Cardiovascular diseases continue to be the Number One cause of death in the U.S.
Among these conditions, the primary causes of mortality are coronary heart disease, angina, myocardial infarction, stroke, and congestive heart failure. Unfortunately, we have reached a limit in our treatment of coronary heart disease using traditional medical interventions.
Over the past two decades, the primary approach to treatment has been to target the top five risk factors: Hypertension, elevated cholesterol and triglycerides, obesity, diabetes, and smoking. The problem is, in cardiovascular medicine, we have developed a false sense of security based on the belief that if we just addressed these five major risk factors, we will be able to prevent most of the incidents of heart attacks, but this is simply not the case. The traditional evaluation, prevention, and treatment of these top five coronary heart disease risk factors still result in a large gap.
The gap implies that, despite aggressive and optimal treatment of these five risk factors, we are still missing something. The gap reflects that about 50% of patients will still develop heart disease or myocardial infarction despite normal levels of these risk factors as defined in the medical literature on their blood tests.
There are important details within each of the five heart disease risk factors that are not being measured by physicians, and thus ignored in the prevention and treatment. To have more impact on cardiovascular disease, we must now look to 395 risk factors and the details within the top five.
Today, some of the most innovative thinking in cardiovascular care is occurring in the field of metabolic cardiology and functional medicine. This means look beyond just the major risk factors to identify the risk mediators, underlying causes, and metabolic and functional disorders that are actually inducing the heart disease. We go to the genesis of what are causing the problem.
To explain our new perspective on heart disease, we must look at the three primary biological responses in the heart that cause disease. These are inflammation, oxidative stress or free radicals, and autoimmune disease of the vascular wall, the vascular endothelium and the heart.
This strategy is for diagnosis, prevention, and treatment growing out of this understanding. The first step in treating the individual patient is to identify which of these three responses is predominating, then we backtrack to the additional triggers that induce the disease in the first place.
This is total revolutionary thinking in the field of cardiovascular treatment. The advantages here are that if we can get these responses under control and then backtrack to identify the triggers, we can be more effective in preventing, managing, and resolving the problem. With this approach, we can address the top five, but as many as 400 or more. We have solid scientific basis for the perspective, because these risk factors have already been identified and documented.
The next point to realize is that there is an infinite number of potential attacks on the vascular system and heart. These include any type of adverse event or stressor, yet all of them can trigger and compromise the heart. They are either biochemical or biomechanical stressors. These stressors may be one of the top five, or they could be another one of the 395 that we do not talk about. It could be a toxin; it could be a heavy metal; it could be a chronic tooth infection or some other environmental issue that we do not even measure, such as persistent organic pollutants in the air. Biomechanical stressors include not only elevated blood pressure and stress in the arteries, but other forms of vascular dysfunction. The biochemical insults, they can include chemicals or toxins that we are exposed to, reflecting either elevated or dysfunctional levels of hormones, glucose, oxidized LDL, which is a bad cholesterol, insulin, and homocysteine. This could be termed our total toxic burden. The list is nearly endless.
There is a new view in the vascular system, a key to understanding this.
The critical understanding is on the nature of the vascular endothelium and its function. The endothelium is a layer of cells that line the heart and every blood vessel in the body. This network is considered an entire organ system, one of the largest in the body. It is a single, monolayer of cells that essentially separates the blood from the vascular smooth muscle.
If the endothelium is healthy, then the blood elements are healthy, avoiding oxidative stress, inflammation, immune dysfunction, or adhesion molecules; CRP levels are normal and platelets do not aggregate or grow.
The heart functions normally, and there is no evidence of hypertrophy, stiffness, or thrombosis. The system functions well. If the endothelium becomes unhealthy, this communicates downstream to the vascular smooth muscles and dysfunction occurs. Vasoconstriction occurs with an increase of blood pressure and causes leakiness in the endothelium, with symptoms that include albumin in the urine, proliferation of growth, foam cells, fatty streaks, plaques in the arteries, and finally, chest pain, angina, or an eventual heart attack. Endothelial dysfunction is the key to understanding how an individual initially develops cardiovascular disease.
When the artery is insulted, there is a trigger of natural responses. The blood vessel says, “I’m going to defend myself, whatever it takes.” The body mounts an immune response. However, when the response is chronic in the form of chronic free radicals, inflammation, or autoimmunity, the patient begins to experience trouble.
The goal here is to identify endothelial dysfunction where it is just beginning and treat it aggressively, which can prevent clinical disease from occurring two, three, or four decades later. Testing for vascular dysfunction is performed in the office, and there are a number of effective tests that can be done. Noninvasive cardiovascular tests have been shown to be accurately measuring endothelial dysfunction, and they are current available.
In addition, measurements of central aortic pressures are also obtained, which are a better correlator of end-stage disease with mortality and morbidity.
Testing for the immune reaction, inflammation, and oxidative stress is performed by using your blood. Inflammation is tested by obtaining a high-sensitivity CRP. Oxidative stress that is free radicals is obtained measuring an oxidized LDL, and numerous other markers in the urine such as MDA and 8-Hydroxyguanosine. The autoimmune reactions can be measured using your immune system and test for T-cells (T4 and T8 helper cells and levels of regulatory cells, as well as interleukin levels and TNF alpha).
These markers will give you an accurate assessment of what you need to do to treat oxidative stress, inflammation, and autoimmune reactions and insults to the vascular system.
We need to identify the initial trigger. We need to remove the chronic insult. We need to turn off the inflammation and remove it from the system. The goal here is to ask why does the patient have cardiovascular disease? Why does he have chronic inflammation, oxidative stress, or immune dysfunction that is causing the heart disease?
This is the time to backtrack and identify as best as you can, which of the 400 different risk factors are causing the disease. This phase calls for careful evaluation, a careful and complete history and physical and sending out appropriate labs, and then beginning the analysis, including gene testing or single nucleotide polymorphism testing. This might be identifying the patient with mercury exposure from old mercury amalgams, so we might go on to measure a mercury level. If elevated, then we will need to carefully remove it. Frequently the inflammation goes away, the CRP protein will go down, and the endothelial function will return to normal. This enables you to reduce your risk at a much earlier phase before you develop heart disease.
In developing a treatment plan, I draw on functional and metabolic medicine and take an integrative approach. I use nutrients along with medication, as well as the medications do not have adverse side effects. Treatment is always subscribed with lifestyle changes, such as weight management and exercise. In terms of nutrients, it is important which nutrient has been scientifically validated and which can be used in conjunction with other nutrients.
It is even more vital to note which nutrients can be used in combination with medications that have been shown to reduce heart attacks and heart failure.
Once I have made the diagnosis, I have a good idea of what the patient’s symptoms are, and I develop a treatment program. This provides an opportunity to be truly integrative. In advanced disease, I start the patient on appropriate drugs as well as a good nutrient protocol with antioxidants, anti-inflammatories, and given nitric oxide support as well as integrative lifestyle management programs.
The goal is to treat the arteries and also the heart. With less-involved cases, those that are less severe, I may not use drugs at all. I simply use a combination of nutrients, antioxidants, and detoxification and tailor-make therapies.
The good news is, that we now have excellent clinical peer-reviewed medical literature which identifies which nutrients can be used to treat high blood pressure, high cholesterol, obesity, and diabetes. There is also research concerning nutrients that are effective in treatment of cases of heart failure, coronary heart disease, and in risk factors.
It is important that we begin identifying people in their teenage years and early twenties who develop vascular disease. We know from autopsy data from the Korean War and Vietnam, that many people just 18-20 years old already have existing coronary heart disease. An integrative perspective on cardiovascular disease could potentially change this treatment of vascular conditions and heart disease, and ultimately save lives.
DEAN R. SILVER, M.D.