Recently, I received tragic news. One of my high school classmates in the prime of his life had died suddenly of a heart attack. He was an outgoing, charismatic father, a Mississippi Highway Patrolman and an all-around likeable guy living and enjoying life to the fullest. He had no prior history of heart disease. And just like that in a blink of an eye, he was gone.
Now that the dust has settled and the tears have dried, we are left to ponder if this tragedy could have been prevented.
In the US, heart disease remains the leading cause of all adult deaths, killing more than 600,000 people each year. If we want to make a positive impact, we must understand the nature of heart disease and why its diagnosis remains elusive despite all of the scientific progress made in the past half century.
Heart attacks are basically caused by a sudden loss of blood flow to part of the heart muscle. Cardiac catheterization, a procedure in which the blood vessels feeding the heart are visualized, looks mostly for evidence of fatty plaques that have narrowed blood vessels that nourish the heart by 50% or even 70% or more.
Unfortunately, this criteria for obstructive coronary heart disease potentially excludes several million adults with concerning symptoms of heart disease.
Even worse, a 2012 study by researchers in Denmark demonstrated evidence that people with less than 50% blockage of their hearts arteries, or so-called non-obstructive heart disease, are at about the same risk of death due to heart attack, stroke, or heart failure. The risk was 14% over five years for men and 8% for women, about the same risk as people with an artery with a 50% or greater blockage.
What this means is that you can have a normal cardiac catheterization and then have a fatal heart attack later the same day.
Cardiac catheterization has been the gold standard for diagnosing heart disease, but newer imaging modalities such as cardiac CT and MRI scans are starting to be employed to determine risk since they can visualize plaque in the vessel wall that is invisible to traditional methods.
Unfortunately, these modalities are still too expensive and are not yet mainstream enough to make an impact just yet. Insurance coverage for these studies can be an issue, too.
For now, risk factor identification and modification remains the core defense in the fight against early heart disease. There are some obvious, well-known risk factors such as diabetes, high blood pressure, smoking, strong family history, and elevated cholesterol.
For many years now, doctors have used the lipid panel to measure a patient’s cholesterol level to determine HDL (good) cholesterol, and LDL (bad) cholesterol levels. The mainstay for treating cholesterol has been statin cholesterol drugs, starting with the first US-approved drug lovastatin in 1987.
Statin drugs have cardiac benefits, including slowing the formation of new plaques in coronary arteries and suppressing inflammation that contributes to plaque formation. They improve the function of cells that line the arteries, enabling them to expand as needed.
Statins may also stabilize plaques, reducing the chance that they will rupture in blocked arteries feeding the heart. Plaque rupture has been identified as the source of 95% of heart attacks.
However, cholesterol measurements alone cannot reliably detect all at risk. According to a major study, 50% of people suffering a heart attack had normal cholesterol levels.
To address this limitation, the American Heart Association (AHA) and the American College of Cardiology (ACC) in 2013 published national guidelines that consider multiple factors in determining a person’s overall heart attack risk, not just cholesterol.
The 10 year Framingham Risk Score (FRS) uses factors including age, sex, race, blood pressure, total and HDL cholesterol, history of hypertension, diabetes, and smoking to calculate a 10 year probability for developing a heart attack or stroke.
A risk of 7.5% or higher is generally considered as the threshold for starting a statin cholesterol lowering medication. When these more recent cholesterol guidelines were applied to a recent study of heart attack patients, they were twice as likely to be eligible for a statin prior to their heart attacks compared to the older guidelines that relied strictly on cholesterol levels. 79 percent were statin-eligible according to the newer guidelines, compared to 39 percent that qualified by the older guidelines.
But what if risk remains uncertain after applying the FRS?
Some patients may have a 10 year FRS less than 7.5% but possess lingering concerns about family history. Others may simply want additional data and reassurance before committing to lifelong statin therapy.
In October 2018, the AHA/ACC refined and expanded the guidelines to include several new options to guide diagnosis and the decision-making process. Coronary artery calcification can be measured using a simple, inexpensive CT scan that costs around $100 per test.
A coronary calcium score, which is a marker of plaque buildup in the coronary arteries feeding the heart, is determined. 0 is preferred--over 100 indicates very high risk.
There are also more advanced lipid studies that can provide information about the size of the LDL particles. While LDL is generally considered bad cholesterol, it is the size of the individual LDL particles that determine the true risk. Large LDL particles are safe, but small dense LDL particles are the most likely to cause plaque buildup and inflammation.
Finally, a marker of inflammation called the highly sensitive C-reactive protein can be used to see if there may be underlying inflammation that could potentially promote plaque instability and rupture.
We have come a long way in our understanding of heart disease risk. The question is not whether or not we can prevent unexpected tragic heart attacks but, rather, can we identify these patients before it is too late.
Our biggest challenge is access to quality, competent primary care for the patients at risk.
A recent study found that more than half of its patients with heart attacks had not seen a physician in two years prior. This is a tragic statement about the current plight of our health care system.
We have all these amazing tools and collective knowledge about identifying and treating heart disease from decades of hard work from brilliant doctors and scientists all over the world. But because some can't get in to see a doctor, people are instead left to have heart attacks, a number potentially fatal, many of which could have been preventable.
The old saying, “What you don’t know won’t hurt you” is a lie, but as a species the human race seems to prefer willful ignorance as opposed to facing the cold hard facts. The key to defeating early heart disease may not be found at the bleeding edge of scientific discovery but rather the more mundane aspect of behavioral change.
The current health care system promotes fear and avoidance for many marginalized by the system.
The lack of cost transparency and the fear of financial hardship caused by the act of simply seeing a doctor and having a few blood tests drive many from seeking care at all. The general loss of trust caused by replacing the doctor-patient relationship with a corporate, high-profit medical industry has eroded the very fabric of our health care system.
It is the very system created to enhance our health and lives that now stands as an obstacle against those we must reach to prevent tragedies like the one I just experienced with my classmate.
The reason I love and practice Direct Primary Care (DPC) is because it promotes positive behavioral change and empowers doctors and patients once again to become partners in health. Behavioral change depends on eliminating the fear of seeking care and that starts with trust. Trust can only be built up with quality time between doctor and patient. Cost transparency reduces the risk of financial harm to the patient.
It is a known fact that DPC patients seek care more often than those in the traditional system. Why? Because when trust is high and barriers are low, patients no longer fear the unknown and are willing to seek care that they need.
DPC may be the key that we have been looking for to breaking the elusive heart disease riddle and making the diagnosis earlier...before it is too late.