Category: Treatment

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Heart Health Metabolic Treatment

Uncovering Sleep Apnea

Sleep apnea is one of the factors we use for a Heart Health Risk Score and address to decrease the risks from such a condition.

Briefly, this is a condition in which the body doesn’t get enough oxygen which can lead to brain and tissue injury.

Sleep Apnea Testing

Traditionally, patients have quite a journey when trying to have their sleep-disordered breathing diagnosed. In fact, quite a few primary care physicians can’t get easy insurance approval for sleep studies.

The idea of in-lab sleep testing, where you spend 1-2 nights in a sleep laboratory, is daunting. While an alternative to this is in-home testing, it’s not that much easier.

Is a sleep test necessary?

Current Clinical Guidelines

Clinical guidelines are useful concepts in Western Medicine that allow clinicians to follow similar algorithms for patients.

However, no two patients are alike, and guidelines, when they must be followed or when they become the standard of care, leave many patients and clinicians on the sidelines.

The AASM linked above recommends that, ideally, an in-lab polysomnography be done in a sleep laboratory for a proper sleep apnea diagnosis. Alternatively, an in-home sleep test can be done but with many limitations.

The AASM recommends against the use of clinical questionnaires for the diagnosis of sleep apnea.

STOP-BANG Questionnaire

The STOP-BANG questionnaire screens for the potential of obstructive sleep apnea (OSA), a subtype of sleep apnea. In fact, OSA is the most common type of sleep apnea by a landslide.

This validated questionnaire is more than enough to establish a very high suspicion of an OSA diagnosis.

Of course, whenever possible, we like to make sure. As in, clients are advised to obtain formal in-lab polysomnography (PSG) or, at the very least, an in-home sleep test.

As health coaches, we cannot advise individuals what to do or not do. But our philosophy is that guidelines should be followed unless immediate harm is possible from having untreated sleep apnea.

For our clients, we recommend that they speak to their physicians to decide if an auto-titrating positive airway pressure (APAP) is appropriate for them even before any testing can be performed.

Once treatment has begun, it’s still possible to undergo testing.

Highest Risk Patients

In our experience, individuals at the highest risk for sleep apnea or complications from sleep apnea are those with:

  • heart failure
  • hypertension
  • obesity
  • dementia
  • older age
  • kidney disease
  • COPD
  • heavy snorers
  • daytime fatigue
  • insomnia

If you’re looking for a hassle-free way to get treatment for OSA and want to take a home sleep test, there are companies like Empower Sleep that make the process easier.

For less than $200 you can purchase your own home testing device to diagnose OSA.

Sleep Apnea & Heart Health

There are plenty of articles linking sleep apnea and heart health; no need to dive too deep into that topic again here.

We approach the topic of sleep apnea and cardiovascular health by educating and empowering our clients. These two conditions have a bidirectional relationship; sleep apnea increases inflammation in the body and elevates blood sugars, and cardiovascular disease can make it harder to oxygenate the body.

Is OSA permanent? Not necessarily; certain underlying conditions can be treated to help reverse sleep apnea.

Can OSA treatment improve heart health? It seems that those who have their sleep apnea managed properly with a CPAP machine drastically improve their cardiovascular health.

The Magic of Masks

A properly fitted mask makes all the difference. Too often, people give up on their machines because they have difficulty tolerating their masks.

Finding a mask with the proper fit makes all the difference. Not only are they more comfortable, but they are also more effective.

We recommend working with a good sleep apnea technician or a great salesperson to help you find the full-face or nasal mask that fits you best.

Making the Habit Stick

Our clients fall into 2 categories:

  • those who stick it out with their machines
  • those who give up after 2 weeks

Any new habit takes time to cultivate. There will be setbacks before the habit becomes part of your routine. With tiny, whisper-quiet devices these days, you can travel with them with ease and help the habit stick.

Commuting to work, exercising, brushing before bedtime – none of these were intuitive habits until you did them enough for them to stick.

The goal is to work with the setbacks and ask:

  1. What went wrong?
  2. What can I do differently next time to improve?

Sleep Apnea Health Coaching

Our role as health coaches is to support clients in achieving their ideal health goals by helping them overcome doubts, fears, and hurdles related to changing habits. We leave clinical decision-making to the clinicians.

The goal as always is to prevent major health consequences from cardiovascular disease. We achieve this by focusing on:

  1. managing sleep apnea successfully and consistently
  2. measuring potential outcomes changes based on treatment
  3. adjusting other relevant risk factors to decrease cardiovascular morbidity risk
  4. empowering individuals with knowledge and self-confidence
Categories
Heart Health Hyperlipidemia Statins Treatment

Reversing Atherosclerosis

Is it possible to reverse atherosclerosis in the coronary arteries or anywhere else in the body? This topic, often called plaque regression, deserves an overview for anyone considering any Heart Health intervention.

Atherosclerosis – The Approach

It’s fair to say that if you are past your teenage years, you will have some atherosclerosis. This is the plaque buildup inside the arteries of the body which causes health problems mostly when it affects the blood supply to the heart, brain, and limbs.

1. Main Approach – Prevention

The main approach to atherosclerosis is preventing it.

With our Heart Health Coaching, the goal is to live a lifestyle that:

  • decreases blood pressure
  • lowers circulating apoB levels
  • decreases inflammation
  • improves mitochondrial health

For many, lifestyle changes are adequate, and we can track serum biomarkers such as lipid levels, inflammatory markers, and serum insulin levels to track success.

For others, chemical interventions may be necessary, even for the prevention stage, such as statins, ezetimibe, or the PCSK9 inhibitor class of medications.

2. Secondary Approach – Treatment

Some clients will already have an atherosclerosis diagnosis. Perhaps a physician noted it on a knee X-ray, or the patient is experiencing symptoms of angina.

The secondary approach is to help prevent major cardiovascular events (heart attack, strokes, peripheral vascular disease) due to the buildup of this plaque.

Must we reverse atherosclerosis for this secondary approach to be successful?

Plaque Regression

Western Medicine states that not all plaque is equal. We have stable plaque and potentially unstable plaque. Though this is a rough categorization, it’s a helpful mental model to follow.

The goal is to minimize unstable plaque but encourage remodeling of existing unstable plaque and perhaps to encourage plaque regression.

In plaque regression, the amount of plaque actually decreases. Tiny intravascular ultrasound (IVUS) or a CT angiogram (CCTA) can confirm this.

Available studies show that high-intensity statin therapy decreases overall plaque volume by 10%, but that may not fully explain the decreased risk of cardiovascular events. So, perhaps stabilization is just as important.

Stabilization vs. Regression

This summary article determines which is better, stabilization vs. regression of plaque. Of course, in real life, we don’t have to choose one or the other – that’s the headache best left for the researchers.

1. Stabilizing Plaque

MIRACL, PACT, CURE, HOPE, and Lyon support the idea that plaque stabilization is effective.

We know from various studies that a lower-fat diet, increased activity, and managing stress/sleep can stabilize plaque, shifting more toward the preferred calcified plaque.

It’s important to mention that statins tend to change plaque composition toward:

  • fibrous volume
  • calcified plaque
  • reduction in fibrofatty volume
  • decreased a necrotic core

2. Reversing Plaque

ASTEROID, REVERSAL, and SATURN studies, on the other hand, focused on plaque reversal as a way to decrease the risk of cardiovascular disease.

We haven’t come across any convincing studies to demonstrate that plaque regression is necessary to help prevent major cardiovascular events.

However, if plaque regression is the goal, high-dose statin treatment should be the treatment of choice.

This answers the common questions our clients ask us about whether to repeat CT angiograms or CACs.

Categories
Heart Health Hypertension Treatment

Blood Pressure Goals

As with all things in medicine, there is much debate about ideal blood pressure goals. 120/80 or under 140/90?

And as with all things in medicine, it’s an individualized approach. Some patients have enough risk that a 120/80 value makes the most sense.

The current standards consider normal values to be under 120 systolic and under 80 diastolic values.

Avoiding hypertension is an important part of ensuring proper Heart Health and avoiding strokes, heart attacks, erectile dysfunction, heart failure, and kidney disease.

One common problem we see in Western Medicine is that kidney disease is diagnosed too late with rather vague guidelines for renal function. Better tests than serum creatinine are available.

Current Approach to Blood Pressure Checks

My patients have their blood pressure checked when they come into the clinic. Or worse, they check their BP at home when they have a headache, feel dizzy, or have nausea.

At best, in this current approach, we measure someone’s blood pressure only 2-3 times per year. At worst, we check blood pressures when they likely will be high due to pathologic factors.

So, the old method is outdated – too little data or dirty data from which a proper decision cannot be made.

Average Blood Pressure Readings

In comes the average blood pressure. This is a far better approach and method to guestimate someone’s baseline blood pressure.

Baseline, meaning this is the blood pressure they are walking around with when not stressed, when not doing a strict meditation routine.

The goal for this blood pressure should definitely be low – closer to 120/80. This is according to the SPRINT trial.

The average blood pressure can be taken with a cuff which you set to inflate every 30 minutes using a timer. Your doctor can also prescribe an ambulatory blood pressure monitor, which achieves the same automatically.

Interventions That Lower the Blood Pressure

When you’re stressed, your blood pressure goes up. Logically, if you can calm yourself down, your blood pressure should and does indeed decrease.

Blood pressure goals can be achieved with lifestyle changes alone. Weight loss, dietary changes, stress management, better sleep, and correcting underlying pathology such as sleep apnea.

The next step is medications. There is a lot of fear when it comes to medications. It’s understandable. Big pharma can’t always be trusted – perhaps. But they do some good, as well.

It’s important to understand that any chemical is a tool, and when used correctly by the right people, it could be a proper solution.

Otherwise, to achieve the desired blood pressure goals, herbal medications or supplements can also be tried.

Categories
Heart Health Hyperlipidemia Treatment

Should We Be Testing for Lp(a)?

No doubt those with elevated Lp(a) have a higher risk of ASCVD, but the question is whether testing for Lp(a) is beneficial if we don’t have effective therapies for lowering it.

Lipoprotein (a)

It isn’t the best nomenclature, but this word refers to a low-density lipoprotein containing a particular molecule called apolipoprotein(a) or Apo(a).

The blood levels of Lp(a) are affected by a few factors, one of which, of course, is the LPA gene that encodes this molecule. Dietary habits, age, or sex doesn’t seem to affect your Lp(a) values.

It’s important to check for Lp(a) in the same lab for monitoring levels, but it may not be the best way to work with this lab value. Most experts will check this once or twice in the patient’s lifetime because it’s meant to indicate overall risk.

Lp(a) is made up of a liporptein plus apoB and Apo(a). The Apo(a) portion can independently elevate the risk for clotting.

Lp(a) & Disease Association

We know from observational studies that those who walk around with higher Lp(a) levels tend to have a higher risk of ASCVD, coronary heart disease (CHD), cerebrovascular disease (CVD), and aortic stenosis.

This molecule is also an acute phase reactant, so those with inflammation will have higher values. Meaning also it shouldn’t be checked during times of inflammation.

From a UK study of half a million individuals, we know that for levels above 20 nmol/L, there was an increased association with ASCVD. Which translates to a 10% higher risk for each 50 nmol/L increment above this value.

Lowering Lp(a)

Unlike someone’s LDL values, we don’t have good tools to lower a patient’s Lp(a). At least, that’s the current widespread consensus. Some experts believe there are treatments (medications) in the pipeline that will lower the serum level of Lp(a) but as much as 80%.

The next question is whether lowering Lp(a) levels would change someone’s health outcome.

With HDL and homocysteine levels, we have seen that changing the value of these in the blood through directly targeted medications doesn’t have an actual cardiovascular disease outcome.

So, we’ll see if medications that lower Lp(a) will change a person’s ASCVD. Some of the upcoming clinical research should reveal that.

How To Treat Elevated Lp(a)

Some countries, such as the UK, regularly test their patients for Lp(a). But all countries are still waiting for final results to determine which Lp(a) lowering treatments will lower the risk of atherosclerotic heart disease.

It’s important to recognize that statin therapy can sometimes elevate Lp(a). Again, this is the tough part of understanding the complicated interplay between the different key players in heart disease.

Fortunately, despite the rise in Lp(a) caused by statins, those at risk will still benefit from statin’s independent anti-inflammatory and LDL lower effects.

1. PCSK9 Inhibitor

Though PCSK9 inhibitors seem to lower Lp(a) values, it’s unclear whether they can lower the risk of heart attacks in those with high Lp(a) values.

2. Lipoprotein Apheresis

Similar to dialysis, though not as severe, this can be used weekly to lower Lp(a) values by 70% or more.

3. Antisense Therapies

Some antisense oligonucleotide treatments are being researched to lower patients’ Lp(a) levels.

4. Inclisiran

Leqvio is a medication for those with elevated ASCVD disease risk who may not be candidates for standard treatment alone.

This molecule works in the synthesis pathway of the PCSK9 protein.

Serum Lp(a) Values

Serum values above 165 nmol/L seem to be associated with the highest risk, such as coronary heart disease death, heart attack, or needing immediate vascular intervention.

Some believe values above 125 nmol/L equate to elevated risk; other experts set that bar at 50 nmol/L. The patient’s clinical history obviously matters a lot.

Categories
Heart Attacks Heart Health Prevention Treatment

Heart Health in Traditional Medicine

Traditional medicine, also called western medicine, is exalted for its evidence-based, scientific approach. It has proven capable of treating some of the most life-threatening and severe conditions. However, heart health in traditional medicine remains less advanced.

First Signs of Heart Disease

Most adults don’t necessarily know they have heart disease. And unfortunately, death is the first presenting symptom in a little less than half of those presenting for the first time.

That means 50% will have a fatal heart attack and not just a high cholesterol level or atherosclerosis seen on imaging.

We haven’t figured out a way to decrease that number fast enough. This means that heart health in traditional medicine can only help 50% of adults.

Traditional Medicine and Heart Disease

In traditional medicine, assuming you have good insurance, you can get excellent care to lower your cholesterol levels and blood pressure by using medications.

This requires regular visits for blood testing to make sure your liver and kidney can handle the medications. Refills cost money and time spent in the pharmacy.

These treatments don’t work for everyone. However, traditional medicine views all high-lipid and hypertensive patients similarly and treats them the same. This is one of the downsides of this practice model.

But if you need a stent or need to be resuscitated, western medicine is as good as it gets. We have incredible talent that can perform heart transplants and perform bypass grafting.

Heart Health is About Prevention

I can treat the high cholesterol with statins and perform a stent in the coronary artery, followed by a coronary artery bypass graft later in life. This is treating the symptom and not the condition.

Heart Health Coaching, which is what I do, focuses on lifestyle factors. It’s more about prevention and diving deep into potential causes for not-so-great metabolic health.

Heart Health and Pills

A pill can lower your blood pressure and decrease the chance of atherosclerosis plaque progression.

But it cannot prevent a heart attack or prevent you from getting fatty liver or diabetes from the factors which lead to high cholesterol or high blood pressure, to begin with.

Perhaps somewhere around 2-3% of individuals have genetic factors causing high cholesterol and high blood pressure. All methods other than pills will likely fail these individuals. For the rest of us, pills may not be as effective.

Prevention + Treatment

In the perfect world, everyone would have a Heart Health Coach and work to overcome hurdles toward ideal heart health.

If that fails and heart disease develops, they have the excellent skills of capable cardiologists, surgeons, and intensivists who can help restore their cardiovascular health.

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Heart Health Treatment

Supporting a Health Client

I trained as a family medicine physician and obtained my MD from UCLA Medical School. There, the mentality has been to intervene to fix a specific medical problem, and less emphasis was placed on supporting the patient.

However, with more years under my belt, I can do more good by supporting my clients and patients instead of offering a fix.

Looking for a Fix

Some clients seek to have their problems solved for them; they hope to be fixed. But this can diminish their autonomy and lead to downstream problems.

Feeling so frustrated and drained is expected that you want someone to take over your care and solve your health problems.

Perhaps you’ve tried all sorts of diets and pills and interventions. Now, you are ready to give up because there seems to be no viable solution.

Patient support always results in better long-term outcomes than offering someone a quick medication or procedure.

Supporting my Heart Health Clients

Empowering my clients means spending long sessions side by side. They and I must understand the exact problem before looking for solutions.

Is the chronic swelling in the legs the problem, or is the underlying fear of heart failure that hasn’t been addressed?

When we support someone, we tell them they aren’t alone. We offer our expertise and resources to them and guide them on their journey.

Quick Fixes are Possible

A client of mine took a beta blocker medication for his hypertension which caused him major dizziness and weakness. He didn’t know this was the side effect of the medication and assumed it was high blood pressure.

We sat down and discussed the symptoms and reviewed his medications. He felt armed enough with the knowledge to bring up the medication side effects with his PCP, who changed it to an ACE-I medication.

The symptoms disappeared. Easy fix, right?

In some ways, it was an easy fix. But suppose we didn’t spend the time to talk about how beta-blockers work and what common side effects they have. In that case, it’s entirely possible he would have bounced from one medication to the next, never feeling like he had some control over his medical condition.

Patient Autonomy

Western medicine can sometimes seem adversarial because physicians feel pressured to fix a clinical problem as soon as possible.

We fear a terrible outcome for our patients, so we take over the wheel. In the long run, this turns out to be an unhealthy patient-doctor relationship.

The intention is often good, but this has resulted in a healthcare system where the physician practices defensive medicine and the patient feels ignored.

Fostering patient autonomy starts with patient education. This empowers the individual and leads to better long-term relationships and health outcomes.

Categories
Diet Heart Health Hyperlipidemia Prevention Statins Treatment

How the Body Regulates Cholesterol

In this article, I wanted to provide a basic overview of cholesterol regulation in the body. I share such articles with my heart health coaching clients whenever necessary. How the body regulates cholesterol is relevant to choose the right method of controlling cholesterol levels.

Cholesterol Regulation

Cholesterol is quite essential. The following key players regulate cholesterol in the body:

  • cells lining the intestine
  • liver
  • pancreas
  • intestinal bacteria

The food we eat has some form of cholesterol which becomes absorbable after manipulation by intestinal bacteria and pancreatic enzymes.

Cholesterol can enter the bloodstream also through the bile system. Whether you still have a gallbladder or not, your liver will produce cholesterol pumped into the intestines.

Cholesterol Absorption Varies

Some individuals are hypoabsorbers of cholesterol. No matter how much high cholesterol foods they consume, their intestinal cells don’t take up much of it.

Others are hyperabsorbers of cholesterol; even the lightest meals can have every bit of its cholesterol extracted and pumped into the bloodstream.

Cholesterol Regulation and Treatment Options

For my hypoabsorber clients, I am less concerned about their dietary cholesterol intake. Their cholesterol production in the liver would be a more important factor.

The hyperabsorbers will benefit a lot from a particular dietary change. Sometimes it helps to cut back on saturated fats, but eating times and gut bacteria are also important criteria.

Dietary change? Statin therapy? Ezetimibe? Evolocumab?

To answer that, I need more information about the person. A generic cholesterol test won’t always tell us the whole story.

The Liver’s Cholesterol Production

How cholesterol is regulated in the body has a lot to do with the liver. This fleshy organ on the right upper quadrant of the abdomen produces LDL, HDL, and VLDL particles.

Statin drugs decrease the production of cholesterol molecules in the liver.

The liver also has LDL receptors and absorbs cholesterol.

From fatty liver to elevation of liver enzymes to problems with the gallbladder, it’s important to consider the health of this organ when assessing my clients.

The Role of Gut Flora and How Cholesterol is Regulated

Some bacteria in the gut convert free cholesterol molecules into a stanol chemical that intestinal cells cannot absorb.

We could call these beneficial bacteria. They can help slow down the absorption of cholesterol for certain individuals.

Ezetimibe is a medication that works similarly, blocking the absorption of free cholesterol molecules.

Categories
Heart Health Treatment

Cardiovascular Biofeedback

cardiovascular biofeedback for heart health

Biofeedback is time intensive and requires you to work with an expert to understand or “feel” your body better. It’s a potent tool that can improve the functional capacity of your heart or other cardiovascular symptoms.

Biofeedback

I explain biofeedback to my patients as a method of interpreting and understanding the physiological functions of the body. It’s a method of becoming in tune with the body.

In the age of modern medicine, it’s a common false belief that only a heart rate monitor or EKG can tell us about the heart’s function. Though these are great tools, they also improve our sense of well-being regarding the cardiovascular system.

I use biofeedback in my private practice with low back pain patients. Especially for those who have an exaggerated pain sensation, musculoskeletal biofeedback can help them better overcome the pain.

Biomechanical Biofeedback

In this article, I don’t want to focus too much on the technical side of biofeedback. There are incredible tools, from virtual reality to implantable sensors. But let’s start with the basics because it’s the most achievable for most of us.

Biofeedback can be broken down into biomechanical and physiologic ones. In biomechanical feedback, I might measure how much range of motion someone achieves with their low back injury.

Sometimes biomechanical feedback utilizes technology to determine how much pelvic pressure someone can exert with their kegel exercises.

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Physiological Biofeedback

Physiological feedback might require some measurement techniques. Neuromuscular feedback may require EEG measurements or gait assessment.

I measure heart rate, respiratory rate, and even cardiac perfusion when providing cardiovascular biofeedback.

Cardiovascular Biofeedback

The common conditions I treat with heart biofeedback include the following:

  • hypertension
  • palpitations
  • shortness of breath
  • exercise capacity
  • chest pain

Individuals with a history of a heart attack want to get back into an exercise routine. Often angina gets in the way. The pain creates a cycle of fear and emotional dissonance, which worsens cardiovascular capacity.

I can show my client on a heart rate monitor what their heart is doing as they increase their activity level. We review this together and dive deep into what they are feeling in their chest, arms, back, etc.

Patient Empowerment

It’s one thing to diagnose a patient using advanced technology, and it’s another to empower a person to manage their own body. Biofeedback methods can empower a person to self-regulate their physiologic processes.

The goal is to work on a particular medical condition or symptoms afflict you. A feedback expert will sit with you and help you recognize signals in the body which you can manipulate to achieve the desired outcomes.

This is powerful in that you can do this yourself moving forward. For most heart-related issues you need a heart rate monitor and an oxygen monitor.