Yup.  "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 365lbs 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.

Anyway, onward . . .

As an ancient engineer, I often use your aphorism.
Your publicly expressed viewpoint must earn a lot of criticism from your colleagues, and undoubtedly there have been financial and other sacrifices on your part.
I would like to offer heart felt appreciation for what you do.
I assume that many colleagues share your point of view. Are there others who have the 'cojones' to speak out?  Is there any degree of cooperation?

I would like to know something of your perspective on potential solutions for cardiology in particular, and healthcare in general. In fact, on the whole "medical-pharmaceutical-insurance-government complex" (to paraphrase the warnings of Dwight Eisenhower).
I grew up under British socialized medicine, and while the delivery to the people is more even, it is not a  solution. Do you foresee some kind of compromise as workable? Should the solution be patient driven? Business driven? Govt. driven?
I recall that in the UK, doctors and the system tend to be viewed as almost god like in their authority, although a few individual Dr. rebels such as. Malcolm Kendrick come to mind.

Yes, I know. This is far too big a topic for your blog, but with the elections coming up, my curiosity just got the better of me!
Note: I promise not to ask any more difficult questions until next Feruary 29!
MikeV

I'd like to echo the comment by Mike V.  The current health care situation in the US is so "unsustainable", to borrow an agricultural phrase, yet having a good view of the UK's NHS (I have English in-laws) doesn't inspire me to wish all of that on myself or the US public, either.  My in-laws in Norway seem to have it better in many ways, but I see some dangerous aspects creeping in over there, too.  We need better options for our nations's healthcare, but I only seem to hear about how well our current system works (for some people) with all the costly high-tech procedures and diagnostics or else warmed-over versions of the UK and Canadian systems, which has some serious flaws, too.

I want healthcare that takes prevention and health promotion into account, not just "disease care" that catches disease "just in time".  I don't want "checkbook science" or "concensus science" dictating what options I have or what information is available to me.  I don't want a "nanny" nor do I want my care determined by healthcare industry lobbyists.  

There must be something better, that does a better job of balancing promotion of good health with treatment of disease, with balancing good intentions without nannyism, with balancing  access to care without over treatment.  We need a system that allows medical personnel to make the best decisions for each individual patient, with a better way of managing the associated costs and compensation for all participants.   It is very hard for physicians to "buck the trends" these days.

As an insider with an insightful view from the trenches of the healthcare industry, I'd love to read more of your thoughts on these issues in future posts, Dr. Davis (your busy schedule allowing, of course).  How can we reform healthcare without pushing the pendulum too far into another harmful direction, in a way that it beneficial to all - patients, medical personnel, medical institutions, medical research, etc?

And then, how do we make it happen?

Webmaster, I love your site. Thank you sooo much for working on it.

What about adding P-5-P to the Niacin?

I've heard things about cinnamon lowering Blood sugar, but I'm not convinced.

Thank you for posting this.  I am exercising everyday sometimes twice a day to equal 45-60 minutes and see some help with the glucose level.  My LDLs continue to be around 100 and my Dr. wants to increase the Niacin.  Will that help?  It's a fine line, keep the sugars down and get the LDLs down. I appreciate your blog!

Cinnamon does reduce blood sugar but the effect is minimal, even at higher doses.

About Karl comment, you can add many supplements to niacin to counteract this effect. Chromium, resveratrol, standarized cinnamon, green tea extract... Life Extension has launched a niacin with quercetin for example (but now out of stock).

Would reducing sugary/starchy carbohydrate intake be an effective way to reduce hyperglycaemia?

Thanks for posting Dr. Davis.

Is splitting 1500 mg of Niacin to two 750mg doses,one in morning, one in evening ok?
Or should  the 1500 be taken all at once?

Both times I started Niacin, I developed Gout.
The second time I cut the tablets in half hoping to avoid another bout but still, Gout in a different joint.

It has been my experience that over time (2-3 Months)the Slo-Niacin I use has less effects on raising blood glucose levels like it does at the onset. It is well advised that everyone should get in the exercise regardless of niacin intake.

I took 500mg of Niacin every day to get my HDL up. Plus, there was niacin in my multivitamin. My HDL didn't go up at all. I exercise plenty too. All I got out of it were a few itchy flushes that made my ears feel clogged. I'm going to finish my bottle of Slo-Niacin and try a red yeast rice that was tested by Consumerlab.com.

Regarding splitting the dose of Niacin.  I am pretty sure I have seen a post from Dr.D saying to take all at once.  

I used to split my dose. I thought I was being smart by distributing the Niacin over the day.  My local pharmacist told me not to split the dose because of impacts to Liver function.

I avoid sustained release niacin.

I get around 80 mg niacin per day in a multivitamin and don't want to add extra.

http://www.lef.org/LEFCMS/aspx/PrintVersionMagic.aspx?CmsID=114620

pomegranate...

Despite the patients’ advanced atherosclerosis, ingesting pomegranate juice produced statistically significant reductions in the thickness of their carotid artery walls, which is correlated with decreased risk for heart attack and stroke. After only three months, the average thickness declined by 13%, and after 12 months, the thickness dropped 35% compared to baseline. During this same 12-month period, the average carotid artery thickness of the placebo group increased by 9%.

Thank you so much for posting this!  I have bee na niacin devotee for about 15 years, and wanted to get my LDL back up after a dx of T2D (with Antibodies) ... and having my niacin "taken away" by my internist.  MY Endo put me back on a lower dose of slo-niacin ... exercise is helping but I may need to up my anti-IR meds.

When is the best time to take niacin?

morning or night?

before or after exercise or meals?

We've had best results dosing niacin with dinner or the largest meal of the day.

Dr.Davis

Just asking this again, could you could please help me out.

Is splitting 1500 mg of Niacin to two 750mg doses,one in morning, one in evening ok?
Or should the 1500 be taken all at once?

I had a terrible time with Niacin and insulin resistance.

I tried exercising but to keep my BG down, I would have to exercise 3 or 4 times a DAY, which is simply not feasible.  Oh, and I am a low-caber, too.

I would exercise extreme caution in starting to use this, with any Diabetes. (I am a T1.5).

Dr Davis,

What kind of exercise would you recommend for a Senior lady who is handicapped?  It is difficult for her to do any exercise, so do you know of something she would be able to do while she is taking niacin?  Or, would it be better for her to stop the niacin since exercise is difficult and try other supplements?  Thanks for your help.

Assuming your recommended Slo-niacin...is it better to split your doses up (500 mg morning and 500 mg at night) or take all 1000mg at once? If its better to take all at once is night or morning better?

I love to practice exercise, i think this activity is the best option to keep our total welfare and it is very fun. When we exercise frequently we can notice a change not only in our shape but in our mood too. Actually we can improve our sexual performance. When some cases when the erectil dysfunction present like a problem  to buy viagra is a great alternative, how ever you must to combine it with exercises and a good feed.

While the net effect of niacin remains positive, the provocation of insulin resistance is not such a good thing. Can it be minimized or eliminated?

Taking niacin before vigorous exercise has one benefit for me.  The flusing is minimized or even eliminated.

I've seen different recommendations for dosing frequency.  Three times a day is the "standard" dosing regimen.  However, when I haved switched to three times a day dosing, I have experienced elevated liver enzymes.  I've never had a problem with twice a day dosing.

I am not aware of any data to support 24% risk reduction for MI with the use of Niacin, can you provide citations?

Primary or secondary prevention?

Bob Hansen MD

Cinnamon doesn't lower blood sugar per se.  The apparent mechanism occurring here is a slowing down of carbohydrate absorption in the gut.  The mechanism is believed to involve a class of molecules known as flavonoids, which either reversibly compete for the glucose receptor or have their own receptor on the GLUT 2 (glucose transport 2) protein.  This action only slows down the absorption of carbohydrates, but all (that's 100%) sugar is absorbed into the body.  It is the only thing you intake that is absorbed 100% and it doesn't matter if it's glucose, sucrose, fructose, or a complex carb.  Anywho, not that I want to debate the finer points of carbohydrate biochemistry.  For more on flavonoids and GLUT2 you can look up this paper (Kwon O., Eck P., Chen S., Corpe C., Lee J-h., Kruhlak M., Levine M. (2007) Inhibition of the intestinal glucose transporter GLUT 2 by flavonoids. FASEB Journal 21, 366-77.).