Live Web Chat Transcript:
Emerging Risk Factors and Preventive Cardiovascular Medicine — May 30, 2007

Stanley Hazen, M.D., Ph.D.
Section Head, Preventive Cardiology & Rehabilitation
Cleveland Clinic Department of Cardiovascular Medicine

Cleveland_Clinic_Host: Welcome Dr. Hazen and thank you for being with us today. Let's begin!

Speaker_-_Dr__Hazen: Thank you for having me. I look forward to answering your questions for the next hour.

Recommended screening for cardiac risk factors

johnK: I get a physical every year. I am 50 years old. My doctor tests my lipid profile, regular blood tests, like a blood count. He also does an EKG. Should I have other risk factors checked too? Is there other blood tests I should have?

Speaker_-_Dr__Hazen: In addition to the studies you mentioned, the following is recommended:

1. Annual blood pressure screening. It is simple, cost effective, and saves lives. Elevated BP is a risk factor for both stroke and development of atherosclerosis, and thus heart attack.
2. Fasting blood glucose - a screen for diabetes.
3. serum creatinine – a test for checking kidney function.

Speaker_-_Dr__Hazen: In addition, we recommend several other less traditional blood tests for screening for increased heart risk. These don’t need to be done every year – and there is no consensus yet on how often if ever they should be used, but each has been shown in multiple studies to be associated with increased risk for developing heart disease. We therefore check them, and then if elevated, consider the individual to be at higher global cardiac risk, and therefore to require more aggressive global risk reduction efforts. This can include closer attention to their risk factors. Sometimes, if there is a clustering of them, we even recommend lower LDL goals than are currently recommended by current guidelines.

• Homocysteine – many studies show increased levels are associated with increased risks. If elevated, we recommend more aggressive risk reduction efforts.
• LP(a) – also called lipoprotein a – this risk factor is strongly linked to increased risk for heart attack and stroke. Individuals with elevated LP(a), especially with strong family history, we recommend aggressive risk reduction efforts in. Aiming for a lower LDL cholesterol goal in these subjects is also something we often do in Preventive Cardiology clinic
• Urine albumin/Creatine ratio – this test is a sensitive measure of early atherosclerosis in the kidneys, and is associated with increased heart disease risks. If elevated, we recommend not only more aggressive cardiovascular risk reduction efforts, but also starting a medication called an ACE inhibitor, as this both helps too reduce the spilling of protein in the blood and is shown to reduce heart disease risks.
• Fibrinogen – this is a protein involved in blood clotting. If elevated, individuals are at increased risk for development of heart attack. Provided there are no contraindications, we recommend low dose aspirin and close attention preventive heart disease efforts in subjects with elevated fibrinogen.

sugarbaby: If you have diabetes, are there special blood tests you should have along with a lipid profile to see if you are at risk for heart disease or vascular disease? Are there some drugs for high cholesterol you should not take if you have diabetes?

Speaker_-_Dr__Hazen: Diabetes is known as a "CAD risk equivalent". This means that subjects with diabetes have the same risk for developing CAD and having a heart attack as experiencing a second heart attack in subjects who have had one heart attack.

Speaker_-_Dr__Hazen: We therefore recommend aggressive LDL goals (Less than 70). In addition to a lipid profile, subjects with diabetes should have routine blood sugar and hemoglobin A1c testing to monitor overall diabetes control. We also recommend checking urine for spilling low levels of protein on an annual basis in all diabetics.

Speaker_-_Dr__Hazen: As for cholesterol lowering drugs, we don't avoid any in patients with diabetes. This question is probably based on the association between niaspan, a cholesterol lowering and HDL elevating medication, and increase in blood sugar in some subjects. For those with diabetes we use niaspan often since their HDL are often low. We simply treat the diabetes accordingly.

maryb: My mom had heart disease, my dad had a stroke. My brother died of a heart attack. Is there any way to find out if I have one of those genes that will tell me what my risk is? What if I have kids? Should they be tested?

Speaker_-_Dr__Hazen: While we are not currently using routine genetic screening in cases such as yours, for subjects with a very strong history of coronary artery disease, we do recommend screening with fasting lipid profile, LP(a), homocysteine in all first degree relatives, including children over the age of 2.

Speaker_-_Dr__Hazen: In addition for adults, we do obtain additional non-traditional risk factors, searching for increased global risk. These include CRP, urine albumin/creatinine ratio, and fibrinogen.

Speaker_-_Dr__Hazen: Close monitoring of blood pressure, diet, exercise are also encouraged.

Early detection of blockage

newpaths: Most males and females have 50% of blockage in their arteries at age 50. Weight-loss, lifestyle changes, nutritional changes and exercise progarms can only go so far. Systolic blood pressure is somewhat helped by esercise. Why not locate the obstructions in the arteries BEFORE more serious complications and remove the obstructions. Thereby, permitting the blood to to flow freely and insuring that systolic levels should be reduced.

Speaker_-_Dr__Hazen: We used to think of atherosclerotic heart disease as a focal lesion observed in the coronary artery. This belief arose from our reliance on cardiac catheterization to observe points of narrowing in the coronary artery lumen, where blood flow is diminished during increased demand, giving rise to symptoms. However, we now know this simplistic “plumbing” view of atherosclerosis is not the case. Rather, atherosclerotic heart disease is a systemic illness. Individuals with narrowings noted in the coronary circulation by cardiac catheterization not only have plaque (fatty build up in the vessel wall) at the points of narrowing, but also often throughout the entire coronary artery.

Speaker_-_Dr__Hazen: Furthermore, many studies have shown that the “culprit” lesion in patients with heart attacks or sudden cardiac death (culprit meaning the site where the heart attack occurred) occur the majority of times in a lesion that has less than 50% stenosis. It seems that the more inflamed, fatty lesions are prone to fissure or crack, causing a heart attack, than the 90% narrowed one.

Speaker_-_Dr__Hazen: Therefore, simply opening every narrowed vessel observed is not the optimal thing to do. Rather, focusing on global risk reduction approaches, including exercise, diet, and medications like statins (to lower LDL (bad) cholesterol), certain blood pressure pills that also prevent progression of heart disease and decrease the work of the heart, and low dose aspirin, are the major preventive approaches recommended.

Risk factor: cholesterol

stevenK: How early should you get your cholesterol checked. If we have a strong history of heart disease, should my children get checked? How low should a child's cholesterol be?

Speaker_-_Dr__Hazen: Heart disease runs in families. If there is a history of high cholesterol and / or heart disease in your family, it is recommended that your children be screened at least once after the age of 2yo.

Speaker_-_Dr__Hazen: If your child is significantly overweight, having a fasting lipid profile is also recommended. The frequency of repeat testing is less clear, and is typically dictated by the results of the initial screening tests.

Speaker_-_Dr__Hazen: The key to prevention is early detection, intervention, and / or alteration in lifestyle. Adopting heart healthy eating habits within the entire family is the best approach for prevention.

Risk factors: HDL cholesterol and HDL cholesterol

katbee: My cholesterol is 217 but my HDL is 104 and my LDL is 97. Is that bad? Can your HDL be too high?

Speaker_-_Dr__Hazen: Current guidelines argue first focus on LDL (bad) cholesterol as a goal. < 100 in a subject without known heart disease is the goal. If there is known heart disease, or other strong risk factors like diabetes, peripheral artery disease, history of aortic aneurysm, or stroke - - essentially any evidence of atherosclerosis - then we argue for a more aggressive LDL goal of < 70.

Speaker_-_Dr__Hazen: As for HDL - < 50 is considered higher risk. Can it be too high? We simply don’t know. More than likely, most of the time, a very high HDL cholesterol level is a good (protective) thing. However, there is more and more data to show that not all HDL is protective. Unfortunately, we don’t have good tests to identify this “dysfunctional” HDL at present.

Speaker_-_Dr__Hazen: One thing that is important is to not look at the high HDL and think that it offsets the need to be attentive to other heart risk factors. Focusing on LDL (bad) cholesterol and other lipid risk factors like triglycerides, along with monitoring blood pressure, and life style factors like diet, exercise and weight are important. Routine screenings for diabetes (fasting blood glucose) and kidney function (creatinine) are also important.

caroline: My HDL is 27. I exercise and I don't smoke. I think I eat ok. How do you raise HDL?

Speaker_-_Dr__Hazen: The major ways to raise HDL is through a routine exercise program. In addition, a modest amount of alcohol can result in mild HDL elevation. In terms of medication, options are limited. Statins, such as Zocor or Crestor can raise HDL. In addition, there are medications related to the vitamin Niacin that can raise HDL. The actual decisions as to when and if, and what type of medication needs to be discussed with your doctor.

berniemd: I have been watching my diet, exercising, and taking Crestor 5 mg. My last labs had LDL of 55, HDL 45. Can your LDL go too low? Is this ok?

Speaker_-_Dr__Hazen: We use an LDL cut off of 25 or less as the safety cut off. This same LDL cut off was used in many of the large randomized trials that demonstrated clinical benefit with LDL lowering of less than 70. The truth is that in these trials median LDL was in the low 60's, meaning half of the people in the trial had an LDL lower than 60. We therefore aim for this level of LDL reduction in people with known cardiac disease and those at high risk.

Risk factor: CRP

Johng: I have high CRP of 6. What should I do? Once you have high CRP do you get it checked again? I don't understand what it is? Can you help explain what it means?

Speaker_-_Dr__Hazen: hsCRP – high sensitivity C reactive protein – is a non-specific marker of inflammation. It also has been shown to be correlated with cardiac risks in many studies. The American Heart association recommends screening with hsCRP for subjects of intermediate heart disease risk. We agree. We obtain hsCRP and if elevated, recommend more aggressive global risk reduction efforts. Aiming for a lower LDL cholesterol goal in these subjects is also something we often do in Preventive Cardiology clinic

Speaker_-_Dr__Hazen: Current guidelines recommend that at least 2 elevated CRP are documented at least 2 weeks a part before one takes it to indicate increased risk of coronary artery disease.

Speaker_-_Dr__Hazen: With an elevated cRP (greater than 2) we recommend more aggressive global preventive risk reduction efforts. In addition, in the Preventive Cardiology Clinic at the Cleveland Clinic, for the past year, we have begun treating toward lower ldl goals in subjects with persistently elevated CRP. While this is not part of current guidelines, we have taken this approach because individuals with elevated cRP have in many studies to be shown to have increased risk for development or progression of their cardiovascular disease.

Speaker_-_Dr__Hazen: It is also important to search for easily correctable causes for persistently elevated CRP. For example, periodontal disease is linked to increased risk for CAD, can lead to elevated CRP and is something which is easily correctable with good oral hygiene.

Risk factor: overweight

hillm_2: Like so many, I struggle with weight loss. I've heard of Rimonabant as being very helpful, but was told I did not meat the qualification for this research medication. When will it be available? Are there other medications being developed to help with weight loss?

Speaker_-_Dr__Hazen: Rimonabant is not currently available. We do not recommend use of drugs as a initial weight loss effort. We recommend a comprehensive program that involves both diet as well as routine exercise for weight reduction.

Risk factor: homocysteine

michgirl: Is homocysteine bad? Does it show you have coronary disease? How do you treat high homocysteine?

Speaker_-_Dr__Hazen: Elevated homocysteine (HCys)has been shown in many studies to be associated with CAD. Further individuals who have a genetic defect that cause an elevated HCys experience premature CAD (even in teen years).

Risk factor - calcium score

roberto: My doctor said I have a high calcium score. What does that mean? Should I not take calcium vitamins any more? What causes that?

Speaker_-_Dr__Hazen: A high coronary calcium score is a sign of calcification in the arteries, which occurs during CAD. You should take calcium if your physician recommends it, particularly if there is evidence of osteoporosis. If it has not been recommended, I would ask your primary physician before taking it.

Speaker_-_Dr__Hazen: While we do not routinely obtain a calcium score on everybody, when it is noted to be high it indicates the presence of CAD. This lowers our LDL goals and prompts a more aggressive preventive approach. We never get multiple calcium scores to look for changes. This is because calcification of a vessel can be as sign of a more stable form of an atherosclerotic plaque.

Prevention of heart disease - wine

jonathan: Should you drink a glass of wine every day or not. I keep hearing different things. Some say grape juice, some say wine. Some people say any type of alcohol. What is the story?

Speaker_-_Dr__Hazen: A modest amount of any form of alcohol on a daily basis is associated with a slight reduction of CAD risk. The type of alcohol matters in as much as some carry many more calories, for example beer, than others. We do not recommend adding alcohol if one does not normally drink alcohol.

Speaker_-_Dr__Hazen: Grape juice carries a lot of calories. We do not recommend it unless it is a small amount and chosen as a fruit serving in place of a normal portion of fruit.

Statins for high cholesterol

Nancy : I have high cholesterol and am a female age 57, not overweight and in good health. Should I consider taking a statin

Speaker_-_Dr__Hazen: YES. Heart disease is the number one cause of death and disability in women. An elevated cholesterol level is a major risk factor for development of heart disease and is easily addressed by existing therapies.

susan: My husband has high LDL. He has tried a couple statin drugs - lipitor and zocor. Both has given him problems and he had to stop. Are there any medications he can take if he is intolerant to statins? I am worried. He already had 2 stents placed and his dad died of heart attack.

Speaker_-_Dr__Hazen: We see this problem often in the Preventive Cardiology Clinic at CCF. Often if an individual has a problem with one or two statins, they may be able to tolerate an alternative one at a low or infrequent dose.

Speaker_-_Dr__Hazen: A medication called Zetia is a cholesterol absorption blocker that results in approximately 20% reduction in LDL. For subjects with known heart disease and statin intolerance, such as your husband, we routinely start daily Zetia and then try to add a low and infrequent dose (even just once a week) of a statin. Then, slowly over time, we raise the frequency of the statin. In addition, we recommend Coenzyme Q10 as this helps decrease the side effects of statins in many patients.

georgep: I am 21 years old. I had a physical and my cholesterol was high. I am overweight. I really don't exercise. But I think I eat good. My doctor mentioned a statin. Does it matter what statin to take? Do I really need to be on a statin? Will it do harm to me? I am only 21.

Speaker_-_Dr__Hazen: Starting statins in a 21 year old is entirely appropriate if the cholesterol level is high. In fact, young individuals who have high cholesterol stand to gain the most benefit from early intervention.

Speaker_-_Dr__Hazen: If the LDL cholesterol is sufficiently high (greater than 160) statins may be helpful. Selection of the statin and its dose should be based on the degree of LDL lowering required.

Speaker_-_Dr__Hazen: Statins have been shown to be extremely safe and effective medications. They can have side effects but these are easily identified and managed. The only serious adverse side effect reported for statins is rhabdomyalisis, a severe inflammation in the muscle. This occurs at a frequency of about 1 in 20,000.

Speaker_-_Dr__Hazen: For women of child bearing age, statin use is contraindicated during pregnancy and nursing.

Speaker_-_Dr__Hazen: Statin therapy should always be combined with a diet and exercise plan.

Natural or herbal products

kathyg: I was told tart cherry juice is good for joint pain and can also decrease risk of heart disease. Is that true?

Speaker_-_Dr__Hazen: Not that I am aware. I don’t believe so.

terrencel: I have heart disease that keeps coming back. I have had 5 stents placed over the last 3 years. I heard about something called Angioprim that will clean out the arteries. What do you think about that treatment. Do you have something that will clean out the arteries?

Speaker_-_Dr__Hazen: Angioprim is a non FDA approved nutritional intervention which has claimed to be a form of "chelation therapy." It is comprised of the amino acid cystine and lysine. The company makes extraordinary claims about Angioprim and has actually been admonished by the FDA about its unsubstantiated claims. Unfortunately because it is a supplement it does not fall under the FDA's authority to enforce the changes needed in their advertising. There is no direct evidence for clinical benefit in placebo controlled trials for angioprim or other chelation therapies.

Speaker_-_Dr__Hazen:Unfortunately there is no "liquid draino" for the coronary arteries. However, taking medications such as statins (LDL cholesterol lowering drugs) have been shown time and time again to lower the risk for heart attack, stroke and progression of coronary heart disease. In someone who has recurrent restenosis or progression of CAD, despite having an LDL cholesterol at goal (<< 70), we search for alternative (non-lipid related) risk factors that may be causing such aggressive coronary artery disease.

hillm: Everyone talks about Co-enzyme 10 for use in Heart disease. Is there any validity to this supplement?

Speaker_-_Dr__Hazen: Co-enzyme Q10 is a vitamin which has unfortunately a lot more press than randomized trials to support these claims. We do recommend Co-enzyme Q10 supplement in individuals who experience muscle aches or stiffness associated with statin therapy. There have been multiple observational studies that suggest supplementation with Co-enzyme Q10 can prevent these side effects.

Speaker_-_Dr__Hazen: As far as I am aware there are no studies that directly demonstrate a direct benefit for taking Co-enzyme Q10 to decrease CAD risk.

fran: How much Omega-3 (in grams) do you recommend taking daily?

Speaker_-_Dr__Hazen: We recommend eating fish for the omega 3 fatty acids in general. Supplementation is not recommended in all individuals and should be discussed with their primary care physician.

Speaker_-_Dr__Hazen: In some subjects we do recommend omega 3 fatty acid supplementation to help with LDL and triglyceride reduction as a second or third line agent. When used, the recommended dose is 3 - 4 grams per day. It often takes awhile to ramp up to this dose. Keeping the fish oil capsules in the freezer can decrease the "fishy burp" side effect.

redway: I have high cholesterol. I do not want to take any medications. My friend told me to take red yeast rice. I found it at my drug store. Does it work? I also heard cayenne pepper pills work. Have you heard of these things. I really don't want to take any medications if I don't have too.

Speaker_-_Dr__Hazen: There are alternatives to cholesterol lowering that are non-prescriptive. Before I list these, I would like to strongly emphasize I believe taking a statin for individuals who have known CAD or are at high risk for developing CAD because of very high cholesterol and or other risk factors, such as diabetes.

Speaker_-_Dr__Hazen: Red yeast rice or Red yeast rice extract capsules contain a "natural" statin. Taking red yeast rice will lower LDL cholesterol about 5 - 15%. It is important to recognize if one eats the rice that it contains calories and have significant carbohydrate load. It's incorporation into the diet should be taken into account.

Speaker_-_Dr__Hazen: I am not familiar with any link between cayenne pepper and cholesterol lowering.

Coronary artery disease prevention - diet

whickey58: What to you think of the extremely low fat diets like Ornish and Pritikin. Supposedly at his death Pritiken had no buildup in his arteries.

Speaker_-_Dr__Hazen: Extreme diets are very difficult to adhere to and if they do result in weight reduction, typically are followed by weight rebound after stopping them. We recommend adopting a dietary pattern which can be maintained as a lifelong effort. The American Heart Association has clear guidelines for a heart healthy diet such as the Mediterranean diet.

Small particle lipids

mattsto: How important are little particle lipids like lp(a)? Should everyone get them checked. What it a high level? How is it treated?

Speaker_-_Dr__Hazen: LP(a) is a risk factor for CAD. We recommend it should be screened at least once after the age of 50. Individuals with an elevated level, particularly with a positive family history for cAD are at increased risk for development of CAD. In Preventive Cardiology Clinic at CCF, we routinely obtain an LP(a) on all new patients and if elevated, recommend both more aggressive global risk reduction efforts and lowering of LDL goals below that which is recommended by current guidelines.

hillm: I recently read about the importance of having a full fractionated Lipid profile, looking at the size of the HDL and LDL particles in addition to their number. When I asked my cardiologist about it, he stated that it was very expensive and not worth the cost, for the information provided. When would this be an appropriate test. What can be gained from this information.

Speaker_-_Dr__Hazen: LP(a) testing is not uniform across all assay types, so the upper limit of normal has to be established where ever you get your LP(a) tested.

Speaker_-_Dr__Hazen: It is unclear when and if lipoprotein particle fractionation (particle sizing) provides added value. I agree with your cardiologist. We do not routinely obtain lipoprotein particle sizing but instead rely on the fasting lipid profile. If triglyceride levels are elevated (greater than 300) we add a apoB 100 level. This serves as a measure of the number of LDL particles.

Low cholesterol and Parkinson's disease

StuLeach: Is there any connection between very low cholesterol and Parkinson's disease?

Speaker_-_Dr__Hazen: There was much fanfare about a recent small study looking at patients with Parkinsons and their cholesterol levels. Individuals with Parkinsons were noted to have a slightly lower cholesterol than their spouses. This was interpreted to indicate that a low cholesterol may be linked to Parkinsons development in the lay press. However, further reading of the same study suggested that subjects that were on a statin (resulting in lower cholesterol) experienced slower progression of their Parkinsons disease. There is no known direct link between cholesterol and development of Parkinsons disease and in fact, some experts have suggested that a trial of statins in Parkinsons disease patients would be of interest.

Speaker_-_Dr__Hazen: Thank you for having me today.

Cleveland_Clinic_Host: If you would like more information regarding cardiovascular disease prevention and treatment, please visit our web site at www.clevelandclinic.org/heart

© Copyright 2007 The Cleveland Clinic Foundation. All rights reserved. rev 6/07