Integrative Cardiology with Dr. Howard Elkin: Rational Wellness Podcast 334

Dr. Howard Elkin discusses an Integrative Approach to Cardiology at the Functional Medicine Discussion Group meeting on October 26, 2023 with moderator Dr. Ben Weitz.  

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Podcast Highlights


Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and in Santa Monica, California and he has been in practice since 1986.  While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle changes, and targeted nutritional supplements to improve their condition.  Dr. Elkin has written an excellent new book, From Both Sides of the Table: When Doctor Becomes Patient.  His website is Heartwise.com and his office number is 562-945-3753.

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. To learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.  Welcome to our first live functional medicine discussion group since before COVID. So thank you so much for joining us. Also, this event will be recorded, and it’ll be included in my weekly Rational Wellness Podcast, which you can listen to on Apple Podcasts, Spotify or YouTube. Let’s see what else. We usually meet on the fourth Thursday of the month. Next month, we’re going to meet on the third Thursday because the fourth Thursday is Thanksgiving, so that’ll be the 16th. We have Dr. Akash Bajaj is going to be speaking about regenerative medicine and stem cells and PRP, et cetera.

                                We’re going to take December off. And then January 25th, we have Dr. Vojdani. And then we’ll go from there. We are being sponsored tonight by Integrative Therapeutics. Steve, would you like to come up and say something about Integrative?

Steve:                   I don’t want to come up there, but …

Dr. Weitz:            Okay. Well, I’m going to bring the microphone to Steve.

Steve:                  I don’t think you need the microphone, do you?

Speaker 3:           No, we can hear you.

Steve:                   So thanks for coming, everybody. It’s weird to be live again. Thanks for filling up the room.

Dr. Weitz:            Can you speak on the microphone?

Dr. Elkin:              Yeah, it is hard to hear.

Dr. Weitz:            [inaudible 00:01:54] up by the recording.

Steve:                   Oh, I’m sorry. Is that okay?

Speaker 3:           Yeah.

Steve:                   We have some samples of some products back here that we do a lot with the cardiologists that we work with. You probably know most of them. The big one is Cortisol Manager for stress. Stress relief is a big part of all this cardiovascular stuff, so the Cortisol Manager. Allergy relief capsules are back there. That’s a nighttime reduction cortisol so you can sleep better. There’s also HPA Adapt, which is our daytime cortisol stress management product.

                                We also have Curalieve, which is our brand-new curcumin technology. This stuff is going to blow you away. It’s way better than our own curcumin, which has been the number one seller at Fullscript for the last eight years. So take samples of everything. There’s also some little bottles of Neurologix, which is our new cognitive improvement product. Those are seven-day trial bottles. Take two, because two weeks you’ll really notice the difference. It’s spearmint extract, citicoline, and saffron. Within two weeks, you’ll get anybody noticing an improvement. So knock yourself out. Have fun.

Dr. Weitz:            Thank you so much, Steve. Tonight, we have Dr. Howard Elkin, integrative cardiologist, and he’s going to help enlighten us about how to manage patients with cardiovascular risk factors. So, Howard, you have the floor.

Dr. Elkin:              Thank you. All right. It’s great to be back here after, what, over three years? I don’t know about you guys. I got really Zoomed out off of all these months of Zoom calls. Anyway, it’s good to be back. So I’m going to talk about heart disease and why are we still dealing with the numbers? Well, let me show you. It’s still the leading cause of death. I don’t care what anyone says, but more than COVID, more than cancer, more than all the cancers combined.  The biggest cause of death in this country is still heart disease, no matter how you slice it, and it affects women and men basically equally and crosses over all ethnic groups. It’s remained the leading cause. We have about close to 700,000 people dying every year of heart disease in the United States. That’s one out of five deaths. One person dies every 33 seconds. That always just amazes me when I hear that. Every 33 seconds someone is dying of heart disease.  Between 2018 and ’19, look at the cost. I mean the direct cost, 407.3 billion, 251 billion in direct costs and 155.9 billion in lost productivity, people that are out of work because of heart disease. More statistics. In 2020, coronary artery disease, the leading cause of cardiac death, which, of course, makes sense. Stroke, 17.3%. Hypertension followed by heart failure and then diseases of the arteries including peripheral artery disease and [inaudible 00:05:01] circulation.

                                Coronary artery disease is the most common type of heart disease, killing about 376,000 people in 2021. Two out of 10 deaths occur in CAD people less than 65. It’s not an old person’s disease. I’ve had many patients in the course of 36 years that had heart attack, bypass in their 30s and 40s. So it’s not just about elderly people. 805,000 people have heart attacks in this country every year, 605,000 with their first heart attack and about 200,000 of those with previous heart attacks.  This tends to be a progressive disorder. It’s like cancer. It does not get better with age. I can promise you that. This is important to know. 40% of the heart attacks are silent. So as opposed to Kaiser and a lot of HMOs that really don’t deal with preventative medicine, I am very scrupulous about my patients and coronary disease. They’re automatically high risk. I study them scrupulously because of the fact that the silent heart attacks are so common, 45%. It was about 25% when I was a student. So it’s increased incrementally since 1980.

                                What about women? Well, over 60 million women, 44% in the United States are living with some form of heart disease, and it’s the leading cause of death in women more than all cancers combined, more than all cancers combined. Now, about 250,000 women die every year of heart disease. About 42,000 die of breast cancer, yet breast cancer gets so much awareness when it comes to women and mortality. Over 310,000, almost 311,000, so pretty equal with men if you look at the big picture. But again, cancer, 42,000.  Now this is important and I didn’t know this until recently, but 56% of women, only 56% recognize that heart disease is the number one killer. Nearly half of the population of women do not really feel that heart disease is their main problem, their main villain, and it is. [inaudible 00:07:19]-

Dr. Weitz:            What do they think is the main killer? Is it breast cancer? Is that what they’re most fearful of?

Dr. Elkin:              Breast cancer always takes the lead because it’s so ominous sounding. I don’t know. It’s always been this way as long as I can remember, but the death rate is quite disparate. Now, so we talk about risk factors like the primary players. These are risk factors that have been unequivocally been shown to be a risk factor of heart disease, unequivocally. So I always mention hypertension first because I think it’s the most important risk factor of all. And then we have smoking, hyperlipidemia, diabetes, physical inactivity or lack of exercise, and obesity.  We’re going to break these down now. So those are the six primary players that I think any cardiologist or any in the health field would recognize as being unequivocally shown to be a causation of heart disease. Now, hypertension, my favorite, it remains the number one primary player when it comes to heart disease, and the reason why … It’s not just heart disease. It’s also stroke, kidney failure, and dementia. Now it’s been shown that people in midlife that have hypertension, they really have a higher incidence of dementia. So it’s not just about the heart. It’s the brain, too.

                                The reason why I’m so big on hypertension is that the big thing now is endothelial function or endothelial dysfunction. You all heard of that. That’s really the beginning of it. I think most doctors don’t really deal with endothelial. They just deal with numbers, blood pressure, cholesterol. We’ll talk more about that in a minute. But that’s the number one thing that hypertension does. It causes endothelial dysfunction, which will set the stage for inflammation and coronary disease.  About half of the adults in this country have hypertension. That’s a phenomenal number, so about 47%. Most are clueless, meaning they don’t know or they’re undertreated. Part of the undertreatment of the patients are the doctors, they’re not that strict about it. I have patients come to me that their blood pressure’s like 148, 150 over 85. It’s not normal. I don’t care how you slice it, it’s not normal.  If you want to have a nice long life, you really need to know your blood pressure. People need to know their numbers. It’s usually called the silent killer because you don’t have to have any symptoms whatsoever. So most patients don’t know they have it, and it’s undertreated because a lot of people don’t want to take medications. A lot of doctors say, “Oh, your blood pressure’s okay,” when it’s really not.

Dr. Weitz:            All right. In terms of the numbers, let’s say we have a patient. What exactly is the number where it’s okay to try to change your diet and use some lifestyle changes?

Dr. Elkin:              Great question. Exactly. What are the ideal numbers? I always tell the ideal blood pressure is 120 over 70, whether you’re 30, 40, 50, 60, 90 or 100. Now, does that mean I actually try to get that number? Of course not, because I would have people on three different medicines. They’d have to see me every six weeks. But that still is the ideal number to shoot for.  Now, of course, that’s idealistically speaking. Now, when I was a student years ago, 140 over 90 was considered borderline. 140 over 90 now is considered unequivocally hypertensive. But the newest guidelines that came out in 2017 or maybe ’18 now, is that the blood pressure should be 130 over 80. That’s still considered high normal. So if you’re 131 over 81, you’re hypertensive.  I don’t think it’s some [inaudible 00:11:13] plot to make everybody take more medication. I think we have outcome studies that have shown that numbers higher than that definitely increase your chance of developing heart disease.

Dr. Weitz:            But what’s the number you’re going to insist that they have to take medication?

Dr. Elkin:              Well, okay, good question. First of all, I get to know the patient. If I see someone for the first time, and unless their blood pressure’s like 180 over 110, I’m not going to treat because I don’t really know much about the patient. So I really talk about lifestyle.

Dr. Weitz:            Let’s say they’re 140 over 90 and-

Dr. Elkin:              I don’t rush to treat. I work with lifestyle-

Dr. Weitz:            What’s that?

Dr. Elkin:              I do not rush to treat 140 over 90. It’s hypertensive, and I tell the patient that. But I-

Dr. Weitz:            What about 150 over 100? Is that still okay to use lifestyle? What’s the safer way-

Dr. Elkin:              See, a lot of people come in and when they see a doctor for the first time, especially a cardiologist, even though I think I’m pretty un-intimidating, they’re nervous. What happens? The nurse takes the blood pressure initially. Then I come, and I meet the patient. I talk to them and kibitz around with them. And then I’ll take the blood pressure when I’m doing part of my physical exam, and I creep up on them.  They don’t know I’m going to take the blood pressure and, invariably, I get a lower blood pressure reading than the nurse. But most doctors do not repeat the blood pressure. They just go by what the nurse does.

Dr. Weitz:            Now, for patients at home, do you often recommend the patients monitor their own blood pressure?

Dr. Elkin:              Yeah.

Dr. Weitz:            And if so, what’s the protocol? Do you ask them to take it three times in a row? Once? Twice? Also, how important is it to have your arm at the level of your heart?

Dr. Elkin:              You want to have the arm at the level of the heart.

Dr. Weitz:            But most medical doctors that I’ve been to don’t do that.

Dr. Elkin:              But that’s incorrect. That’s the way it should be done. I get them involved. If the blood pressure isn’t really within a good number, then I will have them monitor it … I want the patients involved. That’s part of being a medical advocate. Know your numbers, and follow your numbers because they’re seeing me but so often. So I really go by what they’re getting.  I usually have them bring their apparatus into the office and let’s check it against ours because some of them, if it’s within 10 points, I’m happy. If it’s 30 points difference, then it’s time to get a new monitor or that monitor is crap.

Dr. Weitz:            Can [inaudible 00:13:31] also be a significant variation throughout the day? Some people’s blood pressure maybe goes up in the morning when you’re more likely to have heart attacks.

Dr. Elkin:              Characteristically, your blood pressure is highest in the morning because that’s when our stress hormones are raging, epinephrine, norepinephrine, and cortisol. So typically speaking, evolutionarily speaking, blood pressure’s going to be higher in the morning. As the day goes by, it will drop usually. Some people have a paradoxical rise in the evening, and I can’t figure out why. It is the way it is.

                                Usually, after exercise, you can check their blood pressure a half hour after exercise, it’s going to be the lowest because exercise actually dilates the vessels. There’s less stress, and the blood pressure comes down. So it is important. When I have patients do their own blood pressure, I say, “Okay, make a chart, AM, PM, post-exercise.” So they get to see themselves what’s happening. So I get the patients involved.

                                I don’t think most doctors do that. They just keep them on the medication. The reason I don’t jump on medication unless it’s really high is because it’s like saying, “We know you can’t do this on your own, so we’re just going to start you off on medication.” That really dis-empowers a patient, which is against the way I like to practice.

Dr. Weitz:            When is it appropriate to measure 24-hour blood pressure?

Dr. Elkin:              24-hour blood pressure is a great thing. I haven’t done it because I haven’t found a company that I can really rely on. Patients don’t really want … They don’t want to be inflating, deflating all throughout the night and so forth. But I think it’s a great idea. I’m not doing it myself because I’ve not found a good support of a company. I had a couple in mind and wasn’t happy. But I think it’s a good way to monitor.  But even if they do their own spot checks, get your patients in the habit of taking their own blood pressure. If you have any question, they bring the apparatus in and you check it against yours. I’ve had pretty good success that way. Getting the patients involved with their own blood pressure is really important.

                                So moving on. Seven out of 10 people with first heart attacks are hypertensive. Eight out of 10 strokes are hypertensive. So they kind of go hand in hand. Now, it may be quiet. Let me see. Blood pressure is quiet. You don’t have to have any symptoms at all. I actually like when people have symptoms because it’s kind of a barometer for me if they have headaches or some patients, “I know when my blood pressure’s up.” I don’t know how they know, but they know. I’m glad because it’s very pervasive, and it kills. It’s a silent killer.

                                I think next is what is blood pressure? So this is really systolic, the first number, that’s when the heart is actually contracting. And then the diastolic or the second number is when the heart is relaxing. So that’s what really we’re measuring. Hypertensive statistics, this is important to keep it relative. It’s a genetic component here, guys. So if one parent has hypertension, you have a 24% chance of having it yourself. If both parents have hypertension, it’s a 50% chance.

                                We don’t live by our genes, but we do have to keep them in mind because a lot of people just do have hypertension and it runs in the family. Even though we still don’t know what causes it after all these years, we do know that it has a genetic tendency. It tends to be highest in the morning. It’s not really curable, but it’s treatable. [inaudible 00:17:14]-

Dr. Weitz:            What are the most important dietary factors related to hypertension?

Dr. Elkin:              Okay. Well, interesting enough, this whole thing about salt has been debated forever. I was going to get into this later, but there’s a new test out there, a new genetic test. It’s by, they’re in the Bay Area, Vibrant. Now they have a Vibrant Wellness Connection. This new test, it’s called Cardiax, C-A-R-D-I-A-X, and it tests for 25 different genes. It’s really interesting. So with this new test and I’m just getting used to it, I’m not that experienced with it because it’s relatively new.  I think it’s about $300 for the … It’s out of pocket. It’s not covered by insurance. But you can learn what diet does this particular patient do well with based on their genome? Same thing with pharmaceuticals. When is a diuretic indicated? When is a beta blocker or a calcium channel blocker? It’s really fascinating. So I think we’re going to hear more about this in the future as to what is the best.

                                As far as diet’s concerned, I don’t think you need a low-salt diet across the board. It depends if you’re a salt retainer. How do you know if you’re a salt retainer? There’s no test for that. But if they start getting puffy, they start seeing an increase in blood pressure, they’re salt-sensitive and they generally need to reduce their salt. It’s more common-

Dr. Weitz:            With a patient with hypertension. Is it worth if they haven’t tried salt restriction, trying salt restriction? And on the other hand, is potassium, magnesium, the other types of ions, is it beneficial to bring those up as you bring the salt down?

Dr. Elkin:              First of all, I use potassium, which helps to lower blood pressure. Magnesium is also very useful. They’re the two things that I use. Also, I use some other supplements we’ll talk about later. But I always go with weight loss is very important. If your patients lose 10% of their current body weight if they’re overweight, and most of them are, then they’ll drop their blood pressure almost across the board. Almost across the board.  Two things I found in maybe my anecdotal experience in 36, 37 years. Number one is weight loss. Another is retiring from your work. It almost always drops.

Dr. Weitz:            One more quick question in terms of hypotension, what is the number that you worry about if the blood pressure is below?

Dr. Elkin:              Good question. When do I worry about hypotension? I don’t worry about it unless the patient’s symptomatic. I mean some patients have blood pressures at 90. My blood pressure’s 100, 104 systolic. My daughters both have low blood pressure. So it really depends. If they’re not symptomatic, if they’re not complaining of dizziness, I don’t really worry about it.  I have a lot of people with heart failure, and these patients tend to have really low blood pressures because they’re on medication. First of all, their pumping function is decreased. Second of all, they’re on medications which can lower their blood pressure. So I have to be especially careful with them. There’s a new device that I’ll be using soon that can actually help with volume status because we don’t really know the volume status.     One of the things I tell people with heart failure is to weigh yourself naked every morning. Just keep a chart. If it waivers between three points, you’re fine. If all of a sudden, you see a blood pressure rise of five points, it’s water. So those are the kind of tricks that I’ve learned to use over the years.

                                Okay, let’s see what’s … Okay. So get this, folks. 22% of population ages 18 to 39 are hypertensive. So we see it in young people. We’re seeing it in teenagers and school-aged kids now. This is really sad. 54% in the middle age, 49 to 59. And then, of course, 74% for age 60 and over. Though it is age-related, it’s higher in the Black population versus Caucasians. That’s a known fact, and they tend to be salt retainers, for sure. Okay, smoking. More than 50% of adults who smoke-

Dr. Weitz:            By the way, if do you recommend salt restriction, what’s the milligrams?

Dr. Elkin:              I rarely do. I rarely do. Unless once I get to know the patient, if I can discover that they are salt-sensitive, then yes.

Dr. Weitz:            What milligrams? Is it 1,500 a day?

Dr. Elkin:              Yeah. I try not to go really low, maybe 1,500 to 2,000. I don’t make a huge deal about salt restriction. Now, if they’re at heart failure, it’s a little different. But if they’re just walking around and they’re doing okay, I don’t worry about it because I follow the trends. I’m really big on that. So again, smoking is still a major risk factor.   Smokers are almost twice likely to die of a fatal heart attack or a stroke when compared to normies, people that don’t smoke.

Speaker 5:           We’re talking about-

Dr. Elkin:              They’re more likely to die from heart disease than lung cancer, believe it or not.

Speaker 5:           When we talk about smoking, nicotine smoking, right? We have to-

Dr. Elkin:              You mean like vaping and stuff?

Speaker 5:           Well, people vape. People smoke weed. So when you say smokers, I always want to know what you’re talking about.

Dr. Elkin:              We’re getting in reports now about smoking weed, marijuana, and there are no strict recommendations at this point. We’re collecting data. It probably isn’t great for you, but I don’t think it mirrors what we see with nicotine at this point.

Speaker 5:           Right. It’s not [inaudible 00:22:45]-

Dr. Elkin:              We may find out more. Now, since there’s a dispensary in every block, we may find out more in five or 10 years because there are some warnings out there.

Dr. Weitz:            And what about vaping?

Dr. Elkin:              Huh?

Dr. Weitz:            Vaping. Vaping. What about vaping?

Dr. Elkin:              Vaping isn’t any better than smoking. That’s the consensus that I’ve heard. Okay. The good news, the body starts to recover within 20 minutes of quitting smoking. That’s 20 minutes. 50% decrease in risk of smoking-related heart attack within a year of stopping. 15 years of being smoke free, the risk of dying is the same as if you never smoked to begin with. So that’s promising news for smokers.  But it’s not an easy thing to kick. It is an addiction, and you have to know a little bit about addiction. You can’t just say, “Just quit.” I mean they have to quit, but it’s not so easy. I used a myriad of different techniques, biofeedback, just different things to help with … But the important thing is to have a close relationship with the patient, you and your staff, because they do need support.

                                I write, “The cholesterol issue,” because I don’t know about you guys, I’m so tired of … I’m pretty active on social media, and I see so much doctor bashing these days and statin bashing these days. I’m inclined to answer these because I hate doctor bashing and all we do is do sick care and we don’t do well care. I beg your pardon? Some of us do both. I’ve been doing it for a long, long time.

Speaker 5:           Not your thing.

Dr. Elkin:              So the controversy, and I want everybody to really be clear about that. I want to be clear about this because I don’t treat … Oh, that’s good.

Dr. Weitz:            Oh, right there in the corner.

Speaker 5:           Yeah, I couldn’t get that right.

Dr. Weitz:            Perfect. Thank you so much.

Speaker 5:           Thank you.

Dr. Weitz:            Thanks.

Dr. Elkin:              So I tell people when they come into my office, “I don’t treat your numbers. I treat your risk.” There’s a difference. Most doctors treat numbers. I had a lady that came to me yesterday. Her cholesterol was barely 200, and her HDL is high and LDL is like 138 or something like that. She’s healthy. She’s in her mid 50s. She exercises. Incredibly, her doctor wanted to put her on a statin because it’s going to get worse as she gets older. That was the excuse he gave her, “So you’ll need it eventually.” That’s such BS.

                                Anyway, so if you’re talking about primary or secondary, you have to know the difference between primary prevention and secondary prevention. I know that Ben and I have talked about this. So if you have had a previous event, let’s say you’ve had a heart attack or a stroke or a stent, I’m one of those, anything like that or if you have carotid artery disease or peripheral artery disease, which is the same basic process, just different locations, then it is important.

                                We have plenty of outcome studies with people that have had previous events since the ’90s. The 4S study was the biggest one that I remember quite well. So it’s still unequivocal in my mind. These patients do better on statins as at least part of the therapy. It doesn’t mean we ignore diet and exercise and lifestyle, but we need to get their cholesterol much lower than a person who doesn’t have a history. So that, to me, is a controversy.

                                When I see people on Instagram saying, “Well, there’s no room for statins,” it’s just hogwash. Yes?

Speaker 6:           How about people with diabetes? Do you automatically [inaudible 00:26:12]-

Dr. Elkin:              Yes. Now, diabetes is another high-risk group. Why? Because 70% of diabetics will have a heart attack or a stroke in their lifetime. So I do treat them as high risk. I treat them as if they have heart disease, even if they’ve never had any clinical event or anything like that. Good question.  Okay. Now HDL is the healthy cholesterol, and LDL is the lousy cholesterol. That’s kind of how I name it. It’s not quite that easy or simple. Now, if you’re low to moderate risk, so here’s the basic goals. 220 for total cholesterol, less than 220. LDL less than 130, HDL greater than 40 in men and 50 in women. That’s the average population that is considered low risk. I think most people would agree to that. I would not put these people on statins at all, but I would follow them carefully and work on lifestyle. Now-

Dr. Weitz:            Howard, do you think that there’s a number for some of these things like LDL, whether you use LDL-C or LDL-P or whatever, below which there’s no way you’re going to get any atherosclerosis? Is there a way to-

Dr. Elkin:              Okay. This is also-

Dr. Weitz:            Also, in the context, we’ve had discussions about Peter Attia who’s recommending an LDL of 30 and using whatever medication-

Dr. Elkin:              Not just him. Let’s say Steven Nissen, for example. He’s with the Cleveland Clinic, very well-known cardiologist, very conservative. His feeling is that keep the cholesterol as low as you can. 20, 30 is fine. We have outcome studies, those outcome studies for people that are on statins for two or three years. Now, people who are on statin for 20, 30 years, I don’t know about you guys, but I don’t want a good heart with a bad brain and I really worry about that because the brain needs LDL cholesterol.

                                Cholesterol doesn’t just float around in your bloodstream. It needs to be attached to a protein called lipoproteins. So if you didn’t have LDL, you wouldn’t have blood going to the brain. You wouldn’t be able to make new neurons, neuroplasticity, and also myelin sheaths. They’re all dependent on cholesterol. So it’s getting [inaudible 00:28:23] to the brain. That’s a function of LDL.

Dr. Weitz:            The argument that Peter Attia makes is he says all the cholesterol that the brain needs is made in the brain.

Dr. Elkin:              That is not universally accepted. I don’t accept it. It’s got to be really clear cut. Peter Attia is very smart. I’ll say a lot of good things about him, but a lot of it is also his opinion and not always based on what other cardiologists think. He’s not a cardiologist, but he’s very bright, and I’ll give him credit for that. So I’m moderate.   Now, let’s look at the high risk group. So who’s high risk? Confirmed coronary disease, previous heart attack, balloon angioplasty stent, bypass graft surgery, coronary artery calcium scan. Let’s look at the scans. The ideal score is zero. The only time in your life you want a zero score. One to 99 is considered low risk. 100 to 400 is considered moderate risk, and over 400 is considered high risk.

                                But that’s one way to look at it, but you also have to look at the age of the patient. So since I do all my studies at Harbor-UCLA. They have a huge database of 30,000 people. I have a 44-year-old guy that I saw yesterday. 42-year-old guy. He’s got a lousy family history on the paternal side. His father, grandfather, and great-grandfather, they all died early age of heart attacks. So he came in to me because of prevention.

                                So I did this scan on him. He’s got the bad pattern, and his score was like 45, which is considered mild, right, but not when you’re 42 years old. Because they have that database, he was in the 90th percentile. He said, “My score is only …” I said, “Yeah, but it depends on your age.” So that’s why I really like getting all that information. I don’t always just treat to the results of the scan, but if it’s really high … I’ve had patients the score’s over 3,000. Over 3,000, yeah. Yes.

Speaker 7:           Dr. Elkin, isn’t there two different kinds of scans? One’s for hard plaque. One’s for soft plaque. I always mix up which one is which.

Dr. Elkin:              Could you say it a little louder?

Dr. Weitz:            She’s asking the coronary calcium scan for hard plaque-

Speaker 7:           That’s for hard or soft plaque though?

Dr. Elkin:              Yes. Well, I’m going to tell you about a new scan that’s very exciting in a few minutes. We’re going to get to it. Okay, you’re right. The coronary calcium scan only detect calcified plaque. Now, most plaque is not calcified. So it is helpful, but it’s not the end all be all. But I’ll tell you about something else.

Dr. Weitz:            Not only that, but hard plaque, it’s stable and probably less risky.

Dr. Elkin:              If you have calcific plaque, it’s going to be pretty hard for that to break off and cause a stroke or heart attack because it’s hard. There’s somewhat of a protective aspect of having calcified plaque.

Speaker 5:           But that’s different than a carotic ultrasound?

Dr. Elkin:              Well, yes and no. I say peripheral artery or carotid artery disease does also merit statins or a more aggressive approach. It’s really the same process, just a different location. Most people with peripheral artery, they die of heart disease even though they never had an event.

Speaker 5:           Right. But I’m saying when they do the coronary artery calcium scans, it’s different than when they ultrasound your carotid-

Dr. Elkin:              Right. Exactly.

Speaker 5:           That checks for-

Dr. Elkin:              Now, with an ultrasound of the carotid, you can actually see mixed plaque. You could see soft tissue and calcific. But because it’s so easy to detect, you can’t do that with a regular scan with a heart because you’ve had so many things overlapping it. But I’ll talk about this new scan. You’ll be excited to hear. Diabetes, that you mentioned, that is a number one risk factor for me to consider high risk.

                                Come on. Okay. The truth about cholesterol. To put all this stuff over here, you can’t live without it. We need it. Have sex hormones, vitamin D, bowel acids, cell membranes in the brain. So I’m agreeing with all those people on social media that say cholesterol is not the villain. It’s not the villain, but we’re going to talk about the villain in a minute.

                                Culprit, oxidized LDL. I don’t care about your LDL, but if it’s oxidized, I do have to care about it because that means it’s been altered in the body. It’s like igniting a fire. Once you have LDL that’s oxidized, that can get easily into the endothelium, especially if there’s endothelial disruption or dysfunction, and that’s when the whole inflammatory process begins.

                                I’ll tell you, when I was a fellow several years ago, we didn’t know about inflammation. We never even talked about it. You got plaque 50%. Then it becomes 60. Then it becomes 70. Then it becomes 80. Then it becomes 90. Then the patient clots off, and they have a heart attack. It’s not that at all. Most plaques that lead to heart attacks are actually 40 to 50% plaques. But the difference is the stability or the vulnerability of the plaque itself, and that’s where oxidized LDL comes in because with oxidized LDL, it’s clearly more likely to form inflammation and plaque in the arteries.

                                Then it’s the particle size. You’ve all heard this before. Large, buoyant, large, fluffy. Bigger is better. That’s all you got to remember. Bigger is better. We don’t like small dense. Small dent is the kind that is more likely to form plaque. So that really is what we’re really talking about. Small dense promotes inflammation because it can easily get into the endothelial layer, and that’s when it all starts. There’s a cascade of events that takes place.

                                It’s all about inflammation, which I knew nothing about when I was a fellow. By the way, we started treating with statins. I was finishing my fellowship. It was in the mid ’80s. The first one that came out was Mevacor, was lovastatin, and it was derived from the red yeast rice plant from China, which is not surprising because a lot of pharmaceuticals originally derived from botanicals, and they’re altered, of course, in the lab.

                                But interesting about it is that we just thought, okay, it lowers LDL really well. We did have outcome studies, but what we didn’t know back then is that also there’s an anti-inflammatory effect that you get with statins that we did not know about until … I forgot the name of the study now, a study with rosuvastatin maybe about 15, 20 years ago. Then we learned, wow, there’s really an anti-inflammatory effect. So it’s not just lowering LDL, it’s also aiding-

Dr. Weitz:            I think it was the JUPITER trial.

Dr. Elkin:              What?

Dr. Weitz:            I think it was the JUPITER trial.

Dr. Elkin:              Yes, JUPITER trial. Thank you. Great trial. It opened up our eyes to what was happening. What causes oxidation? Trans fats. Nobody should be eating trans fats anymore. Smoking, of course, diabetes, metabolic syndrome. Those two are often linked together. Genetics, I would say a lot of it is genetic, and we’ll talk about that in a minute, too. So small dense LDL is about 35, 40% of the population.

                                How do you know if you have it? You don’t know. You have to get it checked out. Now, if you see someone with low HDL and high triglycerides, which is a metabolic problem, more than likely they’re going to have preponderance of small dense, but not necessarily. So you have to measure to really see, and we’ll talk about testing in a few minutes.

                                At risk for small dense. Genetics, again. High carbohydrate intake, especially starchy carbs, sugar. High trans fat intake, uncontrolled diabetes and high triglycerides and low HDL. So there are things we can do. It’s not just it’s written in your genes. There are things we can do diet-wise to actually lower the amount of oxidized LDL. And of course, metabolic syndrome.

Speaker 7:           Can I ask you a dumb question?

Dr. Elkin:              Yeah.

Speaker 7:           LDL stands for low density?

Dr. Elkin:              Right. Or lousy.

Speaker 7:           HDL stands for high density. We’re talking about high density LDL. I’m confused.

Dr. Elkin:              Okay. So how was this derived? There was a special testing method, and they’re actually measured in angstroms. I’m not a biochemist or a chemist at all. But it’s derived by the density, and it’s a measurement. There are different ways of testing this. We’ll get into that in a minute. But it’s really your standard lipid panel that most doctors, including cardiologists, do is total cholesterol, HDL, LDL, and triglycerides. The LDL, by the way, can’t be measured if the triglycerides are over 400 because it’s a calculated result. So if the triglycerides are over 400, you can’t really tell.

                                Now, with the testing that I do, you can tell, and we’ll get into that in a minute. Good questions. Okay. apoB and LDL particle number, these are more refined ways of looking at LDL cholesterol. If you do specialized tests, they’re going to include these, too. Some people think that it’s more prognostically important that if you have … Because you can have an LDL particle number that’s higher than the actual LDL.

                                So here’s a good way to cheat, guys, is take your LDL. Let’s just say it’s 100. And then what you do is you add a zero on it, and that’s what your LDL particle number should be. So it should be 1,000. What you’ll see when you add that zero, it could be four or five points greater than what you would expect. So LDL particle number is probably more significant. I look at it synonymously together because if you start explaining apoB and LBL particle numbers to patients. They’re not going to get it.

                                Everybody knows the LDL. So I may say to you, “Look at LDL.” But these are definitely considered to be a little bit more accurate and also maybe more prognostically-

Dr. Weitz:            apoB seems to be the new trendy number though.

Dr. Elkin:              Do what?

Dr. Weitz:            apoB seems to be the new trendy thing to look at, the most significant factor.

Dr. Elkin:              I get it with all my testing, so I know what it is. I look at it. But since I do a lot of teaching, I like to teach all my patients, I just talk about LDL. If they get that, I’m satisfied.

Speaker 5:           So if you have an apoB that’s higher than average, does that warrant to do on a statin?

Dr. Elkin:              Yeah. Well, yeah. Yeah.

Speaker 5:           Because the seems-

Dr. Elkin:              But here’s the thing. If your LDL is high, I can guarantee you in almost all cases that your apoB and your LDL particle number are going to be high.

Speaker 5:           So if it’s high, it’s better than just your HDL?

Dr. Elkin:              Right.

Speaker 5:           So if you have high HDLs but your apoB is high, still a statin?

Dr. Elkin:              The thing about HDL, I don’t know [inaudible 00:38:58]. But you also want to know the functionality of your HDL. You’ve heard reverse transport?

Speaker 5:           Mm-hmm.

Dr. Elkin:              So it takes cholesterol from the periphery, brings it back to the liver for disposal. Now, we figured all HDL is great. Not necessarily, really the best numbers for HDL are between 60 and 80. I say, “Well, I see a patient with 120.” It’s like, “Wow, that must be really good.” We found out there was a study about two years ago. I think it was out of Europe, and they said the numbers between 16 and 80 are ideal and if it’s functional.   So the higher the number doesn’t really mean that you’re overly protected. Now, what Cleveland Heart Lab does, they actually do the functionality test. So you could just see not only the number of the HDL, but whether it’s functional. So there’s about three different things that they look for in it, which brings it back to the liver for disposal.

Dr. Weitz:            Just to clarify, maybe to help a little bit, HDL, its main benefit is that it can do reverse cholesterol transport. It can take the cholesterol from the arteries back to the liver. So that’s its functionality. You can have a lot of HDL, but if it’s not doing its job, it’s not picking up any passengers.

Dr. Elkin:              Cholesterol doesn’t just float around in your circulation. It has to be carried by a protein molecule, HDL, LDL, whatever. So the big thing is is it really functional? Because all we had before were the numbers and we thought the higher the better it is for you, but not necessarily.

Dr. Weitz:            Now, Howard, apoB also includes VLDL.

Dr. Elkin:              Yes, it does.

Dr. Weitz:            You hardly ever hear anybody talk about VLDL. What is the significance of it?

Dr. Elkin:              Well, it’s usually when you have a high VLDL, it’s a precursor to triglycerides. That kind of goes to the triglycerides. Well, I’m going to talk about metabolic in a minute, so hold on to that question.  

                                Lp (a), everybody should know their Lp (a). Why? Because about 25% of the population has it. It’s not uncommon. It’s a fragment of LDL. It’s genetic. It doesn’t respond to medication, to exercise, to diet. Niacin can be helpful. I’ve had a lot of success with niacin in decreasing Lp (a). That’s it. Also, estrogen. So if for you women, maybe that might be helpful. Estrogen can be helpful in decreasing your Lp (a).  There is a biologic that will probably be coming out in the next two years. It doesn’t work like Repatha and the PCSK9 inhibitors. It’s specific for Lp (a), and it can decrease it by as much as 40, 50% in as little as six weeks. It’s really important because if you have young people with coronary disease and young people that have had heart attacks and strokes, oftentimes you’ll see the Lp (a) is the culprit. I have a couple patients with levels of over 400.

Speaker 7:           So when you see Lp (a), you’re seeing a genetic predisposition to high LDL?

Dr. Elkin:              Exactly. I tell the patients because they need to know. Part of this is genetic, and there may be some help in the near future. I think that will be coming out within a couple of years because they’ve been really working on this.

Dr. Weitz:            Because there’s no drug, most doctors don’t test for Lp (a).

Dr. Elkin:              Most cardiologists don’t test for Lp (a) because there’s no drug for it. So why do it? There’s no money in it.

Speaker 7:           That’s pretty-

Dr. Elkin:              But I think it’s important for especially young … All my patients that are cardiac patients get at least one Cleveland or Boston Heart, which we’ll talk about. It will definitely demonstrate that.

Speaker 8:           Doctor, I’ve seen the Lp (a) change.

Dr. Elkin:              Do what?

Speaker 8:           I’ve seen the Lp (a) change from year to year.

Dr. Elkin:              Yes.

Speaker 8:           What does that mean? If it’s genetic, why does it change?

Dr. Elkin:              Some people say, “Just do it once. You never have to do it again.” But I agree with you. I’ve seen it change. I’ve seen it change by 100 points or so.

Speaker 8:           What makes it change?

Dr. Elkin:              But usually, it’s with niacin. By itself, it may deviate a few points. I had one patient actually 200 points with niacin alone. It’s variable. Yes?

Speaker 9:           How much niacin do you recommend?

Dr. Elkin:              Okay. It usually requires quite big doses. But the highest I ever go is two grams in the amount of doses. Most people can tolerate 1,000 milligrams twice a day with food. I take niacin. I’ve never flushed ever because I always take it with food. So I don’t even know what the flushing is like. For me, I don’t get it. I take the regular-

Speaker 9:           I remember you talked about this because I listen to your YouTube a lot. I’m a fan. You said the non-flushing kind is junk. Don’t use it.

Dr. Elkin:              It doesn’t work at all.

Speaker 9:           Okay.

Dr. Elkin:              Avoid it. Usually, if you go to Rite Aid and CVS, they sell all the non-flush. But even in vitamin stores, they’ll show it because it sounds good, no flush. But it also doesn’t work.

Speaker 9:           No flush-

Dr. Weitz:            I tried everything with niacin.

Dr. Elkin:              Some people are more sensitive than others.

Dr. Weitz:            I tried 50 milligrams, 100 milligrams, flushed like crazy.

Dr. Elkin:              With food?

Dr. Weitz:            I tried it with food. I tried everything, every strategy.

Dr. Elkin:              Some people are exquisitely sensitive.

Dr. Weitz:            I just couldn’t tolerate it.

Dr. Elkin:              Why? I don’t know. But yeah, I’ve had patients who did the same.

Speaker 5:           It could raise blood sugar, too, like it did-

Dr. Elkin:              Do what?

Speaker 5:           How it raised Carol’s blood sugar?

Dr. Elkin:              Yes. Well, we saw that, right?

Speaker 5:           Yes.

Dr. Elkin:              It can also increase your blood sugar. We saw it with some person who we know quite well.

Dr. Weitz:            Well, of course, statins can raise blood sugar, too.

Dr. Elkin:              I definitely have seen it with niacin. I think that’s over exaggerated with statins. Again, people want to bash statins. It causes diabetes. It causes this. It causes that. Okay. I tell people it’s a risk-benefit ratio. If the benefit outweighs your risk, you do it. But we don’t want the treatment to be worse than the problem.

Speaker 8:           Maybe it depends on the dose of statin. Maybe if your full treatment-

Dr. Elkin:              Yes.

Dr. Weitz:            Absolutely.

Speaker 8:           Sometimes five milligrams does the trick, but then they put you on 20.

Dr. Elkin:              Right, right. I usually start pretty low. If someone’s really fentanyl, I’ll start even 250. You can get 100 milligrams in Vitamin Shoppe and stuff like that. [inaudible 00:45:16] I don’t have a dose that small.

Speaker 8:           What are you talking about, the-

Dr. Weitz:            You’re talking about niacin.

Speaker 8:           I was talking about-

Dr. Weitz:            She’s talking about statins.

Dr. Elkin:              I’m sorry. Statin.

Speaker 8:           You said 250. I was going to-

Dr. Weitz:            Oh, no, no, no, no, no. Statins. Statins people tolerate. Most people tolerate well. But here’s the thing, I never start a statin without CoQ10, never ever. I tell them you have to take CoQ10 because it’ll obviate the muscle soreness and myalgias that you can get. Yeah?

Speaker 8:           Are you seeing that blood sugar rise with niacin in everybody or in some?

Dr. Elkin:              Well-

Dr. Weitz:            I think it’s a small percentage.

Dr. Elkin:              Yeah. Well, what type of niacin-

Dr. Weitz:            Well, it depends how high you go, too. I use 500. I almost never see it.

Dr. Elkin:              Right. But I knew a patient that was taking 3,000 or more on his own. He was wondering why he’s getting palpitations and getting all these weird symptoms. I said, “Dude, you’re taking more than 2,000. That’s max dose, and you take it in divided doses.” But niacin is basically safer than most statins. I mean every now and then, you’ll get a rise in liver enzymes. So I always check that. Not as commonly as you would get it with statins.   But I think despite all the BS you hear about statins and I’ve been using them since they came out, that’s when I was a new cardiologist, they’re pretty well tolerated. But there’s about 20% or so that don’t tolerate it well. It’s usually the muscle myalgias and that kind of stuff and also the liver enzymes.

Dr. Weitz:            Now, some integrative doctors, like Dr. Huston, a lot of times will put somebody on a statin three days a week.

Dr. Elkin:              Yeah, there’s ways of doing it. I tend to try to do it every day because patients, once you start do it every third day, do it every fourth day, I’m lucky if they take it on a regular basis. So I try to make my drug schedules really easy to follow, even when I do things like blood thinners and Coumadin.` We used to use Coumadin all the time. I hate split doses because it’s so confusing. Yes?

Speaker 8:           Sorry for so many questions, but what’s the minimum dose of niacin that you have seen be effective for lowering Lp (a)?

Dr. Elkin:              Good question. There’s not really definitely a lower … I usually start, again, with 500. But if it’s someone who’s really sensitive, I’ll take their score. I can always have them take 250.

Speaker 8:           So for a whole day, not twice a day?

Dr. Elkin:              Yeah. Well, yes. Well, I’ll have them titrate up on their own as tolerated. So if you’re taking 250 for, let’s say, two weeks and you’re doing well with it, then take the full tablet. But I do it twice a day. So if I start them low at 250, which is lower than my normal starting point, I’ll do it twice a day.

Speaker 8:           So you’ve seen that be effective, even that low? Let’s say someone only took 500 milligrams of niacin a day, but they were consistent. Have you seen their Lp (a) go down?

Dr. Elkin:              Yeah. You may get a response. It’s really funny. I’m using lower doses of statins now than I ever have, and I’m seeing pretty decent … Some people, well, their LDL will drop significantly with 10 milligrams of CRESTOR, rosuvastatin. Now, if you go to the hospital and you get a stent, I can guarantee you’re going to walk out of there with 80 milligrams of LIPITOR-

Speaker 8:           80? Wow.

Dr. Elkin:              … an aspirin, a beta blocker, an ACE inhibitor, and Plavix. All of a sudden, you’re on five medicines. Do you need them? I don’t think so. But you do need the aspirin and the Plavix. But everybody’s put on a beta blocker and ACE inhibitor. It’s just crazy. I can almost guarantee you that patients are going to come back with all those medicines when they have been in the hospital. You’ve seen it.

Speaker 5:           What do you think about red yeast rice as compared to statins?

Dr. Elkin:              Okay. Red yeast rice was the precursor to statins. Yeah, you can try it. If it says on there two at night, I usually tell patients take three because it’s a weaker form of a statin. But it’s always worth trying it.

Dr. Weitz:            You got to take four to eight.

Dr. Elkin:              Yeah. How many?

Speaker 5:           Four to eight?

Dr. Weitz:            Yes.

Dr. Elkin:              You take how many?

Dr. Weitz:            Four to eight.

Dr. Elkin:              Wow.

Dr. Weitz:            You got to do 24 to 4,800. So I think most of the products out there are about 600. So you got to take four to get to 2,400. I think that’s [inaudible 00:49:24]-

Dr. Elkin:              Now, a lot of patients, truthfully say they’d rather just take one tablet than taking six. I mean I don’t want to take eight of one thing. I take enough something as it is, but I’m also higher risk because I’ve had a stent before. So I take a statin. I’ve never had a problem, but I always take CoQ10. But some people do have issues.

                                Okay. So let’s go on. I want to get into some of the testing. Do I have to face the computer for this to work?

Dr. Weitz:            You know what? You’re probably behind that little thing.

Dr. Elkin:              Yeah, I’m probably behind it. I’ll be over here. I’ll sit here. Okay.

Speaker 8:           There you go. You got it.

Dr. Elkin:              This is more about apoB. Detects the presence of all the atherogenic particles. In contrast to LDL, this may be better suited to guide lipid-lowering therapy. I don’t really abide by this because, again, since I’m instructing patients, I got to make it really digestible.

Dr. Weitz:            It’s okay.

Dr. Elkin:              But purists do believe that apoB is the best way to take it and also LDL particle. So I would say it is more important, but is it necessary? Probably not.  Okay. apoB is a more accurate marker that can actually identify potential high-risk patients. Now, particle number, same thing. [inaudible 00:50:54], cholesterol present in the blood, does not … When you do the particle number, you’re varying the number of particles. And again, it’s often used as a more accurate number. If you do specialized lipid testing, you’re going to get apoB and you’re going to get an LDL particle number. So you’ll get it anyway.  Here’s another out of context. Genetic is 20. It’s a fragment of LDL. I already said all that stuff. Now, physical inactivity, that was the last risk factor that was made into a primary risk factor in the ’90s, I believe, and for good reason, because only 20% of the adult American population exercises on a regular basis or what we recommend by the American Heart Association, the American College of Sports Medicine. Most people are very sedentary and don’t exercise on a regular basis. So it’s important.

                                So again, it was elevated to major risk factor in the ’90s. Bottom line, the more active and fit you are, the less incidence of heart disease or complications of heart disease. Failure to exercise on a regular basis is as bad as smoking. Okay. Next one is-

Speaker 8:           I’m sorry. Do you agree that sitting is the new smoking?

Dr. Elkin:              Do what?

Speaker 8:           Do you agree that sitting is the new smoking?

Dr. Elkin:              Sitting [inaudible 00:52:15]-

Speaker 8:           Sitting-

Dr. Weitz:            Is sitting the new smoking?

Dr. Elkin:              What?

Dr. Weitz:            Is sitting the new smoking?

Dr. Elkin:              Oh, yeah, absolutely. Yes. Inactive people are twice likely to develop heart disease than people who engage in regular … I mean twice as likely. Why would you not want to exercise? But then again, we’re not the average. 250,000 deaths a year attributed to physical inactivity and it’s not just due to heart disease, but also other diseases such as adult 2 diabetes, hypertension, osteoporosis, and various cancers. It’s a dismal situation.

                                It’s the easiest risk factor to correct, but not everybody does it. Obesity, diets high in fat … This is funny. Now, in 1965, 40% of your calories came from fat, down to 34% in the mid ’90s. And guess what? We got fatter than ever, and we have more diabetes than before. So that was the big low fat, high carb stage during the ’90s, which also popularized by Ornish and so forth. That may be helpful for certain people, but they didn’t know about particle sizes and they didn’t know about the role of metabolic health. I think we know a lot more now.

                                42% of the population in this country is obese. Nearly 79% is overweight. So that takes into consideration the obese and everybody else who’s overweight. That’s two thirds of the population. Sugar is a culprit. It’s not fat. It’s sugar. When people ask me about my diet, first thing I say is sugar. They wonder if you need to go buy low cholesterol and low fat. I say no. I mean I might eventually, but it’s not my number one concern because eating sugar and starchy carbs is like pouring gasoline over fire, and we’re igniting a fire within our arteries. That sets the stage for inflammation. So I’m very upfront about that. It ties into metabolic health.

                                Drugs for weight loss. This is a big craze now, right? Now we’re getting more and more reports about the semaglutide and Ozempic and Wegovy. The new one is Mounjaro. I believe in those drugs for high-risk patients that are obese and diabetic because it does open up a new avenue for treatment. Again, they’re very high risk. But people wanted to lose 10 to 15 pounds and they’re going on this. A lot of people are doing this. They can get it.

                                It’s just ridiculous because now we’re getting more and more reports of complications, things like gallstones, pancreatitis. I don’t know. This could be a precursor to pancreatic cancer. They haven’t been around long enough. We don’t know the full story. But these drugs bother me on a global basis. So yes, I would use them for … I have a few patients, but they’re all diabetic and they’re high risk to begin with, and they’re usually very overweight. Oh, sorry. Going the wrong direction.  All right. Diabetes, bad disease. Need I say more?

Speaker 7:           [inaudible 00:55:24] disease?

Dr. Elkin:              The numbers are getting worse. Right now, I think there’s 10 million diabetics in the country. There’s, I think, 70 million pre-diabetics. Most of them don’t even know it because they don’t know what’s going on. And again, that’s their number one cause of death in diabetics. They have a threefold increase incident of heart disease, and two to four times more likely to die from heart disease. They do not do well. It sticks.

                                Okay. Heart attack symptoms. I’ll try to go fast now. 45% of heart attacks are silent. So if you don’t test these patients and watch them carefully, they will have a heart attack on you. That’s why it’s so important to look at these risk factors. [inaudible 00:56:12] in pain, and dyspnea, shortness of breath, diaphoresis, sweating, nausea, vomiting, lightheadedness. But watch this.

                                This is supposed to be women. Somehow that didn’t get in there. Women with heart disease present differently. They might have pressure in the chest, but oftentimes they don’t. [inaudible 00:56:34] their arms. They get short of breath. They could have just plain fatigue, nausea. The big one is if you have discomfort in the jaw and the teeth, for some reason, that tends to be a thing about women. Cold sweat, nausea, and vomiting.

                                So here’s my dictum about women and heart disease. Anything above the navel, belly button, in a woman is heart disease until proven otherwise. That’s how I look at it because all bets are off. Like you say, most women don’t even think. Well, not most, but only 54% of women in this country really think that heart disease is in their future or their major worry. So it’s a big deal. I mean I think we’ve done a lot better.

                                But when I was a fellow, all the studies done were middle-aged men. If you were childbearing age, you were just excluded and, if you were over 65, you were too old. Women live 30 years more past menopause, right?

Speaker 5:           Question about there’s a lot of confusion around estrogen preventing heart disease in women or bioidentical estrogen. I read everything. Yes? No? What’s your thoughts on that?

Dr. Elkin:              But estrogen you mean? Yeah.

Speaker 5:           Yes.

Dr. Elkin:              Yeah, I’ll talk about that in a minute. In the old days, we thought that you treat with hormones to relieve symptoms, hot sweat, night sweats, hot flashes, insomnia, anxiety. Those are good reasons to treat because I don’t think any woman should have to go through a painful menopause in this day and age. But I also do it for the health benefits, the heart-

Speaker 9:           Exactly.

Dr. Elkin:              … the brain and bones.

Speaker 9:           [inaudible 00:58:09]-

Dr. Elkin:              What I’m really hot on is that it’s one of the best ways to preserve endothelial health is estrogen, and I don’t think most gynecologists even know this. Okay, let’s see. 21st century terms. This is my traditional medicine versus functional, since we’re all functional. If you are a traditional doctor, you’ve got symptoms here. We go immediately to treatment. But our way of doing it, symptoms, we try to get the cause and then we go to treatment.

                                It sounds really simplistic, but this is really the reality of how things are treated. So I always tell people I’m an integrative cardiologist practicing functional medicine. I use functional medicine as the basis for what I do. So let’s look at testing quickly. Treadmill testing is, no one should be doing that. I mean when we have certain insurances, my opinion, we have to get authorization for everything these days, which is ridiculous. They want me to do a regular stress test. On a woman, it’s worthless because there are so many false positives on routine stress testing with women.

                                So I have to fight to get a stress echo, which is a stress test with imaging with the ultrasound. The nuclear stress imaging is with the nuclear. Instead of looking at wall motion, we’re looking at uptick of radiopharmaceuticals and your heart muscle. If there’s normal arrest and if there’s a hole we see with exercise, that means it’s tagged to your red blood cells. So it’s not going anywhere because of a blockage.

                                Nuclear stress test adds about 15% more sensitivity when you compare it to a stress echo. But it’s radiopharmaceutical, so you are getting some radiation. I use nuclear stress testing on the higher risk patients and stress echo more routinely for those that are not. Now, here’s the fun part, ancillary testing. The coronary scan we talked about. It’s really great, but all it does is really tests for calcified blockages.

                                Coronary CT, that’s a great test. Now, it’s an angiogram, but it’s still with a peripheral IV. So it’s not nearly as much contrast, and it’s just a peripheral IV, so you don’t have to lie still for six or eight hours. You’re not getting anesthesia for it, so it’s easier to perform. It’s not as good as routine angiography. It’s pretty good for people that have had bypass surgeries because we really want to know are the grafts open or they closed. Also with stents, are the stents open or closed? So they’re good for that. It’s nothing that I would gravitate toward, at least not initially.

                                But here’s the new kid on the block, the Cleerly scan. Have any of you heard of this? Cleerly combines coronary CT with artificial intelligence, and the images are phenomenal. I’ve done about seven or eight already. I think I’m putting Harbor-UCLA on the map now because I’m ordering so many because now that I’ve done a few, I really see the utility. So what it does, now we can look at things like plaque volume and plaque composition. Before, we couldn’t tell.

                                Now, we can say, “Okay, hard plaque. That’s what the other scan shows us.” Then we can see soft plaque. And then there’s another one which is very scary, that’s called low density soft plaque. That’s vulnerable plaque that is ready to burst. How do we know that unless we did the scan? But I wish I had images because it’s so new that I don’t have any images yet. I’ll get them next time I do this talk. But here’s the important thing. Let me give you an example.

                                I have this 65-year-old guy. He looks 50. He looks great. But on the outside, he looks great. He had a calcium count of over 3,300. That’s the highest I think I’ve had in the practice. I did a nuclear stress test. I think these numbers are going up. This is not looking good. So we did a nuclear stress test. Negative. I said, I’m bothered by this. The numbers are going up every two years, and he doesn’t have symptoms.” So I did the Cleerly he was my first Cleerly scan.

                                Part of his left main and the widowmaker, the left anterior descending artery, have major low density soft plaque. So that puts him at very high risk of plaque rupture and heart attack. So it’s scary. I talked to his wife. He’s been my patient for many years. She said, “Well, I think we should get a second opinion.” I said, “Be my guest. Ain’t nobody around here doing this test, so you’re going to have a hard time getting a second opinion with someone who’s familiar with the test.” But I never heard back from them.

Speaker 8:           How do you treat once you see that?

Dr. Elkin:              if it’s that easily discernible, I would probably do an angiogram. That’s the patients [inaudible 01:03:00] that, even though they don’t have symptoms. This may supplant stress testing in the future. If they can get the price affordable so that insurance covers it, this may supplant stress testing because I’ve had another patient just like every other patient with normal stress test, nuclear stress, which is a pretty important test. And yet, the Cleerly test told me that he’s really vulnerable … I think it’s real.  You can see it. You can visualize it. So again, it’s plaque volume and plaque composition. I mean you never heard those terms before when you’re talking about patient’s risks. So this is brand new. Most people are not doing this.

Speaker 9:           Can you go for imaging on this the same place where you’re sending your patients, the coronary calcium scans?

Dr. Elkin:              Well, I had already done scans on this guy before, and his levels were over-

Speaker 9:           Where do you go for the Cleerly?

Dr. Elkin:              [inaudible 01:03:56] does it really as well as Harbor-UCLA. I’ve been using them for many years just for my routine coronary artery calcium scan.

Speaker 9:           Because it’s so new, are there fewer places that-

Dr. Elkin:              Yeah, they’re doing it. If you look up, it’s C-L-E-E-R-L-Y. But you google them, you’ll see what hospitals. I don’t know if Cedars is doing it or not. I know that since I’ve been working with Mark Rudolph for several years with the calcium scans, they also do really good CT angios. This is an extension of that.

Speaker 9:           How much?

Dr. Elkin:              Okay, good question. If you are Medicare, they will cover a CT angio if you have symptoms. So I often fudge it. They had short of breath. And then I can get them to tag on the Cleerly for sometimes no charge extra. But if you’re going to pay out of pocket, I think their price is going to be, let me think, like 1,200 for the two combined, which is not bad.

Speaker 9:           Yeah. But the CCS, it ranges from 120 to 300 locally?

Dr. Elkin:              That’s a calcium scan.

Speaker 9:           Correct. Out of pocket?

Dr. Elkin:              Yeah.

Speaker 9:           That’s the issue, getting the patients to do it for that reason.

Dr. Elkin:              Yeah. Well, I have, fortunately, a lot of patients that will spend the money for it. The average probably won’t. But when I tell them, “Listen, this is what you’ve got.” So it could be a lifesaver. I think it will be, I think it will be a lifesaver in the future.  Here we are. This is your standard lipid panel that every doctor gets. This is apoB 83, particle number. Boston looks at the concentration of small dense. You want them to be less than 20, and this person has 25. The reason I did the slide, they do called a cholesterol balance test. Cleveland doesn’t do that. It looks at two markers for hyper production, and these markers are for hyper absorption. So we can find out is the problem over production or over absorption because the treatment can be different.

                                Okay, let me see. I’m going to get real fast. This is the metabolic panel down here. Everything looks good. C-peptide insulin. So I’m always interested in the fasting insulin, and I like to see peptides. They test me how hard the pancreas is working because you could have a person who’s got a normal A1C, but the insulin level’s high. The HOMA-IR, which is a homeostatic mechanism for insulin resistance, that’s a calculated number. If that’s high and the c-peptide is high, it means the pancreas is working its butt off to not make you a diabetic. So it’s really important to get that.  Then real quick, I just want to show how Cleveland does it. I got to go over here, don’t I?

Speaker 6:           I have one question. [inaudible 01:06:40]?

Dr. Elkin:              This is genetic testing. So it’s very interesting. Statin-induced myopathy gene, Boston seems to have the patent on that. We can actually find out if a patient is a slow metabolizer to a statin, in which case, depending whether they’re heterozygous or homozygous, you might want to avoid statin completely in a particular group. apoE, you’ve all heard about that. These people tend to have, if they’re apoE, this E3/E3 is the most common genotype, and it’s the best one to have.  But if you have a three and a four or two fours, that means you may tend to hyper absorb cholesterol from the gut, and it’s also a gene for Alzheimer’s disease. Factor V and Factor II are blood things and MTHFR. 60% of us, me included, have one or two variants of the MTHFR gene. Look at this one. The small dense is 60, and that’s huge. We want it to be less than 30. It is 30. I’m sorry. I’m not much on ratios, but let me get to what I wanted to show you.

                                Okay, it’s inflammatory. So CRP protein is 1.6, I think, there. Interleukin-6 is 6.2. So we’re getting a lot of inflammatory markers as well as function tests and metabolic. Let me go back real quick. Look at this, insulin 32. C-peptide 4.77. I mean everything is off the wall. This is a metabolically unhealthy person. Okay, let me move on. I’m going to show you what it looks like with another test that I find quite useful. It was called the PULS test, P-U-L-S. Now it’s called SmartVascular Dx.

                                This is telling me the health of your endothelium where everything begins. So when I say I don’t care about your numbers, I’m being truthful. I care about your risk. I care about the health of your endothelium because if you have endothelial dysfunction, that sets the stage for coronary disease. This person has a score of 14.5. Expected score for his age and sex is 2.82, which gets him both. He’s high risk, both relative risk and absolute risk, for an event over the next five years. it’s not a standalone. I use this with the Boston or the Cleveland.

Speaker 5:           It’s a blood test?

Dr. Elkin:              Yeah. Here let me show you. This is what I’m interested in. This is a map. It tells you where they started. This is pointing out where … See, they went down. And then they went way up. You don’t want to go up. You want to keep on going down. So once you go up, you’re increasing your risk. Endothelial dysfunction will change according to your blood pressure and all these other things that we’ve mentioned. So it’s a great test, and I use it very frequently.

                                This is what the coronary calcium report looks like. This is the one with over 3,000. This tells in each artery, the calcium count in each particular thing. Now we’re talking, this is Boston Heart. No, this is Cleveland I think. But look, all the inflammatory markers are off the wall. 3.4 CRP. ADMA is a marker of endothelial health. That’s abnormal. This is at Cleveland. So what they do differently in Cleveland, they actually measure the size of the LDL particle as opposed just the concentration. So they’re measuring in angstroms.

                                If you see next slide, the pattern is pattern B means bad and it’s 210.3. You want it to be greater than 222.9 angstroms. So it’s easy to follow this. I like Cleveland because it’s easy for a patient to understand where their number is versus concentration. It gives you Lp (a). This is the functionality. I’m not sure what all those numbers mean. But in the green, 0.65 is a normal functionality for HDL. So they do a lot of the same thing.

                                Instead of HOMA-IR, they do what’s called insulin resistance score. Same thing, it’s measuring the degree of insulin resistance. Homocysteine is, again, usually that goes along with the MTHFR, and I do treat it. Now it’s been thought that elevated homocysteine levels are definitely not just a risk factor. My secondary risk factors didn’t show up, did they? Anyway, it’s a secondary risk factor, but it’s definitely associated with endothelial dysfunction. So again, everything’s about the endothelium.

                                They do the fatty acid balance test, which is good. That can help people with their nutrition. And again, this is another way of doing the genetics. KIF6, that was kind of put together by Robert Siburko at Berkeley Heart Lab several years ago. 9p21 is considered the, quote-unquote, “heart attack gene.” His person is actually homozygous carrier. So not good. 4q25 is that you’re at risk for atrial fibrillation down the line, and the Factor V Leiden, MTHFR. That’s basically it.

                                The summary prevalence of cardiovascular disease, it’s an equal opportunity killer in both men and females. It’s the number one killer in this country. Women present differently. We didn’t go over the secondary risk factors. Somehow I lost the slide. We went over the six major ones. The cardiac testing for symptoms, for scheming and specialized lab testing, which we discussed. I have a book that I put out last night about this time last year on both sides of the table and contact information from me. I appreciate having the opportunity to speak to you guys. I guess I’m the first speaker since we’re back.



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.  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 and 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 work, stool testing, sometimes urine testing.  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.


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