Conventional therapy vs. alternative therapy 11. March 2008 William Davis (5) Rose is a 75-year old woman, mother of four, grandmother of many more.Rose's story started after a heart attack 18 months ago that resulted in two stents. She was advised to follow an American Heart Association diet and take Lipitor. However, some months later, after her fourth stent, she became disilluioned in the conventional approach to heart disease and sought alternative therapies to help reduce or reverse her heart disease. She found an alternative health practitioner who advised chelation, antioxidant vitamins for "excessive oxidation," and several homeopathic preparations. Nothing was said about diet or exercise. Nothing was said about the baked flour products and pastries that occupied at least two meals every day. Nothing was said about the candies she indulged in several times per day, nor the soft drinks. Nothing was said about the wildly fluctuating blood sugars, poorly controlled by an oral diabetes agent. Thirty pounds of weight gain over the past 5 years with no exercise or physical activity? No comment here, too. In short, Rose was the "graduate" of the conventional approach, as typically offered nationwide thousands of times a week. She was also the recipient of the insight of at least one alternative health practitioner, eager to reject conventional notions of how to achieve heart health.So I then met her. She was experiencing chest pains every day, several times per day. Blood pressure over 200. At 5 ft, 3 inches, weight: 186 lbs. Initial laboratory results:HDL cholesterol 42 mg/dlLDL 132 mg/dlTriglycerides 263 mg/dlBlood sugar 173 mg/dlYou can fill in the rest. In short, Rose was a disaster. Despite the attentions of several professionals from both the conventional as well as alternative camps, she was careening rapidly towards failure. She'd been given various crutches, Band-Aids, and salves, none of which resulted in any possibility of long-term relief from her aggressive disease.My point: As I've said previously, all we want is truth. We want effective, rational approaches that yield real benefit. A stent? All that provides is temporary restoration of blood flow. Statin agents? They do indeed reduce LDL cholesterol. But what if Rose has 8, 9, or 10 other causes of heart disease unaffected by the statin drug? It will do little or nothing. Nobody had addressed many of the root causes of Rose's disease: insulin resistance, high triglycerides, inactivity, obesity, hypertension (and identifying the reasons why her blood pressure was so high), vitamin D deficiency (virtually guarantted to be severe), junk foods inclu Toggle navigation Home Blog Home Archive Join Now Log in NY Times Jane Brody misses the mark 9. October 2007 William Davis (6) NY Times' health columnist, Jane Brody, recently wrote a bit of fluff for her paper: "CT Scans of the Heart Come With Trade-Offs In her report, she says:Coronary CT scans are being sold directly to the public, and they have found a market in health-conscious people who can afford them. But screening exams can have downsides. They can cause needless worry, and they sometimes reveal other potential conditions that require invasive procedures like biopsies to diagnose.I soon learned that among the strongest proponents of CT scans of coronary arteries were physicians with financial ties to drug companies that make statins and others connected to imaging centers that would profit directly from widespread CT screenings.She then goes on to discuss how the Framingham scoring calculation can tell you whether or not you are at low-, intermediate-, or high-risk for heart disease. She therefore concludes that heart scans are therefore irrelevant for the majority of people. She then proceeds to take a statin agent. This sort of nonsense continues to get published, despite the clear lack of real "digging" for the truth. She clearly fell for the conventional arguments that continue to mis-guide the majority of people, myths like: --the Framingham scoring system is reliable--Reliable it is NOT; it is susceptible to substantial "misclassification" bias, meaning people who appear low risk can actually be high risk, and people at high risk can actually be low risk. Among the latest studies that question the scoring system is Family history of premature coronary heart disease and coronary artery calcification: Multi-Ethnic Study of Atherosclerosis (MESA). This study pointed out how the "Flying in the fog" 2. March 2008 William Davis (3) I received this wonderful response to The Heart Scan Blog post Hammers and Nails:I am 65 years old. I had a stent inserted in the "widow-maker" artery (80% blockage) a year ago. I had passed out a couple of times (heart rate dangerously low - 30s). I rode to the hospital in an ambulance. Tests revealed short LBBB episodes; mild mitral regurgitation, mild tricuspid regurgitation. Catherization showed 3 vessel CAD. I was told that a medicated stent was absolutely necessary given the situation; regardless, I have to accept that. A pacemaker was installed to prevent bradycardia and keeps heart rate from dropping below 60. I have 20% L distal main blockage and 90% lesion of the high first obtuse marginal at the takeoff. The right coronary had 60% posterior lateral branch stenosis.Since then I have reduced TG from 360 to 60, LDL from 89 to 82 (although a few months ago it was in the mid-70s), and increased HDL from 30 to 46. I went from 265lbs to 190lbs and hope to eventually get to 180lb this Spring. I did it by progressing from walking to trotting (slow run) and dietstyle changes (low-GI veggies, fruits, etc.) .On a recent visit the cardiologist said the the LDL needs to be 70 or below to "freeze" the 90% blockage and gave me a prescription for Lipitor. I asked if there were alternatives, like diet, supplements, etc. He admitted that he did not know about those alternative but did know Lipitor. When the only tool you have is a hammer then everything is a nail. I understand that the 90% blockage is important but will not take the Lipitor to achieve the 12 points reduction. Seems like an overkill.I asked him if there was a way to evaluate my current condition. I was told there was no way. Basically, if I have no symptoms, good. If I have symptoms then it will have to be evaluated. Death could be the only symptom. I swear he was about to say bypass surgery ($$$$$$!) was inevitable. Something is wrong with this "fly-in-the-fog-and-hope-you-don't- hit-a-mountain" approach. Hope is not a strategy!I am confident that I can reduce LDL to below 70 based on eliminating wheat-products in my diet plus increasing oat bran in my diet. I also take fish oil daily (EPA/DHA-2g). I am looking for a new cardiologist. I just recently purchased your book and find it very instructive. In the meantime I have an appointment with my primary care physician to discuss implementing the Track Your Plaque program. I realize that the one stent will skew the scan numbers but can be used as a baseline number.Phenomenal weight loss! That alone has likely cut this man's risk in half. But is that it? Is the cardiologist correct--take Lipitor and hope for the best? Of course not. There are many additional strategies to employ. Eliminating wheat from the diet is an excellent idea: HDL will skyrocket, triglycerides drop even further, small LDL will drop like a stone, blood sugar and blood pressure will drop. He will have more energy, get rid of afternoon energy slumps, sleep better. He has already added fish oil. If his cardiologist did not mention this, I would say he was guilty of malpractice. The data supporting the addition of fish oil to the treatment program of anyone with heart disease is overhwelming. GISSI Prevenzione: 11,000 participants--28% reduction in heart attack, 45% reduction in death from heart attack. The Japanese JELIS trial of 18,645 participants--19% reduction in dangerous heart events. It's also clear that omega-3 fatty acids from fish oil also compound the benefits of statin agents, should this man choose to begin Lipitor. Vitamin D brought to normal blood levels is his next "secret weapon" that will further boost his lipids and lipoproteins further into not just "normal" territory, but beyond belief. Even though we aim for 60-60-60 for LDL-HDL-triglycerides in the Track Your Plaque program, adding vitamin D can yield numbers you've never seen before. It's not uncommon, for instance, to see a 10 or 20 mg/dl jump in HDL. Identify all other hidden causes of coronary plaque. If all the causes have not been fully identified, how can anyone hope to gain full control over coronary plaque growth? Re: LDL cholesterol of 89 mg/dl at the start. Of course, this is a calculated value, not measured. Because HDL was low and triglycerides high at the start of his program, this means that true LDL--if actually measured--was probably more like 180 to 250 mg/dl, and it was probably nearly all small. So his cardiologist might have advised a helpful treatment, though for the wrong reasons. Our reader has gone a long way on his own in creating his own prevention program. But there's yet more to do, particularly if the goal is reversal. It is shocking to me that a man like our reader, clearly articulate and motivated, gets virtually no advice beyond "take Lipitor" after all the procedural benefits have been reaped.Even though one artery can no longer be "scored" due to the presence of the metallic stent, a heart scan would still be invaluable for long-term tracking purposes, just as we advocate in the Track Your Plaque program. Copyright 2008 William Davis, MD Goodbye, Dr. Jarvik 29. February 2008 William Davis (0) HeartWire, the news service of www.theheart.org, posted the following report: Pfizer pulls Lipitor ads featuring Dr Robert Jarvik in HeartWire New York, NY - After a series of questions and attacks over its choice of Dr Robert Jarvik to endorse Lipitor in a series of TV commercials, Pfizer has announced that it is withdrawing the ads. As previously reported by heartwire, Jarvik invented the first artificial heart, but he is not a cardiologist, nor does he hold a medical license—factors that drew criticism from detractors and made him and Pfizer a target of a US House Committee on Energy and Commerce investigation into celebrity endorsements in direct-to-consumer advertisements.In a January 2008 statement, committee chair Rep John D Dingell (D-MI) observed: "Dr Jarvik's appearance in the ads could influence consumers into taking the medical advice of someone who may not be licensed to practice medicine in the United States. Americans with heart disease should make medical decisions based on consultations with their doctors, not on paid advertisements during a commercial break."Complaints about Jarvik went up a notch this month when the latest ad in the series depicted the inventor rowing a racing scull across a lake, despite the fact that Jarvik himself does not row and the commercial used a body double.This is typical pharmaceutical industry sleight-of-hand, now you see it, now you don't, that has come to define their policies. And this is just the stuff that comes to light because of some obvious blunders. We can only begin to imagine what sorts of other shenanigans have been swept under the rug, especially adverse effects of drugs that never made it to the light of publication. Is this just another example of how direct-to-consumer advertising has backfired? I now have patient after patient tell me that they have been so overwhelmed and fed up with TV and magazine ads for drugs that they Other media outlets have reported that Jarvik was guaranteed $1.35 million for the ads and that Pfizer spent $258 million on Lipitor advertisements between January 2006 and September 2007. Hammers and nails 28. February 2008 William Davis (4) I'm sure you've heard the old saying that, To a man with a hammer, everything looks like a nail. It couldn't be truer than in heart procedures (the man with the hammer) and heart disease (the nail). What does it take in 2008 to become an interventional cardiologist trained in all the techniques of angioplasty, stenting, intracoronary ultrasound, etc.? Start with your undergraduate degree (4 years), then medical school (another 4 years), then training in internal medicine (3 years), then general cardiology taining (3 years), then an additional year in interventional cardiology. Each step along the way also involves competing for these spaces, a process that requires much time, money, and sweat. The total time investment is 15 years after high school. Many if not most college students graduate with debt. Pile on the substantial cost of medical school. Training after medical school pays a modest salary, enough for a single person. Many trainees by then have spouses and a family, would like to buy a house, have bills to pay. (I managed to buy my first house for $69,000 in Columbus, Ohio and paid my mortgage by sleeping only every other night and moonlighting on my off nights.) By the time the interventional cardiologist-in-training finishes his/her 15 years, they are hungry for a hefty increase in income. After such a time and money investment, I do believe that there is at least some justification for generous income for the years of work involved. Back to our hammer and nail metaphor. Not only do we now have a man or woman with a hammer, but a really expensive hammer that required a substantial amount of effort to obtain. Now, our hapless hammer-bearer is desperate to see everything in sight as a nail. You're seen in consultation by this fresh interventional cardiologist in practice for only a few years. Guess what he/she advises? Go straight to the catheterization laboratory, of course. Throw in the fact that insurance reimbursement is most generous for heart procedures, far more than for consulting in the office, doing a stress test, or other simpler, non-invasive tests, and the incentives are clear. The system, you see, is set up to follow such a path. The path to the cath lab is heavily incentivized, paths in the other direction discouraged, disparaged, or just ignored. My message: Don't get nailed. What is abnormal? 27. February 2008 William Davis (1) What is abnormal?You'd think that the answer would be easy and straightforward. However, consider these instances of medical findings that I have witnessed fall repeatedly into the "normal" category:Diameter of the thoracic aorta: 4.5 cmMild coronary plaque by heart catheterizationCarotid plaque of 30-50%Why isn't a thoracic aorta (the big artery in your chest) of 4.5 cm normal? Because it can be expected to increase in diameter by about 2.5 mm (0.25 cm) per year. Even at its current diameter, it means that stroke risk is greater, since enlarged aortas are diseased aortas that commonly accumulate atherosclerotic plaque with potential to fragment and shower debris to the brain. It means that high blood pressure and/or cholesterol/lipoprotein abnormalities have been uncorrected for years that have allowed the aorta to enlarge. How about "mild coronary plaque"? Followers of the Track Your Plaque program already know the answer to this one. Mild plaque does not mean mild risk. In fact, most plaques that cause heart attack are mild plaques, not severe blockages. While severe blockages can provide symptom warning and are detected by stress tests, it's the mild blockages that rupture without symptom warning and cause heart attack. So "mild coronary plaque" is no less dangerous than severe coronary plaque. Likewise, carotid plaque of 30-50%, while it doesn't justify surgery, can grow within just a few years to a severity that allows it to fragment and shower debris to the brain, i.e., a stroke. As with the enlarged aorta, it means that multiple causes of carotid plaque are likely active, including high blood pressure and cholesterol or lipoprotein abnormalities. Then why would any of these findings be labeled "normal"? Simple. In the minds of many physicians, if a condition doesn't pose immediate risk, or if it doesn't qualify for surgical "correction," then it is labeled "normal" or "mild." Thus, an aorta of 4.5 cm cannot justify surgical replacement until it achieves a diameter of 5.5 cm. It is therefore labeled "normal.""Mild coronary plaque" does not justify insertion of stents or performance of bypass surgery. It must therefore be "normal."Carotid plaque over 70% is surgically removed, but not 30-50%. 30-50% is therefore "normal." The tragedy is that many "normal" or "mild" findings, if cast in the proper light, could lead to corrective strategies that could prevent danger long-term or keep surgery from becoming necessary. The enlarged aorta, for instance, could be stopped and an aneurysm (defined as 5.5 cm or greater) could be prevented, along with dramatically reducing risk for stroke. Carotid plaque, more so than coronary plaque, is a controllable and manipulable condition that should trigger a program of prevention and reversal. Instead, it usually generates advice to have another ultrasound in a year to see if it has yet achieved severity sufficient to justify surgery. Of course, "mild coronary plaque" is the reason for the Track Your Plaque approach, a chance to seize control over this disease years or decades before procedures are necessary and reduce danger now, not years from now.Copyright 2008 William Davis, MD Niacin and hydration 27. February 2008 William Davis (12) Many people know about niacin's curious effect of the "hot flush," a feeling of warmth that covers the chest and neck, occasionally the entire body. However, many people are unaware of the fact that hydration can block this effect. In fact, many people who were not advised of this will come to the office describing miserable experiences with niacin--hot flushes that last for hours, intolerable itching, etc.--only to experience little or none of these effects with generous hydration. The vast majority of the time, two 8-12 oz glasses of water when the hot flush occurs will eliminate the flush within a few minutes. Sometimes, the hot flush will occur many hours after taking niacin. Nine times out of ten, this delayed effect is also due to poor hydration. For instance, you might be engrossed in your work and forget to keep up with fluid demands. Or, it may be warm and you've lost fluids through sweating. That's when you begin to feel the hot flush creep up on you. The cure: Lots of water. In this situation, in which you have allowed dehydration to develop, it may require more than two big glasses. Relief from the flush may also take more time, but it still works nearly every time. On those rare occasions when water by itself is insufficient, then an adult (325 mg), uncoated aspirin or 200 mg ibuprofen can also be used to accelerate relief. Why go to some much bother? Well, niacin remains the best agent we have for reduction of small LDL, raising HDL (although vitamin D is proving to be a powerful competitor in this arena), and reducing lipoprotein(a). How much do statin drugs contribute to these effects? Very little, if at all. Several drug manufacturers are also working on "antidotes" to the hot flush effect of niacin that will be packaged within the niacin tablet. Naturally, it will also boost the cost up many times higher. In the meantime, if or when you experience the niacin hot flush, just think: Put out the "fire" with plenty of water. << Older posts Newer posts >> Newer posts12...656667686970717273...123124Older posts rch has been devoted to understanding the changes in metabolism as we age. Do we still produce everything as efficiently as when we were 20? I suspect not. So, I think we need a little help, and supplements are a key to getting there. Two nutrients that I think are emerging as “super nutrients” are the fatty acids found in fish oil (EPA and DHA) and vitamin D. Where we know these two nutrients are essential for life, we are seeing that they play a huge role in the QUALITY of life. Mood, depression, PMS, wound healing, bone growth, atherosclerosis, and arthritis are clinical areas where we see a direct benefit with doses of omega-3 and Vitamin D that are probably much greater than the RDA. Our current requirements for nutrients are really based on fixing deficiencies and not maximizing health, and maximizing health is where I’m at. Thus, I am very interested molecules like CLA as mentioned above, and other bioactive ingredients such as plant derived ingredients (phytochemicals) called flavonoids that may well help explain why people who have diets high in fruits and vegetables are less likely to have certain cancers and heart disease. Reducing oxidative stress through foods that provide these active molecules (think colored fruits and veggies) is a new and exciting area of research. TYP:The big "diet experiment" in America has clearly steered people in the wrong direction, usually by 50 or more pounds. As a scientist in nutrition, what are your thoughts? Dr. Rockway: The American Heart Association was keen 20 years ago to promote the low-fat diet for all Americans as the key way to reduce cholesterol levels and decrease chance of heart disease, the number one killer of men and women. However, I must admit the nutritional community bought into this one, too. Unfortunately, the general public took this message to reduce percent fat in their diet (and they did a bit), but increased overall calories instead—and a large portion of the increased calories was from simple carbohydrates. I’m convinced that this in itself has been part of the huge rise in obesity…we simply eat more food and it’s not the healthy kind of food either.When you increase sugar intake beyond what you burn off, you will store some of it as glycogen in the liver and muscles, but you will convert most of the excess into fat—and that we can store very efficiently! The fat that is made in the liver is sent to the blood as VLDL’s which are the precursor to the class of lipids called low density lipoproteins (LDL) that are the “lethal” type of cholesterol circulating in our blood. So, Americans now have to listen to a new message that they need to eat more fruits and vegetables in hopes they will cut down on fast foods—tending to be high in fat (saturated particularly), low in fiber and low in nutrients and other high calorie dense foods. We nutritionists have our work cut out for us, that’s for sure. TYP: We are especially excited that nutritionists are assuming a leading role in shining light on the confusion in diet and nutrition that has characterized the last 40 years. Do you have a sense for the emerging important issues for the next 10 years? Dr. Rockway: Certainly, the scientists in the nutritional field are well aware of the problems facing this nation—it’s in fixing them that we fall short! We aren’t very well coordinated to get a single message out, nor do we all agree on what that message should be. I feel that people need to eat healthy MOST OF THE TIME, exercise all of the time, and take supplements that have clear evidence of benefit. Lots of my colleagues would not concur with supplement use. Our bodies were designed to move a lot and eat a lot…we just do the latter now and are paying the price!One emerging and very exciting area that we have to teach Americans is that all fat is not bad. The different types of fat—omega-6 vs. omega-3, are where we need to focus our education. Decreasing the corn oil we pour on everything needs to go out the window! Consume olive oil and eat fish or take fish oil supplements—we simply have tons and tons of research showing the benefits of reducing the ratio of omega-6 to omega-3. Did you know that cattle that are grass fed actually have less omega-6 in their tissues and more CLA? But most cattle are fed corn-based diets, so we have perturbed their natural selection of food and their fat composition. See, it all comes back to CLA!TYP: Thanks, Susie! Susie Rockway, Ph.D., C.N.S.Dr. Susie Rockway is an experienced scientist with accomplishments in both the academic and food and supplement industry business directing science/technology research. Her background includes faculty appointments at the graduate level in teaching and research at Rush University Medical Center and industrial experience managing basic and applied research studies. Dr. Rockway received her Ph.D. in Nutritional Sciences, Biochemistry from the University of Arizona. Dr. Rockway has authored several publications in journals such as the Physiological Genomics, Journal of Nutrition, the Journal of Food Science, International Archives of Occupational and Environmental Health and has published chapters on nutrition on inflammatory bowel diseases. She is a member of the American Society for Nutrition, American Oil Chemists Society, the Institute of Food Technology, American College of Nutrition and is a Certified Nutrition Specialist.We're also proud to add Dr. Rockway to our panel of Track Your Plaque Experts.
NY Times Jane Brody misses the mark 9. October 2007 William Davis (6) NY Times' health columnist, Jane Brody, recently wrote a bit of fluff for her paper: "CT Scans of the Heart Come With Trade-Offs In her report, she says:Coronary CT scans are being sold directly to the public, and they have found a market in health-conscious people who can afford them. But screening exams can have downsides. They can cause needless worry, and they sometimes reveal other potential conditions that require invasive procedures like biopsies to diagnose.I soon learned that among the strongest proponents of CT scans of coronary arteries were physicians with financial ties to drug companies that make statins and others connected to imaging centers that would profit directly from widespread CT screenings.She then goes on to discuss how the Framingham scoring calculation can tell you whether or not you are at low-, intermediate-, or high-risk for heart disease. She therefore concludes that heart scans are therefore irrelevant for the majority of people. She then proceeds to take a statin agent. This sort of nonsense continues to get published, despite the clear lack of real "digging" for the truth. She clearly fell for the conventional arguments that continue to mis-guide the majority of people, myths like: --the Framingham scoring system is reliable--Reliable it is NOT; it is susceptible to substantial "misclassification" bias, meaning people who appear low risk can actually be high risk, and people at high risk can actually be low risk. Among the latest studies that question the scoring system is Family history of premature coronary heart disease and coronary artery calcification: Multi-Ethnic Study of Atherosclerosis (MESA). This study pointed out how the "Flying in the fog" 2. March 2008 William Davis (3) I received this wonderful response to The Heart Scan Blog post Hammers and Nails:I am 65 years old. I had a stent inserted in the "widow-maker" artery (80% blockage) a year ago. I had passed out a couple of times (heart rate dangerously low - 30s). I rode to the hospital in an ambulance. Tests revealed short LBBB episodes; mild mitral regurgitation, mild tricuspid regurgitation. Catherization showed 3 vessel CAD. I was told that a medicated stent was absolutely necessary given the situation; regardless, I have to accept that. A pacemaker was installed to prevent bradycardia and keeps heart rate from dropping below 60. I have 20% L distal main blockage and 90% lesion of the high first obtuse marginal at the takeoff. The right coronary had 60% posterior lateral branch stenosis.Since then I have reduced TG from 360 to 60, LDL from 89 to 82 (although a few months ago it was in the mid-70s), and increased HDL from 30 to 46. I went from 265lbs to 190lbs and hope to eventually get to 180lb this Spring. I did it by progressing from walking to trotting (slow run) and dietstyle changes (low-GI veggies, fruits, etc.) .On a recent visit the cardiologist said the the LDL needs to be 70 or below to "freeze" the 90% blockage and gave me a prescription for Lipitor. I asked if there were alternatives, like diet, supplements, etc. He admitted that he did not know about those alternative but did know Lipitor. When the only tool you have is a hammer then everything is a nail. I understand that the 90% blockage is important but will not take the Lipitor to achieve the 12 points reduction. Seems like an overkill.I asked him if there was a way to evaluate my current condition. I was told there was no way. Basically, if I have no symptoms, good. If I have symptoms then it will have to be evaluated. Death could be the only symptom. I swear he was about to say bypass surgery ($$$$$$!) was inevitable. Something is wrong with this "fly-in-the-fog-and-hope-you-don't- hit-a-mountain" approach. Hope is not a strategy!I am confident that I can reduce LDL to below 70 based on eliminating wheat-products in my diet plus increasing oat bran in my diet. I also take fish oil daily (EPA/DHA-2g). I am looking for a new cardiologist. I just recently purchased your book and find it very instructive. In the meantime I have an appointment with my primary care physician to discuss implementing the Track Your Plaque program. I realize that the one stent will skew the scan numbers but can be used as a baseline number.Phenomenal weight loss! That alone has likely cut this man's risk in half. But is that it? Is the cardiologist correct--take Lipitor and hope for the best? Of course not. There are many additional strategies to employ. Eliminating wheat from the diet is an excellent idea: HDL will skyrocket, triglycerides drop even further, small LDL will drop like a stone, blood sugar and blood pressure will drop. He will have more energy, get rid of afternoon energy slumps, sleep better. He has already added fish oil. If his cardiologist did not mention this, I would say he was guilty of malpractice. The data supporting the addition of fish oil to the treatment program of anyone with heart disease is overhwelming. GISSI Prevenzione: 11,000 participants--28% reduction in heart attack, 45% reduction in death from heart attack. The Japanese JELIS trial of 18,645 participants--19% reduction in dangerous heart events. It's also clear that omega-3 fatty acids from fish oil also compound the benefits of statin agents, should this man choose to begin Lipitor. Vitamin D brought to normal blood levels is his next "secret weapon" that will further boost his lipids and lipoproteins further into not just "normal" territory, but beyond belief. Even though we aim for 60-60-60 for LDL-HDL-triglycerides in the Track Your Plaque program, adding vitamin D can yield numbers you've never seen before. It's not uncommon, for instance, to see a 10 or 20 mg/dl jump in HDL. Identify all other hidden causes of coronary plaque. If all the causes have not been fully identified, how can anyone hope to gain full control over coronary plaque growth? Re: LDL cholesterol of 89 mg/dl at the start. Of course, this is a calculated value, not measured. Because HDL was low and triglycerides high at the start of his program, this means that true LDL--if actually measured--was probably more like 180 to 250 mg/dl, and it was probably nearly all small. So his cardiologist might have advised a helpful treatment, though for the wrong reasons. Our reader has gone a long way on his own in creating his own prevention program. But there's yet more to do, particularly if the goal is reversal. It is shocking to me that a man like our reader, clearly articulate and motivated, gets virtually no advice beyond "take Lipitor" after all the procedural benefits have been reaped.Even though one artery can no longer be "scored" due to the presence of the metallic stent, a heart scan would still be invaluable for long-term tracking purposes, just as we advocate in the Track Your Plaque program. Copyright 2008 William Davis, MD
Goodbye, Dr. Jarvik 29. February 2008 William Davis (0) HeartWire, the news service of www.theheart.org, posted the following report: Pfizer pulls Lipitor ads featuring Dr Robert Jarvik in HeartWire New York, NY - After a series of questions and attacks over its choice of Dr Robert Jarvik to endorse Lipitor in a series of TV commercials, Pfizer has announced that it is withdrawing the ads. As previously reported by heartwire, Jarvik invented the first artificial heart, but he is not a cardiologist, nor does he hold a medical license—factors that drew criticism from detractors and made him and Pfizer a target of a US House Committee on Energy and Commerce investigation into celebrity endorsements in direct-to-consumer advertisements.In a January 2008 statement, committee chair Rep John D Dingell (D-MI) observed: "Dr Jarvik's appearance in the ads could influence consumers into taking the medical advice of someone who may not be licensed to practice medicine in the United States. Americans with heart disease should make medical decisions based on consultations with their doctors, not on paid advertisements during a commercial break."Complaints about Jarvik went up a notch this month when the latest ad in the series depicted the inventor rowing a racing scull across a lake, despite the fact that Jarvik himself does not row and the commercial used a body double.This is typical pharmaceutical industry sleight-of-hand, now you see it, now you don't, that has come to define their policies. And this is just the stuff that comes to light because of some obvious blunders. We can only begin to imagine what sorts of other shenanigans have been swept under the rug, especially adverse effects of drugs that never made it to the light of publication. Is this just another example of how direct-to-consumer advertising has backfired? I now have patient after patient tell me that they have been so overwhelmed and fed up with TV and magazine ads for drugs that they Other media outlets have reported that Jarvik was guaranteed $1.35 million for the ads and that Pfizer spent $258 million on Lipitor advertisements between January 2006 and September 2007.
Hammers and nails 28. February 2008 William Davis (4) I'm sure you've heard the old saying that, To a man with a hammer, everything looks like a nail. It couldn't be truer than in heart procedures (the man with the hammer) and heart disease (the nail). What does it take in 2008 to become an interventional cardiologist trained in all the techniques of angioplasty, stenting, intracoronary ultrasound, etc.? Start with your undergraduate degree (4 years), then medical school (another 4 years), then training in internal medicine (3 years), then general cardiology taining (3 years), then an additional year in interventional cardiology. Each step along the way also involves competing for these spaces, a process that requires much time, money, and sweat. The total time investment is 15 years after high school. Many if not most college students graduate with debt. Pile on the substantial cost of medical school. Training after medical school pays a modest salary, enough for a single person. Many trainees by then have spouses and a family, would like to buy a house, have bills to pay. (I managed to buy my first house for $69,000 in Columbus, Ohio and paid my mortgage by sleeping only every other night and moonlighting on my off nights.) By the time the interventional cardiologist-in-training finishes his/her 15 years, they are hungry for a hefty increase in income. After such a time and money investment, I do believe that there is at least some justification for generous income for the years of work involved. Back to our hammer and nail metaphor. Not only do we now have a man or woman with a hammer, but a really expensive hammer that required a substantial amount of effort to obtain. Now, our hapless hammer-bearer is desperate to see everything in sight as a nail. You're seen in consultation by this fresh interventional cardiologist in practice for only a few years. Guess what he/she advises? Go straight to the catheterization laboratory, of course. Throw in the fact that insurance reimbursement is most generous for heart procedures, far more than for consulting in the office, doing a stress test, or other simpler, non-invasive tests, and the incentives are clear. The system, you see, is set up to follow such a path. The path to the cath lab is heavily incentivized, paths in the other direction discouraged, disparaged, or just ignored. My message: Don't get nailed.
What is abnormal? 27. February 2008 William Davis (1) What is abnormal?You'd think that the answer would be easy and straightforward. However, consider these instances of medical findings that I have witnessed fall repeatedly into the "normal" category:Diameter of the thoracic aorta: 4.5 cmMild coronary plaque by heart catheterizationCarotid plaque of 30-50%Why isn't a thoracic aorta (the big artery in your chest) of 4.5 cm normal? Because it can be expected to increase in diameter by about 2.5 mm (0.25 cm) per year. Even at its current diameter, it means that stroke risk is greater, since enlarged aortas are diseased aortas that commonly accumulate atherosclerotic plaque with potential to fragment and shower debris to the brain. It means that high blood pressure and/or cholesterol/lipoprotein abnormalities have been uncorrected for years that have allowed the aorta to enlarge. How about "mild coronary plaque"? Followers of the Track Your Plaque program already know the answer to this one. Mild plaque does not mean mild risk. In fact, most plaques that cause heart attack are mild plaques, not severe blockages. While severe blockages can provide symptom warning and are detected by stress tests, it's the mild blockages that rupture without symptom warning and cause heart attack. So "mild coronary plaque" is no less dangerous than severe coronary plaque. Likewise, carotid plaque of 30-50%, while it doesn't justify surgery, can grow within just a few years to a severity that allows it to fragment and shower debris to the brain, i.e., a stroke. As with the enlarged aorta, it means that multiple causes of carotid plaque are likely active, including high blood pressure and cholesterol or lipoprotein abnormalities. Then why would any of these findings be labeled "normal"? Simple. In the minds of many physicians, if a condition doesn't pose immediate risk, or if it doesn't qualify for surgical "correction," then it is labeled "normal" or "mild." Thus, an aorta of 4.5 cm cannot justify surgical replacement until it achieves a diameter of 5.5 cm. It is therefore labeled "normal.""Mild coronary plaque" does not justify insertion of stents or performance of bypass surgery. It must therefore be "normal."Carotid plaque over 70% is surgically removed, but not 30-50%. 30-50% is therefore "normal." The tragedy is that many "normal" or "mild" findings, if cast in the proper light, could lead to corrective strategies that could prevent danger long-term or keep surgery from becoming necessary. The enlarged aorta, for instance, could be stopped and an aneurysm (defined as 5.5 cm or greater) could be prevented, along with dramatically reducing risk for stroke. Carotid plaque, more so than coronary plaque, is a controllable and manipulable condition that should trigger a program of prevention and reversal. Instead, it usually generates advice to have another ultrasound in a year to see if it has yet achieved severity sufficient to justify surgery. Of course, "mild coronary plaque" is the reason for the Track Your Plaque approach, a chance to seize control over this disease years or decades before procedures are necessary and reduce danger now, not years from now.Copyright 2008 William Davis, MD
Niacin and hydration 27. February 2008 William Davis (12) Many people know about niacin's curious effect of the "hot flush," a feeling of warmth that covers the chest and neck, occasionally the entire body. However, many people are unaware of the fact that hydration can block this effect. In fact, many people who were not advised of this will come to the office describing miserable experiences with niacin--hot flushes that last for hours, intolerable itching, etc.--only to experience little or none of these effects with generous hydration. The vast majority of the time, two 8-12 oz glasses of water when the hot flush occurs will eliminate the flush within a few minutes. Sometimes, the hot flush will occur many hours after taking niacin. Nine times out of ten, this delayed effect is also due to poor hydration. For instance, you might be engrossed in your work and forget to keep up with fluid demands. Or, it may be warm and you've lost fluids through sweating. That's when you begin to feel the hot flush creep up on you. The cure: Lots of water. In this situation, in which you have allowed dehydration to develop, it may require more than two big glasses. Relief from the flush may also take more time, but it still works nearly every time. On those rare occasions when water by itself is insufficient, then an adult (325 mg), uncoated aspirin or 200 mg ibuprofen can also be used to accelerate relief. Why go to some much bother? Well, niacin remains the best agent we have for reduction of small LDL, raising HDL (although vitamin D is proving to be a powerful competitor in this arena), and reducing lipoprotein(a). How much do statin drugs contribute to these effects? Very little, if at all. Several drug manufacturers are also working on "antidotes" to the hot flush effect of niacin that will be packaged within the niacin tablet. Naturally, it will also boost the cost up many times higher. In the meantime, if or when you experience the niacin hot flush, just think: Put out the "fire" with plenty of water.
Which is better? 4. October 2007 William Davis (12) If you have the common pattern of high LDL particle number (NMR) with small LDL--a pattern highly related to coronary plaque--which is better:Lipitor or a combination of fish oil, vitamin D, and elimination of wheat? Lipitor quite effectively reduces LDL particle number, usually on the order of 40% or so. Effect on LDL particle size: None. Side-effects: plenty, including muscle aches (inevitable in my experience, not the ridiculous 2% they claim) and occasionally mental effects such as impaired short-term memory.Lipitor does seem to exert a modest effect on reduction of C-reactive protein, around 30%. It also reduces cardiovascular events by 30%. A combination of fish oil, vitamin D, and elimination of wheat: Reduces LDL particle number commonly by a similar 40% (though variable, depending on body weight). There is substantial improvement in LDL particle size, a large drop in C-reactive protein, often >50%, a 30% or more reduction in cardiovacular events. On this combination, however, you also:--Lose weight, often substantially. --Improve bone health, esp. osteoporosis and arthritis. --Reduce cancer risk from the vit D supplementation. --Reduce risk of stroke. --Reduce postprandial (after-eating) abnormalities like intermediate-density lipoprotein.--Reduce winter blues. --Experience more energy. --Obtain increased clarity of thought (from elimination of wheat). --Reduce blood pressure. Oh, and there's no muscle aches.
Heart health for stupid people 4. October 2007 William Davis (3) I'm kidding.What I'm referring to is the incredibly lame information I come across that passes as "heart health" on the internet, magazines, and other media. Just to keep abreast of what is being said, I subscribe to multiple newsletters and magazines and I witness the sorts of advice offered to the reading public. A recent long-winded article on a popular website listed the "exciting" strategies available for a healthy heart:Eat healthy--by eating a "balanced" diet low in saturated fatDon't smokeExerciseDon't ignore chest pain symptoms or breathlessnessKnow your numbers! meaning your cholesterol numbers. "If your cholesterol is high, you may need to speak to your doctor about medication to reduce it."Surely they must all believe we're stupid. Otherwise, why would they repeat the same obvious information over and over again? Quit smoking? Gee, you think so?How about some real heart healthy advice:Get a heart scan--since we have to accept that cholesterol values are a miserable failure in detecting hidden heart disease. So is waiting for symptoms to appear.If you have any measure of coronary plaque, ask your doctor to assess lipoproteins, not lipids (cholesterol).Take fish oil for omega-3 fatty acids--At a dose of 1000 mg or more of EPA + DHA, heart attack risk is reduced by at least 28%.Eliminate wheat and other processed carbohydrates --Small LDL has emerged as the number one cause of coronary plaque, not high cholesterol from saturated fat.Get vitamin D assessed--The effects are huge--HUGE. There's already a study in a kidney disease population that showed a substantial reduction in mortality with vitamin D supplementation. More data are coming, including our own.That's a start--truly effective, practical heart healthy strategies that go way beyond the conventional bland advice. Copyright 2007 William Davis, MD
Money, money, money, money 3. October 2007 William Davis (3) I've been asked the question numerous times:Why aren't heart scans more popular? First, let me qualify by saying that heart scan have indeed grown in popularity over the past decade. I think the real question is: Given the enormous usefulness of CT heart scanning to detect hidden, asymptomatic coronary atherosclerotic plaque, why haven't they more readily been incorporated into conventional medical practice? That's easy: There's no money in it.Say, for instance, your doctor orders a heart scan and somehow receives a $1000 for the test. Scan centers would be scanning 100 people a day, falling over themselves to do scans. This would be similar to a heart catheterization. Order a catheterization, do 30 minutes of work, and get $1000. Or, order a nuclear stress test. Depending on how its done and where, $1800-4000 is paid by the insurer. Order a CT heart scan and how much is paid to the doctor? Usually nothing. At most, a nominal fee might be paid if the doctor reads the scan. With heart scans, there simply is no big payoff. We learned the implications of this situation 10 years ago when I was trying to help my friend, Steve Burlingame, the owner of Milwaukee Heart Scan. (I am NOT and NEVER WAS an owner.) Steve was trying to let everybody know about this great new $2 million dollar heart scan device in the Milwaukee area. The first few years were tough for Steve: Carrying the substantial expense of this device while doctors essentially gave the technology the cold shoulder. It simply did not fit into the financial equation. Why change the way things were, particularly when there was virtually no financial reason to do so? To counter this, Milwaukee Heart Scan followed the model many other scan centers have followed and marketed directly to the public.I see this as yet another example of why people need to take control of health care away from doctors and hospitals, the current controllers of the system who are providing a disservice to the public they are supposed to be serving. These institutions, for the most part, serve their self-serving financial interests, not your health interests. It's the same equation that drives food manufacturers to make more and more processed carbohydrate foods that they sell for substantial markups, not green peppers and cucumbers that make little money. I regard heart scans as among the greatest self-empowering tools in health ever conceived. It was that way in 1997; it remains that way in 2007.
The many faces of LDL 3. October 2007 William Davis (13) Ginnie came in for an opinion about her heart scan score of 393. At age 57, this put her in the 99th percentile, a high score.As usual, we did a lipoprotein analysis by NMR (Liposcience). Some numbers:LDL cholesterol: 96 mg/dlThis value puts Ginnie's LDL in the most favorable 25% in the country.LDL particle number: 2140 nmol/lThis value is in the worst 25% of the country and is the equivalent of an LDL cholesterol of 214 mg/dl (take off the zero).In addition, over 90% of Ginnie's LDL particles fell into the small class.Had we run some other values, how would they have turned out? These are my estimates (since we didn't actually run them in Ginnie), but having run side-by-side numbers in past, reasonable estimates would have put:Apoprotein B somewhere in the 120 to 140 mg/dl rangeDirect LDL 100-130 mg/dl range.In other words, conventional calculated LDL is the least reliable of all the ways of examining low-density lipoprotein.It can also go the other way: High calculated LDL, low LDL particle number or ApoB or direct LDL. And, indeed, these other measures have proven superior in their ability to predict "events" like heart attack over conventional calculated LDL.Unfortunately, relying on conventional LDL is like a broken speedometer on your car. You really can't gauge accurately how fast you're going; sometimes you could be way off. While insurance companies and many physicians still continue to balk at this argument, the data have already been generated that show that lipoprotein analysis (my bias is NMR) is not just superior, but enormously superior for accuracy and event prediction.In addition, lipoprotein analysis has proven a crucial tool that accounts for our extraordinary success in reducing and controlling CT heart scan scores in the Track Your Plaque program. I doubt that we could have achieved the same level of success using conventional lipids.I'm also aware of the logistical difficulties obtaining lipoprotein testing in a world enthusiastically supportive of hospital procedures and smugly ignorant of superior prevention tools like lipoprotein analysis. I've learned just how difficult it can be in our Track Your Plaque Member Forum; I've also learned about some strategies for obtaining these tests that I hadn't been aware of, thanks to the resourcefulness of our Members.We will be working on some solutions in the coming months.Copyright 2007 William Davis, MD
What does "Success" mean in the Track Your Plaque program? 2. October 2007 William Davis (11) Say you begin with a CT heart scan score of 400. You correct your lipoprotein pattterns, take fish oil, correct 25-OH-vitamin D3 to 50 ng/ml, correct your other hidden patterns, follow a diet suited to your patterns. One year later, you get another heart scan. What score would constitute "success"?With all of our recent talk about record-setting reductions in heart scan scores, is it really necessary to drop your score that much to succeed? For instance, is our latest record-setting 63% drop in score better than "only" a 10% drop in score? Both represent reversal of coronary plaque. Both signify huge reductions in risk for plaque rupture, or heart attack. You can read about how we view the various forms of success in the program by reading our latest Track Your Plaque Special Report, Winning Your Personal War with Heart Disease: The Track Your Plaque 5 Stages of Success. We are making the Report available to everyone. Just go to the www.cureality.com homepage.