Stanley Hazen, MD
Stanley Hazen, MD

Friday, December 21, 2018 | Noon


Cardiovascular disease is the leading cause of death in the United States, killing over 1 million Americans each year. It is important for you to understand the modifiable and non-modifiable risk factors that are associated with it. Stanley Hazen, MD, PhD, Medical Director of Preventive Cardiology answers your questions about cardiovascular risk factors and how to control them.

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Calcium Score CT Scan

sjm: For someone with high cholesterol, but otherwise very good health, healthy habits, and other low risk factors, how valuable would a Calcium Score CT scan be as a check-in to determine overall risk?

Stanley Hazen, MD, PhD: If cholesterol is elevated, that alone is sufficient to warrant more aggressive preventive risk reduction efforts including those to lower cholesterol (with statins if needed).A calcium score can provide prognostic value and help identify subjects at risk who otherwise are not recognized as being at risk based on traditional risk factors. It is important to realize that a negative calcium score does not guarantee low risk (i.e. among primary prevention subjects (those without known coronary artery disease) 20% of first events occur in subjects with low calcium score. This is because the deposition of calcium in the artery wall is a very late stage of the atherosclerotic process.

allynb: I have the results of a coronary calcium score - what do the different scores mean?

Stanley Hazen, MD, PhD: The coronary calcium score is based on the Agatston scale - the cardiologist who first reported use of radio-graphic measurement of arterial calcium for risk prediction. In general, a value of 100 or greater is intermediate risk, and 300 or more is high risk. We tend to use 100 as the cutoff for implementing more aggressive risk reduction efforts. It is important to realize that interval change in calcium score is NOT PROGNOSTIC. That means, once positive (Over 100), we do not recommend getting another study. That is because it has been shown that the incremental increase does not predict risk for incident heart attack, stroke, need for revascularization or death. Think of it as being like a pregnancy test. Once positive, there is no real value in repeating the test to see if you are even more pregnant. 

TMAO (trimethylene N-oxide)

jonnyl: Can you talk about TMAO and how it fits in with today's risk factors and how it is used.

Stanley Hazen, MD, PhD: TMAO is a gut microbe generated metabolite that is linked to development of hardening of the arteries, and clotting risk (heart attack and stroke). Studies show that it is as powerful (or more) a predictor of cardiac risks as traditional risk factors. When elevated, we recommend:1) More aggressive global preventive risk reduction efforts, including lower LDL goals.2) Use of low dose (81mg daily) aspirin as long as there are no contraindications because it is so clearly linked to heightened clotting risks3) Reduction in animal products in diet. This can mean cutting back on frequency and portion size of red meat (goal toward elimination even if needed...can monitor and individualize to subjects' needs by TMAO level). Recent studies show TMAO levels will reduce (typically 3-fold - but can be as high as 10-fold) over time - within 1 month when switching from a high red meat containing diet to one that uses white meat or non-meat (mostly vegetarian) sources of protein.4) Avoid supplements that contain carnitine, choline, or lecithin as these can increase TMAO significantly.

LDL Cholesterol

frank-p: What should your LDL be - I am not really understanding the new cholesterol guidelines.

Stanley Hazen, MD, PhD: In general - as a guideline - we follow the following goals < (less than) 100 for those considered at "low risk" - primary prevention (meaning they have no known heart disease or major risk factors) <70 for high risk subjects (secondary prevention patients - i.e. they have known heart disease, or diabetes, or other high risk like peripheral vascular disease, or history of TIA or stroke, or aortic aneurysm).

sjm: For people who have trouble taking both statins and red yeast rice, do you have an alternative for lowering LDL? (Aside from diet).

Stanley Hazen, MD, PhD: There is a new family of drugs with a complicated name - PCSK9 inhibitors. These are an injection form of medication (given typically once every 2 weeks) and are very effective at lowering cholesterol (typically 50+ % reduction). And have been shown to reduce heart attack, stroke and death risks in subjects with high cholesterol and statin intolerance.


samual22: What are the latest recommendations for a high triglyceride level? I have heard mixed results for how bad that is?

Stanley Hazen, MD, PhD: High triglycerides (TG) are an increased risk for cardiac disease. Period. There is no debate on that. High TG is defined as > 150. There is evidence that an even lower level (< 100) may provide increased risk reduction. The debate has been over use of omega 3 fatty acids to reduce cardiac risks when TG is elevated. More recent studies have cast doubt on whether all forms of omega 3 fatty acids provide similar effects. I think it is important to mention that when TG is elevated, for most subjects the first line intervention is dietary efforts (reducing fats and sweets/simple carbs), and the first line medication effort is a statin. Most subjects with TG elevation also have elevation in something called VLDL, which is linked to LDL (bad) cholesterol. And TG reductions of 30% on average with a starting dose of a statin is typical (and associated with significant reductions in heart attack, stroke and death risks).

Apolipoprotein A and Apolipoprotein B (Lp(a) and apo B)

tamara: Can you talk about apo a and b?

Stanley Hazen, MD, PhD: First - apo a. By indicated lower case "a", I am assuming you mean apolipoprotein a (also called L(p)a , or "L - P - little a") This is a strong risk factor for heightened cardiac risks (premature development of coronary artery disease) and is also associated with heightened risk for blood clotting. When L(p)a is elevated, we adopt more aggressive preventive efforts including lowering of LDL goals, and low dose aspirin because of the heightened clotting risks. We also recommend first degree family members be screened since elevations of L(p)a runs in families. Finally, L(p)a doesn't change much over one's life time - so we don’t keep rechecking it for interval changes.

Last - apo b (also called apolipoprotein B) is the major protein in the LDL particle. Elevation in apoB is associated with heightened cardiac risks. An apoB level is virtually identical to an LDL particle number (the particle number is actually what is identical to apoB !) We tend not to order apoB levels most of the time. It can be useful in relatively rare situations where either someone is borderline close to LDLc goal or one wants to know if their particle number is lower. Or - when HDLc is exceedingly high - we sometimes order an apoB because HDLc > 100 sometimes can be inaccurate. And some of the very small dense LDL (which has one apoB per particle) can inadvertently be labeled as an HDL in some rare cases.

Risk Factor Reduction

sjm: What (aside from statins) are your most favored efforts for risk reduction?

Stanley Hazen, MD, PhD: There are 4 major pillars of preventive risk reduction effort:

  1. Exercise - this is the cornerstone to lifestyle changes. A good exercise program predicts improved compliance with the second pillar
  2. Dietary efforts - a healthy diet (i.e. Mediterranean diet is associated with 30-35% reduction in CVD)
  3. Lipid levels - maintaining LDLc < 100 if primary prevention, or < 70 if secondary prevention
  4. BP control of course there are other risk factors like smoking, diabetes, weight reduction efforts if needed. But the above 4 are the central ones

kennedy: What do you do for calcium buildup in the arteries - are there things to take to help decrease the plaque and calcium? 

Stanley Hazen, MD, PhD: Calcified plaque is actually a more stable form of plaque. Like a scar. And sites of heart attacks are less likely to be at the site where the calcium build up is high. However, seeing a high calcium in a vessel we interpret as increased risk for the presence of disease in the vessel where you don't see the calcium. And the sites of heart attacks tend to be (80% of the time) where the degree of stenosis is < 50% Atherosclerotic plaque is like insulation in a wire - it is along the entire vessel wall length. And calcification occurs as a very late stage of the process. It is the body's way of scarring over or trying to heal the plaque.

Preventive Cardiology – and Risk Factor Screen

kenneth-idaho: What blood tests should be included in a full cardiac risk profile - are there genetic tests that should be included?

Stanley Hazen, MD, PhD: There are many tests: fasting lipid profile, basic metabolic panel, TSH, and CBC with differential. Some of the specialty tests we run include but are not limited to:

  • L(p)a
  • NT-proBNP
  • Urine albumin/Creatinine ratio
  • hsCRP
  • MPO


gerome: As part of your preventive cardiology clinic - what is included? What type of blood tests and what type of testing? Stress test?

Stanley Hazen, MD, PhD: Preventive Cardiology clinic takes a global approach to helping to reduce cardiac risks. We screen for cardiac risk factors with lab tests that are tailored to the patient history. The selection of blood tests, and whether a stress test is used depends on the patient history and symptoms. We address weight, nutrition, smoking cessation, lipids, blood pressure, diabetes, sleep apnea, renal function, thyroid, exercise, emotional/ stress etc. In each patient we try and identify what are the key drivers of cardiac risks to try and personalize the recommendations.

Children and Risk Factors

saundra: My husband's family has a big history of heart disease and my husband is on a statin. What age should my kids be tested.

Stanley Hazen, MD, PhD: The American Academy of Pediatrics recommends lipid screening before the age of 2 years old to look for genetic abnormalities associated with gross elevations in cholesterol (i.e. Familial Hypercholesterolemia). And then again before the age of 10 or 11.

Fish Oil and Omega 3

camper: I saw a recent article on fish oil - I think that it is saying that i should not take it - but seems like it was supported by pharma companies that only want us to take statins.

Stanley Hazen, MD, PhD: Not all "fish oil" is the same. It is important to read the label and look at Omega 3 content (EPA + DHA)I still recommend taking Omega 3 fatty acids in the setting of high TG I tell patients that "blubber is blubber" and if you extract the oil from the fat of a fish - it can be the same chemical composition as bacon fat. One has to read the label. And make sure one gets EPA + DHA. The recommended starting dose for high TG is 2000 mg of EPA + DHA. One should be able to get that amount with 3 capsules. Over time - the dose can be increased up to 4000 mg daily (typically taken in 2000 mg doses with meals). This can help to lower TG levels.

Reviewed: 12/18

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