News
A LOOK BACK AT HEART DISEASE….AND
A LOOK FORWARD
AT
YOUR HEART
Heart
Disease – Then, Now and in Your Future
William M. Bethea, M.D., F.A.C.P.
I hope that you will allow me to reminisce a bit
since today is my birthday, and I am about to begin
my sixty-fourth year on earth; thirty-seven of
which have been as a physician. During those
years, I have witnessed changes in the treatment
and prevention of heart disease that rival some
of mankind’s most impressive advances. In
fact, man’s first step on the moon, as impressive
as it was, will probably have far less impact on
your life than those advances in medicine that
have made heart attacks much less common, and hopefully
will have the same impact on strokes and senility
as the effect of aggressive preventive medical
care bears its fruit in the coming years.
When I had the privilege of joining the original
five members of Consultants in Internal Medicine
(CIM) in 1977, the world of heart disease was almost
unrecognizable when compared to 2008. The
importance of cholesterol levels was well known,
but the blood levels that were considered “normal” were
anything under 350 mg%! Today that
cholesterol level would approach the threshold
of a biochemical medical emergency! The
idea of “good (HDL)” and “bad
(LDL)” cholesterol had not yet surfaced,
and treatment of high cholesterol levels was essentially
confined to dietary changes. In our daily
lives as physicians, heart attacks were a common
occurrence as reflected by the fact that I once
admitted five patients with that diagnosis on a
single Christmas day! Among the six internists
of CIM, we averaged approximately five patients
in the Coronary Care Unit at all times as they
recovered from their life threatening illnesses. There
were no cardiac catheterizations for “acute
intervention” in the form of stents or bypasses,
and the heart attack was allowed to do its damage
unchecked. Deaths before our eyes were not
uncommon and chronic heart failure as a result
of heart damage was even more common. The
average hospital stay after a heart attack was
two weeks, and the patients were not allowed out
of bed for the first week! At discharge,
the patients were sent home without any specific
program for cholesterol control, and no medicines
were even known then that offered any real hope
of diminishing the incidence of the next heart
attack.
Then the tide began to turn in favor of the responsible
patient! Acceptable Cholesterol levels dropped
dramatically to 300, then 250, and now have fallen
all the way to 170 – less than half of what
was considered normal just 30 years ago! In
fact, current data suggests that you continue to
accrue benefits from the lowering of your cholesterol
levels all the way down to a total cholesterol
level of 132 mg%! The discovery of HDL’s
and LDL’s redirected our preventive efforts
towards reducing LDL’s to less than 70 mg%
in order to trigger what has become known as the “reversal
phenomenon” – an actual reabsorption
of previous cholesterol depositions on the walls
of blood vessels! For the first time
in medical history we had a tool to mimic the effects
of the proverbial “Fountain of Youth”!
The “magic bullet” that allowed us
to shoot a hole in the deadly effects of heart
attacks were the statin drugs, now primarily represented
by Lipitor, Zocor and Crestor. Nothing in
my medical career has had the impact of these drugs
on the quality and duration of the lives of those
that we have cared for for years. When the
effects of aspirin therapy are added to aggressive
cholesterol lowering, tobacco abstinence, maintenance
of normal blood pressure, regular exercise and
adherence to acceptable weight parameters, the
incidence of heart disease drops more dramatically
than we ever envisioned possible!
Almost twelve years ago, the doctors of the Executive
Evaluation Center and what would become the Dedicated
Care Center recognized the possibility that the
aggressive reduction of risk factors might pay
huge dividends for our patients in the form of
a reduction in the incidence of occlusive vascular
disease leading to heart attacks, strokes and senility. With
that in mind, we began and have continued what
is now recognized to be among the most aggressive
protective programs in the country for our patients. We
recognized the value of drastically lowering cholesterol
levels and mitigating other recognized risk factors
when insurance companies and many doctors were
saying that it was “overkill”. But
now the fruits of our patients’ labors are
becoming obvious. The incidence of heart attacks
in our patient population has fallen so dramatically
that I have not seen a heart attack in my practice
in over four years. The average number of patients
that we have under our care each day in the Coronary
Care Units has fallen to a dramatic number – essentially
ZERO! The combination of aggressive cardiac
screening in the Executive Evaluation Center utilizing
stress echo cardiography in symptom-free patients
in conjunction with very aggressive measures for
the lowering of cholesterol and control of clotting
parameters by a combination of daily aspirin and
a statin has yielded dividends that have exceeded
our most optimistic expectations.
And the changes continue to mount! The most
recent data, now hitting your network news and
daily papers, shows that those heart attack patients
previously thought to have been at low risk for
heart disease because of very low total and LDL
(bad) cholesterol levels appear to benefit from
statin (Lipitor, Zocor or Crestor) therapy to the
same degree as those with known threatening cholesterol
levels when a “new” test is used to
identify those patients. In simpler terms,
there are many patients who have normal cholesterol
levels, but elevations of a particular protein
called C-Reactive Protein (CRP) who can diminish
their risks for life threatening heart disease
by adding a statin drug to their program. In
fact the incidence of heart attacks in those patients
with elevated CRP’s appears to be reduced
by 54%, stroke by 48% and bypass or angioplasty
(stent) by 46%!
That “new” test for that threatening
protein is CRP-HS, or C-Reactive Protein, High
Sensitivity.
How new is it? Not very! In fact, we
have included that very test in the EEC protocol
for five years, and have used the results to reinforce
the need for optimization of cardiac risk factors
since its inclusion in our program.
So once again, the aggressively protective principles
of our EEC/DCC practices in effect for years have
become the medical “news” of the day.
For those of you that have followed our recommendations
for years, you can be assured that your risks of
heart disease, stroke and senility have been significantly
reduced. If you fall into that group of patients
with normal cholesterol levels, but a high CRP
level, we will be even more aggressive in suggesting
the addition of a statin to your program. You can
also be certain that we will continue to lead the
way in the efforts to optimize your longevity and
enjoyment of life to the maximum by reversing or
mitigating every risk factor for life threatening
disease that can be identified!
We would welcome further discussion of any questions that you may have on this very important topic.
Recommendations for avoidance of the consequences of occlusive vascular disease:
- Annual stress echocardiography (EEC)
- Aggressive control of Cholesterol levels (Total <170; LDL <70: HDL>40)
- Daily Aspirin therapy
- C-Reactive Protein blood study (EEC) with Statin therapy for elevated tests
- Maintenance of normal Blood Pressure with meds when indicated
- Total tobacco abstinence
- Maintenance of normal body weight
- Regular Exercise
- Consider office & home defibrillator