Totally Freaked Out
A friend of mine recently underwent the grand kabuki of heart surgeries, the quintuple bypass. Amazingly, he didn't have any of the traditional risk factors. His blood pressure was normal, as was his cholesterol. He didn't smoke, eat a high fat diet, or have high iron levels. He hadn't had a heart attack or, for that matter, any symptoms at all.
Nope, his blockages had been diagnosed during a stress test and a subsequent heart catherization. The blockages, he was told, could dislodge at any moment and totally clog up his arterial plumbing, just as deftly and efficiently as if you'd dropped an Idaho potato into the toilet and tried to flush it.
He's fine now, but his doctors have given him some puzzling and often contradictory advice that prompted me to start digging, terrier-like, into cardiology. What I've found has got me totally freaked out. Among the things I've read is an inadvertently scary book titled, "Open Heart," by Jay Neugeboren.
Neugeboren, an apparently healthy man in his early sixties with no overt risk factors associated with heart disease, underwent major heart surgery after being repeatedly misdiagnosed. He too received a quintuple bypass. Luckily, he had four childhood friends, all doctors, who advised him and took care of him.
Given his near death experience, he began researching heart disease and unearthed mountains of disturbing information. Consider first the issue of cholesterol: More than a third of individuals who have heart attacks have normal cholesterol.
And if you look at all the studies, you'll find no evidence that lowering cholesterol prolongs life. Disturbingly, there's a consistent and mysterious increase in deaths from other causes when you reduce cholesterol. And, get this, once you drop cholesterol below 180 mg/dl, the death rate also increases.
Yet every two years, experts from around the world meet and decide that the normal and accepted cholesterol level is invariably lower than it was at the last meeting – without having any solid evidence to back it up.
Regardless of this lack of evidence, the cholesterol boogieman lives on. By the early 1970's, each biochemical step of the chain from dietary fat to cholesterol to heart disease had been mapped out, but the legitimacy of the claim as a whole has never been proven.
The closest they've come is through a study in 1991 funded by the US Surgeon's Office. They determined that if Americans cut the amount of saturated fat they ingested, they could delay 42,000 deaths each year. That means that if a woman who avoided saturated fat her entire life – who otherwise might have died on her 65th birthday – might live an additional two weeks.
Two weeks isn't long, but it might at least allow her to live long enough to find out if Billy, Biff, or Todd is the father of Ashley or Bree's daughter on her favorite soap.
Even so, the role saturated fat plays in heart disease is controversial. Other factors may be involved.
So where did the cholesterol myth originate? You probably need to look no further than the drug companies that manufacture cholesterol drugs.
A recent study involving the cholesterol-lowering drug cholestryamine (Questran) and 1900 patients found that out of those taking the drug, only 30 had a fatal heart attack. And the number of those not taking the drug that had fatal heart attacks? Thirty-eight.
Statistically, that means the cholestryamine, over a course of seven years, reduced the chances of having a fatal heart attack by less than half a percent. However, the drug company interpreting the tests found it preferable to say that cholestryamine reduced the chances of dying from a heart attack by 25%.
Sure, eight fewer deaths out of a total of 38 patient is indeed 25%. As they say, there are lies... and then there are statistics.
But even if cholesterol does lead to severe blockages, these blockages cause at most three out of every ten heart attacks. While doctors almost across the board used to believe that heart attacks were caused by a build up of plaque that would eventually rupture and cause blockages, that isn't necessarily the case anymore.
It seems that if you combine all known risk factors such as wrong kinds of fat in the diet, cholesterol, smoking, high blood pressure, markers for inflammation, and diabetes, they explain only half the risk of developing atherosclerosis.
The answer most often given to explain this conundrum is that it's likely genetic, which, according to Dr. Rich Helfant, a cardiologist, is another way of saying, "We don't know why these things happen."
A relatively recent path of research points at another possible cause: hormone balance. A 2014 article from the Journal of the American Heart Association compiled the results of 100 testosterone studies and found that low testosterone was associated with higher rates of cardiovascular disease and higher rates of mortality in general. Additionally, the severity of the disease correlated with the degree of testosterone deficiency.
Estrogen levels, too, are important in men. When researchers monitored the estrogen levels of 501 men with chronic heart failure, men with estradiol (the most "potent" form of estrogen) in the normal range (between 21.80 pg/ml and 30.11 pg/ml) had the fewest deaths during a three-year period.
Men with the highest levels (above 37.99) had 133 percent more deaths during the same period. However, the men with the lowest estrogen levels (below 12.90) fared the worst as they experienced 317% more deaths.
Clearly, estrogen levels play a big part in the health of your ticker, in addition to the health of a whole lot of body parts, body systems, and body functions.
Still, there's got to be more to it than having optimal testosterone and estrogen levels. There's also the problem of diagnosis itself. "Put a patient with even the slightest set of maladies in front of five doctors, and you might get five different diagnoses, five different prognoses, and five different recommendations for treatment," explains Dr. Helfant.
A 1997 study involving 453 recent medical school graduates found that more than 20 percent of the time, the grads couldn't identify common heart problems with a stethoscope. While that might not sound that bad, given that the lay public probably considers the stethoscope archaic, this simple tool can be incredibly valuable in diagnosing heart problems.
While we seem to hold more technical diagnostic tools in high regard, the truth is much different. Neugeboren cites a British study that found that 75 percent of information leading to a correct diagnosis comes from detailed patient history; 10 percent comes from physical exam; 5 percent comes from routine tests; 5 percent comes from invasive tests; and 5 percent of the time no answers are found.
This epidemic lack of diagnostic success might not be as dire as it sounds because the clinical trials that evaluate ways of treating heart disease are often inconclusive. However, one way this diagnostic ineptitude really is dire is because regardless of whether a doctor recommends bypass surgery, angioplasty, drug therapy, or beating-heart surgery, the results are usually the same.
The sobering fact is that even if a patient receives what the consensus considers to be optimal care and treatment, there's less than a 50 percent chance that the patient will live longer than he or she would have without the treatment.
Even common lab tests are woefully inaccurate. Consider the common blood test for cholesterol. Helfant says that if you send a blood sample to two different labs, there's a strong possibility that you'll get two different results.
As an experiment, Helfant had the same lab repeat his cholesterol test on the same blood sample. The first time, the machine indicated that his total cholesterol was 152. The same sample tested at 176 a few minutes later, a discrepancy of 17%.
"If I had had a 17 percent rise, say from 200 to 234, 34 points above what's considered to be normal, and I'd been seeing all those ads about cholesterol and heart disease, I might have gone on a cholesterol medication for the rest of my life, and who knows what the side effects would be for me down the road since we have no long-term studies of what these medications will do to us," said Helfant.
Neugeboren sums up this worrisome fact by writing, "The troubling news is that when a test is performed more often, the result is both fewer missed cases and more false positive results."
According to Dr. Stephen Oesterle, director of interventional cardiology at Massachusetts General Hospital, over 50 percent of angioplasties performed each year in the US are unnecessary. That translates to over a hundred thousand needless and risky procedures every year.
The other side of the coin is that some patients who really needed treatment are sometimes misdiagnosed and end up dying on a cold sidewalk somewhere.
Could there be something more at work in regards to some of these unnecessary procedures, something more sinister than simple ineptitude?
According to the January 2002 issue of "The Journal of the American Medical Association," 9 out of 10 medical experts who make recommendations concerning the treatment of diseases in general, including heart disease, have financial ties to the pharmaceutical industry. Furthermore, these ties are rarely, if ever, disclosed.
Similarly, many cardiologists and cardiac surgeons own stock in companies that make cardiac stents, surgical instruments, catheters, and drugs. All too often they're also involved in the clinical trials that examine the efficacy of these products.
Doctors for the most part can't agree on what causes heart disease. Sure, there are some statistical probabilities that point to the wisdom of lowering blood pressure and cholesterol, but they don't mean squat if you're one of the 50 percent of men or 63 percent of women who die from heart attacks while not exhibiting any symptoms or strong risk factors.
Similarly, the "correct" treatment is often based on widely varying opinions, outdated science, and even corruption and greed. The only thing that doctors and scientists seem to agree on regarding heart disease is that it's a disease of inflammation.
What's common to just about everyone who dies of a heart attack is a large collection of the white blood cells known as macrophages. These macrophages collect around fatty deposits and they secrete enzymes that digest protein.
The insides of blood vessels are of course made of proteins and in trying to eliminate the fatty deposits, the blood vessels are eaten away, made thinner, and made more susceptible to rupture.
What surprised researchers, though, was that they also found these macrophages in presumably healthy arteries. This indicated that the inflammation was systemic and not localized.
This may be why aspirin, which reduces inflammation, seems to be so valuable in thwarting heart disease. It might also explain why some statins seem to work – not because they lower cholesterol – but because they have an anti-inflammatory effect.
No doubt, if you've read this far, I've pierced the veil of cardiac invulnerability you might have once had. You thought your exercise regimen, along with your healthy fats diet and admirable blood pressure had bulletproofed you against a heart attack.
Unfortunately, it's just not so. We're left with the troubling realization that we could keel over at any minute and face the post-mortem, afterlife embarrassment of having died from something so common as heart disease.
"Geez, I always thought the son of a bitch was healthy. Just goes to show you all that exercise was for nothing."
All I can recommend is that, if you're ever faced with the prospect of cardiac disease, you find a doctor who listens carefully to your symptoms, lest you be misdiagnosed with heartburn and sent on your way. I'd also recommend a second or third opinion from big-city, high-paid docs, even if some are corrupt.
As far as nutritional advice, I have to believe that avoiding trans fatty acids and limiting saturated fat is still sound advice for everyone, but more than that, and given that heart disease seems to be a inflammatory disease, I'd recommend taking the following every day:
- 80 mg. of aspirin (if you're not at risk for hemorrhagic stroke)
- 6 to 10 grams of fish oil, from wild sources (farm-raised fish have different fatty acid profiles)
- 500 mg. of magnesium (crucial to proper heart function, and something most Americans are deficient in)
- Between 90 and 200 mg. of CoQ10 (which is absolutely essential if you're on cholesterol drugs).
- 500 mg. of curcumin (to help fight inflammation)
I also recommend eating as many fruits and vegetables as you can work in or tolerate, along with eating nuts or olive oil (for their monosaturated, heart-healthy fats) every day.
And while it seems that an anti-inflammatory diet and lifestyle is our best insurance against heart disease, we need to also make sure our testosterone levels and estrogen levels are within healthful parameters, as low levels of the former and high levels of the latter appear to play a big part in heart disease.