Integrative Cardiology with Dr. Howard Schwartz: Rational Wellness Podcast 312
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Dr. Howard Schwartz discusses an Integrative Approach to Cardiology with Dr. Ben Weitz.
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Podcast Highlights
4:38 Why do patients get heart disease? Dr. Schwartz explained that eating unhealthy foods, not exercising, chronic stress, and other lifestyle factors combine with genetics to set you up for developing cardiovascular disease. Recreational drugs and other toxins like pollution can trigger the immune system and cause oxidative stress. Oxidative stress along with high fat levels in the bloodstream can lead to damage to the lining of the arteries, referred to as endothelial dysfunction. This allows the inflammatory cells that are in the bloodstream to enter the blood vessel wall along with the fat cells. The inflammation triggers cytokines, which causes oxidized fats within the blood vessel wall and hence, you get a buildup of plaque. This plaque grows over time and eventually that plaque can either obstruct the blood vessel, obstruct flow in the blood vessel or that plaque can actually rupture and then cause a clot to form on top of the ruptured plaque and stop blood flow to the heart, and that’s what we call a heart attack.
9:52 There are some studies with seaweed products using either rhaman sulfate (Arteriosil) or fucoidan (Endocalyx Pro) that have been shown to improve the health of the endothelium. The endothelium is the lining of the arteries and plays a significant role in the development of heart disease.
12:35 Lab testing. LDL has been considered the bad cholesterol and ApoB takes into account not only LDL but other atherogenic lipids, so it provides a more precise measurement. On conventional lipid panels, LDL is an estimated number that reflects the mass of the LDL but LDL particle number is more precise and we also want to know the size of the LDL particles, since small, dense LDL particles are more likely to get into the blood vessel wall and store there. We should also measure Lipoprotein A, Lp(a), is a specialized LDL particle that causes increased blood clotting and increases risk of heart disease.
16:10 Imaging. A new imaging technique that is now available that can be a game changer in terms of prevention is the CT angiogram with artificial intelligence. Prior to this test, the best imaging that we have had for preventative screening is the coronary calcium scan. It was thought that having more calcium in your arteries puts you more at risk. But new data shows that calcified plaque is actually more stable plaque and to be preferred over softer, less stable plaque. The new CT angiogram with artificial intelligence can not only identify if there is plaque, but it can characterize your plaque as soft or hard and measures the density of the plaque, which correlates with the risk. The low density plaque is inflammatory and has a necrotic core and a thin fibrous cap and is most at risk to rupture and create a heart attack or stroke.
21:27 A case study. Dr. Schwartz recalls a 72 year old female patient who had a significant calcium score–a score of 150–and she had some stenosis in her proximal left anterior descending artery. She did not want to go on a statin and did not want to take red yeast rice, since she felt it was too much like a statin. Dr. Schwartz put her on berberine, bergamot, plant sterols, and amla and she did great. He particularly impressed with some of the benefits of bergamot.
28:24 Diet. The studies show that the Mediterranean diet has the most robust data to support that this is the best diet to prevent heart disease and Dr. Schwartz believes that this is due to the anti-inflammatory effects of this diet. The extra virgin olive oil, the omega-3 fats, and the nuts seem to be important factors. Dr. Schwartz does not feel that red wine has health benefits. While it does contain resveratrol and some of the earlier studies seemed to show a benefit, some of the more recent data does not seem to be a therapeutic benefit.
Dr. Howard Schwartz is a board-certified cardiologist with more than 30 years experience. He has been a pioneer in the emerging discipline of Integrative Cardiology. He has studied yoga, Functional Medicine with the Institute of Functional Medicine, and Mind-Body medicine at Harvard Medical School. His website is IntegrativeCardiology.com.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their 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.
Hello, Rational Wellness podcasters. I’m very excited to be discussing how to prevent and reverse cardiovascular disease with Dr. Howard Schwartz. Most of us would like to live a long, active life and in order to do that, one of our goals is to avoid the major chronic diseases that are the biggest killers today, and cardiovascular disease is clearly number one.
Dr. Howard Schwartz is a board certified cardiologist with more than 30 years’ experience. He’s been a pioneer in the emerging discipline of integrative cardiology. He studied yoga, functional medicine with the Institute of Functional Medicine and Mind Body Medicine at Harvard Medical School. Dr. Schwartz, welcome to Rational Wellness.
Dr. Schwartz: Thank you. Thank you. Good to be here.
Dr. Weitz: Good. So maybe we could start by you explaining what is integrative cardiology and how this is different than conventional cardiology.
Dr. Schwartz: Sure, sure, would love to do that. Well, I guess I could talk about it in terms of my own journey, what brought me to become an integrative cardiologist. So my own journey from a personal standpoint was I was always interested in natural approaches to wellness and health. As a teenager even, I took up yoga and meditation, met my wife through a meditation practice, and we built a family. All my children were delivered with natural childbirth at home. I delivered them, three of my children, and one of the most gratifying experiences of my life was to be involved with that.
Dr. Weitz: Cool. Wow.
Dr. Schwartz: And so from a personal standpoint, my values, my foundational values are linked to a natural approach to health and wellness. And then along the line, I actually went to medical school after I had my first child actually, I started medical school, and went through all the training of internal medicine and then four years of cardiology fellowship and then went into practice and used all the tools, all the training that I had received in becoming a cardiologist.
I found myself talking to patients, after they had been hospitalized with heart attacks or strokes or cardiogenic shock and stabilizing them and getting them out of the hospital, I would find them sitting in front of me in my office. The most important thing that they could have done to prevent winding up in the hospital again had to do with behavior, had to do with lifestyle, reducing stress, stopped smoking, being physically active, eating a healthy diet, etc. And I found patients understood what they needed to do in terms of lifestyle, but a large majority of them found it very challenging to change the lifestyle habits that got them into trouble in the first place. So that’s where I found myself after a number of years of practicing conventional cardiology, frustrated that I wasn’t able to effectively help those patients, a significant proportion of them, make those behavioral changes that would have the most significant impact on their health and outcomes.
Dr. Weitz: So why do patients get heart disease? And by heart disease, let’s start by focusing in on coronary artery disease, which is a process where the arteries that supply our heart get clogged and end up eventually possibly causing a heart attack or might require bypass surgery or stents.
Dr. Schwartz: Yeah. So I think a lot of it goes back to lifestyle factors. So if you’re not exercising, you’re going to be at higher risk, if you’re eating unhealthy foods, particularly refined carbohydrates and foods that are high in saturated fats. And if you’re under chronic stress, you’re going to be a setup for cardiovascular disease. And of course, genetics always plays a role as well. So I think the lifestyle behaviors, I should include tobacco use as well, will set you up for developing cardiovascular disease.
Dr. Weitz: We probably should put in fentanyl use and some of the other drugs that are common these days too.
Dr. Schwartz: Sure. Those toxins, pollution and other toxins as well. And so these various stressors on the body, they trigger defensive mechanisms in the body. They trigger the immune system, they trigger inflammation, oxidative stress. And then the combination of high fat levels in the bloodstream and inflammation and oxidative stress leads to the lining of the blood vessels becoming damaged, causing what we call endothelial dysfunction, allowing the inflammatory cells that are in the bloodstream to enter the blood vessel wall along with the fat cells. The inflammation triggers cytokines, which causes oxidized fats within the blood vessel wall and hence, you get buildup of plaque. This plaque, it grows over time with these incitements that people to a large extent bring upon themselves. And then eventually, that plaque can either obstruct the blood vessel, obstruct flow in the blood vessel or that plaque can actually rupture and then cause a clot to form on top of the ruptured plaque and stop blood flow to the heart, and that’s what we call a heart attack.
Dr. Weitz: Right. And a lot of people might be thinking to themselves, what a faulty system. Why would the body want to build up this plaque in the arteries that could end up ending our lives? And the thing you have to understand, as you were just describing, it’s because there’s inflammation, oxidation in the artery wall, and in a sense, the body is laying down that cholesterol as a protection against that inflammation and oxidative stress.
Dr. Schwartz: Yeah, it’s a protective mechanism that has gone awry in the body. Similar to what happened, we all witnessed, with COVID with people getting infected by this toxic agent, and then the body responding to it to defend against the virus and overdoing it and a cytokine storm occurring and then damaging the body. And also, COVID, in large respects, is thought to be a disease of the endothelium, causing inflammation of the endothelium. That’s why people had issues with heart attacks, with heart failure, myocarditis, clots.
Dr. Weitz: Blood blotting. Yeah.
Dr. Schwartz: So it’s similar to that, the same mechanisms. With COVID, it happened in a flash really quickly, overwhelmed the immune system of the body. But in heart disease, it’s more of an insidious, chronic process that builds over time. That happens silently when we’re living our lives and eating, perhaps doing things that are not best for our health and wellness.
Dr. Weitz: And I’ve even seen a few studies using some of those seaweed extracts included in some of the products, nutritional products on the market that are known to potentially improve the health of the endothelium as helping to prevent death in patients with severe COVID.
Dr. Schwartz: Yeah, yeah. There has been studies looking at different nutritional supplements that have products from seaweed, one being rhamnan sulfate, another one being fucoidan, substances that are thought to … or studies showing that they help to bring back to health the endo calyx, a gel-like layer that lines actually all mammalian cells, but in particular when we’re talking about vascular disease, the blood vessels that line our blood vessels, so the endo calyx is a layer on top of the endothelial cells that line our blood vessels.
Dr. Weitz: Now, as you’ve been explaining some of the mechanisms by which atherosclerosis develops, it paints a more complicated picture, and obviously atherosclerosis is not caused by a deficiency in Lipitor. So therefore, what do we know about things we can do to prevent and maybe even reverse this process?
Dr. Schwartz: Yeah. So lipids are definitely, in my viewpoint, a part of the picture, but other parts of the picture is this inflammation, as well as the platelet activation, which occurs with inflammation and makes the blood more predisposed to clot. So how do we prevent it? So the best knowledge we have on that is to lowering, particularly people who are at risk, lowering the cholesterol is helpful, lowering the bad cholesterol is helpful.
Dr. Weitz: Well, actually, which measures of cholesterol do you think are most important to measure? There’s been a lot of discussion whether it’s best to … Conventional cardiologists typically just look at LDL, but a lot of people are talking more about looking at ApoB. I know we’ve measured LDL particle number and LDL particle size. What do you think is the best measurement to assess this?
Dr. Schwartz: Yeah, so I think in terms of the …
Dr. Weitz: This gets into the lab testing. Yeah.
Dr. Schwartz: Yes. So LDL has been considered the bad cholesterol, but there’s other players as well, in addition to LDL. And so the ApoB takes into account the LDL plus the other atherogenic lipids, so that gives you a more precise measurement. When one measures the LDL, it measures the mass of the LDL in a particular quantity of blood. But knowing the particle number is even more precise, knowing the actual numbers of LDL. And then the size on top of that provides additional information because you want the size of the LDL to be large, so-called large and fluffy rather than small.
And the way I usually educate patients with regard to that is we know that fat likes to … When there’s too much fat in the body, it needs to find a place to store itself. We could notice that in people who develop big bellies where fat stores itself in the subcutaneous tissue and in the visceral abdominal fat, but also stores itself inside blood vessels. And the smaller, the more particles you have, the more LDL particles you have and the smaller they are, the more easily they’re able to get inside the blood vessel wall and find a place of storage there.
So all those measurements are important. We shouldn’t forget the issue of the particle known as LP little A, which is a specialized LDL, and that has some additional risk to it than just LDL in terms of causing the blood to clot to a greater degree. The importance of knowing that number, and it’s thought that that is something that should be measured at least once to see if you have that genetic predisposition to elevated LP little A because even if your cholesterol profile looks beautiful, it’s entirely normal, it looks low risk, an elevation of LP little A is an independent risk factor for vascular disease.
But Ben, I think it’s also important that in this whole picture of preventing coronary artery disease that we’re able to identify its presence before it becomes a problem. And I think what’s really … I’ve been finding exciting is this availability of this new imaging modality that’s become available. I think it’s very likely going to be a game changer in terms of preventing and treating cardiovascular disease.
Dr. Weitz: You’re talking about the CT angiograms with the artificial intelligence?
Dr. Schwartz: Yeah. Yeah. I started …
Dr. Weitz: Here we go with artificial intelligence. It’s revolutionizing our world.
Dr. Schwartz: Yes. I guess we try our best to gather and master as much information as we can as humans, but our brains are, at least my brain is limited, and certainly having the help of artificial machine learning type of intelligence-
Dr. Weitz: Robots will help save us before they kill us all.
Dr. Schwartz: Hopefully. Hopefully.
Dr. Weitz: Okay. So let’s talk about the CT angiogram. So prior to that, probably the best measurement is a coronary calcium scan, correct?
Dr. Schwartz: Yes and no. Yes. Before that, I would agree. Well, we thought that … The thinking had been the higher a calcium score is, the more at risk you are. The more calcium you have in your arteries, the more at risk. And so that turned out to not necessarily be accurate based upon more superior imaging. We actually have found, studies have found, that having more calcium in your arteries is actually protective than having less. Especially if you have plaque, it’s more protective rather than less protective. So that’s the power of this new imaging, which characterizes the plaque, which is able to measure the density of the plaque, and the various densities of the plaque correlate with the risk of the plaque, the risk of having events. And you actually want to have, if you have plaque, you want it to be calcified. That means that it’s old plaque. It’s healed. It’s not going to cause any problems in terms of rupturing and causing a heart attack. So I think having this information is very powerful than merely having a calcium score.
Dr. Weitz: Yeah. I think to make this a little clearer to everybody. All things considered, it’s better not to have any plaque in your arteries. If you are going to have some plaque, you want the least amount possible. And then it’s better if the plaque is calcified because then it’s more stable. If there’s soft plaque, noncalcified plaque, then that’s the kind of plaque that’s more likely to, say, rupture and create a heart attack or a stroke.
Dr. Schwartz: Right. Noncalcified and also … So this imaging technology breaks down the plaque and into three different categories based on its density. So in the middle is the noncalcified plaque, and then after that is the calcified plaque that’s more dense, and on the other side of the noncalcified plaque is the low-density plaque, and it’s the low-density plaque that is the plaque that is inflammatory, has a necrotic core in it and has a very thin fibrous cap, and those are the most high-risk plaques. And so you do this imaging study, and depending on what it shows, you are able to more precisely personalize the therapy for the patient in front of you.
Dr. Weitz: Maybe you could give us an example from your practice of a recent patient who had a significant amount of plaque and then what kind of a program did you put them on?
Dr. Schwartz: Yeah. So a patient that comes to mind is this 72-year-old female who came to me a few years ago, and she had concerns. She didn’t have any manifestation of cardiovascular disease but she was concerned about it, had some risk factors, some weight issues, high cholesterol, etc. And so we did a CTA on her actually with a calcium score, and so she had a significant score, around 150 in terms of the calcium score, and she had some stenosis, non-obstructive stenosis in her proximal left anterior descending artery.
She was one of these patients who absolutely did not want to go anywhere near a statin. She believed very strongly in natural medicine approaches and didn’t want to take a statin. And probably someone who sees a lot of different doctors, and every doctor who she had seen had told her she needs to be on a statin, she needs to be on a statin, needs to be on a statin. But she just felt that it wasn’t aligned with her own values and preferences, and so she avoided that. So I used a variety of different supplements with her.
Dr. Weitz: What were some of the highlights of which supplements you used?
Dr. Schwartz: Yeah. So with her, the ones that were emphasized were berberine. She also didn’t want to be on red yeast rice because it had some similar features to a statin, so she didn’t want to be on that. That’s my usual go-to for patients who don’t want to be on a statin and want to use something natural as red yeast rice, but she didn’t want to use that because it has similar effects to statin.
Dr. Weitz: Yeah. I found so far of the natural supplements, that’s the one that potentially moves the needle the most on the LDL particle number.
Dr. Schwartz: Yeah, that’s been my experience as well. It’s one of the more potent nutraceuticals. So what we used with her is berberine and bergamot and plant sterols were the initial ones. She still needed some additional help and so-
Dr. Weitz: What was the dosage of the berberine? Do you know? What kinds of dosages are you typically using?
Dr. Schwartz: Yeah, typically around 500 twice a day.
Dr. Weitz: Okay.
Dr. Schwartz: Yeah. And then the bergamot is also similar. I always have to look these dosages out.
Dr. Weitz: That’s okay.
Dr. Schwartz: I’m pretty impressed with the bergamot as a nutraceutical. There was a study that stands out for me where they took a group of patients and treated one group with Crestor or rosuvastatin, which is a potent statin, of 20 milligrams a day. And the other group they treated with 10 milligrams of rosuvastatin, half the dosage, plus bergamot. And as far as the biomarkers, as far as the lipids, they had comparable effects, but the combination therapy was more beneficial on other metabolic markers of inflammation and blood sugar issues. It’s part of my toolbox, is using bergamot. And then I think with her also, we added a nutraceutical called Amla, which has pretty good data in terms of lowering cholesterol.
Dr. Weitz: Okay.
Dr. Schwartz: So getting back to the patient.
Dr. Weitz: Yeah.
Dr. Schwartz: When I became aware of the clearly analysis, and she was actually the first patient that I used it on, she agreed to have her CTA that was done two years prior analyzed. You can do that. All you need is if someone’s had a CT angiogram in the past, you could take that data and put it through the software analysis to get this plaque characterization assessment. And so we did it with her. And it turned out that at that point in time, two years prior, she had very low plaque burden, no significant stenosis, and the plaque that she had was predominantly calcified. 70% of her plaque was calcified, and she had no low density plaque. So what we saw on her is what you would want to see if you treated a patient with a statin.
Dr. Weitz: Oh. Could you give us a percentage of the change, just to quantify it?
Dr. Schwartz: Yeah. Well, this scan was done even before she started to … She was already doing a good job even before we started on the nutraceuticals to lower her cholesterol.
Dr. Weitz: Oh, okay. Okay. So that was the scan from before. Okay.
Dr. Schwartz: Yeah. So the things that she was doing from an integrative standpoint, lowering inflammation, antioxidants, nutritional issues, she had done a good job already. So what would be interesting to see is what would all this effort with the nutraceuticals to lower-
Dr. Weitz: Yeah. To repeat that CT angiogram now. Yeah.
Dr. Schwartz: And see if it’s improved even further.
Dr. Weitz: What dietary factors do you find most important, do you emphasize with patients?
Dr. Schwartz: Yeah. So I’m driven by the data, the studies that show that a Mediterranean type of diet is the one with the most robust data in terms of cardiovascular outcomes. There is also data with the CTA and clearly analysis with diet, with the Mediterranean DASH diet, and that actually was effective in lowering the plaque burden in the coronary arteries. So there’s a few things that have been shown to do that in clinical trials.
Dr. Weitz: What do you think are some of the factors in the Mediterranean diet that probably account for this improvement?
Dr. Schwartz: I think it’s the antiinflammatory effects of the diet. And when studies have been done to try to pierce out what are the main factors in it, what’s come out is that the oils and the nuts seem to be-
Dr. Weitz: So the extra virgin olive oil?
Dr. Schwartz: Correct. Correct. Yeah. Yeah. I think it’s very useful for the inflammation, reducing inflammation, and the omega-3s that are part of it are probably very important as well. It’s been shown that omega-3 fatty acids also had been shown to reduce the plaque burden.
Dr. Weitz: Right. What do you think about the red wine, because that’s been a controversy for many years? We used to refer to this as the French paradox. Why do the French eat all this butter and high fat food and yet they have lower heart disease? Maybe it’s the red wine. There’s been some hint in the literature that red wine maybe raises HDL. Now more of the experts seem to be leaning against the benefits of red wine. What do you think on the whole? Is red wine a slight positive for heart health, negative, neutral? Where do you think we are with that?
Dr. Schwartz: Yeah, I’ve been following that peripherally for the years that it’s been out there. The most recent data doesn’t really point toward you’re going to have a significant impact on your cardiovascular disease outcome. Perhaps the resveratrol in the red wine might be a positive factor, but perhaps the other negative factors that alcohol has on your system is lessening that effect. But overall, it hasn’t panned out to be the therapeutic factor that it thought it might have been.
Dr. Weitz: So what do you tell patients, should they drink? If a patient says, “Hey, I want to lower my risk of heart disease as much as possible and I enjoy drinking red wine.” Let’s say it’s a male and they enjoy drinking red wine, one or two glasses, couple of days, say three days a week. Would you tell them no? Would you tell them it’s probably okay? Would you tell them yes? What would you say?
Dr. Schwartz: Yeah. I wouldn’t tell them not to if they enjoy it, if they get some benefit out of it. But more importantly, I would tell them to listen to their body and pay attention to what they’re experiencing in their body. And if they find themselves the next day after they have that glass or two of red wine, that they have a good energy level and they’re able to function as well as they could, then that’s good. If on the other hand, they listen to their body and their body is found to be more sluggish and less energy the following day, less thinking, that could be an effect of the wine on their system. That’s what I would tell them more than anything, is to listen to their body. And if it’s having any adverse effect that they might want to lessen the amount. I’m finding more and more people these days are drinking less for whatever that’s worth. It used to be more of more, just in my own circle, social circles, I hear people are drinking less than they had been.
Dr. Weitz: I don’t know statistically if that’s actually true because I think during the pandemic, we saw an increase in alcohol consumption. I think there was a collective increase in liver enzymes as well.
Dr. Schwartz: Yeah, yeah. I certainly heard and read that as well. Yeah.
Dr. Weitz: So we’ve been talking about the coronary arteries, and these are the arteries that supply the heart, which is typically what we think of as causing a heart attack. These are the large vessels, what we might call macrovascular disease, but the smaller blood vessels can be problematic as well. So maybe you can talk about microvascular disease.
Dr. Schwartz: Sure, sure. So one not uncommon scenario that every cardiologist has experience in their career is they have a patient that comes to them and they describe chest pain, chest heaviness when they exert themselves with throat tightness and goes down their arm and then they rest and then it subsides. So they present themselves with symptoms of typical angina. And so you’re almost certain that I’m going to take them to the cath lab and I’m going to see something. I’m going to see some obstructive coronary artery disease. And those are the patients, by the way, that when you see them as a cardiologist, if they’re at very high risk, very high probability of having obstructive coronary artery disease based on their presentation, you go right to an angiogram rather than doing a stress test, for instance, or even a CTA imaging study.
Dr. Weitz: And a stress test for those who don’t know is when you put the person on a treadmill and do an EKG at the same time.
Dr. Schwartz: Correct, correct. And if you think that there’s a very high probability that they’re having obstructive coronary artery disease, unstable, is particularly unstable obstructive coronary artery disease, you don’t want to put them on a treadmill because that could precipitate a heart attack. So you take them to the cath lab, a patient with a high probability of obstructive coronary artery disease, and you do the angiogram and they have no obstruction at all. Their blood vessels are wide open, but they still have these typical symptoms. And so that’s just one class of patients that have problems at the microvascular level. They’re having reduced blood supply to the heart, not because of the large blood vessels, but because of microvascular dysfunction of the smaller blood vessels that you are not able to see on an ordinary angiogram.
Dr. Weitz: And I understand this is more common in women, isn’t that correct?
Dr. Schwartz: Yeah. Yeah, it does seem to be more common in women. That’s just one of the entities where you find the problem of microvascular dysfunction. It can also be a cause of diastolic heart failure, which is when the pump function of the heart is normal but the heart is very stiff and the pressure within the heart goes up and one develops heart failure based on stiffness of the heart muscle. Microvascular dysfunction is found to be very prominent in those patients as well. And other cardiomyopathies, there’s a cardiomyopathy that’s known as takotsubo cardiomyopathy, which is known as the broken heart syndrome. Microvascular dysfunction is thought to be a very big player in that entity as well.
Dr. Weitz: So how do we assess microvascular pathology and what can we do about it?
Dr. Schwartz: Yeah. So there’s invasive means of doing it in the cath lab, and then there’s noninvasive means of assessing for that.
Dr. Weitz: Well, if you do something invasive, how do you even know where to look?
Dr. Schwartz: Yeah. So it’s a physiological challenge. The doctor in the cath lab puts a probe, a doppler probe within the coronary artery, and then gives a provocative agent that dilates the micro vasculature, and the doppler wire is able to measure the flow. So if the flow goes up with the provocative agent, you have normal microvascular. If the flow does not go up with the provocative agent, you have microvascular disease. So that’s in the cath lab. If your cardiologist is really very meticulous and he does the angiogram and finds no obstruction, but he would go ahead and do this provocative testing. So that’s one way.
The other way, which is considered the state of the art in terms of noninvasive testing would be with a PET scan and with provocative testing again to measure. So the PET scan is able to measure blood flow to the heart, global blood flow to the heart muscle. And so you do the imaging at rest, and then you give a provocative agent, and then you’re able to tease out whether there’s microvascular dysfunction, but I would say the PET scan is the gold standard for assessing coronary microvascular dysfunction.
And then that brings us back to if we’re not going to do imaging of the heart, can we do assessments of the other blood vessels in the heart? You can measure endothelial function in other blood vessels of the heart, and that can correlate with what’s going on in the heart because when there’s microvascular dysfunction, it’s not just isolated to one part of the body, it’s more of a systemic issue. And by the way, the thinking is it’s the same triggers that trigger what we were talking about at the beginning, the inflammation and the oxidative stress that caused the blockages in the big blood vessels. That’s also the main reason why people have microvascular dysfunction, is because of the same-
Dr. Weitz: So is the treatment the same as for the larger vessels or is it different?
Dr. Schwartz: It would be very … I would say it’s different in some ways, but-
Dr. Weitz: Well, let’s talk about it. Give us an … Yeah. Sorry.
Dr. Schwartz: As far as the things that trigger the oxidative stress and inflammation, that would be the same kinds of therapy for both. But for instance, you might not … Whereas if you’re going to use a beta blocker in coronary artery disease, large blood vessel blockages, you wouldn’t use that in microvascular disease. But as far as things that are going to positively impact the inflammatory mediators in the body, that would be the same for both types of vascular disease.
Dr. Weitz: Wait. What sorts of things do you do to reduce inflammatory mediators?
Dr. Schwartz: Yeah. Well, there’s a number of substances that come to mind.
Dr. Weitz: We got fish oil, of course, is one thing.
Dr. Schwartz: That work on different areas of the immune system. So you bring up fish oil, and there’s an understanding of non-resolving inflammation in the body as being a significant contributor to vascular disease. So even in patients who are treated with the best medicine has to offer in terms of pharmaceuticals, they still have residual risk. Patients who have heart disease are treated with statins, but they still have events. A large number of them, they’re called the forgotten majority. So then we have this concept of residual risk. We’re addressing everything we can with the best medicine has to offer but there’s still residual risk. And so non-resolving inflammation is thought to be a major contributor to that, and that’s where it’s found that the fatty acids are important mediators in helping to reduce that non-resolving inflammation.
Dr. Weitz: And then we have these SPMs specifically to resolve the inflammation. Do you make use of those?
Dr. Schwartz: Yeah, yeah. Well, that’s where the EPA and the DPA and even arachidonic acid, which gets complicated because a arachidonic acid is considered an inflammatory mediator but it also has some inflammatory benefits also. It works on a particular pathway in the specialized pro-resolving mediators.
Dr. Weitz: Okay. What other strategies can you employ?
Dr. Schwartz: Yeah. So there’s the whole issue of the inflammasome in the body, and supplements that come to mind that are helpful for that would be resveratrol, nicotinic, NAD, is important to impact that pathway, quercetin, curcumin, baicalin, which is helpful for lowering interleukin-6 levels. There’s a whole toolbox on what to use.
And one of the things … See, so as an integrative cardiologist, I’m really focused on getting at the root causes. And so I really focus on trying to understand the immune system and what’s happening in a given patient that gives me clues in terms of what part of their immune system is being triggered. Do they not have sufficient amount of Th1 cells? Is there Th2 cells being too triggered? Are they having issues with their Th17 cells? So one of the things … I always had an interest in inflammation and immunology, but I think over the last several years, I’ve been digging into understanding functional immunology on a deeper level. So the assessments I do give a picture of what particular factors in the immune system need support or over activated, and then I try to-
Dr. Weitz: What does your assessment consist of?
Dr. Schwartz: Yeah. So one thing I look at is the viral reactivation in the body.
Dr. Weitz: Okay.
Dr. Schwartz: And so there’s a number. Looking at certain IgG levels which are elevated if you had past infection to a virus but it’s thought that if it’s five times or greater than the positive rate for that antibody, that you likely have issues with viral activation. And so I’ve been finding that to be the case. And another I look at-
Dr. Weitz: Is there a particular panel you like to run from a certain lab?
Dr. Schwartz: Actually for that, I use an ordinary Quest or Labcorp.
Dr. Weitz: Do you look at viruses like Epstein-Barr and HSV?
Dr. Schwartz: Yes, yes, it includes all those viruses.
Dr. Weitz: CMV.
Dr. Schwartz: And see a lot. I’ve been seeing a fair amount of EBV virus reactivation issues. So that’s one thing. And I’m finding that there’s a cytokine called transforming growth factor beta one, which I think is really, really very helpful to look at. It’s a cytokine that’s activated and when the levels are too high, it triggers fibrosis in the body, so it causes living functional cells in the body to become fibrotic and nonfunctional. And that could lead to issues such as arrhythmias or kidney disease or liver disease, or you name it. When you have significant fibrotic changes happening in the heart, in the body, it causes a whole host of problems. So you could actually measure those levels. And those levels are triggered by ongoing inflammation in the body.
There’s a particular cell in the body called the myeloid-derived suppressor cell that pours out a lot of this TGF-beta. And so if you have high levels of this TGF-beta one, you know that the immune system is being activated is responding to some pathogen or trigger. It just gives you a picture of what’s going on.
Dr. Weitz: I know that’s one of the markers that Ritchie Shoemaker recommends as part of his panel for looking at chronic inflammatory response syndrome.
Dr. Schwartz: Yeah. Certainly mycotoxins would trigger that. Any kind of toxins triggers these myeloid derived suppressor cells. And when they’re triggered, the body pours out a lot of TGF-beta. And one of the most useful things for that is using antioxidants such as glutathione to bring that down. And that’s another measurement that I do, glutathione levels, to see, but I use both blood levels as well as intracellular levels of glutathione to see how much I could push the glutathione in terms of helping to bring down the TGF-beta.
Dr. Weitz: And then you use IV or liposomal glutathione?
Dr. Schwartz: Yeah. So I mainly use liposomal glutathione. And if there’s cases where it’s not working properly, I would consider the intravenous glutathione. And also ensuring that the precursors, glutathione is made up of three different amino acids, glutamine, glycine and cysteine, and so you want to make sure that the patient has a sufficient amount of those precursors to glutathione. And there’s also a fair amount of nutritional things, foods that are high in glutathione, and I do emphasize those as well if patients are having issues with oxidative stress and reduced glutathione.
Dr. Weitz: All right, great. Anything else we want to say to wrap up this discussion about the microvascular disease and then we’ll wrap up our discussion as well?
Dr. Schwartz: I think we covered a lot of ground. I think just that it’s an exciting time in cardiovascular disease prevention. We’re becoming more precise in identifying people who might have issues and being able to pick things up earlier and have a better, more precise estimate of risk and know how to personalize and precisely treat the individual patient that presents to us.
Dr. Weitz: Super. Excellent. Any final thoughts you want to leave us? I guess that’s a good final thought, is now that we’re entering this age of personalized, individualized nutrition, instead of you walk in, you have high cholesterol, take a statin, end of story. Let’s get to the root cause. Let’s understand what’s happening in the body and let’s try to reverse the process.
Dr. Schwartz: Yeah. More personalized, more precise. And like that patient I presented, she didn’t need to be on a statin. She had the outcome that you hope a statin would provide. So by doing that, we can work comfortably and confidently make recommendations.
Dr. Weitz: Great. So how can listeners and viewers find out more about you and get ahold of you if they like to come see you?
Dr. Schwartz: Yeah, so my website is integrativecardiology.com. You can go on to my website and shoot me an email, call my office, and I’d be happy to speak to anyone and give them my best advice and counsel.
Dr. Weitz: Excellent. Thank you. Thank you so much, Dr. Schwartz.
Dr. Schwartz: You’re very welcome. It was a great discussion today. I really appreciate the opportunity.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. That way, more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. That usually means we’re going to do some more detailed lab works, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at (310) 395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
