In 2008, Tim Russert seemed to be at the top of his game. The high-profile TV journalist and host of “Meet the Press” had been voted one of the 100 most influential men in the world. Surely a man as successful as this would have had access to the very best medical care available. But then, suddenly, he dropped dead of a massive heart attack. How could this be?
“Several months before he died, he had the best, most state-of-the-art stress test available,” says Dr. Donald J. Meyer, a clinical lipidologist with a private practice in Cedarburg, Wis. “He passed with flying colors. His LDL cholesterol (low-density lipoproteins, the “bad” cholesterol) was under control. He was being seen by a cardiologist.” Yet the 58-year-old still collapsed and died of a heart attack due to a buildup of cholesterol plaque in his arteries.
“Obviously, he had heart disease that was not diagnosed,” says Meyer, who did not treat Russert, but uses his story as an example. Physicians and patients have known about the importance of adequate cholesterol management for many years. Yet Russert’s case helps illustrate how previous methods of tracking high cholesterol in certain populations of patients may miss the mark.
Unfortunately, Russert was not an isolated case. “We have an epidemic of heart disease in this country,” says Meyer. According to the American Heart Association, nearly 40 million Americans have a cholesterol level so high it makes them candidates for coronary heart disease, such as heart attack and stroke. Even more shocking, almost 70 percent of Americans over the age of 20 are overweight or obese, a prime contributor to high cholesterol and serious “heart events,” as they are called in the profession. The AHA reports that the single leading cause of death in the United States is heart disease.
To address this epidemic, more accurate techniques for measuring cholesterol risk factors are being introduced. One major development has been the creation of a new medical specialty called lipidology. The field is still relatively young, with fewer than 500 certified lipidologists nationwide and just 16 in Wisconsin. Lipidologists receive additional training in cholesterol management, cardiovascular risk assessment and intervention, and are certified by the American Board of Clinical Lipidology. Lipidology, simply put, is the diagnosis and treatment of lipids, probably known to most people as cholesterol.
Why do we need an entirely new field of specialization? One reason is that cholesterol is a much more complex topic than previously realized. “Part of the concern is that many people being treated [for elevated cholesterol] have very high cardiovascular future risk,” says Dr. Brian Rose, assistant professor of medicine and endocrinology at The Medical College of Wisconsin. “Despite meeting treatment goals, they continue to be at risk.”
These cases have led physicians to look beyond the routine lipid panel test for answers. “There is a certain amount of confusion about what is the most
appropriate treatment,” says Rose. “Training and experience for lipid management is not as great as expected. As a result, there is an increasing desire from different organizations to promote education among health care workers, physicians and the community for the reduction of cardiovascular disease.”
Enter the lipidologist. These docs, as well as others who concentrate on reducing runaway cholesterol, are working at coming up with better solutions.
More Nuanced Testing
Some of the biggest changes in the field of cholesterol management have been in how doctors use tests to measure cholesterol risk. It’s now recognized that for certain classes of patients, the common fasting lipid panel blood cholesterol test misses critical information. Although this standard test is certainly a good place to start for the general population, there are instances where it’s just not doing the job. Here’s why:
The lipid panel test relies on a calculation taking into account many factors to assign a general cholesterol number. But the critical issue, it’s been discovered, is not the number itself, but the composition of LDL particles. Meyer offers an analogy.
“Let’s say you are the traffic controller for an expressway and you’re trying to determine if you should widen the road. You can measure traffic two ways. One could be the number of passengers in each car. Many passengers but few cars would mean little congestion. The other is the number of vehicles, and if only one person were in each car, that would represent serious congestion. When we measure the cholesterol content of LDL, we are looking at the passengers.”
The test used to measure LDL is called Apolipoprotein B, or Apo B. One molecule of Apo B sits on every particle of LDL – in other words, one passenger per vehicle. Many particles equals many vehicles, or much cholesterol. “Recent studies show that the LDL particle number may be more predictive of future cardiovascular disease,” notes Rose. So by determining the number of Apo B molecules present, the amount of bad cholesterol can be conclusively determined.
But when it comes to Apo B particles, size matters. Particles come in all sizes. Think of the wall of your arteries as a window screen to keep insects out of your house, or the interior of your artery where cholesterol plaque collects. Big bugs bang against the screen, but can’t get in. Tiny gnats, however, can slip through the screen holes. The same thing happens with LDL particles. Small, dense particles are much more dangerous in terms of plaque buildup and the likelihood of future heart events. Large, fluffy particles float on by. The Apo B test indicates this key marker.
The Apo B test can also help weed out patients who were thought to be at high risk but are really not. These are people who had previously been identified with high LDL cholesterol, but who are not at risk because they have only fluffy LDL particles. They may be needlessly taking cholesterol-reducing medication and possibly incurring its negative side effects for no reason.
Another advancement over the simple lipid blood test is the carotid intima media thickness test (CIMT). “Atherosclerosis begins when the innermost part of the artery wall, called the intima, thickens,” says Dr. Tara Dall, a board certified lipidologist with Advanced Lipidology in Delafield. “This thickening then predisposes the artery to plaque development, which is the underlying cause of heart attack and stroke.” In fact, this is the very reason Russert died – cholesterol plaque in his arteries suddenly ruptured.
“The CIMT exam provides a direct measurement of arteriosclerosis even in its earliest stages, before it starts to block blood flow,” says Dall.
A normal artery is round with a hole in the middle to accommodate blood flow. However, if dense, small LDL particles have penetrated the artery walls over time, a fatty substance begins to form. As the mass grows, the size of the hole for blood flow decreases. If the plaque is hard, it will eventually cause the artery wall to burst. The body reacts by sealing off the wound with a clot, just as it would on your knee if you fell. However, in the artery, the clot now effectively blocks any blood flow at all. What the CIMT can do is detect soft or hard plaque in order to better predict future ruptures.
“These new tests can help identify patients not otherwise considered at high risk,” says Dr. Charles Lanzarotti, a cardiologist and electrophysiologist at Wheaton Franciscan Health Care. “The tests become more important for patients with known coronary disease, but who do not have other risk factors.” After all, Russert had been diagnosed with asymptomatic coronary artery disease, but it was thought to be well-controlled with medication and exercise. The fact that LDL particles had penetrated his artery wall and formed a sizable plaque mass that would eventually rupture was somehow totally overlooked. A simple CIMT would have detected this and could possibly have saved his life.
Dall is quick to point out, though, that not every patient needs this test. It’s most appropriate if certain conditions are present, such as a family history of heart disease, cigarette use, high blood pressure, diabetes or several other risk factors.
Ultimately, knowing your LDL particle count and/or artery wall thickness can help encourage patients to live healthier. “While you can’t change your genetics, such as a family history of heart disease,” says Lanzarotti, “the first line of defense should be behavior. A patient with high cholesterol who smokes can drastically reduce their LDL just by quitting. Anything a patient can do on their own is beneficial.”
For patients, knowledge is power. Armed with the results of these high-powered tests, they can proactively address their health risks. “In our clinic, we are huge advocates of lifestyle changes,” says Dall. “The effects can be dramatic. A patient can drop up to 1,000 particles of LDL just by increasing their physical activity. It’s so important to get the information.”
Janine S. Pouliot is a frequent contributor to Milwaukee Magazine.
Health Tips by Julie Sensat Waldren
Surf the Web, Save Your Brain. Web surfing can improve mental function in older adults, notes a study presented at the Society for Neuroscience annual meeting. The interactive nature of Web browsing improved brain functioning even for adults with little prior Internet experience. The results build on the findings of the Einstein Aging Study, which found that cognitive activities like doing crossword puzzles and playing chess can help stave off dementia.
Boost Heart Health with Vitamin D. In an American Heart Association study, participants with the lowest levels of vitamin D had almost twice the risk of stroke or heart failure, and a greater risk of coronary artery disease. Vitamin D helps regulate blood pressure, inflammation and glucose control. Patients concerned about vitamin D levels should check with their doctors to determine the optimal dose.
Whole Foods Fight Depression. Middle-aged adults who eat a diet of processed foods were more likely to develop depression than those who eat whole foods, notes a study of 3,400 participants in the British Journal of Psychiatry. The whole-foods diet was rich in vegetables, fruits and fish, while the processed-foods diet included sweets, fried foods, processed meat, refined grains and high-fat dairy products. Similarly, an Archives of General Psychiatry study found adults who followed the Mediterranean diet – vegetables, fruits, nuts, whole grains, olive oil and fish – were 30 percent less likely to develop depression.
High Cholesterol Leads to Prostate Cancer. Men with healthy cholesterol levels may have a lower risk of developing prostate cancer, according to two studies in Cancer Epidemiology Biomarkers & Prevention. One study of men 55 and older found those with cholesterol below 200 were half as likely to develop high-grade prostate tumors compared to men with a cholesterol count greater than 200. The other study found that men with the highest levels of HDL (“good cholesterol”) had an 11 percent lower risk of developing cancer than those with the lowest HDL levels.
Sweat Away Strokes. Moderate- to high-intensity exercise may help lower the risk of stroke in older men, notes a study in Neurology. The study found that active men had almost a two-thirds lower risk of suffering a stroke caused by a blood clot than sedentary men. More research is needed to determine if the same is true of women.
