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HDL is the good guy in the lipid family. Doctors say it carries cholesterol out of the arteries to the liver so it can be expelled from the body. Generally, an HDL level greater than 45 is considered good for men and more than 50 is good for women. But it’s not quite that simple.

Dr. Paul Ziajka said HDL comes in two main forms, HDL-2 and HDL-3. Of those, HDL-2 is much better at taking out the trash.

“When we talk about good cholesterol, what we really mean is HDL-2,” said Ziajka, who specializes in lipid management. “If you have mostly HDL-3, then you’re basically out of luck, because your good cholesterol is not that good at all.”

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I love talking about my cholesterol.

I take pride in my plummeting LDL, or bad cholesterol, which has dropped from what my doctor once called a “nightmarish” 203 to an enviable 66. Ask around. That’s a good number.

I get less joy out of my HDL, or good cholesterol, which has fallen slightly when it needs to be climbing. What’s more, some HDL is better than others, and I’m mainly carrying the inferior stuff.

How do I know this? Why do I care? Heart disease runs in my family. Both of my parents have a history of high cholesterol and blockages.

I started going to a cardiologist in 2007 after my hand occasionally fell numb during exercise. Testing ruled out a clogged artery. But a new kind of cholesterol screening suggested I was setting myself up for future problems.

It’s called an advanced lipid profile, and as the name implies, it goes deep into the factors that hint at heart risk. More people are getting these tests, which in some cases are being heavily promoted.

Questions abound. Who really needs one? Can it actually make a difference in your treatment? I talked with three local cardiologists to help sort it out.

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A new study, which is a collaboration of two research groups at Karolinska Institutet and was published in the open-access journal PLoS ONE may concerne not only obese people: The so called bad cholesterol (LDL) inhibits the breakdown of fat in cells of peripheral deposits. The discovery reveals a novel function of LDL as a regulator of fat turnover besides its well-established detrimental effects in promoting atherosclerosis.

It shows that LDL cholesterol slows the rate of fat breakdown (i.e. lipolysis) in adipocytes, the peripheral cells responsible for fat storage. Previously, it has been known that release of free fatty acid from the peripheral fat to the blood stream increases the synthesis of LDL precursors in the liver.

“The results of our study provide evidence of a reciprocal link between the liver and peripheral fat regulating fat turnover”, says study-initiator Dr Johan Björkegren.

The discovery also opens up for new theories for the well-established association between blood lipids and the metabolic syndrome.

“If proven of general physiological importance, therapies lowering LDL, as for instances Statins, may also affect the turnover of peripheral fat,” continues Dr Björkegren.

The study and has been performed on cell cultures and tissues from humans as well as mouse models with different levels of LDL. The inhibitory effect was also shown to be dependent on LDL receptors on the surface of the fat cells.

“The exact intracellular mechanism for how the binding of LDL to the surface of the fat cells inhibits the breakdown of intracellular fat remains to be revealed”, say project leader Dr Josefin Skogsberg.

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A similar diabetes drug, Actos, doesn’t seem to carry same dangers, study finds

The widely used diabetes drug Avandia — already controversial because of cardiovascular side effects — may be riskier than Actos, another drug in the same class, researchers reported Monday.

The risk of heart failure and death for older diabetics appears greater with Avandia (rosiglitazone) than with Actos (pioglitazone), both of which are part of a class of drugs called thiazolidinediones, Harvard University researchers said.

Avandia and Actos are used to lower blood sugar in patients with type 2 diabetes. Recent studies suggested that the risk for heart failure, death and heart attack were increased with Avandia, touching off a controversy that resulted in new FDA-mandated label warnings about the drug.

“By contrast, Actos did not appear to increase the risk of cardiac events,” said lead researcher Dr. Wolfgang C. Winkelmayer, an assistant professor of medicine at Harvard Medical School. “One could get the impression that Actos led to the reduction of heart attacks.”

Indirectly, people inferred that it might be better to use Actos, because Avandia has cardiovascular risks associated with it, Winkelmayer said.

“We did find that patients using rosiglitazone actually had an increased risk of mortality from any cause. We did not find a difference in heart attacks and strokes,” Winkelmayer said. But, he added, more patients taking Avandia were hospitalized for heart failure.

Winkelmayer noted differences in drugs in the same class are not unusual. For example, cholesterol-lowering statins (which include Crestor, Lipitor and Zocor) have different side effects, he said.

The new research, published in the Nov. 24 issue of the Archives of Internal Medicine, received funding from the American Heart Association, as well drug makers Amgen and GlaxoSmithKline, which makes Avandia.

For the study, Winkelmayer’s team collected data on more than 28,000 diabetic patients aged 65 and older who were taking Avandia or Actos between 2000 and 2005. Among these patients, 50.3 percent took Actos and 49.7 percent took Avandia.

After a little more than a year on the medications, 1,869 patients died. The researchers found that patients taking Avandia had a 15 percent higher rate of death compared with patients taking Actos. In addition, Avandia patients had a 13 percent greater risk of heart failure than patients on Actos.

GlaxoSmithKline defended its drug in a statement on the new research released Monday.

The company “strongly supports the safety and efficacy of Avandia based on extensive clinical trial experience and widespread post-marketing use. This new study is inconsistent with evidence from randomized clinical trials and has significant limitations,” the statement said.

A randomized clinical trial — in which participants are randomly grouped and then followed prospectively over time — is typically considered more reliable than an observational study, which is not as well-controlled.

“The primary outcome in this observational analysis is all-cause mortality,” the company statement added. “The Avandia prescribing information includes data from RECORD, an ongoing long-term randomized clinical trial that has shown no statistically significant differences between the Avandia group and the control group regarding death from cardiovascular causes or any cause.”

The continuing controversy over the heart risks of these diabetes drugs began with a 2007 study, published in the New England Journal of Medicine, in which heart expert Dr. Steven E. Nissen, chairman of the Cleveland Clinic’s department of cardiovascular medicine, reported a 43 percent increased risk of heart attack among patients taking Avandia.

In November 2007, the U.S. Food and Drug Administration said that GlaxoSmithKline had agreed to add to the existing “black box” a new warning about the potential increased risk for heart attacks. Previously, the FDA had requested that GlaxoSmithKline and Takeda Pharmaceuticals, the maker of Actos, add a “black box” warning about the increased risk of heart failure associated with both drugs.

In July 2008, an FDA advisory panel said that drugs designed to control type 2 diabetes, including Avandia, should be subjected to more thorough safety reviews to ensure they don’t raise the risk of heart problems. They recommended that all makers of these drugs conduct long-term cardiovascular trials, even if the drugs show no signs of heart problems in initial trials.

But Winkelmayer believes that neither Avandia nor Actos should be used as initial treatment. When they are used, they should be used with caution, especially with patients prone to heart problems, he said.

Dr. Eric J. Topol, director of the Scripps Translational Science Institute and chief academic officer at Scripps Health in La Jolla, Calif., also thinks both drugs should be used cautiously.

“The study reinforces the heart failure risk of rosiglitazone versus pioglitazone,” Topol said. “Interestingly, it doesn’t show any difference in heart attack, which is the one issue that has been so controversial. So it doesn’t really change things that much.”

Of the two drugs, Actos appears to have a more favorable track record, Topol added. “But the possibility of cardiovascular side effects, including heart failure and heart attack, can’t be forgotten.”

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Should they mix?

In an effort to maintain or improve good health, many of us - almost half the population of the United States according to some reports - take herbal supplements such as echinacea, garlic, ginseng, gingko biloba, and St. John’s wort. However, if you are being treated for cardiovascular disease, these agents can conflict with your medication and could result in some rather serious side effects.

A 2001 review of the data that exists from trials done with complimentary and alternative medications (CAMs), authored by Dr. Atul Aggarwal of the Cardiology Unit, University of Vermont, was published in Coronary Artery Disease. In it, he warns of possible adverse reactions for people who are taking CAMs in addition to prescription cardiovascular medications.

Let’s start with garlic - taken regularly by millions of people around the world for a variety of reasons, including its potential ability to lower cholesterol and help prevent atherosclerosis. Atherosclerosis is a term that describes a dangerous buildup of sticky plaques inside the arteries. This buildup, if left untreated, can pave the way for stroke, among other things. According to the data reviewed in the article garlic is effective in decreasing the buildup of platelets within the arteries, although the level of effectiveness varies. While this effect may seem like a good thing, it could increase the risk of bleeding in people who are taking antiplatelet medication such as ASA, clopidogrel, and glycoprotein IIb-IIIa inhibitors. Myocardial infarction was cited among the possible side effects. There is also a risk of excessive bleeding following surgery and stroke.

Ginseng, often used as an immune stimulant and potential antidiabetic agent, has a side effect profile that includes hypertension. This can adversely affect medications that lower blood pressure such as diuretics. The articles states that the use of ginseng should be avoided if you are taking warfarin, heparin, or aspirin.

What about gingko biloba? Rumoured to improve memory, it has been used in traditional Chinese medicine for centuries to treat a number of complaints. And there are clinical trial data to show that a certain type of gingko biloba is able to help stabilize people with dementia, in terms of cognitive and social functioning. However, it can also interfere with platelet activity and should not be used in conjunction with aspirin or anticoagulants.

Moving right along, we have St. John’s wort. Most people use it to help them sleep and fight off depression. However, if you are taking calcium channel blockers, lidocaine, quinidine, amiodarone, or cyclosporine, you should most likely not be taking St. John’s wort, as it can interact with these medications. Apparently, to date, no incidence of interactions with warfarin have been reported, however, that does not mean to say that St. John’s wort should be taken in conjunction with warfarin. Ask your doctor.

In fact, if you are taking any medications for cardiovascular disease, you should always check with your family doctor or cardiologist before taking any other medications - herbal or otherwise.

And finally, we have echinacea. It seems that the flavonoids in echinacea can interfere with medications such as amiodarone, propafenone, cyclosporine, and ibutilide. This interference can cause something called torsade de pointes - described in medical books as a form of ventricular tachycardia. In the simplest of terms - tachycardia is a rapid beating of the heart. This is not a good thing.

Similarly, if you have had a cardiac allograft and are taking cyclosporin, echinacea, being an immune stimulator, may offset the immunosuppressive effects of cyclosporine, which are essential to the success of the allograft.

So, best advice? If you are thinking of taking CAMs, talk to your doctor - even if you don’t have cardiovascular disease but are taking prescription medications. It can’t hurt.

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Once upon a time, it was simple to link your personality type to your risk of heart attack. Thus if, like me, you’re a Type A personality - always in a rush, obsessive, driven, prone to finishing other people’s sentences for them (can I help it if I always know what everyone is going to say even before they’ve thought of it themselves?) - then you were deemed to be at higher risk of suffering a heart attack than your Type B laid back “time to smell every flower because what else is there to do?” brother or sister.

But like all fairy tales, this one too has proved to be allegorical rather than real and most experts now agree that not only is personality type much more complicated than a simple division into Types A and B would have it, and that there must also be specific features of a Type A personality that put some of these people at higher risk. Over the last few years, most suspicion has fallen on hostility as the key feature linked to that higher risk.

“And just what the hell makes up hostility?” some of you may wonder (If that’s how you put it, by the way, I’d get my heart checked soon if I were you). A hostile personality is commonly taken to be a mistrustful and cynical person, and someone easily roused to anger or aggression.

Now, a report in the Journal of the American Medical Association has shown not only how important a cardiac risk factor hostility may be, but also just how early in life it may kick in as a risk factor. In this study, young adults were given personality tests and then examined 10 years later to determine how much calcification (”hardening”) they had developed on their heart artery walls. People who scored above average for hostility as young adults had significantly more calcification 10 years down the line than their less hostile comrades. That’s depressing news for guys like me - I’ve never yet seen another driver who knew what he was doing on the road - when you consider that this discrepancy is only likely to worsen with time.

So though we don’t know if you can lower your heart attack risk by altering your outlook and personality - trying to be more optimistic, controlling anger, etc., - it surely can’t do any harm to try to make such changes, especially when you’re still young. That’s what I told my cynical 20-year-old son (he must have got that attitude from his mother), but he just smirked and left the room. That kid is in big trouble, I think.

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On July 6, 2002, the results from a landmark study of statin therapy were made public. Statins are currently used to lower cholesterol levels only in people who have heart disease and/or high cholesterol. However, the findings from the Heart Protection Study (HPS) show that a great many more people at risk can benefit from statin agents, and this will revolutionize the way in which physicians treat to prevent or slow the progression of cardiovascular disease. The team of investigators involved in the HPS estimate that subsequent changes in treatment guidelines could save tens of thousands of lives every year. They also evaluated the use of antioxidant vitamins - with some very surprising results.

If you are being treated for high cholesterol or heart disease you will most likely be familiar with statin agents, and there are several on the market. They work by preventing fats from being absorbed and turned into cholesterols - such as low density lipoprotein (LDL) - the bad cholesterol, and high density lipoprotein (HDL), at a primary site of conversion - the liver.

The primary goal of the HPS was to determine the effectiveness of statin therapy in preventing cardiovascular disease, hypertension, stroke, and myocardial infarction (MI) in patients not typically considered for statin therapy. They assessed more than 20,000 volunteer patients in the United Kingdom, aged between 40 and 80 years of age. Some particpants had diabetes, some had narrowing of the arteries in their legs, and some had already had a stroke. As well, some patients had average or below average cholesterol levels, specifically LDL cholesterol. Patients were randomly assigned to receive either 40 mg/day of simvastatin, (Zocor®) or placebo treatment. As well, patients were randomized to receive vitamin supplements or placebo. The treatment and follow-up periods averaged five years.

The investigators found that statin therapy provided significant reductions in the incidence of non-fatal MI, non-fatal stroke, and coronary death. It also reduced the need for arterial surgery, angioplasty and amputations.

And, surprisingly, statin therapy reduced the risk of these events occurring in patients who had normal or low cholesterol levels. The import of this result is essentially that statin therapy reduces the risk for cardiovascular disease regardless of whether or not you have high cholesterol levels.

The benefits of statin therapy increased with time, and prevented further major events and deaths from occurring in people who had already experienced a heart attack or stroke.

And, these benefits occurred in addition to the benefits of other treatments that patient were taking such as aspirin, and blood pressure lowering drugs.

The HPS independently evaluated statin therapy in patients over 70 and in women, two populations who had not previously been evaluated. Again, it was found to be safe and effective in both these treatment groups.

And the vitamins? The HPS assessed the ability of antioxidant vitamin supplements, specifically daily doses of vitamin E, vitamin C, and beta-carotene in a subset of the participants who were at high risk of vascular disease. They found that the vitamins did not provide any significant reductions in the five-year risk of heart attacks, strokes, cancers or other major outcomes. However, the supplements were found to be safe, in that they did not increase the risk of strokes due to bleeding, or of cancers at any site. These results are actually contradictory to those of earlier studies which showed adverse events associated with the use of vitamin E and beta-carotene. No doubt the antioxidants will continue to be studied.

As far as statin therapy is concerned - it’s safe and it works in a broad range of people who may be likely to develop cardiovascular disease. For more information - ask you doctor about the Heart Protection Study. It is one of the largest clinical trials ever done, and the findings will be news for months to come.

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It’s cheap, it’s old, it’s in your face, it’s frustrating, and it’s bitter. No, you cynics, that’s not a description of the writer. Rather, the foregoing is a partial description of ASA (acetylsalicylic acid), an old, inexpensive, ubiquitous drug that we’re still not sure how to use properly, especially in preventing heart attacks.

You see, heart attacks occur mostly from blood clots that block coronary arteries, and ASA lowers the blood’s clotting ability by making platelets - blood cells intimately connected to forming clots - less “sticky” and thus less able to clump. So, anyone who’s already had a heart attack significantly lowers their risk of suffering another when they take ASA regularly, and people who have 2 or more risk factors for heart attack, especially diabetics, lower their risk of suffering a first heart attack by taking ASA regularly.

And when it comes to the best dose of ASA to use to obtain this benefit, it turns out that this is another example of the “less is more” phenomenon, because whereas most early studies used doses up to 1000 mg a day to get ASA’s anticlotting effect, more recent studies have used much smaller doses, such as the 80 mg in a “baby” ASA, and have achieved similar results.

But here’s the million dollar question, and, yes, you can call a friend to help but I’m sure your friend won’t know the answer either: should people with no extra risks take ASA, too?

As usual, there are 2 answers: theirs and mine. First, a study in the Archives of Internal Medicine reviewed several studies involving more than 50,000 individuals and found that ASA did lower the risk of a first heart attack overall in this large population (although it didn’t lower the risk of death from vascular disease or of stroke).

Before I hear too many shouts of glee, however, let me say that what bothers me here is that some people read this news and immediately conclude that taking a pill will solve their problems. They then ignore everything else they should be doing for the health of their hearts, and as someone who believes fervently in lifestyle adjustment over chemical intervention, I would caution that no pill can do as much good for the average person’s heart as would attention to a healthier lifestyle. And if you’re already living a healthy lifestyle, I don’t see why you would need any chemical help.

I also want to remind you that ASA is linked to a much higher risk of bleeding ulcers, and sudden rupture of an ulcer, both of which can result in disability and (more rarely) death. And taking coated ASA does not help, because although coated ASA lowers the risk of upset stomach, there’s no evidence it prevents these more serious complications.

So where does that leave you? Well, in the days when doctors still decided things for patients, most of you would have been told to take an ASA (or 2, or not), and that would have been that. Now, we’re in an era of patient empowerment, and the doctor only advises - you have to make up your own minds about what to do. Isn’t it great to be so empowered?

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A common diet that is often used to manage blood pressure and stop hypertension is the DASH (Dietary Approaches to Stop Hypertension) diet. This diet is rich in fibre and nutrients and contains much more potassium, calcium, and magnesium than the average diet.

Many studies shave shown that in as little as several weeks, people on this diet significantly reduced their blood pressure. Many studies have shown that it is a very effective diet in reducing the risk of diabetes, heart disease, cancer, and osteoporosis.

The key to any new diet success is in not making drastic changes all at one time. It takes time to develop new eating habits and make food choices that make you feel healthier and satisfied.

There are some useful tips that you can use to adjust to the DASH diet:

* Add more fruits and vegetables slowly to your diet. Try replacing fatty snacks with a fruit instead.
* Increase your daily intake of dairy products. If you have trouble digesting dairy products, there are lactose intolerance pills that can aid in digesting these foods.
* Replace enriched flour breads with whole grain bread.
* Choose whole grain cereals without large amounts of additives and sugar.
* Eat fruit flavoured gelatin or dried fruit snacks.
* Add more nuts, seeds, and legumes to your daily diet.
* Eat more of potassium-enriched fruits and vegetables.
* Eat protein foods modestly, with preference given to soy, fish, or poultry.

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How long has it been that we’ve been taking blood pressure (BP) readings? About 200 years or so?, I think, which is also, I believe, even longer than Regis has been on television. So given that we’ve been at it for so long, you’d think that we would never err in taking BP readings. This is not rocket science, after all. All that’s involved in taking a BP reading is that a cuff is tied around someone’s limb (most often an arm), the cuff is inflated so that the pressure shuts the artery in that limb. As the pressure is released, the BP reader records the point at which a sound appears as blood re-enters the artery (systolic reading), and the point at which the sound disappears or muffles (diastolic reading). This is so easy that if you had the time and money for the training, you could replace health professionals with apes to do BP readings (no obvious jokes here, please), and that the apes would still get it right every time.

If they did get it right most of the time, however, the news is that the apes would be way ahead of health professionals because according to a study presented at a meeting of the American Society of Hypertension, a significant proportion of BP readings are wrong, most often on the low side.

How can things go awry?

Lots of ways. For a start, we’ve long known that errors occur when a patient is not relaxed enough, when the BP cuff is not the right size (bigger arms need bigger cuffs, something I’m sure they teach all cops in cop school), or even when the BP reading is taken with the patient sitting rather than lying down.

But this study found that inadequate equipment also plays a key role in BP reading errors. You see, unlike the old “mercury-in-the-glass-tube” blood pressure measuring devices that were the standard until a few decades ago and which were virtually fool-proof, the new aneroid devices now used in most medical offices must be re-calibrated regularly because there is no way to tell if and when they have stopped working properly, and according to this study, up to one-third of aneroid devices have not been re-calibrated and are not working properly, and these devices, say the researchers, give misleadingly low BP readings. In other words, lots of you have been told your BP is OK when it may actually be high.

Well, now that I’ve made you all doubt your BP reading, let me destroy your faith in yet another procedure your doctor commonly does on you. Did you know that…Hey! Relax! I can smell your fear. So I’ll simply save that for a future, OK?

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