There’s So Much More to Heart Disease than Just Cholesterol Numbers
The year I graduated from medical school, 1982, a brave new world of cardiology was just beginning. Researchers conducting a trial of the drug lovastatin discovered it lowered cholesterol in a small group of patients with a genetic predisposition for dangerously high cholesterol. Patients with this condition were at substantial risk of stroke and heart attack and often died from these cardiovascular events at an early age.
Statins had been discovered a few years earlier, but until this trial, their promise wasn’t well known. By 1987, lovastatin had become the first commercially available statin. Four decades later, statins have made an enormous difference in how we treat heart disease. In fact, atorvastatin, a generic synthetic statin, remains the most prescribed drug in America.
The story of statins is like a lot of other medical success stories — technological advancements made it possible to better treat diseases that once bedeviled doctors. In the years since statins burst on the scene, we’ve also learned a lot about how to prevent heart disease and substantially reduce risk.
Forty years ago heart disease was the number one cause of death as it had been since 1921. It still is, despite our advancements. Far too many people still succumb to preventable heart disease every year.
What’s going on? Deaths from heart disease are holding steady because of lifestyle choices we’ve made. As a country we’re much fatter and more sedentary than we were in 1982, two things that raise our risk for heart disease and other contributing diseases like type 2 diabetes.
As a physician, this frustrates me. I believe with the right approach, we can prevent most cases of heart disease and successfully manage those we can’t prevent. How? We know that 80 percent of heart disease is preventable, let’s start there.
Spend More Primary Care Time on Prevention and Coaching
First, patients and doctors need to work together on prevention. Preventing heart disease is the goal — we may have great tools to treat it, but it’s better to prevent.
This is hard because most primary care physicians have so little time to practice prevention. If they do annual physicals or wellness visits, they’re often perfunctory. Did you know that the annual wellness visit for Medicare doesn’t even require a physical exam? Only 24 percent of Medicare patients take advantage of them anyway.
Beyond basic prevention, primary care physicians may also lack time to do essential coaching, patient education and follow up. These things are essential to helping patients with lifestyle changes that can reduce heart disease risk.
Patients aren’t doing their part either. From 2012 to 2018, visits to primary care physicians declined by 18 percent for people under 65, according to a study by the Health Care Cost Institute. Furthermore, 25 percent of adults in the U.S. don’t have a primary care provider, according to a 2020 study in JAMA Internal Medicine, most of them younger adults. This is the exact population who are young enough to prevent heart disease.
Primary care visits also cratered during the early part of the pandemic, which left a lot of people short on preventive visits that can help detect heart disease early.
You can lower your heart disease risk by exercising more and eating healthier, getting to a healthy weight, stamping out cigarettes and vape pens if you smoke, and by working closely with your primary care partner. If your PCP is too busy to work with you, find one who has more time.
We all need to do a better job — doctors can work with their patients make lasting lifestyle changes and patients need to get serious about their health.
In my primary care practice, I often worked with my daughter, a nutritionist, to help patients better understand the food choices they were making and the impact on their health. Other doctors in the MDVIP network use the technology on MDVIP Connect to prescribe particular diets or exercise regimes for patients to help address heart disease risk.
These efforts take time — more than most primary care physicians have — and engagement by patients. But when doctors have time to really engage with patients on chronic disease prevention, they can have amazing impacts.
Use the Tools Available to Us to Analyze Heart Disease Risk
Besides prevention, we need to use all the tools available to us. Cholesterol tests and statins are great. We’ve used the former to inform us on patients at risk for heart disease and the latter to treat it for decades. But there’s so many other advanced screenings often ignored by primary care because they’re not covered by Medicare or commercial insurance.
Let’s take LDL particle size. Most doctors draw a standard lipid panel on their adult patients every four to six years (more frequently if you’re at elevated risk for heart disease). This tells you how high your total, LDL and HDL cholesterol and triglyceride levels are.
This is good information, but there’s so much more to heart disease than these four measures. For example, it’s important to know the particle size of LDL (bad cholesterol). Small, dense LDL particles are dangerous because they accumulate longer in the bloodstream, are more readily oxidized into inflammatory forms, and more easily penetrate into the arterial wall. And there’s usually a lot of them, making it easy for them develop into plaque and progress into cardiovascular disease. Ideally, LDL particles should be large and fluffy so that they bounce off artery walls and do not embed into them. Keep in mind, standard cholesterol tests do not measure LDL particle size. This means you can have a normal cholesterol level with a lot of small and very small LDL particles.
Which brings me back to why the standard lipid panel isn’t enough. Half of all people who have heart attacks had normal cholesterol levels. That’s right — people with normal cholesterol levels still have heart attacks and die.
Heart Disease and MDVIP
As an MDVIP-affiliated doctor, I was able to screen for LDL particle size, detect inflammation (which plays an outsized role in all development stages of atherosclerosis — the build-up of plaque in arteries) and other factors that influence heart disease risk. And of course, because I saw fewer patients, I had more time to work with the ones I saw. In my primary care practice, I was able to brag that my patients weren’t having heart attacks.
Nationally, doctors practicing under the MDVIP model are also having remarkable, documented success. Our advanced testing finds 40 percent more patients at risk for heart disease — which is important. You can’t treat small, dense LDL particles if you don’t know about them.
Patients in MDVIP-affiliated practices also use emergency rooms and urgent care centers less often than traditional primary care patients. They also experience 70 percent fewer hospitalizations. We believe the lower utilization is directly related to better heart disease outcomes. Finally, patients in MDVIP-affiliated practices at high risk for heart disease experience 12 percent fewer heart attacks and strokes.
At MDVIP, we aren’t resting on our laurels. We want to see deaths from heart disease go down. Where appropriate, we’ve worked hard to integrate the latest science and technology to help members lower their heart disease risk.
Your MDVIP-affiliated doctor, for example, may be taking part in our new cardiovascular education program, a network-wide effort that helps train primary care doctors on the latest cardiovascular testing and risk management. Because there’s a substantial link between periodontal disease and heart disease, he or she may also be partnering with a local dentist to help detect heart disease risk earlier.
And your doctor may be reaching out to you over the course of the next two months through emails like this one, the MDVIP Living Well Newsletter or even a patient education event to talk to you more about heart disease. When he or she does, pay attention. Your doctor may be sharing information with you that can save your life.
Your heart matters to your doctor and to us.