Uncover all risk factors early to prevent cardiovascular disease
In the United States, 2,150 people die from cardiovascular disease each day, an average of one death every 40 seconds, according to the American Heart Association (AHA). Although death rates attributable to cardiovascular disease declined by 31% from 2000 to 2010, far too many women, men and children needlessly die, say heart disease experts Suzanne Steinbaum, DO, and Sam Fillingane, DO.
This is the third in a series of articles on how osteopathic primary care physicians can better manage patients who have chronic diseases. The first article focused on asthma and the second on diabetes mellitus.
Dr. Steinbaum, a cardiologist, and Dr. Fillingane, a family physician who specializes in cardiovascular risk reduction, have similar missions: to prevent heart disease through early detection of risk factors and aggressive intervention that includes lifestyle changes and, if necessary, medication. Both DOs agree that primary care physicians do not know enough about heart disease and should use more screening tests to identify potential cardiovascular problems before symptoms occur.
Underdiagnosed in women
Cardiovascular disease is the No. 1 killer of women in this country, taking more lives than all forms of cancer combined, points out Dr. Steinbaum, the author of the book Dr. Suzanne Steinbaum’s Heart Book—Every Woman’s Guide to a Heart Healthy Life. Although they may be aware of that statistic, many primary care physicians are unfamiliar with the AHA’s guidelines for preventing cardiovascular disease in women, last updated in 2011, she says.
“The risk factors for heart disease in women are not just high blood pressure, high cholesterol, diabetes, smoking and a family history of heart disease,” Dr. Steinbaum says. “Obesity and stress play a significant role in the development of heart disease in women, as does depression.” Other risk factors include menstrual history, pregnancy history and age of menopause, she says.
“For example, women who’ve had both both preeclampsia and elevated blood pressure during pregnancy have an increased risk of heart disease later on in life,” says Dr. Steinbaum, who runs the Women and Heart Disease program at Lenox Hill Hospital in New York City. “The later a woman becomes pregnant, the earlier she began menstruating and whether she used any form of birth control or hormone replacement therapy—all of these variables play a role in cardiovascular disease’s development. Women who’ve had multiple miscarriages are also at increased risk, as are women who’ve had an early menopause.”
Consequently, when taking a woman’s health history, primary care physicians need to ask detailed questions about menses and pregnancy, stress levels, depression, anxiety and feelings of social isolation to gauge their cardiovascular risk, Dr. Steinbaum says.
“The majority of physicians think that if you fix the cholesterol or lipid problems, then you’ll fix cardiovascular disease. Nothing could be further from the truth.”
Dr. Steinbaum recommends that patients have a coronary artery calcium (CAC) scan, a carotid intima-media thickness (or CIMT) test and a test for endothelial dysfunction. “These are not diagnostic tests, but they give you an idea of whether plaque has started to develop in the arteries,” she says.
“The number of people who die yearly from major cardiovascular diseases in the United States is roughly equivalent to the number of Americans who have died in U.S. military conflicts since 1775,” points out Dr. Fillingane, who runs a cardiovascular clinic in Jackson, Miss., and is featured on “Straight to the Heart,” a nationally broadcast television program about heart health. “Almost all of these cardiovascular deaths could have been avoided.”
When Dr. Fillingane practiced as a primary care physician, three of his patients unexpectedly died back-to-back from heart attacks. “It had a huge impact on me,” he says. “I was just devastated by this, and I vowed I would get better at preventing cardiovascular disease.”
To learn more about heart disease, he started attending the meetings of other medical specialties. “I went to the meetings of cardiologists, endocrinologists, psychiatrists, neurologists and pathologists,” he says. “I found out what each group understood about this disease. Interestingly, I learned that there was a lot of information one group had that the others didn’t have. The various medical disciplines don’t intercommunicate very well.”
What Dr. Fillingane came to realize is that primary care physicians today focus too much on cholesterol as a risk factor for cardiovasulcar disease and aren’t familiar with other significant biomarkers. “The majority of physicians think that if you fix the cholesterol or lipid problems, then you’ll fix cardiovascular disease. Nothing could be further from the truth,” he says.
In fact, he contends, the correlation between inflammation and cardiovascular disease is stronger than the relationship between cholesterol and heart problems.
Many physicians, says Dr. Filligane, simply order a standard lipid profile to determine a patient’s high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides. But this measurement of cholesterol content is misleading, he insists.
Patients with low LDL-C and high HDL-C are often deemed at low risk for heart disease. But insulin resistance—a very common condition in people over age 30—causes LDL-C (the so-called “bad cholesterol”) to decline, Dr. Fillingane notes. In insulin-resistant patients, LDL-C is being exchanged for triglycerides, he says.
Dr. Fillingane recommends that physicians order an advanced lipoprotein profile that measures LDL-P (the actual number of LDL particles), as well as apolipoprotein B (known as Apo B). Both of these measures are more closely linked to cardiovascular disease and are recommended by the National Lipid Association, he says.
“The longer a patient is insulin-resistant, the more misleading the LDL-C value is—measuring so low that the physician thinks nothing needs to be done for that patient,” Dr. Fillingane says. “The measurement of LDL-C instead of LDL-P or Apo B is a leading cause of patients being undertreated for cardiovascular disease.”
“I have no sympathy when people tell me they are too busy to exercise.”
Patients being assessed for cardiovascular disease should also be checked for a gene mutation—methylenetetrahydrofolate reductase (MTHFR)—Dr. Fillingane suggests. “This genetic defect affects a person’s ability to convert folic acid into L-methyl folate, which is necessary to make the neural tubes that develop in the womb and is a cofactor in the production of four major brain chemicals,” he explains. “MTHFR is the No. 1 reason for miscarriage in this country, and it associated with increased cardiovascular risk.
“Yet if you were to ask 100 doctors in primary care what the MTHFR genetic defect is, I don’t think five could tell you. And it’s probably the biggest cardiovascular breakthrough we’ve had in the past decade.”
Dr. Fillingane stresses that there is a strong relationship between endothelial inflammation and heart disease. The best way to prevent cardiovascular problems, he says, is to assess for and address eight disease states that trigger this inflammation: diabetes, dyslipidemia, hypertension, sleep disorders, chronic kidney disease, genetic disorders, autoimmune and inflammatory disorders, and depression and other mental health disorders.
“Psychiatrists have a big piece of the cardiovascular disease puzzle,” Dr. Fillingane observes. “Numerous studies show that people with untreated depression, general anxiety disorder or bipolar disorder have a 40% to 45% increased risk of cardiovascular incidents. To make up for brain chemical deficiencies, the body circulates high levels of adrenaline. And this adrenaline is caustic. It creates inflammation.” Inflammation is what leads to the formation of atheromatous plaque, he notes.
Any of the eight disease states needs to be diagnosed and targeted to lower a patient’s risk of developing a cardiovascular incident, says Dr. Fillingane, who will give a four-hour presentation on cardiovascular risk reduction, divided into two parts, at OMED 2014, which will take place Oct. 25-29 in Seattle.
“I plan on showing how advanced cardiovascular biomarkers can give a physician more than two years of warning before a stenosis-related heart attack would occur and six to eight months of warning before a plaque-rupture-related heart attack would occur if the situation is not addressed,” he says.
If screening tests show abnormalities, primary care physicians need to work with patients to tackle the risk factors, Dr. Steinbaum and Dr. Fillingane concur.
One benefit of having patients undergo a CAC scan is that it shows them whether plaque is beginning to form in their arteries, Dr. Steinbaum says. “Patients are more likely to make changes if you can show them, ‘You have a problem. You have plaque in your arteries because of your lifestyle. And you need to do something about it.’ ”
Dr. Steinbaum asks such patients if they want to be on medication, and the answer is usually no. “So I’ll say, ‘Then the only way you can reduce your risk of heart disease is through diet, exercise and stress reduction.’ ”
She asks patients to write their own heart books by keeping track of what they eat and when they exercise. “If you aren’t aware of what you’re doing, you won’t know the changes you need to make,” she says.
If a patient who has a sedentary job eats breakfast at Dunkin’ Donuts and lunch at McDonald’s each day, for example, Dr. Steinbaum will help that patient come up with more healthful alternatives that are also convenient. She will often suggest that a patient who has an hour for lunch go on a 50-minute walk with a co-worker and then take 10 minutes to have a container of yogurt, an apple, some nuts and granola. And she will advise busy professionals who have to work through lunch to divide exercise up into 10-minute increments throughout the day.
Dr. Steinbaum, who has a 7-year-old son, is extremely busy herself, so she will explain to patients how she incorporates exercise into her own life. She chooses activities with her son that allow her to get a cardiovascular workout while he does something fun. “For instance, he’ll be on a scooter while I run,” she says. She also does calisthenics, such as sit-ups and push-ups, after he goes to bed.
“I have no sympathy when people tell me they are too busy to exercise,” she says. “I do understand this feeling, but we all have to do it. It’s about finding ways to fit it in.”
Dr. Steinbaum also encourages patients to take up transcendental meditation, which research has shown reduces stress. She refers patients to TM.org, where they can search for local classes.
Dr. Fillingane uses what he calls “word pictures” to get his patients to comply with diet and exercise directives that he says are essential to reversing the inflammatory processes that lead to heart disease. He sometimes tailors these scenarios to the patient’s situation.
One patient, a dentist, once argued that he didn’t have time to exercise seven days a week, as Dr. Fillingane had instructed. “So I said, ‘You know how busy I am. You don’t really expect me to brush my teeth every day, do you?’ You have to give patients examples they can relate to, so they will attitudinally change.”
A favorite analogy of Dr. Fillingane’s is marriage. “If you are faithful in marriage, you usually have good outcomes,” he notes. “If you’re not so faithful, problems tend to occur.
“At times, a patient will say to me, ‘Dr. Fillingane, I only cheated on my diet three times last month.’ So I will say, ‘I only cheated on my wife three times last month.’ Patients always look appalled when I say this, but then they begin to understand my point.
“Of course, it’s not acceptable to cheat on your wife three times in a month. But it’s also not acceptable to cheat on your diet three times.”
Lately, Dr. Fillingane has been using another analogy on a patient’s first visit. “I’ll say, ‘There is a fire behind three walls of this room. And there is a door right in front of you that is the only way to get to safety. You have to move quickly.
“If you make excuses, such as ‘I’m too busy to get up right now’ or ‘My leg hurts too badly,’ you are going to burn to death in that fire.”
Dr. Fillingane says his outcomes support his methods, but he can still improve his results. “I have data showing that 73% of my patients have plaque regression. Another 20% of my patients have plaque stability, which means they are not getting better or worse. And 7% of my patients are getting worse.
“The patients with plaque progression are obviously not following the plan of care. That tells me I need to bear down harder. Every patient’s life is worth fighting for.”