This is the first in a series of articles to explain how I diagnose and treat lipid disorders. If you, or a loved one has a stent, bypass, heart attack, or stroke, I encourage you to study these articles, so you can `understand these new concepts. It's no longer as simple as just 1 or 2 numbers. In fact, total cholesterol and calculated LDL's will miss 80% of lipid problems.

LDL (bad cholesterol), HDL (good cholesterol), and triglycerides (fat) are the major components of total cholesterol. Thirty years ago, Dr. Friedewald proposed that we use the equation: Total cholesterol = LDL + HDL + (triglycerides ÷ 5). Rearranging the equation, Dr. Friedewald said we could estimate “calculated LDL” = Total Cholesterol - HDL – (triglycerides ÷ 5). At that time, direct measurement of LDL was not practicable, but now direct LDL can be directly measured without fasting, and it's more accurate.

This article will discuss the advantage of using direct LDL measurements rather than calculated LDL estimates. The direct LDL is more accurate and it does not require fasting. For this article I did a Fasting Lipid Panel at FPH and sent matched specimens, drawn at the same time, on myself, to 3 lipid specialty laboratories that I use: VAP, ALP, and Berkeley HeartLab.

The VAP is the Vertical Automatic Profile (sent to Atlanta ). The ALP is the Advanced Lipid Panel (sent to Springfield , Illinois ). The Berkeley HeartLab panel is the commercial gold standard, both in terms of accuracy and cost (sent to Alameda , California ). I encourage patients to do these Monday, Tuesday, or Wednesday (so that if Fed-Ex is late, the frozen specimen can be run before Friday afternoon).

The total cholesterol was very similar in the four labs: 162, 163,165, and 169. No clinical decisions are made on total cholesterol but many people still want to know what it is. You don't really need it, except to do the math to calculate the LDL.

Adult Treatment Panel III (ATP III) guidelines designate LDL cholesterol as the primary target for diet and lipid lowering medications. The calculated LDL at Foothill Presbyterian Hospital (FPH) was 93 (all lipid values reported are mg/dL). The calculated LDL was lower than the direct LDL: 104, 97, 96. This leads to under-treatment whenever patients are treated according to falsely low calculated LDLs. For most patients, target LDL is less than 100.

I gave myself a very sugar rich lunch after my fasting lipid panel - a glazed donut from Big Dan's Donut Shop next to my office and a Chantico chocolate drink from Starbucks up the street. The VAP direct LDL cholesterol did not change: 104 and 102. I now believe that a direct LDL measurement can be done without fasting.

Most physicians have learned that it is easy to treat elevated LDL with statins (Lipitor, Zocor, Crestor, Pravachol, or Mevacor), and cholesterol absorption inhibitors (Zetia) or the combination of these (Vytorin), along with low-saturated fat and low-cholesterol diet. This decreases risk of heart attack and stroke by 30%.

The next several articles will show ways to prevent 80-90% of recurrent heart attacks and strokes. They will discuss a low-carbohydrate diet for elevated triglycerides, diabetic diet for diabetic patients or insulin resistant/metabolic syndrome patients, fish oil for elevated triglycerides, fibrates (like TriCor) for triglycerides, and Niaspan for low HDL 2b, elevated Lipoprotein (a), or pattern B LDL cholesterol.

Choosing the right lab and test is important to balance cost and accuracy with benefit. The VAP, Lipid Analysis, and Berkeley HeartLab extended lipid panels are available at Foothill Presbyterian Hospital . VAP is available at all Quest/Unilab laboratories. The VAP is $51; direct LDL is available at Berkeley HeartLabs for $30; and at Advanced Lipids for $131.

Additional information is available in Robert Superko's (2003) Before the Heart Attacks or at

www.the VAPtest.com

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This is a technical article, but if I treat you for heart attack, stroke, arterial disease, or if you¡¦ve had a stent or a bypass you should read this and learn about direct LDL, HDL 2b, Pattern B LDL, Lipoprotein (a), c-Reactive protein, and homocysteine.

The VAP is the vertical automatic profile. The ALP is the Advanced Lipid Panel. The Berkeley HeartLab panel is the commercial gold standard, both in terms of accuracy and cost.

Triglycerides are designated as secondary targets by the ATP III. Triglycerides were similar at all labs: 52, 57, and 60, (not requested from Berkeley).

I was most interested in the HDL 2b (the most protective form of HDL). The direct HDL ¡V 2b was only available at Berkeley. HDL 2 was calculated to be 11 and 9 on the VAP and ALP. HDL 2b was 14.5 (23% of total HDL 62, at Berkeley HeartLab). Thus, on the VAP and ALP, my HDL result was estimated to be a little low but on the Berkeley lab it was directly measured to be just above target This means the test is worth the $180.

I used the CRP, homocysteine, and lipoprotein (a) in my risk assessment, and recommend more aggressive treatment for patients with CRP above 3.0 mg/L, as well as treating all patients with elevated homocysteines and lipoprotein (a), although the evidence that this decreases strokes and heart attacks is still preliminary.

All laboratories had a similar high sensitive C-reactive protein value, in the average risk of 1.0-3.0 mg/L category of the American Heart Association. The homocysteines were in a fairly close range 8, 10.6, and 13.6 ƒÝmol/l. Since two values were in the mildly increased risk category above 10, I have started Folgard Rx 2.2 mg (folic acid 2.2 mg, B6 100 mg, and B12 1 mg). Lipoprotein (a) was low on all three extended lipid panels.

The VAP, Lipid Analysis, and BerkeleyHeartLab extended lipid panels are available at Foothill Presbyterian Hospital. VAP is available at all Quest/Unilab laboratories. VAP is only $51, excluding homocysteine and C-reactive protein.

Additional information is available in Robert Superko¡¦s (2003) Before the Heart Attacks or at
www.theVAP test.com.
Neil E. Doherty III, M.D., F.A.C.C.

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Find out what your HDL2b is and you might prevent a heart attack or stroke. Low HDL2b is under diagnosed. I think the reasons are because it requires sending blood out, and is not emphasized in the ATP III guidelines. Increasing HDL2b can decrease heart attacks and strokes 20-30%.

What is HDL2b?

HDL is the “good cholesterol.” HDL is present as five distinct subtypes in your circulation: HDL2a, HDL2b (the “best” cholesterol), HDL2c, HDL3a, and HDL3b. Cardio protection from the HDL is mainly from the HDL2b subfraction. Unfortunately, the fasting lipid panel that is commonly checked measures total HDL but does not measure HDL2b.

Your doctor can order total HDL and percent HDL2b from Berkeley Heart Labs, phone #877-454-7437. The next best test would be a calculated HDL2 from Advanced Lipids or the VAP. This is calculated as Total HDL minus HDL3.

I checked extended lipid panels in 65 patients from my Cholesterol Clinic in the last two months. 55% (36 of 65) patients had low HDL2b or HDL2 versus 25% (16 of 65) on routine fasting lipid panels.

In 18 of 20 sent to Berkeley Heart Labs, the HDL2b was less than Berkeley Heart Labs desirable level, which is above 20% in men and above 30% in women. I found 18 other patients with low calculated HDL2 on Advanced Lipid Panel or the VAP test. The correlation between low HDL2b% on Berkeley Heart Lab and low calculated HDL2 on the VAP was good. There were only two borderline patients with VAP calculated HDL of 10 (desirable above 15) who had HDL2b below desirable level 20%.

Who gets low HDL2b?

This is inherited. HDL2b is lowered by gaining weight, smoking or chewing tobacco. Hypothyroidism, diabetes, and insulin resistance/metabolic syndrome can cause low HDL2b. Hydrochlorothiazide, furosemide, and inderal or other nonselective beta-blockers can also make HDL2b lower. Do not stop medications without doctor’s orders.

How can HDL2b get raised?

All patients with HDL2b should exercise and lose abdominal fat. Aerobic activity up to one hour per day will help raise HDL2b. As little as 5-10 pounds weight loss will lead to a noticeable increase in HDL2b.

If not contraindicated, a little alcohol, such as four ounces of wine, may help raise HDL2b. This may be why drinkers have longer lifespans. Alcohol, however, is harmful in people with alcoholism or cirrhosis.

What medicines can raise HDL2b?

Niacin 1-2 g per day will raise HDL2b by as much as 40%. I prescribe Niaspan 500 mg tablets at bedtime starting with one tablet, increasing to two tablets after four weeks. I monitor for flushing, increase in glucose level, especially in diabetics, gout, stomach or intestinal bleeding. We have a handout, which we are happy to distribute to doctors, and KOS has a nurse available by phone, 1-888-564-2772, 24 hours per day, seven days per week for questions and side effects.

Immediate-release niacin can be taken tree times per day. Good manufacturers are: SQUIBB, (who make 100 and 500 mg tablets), Goldline, Bugby and Twin Labs.

Very extended release niacin causes more liver problems and should not be used. “No flush” niacin does not raise HDL2b. Small doses of niacin 50-100 mg do not increase HDL2b.

In diabetics, Avandia 15-45 mg (Rosiglitizone) raises HDL2b.

What about statins?

Some studies suggest HDL2b loses its protective effect when LDL is less than 80 mg/dL. LDL is decreased by statins and Zetia.

Statins may increase HDL2b 3-10%. Crestor and Zocor may increase HDL2b more than Mevacor, Pravachol, Lipitor, or Lescol. Zetia may lower HDL2b.

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Triglycerides are fat. Triglycerides in your blood increase the risk of heart attack and stroke.

How do you know if you have high triglycerides?

The fasting lipid panel is an accurate measurement of triglycerides. Fat goes up quickly when you eat, then comes down slowly, so the lowest measurements, which are the ones we use, are after fasting 12 hours.

Who should have treatments to lower triglycerides?

If two consecutive triglyceride measurements are above 150 mg/dL, then we recommend treatment. In borderline cases, if VLDL cholesterol (very low density lipoproteins) is elevated, this usually means that there is persistent elevation of triglycerides, and there should be treatment to lower it.

What are the results of triglycerides from different laboratories?

Triglycerides drawn at the same time and sent to different labs are the same value, within 2%, in my survey.

When is it useful to check a VLDL?

We looked at 104 patients and concluded it is useful to check VLDL when triglycerides are borderline, i.e., 150-200 mg/dl.

How do you lower triglycerides?

Most people are able to lower triglycerides to healthy target levels with a doctors help.

There are 6 ways to lower triglycerides. L osing abdominal fat is the most enduring way to lower triglycerides. Exercise lowers triglycerides. Fish oil, 1-6 g per day, lowers triglyceride and decreases sudden cardiac death. Fibrates, such as TriCor 145 mg per day, lower triglycerides. Niacin, 500-1500 mg/day, lowers triglycerides. Statins, especially, Lipitor, also lower triglycerides.

Dr. Neil Doherty is available at Citrus Valley Cardiology Medical Group, at 353 West Foothill Boulevard, in the heart of Glendora . Please call 626-857-7344 to make an appointment for a lipid consultation, such as high triglycerides, or cardiology questions. Medicare and most PPOs are accepted.

Note: Thank you to Andrew Young, Western University Medical Student, for data analysis on triglycerides and VLDL in 106 patients.

He found 7 of 18 patients with mildly elevated triglycerides, 150-200, had high VLDL above 29 mg/dl on VAP. Triglycerides less than 150 rarely had high VLDL. Triglycerides over 200 always had high VLDL.

Neil E. Doherty III, M.D., F.A.C.C.

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What is Lipoprotein (a)?

Lipoprotein(a) is a kind of LDL with an abnormal protein attached to it, which is like fibrinogen. The LDL particle causes cholesterol plaques in arteries. The fibrinogen-like protein increases blood clots. The result is that Lp(a) increases the risk of heart attacks and stroke by 400%, which makes it a very dangerous lipoprotein.

What is the incidence of elevated Lp(a)?

Andrew Young, medical student at Western University , determined that 33% of patients in our Cholesterol Clinic have elevated Lp(a) (52/158 patients).

How do you measure Lipoprotein(a)?

Lp(a) can be ordered on labs at Foothill Presbyterian Hospital or at specialty labs, including: the VAP, Advanced Lipid Panel, and Berkeley HeartLabs.

Elevated Lipoprotein(a) inherited!

Yes. Lp (a) is inherited, autosomal dominant, which means that if either parent has it, then their child has a 50% chance of inheriting the disorder.

Who should get Lipoprotein(a) checked?

I recommend checking Lp(a) in all family members of people who have elevated Lp(a). People with a family history of early heart attacks or strokes, including men below the age of 50 and woman below the age of 60, are at risk, and should also check Lp(a).

How can you lower Lipoprotein(a)?

Niacin is the only treatment that lowers Lp(a). Exercise and diet do not affect Lp(a). There are no other medications that lower Lp(a)

What is Niaspan?

Niaspan is a slow release niacin, which has been extensively tested, and approved by the FDA. It is better tolerated than immediate release niacin with fewer side effects and less flushing. I begin people on Niaspan 500 mg one tablet at bedtime and after four weeks increase this to two tablets at bedtime. The FDA has limited peak dose of Niaspan to 2000 mg daily.

What about immediate release Niacin?

Crystalline pure immediate-release niacin, can be taken as 100 mg or 500 mg tablets, three times per day, but has not been tested by the FDA. It is produced by Squibb, TwinLab, Rugby , and Goldline.

What other beneficial effects does Niacin have?

Niacin increases HDL2b 15-40% by slowing the rate at which it degrades. Niacin decreases the production of LDL and will lower LDL 15-20%. It lowers triglycerides 10-40% by increasing activity of lipoprotein lipase. Niacin decreases fibrinogen levels and lowers hs-CRP. These effects are dose dependent, so bigger doses cause bigger changes. Some patients take up to 1-2 g immediate release Niacin three times daily.

How can patients avoid flushing with Niacin?

Skin flushing and hot flashes are common with niacin, including Niaspan. Flushing with niacin can be limited by taking it with aspirin, food, or psyllium (Metamucil). You can decrease the risk of flushing by avoiding Chinese foods (loaded with MSG), alcohol, caffeine, hot beverages and hot baths or showers, which are all vasodilators. When flushing occurs, it can be diminished by putting a St. Joseph 's flavored baby aspirin under the tongue, which is rapidly absorbed, and immediately inhibits the prostaglandins that cause flushing.

What are the other side effects of Niacin?

People with elevated uric acid may get gout, so we check uric acid before beginning people on Niaspan. Gout can be prevented by prescribing allopurinol.

Niacin raises homocysteine levels in 40% of patients which is another risk factor for coronary artery disease. We treat elevated homocysteines with folic acid plus B6, and B12 prescribed as Folgard Rx 2.2 or FOLTX tablets.

Niacin may raise blood sugar. Niaspan has been approved by the FDA and has been tested to be safe in diabetics up to 1000 mg nightly.

High doses of niacin may cause liver inflammation, so we check liver enzymes in patients on niacin. This was first reported with 24 hour extended release niacin. It is rare with Niaspan and the crystalline pure immediate release niacin products that I mentioned.

The Cholesterol Clinic celebrated it's 11 th year of operation in June 2005, treating all lipid disorders including: elevated total cholesterol, LDL, Pattern B, HDL, Triglycerides, Lipoprotein(a), Metabolic Syndrome, Diabetes related problems, C Reactive Protein, Homocysteine, and side effects of statins (Lipitor, Zocor, etc.), Niaspan, and short acting Niacins. The phone number for appointments is (626) 857-7344, extension 0.

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There are seven subspecies of LDL, with different sizes and densities. When there is a predominance of small dense LDL, this is called pattern B. Researches at Berkeley Heart Labs showed that this greatly increases the risk of coronary artery disease.

Small LDL, or pattern B, is an independent risk factor for coronary heart disease, which can triple the risk of heart attacks and strokes. 50% of men and 30% of premenopausal women with coronary artery disease have small LDL. These people are often overweight, diabetic, and often have high triglycerides and low HDL. The size of the LDL is genetically determined. The small LDL particles can cause big damage.

The patients who have more small dense LDL and have coronary artery disease progress much more quickly.

The major problems with pattern B LDL is an increase in the IIIa, IIIb LDL particles. Some times there is also an increase in IVb, very small particles, which increase plaque instability.

How should pattern B be treated ?

I would like to grow slowly the total LDL and try to shift these small particles to big particles, i.e., change pattern B to pattern A.

Exercise decreases LDL pattern B, especially endurance exercise, which we prescribed at 210 minutes per week, in 30-70 minute increments. This burns 1500 calories per week, which helps lower weight. Decreasing abdominal fat helps to change pattern B to pattern A.

Niacin converts small LDL particles into large or less atherogenic, less dangerous, LDL particles.

Statins (Lipitor, Zocor, Pravachol, Lescol, and Crestor), decreases total number of LDL particles, but does not change in particle size. Resins such as Welchol, decreases total number of LDL particles. Ezetimibe (Zetia), may lower LDL 18%, and when combined with statin may lower LDL particles by 60%.

LDL particle size may be 220-257.4 angstroms equal small, 257.5-263.4 and to equal intermediate, and 263-295 angstroms equal large fluffy LDL.

Dietary recommendations, in addition to lowering dietary cholesterol, is to decrease saturated fat and trans fats. Major sources of saturated fat and diet include beef, pork, lamb, and chicken, dairy products, especially whole milk, ice cream, butter, and also cocoa butter, palm kernel, and coconut oil. We would suggest people to trim all these above fats from meat, do not eat skin, and choose white breast meat.

Major sources of trans fats are vegetable shortening, stick margarine, hydrogenated peanut oil (any time it does not separate when left to stand in) pies, cakes, cookies, pastries, donuts, potato chips, and fast foods.

Neil E. Doherty III, M.D., F.A.C.C.

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By Neil E. Doherty III, M.D., F.A.C.C.

If you have been taking a combination of folic acid, B-6, and B-12, (like Folgard or Foltx), in the hope that it would stop you from having a heart attack or stroke, it is time to stop taking that pill.

“This is the latest in a series of things that when tested in a scientific way do not actually pan out the way people expected,” said Dr. Ray Gibbins, Professor of Medicine at the Mayo Clinic. Beta-carotene, vitamin E, and hormone replacement therapy have also been disappointing when tested clinically in recent years.

NORVIT, the Nor wegian V itamin T rial, the first large study to test folic acid and vitamin B-6 supplementation, was presented Monday September 05, 2005, at the European Society of Cardiology. The research has found that although supplements with 0.8 mg/day of folic acid and/or 40 mg/day of vitamin B-6 lowered homocysteine levels 28%, they offered no protection against heart attack or stroke.

The results are graphed below from the October 1, 2005 article in the Cardiovascular Medicine section of Internal Medicine News , page 60.

GRAPH

Heart attack or stroke occurred in 18% of the placebo (sugar pill) and a similar percentage of those who got folic acid or B-6 alone. However, there was a 20% higher incidence of heart attack or stroke in patients given folic acid and B-6 together. This was statistically significant, meaning that there was less than a 5%, or 1 in 20 possibility that the difference seen was a result of random chance or accident. There was a 30% increase in cancer in patients receiving folic acid. This was not statistically significant, so it might be a chance result.

This study may be refuted because of NORVIT's complex 2X2 factorial design. The study was underpowered to firmly conclude that folic acid and B vitamin therapy was without benefit or indeed harmful. Underpowered is a statistical term that means that the study did not have enough events to detect differences that truly exist.

Twelve more studies will finish in the next few years and more information will be available. Meanwhile, despite finding in our cholesterol clinic that homocysteine levels are above normal in 80% of patients with heart disease, it is probably best to put away the folic acid, B-6, and B-12. Homocysteine is probably an innocent bystander and not a cause of heart attacks and strokes.

Neil E. Doherty III, M.D., F.A.C.C.
NED/ja/jr

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Combination Blood Pressure Therapy April 2006

I would like to discuss combination blood pressure medications after having heard about former Nortre Dame and Pro Football Hall of Fame quarterback Joe Montana’s experience with high blood pressure. Montana is a spokesperson for the BP Success Zone program, an educational campaign sponsored by Novartis Pharmaceuticals Corporation, which has helped Montana make lifestyle changes and work with his doctor to get better control of his blood pressure. Montana has successfully kept his blood pressure under control for nearly three years with a combination medication called Lotrel. Now Montana is motivating others with high blood pressure to do the same.

As a cardiologist, I treat more patients for blood pressure than for any other problem. High blood pressure contributes to so many heart ailments that I attend to it on most of my patients. Last year I saw 43 new patients primarily for high blood pressure.

We found in ALLHAT, which was a national study, for which I directed the San Gabriel Valley Center, that good blood pressure control usually requires more than two medications. Because of this finding, the Joint National Committee 7 (JNC7) recommended in 2003 that we start using more combination pills, which have two medications included in one pill.

Efficacy is achieved by combining drugs, which act by dissimilar mechanisms to produce additive effects on blood pressure reduction. Fixed dose combinations are also less expensive, and sometimes have fewer side effects.

Lotrel:

Lotrel is a combination of amlodipine (a calcium channel blocker) and benazepril hydrochlorothiazide (an ACE inhibitor).

A multicenter trial randomized 308 patients with entry diastolic blood pressure between 100 and 120 mm Hg. In patients older than 65 years, combination amlodipine/benazepril 5/20 mg decreased diastolic blood pressure 17 mm Hg. (Kuschnir et al. Clin Ther 1996; 18: 1213-1224).

Side effects include: cough 2% and dry cough in 3%.

Tarka:

Another combination pill that I prescribe is Tarka.

This is a combination of verapamil SR (a calcium channel blocker) & trandolopril (an ACE inhibitor).

Two hundred and fifty-four older patients with diastolic blood pressure 95-115 mm Hg were treated with 120/0.5 mg verapamil SR/trandolapril once daily and titrated to 180/2 mg verapamil SR/trandolapril at four-week intervals. Average blood pressure was reduced 22/17 mm Hg. (Holzgreve H, et.al. J Hum Hypertens 1999; 13: 61-67).

Side effects include constipation in 3% of patients and bradycardia (slow heart rate) in 2%.

Diuretics Plus ACE Inhibitors or ARBs:

There are seven angiotensin receptor blockers and diuretics on the United States market, including Diovan-HCT and Micardis-HCT. These reduce kidney problems in diabetics. There are eight angiotensin converting enzyme inhibitors plus diuretics, including: Lotensin-HCT, and Vaseretic.

Diuretics Plus Beta Blockers:

There are six beta-blocker plus diuretic fixed dose combinations, including: Lopressor-HCT and Ziac.

Figure for Heart To Heart:

Algorithm for Hypertension treatment, adapted from JNC7.

Information for this article from: Prisant LM and Mulloy LJ. Combination Drug Therapy. Chapter 20 in Hypertension in the Elderly (2005) and drug package inserts.

Dr. Neil E. Doherty is available at Citrus Valley Cardiology Medical Group, located at 353 West Foothill Boulevard, in the heart of Glendora. Please call 626-857-7344, extension 02 to make an appointment to treat your blood pressure.

Neil E. Doherty III, M.D., F.A.C.C.

NED/ja/man

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by Neil E. Doherty, M.D., F.A.C.C.

This month, I thought I would address the issue of diet and heart disease. We generally give our standard American Heart Association step 2 diet, which recommends less than 30% of calories from fat, with less than 10% of calories from saturated fat. This is less than 10 grams saturated fat per day, and less than 200 mg dietary cholesterol. While this is a good, general recommendation, I would like to give several new recommendations based on several good research trials on dietary interventions and reduction of coronary events.

First, it is important to achieve ideal weight, and to decrease excess body fat by exercising daily and eating the proper amount of calories, regardless of how many proteins, carbohydrates, and different fats that you eat.

Second, it is very important to decrease saturated fats. Saturated fats increase LDL cholesterol, whereas polyunsaturated and monounsaturated fats decrease LDL cholesterol. Saturated fats, monounsaturated fats, and polyunsaturated fats, each increase HDL cholesterol 3-4%. Hence, replacement of saturated fats with polyunsaturated fats and monounsaturated fats will reduce LDL cholesterol and increase HDL cholesterol.

In contrast, replacing saturated fats with carbohydrates reduces both LDL cholesterol and HDL cholesterol and increases triglycerides, and overall has minimal benefit on coronary heart disease risk. This is why many people who substitute high fat foods with high carbohydrate foods don’t improve their lipid profile.

Several metabolic studies have shown that trans-fatty acids (processed foods) raise bad LDL cholesterol, lower HDL cholesterol, and increase triglycerides, so that hydrogenated processed foods with trans-fatty acids, and many fried fast foods, clog coronary arteries. Additionally, trans-fatty acids may increase the risk of diabetes.

Fish twice per week or fish oil (1.5 grams per day) may reduce coronary artery heart disease 16-30%. The Omega three fatty-acids that they contain lower serum triglyceride, decrease blood clotting, and prevent cardiac arrhythmias.

People with elevated homocysteine have increased coronary artery disease, heart attacks, and strokes. Folic acid lowers homocysteine. Diets with green leafy vegetables will provide folic acid. Many foods, like cereals, are fortified with folate. Supplementation with folic acid 0.4-1.0 mg and B6 and B12 pills are an alternative.

Replacement of red meat with chicken and fish is a good dietary change.

A daily intake of nuts is good because the predominate fat in nuts are monounsaturated and polyunsaturated, which lower LDL cholesterol. Prevention Magazine suggests a shot glass (1 ounce) of nuts daily.

Fruits and vegetables, particularly green leafy vegetables and vitamin C rich fruits are generally thought to be good.

Consumption of whole grains, rather than processed breads, improves the lipid profile.

The common diet that we often see in people having coronary artery heart disease
when first coming to our cholesterol clinic has too many red and processed meats, sweets, desserts, potatoes, french fries (trans-fatty acids), and refined grains.

A “prudent” diet is characterized by higher intakes of fruits, vegetables, legumes, whole grains, poultry, and fish. In the Indian heart study, patients who consumed a diet with high intake of fruits, vegetables, nuts, and fish, had a 40% reduction in coronary artery disease, 41% reduction in cardiac death, and 38% reduction of non-fatal MI.

The DASH trial (Dietary Approaches to Stop Hypertension trials) also supports the use of diet high in fruits, vegetables, and low-fat dairy foods, to lower blood pressure. Detailed facts about the “DASH Eating Plan” can be accessed at the National Heart, Lung, and Blood Institute’s site at www.nhlbi.nih.gov/indes.htm. For additional information, access the “Heart Center Online” website located at www.heartcenteronline.com.

The amount of protein that is good to have in a diet is debatable. Substitution of soy for animal proteins reduces the LDL cholesterol.

Plant Stanols are similar in form to cholesterol. The body processes stanols as if they were cholesterol by absorbing them rather than cholesterol. Research shows that consuming 2 to 3 grams per day of plant stanols can decrease total cholesterol and LDL cholesterol levels by as much a 9-20%. Consuming more than 2 to 3 grams per day does not offer additional benefit. These foods have been used for many years in Finland and other countries and appear to be very safe. These supplements are in a lite spread containing plant stanols or plant sterols and are recommended for patients with high total and LDL cholesterol and those trying to prevent heart attack. You can buy Benecol at Vons, Glendora in the dairy section. The average LDL reduction with Benecol in our Cholesterol Clinic was 11%. Take control is less potent but seems to be more available.

In conclusion, at least 3 dietary strategies are effective in preventing coronary artery heart disease: substitute unsaturated fats (especially polyunsaturated fats) for saturated and trans-fat; increased consumption of omega 3 fatty acids from fish oil; and consumption of a diet high in fruits, vegetables, nuts, and whole grain and low in refined grains. A combination of these approaches can confer greater benefits than a single approach. Simply lowering the percentage of energy from total fat, however, is unlikely to improve the lipid profile or reduce the incidence of coronary artery heart disease.

In our cholesterol clinic, we have tried for years to get people to read labels and decrease the intake of saturated fats. But we have learned that people need to go further and get a good healthy diet. There is obviously a rather complex change in life style and menus, so we recommend that people consult a dietitian. If you can find one who is willing to develop 5-10 meals for you, this will probably enable you to achieve the ideal diet.

See www.mypyramid.gov.

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What to Do With Chest Pain

Neil E. Doherty III, M.D., FACC

Chest pain is the most important and most frequent problem that we get emergency calls for at Citrus Valley Cardiology (626- 857-7344). We do not dismiss such symptoms over the phone but I do use the patient’s description of their symptoms and their previous history and any recent tests to decide whether we can see them in the office, or if they need to go to the Emergency Room, or they need to call 911. We have a policy to always add on any established patient with angina or shortness of breath, which might be an angina equivalent, and we have a room open to do an EKG at all times. We often add nuclear stress tests the same day as a result of an emergency visit to our office at 353 W. Foothill Blvd. due to chest pain, angina, or shortness of breath. I am in the office 4 or 5 days a week from 8:30 a.m. to noon. Dr.Majed Chane and I are both there many afternoons also.

Angina is described as a deep, poorly localized chest or arm discomfort that is reproducibly associated with physical exertion or emotional stress and is relieved promptly (within 5 minutes) with rest and/or sublingual nitroglycerine. Some patients may have no chest discomfort but present solely with jaw, neck, ear, and/or arm discomfort or epigastric discomfort, like heartburn. Other difficult presentations of the patient with new angina include: shortness of breath (dyspnea), which is common in women and athletes, and sweating (diaphoresis), or unexplained fatigue, which are more common in elderly people, above the age of 75.

When people have chest discomfort for 20 minutes, the possibility of acute myocardial infarction must be considered. If the patient is also dizzy or has fainted, then the risk of sudden death is high. Such patients are encouraged to seek emergency transportation. Transportation as a passenger in a private vehicle is an acceptable alternative only if the wait for an emergency vehicle would impose a delay of greater than 20 minutes.
Although typical symptoms substantially raise the possibility of CAD, features not characteristic of angina, such as sharp stabbing pain, or reproducing the pain on palpation, do not exclude the possibility of an acute coronary syndrome. In the Multicenter Chest Pain Study, acute ischemia was diagnosed in 22% of patients who presented to the emergency department with sharp or stabbing pain and in 13% of
patients with pain with pleuritic qualities (pain increases with breathing). Furthermore, 7% of patients whose pain was fully reproduced with palpation were ultimately recognized to have an acute coronary syndrome.

Traditional risk factors for CAD (Coronary Artery Disease) are: high cholesterol, high blood pressure, diabetes, family history of heart attacks, and cigarette smoking. The presence of risk factors is only weakly predictive of the risk of acute ischemia. This is why men and women without risk factors still need to have chest discomfort evaluated promptly. However, the presence of more than 3 risk factors does appear to relate to poor outcomes in patients with established acute coronary syndromes. Age greater than 65 years, and elevated cardiac markers, more than 2 angina events within 24 hours, prior angiographic coronary obstruction, and ST-segment deviation on EKG also contribute to the TIMI Risk score, which helps quantify the risk of developing an adverse outcome – death, (re)infarction, or recurrent severe ischemia that required revascularization, which ranged from 5% with a score of 0 or 1, to 41% with a score of 6 or 7.
Patients with known coronary artery disease, such as those with history of a myocardial infarction (heart attack), coronary artery bypass graft surgery (CABG) or a PCI (stent or PTCA), are often urged to take an aspirin and go direct to the emergency department if they are having angina at rest, chest discomfort for greater than 20 minutes, syncope (loss of consciousness) or dizziness (presyncope). If it is just a slight change in the pattern of angina, we will adjust their medications and check an EKG in the office
and possibly do a stress test.

We refer all patients with unstable angina to Foothill Presbyterian Hospital
emergency department, where a 12 lead EKG is obtained immediately (within 5 to 10 minutes) and then a history and quick exam is done by a nurse, physician’s assistant, and/or emergency doctor, with blood tests sent to the hospital laboratory to measure CPK and troponin, two cardiac markers, which if they are elevated make the diagnosis that a person is having a heart attack.

If we think the chest discomfort is cardiac, we give 325 mg aspirin immediately and start them on heparin, an intravenous blood thinner. We try to see if sublingual nitroglycerine is helpful, and then start intravenous nitroglycerine. We give a beta-blocker, like metoprolol, intravenously, then as a pill twice a day, to lower heart rate to 50 –60 beats per minute.

If the EKG shows that a person is having a heart attack, we usually transport them immediately to Intercommunity Campus for emergency cardiac catherization and PCI. I think it is better for Glendora patients with severe unrelenting chest discomfort to be brought to Foothill Presbyterian now, because we need to make a diagnosis before we decide to do a cardiac catheterization. Sometimes we find other diagnoses, like a bleeding ulcer, that can cause very similar symptoms, and the treatment is very different. There is a pilot program to see if we can get EKGs transmitted from the ambulance to the Emergency Department doctor, and this could eventually lead to patients with diagnostic EKGs in the ambulance being directed past Foothill to Intercommunity, where Citrus Valley Health Partners has a cath laboratory, and a dedicated Acute Myocartdial Infarction Program, which has taken care of over 150 acute myocardial infarctions from most of the hospitals in the East San Gabriel Valley.

If the patient is stable, and rules-out for myocardial infarction because blood tests did not show any damage to the heart muscle, the patient will likely have a persantine or adenosine nuclear stress test within a day to determine if they need a cardiac catheterization. This nuclear stress test can be done either as an outpatient at our office over a span of 4 hours or as an inpatient in a few days. If the nuclear stress test shows significant ischemia, as it does in 20% of patients done at our facility, then we make arrangements at Intercommunity Hospital to do a cardiac catherization and, if necessary, a stent (80% of PCIs) or PTCA (20% of PCIs).

If you think you are having angina, please don’t ignore it. We’d love to help you.
Give us a call at 626-857-7344. Or call Foothill Presbyterian Hospital’s Emergency Department at 626-963-8411.

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In the East San Gabriel Valley, if you have a heart attack, I think you just might be luckier than people in almost any other area of Los Angeles. Inter-Community Campus of Citrus Valley Health Partners has set up what I consider a state of the art Heart Attack Center, even though it is not labeled as “Heart Attack Center,” and a rapid transport system for people with heart attacks to receive the quickest and best treatment currently available. With her permission, I will share with you the details of Mrs. Phyllis McAuley’s recent heart attack treatment on May 20, 2004.

Mrs. McAuley is a single 65 year old woman who was mowing her lawn in the morning, when she felt severe chest pressure. She rested for 10 minutes. When it did not go away, she called 911 and was brought to Queen of the Valley Emergency Room. An EKG was done within 5 minutes; she was given an aspirin; and the Emergency Room doctor then called me at about 12:45 pm. She had never seen a cardiologist and had not seen a Primary Care Family Practice Doctor, Internal (Adult) Medicine Doctor, or Gynecologist recently.

There are about 7 to 10 doctors on the interventional cardiology panel at Inter-Community and Queen of the Valley Hospitals, who have agreed to evaluate patients with chest pain and EKG changes, and/or to treat them with emergency cardiac catheterization and percutaneous coronary intervention (PCI) with drug eluting stent(s), stent(s), or PTCA (angioplasty) at Inter-Community Campus. At Foothill Presbyterian Hospital, there is a cardiology panel of 5 to 7 cardiologists, which arrange for an interventional cardiologist to provide this emergency treatment. These physicians include: Drs. Jonathan and Kenneth Tye, Dr. Andre Andresian, Dr. Christakis Christodoulou, Dr. Dinesh Samant, Dr. Uday Gadgil, Dr. Chowla, Dr. Demetrious Hechanova, Dr. Raymond Yen, Dr. Sam Mouazzen, Dr. Nagi Kandlaft, Dr. Majed Chane, and Dr. Antonio Lopez.

I was on interventional cardiology call Thursday May 20 and was called by the ER doctor at 12:45 p.m., just as I was seeing my last office patient for the day. He told me that her EKG showed she was having an acute inferior myocardial infarction (heart attack). I asked that the emergency room (ER) call AMR ambulance and said that I would meet her at the Inter-Community Cardiac Catheterization laboratory (cath lab).
A nurse from Queen of the Valley ER went with her and she arrived in the cath lab one minute before me. A similar protocol is followed at other ERs, like Foothill Presbyterian Hospital, except that the cath lab sends over a nurse to assist with transportation. Most of the logistics were worked out two years ago by Lori Palmerin, RN, who was then Nursing Director of the Cath Lab.

Inter-Community Campus, in Covina, opened a new $3 million dollar, General Electric Cath Lab December 15, 2003, with two new digital angiogram cameras. The construction of the new labs was supervised by Joe Powers, RN, the Director of the Heart Center at Citrus Valley Health Partners. Having built my own cardiology office building, I was impressed that Joe enabled Inter-Community Hospital to open the new Cath lab on time and on budget.

The Cath Lab at Inter-Community is directed by Dr. Andre Andresian, whose office is in Covina, and who has an office in the Cath Lab for administrative duties. Under his Medical Direction, the Cath Lab is supervised by Riki Medak-Wolf, RN. There are a lot of people to supervise and schedule, and policies and procedures need to be constantly amended to keep up with new procedures and new regulations.

Each camera is staffed by 3 or 4 people: a Scrub technician or nurse, who assists the cardiologist at the side of the cath lab table; an x-Ray technician; a circulating nurse, who puts in intravenous (IV) lines and administers IV and oral medicines, and pulls equipment like sheaths, catheters, guidewires, and stents as needed by the cardiologist during the procedure; and a CV Technician, who types in a contemporaneous record of the procedure and monitors hemodynamics, like blood pressure and the pressure inside of the heart, and inputs all the data for the American College of Cardiology data base. This enables the Hospital and the cardiology department to compare outcomes and complication rates to over 200 other cardiac catheterization labs in the United States. Dr. Uday Gadgil is Chairman of the Department of Cardiology this year.

Figures 1 –5 are taken from Mrs. McAuley’s digital angiogram, and were annotated by Scott Cochrane, RT, who assisted me in the case.
There are three very good scrub technicians at Inter-Community: Scott Cochrane, Bruce Kupper, and Don Nelson. I usually work with Scott and on this day he was excited that Intercommunity had just received the Angiojet thrombectomy machine for removal of blood clots from coronary arteries. Heart attacks usually have blood clots in the coronary artery, so they are an ideal application for the equipment. Mrs. McAuley was “lucky” she had her heart attack that day because she got to be the first person to be treated with the device at Inter-Community.

By sucking out the clot, we restored good flow to her right coronary artery, stopped her chest pain, and decreased the amount of damage to her heart. We gave her heparin, to prevent clotting, and IV Integrelin to inhibit platelets, because platelet activation is the first step after plaque rupture or erosion that leads to clots that block blood flow and cause the heart attack.

We then put in a TAXUS drug eluting stent, which has the advantage of a low 5-9% risk of restenosis over 6 months, compared to 20% for stents, which was an improvement from 30 to 40% for angioplasty. We use the TAXUS drug eluting stent from Boston Scientific more than the Cypher Drug Eluting Stent from Johnson & Johnson, because Boston Scientific provides an inventory of 80 stents, compared to the smaller inventory from Johnson & Johnson, and because the TAXUS comes in more lengths than the CYPHER, and is more flexible, which makes delivery easier and faster in the not so infrequent twisting or bending coronary arteries that need stents.
We finished in the cath lab by removing the temporary pacemaker that is required when the Angiojet is turned on, removing the femoral venous sheath, than removing the right femoral arterial sheath and closing the needle hole in the artery with an 8 French (2.66 millimeter diameter) Perclose vascular suture closure device, so Mrs. McAuley could get out of bed in 1 or 2 hours.

We observed Mrs. McAuley in the CCU, which had just opened the day before, after renovations that followed the opening of the new Cath Lab, and she thought the new beds were as comfortable as the Heavenly Beds at the Westin hotel. We completed the 18 hour infusion of Integrelin that we began at the beginning of the stent part of the procedure, transferred her to the Definitive Observation Unit (DOU, or step down unit) for one extra day of monitoring, adjusted her medicines, and sent her home after just two days in the hospital, with a very good result.

Her discharge medicines met the guidelines from the American Heart Association recommended for treatment of patients who have had heart attacks treated with stents: Aspirin and Plavix (for at least 9 months) to prevent clots in the drug eluting stent; Diovan (an Angiotensin Receptor Blocker), Toprol-XL (a slow release beta blocker); and Lipitor for LDL cholesterol reduction.

In anticipation of downward revisions in target LDL, as a result of the PROVE-IT trial, I will titrate her Lipitor to target LDL below 70 mg/dl, instead of last year’s target of 100 mg/dl. I will also check an Advanced Lipid Panel for direct LDL, LDL particle size and subfractions (Type A versus B), HDL, HDL-2, Apolipoproteins, Triglycerides, high sensitivity C-Reactive Protein (CRP), and homocysteine, to see if she needs additional treatments to prevent new plaque formation or progression of current plaques, and to decrease her risk of more heart attacks or strokes. Based on these results, she could be treated with additional medicines, like Niaspan (Slow release Niacin), Tricor (a fibrate to lower triglycerides), or Fish Oil (to decrease sudden death and triglycerides).

The HDL problem is discussed in this month’s Ask the Doctor column by Dr. Antonio Lopez. Use of the Advanced Lipid Panel for risk assessment and treatment of complex lipid abnormalities will be treated in a future article. Dr. Lopez and I will have an article next month, or soon thereafter, on low carbohydrate diets for weight loss and lipid treatment, especially lowering triglycerides.

Dr. Doherty did the first Acute MI Angioplasty at Inter-Community Campus July 14, 2000, for a left anterior descending (LAD) coronary artery occlusion in a Fireman, who was last seen in the office May 3, 2004, and has been doing well. He sees patients in his office at 353 West Foothill Blvd, in the heart of Glendora, by appointment, Monday, Tuesday, Thursday, and Friday morning. Established patients can call in for urgent heart problem evaluations the same day, and for pre-operative clearances the same week. Citrus Valley Cardiology Medical Group has in-office chocardiograpy, stress testing, pacemaker, and automatic defibrillator evaluation, and provides expert treatment of all heart problems, as well as cholesterol, advanced lipid, and high blood pressure problems. Please call 626-857-7344 (extension 2) for an appointment, or visit our web page www.citrusvalleycardiology.com for additional information.

Legends:

Figure 1. Occluded Right Coronary Artery (RCA). Ruptured plaque caused blood clot. Absence of blood flow caused heart attack with symptoms of severe chest pressure.

Figure 2. Blood clot in RCA is visible after passing guide wire.

Figure 3. Mid RCA has 25% luminal irregularities following thrombectomy (removal of clot) by Angioget. Blood flow has been restored to normal.

Figure 4. TAXUS Drug Eluting Stent Deployment in RCA.

Figure 5. RCA post drug eluting stent deployment.

Figure 6. Final result after intracoronary nitroglycerine.

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Congestive Heart Failure (CHF) affects over 10% of Americans over age 65. CHF may cause shortness of breath, fatigue, and leg swelling or edema. It is a very frequent inpatient diagnosis. Most cases are characterized by a weak heart, with a low Ejection Fraction (Normal 55%-75%), but some cases have diastolic dysfunction, which means that the heart is stiff or slow in relaxing. The most common causes are: previous heart attacks, coronary heart disease, hypertension, viruses, diabetes, and large amounts of alcohol, but many cases are idiopathic, meaning that we don’t know what caused CHF.

Progress in recognition and treatment of congestive heart failure justifies referral to a cardiology office. In 2002, Citrus Valley Cardiology Medical Group started a Congestive Heart Failure Clinic to help improve treatment of CHF in our area, especially echocardiography, stress testing, and the introduction and titration of beta blockers.

Circulating B-type natriuretic peptide (BNP) is a new blood test, which is useful in the emergency room for distinguishing shortness of breath due to congestive heart failure from that due to other causes, but it can not reliably separate systolic from diastolic LV dysfunction. Echocardiography is very useful for making this discrimination, as systolic function causes wall motion abnormalities and lowered ejection fraction, and diastolic LV dysfunction can be evaluated with doppler inflow velocities across the mitral valve and also tissue doppler, where available.

Echocardiography is a very important test for patients with congestive heart failure. It allows assessment of wall motion and ejection fraction and provides valuable prognostic information.

Many patients with LV ejection fraction less than 35% will die from sudden cardiac death. This is avoidable with defibrillator therapy, but the trouble is in selecting patients who are appropriate candidates for this very expensive treatment ($26,000 for the cost of the device alone). Holter monitoring is a very easy and inexpensive test to select congestive heart failure patients with low ejection fractions who have ventricular tachycardia, and who are good candidates for further evaluation, i.e., E.P. testing to consider placement of an implanted defibrillator.

A frequent question for patients with congestive heart failure is whether they should have cardiac catherization. In the majority of cases, a cardiologist can determine if a routine EKG stress test, nuclear stress test, or direct cardiac catheterization is the best approach for an individual patient.

Current treatment for American Heart Association “Get with the Guidelines” advocates that patients that have congestive heart failure should be treated with ACE-inhibitors. Angiotension reception blockers are indicated in patients intolerant of ACE-inhibitors due to cough or angioedema. Hydralazine and Nitrates are substituted in the small number of patients intolerant of ACE-inhibitors due to hypotension or renal insufficiency.

Beta Blockers should be used in patients with a prior myocardial infarction or a reduced LV ejection fraction, unless contraindicated. Approved Beta Blockers for congestive heart failure include Toprol XL and Coreg.

Toprol XL is usually started at 25mg tablet daily and then advanced every two weeks or every two months. For most patients, we increase the dose every two months, but it can be increased more quickly in the hospital, or in patients who have significant sinus tachycardia, or who tolerate the medicine very well.

Coreg is usually started 3.125mg twice daily with food and advanced at the same speed as Toprol XL.

Digoxin has not been shown to improve survival in patients with congestive heart failure but may decrease hospitalizations and is useful in patients with symptoms from low cardiac output, such as fatigue and low temperature.

Diuretics, usually Lasix, are used to treat fluid retention and shortness of breath. These often have to be supplemented with potassium replacement, and potassium levels have to be monitored.

Spironolactone may be beneficial in patients who have normal serum potassium, adequate renal function, and severe heart failure.

Non-steroidal anti-inflammatory drugs, such as Ibuprofen, most anti-arrhythmic and most calcium channel blockers should be withdrawn as they all may worsen outcomes. Verapamil and Diltizem, in particularly, are deleterious.

Norvasc may not be harmful, but earlier enthusiasm that it might help decrease mortality in patients in congestive heart failure vanished with publication of the PRAISE-2 trial.

Citrus Valley Cardology Medical Group has a Congestive Heart Failure Clinic, at least twice a month. Call (626) 857-7344 for an appointment. Physicians may refer patients directly to the CHF Clinic, or to either Dr. Chane or Dr. Doherty at their office at 353 W. Foothill Blvd., Glendora, CA 91741. Check our web page www.citrusvalleycardiology.com for additional information.

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Dr. Neil E. Doherty, M.D., F.A.C.C.

The beginning of blood pressure control is to convince people to get their blood pressure checked. Doctors can then get it down to target, which for most people is less than 140 millimeters of mercury systolic and 90 millimeters of mercury diastolic (less that 140/90 mm Hg).
Lifestyle modifications that can help lower blood pressure include: salt and sodium restriction, weight loss, exercise, decrease in alcohol consumption, and quit smoking.

The best diet for blood pressure control is the DASH low sodium diet. This diet increases intake of calcium, potassium, and magnesium by increasing fruits and vegetables to 8 servings per day. You can find it on the internet at http//www.heartcenteronline.com.

Earlier this year, the Joint National Commission #7 (JNC7) for control of high blood pressure, recommended initial treatment of blood pressure begin with a diuretic (water pill), such as hydrochlorothiazide (HCTZ) 12.5 mg or 25 mg. This is based on results of the ALLHAT (Anti-hypertensive and Lipid Lowering Heart Attack Prevention Trial), for which I was the regional director in the San Gabriel Valley. The Center for Disease Control (CDC) has asked me to be part of a pilot trial to disseminate the results.

Over several years, fewer people develop congestive heart failure on diuretics than on calcium channel blockers or Ace Inhibitors. All of these drugs decrease heart attack, stroke, and cardiovascular death, which was the primary end point in the ALLHAT study.

If more than one drug is needed to reach target blood pressure, as it is in most people with systolic blood pressure above 160 mm Hg, physicians are encouraged to use beta-blockers (such as atenolol, metoprolol, or Toprol-XL), angiotensin receptor blockers (like Vasotec), or angiotensin receptor blockers (like Diovan), or calcium channel blockers (like Norvasc).

Compelling reasons to select specific medicines include: using angiotensin receptor blockers (ARBs, like Diovan) to better prevent kidney disease in diabetics, and beta-blockers (like atenolol) after heart attacks to prevent sudden cardiac death.

Side effects are monitored by health care providers and differ with medication class. Diuretics and beta-blockers may increase fasting glucose (sugar) a few mg/dl (points), which is not a problem for most people. Potassium may decrease in 8% of people. Doctors may advise patients to eat more potassium rich foods, like bananas and oranges, or they may prescribe potassium pills, to maintain normal potassium levels.
Calcium channel blockers, like Norvasc, may lead to fluid retention. This can be treated by reducing the dose, or using a diuretic.

Angiotensin receptor blockers (ARBs), like Diovan, Cozaar, or Avapro, are often prescribed for diabetics because they protect diabetics kidneys better than the other 4 agents. ARBs sometimes replace angiotensin inhibitors, like Vasotec, because ARBs don’t produce the cough side effect that up to 20% of people get with ACE inhibitors.

If doctors cannot get blood pressure controlled with life style modifications, like low sodium or DASH-low sodium diet, plus these 4 classes of medicines: diuretics, beta-blockers, ACE inhibitors (ARBs), and calcium channel blockers, we can then add other classes of medicines.
Many people require titration of the dose of blood pressure medicines, or more than one medicine to get adequate control.

Dr. Doherty is CEO of Citrus Valley Cardiology Medical Group. He is an expert on treatment of hypertension. Please call (626) 857-7344 for an appointment. (Additional information will be available on our web page, when it is updated.)

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Q: I heard in the news that water pills are better for treating high blood pressure than other types of prescription drugs. Is that true and if it is, should I talk to my doctor about changing my current medication?

A: This is true. I led the local component of the study recently conducted by the National Heart Lung and Blood Institute – a division of the National Institute of Health. The seven-year study revealed that simple diuretics, more commonly called water pills, are cheaper, easier to get, and more successful at treating hypertension or high blood pressure. Water pills may also help to prevent some forms of heart disease.

The study, called the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), tracked more than 40,000 participants of all ages, races and genders from 623 clinics and centers across the United States, Canada, Puerto Rico and the U.S. Virgin Islands. I oversaw the group from the San Gabriel Valley.

During the study, participants were randomly assigned to receive one of four drugs: a diuretic (cholothalidone), a calcium channel blocker (amiodipine), an angiotensin converting enzyme (ACE) inhibitor (lisinopril) or an alpha-adrenergic blocker (doxazosin). Although all of these drugs reduced cardiovascular complications, diuretics performed the best by far.

Those taking the calcium channel blocker were 35 percent more likely to develop heart failure. The risk of stroke was 15 percent higher in patients taking the ACE inhibitor – 40 percent in African Americans. In March 2000, the alpha-adrenergic arm of the study was dropped because those taking the drug had 25 percent more cardiovascular problems and were twice as likely to be hospitalized for heart failure.

The message this study sends is that doctors should order a diuretic first when treating high blood pressure. Patients also need to be informed about their options before they take any medication.

If you are currently taking alternate medications for high blood pressure you definitely should talk to your physician about these findings to determine if a diuretic might be beneficial. Under no circumstances, however, should you stop or change use of any prescriptions on your own. In most cases, additional medications will also be needed.

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Dr. Neil Doherty, MD

What is Zetia?

Answer: Zetia is new class of medications to lower cholesterol. It works by inhibiting absorption of cholesterol in the intestines. There are no reported side effects on liver function. It also does not cause muscle aches, a problem for some patients taking statins. We have found a 20 percent reduction in LDL cholesterol in patients who take Zetia alone.

What is C-reactive protein? How does a cardiologist use it?

Answer: C-reactive protein is a measure of inflammation. Inflammation occurs in coronary arteries, which can lead to plaque rupture and result in heart attacks. The American Heart Association has recommended that patients with C-reactive protein above 3 be considered at high risk. If I have a patient with a borderline LDL cholesterol but elevated C-reactive protein, I will generally increase the dose of their statin or other lipid-lowering medications.

What is the news on fish oil?

Answer: Fish oil has been shown to lower triglycerides and to decrease sudden cardiac death. We generally recommend Omega Rx Zone, three capsules daily.

Should all diabetics take statins?

Answer: All diabetics are at increased risk of heart attacks and strokes. Two studies, just released this month, have shown that Lipitor and Zocor each reduce heart attacks in diabetics even if their LDL cholesterol is normal.

What are fibrates?

Answer: Lopid and Tricor are fibrates, and both lower triglycerides and raise HDL (the good cholesterol). The increase in HDL, although small, results in significant decrease in heart attacks and strokes. Pharmaceutical companies are presently researching other medications to increase HDL cholesterol.

What about exercise?

Answer: Exercise at least 30 minutes every day is helpful for almost every coronary artery risk factor, including: weight, HDL cholesterol, triglycerides, and nitrous oxide vasodilatation of the coronary arteries. Vigorous exercise is even more beneficial than just mild walking, but we generally advise that people get examined by a cardiologist or have a stress test before entering into a vigorous exercise program. Glendora is blessed with numerous exercise opportunities, such as our trails, Citrus College facilities and exercise gyms.

Neil Doherty, MD, runs the Cholesterol Clinic at Citrus Valley Cardiology and has been practicing cardiology there since 1991. His office is located at 353 West Foothill Blvd. in the heart of Glendora, phone (626) 857-7344. www.citrusvalleycardiology.com.

Call the Doctor Connection at 626/814-2479 or toll free 888/456-CVHP for information about physicians on the medical staffs at Citrus Valley Health Partners’ hospitals and the health plans we accept.

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Dr. Doherty has a cardiology practice in Glendora at 353 West Foothill Blvd. He is very active treating and preventing heart attacks. He is also on the board of the American Heart Association for Los Angeles and the Western States. We thought that we would use this opportunity to ask him about the acute myocardial infarction treatment program at Foothill Presbyterian Hospital and Citrus Valley Heath Partners.

Question: Dr. Doherty, How is the acute MI program that you started at Foothill Presbyterian Hospital and Citrus Valley Health Partners working out?

Answer:Great. We’ve treated over 200 patients from Foothill Presbyterian Hospital, Intercommunity Campus (ICC), Queen of the Valley, and at San Dimas at Intercommunity Campus (ICC).



Question: Doctor, what are the keys to the Program’s success?

Answers: Early patient arrival after heart attack symptoms, quick triage and initial treatment in the emergency room by the nurses and emergency rooms doctors, rapid ambulance transport accompanied by ICC nurses like Lori Palmerin RN, a great cath lab team, and interventional cardiologists who respond quickly night and day 24/7/365.

Question: This must be hard on your group.

Answer: It’s hard on all of us, and our families, but we are greatly rewarded by saving so many lives. The grateful feedback of patients like that of Officer Harden, who is highlighted in a separate article this month, make the sacrifices worthwhile. Of course, there is a big rush of adrenalin, and calls, which make it hard to sleep afterwards.

Question: How soon do people go home after a heart attack?

Answer: If they are treated quickly with a stent, usually within 2 days.

Question: Is lowering Cholesterol still important?

Answer: Yes. We find people do much better, both short-term (6 months) and long term (3-5 years) after heart attack, when treated with stents, if they see us in our Cholesterol Clinic, especially if we get their LDL cholesterol below the target of 100 mg/dl. In fact, our target LDL cholesterol is usually 80 mg/dl.

Question: What else is important?

Answer: Plavix and Aspirin help prevent stents from clotting, and decrease the number of new heart attacks.

Question: We hear you want to call ICC a “Myocardial Infarction Treatment Center”. Why such a complicated name?

Answer: The Chest Pain Center is in the emergency room at ICC and they do a great job starting treatment and calling in the lab. But patients come from several nearby ERs, including Foothill, by ambulance, to ICC because of the excellent work in our cath lab, which has the largest experience in the East San Gabriel Valley. ICC is the local center for rapid treatment of Acute Myocardial Infarction (Heart Attacks). I like the name “Myocardial Infarction Treatment Center” because it emphases to the emergency rooms that they should transfer patients to ICC by ambulance.

Question: How do you treat these patients in your new office?

Answer: We are conveniently located at 353 West Foothill Blvd, across the street from Glendora Community News, for outpatient follow up with a state of the art GE Marquette CASE 8000 treadmill machine, double headed cardio 60 Phillips – ADAC Nuclear Camera, and new H-P echocardiogram machine, with a full staff, including myself, to give patient competent, caring, up to date treatment, comfortably and without waiting long. Almost all new patients are seen within one week, including those seen previously by other cardiologists, who are often referred to us for nuclear stress tests or management of cholesterol.

Question: How can patients contact your office for appointments or tests?

Answer: Call us at (626) 857-7344. For further information, visit our web page at WWW.CitrusValleyCardiology.com. We also would like to get feedback at www.cvhp.org in the rate your physician section.

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Every doctor's office has a schedule which allots a fixed amount of time for follow-up visit, and another fixed amount of time for a new History and Physical, Consults referred by other doctors, and Second Opinions. I have found the following pointers help my patients get the most out of their visits to monitor Cardiology problems (Chest Discomfort, Hypertension, Cholesterol, shortness of breath, pre-op clearance, congestive heart failure, sports clearance, dental clearance, etc.

Before You Come

Call the office (626) 857-7344. Find out what documents you'll need to bring or send. If you were recently seen in an emergency room for a heart problem, such as dizziness or an irregular heart rhythm, you will be advised to ask the E. R. to send EKGs, rhythm strips, lab results, and the E. R. Doctor's written or dictated notes. If you ever had heart tests, like an angiogram, or an echocardiogram, it will help us to know beforehand so we can help you to get those records released (with your authorization) and forwarded to us in time for your office visit.

Keep the Schedule

Although many doctors keep patients waiting, I try very hard to avoid this. We realize that our patients' time is valuable, and we make every effort to see patients at their scheduled time. However, occasionally, our office falls behind schedule. We ask for your understanding; we, also, ask that patients provide as much advanced notice as possible when running late for an appointment or when needing to cancel. With this advanced notice, the time can be scheduled for another patient.

Signing In At the Front Desk

At the front counter, you should tell the receptionist if there have been any recent tests that you wish to have reviewed with you. It will save you time if the staff has had a chance to gather this information and put it in your chart. They may be able to get Foothill Presbyterian results off the computer quickly. It takes longer to get results from Unilab or hospitals outside of Citrus Valley Health Partners because we don't share the same computer system.

If you are a first-time patient, please plan on arriving early in order to complete a patient registration form and please bring the following items to the appointment:

Insurance Card (s)

List of all prescription and over-the-counter medications that you are currently taking

Any required co-payment.

Pertinent medical and surgical history information, including copies of the following tests, if you had them within the last five years: EKG, Holter Monitor, Event Recorder, Stress Echocardiogram, Dobutamine Echocardiogram, Transesophageal Echocardiogram, Angioplasty, Catheterization, Pulmonary Function Tests and Electrophysiology Studies

In order that we communicate the results of your visit with your primary care physician, it is important that you bring your physician's name, address, and phone number to your visit, as well as any written referral information.

Insurance and Payment Information We are a provider for Medicare and most PPO plans. Since we provide insurance billing, we encourage all patients to confirm their coverage prior to making an appointment. Co-payments are due at the time of the appointment. If the insurance company does not pay the full balance, or denies the claim, then any unpaid balance is due within 30 days following the appointment.

Please call us with any questions regarding which insurance plans we accept or other billing concerns. Insurance coverage and benefit questions should be directed to your insurance company.

Narrow the Focus to Your Heart

Narrow your focus to the key complaint you're coming in for, and be specific. We look for clue words. I am much more able to help you with your heart if we talk about symptoms in your chest, or areas that you think are related to your heart condition, than if you ask me about unrelated systems, like constipation, or memory loss, unless you honestly feel that these concerns might be related to your cardiovascular system, or to medicines that you are taking for your heart. Tests ordered or done by other doctors are best discussed by the doctor who ordered the test, e.g., if a family doctor or urologist ordered a PSA, then it is better for you to discuss it with them.

List Medicines

It helps to bring a list of your medicines each visit, and give it to the receptionists to copy, or bring a full size copy of the list, if you keep it on a computer or word processor. Make sure the list has the dose (usually in milligrams) and the frequency or time of day that you take it. The nurse practitioner may review the list with you prior to the doctor's visit. For stress tests, your cardiologist may want to hold beta blockers, like atenolol or metoprolol, for a few days before the test.

Refills

Use our prescription line, (626) 857-7344, Ext. 103. Ask your pharmacy to fax refill requests to (626) 857-7340.

List Your Questions

I advise my patients to bring a short list of up to 5 questions they want answered. This can be hand written or typed. One smart patient brings a copy for herself and a copy for me. Bringing a list of questions makes sure that the important questions are addressed in the office.

Bring Your Spouse?

If your spouse, or family member, is going to ask you forty questions when you get home, then you may want to bring them with you so they will hear it directly from the doctor.

Informed Consent

For stress tests, angiograms, stents, pacemakers, TEEs (Transesophageal Echocardiograms) and Cardioversions, we review the procedures, technique, any potential complications, and follow-up with you. Feel free to ask how many similar procedures I have performed.

Privacy

Citrus Valley Cardiology complies with the recently enacted HIPAA regulations, as outlined in our Notice of Privacy Practices. Every effort is made to protect all medical information and records we have about your health, health status, and the health care and services you receive at this office.

Other Questions

You may want to know where your doctor did his training and if he is board certified in cardiology. Such information is available before your appointment at websites such as “WebMD.” If you have further questions, feel free to ask your doctor at this time. Doctors love to tell patients about their training, and it is a good proxy for how much they know about their profession.

Walk-ins (Please Call Ahead)

We see most established patients the same day for urgent heart problems, including hypertension and pre-op clearance, but it does help to call in advance to find a spot in the schedule where you won't have to wait long.

Cell Phones

Please turn cell phones off before, or when doctor enters the exam room.

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Treatment of LDL cholesterol, often referred to as “bad” cholesterol, is reaching for lower targets in some patients. You should talk to your doctor whether new guidelines refer to you. They do if you have had a heart attack, bypass surgery, stent, angioplasty, or if you are at very high risk because you have extra risk factors for coronary artery heart disease, such as diabetes or being overweight.

The long awaited footnote or revision to the Adult Treatment Panel III (ATP III) guidelines from 2001 was published in the American Heart Association’s Circulation on July 13, 2004.

As expected, the July 13 guidelines recommend more aggressive lowering of LDL. These guidelines suggest LDL targets below 70 mg/dL as a therapeutic option for patients with known history of heart attack, stent, angioplasty, coronary artery bypass surgery, or lower extremity arterial disease, and for people at very high risk of coronary heart disease, specifically those with greater than 20% risk of angina (chest discomfort from the heart), heart attack, or coronary artery disease within 10 years as calculated by the Framingham risk score. Previous guidelines had suggested an LDL target below 100 mg/dl.

Framingham is a small town in Massachusetts, similar to Glendora, where most of the community has been medically followed for ten year periods to see if they develop heart disease. Risk factors derived from these studies are: age, total cholesterol, LDL cholesterol, a low HDL (good) cholesterol, diabetes, hypertension, and cigarette smoking. Our Cholesterol Clinic uses a Framingham risk score calculator that you can refer to on the Web at http://www.nhlbi.nih.gov/about/Framingham/riskabs.htm. There are separate calculators for men and women, using either Total Cholesterol or LDL cholesterol. Results are similar for Total Cholesterol or LDL cholesterol, according to research studies, and in 20 patients we compared both ways in our Cholesterol Clinic.

The recommendations from the coordinating committee for the National Cholesterol Education Program were developed as the result of five large research trials published after the 2001 publication of the ATP III guidelines. These studies include: the Heart Protection Study which studied Zocor 40 mg, PROSPER which studied Pravachol in the “elderly” above 65 years old, which is a very large portion of our patients, ALLHAT which studied Pravachol 40 mg in patients with high blood pressure and two or more additional risk factors for heart disease, ASCOT which studied the use of Lipitor in patients with hypertension and two risk factors, and PROVE-IT which studied Lipitor 80 mg to lower median LDL to 62 mg/dL compared to Pravachol 40 mg to lower median LDL cholesterol to 95 mg/dL.
We have been trying to achieve LDL cholesterol 60 mg/dl in more very high risk patients for the last year because of PROVE-IT and the Heart Protection Study. For many patients, we have been able to do it by adding Zetia 10 mg to their current statin, most often either Lipitor 40 mg or 80 mg, or Zocor 40 mg or 80 mg.

Diet and exercise are important. We continue to educate our patients on the importance of weight control by caloric regulation and the value of good foods, such as: fruits, vegetables, fish, avocados, olive oil, nuts, benecol, soy, and fiber. We no longer recommend reducing all fats, just saturated fats and trans-fats. Our exercise prescriptions are guided by treadmill testing, where we try to recommend safe target heart rates during exercise.

Dr. Doherty was a Director of the NIH sponsored ALLHAT study on blood pressure medications and Pravachol. He has received educational grants and Speakers’ Fees from Pfizer, Merck, and Bristol Myers Squibb for lectures to physicians in California and Hawaii.

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Neil E. Doherty, M.D., F.A.C.C.

Now is the time for Medicare patients to calculate their expected 2006 drug costs and pick a plan to administer the new Medicare Part D benefit. Your coverage will start the first day of the month after you enroll. You can enroll in any plan until May 15, 2006.

The table below lists the plans I thought best for my patients. I give an A+ to plans with 98 or more of the top 100 drugs on their formulary. Medicare Part D does not pay for brand name medications if they are not on the formulary, so the more drugs on the formulary the better the plan.

I did not include plans with a $250 deductible because their premiums were only $5 to $10 less per month, far short of the $21 less per month breakeven point ($21/month X 12 months = $252). You can pay your premium directly to your Medicare Part D Plan or you can have it deducted from your monthly social security check.

You pay 25% of any initial drug bills up to $2,250. For example, if the bill is $2,000, you pay $500, and your Medicare Part D plan pays $1,500.

There is a coverage gap between initial and catastrophic coverage. You pay 100% of drug costs between $2,251 and $5,100. After you spend $3,600 out of pocket, in a year, Medicare Part D pays 95% of catastrophic drug costs. This means that over $5,100 total drug costs, you pay 5% of remaining costs. For example, if your total drug costs were $6,100, you would pay $3,600 for the first $5,100 of medicines, and $50 for the last $1,000 worth of medicines.

After reviewing this information, if you have any questions, please call Jill Ashman, my Billing Manager, at 909-477-3243.

Note: This is intended as a public service, therefore, we accept no liability, but offer this as a Good Samaritan. We accept all the PPO plans associated with these Medicare Part D Plans. Citrus Valley Cardiology does not accept HMOs and does not recommend any Medicare Advantage Plans.

For more help, you can go to www.medicare.gov, or call 800-633-4227, or go to www.social security.gov or call 800-772-1213.

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