Lipoprotein(a) Research Foundation 16. April 2008 William Davis (18) There is no longer any doubt that lipoprotein(a) is a major causal factor in heart disease: Meta-analysis (combined re-analysis) of 27 prospective studies:Danesh J et al. Lipoprotein(a) and Coronary Heart Disease: Meta-Analysis of Prospective Studies Lp(a) and "subclinical" atherosclerosisBrown SA et al. The relation of lipoprotein[a] concentrations and apolipoprotein[a] phenotypes with asymptomatic atherosclerosis in subjects of the Atherosclerosis Risk in Communities (ARIC) Study.Lp(a) and oxidized LDL Tsimikas S et al. Oxidized phospholipids, Lp(a) lipoprotein, and coronary artery disease.Lp(a) predicts peripheral vascular diseaseValentine RJ et al. Lp(a) lipoprotein is an independent, discriminating risk factor for premature peripheral atherosclerosis among white men.Peltier M et al.Elevated serum lipoprotein(a) level is an independent marker of severity of thoracic aortic atherosclerosis.Lp(a) across various populationsGambhir JK et al. Association between lipoprotein(a) levels, apo(a) isoforms and family history of premature CAD in young Asian Indians.Weber M et al. Metabolic factors clustering, lipoprotein cholesterol, apolipoprotein B, lipoprotein (a) and apolipoprotein E phenotypes in premature coronary artery disease in French Canadians.Lp(a) and stroke riskJurgens G et al. Lipoprotein(a) serum concentration and apolipoprotein(a) phenotype correlate with severity and presence of ischemic cerebrovascular disease. Willeit J et al. Lipoprotein(a) and asymptomatic carotid artery disease. Evidence of a prominent role in the evolution of advanced carotid plaques: the Bruneck Study.From just about any direction, Lp(a) has been conclusively associated with atherosclerotic disease. We have more than enough data proving association. But there are two areas of desperate need: 1) Data on effective treatments.2) Raising awareness of this widely unknown (among the public) and ignored (among health professionals) genetic condition. Treatment remains a real struggle. In a recent detailed Track Your Plaque Special Report, Unique Treatment Strategies for Lipoprotein(a) Reduction, we summarized the treatment approaches that have some power to reduce Lp(a) and/or its potential for causing heart disease. But, even armed with an appreciation for the world's scientific literature on this genetic condition, full control remains difficult for many people.Track Your Plaque's HeartHawk has Lp(a) and he has struggled with this pattern for the last several years. He details some of his thoughts in a recent blog post. More research and clinical studies are required and we need it soon if we hope to gain better control over this genetic pattern that affects up to 20% of people with coronary or vascular disease. Much of the needed research is sophisticated, background work similar to that being done by Dr. Santico Marcovina at University of Washington, Dr. Angelo Scanu at the University of Chicago, and Dr. Sally McCormick in New Zealand. However, much of the needed research also consists of brief clinical experiences that detail whether or not there is an effect of various potential agents. Larger experiences, for instance, with potential treatment agents such as various phospholipid fractions, acetylcysteine, antibiotic regimens, some hormonal treatments, etc. could be performed quickly and simply. These studies would not require the $20 or $30 million typically spent by a drug company for a study, nor the several hundred million dollars to gain FDA approval of a new agent. They would simply be examinations of existing agents. These studies still cost money, require expertise, staff, and equipment. But the cost is a tiny fraction of the drug industry's investment in research. But it also means that investment return is nil from a drug manufacturer's perspective. Yet there are literally dozens, perhaps hundreds, of agents that hold some promise but have not been thoroughly studied. For instance, if a specific modification of the phosphatidylcholine molecule were to generate a substantial Lp(a) reducing effect, Merck, Pfizer, and AstraZeneca would yawn--it is non-patent protectable, cannot be protected from competitors through the costly FDA approval process, and therefore is simply not worth their investment--regardless of whether it works or not.(This is yet another example of how the drug industry, as well as hospitals and many health professionals, have lost sight of their real mission: to alleviate disease, not to profit from sickness.) HeartHawk and I have discussed on a number of occasions whether a Lipoprotein(a) Research Foundation should be formed, an organization that seeks to fund the smaller research efforts that may accelerate productive research in Lp(a) and perhaps yield useful strategies faster than hoping for somebody to simply stumble on a treatment, or wait for the drug industry to create a unique, patentable entity that returns billions. I'd like to propose that our Track Your Plaque program begin to fund such an effort. But a lot more help will be needed, particularly to generate the money to fund genuine, high-quality research from high-quality researchers. If any readers of the Heart Scan Blog have any thoughts or insights into this process of creating a foundation, we'd appreciate your input.
More on ASTEROID 16. April 2008 William Davis (3) Since we are on the topic of the ASTEROID trial and rosuvastatin, I'd make one more point before I start to sound like I'm plugging this drug (which I definitely am not).In an informative Roundtable Discussion (open to subscribers to the American Journal of Cardiology; sorry) amongst Dr. Steve Nissen, principal investigator behind ASTEROID; and Drs. Vincent Friedewald, Christie Ballantyne, P. Shah, and William Roberts, Dr. Nissen made some interesting comments:Dr. Shah: In ASTEROID, was the magnitude of atheroma volume change seen across different levels of LDL-C and HDL-C?Dr. Nissen: No. There was no plaque regression seen in the 17 persons with LDL-Cs >/= 100 mg/dl, and there was little change in persons with LDL-Cs of 70 to 100 mg/dl. Only in persons with LDLs less than or equal to 70 mg/dl was there significant regression. The study was not powered to look for an HDL-C(which increased by 14.7%)-raising effect. Interesting. In other words, ASTEROID, in a fairly internally consistent way, suggests that the lower the LDL is reduced, the more likely plaque regression is obtained. This is consistent with the Track Your Plaque experience, in which we've advocated reducing (calculated) LDL cholesterol to 60 mg/dl for the past several years. Unfortunately, the message that the ASTEROID Trial sponsors, AstraZeneca, as well as the roundtable discussion panel (later in the discussion) try to make is that there is something magical about Crestor, that it yields benefits superior to other statin agents or other means of reducing LDL. I disagree with this message. In the Track Your Plaque experience, we do aim for a similar LDL target. But we also employ a number of other strategies. We have also succeeded in regressing plaque without use of any statin drugs (though, admittedly, many people do require statin drugs to obtain LDLs in this range). We also witness magnitudes of reversal that often far exceed that seen in ASTEROID. The Rountable Discussion is unfortunately tainted, as is the ASTEROID Trial itself, with deep drug industry financial involvement of the Roundtable participants. In fact, the discussion begins with a listing of the financial disclosures of the participants, a listing that occupies a full column of a two-column page. The potential biases of the participants doesn't necessarily invalidate the arguments, but to me suggests that participants are more likely to argue in favor of the sponsor's drug, or that participants were chosen because of these biases. Why bother to even mention the ASTEROID Trial in a venue (the Heart Scan Blog, that is) that purports to seek unvarnished, unbiased truth in coronary plaque reversal? Because useful information can sometimes be found in unlikely places. Just like the four-year old child who blurts out an unexpected pearl of wisdom, so it can happen with the gobbledy-gook that emerges from the drug industry. Every once in a while, they are worth paying attention to.
LDL cholesterol, statins, and plaque regression 13. April 2008 William Davis (12) The ASTEROID Trial reported in 2006 examined the effects of LDL cholesterol reduction using the statin drug, rosuvastatin (Crestor), with coronary atherosclerosis quantified and tracked with intracoronary ultrasound. The Track Your Plaque report, New study confirms: LDL of 60 mg reverses plaque, on the ASTEROID Trial provides commentary on the results. Though I remain skeptical that a statin-only treatment strategy can reverse coronary plaque in the majority of people, I do believe that the AstraZeneca-sponsored ASTEROID Trial does add to the wisdom on heart disease management. More importantly, it has served to raise awareness among both the public and my physician colleagues that atherosclerosis is indeed a potentially reversible condition.Specifically, the ASTEROID results confirm that, either directly or indirectly, LDL cholesterol reduction achieved with statin agents does correspond to increasing degrees of plaque reversal. The mean (calculated) LDL cholesterol achieved in ASTEROID was 60 mg/dl, the same as the Track Your Plaque suggested LDL target. Though the ASTEROID Trial is not news, I stumbled on a chart posted on the ASTEROID Trial website that clearly highlights how a number of other studies beyond ASTEROID have fallen into this pattern: The graph reveals a linear relationship: The greater the reduction in LDL cholesterol with statin drugs, the greater the plaque regression ("change in percent atheroma volume"). (Several other studies not included in the graph also cluster into the same linear relationship.) I am no supporter of drug companies, nor a defender of their policies and practices. But I do believe that their data can serve to teach us a few lessons. For instance, here is an (cherry-picked, to be sure) example of intracoronary ultrasound cross-sectional images before and after two years of rosuvastatin, 40 mg daily: The color-coded/outlined atherosclerotic coronary plaque is shown shrinking, while the "lumen," or the path for blood to flow, enlarges. The reduction in coronary plaque is irrefutable. (The small circle within the lumen with the white halo surrounding it is the ultrasound catheter.) If you and I were to choose a single treatment approach to coronary disease reversal, then 40 mg of rosuvastatin is probably at the top of the list. However, in the Track Your Plaque program, we do not advocate a single treatment strategy. While the Crestor-only approach is relatively straightforward--one pill a day--few people, in my experience, can tolerate this dose for any length of time. Patients invariably have to stop the drug or reduce the dose severely due to muscle aches when I've had patients try it. Contrary to the ASTEROID results, in my experience the majority of people, perhaps all, eventually give up with this improbable "one-size-fits-all" scheme. The Track Your Plaque approach, while more complicated and involves several nutritional supplements and strategies, in my view addresses more causes of coronary plaque, is better tolerated, and provides health benefits outside of just LDL cholesterol reduction. It also minimizes or eliminates the need for prescription medication. Studies cited in graph:1.Nissen S et al. N Engl J Med 2006;354:1253-1263.2 Tardif J et al. Circulation 2004;110:3372-3377.3 Nissen S et al. JAMA 2006;295 (13):1556-15654 Nissen S et al. JAMA 2004;292: 2217–2225.5 Nissen S et al. JAMA 2004; 291:1071–1080
When is a calorie not a calorie? 10. April 2008 William Davis (8) One ounce of raw almonds (about 23 nuts) contains:This approach works nearly as well as fasting. A half-pound per day weight loss or more is common and painless. You'll also feel great living on low glycemic index foods. (Photos courtesy Wikipedia.)
Dr. Agatston to the rescue 12. January 2007 William Davis (0) Dr. Arthur Agatston, author of wildly successful South Beach Diet, has just released a new book titled The South Beach Heart Program. Dr. Agatston has started on a media speaking circuit to promote his book and concepts. A reporter from Time, who interviewed Dr. Agatston, commented:". . .not enough doctors prescribe niacin for their heart patients, even though the medicine is a proven treatment for raising 'good' cholesterol. Physicians are reluctant, Agatston suggests, because niacin requires diligent follow-up to watch for side effects, taking time that most primary-care practices cannot afford. On the other hand, he says, too many doctors are performing heart operations that represent a financial windfall for hospitals. Bottom line: there isn't as much money to be made in prevention as in treatment."Amen. Dr. Agatston echoes many of the concepts that the Track Your Plaque program advocates. His notoriety is going to help disseminate the idea that 1) CT heart scans are the #1 method to identify hidden atherosclerotic coronary plaque, 2) taking control of your heart scan score is the best way to seize hold of your future, and 3) the present-day popularity of heart procedures like stents and bypass is intolerable, inexcusable, and needs to be reined back.Agatston also brings great credibility and fairness to the conversation and his comments will gain tremendous attention in the press and with the public.
When is a vitamin not a vitamin? 12. January 2007 William Davis (0) When it's a hormone. That's the stand that several researchers in vitamin D have taken and I think they're right. Dr. John Cannell has made a fuss over this in his www.vitamindcouncil.com website. Structurally, vitamin D is most closely related to testosterone, estrogen, and cortisol. You wouldn't call testosterone vitamin T, would you? Vitamins are also meant to be obtained from food. Yes, vitamin D is in milk but only because humans are required to put it there to prevent childhood rickets. Otherwise, the only substantial food source of vitamin D is in oily fish like salmon and then only a modest quantity. Vitamin D is cholecalciferol, a hormone. Deficiencies of hormones can have catastrophic consequences. Imagine that every winter your thyroid gland shuts down and produced no thyroid hormone. You'd get very ill, gain 30 lbs, lose your hair, feel awful. That's what happens when you're sun deprived and thereby deficient in cholecalciferol--you're deficient in a hormone. And it happens to most of us every year for many months. I continue to witness spectacular effects by bringing 25-OH-vitamin D3 blood levels to 50 ng/ml with supplementation, including an apparent surge in success dropping heart scan scores.
An epidemic of heart disease reversal 10. January 2007 William Davis (3) Heart disease reversal is nothing new in my office. However, I have to admit that it's not something that generally happens each and every day. As our approach is refined, we are witnessing an unprecedented frequency of plaque reversal. Since Monday (today is Tuesday), I've seen four people who have regressed their coronary plaque and dropped their heart scan score. Pat was the most recent addition to this list. At age 53, I was honestly surprised at the ease of dropping her heart scan score from 128 to 42 in the space of a year. I was surprised because among her lipoprotein patterns was the dreaded combination of lipoprotein(a) and small LDL, probably the most aggressive risk for heart disease I know of and also among the most difficult to gain control over. She also suffered a deep personal tragedy in her family, an emotional convulsion that can sometimes wipe out any hope of plaque reversal. I'm hopeful that this virtual epidemic of heart disease reversal continues. And I hope that you participate in it.
Second heart scan and heart attack risk 9. January 2007 William Davis (0) At first, Joe felt disappointed, defeated, and frightened. After his heart scan, a radiologist at the center told him that his score of 264 was moderately high. He told Joe that he was at moderate risk for heart attack and that a nuclear stress test was going to be required. This left Joe feeling confused. After all he'd had a heart scan 18 months earlier and his score was 278, 5% higher. I reassured Joe that the radiologist had not been aware that Joe had a prior heart scan. The radiologist didn't know that Joe's heart scan score had actually been reduced. In fact, Joe's risk for heart attack was not moderate--it is now very low, since his score was 5% lower. While growing plaque is active plaque, shrinking plaque is inactive plaque and thereby at far less risk for heart attack.I wrote about this phemonenon in a previous Blog: When is a heart scan score of 400 better than 200? at http://heartscanblog.blogspot.com/2006_09_01_archive.html. When you've had more than one scan, the risk for heart attack suggested by the score takes a back seat to the rate of change of your score. In other words, even though Joe's score of 264 represented a moderate risk (of approximately 3% per year, roughly 30% over 10 years), this no longer held true, since it actually represented a 5% decrease over a previous score. Joe's risk for heart attack is probably close to zero. ALWAYS view your second (or any subsequent) heart scan score in the context of your previous score, not in isolation. Track Your Plaque newsletter subscribers: We will detail more of Joe's story in the coming January 2007 newsletter. If you'd like to read or subscribe to the newsletter, go to http://www.cureality.com/f_scanshow.asp.
Heart scan curiosities #5 8. January 2007 William Davis (1) Despite the controversy over drug-coated stents, I maintain that the best stent is no stent at all. Yes, there are indeed times when such things are necessary, but not with the frequency that they are implanted nowadays. Another reason why stents are an undesirable phenemenon is that they muck up your heart scan. Take a look:The long white object in the center is a stent in the left anterior descending artery of this 60 year old man. Just beyond the stent (at about 1 o'clock from the stent) is a plaque that could be scored. However, you can see that, with the presence of the stent, the bulk of this artery is no longer "scorable". If this man wishes to "track his plaque", he will have to be content with tracking only the circumflex and right coronary arteries, the other two arteries without stents. The stainless steel or similar metallic materials of current stents simply prevent us from seeing through them for plaque scoring purposes. It's best if you can simply avoid getting one for this and other reasons.Track Your Plaque Members: Watch for the upcoming editorial by our Heart Hawk on drug-eluting stents.
One bite or many mouthfuls 6. January 2007 William Davis (0) A reader brought this beautiful series of food photos to my attention:http://www.wisegeek.com/what-does-200-calories-look-like.htmIt's simply a graphic display of what 200 calories of various foods look like. You'll note that vegetables and fruits permit large servings to yield 200 calories. Processed foods, on the other hand, require very little to tally up the same calorie load. In particularly, look how little in the way of wheat products are required to match that amount.
Heart scan curiosities #4 5. January 2007 William Davis (2) Here's an interesting example of a 63-year old man with a heart scan score of 112. However, his aortic valve was also severely calcified (loaded with calcium). In other words, the normally flexible and mobile "leaflets" of the aortic valve were coated with calcium and other tissues that interfere with its free motion. The aortic valve is the starburst white in the center of the heart. This is what the aortic valve should look like on a CT heart scan--you shouldn't see it at all. The first man with the calcified valve will unfortunately require a new prosthetic aortic valve sometime in his future. This is usually determined with the help of an ultrasound, or echocardiogram, a better test for assessment of the aortic valve (though useless for detection of coronary plaque).It's my suspicion that chronic and longstanding deficiency of vitamin D is among the factors that contribute to the abnormal deposition of calcium on the aortic valve. We desperately need more data on this. Nonetheless, perhaps this adds yet another reason to 1)get a CT heart scan, and 2) bring your vitamin D blood level to normal. (We aim for 50 ng/ml year round.)
Fish oil and the perverse logic of hospitals 4. January 2007 William Davis (6) Hospitals are now starting to carry prescription fish oil, known as Omacor, on their formularies. It's used by some thoracic surgeons after bypass surgery, since fish oil has been shown to reduce the likelihood of atrial fibrillation (a common rhythm after heart surgery).Why now? The data confirming the benefits of fish oil on atrial fibrillation has been available for several years. It's now available in hospitals because it's FDA-approved. In other words, when fish oil was just a supplement, it was not available in most hospitals. Whenever I've tried to get fish oil for my patients while in hospital, you'd think I was trying to smuggle Osama Bin Laden into the place. The resistance was incredible. Now that FDA-approved Omacor is available, costing $130 dollars per month for two capsules, $195 for the three capsule per day dose for after surgery, all of a sudden it becomes available. Why would this irrational state of affairs occur in hospitals? Several reasons, most of which revolve around the great suspicion my colleagues have towards nutritional supplements. In addition, there's the litigation risk: If something has been approved by the FDA, their stamp of endorsement provides some layer of legal protection.However, I regard those as pretty weak reasons. I am, indeed, grateful that fish oil is gaining a wider audience. But I think it's absurd that it requires a prescription to get it in many hospitals. Imagine, as the drug companies would love, vitamin C became a prescription agent. Instead of $3, it would cost far more. Does that make it better, safer, more effective? Of course, no drug sales representative is promoting the nutritional supplement fish oil to physicians nor to hospitals. I now see people adding the extraordinary expense of prescription fish oil to their presription bills. In my view, it's unnecessary, irrational, and driven more by politics and greed than actual need. Take a look at the website for Omacor (www.omacorrx.com). Among the claims:"OMACOR is the only omega-3 that, along with diet, has been proven and approved to dramatically reduce very high triglycerides..." This is a bald lie. Dozens of studies have used nutritional supplement fish oil and shown spectacular triglyceride-reducing effects.Their argument against fish oil supplements:"Dietary supplements are not FDA-approved for the treatment of any specific disease or medical condition. Get the Facts: nonprescription, dietary supplement omega-3 is not a substitute for prescription OMACOR." Does that make any sense to you? Should you buy a GM car because only GM makes genuine GM cars? This is the silly logic being offered by these people to justify their ridiculous pricing. How about: "The unique manufacturing process for OMACOR helps to eliminate worries about mercury and other pollution from the environment." Funny...mercury in fish tends to be sequestered in the meat, not the oil. Independent reports by both Consumer Reports and Consumer Lab found no mercury, nor PCB's, in nutritional supplement fish oil. But just suggesting a difference without proving it may be enough to scare some people. Just because something is used by a hospital does not make it better. The adoption of fish oil is hospitals is a good thing. Too bad it has to add to already bloated health care costs to enrich some drug manufacturer.
Repent for past sins 2. January 2007 William Davis (0) If the food temptations of the holidays got the best of you, and you're now 5, 10, 15 lbs or more over your pre-holiday weight (our record is 18lbs!), then it's time for serious action. One easy method to regain the control you may have lost is to pick some period, say, 3 days. During those three days, eat nothing but vegetables--no breads, meats, dairy products, certainly no cookies, cakes, pasta, etc., not even fruit. Follow this routine and weight drops rapidly. Vegetables are wonderful but sometimes boring, so use healthy condiments to spice them up: mustards (hot, brown, yellow, horseradish); healthy salad dressings, which are olive or canola oil-based; salsas, a fabulous garnish with no nutritional downside whatsoever; pesto; tapenades; horseradish added to other condiments or even by itself (wasabi).Of course, fasting in one of its several variations is another rapid method to regain control. My favorite is to use soy milk in a modified fast, usually 4-6 glasses of a low-fat, low-sugar soy milk per day, along with plenty of water. (Please refer to the precautions detailed in the recent Track Your Plaque Special Report, Fasting: Fast Track to Control Plaque , particularly if you fast 5 days or longer or take blood pressure or diabetic medication.) Of course, yo-yoing your weight--up during the holidays, down after their conclusion--is not good for you. It does raise the likelihood of diabetes, not to mention cultivate the patterns that contribute to coronary plaque growth, especially small LDL. But if temptation got out of control and you need to regain lost ground, these two strategies work fabulously well for most people. If you've gained, say, 10 lbs during the holidays, but simply resume your usual habits, chances are you won't lose the weight. Year after year, this can add up to an enormous weight gain. The time to act is now. It's easier to lose the 10 lbs of weight you gained recently, rather than the 50 lbs you've stacked up over the past 5 years.