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Cardiovascular Health
Cardiovascular Wellness
Test
By Brian Vonk, M.D.
You may have gotten to a point in your life where you're asking, "Where is my health going and why am I in
this handbasket?" Or you may be saying, "I feel fine and want to make sure I stay that way."
The fact is, the majority of Americans older than 40 years already have a major health problem. Another disconcerting fact is that the majority
of illnesses are subclinical, meaning they smolder under the surface for many years before they are recognized.
Whatever your condition, sickness or apparent health, accurately assessing your current health is the proper
place to start on your journey to vibrant health.
Since cardiovascular health is key to health in general -- and the lack of it is so common -- it is where I'd
like to begin a health review. Heart disease is the #1 killer of Americans, followed, in order of prevalence, by
cancer, stroke, emphysema, and accidents.
But every 34 seconds an American dies of heart disease!
Consequently, we all know someone with heart disease, or we have it ourselves. If you're interested in avoiding
or ending personal experience with this disease, I have good news for you: the majority of the causes of cardiovascular disease are in our control.
The first and foundational step in gaining or maintaining cardiovascular health is accurately measuring your
current condition. Once that is clearly understood, an effective treatment or preventative plan can be made. In
this article, we'll review the most important factors indicating cardiovascular health or disease. Collect the
information and grade yourself.
Blood Analysis Most of us
have had our blood drawn to determine our cholesterol level. That number alone, however, is actually
quite useless.
There is a huge amount of misinformation about cholesterol, leaving most people thinking it is the grinch who
steals youthful vitality. The truth is cholesterol is vital for health and we'd all be dead without it.
We get disease if cholesterol is too high or too low. But in the broad range of cholesterol levels from 180 to
240 there is no correlation with heart disease. Below 180 there is increased risk of hemorrhagic stroke,
depression, and suicide. Above 240 there is increased risk of cardiovascular disease and ischemic stroke. Over age
70, elevated cholesterol and cardiovascular events no longer correlate. All told, total serum cholesterol alone is
a poor indicator of cardiovascular disease. Half of all heart attack patients have normal total cholesterol
levels.
So why are doctors recommending statin drugs for
cholesterol levels above 200?
Ask the pharmaceutical companies who sponsor the drug studies and also help determine what normal cholesterol levels are. The upper limit of normal total
cholesterol recently went down from 220 to 200, creating "disease" in additional millions of Americans. How
convenient that the drug companies just so happen to have the "cure" for that disease!
I want to help you avoid that treatment trap. In fairness, compared to many drugs, most of the statin drugs are
some of the safer drugs you might take and actually have the beneficial effects of being powerful antioxidant and
anti-inflammatory agents. These beneficial features are likely the reason studies show decreased cardiac deaths
when they are used.
Nevertheless, the statin drugs' potential side effects are significant. In some they deplete coenzyme Q 10
within the liver enough to cause liver enzyme elevations and within the muscles to cause myopathy. Also, and this
is not published to my knowledge, but in my and several of my physician colleagues' experiences, statins cause
depression or loss of motivation in the majority of patients, probably due to alteration of cholesterol metabolism
in the brain. As a result, many of these patients are also on SSRI (selective serotonin reuptake inhibitor) drugs
(eg Zoloft, Paxil, Prosac).
What is it worth to you to avoid depression and loss
of motivation?
There are far safer ways to decrease cardiac deaths and treat abnormal cholesterol levels without risking drug
side effects. Depite this, you would be astounded how many patients would rather take a pill with potential severe
side effects than consider changing anything else.
As noted above, total serum cholesterol doesn't correlate with cardiovascular disease in the range of 180 to 240
but certain fractions of that total cholesterol do correlate. These fractions are HDL and LDL cholesterol. This is
why you need a Lipid Profile (also called a Lipid Panel) and not just a total cholesterol when you get your blood
drawn.
I have compiled two tables below listing the components of cholesterol (ie the Lipid Profile) as well as listing
several other markers for cardiovascular health and disease. The first table has the usually quoted normal levels
and the second table has ideal levels. Normal levels can change depending upon the levels found in the majority of
the population as well as upon what health officials decide is normal. Ideal levels are those which reflect health.
We want the ideal levels for optimal wellness not just normal.
All of the markers listed in the tables are important. For example, you can have normal HDL/Chol ratio, normal
homocysteine, normal fasting glucose, but have ferritin outside the ideal range and have cardiovascular disease as
a result. It only takes one rascal to spill the beans.
Cardiovascular Disease
Markers:
These are the declared "normal" levels that your doctor will use to tell you whether your various serum/blood
levels are "normal" (NOTE: These levels do NOT necessarily mean healthy levels, rather these will include healthy
and many very unhealthy patients):
These levels do NOT necessarily mean healthy levels, rather
these will include healthy and many very unhealthy patients):
"Normal" levels |
Total Cholesterol
(mg/dL) |
Normal range = It
changes with age but quite accurate:
= Upper level is 230 + age, Max 300
= Lower level is 115 + age
Recommended cholesterol level is a moving target. Recently cardiologists are recommending everyones
level should be below 200 at all ages. |
HDL Cholesterol
(mg/dL) |
Normal range =
Males 30-70, Females 35-80 |
LDL Cholesterol
(mg/dL) |
Normal range =
60-150 below age 20
= 70-180 age 30-50
= 80-210 above age 50 |
Triglycerides
(mg/dL)
|
Normal range = It
changes with age but quite accurate: = Males upper level is 130 + age, Max 200
= Females lowerlevel is 80 + age, Max 165
= Males/Females lower level is your age |
C-Reactive
Protein(CRP)
|
Normal range =
Below 10 mg/L (1 mg/dL)
|
Homocysteine
|
Normal range =
Below 17 micromoles/L
|
Lipoprotein a
(Lp a)
|
Normal range =
Below 25 mg/dL |
Ferritin
|
Normal range =
Males 20-300, Females 15-120 ng/ml
Iron overload = Above 400 ng/ml |
Fibrinogen
|
Normal range =
Males 180-340, Females 190-420 mg/dL |
Blood
glucose(8hr fast)
|
Normal =
<120 mg/dL Borderline DM = 120-140 mg/dL
Diabetic = Above 140 mg/dL (W.H.O. definition)
|
Insulin (8 hr
fasting)
|
Normal = Below 20
microUnits/ml
Borderline DM = 21-25 microUnits/ml
Diabetic = Above 25 microUnits/ml |
Hemoglobin A1C |
Normal range =
Below 7.5% of total hemoglobin |
The following serum levels are the most IDEAL (ie.
beneficial) levels for cardiovascular (CV) health. Having any ONE of these outside the ideal range can cause or
indicate CV disease! These ideal or healthy levels are much tighter than the often quoted "normal" levels referred
to by your doctor. Remember "normal" does NOT necessarily mean "healthy". We want healthy, not just normal:
"Ideal" levels |
Total
Cholesterol*
|
Ideal Range = 180
to 200 mg/dL if less than age 70
Ideal Range = Up to 300 if older than age 70 |
HDL
Cholesterol
|
Ideal level =
Above 50 mg/dL |
LDL
Cholesterol
|
Ideal level =
Below 100 mg/dL |
HDL % or
Ratios
|
Ideal levels =
See table below |
Triglycerides(TG)
|
Ideal level =
Below 100 mg/dL |
C-Reactive
Protein(CRP)
|
Ideal level =
Below 1 mg/L (0.1 mg/dL) |
Homocysteine
|
Ideal level =
Below 8.0 micromoles/L |
Lipoprotein(a)ieLp(a)**
|
Ideal level =
Below 10 mg/dL |
Ferritin
|
Ideal range =
20-50 ng/ml (Above 80 is trouble) |
Fibrinogen
|
Ideal range =
150-300 mg/dL |
Blood
glucose(8hr fast)
|
Ideal range =
60-85 mg/dL
Pre-diabetic = 95-110 mg/dL
Diabetic = Above 110 mg/dL
Hypoglycemic = Below 60 mg/dL
Critical levels = Below 40 or Above 450 mg/dL |
Insulin (8 hr
fasting)
|
Good level =
Below 5 microUnits/ml
Best level = 2-3 microUnits/ml
High risk Diabetes= Above 10 microUnits/ml |
Hemoglobin A1C*** |
Ideal range =
Below 6% of total hemoglobin |
* Cholesterol: It is not advisable to have total cholesterol below 150 at any age
due to increased risk for internal hemorrhage, depression, and suicide.
Note: A mneumonic to help you remember that LDL is the "BAD" cholesterol: LDL
= Low Down Loathsome cholesterol.
** Lp(a): LDL + APO(a) =
Lp(a). Artery blockage (plaque) is composed of 90-100% Lp(a) NOT of ordinary cholesterol. Lp(a) is a substitute for
ascorbate (Vitamin C). If you are not getting enough Vitamin C to produce collagen for tissue repair, when your
arteries become injured they cannot heal properly. If there is inadequate Vitamin C, the next best way to repair
your arterial injuries is make a Lp(a) plaque to cover the injury. Unfortunately the plaques tend to continue to
grow. Simply removing plaque without restoring the artery to health is like tearing a scab off a wound. You do not
want to remove the scab until after the tissue underneath has started healing. Your body needs sufficient Vitamin C
so your arteries can heal. Elevated homocysteine can also play a role here and is detrimental because it causes the
binding of Lp(a) to fibrin in very low concentrations thereby encouraging plaque formation in the vessel walls.
*** HbA1C (also called glycosylated hemoglobin) correlates well with your average blood sugar over the last 3
months. Tight blood sugar control makes a HUGE difference in complications in diabetics and prediabetics. When A1C
levels are elevated above 6.5, for every 1 percent reduction in A1C levels there is a 14 percent to 40 percent
decrease in diabetes-related complications! Diabetics with A1C levels of 6.5 or lower only need to have the test
repeated every six months. Those with higher levels should be tested every two to three months until levels drop to
6.5 or lower, while they make corrections with improved diet and additional diabetes medication. Most diabetics
have the disease for 10 years before it is diagnosed, but it has silently been doing damage for all those
years.
Cholesterol Cardiac Risk Factors |
Cholesterol/HDL Ratio (ie Total Cholesterol divided by HDL): |
Cardiac
Risk |
Ratio in
Males |
Ratio in
Females |
High risk (3X): |
9.7 to 23.4
|
7.2 to 11.0 |
Above average risk
(2X): |
5.1 to 9.6 |
4.5 to 7.1 |
Average risk: |
3.5 to 5.0 |
3.4 to 4.4 |
Below average risk
(1/2): |
1.0 to 3.4 |
1.0 to 3.3 |
HDL Percentage: HDL/Cholesterol X 100 (ie HDL divided by Total Chol X
100): |
Cardiac
Risk |
HDL in
Males |
HDL in
Females |
High risk (3X): |
Below 10% |
Below 14% |
Above average risk
(2X): |
10
to 19% |
14
to 22% |
Average risk: |
24% (Range 20 to
29) |
26% (Range 23 to
30) |
Below average risk
(1/2): |
Above 29% |
Above 30% |
LDL/HDL Risk Ratio (ie LDL divided by HDL) Male or Female: |
Cardiac
Risk |
Ratio in
Males |
Ratio in
Females |
High risk (3X): |
6.4 to 8.0 |
5.1 to 6.1 |
Above average risk
(2X): |
3.7 to 6.3 |
3.3 to 5.0 |
Average risk: |
1.1 to 3.6 |
1.6 to 3.2 |
Below average risk
(1/2): |
Below 1.1 |
Below 1.6 |
Besides obtaining blood work, your doctor has other tests he can order to determine your
cardiovascular state including resting EKG, treadmill stress test, CT coronary calcium scoring, echocardiogram,
nuclear medicine scans, and coronary angiography. These are useful if you have known or suspected disease; however,
as you advance from non-invasive to invasive studies there are increased risks for the tests themselves. There is a
one in one thousand chance of dying from a coronary angiogram. This is an average. In your doctor's hands you may
have a much lower risk but it also could be much higher. These tests must be used wisely.
You obviously need to go to a doctor if you want to get the appropriate blood work and the other
procedures listed above. But there are "low tech" and yet very useful evaluations you can do on your own which also
help determine your cardiovascular risk.
The "low-tech" cardiovascular
evaluations
Smoking: The first evaluation is a simple question.
Have you smoked in the past twenty years? The more you have smoked and the more recent
the habit, the more detrimental its effect. Chewing tobacco is also injurious but not
nearly as much as smoking. |
|
Systolic blood pressure: This is the top number of your blood
pressure reading. Above 140 mmHg the risk of cardiovascular disease rises as the blood
pressure rises. |
|
Ankle-Arm Index: This is also called Ankle-Brachial Index
(ABI) and is the ratio of the ankle systolic blood pressure* divided by the arm
systolic blood pressure. A normal index is 1.0 and below 0.9 indicates
cardiovascular disease.
I mention
this test because you may have heard of it, but be aware that it has limited value.
The potential weakness of the test is that it tends to be falsely normal in people
with calcifications in their arteries, people with diabetes, pre-diabetes, or those
with Vitamin K deficiency. Millions of Americans are pre-diabetic or diabetic and
most of them don't even know it. Also, recent studies indicate that significant
Vitamin K deficiency is becoming common.
So, if the
Ankle-Arm Index is normal you must exclude these causes of arterial calcification
before you can assume the test is truly normal. If the test is abnormal, you have
some degree of cardiovascular disease.
* Ankle
pressure is taken with the cuff just above the ankle and the stethoscope listening
just below the cuff on the inner side of the ankle immediately behind the ankle
bone.
|
|
Resting Heart Rate: An elevated resting heart rate is a powerful
indicator of cardiovascular disease in men (however studies have not shown the
correlation in women). Healthy = Below 64 beats/min, Mild risk = 64 to 69 beats/min,
Moderate risk = 70 to 75 beats/min, High risk = 76 to 80 beats/min, Above 80 beats/min
the risk is three times normal. |
|
Heart Rate Recovery: This test assesses how quickly
your heart rate returns to normal after exercise and is quite useful in determining
cardiovascular health. This requires that you can reach 85% of your maximum predicted
heart rate (your maximum predicted heart rate is calculated as 220 minus your age). If
you currently aren't accustomed to that degree of exercise, you should get an exercise
program from your doctor or a fitness coach and build up to that level slowly. Once you
are able to reach that heart rate, you stop the exercise and measure your heart rate 1
minute later. If the rate drops by 12 or less during that minute the test is abnormal
and there is significant risk of cardiovascular disease. |
|
Basal Body Temperature: This is a test of your core body
temperature and is a very useful test to determine if your thyroid hormonal system
is underactive (ie hypothyroid).
What does being hypothyroid have to do with
cardiovascular disease?
Hypothyroidism
causes abnormal lipid metabolism which results in accelerated cardiovascular
disease. Cholesterol and other lipids can become elevated due to diminished
function of lipid metabolism enzymes caused by the lower body temperatures. Many
body enzymes are highly temperature dependent, malfunctioning at abnormally low or
high temperatures. The more abnormal the temperature, the more malfunctional the
enzyme. On a molecular basis, this is why we become listless as our body
temperatures go out of the normal range and we die at temperature
extremes.
Although the
frequency of hypothyroidism has been hotly debated for many decades, I am convinced
that hypothyroidism is common and often unrecognized. The official normal range of
thyroid blood tests are virtually useless except for obvious hypothyroidism and
hyperthyroidism. These blood tests are useful if much tighter normal ranges are
used. Additionally, accurate assessments of thyroid function can be obtained with
basal body temperatures.
Ideally body
temperature is taken immediately upon awakening and while still in bed, but it can
be taken during the day at least 15 minutes after eating or drinking and when you
haven't been exercising. Men and post-menopausal women can take their temperatures
on any day but menstruating women have some restrictions. Their temperature
fluctuates with their menstrual cycle, lowest at ovulation and highest just before
menstrual flow. They can most accurately measure the temperature on the second and
third day of the period after the flow begins. Normal temperatures are: Armpit 98.0
+/- 0.2, Oral 98.6 +/- 0.2, and Rectal 99.0 +/- 0.2 degrees Fahrenheit.
Another
useful assessment is an exceedingly low-tech question, "Do you tend to be very hot
or cold when most others are not"? Characteristically, hypothyroid patients are
very "cold blooded" and are cold to their core even when wearing warm clothes. As a
corollary, these patients rarely can create any significant sweat. As an aside, two
other conditions that can cause low body temperature are adrenal exhaustion and
profound hypoglycemia but these diagnoses are usually quite obvious.
|
|
Gum health: Do your gums bleed when you brush your teeth even
though you don't have a blood coagulation disorder? If they do, you likely have either
have periodontal disease or Vitamin C deficiency or both. Either condition predisposes
you to cardiovascular disease. |
|
Waist size: There are many cardiovascular risk formulas and
ratios that use your waist measurement, but one of the simplest is also one of the
most accurate:
Your waist
size in inches should not be greater than one half your height in inches. The
greater your abdominal girth relative to your height, the greater your risk of
cardiovascular disease.
Insurance
companies are good at making money because their actuaries are very knowledgeable
in determining risks. Why do you think they insist on knowing your height and waist
measurements as part of your insurance physical? Increased abdominal girth is a
strong indicator of hyperinsulinemia, pre-diabetes, and diabetes and consequently a
useful indicator of cardiovascular disease.
|
|
Summary: We have reviewed several of the most important indicators of
cardiovascular health and disease. As Goethe aptly stated, what one knows, one sees. You now have a knowledge of
cardiovascular health and disease that few others have. You are equipped to see what most will overlook.
If you passed most or all of these tests in flying
colors, congratulations, your risk of cardiovascular disease is very low.
If you underperformed on many of these tests, now is the
time to do something about it. As long as there is life, there is hope. You will find instructions on what to do
about abnormal cardiovascular tests in past and future articles here on the website, but the most basic
intervention always is maximizing our daily nutrition.
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