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Value of Assessing for the Presence of Atherosclerotic Disease When Other Risk Factors are Not Present
Our method of risk assessment is rooted in the concept of determining whether or not a patient has silent potentially deadly atherosclerotic disease (cholesterol build up in the wall of an artery). This is a novel concept and contrary to standard care which only assesses risk by looking at common risk factors. Since atherosclerosis is a prerequisite for heart attacks and strokes and it is well documented that many people suffering these events are not identified by common risk factors, we believe our approach is superior. The following cases certainly support this contention.
A very fit 44 year old white male presented to our clinic for evaluation at the insistence of his wife. They had young children and his wife wanted to make sure he would not follow the tragic path of his father or maternal grandfather. His father had suffered a stroke at the age of 58 followed by a heart attack. His maternal grandfather died of a heart attack at age 60.
Other than the family history there appeared to be no risk factors. The patient was in excellent health. He was not over weight. He had no bad habits like smoking. His blood pressure was 120/70. He was on no medications. His cholesterol was fantastic: Total Cholesterol-187 mg/dL; Triglyceride -94 mg/dL; HDL (good cholesterol) -47 mg/dL; LDL (bad cholesterol)-121mg/dL; lipo(a) (an extremely bad form of bad cholesterol)-10mg/dL which is a very normal level. He had no hint of diabetes or pre-diabetes: fasting blood sugar -83 mg/dL; fasting insulin-7; HgA1c –4.2; two hour sugar after a glucose load- 71mg/dL. This information allows the calculation of a risk score for heart attacks (Framingham Risk Score-FRS). We did this calculation and it was a very low risk score of a 1% chance of a heart attack over the next ten years.
Fortunately, as we always do, we looked to see if he actually had atherosclerosis. We found with B-mode ultrasound that he had very significant disease in his carotid arteries. The size and texture of these diseased areas put him at high risk for a stroke. We did further investigation and discovered elevated levels of a substance called myeloperoxidase (MPO). This enzyme is emerging as a very significant issue in atherosclerotic disease. If we had stopped our assessment of his risk after simply looking at the common risk factors, we would have told this gentleman that he was fine and needed no therapy. Our discovery of silent and potentially deadly atherosclerosis lead to further investigation of cause which uncovered the rarely measured MPO. He was informed of his increased risk and is on aggressive management in an effort to make sure he avoids the fate of his father and grandfather.
Arriving a few minutes late to her appointment in her gym clothes, this 58 year old "picture of health" came to us at the request of her husband (also an established patient). She is a vivacious, thin, active woman who has dedicated her adult life to keeping her body and mind healthy and active, attending college courses, and making daily visits to various gym classes. A retired nurse, she now wants to pursue other outlets such as economics and fitness. She has always received regular medical check-ups and has always received "reassurance" that she is "very healthy" and "has no risk factors for heart attacks or strokes". Her only concern is that her brother had a heart attack at the age of 63 although she couched this concern by quickly reporting that "he smokes and is overweight."
Indeed, the current standard of care agrees with her primary care provider – she has a Framingham Risk Score of 1% 10-year risk and has a LDL (bad cholesterol) of 103. Her blood pressure is 120/66, pulse of 52, weight of 133, 5'6", waist 27". She was able to play intense tennis for 2 hrs at a stretch and run effortlessly on the treadmill.
One question had never been asked with this woman….does she have vascular disease? A few non-invasive tests, such as a chest x-ray and B-mode ultrasound revealed that she had coronary and carotid plaque (atherosclerosis). The plaque in her carotid arteries was found to be very inflammatory and large in size. These findings immediately change the platform for which this woman should be treated – she is a very physically fit woman who has a very high risk for a stroke or a heart attack. The standard of care is not set up to identify subclinical, asymptomatic athersclerotic disease (the kind of disease that allows 64% of women to have a heart attack or stroke without any prior warning signs).
The standard of care does not suggest the reason for her vascular disease. The Bale/Doneen method quickly discovered that she was insulin resistant and on the verge of being diabetic (2 hr OGTT of 168). Surprisingly, her fasting blood sugar and 3 month average blood sugar (A1C) were completely normal. She was also found to have the very high risk conditions of Lipo(a) and Myeloperoxidase (MPO).
She is now on treatment and her inflammatory vascular disease is beginning to show signs of stability (blood work testing). She continues to go to the gym every day, continues to attend her college economic classes, and she is now aware of her risk. She is actively taking steps to minimize her risk of a heart attack or stroke– enabling her to live life with knowledge and wellness and the ability to prevent further development of atheroscletoric disease.