"The Bullet out there with your name on it"
Joel Posner, Drexel University College of Medicine,
No One dies of Old Age
Last year, 632,020 people died in the United Kingdom. It is reported that
about 40% of them (250,343) died of diseases of the circulatory system. This
probably underestimates the true number since many of the 70 to 80,000 people
who died of sudden death were probably not included though these deaths are
almost always cardiac. Other major causes of death included malignant neoplasms
(24%) and respiratory system disease (17 %.) Everyone is aware of the role of
smoking, alcohol intake, and land-air-and water pollution on these two later
categories of deaths. The medical tragedy is that most of the cardiovascular
deaths were preventable.
Reversible Risk Factors for Cardio-vascular Disease
- Waist Size: The larger the waist, the more intra-abdominal fat, and the
higher the risk of cardiovascular disease. For men under 40, waist size should
be less than 39 inches (100 cm), for men over 40, it should be under 35 and ½
inches (90 cm) inches, and for women, it should be less than 35 inches (89cm).
- Lipids: It is the quantity of blood lipids and the particles size that are
important. Unfortunately, measurement of particle size is seldom available.
The current recommendations for treatment of lipids are not to be trusted. The
heart protection study (HPS) showed that lowering even those "acceptable" LDL
levels of less than 3.0 mmols/L decreases cardiovascular events by 20%.
- LP(a). This is a protein which predisposes to stroke, heart attack, and
complications of hypertension. It should be less than 30 mgm/dL, though lower
- Homocystein: Elevated levels of homocystein have been estimated to cause
up to 25% of myocardial infarction in the US. Desirable levels are <9 mmol/L.
- Glucose intolerance. Both glucose intolerance and insulin resistance
predispose to heart disease and hypertension. It is worth doing a simple one
hour glucose tolerance test in someone in whom you are trying to determine
total cardiac risks.
- C Reactive Protein (CRP.) This is an indicator of greatly increased
cardiac risk. Desirable levels are <0.55 on the "highly sensitive" assay. Risk
doubles when this levels is 0.56 to 1.44 and triples when this level is >2.1.
- Blood pressure. Desirable blood pressure is <120/75.
- Dietary factors (see below).
- Lack of vigorous exercise. Optimal is 200 minutes/week.
- Infection. Simple chlymidia infections have been shown to predispose to
coronary events. Poor dental hygiene does as well. Flossing daily is cardio
- Isocaloric: Weight and waist should be optimal and caloric consumption
should keep weight stable at that point.
- Fats: Limit total fats to a reasonable 40 to 50 g/day, but most
important, limit saturated fats to under 10%. Additionally: mono-unsaturated
fats should be about half of all fats (olive oil, canola oil), poly
unsaturated fats the other half with Omega 3 oils (fish and flax seed
as high as possible. Certainly it should represent five or six grams of
total fats even if supplementation is necessary.) Transfatty acids
(hydrogenated or partially hydrogenated fats) should be avoided.
- Carbohydrates. Simple sugars should be limited. Simple starches as well.
Avoid carbohydrate with high GLYCEMIC INDEX and high GLYCEMIC LOAD.
Watch for and avoid High Fructose Corn Syrup which is the major
industrial sweetener used in the western world today. Fiber intake is
important and you should shoot for 20 to 30 grams per day.
- In general, diets rich in nuts, colored vegetables, fruits and grains
have been shown to decrease the incidence of heart disease. Fish intake
should be high and animal fats kept to a minimum.
- Vitamins: Folate supplements with B6 and B12 have been shown to decrease
the incidence of heart disease. Vitamin E has not. (Though a mixture of E,
C, Zn, selenium have shown other benefits, particularly in protecting
- Control blood pressure.
- Control lipids: HMG CoA reductase inhibitors decrease heart attack and
stroke and may decrease the incidence of Alzheimer’s (though the evidence
for this is very light.)
- Niacin decreases LDL, LP(a), and triglycerides, and increases HDL. It is
the preferred agent for raising HDL. It must be started at very low doses
and worked up to a limit of 3 g/day. Liver functions, uric acid, glucose,
homocystein must be checked. If used, generous doses of folate, with some B6
and B12 should be added.
- Omega 3 oils can lower triglycerides. Doses can be titrated up to 4 to 6
grams a day if needed.
- A new absorption blocker –Ezetimibe—shows promise particularly in
combination with HMG CoA reductase inhibitors.
- To lower homocystein, use folic acid in increasing doses. You can go as
high as you need, though 4.5 mgm is almost always enough. You should add
restrained doses of B6 (no more than 50 mgm a day) and B 12. If no response,
think of B 12 malabsorption.
- Metformen should be used to lower glucose intolerance and insulin
- Antibiotic use to prevent coronary disease is controversial.