Brewer, Ford; Eldredge, Todd

Introduction

The old model of monitoring and treating just the risk factors for disease does not work as well with heart attack and stroke prevention . This is called secondary prevention .

So , instead of just primary prevention ( i.e . managing risk factors ) , secondary prevention ( finding and managing early disease ) is important in heart attack and stroke prevention . Highlight (pink) - Page 23 · Location 369 Fat is an endocrine tissue . It releases chemicals that make the body resistant to insulin , resulting in prediabetes ( or insulin resistance ) and CV ( cardiovascular ) inflammation . Highlight (pink) - Page 23 · Location 375 CV inflammation causes arterial plaque and ruptured plaque is responsible for the majority of heart attacks and strokes . Summary of the Book Highlight (pink) - Page 25 · Location 393 There are a lot of CV disease patients seeking explanations and direction on a better way to attack their disease . Highlight (pink) - Page 25 · Location 395 Doctors and patients both incorrectly assume that cholesterol and blood pressure tests alone , followed by stress tests , coronary angiograms , and stents / bypasses are the best way to detect and treat heart disease . Highlight (pink) - Page 26 · Location 403 Doctors often have the unenviable position of cleaning up the mess when it is too late - frequently after years of damage to the arteries has already occurred . Highlight (pink) - Page 26 · Location 414 Most of all , this book was written for patient self - advocates . Highlight (pink) - Page 27 · Location 430 Other books which should be on every heart disease patient’s reading list include Dr . Jason Fung’s book “ The Obesity Code ” , or Dr . Valter Longo’s book “ The Longevity Diet ” . Highlight (pink) - Page 27 · Location 435 If we just added two simple , inexpensive , and older tests to the routine preventive assessment of patients , we would revolutionize chronic disease care and prevention . Those two tests are the OGTT ( Oral Glucose Tolerance Test ) and the Insulin Survey . Highlight (pink) - Page 28 · Location 450 Out of necessity , we introduce the concept of CV inflammation and we cover it in more detail later in this book . An introduction to CV inflammation is required to understand the actual mechanism of heart attack events . Highlight (pink) - Page 29 · Location 469 Most arterial disease is caused , in turn , by insulin resistance ( prediabetes or metabolic syndrome ) . Many people first notice this as an increase in the size of their belly , which Highlight (pink) - Page 30 · Location 479 Inflammation is the body's response to injury . CV inflammation starts with injury to the delicate lining of the arteries . Highlight (pink) - Page 32 · Location 512 Stress tests do not detect plaque until there is ≥ 50 % - occlusion ( or blockage ) of blood flow in the artery . Highlight (pink) - Page 34 · Location 548 Carotid Intima - Media Thickness ( CIMT ) is the only non - invasive test that measures arterial inflammation and plaque . That statement is worth repeating . Highlight (pink) - Page 34 · Location 556 CIMT is also the only test that provides critical information on the characterization of the plaque ( e.g . whether plaque is soft and dangerous , heterogenous or echogenic and healed ) . CARDIOVASCULAR DISEASE Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 39 · Location 625 Most of us assume that plaque lines the inside space ( lumen ) of an artery like hair lining the inside of a shower drain where the water flows . That assumption is incorrect . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 41 · Location 654 Inflammation provides an opportunity for an earlier and less urgent warning of impending heart attack . If we can warn patients that their arteries are currently inflamed , they can better understand the importance of the need to cool those arteries back to their normal state of homeostasis . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 41 · Location 658 most arterial plaque contains oxidized LDL cholesterol . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 41 · Location 661 inflammation , as measured by high - sensitivity C - reactive protein ( hs - CRP or CRP for purposes of this book ) or interleukin I ( IL ) - 6 , was strongly associated with future vascular events , independent of the usual risk factors . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 41 · Location 665 Cardiovascular inflammation can be a critical warning of imminent danger . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 42 · Location 672 Brad Bale and Amy Doneen have been teaching methods of CV risk assessment for nearly two decades . In 2014 , they published a book titled BEAT THE HEART ATTACK GENE . ( Bale B , 2014 ) . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 42 · Location 675 The acne - like lesions lining the walls of Russert's arteries in the autopsy were atherosclerotic plaques . One of those “ pimples ” ruptured , spewing its contents into the bloodstream . The inflammatory components of that soft plaque activated the platelets in the blood which caused the blood to form a clot . Highlight (orange) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 42 · Location 678 The clot blocked the arteries providing blood and therefore oxygen to the muscle in Russert's heart . Finally , this oxygen - starved heart muscle created a chaotic rhythm known as ventricular fibrillation . That fibrillation spread to the rest of the heart , resulting in a loss of coordinated pumping function . Blood flow to Russert's body stopped . When blood flow to his brain ceased , Russert lost consciousness . He never woke up . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 43 · Location 692 one of the most common drivers of heart attack & stroke risk is prediabetes ( also called insulin resistance or metabolic syndrome ) . For this book , we will abbreviate using IR for Insulin Resistance . IR is associated with aging or unhealthy fat stores . It dramatically increases the growth rate of plaque within the artery walls . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 46 · Location 733 oxidized LDL gets stuck in the space between the intima and media layer leading to inflammation and arterial plaque formation . The term IMT stands for “ Intima - Media Thickness . ” Which refers to the net effect of this process to the wall of the artery ( e.g . the Intima and Media layers of the artery ) . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 46 · Location 739 Cardiovascular inflammation starts with an injury to the endothelium . High blood sugar , high insulin , or smoking by - products , and other pathogens injure the endothelium . These inflammatory agents make it easier for pathogens like cholesterol to penetrate and get trapped inside the arterial wall . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 46 · Location 750 If the cap of the plaque erodes or ruptures , it releases the liquid plaque ( the necrotic white sticky substance very similar to the substance inside a facial acne pimple ) into the bloodstream . Liquid plaque can cause blood to clot . If this happens and a large clot forms , it can cause a heart attack or stroke by flowing to an artery in the heart , or brain ( respectively ) lodging there and blocking the blood supply to tissue up or downstream . ( Swirski Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 47 · Location 764 Inflammation is simply the immune system's response to any damage in the body . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 48 · Location 770 As the inflammatory process continues , a pool of liquid material forms . This pool consists of immune cells , cytokines , debris , and other types of necrotic or dead material formed by the immune processes . That pool of materials grows to become soft plaque . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 48 · Location 776 Over time , a calcific cap forms over these liquid plaque pools . If the cap breaks , the plaque ruptures and releases the pool of materials contained in the soft plaque into the bloodstream . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 48 · Location 785 This process ( CV inflammation , plaque rupture , clot formation , and artery blockage ) is the most common killer and disabler of humans in the world . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 49 · Location 789 Fortunately , we can now detect and measure inflammation through blood tests and simple artery scans ( CIMT ) . Highlight (pink) - ESSENTIAL BACKGROUND INFORMATION: CV INFLAMMATION. WHAT IS IT? HOW DO WE MEASURE IT? > Page 52 · Location 840 The terms lipid means fat or oil . Highlight (pink) - CARDIOVASCULAR PLAQUE & INFLAMMATION > Page 53 · Location 849 Atherosclerosis means scarring of the arteries . Highlight (pink) - CARDIOVASCULAR PLAQUE & INFLAMMATION > Page 53 · Location 857 what affects the amount of inflammation in our arteries , and the amount of plaque which leads to plaque rupture and ultimately to heart attacks or strokes . . . is what we eat , Highlight (pink) - CARDIOVASCULAR PLAQUE & INFLAMMATION > Page 54 · Location 871 There is clearly a significant under - diagnosis of prediabetes . Both high blood sugar and high insulin levels have been shown to cause arterial inflammation and plaque . Highlight (pink) - CARDIOVASCULAR PLAQUE & INFLAMMATION > Page 54 · Location 874 CV inflammation is often driven by high blood sugar and its partner : high insulin values . Highlight (pink) - THE TESTS FOR ATHEROSCLEROTIC PLAQUE AND CVD DISEASE > Page 62 · Location 978 Unfortunately , patients must spend too much time learning this information if they are to significantly improve their chance of avoiding a CV event . It is a small price to pay for enhancing what could be additional decades of healthy and disease - free living . Highlight (pink) - STRESS TESTS – A LOUSY WAY TO MEASURE PLAQUE > Page 64 · Location 1024 Blood flow compromise ( as indicated by a hemodynamic disturbance ) is not detected at all in stress tests until there is at least ≥ 50 % occlusion ( blockage ) of the artery . Most heart attacks ( over 2 / 3 ) occur with less than 50 % blockage . ( Falk 1995 ) . Highlight (pink) - CAROTID INTIMA-MEDIA THICKNESS (CIMT) TESTING > Page 89 · Location 1386 This original peer - reviewed article showed the effect of reducing CIMT progression on actual cardiovascular events in > 100,000 adults . ( Willeit , Highlight (pink) - CAROTID INTIMA-MEDIA THICKNESS (CIMT) TESTING > Page 89 · Location 1390 In other words – if you treat CVD disease ( heart attack and stroke risk factors ) and use CIMT to monitor the effects of that treatment . . . what you see is strongly correlated and predictive of future CVD events . If you reduce progression of CIMT . . . you will also reduce cardio and cerebrovascular events . If you fail to reduce progression , you will fail to reduce cardio and cerebrovascular events . Highlight (pink) - CAROTID INTIMA-MEDIA THICKNESS (CIMT) TESTING > Page 90 · Location 1417 However , at the time of this book’s publication , no ultrasound school in the country was providing instruction on an IMT protocol , much less instruction on how to get a reproducible IMT exam . Highlight (pink) - CORONARY ARTERY CALCIUM SCORE > Page 110 · Location 1696 However , a more important feature of the Statin drugs may lie in their ability to reduce inflammation in the arterial wall , repair the endothelium lining , and attract minerals such as calcium and collagen to stabilize plaque lesions . Highlight (pink) - THE CT ANGIOGRAM –LOTS OF POTENTIAL, BUT NEEDS TO BE STANDARDIZED IN TERMS OF RADIATION AND USE > Page 112 · Location 1725 range is < 5.7 , so this is right on the border of prediabetes . Arnold's basal insulin Highlight (pink) - PATIENT STORIES, RISK FACTORS, TESTS & MORE SCIENCE > Page 161 · Location 2450 “ Studies … with statins … have yielded mixed results … they still reduce rates of heart attack and stroke . They do this by decreasing the amount of fluid fat inside the plaque , by stabilizing the covering over it , and by calming inflammation . Highlight (pink) - PATIENT STORIES, RISK FACTORS, TESTS & MORE SCIENCE > Page 162 · Location 2459 First , they go low carb which tends to decrease hunger . Second , they narrow their eating window . The most common term used for this approach to weight loss is intermittent fasting . Highlight (pink) - PATIENT STORIES, RISK FACTORS, TESTS & MORE SCIENCE > Page 162 · Location 2463 The biomedical changes demonstrated in research on prolonged fasting make it easy to recommend it as a vehicle to reverse metabolic syndrome and to affect changes in the arterial wall . Recent science indicates it improves health even without weight loss . Highlight (pink) - PATIENT STORIES, RISK FACTORS, TESTS & MORE SCIENCE > Page 162 · Location 2468 After losing 50 pounds , Chuck had a heart attack . He began watching the channel and realized he might have insulin resistance . You will also hear Insulin Resistance called Prediabetes or Metabolic Syndrome . It is the primary cause of CV inflammation and , therefore , plaque . IR is far more common than has been recognized . The CDC estimates there are over 80 million Americans with this condition . Highlight (pink) - PATIENT STORIES, RISK FACTORS, TESTS & MORE SCIENCE > Page 163 · Location 2481 Most situations of plaque reversal involve weight loss or the initiation of statins in people with young plaque . All three applied to my story . Highlight (pink) - PATIENT STORIES, RISK FACTORS, TESTS & MORE SCIENCE > Page 166 · Location 2503 As mentioned before , undiagnosed insulin resistance is the primary driver of arterial disease . That makes it the cause of most chronic disease , death , and disability . Highlight (pink) - PATIENT STORIES > Page 170 · Location 2544 Anna had not heard of Lp ( a ) before coming to our event . She started on niacin and successfully lowered her Lp ( a ) . That was fortunate . Upon leaving the program , she reported feeling immense relief . Highlight (pink) - PATIENT STORIES > Page 173 · Location 2606 It appears that intermittent fasting elicits adaptive cellular responses that improve glucose regulation , increase stress resistance , and suppress inflammation . During a fast , cells activate pathways that enhance natural defenses against oxidative and metabolic stress and those that remove or repair damaged molecules . During feeding periods , cells engage in growth and plasticity ( DeCabo , 2019 ) . Highlight (pink) - PATIENT STORIES > Page 176 · Location 2667 Jeff did not know the Tim Russert story . His cardiologist knew little about CV inflammation . Most cardiologists do not know much about arterial inflammation . Jeff did not know what to do about it . He also probably knew a little about the dangers and ubiquity of prediabetes . Again , most cardiologists know that , but most do not know what to do about it . Highlight (pink) - PATIENT STORIES > Page 178 · Location 2694 Gerry had a simple problem with prediabetes , and he successfully dealt with it . After finding out about his insulin resistance , Gerry lost the weight and got the carbs out of his diet . Before this , his glucose ranged from over 170 to just below 120 . Over time , his inflammation and plaque stabilized , and his health improved . Highlight (pink) - PATIENT STORIES > Page 179 · Location 2715 That gap is the failure to diagnose insulin resistance or prediabetes and other conditions known to cause CV disease , heart attacks and strokes . The CDC knows it and is beginning to publish statements to this effect . Most medical standards committees still seem too focused on procedures and medications to give much attention to this problem . GLOSSARY OF TERMS Highlight (pink) - Page 188 · Location 2832 CIMT ( Carotid Intima - Media Thickness ) - A CIMT is a measurement of the thickness of the intima and media layers ( the inner two layers ) of the artery . A CIMT measurement is a direct measure of the inflammation in the arterial wall and can include the measurement of plaque ( the result of long - term inflammation ) in the arteries when present . Highlight (pink) - Page 190 · Location 2865 Embolism - An embolism is the process of a blockage - causing piece of material , inside a blood vessel . The embolus may be a blood clot ( thrombus ) , a fat globule ( fat embolism ) , a bubble of air or other gas ( gas embolism ) , or foreign material . ( See embolus and thrombus ) Highlight (pink) - Page 191 · Location 2895 Infarction - Loss of blood supply due to an organ or region of tissue , usually by an embolus or thrombus Highlight (pink) - Page 192 · Location 2904 IR ( Insulin Resistance ) - The decreased response of the muscle and liver cell membrane to insulin receptors . IR leads to an inability to get sugar out of the blood and into the cell , where it does less damage . IR is the most common cause of CV inflammation and plaque . Also called Prediabetes or Metabolic Syndrome . Highlight (pink) - Page 192 · Location 2918 Ischemia or ischeamia - Ischemia is restriction of blood supply to tissues , causing a shortage of oxygen . Highlight (pink) - Page 193 · Location 2922 Kraft Insulin Survey - The Kraft Insulin Survey is one of the best methods measuring insulin resistance . It is similar to an OGTT , but it includes insulin measurements at all the blood glucose checks . The Kraft survey also uses 100 grams of glucose instead of 75 . And it typically goes three or four hours instead of two . ( See OGTT ) Highlight (pink) - Page 195 · Location 2967 OGTT ( Oral Glucose Tolerance Test ) - A test for Insulin Resistance . The OGTT is a measurement of Insulin Resistance . There are multiple types . All involve fasting for eight hours , followed by a glucose challenge and then serial measurements of blood glucose . The OGTT measures the body's ability to metabolize carbohydrates . The most common problem is the resistance of the insulin receptors in the muscle and liver cell membranes . Highlight (pink) - Page 198 · Location 3008 Thrombus - A thrombus is a blood clot formed in situ within the vascular system of the body and impeding blood flow .