PCSK9 inhibitors: a major advance in cholesterol-lowering drug therapy

Posted March 15, 2015, 11:02 am

Gregory Curfman, MD, Editor in Chief, Harvard Health Publications

Every so often a medical advance comes along that rewrites the script for treating a disease or condition. After today’s announcements of impressive results of a new type of cholesterol-lowering drug, that scenario just might happen in the next few years.

The new drugs, called PCSK9 inhibitors, are monoclonal antibodies. They target and inactivate a specific protein in the liver. Knocking out this protein, called proprotein convertase subtilisin kexin 9, dramatically reduces the amount of harmful LDL cholesterol circulating in the bloodstream. Lower LDL translates into healthier arteries and fewer heart attacks, strokes, and other problems related to cholesterol-clogged arteries.

http://cen.acs.org/articles/93/i13/Cholesterol-Lowering-PCSK9-Inhibitors-Near.html

HDL,LDL, cholesterol
mmol/L to mg/dL    /    by 0.0259 to get mg/dL
mg/dL to mmol/L    *    by 0.0259 to get mmol/L

HDL,LDL, cholesterol
mmol/L to mg/dL    /    by 0.0259 to get mg/dL
mg/dL to mmol/L    *    by 0.0259 to get mmol/L

Triglycerides
mmol/L to mg/dL    /    by 0.01129 to get mg/dL
mg/dL to mmol/L    *    by 0.01129 to get mmol/L

EXAMPLE 1 DAD

Cholesterol          4.2  mmol/L    162.16 mg/dL
Triglyceride          0.8 mmol/L    70.85  mg/dL
HDL                  1.11 mmol/L    42.85  mg/dL    needs to be >60mg/dL
LDL                   2.7 mmol/L    104.24 mg/dL     needs to be <70mg/dL
Chol/HDL Ratio       3.8  mmol/L

 

EXAMPLE 2 MUM

Cholesterol          7.6 mmol/L     293.43 mg/dL
Triglyceride         1.7 mmol/L     150.57 mg/dL
HDL                 1.71 mmol/L      66.02 mg/dL      needs to be >60mg/dL
LDL                  5.1 mmol/L    196.91 mg/ dL     needs to be <70mg/dL
Chol/HDL Ratio       4.4 mmol/L

 

LDL’s
Bad Fats and promote atherosclerosis (narrowing of the arteries)
An LDL level of less than 100 mg/dL is optimal for CAD prevention,
A level of 70 mg/dL or less is now recommended for persons with existing heart disease
HDL’s
Good Fats and promote opening up of the arteries
> 50 mg/dL (≈ 1.3 mmol/L) man or >60 mg/dL (≈ 1.6 mmol/L) in a woman a reduced risk of atherosclerosis.
>75 mg/dL (≈ 2 mmol/L) man or woman is associated with a very low risk of atherosclerosis.
Less than 40 mg/dL (≈ 0.8 mmol/L) in a man <50 mg/dL (≈ 1 mmol/L) in a woman increases the risk.
TRIGLYCERIDES
Reduction of triglycerides to 60 mg/dl.

 

LOWER YOUR LDL AND CHOLESTEROL

After reviewing many journals and articles I observe the following ways to lower cholesterol

OBJECTIVES

Important
a) Reduction of LDL to 60 mg/dl (Bad Fats)

An LDL level of less than 100 mg/dL is optimal for CAD prevention,

and a level of 70 mg/dL or less is now recommended for persons with existing heart disease

1. b) Reduction of triglycerides to 60 mg/dl.
2. c) Raising HDL to 60 mg/dl. (Good Fats)

> 50 mg/dL (≈ 1.3 mmol/L) man or >60 mg/dL (≈ 1.6 mmol/L) in a woman a reduced risk of atherosclerosis.
>75 mg/dL (≈ 2 mmol/L) man or woman is associated with a very low risk of atherosclerosis.
Less than 40 mg/dL (≈ 0.8 mmol/L) in a man <50 mg/dL (≈ 1 mmol/L) in a woman increases the risk.

1. d) Achieving normal blood pressure (<130/80)

Even a small elevation of blood pressure in diseased arteries can cause increased mortality.

Diseased arteries are fragile and plaque rupture can occur easily.

1. f) Achieving normal blood sugar if Diabetic (=100 mg/dl). Diabetes is a high risk factor for heart disease.
2. g) Reduction of C-reactive protein to <1 mg/l also called (CRP on blood test)

 

THINGS TO DO

1. Smoking Cessation
   Is associated with a 200% increase in the rate of atherosclerosis
2. exercise 45 min cardio daily
3. Treat underlying conditions:
   Hypertension – Olmesartan medoxomil (angiotensin II receptor antagonist these are preferred)
   Diabetes
   High Cholesterol or LDL ie Take a Statin – medication to lower LDL and cholesterol preferred is Crestor (Rosuvastatin) take at night time (as cholesterol is synthesized by the body at night-time)
4. Aspirin 100mg / d
5. Plant Sterols, margarine, 2 g/d The mean one-year reduction in serum cholesterol was 10.2 percent
6. Dietary Modification:
   1. Mediterranean Diet
   2. Cook with olive oil and use Polyunsaturated fats
   3. Avoid milk fats
   4. Decrease red meat increase fish
   5. Avoidance of fried foods and fast food
7. Omega 3 (salmon oil) (specifically focusing on high concentration of high in DHA, EPA where possible >2000 mg per day)
8. Garlic 1g / d
9. Vit B3 500-1500mg. per day (cheap flush version not anything labelled non-flush which contains inositol)
10. Wine—Red wines contain resveratrol, (don’t exceed two glasses/ day else has a inverse effect). Bioflavonoids and anti-oxidants have a strong anti-inflammatory effect.
11. Lechathin
12. Magnesium
13. L-carnitine
14. Vit B6

 

 

 

 

In epidemiologic studies, a low serum LDL-C of less than 75 mg/dL (≈ 2 mmol/L), typically found in vegetarians and those on non-Western style diets, protects against atherosclerotic cardiovascular disease. Dietary saturated fat and cholesterol generally raise the level of LDL-C in the blood and proportionally raise the coronary risk. The related factors of obesity, metabolic syndrome, and type 2 diabetes may have only modest effects on LDL-C levels, but they increase coronary risk by increasing triglycerides and LDL particle concentration, while lowering HDL-C and causing the production of small, dense LDL particles.
• An HDL level of 50 mg/dL (≈ 1.3 mmol/L) or greater in a man or 60 mg/dL (≈ 1.6 mmol/L) in a woman is associated with a reduced risk of atherosclerosis.
• An HDL level of over 75 mg/dL (≈ 2 mmol/L) or greater in a man or woman is associated with a very low risk of atherosclerosis.
• An HDL of less than 40 mg/dL (≈ 0.8 mmol/L) in a man and less than 50 mg/dL (≈ 1 mmol/L) in a woman increases the risk of atherosclerosis.
• Low HDL levels appear as an independent risk factor for CV events when combined with high LDL levels.

 

 

• LDL Cholesterol – Primary Target of Therapy
  

  <100	Optimal
  100-129	Near Optimal/Above Optimal
  130-159	Borderline High
  160-189	High
  190	Very high

• Total Cholesterol
  

  <200	Desirable
  200-239	Borderline High
  240	High

• HDL Cholesterol
  

  <40	Low
  60	High

 

 

LDL

The evidence that high LDL concentrations play a causal role in coronary artery disease (CAD)is quite compelling.

• Many investigators have convincing demonstrated a progressive increase in risk that correlates directly with LDL concentrations.
• Treatments that lower LDL cholesterol reduce the risk of CAD.
• Genetic studies analyzing SNPs show that SNPs affecting LDL cholesterol are consistently related to risk of myocardial infarction. In other words, genetic variants associated with elevated LDL levels are consistently associated with increased risk.
• The presence of LDL in atherosclerotic plaques provides additional evidence of its direct involvement.

Statin Drugs

Statins are currently the most powerful cholesterol-lowering drugs available. They act by inhibiting the action of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase, which is the rate-limiting enzyme in the sequence of steps by which cholesterol is synthesized in the liver. The liver has two sources of cholesterol: it can take up LDL particles from the blood, or it can synthesis cholesterol using HMG-CoA reductase. The diagram to the right illustrates cholesterol homeostasis in a liver cell. LDL (shown in red) can bind to LDL receptors on the surface of the liver. Binding causes the LDL to be taken up by the liver cell and digested in a lysosome. Fatty acids and amino acids in the LDL are recycled, and the cholesterol enters the cholesterol pool in the liver cell. Note that if the liver cell synthesizes cholesterol, this too will be added to the cholesterol pool. If the concentration of cholesterol in the liver cells exceeds a certain level, HMG CoA reductase is inhibited, and the synthesis of LDL receptors is also inhibited.

Statins act by inhibiting HMG-CoA reductase and shutting off internal cholesterol production. In this way, statins reduce cholesterol concentrations in liver cells, which causes increased production of LDL receptors and increased uptake of LDL by the liver. This ultimately results in a lowering of blood concentrations of LDL cholesterol, and this generally results in a slower progression of atherosclerotic plaques and a reduced risk of plaque rupture. However, observers occasionally report regression of atherosclerotic plaques in patient on statins.

While statins are effective in reducing LDL cholesterol levels, they can be associated with side effects.

• Muscle damage manifest as pain, tiredness, or weakness is the most common side effect and ranges from mild discomfort to difficulty in climbing stairs or walking. Statins very rarely cause severe, life-threatening rhabdomyolysis which can result in severe muscle pain, liver damage, kidney failure, and death.
• Liver damage: Statins can also damage liver cells, resulting in elevated levels of liver enzymes in blood. Liver enzyme levels should be monitored when statins are first started.
• Digestive problems: Some people experience nausea, gas, diarrhea or constipation.
• Rash or flushing
• Increased blood sugar or type 2 diabetes is occasionally seen in patients on statins.

Because of their effectiveness in reducing CAD in patients at high risk, some advocated expanding the use of statins to people who did not necessarily have elevated cholesterol levels. A number of large, well-done clinical trials have demonstrated that statins can reduce the risk of CAD in low-risk individuals, but most experts caution against this because of the cost and the risk of side effects.

 

As previously described, ACE inhibition may modify not only atherogenesis and plaque vulnerability but also triggering mechanisms responsible for disease onset.²²⁹ For example, the renin-angiotensin system may interact with fibrinolytic function,²⁵⁴ and ACE inhibition may influence endogenous fibrinolysis, resulting in a reduced thrombotic response to plaque disruption.²⁵⁵ Importantly, ACE inhibition also seems to reduce mortality and reinfarction in the presence of β-blocker therapy, suggesting an independent therapeutic effect.²²⁸

ACE activity may contribute to the development of coronary artery disease and myocardial infarction,²²⁵ and ACE inhibition seems to reduce the risk of major ischemic events (reinfarction, cardiac death, and possibly unstable angina) by about 22% in patients with low ejection fractions,^{226 227 228} probably via multiple beneficial mechanisms.²²⁹ ACE inhibitors may influence both atherogenesis (plaque vulnerability) and triggering mechanisms responsible for disease onset (plaque disruption, thrombosis, and/or vasospasm). The latter are discussed below in the section on trigger reduction. The hypothesis that these drugs are antiatherogenic and prevent or slow progression of coronary artery disease is now being tested in clinical trials.

How to Reverse Heart Disease with the Coronary Calcium Score

by Jeffrey Dach MD

Finally Accepted by the AHA

The AHA (American Heart Association) has steadfastly denied for many years that Coronary Calcium Scoring was a valid marker of heart disease.  Well guess what? They have recanted, and admitted that the amount of calcium in the coronary arteries reliably predicts heart attack risk. This is called the calcium score.(1)

Dr Matt Budoff

UCLA cardiologist, Dr. Matt Budoff, a long-time champion of the Coronary Calcium Scan, and author of the AHA paper says, “The total amount of coronary calcium (Agatston score) predicts coronary disease events beyond standard risk factors.”(1)

Image upper left, courtesy of Wikipedia Rembrandt, The Anatomy Lesson.

Dr. Detrano

Dr. Detrano, in a recent article in NEJM (New England of Medicine), confirms that “The coronary calcium score is a strong predictor of incident coronary heart disease and provides predictive information beyond that provided by standard risk factors”. (31)  The Coronary Calcium Score is a precise quantitative tool for measuring and tracking heart disease risk, and is more valuable and accurate than other traditional markers (such as total cholesterol which is practically worthless as a heart disease risk marker).

What is Coronary Artery Disease?  It’s Plaque Formation.

Coronary Arteries in Cross Section

Age 20-30 years                          Age 50-70 years
In youth, at left, there is minimal plaque formation.  However, at right with passage of time the plaque grows larger. About 20% of this plaque volume contains calcium which is measurable on CAT scan, providing a marker for the total plaque burden.  Calcium score and by inference, plaque volume typically increases 30-35% per year in untreated patients.

Note that even though the right vessel has a larger plaque, the lumen has remodeled so that the inner diameter remains freely open.  Eventually, as we age, the enlarging plaque eventually obstructs blood flow causing a heart attack.  Another common scenario is plaque rupture which exposes the inflammatory debris of the plaque to the circulating blood.  This quickly results in clot formation (thrombosis) resulting in a heart attack and possibly sudden death.

Repeat: The calcified portion of the plaque is consistently 20% of the total plaque volume, allowing use of the calcium score as a marker for total plaque volume.

Arterial Calcification – Why Does it Happen?Image below: Microscopic view of arterial calcification
(yellow arrows outline blue calcifications)

Calcification in the soft tissues (connective tissue, ligaments, muscles, arteries) is found in many disease states, and commonly identified on pathology slides of tissues.  Whenever there is cell death or tissue necrosis (death of cells), the body invokes a process of calcification which can be regarded as part of the healing process.  Arterial calcification is actually a form of bone formation in the wall of the artery triggered by an inflammatory process.  Pathology studies have shown that coronary artery calcium forms in areas of healed plaque ruptures. (21) Calcification and plaque formation increases with age, with calcium score typically increasing 30-35% per year in untreated patients (William Davis MD).

Heart Attack Rate Associated with Calcium Score

Chart below shows increasing heart attack rate as coronary calcium goes up

Chart Above shows that Calcium Score is Highly Predictive of Heart Attack Risk

What is a Heart Attack?
A heart attack is cell death of heart muscle caused by lack of blood flow with  oxygen deprivation.  AS previously mentioned, this is caused by a arterial blockage by enlarging plaque formation which occludes the lumen, or plaque rupture which causes clot formation which occludes blood flow.  If a small area of heart muscle is involved, the heart attack may be silent with no symptoms.  If a large area is involved, there may be severe chest pain radiating to the left arm or jaw, or other symptoms such as shortness of breath.  If the conduction system is involved, there may be irregular heart rhythm called ventricular tachycardia which can cause sudden death.  Some people have chronic chest pain from diseased arteries and this is called angina pectoris, treated with medicines to dilate the arteries such as nitroglycerine.

Common Sites of Plaque Formation – Bifurcations and Mechanical Stress

 

(image at right courtesy of Wikipedia)Above Left image shows xray angiogram of typical ulcerated plaque with stenosis at carotid bifurcation, Above Right Image shows gross pathology of inside of the vessel with darkened plaque (arrow). In this example, we have an artery in the neck that feeds blood flow to the brain.  Plaque rupture and occlusion of the artery in this case caused a stroke, however, the same process occuring in the heart causes a heart attack.

Branching Vessels – Increased Turbulence

Ask any interventional radiologist or invasive cardiologist where they find the plaque formation and obstructions in the arterial tree, and they will say its the same few places over and over again.  These places are the carotid bifurcation, the distal aorta at the bifurcation, the femoral bifurcation, the exit from the adductor canal. And of course, the proximal coronary arteries, and bifurcations of the coronary arteries. A birfurcation is where the vessel branches into two vessels, making a Y pattern.

The bifurcations have maximal turbulance and mechanical stress on the vessel wall.  Remember the blood is flowing under pulsatile pressure, and this mechanical pressure and turbulence, over time, causes little stress cracks in the vessel. The cracks appear at sites of maximal stress.  The coronary arteries are a special case because of the extra motion of the cardiac muscle which moves and stretches the coronary arteries every heart beat, especially as the arteries branch off from the aorta which is relatively stationary, while lower down over the surface of the heart, the vessels move vigorously with each heart beat.  Atherosclerosis is essentially the net result of the healing process for these little cracks in the arterial wall resulting from mechanical stress.

William Davis MD

Advocate of the Coronary Calcium Score

William Davis MD recommends screening CAT heart scans in males over 40 and females over 50.  He would start at younger ages if high-risk features are present, such as strong family history of early heart disease, cigarette smoker, diabetes mellitus, or severe lipid or lipoprotein genetic disorders. (2)(3) The Coronary Calcium Score test is currently covered by Medicare and many health insurances.(32)

Credit and Thanks is given to William Davis MD at the Track Your Plaque Web site for much of the information in this article.  I have added and embellished some of the information.

 

What does Calcium Look Like?Normal                  Calcified

Calcium looks White on the CAT scan (red arrows at right).
(Above) CAT scans of the Coronary Arteries.

The left image shows a normal coronary artery (red arrows), while the right image shows a heavily calcified coronary artery (white line outlined by red arrows) indicating high risk for coronary artery disease and heart attack.

All About Coronary Calcium Scoring

 1) Calcium scoring may be superior to angiography as a means to track plaque. That’s because the vast majority of heart attacks are due to plaque rupture and thrombosis at areas of thickened plaque with minimal lumen narrowing.  Over time, the body’s healing process automatically remodels the areas of thickened plaque, and increases lumen size to compensate for the reduced blood flow.

2) Calcium scoring gives a precise number which correlates with the amount of plaque volume. Although only the hard plaque, or calcium in the artery is actually measured, this is useful because it consistently occupies 20% of plaque volume (Total hard and soft plaque).

3) The new 64-slice CAT scanners provide reliable calcium scoring just like any other scanner, both multi-slice and EBT(Electron Beam Cat).

The Track Your Plaque Program, by William Davis MD(2)(3)

1) Quantify plaque with Coronary Calcium Score with CAT scan (or with Electron Beam CT). Obtain your CAT Scan serially, every 12 months to assess response to treatment and lifestyle modification (track your plaque).

2) Use Sophisticated Lipoprotein Panel (Quest-Cario-IQ , LabCorp-VAP)(7-8)) to uncover hidden causes of plaque progression. LDL particle size and number, Lipoprotein (a). Repeat every 6 months.

3) The Main Treatment Goal is the reduction in Coronary Artery Calcium Score, and by inference, reduction in plaque volume and reduction in cardiovascular mortality. The cardiology community still awaits the hard data on these results (CHD mortality and CHD events, treatment arm vs no treatment arm).  These numbers have not been published as far as I know.

How to Measure Success in Halting or Reversing Heart Disease Plaque

According to Dr. Davis, calcium score typically increases at an astonishing rate of 30-35% per year without treatment. Therefore, Dr. Davis considers treatment success to be reduction in this rate from 30 to perhaps only a 5-10 per cent increase in calcium score per year.  An absolute reduction in calcium score on follow up scanning is the optimal outcome, which is difficult to achieve even with strict adherance to the Track Your Plaque program, in Dr Davis’s experience.

Track Your Plaque Program Details – Attain the Following Targets:

a) Reduction of LDL to 60 mg/dl (LDL should be measured directly, not calculated)

b) Reduction of triglycerides to 60 mg/dl.

c) Raising HDL to 60 mg/dl.

d) Correction of hidden causes of plaque on Lipoprotein profile such as total number of small LDL particles, IDL, and Lp(a).

e) Achieving normal blood pressure (<130/80)  Even a small elevation of blood pressure in diseased arteries can cause increased mortality.  Diseased arteries are fragile and plaque rupture can occur easily.

f) Achieving normal blood sugar (=100 mg/dl). Diabetes is a high risk factor for heart disease.

g) Reduction of C-reactive protein to <1 mg/l

Dietary Modification and Supplements to Attain Above Targets:

Niacin

a) Niacin vitamin B3 (Slo-Niacin Upsher-Smith (44) or Niaspan Kos Pharmaceuticals preferred) 500-1500mg. per day (avoid the no-flush niacin which contains inositol).(6)(44)

Buy Niacin  

on Amazon.

Omega 3 Fish Oil

b) Fish oil (Omega 3 oils) 4000 mg per day (providing 1200 mg omega-3 fatty acids). (molecular distilled pharmaceutical grade).(36)

Buy Purecaps Super-Critical Co2 Extract Omega 3 Fish Oil

Vitamin D

Vitamin D level restored to above 50 ng/ml (Vitamin D3 2000-5,000 u/day), Vitamin K2 also used.  Low vitamin D is associated with increasing arterial calcification and increased heart disease risk. (26)Consumption of calcium tablets by women increases arterial calcification and heart attack risk.(5)

Buy Vitamin D

Read my article on vitamin D which can be found here.(60)

d) Low Glycemic Diet (avoid Fructose Corn Syrup, avoid wheat products), and eliminate wheat products like Shredded Wheat cereal, Raisin Bran, and whole wheat bagels.

e) Consume foods such as raw almonds, walnuts, pecans; olive oil and canola oil. Beneficial for lipoprotein profile.

f) Increasing protein intake, our major building block for body tissues.  Added benefit of protein intake is that it doesn’t increase blood sugar.  This is low glycemic nutrition.

g) Wine—Red wines contain resveratrol, (don’t exceed two glasses/ day). Bioflavonoids and anti-oxidants have a strong anti-inflammatory effect.

h) Fiber – Gound flaxseed (2 tbsp/day)-Extra fiber aids in detoxifying liver and the entire body  by interrupting the enterohepatic circulation. Psyllium (metamucil). Regulates bowel movements and has favorable effect on lipoprotein profile.

Vitamin C – A Genetic Deficiency Disease

Vitamin C (1000–3000 mg/day), is a key player, as it is the vitamin for strong collagen formation, strengthening the arterial wall.  See Linus Pauling’s patented protocol which includes Vitamin C and amino acids Proline and Lysine, the two amino acids that act as receptors for Lp(a).  By consuming additional Lysine and Proline, the receptor sites on the Lp(a) and other lipoproteins are covered up and made less sticky, resulting in less deposition in the artery wall.  The vitamin C is important not only for strong collagen formation, a major component of the arterial wall, but also for all other structural elements of the body, for that matter. (37)(52)(53)(54)(55)(56)(57)

Humans have a genetic deficiency in Gulano-Lactone-Oxidase (GLO), the final enzyme step in the manufacture of Vitamin C, and therefore unlike all the other animals who make their own Vitamin C, we cannot make this necessary vitamin.  We share with all other primates this genetic disease, the inability to manufacture vitamin C, producing a vitamin C deficiency state in all humans.(58)

Also see Thomas Levy’s two books on Vitamin C. (49-51)

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j) Exercise and weight loss- improves insulin sensitivity, reduces inflammatory markers, reduces blood pressure, improves lipoprotein profile.

Magnesium

k) Magnesium supplementation is inexpensive and safe. Magnesium deficiency due to dietary deficiency or thiazide diuretics for hypertension is common, and is associated increased heart disease risk.  Magnesium reduces blood pressure, relaxes smooth muscle in arteries, and is needed for normal endothelial function.(41-43)

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L-Arginine

L-arginine is converted to nitric oxide, an important substance for arterial health. Research by Furchgott and other showed that nitric oxide (NO) relaxes arterial smooth muscle, dilating coronary arteries by up to 50%.(35)  However, Nitric Oxide (NO) is gone after a few seconds, so it must be replenished at a constant rate to keep the arteries relaxed and open. Lack of NO is associated with constricted arteries, damage to the arterial lining, and accelerated plaque growth. L-arginine shrinks coronary plaque,  corrects “endothelial dysfunction”, improves insulin sensitivity, is anti-inflammatory and shrinks plaque.  Dosage: l-arginine 6000 mg twice a day, best taken on an empty stomach.

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Reverse Cholesterol Transport and Essential Phospholipid – Phosphatidyl Choline (PC) (38)(39)

James C. Roberts MD FACC, a practicing cardiologist, lectures extensively on his clinical success with Phosphatidylcholine (IV or in Liposomal Oral Format with EDTA):  Reverse Cholesterol Transport and Metal Detoxification.  A DVD of his lectures is available which describes considerable clinical success with oral EDTA and phosphytidylcholine.  This page contains his DVD lecture material complete with clinical case histories.(61)

Essential Phospholipid is available under trade name Phoschol from Nutrasol which increases Lecithin Cholesterol Acyl Transferase activity (LCAT) (Dobiasova M 1988).(40)(40b)

Activating LCAT is beneficial because LCAT is the crucial substance which transports cholesterol from the arterial plaque back to the liver for metabolic breakdown into bile.  This process reverses atherosclerotic plaque formation.  Usual Dosage is 3 softgels Nutrasol Phoschol a day each containing 900 mg Phosphatidyl Choline.(38)(39)

Berberine

Berberine, also called Oregon Grape, is a botanical which has many benefits. Dr Roberts page on Berberine for Preventing and Reversing Heart Disease.

Thyroid Function

Normalize thyroid function. Broda Barnes MD showed that low thyroid function was a significant risk factor for heart disease. This conclusion was based on autopsy data from Graz Austria and detailed in his books, Hypothyroidism the Unsuspected Illness, and his other book, Solved the Riddle of Heart Attacks. Barnes felt that the thyroid lab tests were frequently unreliable, and he used clinical judgement instead. (59)

LipoProtein (a)

All About Reducing Lipoprotein (a)(2)(3)

Lipoprotein little A, also written as Lp(a) is a genetic variant lipoprotein which is associated with a high risk of heart disease, and therefore identification and reduction is essential.  The problem is that the conventional Lipid panels done in your doctor’s office do not include Lp(a).  Only the more sophisticated lipoprotein panels such as the Cardio-IQ (Quest), VAP (Atherotech) or NMR (Liposcience) panels provide Lp(a) data.

Lp(a) and Lipoproteins:

1) Lp(a) is best to measured in (nmol/l), and target  below 75 nmol/l .

2) Lp(a) measured in mg/dl (weight may not be accurate), then target below 30 mg/dl .

3) Measured (not calculated) LDL target 50–60 mg/dl.

4) LDL particle number target (NMR) of 600–700 nmol/l or apoprotein B of 50–60 mg/dl. Reduce small LDL to <10% of total LDL.

Treating Lp(a) with Niacin

Use Niaspan® (Kos Pharmaceuticals) or over-the-counter Slo-Niacin® (Upsher-Smith).   Both are better tolerated than OTC plain niacin, which may cause the hot flushes. Reduce hot flushed by drinking a full glass of water with each gelcap, and some find adding an aspirin tablet to the routine helps to reduce flushing.

Lp(a) and BioIdentical Hormones

Bio-Identical hormones are beneficial for reducing heart disease.  In menopausal females, estrogen preparations such as Bi-Est are used. Estrogens have been shown to reduce coronary artery calcium score.(46)

In males over 50, bio-identical testosterone cream may lowers Lp(a) by as much as 25% (per William Davis MD).  Medical studies show that optimizing Testosterone levels in aging males can reduce risk of coronary artery disease by 60%. (47)(48)

DHEA can promote weight loss, and improve insulin sensitivity.(45)

 

Lp(a) and L-Carnitine

The supplement L-carnitine can be a useful adjunct; 2000–4000 mg per day (1000 mg twice a day) can reduce Lp(a) 7–8%, and occasionally will reduce it up to 20%.

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Remember, reduction in calcium score on follow up calcium scan is the goal.

What about Statin-Cholesterol Lowering drugs?

Dr Davis admits that the total cholesterol and the LDL cholesterol numbers are of little value in predicting heart disease risk. And he says that the statin drug side effects, ie. muscle pain and weakness, are more common in actual practice than the drug advertising would suggest, making statin drugs difficult to take for the long term.

In my opinion, statin drugs are not recommended for women as explained in my previous article on Statin Drugs for Women, which can be found here (33)

My other article on Statins, Lipitor and the Dracula of Medical Technology can be found here.  (34)

What about Calcium Supplements for women to prevent osteoporosis?

Dr Davis points out that women who take calcium tablets have double the risk of heart attacks than those on placebo.(5)

Check out my earlier Heart Disease Reversal Page here.

Credit and Thanks is given to William Davis MD at the Track Your Plaque Web Site and Blog for the above information.(2)(3)

Individuals with high intake of Ω-3 polyunsaturated fatty acids,
usually associated with a high fi sh and low red meat diet, have
low rates of heart disease. Fish oil concentrates reduce triglyceride
levels and increase LDL particle size, a benefi cial effect when
administered in high doses (6–12 g/day).

 

Patients who had
LDL-C levels of less than 70 mg/dL and CRP levels of less than
1 mg/L after statin therapy had the lowest rate of recurrent CV
events.

 

Effect of Plant Sterol–Containing Fats on Blood Lipid Levels

Background

In the early 1950s, plant-derived sterols were observed to decrease serum cholesterol levels.^{1 2} The effective dose in humans was reported to be between 5 and 10 g/d when given in divided doses. The efficacy of plant sterols with regard to lowering blood cholesterol levels was soon confirmed,^{3 4 5 6} albeit at somewhat lower doses.⁷ On the basis of these data, plant sterols were briefly used in the reduction of blood cholesterol levels before the introduction of pharmacological agents with higher efficacy and patient acceptance. The resurgence of interest in plant-derived sterols is now coupled with the incorporation of these compounds into fat-containing foods. More recent evidence has shown that esterification of these sterols increases their solubility in fat and their efficacy in lowering low-density lipoprotein (LDL) cholesterol levels.^{8 9}

 

Framingham Heart Study Identifying major CVD risk factors

Over the years, careful monitoring of the Framingham Study population has led to the identification of the major CVD risk factors –
high blood pressure,
high blood cholesterol,
smoking,
obesity,
diabetes, and
physical inactivity

Hypertension
Each 20-mm Hg increase in systolic blood pressure or 10-mm Hg increase in diastolic blood pressure doubles coronary heart disease mortality and stroke mortality. Proposed mechanisms by which hypertension promotes atherosclerosis include damage to endothelial cells, promoting activation and incorporation of lipids into subintima, and stimulation of subintimal smooth muscle cell proliferation.

 

 

 

 

For prevention of CAD, the NCEP has determined that an LDL-C level of less than 100 mg/dL is optimal for CAD prevention, and a level of 70 mg/dL or less is now recommended for persons with existing CAD plus other risk factors. Ideal blood pressure was set at 120/80 mm Hg or less by

 

low-dose aspirin, and fish oil—may be considered, depending on the age and estimated CV risk of the patient.

Each 20–mm Hg increase in systolic blood pressure or 10–mm Hg increase in diastolic blood pressure doubles coronary artery disease mortality and stroke mortality.

It is instructive to note that although human LDL-C concentrations tend to cluster from 120 to 200 mg/dL and atherosclerotic disease is the main cause of death in humans, typical nonhuman mammalian LDL-C levels are 10 to 60 mg/dL, and atherosclerosis does not occur unless animals are fed high-fat food.

 

The risk of a coronary event is thought to increase by 2%for every 1%decrease in plasma HDL

 

 

Framingham Heart Study Identifying major CVD risk factors

Over the years, careful monitoring of the Framingham Study population has led to the identification of the major CVD risk factors –
high blood pressure,
high blood cholesterol,
smoking,
obesity,
diabetes, and
physical inactivity

Hypertension
Each 20-mm Hg increase in systolic blood pressure or 10-mm Hg increase in diastolic blood pressure doubles coronary heart disease mortality and stroke mortality. Proposed mechanisms by which hypertension promotes atherosclerosis include damage to endothelial cells, promoting activation and incorporation of lipids into subintima, and stimulation of subintimal smooth muscle cell proliferation.

 

 

 

 

For prevention of CAD, the NCEP has determined that an LDL-C level of less than 100 mg/dL is optimal for CAD prevention, and a level of 70 mg/dL or less is now recommended for persons with existing CAD plus other risk factors. Ideal blood pressure was set at 120/80 mm Hg or less by

 

low-dose aspirin, and fish oil—may be considered, depending on the age and estimated CV risk of the patient.

Each 20–mm Hg increase in systolic blood pressure or 10–mm Hg increase in diastolic blood pressure doubles coronary artery disease mortality and stroke mortality.

It is instructive to note that although human LDL-C concentrations tend to cluster from 120 to 200 mg/dL and atherosclerotic disease is the main cause of death in humans, typical nonhuman mammalian LDL-C levels are 10 to 60 mg/dL, and atherosclerosis does not occur unless animals are fed high-fat food.

 

The risk of a coronary event is thought to increase by 2%for every 1%decrease in plasma HDL

 

 

Diet and exercise

Certain changes in diet and exercise may have a positive impact on raising HDL levels:^[29]

• Decreased intake of simple carbohydrates.^{[30][31][32][33]}
• Aerobic exercise^[34]
• Weight loss^[35]
• Magnesium supplements raise HDL-C.^[36]
• Addition of soluble fiber to diet^[37]
• Consumption of omega-3 fatty acids such as fish oil^[38] or flax oil^[39]
• Increased intake of cis-unsaturated fats^[40]
• Consumption of medium-chain triglycerides (MCTs) such as caproic acid, caprylic acid, capric acid, and lauric acid.
• Removal of trans fatty acids from the diet^[41]

Most saturated fats increase HDL cholesterol to varying degrees and also raise total and LDL cholesterol.^[42] A high-fat, adequate-protein, low-carbohydrate ketogenic diet may have similar response to taking niacin (vitamin B3) as described below (lowered LDL and increased HDL) through beta-hydroxybutyrate coupling the Niacin receptor 1.^[43]

HDL levels can be increased by smoking cessation,^[35] or mild to moderate alcohol intake.^{[44][45][46][47][48][49]}

Pharmacologic (1- to 3-gram/day) niacin doses increase HDL levels by 10–30%,^[53] making it the most powerful agent to increase HDL-cholesterol.^[54][55] A randomized clinical trial demonstrated that treatment with niacin can significantly reduce atherosclerosis progression and cardiovascular events.^[56] However, niacin products sold as “no-flush”, i.e. not having side-effects such as “niacin flush“, do not contain free nicotinic acid and are therefore ineffective at raising HDL, while products sold as “sustained-release” may contain free nicotinic acid, but “some brands are hepatotoxic”; therefore the recommended form of niacin for raising HDL is the cheapest, immediate-release preparation.^[57]

AIM-HIGH trial (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides

As above, but instead of a placebo, patients were given 1,500 to 2,000 mg/day of extended-release niacin.

After two years the niacin group, as expected, had experienced a significant increase in plasma HDL-C (along with some other benefits like a greater reduction in plasma triglycerides).  However, there was no improvement in patient survival.  The trial was futile and the data and safety board halted the trial.  In other words, for patients with cardiac risk and LDL-C levels at goal with medication niacin, despite raising HDL-C and lowering TG, did nothing to improve survival. This was another strike against the HDL hypothesis.

 

CETP. – Dalcetrapib

By 2008, as the AIM-HIGH trial was well under way, another pharma giant, Roche, was well into clinical trials with another drug that blocked CETP.  This drug, a cousin of torcetrapib called dalcetrapib, albeit a weaker CETP-inhibitor, appeared to do all the “right” stuff (i.e., it increased HDL-C) without the “wrong” stuff (i.e., it did not appear to adversely affect blood pressure). It did nothing to LDL-C or apoB.  This study, called dal-OUTCOMES, was similar to the other trials in that patients were randomized to either standard of care plus placebo or standard of care plus escalating doses of dalcetrapib.   A report of smaller safety studies (called dal-Vessel and Dal-Plaque) was published a few months ago in the American Heart Journal, and shortly after Roche halted the phase 3 clinical trial.  Once again, patients on the treatment arm did experience a significant increase in HDL-C, but failed to appreciate any clinical benefit.  Another futile trial.

 

Mendelian randomization

On May 17 of this year a large group in Europe (hence the spelling of randomization) published a paper in The Lancet, titled, “Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study.”  Mendelian randomization, as its name sort of suggests, is a method of using known genetic differences in large populations to try to “sort out” large pools of epidemiologic data.

In the case of this study, pooled data from tens of studies where patients were known to have myocardial infarction (heart attacks) were mapped against known genetic alterations called SNPs (single nucleotide polymorphisms, pronounced “snips”).  I’m not going to go into detail about the methodology because it would take 3 more blog posts., But, the reason for doing this analysis was to ferret out if having a high HDL-C was (only) correlated with better cardiovascular outcome, which has been the classic teaching, or if there was any causal relationship.  In other words, does having a high HDL-C cause you to have a lower risk of heart disease or is it a marker for something else?

This study found, consistent with the trials I’ve discussed above, that any genetic polymorphism that seems to raise HDL-C does not seem to protect from heart disease.  That is, patients with higher HDL-C due to a known genetic alteration did not seem to have protection from heart disease as a result of that gene. This suggests that people with high or low HDL-C who get coronary artery disease may well have something else at play.