A Global Epidemic
If you’re reading this, there’s a high probability you are somewhere on the continuum of atherosclerotic cardiovascular disease, a pathophysiological process that is seemingly inevitable in our species. A large percentage of the global population eventually succumbs to ASCVD, upwards of 33%. But an even more staggering statistic is that coronary artery calcification, a salient pathological feature of cardiovascular disease, is present in upward of 90% of men and 67% of women by the seventh decade of life.
Atherosclerotic Cardiovascular Disease
Cardiovascular disease is a term that is thrown around haphazardly and often used synonymously with events like heart attacks or strokes. However, ASCVD is a complex and compounding pathophysiological process that eventually culminates in a sudden cardiovascular event like a stroke or heart attack after years of “foundational” work.
In approximately 50% of the population atherosclerotic cardiovascular disease begins in adolescence, as evident through fatty streak formation, and continues to progress through adulthood. This multifaceted process begins with lipid infiltration into the subendothelial space of arterials which elicits an orchestrated attack by the immune system in which we see macrophages ingulf the lipids generating the formation of foam cells. Over time, these foam cells begin to aggregate to initiate fatty streak genesis in the arteries. Following fatty streak formation the induction of pro-inflammatory cytokines leads to a proliferation in smooth muscle cells, ultimately leading to plaque formation.
As the plaques expand, it can lead to a narrowing or stenosis of the arterials, impeding the smooth flow of blood. In advanced cases, these plaques can rupture, leading to the formation of blood clots. These clots can partially or completely block blood flow in the affected artery, causing a heart attack if the coronary arteries are involved, or a stroke if the brain’s arteries are affected.
The compounding nature and underlying pathophysiology that precedes cardiovascular events like a heart attack or stroke is of upmost importance as it provides insights into therapeutic strategies predicated on early and aggressive risk management.
Underlying Causes of Cardiovascular Disease
The majority of cardiovascular disease is the result of a complex interplay between an individuals genetics combined with environmental factors such as activity levels and nutrition. In a small subset of the population, this disease progress is almost entirely mediated by a set of genetics variants that effect receptors sites, enzymes, or proteins that impair lipid clearance. This condition is known as familial hypercholesteremia and affects less than 1% of the population.
For the sake of our discussion today, we will primarily be discussing modifiable lifestyle factors that directly influence the progression of this condition.
When it comes to cardiovascular disease prevention I would be remised to fail to inform the reader that indeed smoking is bad for your health, and a major factor for amplifying your risk of atherosclerotic cardiovascular disease.
Outside of smoking, we will integrate all the variables that influence metabolic health, which includes nutrition, exercise, sleep quality, and stress management. These variables have a direct and linear risk association with cardiovascular disease.
Traditional risk factors for cardiovascular disease outside of smoking have often been described as the following:
-Diabetes
-Hypertension
-Physical Inactivity
-Unhealthy Diet
-Hyperlipidemia
These risk factors are interrelated and are a direct function of overall metabolic health or directly influence metabolic health. I.e. low amounts of physical activity mediates impaired lipid clearance, glucose disposal, and increases blood pressure. All of which increase cardiovascular disease risk.
Side note: I would also consider impaired sleep quality and stress induced hypercortisolemia additional risk factors which often do not get enough attention.
Prevention Framework for ASCVD
Exercise more, eat less, and infuse atorvastatin into the public water supply.
If only it was that simple…
I’m a big proponent of personalized healthcare, and I would like to try to lay out the current therapeutic strategy that I implement with patients in my current practice as it relates to ASCVD primary prevention.
Nutrition:
Nutritional status has a direct influence on metabolic health and subsequently cardiovascular disease risk. However, there are a lot of unvalidated yet dogmatic views on which diet seems to be “optimal” for cardiovascular disease risk management. Keto vs. Paleo? The truth of the matter is, outside of the 2018 revision of the PREDIMED study demonstrating that the Mediterranean diet seems to confer cardioprotective effects, we don’t have any really strong data on dietary interventions on cardiovascular disease risk. There is also a high degree of heterogeneity in how patients objectively respond to diet based interventions, which confounds uniform dietary recommendations. However, I am confident that a diet that promotes healthy lipid clearance, glucose disposal, and fasting insulin levels that translate to within-range metabolic biomarkers in the individual of interest seems to be our best therapeutic option.
Exercise:
Exercise is unequivocally our most potent lifestyle-based modality for cardiovascular disease prevention. Effectively, exercise acts as a targeted pharmacological agent when prescribed in the correct dosages as it improves lipid profiles, enhances glucose disposal, and helps to dampen inflammation. More specifically, moderate-intensity aerobic exercise seems to modulate lipid metabolism and subsequent CVD risk/mortality through favorable alterations in LDL-c, HDL, ApoB, and triglycerides. Dosage recommendations for exercise are highly dependent on an individual’s current fitness levels but a long-term exercise dosage goal that incorporates healthy periodization would be close to 4-6 hours a week.
Stress/Sleep:
Chronic stress and fragmented sleep both have a impact on metabolic parameters that directly influence cardiovascular disease risk. Aiming for at least 7 hours of quality sleep a night is a good foundation which starts with a solid wind down routine, an environment that is conducive for high quality sleep, and establishing a regular sleep schedule. Effective stress management on the other hand is a little more complex, but I have seen great responses with the integration of mindfulness and therapeutic breathing techniques.
Pharmaceutical Interventions:
Pharmacological medications have shown a high degree of effectiveness when it comes appropriately managing cardiovascular disease risk. Statins medications are currently the most prescribed drug class and often utilized as a first line therapy for managing high cholesterol. I personally don’t have prescriptive authority so my wheel house is in lifestyle/nutraceutical based interventions, but I am a big proponent of statins when patients can tolerate the medication. Outside of statin medications there are multiple other lipid lowering compounds like PCSK9 inhibitors, selective cholesterol-absorption inhibitors, and CETP inhibitors that are all effective at favorably modulating lipid levels.
Nutraceutical Interventions:
Nutraceuticals is a term used to describe a natural food based derivative that confers clinically validated medical benefits. One of the most well documented and effective nutraceuticals is the clinical application of red yeast rice extract in cardiovascular disease primary prevention. A recent review in the JOUNRAL OF THE AMERICAN COLLEGE OF CARDIOLOGY demonstrated that the use of red yeast rice for a 6-8 week period lead to significant reductions in LDL-c with proportional reductions in ApoB and hsCRP. The effect size seen in RYR is comparable to a low/moderate intensity statin. Another nutraceutical compound called berberine has also recently gained traction as a adjunctive compound that has shown affinity for the PCSK9 enzyme translating to improved LDL receptor mediated clearance.
Kansas Functional Medicine
Our approach to cardiovascular disease prevention is tailored to each individual patient, taking into account their unique needs and preferences. We use advanced diagnostic tools to assess cardiovascular disease risk and work with patients to develop personalized nutrition and exercise plans that are sustainable and effective.
At EvoHealth Kansas, we’re committed to helping our patients live healthier, happier lives by taking a proactive approach to cardiovascular disease prevention. If you’re ready to take control of your cardiovascular health, contact us today to schedule a consultation and learn how we can help you achieve optimal health and wellbeing.