Cardiologist’s Perspective on COVID-19 with Dr. Howard Elkin: Rational Wellness Podcast 156
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Dr. Howard Elkin provides his Integrative Cardiologist’s perspective on COVID-19 with Dr. Ben Weitz.
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Podcast Highlights
7:25 While many of us think of COVID-19 as a respiratory infection, it tends to have a significant effect on the heart, the blood vessels, the kidneys, and on blood clotting and this is part of why it’s so lethal and distinguishes COVID-19 from other respiratory tract infections, like the seasonal flu. At least 20-30% of patients with COVID-19 tend to have an elevation of troponin, which is an enzyme that indicates injury to the myocardium of the heart, such as when patients have a heart attack.
8:48 A lot of patients with COVID-19 have elevations of D-dimer, which is related to the fact that they have increased blood clotting. Normal levels of D-dimer are zero and we’re seeing levels as high as 3,4, or 5000, levels that are unfathomable. This is leading to blood clots being formed rapidly and we are even seeing reports of patients in their 30s and 40s dying of strokes from blood clots. The actor, Nick Cordero, age 41 had to be hospitalized for two months, ventilated, placed into a medically induced coma and have his leg amputated from COVID-19 and is still having some complications. Doctors and researchers are still trying to understand what is going on in these cases of COVID-19. When patients are in the ICU, intubated, in end stage disease, they can develop DIC (disseminated intravascular coagulopathy) where you get fibrin split products that cause small thrombosis throughout the body in the legs, the kidneys, etc. DIC typically occurs when patients have sepsis or acute respiratory distress syndrome. But it is highly unusual to see such clotting in patients in their 30s and 40s.
11:50 Some patients with COVID-19 end up with low oxygen levels and for some patients what is happening is that the iron is being liberated from the heme group in the bloodstream. This free iron ends up feeding the normally inactive bacteria that we all have in our bloodstream and these bacteria grow and secrete toxins which leads to sepsis and this hypercoagulable state. What’s not clear is what is causing what. We’ve learned that these patients don’t respond the way that other patients with acute respiratory distress syndrome (ARDS) that can result from more typical bacterial or viral pneumonias. More typical cases of ARDS usually respond to positive end-expiratory pressure (PEEP) which involves using a ventilator to force more oxygen around the body, but patients with COVID-19 often don’t do as well with PEEP and may do better with a C-pap machine or just oxygen or being placed on a prone position.
15:04 What can we do from a natural prospective to prevent blood clots? We should make sure to include fish oil in our daily supplements and it would be a good idea to combine some vitamin E in the form of mixed tocopherols or tocotrienols can help to protect the omega 3 oils from oxidation, both of which have a mild blood thinning effect. Also omega 3 is a natural anti-inflammatory and we want to reduce the likelihood of having a cytokine storm if we do get infected with coronavirus. Garlic and ginger are also natural blood thinner and can also be helpful. On the other hand, we might not want to thin the blood out too much in case we need to do surgery on these patients.
18:00 Patients with existing hypertension, heart disease, and diabetes have an increased risk of being hospitalized or of dying from COVID-19. If you have pre-existing heart disease or diabetes you have 2-3 times the risk of dying from COVID-19. Patients with kidney failure are twice as likely to die if they contract COVID-19. Obesity is also a risk factor for a worse prognosis and unfortunately, 40% of Americans are obese and 70% are overweight, so Americans are particularly vulnerable to a poor prognosis. Patients with hypertension are vulnerable to a worse prognosis and in the US we have 80 or 90 million people with hypertension and most of them do not even know it. Most of them are not adequately treated to the current standards. Blood pressure of 131/81 is considered hypertension and it should be 120 over 70 no matter if they are 20 or 80 years of age. Diet and exercise are the most impactful lifestyle changes. When it comes to hypertension, the first thing to look at is whether or not you are a salt retainer. Unfortunately, there is no test for this, but if you tend to collect edema, swelling of the ankles or if you’re African American or Mexican American, then you may be a salt retainer and you should try reducing your sodium intake. But sodium is essential for nerve and muscle function and sodium should not be vilified the way it has been as the cause of all hypertension. Dr. Elkin prefers not to prescribe diuretics, which help you get rid of sodium. In fact, we should be more concerned about sugar for the heart than salt. And sugar competes with vitamin C and it weakens immune function. Unfortunately, many people who have been forced to stay home because of this COVID-19 pandemic are finding that they’re baking cookies and eating more candy and other desserts to deal with the stress.
26:31 Certain nutritional supplements can be beneficial for patients with hypertension, including potassium, magnesium, fish oil, CoQ10, and quercetin, which can also be beneficial for fighting COVID-19, since it is a zinc transporter.
28:19 Since patients with chronic disease and who are obese have a worse outcome with COVID-19, it would be nice if as a nation we used this moment to create a focus in our public health programs or policies or with our health care system to focus on using diet and lifestyle to reduce obesity and reverse this chronic disease burden. This would lower our healthcare costs and make people more productive.
32:22 We have seen a number of disappointing studies with hydroxychloroquine and azithromycin, but yet some folks are posting on social media that it is the cure-all, it has been touted by President Trump, and some on social media are alleging that there is some sort of conspiracy to keep doctors from using it. Dr. Elkin noted that he has had patients asking for a prescription for these two drugs in case they get sick with COVID-19. There was one study in New York City that used hydroxychloroquine and azithromycin along with 50 mg zinc twice per day that did get excellent results but this showed more about the benefits of zinc than of hydroxychloroquine. Hydroxychloroquine is a drug for malaria that has also been used in certain autoimmune disorders. But it has some potential cardiovascular side effects, including arrhythmia in about 20% of patients. It can prolong the QT interval, which is something that is measured on an EKG. Azithromycin also prolongs the QT interval, so combined you are looking at 30-40% of patients potentially getting arrhythmia from taking this drug combination, and this arrhythmia can lead to sudden death.
39:27 Does taking certain commonly used blood pressure medications–ACE receptor blocking agents or ARBs (angiotensin receptor blocking drugs) (such as Losartan) make COVID-19 better or worse? We know that the coronavirus attaches to cells and gains entry through the ACE2 receptors. This has led some to speculate that taking such medications might make the infection worse. There are ACE-2 receptors in the lungs, the heart, the kidneys, etc. which is why these drugs work so well. But ACE inhibitors and ARBs are the most commonly used agents for hypertension because you can take them once per day, they work well, and they have few side effects. They also have utility in heart failure, kidney disease, and in diabetes, so we use them a lot. To take all these patients off without any real evidence that they’re bad, could really make matters worse, because what we don’t want is more heart disease, or kidney disease. So, the American College of Cardiology, and the American Heart Association, have both come out with statements saying, there’s no real evidence that it does make it worse, despite the theoretical information that we have, and they may even be beneficial. And the worst thing you want is out of control hypertension, heart failure, or kidney disease and then get infected, and have to deal with more problems.
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. Dr. Weitz is also available for video or phone consultations.
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. Hello Rational Wellness podcasters, Dr. Ben Weitz. Thank you so much for joining me again today.
Our topic for today, is to take a look at the COVID-19 pandemic from the perspective of an integrative cardiologist, Dr. Howard Elkin. Especially since we know that COVID-19 affects the cardiovascular system in a significant percentage of patients, we’ve seen numerous reports that patients with existing hypertension, diabetes, and coronary heart disease tend to fare more poorly with COVID-19. But we’ve also heard about patients with COVID-19, who end up with damage to their heart, including myocarditis, and cardiomyopathy. And these are often in patients who never had any heart disease, and we’ve even seen reports of younger patients in their 30s, and 40s, with blood clots, and even dying of strokes. We’ve also heard of some of the drugs being utilized, like hydroxychloroquine, causing arrhythmia.
Dr. Howard Elkin is an integrative cardiologist, with offices in Whittier, and Santa Monica, California, and he’s been in practice since 1986. Dr. Elkin does utilize medications, and performs standard angioplasty, and stent replacement, and other surgical procedures, but his real focus in his practice is to employ natural strategies for helping patients, including recommendations for exercise, diet, lifestyle changes to improve their condition. He also utilizes other creative, non-invasive procedures like external enhanced counterpulsation, as a non-invasive 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: Thank you. I’m delighted as always to be here with you, Dr. Weitz.
Dr. Weitz: And I’m sporting my pandemic beard here. And as we’re filming this, since the topic is talking about patients with COVID-19, I wanted to start off by asking you a personal question. How has this pandemic affected you, and your practice?
Dr. Elkin: Well, I think it affects everyone. As far as it’s affected me, clearly my outpatient business is down a little bit. Maybe about 20, 25%, which is better than most. I’ve made a real effort to keep us running, because so many patients, while I’m a cardiologist, these are the patients with higher morbidity, and mortality. So my emphasis has been to keep these patients healthy, and build their immune system so they don’t end up being a statistic. So, it’s changed the volume that I see. But it’s also given me a chance to really focus on my own health, and basically, slowing down and smelling the roses kind of thing, so it’s actually been uplifting in a way.
Dr. Weitz: Good. Excellent. One more question before we get into the COVID patients is, I’ve heard reports that there are a drastically decreased number of patients coming into the hospital with heart attacks, and other cardiovascular issues, and this may be partially because patients are afraid to come into the hospitals, because they’ve been told that they should stay away, or they’re afraid they’re going to come into contact with patients with COVID-19. What have you seen in that regard?
Dr. Elkin: You’re absolutely correct on this. In fact, studies have shown in France, and also Spain. And we don’t have quite the data yet on New York, but heart people presenting with what we call a STEMI, which stands for ST-Elevation Myocardial Infarction. It’s a term used for a particular type of heart attack, that basically, it’s a total blockage, or occlusion of a vessel. And we need to get in there right away to intervene, in order to save a life, and to also minimize the size of a heart attack. Now, the number, it’s been reported by the Cardiology Society, is that the number of STEMIs has decreased, anywhere from 60% to 80% in the last couple of months. That’s huge. I still take call about two to three times a month, and I’m in charge of the STEMIs when I’m on call, and the first week we had a lockdown, I had three cases. It was very, very busy. And that was at the very beginning of March. Since then, I get almost no calls at all. And that’s just, I think, an exemplary of what we’re talking about. People are staying home, they’re afraid to come in, which of course, is not a good thing. So we’ve been warned, from the American College of Cardiology, that we’re going to have an onslaught of cardiac cases in a few weeks, because people can’t stay home for so long, right? I mean, this is a heart attack. But I think it’s fear, people not wanting to leave their home.
Dr. Weitz: Yeah, I know that unfortunately, some of these patients who might have come in with less severe disease now, might come in closer to end stage disease.
Dr. Elkin: Absolutely. That’s my fear, and why I’ve blogged about it, I’ve written about it, I’ve been vocal about it on social media. It’s like, we’re open, we want to remain open. We want to be there for you as a source, so that we don’t have to deal with end stage disease.
Dr. Weitz: And in California, where we practice, even though LA has had more in cases in some of the rural parts of the state, our hospital capacity has been not even close to being challenged. So, our hospitals now are starting to, I believe they’re going to start welcoming in patients for elective procedures. So hopefully that will help in that regard.
Dr. Elkin: Right. Our hospital has just released that, in the last week or so. I actually did an elective angiogram on a patient. It wasn’t elective, he actually needed to have it done.
Dr. Weitz: Right. A lot of people don’t realize, I talked to people about elective surgery, and they go, “Oh, you mean plastic surgery?” No. We’re talking about a huge number of important, medically necessary procedures, but they’re just not being done, because the priority has been to keep the ICUs open for COVID patients.
Dr. Elkin: Right. I walked into my hospital’s lobby yesterday because I had a patient, I was doing a cardioversion, which is when you actually shock a patient’s rhythm back into normal, and the lobby is like nobody’s there. It’s so quiet. I’ve never seen a hospital so quiet. It’s surreal. It’s really surreal.
Dr. Weitz: Yeah. So, while many people think about COVID-19 as a respiratory infection, it tends to have a fairly significant effect on the cardiovascular system. And in fact, its effect on the heart, the blood vessels, the kidneys, and on blood clotting, is often what leads to its lethality. And this distinguishes the coronavirus from other respiratory infections, such as the seasonal flu, doesn’t it?
Dr. Elkin: Absolutely. And, this is so evolving. A few weeks ago, we thought… I didn’t really think about it as a cardiac problem. But, in the last few weeks, we’re seeing it really is quite a bit of cardiac involvement. In fact, at least 20% to 30% of patients, depending on what you read, tend to have an elevation in troponin, which is an enzyme that we look for, to detect injury to the myocardium of the heart. And that’s what we measure when people come in with a heart attack. And we follow that, we trend it. So we’re seeing a lot of these patients are having elevated enzymes, which does portend a bad prognosis. In fact, the mortality of people with elevated troponin levels, regardless of whether they end up having a heart attack, it just adds insult to injury. So if you see elevated troponin, it’s not a good sign.
Dr. Weitz: I understand a lot of these patients have elevations of D-dimer, which is related to the fact that they have increased clotting. And I’ve talked to some physicians who are working in emergency rooms, and they’re telling me, I don’t know if this is done everywhere, but they’re starting to routinely put patients on blood thinners when they are admitted for COVID-19.
Dr. Elkin: Yes, our hospital is doing the same. So D-dimer is a chemical test, and what it detects is basically venous thrombosis clots. And, a normal level zero, right? We’re talking levels as high as three, four and 5,000, which is unfathomable. You’d never see that before, even in someone that’s had a vein clot, or pulmonary embolism. So the numbers are astronomical, and then, doctor interventionalists that are intervening with people with strokes, they’re saying that the clot is being formed as they’re intervening.
Dr. Weitz: Wow.
Dr. Elkin: Actually seeing more clot being laid down, which, I can’t imagine that.
Dr. Weitz: And I guess that’s what’s explaining why we’ve seen reports of patients in their 30s, and 40s, dying of strokes from blood clots. And then we heard about that actor, Nick Cordero, who had several strokes, had to have his leg amputated, and is still having some serious problems after being in the ICU for a considerable period of time. What is going on with this clotting, and what’s going on in the blood vessels?
Dr. Elkin: We’re not quite sure, what the chicken, and what’s the egg in this case. First of all, a lot of people with end stage disease, they’re intubated, they’re in ICU, they’re not doing well. They develop this entity called DIC, disseminated intravascular coagulopathy. And so, what happens, you have these, and the end product is something called fibrin split products, and they cause all these little small thrombosis everywhere. Kidneys, legs, everywhere. But that’s just part of the problem. That’s end stage. When you see DIC, usually I’ve seen it in people that have sepsis, or acute respiratory distress syndrome, which of course, is common in these patients.
But now we’re seeing young people, like you say, with strokes, or these thromboses, and part of the problem is, we’re not quite sure why is happening. But we know that these people kept saying to themselves, “This can’t be a stroke, I’m only 30 years old.” Right? And so, they are not seeking immediate, or prompt attention, which is really bad. Because this is something that’s treatable. Just like what I do, as an interventional cardiologist, I intervene, I go in there, and I do a thrombectomy, and then put a stent in. The same thing can be done and a stroke center, which, my hospital is one of them. So, these patients should not be staying home if they have any sign, or symptom of a stroke, at any age.
Dr. Weitz: Now, there’s been some discussion in the literature, how this actually ties in with the breathing problems patients are having, which was originally thought to be typical, to acute respiratory syndrome, and now they’re realizing it has more to do with low oxygen levels. And some of the data is showing that what’s happening, is that iron is being liberated, free iron is is being liberated from… The heme isn’t able to hold the oxygen, and the iron group is dislodged from the heme group, and is floating free in the bloodstream, and I heard one discussion about this. So, if you have more iron in the bloodstream, it turns out our blood, which most people think is sterile, is really not sterile. There’s a lot of bacteria floating around in there, but the bacteria are not really active. Partially because they need iron to actually grow, and reproduce, and flourish. And now there’s free iron is leading to these pathogens in the blood growing, and creating toxins, and that this might be part of the process that’s leading to sepsis, and some of these other coagulable situations.
Dr. Elkin: I agree on that. And this is new information. We’re just really reading about it. Again, it’s the chicken, and the egg thing. what’s happening first? And when I think of sepsis, having been around ICUs for many, many years in my training, and also as a practitioner, I think about, usually bacterial infections of any matter, or form, and then the end result is sepsis. But you do see it, and viremia, and it seems to be common in this virus, in which it’s overwhelming. The body is breaking down, okay? The body is breaking down, and like you say, the heme is being stripped from the red blood cells, with the lack of oxygen. We’re learning so many things, and people need to understand this virus, it’s fickle. It can mutate, it can do all kinds of strange things. We don’t have a handle on it. And so, like, for example, ARDS, we’ve known about that. We’ve treated it for years, acute respiratory distress syndrome. We see it in any type of bacterial, and/or viral pneumonias. But, usually it responds favorably to this thing called PEEP, positive end-expiratory pressure. Okay, but now we have found that these people with COVID-19 are not a homogeneous group. And some really don’t do well with high levels of PEEP. Actually it can lead to oxygen toxicity, and other problems. And that some of them behave more like high altitude sickness. And some of them may need a C-pap machine, or different treatments. A lot of them are being put in a prone position, on their stomach, right? Because they can aerate more lungs. We’re just tip of the iceberg here. That’s why it really is learning process.
Dr. Weitz: So from a natural perspective, if patients are being given blood thinners when they get into the hospital, if I wanted to do what I can, from a natural perspective, to decrease my chances of having a poor outcome if I do get infected, does it make sense for me to consider taking a natural blood thinner, like natto kinase, or maybe increasing my normal intake of fish oil, or garlic, or vitamin E, which may mildly thin the blood out?
Dr. Elkin: Well, that’s a great question. So what do we do? Can we do anything prophylactically? First of all-
Dr. Weitz: And preventatively, yeah.
Dr. Elkin: Preventatively, right. You know the study that came out about a year and a half ago, that’s saying, “Low dose aspirin in the general population of over age 50, really isn’t something we recommend.”
Dr. Weitz: But that’s because it might cause more bleeding.
Dr. Elkin: Right. And I’ve adhered to that principle, even before the study came out. So now we have a different thing. I would say, yeah, first of all, I definitely am a firm believer of… What’s some things you mentioned? Like garlic…
Dr. Weitz: Fish oil.
Dr. Elkin: To me, anybody over the age of 40, and maybe even younger now, deserves to be on fish oil. That’s my number one go to supplement.
Dr. Weitz: And see, fish oil is a natural anti-inflammatory, and we know part of the acute respiratory distress syndrome, where you get this cytokine storm in the lungs, you get a lot of inflammation. Fish oil probably could be beneficial in that regard, too. So maybe a simple solution is just up the normal amount of fish oil you’re taking.
Dr. Elkin: Right. Ginger, garlic, they’re also natural blood thinners. Vitamin E. I usually like mixed tocopherols. These are all things that we can be doing. I haven’t recommend… I mean, my big thing is fish oil.
Dr. Weitz: Yeah.
Dr. Elkin: That’s a great question, because we don’t have the answer. We don’t want to thin it out too much, because what if you have to do surgery on these patients, or an intervention? Then we’ve got other issues on our hands.
Dr. Weitz: Right.
Dr. Elkin: But, these are the questions that really need to be answered.
Dr. Weitz: Yeah. And yeah, I’ve increased my fish oil, and added one of those supplements that has the extracts from the fish oil that decreases inflammation, the inflammatory response modifiers. And, anytime I take fish oil, I always throw in some vitamin E, and the preferred source I’ve been using the last six months is the tocotrienols now, because the data seems to be pretty robust for that. So, we know that patients with existing heart disease, and diabetes, et cetera, high blood pressure, have an increased risk. So, what can these patients do prophylactically to, besides, we’re talking about the blood thinner thing, what else could they do to make sure that they’re most likely going to have the best possible outcome?
Dr. Elkin: And by the way, this is probably the most important question anyone can ask, which is what I’ve written about, blogged about. First of all, keep your appointments with your practitioners. Because-
Dr. Weitz: And, I should say, besides losing 50 pounds, getting your blood pressure totally under control, and doing all those things to have perfect health. But what can they do in his short term?
Dr. Elkin: Right. Okay, so, you’ve mentioned it already. Let me just give you a little bit of a rundown of the numbers. If you have preexisting heart disease, you’re twice as likely to have a negative result, I mean death. Your increase of mortality are doubled. I’m sorry, three times. You’re three times more likely. Same thing with diabetes. So, diabetes and preexisting heart disease are your two biggies. Kidney failure, twice as likely to die. And then the next one is obesity, which is, as you know, about 40% of the American population is obese, and about 70% are overweight. So we’re not dealing with a healthy crowd to begin with. And that’s what I’ve been talking about. Use this opportunity to improve your overall health. If you’re hypertensive, get your blood pressure down. I’m really strict on that one, because, the numbers now are incredible. It used to be 70 million and now there’s 80 or 90 million people in this country with hypertension. Most of them do not know it. Most of them are not adequately treated, at least according to the standards that we’re looking for. So it’s really-
Dr. Weitz: And according to the current standards, and the way you see the literature, what constitutes, what number of systolic diastolic blood pressure constitutes hypertension? And what is the ideal range that they should be in?
Dr. Elkin: Right. I always tell people that the ideal blood pressure, whether you’re 20, 30, 60, 80, or 100, is always 120 over 70. And that doesn’t mean I try to get that in everybody, but that’s the ideal. But the standards now, which have been present for about a year and a half, is that anything above 130, on the systolic range, and above 80 on the diastolic range is considered hypertensive. So if you’re 131 over 81, that’s considered hypertension. Now, does that mean I try to get everybody to that number, that’d be ridiculous, because patients would be on three or four medicines, they’d have to see me every three to six weeks. But, I do pick and choose. On younger people, people that are really proactive about their health, people that really want to get to optimal. Yes, we will do our best to get that way. There’s so much you can do with lifestyle. People think that we should go straight to medicines, and I don’t tend to do that, when I see a new patient, unless the blood pressure is off the wall.
Dr. Weitz: So what are the most impactful lifestyle factors that we can utilize?
Dr. Elkin: Well, it always boils down to diet and exercise, right? I mean, because most of these patients are overweight, overstressed, and they don’t exercise on a regular basis. Same thing with diabetes. So, for me, an ideal diabetic should be in the non-diabetic range. I have many diabetics that start off with high A1Cs, I get them to being a pre-diabetic. Then I get them below 5.7, and they’re really a diabetic, but we’ve got them very well maintained, and it can be done. It’s work but…
Dr. Weitz: What are the most impactful dietary factors, A, for heart disease, and B, for diabetes?
Dr. Elkin: Okay.
Dr. Weitz: Why don’t we start with hypertension?
Dr. Elkin: Right. Then it always comes down to this topic about salt, right? I mean, just this age old problem that’s been going on for years. And, if you are a person with normal blood pressure, you do not have to worry about salt. Okay? It’s just unnecessary. If you have blood pressure, hypertension, it really is going to depend on whether or not you’re a salt retainer. Though there’s not a test that shows whether or not your salt retainer, but, if you tend to collect edema, or swelling of the ankles, if you’re African American, or Mexican American, these people tend to have a higher incidence of hypertension. In the Caucasian group, it really depends. I am not overly strict about sodium, unless they have heart failure, kidney failure, liver failure, or they fall into those groups. Also, kidney failure is a very big one, and you have to be very careful about sodium with them. The average hypertensive, I very rarely give diuretics, which help you get rid of sodium. And I don’t super restrict, I just say, “Use a prudent diet.” I mean, you should be-
Dr. Weitz: And of course, there’s a balance between sodium on one end, and potassium, magnesium, calcium on the other.
Dr. Elkin: Right. People have to understand that sodium is not to be vilified. I mean, it’s important for nerve and muscle function, and it also helps create balance of the body fluids. So it’s essential for life, so I think that’s been over-emphasized. It’s actually been shown, I did a recent reading on this, that sugar, believe it or not, sugar is actually not good for the heart. I don’t know… For us in functional medicine, it’s not major surprise, right? But the emphasis has really never been on sugar. In fact, some of these… On What the Health, was a documentary that came out a couple years ago, which is… I won’t go into my thoughts about it, but sugar was minimized, as far as any mal-effect at all on the body. So, it’s crazy. But back to the preventative stuff you were saying, I’m sorry.
Dr. Weitz: By the way, the easiest way to weaken your immune system, is to eat a bunch of sugar.
Dr. Elkin: Right. And I didn’t know this, but in my research, that sugar actually competes with vitamin C for your immune system. And so, my thing is, why would you want sugar to compete? And why would you want sugar to win? Because it will.
Dr. Weitz: Yeah.
Dr. Elkin: I mean, I’ve had patients who wrote on Facebook, “Wow. Since this pandemic, I’ve stayed at home, I’ve gained 15 pounds, and I’m baking bread and chocolate chip cookies.” It’s like, “You serious?” People are doing this. I mean, I drive by this [inaudible 00:24:51] place, I never stop out there, but on the way to work. And it’s packed. Or I was at CVS, getting some razor blades, about two weeks ago, and I just happened to happen to walk by the candy aisle, it’s like almost everything is gone. These poor kids are at home because they’re not in school, and the parents are probably trying to shut them up, and giving them candy. Terrible. So those are the kinds of things. Sugar is very deleterious to your health, and is the last thing you want if you’re trying to build, or optimize your immune system.
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Dr. Weitz: Are there any particular supplements that patients with hypertension might take at this point?
Dr. Elkin: Yes. First of all, I do use, even though I don’t normally supplement with potassium, I don’t think you normally have to, if you eat adequate fruits, and vegetables. I sometimes will add just a little bit of potassium, because that can help lower blood pressure. Magnesium, so I’m big on minerals. I’m big on minerals. I have a product that has olive leaf extract in it, which has been shown in a population of patients have been effective. It’s also anti-carcinogenic. CoQ10 can be helpful. These supplements have small, but potentially cumulative roles.
Dr. Weitz: Right.
Dr. Elkin: So, I really try to… Fish oil, CoQ10, those two are much.
Dr. Weitz: Of course, quercetin is a product that could be potentially beneficial for COVID-19 patients, because it’s a zinc transporter, but that also potentially can help with hypertension.
Dr. Elkin: Right, exactly. So, minerals, there are things you can do. So, I add them. Plus, because of my standing as an integrative cardiologist, a lot of people come to me because they don’t want to go on medications. They’ve been to three or four doctors, they’ve all put them on medicines, they’ve had side effects. They don’t like it. So they’ve heard about me, and they come to me for that reason. So, these are the people I like to work with. But, it’s always gonna start with lifestyle, number one. We’ll add the supplements, and do my best to avoid going on medications. Lots of times you need it, because, again, to stay out of the hypertensive range, you may need to add pharmaceuticals. But it’s not my go to, at least initially, unless you’re really, really high.
Dr. Weitz: It would be really nice if we utilize this opportunity. If we look at the fact, I’d be curious when we’re done with this, if we see how well the American public has fared with the COVID-19 infection, compared to other countries. But given the fact that we are, I believe, still the number one country in terms of rates of overweight, and obesity, and I’m sure we’ve got to be close to the top on diabetes, and we know heart disease is just rampant, as well as these other chronic diseases, we could use this as an opportunity to focus on trying to get our society healthier. And that would be a great thing for the health of our nation going forwards, and would also be beneficial for every other possible reason, in terms of lowering our healthcare costs, and even making people more productive. I think we should try to seize this opportunity to focus on what we can do to reduce the chronic disease burden.
Dr. Elkin: And I could not agree with you more. And I really laud some of the things that you are personally doing. I mean, you have these Tuesday afternoon Zoom sessions, that people can dial in, and talk, actually share their thoughts about COVID-19. And, I mean, that is a great move. I just put together my own supplement, which is really basic, called ImmunoWise, to help boost the immune system. It’s very basic. It’s got the proper dose of vitamin C, and zinc, and I’m blanking now. But it’s got quercetin, but it’s a nice supplement, in one bottle. If you take three day, it’s going to help with your immune system.
Dr. Weitz: That’s great.
Dr. Elkin: So, we’re doing things, and I’d like to think that a lot of our colleagues are doing the same, taking that opportunity. And also to reassure patients, they don’t have to have negative outcomes, even if you have a heart problem.
Dr. Weitz: By the way, I don’t know if you just came across the bulletin boards. There is a pre-print of a study from hospitals in New York, and they utilized zinc along with hydroxychloroquine, and it turns out that the patients who were taking zinc did remarkably better in terms of mortality rates, and being released from the hospital, or not ending up on a ventilator. And the dosage of zinc was actually quite high. They were using 50 milligrams of zinc, twice per day. So, that’s 100 milligrams of elemental zinc.
Dr. Elkin: Right.
Dr. Weitz: And I think that’s interesting that now you have traditional hospitals utilizing essentially a pharmaceutical dosage of zinc, and getting incredible levels. So, I think it’s interesting to see that some of these natural substances can be quite powerful.
Dr. Elkin: And I think this is, again, why this is such an important learning process. We really don’t know. I avoid this whole hydroxychloroquine, chloroquine Z-Pak thing. We can talk about it. We probably should, because, I mean, I see these posts on Facebook, and I want to just scream, because these people are obsessed about who’s right, who’s wrong, why they’re right. It’s like, “You guys.” I say-
Dr. Weitz: Just make sure when you take your hydroxychloroquine, wash it down with some bleach.
Dr. Elkin: Right. Exactly. Yeah.
Dr. Weitz: And inject some Lysol right after that.
Dr. Elkin: Right. I saw this cartoon of our president, and he’s getting erect, and getting an enema. Oh boy. So anyway-
Dr. Weitz: So yeah, why don’t you talk about… So hydroxychloroquine, or chloroquine. These are drugs that have traditionally been used for malaria. And there are some reasons to see that they may be potentially of benefit. Even though, if they are effective, they’re certainly not going to be the cure all. And, one of the benefits of hydroxychloroquine is that it helps as a zinc transporter. Unfortunately, it has a lot of potential side effects, and maybe you can talk about that.
Dr. Elkin: Right. So, hydroxychloroquine, which has been used, like you say, for a long time, it’s also used in certain autoimmune disorders, rheumatologists use it for-
Dr. Weitz: Lupus.
Dr. Elkin: Lupus. Rheumatoid arthritis. I had a patient that was on it for briefly, for mixed connective tissue disease. She was followed by a rheumatologist at UCLA, and had problems. Here’s the thing. The success stories are basically very anecdotal. There’s a lot of observational studies, and I understand, it’s a new disease, basically, we don’t have a lot of data. But some people are jumping to, “Oh wow, they’re using this in Inglewood, a hospital in Inglewood with great successes.” It’s like, okay, I would not take that as gospel. But anyways, so here’s what we worry about. It can prolong the QT interval. What is that? The QT interval is something we actually measure on a routine EKG. It has to do with your electrical… It’s resetting your electrical setting, electrical activity between beats. So you have a depolarisation, electrical impulse, and then the heart contracts. Then it has to relax in between beats, for the next one. So it’s electrical activity that can be… The certain part of the cardiac cycle can be prolonged, electrically, as a result of these drugs. We’re talking about at least 20% or more of patients on these drugs will develop QT prolongation. Now, if you add azithromycin into it, which is not benign, like people think it is, then you’re probably magnifying that by double. You probably double it. So the two in combination, can really prolong QT interval. Why would you care? Because QT prolongation could lead to malignant arrhythmias. There’s one that we look for called torsades de pointes, which means a twisting of the points in French, and I’ve seen it, and it can be deadly. I mean, this is what can lead to sudden death. So, these patients really have to be monitored. I’ve had people ask me, “Can I have a prescription for hydroxychloroquine just in case?” I said, “Are you serious?” They said, “Just in case.” I’ve actually had people ask me this.
Dr. Weitz: Yeah, just go to the pet store, and get the kind you use to clean your fish tank. You see how that worked out for them.
Dr. Elkin: Right. Right. Exactly. So-
Dr. Weitz: I’m referring to somebody in the news, who consumed that, unfortunately, didn’t have a good outcome.
Dr. Elkin: Yeah, yeah. He thought it would… Amazing. So anyway, another reason to be concerned is because these patients are in ICU, they’re critically ill to begin with. Like I said, about 20% of them are going to have elevated troponin levels, if you look at the new data coming out. So, I don’t know. I would not want to give this to someone with an elevated troponin level, who’s already at higher risk of arrhythmias, right? And then you’re going to potentially worsen that. So, these people that are so pro that combination, because it works, it’s worth… And a doctor in New York, who I don’t know this doctor, I’m sure you’ve heard about him. He’s said it work in every patient he gave it to.
Dr. Weitz: I seen that report, too. Yeah, so I’d like to make a couple of comments about the hydroxychloroquine. One is, in the functional medicine world, people have jumped on this. I don’t know why, but somehow, there’s people especially tend to be attracted to conspiracy theories, and they think that we have this drug that works, but the medical establishment is telling people not to take it, because they want to force everybody to get vaccines. And, I think it’s clear that we really don’t know if it might work. And, I certainly wouldn’t jump on it. And I think there’s an alternative. And then, number two is, there are folks in the natural medicine world, who have figured, “Since hydroxychloroquine may be of benefit, I’ll just give the patients quinine water.” And unfortunately, the amount of chloroquine in quinine water is so low, that there’s no way. If chloroquine, or hydroxychloroquine has a beneficial therapeutic outcome, then the amount in quinine is going to be insignificant. So, forget that idea.
And one of the main things that hydroxychloroquine seems to do is, it increases the ability to get zinc into the cells, they call it a zinc ionophore, and because the cells tend to repel the zinc, and in this recent study in New York, it turns out that the patients on hydroxychloroquine really had few benefits compared to the patients who were taking hydroxychloroquine and zinc, which really what that study shows is that zinc is a real benefit, and that hydroxychloroquine is just getting it into the cells. So, those of us in the natural world use 250, to 500 milligrams quercetin each time you take the zinc, and that’s a natural alternative to getting the zinc into the system. And then one other potential benefit to hydroxychloroquine, is once the coronavirus gets into the cells, it gets put into an endosome, and then it gets pushed out of the cell, where it could spread. And, that that endospore requires an alkaline environment, and the hydroxychloroquine creates an alkaline environment, so it may suppress the ability of the virus to spread. But there’s an actual agent known as Chinese skullcap, that can also do the same thing. So you can combine quercetin and Chinese skullcap with zinc, and you’re probably going to get the same benefits without having any arrhythmia.
Dr. Elkin: That’s interesting. That’s new to me, because I’m familiar with skullcap. It’s an actual anti-inflammatory, but I’ve never seen it in that context. But it’s interesting though, these… And like you said, I think-
Dr. Weitz: That was pointed out to me by Dr. Peter D’Adamo from the Eat Right for Your Blood Type, who I did a podcast with a few weeks ago. I wanted to ask you about one more set of drugs that are used for heart disease. So, we know that this novel coronavirus, they say it’s novel because we don’t have any immunity to it. So, this coronavirus tends to attach to, and gain entry into our cells through ACE-2 receptors, which are found in the lungs, and virtually on almost all the tissues of the body. And so, there’s been some speculation that certain common drugs for hypertension, like ACE inhibitors, and angiotensin response blockers might increase the risk of worse infection. What’s your perspective on this?
Dr. Elkin: Okay, I’m glad you mentioned that. First of all, so there are ACE-2 receptors in the lung, in the heart, in the myocardium, in the kidney. I mean, they’re all over. But, that’s also probably why they work, why they’re so effective in blood pressure. But, so, this started off as an observational study. And I don’t even know if it was in vivo or in vitro, in China, when they noticed this, and it does make sense, right? I mean, if it’s the same port of entry, the virus enters the cell by attaching to an ACE-2 receptor, does it make it worse? And then, the big thing about that, is that okay, well, ACE inhibitors and ARBs are the most commonly used agents for hypertension, and it’s certainly my practice, because generally you can do them once a day, and they are well tolerated with very little side effects.
They also have utility in heart failure, and renal conservation, people that are diabetic, so we use them a lot. To take all these patients off without any real evidence that they’re bad, could really make matters worse, because what we don’t want is more heart disease, or kidney disease. So, the American College of Cardiology, and the American Heart Association, I think, have both come out with statements saying, there’s no… And there’s truly no real evidence that it does make it worse, despite the theoretical information that we have. Some people say, I don’t know if you’ve read about this, that there actually may be some improvements.
Dr. Weitz: Absolutely. And you can think about that, right? If the ACE inhibitors are blocking the ACE receptors…
Dr. Elkin: Exactly. So, I have not taken anyone off of ACE or an ARB as a result of this information. I’ve had many phone calls. I’ve heard about this, but I have dissuaded them from changing. Plus, when you change blood pressure medications, and let’s say you have something, a combo that’s working, you’ve got to start all over again, with a different class of medications.
Dr. Weitz: And the worst thing you want is out of control hypertension, and then get infected, and have to deal with more problems.
Dr. Elkin: Right. Or heart failure, or worse, even kidney failure.
Dr. Weitz: Exactly, exactly. Okay, so I think those are the main topics I wanted to cover. Is there anything else you wanted to tell the listeners, and viewers?
Dr. Elkin: [crosstalk 00:42:38] Just one that’s interesting, I don’t have the answer to this.
Dr. Weitz: Yeah.
Dr. Elkin: But I want to hear your opinion, as well. This whole thing about testing.
Dr. Weitz: Yes.
Dr. Elkin: Should I be tested? Should I not be tested? And then you’ve got, again, the same kind of protagonists, and antagonists in the social media world, saying, “Oh, no.” So, what we look for, and I want to really get your opinion is, we want a test to be 100% sensitive, and 100% specific.
Dr. Weitz: And that doesn’t exist in the real world.
Dr. Elkin: It doesn’t exist in the real world. So, if I am a true negative, that means I definitely don’t have the virus, or never had it, or [inaudible 00:43:13]. So, there’s loopholes, and as far as testing is concerned, it does not clearly confer immunity, and we don’t know how long immunity really will last.
Dr. Weitz: So are you now talking about antibody testing, or virus testing?
Dr. Elkin: Yeah, yeah. Not so much the nasal swab. We know that the nasal swab will be… If the nasal swab is done correctly, and these centers know how to do it.
Dr. Weitz: By the way, it was just approved, I think either this morning, or yesterday, using saliva, a home viral test using saliva where the patients spit into a tube, and send it in. It’s been tested in New Jersey for a couple of weeks now. That was now approved as a new way to test, and that’s going to be a game changer for… We don’t have to worry about having enough of the swabs, it doesn’t require the same reagents, you don’t have to have somebody in a hazmat suit, with full PPE, worried about sticking a swab down someone’s nose, and being uncomfortable, and everything else. So, testing for the virus-
Dr. Elkin: You’ve got to go way up there.
Dr. Weitz: Yeah, this is going to be a big game changer as far as that goes.
Dr. Elkin: So the antibody testing, there’s no perfect test. If you’re going to have it done, and I did have it done, you want to check… Even though I don’t think there’s anything that’s truly FDA approved yet, that takes a while to happen. Okay? You’ve not going to have FDA approval in such a short time period.
Dr. Weitz: Well, what’s been happening is, is there are tests on the market that haven’t gotten any recognition at all, but there’s somewhere around, I don’t know, 80, 90 tests, maybe more, on the market that have been given emergency approval by the FDA. Meaning, hey, you guys have some data, it looks like you guys have done some thorough testing. We don’t really have time to investigate all the details, but go ahead, and put it on the market. It looks like you guys are doing a good job to start with. And so, I would certainly use a test that at least has emergency FDA approval.
Dr. Elkin: Right. And I chose one that does both IGM, and IGG, and it’s quantitative. So, my test was negative. I maybe will repeat that in three months. There’s no set pattern as to when you do it. So, we don’t have the answers. There’s no perfect test. There probably would never be a perfect test. But, we will learn more about testing as we learn more about this virus.
Dr. Weitz: Well, so there’s two types of tests. There’s one test where you prick your finger, and it’s called a blood spot test. And then there’s tests where they take serum. And the serum tests are decidedly more accurate. So, the blood spot tests are some ways in the 50% to 70% rate of accuracy, sensitivity, and specificity. And whereas, the companies that have done a good job with the serum tests are somewhere in the 90% to 100% range.
Dr. Elkin: Correct.
Dr. Weitz: So, I would go with a serum test, rather than a blood spot test. The blood spot tests are the ones where you get the results in 10, 15 minutes. The serum tests, unfortunately you have to send it in to a lab, and get it back.
Dr. Elkin: Right.
Dr. Weitz: But I’d like to make a comment about whether antibodies are protective. Now, it’s good to be cautious. It’s good to be careful. It’s good not to get ahead of the research. And it’s easy for people to extrapolate, make all kinds of claims that aren’t accurate. So, I applaud the medical establishment for being very careful, and saying, “Hey, we don’t know for sure if antibodies are protective.” But, we know that the way our immune system fights against viruses, any virus, is to create antibodies. And this virus is, in many ways, similar to other viruses. And we know that our bodies do mount antibodies, and for the most part, not 100%, not in everybody, but generally speaking, I’d like to say that I think if we looked at the preponderance of evidence, even though we don’t have 100% proof yet, antibodies are going to be protective. That’s the way our body works. If antibodies were not protective, a vaccine will never work, nothing’s ever going to work. Herd immunity won’t work. The whole point of herd immunity is everybody builds up antibodies. A vaccine is to synthetically stimulate your body to form antibodies. So, I know everybody’s being cautious, and fine. But, I’m not saying I have proof for this, but I think methodologically, it makes sense that antibodies are going to be protective. The proof we do have is that they’re using convalescent plasma therapy, which is taking antibodies from patients who’ve been infected, and we’ve seen really good results. Also, they did a study with rhesus monkeys, and for antibody production, I guess, rhesus monkeys are fairly predictive. And they gave the rhesus monkeys the coronavirus, the COVID-19. They tested positive, they got over it, they tested negative, then they reinfected them with COVID-19, and they did not get infected again.
Dr. Elkin: Right.
Dr. Weitz: Because they had the antibodies. And I understand we’re being cautious about making these recommendations, and I think it would be foolish for somebody to say, “Hey, I had a positive antibody test, I’m going to run around without a mask, and infect everybody else, and not worry about anything else.” Because we can’t say 100%.
Dr. Elkin: It’s like you’re having these COVID-19 parties. I agree with you. I [inaudible 00:49:17].
Dr. Weitz: I think for the most part, we should think that antibodies should generally be protective. Don’t you agree with that?
Dr. Elkin: Absolutely. And it always goes back to your immune system. People think, they want to think, and I’m not going to try to politicize this by any way, matter, or form, is that a vaccine is like a magic bullet. A magic pill. Americans, we always want that magic pill or bullet, which doesn’t really exist. Now vaccines can be effective, but you’ve got to remember about, if you look at just the flu vaccine, just that simple, little flu vaccine, about 50% of people do not respond favorably to it. Why? Because they’re obese, diabetic, hypertensive heart disease, renal failure, and they can’t mount an adequate immune response. When we give you a vaccine, we’re really giving you the antigen, we give you an attenuated form of the virus. We’re dependent on your body to form antibodies. And if your body isn’t healthy, you’re not going to have the same response. So it still boils back to the lifestyle, the kind of stuff that you and I talk about all the time.
Dr. Weitz: Absolutely. Excellent, Dr. Elkin, I really appreciate it.
Dr. Elkin: [crosstalk 00:50:22].
Dr. Weitz: I enjoyed the discussion. For those who don’t know, Dr. Elkin’s on the west side, in my office on Tuesdays. And I believe you are probably the only integrative cardiologist on the West Side of LA right now. So, patients should take advantage of the ability to see Dr. Elkin, in Santa Monica. And, I also wanted to say to our listeners and viewers, that in addition to this podcast showing up on Apple Podcasts, where if you give me a positive rating and review, I would really appreciate it. But it’s on Spotify, it’s on all the other places you get podcasts. And there’s also a video version on YouTube. And also, if you go to my website, drweitz.com, you can find a complete transcript, and detailed show notes. And then how can listeners and viewers get a hold of you, Dr. Elkin?
Dr. Elkin: The best place, probably through my website, www.heartwise.com. I’m also on Facebook, at HeartWise Fitness & Longevity Center. I’m also on Instagram. So, I’m all over social media. So, I’d be glad to talk to, meet anyone. Clear pleasure.
Dr. Weitz: Excellent. Great. Thank you. I’ll talk to you soon.
