How To Have a Healthy Heart, Part II: What MDs Aren’t Telling You
Cardiologist Joel Kahn, M.D., FACC, FSCAI serves as Clinical Professor of Medicine at the Wayne State University School of Medicine in Detroit and Director of Cardiac Wellness at Michigan Healthcare Professionals. He has co-authored more than 100 cardiology articles published in medical journals. His first book, The Whole Heart Solution: Halt Heart Disease Now with the Best Alternative and Traditional Medicine, was published by Reader’s Digest Books in September 2014 and in March 2015 he published Dead Execs Don’t Get Bonuses: The Ultimate Guide to Surviving Your Career with a Healthy Heart.
HHN: In part I of this two-part series, you said what most people have learned about LDL and HDL cholesterol is too simplistic to accurately assess their heart health. Would you explain?
JK: Let’s start with LDL cholesterol, the so-called "bad cholesterol." The standard blood test most Americans receive just gives you the raw LDL number, as well as your raw HDL number and overall cholesterol number. But that raw LDL number isn’t enough to ascertain your risk for heart disease. Two people can have the same LDL number, but one may have a much higher risk for a heart attack and the other may not have much risk at all.
The difference in risk largely depends on two other factors that the standard blood test doesn’t measure: the number of LDL particles and their size.
A good analogy is a stretch of highway with 100 passengers. If those passengers are driving 10 to a minivan, then the road isn’t congested—there are only 10 large vehicles on it. But if all 100 passengers are riding in individual cars, you have congestion.
The same thing happens with LDL cholesterol. If you have many LDL particles with only a small amount of cholesterol in each one, that’s of concern, because your arterial highway is very congested. But if you have fewer and more packed particles, your arterial highway might not be congested at all."Two people can have the same LDL number, but one may have a much higher risk for a heart attack and the other may not have much risk at all."This situation typically arises where people have a low LDL number, but it could also occur where someone has a higher LDL number. Let’s say your LDL is 160, and your overall cholesterol number is 240. Without further data, that isn’t looking very good. But if you have a relatively modest number of LDL particles, maybe 1200, the results aren’t so unfavorable. A second person with the same overall cholesterol and same LDL number who has 2500 or 3000 particles has a much higher risk of a heart event.
HHN: What LDL particle numbers and sizes are considered desirable, and which are of concern?
JK: So far, only a few large data sets have looked at these more advanced cholesterol panels, but here’s what we know: An LDL particle number close to 1000 is at the lower risk part of the spectrum, and numbers of 2000 — 3000, which routinely arise, point to a much higher risk.
When it comes to particle size, the bigger the better. Small particles are typically sized 19 nm or under. Hard and dense, they’re like small "golf balls" that knock into your arteries to cause plaque. Bigger particles are generally over 21 or 21.5 nm. They tend to be more spongy and much less likely to harden your arteries. And they’re changeable. Lifestyle changes particle size better than anything, though of course medications can do this too.
So, get an advanced cholesterol panel, at least once. These days insurance companies are covering it pretty routinely. Even when they don’t, the cost is way under $100.
HHN: What additional understandings do we need to be aware of regarding HDL?
JK: A high HDL cholesterol number is not necessarily the good news doctors once believed it was.
We first started learning about HDL in the 1940s and 50s from of the Framingham Heart Study, which tracked measurable variables such as blood pressure, smoking, and weight to assess risk factors for heart disease. A lot of the data basically said that if your HDL level was toward the high end of the spectrum, let’s say over 80, you would by-and-large be free of heart disease. That’s because HDL functioned like a vacuum cleaner, helping to sop up bad cholesterol and take it to the liver for disposal."We're confused about whether the medications that raise HDL are of any value."It wasn’t that the scientists were necessarily wrong. Maybe the studies weren’t long enough in duration, and maybe our environment has changed—there's certainly much more toxicity today, in everything from pollution to food additives. But cardiologists now regularly see people with high HDL numbers, above 100 even, who have calcification and artery plaque.
There’s a new body of data supporting the theory that HDL might be super high in some people because it has a kind of anti-inflammatory property. Perhaps it’s working to fight off an infection, or a food allergy. Perhaps the root cause of the inflammation is obesity, a leaky gut, or something else.
The true science is that we don’t have the right HDL test yet. We want what’s called HDL functionality: Is the HDL vacuum cleaner actually cleaning out our arteries? Is it doing what’s called reverse cholesterol transport? Even if you have a lot of it, until a test measures how well it’s working in your system, the science supporting having that good number remains unclear. I’m optimistic, though, that someone will come up with a test to measure what we need.
HHN: Would your more traditional cardiology colleagues agree with your assessments regarding LDL and HDL?
JK: Yes for LDL. As for HDL, they would agree that we’re confused about its ability to predict heart events, and we’re certainly confused about whether the medications that raise HDL are of any value. Probably only a minority would share my belief in the emerging research that a very high HDL number might sometimes indicate an underlying inflammatory disorder.
Identifying Heart Disease
HHN: You’ve said that it’s easy for health care providers to miss heart disease. How do we know this is true?
JK: In part we know because of anecdotes: people go for a physical, are told everything’s OK, and subsequently have a heart event or worse. Even more so, it’s the limitation of America’s standard diagnostic tests.
Consider the arteries. We all have three heart arteries which are relatively small, about 3 millimeters or a tenth of an inch in diameter on average. They move a lot, they’re flexible, and they’re internal. A physician’s stethoscope is not going to be of any value."It's easy for health care providers to miss heart disease."On a chest X-ray you can’t see them. An EKG will give you some information about heart health, but you don’t see the arteries directly. Compare the EKG to the visual tools we regularly use to identify diseases in other organs of the body: mammography for breast cancer, a colonoscopy for colon cancer, etc. You’re directly imaging the breast or the colon.
But with coronary heart disease, the #1 killer in America, we don’t directly and routinely image arteries. The current recommendations for a physical at age 50 include a routine history, the physical, and some blood work, and if you don’t have any symptoms, that’s about all you’ll get.
Many cardiologists, including myself, believe we should be using good imaging tests to assess arterial health. We have them; they’re just simply not recommended by every medical society.
HHN: What imaging tests do you recommend? Given many people’s natural inclinations not to push doctors too much, what tests are most important to request?
JK: There are two tests, but I’ll just talk about one of them, what’s called Coronary Artery Calcium Scoring (CACS).
Going back about 20 years, as we started to do more CAT scans of the chest, it became obvious that you could see whether heart arteries were calcified, full of calcium, or not.
Now, while calcium is good for your bones, calcium deposits—originating from inflamed arteries with a damaged layer of cells lining the heart—are not good for the lining of your arteries. They stiffen blood vessels, which makes it harder for your heart to pump blood. This drives up blood pressure, which sets the stage for plaque.
Compared to 20 years ago, the time it takes to do a CAT scan is lightning speed. It’s now done in about 20 seconds, and that’s it: there are no injections, no IVs, no sedation."A CAT scan of your arteries is now done in about 20 seconds."A software program connected to the CAT scan asks and answers two questions: 1) Do you have calcified plaque in your arteries? and 2) If you do have plaque, in which of the three arteries does it appear and how much is in each?
There’s a lot of data, going back at least 15 years, that the calcium scoring on this test predicts heart disease. If your calcium score is zero, you have an extremely low risk of having a heart attack or needing a bypass for 5, 10, even more years. And, on the other hand, if you feel good, you’re playing squash, you’re riding your bike, but the Coronary Artery Calcium Scoring (CACS) shows your heart arteries are calcified, you’ll want to get to a heart disease prevention specialist right away.
HHN: Do your more traditional colleagues agree about the importance of getting a CACS test?
JK: The American College of Cardiology recommends this test for everyone who is at some risk for cardiovascular disease: people who have a family history of the disease, who have high blood pressure or high blood sugar, who smoke or are obese, etc. Together, that’s a recommendation for some tens of millions of people."You can look thin, feel good, and still be pretty calcified inside."But what do you do with a 50-year-old with no family history who’s had a perfect lifestyle? Although that person is much less likely to have cardiovascular disease, I still recommend having the test at least once, because surprises do happen. You can look thin, feel good, and still be pretty calcified inside. And once you have this information, you can take the steps to stop or reverse the development.
HHN: If someone has high cholesterol because he/she takes certain medications, is that a different risk category than someone whose cholesterol is high because of lifestyle choices?
JK: It’s not common to see high cholesterol caused by medications alone. First, there aren’t too many medications that affect cholesterol. Those that might raise cholesterol include beta blockers, used for blood pressure palpitation; diuretics, used for swelling or blood pressure; and certain classes of anti-depressants. Second, and most importantly, any uptick in cholesterol as a result of such medications would be modest at best.
The Exercise Rx
HHN: We’ve talked a lot about knowing the state of your heart. Now, can you tell us what the research says about how best to exercise it? "The moderate exercisers—moderate in exertion, duration, and frequency—had the lowest heart disease mortality risk."JK: Sure. The City of Copenhagen’s two-decade-long heart follow-up study confirms how important exercise is in heart health. Researchers looked at thousands of Danish citizens over 20 years, comparing their exercise levels and their mortality from heart disease. The moderate exercisers—moderate in exertion, duration, and frequency—had the lowest mortality risk. Next in lowered risk were the extreme exercisers. The couch potatoes had the highest mortality by far.
There’s no question that exercising lowers risk of heart disease. And there’s significant data that runners live longer than non-runners. So I encourage everyone to exercise.
It may also be possible to overdo it. Other data also indicates that running multiple marathons or doing multiple triathalons might lead to increased risk of atrial fibrillation, fibrosis, or scarring inside the heart.
So, if you’re training for long distance events over and over, ask yourself why. If you’re doing this to prolong your life, the last 5 — 10 years of research question that assumption. But I’d say, if you’re doing it because it’s your passion and you’ve had your heart checked thoroughly as discussed above, go for it.
HHN: A surprising finding you cite is the effectiveness of Transcendental Meditation™ in reducing the risk of a heart attack or stroke.
JK: Yes. Dr. Robert Schneider, an academic physician and long-time researcher of Transcendental Meditation, gathered 200+ people who had survived a heart attack, were under a cardiologist’s care, and were getting nutritional counseling. Half of them were taught Transcendental Meditation, with a mantra and breathing techniques, and asked to practice it 20 minutes each day in a quiet setting."People practicing Transcendental Meditation had a 48% reduction in heart attack risk."The other half received general information about good health practices. And over the next five years, the people practicing Transcendental Meditation had a 48% reduction in heart attack risk compared to the control group.
This is solid research. It was published in 2012 in the extremely fine cardiology journal Circulation: Cardiovascular Quality and Outcomes.
And it makes sense. Stress is the reason we don’t get out of bed and go to the gym. Stress is the reason we blow up and raise our blood pressure through the roof. People who are more relaxed through meditation may be able to make better health decisions through the day, day in and day out.
There are two other forms of meditation I have read quite a bit of research on and would also recommend. The first is John Kabat-Zinn's mindfulness-based stress reduction, developed at the University of Massachusetts Medical Center, which brings together mindfulness and yoga. It’s now available in 200 medical centers worldwide. A recent randomized study found it beneficial in treating chronic insomnia in elderly people.
There’s also a psychiatrist in Tucson, Dr. Dharma Singh Khalsa, who teaches another form of meditation that’s only 12 minutes long and very simple to do, one I often practice myself. Studies at the UCLA School of Medicine show it has anti-aging, anti-inflammatory, and memory-enhancing properties.
HHN: Do we have scientific data showing these two meditation practices are protective against heart disease?
JK: No. Transcendental Meditation has been studied the most and has the best data on heart disease prevention. But there may be other modalities that are just as effective and we just don’t have the research yet.
HHN: In closing, is there anything else you’d like to say to readers about heart disease prevention?
JK: Yes. Remember these three Ds: Denial, Delay, Death.
Don’t deny that you might have the disease that’s the #1 killer of men and women in America.
Don’t delay in getting your heart checked with an advanced cholesterol panel and CAT scan/CACS test. And don’t delay in changing your lifestyle to advance your health.
Most people are not trapped by their genetics. Practice good eating, good movement, good sleep, and stress reduction, and you will change the health of your heart.Protect Your Heart. What MDs are not telling you. Click To Tweetby