Healthy Heart Series Part X

Nearly 10% of men have a diagnosis of coronary heart disease (CHD) which is a term for clogged heart arteries causing angina chest pressure, a MI, and the need for heart stents and bypass surgery.  Tragically, half of the men who die suddenly of coronary heart disease, hundreds of thousands, have no previous warning symptoms and no chance in the traditional medical model to be diagnosed before death. The key message of research statistics is that even if a man has no symptoms, he may still be at risk for CHD and heart death.

After World War II the number of cases of CHD began to rise. Until the early 1950’s, CHD was largely regarded as a feature of aging. Certain keen observers like Paul Dudley White, MD of the Harvard Medical School disagreed and felt a large proportion of MI and cases of CHD could be predicted by “risk factors” developed from research studies like the Framingham Study initiated in the late 1950’s (3).  These studies identified that high blood pressure, high LDL cholesterol, and smoking were the key risk factors for CHD. About half of Americans (49%) have at least one of these three risk factors (4). Several other medical conditions and lifestyle choices can also put a man at a higher risk for heart disease, including diabetes, overweight and obesity, a diet high in processed foods, physical inactivity, and excessive alcohol use (5).  This science led Dr. White to conclude from the 1950’s onward that “Death from a heart attack before the age of 80 is not God's will, it is man's will.” (6) . The matter of heart attack prevention is pressing because over 1,000 people a day in the US alone experience a heart death judged to be preventable by the Center for Disease Control in Atlanta (7). The onset of a MI, stroke or even a sudden death even though the problem, atherosclerosis, was present and undetected for decades.  The following steps are suggested as a comprehensive and effective strategy to identify CHD in men before a HA occurs. 

Step 1: Clinical clues to silent CHD

CHD progresses silently for years before a MI or death occur but there are clues to “sick” blood vessels in other parts of the body that can be an early warning system to CHD.  

1. a) Erectile dysfunction (ED) 

Some men have a built-in warning system for silent CHD. When achieving an erection is difficult or impossible, it can be a sign of clogged arteries in the pelvis that presents before a MI hits a few years later. There are, on average, three to five years between the onset of ED and the finding of CHD, which is plenty of time to detect and to work on preventing heart issues (8). Unfortunately, the norm in clinical practice is a Rx for an erectile dysfunction drug without a consideration of the risk of CHD. A full evaluation for silent CHD has been recommended by expert panels (9). 

1. b) Baldness 

In a comprehensive study of almost 37,000 men, severe baldness at the crown of the head strongly predicted the presence of silent CHD at any age. (10). 

1. c) Gray hair is a clue 

A new study presented in Europe at EuroPrevent 2017 found that a high amount of gray hair is a risk factor for silent heart atherosclerosis. A total of 545 adult men without known heart disease had a CT angiogram of their heart arteries, a very accurate way to identify silent problems. Having equal amounts of gray and dark hair, or mainly gray and white hair, correlated with finding silent heart blockages. The researchers hypothesized that atherosclerosis and hair graying occur through similar biological pathways (11). 

1. d) A diagonal earlobe crease 

One of the strangest of markers, a crease in the earlobe (specifically, an angled crease in the ear that runs diagonally from the canal to the lower edge of the earlobe) has been mentioned in medical research reports as a sign of silent CHD. The ear lobe crease may result from poor circulation or a nutritional deficiency in collagen production. Although some medical professionals have argued that a crease is just a general sign of aging, researchers used the most sophisticated CT scan method to measure silent CHD and found that ear lobe crease predicted CHD even after accounting for other risk factors, such as age and smoking. (12). 

1. e) Calf pain on walking 

This is known as claudication (from the Latin for “to limp”). Atherosclerosis can block leg arteries, particularly in smokers, before CHD is diagnosed. This symptom requires an evaluation without delay. An examination of the pulses in the legs and simple measurements of leg blood pressure and blood flow can confirm a diagnosis of poor circulation and increased MI risk (13). 

Step 2: Determine Arterial Age 

The concept of “arterial age” to predict longevity goes back to the 1600’s when a leading English physician Thomas Sydenham, MD, wrote that “a man is as old as his arteries”. While there are recommendations to search for breast and colorectal cancer, there are no routine screen to identify silent CHD (14). The American Heart Association recently updated its guidelines for the management of cholesterol to consider a simple CT scan of the heart known as a coronary artery calcium score (CACS) as pivotal in deciding on therapy (15).  In addition, a large analysis of the predictive power of the CACS and the use of cholesterol lowering statin medications was published that makes it clear that getting a CACS is the most important step to assess the risk of a heart attack (16). 

A CACS was developed as a screening test for silent calcified heart arteries using specialized CT scanners called EBCT but is now performed on the widely available multi-slice scanner at most hospitals and even some larger clinics (17). The test simply requires holding one’s breath and is independent of heart rate or blood pressure. A second type of heart CT scan called a coronary CT angiography or CCTA requires that contrast agents be injected and is not used as a screening tool. The CACS test takes under 30 seconds and is painless. With modern software algorithms and CT scanners, the radiation exposure is about 1 mSv, or on par with a mammogram. The CACS is not a yearly examination and might be repeated every 5-10 years (or never) so the radiation exposure is considered low. It is a screening test for silent CHD so it is not appropriate for persons with a prior MI, stent, coronary bypass, or known atherosclerosis of other parts of the body like a carotid endarterectomy. Additional considerations are the potential incidental findings (pulmonary nodules, enlarged lymph nodes and thoracic aortic aneurysm). 

The CACS requires calcification of heart arteries, sometimes called hard plaque. Soft plaque that is not yet calcified may also threaten the health of men but will not be identified on a CACS. A digital carotid ultrasound called a carotid intimal-medial thickness (CIMT) can show both hard and soft carotid plaque years before an event (18). A CIMT is a 20-minute ultrasound of the neck that uses advanced software measurements to examine carotid arteries for plaque and also measure the thickness of arteries, another sign of aging. The biggest drawback of the CIMT is finding a quality center that offers it. 

The standard annual wellness examination or even executive physical generally involves the same laboratory evaluation that was obtained 20-30 years ago. Occasionally a marker of inflammation like hs-CRP  is added in by some practitioners. Yet, the field of lab testing for genetic and acquired heart risk is advancing rapidly and widely available. Here are some tests to consider in men.

Advanced lipid profile: Rather than a calculated LDL cholesterol level, advanced panels measure LDL particle number and size directly, which are more accurate and predictive of future heart and stroke events (19). Two people with the same total and calculated LDL cholesterol levels can have widely different particle and size measurements, making for very different risks. (20) 

hs-CRP: The high sensitivity C-reactive protein is a blood test patented by Harvard Medical School to measure inflammation or the “fire” that results from an irritated immune system. The higher the hs-CRP the greater the risk for atherosclerosis, heart attack, stroke and even other conditions like cancer and dementia (21). 

Lipoprotein (a): This is a genetic form of cholesterol that's elevated in about 20% of those tested and unaffected by most lifestyle measures or statin medications. It's rarely drawn even though hundreds of research studies indicate that if it's high, the risk of heart attack and stroke skyrocket. It runs high in many families that have been decimated by heart disease (22).

Homocysteine: This amino acid is produced by a process called methylation. It can injure arteries when elevated. It may be due to a genetic defect in the MTHFR gene, which is easily measured or due to nutritional deficiencies of B vitamins. Homocysteine can be lowered with B-complex vitamins (23).  

TMAO: This is a newly described marker of heart and kidney health that's elevated after eating meat- and egg-heavy diets with an altered gut microbiome. It has been shown to cause heart and kidney damage, and is associated with worsened prognosis (25). 

apoE: This is a genetic marker related to cholesterol metabolism that is measured from a blood sample. For the few that inherit a pattern called apo E 4/4, the risk of heart disease and Alzheimer’s disease is high and may have an onset 15-20-years earlier than average (26). 

Step 5: Calculate a Astro-CHARM Score. 

A major advance in 2018 was the publication of the application called the Astro-CHARM score (27). The online risk calculator is a collaboration of NASA and the University of Texas Southwestern Medical Center and is the most advanced tool available. It permits entering the CACS, the hs-CRP and more traditional measures (age, smoking status, total cholesterol, HDL-cholesterol, and blood pressure) to predict the 10-year risk of fatal and non-fatal MI and stroke. 

Step 6: Review New Prevention Guidelines

The approach to avoiding a MI and CHD may seem complex as outlined here but the core activities of day to day self-maintenance are quite simple. The key recommendations to prevent heart issues have been organized in the 2019 Primary Prevention of Cardiovascular Disease guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) (28). An even simpler version of the guidelines is available and may be more appropriate to share with patients (29). 

By following a heart healthy lifestyle as outlined by the ACC/AHA, and pursuing the advanced testing and evaluation outlined here, there is no reason we cannot fulfill the vision of Paul Dudley White, MD and make CHD an option and not an inevitable outcome for so many men.