Coronary Artery Disease with Dr. Howard Elkin: Rational Wellness Podcast 200

Dr. Howard Elkin discusses Coronary Artery Disease and How to Prevent it with Dr. Ben Weitz.

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Podcast Highlights

3:55  Myocardial Infarctions.  A myocardial infarction, aka, a heart attack, is the end result of a plaque in an artery becoming unstable and rupturing, resulting in no blood going beyond that clot.  Plaques build up in the arteries over time and we don’t know what makes a stable plaque into a stable plaque.  While it was thought that about 25% of heart attacks are silent, a recent analysis published in a Harvard Health letter found that up to 40-45% of heart attacks are silent. [The Danger of “Silent” Heart Attacks]  Such silent heart attacks are usually smaller, which means that a smaller amount of damage occurs to the heart muscle. But a small heart attack will often presage a larger heart attack. We actually don’t know why or how chest pain occurs, since there are no sensory nerve fibers in the heart. Diabetics have a larger percentage of silent heart attacks and diabetes is still on the rise in the US, which is why the number of silent heart attacks is increasing.

8:35  After taking a careful history, if you suspect coronary heart disease as a result of a constellation of symptoms, including chest pain, shoulder pain, arm pain, jaw pain, shortness of breath, fatigue, nausea, and it could present as digestive symptoms, then Dr. Elkin will employ stress testing.  Stress testing means doing either a stress echocardiogram or a nuclear stress test, which adds about 15% more sensitivity to stress testing.  A stress echo is more accurate than just doing a treadmill test.  A stress echo involves doing an echocardiogram to see how the heart functions while at rest and then how if functions after exercise.  If an area of the heart wall is not contracting well, then that indicates that there’s not enough blood flow going to the heart.  A nuclear test involves a nuclear (radioactive) pharmaceutical and it is done at rest and if there’s an area of the heart that doesn’t take up that pharmaceutical, then that’s another suggestion that there is a blockage.

10:40  Given that our body is designed (through evolution) to help us survive, why would our body form these cholesterol plaques in our arteries that can kill us?  The body is responding to inflammation in the artery walls and the cholesterol plaque is coating the arterial wall and protecting it from the inflammation. The inflammation could result from food sensitivities or toxins or chronic infections.  Dr. Elkin explained that when he was studying cardiology in school there was no knowledge of inflammation. They were taught that cholesterol was bad and that you had cholesterol plaques that would get more and more narrow until they led to choking off the blood supply, causing a heart attack. But that really isn’t the true story and most heart attacks are usually with blockages that are less than 50% of the width of the inside of the artery.

13:13  About 50% of those with heart attacks have normal results on standard lipid testing, which is why we want to do advanced lipid testing to pick up additional cardiac risk factors. A number of labs offer advanced lipid testing and Dr. Elkin prefers to use the panels from Boston Heart Diagnostics and Cleveland HeartLab. The standard lipid panel (total cholesterol, estimated LDL, HDL, and triglycerides) is very limited.  An advanced lipid profile will include the standard, plus LDL particle number, aka LDL direct, which actually counts the number of LDL particles, as compared to the standard panel that estimates the amount of LDL.  It also tells you how much of the LDL is small, dense particles, which are the ones that create the most risk, since small, dense are about 30% more likely to be oxidized.  LDL oxidation is a precursor for plaque formation and we also want to measure oxidized LDL as part of the advanced lipid panel.

17:29  HDL we used to think that the larger the particles the better, but now we know it is more complicated.  We also used to think that with HDL that the more the better, but now we want to know about HDL functionality and when we see HDL above 80, it is probably unhealthy.  When HDL functions properly, it does reverse cholesterol transport, which means that it escorts the bad cholesterol out of the arteries back to the liver. HDL functionality is also known as HDL efflux capacity. 20:29  An advanced lipid profile will also measure inflammatory factors, including C-reactive protein and it is a non-specific marker and it can fluctuate for various reasons, like infection, but if it is high on a series of panels, then it is a real concern.  We also want to look at Lp-PLA2, which stands for Lipoprotein-associated phospholipase A2, which is an enzyme that plays a role in the inflammation of blood vessels.  Another marker is MPO, myeloperoxidase, which is a white blood cell-derived inflammatory enzyme that is a marker for inflammation in the arterial wall.  A fourth inflammatory marker is fibrinogen, which is an acute phase inflammatory protein and it is involved in the clotting process, though it is nonspecific. 

21:45  It is also important to look at the metabolic profile, which means looking at fasting glucose, insulin, Hemoglobin A1C, and C-peptide, which tells how hard the pancreas is working to keep that patient a non-diabetic. Dr. Elkin said that 88% of Americans are not metabolically healthy.  Dr. Elkin also likes to look at HOMA-IR, which tells you whether the patient is insulin resistant.

23:59  Homocysteine.  Homocysteine is a breakdown product of protein, so your body wants to break it down to methionine and cysteine, but some of us can’t do that very effectively.  Those who have a genetic variance at MTHFR, which makes it more difficult methylate and degrade homocysteine.  Elevated homocysteine can add to the plaque burden in both the brain and the heart and it can be treated with a series of B vitamins.

25:02  TMAO.  TMAO is a new marker for increased risk for heart disease and stroke, which was developed by Dr. Stanley Hazen from Cleveland HeartLab.  But it is very controversial and to lower it, it is recommended to avoid dietary sources of choline and carnitine and to avoid cold water fish like salmon, which we know are very healthy.

28:00  Genetic factors. APOE is an important genetic factor, esp. if you have APOE3/4 or APOE4/4, which means that you have increased risk of coronary disease and they tend to be hyperabsorbers of cholesterol.  Cholesterol comes from your liver manufacturing it as well as from absorbing it if it is contained in your food. Dr. Elkin often measures if patients are hyper absorbers or hyperproducers, a part of the Boston Heart panel.  APOE4 is also puts you at increased risk for Alzheimer’s Disease.

There are some other important genetic variants, including the rs20455 KIF6 gene variant, which is found in 40% of the population and is associated with a 1.5 fold increased risk of cardiovascular disease and these patients tend to have a more favorable response to statins. There is also the rs10757278 and the rs1333049 variants of the 9p21 gene, found in about 40% of the population, have 1.5-2.0 fold increased risk of cardiovascular disease.  and there is also the rs2200733 and rs10033464 variants of the 4q25 gene, found in 20% of the population, that increases risk of atrial fibrillation, which the most common arrhythmia. This is especially the case in those over the age of 60.

30:23  Prevention.  Dr. Elkin does not believe that there is one best diet for everyone when it comes to heart disease.  Many facts need to be taken into consideration when choosing a diet or eating style, including your lifestyle, travel, athleticism, medical history, metabolic picture, food sensitivities, and the genetics.  Dr. Elkin has found that in general a lower carb diet is usually helpful.  Dr. Elkin personally follows a lower carb version of the Mediterranean diet. Whatever diet his patients choose, Dr. Elkin prefers to do advanced lipid and micronutrient testing to see how they are doing. It is especially the case that those following the more extreme diets, like Vegan or Carnivore, will tend to have a lot of nutritional deficiencies.  Dr. Elkin generally does not like to see patients consuming a lot of saturated fat in their diet, but he has some patients who do and are doing fine. He has one patient who recently starting using the ketogenic diet because he is a 60 year old cyclist who is very lean and he wanted the performance benefits running on fat rather carbs for fuel. His LDL has gone up, but scans have not shown any increase in coronary disease.  Saturated fat will tend to increase your HDL and it tends to increase the size of the LDL particles, which is good.

37:24  Marijuana use and the heart. While there might be some benefit to using marijuana for anxiety, insomnia, pain, and nausea from chemotherapy, we don’t really know the full impact of marijuana for the heart.  We know that smoking cigarettes is bad and there are something like 200 different chemicals with each inhalation, including nicotine, heavy metals, and other toxins, so smoking marijuana is likely to be equally potentially harmful.

39:38  Nutraceuticals.  There are a number of nutritional supplements that can be used in a targeted manner to modulate lipids, prevent or reverse coronary heart disease, and potentially modulate other heart disease risks. While Dr. Elkin does prescribe statins for patients with confirmed coronary heart disease for secondary prevention, but for primary prevention, Dr. Elkin uses pharmaceuticals like statins as a last resort and starts with diet, lifestyle, and nutraceuticals.  Dr. Elkin finds Citrus Bergamot a very interesting nutraceutical because it can both decrease cholesterol production and reduce cholesterol absorption in the gut.  Berberine acts like a natural PCSK9 inhibitor, acting both on the LDL receptors and on liver production.  Berberine also acts like a natural Metformin for improving insulin resistance.  Dr. Elkin includes berberine in his product GlucoWise Plus. Fish oil is very helpful in larger dosages, esp. in reducing triglycerides, and there has been some positive research on some EPA dominant omega 3 products called Vascepa and Lovaza.

42:32  Red yeast rice. Red yeast rice is a precursor to the first statin, Mevacor, which was approved in the 80s. Red yeast rice is statin-like but it’s more natural, has some other beneficial components, and does not have the excipients and other chemicals that are often added to pharmaceuticals. It has fewer muscle pain and muscle weakness and other side effects than statins, but it is still a good idea to add CoQ10 as you should when taking a statin to decrease the potential for muscle problems. The proper dosage is 2400 mg per day at night.  180 mg of vitamin K2 MK7 can be helpful.  And aged garlic reduces the oxidation of LDL.   

46:31  When using a pharmaceutical to control LDL, there are now other drugs besides statins, including Pembadoic acid and ezetimibe, and these can be combined.

48:48  Niacin.  You want to use a controlled release/intermediate release, not the long term/timed release.  Niacin can help both to raise HDL and lower LDL and it can also increase LDL particle size, which a statin cannot do. Niacin can also lower Lp(a), which is a significant cardiovascular risk factor found on an advanced lipid profile.                             


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. Our topic for today is coronary artery disease from the standpoint of an integrative cardiologist, with Dr. Howard Elkin. I just wanted to point out to everybody, in addition to listening to this podcast on Apple Podcasts or Spotify or wherever you listen to your podcasts, there’s also a video version on YouTube.  And if you go to my website, drweitz.com, there will be a complete transcript and detailed show notes all for free. And my ask for you today is, if you enjoy listening to the Rational Wellness Podcast, please go to Apple Podcasts and give us a ratings and review.

                                So, what is coronary artery disease, also known as coronary heart disease? And how does an integrative or a functional medicine approach look at that? When we’re talking about coronary artery disease, we’re talking about a process that results in the buildup or atherosclerotic plaques in the artery walls that gradually leads to a decline and choking off of the ability of the blood flow in that artery wall, leading to potentially a heart attack or a stroke or other damage to the heart over time.  Heart disease continues to be the number one cause of both morbidity, which means sickness, and mortality, which means death, in the United States. From an integrative cardiology perspective, the question is, how do we prevent this from happening? And if this atherosclerotic process has already started, to stop it from progressing and to possibly reverse it.

                                Dr. Howard Elkin is an Integrative Cardiologist with offices in both Whittier and Santa Monica, California. And he has been in practice since 1986. While Dr. Elkin does utilize medications and performs surgical procedures, including angioplasty, stent placement, and putting in pacemakers, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle, exercise and targeted nutritional supplements to improve their condition.  Dr. Elkin also utilizes 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 be soon published. Dr. Elkin, thank you so much for joining me today.

Dr. Elkin:              Thank you, Dr. Weitz. It’s a pleasure being here again. We’ve done a few podcasts together, and they’ve always been so enjoyable.

Dr. Weitz:             And when is your book going to get published?

Dr. Elkin:              Well, let’s say it’s taken me eight years to write it and I’ve had four edits. I’m done with it now, actually. So now, after this … This is Heart Month, so after Heart Month, I’m going to be dedicated my time to getting the book published. I’m self-publishing, so that’s going to be my next … but I promise it’ll be in 2021. I hope.

Dr. Weitz:             Okay, sounds good. We’re going to hold you to that.

Dr. Elkin:              Please.

Dr. Weitz:             So, there’s a lot of things to talk about how an integrative cardiologist looks at heart disease, but let’s jump right into something that’s in the news to start with, which is that about 45% of people with heart attacks known as myocardial infarctions are silent, meaning they didn’t have any symptoms. They didn’t even know they had them. So, maybe you can start by explaining what a myocardial infarction is, and how can it be that this could happen without even knowing about it? And what’s the significance of this?

Dr. Elkin:              Thank you. Well, myocardial infarction is the end result of a plaque being ruptured, which happens … so there’s plaque buildup over a period of years in the arteries, and this is really many years in the making. And we don’t know what makes a stable plaque into an unstable plaque. That’s the million dollar question.  So, what happens is that, when a stable plaque becomes unstable for whatever reason it does, then it ruptures and then you have an actual heart attack, because there’s no blood going beyond that clot. So, now, we’ve heard of this crushing chest pain, radiation of the left arm.   And actually, that isn’t as common as we think it is. And I was always taught that about 25% of heart attacks are silent. However, a more recent analysis was published in a Harvard medical letter saying that really, we’ve underestimated the number of silent heart attacks. It’s more like 40, 45%, which is huge.  Silent heart attacks tend to be a little more frequent … definitely more frequent in diabetics and also in males and elderly. So, that much, we know. But I mean, that’s a huge percentage of people then, so we really have to look at how to assess risk and employ preventative strategies in these folks.

Dr. Weitz:            How could it be that patients don’t have any symptoms when they end up with a clot that damages their heart?

Dr. Elkin:             Well, most of these heart attacks that are silent are generally not really large ones. But it doesn’t matter, because a small heart attack will often presage a larger heart attack. So, a heart attack is a heart attack, but these tend to be smaller, because obviously there’d be some sequelae if it’s a really large one.

Dr. Weitz:            So, when you say the heart attack is small, essentially what you mean is that a smaller part of the heart muscle is damaged?

Dr. Elkin:             Exactly. It’s all about how much damage takes place, which is why we tell patients if they’re having chest pain, they think it may be the real thing, get to the hospital because time equals muscle. And that’s when we do employ emergency angioplasty and stent placement, which is life-saving.  But we’ve known for years that diabetics tend to have different pain thresholds. No one understands this. In fact, no one understands really why and how chest pain occurs, because there’s really no nerve fibers in the heart. Most of the pain that we experience with heart pain or angina is really through dermatomes and poorly-explained mechanisms.  So, for some reason, diabetics tend to have a higher percentage of silent heart attacks. And let’s face it, diabetes is on the rise. I mean, it’s becoming an epidemic, so that could be part of the explanation as to why the number has increased.

Dr. Weitz:           So, when taking a patient’s history, what facts would make you suspect that they’re suffering from coronary heart disease?

Dr. Elkin:             That’s a great question. This always goes back to taking a good history. So, you want to take chest pain. It could be shortness of breath and exertion. It could be just fatigue. With women, it’s very interesting. If I have a woman, I’m going to have this little dictum that, if it’s above the belly button in a woman, it’s probably heart until proven otherwise, because women have such different presentations. In fact, just nausea, sometimes just overwhelming fatigue can be a presenting complaint with women. So, this whole thing about-

Dr. Weitz:           They could think they’re having digestive symptoms, right?

Dr. Elkin:             Absolutely. And oftentimes, they’ve come for a GI workup. And if it’s a good GI doctor, they say, “You better get your heart checked out first, before we do any testing on you.” So, you look for symptoms and …

Dr. Weitz:            They could have other symptoms too, right? They could have pain in their shoulder or their back, or …

Dr. Elkin:             Yes. Yes. I’ve had people presenting with back pain, like mid-scapular pain. So, there’s a constellation of symptoms, but it’s really a gestalt that you have, like taking a good history, listening to the patient. If they’re going to explain to you that their lifestyle has changed because of these disabling symptoms, then that tells me one thing. And then, that needs to be worked up.  So that’s number one on my list is, is it really cardiac? And if they’re having symptoms, then I’d probably go to my first major thing, which is employing some type of stress testing.

Dr. Weitz:            So, what does that mean, “some form of stress testing”?

Dr. Elkin:              Okay, so stress testing, so I want to see … Stress testing is still the major way of … Is a patient ischemic? In other words, by the term “ischemic” means, are they getting adequate blood flow to the heart and muscle? So, I’d like to do it … In the old days, we just did treadmill testing, but there’s a large amount of false negatives with that and also false positives.  So I usually use some type of imaging, either an echocardiogram or nuclear stress testing. Nuclear stress testing adds about 15% more sensitive over the stress echo, but I use them both. And so, when I do a stress echo, I look at the heart muscle at rest, and then once we-

Dr. Weitz:            By the way, what is a stress echo for patients?

Dr. Elkin:              Sorry. Basically, it combines a treadmill test with an echocardiogram, which is an ultrasound of the heart. So, first we do a resting echocardiogram and see how the heart functions. Is it totally normal function? Does all the segments contract normally? And then, we exercise the patient. And then as soon as they finish exercise, we re-scan them and we see if there’s any change in wall motion.  So, let’s say you have a normal wall motion at rest, and then with exercise, you see an area of the heart that’s not contracting well. That’s a hint that there’s not enough blood flow going to the heart. So, that’s how a stress echo works.  A nuclear test is different. It’s actually a nuclear pharmaceutical, and we do it at rest to see … Usually, it’s going to be a normal uptake, and then if we see, after we stress them, that there’s an area of the heart that doesn’t take up that pharmaceutical, then that’s another huge suggestion that there’s a blockage.

Dr. Weitz:            So, one of the important parts of this heart disease process is that we get a buildup of these cholesterol plaques in the arteries. Why would our body do something that’s harmful for us? Meaning, forming these plaques that eventually could kill us?

Dr. Elkin:              Well, it’s because the body is trying to protect itself. And I think we could all relate to what happened with COVID-19, is that, why do some people go on to have this thing called a cytokine storm? In which the body’s actually … It’s not just so much the virus, it’s the offshoot of all the inflammatory cascade.  So, similar things happen to the heart. And so the heart, let’s say there’s a plaque, and there’s inflammation in the arteries that lead into the heart. And the heart wants to contain that. Your immune system is activated. It wants to contain that, and so it sets off this process that attempts to do just that. And sometimes it works, and sometimes it doesn’t. And that depends on the individual’s immune system activation.

Dr. Weitz:            Essentially, there’s inflammation in the artery walls, which could result from a whole series of things. It could relate to food sensitivities or toxins or a whole series of other reasons why there’s inflammation or chronic infection, et cetera. You mentioned viral infections. And then the body uses the cholesterol to kind of calm, coat the artery walls to reduce the inflammation, right?

Dr. Elkin:              Right. I mean, cholesterol and even LDL, which I like to think of LDL as lousy, HDL as healthy, but it’s really not that simple. It’s just an easy mnemonic. But we need cholesterol. It’s essential for life. So, it’s just what happens in this constellation of events with inflammation and so forth.  When I was a fellow several years ago, studying cardiology, we didn’t know about inflammation. That term never came up. We just figured you have a blockage called a “stenosis” and over a period of several years, it gets more narrow and more narrow and more narrow, and eventually you have a heart attack.  Well, that really isn’t the real story. In fact, most heart attacks are usually with blockages that are less than 50%. I mean, occupies less than 50% of the inside lining of the heart. And we were clueless back in the ’80s with this.

Dr. Weitz:            And another interesting fact about heart attacks is that 50% of them, when you just do normal, standard lipid testing, look perfectly normal.

Dr. Elkin:              Absolutely, absolutely. Which is why … Then we get into the whole category of advanced lipid testing or advanced cardiac testing, which is, I think as integrative cardiology, it’s essential. I mean, I would like to think that all cardiologists would do this, but they don’t. Normally, what they order is that standard lipid panel, which is total cholesterol, LDL, HDL, and triglycerides. And that’s the standard panel that everybody orders.

Dr. Weitz:            And the LDL is actually calculated. They actually don’t even measure the LDL.

Dr. Elkin:              Right. Absolutely. And-

Dr. Weitz:            And it’s very common for patients to say, “Well, I had all my lipids done. Everything’s normal. They think that every test that could be run was run. Unfortunately, that’s not the case.”

Dr. Elkin:              And even most cardiologists order that standard panel. Your traditional cardiologist doesn’t really get into the more advanced testing. It astounds me, but …

Dr. Weitz:            And really, by all the research that has come out, doing this advanced lipid testing really should be the standard, right? In 2021?

Dr. Elkin:              Absolutely. It really should be. I mean, I’ve been employing it for years. I can’t imagine any other type of workup, you know?



Dr. Weitz:                            I’ve really been enjoying this discussion, but now, I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements. Pure products are meticulously formulated using pure scientifically-tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners and preservatives.

Among other things, one of the great things about Pure Encapsulations is not just the quality products but the fact that they often provide a range of different dosages and sizes, which makes it easy to find the right product for the right patient, especially since we do a lot of testing and we figure out exactly what the patients need. For example, with DHEA, they offer five, 10 and 25-milligram dosages in both 60 and 180 capsules per bottle size, which is extremely convenient.

                                                Now, back to our discussion.



Dr. Weitz:           So, let’s go into what is involved in an advanced lipid profile.

Dr. Elkin:             Okay. Well, first of all, you will get your standard lipid profile like you do, and they’ll also do what’s called “LDL particle number.” LDL, just remember one thing: Bigger is better. I tell my patients that bigger is better. The larger the size of the LDL, the more beneficial it is.   Why? Because small dense is about 30% more likely to be oxidized. And now, we can actually measure oxidized LDL. There are a couple labs that measure that, and that’s important because if you have oxidized LDL, that is the setup for inflammation and coronary disease. I don’t care what your LDL is. I mean, I do but I don’t. But if it’s oxidized, then that’s a big concern, because then that’s the whole cascade of events. That’s what starts off.

Dr. Weitz:            So, the bottom line is, you could have an LDL, as you mentioned, say a conventional LDL number of 80, and your doctor would say, “Everything’s fine. It looks perfect.” But it turns out that if your LDL particle number is 1200, the reason why it’s 1200 is because you have the same amount of LDL, but because more of the particles are small and dense, which are more likely to be problematic, you actually have a larger number of particles, and that’s what’s significant.

Dr. Elkin:             Right, so we look at the number and we look at the size. Now, HDL is … It’s really interesting because we used to think bigger is better with that. And I’ve been around long enough to note that there were like, at least three trials that come to my mind, which we tried to increase HDL because HDL was thought to be healthy, right?

Dr. Weitz:            Yeah, people often refer to LDL as the “bad cholesterol,” and HDL as the “good cholesterol.”

Dr. Elkin:             And I think there really are some really things about HDL. We’re just learning about it now, but it’s more than just the size or the amount. We used to think, “Wow, the higher the number, the better.” Now, we think that if an HDL is much greater than 80, it probably is unhealthy.  I’ve had patients that have HDLs of 100. It’s like, “Wow, this must be really good.” And we’re finding out that it really isn’t. We’re now going into HDL functionality and this … What do you call it? Reflux capacity. And these tests aren’t really standardized, so they’re really kind of new.   They are coming out, but I think we’re going to see some new tests in the future, hopefully in the next two or three years, that are going to help us more with HDL. Now, Boston Heart and Cleveland measure the size of the HDL particle. So, again, we thought bigger is better. It’s probably more complicated than that.

Dr. Weitz:            But the bottom line is, the reason why people often refer to HDL as the good cholesterol is because one of the functions of HDL is something called “reverse cholesterol transport,” meaning that the HDL can escort the bad cholesterol out of the system. It’s like the security guard who grabs your arms and says, “You got to leave.”

Dr. Elkin:              Right. That’s exactly right. And that does take place. That actually does take place, but …

Dr. Weitz:            And so, when you talk about HDL functionality, really what we’re talking about is, “Is HDL doing its job of reverse cholesterol transport? Is it removing bad cholesterol?”

Dr. Elkin:              Right. And that’s what these new tests are going to be showing, I think. It’s called … There’s a term for it. I can’t think of it now, but it’s a reflux thing. And I think once we get better testing that’s standardized, and we don’t have it yet …

Dr. Weitz:            Right. I think Cleveland has a test for it, right?

Dr. Elkin:              They’re working on it. Yeah, they’re working on it. And I think Boston is too, so I think within the next two years, we’ll know more about HDL functionality and what’s really good, and what’s neutral and what’s maybe harmful.

Dr. Weitz:            So, what are some of the other things that you measure in an advanced lipid profile besides LDL particle number, LDL particle size and HDL particle size?

Dr. Elkin:              Well, there’s three major things that I want to gather in addition to that. Number one is inflammatory profile. Is there inflammation going on? So, there’s four major factors that we look at. One is the C-reactive protein. Everybody should know their C-reactive protein. It’s a routine test.  It astounds me that most doctors don’t order it. Cardiologists don’t even order the test. And now, we know it’s a totally non-specific test. But if I follow a patient and I continue to see serial CRPs that are high, I’m very concerned. I’m going to work it up.  But inflammation of any cause that’s chronic leads to the four major diseases of aging, so it’s heart disease, cancer, autoimmune disorders, and Alzheimer’s. They all have that in common, inflammation. So, I definitely want to know about inflammation.  So, we look at the C-reactive protein. There’s a couple of tests that are a little more specific for the heart. Something called Lp-PLA2 which is actually an enzyme. Another test is called MPO, myeloperoxidase. And they point more in the direction of inflammation in the vascular system itself.   And there’s also fibrinogen, which is an active phase reactant, which means like CRP, it’s terribly nonspecific. So, I want to look at the inflammatory profile.

Then, I want to look at the metabolic profile, and I’ve mentioned this on one of my YouTube Lives, is that only 12% of the adult American population is metabolically healthy. That means 88% are not.  And there’s definitely association between metabolic health and heart disease, diabetes and heart disease. So, we’ll learn about hemoglobin A1c. How well has the blood sugar been controlled for the previous three months? And their fasting insulin level. And that’s important.  And also something called C-peptide, which tells me how hard the pancreas is working to keep that patient a non-diabetic. So, these are really useful tests. And then, you and I talked about another one to assess insulin resistance, and there’s a few different ones, which-

Dr. Weitz:            And one of the things to look at is fasting insulin as well as fasting glucose.

Dr. Elkin:             Right, right. Exactly.

Dr. Weitz:            And the point of that is, you don’t want your blood sugar to get too high. You don’t want it to get too low either, but if you’re keeping your blood sugar in a normal level, only by producing a lot of insulin, then you’re masking this pre-diabetic condition where your pancreas is working overtime, producing more insulin to manage your blood sugar.

Dr. Elkin:             I like this test called HOMA-IR, which stands for Homeostatic Model Assessment of Insulin Resistance. It’s a calculated value, but you need to know your fasting insulin and your fasting glucose, and then there’s a calculation, an algorithm, and it lets me know whether a patient truly is … It tells me more whether the patient’s truly insulin-resistant.  It takes those things into account, and there can be a disparity between blood sugar and insulin on a given day. That’s why this is an additional test that I like to see. Okay, so we have the lipid test which shows particle size and particle number. We have the inflammatory profile. We have the metabolic profile, and then we also have a few genetic tests that are pretty useful when it comes to evaluating heart disease and coronary disease.

Dr. Weitz:            And let’s not forgot homocysteine as well.

Dr. Elkin:             Right, right. So, homocysteine, thank you. Homocysteine is a breakdown product of protein, so your body wants to break it down to methionine and cysteine, but some of us, it can’t do that very effectively. And there’s a genetic test we’ve heard of, the MTHFR?   And usually, whatever lab you’re using, they’re testing two different copies, and about 60% of us, I’m one of them, that has one or two copies. And that can affect our ability to methylate, and therefore really degrade homocysteine.   So, why do I even care? Because homocysteine in elevated numbers can affect the … can add to the plaque burden, both in the brain and in the heart, so it’s so easy to treat, a series of B vitamins, so I always check it. And I mean, I see levels of 15, 16, 20, over 20 sometimes. And it’s almost always … That genetic test is always going to be positive.

Dr. Weitz:            There’s another marker … and of course, they’re always coming up with new markers, because bottom line is, we have this 15% of people who weren’t picked out the first time. So, a new marker. We’ve discussed this before, but I think we should mention it again, is TMAO, which Stanley Hazen from Cleveland Clinic developed. And this is something found in the blood that correlates with increased risk for heart disease and stroke, but it’s very controversial. What’s your perspective on it?

Dr. Elkin:              My perspective is, I look at it and I follow it, but … because really, to lower TMAO levels, you have to decrease things like choline, and you have to make some dietary changes. I think it’s really a reflection of the gut bacteria responding. There’s so many other things that I look at first, so if I see an elevated TMAO level, but other things are looking pretty good, I’m not terribly concerned because it is controversial.

Dr. Weitz:            Yeah. Yeah, I think a couple of reasons why it’s controversial is, number one, the food that is highest in TMAO is cold water fish like salmon, and there are just unbelievable amount of studies showing that eating fish is correlated with lower risk for heart disease, as well as fish oil, EPA and DHA.  So, it’s just a complete contradiction with that. And then, the other way you get TMAO is that you consume TMA, which is found in substances like choline and L-carnitine, which we also know are super important for you. L-carnitine is super important for the heart, for the mitochondrial function. Choline’s super important for brain health, and then the foods that these are often found in. But they’re converted into TMAO in the microbiome, so perhaps this is really a marker for an unhealthy microbiome that’s converting these into TMAO.

Dr. Elkin:              Good point, and that may be a good reason to work up the gut with a stool test, to really investigate the microbiome. So, if I see it persistently … If it’s a little borderline, I mean, I will tell you, and all the testing that I do, I don’t see that much TMAO in my patients. It is prevalent, but not as much as you would think, but it’s-

Dr. Weitz:            Yeah. And of course, you’re talking about the … There’s been a lot of talk about the gut-brain connection, and the gut immune connection, and now you’re mentioning the gut-heart connection. At some point, we need to do a whole podcast about that. But you mentioned genetic factors. Let’s touch on a few of the genetic factors that you find most helpful, maybe starting with APOE?

Dr. Elkin:              Right. So, APOE is an interesting one. You get one allele from each parent, so if you have the APOE-3 is the preferred pattern, but if you have 3/4, it means you have one good gene and one that’s not so good, and you can also have 4/4, which is even worse. That means you got a bad gene from each parent.  So, what’s the significance? Well, people that have APOE can predispose to coronary disease, and they tend to be hyper absorbers of cholesterol from the gut. So, there’s two ways you can get cholesterol in your bloodstream. One is through production. I mean, your liver’s going to make cholesterol no matter what, because it’s essential for life.  And the other way is hyper absorption, meaning it absorbs more from the gut, from the food that you eat. So, people that are APOE-positive tend to be hyper absorbers, and we can measure that. Boston heart test does that quite nicely.  And then, it also is a gene for Alzheimer’s, which is important to know, and the reports that come from the lab don’t really tell you that, but I mean, any person can just look on the internet and find that out. So, I do tell the patient. I let them know if they have APOE/4 or 4/4, I let them know.

                                So, that’s one. There’s another one. A couple that I like is KIF6 and 9p21. I don’t know. These are all based on chromosomes, and they’ve been shown several years ago, by Dr. Superko … At that time, it was the Berkeley Heart Lab, and these patients tend to have increased incidence of heart disease, coronary disease.  KIF6 is interesting, because those patients have been shown to respond favorably to statins, like pravastatin. 9p21 is seen, really, about 15% of the population, which makes sense when you think about coronary disease. And there’s another one that’s new called 4q25, which actually predisposes people to atrial fibrillation, which as you know, is the most common arrhythmia in those over the age of 70. However, I’ve seen it in people of all ages.

Dr. Weitz:            So, let’s get into some of the preventative stuff. Let’s start with diet. Is there a best diet for coronary artery disease? Does it depend on the person? What’s your preference? Do you prefer a vegetarian diet for most patients, a Mediterranean diet, a paleo diet, a carnivore diet? Should we eat all vegetables, all meat?

Dr. Elkin:              The answer is, in my book, all of the above because there is not one diet for one person. In my book, I talk about why there can’t be one diet for all people, because like you say, there’s so many things to take into consideration: lifestyle, travel, athleticism, history, metabolic picture, food sensitivities.   I mean, there’s so many factors, so many variables. So, is there a heart-perfect diet? My basic diet tends to be low carbs, because whether you’re a cardiac patient or not, that’s going to be your better diet for aging. I think if a person prefers to be vegan or vegetarian, that’s great.  I think whether you’re straight vegan or straight carnivore, I think what you need to do is do, within a few weeks or months of being on that type of diet, you should get … It’d be nice to have micro-nutrient testing, because in those particular diets, it’s not unusual to have some deficiencies. We know, with vegan diets, there’s going to be a lack of B-12, of carnitine, carnosine …

Dr. Weitz:            Omega-3.

Dr. Elkin:              Omega-3, yeah. So, it’s really important to account for that. But if it works for someone, I’m okay with it. And again, I’m going to look at their … I’m going to continue to follow their advanced cardiac testing while they’re on these diets, so the bottom line … I’m not into low-fat, low-cholesterol diets anymore.   I went to a conference, Orange County. It was the preventative cardiology conference. They do it once a year, and they’re still counting the benefits of low fat. But they also say that canola oil is good to take. I beg to differ with them. So, it’s really an individual thing.

Dr. Weitz:            So, what’s the deal about fat? Does fat lead to heart disease? Does saturated fat lead to heart disease?

Dr. Elkin:              Okay, so saturated fat, I have a patient that I’m calling right now, who … very interesting. He has documented coronary disease, by coronary calcium scan. However, he’s an athlete. He’s 60. The guy does … big time cyclist. He’s in impeccable shape, lean as can be.  And he went ketogenic. I said, “Okay, if you want to do it, do it.” I mean, he didn’t have any weight to lose, but he was interested in the anti-aging effects of going ketogenic. So, we watched his LDL go up, but his scans have not shown any increase in number of coronary disease.

                                But do I care about that? Depends. And this is an unusual guy, who’s in unusual shape. The average person who has coronary disease … It’s very controversial about saturated fat. Some people say it’s not the culprit at all.  There’s a couple of good things about saturated fat. It can increase your HDL, which is supposed to be good, the healthy cholesterol. And it can also increase the size of the LDL particle, which we know is good, right? Because bigger is better when it comes to LDL.  So, there are some benefits to saturated fat. I kind of like combining things. I’m not [inaudible 00:34:08] saturated fat. I’m really neutral until we get really information that says, “This is what we should be doing.” And I don’t think it’s going to come. I think it really depends on the individual, based on all the variables we’ve discussed.

Dr. Weitz:            But you are somewhat worried about consuming too much saturated fat, right?

Dr. Elkin:              Yeah. There’s also a gene you can check. I can’t remember the … You can do it with 23andMe and Ancestry. It’s a specific gene, and I can’t remember the name of it right now, but these people that have this specific genotype actually do very poorly with saturated fat. So, that’s another thing. Do you have the genetics for it?

Dr. Weitz:            And from my experience, I know there’s controversy about this, when I’ve had patients who had the APOE-4 gene, they don’t tend to do very well with a high saturated fat diet.

Dr. Elkin:              Interesting. I don’t know that about the APOE, but you may be right. I’ll have to check that.

Dr. Weitz:            Yeah. I have a patient, a guy 40 years old, in good shape, exercises, was following a paleo type of high fat diet with the Bulletproof coffee, with the fat in his coffee. And he had a heart attack at age 40.

Dr. Elkin:              Wow. I get concerned about any kind of extremes. There’s this talk about … I’m sure you’ve read some of these people that are into the carnivore diet.

Dr. Weitz:            Yes.

Dr. Elkin:              And there may be a place for it. I mean, I think if you had a lot of gut issues and you want to put your gut at rest, I think being on a carnivore diet for a few weeks might be useful. But I have a couple of people that have been on it for a long time, and they swear they’ve never felt better from the gut. Is it the best thing on the heart? I don’t know. I worry about these extremes. I’m a middle-ground kind of guy.

Dr. Weitz:            One thing about food sensitivities, there’s a lot of controversy about these tests. But from my experience, one of the things I’ve noticed is, when people eat certain foods over and over, like the same foods day after day, meal after meal, they tend to come up positive on those food sensitivity tests.  And people always get bummed out about that, but I do think that the immune system, when it’s constantly bombarded with the same types of amino acids, and I think that it starts to develop sensitivities to that. And that’s one thing I wonder about a carnivore diet, where people are essentially eating a very limited number of foods over and over again.

Dr. Elkin:              Right. Well, these people are totally polyphenols, when there’s a plethora of material, from olive oil on down, that helps the importance or the significance of that.

Dr. Weitz:            There’s different versions of the carnivore diet. Some who follow the carnivore diet say that, to really be healthy, you actually need to eat the intestines of the animal, including what’s in the intestines, which could include plant matter, but it seems like a crazy way to get some plants.

Dr. Elkin:              Right. Yeah, you’re talking about the nose the tail?

Dr. Weitz:            Yeah.

Dr. Elkin:              Seriously, it’s …

Dr. Weitz:            So, I just wanted to mention something. Marijuana use is on the uprise in many ways. People are eating it, but they’re also smoking it, and they’re also vaping it. And we’ve known for many years that a major, major factor in increasing risk for heart disease is smoking cigarettes. What’s the story about smoking pot and/or vaping pot?

Dr. Elkin:              Well, it’s a great question. And I’ve been to a conference in which there was pros and cons. I don’t necessarily recommend it for the heart. Now, that said, there could be really utility in marijuana. It can help you with extreme anxiety, insomnia, pain, nausea from chemotherapy. There’s a definite role for certain things. I don’t know the full impact on the heart. I don’t think anyone really knows.

Dr. Weitz:            But even if there’s a benefit to taking CBD and possibly THC as well, or even a whole marijuana plant, it seems to me that smoking it is probably liable to be a problem.

Dr. Elkin:              Yeah, I think so. I mean, with cigarettes, what are there? 200 different chemicals with each inhalation? It’s something like that, ridiculous. It’s not just the nicotine, right? There’s lots of different things.

Dr. Weitz:            Right.

Dr. Elkin:              And heavy metal and all kinds of garbage. I tend to believe-

Dr. Weitz:            And by the way, you’re smoking a tobacco plant. So, for people who say, “Well, marijuana’s natural and cigarettes are not,” well, I mean, cigarettes to some extent are natural too.

Dr. Elkin:              Right. Tobacco is a plant. Right, exactly. So, we’d still need to learn more about it. But I agree with you. I don’t feel comfortable smoking, especially if you’re a cardiac patient. It can also impact your sympathetic nervous system, right? Which isn’t great if you’re a cardiac patient. Depends if you’re stable or not, but it’s not one of my go-to things.

Dr. Weitz:            So, let’s get into nutraceuticals, i.e., specific use of targeted nutritional supplements to help modulate lipids, to either prevent coronary heart disease or to stop it, or possibly reverse it. When you have somebody with unfavorable lipids, a lot of small dense LDL, high LDL particle number, what are some of your favorite go-to nutraceuticals?

Dr. Elkin:              Right. First of all, a lot of people come to me for that one reason, because they know that I’m not just a standard cardiologist who’s going to put them on statins. And again, it depends on the risk of the patient. I mean, I do use statins on patients that have confirmed coronary disease, that have had multiple procedures and there’s no question for secondary prevention.  We’ve known that since the ’90s, really. But yes, there are some go-to things that I do. I like bergamot, that can help … Bergamot’s a very interesting nutraceutical, because not only can it increase production delivery, it can also decrease absorption in the gut. So, it kind of can work two ways.  

                                Berberine’s kind of an interesting one. It kind of acts like this new class of drugs that we call PCSK9 inhibitors, which works on the LDL receptors, on the liver itself. And these are new drugs, and they’re injected twice a month subcutaneously. Very expensive, but they do an amazing job of decreasing your LDL by as much as 70%, so berberine is kind of a natural nutraceutical to use for that.

Dr. Weitz:            Also, some people regard it as a natural metformin, because it modulates blood sugar in the body.

Dr. Elkin:              Yes. I use it more, actually, for … I use it in my own product called GlucoWise Plus, because it has been shown to be, in some studies, to be as effective as metformin, and not as difficult on the GI tract. There are my two big ones. Fish oil … and I use a lot of fish oil, really, for triglycerides. But you need big doses.   Now, there’s two new drugs out. “New” meaning in the last few years. Vascepa and Lovaza. And those are pure EPA. Pretty much pure EPA, but they’ve been shown in studies to be very effective in decreasing triglycerides. So, the problem is that you need like two grams twice a day. That’s four grams a day.  It’s true, but you could also do the same with … I like using regular fish oil, because I like combinations of EPA and DHA. In fact, I often use DHA by itself to augment the … make [inaudible 00:42:28] patient because it’s good for the heart, the brain and for vision.

Dr. Weitz:            What about red yeast rice?

Dr. Elkin:              Okay, I use a lot of red yeast rice. Now, it’s very important. Boston has an interesting test called the SLCO gene test. It tells you if you are a hyper responder, which means that the statin will last in your system longer than usual. So, you have to be very careful about using a statin in these patients, especially if they have two alleles versus one.   So, how does it relate to red yeast rice? Because red yeast rice supplement actually is a plant from China, and it was a precursor to the very fast statin that was approved in the ’80s, Mevacor. So, it is statin-like, but it’s not as potent, and it’s a little more natural without so many excipients and things that you see in pharmaceuticals. So, I think that-

Dr. Weitz:            Well, the other thing is, while a statin is pulled out of red yeast rice, red yeast rice has a number of other components that can all help modulate cardiovascular risk in a positive direction.

Dr. Elkin:              Right. In fact, a lot of my patients would rather do that than statins and I’m fine with that. I’ll try it.

Dr. Weitz:            And doesn’t it have less side effects than statins, potentially?

Dr. Elkin:              Yeah. It can. I mean, some patients will still experience muscle cramps or muscle weakness. I’ve had it with a few, which is why that SLCO gene is … I would be a little more cautionary with that, but I’ve found-

Dr. Weitz:            And of course, you want to add CoQ10 with it to decrease the potential for that.

Dr. Elkin:              Absolutely, yeah. So, whether I use a statin or red yeast rice, I … First of all, all my patients are on CoQ10. It’s just one of my go-to things for people over the age of 40, but it’s essential for statins or red yeast rice supplements. And I think it’s Mark Houston, he uses really large doses, doesn’t he? Of …

Dr. Weitz:            24 to 4800 milligrams at night.

Dr. Elkin:              Yeah. I use like 2400. I haven’t gone to that large dose yet. But I may try it. But it’s well-tolerated. Let’s see. So, we’ve discussed red yeast rice, fish oil, berberine, bergamot. They’re the main ones that are helpful.

Dr. Weitz:            But what would be your go-to combination for somebody … Let’s say somebody gets a coronary artery, a calcium artery scan, and they have plaque. What’s your go-to for reversing it? What combination of things would you put them on if they want to do natural stuff?

Dr. Elkin:              I think the things you’ve just mentioned, really. And then, pending the results … So, once I see a coronary calcium scan … and the reason I do a lot of them, because it’ll tell me not only what your value is, which is nice. I mean, the perfect value is zero. You don’t want to have any calcium in your arteries, but that’ll be less lucky as we get older.  But it’ll also tell me, “Okay, if you’re 60 or 50, how do you compare with other 50-year-old females or 50-year-old males?” So it lets me know, “Oh, you’re in the 30th percentile. You’re in the 50th. You’re in the 80th or 90th.” I’ve had folks in the 80th and 90th percentile that have no symptoms.

Dr. Weitz:            Would you add vitamin K2 to the mix?

Dr. Elkin:              Yes. Yes. They all go on vitamin K2. Vitamin K2, specifically I like MK7 because it’s longer-acting, and that’s a little bit debatable, but I like vitamin K2. And people are interested-

Dr. Weitz:            And what dosage are you using these days?

Dr. Elkin:              I use 180, but you should use at least … Dr. Sinatra and I have discussed this, Stephen Sinatra, but at least 150.

Dr. Weitz:            Yeah, he’s actually recommending 360 now.

Dr. Elkin:              Oh, he’s gone up now? Okay.

Dr. Weitz:            Yeah. Aged garlic, have you used that?

Dr. Elkin:              Yes. Garlic is very good because it also cuts down on the oxidation of LDL, right? We’ve talked about that LDL, in itself, isn’t the culprit, but once it’s oxidized, okay, that’s when the whole inflammatory process begins. So, I use kale and garlic. Aged garlic is very useful in that. So, there’s so many things we really can do.

Dr. Weitz:            What about when we go to pharmaceuticals? It used to be that pretty much, if you had a problem with coronary heart disease, you would go on a statin. But now there’s a number of other alternatives, what would be your favorite drug or combination of drugs for patients who don’t want to take a statin or are intolerant to taking a statin because they get a lot of muscle cramping or other symptoms?

Dr. Elkin:              There’s a new one out, Pembadoic acid. It’s relatively new. I’m just starting to use it, so I don’t have a lot of experience with it, but it works on the liver like a statin, but it’s at a different site. It’s not an HMG-CoA reductase inhibitor. So what it does, it really is very good for those that are prone to muscle aches and pains and weakness. So, it obviates that step.  It seems to be perhaps a little less hepatotoxic, at least potentially, so it’s an interesting drug. And they have it by itself, and they have it combined with ezetimibe, which is a drug that cuts down on the absorption of cholesterol.  So, again, I’m just starting to use them now. But it’s an interesting class, and I think a little bit better-tolerated than statins. The drug companies, they kind of downplay this, but I would say there’s at least 20, 30% of people that have side effects with statins. Usually, it’s muscle myalgias, weakness, muscle weakness.  And what I do, whenever that happens, I say, “Okay, let’s stop it. Let’s see how you do. Come back in two, three weeks. I’m not worried about your cholesterol in that time.” And if the pain goes away, then basically, I’m going to believe the patient, right? I believe in patient smarts, so there’s your answer.

Dr. Weitz:            Do you ever sometimes just drop the dosage to see if that takes care of it?

Dr. Elkin:             It is somewhat dose-dependent, but at the same token, I usually use low … I don’t ever use huge doses of statins. I mean, for obvious reasons. I have very few patients that are on top-level atorvastatin or rosuvastatin which is Crestor, because I use combinations and I use supplements with it, so I don’t usually use it or need it. But yeah, that’s a concern.

Dr. Weitz:            You know what? When we were talking about natural supplements, I know there’s a natural product they use quite a bit, we didn’t mention, is Niacin.

Dr. Elkin:             Oh my God, yeah.

Dr. Weitz:            Maybe talk about Niacin, because Niacin, I would say for the last several years, is really not seen as a good thing to take by most conventional medical doctors.

Dr. Elkin:             Well, I think for a couple of reasons. First of all, it’s not really … It’s more of a supplement than an actual pharmaceutical, so there’s no real money in it. Now, there are couple of … There is a Niacin that you can get through pharmacy, I mean, pharmaceutical brand.  However, it’s the sustained release one that you take at night, and you have to take it with food. And I don’t really like people snacking at night if they don’t have to, number one. Number two, they often wake up at 2:00 am with flushing. And number three, it’s more hepatotoxic, so I haven’t used that one in years. So, I use the standard supplement ones that we all carry in our office, and I-

Dr. Weitz:            But a controlled release one. That’s important, right? Because you don’t really want-

Dr. Elkin:             Right. So, mine is not an immediate release. It’s medium. It’s kind of intermediate.

Dr. Weitz:            Yeah, intermediate release is good. Yeah.

Dr. Elkin:             It will take longer. Right. So, you take it two or three times a day, depending on the dose. It has been effective. I’ve had maybe a couple of patients that have had liver abnormalities with it, but much less so than a statin.   If you do a good prep, usually the flushing is pretty well-tolerated, and it could be very effective. It doesn’t work as well as the statin. If you’re just interested in LDL lowering, which is what most cardiologists are interested in, it’s not going to do the same thing as the statin, so that’s why they go to a statin.

Dr. Weitz:            Except that a statin is not going to increase the LDL particle size, and Niacin can do that.

Dr. Elkin:             Right, it can do that. It also can, in large doses, decrease Lp(a), which we haven’t really talked about. It’s another kind of inherited trait, that it’s sticky, inflammatory, and it’s not good. Most cardiologists don’t even order it, because there’s no pharmaceutical for it. At least, to-

Dr. Weitz:            Yeah, we left out Lp(a) in the advanced lipid profile.

Dr. Elkin:              Right. It’s very common. I check it. It’s part of my advanced cardiac testing. It’s always included in Cleveland, and also in … You should do it at least once [crosstalk 00:51:18]

Dr. Weitz:            Now, some of my patients come to me, and we do the testing. And then sometimes, they’d rather see if they can get the testing through their MD. More likely, it’s going to be covered by insurance, and so a lot of times, we get a lot of opposition when I say, “Include the Lp(a).” They say, “Oh, there’s no point in doing that. It’s hereditary. You can’t do anything about it, so what’s the point?”

Dr. Elkin:              Well, it’s nice to know if you have it, because that … Again, I always tell people, I just wrote my blog for Heart Month, and it’s like, it’s not about how low you can go. It’s about knowing your risk, so my whole thing-

Dr. Weitz:            And even though there’s no prescription drug yet on the market, they’re working on one. But things like Niacin and L-carnitine, and there’s some natural products that can help to modulate it.

Dr. Elkin:              Right. Fish oil may be helpful, and also for women, estrogen can be helpful. And they are working … There’s something in the pipeline, and I reported this about a year ago at UCSD. There’ll be another biologic similar to Repatha, those …

Dr. Weitz:            And the PCSK9 inhibitors.

Dr. Elkin:             It’s very interesting. It can decrease your Lp(a) by like 60% in like four weeks. It’s amazing. But that may be … That’s in the future. I don’t know when that’s going to happen.

Dr. Weitz:            Right, okay. I think that’s pretty much a wrap. Final thoughts for our listeners and viewers?

Dr. Elkin:             Well, I think the thing … My take-home message is, look beyond the numbers. Like I said, it’s not about how low you can go. I mean, a lot of my colleagues now will want their patients with coronary disease to have levels of like 40, 30, even 20.

Dr. Weitz:            Or like the LDL you talked about.

Dr. Elkin:             Yeah, and it really frightens me because … And then they’ve got a couple studies saying, well, we’ve got long-term studies. Long-term studies, two to three years, which hasn’t been damaged. I really worry about the effects on the brain, because I don’t know about you. I don’t want a good heart with a bad brain, and LDL is very essential for the brain.  So, it’s more about how low you can get, it’s really knowing your risk. And I would like to employ these advanced lipid testing and either coerce their doctor to order it, or find a doctor who does it, because there’s a lot of us that do this kind of testing, and it really has major benefits.

Dr. Weitz:            Yeah, I was just having a discussion with somebody about vitamin D and he said, “Well, I go out in the sun. How could I have a vitamin D of super low?” It was one of my employees, and her vitamin D is like … I think she said it was close to zero. And one of the reasons why vitamin D levels are low is that the body makes vitamin D when the sun hits the skin, and it uses cholesterol to produce the vitamin D.

Dr. Elkin:             Right. You need cholesterol.

Dr. Weitz:            Another example of reducing our cholesterol too low is, you make it very difficult for the body to make vitamin D.

Dr. Elkin:             And sex hormones, and bile acids.

Dr. Weitz:            Absolutely.

Dr. Elkin:             I’m with you, and I’ve been this way for a while. But cardiologists, mainstream cardiologists, and I’m not trying to be negative, they just … it’s like they have tunnel vision and they’ve heard about how low you can go, and it still seems to be the prevalent view. I mean, I go to conferences and I hear this all the time. Now, they want to combine PCSK9 inhibitors with statins. I generally … So, anyway.

Dr. Weitz:            Right. How can our listeners get a hold of you, find out more about your information, and how can they contact you?

Dr. Elkin:             Thank you. Well, I’m pretty active on social media. First of all, my website is heartwise.com. And then, on social media, if you want to check me on Instagram because I try to post regularly, it’s dochelkin, D-O-C-H-Elkin. And I’m also on Facebook, HeartWise Fitness and Longevity Center. So, I try to be pretty current and I’m also on YouTube Live now.  I do it every two weeks on Thursday nights at 7:00 pm, which is a lot of fun, because I pick a topic, I talk for no more than 10 minutes, and then we have the audience chat in questions. So it’s fun. You can stump the cardiologist. It’s fun.

Dr. Weitz:            Awesome. Thank you, Howard.

Dr. Elkin:             All right. Thank you, Ben. It’s a pleasure. I always enjoy doing this with you. Take care.


Dr. Weitz:            Well, thank you, listeners for making all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts and give us a five star ratings and review. That would really help us, so more people can find us in their listing of health podcasts.  I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111. And take one of the few openings we have now for a individual consultation for nutrition with Dr. Ben Weitz. Thank you, and see you next week.


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