Prevent Cardiovascular Diseases

CardioCardiovascular disease is the number one killer of men and women in the United States and is responsible for approximately one million deaths. The focus of our institute is the prevention of heart attack, strokes, and cardiovascular death and also the development of diabetes rnellitus. We aggressively target the risk factors responsible, which includes lipid disorders, hypertension, diabetes mellitus, prediabetes mellitus, cigarette smoking, obesity, and metabolic syndrome. We realized years ago the importance of treating not just the elevated LDL (bad cholesterol) but also raising HDL (good cholesterol) and lowering triglycerides (fats).

Thus, our institute became a pioneer in the San Joaquin Valley in aggressively treating patients with combination lipid affecting therapy thereby correcting all of the abnormal lipid parameters. Our lipid clinic is recognized as a referral clinic throughout Central California. Our commitment to this leadership is exemplified by the fact that both Dr. Nelson and Adela Robinson RN, MN, NP, CLS were the first board-certified lipid specialist in the San Joaquin Valley and both have been elected to the Board of Directors of the Pacific Lipid Association. In addition, Dr. Nelson was a founding member of the Pacific Lipid Association and serves as President-Elect on its board of directors.  Dr. Nelson was also elected in May 2010 to the Board of directors of the NLA.  Dr. Nelson and Adela Robinson were among the first 150 physician and allied health professionals to be awarded Fellow status in the NLA.

Most people are familiar with LDL cholesterol or "bad cholesterol", which is an independent risk factor for heart attack, stroke, and cardiovascular death. However, many people are unaware that low HDL (good cholesterol) and high triglycerides (fats) in your blood are also independent risk factors for heart attack, stroke, and cardiovascular disease. The benefit of statins in safely lowering cardiovascular risk by approximately 35% has been shown in multiple clinical trials. However, many people are not aware of the fact that studies have also shown the benefit of statin in patients with coronary heart disease, multiple risk factors, and diabetes mellitus with cholesterol levels that are not elevated.

Furthermore, HDL and triglycerides appeared to be more important risk factors in women then in men. Over 20 years ago Dr. Gordon published in circulation (1989: volume 79: pages 8-15) from Meta-Analysis of 4 large trials that for every 1 mg/dL increase in HDL plus there was a 2% reduction in coronary heart disease risk in men; however, there was a 3% reduction in coronary heart disease for women. Dr. Hokanson published a Meta-analysis of 17 prospective population studies (journal of cardiovascular risk: 1996: volume 3: Pages 213 to 239) that for every increase of 88 mg/dL of triglycerides, the coronary heart disease risks increased 14% in men and 37% in women. Triglycerides were also found to be an independent risk factor in women in a 14 year follow-up in the Framingham study American General of Cardiology:1992: volume 70: 3H-9H). Thus, this is why it comes as no surprise that if you just treat the "bad" cholesterol, that is you lower the LDL cholesterol with statin you are still leaving the patient with approximately 2/3 of the adverse events which would occur if you fail to treat all of the cardiovascular risks.

Furthermore, studies have shown that the majority of high risk patient's including diabetics with low good cholesterol (HDL) are not being treated with non statin drugs such as Niaspan ER, fibrates or fish oil such as Lovaza. As mentioned the HDL cholesterol is especially important in women patients with diabetes mellitus, and patients with vascular disease such as coronary heart disease. Multiple studies in the patients receiving combination lipid lowering therapy (for example a statin and niacin) have shown marked reduction in cardiovascular disease events and regression of plaque.

For example in the HDL-atherosclerosis treatment study (HATS) (New England Journal of Medicine 2001: volume 345; pages 1583 to 1592) patients with known coronary artery disease with low HDL cholesterol who were treated with both a statin and niacin had an impressive 90% reduction in cardiovascular disease events. Furthermore, these patients underwent repeat coronary arteriography and the patients that receive both niacin and the statin had a reduction in coronary arteriosclerosis whereas the patients receiving placebo had a significant increase in atherosclerosis. In another study demonstrating the power of combination lipid lowering therapy and reducing the incidents of cardiovascular events (Familial Atherosclerosis Treatment Study) the patients that received either niacin plus a bile acid sequestrant or a bile acid sequestrant plus a statin and dramatic reductions of death, heart attack, and stroke of respectively 78% and 66%. Furthermore, even more impressive was during an open label extension of this study over an 8-year period those patients that were on a bile acid sequestrant, statin, and niacin had a 93% reduction in mortality rate.

 

We are now living in an era or an epidemic of prediabetes, diabetes, and metabolic syndrome, Which is being fueled by the parallel epidemic of obesity.  Not only has the California Cardiovascular Institute taken a leadership role in aggressively treating lipid disorders with combination lipid affecting therapy but also in the treatment of prediabetes. Prediabetes is defined as a fasting glucose of 100 to 125 mg/dL (impaired fasting glucose) or a 2-hour glucose tolerance test, glucose level of 140 to 199 mg/dL (impaired glucose tolerance). According to the American Diabetic Association (ADA) 54 million Americans have prediabetes mellitus.

Thus, lifestyle change is front-line therapy to help prevent the development of diabetes mellitus and cardiovascular disease. Patients with prediabetes mellitus need to now they have already lost approximately 40% of their beta cell numbers or function that produce insulin. Also, they are already at increased risk for heart attack and cardiovascular death. Moreover, a high percentage will develop diabetes over the ensuing 10-year period. The risk of a patient with diabetes-mellitus having a heart attack over 7 years (20.2) is approximately the same as a nondiabetic with a prior heart attack having a second heart attack during the same time (18.8%), this is why we consider diabetes mellitus a coronary heart disease equivalent (New England Journal of Medicine 1998; volume 339; pages 229 to 234).

This is also why it is so very important to reduce the development of diabetes mellitus as in that study the patients with diabetes and a history of prior myocardial infarction had a 45% likelihood of having a second heart attack over that 7-year period. Thus, what is your fasting blood glucose? If on repeat testing it is between 100 and 125, you are prediabetic (if it is 126 or more mg/dL you are considered to have diabetes mellitus). Furthermore, if you are prediabetic, you still may be diabetic, and you still may have diabetes mellitus,. Many patients are unaware that there are four definitions of diabetes mellitus, not just a fasting glucose of greater than or equal to 126 mg/dL. The three other definitions for diabetes:

 

Therefore, if you have a fasting glucose of between 100 and 125 mm/dL here at the institute, we will automatically get a 2-hour lucose tolerance test to make sure you do not have the diagnosis of diabetes mellitus by that definition. Finally, as mentioned previously if you do have diabetes mellitus statin therapy is recommended regardless of your cholesterol level.

Metabolic syndrome also known as the Insulin Resistance Syndrome is a growing epidemic in our society, especially among women and is associated with an increased risk not only of developing cardiovascular disease but also of developing diabetes mellitus (circulation 2005; volume 112; pages 3066 to 3072). Metabolic syndrome is defined by having any three of the following characteristics (circulation 2005 volume 112; E285 to E290):

The prevalence of metabolic syndrome from 1994 to 2000 has increased from 23.1% to 26.7% of our population. However, the prevalence in women increased by 23.5% compared to only 2.2% in men (diabetes care; volume 27: pages 2444 to 2449; 2004). The increases in high blood pressure, waist conference, and high triglycerides in the blood accounted for much of the increase in the metabolic syndrome for women.Now you can see how the epidemic of obesity is driving the insulin resistance syndromes including metabolic syndrome and diabetes mellitus, which is contributing to the development of atherosclerosis and ultimately in many patients resulting in stroke, heart attack, and cardiovascular death.

Furthermore, type 2 diabetes mellitus as a growing epidemic is now estimated to affect 19.3 million Americans (diabetes care volumes 29; pages 1263 to 1268; 2006). The dual defect of type 2 diabetes mellitus is characterized by insulin resistance and beta cell dysfunction. The lipid abnormalities, diabetic dyslipidemia is characterized by low HDL cholesterol, elevated triglycerides, and small dense LDL, all of which are associated with an increased risk of cardiovascular disease and adverse cardiovascular events. Thus, the treatment of diabetes should not only focus on the improvement of glucose control and improvement in the beta cell function, but also to reduce insulin resistance and correct the lipid disorder. Pioglitazone (Actos) has been shown to not only improve insulin sensitivity, but also to reduce insulin resistance, improve diabetic dyslipidemia (lower triglycerides, raise HDL cholesterol, and lower small dense LDL) and has been shown to reduce the progression of atherosclerosis not only in the carotid arteries (JAMA: volume 296: 2572 to 2581: 2006) but also in coronary arteries (JAMA, volume 299: pages 1561 to 1573: 2008). Thus, as you can see, it also comes as no surprise in a recent study by Dr. Davidson published this year and Circulation (Circulation 2008 volume 117; 2123 to 2130) that the increase in the HDL in these patients with type 2 diabetes mellitus by Pioglitazone is what predicted the reduction of the atherosclerosis in the study, which measured the atherosclerosis in the carotid arteries.

In conclusion, at the Institute we strive to bring all lipid values to within our goals of reducing cardiovascular risk. Our practical expertise has been gleaned from the daily management of thousands of patients with complex lipid disorders over many years and our desire to continue to be a pioneer and at the forefront of the most recent advances in lipid-altering therapy.

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