The month of February always carries a special meaning for me. It's early enough in the New Year to set goals on many levels, the most important from my point of view being health-related. But it is also Heart Month and being that heart disease is still this nation's biggest killer, it is relevant to reflect on what is, and what can be! Yes, with current technology over the last thirty plus years we have been able to save the lives of countless people from fatal heart attacks, if and when they present early enough to the Emergency Room after the onset of symptoms. Coronary intervention with balloon angioplasty and stenting has become the gold standard for emergency treatment for those presenting with an acute heart attack, or myocardial infarction.


But how have we done on the preventative front? It's a lot more complex than taking a blood pressure pill or a statin to lower your cholesterol. After all, fifty per cent of folks that suffer a myocardial infarction have normal cholesterol levels. So to really make a difference with prevention, we have to look outside the box and employ new methodology to better stratify which patients should undergo a specific treatment. One size definitely does not fit all, in spite of what you might hear from a very well known HMO that broadcasts on essentially every radio station!

For me, it is of key importance to utilize appropriate testing to help guide both physician and patient. I'd like to center this discussion on advanced cardiac testing which is regularly performed here at HeartWise Fitness and Longevity Center. Most physicians, including most cardiologists order a simple coronary risk panel or lipid panel. What one obtains is a measurement of the total cholesterol, the Hdl (or favorable cholesterol) and the triglyceride level. The Ldl, known as the “lousy " cholesterol since it is the one most often associated with heart disease is not even measured, but calculated from the triglyceride level. Moreover, if the triglyceride level is above 400, the Ldl cannot even be measured with any degree of accuracy. So there are major pitfalls to the standard lipid testing.

Enter newer, insurance approved cardiac laboratory testing. There are several good labs that perform such testing, I happen to prefer Berkeley Heart Lab, because it has been around the longest and offers the most up to date testing. Furthermore, they have been taken over by Quest Laboratories in recent years which make such testing easily accessible since Quest is the single largest laboratory in the United States.

A very useful measurement that can be determined is Hdl and Ldl particle size by subfractionation analysis. What is measured here is the actual size of both the Hdl and Ldl particle. The larger the particle size, the better the prognosis and a lower likelihood for cholesterol plaques in the arteries. It's important to understand that not all LDL is bad. In fact if there was inadequate Ldl cholesterol there would be inadequate cholesterol stores in the brain which are essential for optimal brain function as we age. The smaller the Ldl particle the more likely it is to be oxidized. Small dense Ldl particles are 40% more likely to be oxidized than large buoyant particles.  Furthermore, the treatment is different as is the dietary recommendations. The therapeutic goal in such patients is to alter, more specifically increase the size of the Ldl particle. Statins, the most widely used medications in cardiology lower the total  amount of Ldl, however, they do nothing to increase the size of the Ldl particle. A different class of drugs is more useful here, as is a lower carbohydrate diet.

So you can see that a simple lipid panel, which is the usual test employed by most physicians, is grossly inadequate in stratifying what recommendations are given to a patient.

Another important aspect in assessing risk is evaluating a given patient's inflammatory profile. We now know that inflammation is the bane of our existence when it comes to diseases of aging, and clearly inflammation is the basic process leading to coronary heart disease. But this is still relatively new information. When I was a cardiac fellow studying cardiology a mere 30 years ago, the term inflammation was not even mentioned. Now we know its importance.


There are a few tests that help in assessing individual risk here. Highly sensitive C-reactive protein is a non-specific marker for inflammation. The values would be expected to be elevated in times of an active infection such as a cold or flu. But there are many people walking around 24/7 with elevated values which is not a good thing. Obesity, sleep apnea, poorly controlled diabetes, cancer, gum disease and chronic sinusitis are just a few culprits here. But what you need to know is that a level persistently above 1 is considered abnormal. It matters not what the actual cause is, but persistent elevations in CRP can be a harbinger for coronary heart disease. 

There is quite a lot of useful advanced cardiac testing available today. Outside of the HMO setting, most of this testing is approved by Medicare and most PPO insurance. What I have mentioned here is merely the tip of the iceberg. In the next installment I will elaborate on advanced cardiac testing as well as some important genetic markers that I like to employ for my patients with a positive family history for heart disease. 

I may be known as the Medical Advocate. but my wish is for all of you to do your research and take charge of your health—in turn, you become your own best medical advocate! After all, whose body is it? So please, stay in the driver's seat when it comes to your health and well-being. Use the information in this blog to help guide you on your journey to wellness.

Dr. Elkin is a board-certified internist, cardiologist and anti-aging medical specialist.

VERY IMPORTANT NOTE / DISCLAIMER: I am offering—always—only general information and my own opinion on this blog. Always contact your physician or a health professional before starting any treatments, exercise programs or using supplements. ©Howard Elkin MD FACC, 2013

*Originally Published Tuesday, February 17, 2015

chelsea barocio