Joel Posner, Drexel University College of Medicine, Philadelphia

June, 2003

Last year, 632,020 people died in the United Kingdom. It is reported that about 40% of them (250,343) died of diseases of the circulatory system. This probably underestimates the true number since many of the 70 to 80,000 people who died of sudden death were probably not included though these deaths are almost always cardiac. Other major causes of death included malignant neoplasms (24%) and respiratory system disease (17 %.) Everyone is aware of the role of smoking, alcohol intake, and land-air-and water pollution on these two later categories of deaths. The medical tragedy is that most of the cardiovascular deaths were preventable.

1. Waist Size: The larger the waist, the more intra-abdominal fat, and the higher the risk of cardiovascular disease. For men under 40, waist size should be less than 39 inches (100 cm), for men over 40, it should be under 35 and ½ inches (90 cm) inches, and for women, it should be less than 35 inches (89cm).
2. Lipids: It is the quantity of blood lipids and the particles size that are important. Unfortunately, measurement of particle size is seldom available. The current recommendations for treatment of lipids are not to be trusted. The heart protection study (HPS) showed that lowering even those "acceptable" LDL levels of less than 3.0 mmols/L decreases cardiovascular events by 20%.
3. LP(a). This is a protein which predisposes to stroke, heart attack, and complications of hypertension. It should be less than 30 mgm/dL, though lower is better.
4. Homocystein: Elevated levels of homocystein have been estimated to cause up to 25% of myocardial infarction in the US. Desirable levels are <9 mmol/L.
5. Glucose intolerance. Both glucose intolerance and insulin resistance predispose to heart disease and hypertension. It is worth doing a simple one hour glucose tolerance test in someone in whom you are trying to determine total cardiac risks.
6. C Reactive Protein (CRP.) This is an indicator of greatly increased cardiac risk. Desirable levels are <0.55 on the "highly sensitive" assay. Risk doubles when this levels is 0.56 to 1.44 and triples when this level is >2.1.
7. Blood pressure. Desirable blood pressure is <120/75.
8. Dietary factors (see below).
9. Lack of vigorous exercise. Optimal is 200 minutes/week.
10. Smoking.
11. Infection. Simple chlymidia infections have been shown to predispose to coronary events. Poor dental hygiene does as well. Flossing daily is cardio protective.

1. Dietary:
   1. Isocaloric: Weight and waist should be optimal and caloric consumption should keep weight stable at that point.
   2. Fats: Limit total fats to a reasonable 40 to 50 g/day, but most important, limit saturated fats to under 10%. Additionally: mono-unsaturated fats should be about half of all fats (olive oil, canola oil), poly unsaturated fats the other half with Omega 3 oils (fish and flax seed as high as possible. Certainly it should represent five or six grams of total fats even if supplementation is necessary.) Transfatty acids (hydrogenated or partially hydrogenated fats) should be avoided.
   3. Carbohydrates. Simple sugars should be limited. Simple starches as well. Avoid carbohydrate with high GLYCEMIC INDEX and high GLYCEMIC LOAD. Watch for and avoid High Fructose Corn Syrup which is the major industrial sweetener used in the western world today. Fiber intake is important and you should shoot for 20 to 30 grams per day.
   4. In general, diets rich in nuts, colored vegetables, fruits and grains have been shown to decrease the incidence of heart disease. Fish intake should be high and animal fats kept to a minimum.
   5. Vitamins: Folate supplements with B6 and B12 have been shown to decrease the incidence of heart disease. Vitamin E has not. (Though a mixture of E, C, Zn, selenium have shown other benefits, particularly in protecting vision.)
2. Medications:
   1. Control blood pressure.
   2. Control lipids: HMG CoA reductase inhibitors decrease heart attack and stroke and may decrease the incidence of Alzheimer’s (though the evidence for this is very light.)
   3. Niacin decreases LDL, LP(a), and triglycerides, and increases HDL. It is the preferred agent for raising HDL. It must be started at very low doses and worked up to a limit of 3 g/day. Liver functions, uric acid, glucose, homocystein must be checked. If used, generous doses of folate, with some B6 and B12 should be added.
   4. Omega 3 oils can lower triglycerides. Doses can be titrated up to 4 to 6 grams a day if needed.
   5. A new absorption blocker –Ezetimibe—shows promise particularly in combination with HMG CoA reductase inhibitors.
   6. To lower homocystein, use folic acid in increasing doses. You can go as high as you need, though 4.5 mgm is almost always enough. You should add restrained doses of B6 (no more than 50 mgm a day) and B 12. If no response, think of B 12 malabsorption.
   7. Metformen should be used to lower glucose intolerance and insulin resistance.
   8. Antibiotic use to prevent coronary disease is controversial.