What have we learned since 1955 about heart care?
What can we do different in 2018 by studying the miraculous survival of Bob Harper and John Warner, MD? Read on and you will find out.
Maybe you are not Bob Harper, celebrity fitness trainer on The Biggest Loser who suffered a near fatal heart attack in early 2017 reportedly due to an unknown genetic cholesterol elevation called lipoprotein. And perhaps you are not John Warner, MD of Dallas, President of the American Heart Assocation who the day after giving a keynote address to thousands of cardiologists suffered a near fatal heart attack only aborted by his family and capable hotel guests.
What you are, however, is a hard driving executive and with goals to develop your company, your portfolio, your family’s security, and your future retirement. Nothing can stop you as you are at the top of your game. Nothing, that is, except a health crisis. The most likely sudden detour to your career plans is the sudden closure of an artery to your heart or brain causing an instant heart attack or stroke, perhaps fatal, or perhaps just leaving you disabled. Your plans change in a second as do those of your company and family. Yet the problem was progressing for years. How was it not detected? How did you not have a chance to know about? How were you denied opportunities to adopt therapies to stop it and even reverse it? As I titled my book, Dead Execs Don’t Get Bonuses, they also don’t get vacations, attend weddings, or see children graduate college. Do not wait. Do more. Get checked at an executive level this month. Here is your marching orders.
1. Ask for a coronary artery calcium scan (CACS)
Why? You turn 50 and your health care provider turns to you and says, “we need to schedule your screening tests”. It might be a colonoscopy to search for pre-cancerous polyps. It might also be a mammogram to screen for abnormal breast tissue. But what disease silently progresses towards disability and death and is rarely discussed in terms of early detection and prevention? The #1 killer of executives worldwide, atherosclerosis. Yet it can be screened for in a highly accurate, safe, and available manner. The heart gives no warnings until arteries are badly blocked, and the first symptom you have may be the day you die. What if your provider turned to you and said, “we need to schedule your CACS so we know if you are developing any silent calcified arteries that risk your life and work”? A CACS is a CT scan of the heart that takes under 1 minute, uses no dye or needles, exposes you to very low dose radiation, and costs about $100. It is far more accurate for screening for early atherosclerosis than any kind of stress test or MRI on the planet. Your CACS score should be zero and anything higher should prompt you to see a preventive cardiology expert to examine your risks, lifestyle, stress management and institute an aggressive plan to reverse the disease and the risk it carries.
2. Ask for a carotid intimal-medial thickness (CIMT) scan
A CACS is an amazing advance in identifying silent aging of your heart arteries but it requires calcification, or hardness, of your arteries to be abnormal. There is also a pathology called soft plaque that may threaten your health and identify sick arteries. A CIMT is a 20-minute painless ultrasound of your neck that uses advanced software measurements to examine your carotid arteries for both soft and hard plaque as well as measuring the thickness of the artery which is another sign of disease. The biggest drawback of the CIMT is finding a quality center that offers it as it is often not covered by routine insurances even though over 2,000 research studies have used this approach. In my office, I perform a baseline CIMT and if plaque or increased thickness is present, a repeat one is done at least yearly to document the reversal of artery aging from the diet, lifestyle and supplemental program I institute. I see reversal of plaque routinely using the CIMT.
3. Ask for advanced labs. You are worth it.
I’ve had 30-plus years of training and practice and I can tell you that you’ll probably have the same lab tests at an annual physical now as you would’ve in the 1970s when I started my training. This isn’t just outdated, it’s unacceptable as there have been major advances in laboratory testing in the past 40 years. I suggest asking for the following tests:
Advanced lipid profile: Rather than giving you a calculated LDL cholesterol level, advanced panels measure LDL particle number and size, which are more predictive of future heart and stroke events. Two people with the same cholesterol levels can have widely different particle and size measurements, making for very different risks and you need to know yours.
Lipoprotein a: This is a genetic form of cholesterol that’s elevated in about 20% of those tested. It’s rarely drawn even though hundreds of research studies indicate that if it’s high, the risk of heart attack and stroke skyrocket. There’s even a foundation dedicated to educating the public of the risk.
Homocysteine: This amino acid is produced by a process called methylation. It’s important for artery and brain health, and when elevated, it may be due to a genetic defect in the MTHFR gene, which is also easily measured. It can be treated with methylated B complex vitamins, and the level will return to normal.
Inflammatory markers: The best known is hs-CRP, but there are at least five others I measure in my practice, like MPO and oxLDL. If you want the cutting edge, a new panel called the PULS score is available and I learn a lot about risk from the results in my clinic. If there are markers of inflammation in the blood, a hunt is on for insulin resistance, infections, food allergies, skin conditions like psoriasis, a diet rich in processed foods, central obesity, gingivitis, and sleep apnea among others. Inflammation can be reduced by addressing these root causes.
TMAO: This is a newly described marker of heart and kidney health that’s elevated after eating meat- and egg-heavy diets with an altered gut microbiome. It has been shown to cause heart and kidney damage, and is associated with worsened prognosis — if you have high levels of this, you may want to make a transition to a more plant-based diet.
apoE: This is a genetic marker related to cholesterol metabolism that is measured from a blood sample. If you are the unlucky few % that inherits a pattern called apo E 4/4 from your parents, your risk of heart disease AND Alzheimer’s Disease is high and may have an onset 20-years earlier than average. The good news is that a preventive lifestyle of diet, fitness, weight management, nutritional supplements, sleep and stress management all show promise to prevent these diseases if identified early in life. I push my patients with apo E4/4 hard to adhere to an exemplary lifestyle and to follow a diet low in saturated fats as the medical literature advises.
4. Never leave an ER without a complete evaluation
If you do not pay attention to your heart risk and if you skip the CACS and CIMT you might end up in an emergency room. Don’t go to an urgent care clinic with chest pain, pressure, tightness, squeezing, or compression. Go to an emergency room.
That said, ERs have pressure on them to turn over rooms. I’ve reviewed charts from dozens of young people sent home with cursory evaluations, only to die or be maimed by massive heart attacks within days.
ER Bottom line: DON’T GO HOME without a thorough evaluation. Second, ask for “serial” cardiac enzymes that are repeated two or three times, every four to six hours. Third, ask for a repeat ECG to compare to the one you got initially. Finally, ask for a definitive test before discharge. This may be a treadmill stress test with echocardiography (no radiation) or nuclear imaging (radiation). In some ERs, the CACS or the advanced coronary CT angiogram (dye injection) may be available. If you’re not severely allergic to iodine dye, this is by far the most accurate way to be sure your arteries are clean. If they aren’t clean, a cardiologist will have to evaluate your status, but you’ll know the score and — most importantly — be alive.
In 1955 President Eisenhower had a massive heart attack and was cared for by Paul Dudley White, MD of the Harvard Medical School. In commenting on his care, Dr. White made the shocking statement that “a heart attack after age 80 is an act of God but a heart attack before age 80 is a failure of the medical system”.
All these years later we focus on learning CPR and having AEDs in gyms, wonderful and lifesaving programs, but miss the main point: the early identification, prevention and reversal of the silent disease that chokes off our vitality. While most executives are approached similar to President Eisenhower’s care, waiting for the big one to hit as the first sign of heart disease, we can do better and we must do better starting today. You simply cannot count on being unbelievably lucky and fortunate like Bob Harper and John Warner, MD.
Living executives DO get bonuses which is much more fun. Plan on being one.