two partial blockages 40% and 70% in the LAD. I was treated with drugs as stenting was too risky in my case due to slender arteries, EF was 75%. I recently had another one done, this time there was one blockage in the LAD of 60% and a new one in the CR of 20%, EF only 51%, drug treatment to continue, I meantime have had A/fib for 9 years, ablated unsuccessfully three times in the last two years, do you think the underlying CAD caused this or are they unrelated. Is there any other option for me apart from drugs for either of these conditions? Many thanks.

Stanley_Hazen,_MD,_PhD: The AFib is likely related to atherosclerosis. Regardless, it is separate from the CAD now – and treatment for the two is somewhat different. The chronicity of AF is associated with remodeling of the atrial tissue/conduction pathways, so chronic AF can become very recalcitrant to conversion to normal sinus rhythm. And life long anti-platelet or anticoagulant intervention to prevent stroke risk is typical (until risk of falling or bleeding outweighs the potential benefits…very late in life with fall risks, etc).

As for the Cardiovascular disease- it looks like it has progressed. So aggressive risk reduction efforts in a preventive cardiology program to try and halt or retard progression are recommended. Sometimes (often) we recommend treating outside (more aggressively) than the national guidelines recommendations, especially in subjects that appear to have progressive disease despite LDL being treated to typical goals. If you lower the LDL low enough, it removes the “fuel from the fire” and will pacify what is going on in the artery wall, and help retard atherosclerosis progression.

JonathanS: Related to the research on heart disease and the risk factors for heart disease, if you were calculating risk of heart attack - would you still use the Framingham Risk calculator? Or is there a better risk profile?

Stanley_Hazen,_MD,_PhD: We routinely do the Global risk score that is based on the Framingham risk (but includes diabetes). We also take into account CRP and family history of CAD/MI- which are incorporated into the Reynolds Score, which we sometimes calculate as well.

symphony: Hi Dr.Hazen, I am a 53 year old, non-smoking, non- overweight, female who was diagnosed with left branch bundle block last year before knee surgery. I had all the tests, now have a cardiologist, and there were no other problems found. However, this summer I had a weird episode of early morning pain between my shoulders, and then felt heaviness in the center of my chest emanating to the left. I went to our local hospital, spent the night as an outpatient in cardiac care unit, had another echo, and the morning I left I had a catheterization. Arteries were fine, and I have felt ok since. I did notice that my ejection fraction is now 50, last year it was 56....they say it is low normal. I am constantly trying to keep the cholesterol levels in check, which have been borderline high, although my hdl has improved, it is now 53. I could lose 10 lbs to be at a target weight (I exercise every day). Should I be doing more to protect my heart in years to come? Thank you.

Stanley_Hazen,_MD,_PhD: This is a complex question, and not enough information is in your note. I recommend seeing a preventive cardiology specialist to make sure you are addressing all the issues that you can to lower your cardiovascular risks.

sax64: I am a 66 yr old Indian lady living in Sweden. Having 206mg/L Total cholesterol, I got a heart attack two years ago and got four stents in my right coronary artery. Since then on 75 mg Thrombyl, 2.5 mg felodipin and metoprolol 50 mg(now reduced to 25 mg for the past one and half month). Now Total chol 117mg/L, LDL 54.6mg/L, HDL 39mg/L TriGl 115.7mg/L. BP average 120/75, pulse 69. But I don’t know what are my risk factors and what more should I control. I eat fish or vegetarian, little fat free milk products. I was told that my heart problem was hereditary because everyone in my maternal grandmother's family had it. So I cant prevent much. My parents died of cancer but my sister and brother both have heart problems. Please tell me what other risk factors I can control. I am active. Daily I walk for 45 mins and practice Yoga for 45 mins (since 1976). I would be thankful if you suggest what to do. My son,42 yrs., has no problem now. But what should he do for prevention? Thank you!

Stanley_Hazen,_MD,_PhD: A global preventive risk strategy includes not only treatment of LDLc, but also other lipids (e.g. TG), diet, exercise, BP control, diabetes/pre-diabetes screening, monitoring of renal function, thyroid, and other factors- all of these should be addressed by your physician. In subjects with strong Family History, we also look at LPa, since premature cardiac disease often is seen in subjects with high LPa. If this is the case, then aggressive anti-platelet prophylaxis, and screening also of first degree relatives for LPa is recommended, because even in those without known CVD, if LPa is high, we take a more aggressive risk reduction posture because there is increased risk.

BrerDOM: What are the early signals that indicate development of atherosclerosis?

Stanley_Hazen,_MD,_PhD: Unfortunately there are not early signs. Typically, individuals often present with more advanced disease - those that present with a heart attack, often don't survive (~20%). Early signs of more advanced atherosclerosis can include chest discomfort, shortness of breath, shoulder or jaw pain, even neck and back pain that is brought on by exertion, stress or post a large meal.

mlg944x: If you think you're having a heart attack, after calling 911, what is the best advise until help arrives? Take a full 325mg aspirin and sit down?

Stanley_Hazen,_MD,_PhD: Yes- sounds good. A non-enteric coated aspirin is fact - you can chew the aspirin to speed absorption. If the individual has known heart disease they should have SL NTG pills with them and at their home - and should take those as prescribed.

Atherosclerosis Reversal

rickstr: What is your opinion of Dr. Esselstyn's no-oil vegan diet as an intervention to prevent and even reverse atherosclerosis?

Stanley_Hazen,_MD,_PhD: A strict plant based vegan diet is a personal choice. There is no robust data demonstrating benefit (or harm) from this diet. Especially the idea of “reversal” – that aspect of the naming of the diet I think is unfortunate, because it belies a result that is simply not substantiated with robust data. It makes sense in some aspects, but is a very difficult diet to adhere to. It also is accompanied often with a very high carbohydrate diet – and subjects with diabetes issues can often run into trouble with this diet.

It also should be recognized by its users/proponents that outcomes (reductions in heart attack, stroke and death rates) has not been shown with the diet. In contrast, the Mediterranean diet, which included 4 tablespoons of cold pressed, extra virgin olive oil every day (and no red meat) has been shown in randomized trial to reduce risk of hard outcomes (MI, stroke and death) by 30% (recent New England Journal of Medicine paper – the trial was performed in Spain).

ozzieguy: I failed a stress test and had a cath. My doctor wants to put two stents in. I would rather do a Reversal and Prevention program which I learned about on Sanjay Gupta's program. Can you describe what that entails and the success rate of avoiding intervention with these types of programs.

Stanley_Hazen,_MD,_PhD: If you were my family member I would say- ARE YOU KIDDING ME??!! There is no data that a so called "reversal diet" reverses atherosclerosis, and is a treatment that would make sense INSTEAD of revascularization in your case. Your diet choice is something to do IN ADDITION to medical therapy. It will not unclog the arteries in the time frame (if at all) that you hope. I strongly recommend listening to your Doctor.

Johnvanwinkle: Do you believe that reversal of atherosclerosis possible through lifestyle change and diet?

Stanley_Hazen,_MD,_PhD: Frankly - no....not with lifestyle alone. That is because, even with very aggressive LDL lowering with high potency statins, and aggressive lifestyle and dietary efforts (all together), regression is very slow where it has been quantified in exact manner (something called IVUS). These studies do show that CAD can be halted in its tracks in most subjects- so there is no cause for alarm!!! I think in the future there will be medications that can help achieve enhanced regression- but these are not yet available.

Lab Values: Total Cholesterol; LDL; HDL; TG; CRP and others

RobertLC: I have read about particle size but when you get a lipid profile they don't include that. are there certain people or risk factors that make a physician order particle size as part of an evaluation?

Stanley_Hazen,_MD,_PhD: I don’t use LDL particle size or number in my decision making because I think I can get the information I need from the lipid profile that includes VLDL, and an apoB (which automatically gets done if needed). ApoB provides identical information to an LDL particle number. But other physicians, equivalently, use LDL particle number (instead of apoB). It really depends on the situation. Most of the time 95% if the information needed is in the simple fasting lipid profile. Also – a calculation called nonHDL cholesterol (total cholesterol – HDL cholesterol) gives a good estimate of atherogenic lipoprotein risks (LDL + VLDL combined) If TG is elevated, LDL cholesterol calculation becomes less accurate.

BarbaraFLA: I was told I have high triglycerides. My LDL and HDL ratio is ok but have high triglycerides. My doctor told me not to worry as long as the ratio is ok. I want to know what causes high triglycerides and if they should be treated if they are high.

Stanley_Hazen,_MD,_PhD: Yes – if TG Are high they need to be treated as it is a risk for CVD. TG can be elevated from diabetes, medications, genes, many things (even low thyroid function). You should see a preventive cardiology group for education and recommendations.

mlg944x: I am a male age 54 with high BP & High Chol I'm being treated for. I want to have a C-Reactive Protein blood test done, at which CRP test result should I be concerned and consult a specialist?

Stanley_Hazen,_MD,_PhD: high sensitivity C reactive protein testing is what is recommended in intermediate risk individuals. If elevated, we take a more aggressive preventive risk reduction posture because the data shows higher risk for CVD and its adverse events. Your primary care physician should be able to address this with you. Alternatively, you can see a preventive cardiology specialist. Cleveland Clinic has a Preventive Cardiology Clinic that routinely uses hsCRP for the appropriate patients/situations. National guidelines are not quite caught up with the most current data out there.

cicicinci: Would you suggest medication management for someone whose HDL is 51 and LDL is 191, if the LDL is the only risk factor that you have?

Stanley_Hazen,_MD,_PhD: YES!! Ignore the HDL. LDL of 191 is quite high.

Cholesterol Treatment

Charlene: How long can I try diet to lower my cholesterol before going on a med. My doc wants to put me on a statin but I really want to try diet first. How long will it take to see if it worked?

Stanley_Hazen,_MD,_PhD: We used to recommend diet first, and if that fails, then start meds. But we found so many individuals were being lost to follow-up and weren’t lowering their LDL. Dietary effects on cholesterol are important, but also modest (typically 10-20% at best in most individuals) – and dietary effects take months to show effects typically. A lot of cholesterol (most) in plasma comes from not what we eat, but what we make – and that is what statins help lower. So current national guidelines do recommend not waiting, but instead, starting the statin and simultaneously, the diet. Later, if you lose weight, adhere to diet, one can look at where things stand and with their Dr. maybe decide to try lowering the dose or seeing where things stand off the statin for a month to convince themselves whether it is needed or not…this is something you need to work through with your physician.

BonnieZ: I'm the one with an extremely high LPa and high cholesterol at 325.I cannot tolerate statins or niacin. What should I do?

Stanley_Hazen,_MD,_PhD: You should work with a Preventive Cardiology Specialist to see what can be done to help lower LDLc optimally, and also globally reduce your risks. In subjects with elevated Lpa we also recommend, if not contraindicated, aspirin prophylaxis (e.g. 81 mg twice a day) since elevated LPa is associated with increased risk for MI and stroke. Our experience with statin intolerant patients within the preventive cardiology clinic we recently published (looking at over 1000 of the past subjects with 2 or more documented statins they had issues with). On average we brought LDLc down an additional 30-35%. We often use atypical regimens at lower (pediatric) doses and frequencies (e.g. even start at 1/2 of baby dose once a week initially). I recommend seeing an expert in lipids with your lab results.

hughesrl7: Why is Niaspan so expensive? Isn't it simply extended-release Niacin?

Stanley_Hazen,_MD,_PhD: I can not explain medication pricing... Niacin comes in several forms. There are multiple intermediate and longer acting forms and these are on patent, so more expensive. The important question to ask is why you are on the Niacin to begin with. While it is an excellent drug and shown to reduce cardiac risks when used alone, statins are the drug of first choice for LDLc lowering. We recommend getting to LDLc goal using statins (the national guidelines agree). We do use Niacin in certain situations though- if the LDLc can not get to goal on max tolerated statin dose. More recent studies have questioned whether addition of Niacin to existing statin therapy if the LDLc is already at goal helps to reduce risks. However, if the LDLc is not at goal, and one is already on a statin at max dose (tolerated), then addition of Naicin to the regimen to help to get LDLc to goal is a scenario where we might use the Niacin. I suggest you review your medications with your physician.

Johnvanwinkle: FYI, Niaspan ER just went generic last month, prices will drop.

Stanley_Hazen,_MD,_PhD: Good to know. Thanks!

GeorgeBMac: I have heard that statins weaken muscles and a recent study has shown a 20% increase in musculoskeletal injuries by those taking statins. Is this true and, if so, what can be done about it?

Stanley_Hazen,_MD,_PhD: There is an association of muscle aches and strains on statins. But this also is, thankfully, not frequent. Further, it needs to be interpreted in the context that the statins are saving lives, reducing heart attacks, strokes and death. I am not sure that there is anything to do specifically for this other than what is recommended for reducing muscle aches/strains/etc. in general - warm up. Do stretching program/exercises. Warm up in advance, and warm down after exercises. This is good general practice anyway.

Bobbyk: I have had a history of high cholesterol. I am currently on crestor and my numbers a pretty low now. I am wondering if doctors ever do a trial to stop the medicine now that I am on a very low fat diet - not vegetarian but low fat - and exercise regularly. If so - would you try it off meds for 3 months or so to see if my numbers are down enough to come off the medication? Is that reasonable?

Stanley_Hazen,_MD,_PhD: It depends on where you started, and what your other risk factors are. In some cases it is reasonable. In others, where risks are high (e.g. known CAD, a diabetic), I would not recommend stopping the statin. Even with "normal" LDL levels, being on a statin has been shown to reduce CVD event risk. So, in subjects at high risk because of known CAD or a CAD risk equivalent, we would not recommend ever stopping statins (unless they were not being tolerated due to side effects).

Omega 3

CynthiaD23: I have heard a lot of information about omega 3s and fish oil. Some doctors say no, they are harmful. Some say they don't do anything so don’t take, and other doctors say take them for the heart. What is your thought?

Stanley_Hazen,_MD,_PhD: There is data supporting omega 3 FA and reduction of CVD risks in some very good randomized trials. Others have not shown the benefit. None have shown harm. For subjects with high TG and known CVD I recommend them. Key is to add up the omega 3 FA on the label (EPA + DHA) - these should be at least 2000 mg - and should be able to get that much with 2-3 capsules worth. If it takes 7 capsules to get that much DHA + EPA then it is not optimal. I like saying blubber in a white fish can have fish oil extracted, but blubber is blubber – and the oil could be nearly the same composition as bacon fat. It is the omega 3 fatty acids EPA and DHA (not CLA) that are the beneficial ones.

Blood Pressure

tabialex: Female, age 71, 5'1", 108 lbs. I take 3 BP readings at a time. After resting, I find the 1st systolic BP number much higher than the subsequent two, taken with rests in-between. The diastolic numbers remain fairly constant. For example, 9/5/13 the numbers were 139/68, 126/64 and 125/64, heart rate 53,54, and 53. Am I not resting enough before taking the first reading? Does compression of the artery cause the subsequent systolic numbers to drop? Do I average the results for a final number? Would continuous blood pressure monitoring be the answer to this question? I do have "white coat hypertension", BP 185/75 at the doctor's office, and take lisinopril 2.5mgm daily as needed. I am trying to keep my blood pressure normal because coronary artery disease runs in my family. Thank you very much for your help.

Stanley_Hazen,_MD,_PhD: Having this history I think pretty much cinches that you can have “white coat HTN” in as much as such wide swings in SBP are seen (up to 185). The first one is likely higher simply because of involuntary anxiety/anxiousness. Take the average of second and third readings. Home BP monitoring is recommended. I recommend to my patients that do home BP monitoring that sometimes they check it in the am, and other times in the pm, because individuals can run high at different times of the day (the pattern is usually the same for a given person), and you want to make sure you are not having high SBP and not realizing it.

sinaihospital: I have high blood cholesterol, hypertensive heart disease, high blood pressure, aortic valve stenosis, left ventricular hypertrophy. Also have type 2 diabetes plus I am overweight. My dad died at the age of only 48 of heart problems in the hospital. I am only 48 years old. Am I at high risk for a heart attack at my age?

Stanley_Hazen,_MD,_PhD: You have numerous CVD risk factors and a strong family history of cardiac disease – so yes – these all place you at increased risk. You should meet with your doctor to address these issues and try and lower your cardiovascular risks by treating those that are correctable.


MarkPS: If I am diabetic and have high cholesterol, are there certain medications for cholesterol that have a better impact on blood sugars than others?

Stanley_Hazen,_MD,_PhD: The treatment of diabetes (medication choice) is independent of cholesterol level or cholesterol lowering medications. By asking this question I suspect you are possibly thinking of the reports that statins are associated with increased diabetes frequency. I want to mention a few things about this- because so much misinformation is out there on this topic.

First- the effect is miniscule. It took tens of thousands of patient years to see. The net effect is the diagnosis of diabetes is accelerated by two-three months when on a statin. That is all. The HgbA1C, a measure of overall glucose control, on average is 0.1 or less higher on a statin. MOST IMPORTANTLY, diabetic subjects benefit the most from statins! They have the largest risk reduction in heart attack, stroke and death. So - it is precisely the diabetic subject that stands the most to gain by being on a statin. Hope this helped.

Johnvanwinkle: I'm 51, had a heart attack last year 100% blockage LAD, 5 other locations with ~50% blockage. Total Chol 93, LDL-C 36, HDL-C 50, Tri 57, non-HDL-C 43 | Insulin 18, Glucose 103. I follow the South Beach Diet, exercise 4-5 days/week, medications (Effient, Toprol, Ramipril, Niaspan ER, Lipitor) Omega-3 supplements. Any further advice on lifestyle changes?

Stanley_Hazen,_MD,_PhD: Your labs look pretty good and the life style efforts sound spot on. I do note your fasting (was it fasting?), glucose is in the pre-diabetic range (100-125). What is your HgbA1C. Have you been evaluated for diabetes ?

Johnvanwinkle: HbA1c 5.6 pre-diabetic >> South Beach (low carb).

Stanley_Hazen,_MD,_PhD: Prediabetic is defined as either HgbA1C 5.7-6.4; or fasting glucose 100-125; or Impaired 2h glucose tolerance test result (>140 and <200). Your HgbA1C is at the upper end of the normal range.


GeorgeBMac: Lowering cholesterol has been pretty well researched and publicized. How do you lower inflammation?

Stanley_Hazen,_MD,_PhD: Good question. Easier said than done. Diet efforts to reduce saturated fat content, and high glycemic index sorts of foods, seem to help. Treating the original source of correctable chronic inflammatory issues also is important. So - regular dentist checks and treatment of periodontal disease (e.g. diabetics and known CVD patients at least once, preferably twice a year). Statins actually have anti-inflammatory effect, in addition to lowering LDLc.

Rheumatoid Arthritis

Marthavinyard: Can you talk about the association between rheumatoid arthritis and risk for heart disease? My mom has RA and has had a heart attack. I have mild RA and wonder if I am at risk too. I am 40 years old, eat well and exercise.

Stanley_Hazen,_MD,_PhD: Great question. Rheumatologic disorders, like RA, and SLE, and vasculitis, have been shown to be associated with increased CVD risks. For RA, it is probably a two-four fold risk. For SLE it is a whopping 50-fold increased risk for MI! For this reason, we work closely with the Rheumatology Dept. and target subjects with rheumatologic disorders for aggressive global CVD risk reduction efforts. It is not part of national guidelines yet (though I personally think it should be). SOP in your case- I would recommend a screen looking at your BP, basic chem panel, fasting lipid profile, LPa, BP, general- being evaluated by a preventive specialist, to see if anything more should be done.


WarrenGL: Do you have a study at Cleveland Clinic that removes cholesterol from the arteries?

Stanley_Hazen,_MD,_PhD: There are some studies being done that change HDLc levels (raise them). We don't know yet if the specific interventions being studied will "unclog" arteries ....or reduce cardiac events. That is why it is research. The HDLc elevating trials thus far out have not been successful. But some of the more potent drugs that I believe will show benefit are in trial format now. However, it should also be mentioned that these drugs also lower LDL and LPa, and seeing benefit, we wouldn't know if it was due to HDLc elevation or lowering of these atherogenic particles. I guess that doesn't matter to the end user - if they show benefit. We will have to wait and see what they show.

Johnvanwinkle: In what areas of research in preventative cardiology do you see the most potential over the next 5 years?

Stanley_Hazen,_MD,_PhD: I am bullish on science and discovery - it can happen at any time.


zenrunner53: What is the future of the TMAO testing and what should high risk individuals be doing now with regard to this possible endovascular toxin?

Stanley_Hazen,_MD,_PhD: TMAO testing will be available for clinical use in the future. It recently became available for research use. We are still working on how to incorporate it into clinical decision making – because we don’t know what will lower it other than, presumably, aggressive dietary efforts (cutting out all red meat, reducing egg yolk, high fat cheese and other meats, and reducing intake of certain types of fatty fish like cod, tilapia). Like other risk markers, if elevated, we do think it prudent to take a more globally aggressive risk reduction posture, and perhaps shoot for a lower LDL, better/tighter attention to BP control, improved cardiovascular fitness with exercise, and as mentioned more attention to dietary efforts. We are still early in this area of investigation.

CharlesfromCA: I read your articles on TMAO and gut bacteria. What are the next steps in your research? Where is this going? Have you changed your recommendations to patients based on these studies?

Stanley_Hazen,_MD,_PhD: We are working on many fronts. These include - translating these findings into a better understanding of how TMAO is linked to increased risk of heart attack and stroke - increasing dietary efforts - and studies to see how these influence TMAO levels. Development of drugs targeting the pathway to lower TMAO and reduce atherosclerosis - testing if we can develop a probiotic that might reduce TMAO and see if this can reduce atherosclerosis in preclinical studies. Many other areas as well.

GeorgeBMac: How does TMAO affect the arteries? What does it do (and how does it do it)?

Stanley_Hazen,_MD,_PhD: TMAO has been shown to influence cholesterol and sterol metabolism (bile acid synthesis, composition, and transport). It makes it easier to have cholesterol accumulate in the artery wall with the same LDLc level. It inhibits the "reverse cholesterol transport" process.


zenrunner53: Do you think endurance athletes have a risk of endothelial damage associated with the stress of exercise and do you think statins and bet blockers might be protective?

Stanley_Hazen,_MD,_PhD: Yes and Yes. Global risks in marathon runners are actually a little higher. The exercise vs. risk/benefit curve is J shaped. At the far right (high exercise end) one can see a slight upswing in risk. For cardiovascular benefits, I recommend to my patients, based on my interpretation of the various studies, that all that is needed is a brisk walk (e.g. 3.5 mph or faster) for 30-45 min. per session, three-five (ideally) days per week. Or any equivalent amount of sustained activity (biking, swimming, treadmill, elliptical, jazzercise, etc.) whatever you enjoy and will do. Key is to FIND THE TIME.


Islip1717: What is the recommendation for dark chocolate for heart attack prevention?

Stanley_Hazen,_MD,_PhD: There are no recommendations per se. Certain polyflavanoids are present in dark chocolate that may have some beneficial effects based on mostly small studies. I don't recommend a "dark chocolate regimen" for my patients.

sungal64: What do you think about eating activia or other yogurts like that to help with gut flora?

Stanley_Hazen,_MD,_PhD: I think there is no good reason at present to do this. Eat it if you like it – but remember portion sizes and read your labels.

GeorgeBMac: The popular diets lately seem to be the low carb, low fat diets. Yet the evidence seems to point to the Mediterranean Diet being the most effective -- yet that is higher fat and higher carbs. Do have recommendations or preferences or clarifications on this seeming contradiction?

Stanley_Hazen,_MD,_PhD: I'm partial to the Mediterranean Diet because it has the data showing risk reduction in terms of reduced heart attacks, stroke and death.

kathyskl24: Have you heard of drinking certain juices such as beet juice or pomegranate juice to lower blood pressure? Are there any foods that you tell people to definitely include in their diet to help with risk factor management?

Stanley_Hazen,_MD,_PhD: For BP control- I do not recommend inclusion of specific juices. I instead recommend avoidance of salt (sodium) in the diet, and a routine exercise regimen, as both have been shown to reduce BP. I recommend including fruits and vegetables. I actually made up a recommendation called the "caloric density" diet....look at your plate and see what has high calorie content and low volume (i.e. high caloric density)- replace it with something of LARGER volume but less calories. Do that every time and you will eat less calories and not feel hungry....easier said than done.


Lois: Can't red yeast do the same as a statin but naturally?

Stanley_Hazen,_MD,_PhD: Yes – but it has very modest levels, (actually lovastatin is in red yeast rice – a fermented rice) – and amounts vary lot to lot. I recommend FDA monitored prescriptive pills rather than fermented rice extract to my patients.

vascmom: When Vitamin K is recommended, is there any benefit to Vitamin K 1 versus Vitamin K 2?

Stanley_Hazen,_MD,_PhD: I am not aware of any preventive cardiovascular benefit for vitamin K (any form) - so recommend instead getting all of your vitamins through fruits and vegetables (unless a hematologist or your physician specifically recommends otherwise).


GNT: Three months ago I completed a Cardiac Calcium CT scan showing a total calcium score of 145.7 (2007 was 93.5) of which 28.7 (2007 was 8.6) is in the left main, 103.5 (2007 was 85) is in the left descending, Circumflex 2.4, (2007 was 0) Right coronary 11.2 (2007 was 0). Two months ago my doctor put me on a daily dose of 20mg of Lipitor. Also taking daily baby aspirin and 50mg of cozaar since 2011 (BP normal). My total cholesterol went from 124 to 99, (has also been under 150 for the past 10 years), LDL particle number was 829, LDL 64 to 33, HDL 59. I exercise daily, 6'2" 180 pounds. Eat a heart healthy diet, not smoked in 35 years, 68 years old, but family history, dad died at 59 of 3rd heart attack. Any other recommendations to slow or reduce atherosclerosis? Atherectomy at some point if continued progression? Are there any studies being done on reducing cardiac calcium which I may be a candidate?

Stanley_Hazen,_MD,_PhD: Atherectomy is not recommended (and your cardiologist wouldn’t do that as a way to reduce atherosclerosis). Atherosclerosis is a systemic disease. It is not just focal lesions – think of it as a manicotti – or the insulation on a wire. Not just focal narrowings. In a preventive cardiology program, such as at Cleveland Clinic, we would take a posture of global preventive risk reduction effort. That means in addition to aggressive LDL lowering with a minimal goal of < 70 (and even lower would be good), focusing on blood pressure, diabetes/blood glucose, weight, exercise, diet, anxiety/depression, sleep, smoking cessation and where appropriate, anti-platelet (preventive/prophylaxis) related efforts. Calcium reduction per se is not monitored. No studies on that – and no need ever to get another calcium score since studies have shown that the delta in calcium score is not a predictor of outcomes. That is because calcification is a late stage of the atherosclerotic process, and can actually be a sign of plaque stabilization and fibrosis – with can have a decreased risk of thrombotic events associated with that change.

lovebird: Question: Can a calcium level of 8.8 prevent a doctor from going ahead with surgery?

Stanley_Hazen,_MD,_PhD: Almost all people over 35 have calcium levels "in the 9's" almost all the time. This is a complicated question, and depends on the context. You need to discuss this with your Dr (surgeon).

Valve Disease

ceanurse: Woman of 76 years, have determined to have three blockages and need of aortic valve replacement and repair/replacement of the mitral valve. Should the blockages be addressed first and then attack the valve problems at a later time?

Stanley_Hazen,_MD,_PhD: This is a case where a specialized heart center, such as Cleveland Clinic, is recommended. And this decision has to be discussed with your cardiologist and CT surgeon (a team approach).

hatterasjack: I am 83 male. Have mild to severe Aortic Stenosis. PCP indicates no treatment necessary unless symptoms appear. Have had echo and ekg. Still want to wait. What are your thoughts on this?

Stanley_Hazen,_MD,_PhD: Sounds correct.


BelindaW: My husband had a DVT this past summer. He has been on coumadin. I am wondering it that makes him at risk for heart attack? Should he be on a special diet? How much exercise is suggested for a 60 year old man? He had his cholesterol checked last year and it was ok but has only had INRs checked since - should he have other testing to look at his risk?

Stanley_Hazen,_MD,_PhD: It is somewhat unusual to have a DVT while on coumadin- and makes me wonder if the INR was in the therapeutic range. Regardless- having a DVT is not a risk factor per se for development of atherosclerosis. Though subjects who get DVT tend to also have other risk factors for development of atherosclerosis (they tend to be older, more over weight, less active, etc.). As for amount of exercise for a 60 year old- walking at a brisk pace (3.5 mph) or an equivalent amount of effort, for sustained period of 30-45 min per session, three-five days/week, is recommended as a goal. Most important is to find the time- and find something that is enjoyed, so it is maintained and enjoyed, not thought of as a chore.

Moderator: We are ending the chat. Thank you for participating today. A lot of great questions.

Johnvanwinkle: THANK YOU for all your GREAT work!!!

Reviewed: 10/13

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