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Cardiovascular Considerations
Cardiovascular problems are very frequently diagnosed and first treated by primary care doctors. The doctor will test the cardiovascular system by performing a battery of tests. Some tests are blood based and other tests are more complicated. Here is a synopsis of what can be done and how to do it the right way:

Testing for Heart Conditions

Testing for heart conditions starts with a simple two-minute procedure popularly known as the EKG, but this only leads to the discovery of some of the potential problems. Even though every emergency room drama on television seems to rely solely on this common and simple test, the fact is that the EKG may not always reveal even big heart problems right away, if at all. Nevertheless, if the EKG results do not come back favorable or if there are any strong suspicions of cardiovascular illness, the heart needs to be checked further in three different ways.
When you take your automobile to the repair shop, several diagnostics tests are performed on the various systems. The same holds true for testing on the human heart.

1. The Electrical System. The electrical behavior of the heart is checked with a 24 Hour Heart Monitor also called a Holter monitor. This is a small box attached to the patient that continuously records an EKG for twenty-four hours. The box keeps track of and records every heartbeat. The collected data is reported via computer and contains important information for doctors: if the heart slowed too much or beat too fast, or if any dangerous electrical abnormalities or erratic rhythm occurred. If the patient experiences any palpitations or chest discomfort, he or she documents the time of those symptoms, so the EKG recording for that particular time can be re-examined at a later time and be correlated with patients’ symptoms.

2. The Mechanical System. We check the mechanical properties of the heart viaan ultrasound, commonly known as an echo cardiogram, or simply echo. This noninvasive, completely harmless, painless procedure generally lasts for ten to fifteen minutes. A technician places a small amount of gel on the chest, and then moves a transducer over the area, allowing the recording of real time images of the heart. The heart will be checked for overall strength and weakness, valve closing, leakage or tightness, structural integrity, and an important number called the Ejection Fraction (EF). The EF percentage represents how much blood is pumped out of the heart compared to how much blood the heart holds. During a heart contraction the EF shows how much blood (in percentages) is pumped out in contraction versus the relaxed, full of blood, non-contracted heart just prior to contraction. A normal range for EF is 52 to 65 percent. If the percentage is higher or lower, depending on many other factors, it may indicate a problem (heart failure).

3. The Liquid Flow. Like gas and oil flow in a car, our bodies must have an ample supply of blood and oxygen flow to the heart. Flow restrictions to specific parts of the heart can be diagnosed by a more complicated procedure, called a stress test. A stress test checks how appropriate is the blood supply to the heart during times of high stress or higher physical demand. When there is a stronger demand for blood flow and oxygen due to physical exercise or extra stress and worry, the vessels that feed the heart are supposed to dilate to accommodate a proportionately higher amount of blood. A stress test will determine if the blood vessels feeding the heart have the ability to dilate properly when there is a need for them to do so.

When a vessel is partially blocked with calcified plaque, it will be more rigid; the calcified plaque is like a rigid ring around the blood vessel. Because the calcified ring will not dilate, below the ring,even in conditions of higher overall demand of blood and oxygen, there will be no extra supply. The ring is not flexible and will not allow the blood vessel to dilate properly in order to accommodate a much needed higher supply of oxygen.

In other words a stress test is a method by which we test the blood and oxygen supply to specific parts of the heart first on are sting, normal state, and then we artificially dilate the blood vessels to verify if the blood flow will increase, as expected and as appropriate in healthy conditions. If this does not happen, the patient has failed the stress test.

There are many types of stress tests; however, there are only two categories: the chemical stress test, which requires no physical effort from the patient; and the treadmill stress test, in which the patient will exert some physical effort.

The general process of the chemical stress test involves a vasodilator substance being given to the patient intravenously for a very short time, just three to four minutes. The purpose is to chemically trick the heart into thinking that the body is exercising and, thus, the body and the heart requires more blood.

A good number of patients feel nothing when the chemical agent for stress test is injected. Others may experience symptoms similar to those they would feel during intense exercise. This may seem very odd and even unsettling to a patient who is just sitting there and begins to feel flushing, redness of the face, some huffing and puffing, and even nausea or lightheartedness. These side effects are very short lived and only last two to three minutes. Most of these symptoms can be alleviated by deep, long breathing, by moving one hand, or in other simple ways. Some chemical agents do not raise the heartrate; in fact, some may lower it. If the heartrate increases, when it is not supposed to, it is often due to the patient’s nervousness about the procedure.

The recommended chemical agent for a stress test is adenosine, a naturally occurring substance that our bodies already manufacture. The stress test deliversthis substance from an external source, in a higher amount and a more sustained fashion for just about four minutes. For patients with more advanced pulmonary problems, another chemical agent called Lexiscan may be used.

A treadmill stress test is not recommended. A treadmill test, the one where the patient exercises, is only about 50 percent sensitive and accurate, meaning that it usually misses just about half of the existing heart problems. Truthfully, one may fare better by just flipping a coin. For this reason, the treadmill stress test is generally recommended in limited circumstances, usually for younger individuals who are generally in better overall shape and lower risk than older patients.
The vast majority of stress testing should be chemical/nuclear stress testing. They are more accurate, safer, easier to administer and manage, and usually do not require antidotes. Adenosine, for example, burns out in seconds; therefore, if there is any problem, the technician can simply stop the IV push, and the body will quickly return to normal in seconds. When adenosine is stopped all symptoms vanish in a matter of seconds.

Please avoid dobutamine as a stressing agent. Dobutamine is an older agent that significantly raises the heartrate and the test requires a heartrate target for the overall stress test to be accurate.

A chemical stress test may take up to a few hours. The first image set requires ten to fifteen minutes. The blood vessel dilationpart called the stress part may take four minutes, which is then followed by ten to fifteen more minutes for a second set of pictures. Due to the required waiting time and a small snack in between, the process can stretch from two to three hours.

When a patient fails one of the three tests in a significant way, in a way that reveals something more serious is going on, other than minor problems or borderline issues, then further cardiac workup is recommended.

Most of the time, a standard cardiac catetherization is the next step. The cardiac catetherization is an invasive procedure that usually requires an overnight stay in the hospital. It is performed typically in an operating room setting and has some mortality risks and possible complications associated with it, even though minor.

How is the cardiac catheterization performed? First, a catheter (a wire) is introduced through the groin. Then, the heart doctor will advance the wire to the heart, to the origin of your coronary arteries and release contrasting dye that will be visible on the monitor. Based on how this dye spreads out and disperses, the heart doctor can check for any narrowing of the vessel caliber.

If blockages are discovered that can be remedied with stents, this is typically done in the same setting. If the blockages are too extensive, a bypass surgery may be recommended. This recommendation depends also on where exactly the blockages are located in the branched vascular system of the heart.

There is a possible alternative to cardiac catheterization for patients having low risk of a heart condition. For patients who fail a stress test but have only borderline or low risk, a noninvasive procedure called a CT angiogram (CTA) of the coronaries can sometimes make the cardiac catetherization unnecessary.A CT angiogram of the heart is like a regular CAT-scan and can be completed in twenty minutes, on an outpatient basis; it is like a cardiac catetherization done outside the hospital.

If a CT-scan can be used in many cases, you may be wondering why the traditional cardiac catetherization is so often used. The CTA can infringe on the business of the cardiologist, and many cardiologists do not appreciate that.

There are some problems with the CTA: CTA success is very dependent on the reading skill of the one that interprets the test.Some readers have done a lousy job, and this fact combined with some degree of fuzziness and some mild inaccuracies at higher calcium levels led to a compromise in the end between the CTA technology and the cardiology clan. The cardiologists maintain that CTA is not very accurate at more than 50% blockage. That may have been the case 10 years ago, however with today’s technology CTA can deliver the same or even a better evaluation of the coronaries than cardiac catheterization. CTA will also detect soft plaque which is the type of blockage that is most likely to rupture and cause a heart attack, therefore is more dangerous.

The compromise, the “peace agreement” so to say, is that the CTA would not be particularly precise or committed for blockages over 50%. The CTA report will only say if blockages are over or under 50%. For any blockages over 50%, the CTA report would only say that there is a blockage of more than 50% in this exact anatomical position, even though it could easily say that it is likely 90% blockage. They would not report it that way for the above political reasons.

If the CTA shows blockages of over 50% then usually further investigation—aka invasive cardiac catheterization—is typically necessary. Thus, in hindsight, when blockages are diagnosed by CTA of over 50%, the case may be constructed that the CTA was not only anunnecessary procedure, but the procedure was loading the patient with an extra load of contrast dye, and extra radiation. After all, the patient ended up in the hospital anyway.

If blockages are less than 50%, then in hindsight, CTA can also be deemed a very useful procedure, one that will prevent an expensive and invasive procedure, along with a hospital admission.

Clearly, for high-risk individuals, a standard cardiac catheterization is recommended from the start without a CTA, however, for any borderline and low-risk patients, a CTA may be a good idea before we consider an invasive cardiac catheterization.

An important caveat needs to be mentioned here: It is assumed that the higher the degree of arterial blockage, the higher one’s risk of heart attack may be. This is statistically not so. The calcified plaque, the rigid element that blocks the vessel, is more stable. It is when this plaque becomes softer in place, when it is ulceratedand becomes what we call unstable plaque, it is then that a piece of it may rupture and travel downs the vessel,resulting in a heart attack.

Statistically, most heart attacks happen in people with 30 to 50% blockages of their coronary arteries.This means that if the cardiologist performs a cardiac catheterization and tells the patient they are “fine” because they only have a 30-40%blockage; the risk of heart attacks is not really much lower. Being “fine” in this case only means that the patient is not a candidate for stent placement or open heart surgery at this time.

The teaching moment is that the patient should take these findings quite seriously, because they could easily be at higher risk for a heart attack. The right way to respond to these findings is to let them be a wake- up call and trigger a time for major changes in diet, stress level, and measuring, monitoring and lowering of several cardiovascular risk factors.

The Risk Factors

There are many risk factors that increase chances of having a cardiovascular disease or a heart condition. Some are independent of other factors, while others are not. Some factors are entirely out of our control, such as our sex or age; however, the good news is that we do theoretically have control over other factors, such as smoking, or stress management.Some factors are in between, that we may have some degree of control over them.

Independent Risk Factors
In addition to sex, age, family history and stress level, there are several risk factors that we may not have much control over. Some of these factors are:

  • High blood pressure (can be related to weight issues and stress factors)
  • Cholesterol*(genetic and metabolic factors, as well as diet)
  • Triglycerides (hereditary and poor diet)
  • Insulin level (diabetes and pre-diabetes)
  • Depression, sleep apnea, stressful conditions
  • C-reactive protein (inflammation, lupus, rheumatoid arthritis)
  • Homocysteine (aging and nutrient deficiencies)
  • Insufficient vitamins (Vitamin D and K)
  • Insufficient Omega-3 Fish Oil (or other oils), leads to rigidity of blood vessel walls.
  • Fibrinogen (over-coagulation)
  • Insufficient hormones (testosterone in males)

*We will discuss cholesterol in a different chapter, as many people know only enough about this very serious issue enough to be dangerous.

The conclusion we may come to from contemplating the list above is that most doctors choose to narrowly focus their lackluster fight against heart disease on just one or two risk factors. For instance, most cardiologists are absolutely obsessed with the idea that the lower the cholesterol, the better, and many would probably love to drive the cholesterol levels down to zero. In their quest to drive the cholesterol lower, cardiologists totally ignore the price their patients have to pay in terms of side effects, disability, early aging, memory loss, weakness, Parkinson’s, Alzheimer’s, fatigue, and even cancer. Too many times, cardiologists are so focused on the heart that they do not bother to monitor or consider their patients’ side effects or their overall quality of life.

It is ironic that so many cardiologists’doctors are doing this, but it comes as no surprise, since pharmaceutical companies have been spending serious money for decades to indoctrinate most cardiologists of the world.

There is a point I am trying to make here: The point is that it is not going to be your cardiologist or even your doctor’s job to keep a keen eye on all your cardiovascular risk factors. They should do it, but they never do. There are never enough resources, awareness, time, or expertise to address all these factors correctly and in the right context and right order.

We,as more educated patients, are the ones we need to be pro-active,to request and insist that all our cardiovascular risk factors are carefully measured and monitored.

Some cardiovascular risk factors are easy to change, with medications, diet supplements or even exercise, while others are more difficult. Our strategy on how to conquer and mitigate these factors will emerge when we begin to recognize how important each risk factor is.

My advice is to see the whole metaphorical ”forest” first, then act in places of dire need based on your evaluation, rather than trying to beat only one “tree” down (thecholesterol), meanwhile ignoring damaging side effects and real life issues, as many cardiologists are prone to do.

No One Today Should Have Heart Attacks

Based on what we now know about risk factors for heart disease and based on the tests and treatments that are now available, there is really only one serious conclusion to make about heart disease: Virtually no one should be having heart attacks today!

Blood tests reveal cholesterol components and particle size, and more comprehensive blood tests can evaluate the rest of cardiovascular risk factors. Everyone with a heavy genetic legacy of heart problems should take at least two blood tests, and then periodically repeat only those indicators that come back with abnormal values.

If you are just curious or have a high risk of heart disease based on your family history, smoking or high stress level, ask your doctor for the following: adetailed cholesterol particle analysis, a test called VAP (Vertical Auto Profile); and acomprehensive cardiovascular analysis panel, which measures other risk factors besides cholesterol like CRP, insulin level, homocysteine, apolipoproteins A and B and others.

There are now new and extraordinary accurate tests to determine the risks, and even the heart status and function; there are now tests that would predict with a good degree of accuracy heart attacks BEFORE they happen. Tests based on a new technology called Single Molecule Count (SMC) are now developed. They can perform more accurately traditional heart blood tests like BNP or Troponin I, as well as newer tests for cardiac risk factors previously not considered like inflammation level in small blood vessels, plaque ready to rupture, a degree of heart strain before it is failing. Some of these tests are measuring IL6, IL -17A, TNF alpha, and Endothelin.

A good question people may ask is why there are so many heart attacks and strokes when proven ways exist to detect, mitigate, and correct the known risk factors.Yes, ignorance could have been an excuse ten to twenty years ago, when a limited number of studies and the internet was not as extensive. Nowadays, however, based on several decades of intensive scientific research, the underlying causes of cardiac events are not a mystery anymore.

It is the convenient ignorance of what is sitting right in front of you, apathy, ignoring the evidence, along with massivedrug company propaganda. These can be blamed for the fact that a great majority of older individuals are walking around with time bombs ticking in their chests. Not only are many failing to do anything to prevent possible heart attacks, but some people are even working hard to promote them through serious destructive behavior, killing themselves unaware of alternatives. Others are making such minimal effort that they are really only postponing the inevitable.

I can only hope that you, the reader, are not in the above categories, but one who desires to be aware, pro-active, appropriately concerned and in full charge of your own health.

Chapter Summary

  • Beware of the over- or under-diagnosing specialist, because they can both do great damage to your health and your relationship with your primary doctor.
  • If at high risk, undertake a 24 hour monitor, an echocardiogram, and a stress test Insist on a chemical stress test instead of a treadmill one.
  • If your test results indicate some suspicion, CT angiogrammay be useful.
  • Measure, monitor and mitigate your cardiovascular risk factors.
  • Measure detailed cholesterol fractions and all other cardiovascular risk factors.