A Change of Heart

A new wave of doctors is relvolutionizing the way Western medicine prevents and treats heart disease. Here's what you need to know to keep your heart healthy for many beats to come.
By James Keough

Ever since the 1950s, when the Framingham Heart Study established a correlation between high cholesterol and heart attacks, doctors have focused on lowering cholesterol as a way to prevent heart disease. For years they’ve told us to accomplish this by eating a low-fat diet and exercising and, if that failed, by taking cholesterol-lowering drugs called statins. But as grim statistics keep piling up—79.4 million Americans have one or more forms of cardiovascular disease—an increasing number of doctors, some of whom call themselves the new cardiologists, have begun to question this single-minded approach.

Another statistic helps explain why: More than half of all heart attacks occur in people with normal cholesterol levels. That means their total cholesterol score is below 200 mg/dl, the limit set by the National Cholesterol Education Program in 2001. Does that mean you don’t need to worry about cholesterol? Simply put, no. “Cholesterol’s important,” says Stephen Devries, MD, associate professor of medicine, Division of Cardiology and Center for Integrative Medicine at Northwestern University, “but it’s one part. There are other metabolic risks that are not typically measured in most medical encounters.”

The new cardiology arose out of a collective realization that new opportunities existed for better (and earlier) diagnosis, creative noninvasive treatment, and even outright prevention. In redirecting their energies and practices—often at a significant loss of income since they perform fewer interventions—the new cardiologists use more refined tests that measure more than cholesterol. And they’ve developed new protocols for nutritional supplements to correct the imbalances those tests reveal.

None of them has completely abandoned the more traditional tools of cardiology, however. They instead seek to use them more appropriately and generally only after trying natural approaches. Devries says simply, “I’m very goal oriented, so I try natural approaches first, and if they don’t work and I believe that someone needs to get his cholesterol down, I move on to statins. And I think that’s a good thing. I’m glad they’re around.”

Old school
In the more conventional view of heart disease, elevated cholesterol levels in the blood create plaque in the coronary arteries, which causes them to narrow and become diseased. Doctors used to think the plaque itself blocked arteries and caused a heart attack, but they now know that a specific type of plaque ruptures and starts a chain reaction: Blood clots form to stanch the wound, and then part of the clot breaks off, dams up an already narrowed artery, and causes a heart attack.

Until recently, determining who had heart disease was difficult without actual symptoms, primarily chest pain, shortness of breath, and fatigue. So cardiologists put patients through a stress test (such as running on a treadmill) to see if they experienced pain or fatigue and to measure their heart function. Stories abound of people given dramatic life-saving treatment after abnormal stress tests, though many simply go on medication.

But even those who pass don’t automatically receive a get-out-of-jail-free card. A stress test detects blockages that obstruct about 70 percent of the artery, says Dennis Goodman, MD, senior cardiologist in the Scripps Integrative Medicine Department at Scripps Memorial Hospital in La Jolla, California. “But two-thirds of patients who have a heart attack have it at a spot of blockage that’s less than 50 percent, which means if we did a stress test on those people the day before they had their heart attack, they could pass it.”

That makes predicting and preventing heart attacks very difficult. In fact, half of the time, cardiac arrest is the first symptom people have of heart disease. These limitations of conventional methods drive the new cardiology. “We have a huge responsibility now,” says Goodman. “We’re focusing on how we can screen people while they’re still asymptomatic, and the more risk factors they’ve got, the more aggressively we’re going to screen.”

Beyond cholesterol
if you’ve had a routine physical in the past five years, you should know your cholesterol level—including total cholesterol and both the LDL (bad) and HDL (good) varieties. Considering the emphasis on this risk factor, a shocking number of people don’t. An American Heart Association survey in 2003 found that less than 30 percent of women knew their cholesterol levels. That’s reason for concern, because with just those numbers, you can get a first-step reading of your heart health.

Far too often, we and our doctors focus too much on that total number and lose track of the LDL and HDL levels. “You could have a total cholesterol of 150 and think that you’re in great shape,” says Devries, “but if your HDL is very low, say 20, associated with your total of 150, that’s not a good thing. According to some measurements, that would be listed as normal cholesterol. I would say it’s a very abnormal cholesterol.”

The Framingham Heart Study backs Devries up on this. As Julius Torelli, MD, points out in Beyond Cholesterol, 7 Life-Saving Heart Disease Tests That Your Doctor May Not Give You (St. Martin’s Griffin, 2005), it found that “people with a cholesterol/ HDL ratio (total cholesterol divided by HDL) of 3-to-1 or lower were least likely to have heart attacks.” The average ratio in America, he writes, is 4.5-to-1; for people with heart disease it’s often 5.5-to-1. Goodman says he likes to see the cholesterol/ HDL ratio below 4 and the LDL/HDL ratio below 3. That means you could have a total cholesterol level in the 190s, an HDL of 50, and an LDL in the 130s and still be healthy. (The HDL and LDL numbers don’t add up to 190 because total cholesterol also includes a number for triglycerides.)

But say you achieve these healthy ratios. You’re still not off the hook, because, as Devries says, cholesterol is not the only risk factor. And most new cardiologists agree with him. They, in fact, seem more worried about inflammation within the arteries—the primary thing that causes unstable plaque to rupture and set off the whole heart attack cascade.

To detect these other risk factors, the new cardiologists turn to a series of blood tests that measure the levels of other blood fats like Lp(a) and markers of inflammation like C-reactive protein (CRP), homocysteine, and fibrinogen. A new test in their arsenal—the PLAC test—measures lipoprotein phospholipase A2 (Lp-PLA2), a marker specifically for inflammation inside the blood vessels. And since high levels of oxidation are linked to inflammation and heart disease, another test measures ferritin, a marker of oxidative stress. (See “The 7 New Tests” below for more info on what the tests measure and what the values should be.)

None of these tests is terribly expensive, especially when bundled together. And they play a crucial role in the early detection of heart disease, when there are no symptoms and there’s still time to stabilize and even reverse the condition.

Picture of health
Depending on the results of these blood tests, you and your doctor may want to investigate further. In the old cardiology, you would need an angiogram, an invasive procedure that always presents an element of risk (however small) for heart attack or stroke. New, more powerful, and faster scanning devices have made angiograms less necessary. One, called an ultra-fast CT scan, takes 10 minutes and costs anywhere from $250 to $600. It produces a calcium score by measuring the amount and density of calcium deposits within the arteries. Since arteries contain calcium deposits only when they’re embedded in plaque, the higher one’s calcium scores, the more severe one’s heart disease. A 2003 study in Circulation scanned 5,000 men and women with no cardiac symptoms and found that the men with the highest calcium scores were more than 10 times likely to need angioplasty or bypass surgery as those with moderate or low scores.

The second scan looks at the carotid arteries, which run up the sides of the neck and supply the brain with oxygen and nutrients. This can detect thickness in the internal layer of the carotid, says Goodman, “and if it’s thicker than it should be for someone’s age, we know we’ve already got plaque.”

Goodman strongly recommends these scans for individuals with high risk factors but no symptoms because they can confirm a diagnosis and help determine how aggressively an individual needs to be treated. But he also sees value for people who simply want to know if they—or more often their spouses—have heart disease. “People actually give their spouses a CAT scan for their birthday,” he says. “It sounds weird, but you know it could be their biggest birthday present ever. It can change someone’s life because they end up actually making changes or they end up having bypass surgery or angioplasty when they didn’t realize they had a problem.”

Take action
People love to point out that denial is not a river in Egypt. When it comes to heart disease, however, it might as well be the river in Hades across which Charon ferries the dead. People who ignore symptoms often find themselves in dire circumstances, but what about those who feel fine? According to Goodman, the new cardiology tries to “get people to focus on the idea that you can prevent these bad things happening if you actually do something about it while you think you’re healthy.” That means stopping for a second, he says, and asking yourself what your risk factors might be and what you can do about them. “We all talk ad nauseam about diet and exercise,” he says, “but if people don’t take that onboard for themselves, the next big thing they’re going to worry about is how they’re going to stop their second heart attack.”

Simply dieting won’t suffice, though. The primary concern isn’t losing weight. Nor will a low-fat diet do the trick—getting rid of all fats throws out the baby with the bathwater. Instead, you want a diet low in bad fats and high in good ones—like the Mediterranean diet, which most of the new cardiologists recommend. They base this choice on the 1990s Lyon Diet Heart Study in France, which found that heart attack survivors who followed a Mediterranean diet had a lower incidence of second heart attack, unstable angina, heart failure, or cardiac-related death than those who followed the low-fat diet endorsed by the American Heart Association.

Anyone who’s visited the region knows that following this diet is hardly a sacrifice. Rich in fruits, vegetables, nuts, and fish and drenched in olive oil, the Mediterranean diet provides an ample supply of healthy fats, antioxidants, and anti-inflammatory fatty acids—as well as low levels of sugar, saturated fats, and refined carbohydrates. (For more information on anti-inflammation diets, see “Cooling the Fires Within” at naturalsolutionsmag.com.)

If making such a change seems daunting, Goodman says, “start off by just avoiding the bad stuff . . . the trans fats and the saturated fats. Then get yourself in shape at whatever level is right for you.” Depending on your current physical condition, this may range from being able to walk slowly around the block to long-distance running or bike riding. After healthy eating, getting regular exercise may be the best thing you can do for your heart. Numerous studies point clearly to the protective value of just 30 minutes of exercise a day, even for someone who’s obese. Regular exercise lowers total cholesterol, triglycerides, and blood pressure, and it raises HDL. In addition, it relieves stress, an important risk factor for heart disease.

Even perfectly healthy people can find it difficult to summon the energy to get off the couch and exercise, but people with heart disease (or those who’ve had a heart attack or who have heart failure) face more than just a lack of willpower. For them the question is largely physical—they don’t have much energy to summon. Their heart cells lack the oxygen and fuel they need to drive the circulatory system. And when the heart lacks energy, so does the rest of the body.

One branch of the new cardiology—Stephen Sinatra, MD, founder of the New England Heart and Longevity Center, calls it metabolic cardiology—has found a supplement regimen to address this problem. Basically, says Sinatra, heart disease reduces the ability of each heart cell to produce ATP, the biochemical fuel that powers every bodily function. He and James Roberts, MD, discovered that if they gave their patients magnesium, Co-Q10, L-carnitine, and D-ribose—they call this combo the awesome foursome—their quality of life improved dramatically. They could breathe more easily, walk farther, exercise more, and participate more actively in life. The doses Roberts and Sinatra use are therapeutic and generally tailored to the individual, but in The Sinatra Solution: New Hope for Preventing and Treating Heart Disease (Basic Health Publications, 2005), Sinatra also recommends an age management/cardiovascular prevention program of 90 to 150 mg Co-Q10, 250 to 750 mg L-carnitine, 5 grams D-ribose, and 400 mg magnesium—plus a multivitamin/ mineral and a gram of fish oil.

Get extra help
Eating heart-friendly foods and getting adequate exercise may be all you need to prevent heart disease, but what about people who already have one or more risk factors? Depending on individual circumstances and test scores, the new cardiologists will devise a course of supplements and nutrients to address specific problems. (Note that many of these substances do double or even triple duty on the front lines of heart health.) Very broadly, they can be broken down into two groups: those that help lower cholesterol within healthy norms, and those that have antioxidant properties, and therefore lower levels of inflammation and free radicals, or otherwise protect the heart and coronary arteries.

To help manage cholesterol, the new cardiology turns to one or more of the following:
Niacin, a B3 vitamin, lowers total cholesterol and LDL while raising HDL.

Pantethine, a form of vitamin B5, reduces cholesterol production in the liver.

Policosanol, a mix of essential alcohols derived from sugar cane, damps down the body’s cholesterol production.

Garlic bulb and soy isoflavones reduce bad cholesterol and raise the good.

Grape-seed extract blocks the enzymes that help process dietary cholesterol.

Plant sterols, a form of fat found in nuts, vegetable oils, corn, and rice, also block the absorption of dietary cholesterol because they look like cholesterol to receptor sites in the intestines.

High amounts of inflammation and oxidative stress—detected by tests that measure CRP, Lp(PLA-2), and ferritin levels—call for one or more of the following:
Vitamin C reduces arterial stiffness and raises HDL levels.

Vitamin E protects against the formation of plaque and reduces total cholesterol.

Fish oil reduces inflammation and may reduce plaque, but it also promotes heart health in general.

N acetyl-L-cysteine (NAC) boosts levels of glutathione, a powerful cellular antioxidant.

Alpha lipoic acid (ALA), an antioxidant in its own right, also helps recycle the antioxidant vitamins C and E and glutathione.

Having read this far, it should come as no surprise to learn that heart disease is a complex issue—and that no simple solution exists. “People will grab one thing and say that’s the important thing,” says Devries, “and I think that’s misleading . . . [heart disease] is a metabolic stew, and if you take one thing and say this is what makes the stew, it’s wrong. It’s the whole thing that makes it.”

With that clearly understood, the new cardiology marshals an ever-expanding array of natural and high-tech weapons in the fight against America’s leading cause of death. But it never loses sight of the role each individual plays in maintaining her heart health—and neither should you. “You cannot rely on a drug to make you healthy,” says Goodman. “You’ve got to do it for yourself as well. You’ve got to be part of your team.”

What are you waiting for?

Reduce your risk factors

On Your Own:
Stop smoking: Lighting up lowers HDL levels, causes arterial inflammation and high blood pressure, and stimulates the formation of blood clots.

Get more exercise: Thirty minutes of brisk walking a day can lower risk of heart attack by 18 percent; intense aerobic exercise (running) and regular weight lifting lower risk even more.

Control your weight: Losing as little as 5 percent to 10 percent of your body weight can lower your risk.

Eat healthy foods: Try to adopt a Mediterranean-style diet high in whole grains, fish, fruit, vegetables, unsaturated fats, and olive and nut oils.

Drink in moderation: Two drinks a day may raise HDL levels (but possibly increase breast cancer risk too).

Lower your stress levels: Take a break by practicing yoga, meditation, biofeedback, or other forms of relaxation.

With a Healthcare Professional:
Get regular checkups: Ask for a full complement of blood tests, and know your scores.

Manage your cholesterol: If diet and lifestyle changes still leave you with cholesterol problems, look to supplements, other nutrients, and, if your situation warrants, to cholesterol-lowering statins.

Lower your blood pressure: If diet, exercise, and stress reduction don’t get you to normal levels, look to medications—when combined with other risk factors, high blood pressure increases heart disease risk several times.

Treat diabetes: About 65 percent of people with diabetes die of some form of heart or blood vessel disease.

Measure inflammation: A host of new blood tests can keep tabs on this risk factor for heart disease (see “The 7 New Tests” below).

Statins: the Good, the Bad, and the Ugly
What they do: Statin drugs lower LDL cholesterol (up to 60 percent, at high doses) as well as reduce inflammation and C-reactive protein (CRP) levels.
The stats: Some 15 million to 20 million people currently take statins. Drugs like Crestor, Lipitor, and Vytorin have become the first-line treatment, with some doctors even suggesting every adult should take them proactively.
Who can benefit: People with known cardiovascular disease and high levels of inflammation, CRP, and LDL cholesterol. In Reverse Heart Disease Now: Stop Deadly Cardiovascular Plaque Before It’s Too Late (Wiley, 2006), James Roberts, MD, and Stephen Sinatra, MD, write that men aged 45 to 65 with proven coronary artery disease have “the most to gain and the least to lose” from taking statins.
Who should avoid them: People who have no signs or symptoms of coronary heart disease. “If someone’s at low risk for cardiac disease and they go on statins,” says Roberts, “their yearly event rate may fall from 2 percent to 1 percent—a 50 percent reduction, but it’s kind of meaningless.” Adds James Wright, MD: “There’s fairly good evidence that we’re not accomplishing anything by all these people taking these drugs.”
The risks: The perceived wisdom says that statins’ only side effects are rare cases of muscle damage. “But,” says Wright, “that’s clearly not the case. There are a growing number of other serious side effects.” He mentions three: a numbness in the hands and feet (peripheral neuropathy); the collection of fluid in the lung sacks (interstitial pneumonitis); and a loss of memory or other cognitive powers. “Some of these patients appear to have permanent effects,” he says, “so I think we still have a lot to learn about these drugs. And it’s not surprising because they are blocking an enzyme that has a lot of important functions downstream [from the liver] and is present in a lot of cells.”
The unknowns: While some of statins’ adverse effects have already reared their heads, other longterm ramifications may still lie undiscovered. Until doctors learn all the ways statins affect you, more and more cardiologists advocate first using natural approaches to lower cholesterol and then, failing that, statins. Says Roberts, “I think in 10 years, we’re going to look back at this statin mania with some regret.”

The Food Solution
Forget fad diets. Instead, pattern your eating habits on Mediterranean cuisine, which is low in meats and dairy and rich in fruits, vegetables, whole grains, nuts, and olive oil. Many studies have shown it reduces not only the risk for heart disease but also the risk of premature death. For delicious Mediterranean recipes, go to naturalsolutionsmag.com.

New to the Scene: Plant Sterols
Just a few grams of phytosterols—compounds found naturally in plants—can lower cholesterol 5 percent to 10 percent in just a couple weeks. To get a therapeutically effective dose, look for foods labeled as phytosterol-fortified, such as a growing number of yogurts, cheeses, cereals, oatmeals, juices, and granola bars.

Three Simple Changes
1. Get eight hours of sleep. This helps lower blood pressure and increases your metabolism.
2. Lift weights. Gaining 5 to 10 pounds of lean muscle significantly increases your fat-burning ability.
3. Meditate. Research shows this lowers stress, blood pressure, and the risk of heart attack and stroke, and it also may reverse atherosclerosis.”