Henry’s Page

When and Where does Cardiology Drop the Ball

By Henry Seagull, ’71 GS

with Robert V. Carida, Sr., M.D., ‘65P&S

Changing jobs in the Spring of 2006 came with new insurance and a new primary physician. I was not happy when the doctor greeted me with “Ola.” After taking a brief medical history, I was told I would be having an EKG. I objected, saying I had an EKG only three months prior, and never having any heart problems, was declared healthy. The doctor insisted, stating he was now my doctor and he had not seen the past results, adding it would be done quickly right then in his office.

Minutes later, the physician approached me with that dreaded incomprehensible long graph with the jagged lines that only they can read. But he showed me one peak and said, “This should be going down, but it is going up,” and thus taking ownership of my health he moved from “the new physician,” to my new physician.

He asked if I have ever taken a stress test. At 59 years old, I thought that would be a good idea. I am a swimmer, bike rider and daily walker, and breezed through the test. The cardiologist who was monitoring me was busy chatting with other doctors as they passed by with talk of upcoming holiday plans. All of a sudden the doctor did a “double-take” and started waving his colleagues over to observe my monitor. They were all pointing, and grew silent. Finally, I said in my best Vince Lombardi imitation, “What the hell’s going on here?”

He told me with the test ending 12 minutes before, my heart was still racing whereby it should have slowed back to normal  before then. He called an orderly over to arrange a seat for me and oxygen. I was flabbergasted, having still not experienced any symptoms of heart problems! No pains, no shortness of breath, no nothing.

Further tests were ordered from an intervention cardiologist, and I remember being awakened during a catheterization and told, “See all these white lines, they are the arteries that feed your heart? They are all blocked.” I saw these teeny-tiny lines on the monitor and realized that if all the cheesecakes and steaks I have eaten had to run through those teeny arteries, I was a dead fishie for sure: I say that because I enjoy swimming at night, so the cleaning people would find my body floating one morning in the clubhouse pool.

I was told that my bypass surgery was as commonplace as gallbladder surgery, which sounded reassuring; “It’s the germs in the hospital that will kill me,” the surgeon added. I drove myself home in my stick-shift convertible only four days after the quintuple bypass surgery, laughing in disbelief. I was thankful that I quit smoking 6 years before, because after being frozen in order to have my heart stopped and chest cracked open, the hardest part was adjusting to breathing productively after the trauma inflicted on my chest during the surgery. I remember thinking to myself while recovering in the intensive care unit, that I had a new lease on life: no more cheesecake, and no steak, well, only once a week. Five years later, all that changed when I met Robert V. Carida, Sr., M.D., ’65 P&S.

When he introduced himself as a four-board certified preventive cardiologist at a Columbia alumni club meeting in Palm Beach, he laughed loudly when I told him he was too late. (How many cardiologists LOL?) He said no, he was not too late, and went on to explain that based upon my weight and body proportions he could tell I was a candidate for his services, should I be so disposed to avail myself of them. Stocky, yet younger looking than his age, Dr. Carida recommended I receive an advanced lipid analysis.In addition he mentioned there were many others who had been managed by the Internet from as faraway as Chicago and the Northeast. In fact with the help of his smart phone apps, it is possible to manage anyone worldwide despite differences in language.

As recommended, I then went to his website www. Healthiest-Heart.com and discovered that indeed there were others in the same boat as me. One was a 51-year-old Marathon runner who at the age of 33 developed symptomatic coronary heart disease and spent two years as a hospital frequent-flier with multiple interventions including balloons, stents and bypass surgery. It was successful aggressive lipoprotein management that finally arrested his nightmare of symptoms and disease manifestation and allowed him after 15 years to be issued a standard life insurance policy.

Another was a pre Medicare patient on a statin who was warned by his daughter that he could still be developing coronary artery disease unless he was checked with advanced biomarkers and lipoprotein analysis. He pressured his internist into the test but received no treatment because of lack of provider understanding. The patient consulted some cardiologist friends and the answer was the same. Six months later he suffers a heart attack and then needs and receives a coronary stent. He then pressures his interventional cardiologist as to the answer. The answer proved to be in his advanced lipid analysis which showed that he, like myself, had considerable residual risk.

Similarly Dr. Carida related that this gentleman requested that his wife be seen because she had developed a carotid artery plaque. His wife had an extremely high HDL-cholesterol of 109 and previously was told that she was safe, another concept contradicted by her daughter. Sure enough with Dr. Carida’s aggressive lipoprotein management the carotid artery plaque has significantly regressed.

Despite my being on a statin with an over-the-counter niacin and my regular lipid panel near NCEP goals - with total cholesterol of 180 with an LDL cholesterol of 116 - my advanced lipid analyses demonstrated that I was still in the most undesirable 20% of the US population and had an unrecognized hidden risk factor called LPa. Dr. Carida told me that for five years since surgery my arteries had continued to be bathed in high-risk disease-producing lipoproteins that caused me to initially have bypass surgery. By simply adjusting and upgrading my medications, my total cholesterol is now 115 with a LDL cholesterol of 53. More importantly, my LDL particle number went from a high risk of 1704 to a safe 684. My advanced lipoprotein analysis is now at least better than the best 5% and probably in the best 2%. My present medical regimen, for brand medications, costs less than $2.50 per day. If I had received this treatment prior to 2000, it is unlikely that I would have ever needed aorto-coronary bypass surgery.

For the first 25 years of his career, Dr. Carida practiced cardiology as taught in the standard cardiology training programs. Standard cardiology can be summed up as “wait until the patient becomes symptomatic before treating.  After all, we have all these marvelous interventional procedures as well as bypass surgery as a backup.” The unfortunate problem with this approach is that for 30% to 50% of people with heart disease, the first symptom is sudden death(e.g. the late James Gandolfini of HBO’s Soprano fame).

For the last 15 years of his career, Dr. Carida has examined the presence of abnormal disease producing lipoproteins (cholesterol) secondary to the expression of undesirable abnormal lipoprotein generating genes as well as other biomarkers (body indicators of cardiovascular disease in progression). He has discovered that in the vast majority of cases these abnormal lipoproteins can be converted to lesser amounts of the more desirable, healthy ones, simply by adjusting medications based upon sophisticated blood work he orders.  The identification of these abnormal lipoproteins, biomarkers and their biochemistry is the most accurate way of predicting heart attack risk and most strokes being more accurate than expensive imaging modalities such as nuclear stress test, MRIs, CAT scan coronary angiography, which can be superfluous. These expensive procedures should be reserved for the symptomatic or acutely ill individuals.

Since the 1960’s, a time period in our history that has had the greatest mortality rates from cardiovascular disease, there has been virtually no decline per 100,000 population in the incidence of heart attacks.  We have an estimated 800,000 first time heart attacks per year, and an additional 350,000 to 400,000 recurrent heat attacks.  There are more than one million cardiovascular deaths per year, more than 600,000 aorto-coronary bypasses per year, and close to 1.74 million hospital discharges for chest pain due to acute coronary syndrome (ACS).  This disease despite all claims of our progress remains an epidemic.  

Dr. Carida feels that everyone should know their heart attack risk.  Genetics plays a 75% to 90% role while environmental factors contribute less than 10%.  This is why many people who exercise regularly and make healthy food choices still suffer heart attacks.  If a person knew their risk and was able to reduce and maintain that risk to the best 15% of the people in the world who do not suffer from this disease, they would never experience a heart attack.”

Although this preventative approach is not well known, it has been available for more than 13 years.  Certainly this proactive cardiovascular risk reduction approach is less traumatic to the body than current procedures such as coronary interventions and bypass surgeries, and over a lifetime it is also infinitely less costly. 

Proactive treatment tailored to the individual is superior medical care.  Withholding treatment until one becomes symptomatic or events occur is an unfair, possibly immoral, outmoded standard that results in patient’s downward spiraling of the quality of life filled with anxiety, disability, and early risk of death.  This is a not a highly desirable scenario especially considering today’s cardiovascular risk can be predicted by advanced lipoprotein and genetic analyses that can differentiate years before who has high or moderate potential for heart attack.

“Why did my provider or cardiologist not tell me about this?” or “Why isn’t this preventive approach more well- known and utilized?”  The answer is twofold.  Change can be slow both for the provider, especially in a system that profits from interventional treatment and hospitalizations, and a patient who would prefer to defer thinking about unpleasantries or would prefer to allocate their money to more pleasant pursuits.

Currently there are only a relatively small number of physicians with this advanced knowledge and expertise to treat patients.  Of the approximate 16,000 cardiologists in the country there are less than 100 who are well trained in lipoproteinology; less than 50 have demonstrated a minimal competence.

Cardiologists today must possess an aptitude for physiology which requires an understanding of basics physics, i.e. mechanics, fluid dynamics and electrical phenomena. Dr. Carida’s undergraduate major was physics. Tomorrow’s cardiology will require additional expertise in biochemistry and lipoproteinology.

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In the future it will be the responsibility of the individual to maintain healthy cardiovascular life. Proactive cardiovascular risk prevention is the effective and inexpensive solution.

How does partial or inaccurate information affect our beliefs about who is at risk for a heart attack and the choices we have when it comes to making decisions about our cardiovascular health?

First, all us of have an element of self-denial and an unwarranted desire or feeling of invincibility. We have been taught that total cholesterol and LDL cholesterol number determines our risk for a heart attack.

Our cardiovascular destiny is determined not by the absolute value of the level of the total or LDL cholesterol levels in our body but rather the desirable number and composition of lipoprotein particles in our bloodstream and how well the body rids itself of accumulated cholesterol. The desirable and healthy functioning number of lipoproteins are absolutely essential for healthy event-free cardiovascular life. All of the cells within our body should ideally be composed of the properly maintained amounts of lipoproteins as well as proper amounts of hormones.

In general high intra-cellular cholesterol levels cause early cell death (apoptosis), premature aging and premature destruction of all body and vascular cells as well as vascular disturbances such as male sexual impotence. The quality of one’s cardiovascular health depends upon this proper lipoprotein balance, controlled mainly by the expression of our individual genes and to a lesser extent modified by our environment.

What does this proactive cardiovascular risk reduction or interventional lipoproteinology do?  This approach prevents hardening of the arteries and heart attacks and should be initiated years before the disease is allowed to progress to the point of becoming symptomatic.

Except for the noncompliant, uninsured, impoverished and the uninformed, American citizens with regard to cardiovascular disease (hardening of the arteries), live longer today, because they are more cognizant of cardiovascular disease and once they become ill their providers are better at keeping them alive with high-tech procedures,. Nevertheless, once one becomes symptomatic with cardiovascular disease there is, for the vast majority, a most certain decline in the work capacity and quality of life as well as encountering the most expensive medical delivery system in the world.  Never developing cardiovascular disease leads to the best quality of life and is the least expensive for society and the individual. 

While it may be unrealistic to think that a heart attack free life could be achieved for all, it can easily be obtained for 1 to 5% who are proactive, thoughtful, insightful, and motivated.  It is absolutely true that, if done properly, cardiovascular disease for the vast majority is a totally preventable disease. Avoid the fate of James Gandolfini, one of the more famous of Dr. Carida’s undergraduate school alumni. I am sure you have forgotten the demise of Tim Russert, the commentator of Meet the Press . There have been millions of sudden cardiac deaths due to heart attacks in between these two, none of which has raised the level of concern as compared to Gandolfini and Russert.

 “It makes sense to determine your risk for a heart attack and then to do what is necessary to manage your lipoproteins and biomarkers so that you never have an event.” 

In conclusion, as Horace Rumpole would say: despite being in good physical condition, physical exercise placed me on a “shortcut to the cemetery.” I have thus far avoided certain death not once, but twice.  And as far as cardiologists are concerned, “Just when I thought I was out, they pull me back in,” from The Godfather, Part III. I do know that in August of 2012 I went from total cholesterol of 180 to 115 in April 2013, and LDL lipoprotein particles of 1704 to 684.

My prescription: email your contact information to Dr. Carida at cvrusa@gmail.com