San Diego Magazine / October 2004 / You Gotta Have Heart

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You Gotta Have Heart

CHANCES ARE you have a passing familiarity with the numbers closely associated with heart disease, the nation’s number-one killer for men and women. You likely know it’s desirable to have a low reading of LDL (lowdensity lipoprotein), the socalled “bad” cholesterol, because it’s the major component of plaque that builds up inside arteries and blocks blood flow. You probably also know the reading for your “good” cholesterol, the HDL particles that transport cholesterol back to the liver (where it’s produced) for excretion.

The target guideline numbers, though, are changing as doctors learn more about heart disease treatment and prevention. “For patients at high risk, the previous LDL goal was less than 100, and now it’s 70,” says Dr. Daniel Blanchard, a professor of medicine at the University of California, San Diego, and director of the Cardiology Fellowship Training Program at UCSD Medical Center. High-risk patients are those who have had, for example, a coronary bypass, unstable angina, a recent heart attack or those who have diabetes.

“For people at low risk,” Blanchard says, “LDL of less than 130 still looks okay, although frankly, I would like mine under 100.” Previously, he says, an HDL reading of less than 35 was considered a risk factor that might lead a doctor to recommend therapy to bring down a patient’s LDL. Now the HDL number is less than 40. “This means doctors will recommend a lot more people take medicine to lower their LDL and their cardiac risk,” says Blanchard.

The recommended goal for triglycerides, energy-producers that are the most common type of fat in the body, remains at 150 or less, he adds.

Other diagnostic steps that may be useful in detecting heart disease in otherwise seemingly healthy patients include tests for a blood fat known as lipoprotein(a), or Lp(a). “It can be high in some patients with coronary disease despite low or ‘normal’ LDL levels,” Blanchard says.

Testing for CRP (C-reactive protein) also may help detect heart disease. “The CRP blood level is a marker of inflammation within the body and is an independent risk factor for coronary artery disease,” Blanchard says. “Regardless of a patient’s LDL level, the presence of a high CRP level—3 or above—significantly increases the risk of a cardiac event.”

In recent years, cholesterol-lowering drugs known as statins have achieved household-name status, thanks to the frequency of advertisements for such drugs as Pravachol, Zocor and Lipitor. In many cases, statins halt the progress of coronary artery disease, and sometimes the condition even improves, says Blanchard, who adds that doctors have begun to prescribe higher doses of the drugs. A new drug, Zetia, is being added to the medical repertoire to treat high cholesterol. Unlike a statin, which works in the liver to reduce the production of LDL, Zetia only works in the intestines to block the absorption of the bad cholesterol. Taking the drug in combination with a statin is likely to cut a patient’s LDL 15 percent to 20 percent more than use of a statin alone, Blanchard says.

Researchers also are investigating a new way to prevent heart attacks by raising a patient’s HDL, or good cholesterol, level. Clinical trials for the drug torcetrapib have produced “quite promising results,” Blanchard says, and it’s anticipated the drug will be available in a few years. If approved, it could be taken with an LDL-lowering statin.

Blanchard notes that new drugs, such as Lotrel, that combine the properties of ACE inhibitors and calcium channel blockers, are making it easier to treat high blood pressure. A blood pressure reading of no more than 130 over 85 is the most desirable, he says, and these numbers should be lower in patients with kidney disease or diabetes.

Up to 30 percent of Americans take some form of antioxidants —notably vitamins E, C and beta carotene, a form of vitamin A—as a way to reduce the risk of cardiovascular disease, according to the American Heart Association.

“I don’t have anything against herbal medicine, but nothing has shown that these [supplements] are effective in preventing heart disease,” Blanchard says.

Combining drugs with medical devices is another way science is making headway in the treatment of heart disease. The Food & Drug Administration last year approved the first drugeluting stent for angioplasty procedures to open clogged coronary arteries. A drug-coated stent, a tiny metal mesh tube, is left permanently in an artery to keep it open after angioplasty. The stent slowly releases a drug to prevent the buildup of new tissue that can reclog the artery (a problem known as restenosis that must then be treated again with angioplasty or bypass surgery). Drugeluting stents reduce the rate of restenosis by about two-thirds.

Heart failure has become the most common reason for hospital admission in the United States, Blanchard says. While it doesn’t mean the heart has stopped working, heart failure is the end result of multiple heart attacks as well as uncontrolled hypertension. “This statistic tells us that although we have made really significant progress in the prevention, or delay, of cardiac events, we can still do better,” Blanchard says.