Can you tell the difference?

12. October 2006 William Davis (0)
Stan is 55 years old. He feels fine, is in moderately good physical condition. His LDL cholesterol is 135 mg/dl, HDL 43 mg/dl, triglycerides 167 mg/dl, total cholesterol 211 mg/dl.

Can you tell me whether Stan has heart disease or not?

How about Charles? Charles has an LDL cholesterol of 127 mg/dl, HDL of 44 mg/dl, triglycerides of 98 mg/dl, and total cholesterol of 191 mg/dl. He is also reasonably fit and feels fine. Can you tell whether Charles has heart disease?

If you can't, don't feel bad. Neither can your doctor. But this is the folly of using cholesterol for risk prediction.

Stan's heart scan score: 0

Charles' heart scan score: 978

Look even more closely at Stan's and Charles' cholesterol numbers. Is there some fine distinction we overlooked? What if we calculated total cholesterol to HDL ratio? Or LDL/HDL ratio?

No matter how you squeeze it, shake it, beat it with a stick, you simply cannot use cholesterol numbers to predict heart disease in specific individuals. Yes, the higher your LDL cholesterol and lower your HDL, the higehr your total cholesterol to HDL ratio, the greater the likelihood of heart disease. But you can simply cannot tell in a specific individual at a specific point in time. If you've seen your doctor puzzle over the numbers, understand that he/she is trying to make sense out of something that doesn't make sense, no matter how hard he/she tries.

You simply need to measure the disease itself: get a CT heart scan, the only measure of atherosclerotic coronary plaque that you have access to.

By the way, if you haven't seen it yet, go to the Track Your Plaque website (www.cureality.com) to see the news piece reporting the American Heart Association's much overdue position statement on CT heart scanning. The AHA has finally released a statement which, in effect, provides their "official" endorsement. Blocked by political shenanigans behind the scenes for several years, the guidelines finally made it to press. The only real difference it makes to me is that my patients may finally get their heart scans paid for by insurance, once the insurance companies realize that it's getting tougher and tougher to dodge their responsibility.
Tags :

Add comment

Loading
How much omega-3s are enough?

How much omega-3s are enough?

8. May 2007 William Davis (7)
The basic dose we advocate for the Track Your Plaque program is 1200 mg per day of EPA + DHA, the essential omega-3 fatty acids.

1200 mg EPA+DHA is generally obtainable by taking 4 capsules of 1000 mg of fish oil, since the majority of preparations contain 180 mg EPA and 120 mg DHA per capsule.

But how will you know if a higher dose wouldn't be even better?

The principal parameter to look at is triglycerides. If triglycerides remain above 60 mg/dl, we usually consider increasing fish oil.

Another measure that's very important is intermediate-density lipoprotein, or IDL, also called "remnant lipoproteins" on a VAP panel. Persistence of any IDL or remnant lipoproteins is reason to consider more fish oil. Most commonly, if there is some persistence of either, we increase fish oil to 6000 mg per day of a standard preparation, or 1800 mg/day of EPA+DHA.

The only time we see persistence of IDL or remnant lipoproteins with this higher dose is when triglycerides are really high. If starting triglycerides are, for instance, 500 mg/dl, then even this higher dose may be insufficient. This is when more highly concentrated preparations of fish oil may be necessary, occasionally even the prescription form, Omacor. (We currently use Omacor only when high doses of EPA+DHA are required, most because of its outrageous cost. Two capsules per day costs around $120 per month; three capsules per day to provide 1800 mg/day of EPA+DHA costs $180 per month. I think this is outrageous and so we use it only when absolutely necessary.)

You might even argue that a higher dose of 1800 mg EPA+DHA, or 6000 mg of a standard capsule, might be preferable for more assured reduction of heart attack risk--even when triglycerides and IDL are perfectly under control. I wouldn't argue with you. But you won't observe any measurable feedback that tells you that a heightened effect is being obtained. I take that dose myself, in fact, despite the fact that elimination of wheat products and weight loss was sufficient to drop my triglycerides to the target level. I figure it's a small additional effort for added peace of mind.
Tags :

Comments (7) -

  • Anonymous

    5/8/2007 7:46:00 PM |

    I have just joined the Track Your Placque Site.  I take fish oil daily, 3200 EPA/1600 DHA.  At this dose my AA/EPA score is 2.14.  When I had LDL electrophoesis done, my pattern was A pattern and I was not on the fish oil at that time.  I am wondering whether it would be better to have an NMR test or a VAP test, or both?

  • Dr. Davis

    5/9/2007 1:57:00 AM |

    Hi,
    In general, I prefer the NMR. However, the electrophoretic test you already had should provide more information than just breaking your LDL pattern down into types "A" or "B". The real numbers to pay attention to are the LDL subclasses III and IV. Add up those numbers to determine how much small LDL you really have (in percent). Anything more than 10% we regard as sigificant.

  • Mike

    5/9/2007 8:00:00 PM |

    Is there any reduction in triglycerides from taking flax seed or other non-EPA/DHA sources of omega-3s?

  • Anonymous

    5/10/2007 12:18:00 AM |

    Thank you.  The report is broken down into the various LDL subclasses.  This information is helpful.

  • Dr. Davis

    5/10/2007 12:28:00 AM |

    Mike-
    No, unfortunately not. Only fish oil exerts the sort of triglyceride and lipoprotein correcting effects that we need.

  • Anonymous

    5/12/2007 10:12:00 PM |

    Dr., what do you think of Krill oil? Is it better than "regular" fish oil?

  • Dr. Davis

    5/13/2007 3:25:00 AM |

    We've actually had a fairly extensive conversation on this question on the Track Your Plaque Forum. Fish oil is tried and true, and the advantages of krill oil--purportedly containing less pesticide residues (no less mercury since fish oil does not contain mercury) and virtually pure DHA--are not fully worked out. However, if you choose to give it a try, let us know what kind of results you get.

Add comment

Loading