Untangling Cardiovascular Disease, Part 3

It's a toxic world

This article is dedicated to my dear brother Jeff, may he rest in peace, taken from those who loved him by a heart attack at only 59 years old. May the information I’ve spent many months researching help you, and those you love.

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Arrogant Armor

When confidence is present in abundant disproportion to the level of competence, is it arrogance? Or for the threshold of arrogance to be met, must it also include condescension, bragging, and being an all-around jerk? I’m not sure where that fine line falls, but I’m pretty sure that I had crossed it for the first couple of years of medical practice.

Fresh out of residency in 1996, full of textbook knowledge, boundless determination, and still in possession of most of my hair—I didn’t know what I didn’t know.

I remember one particularly shameful episode from over 25 years ago. I was at a medical conference in Michigan, hovering around the lunch buffet, going back for more watermelon, when I was approached by a short, stocky, slow-witted bald man who turned out to be an alternative medicine doctor.

At the time, to my discredit, I judged the book by its cover. Starting back in 1999, several major medical centers began incorporating integrative medicine into their programs, and it’s become far more mainstream ever since. But that wasn’t the case during my medical training—During my residency experience as an allopathic doctor in the mid-90’s, alternative medicine was openly ridiculed.

I’d like to think that I’m impervious to brainwashing, but sadly no. I remain human—Flawed and influenced by others around me. And as soon as I learned that he was an alternative medicine doctor, there was nothing he could say that I’d take seriously.

He told me that his vascular disease patients were getting remarkably better with a certain medical intervention (which I’ll discuss later, but I want to do so fully to give a nuanced appraisal). He spoke for about 20 minutes, sharing anecdotes of amazing improvements in quality of life metrics and cardiovascular outcomes, during which time my mind was racing, evaluating strategies to politely excuse myself.

At one point I caught myself rolling my eyes, and at least had the self-awareness to feel guilty, but it only lasted a minute. I did eventually excuse myself, but not in the polite manner I’d hoped. I was brusque and abrupt when I thanked him and left, but I just had to get away.

Heavy is the Head

I think arrogance is a helmet—Difficult to wear for long, but sometimes helpful in the short term. Physicians can effectively wear a bit of arrogance like armor, to help appear and feel authoritative when we’re just not there yet. But balance is key.

“As a surgeon you have to have a controlled arrogance. If it's uncontrolled, you kill people, but you have to be pretty arrogant to saw through a person's chest, take out their heart and believe you can fix it.”—Dr. Mehmet Oz

But I couldn’t balance it. That clumsy helmet blocked my view of things, limiting the information I took in. I don’t know how many years it would have taken me on my own to realize that I needed a humility check—But that, and a million other wonderful reasons, is what Moms are for—She brought me down to Earth over chicken and broccoli at a Chinese restaurant. And I’m forever grateful for that.

I only saw truly again once I took off that stupid headgear, and when I did, I realized that I’d just walked a dangerous path. My mind went right to the arrogant cardiologist who dismissed that my father’s end-stage heart failure could have been caused by Lyme—I’d never want to be anything even remotely like him. Good riddance to that dumb hat.

Whereas arrogance may be like armor, humility is like a pair of old shoes. Although comfortable, it may feel like they don’t offer the protection of the helmet, but that’s an illusion. As I’ve gotten older, I’ve realized that I never needed being protected in the first place.

And so it’s with humbled eyes that I’ve watched, at first hopeful, then disappointed, and now jaded, as doctor after doctor—Over the past 25 years—Has only recommended interventions to my patients which are profitable to either pharmaceutical companies or hospitals.

Turf War

If this sounds outlandish, take a look at what happened with CT coronary artery calcium scores. Despite compelling evidence from 2004 that these tests can non-invasively detect coronary artery disease that leads to heart attacks when stress tests often fail to do so, they were not embraced by cardiology medical societies until the data became too overwhelming, in my opinion embarrassingly so, to ignore.

From NBC:

“Among the 1,119 patients who had normal stress tests, 56 percent had calcium scores greater than 100, and 31 percent of patients had scores greater than 400…Calcium scores of zero are the "best" scores. Patients with calcium scores from 100 to 400 are at increased risk for cardiac events such as heart attacks, while patients with scores above 400 have the highest risk for a heart attack.”

A calcium score greater than 400 carries a risk of heart attack or stroke of more than 20% within 10 years—A clarion call which requires action to save lives, but which would have been completely missed in about one third of normal nuclear stress tests.

Here’s the study to which the NBC piece is referencing:

“Of 1,119 normal MPS [myocardial perfusion single-photon emission computed tomography, also known as a nuclear stress test] patients, CAC [coronary artery calcium] scores were >0, >or=100, and >or=400 in 78%, 56%, and 31%, respectively…low CAC scores appear to obviate the need for subsequent noninvasive testing. Normal MPS patients, however, frequently have extensive atherosclerosis by CAC criteria. These findings imply a potential role for applying CAC screening after [I put this in bold because in the article it was italicized for emphasis, and this quote is already italicized] MPS among patients manifesting normal MPS.”

This study found that 31% of patients with normal nuclear stress tests had extensive coronary artery disease as diagnosed by calcium scores. And yet, even though the authors state that a low calcium score removes the need for further non-invasive testing, they still advise that calcium scores be done after nuclear stress testing. They even emphasize the word “after”—Why? Could it be due to a medical turf war, with seriously ill patients caught in the crossfire?

$$$

Like similar studies across many fields in medicine, a study from Duke University researchers found that doctors who profit from ordering cardiac stress testing were markedly more likely to order them:

“The adjusted OR [odds ratio] of stress echocardiography testing among patients treated by physicians billing for both or professional fees only were 12.8 (95% CI, 7.6-21.6) and 7.1 (95% CI, 4.0-12.9), respectively, compared with patients treated by physicians who did not bill for testing (P < .001).”

This means that cardiologists who make the most money from cardiac stress tests, scandalously ordered almost 13 times more of these tests than similar doctors who didn’t profit from them.

And it’s not just me who’s noticed that something is amiss. Whereas I may not be delicate in my revelations of the rampant financial conflicts of interest in medicine, others have certainly noticed the calcium score elephant in the room. Over a decade later, despite voluminous supportive research, in 2015, calcium scores were still not widely embraced by mainstream cardiology:

“Coronary artery calcium (CAC) scanning for risk assessment in the asymptomatic population has been the subject of more than 2,500 papers in the peer-reviewed literature. Yet its role remains controversial, incorporation into guidelines has been variable, and insurance coverage is virtually nonexistent, with at least 1 major carrier labeling it investigational (2). Despite the overwhelming peer-reviewed data supporting the role of CAC in the primary prevention of coronary heart disease (CHD), its penetration into clinical practice has been inexplicably low.”

Inexplicably low? Or readily explained?

Toxic World

Collusion between government and industry almost never ends well. Some think, myself among them, that the capture of the EPA by the industries it’s purported to regulate has resulted in the widespread use of highly toxic chemicals, an epic failure which has been reverberating for decades—And which will continue to do so for generations to come, hence the term ‘forever chemicals.’

The EPA has likewise repeatedly failed to protect the public from dangerous heavy metals, in particular arsenic, cadmium, chromium, lead, and mercury.

“Their [heavy metals] multiple industrial, domestic, agricultural, medical and technological applications have led to their wide distribution in the environment; raising concerns over their potential effects on human health and the environment…Because of their high degree of toxicity, arsenic, cadmium, chromium, lead, and mercury rank among the priority metals that are of public health significance. These metallic elements are considered systemic toxicants that are known to induce multiple organ damage, even at lower levels of exposure. They are also classified as human carcinogens (known or probable) according to the U.S. Environmental Protection Agency, and the International Agency for Research on Cancer.”

You may be thinking, “Ok, but are there real world consequences from these exposures?”—How much time you got? It’s enough for a book, affecting us in countless ways. Did you know that sperm counts are plummeting to the point that by about 2050, natural conception may be a thing of the past?

I can imagine a conversation in 2060 between little Jimmy and his grandfather:

“Really Pop? You didn’t go to the IVF clinic to make Mom?”

But that’s a subject for another day. Jimmy will have to wait. Today is all about vascular disease.

There’s abundant data that exposure to both heavy metals and pesticides are associated with shockingly increased risks for cardiovascular disease.

“…exposure to pesticides chlorpyrifos, coumafos, carbofuran, ethylene bromide, mancozeb, ziram, metalaxyl, pendimethalin and trifluralin was associated a risk of 1.8 to 3.2 for acute myocardial infarction [heart attack]…Environmental contamination by tetrachlorodibenzo-p-dioxin was associated with CVD with risk of 1.09 to 2.78 and organochlorine, 1.19 to 4.54…”

To understand how incredibly important this is, let’s put it in perspective— The magnitude of these increased risks for heart attack are comparable to the increased risks we see from smoking, high cholesterol, diabetes, and high blood pressure.

Yet these 4 horseman of the cardiovascular apocalypse are almost always the only actionable items addressed in a cardiologist’s office—When was the last time your heart doctor discussed the cardiovascular risks from pesticides or heavy metals?

According to a large, long term study in The Lancet Public Health, out of 2.3 million deaths in the United States in a year, 412,000 were attributable to low level lead exposures:

“We included 14,289 adults in our study…median follow-up of 19.3 years…An increase in the concentration of lead in blood…was associated with all-cause mortality (hazard ratio 1.37, 95% CI 1.17–1.60), cardiovascular disease mortality (1.70, 1.30–2.22), and ischemic heart disease mortality (2.08, 1.52–2.85). The population attributable fraction of the concentration of lead in blood for all-cause mortality was 18.0% (95% CI 10.9–26.1), which is equivalent to 412,000 deaths annually. Respective fractions were 28.7% (15.5–39.5) for cardiovascular disease mortality and 37.4% (23.4–48.6) for ischemic heart disease mortality, which correspond to 256,000 deaths a year from cardiovascular disease and 185,000 deaths a year from ischemic heart disease…the estimated number of deaths from all causes and cardiovascular disease that were attributable to concentrations of lead in blood were surprisingly large; indeed, they were comparable with the number of deaths from current tobacco smoke exposure.”

If this isn’t a wake up call that the field of cardiology is missing a very big boat, I don’t know what is.

And a huge meta-analysis published in The British Medical Journal found:

“The review identified 37 unique studies comprising 348,259 non-overlapping participants, with 13,033 coronary heart disease, 4,205 stroke, and 15,274 cardiovascular disease outcomes in aggregate. Comparing top versus bottom thirds of baseline levels, pooled relative risks for arsenic and lead were 1.30 (95% confidence interval 1.04 to 1.63) and 1.43 (1.16 to 1.76) for cardiovascular disease, 1.23 (1.04 to 1.45) and 1.85 (1.27 to 2.69) for coronary heart disease, and 1.15 (0.92 to 1.43) and 1.63 (1.14 to 2.34) for stroke. Relative risks for cadmium and copper were 1.33 (1.09 to 1.64) and 1.81 (1.05 to 3.11) for cardiovascular disease, 1.29 (0.98 to 1.71) and 2.22 (1.31 to 3.74) for coronary heart disease, and 1.72 (1.29 to 2.28) and 1.29 (0.77 to 2.17) for stroke.”

This means that:

• Arsenic, lead, cadmium, and copper increased risks for cardiovascular disease by 30%, 43%, 33%, and 81%, respectively;

• Arsenic, lead, cadmium, and copper increased risks for coronary artery disease by 23%, 85%, 29%, and 122% respectively;

• Arsenic, lead, cadmium, and copper increased risks for stroke by 15%, 63%, 72% and 29%, respectively.

Major increases in cardiovascular risks from both pesticides and heavy metals have even been published in the Journal of the American Heart Association—Enough for prime time discussion by US cardiologists—At least one would think.

But even if cardiologists were to take notice of this research, what could they do? What tools do they have in their toolkits to diagnose and treat these problems? The simple answer is virtually none—This just isn’t being taught.

A plan to mitigate these risks starts with an understanding of the mechanics by which both pesticides and heavy metals induce cardiovascular disease—And it turns out that it’s the same mechanism by which other more commonly recognized risks for vascular disease also do their damage—Endothelial dysfunction.

Hot Topic

I say it a lot—Not all remedies come in a pill—Yet this important intervention against so many disease states is almost never discussed by doctors.

From Mayo Clinic Proceedings:

“Several observational and interventional studies suggest that regular or frequent sauna bathing reduces the incidence of vascular and nonvascular diseases, such as hypertension, cardiovascular disease, dementia, and respiratory conditions; may improve the severity of conditions such as musculoskeletal disorders, COVID-19, headache, and influenza; and increases the life span…Frequent sauna bathing appears to offset the adverse impact of systemic inflammation, low socioeconomic status, and high systolic blood pressure on outcomes such as cardiovascular disease, pneumonia, chronic obstructive pulmonary disease, and mortality.”

Before writing more about sauna, I’d like to point out its risks, as patients with unstable cardiovascular disease could put themselves in jeopardy with sauna use. And exposure to both electromagnetic fields and volatile organic compounds vary considerably based on sauna design. With my patients, we only pursue sauna under medical supervision.

I became interested in sauna when I learned about its benefit to dementia in Finnish patients. Did you know that Finland has an extraordinarily high rate of Alzheimer’s?

“The country with the most cases of Alzheimer's Disease is Finland. There are 54.65 cases of Alzheimer's for every 100,000 people in this country. These numbers and statistics put Finland in the extremely high occurrence and high prevalence range for the disease. Interestingly, females are much more likely to have Alzheimer's in Finland than males. For every 100,000 people, Alzheimer's impacts 55.32 females compared to just 52.10 males.”

And sauna is an integral part of the Finnish culture. So it’s not surprising that its role in preventing dementia was studied in Finland:

“In analysis adjusted for age, alcohol consumption, body mass index, systolic blood pressure, smoking status, Type 2 diabetes, previous myocardial infarction, resting heart rate and serum low-density lipoprotein cholesterol, compared with men with only 1 sauna bathing session per week, the HR [hazard ratio] for dementia was 0.78 (95% CI: 0.57-1.06) for 2-3 sauna bathing sessions per week and 0.34 (95% CI: 0.16-0.71) for 4-7 sauna bathing sessions per week.”

This means that the use of sauna 2-3 times per week was associated with a reduction of dementia risk by 22%, and its use 4 or more times per week was associated with a 66% reduction in risk.

The mechanism of action is thought to be due to the induction of the heat shock protein response, which allows for the correction of misfolded proteins.

This heat shock response is also protective against atherosclerosis, with associated improvements in endothelial dysfunction. So of course, the Finns also studied how sauna could affect cardiovascular risks, but this time with the help of researchers from Cambridge and Emory University:

“Sauna bathing habits were assessed at baseline in a sample of 1688 participants…The risk of CVD [cardiovascular disease] mortality decreased linearly with increasing sauna sessions per week with no threshold effect…compared with participants who had one sauna bathing session per week…participants with two to three and four to seven sauna sessions per week…After adjustment for established CVD risk factors, potential confounders including physical activity, socioeconomic status, and incident coronary heart disease, the corresponding HRs (95% CIs) were 0.75 (0.52 to 1.08) and 0.23 (0.08 to 0.65), respectively. The duration of sauna use (minutes per week) was inversely associated with CVD mortality in a continuous manner…Higher frequency and duration of sauna bathing are each strongly, inversely, and independently associated with fatal CVD events in middle-aged to elderly males and females.”

So this means that compared to sauna use once per week, its use 2-3 times per week was associated with a reduction of cardiovascular death by 25%, and its use 4 or more times per week was associated with a reduction of cardiovascular death by 77%.

I’d like to also point out that both heavy metals and pesticides can be excreted through sweat. Although some doctors have given interviews to newspapers saying that sweating doesn’t result in the excretion of these toxins, those opinions appear to run counter to the published evidence that more heavy metals and pesticides are excreted in sweat than in urine.

As we stumble toward truth, disagreement in science is part of the process.

Please join me in part 4 of Untangling Cardiovascular Disease. I hope that the perspectives I’ve shared with you today are helpful.

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