How accurate is LDL cholesterol?

17. August 2006 William Davis (0)
Watch TV and you'd get the impression that the world revolves around LDL cholesterol: Commercials for Lipitor, Zetia, Vytorin, etc., all drugs to reduce cholesterol (total and LDL). Your doctor looks first and often only at LDL cholesterol.

If there's so much attention paid to LDL, how accurate is it? 100%? 90%? 80%?

Well, it varies widely. Occasionally, it's truly accurate, but most of the time it's miserably inaccurate . Every single day, I see people with LDL cholesterols that underestimates true (measured) LDL by 40%, 50%, and even over 100%. In other words, LDL cholesterol might be 120 mg/dl by the conventional method, but the genuine measured value might be 160 mg/dl, or even 240 mg/dl. It can be that far off--and it's not rare.

The converse can occasionally be true, though rarely in my experience: that conventional LDL overestimates true LDL. I saw someone in the office today like this, with a conventional LDL of 142 mg/dl but a true measured LDL of 115 mg/dl. I may see one or two more people like this the rest of this year.




Why is LDL so inaccurate? Several reasons:

--LDL in most labs is calculated, not measured. The "Friedewald calculation" derives LDL by substracting HDL and triglycerides (divided by 5) from total cholesterol. The higher triglycerides are, especially above 150 mg/dl, the more inaccurate the calculation becomes. As HDL drops below 50 mg/dl, this also introduces greater and greater inaccuracy.

--LDL particles vary in size. A more accurate representation and measure of LDL's dangers are therefore found in measures of LDL particle number , rather than a weight-based measure or calculation. LDL particle number can be measure as just that, LDL particle number (NMR), or as apoprotein B, the protein in LDL that occurs one apoB per LDL.

I liken conventionally calculated LDL cholesterol to a broken speedometer. You simply won't have an accurate measure of how fast you're going, though you may have a ballpark sense. But try telling that to the state patrol.

Or, as a cardiologist colleague said to me in a similar conversation about LDL: "Well, it's better than nothing!"

The lesson: If you're interested in plaque control, and control or reduction of heart scan score, you need a measured LDL, preferably LDL particle number by NMR or an apoprotein B. Another option is "direct" LDL.
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Apple Cranberry Crumble

Apple Cranberry Crumble

18. November 2012 William Davis (0)
Apple, cranberry, and cinnamon: the perfect combination of tastes and scents for winter holidays!

I took a bit of carbohydrate liberties with this recipe. The entire recipe yields a delicious cheesecake-like crumble with 59 “net” grams carbohydrates (total carbs – fiber); divided among 10 slices, that’s 5.9 grams net carbs per serving, a quantity most tolerate just fine. (To reduce carbohydrates, the molasses in the crumble is optional, reducing total carbohydrate by 11 grams.)

Other good choices for sweeteners include liquid stevia, stevia glycerite, powdered stevia (pure or inulin-based, not maltodextrin-based), Truvía, Swerve, and erythritol. And always taste your batter to test sweetness, since sweeteners vary in sweetness from brand to brand and your individual sensitivity to sweetness depends on how long you’ve been wheat-free. (The longer you’ve been wheat-free, the less sweetness you desire.)


Crust and crumble topping
3 cups almond meal
1 stick (8 tablespoons) butter, softened
1 cup xylitol (or other sweetener equivalent to 1 cup sugar)
1½ teaspoons ground cinnamon
1 tablespoon molasses
1½ teaspoons vanilla extract
Dash sea salt

Filling
16 ounces cream cheese, softened
2 large eggs
½ cup xylitol (or other sweetener equivalent to ½ cup sugar)
1 Granny Smith apple (or other variety)
1 teaspoon ground cinnamon
1 cup fresh cranberries

Preheat oven to 350° F.

In large bowl, combine almond meal, butter, sweetener, cinnamon, molasses, vanilla, and salt and mix.

Grease a 9½-inch tart or pie pan. Using approximately 1 cup of the almond meal mixture, form a thin bottom crust with your hands or spoon.

In another bowl, combine cream cheese, eggs, and sweetener and mix with spoon or mixer at low-speed. Pour into tart or pie pan.

Core apple and slice into very thin sections. Arrange in circles around the edge of the cream cheese mixture, working inwards. Distribute cranberries over top, then sprinkle cinnamon over entire mixture.

Gently layer remaining almond meal crumble evenly over top. Bake for 30 minutes or until topping lightly browned.
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Wheat five times a day

Wheat five times a day

20. April 2007 William Davis (3)
Terri couldn't understand why her weight wouldn't drop.

At 5'3", 208 lbs., she had the typical mid-abdominal excess weight that went with small LDL, low HDL, high triglycerides, a post-prandial (after-eating) fat clearance disorder, high blood sugar, increased c-reactive protein, and high blood pressure.

She claimed to have tried every diet and all had failed. So we reviewed her current "strict" diet:

"For breakfast, I had Shredded Wheat cereal in skim milk. No sugar, just some cinnamon and a little Splenda. For lunch, I had low-fat turkey breast sandwich--no mayonnaise--on whole wheat bread. For snacks, I had pretzels between breakfast and lunch, and a whole wheat bagel with nothing on it before dinner. For dinner, we had whole wheat pasta with tomato sauce and a salad. While we watched TV, I did have a couple of whole wheat crackers.

"I don't get it. I didn't butter anything, I didn't sneak any sweets, cakes, I didn't even touch cookies. And I love cookies!"

Did you see the pattern? I pointed out to Terri that what she was doing, in effect, was eating sugar 5 or more times a day. Many of her meals, of course, contained no sugar. All were low fat. But the excessive wheat content yielded quick conversion to sugar--glucose--immediately after ingestion.

Repeated surges of blood sugar like this trigger the excessive insulin response that yields low HDL, higher triglycerides, small LDL, etc., everything that Terri had.

Terri was skeptical when I suggested that she attempt an "experiment": Try a four week period of being entirely wheat-free. This meant more raw nuts and seeds, more lean proteins like low-fat yogurt and cottage cheese, chicken, fish, lean red meats, more vegetables and fruits.

After only two weeks, Terri dropped 5 1/2 lbs. She also reported that the mood swings she had suffered, afternoon sleepiness, and uncontrollable hunger pangs had all disappeared. The mental cloudiness that she had experienced chronically for years had lifted.

What happened was that the load of sugar from wheat products, followed by an insulin surge then a precipitous drop in sugar, and finally fogginess, irritability, and cravings for food all disappeared. With it, the entire panel of downstream phenomena (small LDL, CRP, etc.) all faded.

Though she started out intending to complete a four week trial, I believe that, having seen the light, she will continue to be wheat-free, or nearly so, for a lifetime.
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Comments (3) -

  • Anonymous

    4/27/2007 9:20:00 PM |

    This description fits me to a 'tee' - including the unsuccessful attempts at dieting.

    I was a low-fat vegetarian with a wheat-heavy diet for 12 years.  I was convinced of the healthiness of my eating plan, despite the slow weight gain, ever-higher blood pressure, tryglicerides and cholosterol numbers.  It wasn't until my doctor shocked me with a diagnosis of Type 2 Diabetes that I realized the problem was how I was eating.

    After 9 months of a wheat-free and starch-free diet, a re-introduction of animal proteins from free-range poultry and wild seafoods, and much organic produce and nuts and seeds, I have shed 60 pounds - almost effortlessly.  My waist circumference is back to normal as are all my 'numbers'.  Without any medication.

    But no one could have convinced me prior to the diagnosis shock:  I was that successfully brainwashed by the conventional low-fat wisdom.

  • Dr. Davis

    4/28/2007 2:22:00 AM |

    Eloquently said.

    I fear that there's an entire nation that would concur, if they were aware. Sound the alarm!

  • Jonathan Byron

    4/22/2009 1:41:00 PM |

    You have repeatedly mentioned wheat and corn starch as culprits in a wide variety of disease factors. How much of this is specifically those two foods, and how much is the carb content (and the fact that these are so widely consumed in the west)? Our household is wheat-free (hashimoto's disease in one member), but we eat corn chips, corn tortillas and and corn noodles. Would switching from corn to rice be a logical next step, or would a low-carb diet with fewer grains of all types be better??

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"I don't know what I'm doing here"

"I don't know what I'm doing here"

25. October 2006 William Davis (0)
Jim came to the office at the prompting of his wife.

At age 52, Jim was semi-retired, having to work only a few hours a week to maintain his business. He'd had a high cholesterol identified about 10 years earlier and had been taking one or another statin drug ever since.

However, Jim's wife was a pretty savvy girl and understood the inadequacies of the conventional approach to heart disease prevention. Nonetheless, when Jim came in, he declared, "I feel great. I don't know what I'm doing here!"

I persuaded Jim to undergo a heart scan. His score: 2211, in the 99th percentile (the worst 1% for men in his age group). However, it was worse than that. Any score above 1000 carries a heart attack risk of 25% per year unless prevention issues are fully addressed.

Indeed, Jim proved to have far more than a high LDL cholesterol. Among the patterns uncovered with his lipoprotein analysis were small LDL, the postprandial (after-eating) abnormality of intermediate-density lipoprotein (IDL), and high triglycerides and VLDL. All would require correction if Jim is to hope to gain control of his extensive coronary plaque.

The message: Trying to discern risk for heart disease from cholesterol is complete folly. This man was going to die or have an urgent major heart procedure within the next year or two, all while taking his statin drug.

Discard the silly notion that cholesterol tells you everything you need to know about heart attack risk. It does not. It helps a little but leaves vast voids in risk determination. Fill those gaps with a heart scan, plain and simple.
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Back to basics: Coronary calcium

Back to basics: Coronary calcium

30. January 2012 William Davis (42)
After having my attentions pulled a thousand different directions these past 6 months, with the release of Wheat Belly and all the wonderful media attention it has attracted, I've decided to pick up here with a series of discussions about the fundamental issues important to the Track Your Plaque program and prevention and reversal of coronary atherosclerotic plaque.

I fear the discussions at times have drifted off into the exotic. This is great because this is how we learn new lessons, but we can never lose sight of the basics, else we risk losing control over this disease.

Imagine you've got a beautiful new car. You wax it, gap the spark plugs, rotate the tires, etc. and it looks brand-new, just like it came off the dealer's lot. 50,000 miles pass, however, and you realize you've forgotten to change the oil. Ooops! In other words, no matter how meticulous the attention to transmission, tires, and paint job, neglect of the most basic responsibility can ruin the whole thing. We can't let that happen with heart health.

If we propose to reverse coronary atherosclerotic plaque, we've got to have something to measure. First, it tells us whether we have atherosclerotic plaque in the first place, the stuff that accumulates and blocks flow and causes anginal chest pains, and ruptures like a little volcano and causes heart attacks. Second, it gives us something to track over the years to know whether plaque has grown, stopped growing, or been reduced. Without such a measure, you will be driving without a speedometer or odometer, just guessing whether or not you've gotten to your destination.

Of course, the conventional approach to heart disease and heart attack is not to track atherosclerotic plaque in your coronary arteries, but to track some distant "risk factor" for atherosclerotic plaque, especially LDL cholesterol. But LDL cholesterol is flawed at several levels. First, it is calculated, not measured. The nearly 50-year old Friedewald equation used to calculate LDL cholesterol is based on several flawed assumptions, yielding a value that can be 20, 30, or 50% inaccurate as a rule, only occasionally generating a value close to the real value. (No point in publicizing this problem, of course: Why compromise a $27 billion annual cash cow?) It also ignores the effect of diet. (No, cutting fat does not reduce LDL for real, only the calculated value. Cutting carbohydrates, especially wheat--"healthy whole grains"--slashes measured LDL values like NMR LDL particle number and apoprotein B.)

But all risk factors are, at best, snapshots of the situation at that moment in time. They change from day to day, week to week, month to month, year to year. If you do something dramatic in health, like lose 50 pounds, you can substantially change your risk factors values, like LDL cholesterol and HDL cholesterol. But you may not modify the amount of atherosclerotic plaque in your heart's arteries.

Measuring the amount of atherosclerotic plaque in your heart's arteries is, in effect, a cumulative expression of the effects of risk factors up until the moment of measurement.

There are several stumbling blocks, however, in the concept of measuring coronary atherosclerotic plaque. We cannot measure all the unique components of plaque, such as fibrous tissue like collagen, or degradative enzymes like collagenases, or inflammatory proteins like matrix metalloproteinase, or the debris of hemorrhage and inflammation. We struggle to contemporaneously mix in measures of bloodborne inflammation, coagulation and viscosity, and physiological phenomena of the artery itself, like endothelial dysfunction, medial (muscle) tone, and adventitial fat.

So we are left with semi-static measures of total coronary atherosclerotic plaque like coronary calcium, obtainable via CT heart scans as a calcium "score." No, it is not perfect. It does not reflect that moment's blood viscosity, it does not reflect the inflammatory status of the one nasty plaque in the mid-left anterior descending, nor does it reflect the irritating sheer effects of a blood pressure of 150/95.

But it's the best we've got.

If anyone has something better, I invite you to speak up. Carotid ultrasound, c-reactive protein, ankle-brachial index, stress nuclear studies, myoglobin, skin cholesterol, KIF6 genotype . . . none of them approach the value, the insight, the trackability of actually measuring coronary atherosclerotic plaque. And the only method we've got to gauge coronary atherosclerotic plaque that is non-invasive and available in 2012? Yup, a good old CT heart scan calcium score.
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Comments (42) -

  • cancerclasses

    1/30/2012 4:58:24 AM |

    What about Pulse Wave Velocity (PWV) and Digital Pulse Analysis (DPA)?  
    From the Townsend Letter May 2010 article "Breakthrough in Clinical Cardiology: In-Office Assessment with Pulse Wave Velocity (PWV) and  Digital Pulse Analysis (DPA) by Brian Scott Peskin, BSEE, with Robert Jay Rowen, MD":  http://goo.gl/vihZO
    "This article explores an exciting, noninvasive, easy-to-use, and economical method of assessing patients’ cardiovascular physiologic status that is backed by more than 25 years of advanced research in medical physics. A 2007  Clinical Medicine article points the way to better clinical treatment of CVD, stating: “Arterial stiffness measured by pulse wave velocity (PWV) is an accepted strong, independent predictor of cardiovascular events and mortality.” 1   Anesthesiologists are well aware of this technology, used for monitoring purposes. While pulse oximetry became standard in the operating room and in other critical care areas as a detector of hypoxemia – all pulse oximeters are fundamental photoelectric plethysmographs – PWV has been largely ignored. This is unfortunate, as PWV (plethysmographic) information itself may provide important clues regarding the CV condition of the patient.2  With this advanced technology, cardiovascular science has moved forward, but many physicians have yet to appreciate these advances. As stated in the 1993 issue of the Journal of Hypertension, “Wave reflection is not a subject with which most physicians are familiar and only given mention in undergraduate physiology courses.” Little has changed.

    As this article was going to press, however, “Arterial Stiffness
    and Cardiovascular Events: The Framingham Heart Study,” by
    Gary F. Mitchell, MD, et al. (Circulation. 2010;121:505–511)
    was published and featured on Medscape, stating: “In this
    study, we assessed the incremental value of  adding pulse
    wave velocity [PWV] ... to a risk model that includes standard
    risk factors for a first cardiovascular event. … Adding pulse
    wave velocity led to significant reclassification of risk and
    improvement in global risk prediction. … [W]e need to focus
    our efforts on identifying and implementing interventions that
    can prevent or reverse abnormal aortic stiffness in order to
    prevent a marked increase in the burden of disease potentially
    attributable to aortic stiffness.”  The specific intervention/
    solution will be given later in this article."

    Also, "This video is a preview of a lecture given at the 2010 18th international A4M conference in Orlando."  http://goo.gl/S1xth

    Disclosure: I have no known conflicts of interests in conveying this information, I do not own stock or any financial interests in any of the companies making or distributiing this equipment.

  • Anne

    1/30/2012 5:55:03 AM |

    Hi Dr. Davis, I had a CT scan done about 5 years ago and the results were frightening, it was 1050. I was shocked because I ate healthy, low fat, plenty of healthy  wheat, how could this happen. My Dr. sent me for an EKG ultrasound and ever test possible and all  the tests were perfect. As you know I have changed to no wheat, high fat, low carb way of eating and I gained 5 lbs but my triglycerides came down to 61, LDL is 153 . My other numbers are high but I read that can happen when you have hypothyroidism c reactive protein is 0.7 MG/L. My Dr. said that the clinic that tested my CT scan are no longer in business in Michigan so I don't know if the plaque improved or got worse, any suggestions?

  • Donald Kjellberg

    1/30/2012 7:58:51 AM |

    I have been thinking about the subject of getting back to the basics a great deal lately.

    Trying to synthesize everything into one concept made me realize how complex this whole process of prevention is. I too have been peering into windows on the road of better health.  What a complex and wonderful set of the diversity our homeostatic responses convey.

    What are the basics to me now? I'll serve it up in one word, food . . .

    What we eat determines profoundly how our body responds to the many factors contributing to heart disease (and other systems dysfunctions). One thing I learned along the way is over 50 different species of bacteria have been identified in arterial plaque (in addition to other pathogens).

    Going back to the basics tells me to eat foods that not only reduce markers associated with heart disease but also considers dietary factors that may optimize immune responses and pathogen suppression. Cutting out wheat provides great capital in healing the gut. It sets the groundwork for improved cellular communication and neurological feedback mechanisms.

    . . . and that's getting back to the basics. It sure isn't simple, but learning to prepare and serve up the right type of foods sure can sweeten the journey even if it gets us of track every now and then.

  • JC

    1/30/2012 1:06:30 PM |

    I have a friend who had a 16 slice scan and had a 0 calcium score.Several week after the scan he had a heart attack.Can you point out some studies which show the correlation of calcium scores to cardio incidents?What is the data to suggest it's a better marker than the others such as cholesterol,CRP,etc.

  • JC

    1/30/2012 1:17:26 PM |

    I'm on a near vegan diet as recommended by Dr Joel Fuhrman.It did not solve all my medical issues but it did tame my blood glucose(from the 130s to the low 80s)and my blood pressure(from 210/110  to 125/70).When I tried a diet heavy in meat and fat and low in carbs(50G/day)my blood pressure went up to 150/85.I have a type of salt sensitive hypertension(low renin) that may be a factor.Comments?

  • nina

    1/30/2012 7:57:37 PM |

    I have a friend who has had a stent, bypass and several cardiac incidents.  I find it tough to persuade him to follow your regimen and he's terrified that areas of his heart muscle have died and that there is no hope for him.

    Do you have examples of people who have successfully recovered from such a dire state of health in their 60's?  

    Nina

  • Ronnie

    1/31/2012 1:07:20 AM |

    My 54-year old husband also received a score of 0 on his 64-slice CT scan.  He's had no heart issues, however, he is overweight, has hypertension, he's insulin resistant and he has low HDL and elevated ApoB and LDL-P.  Because of his 0 score he feels he's not at risk.  How can I convince him otherwise?

  • Dr. William Davis

    1/31/2012 2:27:23 AM |

    Yes, I have, Nina. But the answers cannot be found in conventional healthcare with yet more procedures and drugs.

  • Dr. William Davis

    1/31/2012 2:29:13 AM |

    There's no comparison. Coronary calcium scores as a measure of coronary atherosclerosis wins, hands down.

    But it is not perfect. While heart attacks at a score of zero are distinctly uncommon, they can happen.

    For a full discussion of the studies documenting this, I would invite you to read the Track Your Plaque book available through the www.trackyourplaque.com website.

  • Dr. William Davis

    1/31/2012 2:29:49 AM |

    Hear, hear, Donald! You are singing my tune.

  • Dr. William Davis

    1/31/2012 2:30:54 AM |

    Hi, Anne--

    Yes, simply find another center that performs heart scans. They are actually done fairly widely now. It's often not advertised since, like mammograms, they don't make any money.

  • Dr. William Davis

    1/31/2012 2:31:49 AM |

    HI, Cancer-

    You are getting in to issues like endothelial dysfunction that are beyond the scope for this discussion.

    Perhaps something to talk about in future.

  • cancerclasses

    1/31/2012 9:22:08 PM |

    Well to me it''s kinda all the same but I''m also not a practicing cardiologist, and I may have been influenced by this: http://goo.gl/lfsQ7
    "Endothelial dysfunction is thought to be a key event in the development of atherosclerosis and **predates** clinically obvious vascular pathology by many years. This is because endothelial dysfunction is associated with reduced anticoagulant properties as well as increased adhesion molecule expression, chemokine and other cytokine release, and reactive oxygen species production from the endothelium, all of which play important roles in the development of atherosclerosis. In fact, endothelial dysfunction has been shown to be of prognostic significance in predicting vascular events including stroke and heart attacks. Because of this, endothelial function testing may have great potential prognostic value for the detection of cardiovascular disease, but currently the available tests are too difficult, expensive, and/or variable for routine clinical use."  

    I know tests have real costs associated with them, but is seem like DPA/PWV  plus the 64 slice MDCT plus coronary calcium would give a fairly complete picture.  I notice two of the three used in this report with the DPA performed at a later date. http://goo.gl/MS6Gp

  • cancerclasses

    1/31/2012 10:32:21 PM |

    The Oxidized LDL Triple Marker test?

  • PeteKl

    2/1/2012 3:02:01 AM |

    Hi Nina,

    It is hard to say what your friend''s future might hold without knowing how much damage has been done by his "cardiac incidents".  However assuming he is not bedridden, I wouldn''t call his situation hopeless.  If he can still walk around and climb a flight of stairs, I would guess there is still a reasonable amount of heart function left to enable him to live a mostly normal life.  He just needs to avoid losing even more.

    I am younger than your friend (48), but I also had a (very unexpected) MI and emergency bypass a little over a year ago.  My MI was rather mild, but it definitely did some damage.  I am well aware of the fear and sense of hopelessness that your friend is feeling.

    I started following the Doctor''s program about 10 months ago.  I can''t say for sure whether it will help or not, but it definitely makes my numbers look good so I am optimistic.  I would like to have a heart scan to track my own situation, but most places won''t do them if you have already had bypass so I am flying a little blind (BTW Doctor, has there been any change in this situation?).  I also started cardiac rehab a few weeks after my surgery and now exercise at least an hour a day 5-6 times a week.

    I''m not sure what to attribute this to (probably a combination of things), but I am pretty much back to normal.  I was never a super athlete, but I feel I can do anything a normal, fit 48 year old man can do and then some.  This was even confirmed by a recent stress test.  

    For example, I am currently on vacation and spent my afternoon swimming in the ocean and walking several miles up and down the boardwalk.  If someone had told me something like this was possible a year ago, I would have told them they were full of it.  Yet here I am.  

    So do I think your friend could recover? Yes I do.  He may not do as well as I have, but I suspect he can likely do much better than he thinks possible.  However it will take time and effort and may require taking  a few chances like trying the Doctor''s program (his own doctors probably won''t be thrilled).  Sitting at home waiting for a miracle likely won''t work.

    One thing I should mention is that resolving your friend''s difficulty may require more than just fixing his heart.  Having a major cardiac event is extremely traumatic.  Depression and anxiety disorders are common afterward.  From what I have heard, as many as 80% experience it.  Unfortunately most doctors won''t tell you this and they definitely don''t want to deal with it.  At best they will prescribe another pill.

    I was fortunate to have a sister who is a professional counselor.  She realized how distraught I was after my surgery and immediately recommend I start seeing someone.  It was great advise.

    The counselor I saw didn''t have any magical advice that suddenly made me feel better.  What she did  was help me work through what had happened and put it in proper perspective.  Once I could  do that, I started finding increasing motivation to get well.  It took a while (I have had at least 30 sessions over that past year), but it works.  BTW, most insurance will usually cover it.

  • Joanna

    2/1/2012 5:12:55 PM |

    I agree with you Pete, my husband, mid-50''s had a very serious MI about four months ago, also completely unexpected as he appeared in great health with no risk factors.  And although we don''t have all the answers yet about how much damage was done, we know it was a lot.  He is exercising at rehab (he was a regular exerciser before) as well as on his own and has been feeling almost like himself - and considering how serious his condition was this is pretty amazing.  He was already doing a number of the things Dr. Davis advocates and has since added more.
    Pete, if I may ask, do you know what your ejection fraction is now and what it was post MI?  We are struggling to get answers at this stage as to whether this will ever improve and how long it may take.  His is still low despite how well he feels.

  • nina

    2/1/2012 8:26:07 PM |

    Many thanks for the responses.  

    I know that conventional treatments aren''t the answer, but convincing my friend of that is another challenge.  I seem to have several friends who think reducing carbs is harmful and unnatural.  (I''m off sugar and grains, substituting almond flour, flax and desiccated coconut without any problem.)

    Nina

  • Ronnie

    2/2/2012 2:29:40 AM |

    Why aren''t most doctors doing calcium scoring tests instead of stress tests that only show late stage blockages?  If heart attacks occur when arteries are slightly blocked, it appears that calcium scoring should be the first test done on high risk patients.  Is it because the medical community is slow to accept change from the usual way of doing things?  Or is it the fault of the insurance companies who are notorious for not paying for new fangled tests?  I''m a total layman, but I''m high risk (APOE4) and the only test I received was a nuclear stress test (which was negative).  If I want to know my calcium score, I would have to pay $500 out of my pocket to Princeton  Longevity Ctr to have them do it as my doctor will not order it.

  • PeteKl

    2/2/2012 6:46:48 AM |

    Hi Joanna,

    As I mentioned, my MI was rather mild and I don''t think my EF ever went down substantially.  During my surgery (which started about 12 hours after my MI) my EF was measured at 55 percent.  A few weeks ago when I had my stress echo I measured 60 percent at rest and 55 percent under stress (to my knowledge these values are considered normal for most people).  I will admit that overall I was luckier than most people in this area.

    However keep in mind EF only gives you part of the picture.  There are many other variables.  A person can have a completely normal EF and still have major problems.  During my surgery my heart rhythm was very unstable.  My surgeon originally wanted to do a triple bypass but he ended up skipping the third one because he decided it was too risky.  On the other hand someone can have a low EF and still live a long and active life.

    Even if I had your husband''s full medical record, I can''t tell you exactly what his EF means.  You really need to discuss this further with his doctor.  However the following statement you made I think gives a good indication of where you probably stand:

    “He is exercising at rehab (he was a regular exerciser before) as well as on his own and has been feeling almost like himself – and considering how serious his condition was this is pretty amazing.”

    You are right.  This is pretty amazing.  Based on my own experience at cardiac rehab this doesn''t always happen.  I know it isn''t very scientific, but if he looks good and feels good he is probably doing just fine.  His EF might be low, but it must be high enough or he would be having all kinds of problems.

    While it might be nice to see a higher EF, from what you have described I''m not sure it would make a big difference.  It sounds like he either can or soon will be able to do everything he was capable of pre-MI.  If this is correct, it is fantastic news.  Personally I would probably stop worrying about his EF and instead concentrate on making sure he continues to retain every bit of heart muscle he has left.  

    However I am by no means an expert on all of this.  Perhaps the Doctor can weigh in with some better advice.

  • Renfrew

    2/2/2012 4:40:55 PM |

    Now, the most important question:
    HOW do we get rid of the calcium in our arteries ???
    Does Magnesium help as a calcium  antagonist? Chelation?
    Renfrew

  • Gene K

    2/2/2012 7:44:52 PM |

    Why $500? I paid $85 to have my calcium score heart scan done at a local hospital in the Chicago area. Check with radiology departments in the area hospitals.

  • Gene K

    2/2/2012 7:46:25 PM |

    Read Dr Davis''s Track Your Plaque book, 2nd edition, to get the answer.

  • Renfrew

    2/2/2012 8:04:53 PM |

    Dr. Davis,
    I am living in Germany and cannot get the book. About 6 months ago you said you will make it available in downloadable pdf format. Any progress on this front?
    Thanks.
    Renfrew

  • Ronnie

    2/2/2012 8:50:03 PM |

    I was thinking that the 64 slice CT scan was  the only test that measured calcium score, and Princeton Longevity charges $500 (give or take) for it.  I could get it there without a prescription; I would think I''d need a prescription to get the test at a hospital.  I''ll look into it, thank you.

  • Joanna

    2/2/2012 8:50:11 PM |

    Thanks so much Pete.  And you are right, we are doing everything we can to retain as much heart muscle as we can - unfortunately we have been told that with such a low EF, even if he feels great, he is at much greater risk of sudden cardiac arrest and may need an ICD (an internal defibrillator) implanted - something that is both very expensive and may interfere with some of the work he does.  So we wait.  We have been told that his EF may come up over time but no one will give us any odds of this happening (for some people it seems it never does) or over how long a period of time it may take to improve.  

    I would also like to tell Nina to urge her friend to do cardiac rehab/exercise as this seems to be one of the differences between people who are successful in their recovery and those who aren''t.

  • Gene K

    2/2/2012 9:34:12 PM |

    No prescription was necessary in my case. They sent the results to me directly, and also to the doctor who they asked me to specify.

  • Gene K

    2/2/2012 10:16:57 PM |

    Yes, the book is available for download for TYP members.

  • PeteKl

    2/3/2012 6:12:17 AM |

    Hi Joanna,

    I''m going to make a guess here (and hopefully someone who knows more about this will correct me if I am wrong), but I suspect the issue isn''t so much a low EF by itself, as much as it is that a higher EF indicates greater recovery of the damaged heart muscle.  My understanding is that when an MI causes damage to heart muscle, it usually isn''t the loss of pumping capacity that causes death.  Instead the loss of muscle causes an electrical disturbance in the heart''s rhythm causing it to lose its ability to pump  blood.  This is why even a mild MI like mine can be fatal and explains why my surgeon was so concerned (See http://en.wikipedia.org/wiki/Myocardial_infarction#Pathophysiology).

    I suspect what your husband''s doctor might be concerned about is that he may be having a certain amount of arrhythmia because of the damage to his heart.  Apparently this is quite common after an MI and it is also something doctors don''t typically explain very well (at least mine didn''t).  

    After my surgery I was put on the drug amiodarone to help control my heart rhythm (which it did).  However this drug has some rather nasty side effects so they try to pull you off of it as soon as possible.  I stopped taking it after about a month and almost immediately developed some arrhythmia.  

    Fortunately the type of arrhythmia I developed (PVC''s) are usually considered benign.  But it was still extremely disconcerting since no one really explained to me what was going on.  The only thing I was ever told (or at least ever heard) was probably the same thing you have heard 50 times – “if you have any chest discomfort or shortness of breath, go to the emergency room” (needless to say this is not comforting advice).

    I am still having some PVC''s, but they have become increasing less frequent.  The bottom line is that the heart can essentially rewire itself, but it takes time.  Part of the point I am trying to make is that this might occur even if his EF doesn''t change.  

    Again this is a guess since I don''t have much information, but I suspect your husband''s doctors may be waiting to see how well your husband''s heart repairs itself (which may take a year or more) and they will then decide if he needs an ICD.  I''m also guessing they are currently controlling his heart rhythm with some type of drug (there are many) and they eventually want to take him off of it.

    Unfortunately it is my understanding that all you can do is wait.  There is currently no way of predicting who will fully recover and who won''t.  There are simply too many variables.

    However I think there are several factors in your husband''s favor.  The first is that he is young and most of his body''s natural repair mechanisms (which are considerable) are still functional.  

    He is also enthusiastic about doing his cardiac rehab.  The gradual stress of exercise essentially helps remodel and strengthen the heart.  Oddly enough many people don''t do this.  I''m sure your husband has already noticed that many patients quit cardiac rehab (and most likely stop exercising)  at the end of Phase II (about 12 weeks).  Just the fact that your husband is willing to continue with an exercise program puts him in a completely different class.

    Finally he is willing to modify his lifestyle.  He is changing the way he eats and, unless you are withholding something, probably doesn''t smoke or have some other equally bad habit.  When I was recovering from my surgery, my younger brother was in one of the waiting rooms when another patient, who had obviously also recently had heart surgery, was wheeled into the room next to him and started a conversation.  At some point during the conversation the man turned to my brother and said “I really hope when I get out of here they will let me smoke again”.  Like I said, your husband is in a completely different class.

    I know there are at least a few supplements out there that may help heal a heart''s electrical system.  Magnesium and CoQ10 are two that I have heard might help (try googling them for more info).  I doubt they will cause a miraculous recovery, but they might give him that little extra kick that helps him avoid the ICD.  I''m sure there are others on this site that know a hundred times more than I do.  Assuming what I have discussed is even roughly correct, perhaps a few of them can make an even better recommendation.

    I know all of this is frustrating, but try not to give up hope yet.  Four months is still early in the recovery process.  I remember being told that recovery would take at least a year and that turned out to be about right.  Also keep in mind (as I''m sure you have already discovered) that the recovery process is typically a series of two steps forward and one step back.

    BTW, no matter what might happen, please remember your husband is extremely fortunate to have you by his side.  There are many people who don''t have a person they can rely on to help figure this all out.  I doubt my recovery would have been as successful as it has been without the help I received from my partner and my family.  I now understand why so many people simply give up.  The recovery process simply becomes too overwhelming.

  • Roger

    2/4/2012 10:01:12 PM |

    I''ve gotten my calcium score for $50 at a DFW hospital with a 50% off coupon.  The result didn''t take 10 minutes to come out: a big zero! I will be back in 5 years.

  • Ronnie

    2/5/2012 2:47:57 PM |

    Gene, how was your score if you care to share?

  • Gene K

    2/5/2012 6:49:23 PM |

    No secret here, but unless zero, the dynamics are more important than the absolute number. At least, if I understand the whole TYP program correctly. My score was 213 in Feb 2010 and 191 this time, in Sep 2011.

  • Ronnie

    2/5/2012 10:05:46 PM |

    You''re going in the right direction, Gene.   That''s great!

  • Dr. William Davis

    2/7/2012 3:59:06 AM |

    Hi, Renfrew--

    We make the Track Your Plaque Guide available to our members without charge (except our membership fees to cover the costs of operating the website).

  • Dr. William Davis

    2/7/2012 3:59:40 AM |

    Hi, Ronnie--

    The laws differ from state to state. You can always call a center and ask.

  • Stan (Heretic)

    2/9/2012 3:25:12 AM |

    @JC,

    I hope Dr. Davis will respond, and I hope you don''t mind if I respond meantime. (Dr. Davis, please  correct me if my post is not accurate enough)

    I am not a doctor but 150/85 that you had on a high meat, fat and low carb, seems still OK!   Its not clear to me why did you have to change that diet?   Have you not quit a LC diet too prematurely  perhaps?  Experiences of other high fat low carb nutrition proponents in Europe (see especially  books by Dr. J.K.)  have shown that it takes about 2 years to see a significant effect upon cardiovascular health for patients with advanced arteriosclerosis.      

    I hope Dr. Davis can step in to, clarify this.  I know you are above retirement and male but it may help to provide your exact age and a history of your hypertention.  Even if you were practicing some sport and have clear coronary arteries, your peripheral arteries may still be partially occluded creating a condition conjusive towards a hypertention.   AFAIK it is possible to have clear coronary (heart) artieries and at the same time have occluded peripheral arteries.   Also your pre-diabetes may have been a factor too on the SAD since high insulin makes arteries less flexible.
    Stan

  • JC

    2/9/2012 1:40:33 PM |

    Thanks Stan,I looked at my old blood pressure readings to refresh my memory and many of the readings were in the low 170s/90 but the median score was around 156-160/85-88.The rapid rise scared me but it was fun while it lasted because I love butter,meat,cheese,and tons of fat.I don''t know how my low renin hypertension fits into this but I am very sensitive to sodium/salt.The only salt/sodium I get is that found naturally in vegetables,beans,nuts,and potatoes.
    Many years ago (around 2006) you posted some data that correlated blood pressure with cornary events and the link was not as strong as you would expect given all the hysteria about blood pressure.I would have to be convinced blood pressure in the 170s and 180s was not that serious before I would go back to the paleo style diet again.My near vegan diet has also tamed my blood glucose which is now consistently below 85.Before that in was in the 97-99 range.A number of years ago before I lost about 80 lbs it was in the mid 130s.

    So going back to a plaeo style diet I would have to accept higher blood pressure and blood glucose levels....170sBP and high 90s FBG.If I am convinced that those levels are safe it would change my perspective.

  • David

    2/12/2012 8:08:15 AM |

    Dr. Davis,

    Can you clarify the issue of measuring soft plaque?  My understanding is that soft plaque is more unstable and therefore more of a concern that hard plaque.  Does a Ca score infer soft plaque so gives us some sense of soft as well as hard plaque, or gives us no indication at all of soft plaque?  Would the PLA2 test be a better marker of soft plaque than the Ca score?

    Thanks for your great work!
    David

  • David

    2/22/2012 5:09:52 AM |

    Followup to my last question:
    wouldn''t a carotid ultrasound give us a better sense of soft plaque?  Combined with results for PLA2?

    David

  • Emidio

    3/12/2012 11:33:53 PM |

    Another form of very dangerous form of LDL...the glycated one:
    http://diabetes.diabetesjournals.org/content/60/7/1973.full

  • Dr. William Davis

    3/16/2012 12:34:28 AM |

    Absolutely. See the several blog posts back some time about this.

    Also a full length Special Report on the Track Your Plaque website will be coming out.

  • Joanie

    2/8/2013 8:46:56 PM |

    Can someone clarify which CT scan is the recommended "coronary calcium score"? I have been told by 2 medical centers here that they perform BOTH 1.) a "coronary calcium score" CT scan which costs (approximately) $150 and uses no contrast material. In that test, they scan the area from the top to the bottom of the heart, and visualize calcium that may exist in that field. This would include part but not all of the lungs, plus all of the heart.

    2.} a coronary calcium scan CT which costs (approx) $1,700 and does use contrast material, injected into a vein. The scan visualizes the heart aided by the contrast in the vessels. This also is a way to measure calcium.

    WHICH test does Dr. Davis recommend? I've been searching the blog and find repeated mentions of "calcium score" but must have missed a way to discriminate which CT test is the right one? Would appreciate any help with this. Thanks!

  • patricia sage

    3/13/2014 10:49:16 PM |

    I take Calcium with Vitamin K2.
    Vitamin K2 helps direct calcium to the bones and teeth(where it belongs), keeping the calcium from attaching itself to the arteries.
    Natural sources are Natto, egg yolk, butter...problem is I don't like the cholesterol in egg yolk and butter and I don't like the taste of Natto.
    I found this online and order it online as well http://tinyurl.com/q8fjc93
    It is made in USA; head office is in California. That's why delivery and shipping is free in USA. Delivery took about 3 to 7 days.  It has Omega 3+ as well as CoQ10 and Vitamin K2 and it is Extended release(long-term effect).

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A stent--just in case

A stent--just in case

26. March 2007 William Davis (3)
Burt came to me last week. He'd received a stent a few months earlier. He'd been feeling fine except for some fatigue. A nuclear stress test proved equivocal, with the question of an abnormal area of blood flow in the bottom (inferior wall) of the heart.

"The doctor said I had a 50% blockage. Even though it wasn't really severe, he said I'd be better off with a stent, just in case."

Just in case what? What justification could there be for implanting a stent "just in case"? (The artery that was stented did not correspond to the area of questionable poor blood flow on the nuclear stress test.)

Just in case of heart attack? If that's the case, what about the several 20 and 30% blockages Burt showed in other arteries? The cardiologist was apparently trying to prevent the plaque "rupture" that results in heart attack by covering it with a stent. Why stent just one when there were at least 7 other plaques with potential for rupture?

That's the problem. And that's why stents do not prevent heart attack (unless the stent is implanted in the midst of heart attack, when the rupturing plaque declares itself.) Of course, when no plaque is in the midst of rupturing, as with Burt, there's no way to predict which plaque will do so in future. Since only one plaque was stented, there is a 7 out of 8 chance (87.5%) that the wrong plaque was chosen. And that's assuming that there aren't plaques not detected by catheterization angiogram; there commonly are. The odds that the right plaque was chosen would be even lower.

In other words, stenting one blockage that is slightly more "severely blocked" in the hopes of preventing heart attack is folly. If it's not resulting in symptoms and blood flow is not clearly reduced, a stent can not be used to prevent plaque rupture. A stent is not a device to be used prophylactically. It is especially silly when an approach like ours is followed, since plague progession is a stoppable process.

Note: This issue is distinct from the one in which symptoms and/or an abnormal stress test show clearly reduced blood flow and flow is restored by implantation of a stent. While some controversies exist here, as well, a stent implanted under these circumstances may indeed provide some benefit.
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Comments (3) -

  • Anonymous

    3/26/2007 12:45:00 AM |

    Interesting blog.  I have a question: would you be able to offer some comments on Dr. Ornish reversal programme and low fat vegan diets (in reversing CHD), based on your professional experience?

    We are having a little discussion about various pros and cons of various therapies and dietary approaches on the Web MD forum:

    http://boards.webmd.com/webx?14@1016.MAjDbu7Matv.0@.5987f44c

    We would really welcome you and would greatly appreciate some professional comments.  Sincerely,
    Stan Bleszynski (Heretic)

  • Dr. Davis

    3/26/2007 11:36:00 AM |

    Super low-fat diets, while an improvement over a conventional modern American diet of high saturated fat and processed foods, seriously exagerrate the small LDL particle pattern that is among the most powerful causes known of heart disease. It also reduces HDL and raises triglycerides, sometimes substantially. Dr. Ornish would argue that these are inconsequential changes, since his patients regress. Unfortunately, the methods he uses to gauge regression of atherosclerotic plague are flawed: angiography and nuclear imaging. Both can be envisioned as measures of flow, not of atherosclerotic plaque. Only CT heart scans or intracoronary ultrasound actually measure artery plaque. I tell my patients that, if you want heart disease, follow the American Heart Association diet. If you want heart disease and diabetes, follow Dr. Ornish's diet.

  • Cindy

    3/28/2007 12:47:00 AM |

    I know several people who have gone for a "routine" check with a cardiologist, sent for an angio, and ended up with at least 1 stent. (NO symptoms prompted these visits, just "high cholesterol".

    I also know a couple of people that have 9, 10, or more stents!

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