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Quick Summary tl;dr
Heart disease is not as simple as it sounds; it is not as simple as maintaining a cholesterol level within normal range. Heart disease is an intricate disorder of genetics, metabolism, inflammation, oxidation and plaque formation.
A high-speed CT or (EBT) scan of the heart will show you a picture of the amount of plaque in your arteries. A calcium score higher than 100 is a concern, and a score higher than 400 indicates severe risk of cardiovascular disease.
The risk of heart disease can be lowered by following a low-carb or ketogenic diet.
Prevalence and Risk of Heart Disease
Normally the heart pumps blood and oxygen to the body's cells through veins and arteries.
Heart disease describes a group of problems that occur when the heart and blood vessels aren't working the way they should. For example a blood clot blocks an artery and the heart muscle is starved of oxygen, heart muscle cells die and this leads to a heart attack; or if blood flow to the brain is blocked or a blood vessel is ruptured, a stroke occurs.
Most diseases of the heart (coronary artery disease, congestive heart failure) can lead to a heart attack (1, 2, 3).
Heart diseases are responsible for 31% of deaths globally ( 4). In men, the risk for coronary heart disease increases starting at age 45. In women, the risk for coronary heart disease increases starting at age 55.
Symptoms of Heart Disease
Knowing the symptoms of heart disease can save your life. Initial symptoms may start as a mild discomfort that progress to significant pain typically lasting 30 minutes. Do not ignore it.
The most common symptom of heart disease is chest pain; described as a discomfort, heaviness, pressure, aching, burning, fullness, squeezing, or painful feeling in your chest, shoulders, arms, neck, jaw or back. It can be mistaken for indigestion or heartburn.
Other symptoms include:
- Shortness of breath, anxiety
- Palpitations (an irregular "flip-flop" feeling in your chest), faster heartbeat, or increased awareness of your heartbeat
- Fullness, indigestion, or choking feeling (may feel like heartburn)
- Sweating, nausea, vomiting, or dizziness
- Some people have a heart attack without having any symptoms, which is known as a "silent" myocardial infarction (MI)
If you think you are having a heart attack, get help immediately. Quick treatment is very important to minimize the amount of damage to your heart.
What Are the Emerging Predictors of Heart Disease?
Not too long ago normalizing cholesterol levels was viewed as a high priority in heart care. What we thought was very important in regards to “Good” and “Bad” cholesterol is not so.
While cholesterol still counts, we now know to focus on types of blood lipids: LDL size, HDL/cholesterol ratio and triglyceride/HDL ratio. Although experts disagree on this, large particle LDLs may not be harmful to your health while the smaller, denser LDL particles can more easily oxidize and trigger inflammation.
Today we know oxidation, inflammation, blood clotting factors, plaque and genetics all predict heart disease. If you are interested in heart health, expand on your discussion with your doctor to include these 4 risk categories to help identify heart disease risk early. A quick interesting point is that many of these risks for heart disease are also diabetes risks as well. ( 5)
1. Inflammation
Inflammation is a natural part of the body’s immune system. It is a response to help repair different types of damage.
Inflammation can be acute (healthy) or chronic (unhealthy). Acute inflammation occurs over seconds, minutes, hours, and days; for example swelling after an injury; while chronic inflammation occurs over long periods of time and is associated with chronic diseases such as diabetes, heart disease and obesity.
How to Identify Inflammation?
Cytokines such as the ones below help identify inflammation ( 6):
- Tumor necrosis factor alpha -1 receptor (TNF) is a cytokine secreted in fat tissue involved in signalling and regulating normal body functions like the immune response. High levels are linked to heart disease and other medical conditions like cancer, rheumatoid arthritis and diabetes. Less than 5.6 pg/mL is normal.
- Interleukin 6 (IL-6) is both a pro-inflammatory cytokine and an anti-inflammatory myokine secreted by T cells and macrophages to stimulate an immune response leading to inflammation. Less than 5.0 pg/mL is normal.
- High-sensitivity C Reactive Protein (HS-CRP) is a protein that increases in the blood with inflammation. Less than 1 mg/L is normal, ideally below 0.7 mg/L.
- Homocysteine is an amino acid produced as part of the body's methylation process (also related to genetics, see below). High homocysteine levels contribute to plaque formation by damaging arterial walls leading to increased risk of heart attacks and strokes. Less than 15 mcmol/L is normal.
2. Oxidation
Fat and mineral imbalances contribute to oxidation (cell damage from excessive free radicals). Each nutrient imbalance carries its own specific risk for heart disease. Too much polyunsaturated fat and iron increase risk while deficiencies in magnesium can contribute to heart disease.
Fat Imbalances
Lipid peroxides (oxidized lipids) are the products of free radical damage to fatty acid cell membranes ( 7). Free radicals "steal" electrons from the lipids in cell membranes, resulting in cell damage.
Polyunsaturated fats (PUFA) are more readily oxidized because they contain methylene –CH2– groups. That’s why diets high in PUFA contribute to oxidation and increase risk of heart disease. Like TNF and other inflammation markers, lipid peroxides are not just tied to heart disease, there is a link with diabetes, cancer and neurodegenerative diseases including Parkinson's disease and Alzheimer's disease.
Thiobarbituric acid reactive substances (TBARS) is a marker that measures lipid peroxides (oxidative breakdown of fats). It is a strong and independent predictor of coronary heart disease ( 8).
Magnesium Imbalance
Magnesium is a mineral that acts against oxidation and is a co-factor for over 300 enzymes in the body. Its relation to heart health is deep ( 9).
Magnesium deficiency leads to an increase in both sodium and calcium deposits in the heart, and therefore increased risk of heart disease. Artery calcification is the basis for plaque build-up in the arteries and is measured with a total calcium score (no evidence of CAD: 0 calcium score, minimal: 1-10, mild: 11-100). Normal magnesium level range is 1.7 to 2.2 mg/dL.
Iron Imbalance
Iron is a mineral that carries oxygen in the hemoglobin of red blood cells helping cells produce energy. Men and post menopausal women are at higher risk for heart disease if iron is too high. Healthy levels range between 40-60 ng/mL ( 10).
3. Genetics and Metabolic Markers
Associations continue to build between heart disease and both genetic factors and metabolic markers. Genes have been found to regulate lipid and cholesterol metabolism, while metabolic markers, such as blood sugar and insulin, are already cemented in science.
Apo E Genes and Heart Disease
Apo E genes influence heart disease risk by providing instruction for making a protein called apolipoprotein E. This protein combines with fats (lipids) in the body to form molecules called lipoproteins. These lipoproteins are components of cholesterol. The ApoEε4 mutation raises risk of CHD, while ApoEε2 allele lowers risk of CHD ( 11).
MTHFR and Heart Disease
Methylenetetrahydrofolate reductase (MTHFR) is an enzyme regulated by the methylenetetrahydrofolate gene. It plays a role in processing amino acids, and it is important for chemical reactions involving forms of the vitamin folate and converting homocysteine to another methionine. If there is a mutation in this gene there is an increased risk of heart disease ( 12) and homocysteine levels will be high.
Insulin and Heart Disease
Insulin is a fat storing hormone automatically released after sugar or carbohydrates are consumed. Insulin is directly related to elevated triglycerides (therefore raising the TG:HDL ratio) and weight gain in the belly (increased level of visceral fat - a well known risk factor for heart disease). A healthy fasting insulin level is less than 3-5 mcU/ml.
Diabetes and Heart Disease
Diabetes (Type 1 and Type 2) contributes to heart disease as high circulating blood sugar levels can contributes to sugar laden plaque build up.
Even when blood sugar levels are within pre-diabetic range 100-125 mg/dl risk of heart disease increases ( 13). One study completed by Cleveland Clinic showed that compared with individuals whose blood sugar was below 79 mg/dl, those who had blood sugar between 100-125 mg/dl had a 300% increase of coronary heart disease risk ( 14).
4. Artery Plaque
Blood clots and calcium build up in the arteries (calcification) are physical (vs. biochemical) contributors to heart disease risk factors.
Fibrinogen and calcium are two of these underlying factors in heart disease.
Fibrinogen and Heart Disease
Fibrinogen, or factor I, is a blood protein made in the liver. Fibrinogen is responsible for normal blood clotting. Elevated fibrinogen may decrease blood flow, especially through partially blocked arteries, and may promote the formation of abnormal blood clots inside coronary arteries and directly contribute to the atherosclerosis process by binding to LDL. Fibrinogen should be less than 300 mg/dl.
Calcium and Heart Disease
Calcium along with fat and cholesterol deposit as artery plaque over time. The imaging test provides an early look at calcium build up. If calcium is deposited there is stiffening and narrowing of the artery which can restrict blood flow or trigger a blood clot causing a stroke or heart attack.
Can a Ketogenic Diet Lower Heart Disease Risk?
Despite its complexity, the risk of suffering heart disease can be lowered with a simple dietary change: by lowering carbs to less than 45% of total calories and with a ketogenic diet ( 15, 16).
Many of the risks associated with heart disease should be included as part of heart health check ups. It is wise to understand the symptoms and totality of the risks to maintain good heart health.
Next time, we’ll explore exciting research that that looks at mechanisms to lower the risk and prevent heart disease.
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