'Making sure that you're getting enough sleep, that your weight is maintained correctly and you exercise regularly.'
Why are so many young Indians dying of heart disease?
Is it only poor lifestyle habits and neglect of our health? Or is there more to the picture?
Are other factors possibly in play?
In Part I of the interview with Dr Basil Varkey, we learnt there's a chance your parents might have genetically passed on a proneness for increased values of lipoprotein(a), an LDL that transfers lipid fats to the cells of the human body.
This inherited incumbrance can lead to early heart disease, should you not be careful in looking after yourself.
Further South Asians have a higher risk of developing elevated values of lipoprotein(a)and that is one of the reasons why you might hear about the early demise of so many Indians from premature coronary artery disease.
Dr Varkey, professor emeritus of medicine, Medical College of Wisconsin, has published a research paper on the underrecognised genetic risk factor for malignant coronary artery disease in young Indians along withIllinois-based senior cardiologist Dr Enas A Enas and their colleagues.
In Part II of a multi-part interview, Dr Varkey suggests measures for keeping healthy even with elevated Lp(a) to Vaihayasi Pande Daniel/Rediff.
Supposing you do a Lp(a) test and discover you have an above normal level, then what kind of tests should one routinely do to monitor for the onset of heart disease without being too alarmist?
Unlike a genetically transmitted disease like Huntington's chorea, where the die is cast and nothing can be done to alter the course, having a high Lp(a) is not something to be alarmed about.
Lots can be done to positively influence the course. And there is no reason why one shouldn't have a much more extended life without problems, if dealt with in the proper way.
First a risk assessment needs to be done: Do you smoke? Do you have prediabetes or diabetes? Do you have high blood pressure? Do you have high cholesterol?
Each of these, in the milieu of high Lp(a), accelerate atherosclerosis and plaque formation. Therefore, all of these risk factors need to be addressed promptly and if medications are needed, they should be used in sufficient doses to reach target levels and the medications used need to be sustained.
The target levels should be set taking into account the higher risk of Lp(a).
An example the target LDL-C should be 70 rather than commonly accepted 100.
The benefits of bringing the blood pressure and high blood sugar to normal are not theoretical but real and proven as cardiovascular events will be reduced.
One additional test that is useful to assess risk and to plan on medications and or other interventions is coronary calcium scoring by radiographic imaging.
It requires good physician-patient cooperation and the physician has to be well informed on how to manage (your condition), because, unfortunately, there is hardly any type of treatment available for reducing the level of LP(a), except for by apheresis, which is removal by an invasive and expensive process, something like dialysis, on a twice weekly basis or using expensive drugs of which one group is available.
What can the patient do to stave off the other risks?
Besides what we just discussed on prompt and aggressive management of major risk factors there are lifestyle changes that need to be undertaken.
Dietary adjustments so that you're not consuming too much fat. Definitely a big step.
Making sure that you're getting enough sleep, that your weight is maintained correctly and you exercise regularly.
If you are overweight to reduce weight to optimal level. It is also advisable to abstain from alcohol use.
Foremost, are dietary adjustments. Definitely a big step. Making sure you markedly reduce or eliminate saturated fats, processed foods and simple refined carbohydrates.
But these measures will prevent the onsetor progressionof CAD but won't necessarily bring the Lp(a) level down, right? Because Lp(a) levels don't reduce, they are like a given, a genetic given?
That is correct. It won't. In fact, even statin drugs that are used for LDL-C reduction will not bring Lp(a) level down.
It will increase it slightly, I believe?
That is correct. Not substantially, but may be by about 10 to 20 per cent.
There are no specific drugs to reduce it.
But I want to stress again, the positive element. Looking after these aspects together (blood pressure, blood sugar etc) have proven benefits on reducing risk.
So do not lose hope and don't take this is like a big warrant out on you or your die is cast. Not at all.
To use poker language, 'This is a card that I've been dealt and I'm going to play with it' and it's a person's responsibility then to take these preventive actions.
If either of my parents have elevated Lp(a), I may or may not suffer elevated levels too? But I understand it's very strongly genetically transmitted.
Correct. It's a dominant gene and you have a 50 per cent chance of inheriting it if one of your parents have it.
So, if a child has inherited it, will his/her Lp(a) be high right from a young age?
The answer is yes.
So, I am going to anticipate your next question... If you have a premature heart disease in your family (as I had defined earlier) then it is best to have the Lp(a) test done at a young age.
Though there is no consensus on a specific age, I would suggest between five to eight years of age.
If it is normal, no more repeat tests need to be done.
Lp(a) does increase over decades, but does not go from normal to very high. But if the Lp(a) is in the grey zone, I would recommend testing it again between the ages 15 and 18.
But testing doesn't have to be very, very, very frequent.
What is the right number for Lp(a) and what is the grey zone?
Everybody is so keen on knowing exact numbers, because we all know what normal blood pressure is, what a normal sugar is, and so on.
But with Lp(a), it is better to look at it as a continuum rather than getting fixated in one particular number. A value of Lp(a) below 30 mg/dl is desirable.
To put it in a different way: Below 30 is normal and over 50 mg/dl is very high. Then you have the in-between zone between 30 and 50, which can be either called high or a gray zone.
Here the whole person needs to considered (all his risk factors) for management decisions.
Though individuals A and B may have identical levels (say 40 mg/dl) if B has risk factor(s) than B would be managed differently than A.
Supposing from a young age, maybe in your mid 20s you discover you have high Lp(a) and there is cardiac family history, do you already consider starting a statin? At what age do you start taking a statin?
Statins have an excellent safety profile. Statins can be used in children as young as 8 years of age.
The rationale for the use of a statin is to bring down the LDL-C (bad cholesterol).
The reduction of LDL-C level achieved is related tothe dose of statin.
What level of LDL-C should we aim for? The simple answer is the lower the better and it should be brought down to below 70 and sustained at that low level. (LDL-C level as low as 25 is well tolerated).
Bringing down your LDL is the best thing one can do (even though it does not reduce Lp(a) ) to reduce the risk of heart attacks.
IMAGE: Dr Basil Varkey. Photograph: Kind courtesy Dr Basil VarkeyBesides, reducing your LDL-C with a statin, more important are the lifestyle changes?
Both are important and work together well.
We are talking about a lifelong disease, atherosclerosis, and the process (that involves plaque buildup) takes a long, long time.
You're trying to really fight that process (buildup) by knowing, as I explained, what the underlying pathological issues are and trying to modify or reduce or stop those and have a longer life.
Let me give you a scenario, where the person is a non-smoker, physically active, and takes care of himself very well and has normal blood sugar and blood pressure and a LDL-C of 70 (incidentally high Lp(a) is not always associated with high LDL-C) then you have a leeway to rely on the lifestyle factors I just mentioned and not start a statin.
In reality most people with high Lp(a) would need a statin.
Feature Presentation: Ashish Narsale/Rediff.com
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