August 3, 2010
Stanley Hazen MD, PhD
Section Head, Preventive Cardiology & Rehabilitation Department of Cardiovascular Medicine Miller Family Heart & Vascular Institute
Cardiovascular disease is by far the leading cause of death in the United States. The more risk factors you have, the greater your chance of developing cardiovascular disease. Research about cardiovascular disease risk factors suggest that making even small lifestyle changes can reduce the risk of coronary artery disease, heart attack, stroke and other serious cardiovascular conditions. As a leader in heart care, Cleveland Clinic’s preventive cardiology program uses the very latest technology in diagnosis and treatment. Dr. Hazen, section head of the Preventive Cardiology & Rehabilitation program answers your questions about prevention of cardiovascular disease.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Stanley Hazen. We are thrilled to have him here today. Thanks for joining us Dr. Hazen, let’s begin with the questions.
Dr__Stanley_Hazen: Thank you for having me.
Coronary Artery Disease, Risk Factor Management
Jimb: I had triple bypass surgery 11/2008 at 47. I’ve been active my whole life (runner/marathons). No MI, I just felt funny. After surgery followed all medical advice-ate right, exercise, tried to alleviate stress. Went back to work fulltime in 9/2009. In 1/2010 one of my bypasses 'failed', nothing to be done (physical intervention), but follow a strict vegan diet & more stress reduction (Spectrum Program by Dean Ornish). I follow Spectrum diet to the best of my ability (no programs in Lancaster PA) and continue to exercise. Not back to work-worried that the stress will cause more damage. RX: Metoprolol, Ranexa, Crestor, Zetia, Plavix, Paxil, Singulair. (Patanase & Fluticisone when needed) OTC: aspirin, claritin, multi vitamin, omega 3, Zantac. I don’t have much energy. I exercise but need a nap in the afternoon. I try to push through, but hit a wall. I want to push through but afraid of another bypass "failing". We have a 14 y/o daughter and 7y/o son. I want to keep up… Is there anything to be done-change in meds? Change in outlook? Or should I accept my energy will be limited? Thank you.
Dr__Stan_Hazen: This is difficult to answer in a simple webchat. You have a complex medical history, and we need to review not just the history and medications, but where the labs are, how you are coping with the disease and your medications, etc.
A program like our Preventive Cardiology Clinic includes a multidisciplinary team of physicians, nurses, exercise physiologists, nutritionists, and behavioral health physicians and health providers. For example, we have a "Cardiovascular Behavioral Health" clinic within prevention where issues related to anxiety; depression and stress are a focus.
neila01: I am 49 years old. I had bypass surgery at age 46 and 2 stents after that due to scar tissue. I have continued to have chest pressure since then and for some reason Dr's say I am not getting enough blood flow to my heart, even though arteries are open. I have been used as a case study and no one can come up with an answer. I take Atenolol, Norvasc and recently added Renexa 1000 mg x 2 . The only way I can even walk on treadmill (flat) is with nitro tabs. Incline and hills are not an option for me. Dr's are baffled and I just want to be normal again. I was very active prior to this. No other major health problems. I never had high BP, high cholesterol, or anything. Any suggestions on how I can get more blood flow going to my heart>
Dr__Stan_Hazen: This is a very difficult question.
First, don’t take “no flush” forms of niacin – they don’t level LDL, and have no beneficial effect. They are not even the same thing as the niacin used to lower LDL and heart disease risks.
Sometimes, especially in women, development of atherosclerosis in the smaller vessels can result in chronic angina (chest discomfort). The medications you are on sound appropriate. Working with your physician, and also looking for non-cardiac potential contributors to chest pain (which are common) are my recommendations – that and globally aggressive preventive risk strategies, which includes not only medicinal, but also lifestyle efforts. Sometimes alternative medicine approaches can also be helpful for individuals, including meeting with psychologists to see if there are stressors in one’s life that can be identified, and helped to understand/cope with.
jellybeans: I am losing weight by exercise and my doctor has put me on a low sugar, low fat diet and was started on medications - can I expect to come off medications and how long does it take? I have appt in a couple months
Dr__Stan_Hazen: I can’t answer this with the information provided. In general, some medications can be tapered with weight loss - for example, if high blood pressure is seen, anti-hypertensive medications can sometimes be reduced with weight reduction - If the BP becomes normalized without the meds. Other times, meds can’t be stopped. You need to review this with your physician
coral: Is it possible to lessen or reduce plaques in arteries through diet, exercise, and statins
Dr__Stan_Hazen: The short answer is yes. The long answer is that this is a slow process, and studies have shown that it takes a significantly lower LDL level (<70 typically) to start to see gradual plaque regression. Higher HDL levels help with this too.
The good news is it is much easier to halt progression of heart disease with aggressive preventive efforts. So focus on that for starters.
Mayflower: Dr. Hazen, 1) Can high LP(a) cause blood stickiness? 2) Fish Oil contains Cholesterol. Does it contain HDL or LDL? ) can exercise lower LP(a)? Thanks!
Dr__Stan_Hazen: a) LPa does not cause blood “stickiness” – it is associated with increased risk for atherosclerosis, and its complication like heart attack , stroke and death. When we see elevated levels , we become more aggressive with our overall global preventive cardiology goals. When we see elevated levels , we become more aggressive with our overall global preventive cardiology goals.
b) Fish oil should not contain cholesterol. The goal in selecting fish oil is to look at the label and count up the omega 3 fatty acids (DHA + EPA). A typical supplemental dose is 2000 mg daily – which should be able to be done with 2-4 capsules. If it takes more than 4 capsules, the “fish oil” is low in omega 3 fatty acids.
Exercise – while good for you, won’t lower LPa. We don’t have many good drugs for that. We focus first on getting LDL (bad) cholesterol to goal. Niacin preparations at higher doses (e.g. 1500mg or higher – typically 2000 is used) can help lower LPa a little. But frankly, we don’t chase after lowering LPa – and instead, focus on more strict LDL goals, and global prevention goals, in someone with elevated LPa.
Finally – don’t take “no flush” forms of niacin – they don’t level LDL, and have no beneficial effect. They are not even the same thing as the niacin used to lower LDL and heart disease risks.
BobB: I am a 61 year old male in good health. I have none of the "normal" risk factors for CAD. In March 2009 (when I was age 60) I had a heart attack. Went into cardiac arrest at the hospital. Had two stents put in my LAD artery. I have since learned that my Lp(a) was 60. This is, of course, about 4 times the recommended level of 15. In addition to other medicines I take, I take 80 mg of Lipitor and 1,500 mg of niacin each day. Is there anything else I can do to lower my risk of another heart attack? Anything else I can do to slow the accumulation of plaque in my arteries? Could the Cleveland Clinic help me?
Dr__Stan_Hazen: LPa is a known risk factor for atherosclerotic heart disease. Elevated levels (we use 30 as the cutoff for increased risk the assays performed in Preventive Cardiology at the Cleveland Clinic) are associated with increased risk for major adverse cardiac events including heart attack, stroke and death. Recent genetic studies show that LPa is genetically linked to cardiac disease, and in a large recent study done at the Cleveland Clinic, we show that in subjects with elevated LPa, when the LDL cholesterol level is treated to very low levels (<70), the risk associated with elevated LPa is attenuated, and increased risk isn’t observed. This was an association study - not a prospective intervention trial. The results none-the-less argue that aggressive lipid lowering and global overall preventive strategies are warranted with elevated LPa.
Since LPa is also associated with increased risk for thrombotic events (MI or stroke) and the protein has homology to clotting factor proteins, we typically recommend increased anti-platelet prophylaxis (162 mg aspirin) in subjects with elevated LPa – provided there are no clear contraindications for aspirin use (e.g. GI bleeding, gastric irritation, history of hemorrhagic stroke, concurrent anticoagulation therapy).
dav_001: I am on a statin and my LDL has decreased to 72, my HDL is 41. My LPa is still high. Is that ok. If your LDL is reaching goal do you still try to lower LPa?
Dr__Stan_Hazen: Elevated LPa is an independent risk factor, but we don't have good drugs available to lower LPa. If LPa is > 30, we recommend aggressive LDL lowering (< 70). Niaspan (an intermediate acting niacin agent) helps to both lower LDL and can help lower LPa. In patients with known heart disease, if there are other risk factors we sometimes recommend combined therapy. This has to be individually tailored and discussed with the patient. I recommend coming to a preventive cardiology expert.
Mayflower: I’m 41. Recently found high LP(a)=102 and mild Heart Valve Regurgitation, Irregular Heart Beat on24-hour Monitor (many PVCs & PACs). My Echo, Stress Test , LDL (84), HDL(56), Total Cholesterol (155), Triglycerides (74), CRP (0.5), Homocysteine (9.2) were normal, but I have chest pain, tingle/numb in legs/arms, feel clotting moving in artery/veins. Easily bruised without knowing causes. 3 years ago diagnosed with: Pituitary Enlargement, Premature Ovarian Failure, Osteoporosis, elevated Rheumatoid Factor, abnormal anti-smooth muscle antibody. Questions: 1) given my tests, symptoms & family history (mother has Atrial Fibrillation, Heart Valve Leakage and Heart Enlargement), should I be treated? 2) What cause LP(a) to elevate? How to lower it? 3) What’s my risk with LP(a)=102 but LDL=84? 4) Can Aspirin lower LP(a)? 5) Which is better for me, Fish Oil or Flaxseed Oil? 6) My doctor wanted to treat my Osteoporosis with Hormone Replacement. Is it risky for me?
Dr__Stan_Hazen: See above for comments about elevated LPa. You should see your family doctor for preventive cardiology program. We would be happy to see you in Preventive Cardiology Clinic.
mayflower1000: to follow up the LP(a) - it's done in Quest and the normal range is <75 nm0l/L and mine was 102. Is it considered mildly or severely elevated and need treatment?
Dr__Stan_Hazen: Your results are elevated outside of the normal range. I suggest you follow-up with your physician who ordered the test, or a preventive cardiology clinic.
mayflower1000: I’m 41. Had premature ovarian failure at 37. Is my risk for heart disease elevated due to this? My doctor wants to treat my osteoporosis with Hormone Replace. Should I take it given my LP(a)=102?
Dr__Stan_Hazen: Sounds like you have a lot of preventive issues to consider. Perhaps you may benefit by seeing a Preventive specialist to help provide information that allows you to better make some of these decisions. We would be happy to see you in Preventive Cardiology Clinic (such as at the Women's Center for Cardiovascular Disease).
mayflower1000: My LP(a)= 102, LDL=84. Is my LP(a) mildly or severely elevated? Should I take Aspirin 81mg daily?
Dr__Stan_Hazen: An LPa > 30 is considered high (at least with the labs done at Cleveland Clinic). LPa is a lab that has considerable variability from one platform (manufacturer) to another. You need to see what the normal range is for the lab done.
Lynda: I am a 60 year old female who recently had a lipid panel. Cholesterol 233, HDL 78, LDL 137, CRP .02. Blood pressure 92/64 Pulse 62. I have been labeled as having hypercholesterolemia because of my elevated LDL. Should I be concerned?
Dr__Stan_Hazen: Concerned is a strong word. The elevated LDL is a risk factor for development of atherosclerosis. And being 60, you may be postmenopausal, and this too is a risk factor for heart disease.
I recommend that you focus on diet and exercise efforts to lower the LDL toward a goal of < 100. If in 3 months and repeat screening it is not lower, you may benefit from a lipid lowering agent. I suggest meeting with your physician to discuss options once you try the above diet/exercise regimen and are retested.
rbaldassari: Follow-up question from BobB - My LDL is now 18; HDL is 33; Trygli is 32. Should I try to get the LDL lower?
Dr__Stan_Hazen: All of the major trials examining how low of an LDL is too low used an LDL of 25 as the lower limit. At an LDL of 18, you are below that. So I would recommend gently easing up a little on the efforts there! We haven't seen harm in a LDL < 25, but believe there has to be some lower limit where below there is harm.
eikcaj: On a regular cholesterol panel my ldl is 143, but on a recent vap test it is ldr 69 lpa 10 IDL9 what does this tellme JK
Dr__Stan_Hazen: The lab results you describe don’t sound correct. Something isn’t adding up. The VAP test is a subfractionation of the lipoproteins, but the sum of the parts should equal the whole. I recommend discussing the results with your ordering physician - and possibly having a repeat simple fasting lipid profile done. If the LDL returns at the original level of 143 - you are at increased cardiac risk.
Jon: I have HDL in the 130 range, and just had a heart blockage stented. Is Dr. Hazen's test for Dysfunctional HDL up and running yet?
Dr__Stan_Hazen: It is only available in research format at this point in time. We are working on it – but haven’t gotten it quite ready for use in the clinic yet.
eikcaj: how does one become a candidate for your research. My HDL was 161 when my stent was inserted in June of 2010
Dr__Stan_Hazen: You can contact Preventive Cardiology at the Cleveland Clinic. Cindy Stevenson is the research nurse manager (216-444-9417)
Lipids and Hypothyroid
8882wr: I have hypothyroidism and elevated cholesterol levels. Are they related? I have not been prescribed a dose of several medications and they cannot seem to control the cholesterol problem and I always get side effects. Not sure what I should do at this point.
Dr__Stan_Hazen: The may be - subclinical hypothyroidism is associated with secondary changes in lipid levels, including mild elevations in cholesterol or triglyceride levels. That is why we often check thyroid function when first seeing someone with lipid abnormalities. Sounds like you should either work with your physician, or see a specialist (lipid clinic, like Preventive Cardiology). We work with primary care MDs to help patients get to LDL goals who have difficulty achieving lipid goals, whether because the levels are not responsive to medications, or medications are not well tolerated.
C reactive protein
carolccee: Why is C reactive protein not a standard test all MD are doing ? Isn't it just as important as cholesterol? My doctor does not do it and I wonder if I should get one
Dr__Stan_Hazen: C reactive protein has been shown to be associated with cardiac risks - but studies also show it is not likely directly mechanistically causing or contributing to heart disease. This has delayed acceptance of the test - and perhaps rightly so. There is clear evidence that the test can help identify individuals at risk for heart disease that otherwise would not be identified by traditional risk markers.
Calcium Screening Heart Score
roses57: I had calcium screening heart score of 700 - I am trying to figure out what this all means. Can you talk about the calcium score and significance?
Dr__Stan_Hazen: An Agaston score (what is used for Calcium scoring) of > 100 is considered abnormal (evidence of atherosclerosis heart disease). This places you at higher risk, and accordingly, we recommend more aggressive LDL goals, and global preventive efforts in someone with positive calcium score. Serial calcium scores are of no benefit - so no further calcium score are needed. You have heart disease. Additional testing won’t change that. Focusing on preventive efforts is the next step.
Statins, Cholesterol Lowering Agents
james09: What is the best statin to use to lower LDL cholesterol?
Dr__Stan_Hazen: All of the statins show cardiovascular benefit, and in general, the degree of LDL lowering by a statin correlates with the benefit. All of the statins show similar side effect profiles. Selection of the statin and dose for a subject is related to both the degree of LDL reduction needed, and the possible interactions with other medications (because there are differences in statins with respect to metabolism and drug interactions).
Michael: Have you received any results in your study of the ability of cholesterol-reducing drugs to slow the progress of aortic stenosis?
Dr__Stan_Hazen: While it is true that aortic stenosis has pathology characteristics of inflammation within the valve leaflets /apparatus, and for this reason, it was thought that some anti-atherosclerotic drugs (e.g. statins, or other cholesterol lowering agents) might prove beneficial in slowing the progression of aortic stenosis – unfortunately, studies thus far haven’t shown benefit in this area.
IchiroFan: How do you know if statins are working other than looking at the lab results?
Dr__Stan_Hazen: That is a good question. We can not feel cholesterol entering our vessel walls either. Bottom line is this - study after study shows that taking a statin helps lower risk for heart attack, stroke, need for revascularization (bypass surgery or other coronary interventions) and death. Taking the statin should be like taking a sugar pill- you feel nothing. thankfully, most subjects taking statins don't experience adverse side effects.
Diet and Non-Medication Efforts to Treat Cholesterol and Heart Disease
craig_s: My husband had a heart attack in last year and 2 stents were placed. We are looking to make lifestyle changes instead of prescribing medications. Can you comment on diets such as the Ornish diet and Dr. Esselstyn's diet and if you incorporate those into your program?
Dr__Stan_Hazen: We try and tailor the dietary regimen to the patient's desires and wishes. Our registered dietitians are expert in preventive cardiology, and can help craft diet recommendations including named diets such as you named, or more traditional ones like Mediterranean diet, etc. With a history of cardiac disease and intervention, nutritional/lifestyle changes alone are often not enough, and we recommend medications as these have been shown to decrease heart attack, stroke and death....the real goal. We understand that many individuals really don't want to take medications and will work with patients to try and find things that work for them. But always tell them what our best advice is based on the medical literature too- and then they can make an informed decision.
yulla: I've been vegan for about a year and I have high cholesterol still. My LDL and Total cholesterol are both high. I am only 25 years old but my dad also has high cholesterol also I know that has an impact. What more can I do without going on medications
Dr__Stan_Hazen: A vegan diet does not mean it is low in cholesterol. There are many non-prescriptive approaches that can also help with LDL lowering. I suggest that you try one or more of the following non-prescriptive methods of cholesterol lowering like:
Psyllium, which is in Metamucil. Metamucil is available in powder, wafers, and capsules. Take 4 capsules per day, or the equivalent of 2 grams in the wafer s or powder. When taken just before the major meal of the day, this can help lower LDL up to 5-7%.
You may also try Ground Flax Seed (1-2 Tablespoons per day). Ensure that the flax seed is ground, store it in the refrigerator to prevent it from spoiling. You may put ground flax seed in yogurt, oatmeal, salads, or smoothies. Ground flax seed can be purchased at most grocery stores. It can be found in the cereal aisle near the oatmeal, in the baking aisle near the flours, or in the health food section. Flax seed oil also comes in capsule form. When taken daily, some studies have shown it can help lower LDL up to 5%.
You may also switch from butter or margarine to margarine spreads that contain plant stanols like Benecol or Take Control. For ease of use you may consider using a sterol supplement like CholestOff capsules, 4 grams per day. You may also consider trying Minute Maid Premium Heart Wise orange juice that contains plant sterols. Yoplait Heart Healthy yogurt and Nature Valley Healthy Heart granola bars also contain cholesterol-reducing plant sterols.
You may also take fish oil supplements, which contain Omega-3 fatty acids. Omega-3 fatty acids may help lower triglycerides and raise HDL (healthy cholesterol). They may also have an anti-inflammatory effect, and lower blood pressure. Start with 2,000mg of fish oil supplements per day. Store the capsules in the freezer to prevent experiencing a fishy burp. You may also increase your intake of fish to 2 meals per week. Cold water varieties of fish like mackerel, tuna, salmon, sardines and herring contain high amounts of omega-3 fatty acids.
We also suggest that you increase your intake of dietary fiber to 20 - 25 grams per day using soluble fiber sources such as whole grains, legumes, whole fruits and vegetables. You may add 20 - 25 grams of soy protein per day to your diet. This could include tofu, soy milk, soy burgers, soy nut butter, etc.
Duke: which if any supplements have been proven to help protect the heart and other general health? thanks. duke
Dr__Stan_Hazen: In general, most nutritional supplements have not been studied with randomized placebo controlled studies (the best kind for answering this question). I recommend focusing first on a healthy diet that includes plenty of fruits and vegetables- to get the nutritional supplements the natural way…
Cara: HOW MUCH KRILL OIL SHOULD I TAKE DAILY??? Do you have any thoughts about this?
Dr__Stan_Hazen: I have never heard of Krill oil. I do not recommend it. I instead recommend focusing on a prudent heart healthy diet with plenty of fruits and vegetables. Something that you enjoy, is not high calorie, and is relatively low in cholesterol and fats. The goal is not to focus on a “diet” – but a healthy sustainable lifelong eating habit.
mayflower1000_1: which one is better to lower LDL, Flaxseed oil or fish oil?
Dr__Stan_Hazen: neither lowers LDL much, but flax seed can help lower it a little more. Fish oil (omega 3 fatty acids) are better at lowering triglyceride levels. they are also better studied - with several randomized trials showing risk reduction with supplementation on omega 3 fatty acids.
Red yeast rice is a fermented form of rice that has a natural statin in it. In fact, the agent in red yeast rice that lowers cholesterol is identical chemically to mevocor (lovastatin) the first ever statin sold in the US many decades ago. We sometimes use red yeast rice (or capsules) as an alternative for LDL lowering- but only when the patient has strong feelings about never wanting to take prescriptive drugs. While red yeast rice can lower cholesterol, there is considerable variability in the active ingredients from lot to lot, and manufacturer to manufacturer - also- the FDA doesn't monitor it. So getting ones statin with a prescriptive form is best.
Supplements, Vitamins:Calcium Supplements and Heart Disease
Bobbie: Are Calcium supplements bad for your heart? I had open heart surgery one year ago and take 3 -600 pills per day.
Dr__Stan_Hazen: Another person also asked this question: She asked: Can you talk about the news report on Calcium- Calcium supplements, which many people consume hoping to ward off osteoporosis, may increase the risk of heart attack by as much as 30 percent, researchers reported Friday.
Dr__Stan_Hazen: This is an interesting and complicated area. Recent statistical studies (something called meta analyses) have suggested there may be a link between calcium supplements and increased atherosclerotic risk. This is very difficult to tease out, however, from combining multiple studies together that were not intended to test this hypothesis, because elderly subjects are both more likely to take Ca supplements and to have cardiac disease. If one has significant osteoporosis (thinning of the bones) - hip fracture, or spinal compression fractures, can be significant and life altering health ailments. Taking calcium supplementation alone has been questioned for its benefits, but when taken in combination with other medications under Dr supervision for osteoporosis treatment, there can be effective slowing of progression of bone thinning and associated morbidity.
It is important to realize that prior studies examining calcium intake and heart disease risks failed to show a connection until this recent larger meta analysis was performed. Meta analyses are really hypothesis generating studies – they do not prove outcome, and are weaker than a randomized trial. Unfortunately, there are no randomized trials on this topic yet. The recent meta analysis reported may serve as ammunition to help fund such a trial.
At this point I do not think the data is strong enough to recommend to my patients that they stop their prescribed calcium supplements if they have osteoporosis. I do recommend re-evaluation of the use, and if they have osteoporosis, I recommend they discuss the options and treatment strategies with their doctor treating the osteoporosis.
Anxiety and Heart Disease
lion442: does anxiety contribute to heart pain and angina
Dr__Stan_Hazen: It can. Any form of stress can affect one's health - with different persons responding differently.
Exercise and Heart and Vascular Disease
shf_123: How long does it take, on average, for exercise to begin having a positive effect on cholesterol levels?
Dr__Stan_Hazen: In general, exercise doesn't have a big effect on cholesterol levels. it can have a modest effect (LDL lowering, HDL raising) and this tends to take weeks to months - and is best seen if accompanied by weight loss.
What exercise does have a profound effect on is lowering triglyceride levels, an alternative lipid marker associated with cardiac risks. It also helps with diabetes control, reduction of insulin resistance in subjects with "prediabetes". It also helps to lower blood pressure. The average [person who begins a routine exercise regimen that consists of walking at a brisk pace for 30-45 min, 5d/week, can expect to see approximately a 10 mm Hg reduction in systolic blood pressure - that is as good as (and additive to) a blood pressure medication.
Jeff: Can you talk about PAD Rehabilitation and strategies for prevention of PAD.
Dr__Stan_Hazen: Peripheral artery disease (PAD) is a significant risk factor for heart disease. The same sorts of global preventive efforts for heart disease apply to PAD. – but exercise here is particularly important. Walking until it hurts, and then a little further, helps to induce new blood vessel growth into the legs where PAD often exists.
Aggressive lipid lowering with statins, low cholesterol diet, and smoking cessation are key. Low dose aspirin and other platelet therapies are also important – under the supervision of your physician.
Coronary Artery Disease
lion442: I never had a heart attack but to have angina at times of over eating I do have some blockage in my arteries but have no need of surgery at this time follow a strict vegan diet and have low ldl and blood pressure no diabetes and I been on this program for 2 years what can I do to relieve my angina after meals total cholesterol 99
Dr__Stan_Hazen: Are you sure it is angina? Angina is chest pain caused by cardiac cause. After e4ating, it can be cardiac etiology, but also can be GI in origin (ie reflux, esophageal spasm, etc).
If it is cardiac in etiology, we would typically focus on intervening to prevent the pain. I recommend reevaluation with your cardiologist first, and if he/she indicates the pain is likely not coming from cardiac origin, to then follow-up with your primary care physician.
rbaldassari: what factors are considered in the decision to use drug-eluding or non-drug-eluding stents. Please pardon the misspelling.
Dr__Stan_Hazen: the choice of stent type is complex, and best discussed with your interventional cardiologist.
Cleveland_Clinic_Host: I'm sorry to say that our time with Stanley Hazen MD, is now over. Thank you again Dr. Hazen for taking the time to answer our questions about Cardiovascular Disease Risk Factors.
Dr__Stan_Hazen: thanks for having me.
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