How I want my own heart disease to be diagnosed and treated
It won’t surprise you to learn that I receive a huge number of questions about diagnostic testing and treatment for heart disease.
Sometimes these questions come from patients and sometimes they come from friends or family.
They’re almost always personalized - Should I get this test? Should I be on this treatment? Should I ask my doctor about doing this?
To answer these questions well, you often need a considerable amount of context about the specific situation.
But having a framework for how to think about problems is important. Without a framework each question feels like it needs to be approached with a brand new deep dive, which isn’t how I process medical information or how I treat my patients.
So for today’s newsletter, I’m going to talk about the approach to how I would want my own heart disease to be diagnosed and treated.
Let’s make sure we are on the same page with some of the vocabulary
Heart disease isn’t disease of the heart, it’s disease of the blood vessels around the heart. It’s vascular disease.
The medical term for this is coronary artery disease, a disease that falls under the umbrella of atherosclerosis (also called atherosclerotic cardiovascular disease or ASCVD).
Atherosclerotic cardiovascular disease (ASCVD) is the general term for this disease of blood vessels.
All of these names are used interchangeably, and so it can feel confusing (even for doctors) to hear the same problem described with a number of different terms.
This is a systemic illness, and if the arteries around your heart are impacted, the arteries to your brain, your kidneys, your intestines, and everywhere else in your body is at risk.
When I am considering diagnostic testing for cardiovascular risk, I’m trying to make a diagnosis about the presence or absence of any atherosclerosis.
I’m asking whether any arteries in the body are impacted by this process, and I am not looking at each individual group of blood vessels as notably different than any other.
My goal for most cardiovascular testing is to make a diagnosis
There are a lot of different tests that we can use to look for ASCVD. All of these tests involve looking at blood vessels either directly or indirectly.
I’ve written about a lot of these tests before: calcium scores, coronary CTAs, and stress tests.
Other tests that can look for vascular disease include carotid artery ultrasound (CIMT testing), renal artery ultrasound, ankle brachial index testing (ABI), or any CT scan that can see calcium buildup in the blood vessels.
If this testing is being done on me, I want it to be able to inform me about whether I have any evidence of vascular disease.
This means I want to look at my carotid arteries and coronary arteries thoroughly.
If a calcium score shows even a speck coronary calcium, then the diagnosis has been made. Atherosclerosis is present.
If a carotid ultrasound shows increased thickness of the artery wall, then the diagnosis has been made. Atherosclerosis is present.
If a coronary CTA shows that there’s a blockage in one of the arteries around the heart (even if that blockage is minor and doesn’t have any calcium), then the diagnosis has been made. Atherosclerosis is present.
If my testing reveals the presence of any vascular disease - any calcium in my coronary arteries, any thickening of my carotid arteries, any evidence of a blockage in a single artery, that says that I have atherosclerosis.
At that point I’m done with testing. I don’t need multiple tests to confirm the diagnosis. I don’t need to look at my carotid arteries if I’ve already seen something in the coronaries.
I don’t view these tests as isolated pieces of information because they are all informing me about the diagnosis of atherosclerosis, which, as we discussed, is a systemic disease.
Once you have made a diagnosis, then it’s time for treatment
Atherosclerosis is a progressive disease. It gets worse if it’s not treated.
By the time most people make it to medical attention, they’ve had this process going on for decades.
Something that’s been happening for so long doesn’t get reversed overnight - treatment for a chronic condition will almost always be long term.
And so once it’s been established that I have vascular disease, I want to be maximally treated in a few different areas.
Lipid treatment - lower my LDL-C (or apolipoprotein B)
I would like to get my LDL as close to zero as possible. I would probably rather use apolipoprotein B as the metric to track (it’s better than LDL-C in every discordance analysis), but the result is going to be pretty similar regardless of which one we use.
Get me on the maximal doses of medications that I tolerate so that we can get the numbers down.
By tolerate, I mean that I don’t develop side effects. That means I’ll probably end up on a high potency dose of a statin (rosuvastatin or atorvastatin, most likely).
Since you’re going to ask about the side effects, and lots of my patients are, here’s my response to the most common ones:
Myaglias: If I get muscle aches, I’ll stop the statin and try a different one.
Diabetes risk: I’ll be monitoring by blood sugar regularly to ensure that it doesn’t go up. The risk of a rise in blood sugar is small and it pales in comparison to the benefit for cardiovascular disease
Dementia concerns: I find the data on the vascular contribution to Alzheimer’s to be persuasive, and I’m also worried about vascular dementia if I already have vascular disease. And also, the observational data suggests that statins decrease dementia risk anyway.
If my numbers are still high, I would also like to be on a PCSK9 inhibitor (I think the data is stronger for alirocumab, but I’d be happy to evolocumab as well).
I want my apolipoprotein B to be around 40 and my LDL to be similarly low. I find the evidence that lower is better to be compelling enough to implement for my own care.
Blood pressure treatment
I want my blood pressure to be as low as possible without causing lightheadedness or orthostasis.
The data keep adding up that a blood pressure of anything over 120/80 is likely putting patients at increased cardiovascular risk and that getting the numbers lower makes a big difference in outcomes, especially over the long term.
If my blood pressure were rising, I would certainly be willing to implement a few months of lifestyle changes - more cardio, working to improve my sleep, stress reduction, testing for sleep apnea - but I would try not to fool myself into thinking that it’s alright to spend years with suboptimally treated blood pressure until I get my lifestyle factors optimized.
If a 3 month trial of trying to lower it on my own didn’t work, I’d be happy to start on an ARB or an ACE inhibitor with willingness to add medications if the pressure didn’t come down.
My limitation to this wouldn’t be the number of medications or the doses. It would be whether my numbers were at goal and whether I was having side effects from the medications.
Tackling my residual risk - inflammation, triglycerides, thrombosis, metabolic disease, and Lp(a)
The concept of residual risk is often purported to be the present and future of personalized cardiovascular disease prevention.
This makes sense on one level - we know that things like elevated inflammation and high Lp(a) put patients at higher risk.
You will read a lot of state of the art review on cardiovascular disease about the right patients to have on medications like colchicine (to reduce inflammation) or Vascepa (if the triglycerides are high).
Graphics like this one make their way into a lot of the literature:
But my experience is that in practice this concept ends up being overcomplicated and lends itself to majoring in the minor.
That’s because most residual risk is driven by metabolic syndrome, which is treated with diet, exercise, sleep improvement, and stress mitigation.
Look at that residual risk graphic above - residual inflammatory risk, thrombotic risk, triglycerides risk, and diabetes risk are all manifestations of metabolic syndrome.
Thrombotic risk deserves its own bucket for some patients, but metabolic dysfunction certainly drives quite a bit of that risk for many.
Get the apolipoprotein B as low as you can, control blood pressure, and maintain a healthy metabolic state, and the number of patients who will benefit from additional personalized residual risk reduction with medications is quite low.
A few sentences on “lifestyle”
We could spend hours discussing the things that make up lifestyle: sleep, nutrition, movement/exercise, and stress.
I’m not going to spend time discussing them because this is a description of the medical treatment I would want, not the lifestyle changes I would implement (although perhaps that’s worth addressing at another time).
But let’s also state the obvious: if you aren’t engaged about making lifestyle adjustments, the best medical treatment in the world often will never solve all of your problems.
The obvious question to ask - is this overmedicalizing?
Maybe it is.
But that’s how I would want to be treated.
When I consider the downside risk in both cases, my assessment is that the risk is asymmetric.
If I overtreat, and I’m wrong, I am exposed to medication side effects and toxicities. With the majority of treatments for cardiovascular disease, there’s a pretty long track record of safety and effectiveness. I feel comfortable that I understand these risks well. And medication side effects go away when you stop a drug.
If I undertreat and I’m wrong, I am exposed to additional risk of heart attack and stroke.
Even though most heart attacks and strokes are minor, they aren’t all minor. There’s a chance my life could be permanently altered in a terrible way.
That’s the asymmetry in risk - the worst case of being wrong with overtreatment is less bad to me than the worst case of being wrong with undertreatment.
Most of my patients disagree with this approach
For every patient I have who is persuaded by this case, there are probably 10 who think I’m wrong.
I’m not sure why that’s the case, but my observation is that most patients hate the idea of taking more medications and are almost always wondering when they can stop taking the pills that have been prescribed.
When I suggest adding more medications because blood pressure or LDL are not at goal, I almost always get pushback or the question of “do I really have to take more pills?” or “I was really hoping that you were going to stop some of my meds.”
My answer is always the same to my patients: you don’t have to take anything that you don’t want. My job is to explain my thought process and make recommendations (which are derived from a lot of deep thought and study about the issue) and then we make a decision together.
In other words: you’re not a child and I’m not your parent. I don’t run a dictatorship in my medical practice.
I’m consistently struck by how few people agree with my impression that we should be doing everything possible to lower cardiovascular risk after vascular disease has been identified on imaging.
So when I read stories about the WHO report suggesting that 4 out of 5 patients with hypertension aren’t adequately treated, I am totally unsurprised.
There’s a huge gap between how I think about this issue and how many of my patients think about it.
And I’m not sure how to better bridge that gap.
Getting back to the bottom line: treating vascular disease well can stop its progression
More people die of cardiovascular disease than any other cause.
Cardiovascular disease is also a gigantic cause of disability and loss of independence.
And lots of people have zero symptoms until something catastrophic happens.
Fortunately, the treatments for heart disease are safe, accessible, and effective.
For my own cardiovascular health, I want to be thorough in screening for vascular disease before it has caused me a single problem.
And once I have a shred of evidence of vascular disease, I want to be treated aggressively to optimize everything.
The reason that I want to be maximally treated is because that’s how you stop the progression of this disease in its tracks.
You can make treatment for heart disease very complicated, or you can make it very simple. The simple way forward is: lower LDL-C (or apoB), keep blood pressure optimal, don’t smoke, and maintain good metabolic health.