Coronary Heart Disease:

While the heart pumps blood, the muscle gets it’s nutrition from the pumped blood coming back into the muscle via the "coronary arteries." The "left main" artery branches into two major arteries, the "circumflex" and "left anterior descending (or "LAD")" arteries (which have branches also). The "right coronary" artery usually supplies the heart’s natural pacemaker areas. Blockages, inflammation, infections, clotting disorders, and artery wall motion abnormalities are responsible for most coronary artery disease.

The coronary arteries can develop blockages from cholesterol problems, diabetes, clotting problems, abnormal anatomy or bulges (aneurysms), cigarette smoking, high blood pressure, anger, time pressure, and family history. These blockages build up and reduce the blood supply - causing "angina pectoris" with exertion. When the blocked area ruptures, it bleeds into the artery - causing a clot. It’s the clot that causes a heart attack. The most important treatment for heart attacks involves resolving the clot and preventing new ones. Rhythm disturbances (arrhythmias) are a common cause of death from both angina and heart attacks. Some authorities believe that up to 80% of angina episodes, and 20% of heart attacks are "silent" (without chest pain) - especially in diabetics.

The severity of coronary heart disease can be evaluated by stress tests and angiograms (cardiac catheterization - where a tube is inserted through the groin, passed up to the heart, and injected with dye for X-rays). Treatment involves a low fat diet, lowering the cholesterol, increasing exercise tolerance, medications, quitting smoking, reversing high blood homocysteine levels, stress management (especially learning to deal with time pressure and reducing anger), taking supplements (like L carnitine and Co Q10) and antioxidants (Vitamins C & E, beta carotene, selenium and some medications) and sometimes balloon angioplasty - usually with tunnels called "stents" placed into the artery - or bypass surgery.

Heart Failure:

Normally the heart pumps between 55-75% of the blood out during each heartbeat - this is called the "ejection fraction." When the number is low, "heart failure" results (also called "left ventricular dysfunction"). 50% is acceptable in seniors, less than 20% usually results in death. The most common causes are coronary heart disease (sometimes reversible), previous heart attack, high blood pressure, diabetes, alcohol abuse, and some viral infections. Diagnosed by echocardiogram (sound waves) and other techniques. Treatment consists of exercise, salt restriction if needed, medications, reversal of any reversible condition, supplements like L carnitine and Co Q10, and heart transplants. Medications like ACE inhibitors, beta blockers like Coreg, and spirolactone can all reverse heart failure if tolerated. "Diastolic heart failure" occurs when the heart muscle is stiff and has trouble filling properly with blood.

Arrhythmias (rhythm disturbances):

The heart normal beats regularly 60-99 beats per minute in "normal sinus rhythm." Abnormalities include skipped beats, fast or slow beats, irregular beats, premature beats, dangerous rhythms, and no heartbeat. Up to 6 extra beats per minute ("PVC’s") is considered normal. The causes can include medicine, stress, medical problems, structural heart problems, enlarged heart muscle (left ventricular hypertrophy), coronary heart disease, and heart failure. Treatment depends upon the condition, but can include avoiding certain chemicals and foods, medication, pacemakers, implantable defibrillators, or electrically destroying tissue.

Heart Valve problems:

Most significant valve problems come from strep throat (rheumatic heart disease). Valves can be too tight, leaky, or both. Mitral Valve Prolapse is common (20% of women), and is rarely serious, usually causing palpitations under stress. Diagnosed with an EKG and heart monitors. Treatment involves watching, medicine, angioplasty and surgery - and antibiotics must be taken for dental work and other procedures.

Peripheral Vascular Disease:

The same process as coronary artery disease, but in the leg arteries. The main symptom is pain with exercise that stops with rest. Rest pain is very serious. Treatment is the same as coronary disease.

Carotid Artery Disease (stenosis):

The main arteries to the brain are on either side of the neck. Blockages occur from the same process as coronary artery disease. It can be without symptoms, with dizziness, or a stroke (temporary or permanent). Treatment is the same as coronary disease. Surgery is indicated for blockages 60% or higher (especially 80-99%), but carries a significant risk of stroke from the operation.

Aortic Aneurysm:

A bulging weak spot in the artery. Rarely has symptoms until it’s too late - and the only treatment is surgery and controlling high blood pressure. Something to look for with a family history or with high blood pressure and other coronary risk factors.

ALCOHOL and the prevention of coronary heart disease:

1-2 drinks of alcohol daily for men and ½ -1 daily for women is associated with a significant reduction in heart attacks and diabetes risk. This may balanced by an increased risk of stroke, accidents (especially automobile fatalities), cirrhosis, depression, and alcoholism. With rare exception it is not advisable to begin drinking alcohol to prevent heart disease. Red wine is probably not more beneficial than other drinks, and grape juice won’t work.

Other preventive measures:

81 mg aspirin is associated with a 30-50% reduction in heart attack, stroke and an 85% reduction over 15 years in colon cancer risk. A low fat diet is profoundly important, as is quitting smoking, mental health, exercise, and for women to take hormones (estrogens) after menopause. More information is needed about infectious causes of heart diseases before recommendations can be made in this regard.

CHOLESTEROL:

There are different types of cholesterol (or "lipids") - HDL (good cholesterol), LDL (bad cholesterol), and triglycerides (fat in the blood). Very high HDL levels (above 65) are associated with the "longevity syndrome" and the cholesterol does not to be treated in this case. High LDL levels are clearly associated with blocked arteries. The ratio of total cholesterol to HDL is an extremely important predictive number - it should be less than 4.5 to 1 - the lower the better.

Diet is important - a low fat diet for men is usually 65 grams of fat daily. Tremendous benefit occurs with a diet of 20 grams of fat daily or less. For some people diet has little effect on the blood cholesterol. While eating cholesterol has some effect, it’s the dietary fat (particularly "saturated fats" like butter, palm oil and meat fat) that causes the problem.

Medications are very effective, and reasonably safe. They are expensive. The most commonly prescribed type are the "HMG co-reductase inhibitors" such as Lipitor, Mevacor, Lescol, Pravachol, Baycol and Zocor. They prevent the body from making cholesterol, and have anti-inflammatory effects as well. Other medicines include Tricor, gemfibrozil (Lopid), and the difficult to take niacin and Questran (which have their risks as well).

Many studies have proven that blocked arteries can be reversed by profoundly lowering cholesterol (especially by lowering the LDL to less than 100). Approximately 2/3 of all deaths after age 65 are due to complications of blocked arteries. Coronary artery disease causes 535,000 deaths per year (one per minute) - and half of all heart attacks occur with cholesterol levels less than 220. Lowering the cholesterol is a major part of preventing and treating diseases from blocked arteries.

10/20/99