By now, most of you know the importance of being your own best Medical Advocate; It’s about taking control of your health and remaining in the driver’s seat at all times. Nothing can be more vital when it comes to preventing heart disease.

In celebration of American Heart Month, let’s take this opportunity and apply it clinically. Many of my colleagues expend a lot of energy touting the importance of cholesterol lowering, more specifically LDL(LDL-C), or what I call “lousy” cholesterol. Low LDL-C is clearly a risk factor for coronary heart disease (CHD). However, Medical Advocates go beyond this way of thinking.

IT’S NOT ABOUT HOW LOW YOU CAN GO, BUT ABOUT KNOWING YOUR ACTUAL RISK!

When I evaluate a patient with either confirmed or possible coronary disease, I go through checklist to help identify and stratify his/her risk. As Medical Advocates we don’t simply lower LDL-C indiscriminately, we assess one’s individual risk.

But first, THE FACTS: Heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States. One person dies every 36 seconds in the United States from cardiovascular disease. About 655,000 Americans die from heart disease each year—that's 1 in every 4 deaths.

WHAT ABOUT HEART ATTACKS?

• In the United States, someone has a heart attack every 40 seconds.

• Every year, about 850,000 Americans have a heart attack. Of these, 605,000 are a first heart attack.

• About 45% of heart attacks are silent—the damage is done, but the patient is not aware of it.

The enormity of the problem is obvious. Now how do I, The Medical Advocate approach the patient? These are some my current tools:

• Exercise stress test (stress echo or nuclear stress)

• Advanced cardiac lab testing

• Coronary artery calcium scan

• PULS test

STRESS TESTING: If the patient is having chest pain or a symptom that might suggest a cardiac etiology (cause), I will more than likely order an exercise stress test. This is a physiologic test, because it reflects how the body works. A positive test suggests that the patient’s heart may be deprived of oxygen. A blockage or stenosis is generally the culprit here.

LAB TESTING: In assessing a patient’s risk, I’m looking at a lot more than mere cholesterol levels. I’m evaluating the size of the HDL and LDL particles, as well as the presence or absence of Lp(a). Bigger is better. Large buoyant LDL is less likely to cause plaque than small, dense LDL. Lp(a) is an inherited fragment of LDL-C which is extremely sticky and inflammatory. I’m also interested in assessing an individual’s inflammatory, metabolic, and genetic profile.

• Is inflammation present? Chronic inflammation fuels CHD.

• Is the patient prediabetic, diabetic, or have metabolic syndrome?

• Does the patient have an abnormal genotype that predisposes him/her to CHD?

Standard lab testing is simply not sufficient. What is needed is advanced lipid testing such as that obtained from Boston Heart Diagnostics and Cleveland Heart Lab. Your average cardiologist doesn’t order this testing, so as Medical Advocates you may have to request such testing or search for a physician who performs it.

These tests are incredibly valuable, because the results can help identify high risk individuals. My clinical decision making is often based on these results.

CORONARY ARTERY CALCIUM SCAN: This is a rapid CT scan which detects the amount of calcified plaque in the coronary arteries. As opposed to an exercise stress test which is a physiologic or functional test, this scan is purely anatomical. This test gives a numerical score. A perfect score is zero, which becomes less likely as we age. Typically, a score of more than 400 indicates an increased chance of developing heart disease or suffering a heart attack in the next two to five years.

I often repeat this scan every two years to gauge the success of my preventative program. A 5-10% annual increase in score is commonly seen in the average patient. My goal is to lower that range, and therefore, the risk.

One caveat with these scans; they only detect calcified plaque. Plaque starts out as a waxy substance comprised of cholesterol and fat. Over time, calcium is laid down and the plaque hardens. You can have a negative or low calcium score yet have soft plaque in the coronaries which escapes the detection of the scanner. SO, DON’T BE FOOLED BY A LOW SCORE! Soft tissue plaque can be particularly ominous since it is the usual culprit in precipitating acute heart attacks.

PULS TEST: This is the new kid on the block, at least from my perspective. This test fills a missing gap. As you can surmise, the evolution of plaque is years in the making. One can have a stable calcified plaque for quite some time. That is detected quite nicely by the coronary artery calcium scan. However, and without warning, a stable plaque can become unstable. These unstable or vulnerable plaques can rupture, leading to an acute heart attack or stroke.

PULS is a blood test. It detects the early stages of coronary disease by evaluating what is happening at the endothelial level. The endothelium is a one cell thick layer which lines our entire arterial system. Once damaged, inflammation occurs, setting the stage for plaque.

Once the endothelium becomes damaged, the body’s immune system is activated. The PULS test measures multiple biomarkers of the immune system ‘s response to arterial damage. It can help predict whether a cardiac lesion could rupture within a 5-year period.

Why is this important? You can have a heart attack without even knowing it. A silent heart attack accounts for 45% of heart attacks and are more commonly seen in males. Each year in the United States, 400,000 to 460,000 persons die of unexpected sudden cardiac death in an emergency department or before reaching a hospital. Reducing the proportion of out-of-hospital sudden cardiac deaths would decrease the overall incidence of premature death in the United States.

The PULS test and its ability to detect the immune system’s response to endothelial damage can be useful in cutting down the number of these deaths. Waiting for lesions to calcify may be too late.

PUTTING IT TOGETHER

Utilizing the various tests profiled above allows for stratifying a patient’s cardiac risks. Such a multifactorial approach is the Medical Advocate way to practice prevention.

As a patient, you can and should be your own best medical advocate. Speak up, be heard, do your research, and always stay in the driver’s seat as it related to your health.

Happy Heart Month!

Howard Elkin, MD

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this blog. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2021.