Our healthcare system is focused on treating advanced disease.  Current guidelines seem to suggest we start getting aggressive once symptoms or signs of disease immerge, though this strategy has never made real sense to me. William B. Kannel, MD, who was at Boston University Medical Center, said, "Awaiting overt signs and symptoms of heart disease before treatment is no longer justified.  In some respects, the occurence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment". Once heart & vascular disease is advanced, it is much harder to treat. Even screening tests can be deceiving and give an individual a false sense of security. Health is not the absence of disease, but a state where the individual is in balance with any disease present. 

​

Screening for disease is very controversial.  The issue is who do we screen and does the cost make a difference?  Cardiologists have not resolved this argument.  Heart & vascular disease is the number one cause of death in men and women.  Dr. Khot et al., noted in his 2003 paper published in JAMA that 82.4% of patients with coronary heart disease had no or only one risk factor for heart disease.  Another study then noted that 68% of those adults who suffered a heart attack had LDL-Cholesterol levels of less than 130 mg/dL and would not have qualified for preventive treatment. 

Over half of those who die suddenly from heart & vascular disease never experience any real symptom or warning, and sudden cardiac death was their first sign that there was a problem.  An article in Medicine At Michigan discussed prevention with Drs. Rubenfire and Eagle.  They stated what I have taught my patients for over 20 years.   "We know it's not the degree of blockage that's most worrisome", explains Kim Eagle, MD, the Albion Walter Hewlett Professor of Internal Medicine and director of the U-M Cardiovascular Center.  "More dangerous are the smaller deposits of plaque that rupture and cause a heart attack."   This plaque can begin at "an astonishingly early age.  In autopsies of teenagers who die in auto accidents, soft waxy plaque is often found in their coronary arteries and brain vessels," says Rubenfire.  "It can be seen in children by age 5." 

Some people confuse screening with prevention.  Everyone is talking about screening programs.  They bring us reports that basically note "Mild plaque, no significant blockages or aneuryms."  The disclaimer on the results states, "...for informational use only and is in no way diagnostic or conclusive".  What?  This is true since the sensitivity of any imaging procedure has limitations.  Even "normal" heart catheterizations or coronary angiograms aren't necessarily "normal".  Individuals can have "normal" coronary angiograms showing all the arteries are open and no flow restriction or narrowing, yet suffer a heart attack and have moderate, diffuse plaque or atherosclerotic build-up found at the time of autopsy. The heart's arteries can compensate for the plaque build-up early on and hide 40% of its volume outside the arterial lumen (center tube of artery where blood flows and the portion of the arteries evaluated by standard coronary angiography). [SEE IMAGE  BELOW - NEJM 1987]

​

I find it interesting when an individual tells me that "nothing important" was seen on their screening tests and they feel they can continue their current lifestyle.  I understand they did not find a large, bulging abdominal aneurysm or a blocked carotid artery, but there was mild, atherosclerotic plaque in the arteries.  This requires treatment.  Risk is based on millimeters of thickness in the arterial walls that we assess with Carotid CIMT. Waiting to start treatment in the advanced stages has never made any sense to me.  Our current healthcare system tends to focus on detecting problems in the advanced stages.  The problem?  Outcomes are not too favorable when trying to treat advanced disease, even after stents and bypass procedures.  

The goal, when screening is done correctly, is to try to determine the individual's current heart and vascular age, condition and risk.  This takes a fairly comprehensive approach. This information, combined with careful history and physical examination,  can assist us to guide the individual towards a more favorable path if possible, to thrive, and not just to survive.  I recently saw a man in his early 50s who already had bypass surgery and at least 15 stents placed into his native heart arteries and grafts.  Surviving.  Still having chest pain ( angina or ischemia ) related to lack of adequate flow to his heart from diffusely diseased arteries.  He had not changed anything about his lifestyle, was still smoking, overly stressed, not sleeping well and stuck to his couch.  He still wanted a quick fix.  He already had several quick-fixes that were not solutions. He was not ready for change and just surviving from heart attack to attack - stent to stent. 

​

Preventive measures do not guarantee we live longer or skip future heart attacks. The goal is trying to reduce one's chances (risks) for having another heart attack and avoiding the disability that so often follows major events. It requires reduces inflammation, improving fitness, quality sleep and stress reduction for starters. The Courage Trial was an important study looking at lifestyle and medical therapy versus invasive therapies. There is a place for both in the treatment of heart and vascular disease. We have not yet proven that we prevent heart attacks by placing stents into the narrowings of heart arteries to restore flow and we don't increase life expectancy with these invasive procedures, yet they still have there role in the treatment of heart and vascular disease. 

​

INTERHEART and INTERSTROKE STUDY findings are key components in the prevention and treatment of heart and vascular disease. The INTERHEART study found that heart attacks were associated with the balance of ApoB to ApoA1 lipoproteins in the blood. ApoB and ApoA1 are the protein components that make up the central core of LDL and HDL cholesterol respectively. The next most common factors were smoking, psychosocial stress and then diabetes. In our clinic, we assess the ApoB, ApoA1 and Lp(a) levels as well as hsCRP. These are only a small part of the advanced lipoproteins we evaluate, but are clearly important. LDL-C is often only calculated and varies widely, but can also be helpful tools to assess preventive therapy. The MAXPULSE Arterial Waveform evaluation has given us a tool to assess the stress component that is not always apparent on physical exam.