Integrative Cardiology with Dr. Howard Elkin: Rational Wellness Podcast 248

Dr. Howard Elkin speaks about Integrative Cardiology with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on February 24, 2022.

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Podcast Highlights

6:29  February is Heart Month and heart disease is a disease of excess: Excess blood pressure, excess smoking, excess cholesterol, excess blood sugar, obesity, excess fat and a lack of physical activity.  Heart disease is still the leading cause of death and we have about 650,000 deaths a year in the US from heart disease.  This is considerably more than from COVID.  About 850,000 Americans suffer a heart attack each year and for 605,000 of them, this is their first even and they didn’t know that they had any cardiac problems. 45% of these events are silent.

8:05  Age and Family history are somewhat immutable risk factors, but about 70% of the risk factors are lifestyle dependent. Major Risk Factors: Hypertension is the number one risk factor, followed by smoking, elevated cholesterol, physical inactivity, obesity, and diabetes. Minor risk factors: Elevated triglycerides, elevated Lp(a), elevated homocysteine, elevated C reactive protein, periodontal disease, inflammatory markers that include Fibrinogen, Lp-PLA2, and Myeloperoxidase, genetic markers, environmental pollution, stress, and depression. 

9:40  Blood Pressure. The thinking about blood pressure has changed from 2003 when hypertension was not considered until you get to 140/90. Starting in 2017 we started to consider above 130 for systolic and above 80 for diastolic would be considered hypertension. Ideal blood pressure is now considered to be 120/70. Therapy for hypertension should be individualized and should include lifestyle, supplements, and medications.  Since blood pressure tends to be higher in the early morning hours, which is why some recommend taking hypertensive medications at night.


Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and in Santa Monica, California and he has been in practice since 1986. His website is HeartWise.com.  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 diet, lifestyle changes, and targeted nutritional supplements to improve their condition.  He also utilizes non-invasive procedures like External Enhanced Counter Pulsation (EECP) as a non-invasive 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.

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 and also athletic performance, 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.

Welcome to the functional medicine discussion group meeting tonight, and we’re very happy to have as our speaker, Dr. Howard Elkin, integrative cardiologist. So now, I’d like to introduce Steve Snyder from Integrative Therapeutics, our sponsor for this evening, to give us some information about some of Integrative products. Steve?

Steve Snyder of Integrative Therapeutics:                   Hello, everyone. Sorry, it’s dark in here so I look a little scary. We are excited to hear Dr. Elkin speak. I know in his little introduction he talked about metabolic markers and lab tests for that, and I just want to let people know about a couple things that we have. Well, they’re all three of these are our biggest or in our top 10, but we have a berberine that is at the study dose that is in all of the research for all these reducing or improving metabolic markers for lipids and cholesterol and all that. It’s important to differentiate.  There’s different kinds of berberine, and a lot of the brands try to make them interchangeable. The berberine extracts from botanical extract are more effective as antimicrobial agents, and the purified berberine that was in the research is a berberine HCl at 500 mg. That’s a different animal, I guess, and it’s important to make sure that you get the right one for what you’re trying to do. We have both, and our berberine HCl is unique in that it’s about 10 bucks cheaper than the other brands out there for the same 60 cap 500 mg bottle.

The other one I wanted to mention, I feel like I mentioned this every week because it’s so good for everything, is our Theracurmin, the high bioavailable curcumin preparation, and there’s some pretty good research showing that curcumin lowers lowers cholesterol and improves or increases LDL receptor mRNA. So with the high bioavailable like Theracurmin, you’re going to get blood levels that will give you the effects you’re looking for.

Then the last one is, again, this is one of our popular products, is Cortisol Manager. We all know how elevated cortisol can affect inflammation and lipid metabolism and belly fat. Typically, people use Cortisol Manager to help them fall asleep, but we do have a lot of people that use it for metabolic purposes and even the Los Angeles Dodgers use it to decrease belly fat, believe it or not. So all three of those we have samples of, and if anybody wants to try them this, let me know. We can get you set up.

Dr. Weitz:            By the way, we’re all practitioners listening here. If anybody hears this afterwards who’s not a practitioner, the samples are for practitioners only. Sorry.

Steve:                  Yeah. Forgot to mention that, but thank you.

Dr. Weitz:            Yeah. Absolutely. Thank you, Steve.

Steve:                  Yup. Take it away, Dr. Elkin.

Dr. Weitz:            Okay. So Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and Santa Monica, and he’s been in practice since 1986. While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is in playing natural strategies for helping patients, including recommendations for diet, lifestyle, nutritional supplements to improve their condition.  He also utilizes noninvasive procedures like external enhanced counter pulsation as a noninvasive alternative to angioplasty and bypass surgery. Dr. Elkin has written a book from both sides at a table, When Doctor Becomes Patient, and is that about to be published or did you just publish it?

Dr. Elkin:              Yes. It’ll be out within the next month or two. We will be announcing the launch, the preview.

Dr. Weitz:            Of course, I got that intro from another time you spoke. It was still soon to be published, but, Howard, you have the floor.

Dr. Elkin:              Okay. Thank you. Hi, everybody. Thank you so much for being here tonight, and I want to thank Dr. Weitz for having me speak again. So I’m delighted to be here. So this is my first time doing a little Zoom conference. Okay. Here we go. All right.

So integrative cardiology, what is it? I made my own definition. It’s going above and beyond. I want to make this distinction because there’s a lot of stuff on the social media these days, on Facebook, and certainly Instagram, and not so much doctor bashing, but bashing doctors who use drugs, statins are ridiculous. We call them the cholesterol deniers. There’s, “Why use drugs? You don’t need to.”  Whether it’s traditional cardiology or integrative cardiology … Anybody unmuted because I’m getting this … Okay. Good. So they’re not mutually exclusive. So traditional medicine needs integrative medicine, and we need one another. So that’s my point. I feel honored and humble that I do the whole gamut. I work with some of the old patients when I’m on call three times a month when I have to open up an artery heart attack to what I do on a regular basis with preventative medicine.

Why heart month? As you know, February is heart month, a special time of the year because heart disease is still so prevalent, and we call this a disease of excess. So it’s excess blood pressure, excess smoking, excess cholesterol on your diet or on your blood, excess blood sugar, obesity, excess fat, and a lack of one thing, and that’s physical activity.  So really, it’s the disease of excess. It’s still the leading cause of death. So we have about 650,000 deaths a year. That’s one out of four. You’ve heard a lot about COVID. Just to put things in perspective, in the two years that COVID has been happening in this country, we’ve lost about 900,000 people, which is a big deal, but that’s still small in comparison to what we see every year in heart disease. So one dies every 36 seconds of heart disease.

What about heart attacks? Okay. So about 850,000 Americans suffer heart attack on an annual basis. Now, 605,000 of those individuals, that’s their first event. They don’t even knew they had any cardiac problems beforehand. So it tends to be very dramatic, and 45% are silent. When I was a fellow gazillion years ago, there were 25% of heart attacks were silent, and all of a sudden, 45% silent. I personally think it’s because we have a older population and a lot of diabetics, and diabetics tend to have very unusual symptoms if they have symptoms at all. So simple important thing to keep in mind.

Now, we have these immutable first factors, age and family history. There’s nothing we could do about it, but yes, there is because people say, “Oh, okay. It’s in my genes,” and I think most of us in the functional medicine field who really believe in epigenetics will attest to the fact that about 70% of 30% of what happens to us in our life is probably genetically determinant, but 70% is actually lifestyle dependent, and that’s the whole epigenetic we’re looking for.  So even though you may have a positive family history doesn’t mean you’re going to come down with a disease, and that’s not true about just heart diseases, also with Alzheimer’s and other genetic disorders.

So let’s look at the major players. Hypertension is still the number one risk factor no matter how you slice it. So it’s very important. Then we have smoking, elevated cholesterol, which we will get into in a few moments, physical inactivity, obesity, and diabetes. These are the six modifiable major risk factors. What I mean major players, it’s unequivocal that these play an important role in heart disease, and all of them are modifiable or preventable. So it’s very important to keep that in mind.

Then we have the minor players, elevated triglycerides, elevated LP(a), which we will talk about later, elevated homocysteine, elevated C-reactive protein, periodontal disease, other inflammatory markers like fibrinogen, Lp-PLA2, and myeloperoxidase. Genetic markers, environmental pollution, which I don’t think has been really emphasized as much as it should be, and stress and depression.

So I just want to go over one thing about blood pressure because I want to make this point quite clear. If you look at the old GNC recommendations from 2003, hypertension really wasn’t considered much until you got to 140/90. Now, when I was a student many, many years ago, that was considered borderline. We didn’t even consider that hypertension, but from 2003, it was considered stage one hypertension.  Now, if you look at what’s happened, this is 2017, anything greater than 130 for the systolic and 80 for the diastolic is considered hypertension. So let’s say there’s a blood pressure of 131/81. That is considered hypertensive, okay?  I’m always asked this question. “What’s the best blood pressure to have if you’re 20 or 40 or 60 or 80 or 100?” It’s always the same. The ideal blood pressure is always going to be 120/70. Does it mean I look for that every patient? No, because I would be having patients on three medications or more, and I have to see them every three weeks. So depends on the patient. I individualize, customize therapy. Often see younger patients that are really interested in lifestyle. I’m going to do my very best to get their blood pressure down, but these are the recommendations that I do adhere to, and it’s not just some a right reading block to make people go in pharmaceuticals. It has been shown, without a shadow of a doubt, that patients with lower blood pressures do better with less heart attacks and strokes.

Dr. Weitz:            Howard, what do you think about the difference between nocturnal blood pressure versus daytime blood pressure?

Dr. Elkin:              That’s a great question. First of all, the way it usually works is that blood pressure tends to be higher in the early morning hours, and that’s really evolution at work. So the cortisol, epinephrine, norepinephrine, those messengers are higher in the morning when we awake, which is why we think there are more heart attacks and strokes in the early morning hours. As the day goes on, usually the blood pressure will drop in the average person unless you’ve had a very stressful day, and exercise, which helps to relax your arteries, usually blood pressure will be lower if you do a blood pressure about a half hour after.  So nocturnal is not the general rule. Usually, it is better at night. Now, the new thinking now is to give your antihypertensive medication at night versus the daytime. Even though, theoretically, it’s supposed to work 24 hours, it’s been shown that to cut down all those early morning hour heart problems, heart attacks, and strokes. So that’s the general rule of thumb. Okay.

So when I talk about treatment, lifestyle is always number one. So for those people that look down on traditional medicine, this is still number one. Lifestyle is number one and my book for everything, diet. So diet’s very important. Caloric restriction, caloric restriction, and I should say weight loss, and now the new thing is intermittent fasting, intermittent fasting is a useful way to lower your blood pressure. It’s also useful in lowering your cholesterol and your blood sugar, and you will lose weight, but it is helpful in lowering your blood pressure.

Now, for every pound you lose, you theoretically can drop up to one millimeter mercury of the systolic blood pressure. I don’t really know how true that is, but I will tell you in all my years of treating that if a person loses let’s say 10% of their body weight, so ;et’s say you’re 200 pounds and you lose 10% or 20 pounds, you have a significant drop in blood pressure.

So I never underestimate the role of diet and weight loss. It can be very, very helpful when it comes to treating hypertension and, of course, exercise. I’ve already mentioned that exercise helps relax the arteries. So there’s less constriction of flow, so blood pressure tends to come down. Okay.

Then we have supplementation. Okay. Potassium, it’s very, very important in lowing blood pressure. In fact, there’ve been studies recently shown that if you use this supplement called … Actually, it’s not supplement, it’s a salt substitute. I think it’s called Nu Salt, too. Anyway, that can be useful in lowering blood pressure. I don’t routinely prescribe potassium as a supplement because it’s so ubiquitous, especially in plant-based foods, but it’s a mainstay in lowering blood pressure as is magnesium.

Now, magnesium, probably about 65% of Americans are deficient in magnesium. It’s very important in blood pressure control and in other things as well. The other ones that I like that have additive effects on blood pressure, CoQ10, fish oil. Hawthorn berry can also be useful. Pressure-wise, that’s my own product, but the component is olive leaf extract, and that’s been shown in multiple studies, and this is the out of leaf itself extract, to actually lower blood pressure. It doesn’t work at everybody, but I’ve had some luck on several patients that just want to exhaust supplements before they go to medications.  So these are all possibilities, and you can add these together because you’re not going to get the same effect as you would get medication, but you will get a nice add of effect and goes very well with diet and exercise.

Dr. Weitz:            Howard, two quick questions on diet. Is there particular style of diet like the dash diet or is there a particular type of diet that you find to be more beneficial and certain dietary factors? What about the sodium question? Then somebody also asked a question, what kind of magnesium do you find most effective for hypertension?

Dr. Elkin:              Well, I don’t think it matters so much what magnesium is best. I like magnesium glycinate because there’s very low incidence of diarrhea, well-tolerated. That’s generally what I use, and I have not found the need to use anything else. As far as diet is concerned, the sodium question, in fact, there’s a slide coming up. You beat me to the punch here. Well, since I was a student, I mean, salt restricted. There’s no question that we can reduce your blood pressure in hypertensive people that are out of control by reducing their salt. Okay. That’s little question. There is no benefit, and having a low-salt diet if you’re normotensive. I mean, in fact, it could actually be dangerous.  We need sodium. It is a critical electrolyte. So when is it useful? First of all, if you’re a salt retainer, who’s a salt retainer? Well, it tends to be more in African- American population. They tend to retain sodium. There’s not a test for sodium retainers, but people should just know after a while, “If I ate this and my blood pressure is that, it’s probably diet related.”

The problem is about 80% of the sodium in our diet. It’s not from the salt shaker, it’s from all the processed foods. So that’s my number one rule. Avoid processed foods like the plague. Avoiding breads. Breads are very high and sodium, pancake mixes, waffle mixes. Any of those processed foods are generally going to be very high in sodium. TV dinners, I mean, anything process is the thing I stay away from. I’ve never really been that heavily … I don’t subscribe to a really low-salt diet unless it’s a patient of mine that has heart failure. Then I have to be more stringent or liver problems or kidney problems.  So those are the three or, again, salt retainers, but if you’re average person with hypertension, I don’t spend a lot of time on … I don’t subscribe to the dash diet. I don’t really think it’s necessary, but it’s something that we can add to what we’re doing to lower the blood pressure. Good question.

Then I think for completeness’ sakes, we have to mention medications, which I do have to use a lot. I want to emphasize this one point. If you need medication to lower your blood pressure, you should take it. This is one risk factor that I am just, there’s no question about it. We need to lower the blood pressure. It’s still the biggest risk factor for heart attack and stroke. So if you need it, you need it. I’m not a person that pushes a pill, anyone that knows me.  So ACE inhibitors and angiotensin receptor blockers are the class that I generally like. They’re good. Usually, it’s once a day. They’re very well tolerated with little side effects. Calcium channel blockers are actually vasodilators, and they can also be very useful. The one thing about calcium channel blockers, works very well in the African-American population, and also, they tend to work faster. If I start someone on a ACE or an ARB, it may take two, three weeks to really see the full effect. Whereas calcium channel blockers, you generally see a faster, a more rapid effect.

I didn’t put in hydralazine. That’s an old-fashioned medication. I still use it on very difficult management cases because it’s very kidney-friendly, but it has to be taken two or three times a day. Then beta blockers, which are very useful, I don’t really use them much for blood pressure, certainly not as a primary medication, but something secondary.

Sodium restriction we’ve already talked about. It’s going to always be there. Again, it really depends on the individual, and being your own medical advocate, you should begin to learn really, “Does sodium affect my blood pressure?” That’s really important, and for a lot of people, it doesn’t.

Dr. Weitz:            So basically, what you’re saying is if you’ve got a patient with hypertension, do a trial of a lower sodium diet. What level of sodium would you say would be appropriate in that case?

Dr. Elkin:              So the world health organization recommends you have two grams of sodium a day, which is five grams of salt, by the way, okay? Now, the American Heart Association came up with this 1.5, which is ridiculous. That’s really lower than you ever need to go. I think the CDC, it’s 2.5 milligrams of sodium. So you see, there’s a little bit of disparity between the three major organizations. I don’t usually count grams, but it’s always worth a trial, and I’ll add it to. If I have someone who’s difficult, I always ask about diet. So most of the patients that I see that are into functional medicine don’t eat a lot of processed foods, but a lot of people, most of the people in this country are not functional medicine people or patients.  So that’s why as a cardiologist I have to know all of this stuff because it’s really individual, and you really have to ask what are they eating, take a good diet history because, again, most of it really comes from the process.

Dr. Weitz:            Howard, somebody has a question about Celtic salt. So today, when we talk about salt, we’re not just talking about sodium iodide. So we have all these salts, especially in the functional medicine and natural health world, Celtic, salt, Redmond sea salt, Himalayan pink salt, and these different salts have different minerals, compositions in them. Do you have any thoughts about that?

Dr. Elkin:              Yeah. I really don’t. I think a lot of that is marketing hype. I don’t really think it matters, especially when you’re talking … There may be some advantages of Himalayan salt or Celtic salt, but most of what I’ve read about it, I don’t see there’s much data that is that advantageous. So I don’t make a big deal about it myself.

Dr. Elkin:              Okay. Advanced cardiac testing is really what separates the traditional cardiologist from what we do in integrative cardiology. So the components are complex lipid testing, inflammatory profile, metabolic profile, and genetic profile. So it’s not just about lipids. We have to put all this into consideration when we put together a plan for individual patients.

Dr. Elkin:              Okay. So let’s look at the cholesterol part of it. The standard lipid panel, and I want you to know that average cardiologist is still sticking to the standard lipid panel, total cholesterol, HDL, LDL, HDL healthy, LDL lousy, that’s what I call it., and triglycerides. You got to remember that in your standard lipid panel that most people, cardiologists included, order, the LDL is actually, it’s measured. I’m sorry. It’s calculated. It’s not measured. So if you have a triglycerides level that’s over 400, you can’t calculate it. It’s totally not something you can use.

Dr. Elkin:              Now, Boston Heart Lab, for example, will actually measure the LDL cholesterol, but most standard quests or lab core will not. So that’s your standard lipid panel that I don’t order. Then you have your advanced lipid profile, which is I think what separates men from the boys here. So why do we care about these advanced tests? Because 50% of coronary heart disease diagnosis occur at the time of sudden death. Can you believe that? 50% of people don’t know they have a problem until they die.

Dr. Elkin:              Most patients with coronary disease do not have cholesterol level disorder. 50% of people that have a heart attack have normal cholesterol levels. Okay. More people on a statin drug have an event than the numbers that actually prevent it from having an event. So statins are not the end all be all. There is clearly a role in secondary prevention, but it’s not the end all be all. Advanced disorders are more common than low density cholesterol, which we’ll get into a minute, and coronary disease. It’s a family disease.

So advanced cardiac testing, the advanced lipid panel, LDLP, that’s particle number. So what is particle number? How does it different from LDL? First of all, it’s measured and we’re measuring the number of particles in a given sample versus just LDL mass. So why is it useful? Because it’s been shown to be more prognostically significant. So an LDLP is since to give us more information than just LDL. Now, there’s a cheap way of doing this. If you take your LDL and add a zero to it, that’s where your LDLP should be. So let’s say you have an LDL of 94. Then you would expect your LDLP to be around 940, but let’s say it’s 1400 or so, then it’s not a good thing. That means your LDLP is greater than the LDL. As a general rule of thumb, you want LDL particle number to be certainly less than a thousand.

Now, here’s the one that I think is most important. That’s the LDL size, the size of the LDL particle. Again, traditional medicine, I don’t know, I’ve been doing this for over 20 years. I learned from Dr. Superko, who was with Berkeley HeartLab, who put this on the map. I spent two days with him several years 23 years ago. So LDL size is very important, and we’ll get into that in a minute.

Then it’s also LP(a). LP(a) is a fragment of LDL, and it’s sticky, it’s inflammatory, and it’s very atherogenic, and it’s totally inherited. You can’t reduce it by exercise or the usual medication, but we’ll get into that in a second, what we can do for it.

HDL functionality is a new test that Cleveland HeartLab does because we’ve known for years that HDL tends to be healthy, right? We thought the higher the number, the better off it is. Then we learned that people that have HCls of 100, 110, 120, maybe it’s not healthy. Maybe it’s dysfunctional HDL, and we’re learning that with this test that Cleveland HeartLab is now doing.

So if you want to have increased cholesterol efflux, it also tends to be less inflammatory and less thrombogenic. So that’s part of their panel now, and it’s very useful to be able to look at the functionality. Now, then Boston does a different test. They look at hyper producers versus hyper absorbers, and there’s two ways you can get cholesterol on your bloodstream. One is that you produce it from your liver. You cannot live without cholesterol. It’s essential for life. So your liver’s going to produce it no matter what. Some of us are genetically prone to make more than we want to make, and that’s liver, but about 20% of people are hyper absorbers, meaning they absorb more from their gut.

So there’s markers that Cleveland HeartLab uses to help distinguish this, and I believe they have a patent on this. So if you look at the slide here, the red are these two production markers, lathosterol and desmosterol. Those are production markers. If they’re high, then it’s telling you that patient tends to have high production, and the absorption markers, beta-sitosterol, campesterol are in the green, and that means their absorption level is low.

Now, here’s the opposite in which you have the production markers are in the green, which is good. The absorption markers are in the red, and it makes the difference in therapy, which I will explain in a minute. So lots of times, you will see a mixture of these. It’s not going to be just all green or all red. So this is an ideal world here. Okay. Now, how do we treat these? Diet, exercise. Back to the basics, right?

Now, this is a slide that I like because, as you know, back in the ’90s, some of us are practicing back then, everything was low fat and high carbs, right? Remember the Dr. Ornish trial? These a very low fat diet. I think it was 10% of your calories came from fat. So what happened is that country did not do well. First of all, people got fatter than ever, and diabetes became an epidemic. So it really was a failure.

So we have a couple of trials here. This is Women’s Health Initiative, a very large trial of close to 50,000 women. Actually, the low fat diet really had no effect on stroke or coronary artery disease. Really, what we’re interested in is the events, heart attack, strokes or death from heart attacks. The look ahead was a smaller trial and that actually was close early for a futility did not work, a lower fat diet, but the study that put on the map was a PREDIMED study, and it was published to the New England Journal in 2013.

This is a European study based mostly from Spain, 7,400 patients at risk for coronary disease, and they found, and there were different groups. One was with olive oil, one was with nuts. I have all the details in my book, but what you got to remember is that the study was landmark because it was the first time that a Mediterranean diet actually showed evidence for decreasing heart disease. No other diet has been able to show that, not even a vegan diet. People want you to believe that a vegan diet has been shown to decrease … Again, we’re talking not about cholesterol, we’re talking about events.

Dr. Elkin:              So the Mediterranean diet has been shown to actually produce less events, which is a very important landmark study. Treatment, diet and exercise. People are amazed when they say, “Aren’t you going to tell me to have low fat and low cholesterol?” “No. Go ahead have eggs. Eat egg yolks.”

Dr. Elkin:              Again, we’ve known at least, I forgot how many years now, that cholesterol in your food does not equate to cholesterol in your blood. So have egg yolks, have lobster, and have shrimp, but I’m also a moderate. I believe in eating in moderation. I’m not against saturated fat. I’m not a carnivore. I mean, I don’t think I could eat meat every day of the week. I don’t think anything in extreme is actually useful.

Dr. Elkin:              So I don’t spend a lot of time on … I had two patients in the last two weeks when I was on call that had heart attacks and I was able to open the artery during a stemmy and acute heart attack. The first thing they asked me, and they’re really interested, unfortunately, they’re going to remain my patients, “Well, should I cut down a meat? Should I cut down?”

Dr. Elkin:              I said, “Let’s get some blood work. Let’s do you’re Cleveland. Let’s do your Boston. Let’s get into some basic exercise and basic diet principles and so forth, and we’ll get into the particulars later.”

Dr. Elkin:              So I’m not into heavily reduced, I’m not into one diet or the other. I use a blend. I definitely believe that sugar and carbohydrates, starchy carbs are not great. We’ve known for years that sugar is extremely inflammatory. I tell people that eating sugar, eating starches is like spraying gasoline over a fire. We already know that coronary disease is an inflammatory process, and we need to cut that down on that. It begins with diet.

Dr. Elkin:              So I spend much more time, just much more time and effort to counseling people on a low-carb diet than I do on low-fat or low-cholesterol, and exercise goes without saying. For years, all the information was really placed on aerobic exercise, but also resistance training has been very useful in helping with lipid disorder. So there’s a role for both.

Now, supplementation. There’s a lot of things that I use, red yeast rice supplement. Now, red yeast rice actually is from a plant in China. In fact, the very first statin that came out in the ’80s, I think I was finishing my fellowship then, it was called Mevacor, a lovastatin, and it was derived from the red yeast rice plant, which is not unusual because a lot of botanicals, a lot of pharmaceuticals originally came from botanicals. Of course, then they changed it in the lab and things are different.  So red yeast rice, it’s still useful. The important thing and, Dr. Weitz, worth is up to me, is the dose. The dose on the bottle may not be a dose that you’re going to see results. So if it says you should have 1200, you probably did have what, Ben, about three grams?

Dr. Weitz:            2400 to 4800.

Dr. Elkin:              That’s not what’s on the bottle. So you have to remember if you want … We don’t just give up after you’ve had two at night. So I’m starting to do this myself. There’s a lot of patients that really want to avoid statins if they can. Now, you can still get some side effects of red yeast rice supplement. There are some patients that will still get myalgias. I’ve never seen any liver problems, but there are some people that are very sensitive may still get myalgias and so forth.

Niacin is very useful. I use a lot in my practice, actually, vitamin B3. However, when using the doses that we need to use for lipids, it becomes more like a drug, and it’s useful. First of all, it can help to decrease triglycerides. It can help increase your HDL and also augments your HDL functionality, and also can decrease LP(a). It’s really the only thing that we know of that can decrease LP(a) at this point. There are some biologics that are being worked on, especially at UCSD but they’re not available yet. So niacin can help, not in everybody, but it can help. The other really good thing about niacin, it can help to increase the size of the LDL particle.

Let’s get back to the LDL size. I always tell my patients, “If you remember one thing that I say, bigger is better.” The larger the LDL size, the better it is, the less likely it is to oxidation. Once an LDL particle is oxidized, it can easily get into the endothelium of the artery, and that’s when we start the pulmonary cascade. So we really want to cut down an inflammation. We want to make small into a large, and niacin can do that. It’s the only one that can do it. Fibrates may be able to help, but really, it’s mostly niacin that can help make a small into a large. Also, a lower carb diet can also help, low-starch diet.

By the way, saturated fat can also help to increase the size of the LDL particle, and also useful information. Berberine is interesting. It seems to have an effect on the LDL receptors. So I use that sometimes as well. Artichoke extract is useful in decreasing the absorption of cholesterol. So it’s very good for the hyper absorbers. Soluble fiber, which is psyllium, can be useful. Probiotics, I think, are important. Plant steroids have been used in the past. They’re not used that much today, and there’s some controversy about their use. My own product, CholesterolWise have bergamot in it, and bergamot is interesting. It’s from a citrus plant in Italy, in Southern France, and actually, it works on both the liver and in the gut. So it can actually decrease production and also decrease absorption. So these are supplements that can be very useful.

Dr. Weitz:            Howard, we got a couple of questions about niacin. People are asking what form. Do you recommend time release? Do you see a role for any D infusions? Somebody else asked, “Flushing, non-flushing?”

Dr. Elkin:              Yeah. Okay. First of all, non-flushing doesn’t work. It’s useless. Non-flushing niacin has been actually chemically altered. So yeah, you don’t get the flush and you don’t get the effect. Sinatra and I have talked about this many a time. Okay. When it first came out, immediate release was well popular, and you really get flush with that. I don’t think anyone use that anymore. The intermediate release is what I use in my office, and you take it two or three times a day with food. So you will flush, but as long as you take it with food, it’s useful. I don’t use sustained release, which there’s a pharmaceutical brand of niacin. I think it’s called Slo-Niacin. Anyway, you take it at night with a snack and then you wake up at 2:00 AM flushing. I don’t find that helpful, number one, and number two, it can be harsh on the liver. So I like the intermediate release or the time release, but not the sustained release that you take once a day, if that makes any sense.

NAD is really big now in the anti-aging world, mitochondrial regeneration. It’s got a lot of effects. First of all, it’s expensive. I don’t think it’s what you need. Nice and expensive, and it’s very useful. So I use plain old niacin, whether it’s zymogen or molecular, designed for health. They all make a very similar product that’s good. So basically, they call it sustained release, but it’s not long-acting or once a day.

Dr. Weitz:            Yeah. Another other supplement that’s pretty popular that somebody just asked about is citrus bergamot.

Dr. Elkin:              Right. So citrus bergamot is in my … I’m sorry. Yeah, that’s in my CholesterolWise product. That’s the product I was talking about. It’s actually a citrus fruit from Southern France and Italy. Yes. It’s useful. It could very useful. You have to have at least 1,000 milligrams. So that’s important to keep in mind, and also with berberine. They both require at least 1,000 milligrams to 1,500 milligrams a day. So that’s important on those two supplements.

Dr. Weitz:            Can I ask you about two more supplements? Have you worked with any of the nitric oxide stimulators like L-citrulline and/or beet root extract?

Dr. Elkin:              I haven’t. These are the ones I deal with mostly because they have a good track record with me. So I haven’t on the need to go outside of these, but it doesn’t mean they’re not useful. I just don’t have experience with them.

Dr. Weitz:            There’s also a product called Arterosil, which has been shown to help with the endothelium.

Dr. Elkin:              If you can hold that one until we get to the pulse test. It’s what I use for that. Thank you. That’s a great question. So these are the basic supplements. By the way, CholesterolWise is bergamot, just bergamot, but the medications we still use, ezetimibe, which is Zetia. It’s interesting. It’s now generic. It comes in one size, 10 milligrams. It is very well-tolerated, and it helps to decrease the absorption. So if I don’t get where I need to with probiotics and with artichoke extract, I may add Zetia. It decreases your LDL cholesterol by about 10% to 15%. So it’s not insignificant.  Cholestyramine is a bowel acid resin. It binds bowel acid and you excrete them. It was very useful many years ago. It’s a powder. It doesn’t taste very good, and it can be very constipating. You have to drink a lot of water with it. It’s really gotten out of favor because ezetimibe does as good a job, if not better, and with no side effects.

Statins have been around. Again, it started in the ’80s from Mevacor, which is the first one derived from the red yeast rice plant. There’s no question statins have their role. Despite what you may hear from people on Instagram and functional medicine, there’s a discrete role for statins, and that is in secondary prevention. If you had a heart attack or a stroke or a stent or bypass, we have a lot of coronary artery disease, there’s no question, and we’ve known this since the ’90s that statins can decrease, again, events, events. We’ve talked about events.

So I don’t understand the arguments about they’re bad for you or you shouldn’t be on them. It’s the patient we’re looking. Primary prevention is different than secondary prevention. So with secondary prevention, I don’t mess around. I use what I need to use to get these numbers down. Also, what we didn’t know about these medications years ago, we just thought, okay, they’re really good at decreasing LDL and cholesterol, but we learned, I forgot the name of the trial, but in about 15 years ago, there’s also an anti-inflammatory effect from statins that we didn’t really appreciate. We found that out with a trial with Crestor, which is rosuvastatin. I just can’t think of the name of the trial now. Anyway, so they have their role.

Fibrates are very useful in patients that have very high triglycerides. So a lot of your diabetic patients have very high triglycerides if they fail diet, which they shouldn’t, but a lot of them do, but we’re also talking sometimes triglycerides levels of over 1,000. You cannot mess around with that. These patients are high risk of pancreatitis, which can be life-threatening. So I do use fibrates for that. It can help with increasing the size of the LDL particle, but not nearly as effective as niacin.

The new kid on the block, which is not really new anymore, is the PCSK9 inhibitors. Those are biologics. They’re monoclonal antibodies. They’re given twice a month via injection. Patients get their own injections with the subcutaneous needle, and it works in the LDR receptors. It does a great job of decreasing LDL cholesterol. So let’s say this. If statins can get your LDL down, let’s say Zetia, 10% to 15%, statins, 25%. PCSK9 inhibitor, 50% to 60%, not in everybody.  I’ve had a few patients that basically failed, and they probably have some unusual genetic factor that we haven’t been able to determine yet, but I have several patients on PCSK9 inhibitors. These are my high risk patients that really do need it. So they are expensive. You have to get prior authorization, but normally, I’m pretty successful in getting that. So again, it’s another tool in my toolkit. Now, let’s look at the inflammatory profile because-

Dr. Weitz:            Howard, just real quick. Have you worked with bempedoic acid with your patients yet?

Dr. Elkin:              You know what? Yes. First of all, no one’s covering it. I think the reps have gone off the face of the earth. I mean, they gave me the medication, they gave me a briefing on it, and I have followed it. It’s an alternative to a statin. It’s not as effective as a statin, but it does work on the liver, but the interesting about … Actually, I forgot the trade name, but yeah, bempedoic acid, they don’t cause the myalgias, the muscle aches and pains, and the muscle weakness that statins do. I’ve had one or two people on it, but then when I try to get it through insurance, they won’t cover it.

I mean, basically, I can get a PCSK9 inhibitor, which is more expensive, than I can get that. Right now, there’s a war on branded drugs. It’s just impossible, but I do have some experience with it. It sounds good on paper. It’s not as effective, but it’s a good alternative, but the big challenge right now is to get insurance to cover it. Great questions.

So the inflammatory profile, what we’re interested, and we all know that all the diseases of aging are inflammatory base, whether it’s heart disease or cancer or immune disorders or Alzheimer’s. They all have that thing in common called inflammation. Everybody, everybody should know their C-reactive protein. It’s extremely nonspecific, and if it’s greater than one, one or greater, you’ve got inflammation going on. Fibrinogen is an acute phase reactant. So usually when CRP is elevated, fibrinogen will be elevated as well.

Then you have two that are more specific for vascular inflammation, Lp-PLA2, which is based on an enzyme and MPO, myeloperoxidase. Myeloperoxidase is actually, it’s released from white blood cells when you’re dealing with a vascular inflammation. They’re actually part of the release, foam cells from monocytes and also from polymorphonuclear leukocytes when they get into the area of the vascular system and initiate the inflammatory cascade.  Lp-PLA2 also affects the endothelium. So that also is telling me there’s a problem with the vascular. You can have a normal CRP and still have inflammation in the vascular level. So you really need to follow these patients about what’s going on.

Okay. So we’ll work up. What do you do about it? You got to look at the underlying cause. Is there any infections, chronic infections going on? Very important. Active cancer certainly would be … It can be inflammatory base. Periodontal disease is a big one. I’m maybe one of the few cardiologists that actually recommended my patients go get checked out by a periodontist if they have persistently elevated C-reactive proteins. We’re talking levels of three, four, and five, and above.

When I see persistent elevations, I get concerned. I let the patients know that I’m concerned and they go, “I go to a dentist,” or “I don’t have any bleeding,” or “I don’t have any pain.” That doesn’t mean anything. The average dentist, and I don’t mean to degrade dentists at all, but a lot of dentists will bypass a four and five pocket, millimeter pocket. I’ve had patients that go to a periodontist and they found six and seven millimeter pockets. That’s really bad. That’s deep pocket and just full of red bacteria ready to cause inflammation.

So about 70% of the American population has gingivitis, one degree or the other. These are a very important cause of ongoing chronic inflammation. One thing I didn’t mention here, well, let me see. Of course, dysbiosis and gut issues. So what I do in these patients that have chronic inflammation, I send them through a periodontist for a least an evaluation, and I will tell you that 80% of the time they’re going to have some major disease going on in their oral cavity. It’s that common, especially with the diet that people eat and the stress that they were under today.

Then, of course, fortunately, I have a nutritionist on staff here at HeartWise, and her specialty is the gut. So we do a GI map, and most of these patients have gut issues. So I don’t just give a bunch of fish oil and turmeric and say, “Okay. Don’t worry about it.” I try to look for underlying cause, and that’s what we do in functional medicine. That’s one thing I did leave out and I apologize both for hypertension and for inflammation and that sleep deprivation, especially sleep apnea, obstructed sleep apnea is definitely a cause for inflammation. I think sleep deprivation in itself is, but also sleep apnea can also be underlying cause for hypertension.

I had a patient several years ago, when I treated his sleep apnea, I could not control the blood pressure. Of course, he was overweight and wasn’t exactly compliant with diet, but once we had the sleep apnea under control, his blood pressure got much better. So very interesting. Okay. So that’s the workup.

Supplements, I’m pretty basic. There’s a lot of supplements you can use, but fish oil, turmeric, ginger, quercetin, these are the ones that I use most often in my practice. There’s a handful of others. Again, I’ll try to keep things really simple. Oops, sorry. Oops, I didn’t me to do that. Okay. I’m sorry.

Okay. Then we do the metabolic panel, which is extremely important. Keep in mind that 88% of the American population is metabolically unhealthy, okay? So for metabolic syndrome, waist circumference is greater than 40 for male, 35 for female, elevated triglycerides, hypertension, elevated fasting blood sugar, and low HDL, 88%. Okay.

Dr. Weitz:            Hey, Howard. Can you comment on insulin levels and what do you see as a goal for optimal insulin levels?

Dr. Elkin:              Well, these are the tests that I commonly order always when I do advanced panel. So let’s look at the A1C first. So A1C, as everybody knows, it’s a marker on the red blood cell. It tells me how the blood sugar has been managed in the preceding three months. So when someone comes in today, I say, “Okay. So we’ll redo this in three months? We’re going to see what’s happening from this day on.” Fasting insulin, my level, I like it to be under H, I really do.

Most that I see, if they’re not really attuned to diet, it’s going to be 10, probably 20 and 30, 40. I mean, usually the heavier they are, the higher their fasting insulin levels. So I do look at that. I try to get levels definitely below 10 if I can. Interestingly enough, of all the athletes that I have, the ones that do best with insulin levels, are body builders. They’re metabolically the healthiest people. They have low level insulins, healthy from that regard, not another regard.

C-peptide is another useful test. It tells me how hard the pancreas is working. The pancreas is really working hard pumping out insulin. With hyperinsulinemia, it’s going to be elevated. I tell patients this is a problem because your C-peptide eventually is going to poop out. Right now, I’m working up two patients that their A1Cs are very high, but their fasting insulin levels and their C-peptide levels are very low, which means they’re probably at the end of their game, which means they’re probably going to need to have insulin, and at which time I turn them over to endocrinologist because I don’t want to deal with insulin.

So you really want to follow these patients because you’ll see the numbers go up, and if they start to drop and precipitously drop, and the insulin level is really low, less than five we’re talking, and a C-peptide that’s low, that means school’s almost out, and there’s nothing more you can do with these patients as far as lifestyle, then they’re going to have to go to insulin, which is not what I like.

So the test that I like to use to really gauge insulin resistance is something called HOMO IR. That stands for homeostatic model for insulin resistance. It’s a calculated value based on your fasting blood sugar and your fasting insulin level. Boston Heart records this. Cleveland has something called the insulin resistance score. I’m not quite sure the difference, but they’re both are very similar and they’ve given you an idea of insulin resistance. So that’s the metabolic profile, and it should be a part of your workup if you’re really interested in cardio metabolic health supplements. Oops. That’s going wrong direction.

Okay. Genetic profile. So this is important. I do this in all my patients when I can because it gives me an idea of where we are. KIF6 stands for kinase something. It’s on the sixth chromosome. Anyways, it tells me if a patient is genetically prone to have premature coronary disease and if they have one or two alleles that are positive, not only are they at high risk, these patients tend to do quite well with statins, by the way. It’s been shown that they do well with statins. This is some of the original work with Dr. Superko at Berkeley HeartLab, who I worked with for a couple days several years ago.

9P21, that’s off the ninth chromosome. First of all, about 50% of the population has one allele that’s positive. If you have two alleles, that’s 25% of the population. So that’s not surprising because of how prevalent heart disease is. These patients are also prone to premature heart disease, coronary disease.

APOE, everybody needs to know their APOE level. First of all, what we use it for in cardiology, of course, is a measurement of cholesterol management. These patients tend to be hyper absorbers, by the way. So they tend to absorb a lot of cholesterol in the gut.

Now, the other thing is that is clearly a marker for Alzheimer’s disease as well. I do tell the patients this, although the lab printouts don’t say it. It’s very interesting. They don’t say anything about it, but all you got to do is go to the internet and read about it. So I do mention it to it. If you have one allele, I think two to three times more likely they have Alzheimer’s, and if you have both, it’s 12 times more likely to develop Alzheimer’s.

Dr. Elkin:              So I tell people it’s just a gene, but it’s good to be on the alert because let’s work now on diet, and exercise, and lifestyle, and supplements and so forth and so on. It’s a basis for … I have about three patients right now that I’m working with on this one thing.

Dr. Elkin:              4q25, these patients tend to have a higher risk for atrial fibrillation, which as many of you know, it’s the most common arrhythmia over the age of 70, but I’m seeing it on ages. I mean, two of my best friends had ablations in their early 50s, and I had one patient who’s 29 had an ablation a year ago, but there is a genetic basis for atrial fibrillation that we understand.

Dr. Elkin:              Factor V Leiden is a genetic factor and these people are prone to blood clots. So when you have someone that develops a blood clot, that should be definitely part of it, but I do it as part of my cardiac screening to see there’s no surprises.

Dr. Elkin:              MTHFR, methylenetetrahydrofolate reductase, 60% of us have one or two alleles. We’re poor methylators and in cardiology, what we’re most concerned about, this can lead to elevated homocystine levels, which is very common in my practice. So I mean, I have levels as 30 and 40, I mean, really high levels. Also, other things can cause it, and people that have renal insufficiency tend to have high MTHFR levels.

Dr. Elkin:              Again, I think it’s nice to know these markers. If could only pick two of them, I would be APOE and MTHFR. I think everybody should know those two because insurance probably won’t cover these, but if you’re with Boston Heart, they have a deal in which they will charge you $25 for each one of these markers, which is not bad. Okay. I forgot how Cleveland does it. So you can’t get these. It’s part of the profile and it’s pretty reasonable. I think they’re important.

Dr. Elkin:              Okay. I’m going the wrong direction. Okay. Okay. We’re fetching up soon. Coronary calcium scan, so it’s nice to know when you do these extensive testing. First of all, if you want to stratify your patient, do they have coronary disease? We’ve done all this testing. We know that they’re at risk, but what’s really going on? So we do a coronary calcium scan. It’s best done at Harbor-UCLA. I swear I sent all my patients to Dr. Matt Budoff. He’s been doing this for many years. Some of the best research in the countries out of that facility. So it tells me if there’s any calcified plaque in the coronary arteries. So it looks at all. It’s a five-minute scan doing on a fully clothed. So you’ll get a score. The perfect score is zero.

Dr. Elkin:              You know we have calcified arteries, right? As you get older, that’s unlikely. So we find out what your score is, and there’s three main coronary arteries and you’ll get a composite score, but the good thing about at Harbor-UCLA is that you’ll also learn, they have a database of 30,000 people. So they can say, “Okay. How do you compare to other 58-year-old men or 60-year-old women?” So they have a great database. “Okay. You’re in the 10th, 20th percentile. Not too bad. 40th to 50th, okay, average. 80th and 90th, that’s pretty serious.” By the way, you don’t have to have any symptoms. So it’s a useful test to have. I probably do it every two years or so on interested patients, people that are interested in being proactive.

Dr. Elkin:              I had one patient there. I’d tell you this funny story. So I did him and he had a level 1200 when I first did it. I said, “Holy shit!” Then I did it repeatedly every two years, and we kept on going up and up. He wasn’t compliant with diet. He was a diabetic. Finally, after 2,000 I said, “I’m done. I’m more nervous than he was. It took seven or eight years before he finally had a heart attack, but he had very, very high levels. So again, it doesn’t necessarily equate to events. Although if it’s a score over 800, it’s supposed to be very highly correlative, but obviously in this patient, it didn’t make that much of a difference. I mean, really, I saw this go up every year until I stopped ordering the test. So that’s one test that I do find useful.

Dr. Elkin:              I like the PULS test. PULS stands for protein, wait, protein. Oh, gosh! I hate these. Anyway, it’s a test. It’s an interesting test. Oops. That’s the company that does it, and it’s a very different test. I do the coronary calcified test. It’s telling me if there’s calcified lesions in the coronary arteries. It doesn’t tell me whether it’s a vulnerable plaque or stable plaque. We tend to think that calcified arteries are actually somewhat safe because they’re calcified. You’re not going to have a calcified lesion just break off and cause heart attack or a stroke. It would be unlikely.

Dr. Elkin:              It’s the soft lesions that we call the vulnerable plaque that we don’t see. We cannot pick up on a coronary calcium scan. So any information we can get from other tests are very useful.

Dr. Elkin:              There is a test that they’re working on now with artificial intelligence. Well, very few centers do it. There might be one. I’m not doing it. It’s $6,000 for this test minimum if you want to be able to really see what soft plaque looks like, but this quantifies damage at the endothelial level and identifies risk and predicts, most important, acute coronary syndromes.

Dr. Elkin:              So when I’m on call, I’m called to see someone, an acute coronary syndrome, meaning they’re either having a massive heart attack or not so massive heart attack, but they need to be admitted and they need to be studied. These are not stable patients. So it’d be nice if we can predict this before it happens. So it’s an interesting test.

Dr. Elkin:              The important thing that I’ve learned is that this whole disease process starts off at the endothelial level, which is the one cell thick that aligns all your arteries, small, medium, and large. As long as is that one cell thick is untethered and undamaged, I don’t care what your cholesterol is, I think it’s going to happen, but with age, genetics, stress, cholesterol, hypertension, smoking, environmental pollution to know there’s damage that takes place in that endothelial, which sets ourself for disease.

Dr. Elkin:              Okay. So this is what a-

Dr. Weitz:            Howard, I just wanted to maybe help if people are a little confused about the coronary calcium scan. Just to maybe put it in a different way what you said, which is that somebody can have … Look, it’s better not to have any plaque at all, but if you are going to have plaque, when you do the coronary calcium scan, it’s measuring calcified plaque, and if you had a choice between having calcified plaque and uncalcified plaque, calcified plaque is more likely to be stable.  So it’s when the plaque is unstable and breaks off, then it’s more likely to create an event. So therefore, just because you have calcified plaque, it doesn’t necessarily mean that you’re as much of a risk as if you had soft plaque, which doesn’t show up on a coronary calcium scan, unfortunately.

Dr. Elkin:              I tell the patients, just like you said it, there’s somewhat protective measures having calcified plaque, but it means you do have plaque. Okay? If it’s calcified, it’s probably been there for a while because calcium doesn’t just … If you look at plaque under a microscope, if you could do that, first of all, it’s endothelial damage, then you have oxide LDL getting into intima itself, then you have the cascade of events and foam cells and macrophages and blah, blah, blah, and eventually, you have cholesterol entering the area. Smooth muscle cells entering the area. Eventually, calcium is deposited. It’s probably meant to be a protective measure, but if you see it, it means you do have plaque, which means you’ve got coronary disease.

Dr. Elkin:              Now, with the PULS, we’re looking at nine different biomarkers here. Unfortunately, I don’t have a pointer, but this is what the port looks like. So everything in the red is bad. That’s above the line. Everything in the green is good. So there’s two that we don’t measure. Your age and your genetics are not really biomarkers. These biomarkers, I’ve never heard of before, interleukin 16, IGF, exotoxin, FAS, FAS ligans. I said, “What the hell?” It doesn’t matter because we’re not treating the individual biomarkers. We’re treating your risk.

Dr. Elkin:              The the way this was devised, and this test has been done by four different cohorts approved by FDA and on total number of 40 almost patients. So the history of PULS, if you ever want to look it up, go look at pulstest.com and you’ll see how this was derived. It was a carefully derived test.

Dr. Elkin:              So we’re looking at biomarkers that tell us, “There’s stuff going on in the endothelium now.” The calcium test tell me what’s been going on in the past. Who knows? It could have been that way for two years, but if you have an abnormal PULS scan, it’s telling me what’s happening now.

Dr. Elkin:              Now, look at this person. He’s high risk and his score is 9.02 if you look at the bottom. Now, if he was the same, I don’t know the age of this patient, but what his expected score for the age and sex is 1.19. So we look at the gap, which is 7.58, which is not good. That puts him at a high risk category. So you’ll end up with a high, moderate or low risk. Now, let me just go into the next slide. You’ll see what I’m talking about.

Dr. Elkin:              Okay. So this is a person who’s had two scans, two PULS tests. First one is 18.19, okay? Now, what I want a combination is … Okay. The first test doesn’t mean much to me. It just tells me that you’ve got junk going on in your endothelium. What I’m more interested is in your second and subsequent test because I want that number to go down. Now, in this patient, guess what? It went up. He went from 18.19 to looks like 30 something. That’s not good. We want the graph to go down not up.

Dr. Elkin:              So how do we treat it? So this is the area we get into. So I’m now treating these patients. Well, you mentioned Arterosil, which is a very good supplement. I use something from Ortho Molecular. It’s called Vascuzyme, and their proteolytic enzymes. What happens? These proteolytic enzymes help to get rid of unwanted proteins that chew up your endothelium.

Dr. Elkin:              I use two of those first thing in the morning. I’m taking it myself, actually. First thing on empty stomach in the morning, then I have another product they use, and I changed the title to EndoWise because it’s a very difficult title to remember. Basically, there’s three components, pomegranate extract, pine bark extract, and olive fruit extract. Those three together are very, very useful in building the integrity of endothelium.

Dr. Elkin:              So I’m using a double product approach to treat the endothelium. One, to get rid of one protein with proteolytic enzymes and the other is a compound that would help to maintain a stable endothelium. Now, I’ve been doing this for six months now and I don’t have a study yet, but I have seen my graphs go down in addition to lifestyle and other things that we’re doing because I have one patient, she’s a judge. Okay? Past family history, father had a heart attack at early age. Her LP(a) is elevated. She’s got cholesterol issues. I have her on niacin. Mild hypertension, and she’s early 60s.

Dr. Elkin:              I did a coronary scan. I’ve done two of them. They were normal. I said, “You know what? We should do a PULS test.” She’s high risk. You can have a negative coronary calcium scan and a high risk PULS scan, which tells me even though it’s not showing up at this time on a calcified scan, there is stuff happening at the endothelial level that we’re not aware of because we can’t visualize what’s happening in the soft plaque. So we put her on these two supplements. I mean, her graph has gone the other direction than this graph. So it’s just very interesting.

Dr. Elkin:              So I have not studied Arterosil, but I know it’s similar. It’s the same principle. We want to treat the endothelium because that’s really where everything starts. We’re not just looking at LDL cholesterol anymore. We’re not even looking at just the size of the cholesterol. We’re looking at by maintaining the endothelial function, can we actually decrease risk. I’m finding that. So I’m really enjoying doing this because it’s telling me a lot.

Dr. Weitz:            Howard, what was the name of that supplement from Ortho Molecular with the proteolytic enzymes?

Dr. Elkin:              It’s called Vascuzyme, V-A-S-C-U-Z-Y-M-E, Vascuzyme. So you take two of those first thing on an empty stomach. Those are proteolytic enzymes. The other one is one twice a day with or without food, and I forgot the name, but it’s Oxy something, but it’s pomegranate extract. If you look up Ortho Molecular, pomegranate extract, pine bark extract, and also olive fruit. Ortho Molecular has done some good stuff in the cardiometabolic field. That’s why I like them. Every company, these major companies have good supplements, but they’ve got a few good products that I really like that I use on my cardiometabolic patients.

So finishing up here, what about stress testing? We don’t ignore chest pain. If anyone, if you have a patient that’s complaining of chest pain, they should be worked up. Again, 45% of heart attacks are silent. We want to improve that. If it’s a diabetic patient, do not mess around. Refer those patients for a stress test. If it’s a woman, if it’s anything above the belly button, it’s heart until proven otherwise. A lot of women have unusual symptoms. They can have pain in the jaw, in the teeth, in the neck, no pain at all, fatigue.

So I think we’ve learned over the years, when I was a fellow, all the studies that I looked at were based on middle-aged men. Women were excluded. So we now have learned that women are different diagnostically and also treatment-wise, and they respond differently and they tend to be older.

So I do stress testing. Of course, I’m a cardiologist, I don’t have it in my office and I do imaging as well, but it’s very important to do that. There’s special considerations. A lot of your patients will complain of palpitations. When do you worry about it? I have a patient today that I did a monitor on him and he’s in atrial fibrillation 16.9% of the time, which is not great, but he had an episode that’s over five hours. He is getting worse because if you have an episode over eight hours, you’re high likely to have a stroke, 40% more likely to a stroke.

Cryptogenic stroke is a stroke that we don’t know why it happened, but we’re now thinking that most cryptogenic strokes are really from atrial fibrillation. So besides doing arrhythmia detection, you can also do what’s called a loop recorder, and I have a few patients that have that. They’re very small device. You put it under the skin. There’s no wires. It actually detects bouts of afib.

So that’s basically … The medical advocates take the high road. So I’m called the medical advocate because I learned by being a patient twice that I had to suffer to the plate and be my own medical advocate because I learned real quickly that traditional medical model was not the end all be all. So that’s what I hope for my patients and for all of you. So any other questions? I’m happy to take them.

Dr. Weitz:            Yeah. One other question somebody asked, “What is your approach to afib?”

Dr. Elkin:              Okay. Okay. That’s a great question. First of all, it should be treated. Now, here’s my thing. Sinus rhythm, normal rhythm is much more favorable than atrial fibrillation. So why? What do we worry about atrial fibrillation? The most important thing to be concerned with is stroke. Again, if you have an episode that lasts eight hours or more, whether it’s permanent or paroxysmal, there’s a high likelihood of a stroke. So these patients should be at a blood thinner. I got a patient say, “Well, I’m taking fish oil I’m taking ginger. I’m taking garlic.”

I’m saying, “That’s fine.” Nattokinase or serrapeptase, there’s no studies on those supplements. So I tell patients, “It’s probably nice that you’re doing that, but if you really want to prevent a stroke, you probably should be on something that’s definitely been approved and studied.” Sinatra and I have talked about this. He also agrees with me. You don’t mess around with afib because strokes tend to be big.

Dr. Elkin:              See, what happens when the part is pumping, when it’s beating irregularly irregular, little clots end up in the left atrial appendage and they can break off anytime and go up the order to the carotid and usually plug up a dividing point, a bifurcation. So the strokes tend to be big. They’re not small strokes. So you want to avoid that, number one.

Dr. Elkin:              Number two, I had another patient about years ago, he didn’t want to go through invasive testing. He already had a heart attack and stent, by the way. His heart rate was 110 doing nothing. I said, “Okay. I hate to break it to you, but you’re going to develop heart failure because your heart’s not going to be able to take this but so long.” So I finally was able to convince him to go on a beta blocker and his heart rate is less. So there’s a definite increase incidence of heart failure in patients with afib.

Dr. Elkin:              Then the other one is dementia. It’s now been shown recently that whether it’s permanent afib or paroxysmal afib, there’s a definite increase incidence in dementia probably because of the sporadic nature of the pumping of the blood going to the brain. We don’t know exactly why, but there’s definitely increased incidents.

Dr. Elkin:              Number four, which is more lifestyle, is that they feel like crap. I mean, if you don’t have the atrial kick, see what happens in afib, the atrium and the ventricles, and they’re not working in concert because you don’t really need the atrium. The ventricles are doing the major pumping whether into the right ventricle or the left ventricle into the aorta. You don’t really need to have the synchrony, but what happens when you lose the atrial kick, you lose about 15% or 20% of the cardiac oomph, the output, and that’s per beat. So these patients have a difficult time exercising. They get fatigued very easily.

Dr. Weitz:            A question came in about the myocarditis and pericarditis that could result after having a certain well-known virus.

Dr. Elkin:              It’s real. It’s real. I mean, I think it’s funny. Being on call as long as I have been during this entire pandemic, I’ve seen arrhythmias. I’ve seen a couple of heart attacks. I’ve seen one or two myocarditis. They tend to do okay. Now, the consensus of opinion, if you can believe it, is that people that have myocarditis as a young male post-vaccine, post-booster, I’m sorry, tend to do pretty well for the most part. Very few end up being hospitalized and very few have any residual symptoms or signs. The ones that are hospitalized with myocarditis is a bigger deal.  Now, I will tell you, if you were hospitalized, so let’s say you look at your COVID population, 80% never hits the hospital, 20% do. Of that 20%, at least 30% or 40% will have elevated cardiac enzymes, which means they’re having cardiac injury on one way level four. It could be a heart attack or it could be a myocarditis. So I have seen it.

Dr. Weitz:            What about from an integrative approach? If we have patients with that, what protocols have you found to be effective?

Dr. Elkin:              Okay. Well, if it’s acute, you’re going to do acute congestive heart measures like if they need diuretics, you give them diuretics, meaning intravenous diuretics.

Dr. Weitz:            Right, but let’s say in a chronic stage. Patients coming in our office still are having some lingering.

Dr. Elkin:              Got it. All right. So I use formation supplements for these patients, CoQ10. If they definitely have any significant heart muscle dysfunction or low cardiac output, you need high doses, at least 300 milligrams. By the way, both Cleveland Heart and Boston Heart will do CoQ10 levels as part of their profile, and you want patients with heart failure to have levels of over four if you can get it, okay? That’s going to be minimum of 400 milligrams a day of CoQ10. So that’s the mainstay.  

Then I also use d-ribose, which is the major energy substrate for every cell in your body, especially your heart cells. So you can have all the CoQ10 in the world, but if you don’t have enough d-ribose as a substrate, you won’t be able to really generate enough energy. So it helps with contractility.

I also use L-carnitine because it helps to transport fatty acids from the cytoplasm cell to the mitochondria, where energy is produced. So I use those three together, and I also use magnesium. So I use those in my heart failure. I mean, I try to get all my heart failure patients on supplementation. One thing I tell them, a failed heart is a starved heart, and the pharmaceuticals can be very good, but they’re not going to replete the nutrients that you need.

So definitely, I’m so glad you brought that up because I couldn’t talk about everything, but it definitely helps with my patients, whether it’s myocarditis. Now, a lot of myocarditis, I’ve had patients with myocarditis over the years, whether it’s COVID or not, they improved. Their [inaudible 01:13:57] will improve. Generally, if I can withdraw the drugs, I’ll probably keep them on supplements. I think it’s important, but a lot of my cardiomyopathies, good luck at the draw. Some don’t improve, and they were left with ongoing disease.

Dr. Weitz:            Does current research support the use of low-dose aspirin?

Dr. Elkin:              Good question. Now, I will let you know that from the very beginning I know I’ve been one of those cardiologists who say everybody with the age of 50 should be on low-dose aspirin. It’s controversial now. Here’s my thing on it. It’s a doctor’s decision to decide whether or not you should be on it. If you’ve had a stent, if you had a heart attack or a stroke, you probably should be on baby aspirin the rest of your life. If you are just a patient with coronary disease, and this is going to be extremely variable depending on your belief system. It’s always a benefit risk ratio. So I think the benefit is going to outweigh the risk. Yeah, I would probably do baby aspirin.  Again, I would be more wary of that in the elderly population. They’re the ones that get to be concerned most with the bleed as opposed to a younger person, but I still use aspirin, but I never use it universally, never. I’ve always done it on individual basis, but in-

Dr. Weitz:            So there’s been a lot of discussion in the literature, and for many years it’s been a consensus to you that low-dose aspirin is a good preventative for pretty much everybody, and then recently, after looking at the data and considering the fact that some patient is going to benefit from blood thinning and some patients are going to get worse from blood thinning because they may have bleeding events that in general it’s not recommended, but what you’re saying is individualized medicine. It depends on the person. If the person is more likely to have an issue with clotting, then it makes sense.

Dr. Elkin:              Especially if it’s a secondary prevention. Secondary prevention mean you’ve already had the diagnosis, you’ve had something happen versus just primary prevention. So again, really, it’s a benefit risk ratio, and I just customize my therapy, but I’m going to be doing a YouTube live on this in a few weeks because it’s so important.

Dr. Weitz:            An important supplement you didn’t mention is K2.

Dr. Elkin:              Oh, yes. I use it all the time. Okay. So here’s why I like to use it. K2, you all know about vitamin K. So there’s K1 and K1. That’s another one. K1 is important for blood clotting, okay? K2, it actually helps to shunt calcium from your gut to where we want it to go, which is two places, bone and teeth, but we don’t want to go to the heart, meaning the heart valves and the coronary arteries.

There’s some really good studies coming out talking about that. It also helps with decreasing the stiffness of the ventricle and it helps with diastolic dysfunction. So there seems to be more and more coming out now about vitamin K2. So yes, I use it. There’s a product actually by Ortho Molecular that I like, and it contains 5,000 of D3 along with 180 micrograms of K2. So Sinatra and I have just had this discussion. We think at least 150 of K2 would be important to take a day. You can take more than that, but that’s seems to be … Yes, I use it on almost all my patients that have demonstrable disease. I just go from D3, and it’s a combination. One capsule does both.

Dr. Weitz:            Somebody asked a question about blood pressure and what you said about blood pressure earlier about how blood pressure is typically lower in the afternoon and higher in the morning. What if the opposite? What if the patient has lower blood pressure in the morning and higher and later in the day?

Dr. Elkin:              It can happen. I’ve seen it happen. It’s the minority, but I’ve had some people who have these paradoxical rise in the evening. Okay. Then you got to be creative. Also, that’s why you have to really figure out what they’re eating, but assuming that their salt intake is not great, that they’re very careful, and their diet is pretty clean, I might need to add something. I might do a twice a day medication, which I don’t like to do. I like to do once daily, but sometimes I do have to use a second medication. So I may use hydralazine, which is a vasodilator, which can work pretty effectively. It’s an old-fashioned pharmaceutical. I mean, it was out when I was a student, but it’s still one of the best ones, and it causes less edema and swelling than the calcium channel blockers.

Dr. Weitz:            I would also recommend doing an adrenal cortisol stress test. If you see a rise in their cortisol level in the afternoon or evening, that’s where a product like Integrative’s Cortisol Manager can be perfect, and you can time it with when they have the rise in cortisol.

Dr. Elkin:              Yeah. I just had a patient today, actually. She had adrenal test, saliva test with CAR. Her CAR was 200% increased. She did great. She has a normal curve, but she has a very high anxiety going now. She want to go on an SSRI, which I didn’t really want to do. Anyway, so she’s got a normal curve, and then right when she’s going to bed there’s a jump, and that actually was effective. So yeah, she doesn’t have hypertension, so that’s a useful thing, but yes. It also depends. I think that’s a good point. Adrenal testing is always useful. Some people don’t don’t believe in it, but I do. We do a lot of adrenal testing.

Dr. Weitz:            Somebody asked about Boston Heart or Cleveland labs for a patient as a preventative test. So I think, basically, the question is, would you do advanced lipid testing for patients who aren’t necessarily heart patients? I would say, for me, I make that a part of every one of my patients that we’re screening for-

Speaker 4:           Sorry, Ben. I was actually asking if you had only one choice because this is for someone who you’re trying to optimize, who does not yet need a referral to a cardiologist. Does he like the Boston Heart or the Cleveland better?

Dr. Elkin:              Okay. Good question. I like them both. I am a spokesperson for Boston Heart, and they’re both very similar. Again, Boston Heart has a couple things that I really like like the hyper absorption, hyper producing test that they have. They have a patent on that one. Also, a genetic test that I didn’t mention called the Slow Code Gene. So you can actually find out whether a patient is a slow metabolizer of a statin, which is really important to know because if they are, either you want to minimize the use of a statin or you use a water-based statin that won’t be as nearly as potent. So those are two tests that they do.  They do a few other of tests. They do it. I like Cleveland Heart. They do the HDL functionality tests, which is new. So they both basically, and the genetic tests, both can do. They’re specialty labs, and I think they’re both very good labs to use.

Dr. Weitz:            What about insurance coverage for one lab over the other?

Dr. Elkin:              Okay. Well, Cleveland was taken over by Quest about three years ago, which is an advantage, for sure, because a patient can go simply to a Quest lab and get Cleveland drawn. Okay? So it’s very easy. Whereas with Boston Heart, you have to find a lab that will draw them. Now, we compound that, but I’m in your office. We can have your phlebotomist do the labs. When I’m in Whittier, we found a service that’s very good that will PULS, they’ll do Boston, they’ll do Genova, any of these laboratory tests. So insurance, Quest, I think it’s even large in lab core. So they have the monopoly when it comes to insurance coverage.  Now with Boston, they do accept Medicare, also Blue Cross, and the Blue Cross, they recently acquired that one. They also have Aetna, which is the insurance that I have. Blue Shield does not follow. They don’t have Blue Shield yet. So there’s more coverage with, for sure, with Cleveland because it’s Quest, but I think they’re both very good tests.

Dr. Weitz:            I just want to mention, we bring a little phlebotomist in the office usually every two weeks. If you have need of a phlebotomist, you’re welcome to send your patients over when she comes out because if we had more patients for her to draw, she’d give us a better deal, and if you want to, just feel free to call my office, which is 310-395-3111. Then Howard, how can everybody get ahold of you? Where’s your last slide with your information? There you go.

Dr. Elkin:              Oh, I didn’t know the music. Wait a minute. Oh, okay. Here we go. Heartwise.com is my website. Somehow, Instagram didn’t get on here, but I do a lot on Instagram. So it’s DocHElkin, D-O-C-H-E-L-K-I-N, and YouTube, I’m usually on every two weeks and it’s the Medical advocate, Howard Elkin, MD, and also on Facebook, and that’s HeartWise Fitness and Longevity Center. So I’m pretty active on social media. I have my books will be coming out in a couple months, but if you follow me on social media, you’ll be hearing about the pre-launch.

Dr. Weitz:            How often do you do the YouTube lives?

Dr. Elkin:              I do it every two weeks unless I’m out of town or there’s a holiday, for example, but I try to do it twice a month.

Dr. Weitz:            I guess one final quick question. Somebody said, “Does Medicare only cover an advanced lipid profile every five years?”

Dr. Elkin:              No limit. I’ve never had that problem. I mean, I deal with a high popular of patients or a patient that have abnormalities. I do it every three, four months if I have to. If I start a therapy, whether it’s lifestyle or supplements and/or medications, I want to know where it’s working. So I will repeat usually three months, sometimes four months. So there’s no limitation. I have not had that problem.

Dr. Weitz:            Okay. Thank you, Howard. That was great. Thank you to everybody. We’ll see you next month.

Dr. Elkin:              All right. Thanks.



Dr. Weitz:            Thank you for making it all the way through this episode of the Rational Wellness Podcast. If you enjoyed this podcast, please go to Apple podcasts and give us a five-star ratings and review, that way more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts. I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports, Chiropractic and Nutrition Clinic. So if you’re interested, please call my office 310-395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.


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