Monday, February 22, 2010

Focusing on Blood Pressure -- Waiting for VAP

I'll be taking the VAP lipid panel in early March. That will give me a good sense of how I'm progressing towards my goal of reducing the point score of 835 on my next calcium heart scan in the summer of 2011. The VAP gives essentially the same information as the Berkeley Heart Labs panel.

In particular, I'll be look at any changes in the "Pattern A/B" score. This score is the one that shows how "bouyant" your lipids are. I've been mostly in the "B" area with those small, gritty lipids. But if I can tolerate 5mg of a statin -- remember, I've had problems with statins before -- then I have a chance of moving to the desirable "Pattern A," especially with the new Trilipix and niacin.

So far, I'm tolerating the time-release niacin (Niaspan) at 2 500mg/day. I will hold at this until the next VAP test. At my last test (referenced in the first posting) I improved in every area, but the remaining area is to up my HDL to 60. More niacin is the key here. I scored 45 (which is good for me, but not particularly high) previously taking only 1 500 mg niacin/day. If I can get my HDL up to 50 with 2/day, I have a shot at 60 with more niacin. I think I can tolerate 3/day (1,500mg), but more may be needed to get to 60.

Here I am concerned about the drug interactions. My overall cholesterol was 140 last time and it is sensitive to niacin as well. I don't want to go too low here! Also, the Niaspan, Trilipix, and Crestor (even at 5mg) may elevate my liver enzymes and/or have other consequences, so I'd like to see the lipid profile results before upping my Nisaspan over 2/day. (My specialist thinks I can do 3/day -- I hope so. It may take 4 to up HDL to 60.

So in the meantime, I've been watching my blood pressure with a neat, new iPhone App called HeartWise. You need to have your own monitor (mine is an Omron automatic blood pressure monitor, Model HEM-711), but it is very easy to enter data into the app and it produces very nice information. Here is a graph which it put into my photo library on my iPhone.

What became apparent seeing my data in graphical form was that my systolic scores were often over the 120 mark -- the beginning of the new "pre-hypertensive" range, even though my diastolic scores were fine. This meant that with a modest dose of a good ace-inhibitor (say, generic trandolapril), I might be able to stay under the 120 threshold for the most part. I'll keep you posted on my success (if any) here. I've been taking trandolapril for several days now, and at the beginning, my systolic pressure remained under 120. Too soon to pick up a real trend yet, though.

HeartWise charts your weight and pulse as well. I was surprised at how low my pulse is as a result of exercise over the years, often about 50 in the morning.

Friday, February 5, 2010

Berkeley Heart Labs -- The Gold Standard

My sister just shared with me some information that she got from her Berkeley Heart Labs tests. This included an Apo E genotyping test to determine if one has a familial lipid dysfunction. She does, I do, we do. It is Type III hyperlipoproteinemia (also known as familial dysbetalipoproteinemia).

I knew that once. It may be connected to the "low-HDL, elevated overall cholesterol and elevated triglycerides" syndrome that I and my brother have (but not my sister -- she has great HDL). This sometimes triggers the "consider metabolic syndrome) on these tests. This site has more information on Apo E. (A sobering thought is that this very same test can also diagnose late onset Alzheimer's.)

The KIF6 genotype. This is a genetic marker that predicts heart issues. Here is Berkeley Heart Labs own web information on this. My sister has this gene; I don't know whether I do.

The "PLAC" test. This is a test to determine how much plaque you have likely built up. This is like the CRP test for inflamation. It is not a direct test. It is officially for Lp-PLA2. My sister got a good score here about about 100. My CRP was 0.17 last time -- little or no inflamation - a good sign.

NT-proBNP - A study of this factor reveals potential For NT-proBNP as a marker to predict cardiovascular risks from anti-inflammatory drugs, such as aspirin or ibuprofen. My sister was "green" on this one. It is also used in exercise physiology.

LDL Patterns. My sister scored well here, too, with Pattern A -- the bouyant lipids. I'm probably still Pattern B, but hopefully moving up.

"Small LDL trait" - what is worse than having elevated LDL? Having small, elevated LDL. This can be tested by the ApoB test. Check the Ladies Home Journal article on this. There is some evidence that heart incidents are more closely correlated with high, small LDL levels than with any other lipid group. (It used to be overall cholesterol. Now LDL is a better indicator, and small LDL a better indicator still.)

The VAP tests very likely offer similar or comparable tests to the ones above, but I must say that the Apo B, the Apo E, the KIF6, the PLAC test, and the NT-proBNP were new to me. My (or, "our") familial predispostion was already diagnosed in my case, but the other genetic indicators -- rather, their use as predictors -- is new to me. Maybe I'll press for a Berkeley Hearts Labs test at some point in the future rather than the VAP test.

Visit With Specialist - A Bit Anti-Climactic

My specialist had to reschedule me because of an emergency, but I found him calm and collected yesterday when I met with him. I had prepared a ton of questions for him, but found him quickly to say in a very matter-of-fact way, "no obstructions."

I think the consultation might have ended there but for my list. The report was in the form of a text, so I couldn't see my pictures. (I had seen them in the preparation phase just after my stress test. They show "before and after" blood flow when resting and exerciing - thus showing points of blockage (if any). See this site.)
I did order them and will report on them later. The point was that while there is plaque buildup in the heart, I am, do now remain, and very hopefully will remain, asymptomatic. Probably, the thalium stress test should have preceded the calcium scan because it confirmed what I've known: that exertions like Cycle Oregon don't produce heart-issue symptons like chest pains, dizziness, fainting, clammy sweating, and so on. The Dr. recommended a follow up visit in a year.

So my specialist and my doctor essentially convinced themselves that I'm asymptomatic. But what of follow-up? When I tried to schedule an appointment a year hence, the receptionist smiled and said they didn't book that far ahead, but to put it on my calendar. But what would the doctor do in 12 months? Check blood pressure, lipid panel, etc., and perhaps do another thalium stress test. That may provide a good "before and after" but I believe that the HBCT heart scan provides a better picture of "before and after."

For example, the January scan identifies 5 areas of interest in the Left Anterior Descending Artery (LAD) and gives a total point score for these areas. Mine is 283 at present. There are 5 such areas in the Right Coronary Artery (RCA), the point score is 552. Total for both: 835.

If one follows the recommended regime (described before, but in short, keeping the LDL about 70; triglycerides below 100, and upping the HDL to 60), one should see at least a stabilization, possibly a slight reduction of these numbers next year. My RCA score might fall to 525 and my LAD might stay even at 284, for example. That would provide some reinforcement for taking the statin and enduring the flushes of Niaspan. Persistence in taking these medications might result in further reductions two years out and so on. All this depends, of course, on tolerating these non-trivial drugs which are taken in non-trivial amounts.

My specialist did link Niaspan with increasing my HDL, a key piece of the puzzle, since mine is low and need to go from 45-60. He said that nothing works as well a niacin-based prescription for increasing HDL. He prescribed 3 per day or 1,500mg a day. I am now up to 2 per day with endurable side-effects (some flushing and "pre-flushing" tingles). But I was only taking one a day at the time of the lipid panel together with one Trilipix (134mg) and one Crestor (5mg). I suspect 3 Niaspan keeping the others the same would be too much. (Happily, my liver enzymes were normal when tested at the same time.)
On other matters, I shared some data with him on training and Heart Rate Variationl (HRV), since mine was good after the Wednesday ride. He saw the value of HRV monitoring to be on the part of those who have had heart attacks, or even heart transplants. In short, the possible use of HRV in exercise training didn't appear to be on his radar. See Canutes' site for some more thoughts, in particular, this blog.

So for the present, when I resume Trilipix (I'm out of the samples and have not yet received the #90 Rx from Medco), I'll keep the Niaspan to no more than 2 and have a VAP test in March before seeing my GP. So far so good. I'll report on the VAP test, which addresses the "small-LDL trait" -- you know, the tiny, gritty, non-bouyant lipids. We'll see if this medication regime can up my bouyancy. :)

Tuesday, February 2, 2010

HRV -- Beginning to Make Sense of It All

HRV (Heart Rate Variation) is an indicator of fitness. But how best to see this. Polar has software with a program called OwnOptimizer built in. This uses HRV in an orthostatic test to test overtraining. Overtraining affects HRV by diminishing it. But it is a little harder to use HRV in a positive way. For example, look at my test results this morning. The "amplitude" of the RR wave is good, tailing off slowly after standing to less amplitude and less HRV.
The different measures of HRV are shown. The RR bar graph shows good HRV, as does the one to the right, which is simply different heart rates over the 8 minute time period.
The waves show good high-frequency HRV (the yellow). So do the non-linear graphs on the bottom (the Poincare plot in particular). The lower-right-most graph shows a "bend" counter-clockwise (green) versus the lower (red).
All in all, these Kubios HRV measures show satisfactory HRV during an ortho-static test. They were recorded by my Polar 810i. The saved *.hrm file is readable by Kubios. This is a good bench mark, or starting point. We'll see how these measures change as I move to a more demanding exercise routine.