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Cardiovascular Risk Management

November 17, 2017

• Cardiovascular risk prevention is an integral part of a longevity program. Significant information can be obtained with noninvasive exams.
• The Calcium Score developed by Dr. Agatston is a key factor in preventive cardiology.
• Cholesterol testing and blood work identifying chronic inflammation are important.
• Blood pressure assessment and management is essential to decrease cardiovascular risk.
• SphygmoCor is a valuable tool to assess peripheral and central blood pressure in a noninvasive fashion.
• Testing for mercury and lead can identify a source that stiffens the blood vessel leading to a higher blood pressure. Look at your Oligoscan for nutrients and toxic heavy metals that was done in my office.
• Other currently available exams related to heart and blood vessel structure and function are reviewed.
• Data from multiple tests can provide information identifying significant risk and direct the aggressivity of treatment.
I graduated from medical school in 1975. This allows me to reflect on advancements and changes in medicine. As a surgeon, on critically ill patients who needed careful cardiovascular and pulmonary management, I learned to place various lines and plastic catheters with the tip positioned in the lungs, heart, and large arteries and veins located inside the body. There was always some risk with the procedure since it was invasive. It was also time consuming to perform and required monitoring by nurses and careful supervision by physicians. During the time of my training the main preventive measures being pushed for cardiovascular risk were management of blood pressure, cholesterol, and blood sugar.

Now move 42 years ahead. Remarkable is the technology that currently enables us to provide top-notch assessment and prevention in the cardiovascular field.

Here is a 2011 CNN report by Dr.Sanjay Gupta. At that point the calcium score, as developed by Dr. Agatston, became a big step forward in preventive cardiology. Although there may be no current symptoms, the calcium score can identify patients with increased risk for blockage in the coronary arteries. With an unexpected, acute heart attack, 50% of patients do not make it to the hospital alive.

The calcium score is most frequently done with CT scanning. Another imaging device is an electron beam tomograph (EBT). Besides calcium score for cardiac health, the EBT can also produce images of internal organs in the chest and abdomen. This allows a very comprehensive study including identification of silent issues that have not caused symptoms. The biggest advantage compared to total body organ imaging done by CT scan is that the EBT provides much less radiation exposure. Click to view an EBT scan Only about 50 units are available throughout the world and there is one in New York City. The exam can be done in 30 minutes with minimal preparation.

Besides heart events, there are other significant areas of cardiovascular disease that require attention. Strokes usually do not kill immediately but lead to long-term disability. Gangrene and loss of limb is another cardiovascular condition. Prevention is important here.

What bloodwork is used in the evaluation?

First of all there is cholesterol. This is a very important chemical to the body. It makes up every cell membrane, serves as a neurotransmitter in the brain, and is used to make sex hormones and vitamin D. Suboptimal levels of testosterone and vitamin D will be associated with an elevated cholesterol. Optimizing vitamin D and testosterone levels lower cholesterol without medication.

In patients with persistently elevated cholesterol, a blood test is available to look more specifically at the good and bad cholesterol. Instead of relying on a total number, the so-called bad cholesterol can be quantified into a number of particles. Some of these are associated with significant atherogenic risk. Others are not so bad. The good cholesterol should contain many particles that have a protective effect. Looking at the sub particles can give a better idea of how aggressive to be to lower the cholesterol numbers. There are definite side effects from the statins such as a decrease in cognitive function and dementia. More detailed data about cholesterol helps determine cardiovascular risk and can direct how aggressive and extensive a program should be developed.

High Cholesterol: New Strategy for an Old Battle Next, consider sugar. The metabolic syndrome consists of obesity, elevated cholesterol, and high blood sugar and represents metabolic changes that have occurred in the body. Rather than treat numbers there is a need to look at the overall picture and attempt to improve metabolism to lower sugar and decrease insulin resistance. Testosterone improves sugar metabolism. Hemoglobin A1c, insulin, and cortisol as well as triglycerides and VLDL cholesterol are important markers for sugar.

There are blood tests to identify increased chronic inflammation that directly affects the lining of blood vessels. Inflammation leads to building plaque or blockage in the vessel. Even without much plaque, the inner lining can become unstable from chronic inflammation and lead to an unpredicted obstruction like a clot. Cardio CRP and homocysteine are the most common blood tests for inflammation. Those more specific for chronic inflammation affecting the lining of blood vessels include myeloperoxidase and another called the PLAC test. Others like fibrinogen, serum insulin, ferritin, and most recently one called ceramides enhance the ability to identify patients with significant chronic inflammation. Improved risk assessment directs the aggressiveness of treatment. Changes in these tests can also be used to determine the effectiveness of the treatment program. The levels can be monitored as a response to medical treatment.

Nitric oxide is vital as far as blood vessel health and can be measured with a simple office exam using a sample of saliva. Nitric oxide is protective for the health of the interior lining of the artery by affecting lipid oxidation. It also relaxes smooth muscle cells in the walls of blood vessels that allows them to dilate. This certainly improves blood pressure.

A sonogram (sound waves) is used to look at structure and flow through various superficial and deep blood vessels. Other anatomic structures can also be identified. In the neck, for example, the thyroid gland and lymph nodes can be seen. A sonogram will identify plaque that may be forming in the carotid arteries in the neck. Plaque One photo demonstrates a blood vessel plaque that has been removed from an artery during surgery. The flow of blood was over this surface. The second is a cross-sectional area across a plaque that had nearly occluded the blood vessel with only a very tiny, remaining opening for flow. Look at the plaque. It is not homogeneous. Something else is going on there. That is inflammation affecting the plaque.

Even in the absence of plaque an assessment of the inner lining also can indicate increasing cardiovascular risk. This evaluation is called the CIMT and evaluates the thickness of the blood vessel lining and demonstrates characteristics such as the quality and the lining surface. These can indicate early changes due to atherosclerosis and be used to determine risk and direct the treatment program. CIMT In the top photo you will see a thin green line which demonstrates a normal inner lining and minimal thickness. The bottom ultrasound exam shows a thickened, fragile, and inflamed inner lining. This patient was told he had no blockages when a heart cath was done. He developed an obstructing blood clot and died suddenly. No plaques, just a sudden clot occluding a diseased blood vessel.

A sonogram of the heart is known as an echocardiogram and can give detail about structure and blood pressure inside the heart and major arteries, the function of valves (too tight or too leaky), and actual pumping ability of the heart muscle. Echo Heart muscle function is measured as an ejection fraction and the echo can demonstrate any localized area of abnormal muscle activity which would indicate an inadequate blood supply suggestive of a blockage in heart blood vessels. Based on this information, further evaluation can be done with a heart catheterization. So noninvasive studies first before invasive testing.

One risk factor that increases cardiovascular risk is high blood pressure. How can that be evaluated in a preventive or treatment fashion? 140/90 is considered on the border of the high zone. When arm blood pressure is borderline by accepted numbers, further data can show how significant this may be and direct how aggressive to be in treatment.

There is a noninvasive blood pressure monitor called the Sphygmocorp. This goes through a series of measurements and can tell several things about the blood vessel.

A. First, it will give the stiffness of the blood vessel. This is reflected as the box labeled central augmentation index. Normal arteries and veins are able to dilate as the muscle wall relaxes. As we get older, atherosclerotic changes in the blood vessel or accumulation of heavy metals may make the blood vessel more stiff and the blood pressure goes up.

B. Second, measurement of arm blood pressure is then correlated with pressures from deeper blood vessels inside the heart, lungs, and the big blood vessel leading out of the heart called the aorta. Monitoring the aortic pressure has been shown to be more significant than arm blood pressure (systemic) for stratifying cardiovascular risk. This link shows the arm blood pressure was 134/84 and the aortic pressure was 120/86. If the aortic pressure is acceptable then treatment with medication may not be the first step in patients with borderline arm blood pressure. There are side effects with many blood pressure medications and one of the more common includes impotency. Again, useful clinical data can be helpful to direct treatment.

Increased mercury and lead accumulation in the blood vessels make them more stiff. This is subtle with no acute symptoms, except mild blood pressure elevation. Looking at tissue levels for these heavy metals is helpful because signs and symptoms of heavy metal toxicity can be very deceiving. Click here to view an Oligoscan Besides raising blood pressure, these heavy metals can affect cardiovascular risk by increasing inflammation and fragility of the inner lining. They adversely influence the immune system predisposing to the development of cancer or aggravation of immune disorders such as rheumatoid arthritis or conditions such as psoriasis. The rash from psoriasis can be improved many times through a detox of heavy metals and other toxins. The skin is the largest organ for secreting toxins and when I see odd skin rashes I consider toxicity as a possible source. I have seen rosacea disappear when significant mercury levels were decreased.

Finally, there have been tremendous advances in genetic testing. This can give information about genetic risk for cancer, cardiovascular disease, and other inherited degenerative conditions. The more baseline data known helps dictate the direction of a preventive program.

Information obtained can give an idea of risk, what further needs to be evaluated, what should be treated, and demonstrate the effectiveness of the treatment program. Some exams presented here may not be available in your medical practitioner or cardiologist practice.

Cardiovascular risk improvement and avoidance of cancer are two primary goals in a longevity program. The key is to provide appropriate clinical information which helps direct a more worthwhile personal preventive program. As far as cardiovascular health, there are significant recent developments in noninvasive testing. These are actually as good or better in supplying reliable clinical information when compared to the procedure of placing invasive lines in a patient for monitoring.

So, this is a summary regarding prevention on the cardiovascular side of age management. Hope it helps.


Posted in Blog by jbosiljevac

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