Dr. Michael Ozner: Cardiac Prevention

Dr. Michael Ozner, who serves as medical director for the Cardiovascular Prevention Institute of South Florida and is a member of Life Extension^®’s Scientific Advisory Board, organizes the largest and most prestigious cardiovascular disease prevention symposium in the world. For our readers who could not attend, Dr. Ozner met with Life Extension^® to discuss some of the important highlights of this four-day meeting.

Dr. Michael Ozner

LE: Every year, you attract the most innovative doctors from around the globe to discuss the latest thinking in heart disease prevention. Yet for all the billions and billions of dollars spent on statins, bypass surgery, stents, and medical diagnostics, heart disease is still the major killer of humans worldwide. To an outsider, it would seem we are not making a great deal of progress. But you are involved in the latest research; what is your opinion? Are we making progress?

MO: That’s an excellent question. There is progress on all fronts. The progress for fighting the epidemic of heart disease must come from prevention. From my particular view, the most effective way to avoid coronary heart disease and the need for expensive and high-risk surgical intervention is through lifestyle intervention. We need to get people to begin eating the right foods, exercising, reducing stress, and moving from the disease model to the wellness model. We know from years of experience, and the clinical data repeatedly supports this, that people can largely avoid heart disease, medication, and surgical interventions with the proper lifestyle. At the meeting, we had Dr. Vasanti Malik from Harvard Medical School discuss the role of nutrition in cardiovascular disease prevention. Based on research, which includes clinical trials, meta-analyses, epidemiological studies, cohort studies, the scientific evidence demonstrates that a traditional Mediterranean diet and related lifestyle is the optimal approach for preventing cardiovascular disease.

LE: That’s impressive.

MO: We have become a very sedentary society and do a lot of sitting. At the symposium, we had a wonderful lecture about the relationship of sitting time as a direct correlation with all-cause mortality and cardiovascular disease risk and mortality. The longer people sit, the more dangerous it is. Most people sit while at work, come home, eat dinner, and then sit at night to watch TV. One of our speakers, Dr. Peter Katzmarzyk, has published extensively on this topic. For example, when people get on an airplane and fly a long distance, they can increase the risk of blood clots in the legs. So if one is in a sedentary occupation, you need to get up after an hour of sitting and go for a five- to 10-minute brisk walk and then go back to your activity.

LE: As part of the lifestyle modifications along with the Mediterranean diet comes stress reduction. Stress is mainly invisible and easy to miss. So, what role does stress play in heart disease?

MO: We know that stress plays a major role in cardiovascular disease based on extensive studies. What’s interesting about stress is that we used to think that Type A personalities were the ones who were at increased risk for heart attacks and it turns out that it’s not so much the person who’s striving to get ahead; it’s the person who is angry and hostile.

LE: The message is that physicians, especially cardiologists, need to understand their patient’s life and what’s going on with them and not just rely on a set of numbers from blood tests.

MO: No question about it.

LE: I noticed on the symposium agenda a presentation by Dr. Michael Blaha from Johns Hopkins titled “Erectile Dysfunction: An Early Sign of Cardiovascular Disease.” Can you elaborate on this topic?

MO: Men who develop erectile dysfunction should be screened for cardiovascular disease, rather than just given a prescription for Viagra ^® or any of the other pharmaceutical approaches. Very frequently we’ve seen men present with erectile dysfunction and then drop dead a year later from a heart attack.

Erectile dysfunction is really a vascular disease and vascular disease rarely affects just one area of the body. So if we have vascular disease in men who develop erectile dysfunction, usually they also have vascular disease affecting the heart, and there could be some very easy, noninvasive tests that can screen men for this.

LE: The ads for erectile dysfunction products such as Cialis^® and Viagra^® do not indicate anywhere that if you have this condition, you should see your cardiologist. I don’t think the public or even most physicians see the connection between erectile dysfunction and cardiovascular disease.

MO: That’s a good point and this was brought up at the meeting. When it comes to erectile dysfunction, red flags should be raised in the mind of the physician writing a prescription for Cialis^® or Viagra^®. Many of these patients are being seen by their primary care physician who needs to start saying, “Hey, we’ll address your erectile dysfunction, but just as importantly, we need to address the fact that you’re at increased risk for a heart attack.” There should certainly be a discussion and a workup.

If we’re going to truly practice cardiovascular disease prevention and prevent heart attacks, what we need to do is be able to recognize these presentations that put people at increased risk. In men, erectile dysfunction is a huge red flag of lurking heart disease. You can add to that list low vitamin D, low omega-3 levels, and many other metabolic disorders. All of these factors can be discovered with simple blood tests. Targeted blood tests are an important tool to catch people with cardiovascular disease before they have a heart attack. You don’t want to wait until somebody is in the throes of a heart attack because half of them won’t even make it to the hospital.

LE: Your symposium seems to show that science is gaining a deeper understanding of cholesterol and all its complexities.

MO: Yes, the scientific understanding of lipids is rapidly expanding. When we talk about lipids, we’re talking about cholesterol, as opposed to lipoproteins, which are the particles that carry cholesterol. In the past we’ve always used the term “good cholesterol” and “bad cholesterol,” which are really incorrect terms. For example, HDL, which was always called “good” cholesterol, can, in reality be good or bad. We could have what’s called “dysfunctional HDL.”

LE: Can you explain why HDL is not the perfect solution for protection from heart disease?

MO: It can get a little complicated because HDL wears many hats. HDL is involved in reverse cholesterol transport, which means it takes cholesterol from the arterial wall and brings it back to the liver for processing. This is a good thing because this decreases atherosclerosis. Cholesterol, as we know, is needed by every cell membrane in the body. It’s needed to create steroid hormones for bile acid production, so it serves a very worthwhile purpose.

The problem is that HDL can become dysfunctional for a variety of reasons. There could be too many free radicals that affect HDL’s function. There could be various types of genetic anomalies that could affect HDL function, and as a result, HDL no longer functions in a beneficial sense, but can actually function in a detrimental sense by promoting heart disease rather than preventing heart disease.

One of the problems we’ve had was not having a blood test that will identify functional HDL versus dysfunctional HDL. Currently, researchers are developing such a test, but they are very expensive and not ready for routine clinical use. But once those tests are available to physicians, we will have another important tool for preventing heart disease.

LE: And what about LDL?

MO: There is no controversy when it comes to LDL. If you have too many cholesterol-carrying LDL particles, these particles can then enter the artery wall and initiate an atherosclerotic plaque, which essentially is like a pimple on the artery wall. When that plaque ruptures, you get a blood clot at that site and depending on how large that blood clot is, it could either cause chest pain, a heart attack, or sudden cardiac death.

However, what we can do today is stabilize plaques. If you have a highly inflamed, unstable plaque, it can rupture. But the plaques that become stable and never rupture will never cause a problem. Therefore, our goal through lifestyle modification and medication, when needed, is to decrease LDL particle numbers and reduce inflammation in the vascular wall to stabilize plaques so they don’t rupture and lead to heart attacks and strokes.

LE: How do you identify people with potentially unstable plaques?

 

MO: Predominantly through blood tests. At the end of the day, cardiovascular disease is really a metabolic disorder and if we could identify on a blood test the metabolic derangements that lead to vascular disease, we could correct those metabolic abnormalities with lifestyle intervention and medical therapy and therefore convert an unstable plaque to a stable plaque.

The analogy I often make is if we had a member of a bomb squad who identified an active bomb that could go off, and they defused the bomb, that bomb would never explode and lead to injury or death.

And that’s really what we do as preventive cardiologists. Through lifestyle intervention and medical therapy, we defuse these little bombs called atherosclerotic plaques in the coronary arteries in the heart to prevent heart attacks, in the cerebral arteries in the brain to prevent strokes, and in the peripheral arteries that can lead to peripheral vascular catastrophes.

Contrast this with stents and bypass surgery, which just put a Band-Aid on a specific, small area of our vascular tree. That’s why we know that vascular intervention with stents or bypass surgery in stable individuals has never been shown to reduce the risk of a future heart attack and reduce the risk of death from cardiovascular disease compared to medical therapy. Because you never know which plaque (and there could be literally thousands of them) is going to suddenly rupture.

However, in an unstable patient, acute treatment with stents can be lifesaving—and now it has been shown that endovascular catheter intervention in patients with an acute stroke can be highly beneficial. We’ll discuss this in more detail later in the interview.

LE: It seems that triglycerides are now being included in the discussion about cardiovascular risk factors. Previously, it just seemed that physicians were mostly concerned about LDL, but now triglycerides are being considered as part of the cardiovascular risk equation.

MO: You are absolutely correct, triglycerides are a cardiovascular risk factor.

LE: Life Extension^® magazine has consistently reported that fish oil is very effective toward lowering triglycerides.

MO: No question about it. Obviously people with high triglycerides need to reduce their intake of sugar and refined carbohydrates, as well as saturated fat, in their diet. Fish oil is definitely effective in lowering triglycerides.

LE: Earlier we discussed erectile dysfunction as a red flag for heart disease. Another red flag is excess weight that creates havoc throughout the body.

MO: That 100% correct. This is another situation where blood tests are invaluable. You can determine if there is impaired fasting glucose and measure inflammatory markers. In people with excess weight, their visceral fat cells will start releasing inflammatory markers like interleukin 6 and C-reactive protein. If you have elevated blood pressure combined with mild blood sugar elevation and increased inflammation, that’s a sign that you have sick fat. As your amount of adiposopathy or sick fat increases, your triglyceride levels also go up, small dense LDL particles rise, and HDL will decline.

So when you start looking at metabolic syndrome, it’s a reflection of this whole process of smoldering insulin resistance and it’s one of the precipitating causes of cardiovascular disease. Exercise is of great importance because it burns triglycerides and fat.

Dr. Katherine Esposito and others have shown that people who were placed on a Mediterranean diet for one year significantly lower their risk of metabolic syndrome.

LE: Most people see excess weight, that extra 10 pounds, as a cosmetic issue because they can’t fit into their clothes. But as you point out, it’s really a serious warning sign that the body is in a dysfunctional state.

MO: What people should understand is that this extra fat is an active endocrine organ just like the thyroid or the pituitary gland and it pumps out all of these inflammatory cytokines and angiotensinogen.

For people who develop diabetes who cannot successfully tame the condition through lifestyle, doctors have used the drug metformin with good results. What happens with a lot of these pharmaceutical interventions is people think that they’ll go on medications like metformin or a statin and they can eat whatever they want and not adhere to a healthy lifestyle.

One other thing about the Mediterranean diet I want to mention is that it provides an abundance of fiber that lowers fat and carbohydrate absorption and improves beneficial gut flora, which is an evolving area of interest for scientists. Researchers are looking at gut flora as being intimately connected to specific areas of brain, heart, and immune health. At our next symposium, we will have the world’s foremost authorities discuss the role gut flora plays in cardiovascular health.

LE: What are some of the innovations on the horizon with regard to cardiovascular disease prevention?

 

MO: There were a number of landmark clinical trials recently presented at the International Stroke Conference that have to do with people who’ve had an acute stroke. Patients would usually receive a clot buster drug known as TPA, which breaks down a blood clot in the artery, assuming they have an occlusive stroke and not a hemorrhagic stroke. But now there’s a new interventional technique called endovascular catheter intervention therapy that can lower the risk of death from a stroke 50%, if it’s initiated early on in the stroke process.

LE: How does this work?

MO: A catheter is inserted in the artery in the brain and the doctor removes the clot. This is going to be a paradigm shift. In the past, people who had a stroke were taken to just any hospital and given intravenous TPA. And now because this procedure has been shown to make such a significant difference, the stroke victim will be taken to a specialized stroke center, where specially trained physicians will perform this procedure that can make the difference between life and death. This really represents a major shift in stroke treatment. The key is that people need to recognize stroke symptoms—slurring of speech, numbness or weakness on one side of the body, garbled speech, and drooping on one side. If you get the person early and you take out that clot, they’ll regain blood flow and may completely regain neurological function.

LE: From everything we have discussed, it appears that cardiovascular prevention is entering a new phase to beat the cardiovascular epidemic.

MO: Increasingly, more and more doctors realize that standard routine cholesterol testing is not enough. Physicians need to be measuring LDL cholesterol particles, vascular inflammation, omega-3 levels, vitamin D levels, and other important biomarkers that can predict an increased risk of heart attack or stroke. For instance, it has been shown that people walking around with low vitamin D levels are at increased risk for heart attacks. And if you replace the vitamin D, you can reduce that risk.

One of the most exciting new developments, which is now in Phase III clinical trials, are PCSK9 inhibitors. PCSK9 is a protein produced in the liver that lowers the number of receptors on the liver that pull LDL cholesterol out of the bloodstream to keep LDL cholesterol down. By inhibiting PCSK9, LDL cholesterol is reduced and clinical studies have demonstrated a highly significant reduction in risk of heart attack in those receiving PCSK9 inhibitors.

LE: Very impressive.

MO: Inhibitors of PCSK9 have been shown to be safe and have been shown to significantly lower cholesterol and reduce the risk of cardiovascular disease.

We now have an opportunity to really make a major dent in reversing plaque because when you get levels that low, we’re talking reversal. And more importantly, we’re talking about getting significant stabilization of plaques and lowering the risk of heart attacks. The drug is going to be approved soon.

Additionally, there are many people who are intolerant to statins who would benefit from PCSK9 inhibitors. So the future with PCSK9 inhibition is very promising.

Now, despite all the promise of this new drug, I still stand by the fact that lifestyle is first and foremost your best avenue for preventing heart disease.

LE: There has been a lot of controversy over the new statin guidelines that seem to say that everyone over 50 needs to be on a statin. What are your thoughts on this new edict?

MO: This topic was discussed in detail at our symposium. Increasingly, we see evidence that statin drugs used to lower cholesterol can raise blood sugar, and can actually tip certain people with prediabetes into diabetes.

While statin medication has been shown to be beneficial in men and women who have cardiovascular disease or significant risk factors, I don’t think we should be mandating that everyone goes on a statin who is otherwise healthy. You know, all of these debates are settled with science. And we just don’t have the science to say that we need to take every person walking down the street and start putting them on statin medications. Healthy lifestyle recommendations are always the first choice.

LE: You are proposing a sound strategy. Blood tests to determine your status, lifestyle adjustments including diet, exercise, and stress reduction, all of which make patients responsible for their own health. And finally, if this does not work, then we will consider medication. Medication is not always the first option.

MO: No question about it. And first and foremost is “do no harm.” And that’s where Life Extension^® is really ahead of the curve with its emphasis on prevention. You know a lot of the interventions in cardiovascular medicine carry risk. The excessive reliance on CT scans with radiation exposure, surgery, and stent placement all come with potential side effects. We should reserve all those things for people who really need it. For the vast majority of healthy Americans, let’s focus on a healthy diet and lifestyle and supplements or medications, if necessary, to correct metabolic abnormalities—in most cases, that’s going to be adequate.

LE: Thank you for your time, Dr. Ozner, and the information.

If you have any questions on the scientific content of this article, please call a Life Extension^® Health Advisor at 1-866-864-3027.

Michael Ozner, MD, FACC, FAHA, is one of America’s leading advocates for heart disease prevention. Dr. Ozner is a board-certified cardiologist, a Fellow of both the American College of Cardiology and the American Heart Association, Medical Director of Wellness and Prevention at Baptist Health South Florida, a well-known regional and national speaker in the field of preventive cardiology, and a member of Life Extension^®’s Scientific Advisory Board. He is symposium director for Cardiovascular Disease Prevention, an annual international meeting dedicated to the treatment and prevention of heart attack and stroke. He was the recipient of the 2008 American Heart Association Humanitarian Award and was elected to Top Cardiologists in America by the Consumer Council of America. Dr. Ozner is also the author of The Great American Heart Hoax, Heart Attack Proof, and The Complete Mediterranean Diet.

For more information on Dr. Michael Ozner, visit www.drozner.com.