Arteriosclerosis

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[edit] Arteriosclerosis ( The "Missing Link" Between Strokes And Heart Attacks)

Introduction:

The Framingham study and many other newer prospective studies have shown that the degree of hardening of the arteries throughout the body, called "arteriosclerosis", determines the risk of whether or not we are developing strokes and heart attacks (Ref. 1, 5 and 6). The risk factors for heart attacks are identical to the risk factors for strokes and vice versa. The newest research findings are that gum disease and tooth decay that is left alone will cause hardening of the arteries, heart attacks and strokes. Strangely enough, brushing your teeth regularly and flossing will prevent heart disease and strokes.

The following risk factors for arteriosclerosis have been identified:

1. Smoking

2. High LDL cholesterol (low density lipoprotein, also known as "bad cholesterol") and low HDL cholesterol (high density lipoprotein, also known as "good cholesterol").

3. Hypertension, which is not controlled.

4. Lack of physical activity (sedentary life style).

5. Excessive weight and the associated high triglyceride levels.

6. Diabetes mellitus when not closely controlled.

7. male sex: women live on average 10 years longer likely because of the cholesterol lowering effect of the female hormones (estrogen effect) during their reproductive years.

8. Hereditary factors: certain hyperlipidemias and homocysteinuria are associated with heart attacks at a young age. They require a close follow-up by a cardiologist or internist with a special interest in these metabolic diseases.

The crucial question is: What can be done to prevent premature arteriosclerosis? Here are some suggestions (Ref. 2 and 3):

This can be done to prevent heart attacks and strokes:
factor to change:	Comments regarding facor to change:
Balanced diet	20% fat, low cholesterol, 55% natural carbohydtrates, 25% protein (zone-like)
Diabetes	needs to be controlled tightly
Exercise	all studies show that this reduces risk significiantly
Hormone replacement for women	controversial; women have an advantage over men due to estrogen in their blood; growth hormone unsafe
Medical problems	high blood pressure needs control; high levels of cholesterol, triglycerides or homocysteine need appropriate treatment
Stop smoking	all medical studies show a clear risk reduction
Vitamins and supplements	vitamin C and E, Omega-3-fatty acid,
Weight reduction	achieved by combination of exercise and balanced diet

Exercise: with this I mean to walk briskly 30 to 40 minutes 4 to 5 times per week, better even every day. Even such moderate exercise is effective in reducing heart attack rates and strokes by 50%! Exercise will increase the HDL blood level thus protecting the LDL cholesterol from being oxidized. This prevents or reduces arteriosclerosis.

STOP SMOKING : To stop smoking is likely the single most important step in your life to reduce your risk for a heart attack, lung cancer, stroke etc.

Use nicotine patches, nicotine gum, self hypnosis cassettes with "stop smoking" suggestions. I don't care how, but stop smoking. The Internet has helpful sites re. quit smoking as well. One helpful medication that came out recently is bupropion (brandname: Zyban), an antidepressant, which helps with the craving aspect of smoking. Why am I so adamant about this? Because cigarette smoke has a myriad of chemicals, which are readily absorbed through the lungs directly into the blood stream. These chemicals will increase and oxidize the LDL cholesterol, decrease the protective HDL cholesterol, attack the arterial wall and make the coronary arteries constrict ( this is called the nicotine effect). In short, it leads to premature and severe arteriosclerosis. Apart from this it also leads to many cancers, in fact it causes 40% of all cancer deaths in males and about 20% of all cancer deaths in females.

Low fat diet and reduction of excessive cholesterol intake: Most North Americans eat 25 to 50% of their daily calorie intake as fat. If this is reduced to 10 to 25% in the daily calorie intake, triglycerides in the blood as well as LDL cholesterol are significantly reduced. The reason the total cholesterol intake matters is that about 50% of the body's cholesterol comes directly from our diet, the other 50% is manufactured by the liver. Our circulating LDL cholesterol (the "bad" cholesterol) will automatically be reduced, if we cut down on the consumption of meat, poultry and dairy products and if we switch to more fish, soybean, vegetables and grains. Meat and dairy products have hidden fats in them, which are metabolized by the liver into triglycerides, which in turn will circulate in the blood and then get stored as fat around breasts, in the chest wall, the abdomen and abdominal wall, buttocks and thighs. Here is a blog that may help you to lower your fat intake. It is much easier than many people think.

Fat is not good for you as can be seen from this graph where it is shown that a higher fat percentage in the food of one country leads to a higher mortality in that country. Fat won't sit still, it gets metabolized or "turned over", which in turn will elevate the fatty acid (triglyceride) blood levels. These lead to fat deposits in the arterial wall, which is one of the hall marks of arteriosclerosis (also called "atheromatosis"). Over time this calcifies and can be visualized by CT scanning as hardening of the arteries. When obesity with increased body weight has been established, a particularly dangerous condition, the insulin resistant syndrome (IRS) can develop. This has nothing to do with the IRS that collects U.S. Citizens' tax money. The IRS syndrome is worse: it takes life away by a combination of high LDL cholesterol, high triglycerides, low HDL cholesterol levels and high insulin levels leading to an accelerated arteriosclerosis development with frequent strokes, heart attacks and blockage of arteries to the legs often requiring amputations. By changing the factors mentioned above the IRS syndrome can be reversed and a normal life expectancy can be obtained! The bottom line is that the low fat diet factor can cut heart attacks and strokes into half over two decades or more. But even 1 or 2 years of a low fat diet will reduce the risk significantly.

Control medical problems that would affect arteriosclerosis: If you have hypertension (high blood pressure) make sure to see your doctor to control it with adequate medication. Buy your own blood pressure monitoring equipment to be able to know how well your blood pressure is controlled. By doing this you prevent a hemorrhagic stroke, heart disease, kidney disease and help prevent accelerated arteriosclerosis.

A minority of people may have a genetic trait such as hypertriglyceridemia or homocysteinuria, which requires other medicines or specific vitamins, which the doctor or cardiologist needs to prescribe. If the other measures mentioned above have not lowered the cholesterol, it may be necessary for you to take one of the "statin" family of medications (CoA reductase inhibitors) to achieve normal LDL blood levels. These medicines, which the doctor will prescribe for you, inhibit a liver enzyme thus lowering the LDL and often at the same time increasing the HDL cholesterol as well, resulting in a lowered arteriosclerotic risk.

Control of excessive weight: Weight loss can be achieved fairly easily by a combination of regular exercise, low fat food, avoidance of sweets and reduction of excessive starchy food intake. Often patients who are newly diagnosed with diabetes at age 40 years or more will normalize their diabetes on such a diet, if they were obese at the time of the initial diagnosis. Such a diet, low in fat, low in sugar and starch with an emphasis on vegetables, will slow down the aging process by postponing arteriosclerosis. Self hypnosis cassettes that you listen to daily for some time can also be very effective for weight loss provided you combine this with the other measures mentioned above. Read more about low glycemic, low fat foods and on basic exercises to improve your fitness under these links.

Diabetes mellitus needs to be controlled tightly: The best control of diabetes is usually achieved by insulin injections two or three times a day in combination with home glucosometer readings and three monthly blood tests where the hemoglobin A1C level is determined.

Only when the hemoglobin A1C values and the home glucosometer readings are close to normal levels, will the major target organs such as the brain, heart, the kidneys and the eyes stay healthy. If the blood sugars are chronically elevated, lipid abnormalities develop, which accelerate arteriosclerosis and brings damage to the target organs. The end result is blindness from diabetic retinopathy, brain damage from diabetic encephalopathy, heart attacks, strokes and damage to the arteries of the hands and lower legs resulting in gangrene and amputations. I cannot overemphasize :

Remember: Prevention always has been and always will be more powerful than any cure and yet many people foolishly ignore this.

Vitamins and supplements:

a) Recently many trials have been published, which convincingly give evidence that vitamin E lowers cholesterol. At least 200 IU or more (typically 400 to 800 IU per day) will reduce LDL cholesterol. Heart attacks and strokes are reduced by 40 to 50%, which is a highly significant finding and just as effective as exercise and the "statin"type cholesterol lowering agents (Ref. 4).

b) Beta-Carotene, a precursor of Vit. A, has also been shown to reduce heart attacks and strokes, although a few studies could not prove effectiveness. The dose is 20 mg every other day. However, two carrots a day will do the same and in one study it has been shown to cut the risk of stroke in half among men who were at risk of heart disease.

c) What about bioflavonoids? These cholesterol lowering phytochemicals are found in red grapes, red wine, broccoli, apples and

many other fruits and vegetables. A small glass of red wine per day (less than 4 oz.) Will prolong life significantly by lowering cholesterol. The key is: low dose, but regular. However, alcoholics should refrain from this approach because this alcohol content could trigger a loss of control. For them the old saying counts (as well for those who do not like red wine):" an apple a day keeps the doctor away..." Yes, we now know that it's the fiber and the bioflavonoids that does the trick. A Dutch study of elderly men showed that with the regular intake of the equivalent amount of bioflavonoids found in one apple per day, there were 50% less heart attacks in that group of men than in the control group who did not take the bioflavonoids.

d) Garlic, anyone? For centuries it was postulated that garlic would prolong life. Several well controlled studies have shown now that this in fact is true. Garlic lowers blood pressure marginally, lowers LDL cholesterol and has an important anti clotting effect, which in combination will reduce heart attacks and strokes by 40 to 50% when taken regularly.

I would caution that the anti hypertensive effect is rather mild and would have to be combined with conventional blood pressure medication for people with high blood pressure.

e)Other vitamins: Vitamin B3, B6 and B12 have their place in certain metabolic diseases such as for instance mild cases of homocysteinuria. Vitamin C has been studied extensively and has use as an antioxidant preventing oxidization of LDL cholesterol, but not every study has been conclusive. As a contrast, all studies showed that Vit. E consistently demonstrated powerful antioxidant effects . However, Vit. C has other useful effects as it has been shown to prevent many types of cancers.

The controversy of hormone replacement: Recently several large studies were published, which investigated women in menopause with or without estrogen replacement. There was a 40 to 50% reduction of heart attacks in women who supplemented with estrogen compared to women who did not supplement. Not every postmenopausal woman should necessarily take estrogen replacement and you should consult your doctor for more details. However, an overview of the literature showed (see Family Practice, Oct.5, 1998) that the benefits outweigh the risks for most postmenopausal women. Men cannot take advantage of this form of therapy as they would change their nature and physical appearance. Postmenopausal women on estrogen simply feel younger for longer. The reason for this is that HDL cholesterol is elevated and LDL cholesterol reduced, which effectively postpones arteriosclerosis. I mentioned earlier that women through their reproductive years gain a 10 year survival advantage over men. This is due to the accumulative estrogen exposure effect from the ovaries. This effect, researchers think, can be prolonged possibly by another 5 years, if not more, by estrogen replacement after menopause. Progesterone replacement (the other ovarian hormone) will NOT have this arteriosclerosis postponing effect.

What about the downside risk of estrogen replacement? The breast cancer risk of long term estrogen replacement is a 1.3 to 1.6 fold factor, which would increase the lifetime risk for breast cancer from 2.5 women/1000 women per lifetime to 3 to 4 women/1000 women per lifetime. If all women have a yearly mammography these cases can be dealt with at an early stage, which will prevent additional mortality from breast cancer. The risk for uterine cancer, which is about 2-fold on estrogen replacement after 10 years, gets neutralized to a certain extent by the addition of progesterone as the lining of the uterus sheds itself. Ask your physician for more details.

The bottom line regarding hormones is that they are powerful biological agents, where even doctors have difficulties assessing the longterm consequences. The safest way to postpone aging through postponing hardening of the arteries is the combination of calorie restriction, low carbohydrate, low fat diet and exercise. The older person in particular should not forget to exercise as this will normalize the hormone balance and lead to stronger bones (prevents osteoporosis and fractures).

For further details read the chapter on health, nutrition and fitness. You can use this link. It gives detailed suggestions regarding life style changes for better health.

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Cardiovascular disease

Strokes

References:

1. M L Kashyap Annals Academy of Medicine,Vol. 26, No.4 (July 1997).

2. LT Mahoney et al. Am J Cardiol. 2001 Sep 1;88(5):509-515.

3. W E Boden Am J Cardiol. 2000 Dec 21;86(12A):19L-22L.

4. M Suzukawa et al. Biofactors 7 (1998): 51-54. IOS Press.

5. Y. Liao et al. American Heart Journal Volume 137 (5),1999: 837-845.

6. RB D'Agostino - Am Heart J - 01-Feb-2000; 139(2 Pt 1): 272-281.

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