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Reduce Your Risk Factors for Cardiovascular Disease (Dr Frid 4 5 10)

April 5, 2010
Dr. David Frid

David Frid, MD
Department of Cardiovascular Medicine


Research about cardiovascular disease risk factors suggests that making even small lifestyle changes can reduce the risk of coronary artery disease, heart attack, stroke and other serious cardiovascular conditions. Dr. David Frid, Cardiologist at Cleveland Clinic answers questions about reducing your risk factors.

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Cleveland_Clinic_Host: Welcome to our Online Health Chat with David Frid, MD. We are thrilled to have him here today for this chat. Thank you for joining us Dr. Frid, let’s begin with the questions.

Speaker_-_Dr__David_Frid: Thank you for having me today.

Total Cholesterol, HDL, LDL, Triglycerides, and other lipoproteins

DonnaS: I have very high HDL - I always thought that was good - but then a friend told me not all high HDL is good. Sometimes it can be bad if it is very high. Can you talk about that?

Speaker_-_Dr__David_Frid: That is an interesting question. There are different types of HDL but at present we are unclear as to whether or not having the different types of HDL makes that much of a difference. If you just look at the HDL number it has been found that the higher the number the lower the risk of heart disease. But you also can't take HDL by itself. You have to look at it in the context of all your lipid numbers.

butterfly: What are triglycerides and how do they differ from cholesterol or the LDL that they are always talking about - are they not as important?

Speaker_-_Dr__David_Frid: Triglycerides are fats in your blood just like cholesterol but they are the fats that your body first absorbs when you consume food. The body takes the triglycerides to the liver where they are used for a number of functions including energy and are converted into cholesterol as well. Triglycerides have been found to be associated with developing heart disease but not to the same extent as LDL cholesterol. Triglycerides if very elevated can also be a problem in that they can cause pancreatitis. It is important to have your triglycerides evaluated as much as LDL, HDL and other lipid components.

pingpong57: What is LP a? what is the significance?

Speaker_-_Dr__David_Frid: LP a is a lipoprotein that is created in the body much like LDL or HDL. The difference is that it is not specifically involved in the transport of cholesterol throughout the body. The importance is that it often indicates inflammation and may indicate that a process such as coronary artery disease is a higher risk if LP a is elevated in a patient with abnormal LDL. Thus, it is often used as an additional marker to help determine if someone is at higher risk and their treatment needs to be more aggressive at lowering LDL and other risk factors.

Lipid Lowering Medications

PaulK: I have had cholesterol - I have taken Crestor and was unable to take it due to muscle aches. Not sure what to do. Right now I am just watching my diet but should I try something else - would niacin help?

Speaker_-_Dr__David_Frid: There are a number of different medications to treat elevated cholesterol. The statin medications (which Crestor is one) are the most effective. Sometimes people will have side effects such as muscle aches but may not have the side effects from a different statin. We often try different statins if a patient can not tolerate one. It may be worthwhile having your physician try a different statin.

Niacin does have an affect on cholesterol and it is one of the medications that are used, but like all medications, it has side effects and has to be used in a correct manner that is directed by your physician. We deal a lot with patients who are intolerant of cholesterol lowering medications and the Preventive Cardiology Clinic at Cleveland Clinic would be happy to help you determine what the best treatment for you would be.

ejung1: Is it true that statins and Niacin should not be taken together. Niacin is available as a health supplement. I had been taking it along with Crestor but recently read in the newspaper that the two do not go together?

Speaker_-_Dr__David_Frid: Very good question. The use of niacin and statins together is sometimes done when certain affects on the lipid profile are needed. This is something that normally is determined working with whoever is managing your lipid lowering therapy. The problem with using the two together is that there is a greater risk of side effects than when either is used by itself

Thus - it is important to use the combination only when necessary and appropriate and to do it in a setting where monitoring for potential side effects and problems can be done. One should not just go out and add the use of niacin to their lipid lowering therapy without being instructed by their physician.

Kathleen: If you check your liver enzymes and the doctor found they were slightly elevated - should I still stay on my lipitor? He said that is not too much to worry about. Am I looking at damage over time?

Speaker_-_Dr__David_Frid: Elevations in liver enzymes is one of the side effects from statin medications, such as lipitor. This is because their effect is on one of the enzymes that produce cholesterol which is located in the liver. Depending on what is meant by "slightly elevated," it is often safe to keep the patient on the medication without concern with long term damage. This is something that you should discuss more thoroughly with your physician if you have significant concern.

Peppy: There was a recent article in the March issue of Time magazine about the ineffectiveness and increased side effects of statins in women. Please comment. Would Niacin and lifestyle be a good replacement for those of us that just cannot tolerate them?

Speaker_-_Dr__David_Frid: Statins have been studied in both men and women and have been found to be effective in both genders. The benefits of cholesterol lowering is well known and there are a number of different treatments in addition to statins that are effective of lowering cholesterol but not to the same degree as the statins.

Niacin is one of those medications and in some people may be more appropriate than a statin or may be needed in addition to a statin. Recommendations as to what is the best and most appropriate therapy is based on the individual's lipid profile as well as their tolerance of the various medications.

Supplements, Herbals and Vitamins

GeorgeB: I take fish oil capsules - one per day. Is there a certain type I should look for? I like the one I take but my coworker said that I should look for a specific kind.

Speaker_-_Dr__David_Frid: What we are looking for in fish oil is the amount of omega 3 fatty acid and that is the key component that one should look for in choosing one to take.

Peppy: Supplement studies recently seem to have determined that they are not beneficial and can cause harm in some cases. Should we not use dietary supplements to keep our hearts/health optimum?

Speaker_-_Dr__David_Frid: The use of supplements in preventing heart disease has not been specifically shown to be of benefit. In the past it was suggested that vitamin E, vitamin C, some of the B vitamins as well as other herbs and supplements might be useful. Studies to date have not confirmed that and in fact with vitamin E have found that high doses may actually be harmful. Thus it is appropriate to discuss the use of any supplements - especially in large quantities - with your physician as they may not only be harmful by themselves but may have interactions with other medications that you may be taking.

ejung1: Does taking fish oil - omega 3 fatty acid - help and what specifically does it do?

Speaker_-_Dr__David_Frid: There is research that suggests adding fish oil to ones diet is beneficial. From a heart prospective - usually the recommendation is to consume cold water fish such as salmon to obtain the appropriate amount of omega three fatty acid.

Fish oil supplements are often used in patients with high triglycerides and may be beneficial in patients with very high risk for coronary artery disease. The benefits of fish oil come from its effect on the lipids primarily triglycerides but there is some data that it may help in preventing blood clots similar to aspirin but in a slightly different mechanism.

shaneme123: Read a recent article that stated we are getting too much folic acid (daily supplements + food); heart damage (of some sort) is referenced; any comment?

Speaker_-_Dr__David_Frid: Folic acid was added to grain products a number of years ago because of birth defects that were seen due to a low intake of folic acid by the US population in general. The addition of the folic acid actually appeared to have some cardiovascular benefits as homocysteine had been identified as a cardiovascular risk factor that was treated with folic acid supplementation. It does not seem to be as much of a problem as it was before the food supplementation.

Unless one is taking in an abnormal amount of grain products or is taking a folic acid supplement on top of their normal daily intake, it would be surprising for someone to take in a potentially harmful amount of folic acid.

Diet and Lowering Cholesterol

Peppy: What type of diet seems to prevent or even reverse heart risk factors best and is backed by research?

Speaker_-_Dr__David_Frid: There has been much looked at and written about diet and its benefits on the heart. In a nutshell, a diet that is low in saturated fats, low in salt, high in fiber, and of appropriate caloric intake to maintain a healthy weight is the best way to describe the appropriate diet. There is quite a bit of information on our website on nutrition strategies - see

Peppy: Raw walnuts and various nuts are said to lower LDL. Do they or do they cause plaque in the arteries?

Speaker_-_Dr__David_Frid: Studies have shown that walnuts as well as other nuts may reduce the risk of heart disease. This may relate to the type of fat content that is contained in the nuts that is whether it is high in saturated fats vs. mono-unsaturated or poly-unsaturated fats. Again, much of this depends on the type of nut one is consuming and the benefits may relate to the amount that is consumed. This is a situation where more may not be better. Again - one also has to look at the consumption of walnuts or any other nuts in the context of their entire diet. Here is an article that may interest you -

ejung1: Is there a difference in the benefit between wild caught or farm raised salmon?

Speaker_-_Dr__David_Frid: That is an interesting question. We know that salmon as a cold water fish contains a significant amount of omega 3 fatty acid. Unfortunately I cannot tell you whether the wild raised have a larger and or better amount of omega 3 fatty acid than the farm raised. Here are some sources for you for information–

Based on this table - there does not appear to be a significant difference between the two.

Symptoms of Heart Disease

ejung1: What are typical first symptoms of heart disease once beyond the precursors like LDL and the other risk indicators?

Speaker_-_Dr__David_Frid: They can come in a multitude of symptoms - usually people think of having chest pain as the first symptom that one gets when they have coronary artery disease. Usually by the time someone has symptoms, the disease is significant and is at the point where some type of medical intervention is needed.

The ideal is to prevent the development of symptoms by starting early and addressing ones cardiac risk factors before the development of symptomatic coronary artery disease. Thus one should evaluate their cardiac risk at a young age and try to change those factors that can be altered. Cardiac risk factors include smoking, cholesterol, diabetes, high blood pressure, lack of exercise, being overweight, stress and all of these can be addressed by evaluating one's lifestyle and making changes and improvements when necessary.

Testing of Cholesterol in Children

Tom: If I have high cholesterol and my dad had high cholesterol - at what age do you recommend my children to get tested for high cholesterol?

Speaker_-_Dr__David_Frid: Testing in children with a family history of elevated cholesterol or a family history of coronary artery disease is usually recommended by the time they are 18 yrs old. The best way to have this addressed is to discuss with your children's pediatrician the fact that you have elevated cholesterol as well as the family history of elevated cholesterol and work with them to determine whether screening is appropriate at an earlier age.

Thyroid and High Cholesterol

jeffreyw: Is there a connection between cholesterol and thyroid problems?

Speaker_-_Dr__David_Frid: Yes - it is known that one potential cause of hypercholesterolemia is hypothyroidism or low thyroid levels. Though it is not the common cause - it is something that should be screened for before determining that the cause of the elevated cholesterol is due to either genetics, diet or some other possible reason that cannot be easily addressed.

Having a low thyroid as a cause of cholesterol elevation is called a secondary cause and in addition to low thyroid people with kidney problems can also have elevated cholesterol due to their underlying kidney disease - so that is something that is also usually evaluated when we first identify someone with elevated cholesterol.

Aspirin Therapy

SmithC: Should everyone take a daily baby aspirin. My husband takes one but I have never been told to take one - I am 49 - what do you tell your patients?

Speaker_-_Dr__David_Frid: Taking a daily aspirin is something that has been discussed for a number of years. It is known that in people with coronary artery disease and other known atherosclerotic diseases, that an aspirin a day has significant benefit.

The real question becomes in people who don't have coronary artery disease and is there a benefit? Studies have shown that there is a benefit whereas other studies have not shown the same benefit. Part of the difference between the findings may relate to the dose of aspirin that is taken as well as the cardiovascular risk profile of the person. Thus it is hard to recommend cart blanche that everyone over a certain age or of a certain gender should be taking an aspirin a day. This is something that is best determined by a discussion between the patient and their physician since a number of factors need to be taken into consideration.

Stress Test

pgonzalez: I am 40 years old and I am currently taking Metoprolol for PVC's that were found on my Holter Report. I also have low blood pressure but my heartbeat is rapid. Most of my PVC's occur during the night time. I have been to my cardiologist several times and they have never conducted a Stress test on me. I feel they may not want to do this because of my age. How should I approach my Cardiologist with this concern?

Speaker_-_Dr__David_Frid: The best way to approach your cardiologist is to be up front about what your concerns are. If your concern is that you may have coronary artery disease as the cause of your PVCs then it is worth discussing this and determining whether a further evaluation is truly needed. Your cardiologist most likely has included coronary artery disease as one of the possible causes and felt that based on your history and risk factor profile that a exercise test which primarily looks for coronary artery disease was not necessary. The best way to understand his reasoning is to ask.

Calcium Score

rtbew: What do you think about calcium score tests?

Speaker_-_Dr__David_Frid: Coronary calcium testing is often used to determine if somebody has early changes that might indicate higher risk of developing coronary artery disease. It shows calcification of the coronary arteries which may indicate early changes.

So far, it has not been shown that finding coronary calcium is better than just evaluating the traditional risk factors such as cholesterol, high blood pressure, and diabetes, to determine if someone is at higher risk. It is most useful in the person who is at low to moderate risk to sometimes determine if or if not therapy should be initiated. To date, it has not been accepted as a standard screening tool for coronary artery disease.

Alcohol and Cardiovascular Disease

caroldm: Is it ok to drink a drink per night or not - I keep hearing differing opinions?

Speaker_-_Dr__David_Frid: The data suggests that one drink a day may help reduce your risk of heart disease. Some of the controversy relates to what type of alcohol is the best and there is some suggestion that red wine - because of some of the anti-oxidants and other components in it - may have the best effect.

One thing to keep in mind is that in regards to alcohol - more is not better. There are other ways that one can reduce their risk of heart disease such as stopping smoking, exercising, and addressing risk factors such as high cholesterol, high blood pressure and diabetes that may be more effective than adding alcohol.

Valve Disease

shaneme123: Have aortic stenosis; valve surgery coming up in the next couple years; what can I do to reduce risk now for the upcoming surgery as well as once it is performed, how do you max. the valve life?

Speaker_-_Dr__David_Frid: To reduce risk, you need to be in the best health possible at the time of your surgery. So - anything you can do to either reduce your risk factors for cardiac disease, diabetes or other health problems, will be in your best interest. This includes stopping smoking, exercising, reducing your weight if over weight, and making sure any other medical problems or conditions are addressed and controlled. There is nothing specific that we know will increase or prolong the life of an artificial valve other than leading a healthy lifestyle and addressing medical issues as they come about

macee61: I am 61 years old and have mitral valve prolapse. I go to the gym three times a week, but am unsure how hard to work out. I do follow the posted chart and keep my heart rate at about 120 bpm. Suggestions?

Speaker_-_Dr__David_Frid: Keep on exercising. The fact that you have mitral valve prolapse should not preclude you from continuing with your exercise program. If you are concerned that your exercise regimen may not be appropriate, you could meet with an exercise specialist to determine an appropriate exercise program. Here at the Cleveland Clinic, in Preventive Cardiology Program, the exercise specialists are available to do exercise prescriptions.

ejung1: Great program, thank you Doc!

Speaker_-_Dr__David_Frid: Thanks for having me - it has been a pleasure. I look forward to doing it again sometime.

Cleveland_Clinic_Host: I'm sorry to say that our time with David Frid, MD is now over. Thank you for joining us and thank you again Dr Frid for taking the time to answer our questions.

Technology for webchats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 04/10

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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