Integrative Approach to Heart Disease with Dr. Howard Elkin: Rational Wellness Podcast 147

Dr. Howard Elkin discusses an Integrative Approach to Heart Disease with Dr. Ben Weitz.

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Podcast Highlights

3:42   What is coronary artery disease and why are so many patients dying of heart attacks?  There are close to a million heart attacks per year in the US and heart disease is still the number one killer of both men and women.  Heart disease is a disease of excess–excess blood pressure, excess cholesterol, excess sugar, excess stress, excess smoking, however there is a lack of one thing and that’s exercise.

4:35  Why does cholesterol build up in the walls of the arteries, given that our bodies are designed to protect us and promote our survival?  It is because of inflammation in the endothelium, which is in the lining of the artery walls.  We now know that the simple theory that heart disease was caused by eating cholesterol and saturated fats is not correct.  Cholesterol is actually very important for many functions in the body, including the absorption of fat, vitamin D, sex hormones, acids, myelin sheath in the brain also with new nerve cell formation, it’s essential. We cannot live without it.  When it comes to cholesterol, it’s not as simple as just thinking of LDL as bad and HDL as good.  Particle size matters and larger particles of both LDL and HDL are better, while small dense LDL is more likely to cause arterial plaque.

7:05  Cholesterol in our diet does not equate with cholesterol in our blood.  Saturated fat can be an important factor and there were several often cited studies published in the 60s and 70s that appeared to show that saturated fat was associated with an increase in cholesterol. Since then, these studies have not quite stood the test of time and saturated fat is not as bad as we thought it was.  But then we learned that we need to look not just at cholesterol as a risk factor, but we broke it down into (bad) LDL and (good) HDL.  In recent years we have learned that the size of the cholesterol particles is potentially even more important and generally speaking bigger is better.  Oxidation leads to inflammation and because of inflammation, the LDL particles can burrow into the wall of the artery, which is coronary artery disease.  Eating fruits and vegetables can supply antioxidants that can reduce the oxidation.

8:35  There are a number of factors that can result in inflammation, including toxins, stress, food sensitivities, and inflammatory foods like sugar and refined carbohydrate foodsChronic infections can play a role in inflammation, including periodontal disease caused by P. gingivalis infection in the gums. Inflammation can be monitored with HsCRP serum levels. Additionally, gut health and uncorrected sleep apnea are also both causes of inflammation. 

10:40  The Functional Medicine approach gives you such a different perspective on heart disease. The average person finds out they have high cholesterol and they see a cardiologist and they get put on medications like statins, end of the story. But this doesn’t consider what are the root causes of the inflammation that results in the cholesterol building up in the arteries.  Functional Medicine model helps us to look for the periodontal disease, the gut dysbiosis,food sensitivities, toxins and heavy metals that may be some of the underlying reasons for the inflammation that results in heart disease.  If you see a traditional cardiologist, you will get a prescription for a statin and probably an aspirin or blood pressure medication, if the problem is blood pressure.  Dr. Elkin’s approach if a patient has high blood pressure, he prefers not to place them on medication and instead would rather give them a few supplements and talk to them about lifestyle. 

12:56  The recommendations for aspirin have been updated recently.  Doctors have been recommending that patients take aspirin to prevent heart disease to prevent heart attacks and strokes, since aspirin thins the blood out a bit.  It turns out that there is more risk of a major bleeding event from taking aspirin, like an intracranial hemorrhage.  This was shown in the ARRIVE trial (Aspirin to Reduce Risk of Initial Vascular Events) published in Lancet in September 2018: The use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomized, double-blind, placebo-controlled trial  and the ASCEND trial (A Study of Cardiovascular Events in Diabetes) published in NEJM in October 2018:  Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus.   

14:36  A plaque in a coronary artery can be stable or unstable and that plays a big role in whether or not it leads to a heart attack or a stroke.  If plaque has a larger lipid pool and thinner margins, it is more likely to rupture and form a blood clot and this can lead to a heart attack or a stroke. Dr. Elkin recommends that a lot of his patients get a coronary calcium scan, which tells you the degree of calcium in the three major arteries to the heart. It helps to stratify your risk, but it only shows calcified plaque and it doesn’t tell you if you have soft plaque and it also doesn’t tell you if the plaque you have is stable or unstable.  A calcified plaque, because it tends to be more stable, is less risky than an unstable plaque that is more likely to rupture.

19:07  There is a new lab test called a PULS (PULStest.com) that Dr. Elkin is running that utilizes biomarkers to determine the likelihood that a plaque is stable or unstable.  Once you identify a patient with an unstable plaque, you need to be very aggressive with treatment and this is where the full Functional Medicine workup can be very beneficial.

20:57  The standard lab panel that your primary doctor orders is usually governed by what the insurance company will pay for, so it is usually very limited and usually only involves total cholesterol, estimated LDL, HDL, and triglycerides.  It is much more accurate to run an advanced lipid profile looks at LDL particle number (instead of estimating it), LDL and HDL particle size, Lp(a), oxidized LDL, homocysteine, HsCRP, and other tests. But this does not fit into the standard cardiology or primary care practice model and it takes more time and insurance companies do not reimburse doctors for time spent with patients. So doctors are forced into a short (5-10 min) office visit and they need a quick, cookie cutter approach, such as your LDL is above 100, so take this statin.  End of story.


Dr. Howard Elkin is an Integrative Cardiologist and he is the director of HeartWise Fitness and Longevity Center with offices in both Whittier and Santa Monica, California. He has been in practice since 1986. While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for exercise, diet, and lifestyle changes to improve their condition. He also utilizes non-invasive procedures like External Enhanced Counter Pulsation (EECP) as an alternative to angioplasty and by-pass surgery for the treatment of heart disease.  Dr. Elkin has written a book, From Both Sides of the Table: When Doctor Becomes Patient, that will soon be published. He can be contacted at 562-945-3753 or through his website, HeartWise.com.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts, and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Rational Wellness Podcasters, thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to Apple Podcasts and give us a ratings and review, or wherever you listen to your podcasts. Also, if you would like to see a video version, please go to my YouTube page, Weitzchiro. If you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

Our topic for today is Natural Approaches to Preventing and Managing Cardiovascular Disease with integrative cardiologist, Dr. Howard Elkin. Heart disease continues to be the number one cause of death in the US and around the world. This is an incredibly important topic. However, despite many improved treatments, especially heroic lifesaving procedures, we often fail to identify ahead of time who is going to have a heart attack. More than 50% of heart attack patients have normal cholesterol based on a standard lipid profile, but deaths from heart attacks are potentially preventable.

For this discussion, we are going to try to split our time between coronary artery disease and arrhythmia, and I know it’s going to be difficult because coronary artery disease could probably take up three hours, but we’re going to see what we can do. Coronary artery disease is all about cholesterol and lipids, and the prevention of heart attacks and strokes.  For the rest of the discussion, we are going to talk about arrhythmia which is a condition not often discussed, especially in functional medicine quarters. An arrhythmia refers to problems with the rhythm of your heart that occurs when the electrical impulses that coordinate your heartbeats don’t work properly.  This results in the heart beating too fast, too slow, or irregularly. There are a number of forms of arrhythmia. As with arterial disease, we will focus on a functional medicine natural approach to arhythmia.

Dr. Howard Elkin is an integrative cardiologist with offices in Whittier and Santa Monica, California, and he’s been in practice since 1986.  While Dr. Elkin does utilize medications, and he performs angioplasty and stent placement, and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for exercise, diet, and lifestyle changes to improve their condition. He also utilizes noninvasive procedures like external enhanced counterpulsation as a noninvasive alternative to angioplasty and bypass surgery for the treatment of heart disease. Dr Elkin has written a book from both sides of the table, When Doctor Becomes Patient, that will soon be published. Dr Elkin, thank you so much for joining me today.

Dr. Elkin:              Thanks. I’m delighted to be here, Dr. Weitz.

Dr. Weitz:            Excellent. Let’s start by having you explain, what do we mean by coronary artery disease and why are so many patients still ending up with heart attacks?

Dr. Elkin:              Well, here’s the thing, coronary artery disease, there’s close to a million heart attacks in this country every year, and I believe every 39 seconds, there’s a person that dies of heart disease. So it’s really prevalent, it’s your number-one killer of both men and women, so it’s very common. It’s a disease of excess. We’re talking about excess blood pressure, excess cholesterol, excess sugar, excess stress, excess smoking, it’s really a disease of excess, however there is a lack of one thing and that’s exercise.

Dr. Weitz:            Can you explain why would cholesterol, which is a fat in the body, why does it start to build up in the walls of the arteries?

Dr. Elkin:              It’s really funny, this whole cholesterol hypothesis started way back, it’s been for several years now, in the ’50s. The ’60s and ’70s, there were studies that were going on saying that, “Okay, well cholesterol and saturated fat are really the culprit when it comes to causing heart disease.” And it’s not that simple. We’ve learned other things in the last few years. So-

Dr. Weitz:            Well, I just wanted to also add in here, when I ask why would cholesterol build up? I just want to make sure everybody has in their minds the fact that our body is basically designed for us to work properly, to protect us. It’s a normal part of the life cycle for us to eat, for us eat animals. We’ve been doing it for thousands of years, and animals are going to contain fat, there’s going to be cholesterol, saturated fat. So what’s going wrong that there’s cholesterol starting to build up in the arteries?

Dr. Elkin:              It’s just one term called inflammation, and when I was a fellow studying cardiology several years back, we didn’t know anything about inflammation, we didn’t know anything about endothelial injury.  We just thought that there was a blockage in the artery that got worse and worse, it was probably related to cholesterol. Around that time when I was finishing my fellowship, the first statin came out, so that was what we thought, but we really-

Dr. Weitz:            By the way, for those who don’t know, you mentioned endothelial and that’s related to the arteries, the inside of the arteries is the endothelium, and a statin is a medication used to lower cholesterol.

Dr. Elkin:              Correct. Thank you. So let’s face it, cholesterol is essential for life, we wouldn’t be here if it wasn’t. It does everything from help with the adsorption of fat, vitamins, vitamin D, sex hormones, bile acids, the myelin sheath in the brain, also with new nerve cell formation, it’s essential. We cannot live without it. But it got a bad rap because of this whole thing, this assumption that it really caused coronary disease.  Now a couple of things you need to know, as far our audiences are concerned, we now know that cholesterol in our diet does not equate to cholesterol in the blood. So if anyone is still eating egg white omelettes, is just like totally out now. We know that doesn’t exist. Now the whole thing about saturated fat, that’s an important thing. That came out in the ’60s and ’70s and these were like small, short studies based on… They were short term studies first of all and they showed that saturated fat was associated with an increase in cholesterol.  As we learned to classify cholesterol, most specifically LDL. Just think of LDL is lousy and HDL as healthy, it’s not quite that simple.  So what we’ve learned in recent years is that it’s about the size of the particle and all your audience really needs to know, is that bigger is better. Whether it’s HDL healthy or LDL lousy, the bigger the particle size, the less likely it is to get oxidized. Oxidation is what leads to inflammation, which is really a long answer to your question. Because once we have inflammation, okay, that LDL particle can burrow into the wall of the artery and that’s where we really develop coronary artery disease and also progressive coronary artery disease.

Dr. Weitz:            So obviously oxidation if we’re consuming lots of fruits and vegetables, those are going to contain antioxidants. But other than consuming fruits and vegetables, what other factors result in inflammation in the walls of the arteries?

Dr. Elkin:              Lot of things. First of all, the environment, air pollution, we know that’s effective. Toxins in the environment.  Stress is a big one. Stress affects everything. Also eating foods.

Dr. Weitz:            Food sensitivities.

Dr. Elkin:              Inflammatory foods that add inflammation, I tell people all the time. Sugar is our biggest villian, it’s not cholesterol, it’s sugar. Eating sugar and carbohydrates and grains that break down to sugar, it’s like pouring gasoline over fire. These are major culprits that lead to inflammation in our arteries and source coronary artery disease and heart attacks.

Dr. Weitz:            Also chronic infections, and I know you like to look at the gums.

Dr. Elkin:             Right.

Dr. Weitz:            as one of the sources of that.

Dr. Elkin:              I think I mentioned when we talked earlier is that when I have a person, a patient that’s persistently demonstrating inflammation, just a systemic  inflammation, which is a simple lab test, I have to ask why.

Dr. Weitz:            Which is high sensitivity CRP.

Dr. Elkin:              Right. Let’s say it’s three or four, it remains that way for like several months. Then I say, can we have to look further? What’s happening? One of the major causes of inflammation is the oral cavity or Periodontal disease. A lot of people say, oh, well my dentist says that everything’s fine. But not every dentist really knows how to evaluate periodontal disease. You often have to go, I send people to periodontists all the time because a pocket of 4 is not o.k., it’s like not good. It’s not okay. That’s a nidus of infection and inflammation based on that infection. The other one is the gut.  That’s probably the second most common cause that’s very important.  Also uncorrected sleep apnea. These are all things that lead to systemic inflammation and whether it’s heart disease, cancer, autoimmune disorders or Alzheimer’s. All four of those big causes, the pillars of aging, have to do with inflammation. It’s like the common denominator.

Dr. Weitz:            Yes. I think the average person out there when they’re worried about heart disease, they’re thinking, okay, I just need to go to cardiologist and I need to get put on some medications. But if you really utilize the full functional medicine model, that’s really the only way you can start to consider some of these underlying causes rather than, okay, you have high cholesterol, you have high blood pressure, you take this medication, end of story.  You’re talking about looking at the underlying factors that create the inflammation and it is possible, but you need to cast a wider net. You need to consider P. gingivalis infection in the mouth, gut dysbiosis, food sensitivities, toxins, heavy metals.  All these things are possibilities when you clear some of those underlying causes of inflammation that can cause the underlying reason why you have cholesterol buildup in the first place and that’s truly getting to the root cause. It’s one of the reasons why I think the Functional Medicine model can be so effective for heart disease prevention.

Dr. Elkin:              You’re absolutely right. The model that we use in Functional Medicine, it’s really the only way because if you go to traditional medicine, and in my case traditional cardiology, if you have high cholesterol they’re probably going to give you a statin.  They’re going to probably tell you to maybe take an aspirin or there maybe… Or if you have high blood pressure, they’re not going to wait and see whether you can get it down on your own.  They’re going to put you on a blood pressure medication. We’re masking things by giving people medications.  Not that there’s not a role for medications, there is.  But it’s like we jumped to medications.  I have a patient yesterday came to me, she was a registered nurse and she’s telling me she’s struggling with her blood pressure’s bad.  I said, it looks like you will probably need medication, but let’s not jump to that right now.  It’s not so high that I need to worry about it.  So let’s track it, let’s go on a couple of supplements, let’s talk about lifestyle and where we evaluate. The average doctor or cardiologist would not do that.

Dr. Weitz:            Right. Absolutely. By the way, you mentioned aspirin, I guess the recommendations for aspirin have been taken back a bit, huh?

Dr. Elkin:              Yes, thank goodness. I really never believed that everybody over 50 for prevention should be on aspirin. But for years it was given as primary prevention. So let me just segue away for a minute. So primary prevention is to prevent a heart attack or a stroke and someone who has no known coronary disease whatsoever. But now secondary prevention is someone that’s had a heart attack or a stroke, they’ve had a stent, they’ve had bypass.  This is a higher risk population and we still think that these patients should be on aspirin for the duration of their life.  But at the study that came out whose name I can’t remember right now, came about actually about a year or so ago,  that it’s overkill and actually there’s more bleeding from aspirin, then saving heart attacks and strokes. So that was changed.

Dr. Weitz:            So essentially the reason why aspirin was being given was because aspirin and all nonsteroidal anti-inflammatories tend to thin the blood out a little bit. So if the blood is a little thinner, it’s likely to clot and form strokes. Form clots, lead to strokes and heart attacks. What they found was that while it thins the blood out, the risk of having a bleed somewhere’s counteracts the potential risk of a clot, unless you really know the person’s at higher risk of a clot, it’s not worth it.

Dr. Elkin:              That’s right. I should mention, just to understand this thing about blood clot. So you have a plaque in the coronary artery and it could be there for years and it often is there for years. We still don’t know in 2020 what makes a stable plaque become an unstable plaque. We don’t know that.

Dr. Weitz:            Okay. Can you explain what a stable plaque is.

Dr. Elkin:              A stable plaque is just, mostly, it’s going to be more… It’s a cholesterol smooth muscle plaque. But the composition, it actually, it has more fibrous tissue in it, more scar tissue in it. So the lipid pool, the fat pool is actually less and these can stay. There’s certain way to look at an artery, tell that from a scan, but we know by looking at them at autopsy and so forth if this is a stable plaque.  I think with plaque has a larger lipid or fat pool and thinner margins, the thinners fibrous tissue, and those can rupture at any time without warning. Once that plaque ruptures, and it can be a 40% blockage, once that plaque ruptures, then a blood clot forms and that’s where aspirin can help.  So it’s a plaque rupture that leads to a blood clot or thrombosis and then you have a heart attack or a stroke depending on the location.

Dr. Weitz:            So you have this plaque that’s blocking, say 20, 30% of the artery and it becomes, it can lead to a heart attack if either A, it blocks the entire artery, continues to grow and grow, or a piece of it breaks off, and that’s what we mean by this unstable plaque. Then you get this inflammatory reaction and you get this clot formation, and that then blocks the artery, right?

Dr. Elkin:              Right. You remember there’s still almost a million heart attacks a year in this country. That’s a lot and probably 50% of these people have normal cholesterol levels.

Dr. Weitz:            So a lot of doctors that have been having patients get a test called a Coronary Artery Scan and that’s to look for these plaques. But what does that really show?

Dr. Elkin:              It’s a good test, I use it a lot. It helps me to prepare my patients for their treatment protocol.  I’ll tell you how.  So you get this test done and it tells you the degree of calcium in their three major arteries. It tells you the degree of calcium…

Dr. Weitz:            The three major arteries that go to the heart.

Dr. Elkin:              Yes. So you get what’s called a coronary artery calcium score. A perfect score is zero. You don’t have any calcium in your arteries but it’s unlikely as you get older. But then what happens… I happen to like Harbor-UCLA because they have a very large database and they have a wonderful doctor who’s been researching this scan for over 25 years. Anyway so they have a database of 30,000 patients who I say, okay, this is how you compare to other 60-year-old males. You’re in the 30th percentile. Not too bad. You’re in the 40th, 50th. Well, that’s a little worrisome. You’re in the 80th, 90th, that’s high risk. So it does help stratify your risk, but it doesn’t tell you who has a stable plaque or an unstable plaque.

Dr. Weitz:            It also doesn’t tell you… It only shows calcified plaque, not soft plaque.

Dr. Elkin:             Really if you look at a plaque, if you could microscopically, about a third is calcium and the two thirds is like soft tissue that you do not detect with that scan.

Dr. Weitz:            So you get a coronary calcium scan. It can be helpful if you have a calcified plaque.  But even if you have a score of zero, it does not mean you don’t have any plaque.

Dr. Elkin:             I was one of those people.

Dr. Weitz:            Exactly. It just means you don’t have any calcified plaque. Noncalcified plaque tends to be less stable, right?

Dr. Elkin:             Right. 

Dr. Weitz:            Less stable means that it might break off, in which case it could form a blockage.

Dr. Elkin:             Right. The end result is always going to be a thrombosis or a blood clot and that’s where the aspirin does come in. But yeah, so that’s what it’s really based on knowing different calcified plaque actually could be considered protective. It’s less likely to rupture.

Dr. Weitz:            Is there a way to test if you have a calcified plaque or not?

Dr. Elkin:             Well, calcified plaque is very well done with the coronary artery scan, it’s how can we detect…

Dr. Weitz:            Unstable plaque?

Dr. Elkin:              So as we were starting, I told you there’s a new laboratory test. It’s relatively new, it’s not been used much in this country. It’s called a P-U-L-S, PULS. It started off, it actually, I forgot what it stands for, but it was started off in Canada and now it’s being adopted in the United States. What they’ve done, they’ve set a number, like over 100 biomarkers to detect an unstable plaque and they tested three different centers and they all came down with nine biomarkers, I’ll explain that in a minute, and then taking those biomarkers into consideration, if you take someone’s blood sample, it can give you a score.  So the higher the score, the worse off you are. So you wouldn’t have a score less than 10. Although it’s new thinking and it’s a new test, what a great novel idea because it can take someone who’s got risk factors, who’s totally asymptomatic, but who has a high score. That means there’s endothelial damage in that vessel and there’s ongoing inflammation that we cannot see and that can presage a heart attack. So it’s very exciting to be able to do this and I think we’ll be getting more of this the next couple of years. It’s a simple blood test.

Dr. Weitz:            So therefore, once you find a patient who has an unstable plaque, this is a person you need to really focus on and be very aggressive with treatment.

Dr. Elkin:              Right. This is when what we do in functional medicine really makes a difference. It’s more than a statin, it’s more than a beta blocker or an aspirin, it’s involves lifestyle and that’s what we do.

Dr. Weitz:            Now, when you go to your standard, get your standard physical exam from your primary care doctor, they do what’s called the lipid profile as part of the blood screen if you’re lucky. Because insurance companies are so strict these days, they hardly want to cover any lab testing and it’s only gotten worse and worse over time. So if they do this standard lipid profile, it looks at total cholesterol, it looks at estimated LDL, it looks at HDL and triglycerides. But that’s not really an adequate way to screen for heart disease, is it Dr. Elkin?

Dr. Elkin:              Not at all. But I will tell you that most cardiologists do that simple lipid profile that you can get from a family practice or general interest. It just tells you what’s normal and what’s abnormal. But it doesn’t tell you anything else because once I get a LDL, let’s say it’s 110, which is barely above normal. As soon as it tells what’s going on, and so I want to know more so we can order what you and I know about is called advanced cardiac testing or advanced lipid testing. That tells us about the particle number and even more helpful, the particles’ size. Remember like I said, bigger is better. You won’t know that unless you do a more advanced test. 

Dr. Weitz:            Why is it that the average cardiologist is not taking advantage of this available testing?

Dr. Elkin:              I think to be perfectly frank with you, I think there’s a lack of time and effort because the way medicine is practiced today, it’s so robotic. It’s like, “Oh, do you have this? You want a statin and you have this, you got it…” That’s why I practice on my own so I can do the type of medicine that appeals to me and I think really helps people and saves lives.  I think it’s, the doctors are burnt out as standard medical doctors and I think they said that they still have all the surveys I’ve read the major one complaint that patients have about their doctors, they do not feel heard. They say, oh, he got one foot on the door, one foot out the door. Or they’re sitting there typing while the patients… I don’t bring my laptop in the room with me, I can’t do that. I can’t focus on the patient. So it’s time-intensive. I have to do a lot of education and I have a nutritionist that’s in my office two days a week that does a lot of… As far as chips a lot. But when it comes to limits, I’m the guy and lifestyle because I have to walk my talk.

Dr. Weitz:            Yeah. [inaudible 00:23:39] is unfortunately and I’m not sure if all the patients are aware of this, but the healthcare system today is essentially controlled by the insurance companies and doctors unfortunately do not get reimbursed by insurance companies for the amount of time they spent. So therefore based on the way the insurance controls stands and the reimbursement, medical doctors, primary care doctors and cardiologists are basically limited to a five or 10-minute office visit. Unfortunately, you can’t go into having time to explain this kind of detailed testing and lifestyle recommendations and diet in a five or 10-minute office visit.

Dr. Elkin:              You really can’t. Let’s just take whether it’s Cleveland HeartLab or Boston HeartLab, and they’re both very good [inaudible 00:24:33].

Dr. Weitz:            Those are examples of advanced lipid profiles.

Dr. Elkin:              But when I get the test packet, after much over the liquid virus and I’m just saying, “Okay, this is your inflammatory profile. You have inflammation, this is your metabolic profile. You’ve got diabetes or prediabetes or you’re at risk of diabetes.” There’s so much to explain. You cannot do it in five or 10 minutes.

Dr. Weitz:            Right. So these advanced lipid profiles, they vary. But typically besides the things you mentioned, like LDL particle number and particle size, and also look at the size of the HCL. They also look at a particle known as LP(a). They look at homocysteine, they look at so many inflammatory factors like, high sensitivity CRP. They look at whether the LDL is oxidized.

Dr. Elkin:              Yes. Really useful information.



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                                                Now, back to our discussion.




Dr. Weitz:             So let’s go over some of the particular things that are found on advanced lipid profile and some of the recommendations we can make from a natural approach for helping these patients. So let’s say we have a patient with an elevated LDL particle number and/or an increase in small dense LDL.

Dr. Elkin:              Okay. Remember, bigger is better. So if you have a small dense particle size versus a large buoyant, it’s not in your favor because it’s about 30% more likely to get oxidized, which we know leads to inflammation and clot. So what can we do? First of all-

Dr. Weitz:            What type of diet to start with is beneficial for these patients?

Dr. Elkin:              Absolutely a lower carbohydrate diet. That definitely does better when it comes to, if you want to decrease the size…, if you want to increase the size of the LDL particle.

Dr. Weitz:            Why are you mentioning carbohydrates?  Most cardiologists would say, hey, you got to lower the fat.

Dr. Elkin:              Right. I know it goes against what everybody’s been taught. If you look in the ’90s, everything was low fat and high carbs and what happened? The country got fatter and we have more diabetes than ever before. But definitely I put them on a low carb diet and you have to explain to them, because a lot of their standard cardiologists are still telling me to go low fat. Why? I don’t know.  When we have signs that tell us otherwise. Then I use niacin, which is actually a vitamin, vitamin B3. I’m using it in a larger dose and I would if I was giving it as a vitamin, but niacin can do what statins can’t. Statins are very good at one thing, lowering your LDL but it will not lower… It will not make a small particle into a large. It won’t effect [inaudible 00:28:53], it won’t effect HDL, it won’t affect Lp(a), whereas niacin has the potential to do all those things. It’s pretty well tolerated and guess what? It’s been around a lot longer than statins have and it’s a supplement. So I do use that quite a lot of my [crosstalk 00:29:10].

Dr. Weitz:            I will say that if you ask the average standard primary care doctor, they will tell you that niacin, that the study show that niacin doesn’t work.

Dr. Elkin:              It’s based on one crummy study that really wasn’t well… It was a flawed study about just a few years ago. It really…

Dr. Weitz:            Yeah. There were a couple of studies and they were both terrible. One of them actually didn’t use niacin. It used niacin in combination with a drug that prevented the flushing. There’s all sorts of side effects that come with that drug and they reported the study as being a study on niacin.

Dr. Elkin:              Here’s another problem that a little off the record here is that, see when you’re in medical school, you go through your training, you are taught how to evaluate studies. We learn about statistics, we learn about meta-analysis, Beysian analysis, all that stuff. But when you’re in practice, you forget all that stuff. There’s no time to think. Oh, so this drug rep comes and tells you what this is and you just buy it. That’s another thing about the current medicals and that really gets to me. But niacin can be very useful. I’m using it for years and again, it does things that statins don’t.

Dr. Weitz:            What about using Red yeast rice?

Dr. Elkin:              Red yeast rice is also, so actually if you look at the original statin that came out, when I was a fellow in the early mid ’80s, it was red yeast rice, which actually is a supplement that came from a plant in China.  There’s certain patients that refuse to take a statin, just refuse and I don’t try to fight it even if they have coronary artery disease. I always believe in patient’s match and what they feel comfortable doing. But I’ve had some success with red yeast rice supplement and I believe Dr. Mark Houston uses a much larger dose, but he’s got success. But I have found to be useful. What else?

Dr. Weitz:            Adding tocotrienols.

Dr. Elkin:              Yeah. So tocotrienols it’s like a form of vitamin E, it’s got tocopherols and tocotrienols and there’s various subclasses with each. But the tocotrienols are an interesting class, which actually lower cholesterol and do it quite nicely. So that’s another thing. Another thing that can be helpful is bergamot. Bergamot is a supplement that you can get and it actually works two ways. It works by decreasing cholesterol production by the liver and also by decreasing cholesterol absorption in the gut, which is kind of unusual.  But I’ve had some success with that. Is it as good as a statin? No, probably not. But it depends on what I’m after and I also get, I listen to what a patient’s preferences are.

Dr. Weitz:            So besides statins, what other medications are there for lowering LDL levels?

Dr. Elkin:              One say we talked about Red yeast rice, we talked about niacin, we talked about bergamot, there’s also berberine. Berberine is another herb that we use a lot. We use it, well, we use it in for functional gut disease, also we use it in diabetes and prediabetes. But it also has an interesting effect, and I didn’t want to go into all this detail, but there’s a new class of drugs that are very expensive that you take twice a month subcutaneously called a PCSK9 inhibitor and I don’t mean to bore the audience here.  If there are receptors, PCSK9’s receptor is in the liver. We know that that’s where cholesterol is produced. But basically berberine is a natural PCSK9 inhibitor. So the supplements can be very additive. I don’t necessarily think that one would do the entire trick, but it depends on what you’re after and how low do you have to lower cholesterol anyway, unless you are at high risk.

Dr. Weitz:            Right. By the way, one of the reasons why sugar and carbohydrates are such a problem is when you look at the mechanism by which these drugs work, like statins and PCSK9 inhibitors, they’re not binding with cholesterol and taking it out of the system. They’re reducing the body’s production of cholesterol. That’s right. Most of the cholesterol that’s in the bloodstream is being produced by the liver, and the liver makes cholesterol from glucose. So that’s how the statins and these other drugs work. Now there’s a new cholesterol lowering medication that works by a different mechanism.

Dr. Elkin:              Yeah, I forgot the name of it. It was just a…

Dr. Weitz:            Bempedoic acid.

Dr. Elkin:              It just was approved by the FDA I think it was a couple of weeks ago. It’s not a statin, I think it does work in the liver. It’s a different, I don’t know where in the chain of events, but it will have a modest effect on decreasing out our costs. So I think if you look at Statins can decrease at 30% or more and then [inaudible 00:34:14] which works on decreasing cholesterol [inaudible 00:34:17] and got maybe 10%.  This is like in between my 20, 25%. So it’s another tool to use are certain people that are statin intolerant or who won’t take statins. But again, I would probably want to use this more in my higher risk patients versus just anyone with an elevated cholesterol level, but I’m sure it will be misused. [inaudible 00:34:39]

Dr. Weitz:            So now let’s say we have a patient who’s has low HDL. Now HDL is the potentially protective lipid that HDL if it’s effective, if it’s functional will produce reverse cholesterol transport meaning it takes the bad cholesterol, the LDL out of the system. So ideally you want to have a higher HDL level.

Dr. Elkin:              So where did we see low… I’m talking levels like 20, 30, really low level. First of all, it tends to be genetic. I’ve got enough families that it’s in my career to see that. It tends to be low with obese individuals. So weight loss can be important and actually improving the HDL. Omothyroid is one other condition. I want to check the thyroid status. Smoking. Smoking is known to be a factor in decreasing HDL.  But again, there’s also a genetic component. Also, there’s a metabolic situation. If you look at your diabetics, your prediabetics or your metabolic syndromes, they tend to have kind of like low HDL, high triglycerides and moderate LDL. So there’s a pattern we look for. They tend to have a very low HDL as well. Now, so what did we do about it?

Dr. Weitz:            Then we have bodybuilders on steroids who are on very low HDL.

Dr. Elkin:              I have seen in my practice, women, who seek competitors that take both of those, they still called safe steroids. I don’t know what safe means anymore and I’ve seen single digit HDLs, really scary, like levels of eight, nine. Very scary. So yes, certain drugs can certainly cause that.

Dr. Weitz:            So how do we elevate HDL?

Dr. Elkin:              Weight loss, smoking cessation, you have to just quit. Note, it’s not an exercise. Probably more cardio [inaudible 00:36:42] activity. So that’s going to be important. So a lot of lifestyle can improve HDL and I haven’t seen gone like 10, 15 points. Would that really employ those methods. I will tell you that in the last 25 years it’s been at least three different trials based on different medications that we thought would improve HDL or augmented.  What happened, all these trials they were halted midway because they actually found more depths from those taking this medication. That was before we knew about particle size and functionality. Like we’ve learned that some HDL was functional and some isn’t and it’s more than about what’s the number is.

Dr. Weitz:            [crosstalk 00:37:21] there are patients who have very high HDL that tends to be nonfunctional, right?

Dr. Elkin:              Right, exactly.

Dr. Weitz:            They have HDL of 90 or 100 or…

Dr. Elkin:              It’s got great, but it’s not necessarily good at all. So drugs have not been helpful in that regard. Now diet is very interesting. So although saturated fat has been maligned or vilified, like beyond, yeah, I believe saturated fat has a few advantages. It can actually increase your HDL level. It can actually decrease LP little a which we haven’t really talked about and can also increase the size of the LDL particle, which is really interesting. So even though it’s been maligned, it does have some potential benefits when it comes to this cholesterol thing.

Dr. Weitz:            Yeah, I’ve used coconut oil with some patients and seen a rise in the HDL. What about fish oil for improving HDL?

Dr. Elkin:              I haven’t seen it do… But basically anybody with age of 40 it’s going to benefit. I use it as my right hand supplement.

Dr. Weitz:            Very cardioprotective, reduces inflammation…

Dr. Elkin:              It can also help with blood thinning and in a protective way as opposed to causing bleeding that you would get from aspirin. It also can help prevent, but we’ve talked about [inaudible 00:38:48] prevent sudden death. It’s been shown to be useful there. So as far as HDL, it may have an additive effect.

Dr. Weitz:            I think it can help somewhat with HDL, right?

Dr. Elkin:              Definitely. I’ve had niacin and I’ve had people increase like 15 points with taking [inaudible 00:39:07] to be dose dependent when they can tolerate and I usually go up to like max two gram today. I don’t feel comfortable going beyond that.

Dr. Weitz:            Yeah. I think there’s some other nutraceuticals like Copine some other…

Dr. Elkin:              I’m kind of basic. I stick to the ones that I know work that I’ve had good experience with. But I’m always open to new ideas and suggestions.

Dr. Weitz:            Right. Another factor on advanced lipid tests is homocysteine, which is another protein found in the blood that increase the risk of heart disease.

Dr. Elkin:              Right. So homocysteine is really a big thing now. It’s really an amino acid and your body normally wants to break it down to something called [inaudible 00:39:48] but some of us aren’t able to do that and so the homocysteine is built up in the arteries and they could also cause plaque of the arteries especially in the heart and in the brain, so it’s not a good thing.

Now that we’ve done a lot of genetic testing, which [inaudible 00:40:02] there to talk about now, there tends to be a propensity of people that have this thing called MTHFR. They have a variant, it’s that which is basically a typo in your genetic makeup. But these people, and I’m one of them, but I’ve [inaudible 00:40:20] my genes not being expressed.

But 60% of us have this and that can lead to high homocysteine levels. So it’s easy to decrease homocysteine levels and I have my own kind of product that put together and it’s B vitamins. But it’s higher dose B vitamins [inaudible 00:40:35]. So it’s always worth to try that because again, if you’re high risk, you want to be able to decrease that risk easily and you don’t need a medication. It’s simply a combination of B vitamins.

Dr. Weitz:            Yeah. One other nutrient is trimethylglycine and also can be very effective for homocysteine.

Dr. Elkin:              Naturally I include that in my supplement. So [inaudible 00:40:56].

Dr. Weitz:            What about LP little a? Now LP little a is the particle that the trainer Bob Harper from The Biggest Loser who had a massive heart attack, he had an otherwise great clusteral profile except he had elevated LP little a.

Dr. Elkin:              Lp(a) is the biggest bugaboo I know and it’s part of the advance of the profile. So you’re going to get the value. In my younger patients that have heart attacks and I have quite a few, invariably you’re going to see oftentimes I should say, at least elevated LP little a. It’s a fragment of LDL, it’s very sticky, very inflammatory, and it’s like not a good thing to have. Unfortunately diet and exercise won’t touch it.   So it doesn’t have much role there other than perhaps saturated fat might help. There’s no medication that has been really useful. Again, I’ve had some good success with niacin. It doesn’t always work, but I have had someone drop their [inaudible 00:42:07] as much as 100 points with high dose niacin. So I have had success. There is something in the pipeline I [crosstalk 00:42:15].

Dr. Weitz:            I think there’s a drug that is in the final stages of testing and we’re close to getting improved…

Dr. Elkin:              [inaudible 00:42:23] and we’re talking about a 70% reduction in like less than six weeks, which is amazing. However, it’s a drug. It’s going to be a biologic, which means it’s going to be, have to be injected probably a couple of times a month.

Dr. Weitz:            It’s probably thousands of dollars per month.

Dr. Elkin:              But in those that are really high risk, it could be a life saving [inaudible 00:42:47]. So it’s a beautiful thing.

Dr. Weitz:            Right. Let’s bring up one more particle and then we’ll move on. Arrhythmia is T-M-A-O, which is very controversial and I know that you’ve been starting to test it as part of the Boston HeartLab. TMAO is another protein in the blind that was developed by Stanley Hazen from Cleveland HeartLab that’s been shown to correlate with higher rates of heart disease.  But it’s very controversial and I’m skeptical of this concept because when you consume fruits like fish or eggs that have choline or L-carnitine or fuss with title choline that increases the levels of TMAO and we know that those foods are hard healthy and yet we’re being told that these nutrients like choline and L carnitine, which we know are super helpful for patients with cardiovascular problems are, we’re being told that they’re harmful.

Dr. Elkin:              Also brain-healthy for that matter.

Dr. Weitz:            Choline, crucial for brain health.

Dr. Elkin:              I look at it because I do a lot of [inaudible 00:44:06] HeartLab testing and it’s kind of standard. I will tell you, most of the patients that I test don’t have a, I wonder whether it’s over emphasized because I see a lot more abnormalities when I study, when I look at profile. But with some are elevated. But I would say the majority of those that I’ve tested really aren’t. So what do I do? Right now I’m just observing because it’s like, okay, what do I know that can help a patient [inaudible 00:44:33]? Particle size, LP little a, homocysteine, working on their diet.

I totally agree with you, choline is lacking in so many people and their diets as it is and it’s so useful and as far as [inaudible 00:44:48] but it’s like very important in cardiovascular health. Because it helps you bring nutrients to the mitochondria if it reduce. So I just don’t see at this point, I’m not changing people’s diet because of it. Also, is it really the food or it’s because the gut isn’t healthy? Is there a microbiome problem?

Dr. Weitz:            Right. Yeah, absolutely. So that’s something to continue to discuss over time. So let’s move on to Arrhythmia. This is a topic not often discussed but is increasingly common, especially among us aging baby boomers. Perhaps you can tell us what is Arrhythmia.

Dr. Elkin:              Okay. Arrhythmia is really a rhythm disturbance. So you have this thing called normal sinus rhythm or sinus rhythm which is your standard rhythm that most of us have. Even if you have a disruption in that, it’s an Arrhythmia. So it’s kind of a wastebasket term for a lot of different things. Let me break it down to what type of Arrhythmia is it, are they isolated atrial beat or premature beat, or it’s something that’s sustained. [crosstalk 00:46:00]

Dr. Weitz:            Or somebody who just can’t dance.

Dr. Elkin:              It’s interesting. So a very common complaint in the cardiologist office is palpitations. Now I for one, have never had a palpitation [inaudible 00:46:23]. So I have to really delve into, I have to really ask people, what does it mean? Is it skipping, is it fast, is it slow because I can’t relate. But fortunately there are two ways we can monitor patients.

Now, mostly with me is [inaudible 00:46:37]. So what I’m treating are symptoms and [inaudible 00:46:42] out. But some are malignant like ventricular tachycardia, atrial fibrillation that leads to sudden death. So part of my job is to figure out what’s really important and what’s not and if it’s not important, what can I do to assuage the patients feel, they’re uncomfortable with feelings because it can really run you.

Some patients are very debilitated by the presence of palpitations and arrhythmias. What I’ll talk about briefly is that what I’m seeing more and more of is atrial fibrillation, which used to be the most common Arrhythmia that we saw in people over the age of 70. But I will tell you, I’m seeing the younger, younger people with it now. Two of my closest friends had to have ablations in their early 50s because if such refractory [crosstalk 00:47:30].

Dr. Weitz:            What’s an ablation? Can you explain what that is?

Dr. Elkin:              So ablation is done by a cardiologist like me but they specialize in electrophysiology. So they specialize really in Arrhythmias and trying to study with me as, and if they find something that… Because Medicaid patients are really suboptimal. Tons of side effects that can actually make arrhythmias worse. So with ablation, it’s a procedure in which you go through the heart, into map out where the Arrhythmia emanates from and then you can sap it with either radio frequency waves or cryotherapy, which is cold. You can potentially cure an arrhythmia problem with ablation. So it’s evasion…

Dr. Weitz:            So basically damaging, either burning or freezing a part of the nerve that is leading to that contraction of the heart.

Dr. Elkin:              Sometimes part of the heart muscle but we don’t want to do that. But it’s pretty actually in the proper hands, the side effects are pretty low. So [inaudible 00:48:38] I’m a solo practitioner. I probably get three or four new cases of atrial fibrillation every month in my office. It’s so common. That’s probably the most significant thing because we used to think that, okay, well it’s important to treat because the kinds of hearts beating irregularly, irregular is [inaudible 00:49:05] for blood clots to form in the heart and to break off and cause a stroke which is devastating or could be potentially devastating. But also what we’ve learned in recent years, it can be a cause of heart failure, progressive heart failure. But here’s the new one that we have found is that it also can lead to early dementia. Maybe there could be a little microemboli go into the brain that we don’t really recognize as strokes. So it’s not a good thing.

Dr. Weitz:            So which dietary factors are important for helping to manage a patient with Arrhythmia?

Dr. Elkin:              It’s a good point. Well, first of all, magnesium is always important. Actually if you look at the sodium, potassium, magnesium, they all or your basic minerals and they deal with… They’re essential for proper nerve and muscle and nerve function. Well, sodium regulates body fluids. So you want to…

Dr. Weitz:            Do you want to add salt or you want to remove salt?

Dr. Elkin:              I don’t usually deal with removing salt unless I’m dealing with a patient with heart failure, liver failure or kidney failure. I think this whole thing about salt, we pretty much have discounted the importance of it. I know that the heart association is still saying low salt diet or less than 2.5 grams a day. I don’t. If you’re active person, that’s nothing. It’s nothing. So I don’t think salt affects your heart rhythm at all. So what affects it? Stress is a big one. I think fatigue, another big thing is sleep apnea, uncorrected sleep apnea. So there are things that we have to look…

Dr. Weitz:            Caffeine, energy drinks.

Dr. Elkin:              Yeah. Energy drinks are the worst because they not only can be [inaudible 00:50:59], they can also is an EKG abnormality called a long QT interval, which doesn’t mean much, but it’s an EKG diagnosis and that itself can lead to life threatening with news as in sudden death. It’s been reported in the young people like not good things to have.

Dr. Weitz:            One of your articles I read said that celery, garlic and onions can play a role. Have you heard that?

Dr. Elkin:              I haven’t heard that. I’m a big user of magnesium and hydration in general. I also use an amino acid called taurine, useful. Magnesium tends to quiet the heart and it can be very important, especially people that have bothersome palpitations. Another thing in women that are going through menopause is hormone replacement therapy. It’s not the only reason they need to go it, but low progesterone is a very important factor and causing irregular heart rhythms which I didn’t learn, I didn’t know that until I did my anti-aging medical township. I didn’t learn it at all in cardiology.

Dr. Weitz:            Now what about hawthorn extract?

Dr. Elkin:              Hawthorn berry is good for the heart. It’s not my go-to, but it’s something that it’s additive and a lot of patients take it and they’ve heard about it. They see it on the Internet and they’ve heard the utility of it. So it can be useful for heart rhythm. Yes.

Dr. Weitz:            What about CoQ10?

Dr. Elkin:              Definitely CoQ10. Yeah, that’s…

Dr. Weitz:            I’ve also seen some articles mentioning vitamin C and of course vitamin C there’s actually a protocol for using vitamin C for LP little a, right?

Dr. Elkin:              Yes. So definitely, so vitamin C, magnesium for sure. Taurine it’s for sure and also looking at the lifestyle. Smoking is bad, fatigue or poor sleep habits are not good. Lifestyle today, we’re living very stressful times along with political scene, but we all know what’s happening. People are stressed. I think when they come into my office but I can’t say it over the air. But they say, you know why my blood pressure is high? [inaudible 00:53:12].

Dr. Weitz:            I hear you Howard. Well, we’re going to try to stay away from politics. Can maneuvers that stimulate the vagus nerve be helpful?

Dr. Elkin:              Okay. That’s interesting. I do this diagnostically. If someone has an arrhythmia in my office and I’m trying to… Yeah, you can actually do vagus maneuvers like it’s called a carotid massage. A carotid massage will activate the Vegas nerve cause you’ve got a sinus in there. I’ve had it actually break Arrhythmia, it can be very useful. So I use that. I don’t use drugs per se for that because they can have some nasty side effects. But I do use it. I tell my patients if they’re having what’s called SVT or supraventricular tachycardia, which is very common. I say, okay bear down, cough a lot.

Dr. Weitz:            Coughing [inaudible 00:54:09] flax.

Dr. Elkin:              I put your head in a bowl of ice water. If you have a partner or someone, it’s hard to do your own carotid massage because people are turning to the extreme. You have to get on top of the carotid artery and go up and down kind of firmly and it’s not real comfortable so every person want to do it on their own. But if they have a partner or a friend or bystander, they can do that.

Dr. Weitz:            Then what about natural procedures that reduce stress like yoga, meditation, and I know you were involved in a study on grounding as well.

Dr. Elkin:              Yes. So grounding, I did a study with Dr. Sinatra. We did it mostly looking to see the effects of blood pressure and it can really reduce blood pressure. It’s really cool. But it’s also anti-inflammatory and it’s also an actual blood thinner. It also helps us sleep. I love it because it’s free. You’re just using the electrons or surface but…

Dr. Weitz:            I should consider seeing if it has a positive effect on Arrhythmia, I would think it probably would.

Dr. Elkin:              Yes. We didn’t study that per se because we were looking at one component and blood pressure is such a big target. But these are all additive things. I think a lot is on lifestyle and hormonal and environmental and we live in a very toxic world. Pesticides, there’s formaldehyde in everything. I didn’t even know that until recently. I got scared when I started seeing all the things in our household that could potentially contain formaldehyde. Do you believe that? Like our carpets. That’s why I got rid of all the carpets.

Dr. Weitz:            Yeah. They have those flame retardant chemicals and yeah, a lot of furniture. You got to really try to go nontoxic as much as you can. Well, this has been a great discussion, Dr. Elkin. Any final thoughts for our viewers and listeners?

Dr. Elkin:              Well, here’s my final thought is that I believe in patient smart and I tell patients you need to become your own medical advocate. Yes, you want excellence in doctors and nurses and health care. You don’t depend on your doctor, the hospital, your insurance plan or the federal government to take care of you. So do your research, try to find functional medicine people.  If you have a doctor that’s traditional, you can develop your own dream team because you need to look at those lifestyle factors, nutrition on stuff that we talked about. That’s really what I like to leave people with is that stay in the driver’s seat when it comes to your health. That’s a very important message that I always try to get across. I’m your second and you’re your first.

Dr. Weitz:            Exactly. I think that’s also very important. A lot of times people will see different doctors as, is this doctor, is it better to go to a conventional doctor or should you go to an alternative doctor? Really they both have their place and you’re suggesting for ideal health, for optimal health it’s best to have a team and there’s some great benefits to having a conventional primary care doctor and there’s all kinds of routine testing and it’s great to see them for infections and things like that.  But on the other hand, it’s also good to have a functional medicine doctor as part of the team to look at some of those underlying causes of some of these chronic diseases so you can look at things from different approaches and really get to the root causes.

Dr. Elkin:              [inaudible 00:58:02]

Dr. Weitz:            So how can listeners and viewers get hold of you, Dr. Elkin?

Dr. Elkin:              Okay. Well, if you go to my website, it’s www.heartwise.com, you learn about me and I try to put things there on a regular basis. On Facebook is HeartWise Fitness and Longevity Center and on Instagram, it’s Doc HElkin and I always try to post some things couple times a week. So I try to keep current and I try to inform people what’s happening. So it’s kind of a, I like to be contribute in that matter.

Dr. Weitz:            Thank you, Howard.

Dr. Elkin:              Alright, great. Thanks, Ben. I loved it. Very good. Thanks.

Dr. Weitz:            Me too.


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