Diet Heart Health

The Low-Fat Diet Myth

Fortunately, this particular myth has been addressed enough that many of our clients know that the type of fat or oil they consume is more important than the quantity. The low-fat diet myth perhaps originated from good outcomes when people cut out the most unhealthy and, at the time, most ubiquitous fats.

Healthy Fats

We won’t get into what is healthy fat and what isn’t because such information is readily available online and reliable. The AHA has good information on the topic of healthy vs unhealthy fats.

What we want to address here is that fat is quite important and rarely the cause of atherosclerosis or obesity, even though these two conditions are often associated with fat intake.

It plays an important role in satiety and vitamin absorption. Without healthy fats, the body will have a harder time absorbing and holding on to nutrients.

Low-Fat Diets

There is a difference between low-fat and non-fat diets or what some might call a very fat-restrictive diet. The low-fat diet myth claims that with lower fat intake, you have a lower risk of heart disease and lose weight. In fact, the opposite is true.

A dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women and achieved only modest effects on CVD risk factors.

WHI Study

However, there are instances when a low-fat diet makes sense. And, of course, for anyone who benefits from a better calorie balance, it might make sense to cut out the most calorie-rich foods, such as oils and fats.

Our colleagues over at Mastering Diabetes are major proponents of a low-fat diet, and it makes perfect sense in their program. This isn’t to say that everyone with normal A1Cs should consume a low-fat diet.

The Source of Fat

Fats and oils end up being used interchangeably in our common vernacular. Arguments over whether seed oils, olive oil, or butter are good or bad are common. They often end in stalemates, and opinions tend to trump science.

At Heart Health Coach, we don’t believe there is any fat that is necessary for good health. Meaning you don’t need olive oil to be healthy or that coconut oil is a must for anyone who wants to prevent dementia.

However, if our clients are going to consume butter, we want them to obtain it from a good source. The same is true for any oil or fat.

Within species (like cows), the diet of the animal can impact the nutritional profile of the butter. Grass-fed cow’s butter, for example, often has a higher omega-3 fatty acid and vitamin K2 content than grain-fed cow’s butter.

When cattle are finished on pasture, the resultant meat and dairy products are higher in omega-3 fatty acids and have an improved omega-6:omega-3 ratio. Grass-based diets have also been shown to enhance total conjugated linoleic acid (CLA) isomers, trans vaccenic acid (a precursor to CLA), and antioxidants in beef.

BMC Nutrition Journal

Low-Fat Diet Myth

The low-fat diet myth has led to egg white omelets, non-fat milk, and fat-free cookies. These dietary modifications are not only ultra-processed, but they also provide the person with a dietary intake profile that skews nutrient absorption.

When we meet with clients, we spend quite a lot of time on gathering a proper nutrient profile. We develop a diet risk score to help us make further dietary suggestions.

The PURE trial found that contrary to prevailing dietary guidelines, higher fat intake was linked to a reduced risk of mortality, while high carbohydrate intake was linked to an increased risk.

This isn’t to say that this trial is the end-all-be-all on this topic. It has plenty of limitations, but it’s safe to say that historically people have done well eating a well-balanced, nutrient-dense diet that included fats. It’s the quality of fat that might be in question in the low-fat diet myth.

Afib Heart Health Prevention

Proven Ways to Prevent Afib

It’s not on most people’s radar, but there are proven ways to prevent Afib – Atrial Fibrillation – a cardiovascular condition that increases the risk of strokes and heart failure.

Lifetime Risk of Afib

The lifetime risk of Afib is 1 in 4. A good 25% of us will have Afib when we get older. Over the age of 65, it can be as high as 1 in 3.

We work with our Heat Health Coaching clients to identify their risks and adopt a way of life to help decrease that overall risk.

Healthy aging is a major program for us here at Heart Health Coach, and we address all such risk factors.

Proven Ways to Prevent Afib

Here at HHC, we take evidence-based medicine seriously. We don’t just look at the latest and greatest research published without considering its biases. Instead, we focus on data that has been proven time and time again and work our way towards the factors less based on strong science.

1. Age

There are modifiable risk factors and nonmodifiable risk factors. We mention age because as Afib risk increases with age, it’s even more important to modify the factors that can help decrease our lifetime risk of developing this condition.

2. Family History

Also not a modifiable risk factor, but nevertheless among the strongest drivers of Afib, having other family members with Afib increases our risk of developing Afib at some point in our lives.

3. Hypertension

From causing left atrial enlargement to increased sympathetic activity, elevated blood pressure is a major driver of Atrial Fibrillation.

It’s a modifiable risk factor. Those who manage their blood pressure even with medications will see a 26% decrease in the lifetime risk of developing Afib.

4. Excessive Exercise

Younger athletes who train quite hard may be at increased risk of Afib. Fortunately, their cardiac arrhythmia may not necessarily increase their risk of stroke – the main side effect of having this condition.

Nevertheless, if family history is present and if any other abnormal rhythms are present, it’s worthwhile to investigate the potential for paroxysmal Afib further.

5. Sleep Apnea

Decreased blood oxygenation, elevated pressure on the heart, and increased risk of PACs may all contribute to developing Afib if Sleep Apnea remains poorly controlled.

A study over a 5-year period showed that controlling Sleep Apnea with a CPAP device may decrease the risk of developing Afib by 40%.

6. Endocrine Problems

Obesity, blood sugar dysregulation, and thyroid problems can contribute to Afib.

Don’t Fear Afib

Fortunately, we have medications to treat Afib, and this is important to mention because this article isn’t meant to be fear-inducing.

Some will even develop transient Afib brought on by stress, sleep, or dietary changes which might resolve on its own.

From medication to ablation to lifestyle changes, there are ways of treating Afib, which we’ll discuss in future articles. One of our clients cut out alcohol and with it, her Afib disappeared.

Diet Heart Health

Diet Risk Score

Here at Heart Health Coach, we generate an overall risk score for our clients to help them decide which areas to focus on first. The diet risk score is a portion of the overall score, and here is how we calculate it. We don’t ask what you eat like other traditional dietary intake forms.

Mainstream Dietary Assessment

So, let’s ask our medical director, Dr. Mo, what his diet was today. He’ll likely list what he ate and what time he ate them. The ingredients might be simple if he made everything from scratch, but that’s not the reality.

Our clients who tell us they never eat sugar or processed foods might have mayo, dates, and the occasional chips. It’s so infrequent for them that they use the term “never.”

Observational or questionnaires on food intake are notoriously inaccurate. Instead, we use an alternative diet assessment questionnaire.

Diet Questionnaire

  • Where do you shop for groceries?
  • Who does the grocery shopping?
  • What’s in your fridge and cabinets?
  • What was the last thing you put into your mouth?

These are high-yield diet-related questions that are more telling than asking someone about their diet directly.

News and media have made food and diet a bit of a complex topic; too complex and subjective for traditional diet questionnaires to be accurate.

Diet Risk Score

Based on the answers above and a few other questions, we calculate the diet risk score of the client.

Buying at mainstream grocery stores often will result in less nutritious food with a higher chance of eating processed meals.

If the person is quite particular about doing their own grocery shopping, it indicates that they have a specific dietary goal they are trying to achieve.

The contents of our fridge and pantry can say a lot about what ends up in our stomachs. Perhaps the box of Wheaties won’t be eaten, maybe it’s for the significant other or the kids, but it’s in the house, and it’s processed.

The last thing that went into someone’s mouth could be a bite of a donut because a coworker offered them one, or it could have been an energy bar because they missed their lunch.

Absolute Risk Score Value

At HHC, we don’t worry too much about the actual score – the number itself is irrelevant. What matters is how this number changes over time.

For some, diet will be the biggest factor in their overall Heart Health risk, and by making some changes based on this dietary risk score, their overall cardiovascular risk should improve.

Using trends, our clients don’t get into the habit of comparing themselves to others. Instead, they can focus on how their risk scores change over time using their own N=1.

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
Heart Health Hypertension

Approaching Hypertension

Western medicine refers to elevated blood as essential hypertension, which is a somewhat confusing term, but it means that a patient has a high blood pressure of unknown cause.

Approaching hypertension appropriately requires uncovering why a person has high blood pressure before assuming it’s due to an unknown cause. Here is our approach.

Essential Hypertension

The most common form of hypertension is idiopathic hypertension which Western Medicine calls essential hypertension.

This distinguishes it from secondary hypertension, which has various other causes:

  • kidney disease
  • hormone imbalances
  • pregnancy-induced

However, many clinicians will argue that most of this essential hypertension, in fact, has other known causes which aren’t addressed.

Approaching Hypertension

Our Heart Health Coaching addresses hypertension by reviewing its major risk factors. Both in terms of what can cause it and the major risks of living with elevated blood pressure.

Our goal is in the neighborhood of 120/80, depending on various risk factors and family history.

1. Obesity

Liposuction won’t solve obesity-induced hypertension. The lifestyle changes leading to weight loss seem to be the curative factors for bringing blood pressure back to normal.

2. Elevated Uric Acid

Diets high in fructose and meat tend to elevate uric acid. Even if there are no problems with gout, a lower uric acid is desirable.

Alcohol, especially regular alcohol use, tends to elevate uric acid levels as well.

Some experts recommend keeping this value under 6 mg/dl; others want it as low as 4.

3. Elevated Blood Sugars

It’s hard to know whether elevated blood sugars or elevated insulin levels are the main cause of elevated blood pressure. Either way, we recommend our clients have optimal levels before considering that the blood pressure problem is idiopathic.

4. Sleep Apnea

Sleep apnea goes undiagnosed quite frequently. Good home tests are available these days, but the treatment – sleep apnea device – often has a low compliance rate.

Sleep apnea can cause elevated blood pressure, fatigue, headaches, and difficulty focusing.

5. Fatty Liver

Visceral fat, in general, especially fat around the liver, seems to cause a disruption in the normal hormone cycles of the body.

Non-alcoholic fatty liver disease (NAFLD) is bidirectionally associated with other metabolic disorders. Therefore, we screen for NAFLD in our decision algorithm.

Measuring Improvements

In most, doing even some work towards improving the factors above is likely to yield good blood pressure improvements.

The obvious method is regularly checking blood pressure numbers, focusing on a daily average called ambulatory blood pressure.

A secondary method is to monitor kidney function levels, called glomerular filtration rate (GFR), which creatinine or cystatin C measures.

Heart Attacks Heart Health Hyperlipidemia Statins

apoB and Cardiovascular Disease

Most clients in our Heart Health practice show up with their lipid profile in hand, most concerned about their LDL and HDL numbers. In this article, we’ll share our viewpoint on apoB and cardiovascular disease risk.

Old, Discarded Viewpoints

Lipidologists and preventative cardiologists no longer rely on LDL-C as a way to risk stratify someone for heart disease.

In most laboratories, LDL-C is often calculated and rarely measured directly, making LDL-C an even less reliable marker for cardiovascular disease risk.

Once believed to be protective, HDL-C is no longer believed to serve much value when assessing a lipid profile.

Modern Lipid Profile Analysis

If you have one of your old lipid profiles lying around, you can calculate your non-HDL cholesterol, which, 97% of the time, corresponds to apoB levels.

(Total cholesterol) – (HDL cholesterol) = non-HDL cholesterol

You can also use an online calculator.

Triglyceride Levels

these days, we mostly use triglyceride levels to determine if somebody’s dietary intake of simple carbohydrates is excessive.

The higher triglycerides are, or the more insulin resistance somebody is, the more likely they will have excess cholesterol needing transportation by apoB lipoproteins.

apoB Targets

apoB can be cheaply measured ($20 – $60) in most laboratories. Insurance often covers it, but that’s hardly necessary for lab testing.

The way we determine apoB targets is to determine a person’s overall cardiovascular disease risk.

1. Very High Risk

Those at very high risk should have apoB levels below 60 mg/dl.

If apoB isn’t available, their non-HDL-C should be < 90 mg/dl.

From the old LDL-C understanding, the goal would be an LDL-C below 70 mg/dl.

2. High Risk

Those at high risk should have the following numbers with a little more wiggle room compared to someone who is at very high risk:

  • apoB < 75 mg/dl
  • non-HDL-C < 120 mg/dl
  • LDL-C < 100 mg/dl

ApoB and Cardiovascular Disease

The biggest drivers of Atherosclerotic Cardiovascular disease (ASCVD), sometimes also referred to as cardiovascular disease (CVD) are the following:

  • tobacco use
  • hypertension
  • elevated apoB
  • elevated Lp(a)
  • elevated fasting insulin levels

How to Lower apoB

It’s hard to know who responds to what treatment. Some may not be able to tolerate statins even though their apoB drops drastically.

Others may see a massive drop in apoB by changing their diet, especially if they are hyperabsorbers of cholesterol.

Just as we have hyperabsorbers, those whose intestines squeeze every last bit of cholesterol from the food, we have hyperproducers.

The hyperproducers produce a lot of cholesterol from the liver, which finds its way into the circulation, causing elevation of apoB.

These changes partly explain why some will respond well to statins and even better when we add ezetimibe.

Repeat Testing of apoB Lipoproteins

In general, we advise our clients to check their apoB levels annually. As soon as it starts to get out of range, we discuss various interventions.

build a chance of a sudden rise in this lipoprotein level is low, regular monitoring will allow for immediate intervention.

apoB Lowering Through Exercise

When it comes to lowering certain risk factors, blood pressure is quite amenable to lifestyle changes.

It does not seem to be the same case with apoB levels. For those with a high elevation of this molecule, it is always advisable to start with lifestyle modifications first.

And certainly, there are certain dietary changes, such as a very low-fat diet, that can greatly improve someone’s apoB levels. Unfortunately, this is rarely reachable.

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.

Heart Health Prevention

Autoimmune Disease and Heart Health

Many individuals live with autoimmune conditions where the body’s immune system engages in an inflammatory response. Autoimmune disease and heart health are related due to this underlying inflammation and the medications prescribed for such conditions.

In this article, we’ll discuss how we address cardiovascular health in our clients who experience autoimmune conditions.

Autoimmune Diseases in Western Medicine

Thanks to advances in lab testing and the development of biologics, many autoimmune conditions that previously were tragic can be managed quite well.

Lupus, Rheumatoid Arthritis (RA), Crohn’s, and Ulcerative Colitis are some medical conditions. Among the most common are Hashimoto’s Thyroiditis and RA, and Type 1 Diabetes Mellitus (T1DM).

Due to the nature of our healthcare system, it’s common to have multiple specialists involved who cannot properly communicate with each other.

The Gastroenterologist is working with the individual on the proper infusion regimen, and the Primary Care doctor is helping coordinate care.

Autoimmune Diseases Affecting Heart Health

This study offers a thorough overview of the increased risk of heart disease in certain autoimmune diseases. The increased risk is listed as a hazard ratio, a statistical lingo where 1 would indicate no increased risk, 2 would indicate double the risk, and 0.5 would be half the risk, and so on.

Inflammation may be at the heart of this relationship, and the goal at Heart Health is to measure and help decrease any potential inflammation in the body.

Since inflammation accelerates atherosclerosis, it’s an important lever to lean on. Always gentle, always wholistically, and always with the individual in mind.

Autoimmune diseases are taxing enough on the person, add to it the fear of heart disease, and only add to inflammation. That is not the point of this article.

Though the risk of heart disease is higher in autoimmune conditions, it’s certainly not a guarantee that any negative consequence will occur.

Improving Cardiovascular Health

Current goal lipid levels are debated constantly by different groups, from the ADA to AHA to CDC. What should your ideal lipid panel look like?

Education and empowerment have been our mantra at Heart Health Coaching since the beginning. We are good at compiling relevant information and empowering our clients to make their own best health decisions.

An individual with Rheumatoid Arthritis who rarely has any flares and is well-managed with a single agent may do well with a low ApoB. In contrast, someone with a more aggressive disease and other autoimmune diseases would benefit from a stricter Heart Health regimen.

We recommend clients measure their inflammatory markers, have lower fasting insulin levels, decrease their visceral fat, adopt a slightly higher-protein diet, and decrease their excess oil/fat intake.

Factors the Client Can Modify

The following factors, directly and indirectly, affect inflammation in the body. Not only does the cardiovascular risk decrease by modifying these factors but so does the autoimmune condition itself.

Adopted from the wonderful book of Integrative Rheumatology.

  • Mind
    • Breathing techniques
    • Reduce reactivity
    • Prayer
    • Creative outlets
    • Laughter and lightheartedness
  • Body
    • High fiber diet
    • High-quality proteins
    • Low-glycemic carbohydrates
    • Healthy fats
    • Supplements
  • Activity
    • Zone 2 training
    • Zone 5 training
    • Resistance training
    • Stretching
    • Meditation
    • Nature exposure
  • Spirit
    • Employment
    • Relationships
    • Purpose, hope, and meaning
  • Treatments
    • Physical manipulations
      • Massage
      • Acupuncture
      • Herbals
      • Topicals
      • Prescription medications
    • Psychotherapy
    • Guided Imagery
    • Eye Movement Desensitization and Reprocessing
Heart Attacks Heart Health

Understanding Atherosclerosis

Atherosclerosis, or plaque, is the process in which the arteries in the body become narrowed. Unstable plaque can sometimes rupture and lead to blood clots which cause a heart attack.

In nerd speak, atherosclerosis is referred to as atherosclerotic cardiovascular disease (ASCVD).

Understanding Plaque and Angina Symptoms

It’s normal for patients to have some plaque buildup in their coronary arteries as they age. Stable plaque rarely causes any medical problems.

The coronary arteries are under a lot of pressure, and their anatomy and blood supply make them a perfect target for plaque buildup.

Combine that with a person’s lack of exercise and stiffness of the arteries, and you can get a condition called angina, an overtreated diagnosis that we’ll discuss in future articles.


Angina is the medical term for heart-related pain. It’s when the heart doesn’t get enough oxygen temporarily when it has extra demand.

When the person stops exercising, or their anxiety level comes down, the heart’s oxygen demand goes down, and enough blood passes through the narrowed coronary arteries, stopping the chest pain.

A Heart Attack from Lack of Oxygen

A heart attack differs from angina in that the heart gets no oxygen whatsoever due to unstable plaque. It also remains starved of oxygen long enough that damage occurs.

If stable plaque is lining a coronary artery and it becomes unstable, it could break off. In its place is left a raw area on which clotting occurs.

This blood clot can grow and completely block off the artery. Without anything to break up the clot or manually open up the artery, that part of the heart muscle will die off.

That’s a heart attack.

Understanding Atherosclerosis & Cholesterol

Cholesterol is what we commonly measure in the blood. The total cholesterol value, for example, tells me how much total cholesterol is floating around in my bloodstream.

LDL cholesterol (LDL-C) tells me how much cholesterol my LDL particle carries.

Triglycerides (Tg) are a different lipoprotein altogether, not cholesterol; though they carry quite a bit of cholesterol. Tg isn’t as important when it comes to understanding atherosclerosis.

Other tests, such as HDL cholesterol and VLDL cholesterol, tell us how much cholesterol those particular proteins carry.

High cholesterol leads to atherosclerosis

The above statement is not fully accurate. Higher apolipoprotein B (apoB) directly increased atherosclerosis.

The cholesterol measurements are just surrogates for this ApoB molecule. For whatever reason, we aren’t accustomed to measuring this in the blood.

The Goal of Treating Atherosclerosis

To understand atherosclerosis, it’s important to realize that apoB is the main molecule that must be managed.

We aren’t trying to lower LDL-C or Triglyceride or raise HDL; none of that! It’s important to understand how those relate to the apoB molecules, but they don’t correlate in some individuals.

Some patients have high cholesterol, and they have no atherosclerosis. Others have low cholesterol and a lot of atherosclerosis.

This isn’t confusing. Remember that the vehicle is the lipoprotein – the apoB – while the passengers are the cholesterol molecules.

When we measure the LDL-C, then we are only told how many passengers exist on the bus. But the bus is what actually causes atherosclerosis.

Measuring Atherosclerosis

We can look for symptoms like angina or signs of limb ischemia which can tell us there is atherosclerosis.

X-rays of the body will sometimes show calcified vessels. This is the calcium deposit inside atherosclerotic arteries.

Coronary CT Angiogram

CT angiograms aren’t the most accurate studies for visualizing coronary arteries. But they have a place in certain populations.

Angiograms visualize the coronary arteries by injecting dye into the coronary artery directly.

Some studies show that a CTA can show high-risk plaque and help us identify those at the highest risk of plaque rupture.

Coronary Calcium Load

Another common test is the coronary artery calcium measurement; often referred to as the CAC score. This also utilizes a CT scan to calculate the amount of calcified plaque in the coronary arteries.

When understanding atherosclerosis, it’s important to point out that in most coronary vessels, calcified plaque makes up about 20% – or the tip of the iceberg – while fibrotic plaque and lipid-rich plaque make up the other 80%.

The most accurate measurement is intravascular ultrasound, but that’s not yet a viable option.

Developing Atherosclerotic Plaques

How do these “atheromatous plaques” develop?

There are many theories, but we know that something inflames the inner endothelial lining of the arteries, making it susceptible to fatty deposits.

The floating LDL particles (different from LDL-Cholesterol) can enter the endothelium. The cholesterol particle might then release and oxidize there, which starts the inflammatory cascade.

HDL particles can extract some of this cholesterol and return it back to the liver. But that process wouldn’t be enough on its own. Which is why raising HDL doesn’t help.

Heart Health

What’s Your ABI? Peripheral Vascular Disease

Knowing your Ankle-Brachial Index (ABI) can not only help you determine your risk of cardiovascular disease but helps you prevent major complications of peripheral vascular disease. What’s your ABI?

Measuring Your ABI

The easiest way to measure your ABI is with a manual blood pressure cuff and a handheld Doppler.

Not all clinics can do this, but any vascular office can do this for you. Many of our patients will perform this themselves if they are at risk for peripheral vascular disease.

Peripheral Vascular Disease

Cardiovascular disease often manifests with atherosclerosis which can lead to calcification and/or hardening of the arteries.

This stiffening of the vessels will often cause the ABI (ankle blood pressure divided by arm blood pressure) to be low and, in some instances, too high.

Stiffening of the arteries in the lower extremities, which is the hallmark of Peripheral Vascular Disease (PVD) can present with weakness in the legs, cramps, or pain.

ABI normal ranges for ankle-brachial index

The ideal ABI is in the 1.0 – 1.4 range. Any value of 1.4 could indicate stiffness of the arteries. If the value is below 0.8, it would indicate blockage of the arteries in the lower extremities.

ABI Testing at Home

The best way to test your ABI at home would be to purchase a manual blood pressure cuff and obtain a handheld Doppler, which measures fetal heart rate.

Both of these are quite inexpensive and you can purchase them online or at most medical supply stores.

Inflate the cuff to make the arterial sound disappear, and release pressure until the sound reappears. This is the systolic reading for both the arm and the leg.

Great ABI Video from Standford

The following video shows how to measure your ABI in the ambulatory (outpatient) setting to determine someone’s risk for PVD.