By Charles Gebhardt, MD

(12/3/17)

You Don’t Have to Wait Until it is too Late

Heart attacks are the most frequent cause of death for both men and women.  They are caused by what is commonly called “hardening of the arteries,” or what is technically termed atherosclerosis.  Since atherosclerosis affects all the arteries of the body, the same process also causes many other catastrophic events such as strokes and the blockage of blood flow to our legs which could require their amputation.

While modern medicine has been making progress is slowing this disease process, we now have the tools to almost eliminate the devastating effects of atherosclerosis – if only we use them as effectively as possible.

For those who just want the key message of this article, I will briefly summarize the main points here:

1. The key to eliminating most of the risk this disease process creates is to find it early and aggressively manage it when it is present.
2. We have very effective scans that show calcification in the arteries. Calcium found in the lining of our arteries is an excellent marker for the presence and severity of atherosclerosis.
3. Any calcification found in any artery of the body means the disease has started and effective management is essential.
4. Who should be screened:

• Men over 40
• Women over 45
• About 10 years earlier for anyone with a strong family history or very high LDL cholesterol levels

5. If disease is found and treatment begun, the appropriate scans should be repeated on a periodic basis to ensure that the treatment is effective.

If you want to take advantage of this way of preventing heart attacks, stroke and other catastrophic diseases that can result from atherosclerosis, just ask your physician, nurse practitioner or physician assistant during your next office visit.

Here are the answers to some common questions we get about these scans:

• Are they painful or uncomfortable?  No, no injections or invasive procedures are involved.
• Are they expensive? Screening your entire body for the presence of this disease is available here in Albany for $149 (total cost for all 4 scans).

If you want a more in-depth explanation of what is known about this disease, and the specific reasons for these recommendations, just continue to read down this page.

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Due to my Medical Nutrition specialty, other physicians have been referring many of their patients with difficult to control cholesterol to me for over two decades.  As I have worked with thousands of patients with these problems, and carefully followed the results of their treatment, I have been able to develop an approach that is extremely effective in slowing or stopping the diseases that result from atherosclerosis.   The rest of this article will give you a fairly in-depth orientation to what we know about this disease and what I have learned from a very conscientious effort to prevent the damage it causes.

THE BASICS OF ATHEROSCLEROSIS IN A NUTSHELL

As I mentioned above, atherosclerosis is a systemic disease.  What I mean by this is that it is a disease that can affect every part of the arterial system on which every part of every tissue throughout our body is dependent.  This system supplies oxygen and nutrients to our tissues and if any part of the blood supply is blocked, the tissues will die, often very quickly.  The death of tissue in this way is called an “infarction.”

The heart and the brain are the two main organs where infarctions or symptoms of inadequate blood flow (called “ischemia”) first show up when atherosclerosis is in its advanced stages.  This is not a hard and fast rule, though, since sometimes a different pattern, such as pain in the legs from ischemia due to peripheral vascular disease, may be the first sign of atherosclerosis.

Once clear signs or symptoms of atherosclerosis develop in one part of the body, though, it is a safe bet that it exists in other parts.  It is also important to be very aware that you can have very advanced disease in your arteries and still feel completely well.  Almost half of the time that this disease process is discovered, it is when the victim dies suddenly from a heart attack, a stroke or a ruptured abdominal aneurysm, with no warning.  Obviously, it is much better to find and treat this disease process early rather than late.

We have long known that the damage to the body’s arteries starts as very mild defects in the inner lining of our arteries (called the intima) and usually develops slowly.  It usually takes six to ten years, or even longer, for a plaque to grow from its earliest form that pathologists call “fatty streaks” on the inner surface of arteries, to eventually become advanced blockages that cause ischemia or devastating infarctions.

The slow speed of development of this process gives us an important opportunity to stop it!  It means that using reliable means to test for these early plaques, we can follow the disease progression and this allows us to intervene to slow or stop it

Next, it is very helpful to understand how these arterial blockages (called plaque) partially block blood flow to cause ischemia or completely block blood flow and cause infarction.  The most basic process is the accumulation of fat and cholesterol and the formation of scar tissue that slowly grows and gradually blocks more and more of the flow of blood within the artery.  When this happens in the heart, it often causes angina (chest pain of cardiac origin) and tends to be provoked by exercise or exertion.  If this was all there was to it, though, the disease would not be anywhere near as deadly as it is since we would usually have angina as a warning.

Unfortunately, it isn’t just that the plaque progressively blocks the artery as it grows.  It also becomes weak and fragile and the lining that coats the inside of the artery can fracture spontaneously, an event that gets more and more likely as the plaque swells and gets larger.  This sets the stage for two very fast processes that can result from the fracture of the arterial lining.  When I say fast, I mean the flow of blood through the artery can go from normal to completely blocked in a matter of seconds.  This is what usually causes catastrophic large strokes and sudden cardiac death.  It may give absolutely no warning.  That is why it is so important to have some way to find this disease process before it becomes severe enough for symptoms or infarctions to occur.

One of these very fast processes is for blood to leak into the plaque once the surface ruptures.  This can cause the plaque to expand quickly and completely block the artery.  The second process is for a clot to develop on the surface of the plaque and begin to grow there.  It can grow big enough to block the artery where it forms, or it can break off from this site and get carried downstream in the blood stream to block other arteries.

Understanding something about these processes helps us in several ways.  For one thing, it explains how aspirin works to help prevent heart attacks and strokes.  Aspirin will not stop plaque from forming, nor will it protect its surface from rupturing, but it will do a good job of slowing clot formation on the surface of fractured plaque.  I always recommend aspirin for someone who has known atherosclerosis, if they can take it safely.

Also, by understanding that ruptures and clots only develop on the surface of an artery damaged by plaque, you can see why the more artery surface you have involved with plaque, the higher the probability it will rupture somewhere.  The probability of rupture also increases as the plaque gets thicker.  From all this, we now know we have several processes to stop once atherosclerosis is present in the arteries.  We want to stop the formation of new areas of damage, we want to stop existing areas from getting worse (thicker) and we want to prevent the surface of existing plaque from rupturing.

It would be nice if we could completely reverse this process once we discover it, but this is rarely possible with our current knowledge.  We have learned, though, that the same treatments that prevent new plaques from forming, and which prevent existing plaques from getting thicker, also stabilize the surface of the artery covering the plaque and greatly decrease the chance it will rupture!  Sometimes aggressive management will shrink the plaque a little, but it is the stabilization of the lining that is most important, and this improvement starts as soon as effective treatment is started.

Given this basic orientation to this disease process, next let’s discuss nutrition and the role of medications in controlling this disease process.

HOW DIET AND DRUGS AFFECT THE RISK OF ATHEROSCLEROSIS

I think that it is fair to say that most Americans believe that heart attacks and stroke are due to poor food choices which cause us to have high cholesterol levels in the blood.  This is partially true.  High cholesterol and high fat intake (particularly saturated fats) in someone’s diet do usually increase the atherogenic potential in the blood by raising the LDL cholesterol level (often called “bad” cholesterol).  However, if we could magically put every American on a very healthy low fat, low cholesterol diet, I would estimate we would decrease the amount of heart attacks and strokes by only about 20% — at the most.   This is because many people have either high LDL or low HDL (often called “good” cholesterol) that is not due to their food choices, nor do the abnormal levels respond adequately to diet alone.  Don’t get me wrong, diet is very important.  Sometimes it is very effective, and even if a heart-healthy diet doesn’t improve the lipoprotein levels much, it will help medications to be more effective.  Unfortunately, though, we need a lot more than just a good diet to make the kind of improvements that are possible in these diseases.

One of the biggest successes in modern medicine in the last few decades has been the development of very effective medications to modify the lipoprotein levels in the blood.  When I first started practicing medicine in my residency training, atherosclerosis was very frustrating to treat.  Strokes, heart attacks and similar problems were very, very common.  As the new lipid modifying medicines became available, particularly the “statin” class for lowering LDL, I began to see less heart attacks and strokes as a result of a better ability to improve my patient’s lipoprotein profiles.  While this was the first major improvement, an even bigger improvement is now available with another advance: new ways to screen patients to find the disease early — when it is most responsive to treatment.  In recent years, I still have a few patients with heart attacks and strokes, but only a small percentage of what it used to be.

Let’s get into the main point of this article now: the effectiveness of new imaging technologies to show us what is happening within our arteries before medical disasters can occur.

VERY EFFECTIVE SCREENING FOR ATHEROSCLEROSIS

Recall what I said earlier in this article: this disease first starts six, eight, ten or even more years before it begins block blood flow and cause catastrophic losses of our essential organs.  Since we have very effective treatments to slow or stop the disease, what we need most is to have a safe, effective, cost-efficient way to search for the disease before it becomes advanced to the point that it starts causing health disasters.  Ideally, we want to know as soon as it begins to develop. We also need to know where the disease is forming and how advanced it is.   Once our treatment starts, we also need to know how it is responding to our treatments.

It turns out that as plaque begins to develop, it picks up calcium from the blood.  This is not a very important factor in the disease process, but it is a superb marker for the disease, especially since we have several good, non-invasive ways to look for these calcium deposits.  Normal arteries have NO calcium in their lining.  Well-designed studies have also shown that there is an excellent correlation between the amount of calcium found on arterial scans and both the extent and severity of the disease process present there.

I use two techniques to look for and follow the progress of this disease.  The most important is a CT scan of the heart (no contrast injection is necessary) which is used to produce what is called a “cardiac scoring.”  It is most important because it produces a precise measure of the severity of the disease.  The presence of any calcium, even trace amounts, means the disease has started there.  The bigger the number, the worse the disease.  How quickly the number is increasing (or decreasing) shows us how effective the treatment is in controlling the disease.

Ultrasounds are also very useful.  They can easily be used to measure the presence of the disease in the neck arteries and the aorta in the abdomen.  Unfortunately, they aren’t as precise as a cardiac scoring in following the changes in the severity of the disease, but finding the development of plaque anywhere tells us the disease has taken hold, and this information is vital.  No matter which study we employ, when even a small amount of calcium is found, the disease has gotten a foothold and very aggressive management is called for.   The more calcium we find, the more imperative the treatment and the higher the risk if we fail to treat it effectively.

Perhaps the most significant thing I have noted with the extensive use of theses scans is that there are a very large number of people with normal lipoprotein patterns who already have established disease.  Many of these folks are non-smokers, have good blood pressures and no diabetes, yet despite cholesterol that is considered desirable, they still have disease.  What I have learned from this is that these “normal” patterns are still too high for them.  Even more importantly, I have found that if I treat them aggressively enough with medications, the plaques almost always stabilize (that is, they stop getting thicker and previously healthy arteries stop developing becoming involved).

In contrast, sometimes I have been able to avoid drug treatment for many years in people whose lipoprotein profiles would normally be treated with medications.  When scans show there is no disease present, and someone already on a good diet wants to avoid medications, I repeat these scans every few years to make sure it hasn’t begun to form.  I have found this to be safe, less costly and involving less risk of medication side effects.

Every once in a while, I pick up early disease, treat it aggressively, and find it is gone on the next scan! (Though I have never seen it completely resolve in moderate or advanced disease.)   I have accumulated dozens of cases where this has happened.

In a couple cases, using a cardiac scoring, I have discovered advanced disease in people with no symptoms of disease, sent them for stress tests, and they went on to have life-saving emergency surgery because of the extremely critical nature of the blockages found.

I have also found some folks who have disease that continues to get worse, as shown by serial scans, despite achieving the most aggressive target levels of lipoprotein levels currently recommended.  Because there has been no other good option, I have pushed the LDL even lower, and usually this stops the deadly progression of this disease process.

In conclusion, some of the approaches I recommend here will not be found anywhere else – as yet.  But we do not have to wait for the mainstream to catch up; we can make use of this life-saving technology now.  By aggressive use of medications and diagnostic tests we now have available, almost all of the deadly results of atherosclerosis are preventable!