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Thursday, May 24 2018

New advances in cardiac risk assessments

Most people who get their annual physical nervously await the result of their cholesterol levels.  We have been conditioned by the mass media that high cholesterol is the gold standard for predicting risk for cardiovascular events such as a heart attack or a stroke.  However, most people would be surprised that50% of people who have a heart attack have normal cholesterol levels.  Conversely, there are many who have high cholesterol who live out their lives without any cardiac episode. 


Many cardiologists also use EKG’s, stress tests and angiograms to assess overall risk. These are useful, and we shouldn’t ignore the cholesterol markers either, but a coronary artery must narrow by 60% to show as a problem on a stress test and angiograms are invasive and very expensive (4,000.00).  Here are some newer techniques and tests that someone should consider if they or someone they love is concerned with their heart health or if a doctor has recommended taking a statin drug. 


CT Coronary Artery Calcium Score

Computerized tomography is an x-ray technique to view the coronary arteries of the heart.  These arteries can become clogged or develop plaque that can break free and cause a stroke.  This plaque is also referred to as atherosclerosis or hardening of the arteries.  Its consistency can be hard due to calcium build up in the artery, or it can be softer from the waxy buildup of cholesterol.  If the artery has calcium deposited inside it, the CT scan will be able to see it.  The CT coronary artery calcium score is a detailed picture of all the arteries of the heart and the calcium deposits lining those coronary arteries.  It takes about 5 minutes, and a score is made assessing risk like below:

0-10 = normal

11-99 = mild disease

100-399 = moderate disease

400 and above = obstructive atherosclerosis


The Journal of the American College of Cardiology published a study by Dr. Harlan M. Krumholz and Dr. Khurram Nasir on using CT coronary artery calcium scores. They studied nearly 4000 multi-ethnic men and women aged 45-84 and found that those with calcium scores of zero had a reduced risk for a heart attack.  Half of the people, some with high risk factors had no calcium visible on the scans and they were followed for 10 years.  Dr. Krumholz said “Maybe this is a tool to actually do less”.  Because current guidelines have vastly increased the number of people who are eligible to take statins, Dr. Nasir reasoned that this technology could identify lower risk individuals with high cholesterol who could avoid statins and give them some measure of ease about their risk for a heart attack


University Radiology in Somerset offers the test and they only charge 99.00 for it. 





Blood tests

There are important markers other than just cholesterol and triglycerides to check.  The NMR Lipoprotein Profile test is something to consider.  This test includes vascular inflammation markerssuch as:

Homocysteine: A naturally occurring amino acid produced as part of the body’s methylation process. When elevated it is indicative of a B12, folic acid, or B6 deficiency

C-Reactive Protein: Is an inflammatory marker.  It is best to see this at a level under .5 even though many labs will report it as elevated only when above 5.0.

ApoB-100: Is an inflammatory marker that is involved with metabolism of lipids. It is a form of cholesterol that is associated with familial hypercholesterolemia. 

Lp(a) Lipoprotein (a), is a particle that carries cholesterol.  It is a genetic risk factor.


The NMR test also tests particle number and the size such as:


and clotting factor tests such as:

Plasminogen: Is synthesized in the liver and is the precursor to plasmin which dissolves clots. 


The PULS cardiac test

The PULS test (protein unstable lesion signature), is a new test developed by GD Biosciences and Cleveland Heart Labs. The test has markers that signals damage is actively occurring within the artery.  The data so far shows that the PULS Cardiac Test CADPA (coronary artery disease predictive algorithm) has been able to reclassify patients risk better than the mFRS (Framingham Risk Score), the previous standard of risk assessment. 


Omega Check:  Check levels of omega 3 and omega 6 fatty acids.

Adiponectin: Helps support proper endothelial functioning mainly by inhibiting macrophages forming foam cells, one of the first steps of atherosclerosis.

OxLDL: Is a marker for oxidized cholesterol.  Oxidized cholesterol is more likely to damage the inner lining (endothelium) of the arterial wall.

ADMA/SDMA: Are markers for endothelial damage due to the loss of nitric oxide which is protective of the endothelium.

Lp-PLA2: Is a measure of the active build-up of cholesterol inside the artery walls.

MPO: (Myeloperoxidase), is a measure of the body’s response to a damaged endothelium that has become thin, cracked, and unstable. 

Microalbuminin: (a urine test) Is a protein found in the blood but not the urine.  If even a small amount of microalbuminin is in the urine, then you may have damage to the endothelium of the kidney.  It is usually elevated with high sugar and high blood pressure.   

F2-IsoPs: These compounds are formed from arachidonic acid, cause the blood vessels to constrict which could result in elevating blood pressure.

TMAO: When animal products are digested various metabolites including TMA (trimethylamine) are released into the blood.  In the liver it becomes TMAO (trimethylamine N-oxide), which is involved in the development of atherosclerosis.



The CT coronary artery score is an inexpensive, underutilized diagnostic method of determining cardiac risk.  For those with a high score showing calcium buildup it would probably indicate a low vitamin K2 level in the body.  I wrote about this in a previous newsletter.  It is probably not an indicator of a need for a statin drug, but that is something everyone must decide for themselves.  It may not even be an indicator for having an occluded coronary artery.  However, a high score would be an indicator for additional testing such as some of the blood work mentioned above, a stress test or even an angiogram.  Keep in mind that some calcification is common.  CT scans of Egyptian mummies have shown calcification of coronary arteries even in times of antiquity. The downside is, if the plaque is not calcified, the CT scan cannot see it. 

On the other hand, blood tests like the NMR lipoprotein particle profile and PULS cardiac test could indicate risk factors from a poor lifestyle resulting in an inflammatory build-up of atherosclerotic endothelial damaged tissue. 


A high cholesterol reading, along with other risk factors such as elevated blood pressure, family history, physical inactivity, obesity, diabetes or prediabetes, and smoking should be equally factored in to the equation of heart health.  Relying only on a total cholesterol score should no longer be held as a complete barometer for heart health, or the prescribing of statins, especially now that we have the technology described above.


I’m currently working on getting The PULS cardiac test for you to get tested here. If you want to be notified, click here.

Posted by: Dr Goldstein AT 08:09 am   |  Permalink   |  0 Comments  |  Email

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