The dreaded small LDL particle

1. September 2006 William Davis (0)
Brian is a 59-year old landscape architect whose starting CT heart scan score was 276.

Brian's food choices at the start were deplorable: a pound of sausage per week, sometimes more; butter on anything and everything; up to two pounds of cheese per week; hot dogs; etc. His lipoproteins were accordingly just as miserable: low HDL, high triglycerides, excessive (postprandial, or after-eating) IDL. Small LDL was a particularly stand-out pattern, with 95% of all LDL particles in the small category.

Brian made a dramatic turnaround in lifestyle and corrected all of his patterns--except for small LDL. After one year, small LDL still occupied 95% of all LDL particles, even though the quantity of LDL had been reduced. In order to help convince Brian that correction of his small LDL was going to be necessary to achieve control oover coronary plaque, I suggested that he undergo another heart scan. His score: 435, or a 57% increase.

Each day that passes, I gain more and more respect for small LDL as a cause for coronary plaque growth. Conventional thought among lipid experts is that small LDL should no longer be a factor if total LDL (e.g., LDL particle number) is reduced. But our experience suggests otherwise: when small LDL persists, we tend to see continued, sometimes frightening, plaque growth.

I therefore asked Brian to intensify his efforts: additional weight loss off his somewhat prominent abdomen (since visceral fat increases small LDL), further reduce wheat products and processed carbohydrates, increase niacin (to 1500 mg per day), and use more raw almonds and oat bran.

Don't let small LDL get the best of you. It is a nasty, sometimes persistent abnormality that has impressive effects on plaque growth.
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Surviving a widow maker

Surviving a widow maker

11. September 2010 William Davis (19)
Gwen came to me 5 years ago. In her late 60s, she'd been having feelings of chest pressure for the past 4 weeks with small physical efforts, such as climbing a flight of stairs or lifting her grandchildren.

She sat in my office, heaving small sobs, accompanied by her daughter.

Gwen had already undergone a heart catheterization at a hospital near home by a cardiologist who I knew to be honest and competent. She'd been told that she had a 90% stenosis ("blockage") of her proximal left anterior descending (LAD) coronary artery. He called it a "widow maker," since closure of the artery at this point can be fatal within minutes. He advised bypass surgery as soon as possible. Though a stent could be placed at this location, he felt that its proximity to the left main stem (i.e., the "trunk" that divides into the LAD and circumflex arteries) might be jeopardized by expanding a stent in this bulky plaque, what I felt was a reasonable concern.

I reviewed the images that she brought with her. Yes, indeed: a widow maker. The portion of the left ventricle (heart muscle) fed by the LAD was also impaired ("hypokinetic"), reflecting reduced flow through the artery.

I advised Gwen that her first cardiologist's advice was sound: This was a potentially dangerous and severe condition. Either a bypass or stent should be performed near-future, the less delay the better.

But Gwen and her daughter would have no talk of any more procedures. She'd come to me because she heard about the (then rudimentary) effort I'd been making at reversing coronary plaque. "I admire your commitment, Gwen, but I am concerned that there may not be sufficient time to implement a program of prevention or reversal. Prevention is very powerful, but very slow. When symptoms like yours are active, also, it can mean that we won't have full control over the plaque causing the symptoms. This risks closure of the vessel, since flow characteristics in the plaque are abnormal. I think that you should go through a stent or bypass. We can then start your prevention/reversal program once we know you're safe."

Gwen would still have none of it. I asked her to return in a few days after thinking it over. In the meantime, we drew her lipoprotein blood samples while she added fish oil, l-arginine (back then I used a lot of l-arginine for its endothelial health effects), and began the Track Your Plaque diet a la 2004. This was in addition to the aspirin, beta blocker, and statin prescribed by the first cardiologist.

Several days later, Gwen and her daughter returned, as committed as ever to not having a procedure and proceeding with our prevention/reversal efforts.

So off we went. I was nervous about Gwen's safety, but she had clearly made her mind made up. Gwen's lipoprotein analysis revealed a severe small LDL pattern along with markers for prediabetes (high insulin, high blood glucose, hypertension, along with the loose tummy of visceral fat). So I counseled her intensively in diet and added niacin.

Within 2 weeks, Gwen no longer had chest pain. Whether this was due to her efforts or to some resolution of an intraplaque phenomenon (e.g., resorption of internal plaque hemorrhage), I don't know. But her symptoms did not return.

As the program evolved, we added the new strategies along the way--vitamin D supplementation; elimination of all wheat along with other changes in diet; iodine and thyroid normalization; as well as discontinuing l-arginine after the initial two years. She also got rid of the statin drug after losing around 20 lbs on the diet.

It's now been six years with her "widow maker" and Gwen has been fine: no recurrence of her symptoms, all stress tests performed have been normal, reflecting normal blood flow in her coronary arteries.

Should ALL people with symptomatic widow makers undergo such an effort and avoid procedures? No, not yet. Prevention and reversal efforts are indeed powerful, but slow. Some people just may not have sufficient time to accomplish what Gwen did. The fact that Gwen showed evidence for reduced flow in the LAD worried me in particular. There is no question that mortality benefits for stenting or bypass of this location are not as large as previously thought (see here, for instance), but each case needs to be viewed individually, factoring in flow characteristics in the artery, appearance of "stability" or "instability" of the plaque itself, not to mention commitment of the person.

But it can be done.
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Comments (19) -

  • Anne

    9/11/2010 4:37:03 PM |

    WOW! That could have been me. I was in my late 50's with a 90% blockage of my LAD. I underwent stenting 3 times and ballooning once. A these procedures failed and I went on to bypass. The only advice I was given was to take an aspirin and eat a "heart healthy low fat diet" and exercise.

    I did not feel well after bypass until 3 years later. I was still short of breath and had edema in my legs. I gave up all gluten grains and my symptoms disappeared.  Now I follow TYP dietary guidelines and take lots of fish oil, D and some other supplements.

    I wonder what would have happened  had made the dietary changes before they started putting stents in me?

  • Tommy

    9/11/2010 6:12:38 PM |

    Last year my lab work was:

    Total- 191
    Triglycerides -87
    HDL-65
    LDL 109
    I had been eating a good diet and exercising for 30 years. Shortly after my blood work I had a heart attack anyway. (Completely blocked and collapsed PDA). I was also told that I still have a 40-60% blockage somewhere at the bottom of my heart.  They are “hoping” (I hate that) that the statin keeps it stable (yikes!).  
    I’m now on a statin but also adjusted my diet.  My next labs, 4 months later  were: Tri=67, HDL=40, LDL= 63.  I didn’t like that. So I adjusted my diet again.
    I cut out all wheat, no refined cabs at all, no sugar or anything containing sugar….none.  I’ve been taking extra fish oil (1800 EPA/DHA).
    Two weeks ago I had labs done.
    Total -129
    Triglycerides -43
    HDL - 46
    LDL – 74

    But at this point I don’t know if it’s the statin, the diet or the fish oil…or a combination of all three.  I can’t stand reductionalist methods and to me fish oil is just taking a part out of a whole thinking it is what makes you healthy.   “hmmm, people who eat fish are healthy, so lets take the healthy stuff out and use it.”  

    I may move away from the fish oil and see how just diet and exercise suit me.  I have read some issues with fish oil. Of course you know there are always two sides to everything…lol  I’d like to raise  my HDL. Since taking the statin it dropped . Does that stuff just lower everything?  I take simvastatin.   I’m hoping that the 40-60% blockage reverses.
    .    I’m also exploring coconut oil but can’t seem to get both sides of the story on that one.

    Any thoughts Doc?

    Thanks

  • Dr. William Davis

    9/11/2010 7:41:57 PM |

    Hi, Anne--

    Yes, indeed. Something we will never know.

    However, I believe it is entirely possible to make your first procedure your LAST procedure, aiming to gain full control over your heart disease so that you never require any more stents, bypass, etc.


    Hi, Tommy--

    This looks like a weight loss effect to me. That is, eliminate wheat, cornstarch, sugars, and weight drops. At first, HDL will also DROP, only to rebound upwards over the ensuing months.

    That's why I tell everyone on our Track Your Plaque Forum discussions that patience often pays.

  • Ellen

    9/11/2010 8:11:17 PM |

    Tommy, try the coconut oil. My lipid profile was very much like yours-- low everything and when I implemented coconut oil (at least 2 TBS a day)-- my HDL skyrocketed up to 81! LDL went up too, it wasn't bad. Trigs stayed low.

  • Tommy

    9/11/2010 8:25:56 PM |

    I've been doing some coconut oil but being conservative. Using it in cooking and taking a tablespoon here and there....not exactly daily. I'll try upping this.


    Thanks

  • Anonymous

    9/11/2010 9:31:05 PM |

    Dr. Davis, why did you decide to stop the arginine for this patient?  When you use, it what is the dosage?

    Thanks,
    Art

  • Paddler Peril

    9/12/2010 7:59:59 AM |

    Hoping I can achieve a similar result, but having to go it alone as I haven't found a GP or cardiologist able to assist. MI in June '09 with three stents in proximal LCX/OM1 and 2 stents in D1/LAD. Stenosis in RPDA untreated.

    Am following Mark Sisson's Primal Blueprint and supplementing with Nicotinic acid, fish oil, Vit D, magnesium and an ACE antioxidant complex. Feeling 110% since giving up the prescription meds

  • Anonymous

    9/12/2010 12:06:30 PM |

    Dr. Davis, wondering about Gwen's LAD stenosis 6 years later.  I know we don't want to schedule unnecessary heart caths, but a situation like this it would seem well worth the effort to take a look again to see if there truly is regression of that plaque.  If there was, it would make for a fascinating presentation at conferences, and would turn a majority of the specialty on its ear.

  • Alfredo E.

    9/12/2010 3:08:45 PM |

    Dr. Mark, I also would like to know the reason you eliminated the L Arginine supplementation.

    Thanks

  • Anonymous

    9/12/2010 5:55:02 PM |

    Thanks for the post.  I like the way you caution the woman and advise a stent, rather than blithely indicating that a diet change can magically make her risk free overnight.  Of course she had the choice, as an adult, to refuse the procedure, but at least she knew the seriousness of the situation.

    Nina

  • Dr. William Davis

    9/12/2010 7:53:07 PM |

    I believe that l-arginine's effects overlap greatly with that of vitamin D, as well as several other strategies, including fish oil and the diet I use.

    While l-arginine provides benefits upfront, I believe that other strategies eventually provide similar effects, making the arginine redundant.

  • Eva

    9/13/2010 4:15:30 AM |

    Interesting, I wonder if chest pain abated due to increased health of the heart itself.  When my mother went paleo she had rapid improvements in blood pressure and heart rate.  Heart rate went from about 90 beats per minute to about 70. This only took a few weeks and her energy level soared.  Perhaps the heart responds rapidly to a healthy diet.

  • mikroenjeksiyon

    9/13/2010 1:55:44 PM |

    It's very interesting. Thanks to the author....

  • Jonathan

    9/13/2010 2:06:10 PM |

    @Tommy - Please consider stopping the statin.  It will make your HDL go down as well.  Your trig came down because of the carb reduction.  The lower you get your total the more risk you are at for cancer, infection, and host of other all-cause-mortality.  Plus, if you look at heart attack risk charts, the farther below 200 you go on cholesterol, the more risk you are at (it's an upside down bell curve).  Artificially lowering cholesterol is not good! Fixing the underlying cause that the body is producing more cholesterol to fix is more important.

  • Anonymous

    9/13/2010 6:15:05 PM |

    Thanks for your reply Dr. Davis.  

    Nick

  • Anonymous

    9/13/2010 11:41:41 PM |

    Can anyone recommend a good coconut oil? Do you take capsules? Do you heat up a solid and spoon it down?

    -- Boris'

  • Anonymous

    9/14/2010 12:30:11 AM |

    Tropical Traditions has very good coconut products.
    www.tropicaltraditions.com

  • auntlaura

    9/14/2010 3:04:41 AM |

    I keep reading and find nothing about aortic stenosis--I have been diagnosed with mild to moderate, plus mitral valve regurgitation. Will the changes I read on this blog help this? I have been told I have to wait for valve replacement until it is worse.

  • dave48_australia

    9/15/2010 5:26:41 AM |

    A year ago I failed an exercise stress test and had an angiogram which revealed 70-90% blockage of 3 arteries. I was recommended for immediate triple bypass surgery. I also had typical high cholesterol, high triglyceride, high LDL low HDL.

    Having a deep distrust of the medical machine, and desperately searching for a solution, I luckily found your blog and have dutifully carried out your recommendations regarding diet and supplements and exercise.
    I feel so much better already after only 3 months off wheat. I am not breathless anymore when exercising -(interval training on stationary bike), no more blocked sinuses and my fat profile has improved out of sight.
    I finally had the courage to tell my cardiololgist- "NO", my body has enough intelligence to heal itself thanks. I don't want your patch up job!
    Thanks Dr. Davis for sharing you insights with the world! I am so glad I found you!

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Heart Defects Simplified

Heart Defects Simplified

12. October 2009 William Davis (0)


For as long as I've known him, echocardiography technologist, Ken Heiden, has had a deep fascination with congenital heart disease. Ken has just written a wonderful book on congenital heart disease called Heart Defects Simplified.

While this is a bit off-topic for the Heart Scan Blog, I know that there is a serious lack of helpful information for people with congenital heart disease and parents of children with congenital heart defects. So I asked Ken to tell us something about his book.



WD: I've reviewed your book and have been thoroughly impressed with the clarity and detail with which you handle a complicated topic. You somehow manage to make it easy to grasp, far more than any other resource I've used in past. Do you feel that your book serves a previously unmet need?

KH: This book serves an unmet need in that it presents the complex subject of congenital heart defects in a simplified manner. Most books on this subject are anywhere from 300-1700 pages in length and tend to be written for doctors. Further, most of these books have very few diagrams, and they rely upon their explanations to describe these defects.

Heart Defects Simplified is 104 pages in length, describes the most common defects, including surgical repairs, in a two-page format with full-color diagrams on the left and complete descriptions on the right of each chapter. The book is particularly written for sonographers, nurses and parents, but it is valuable for anyone interested in this subject. It is particularly useful in clinical situations because it is convenient to lay out at your side with a coil-bound format and durable pages. Further, there are appendixes which include "Surgical Procedures in Alphabetical Order," "Prevalence of Congenital Heart Disease," "Scanning Protocols for Echocardiographers," "Imaging Tips," a glossary and a worksheet for echocardiographers.


WD: I know that many people with loved ones who have congenital heart defects, particularly parents of children with such conditions, are often kept in the dark about the details of the condition. Is your book suitable for the non-technical reader, such as parents?

KH: This book is an excellent resource for parents. It is written in language that is understandable by parents as well as technologists and nurses. The full-color diagrams provide invaluable insight into this very complex world. Most importantly, this book attempts to make the subject of congenital heart defects accessible to anyone who wishes to comprehend this subject.


WD: I understand that people with congenital heart defects and parents are active participants in online discussion groups. Will your book serve as a resource for people who participate in these groups?

KH: This book is not only a resource for sonographers and parents, but the book is accompanied by a blog (HeartDefectsforEveryone.blogspot.com) that attempts to address many of the concerns commonly encountered with congenital heart defects. This blog is a work in progress, but I hope to provide a forum for parents, healthcare personnel, and others to share their questions and concerns about congenital heart disease.
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