Extreme Lipids II

There aren’t many lipid panels that stun me, which is probably a bad sign – that we are becoming more tolerant of slothen behavior and excessive hyperlipidemia, knowing that there are medications to rescue one from years of lousy self-care.

This gentleman had a most impressive lipid panel, perhaps forcing you to ask how he is even alive.

Total Cholesterol    1248  (normal < 200)

LDL                         n/a  (normal < 130)

- invalid when Triglycerides > 300

HDL                        n/a  (normal >39)

- invalid when Triglycerides > 1200

Triglycerides          8062  (normal <150)

This very nice 40-something gentleman presented to me in clinic in DKA (Diabetes KetoAcidosis) – his first doctor visit in 10+ years.  He was continually thirsty (polydipsia), continually urinating large amounts (polyuria), and had lost 40 pounds over the past 3 months . . . unintentionally.

He knew that he had Diabetes Mellitus, for he had witnessed the disease in nearly all of his family members and recognized these classic symptoms.  Unfortunately, he waited to the point that he developed DKA. 

DKA is a complicated process – briefly, the body is so overwhelmed with high glucose in the bloodstream that it is no longer able to utilize glucose in the tissues (muscle, brain, etc.) and the pancreas is exhausted from pumping out so much insulin that it stops doing so.  The result is that the body cannot utilize glucose as a fuel source and must resort to breaking down fat (hence the weight loss) to provide fuel for the tissues.  This process creates a toxic acidic environment in the bloodstream, potentially deadly.

I admitted him to the hospital, and we achieved control over his diabetes.  It appears that he does, in fact, have Type 2 Diabetes Mellitus (DM) - formerly known as Adult-Onset Diabetes Mellitus.  DKA is far more common in Type 1 DM, but occasionally does occur in Type 2 DM.

But, about those lipids . . . there a couple notable findings:

• the person who drew his blood immediately noticed how fatty the blood appeared
• he had Xanthomas (cholesterol deposits) on his elbows
• the in-house glucose machine misread his glucose as normal (the true serum test drawn at the same time was markedly elevated)
• he had no problems with his pancreas – he dodged a bullet.  When the triglycerides are above 500, one is at risk for pancreatitis.  At 8000, it’s a miracle he didn’t kill off his pancreas (or maybe he did, and that’s why he’s not making insulin – regardless he didn’t have any lab evidence of pancreatitis)

  The quickest and easiest treatment for such severe hyperlipidemia and hypertriglyceridemia in a person with diabetes is correction of the diabetes.  I’m anxiously looking forward to rechecking those numbers, now that he is on a treatment regimen.  I’ll post an update.

Extreme Lipids I

I saw a woman a few months ago who had concerns about a strange sensation in her chest.  She had had her cholesterol panel checked a few months prior by her gynecologist at her yearly female exam.  The gynecologist communicated to her that her total cholesterol was too high at 240 and that she should follow-up with my clinic.

Sure, 240 is high for a total cholesterol is high, but the details of the individual lipid measurements are far more telling than a “total”.  This woman’s lipid panel is a perfect case in point.

  Here’s the panel – refer to this post for details on the significance of each value.

Total Cholesterol    240  (normal < 200)

LDL                         111  (normal < 130)

HDL                        117  (normal >39)

Triglycerides            61  (normal <150)

So what?  This panel achieves one of my fantasy goals for cholesterol numbers - an HDL greater than the LDL [without cholesterol medication].  There was one other patient who came close.

Her total cholesterol is high in part due to the very high HDL cholesterol, but if you’re going to have a high total cholesterol, this is the way to do it.

Why is a high HDL a good thing?  HDL protects the heart and brain by it’s “scavenger” effects on plaque in blood vessels.

That’s no easy task, although favorable genetics certainly help.  The hightest HDL’s I’ve seen are generally in alcoholics – unfortunately, the HDL-raising benefits of alcohol are outweighted by its deleterious effects.

The best way to raise the HDL is through regular, intense exercise.  There was a study from years ago that analyzed HDL’s in runners: the more miles they ran in a week, the higher their HDL.

How you can create the Polymeal at home

It’s nice and all to identify the ingredients in the Polymeal, foods that can reduce your risk of cardiovascular disease by 76%, but how can these be incorporated into a sensible meal rather than simply eating each ingredient independently?

Leave it to the British Medical Journal – they encouraged a follow-up recipe contest to incorporate the Polymeal ingredients in a recipe that would be judged on six criteria: presentation, tastes and textures, creativity, method, clarity of setting out the recipe, and adherence to the recommended quantities of the essential ingredients.

Here is a list of the submitted recipes. [Beware . . . may be British humor within this link]

Here is the winner of the Polymeal recipe contest.  Interesting, although I question the value of cooking with all that butter – doesn’t that negate some of the benefit of the Polymeal?

 I have to say – I agree with this commenter:  Keep it simple.  However, I greatly enjoy the creativity in these recipes.

Better than a Polypill: try the Polymeal to reduce risk of heart disease

The Polypill concept evolved as a multi-drug regimen, all of which have documented evidence of cardiovascular (CV) risk reduction. In theory, this regimen would decrease one’s risk of heart disease, stroke, etc. by 80-88%! Pretty remarkable. However, it is limited by the risk of adverse effects associated with the individual medications that comprise the Polypill, estimated at 8-15%.

No one likes taking medications (if you do, you are more ill than you think). n an issue of the British Medical Journal, Franco, et al. recognized that there is similar evidence for food items in lowering cardiovascular risk, and that ingesting a “Polymeal” of these food items would certainly be a safer, more natural, and less costly alternative to taking a Polypill, not to mention tastier.

Here’s what they learned on their review of the literature:

• Wine (150 mL) daily reduces CV risk by 32%
• Fish (114 gm) eaten 4 times weekly reduces CV risk by 14%
• Dark chocolate (100 gm) daily reduces SBP by 5.1 mm Hg and DBP by 1.8 mm Hg, corresponding to a CV risk reduction of 21%
• Fruit and vegetables (400 gm) daily reduces SBP by 4.0 mm Hg and DBP by 1.5 mm Hg, probably similar CV risk reduction of 21%
• Garlic (1.8 – 2.7 gm) daily reduced total cholesterol by 17.1 mg/dL (0.44 mmol/L), calculated to reduce CV risk by 25%

Now, for the good stuff:

– Eating this combination of Polymeal ingredients was calculated to reduce the risk of cardiovascular disease by 76%. It’s not fair to compare directly to the Polypill results because the two groups measured endpoints differently, but it is likely in the same ballpark.

As far as side effects go, there are no reported serious adverse effects reported for these ingredients. They mentioned that garlic may cause body odor, flatulence, and abdominal pain (wimps!). In addition, there is potential risk of mercury exposure when eating large quantities of fish regularly.

Only the Brits would finish the article with this kind of analysis:

1. Expected weekly cost (in the 2004 economy): $28.10 (€ 21.60, £ 15.20)
2. “Although we do not recommend specific brands, spending more – for example, on your favorite bottle of wine or brand of chocolate – might also be rewarded by an improved quality of life.”
3. “. . considering the disturbing adverse effects of garlic, we do not recommend taking the Polymeal before a romantic rendesvous, unless the partner also complies with the Polymeal.”

Reduce risk of heart disease with the Polypill

This paper published in the British Medical Journal ranks among my favorite, but there’s an even better sequel to it that I will review next.

The concept of a Polypill was introduced in 2003 by Wald and Law as a combination of medications and vitamins that would significantly reduce the risk of heart disease in a population.  Obviously, medications are no substitute for a healthy lifestyle, as there is inherent risk to taking any exogenous substance.  Their approach, however, was a theoretical look at combining the pharmaceutical agents and vitamins that have the best evidence for lowering cardiovascular disease risk.

They focused on the following cardiovascular risk factors:

• LDL cholesterol
• Hypertension (elevated blood pressure)
• Homocysteine
• Platelet function

Evidence of cardiovascular disease risk reduction was based on analysis of previously published results. 

• LDL cholesterol would be treated with a statin.
• Hypertension would be treated with a 3-drug combination of the 5 main classes of blood pressure medications (thiazide diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, and calcium channel blockers).
• Homocysteine would be reduced with folic acid supplementation.
• Platelet function would be addressed with aspirin.

Without going into detail about the numbers, let’s just take a look at the final analysis.  Wald and Law estimated that the cumulative risk reduction of treating all 4 of these factors by the Polypill would reduce risk of ischemic heart disease (e.g. heart attacks) by 88% and risk of stroke by 80%.

Previous studies have demonstrated that treating one risk factor has the same proportional effect (same percentage reduction) on risk irregardless of the other risk factors, so treating each risk factor does contribute an additive effect on risk reduction.

On average, they predict that this approach could result in a gain of 11-12 years of like free from heart attack or stroke for each person taking such a regimen.

Side effects from a component of this drug combination were estimated to affect 8-15% of individuals, most concerning of which would be bleeding from aspirin.

Heart disease is still the #1 cause of death in the US, and not everyone wants to take medications indefinitely to reduce their risk of heart disease.  So, who would be a candidate for this Polypill?  For individuals at relatively low risk for cardiovascular disease, there is no known significant benefit to an approach like this.  Oftentimes, the risk of side effects will outweigh benefits.  For people at high risk of heart disease, however, there may be some credence to such an approach, particularly older individuals or those with history of vascular disease.

Again, remember that this is purely a theroretical approach to reducing heart disease based on previously published studies demonstrating risk reductions of the various components of the drug combination.  In a health system that recognizes the importance of preventive medicine, this Polypill may one day become a reality.

Calculate your cardiac risk

A lot of what we do in medicine is driven by a patient’s estimated cardiac risk, for example when to start cholesterol-lowering medication or when to start taking prophylactic aspirin. 

Use this calculator to estimate your risk based on some simple health data, which everyone should know.  If you don’t know these numbers, I would encourage you to find out.

Obviously, this risk estimator is only an estimator: someone with a low calculated 10-year cardiac risk could die of a heart attack tomorrow.  (note: it does exclude individuals with a history of heart disease)  It’s only a calculated risk for the general population based on those measurements, but it’s a good place to start, especially if it means calling an individual’s attention to his/her health condition.

When heartburn is not heartburn, and be careful whom you challenge

Sure enough, there might have been something to say for the prediction of an increased incidence of heart attacks around a major sporting event.

A 50-something gentleman came into clinic yesterday with “burning around my heart”. [side note: I'm always intrigued by the choice of words used in an individuals "chief complaint" - there's something about that phrase that just has to make you feel uneasy. Reminds me of an amazing patient I had in residency - that's for another day.] The guy has a history of heart problems – which I later realized when I finally got my hands on the archaic stone tablet, er . . . paper chart. His pain was actually quite unusual to be blamed on the heart, in the sense that he has huge physical demands on his job that never exacerbated the pain. Interestingly, the pain had been stuttering along for a few days and he just wasn’t his normal self for the Super Bowl party he attended. I requested an EKG on him right away because it just didn’t sound right.

EKG looked like an early MI (heart attack), with a finding that is a bit subtle, but nonetheless inexcusable to miss. An ambulance was summoned, and the daft baboons on the ambulance squad had the nerve to argue with me about whether or not the EKG was concerning for heart disease. [insert deep inner rage] Here I spend 40 minutes with the guy and have a ridiculous number of years of training, and some poser medic with no real patient care experience tries to tell me I’m wrong. If I wanted help reading an EKG, the paramedics would be among the last people I would ever ask – pick him up and get out of here. Now, ask me if I would feel comfortable with these baboons caring for my family in an emergency. . . yikes!

Lo and behold, he had an MI, went to the cath lab immediately, and had a near-total occlusion of the dominant heart vessel that got the “roto-rooter” treatment and was stented. I’ll be having a [not-so-kind] word with the ambulance company later today.

What do my cholesterol numbers (lipids) mean?

Of all the potential lab work that could be performed as a screening tool for certain ailments, the only one universally recommended for otherwise healthy individuals is cholesterol screening.

The most aggressive recommendation for cholesterol screening comes from National Cholesterol Education Program (NCEP III) guidelines, recommending lipid screening every 5 years for all persons over the age of 20.

According to the United States Preventive Services Task Force (USPSTF) statement in 2001, routine screening for cholesterol should begin at age 35 regardless of health, after age 20 if any risk factors for heart disease exist.

I tend to follow the NCEP III guidelines for a couple reasons: 1) a disturbing percentage of people are overweight and/or relatively inactive, 2) many people are not aware of their family history (e.g. whether or not their parents have high cholesterol), 3) abnormal numbers give me something better to stand on to encourage lifestyle changes, and 4) I want to emphasize the importance of knowing these numbers and doing something about them.

Below is a brief summary of the normal ranges of each component of a typical “lipid profile”, what behaviors tend to make them abnormal, and what you can do to improve them.

Total Cholesterol [normal < 200 mg/dL]

• not as important as the ratio of total cholesterol/HDL

LDL [ normal < 130 mg/dL for normal-risk individuals]

• the “bad” cholesterol
• increased by poor diet, inactivity
• lowered by dietary changes (esp. eating oatmeal) and physical activity
• medication: statins

HDL [normal > 39 mg/dL]

• the “good” cholesterol
• lowered by inactivity, poor diet
• elevated by regular physical activity – the more intense, the higher the HDL
• elevated by alcohol intake (but, only beneficial in moderation; beyond that, it’s other effects negate the benefit of HDL-raising
• medication: niacin, some effect from statins

Triglycerides [normal < 150 mg/dL]

• “fatty acids”
• increased by poor diet
• lowered by diet, exercise
• medication: fibrates, statins

TC/HDL ratio [normal < 5.0]

• increased by a) low HDL or b) high total cholesterol
• see above under individual components

Super Bowl stress on the heart?

This recent New England Journal of Medicine article was cited by some as a reason to be concerned about an increased incidence of heart attacks this weekend because of the Super Bowl.  Apparently, some people live and die by their favorite sports teams, and this obsessive spirit puts added stress on their hearts. 

I’d be more concerned with the indulgences – junk food and alcohol – than emotional excitement, but apparently the east-of-the-Atlantic football (soccer) fans are generally more passionate about their sports teams than the west-of-the-Atlantic football fans.  To each their own. 

Eat healthy today and tomorrow, go ahead and splurge on Super Bowl Sunday, and then get right back on track with a healthy diet.

The Vasculopath

I had an incredibly frustrating patient encounter yesterday – a 60-something gentleman who was recently in the hospital for an ischemic stroke. When I admitted him (late at night – curse this job), I mustered enough good charm to suggestively congratulate him on his first day of having quit smoking (I knew he wouldn’t). Super pleasant guy, with a supportive family all huddled around him in the ICU, but I just knew he couldn’t be reached on the smoking thing, even though he’d just dodged a major bullet by reversing all of his stroke symptoms after receiving the “clot-buster” medication just hours before.

Problem was, this guy is the ultimate “Vasculopath”. What is a “vasculopath”? It’s a rather informal term I apply to an individual with significant vascular disease, of which there are many risk factors and many manifestations. This guy had them all: high cholesterol, smoker, high blood pressure, family history of heart disease, age (>55), male sex, obesity, Diabetes Mellitus, and worst of all – personal history of heart disease, having had an MI (myocardial infarction) in the past. His regular physician had done marvelous work on him: normal blood pressure, controlled diabetes, normal cholesterol, had him taking aspirin – all the right things, but he refused to give up his cigarettes. As the saying goes: You can lead a horse to water, but you can’t make him drink.

Anyway, he convinced everyone at his bedside (at my less-than-gentle prodding) that he would quit smoking as a result of his stroke. I saw him back in clinic today and inquired about his 9 days since being admitted for a stroke – of course he’s right back to smoking with no intention to quit. [Deep breaths . . . count to ten] As I mentioned before, you choose your own death, in a sense. He’s basically playing a form of Russian Roulette – one of these days he’ll have “the big one”. My suggestion to clean up his diet and learn how to incorporate some physical activity into his daily routine fell on deaf ears, but he reluctantly agreed to try Chantix (a wonderful new addition to our smoking cessation arsenal) for the sake of his wife. [Mr. Passive-Aggressive, himself]

I can only hope that he sees the folly of his ways before it’s too late. A patient like this reminds me that I can do only so much as a physician – it’s times like this I just feel like a glorified advice-giver. It feels like a waste of my time, but maybe one of these times I’ll get through to him.