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Beating heart disease.

If the recent American Heart Association convention is any indication, 1989 will go down as the "year of the heart"

My favorite relaxation activity is reading letters from children with questions about health and answering as many as I can. The following letter is from a young reader worried because her grandfather suffered a heart attack. It is the kind of letter I like to answer, because when this little girl asks what she can do to help, there really is something she can do.

Dear Dr. Cory:

Can you tell me how a heart attack can happen? What can I do?

Jaime Brannock, Versailles, Kentucky

[Her mother had added a clarifying note:]

My daughter (9 1/2) brought this to me to mail to you, and I see that she is very concerned about her grandfather, who just had a heart attack. She is "his little girl." They are very close. Any help you could give me with helping her to understand would be greatly appreciated. Of course, we are all devastated.

Tina Brannock, Versailles, Kentucky

Dear Jaime:

You can help your grandfather by asking your mother to take you to a doctor's office or a medical laboratory to have a test to screen for cholesterol in your blood. Cholesterol is just a long name for the fats in your body. There is bad cholesterol that makes sticky spots inside your blood vessels, and there is good cholesterol that flushes out the bad cholesterol to keep your blood nowing to every part of your body.

In your grandfather's case, it may well be that he had too much of the bad kind and not enough of the good kind.

What often happens in heart attacks is that the sticky bad cholesterol closes off some of the blood vessels to the heart; without blood and oxygen, that part of the heart can no longer pump blood. When this happens, the heart (which is mostly muscle) tries to pump and doesn't have any oxygen, and it usually becomes very painful.

We know a lot more now about who will suffer a heart attack or even a second heart attack than we did when your grandfather was young. We know that family members tend to have similar cholesterol patterns. We also know how to help those families in which the bad cholesterol tends to run dangerously high. Doctors can find out if a grandfather has this tendency by looking at the cholesterol of the man's children and grandchildren. That is where you come in.

If your cholesterol is higher than normal for a child your age, you can ask your mother to have a "fractionation of your cholesterols" done. This would tell whether your good cholesterol runs too low or whether your bad cholesterol runs too high. If either is true, naturally your mother and your grandfather would want to have theirs checked too. Then you could become an authority on how to get the family cholesterols into line so that none of your family members would remain in the "high risk" zone for a heart attack.

You can learn how to cook with good oils and how to avoid bad oils when you help your mother make favorite dishes for your grandfather. You can also help your grandfather take seriously the exercises his doctor prescribes. Good exercise habits help keep the cholesterol in balance.

Heart specialists, such as Dr. Ken Cooper of Dallas, write whole books on what they have learned about the importance of exercise and diet and what people can do to prevent a heart attack.

I've always found it's a good idea to challenge children by telling them the truth about a lot of things they will have to reach up to understand. I've found that when you teach children something not found in your ordinary third-grade textbooks, they often respond in a most favorable manner.

There is so much known that needs to be acted on regarding the heart. We could prevent thousands of premature deaths if we could reach all the children through the schools and thus get to the parents whose health habits cause heart attacks.

The urgency of this need was never more graphically brought to my mind than last November, when I attended the 61st annual conference of the American Heart Association.

No less than 28,000 cardiologists, scientists, and members of the press attended this meeting, held at the convention center in Washington, D.C. Even in that enormous facility we found ourselves having to sit on the floor to hear research papers being presented. There was a feeling of urgency in communicating the lifesaving changes in lifestyle to everyone.

The international session brought scientists from 38 countries. A third of the papers presented were from overseas. Dr. August ("Gus") Watanabe, chairman of the event for the past three years, explained for our readers just what is involved in organizing such a gathering of high-powered cardiologists. A committee of 20 decides which abstracts will be presented, he said, This year, the committee received 8,000 papers, from which 2,600 were selected. Each paper is graded on a scale of one to ten. The grades are put into a computer. All this is done in July, before the meeting.

"The meeting has two main objectives," Dr. Watanabe said. "One is to provide state-of-the-art symposia and continuing medical education for physicians and nurses who take care of patients. The other is to present original research that has not yet been published. So it's very new stuff."

The silent heart attack was one of the most interesting subjects discussed at the November meeting. A portion of the heart can have its blood supply cut off without pain resulting. Until now it had been believed that ischemia (lack of oxygen) of the heart muscle would cause pain. The papers presented showed that this is not always the case.

Post: Exactly what is a silent heart attack?

Dr. Watanabe: So-called silent ischemia refers to ischemic heart disease and myocardial ischemia-lack of blood flow to the heart musclethat doesn't cause any symptoms, so the patient may even be having a heart attack and isn't aware of it. This is a relatively new clinical entity that we've just, in the last few years, begun to realize is fairly common. And it's important. At the symposium, they discussed how one detects this, what the prognostic implications are, who we should screen for this problem, and so forth.

Post: How do you screen?

Dr. Watanabe: You have to do a certain kind of continuous electrocardiographic monitoring, sometimes called Holter monitoring. And if you set it up in the right way you can see changes in the EKG that indicate ischemia even though the patient may not be having any symptoms.

Post: Is it necessary to do the monitoring on a treadmill?

Dr. Watanabe: No, not necessarily, because the problem with it is it can happen at any time, while the patient's at home, maybe while he's sleeping at night or eating dinner. If it only happened on the treadmill, then we could detect it easily, but in these cases, it often happens even when the patient may not be exercising. The problem is it doesn't give them any symptoms-that's why it's called silent-and since they don't have symptoms, they don't know that anything is happening to them.

Post: How dangerous is a silent heart attack?

Dr. Watanabe: It might be damaging to the heart muscle. It might even, in some cases, cause sudden death. In other words, it's very dangerous.

Post: What causes silent heart attacks, and how many people do you think suffer from this problem?

Dr. Watanabe: Well, it's caused by coronary artery disease, generally; sometimes by spasm of coronary arteries, but mostly by coronary artery disease, which is to say arteriosclerosis of the coronary artery. We really don't know [the percentage of patients affected], but the main point here is that this entity is now being recognized, and it will be studied further. I'm sure people will hear a lot more about it.

Post: What about the heart drug TPA? TPA's passage through the FDA approval process created a stir on Wall Street as well as in medical circles.

Dr. Watanabe: That was a real controversial thing. There were a number of editorials written and letters to the editor, and the FDA Cardiovascular and Renal Drug Advisory Committee that advises the FDA on such decisions took a lot of heat. In fact, I think there were articles in the Wall Street Journal and other lay press about it. One of the reasons that there was so much interest in it was that TPA is made by Genentech, which is, as you know, one of the high-pro file biomedical recombinant DNA-type drug companies, and this delay affected the value of their stock. So Wall Street got involved as well, but eventually TPA was approved-I believe about a year ago. Now it's being used widely. The main problem with TPA is it's very expensive. It costs several thousand dollars to treat a single patient, and it's much more expensive than the other alternative to TPA, which is streptokinase, People are still arguing that we need to prove that TPA is better than streptokinase.

Post: Is TPA better?

Dr. Watanabe: Well, there are suggestions that it is, although there are currently some head-to-head studies being done that will prove once and for all whether or not it is better.

Congestive heart failure, "still one of the real difficult problems that we have," Dr. Watanabe said, was another important topic of discussion at the meeting. In one session, newer drugs for treating heart failure were discussed, and in another session, the role of heart transplantation. "It turns out that heart transplantation is by far the best way of treating advanced refractory heart failure," Dr. Watanabe said. "The data are the best with transplantation, much better than we can get with drugs. The problem is that we can't get enough organs, so it's still a treatment that's limited to only a small percentage of the patients who might benefit from it."

Post: How about the artificial heart?

Dr. Watanabe: There was really very little discussion of artificial hearts at this meeting. I think that means that we're not really making much progress right now. There's a real problem as far as coagulation difficulties and so forth.

Post: Perhaps the study that attracted the most interest from the press came from a comparison of varying treatments for heart attack victims.

Dr. Watanabe: This was a large study in which they evaluated patients who had a heart attack and received thrombolytic therapy within four hours of the onset of chest pains. The patients were randomized into one of two groups. One "conservative management group," meaning that they just did the normal conservative treatment of heart attack patients. A second group that was randomized too was the aggressive treatment group. All those patients had heart catheterization, and then, if appropriate, they had balloon angioplasty or coronary bypass surgery. So that group was much more aggressively managed.

It was an interesting conclusion because what they found was that the results were no better in the aggressively managed patients than in the conservatively managed ones as far as left ventricular function is concerned, and they looked at several other end points too. On the other hand, the aggressively managed group, the ones that had heart catheterization, had more complications. More of them bled, more of them needed blood transfusions, and then of course, the cost was much more for that group of patients than for the conservative group. That was an important study, because it has implications for how to treat patients with heart attacks, and it looks like a more conservative approach will lead to as good an end result as the more aggressive approach.

Post: What is the conservative approach, today?

Dr. Watanabe: Well, in this particular case it was thrombolytic therapy with TPA, and then they continued the patients on heparin and aspirin and took care of them in the coronary-care unit like you normally would. Prior to discharge they were given a limited stress test. If the stress test was positive, they went ahead and studied them, but if it was negative, they just sent them home and followed their conditions.

Post: Heart attack deaths are decreasing in the United States. What is causing this if it's not our aggressive treatments?

Dr. Watanabe: Well, we really are making substantial progress in decreasing mortality from cardiovascular disease. I can't quote you the exact percentage reduction in the last ten years, but it's really pretty dramatic, and I think it's important for the public to be aware of that. This is very different from any other major category of disease. For example, cancer: although we've made some progress in early diagnosis and better therapy, there are no dramatic reductions in large populations of the mortality from cancer.

But there are clear-cut, dramatic reductions of mortality from cardiovascular disease, and I think that's due to several things. For one, better awareness by the public of risk factors such as smoking, dietary factors, cholesterol, etc. I think there is generally a better awareness and people are changing their lifestyles.

The second major thing is that we've got better drugs, particularly for treating hypertension, and therefore, we've reduced hypertension as a risk factor.

The recent data regarding cholesterol pretty convincingly show that it is an important risk factor, and that if you lower the cholesterol you'll reduce the risk for cardiovascular disease. I think that is going to help our reduction in mortality even more.

Also, coupled with that is the development of some new cholesterollowering drugs such as Mevacor, and there are many others coming down the pike.

Post: Doesn't Mevacor, like niacin, have side effects on the liver?

Dr. Watanabe: Yes. When you take Mevacor you have to follow your liver functions every four to six weeks, and the other problem with Mevacor, it's very expensive. It's over a dollar a pill.

Post: Is the risk of taking niacin justified for patients who can't afford Mevacor?

Dr. Watanabe: Yes, however, it is important to follow those tests to make sure there are no abnormalities developing.

Although prevention was a topic of numerous sessions at the symposium, Dr. Watanabe explained that among medical specialists, sessions about new drugs and new treatments generally draw the big crowds. "Most of the big symposia don't deal with primary prevention of heart disease, unfortunately," he said. "What they deal with is how do you treat it after the disease is there.

"Primary prevention-changing the diet, stopping smoking, those sorts of things-is also very important, probably even more important."

Post: Is there a huge difference in coronary artery disease in areas where the diet is radically different, as in Africa?

Dr. Watanabe: Well, it's a lot lower there, yes.

Post: What about Asians, now that they have a higher standard of living? Is there more heart disease?

Dr. Watanabe: It's low in Japan. But it's probably intermediate in the Japanese who live in Hawaii. In Japanese who live in the [continental] United States, it's just the same as Caucasians who live in the United States. That indicates that the cause of coronary artery disease is importantly related to diet.

To learn about the latest research in prevention through diet and exercise, we interviewed an old friend, Dr. Kenneth Cooper, the father of aerobics and the man New York Medical College called "the leader of the international physical-fitness movement who has motivated more people to exercise in pursuit of good health than any other person."

Dr. Cooper does research at the Cooper Clinic in Dallas, Texas, where he is the director of the Aerobics Center. His seventh book, Controlling Cholesterol, appears to be a permanent resident on the bestseller list.

Post: Your book Controlling Cholesterol has been on the bestseller list for weeks. Can you explain why it is so popular?

Dr. Cooper: It's been amazing to me. The book has sold almost 200,000 copies in hardback form, and the first printing in January in softback is 700,000. But I'll tell you, I'm speaking constantly-three or four times a week, literally all over the world-and whenever I hit cholesterol, that is the key topic. Fitness, yes, but cholesterol-everybody has questions about cholesterol. The thing about it is it's something that we can do. If we have a problem, we can correct the problem. That's the exciting thing. Now, with medications in cases where patients don't respond to a more conservative approach, there's hope. I think that's why people are so turned on to cholesterol.

Post: At your clinic you emphasize exercise for controlling cholesterol.

Dr. Cooper: Exercise, diet control, and weight loss-those are the principal three. We try to correct the things that may be having an effect on the cholesterol ratios-such as cigarette smoking, the birth-control pill, and obesity, which lower the HDL [the "good" cholesterol]. You may have seen the American Journal of Cardiology article by Peter Wood and the group that's really been misinterpreted in the literature. I saw something in the Dallas Morning News a couple of days ago-it was an AP wire-that talked about exercise being not as valued in increasing the HDL. The Peter Wood study from Stanford showed that in a wellmatched group, one group lost weight by exercising and one group lost weight by dietary restriction. They both had the same results as far as decreasing the total cholesterol and increasing the HDL. So some reporter assumed that exercise [itself] has no effect on increasing the HDL, and that it is actually the weight loss from exercising that causes the HDL to increase. That is simply not true. We have at least three published articles that have shown that people can increase the HDL even though the weight remains constant if they get involved in good aerobic exercise. So that's sort of a controversial thing.

It's the same as the Ralph Paffenberger study when it came out saying that you had to expend 2,000 calories per week to get an extension of your life span of 2.4 years. Some reporter said you've got to run 20 miles a week then, because running a mile is worth about 100 calories. Well, that's not what Paffenberger said. He was completely misquoted. What Paffenberger showed was total activity, not just strictly regimentedtype physical activity in a conditioning program. That 2,000 total expenditure per week includes your exercise program plus walking up and down a flight of stairs plus walking to the store plus to the bus stop. In fact, you'll find that if you compare my work recommending 30 points per week and Paffenberger's work recommending a total of 2,000 calories per week, there's really not that much difference. So again we're trying to quantify these things.

We know that the press does tend to misinterpret, and certainly they did with HDL cholesterol and exercise, because if you want to improve the HDL cholesterol, food's not going to do it. Stopping smoking, stopping using the birth-control pill, losing weight, and aerobic exercise increase the HDL cholesterol. The worst offender without question for lowering the HDL cholesterolis anabolic steroids.

You see the lowest HDLs and the very highest ratios in these weight lifters who come to us and know that we know they're taking steroids. Then I can look at that without even checking their urine or anything else, and I can tell these people what they're doing.

We had a young man who was a typical weight lifter who came in the other day. He's about 25 years of age, about 5'9", 240. His total cholesterol was 350 and his HDL was 7. He had a ratio of 50.2. The ratio should be less than 4.6. I would love to have known if [the Olympic contender] Ben Johnson had any blood studies done. I would love to have known what his HDL cholesterol was. I'll make you a bet it was low, because anabolic steroids seem to be the worst offender of all to lower the HDL cholesterol.

Post: What about some of the new drugs, such as Mevacor, to lower cholesterol?

Dr. Cooper: We're one of the testing sites for Merck Sharp and Dohme in the longitudinal studies to see if there are any side effects from Mevacor. I use Mevacor quite regularly now, but I use it only on patients who have had bypass surgery, who have had heart attacks, and are not responding to anything else. My best success is when a person will respond to a 20 mg tablet taken at night. Theoretically, you should take it right before you go to bed because that tends to slow down the production of the LDL cholesterol that occurs about 3:00 a.m. That's when the body produces most of its LDL cholesterol. That's what the people at the University of Texas Southwestern Medical School tell us.

Post: And that's why most heart attacks come at 4:00 a.m.?

Dr. Cooper: That's right. There may be a relationship, but again their recommendation is to take a 20 mg tablet right before you go to bed at night. So five to six hours later you still have that effect. We've found a lot of people can't take it that way because of gastric distress, so they take it at the evening meal. I'm finding just about as good a result in the total lowering of the cholesterol, including the HDL, if you take one at the evening meal.

Post: Do you use niacin?

Dr. Cooper. We've got to be careful about niacin because there are questions about Robert Kowalski's book [The Eight-Week Cholesterol Cure]. I've heard there have been problems because he really plays down the harmful side effects of niacin by saying it only causes skin rashes and flushing. I've noticed in later editions of his book that he really cut way down in recommending niacin. I could have told you that 15 years ago. I've been using niacin for that period of time. It works in some cases, but you've got to follow patients at least at six-week intervals, because a certain number will develop severe liver problems in conjunction with it. I've hospitalized at least six patients as a result of niacin problems.

Post: Getting back to diet for lowering cholesterol: we have a friend who after triple bypass surgery is trying to stay on the Pritikin diet.

Dr. Cooper: You don't have to be that restrictive, we're discovering. We have a Saudi Arabian princess coming over soon who is about 100 pounds overweight. She's going to spend three months with us expressly to get that 100 pounds off. Now, whether we can do that or not -whether it's appropriate or notonly time will tell, but I'm delighted that she selected our center. I feel our programs are more realistic, because you can stick with them once you get down to the desired level. We still work at 60, 15, and 25; that's where we get our best results. That's 60 percent complex carbohydrates, 15 percent protein, and 25 percent fat, and that along with 100 to 300 mg of cholesterol. We find that we can lower the cholesterol by 13 percent in a period of 13 days and lower triglycerides about 20 percent in 13 days. It works faster because the people are here in residence. So if you look at our statistics compared to the Pritikin statistics in response to an inresidence program, I will bet our statistics are equally good and in some cases better, yet we don't have that high triglyceride elevation because of that 80 percent complex carbohydrate they use in the basic Pritikin diet. We try to give our people a program that they can live with from now on.

Post: Twenty-five percent fat is acceptable in a low-cholesterol diet?

Dr. Cooper: Yes, if you have it divided roughly into thirds: one-third mono, one-third poly, and one-third saturated fat. That's the secret. If it was all 25 percent saturated fat you couldn't do it, but you've got to evenly distribute among the three fats.

Post: The automatic finger-prick tests for cholesterol may not be completely accurate. What do you recommend for people who test over 200 on one of these?

Dr. Cooper: Those results can be plus or minus about 10 percent. If you test 250 that means you could be 275 or 225, which is still too high. But if you go less than 200 1 am satisfied. Even with a finger-stick test, that is fine. Don't worry about fractionating it [breaking cholesterol down into types]. If you are 200 to 240, you ought to get it repeated, and if it is closer to 240, then you probably should get it repeated in a standard lab. Don't use a finger stick. But the first thing, if it is 200 to 240, go back and get a finger stick the second time; that is the cheapest way. If the second one comes out close to 200, 1 would not worry about it. Now if it's above 240, and if the repeat is above 240, by all means, it will need to be fractionated because you might find as I did today-a woman had a cholesterol of 225 but she had an HDL of 88. She had a ratio of 3.2 or so. That is fine, because the best predictors, I am convinced, of future coronary events are the HDLs and the total cholesterol, plus the ratio of those two. So I encouraged that woman by telling her that her cholesterol elevation, which seemed to be elevated, really was not that important because of the primary HDL elevation. So what you need to do is raise the HDL.

Post: Could you tell us what is new, in your research beyond your work with HDL?

Dr. Cooper: One thing you might be interested in is a new book in my preventive-medicine series that will be out early this year. It is on preventing osteoporosis. I am really excited about that. American women in particular are developing osteoporosis symptoms because we are getting so concerned about cholesterol that we are throwing the baby out with the bathwater.

Post: You are referring to the lack of calcium.

Dr. Cooper: Yes, we are getting a deficiency in calcium. I suspect this will increase dramatically. The average woman who comes to our clinic is consuming no more than 400 mg of calcium per day, not far off the national average. To get through the menopause, women need 1,500 mg per day. This discrepancy is bound to establish osteoporosis in the future.

Post: What is the best kind of calcium supplement?

Dr. Cooper: Citracal. That is the one developed by Dr. Charles Pak in the University of Texas Southwestern Medical School.

Post: Pak says some people get gas from calcium carbonate and those persons have no further problems if they change to calcium citrate.

Dr. Cooper: Well, you have to accept the fact that calcium in foods is a lot easier and better absorbed than the calcium in any kind of supplement, Citracal or otherwise.

Post: We understand that calcium doesn't deposit correctly unless the magnesium is in proper balance. What do you think about Slow-Mag? We heard a lot of discussion about it at the American Heart Association meeting.

Dr. Cooper: For years, as you may know, I have suspected a relationship between cardiac irritability and magnesium deficiency. We talked about this first in our studies years ago on the Boston marathoners. We found that after the 24- or 26-mile run, they were deficient in magnesium. They were not lacking in blood sugar, but there was a loss in magnesium through sweat, and in the past we had thought that magnesium was lost primarily through the stools.

Post: I remember that you had a man pass out in your clinic.

Dr. Cooper: Yes, we had to defibrillate, and the man had a low magnesium. Boy, do you have a good memory! He's still alive and doing well. That was about 12 or 13 years ago. He had been in a marathon in California the day before, and we theorized at the time that he might have become magnesium deficient, stressing his muscles during the marathon. The lights were out. We were ' showing a film. We didn't know just how long he had been passed out. When they turned the lights on, he was stooped over on his desk, slumped over in his chair. We defibrillated him. It was the only time we've used a defibrillator on our premises. When he came to we assumed he'd had a coronary, but we couldn't ever find any of the enzyme changes or any evidence whatsoever of a coronary. The only thing we ever found was that he'd become magnesium-depleted.

Post: That Americans are finally getting interested in preventing heart attacks through diet and exercise must be exciting for you. But what about the rest of the world?

Dr. Cooper: Our work is so international. I just got back from 17 days in Europe. We are establishing a very good relationship with the Polish government. Even the Communist government is trying to get the preventive medicine program going there. Poland has had a 36 percent increase in deaths from heart attacks in the last ten years. We were there for the first time at the invitation of a young physician from southeast Poland, a place called Ustron. The people were so enthusiastic about what we are doing and what has happened here that they immediately made arrangements for one of their doctors to come back and spend ten days with us. He'd never been out of the country before. We are going to have him come back with his wife and will train him in our concepts and ideas.

So the door to Poland is wide open to us, but that is true all over the world. I spoke at the medical school in Beijing, China, last summer, and I met with the people in Shanghai. As a result, we are getting all sorts of requests to work with the Chinese, wanting us to translate my books, to come back and do some national screening.

Post: That's exciting.

Dr. Cooper: It's intriguing. I have such a burning desire to get this program going. And it is moving. I think that, literally, we have just scratched the surface.
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Author:SerVaas, Cory
Publication:Saturday Evening Post
Article Type:Interview
Date:Mar 1, 1989
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