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.

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. :)

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.

Using Indirect Measures -- Polar's OwnIndex

From the previous posts it's clear that my goal is to increase overall fitness, improve diet, continue to lose weight, and meet the lipid profile goals associated with my recent calcium heart scan. (LDL cholesterol below 70mg/dl -- now at 77mg/dl; HDL cholesterol > 60mg/dl -- only at 45 but possible if I can tolerate more Niaspan; triglycerides beloww 100mg/dl -- already achieved with Trilipix, hopefully sustainable.)

Fitness is a key, but isn't controlling by itself as I had thought (or hoped)during previous years. For this post I want to focus on fitness and a key indicator of fitness -- O2Max as yielded by Polar's program called "OwnIndex", a fascinating indirect measure of O2Max.

O2Max, of course, is a measure of how much oxygen you can burn at your peak performance level. The more the better. Lance Armstrong has one of the highest measures (he has been described as the "oxygen-burning machine"). The highest scores are in the 90's and are held by Norwegian cross-country skiers.

Interestingly, having among the highest O2Max scores does not guarantee a gold medal in track, but it certainly helps, and when combined with running efficiency, good stride, balance and all of the other good running characteristics, will make you a super competitor. It is regarded as the single best indicator of overall fitness. It is often called the "gold standard" of fitness indicators.

As with many other things, it tends to diminish with age. For my age category, an O2Max in the 40's is considered excellent. But I have not had my oxygen-burning capability directly tested in a lab. That is where they actually hook you up, put you on the treadmill, and measure the amount of oxygen you burn. But I have been tested by the Polar program, which has a .97 corrleation coefficient with direct O2Max testing. And it is done on a bed -- no oxygen mask or treadmill.

In fact, you may have this tool if you have a Polar monitor. It's on the Polar 725 or 810, for example, and probably on most new Polar monitors selling for above $150.

The test consists of wearing the Polar transmitter and setting the monitor on "fitness test". You lie quietly for about 5 minutes. Within that time the monitor reads your heart rate and your heart rate variability (HRM). HRM is an extremely intriguing measure -- the more variability, the greater the indication of fitness. More about this in future posts. You have also entered your age and weight and your current exercise level. On this basis, the Polar gives you a number (mine is currently 41) that is, essentially, the number you would get if you did a direct O2Max test. On the Polar web site, there are tables that intepret your score by age. Mine is shown as "excellent".

These scores are remarkably consistent. If I am a "41" on my 810, my 725 will typically also read "41". They improve slowly over time in accord with an exercise program. I made it to "43" after the last Cycle Oregon. Several years ago it was in the high 30's, so I have made some progress over the years.

According to the Polar literature, movement from an OwnIndex/O2Max score of 40, for example, to 45 would take about 3 months with a more rigorous program.

So I think it is realistic to shoot for an OwnIndex of 45 about 3 months from now, if I am able to ratchet up my weekly exercise level in the right way. If I can keep my weekly mileage within the 100 mile range and do some cross-training -- some running and some hiking, getting up to a 45 by April 24th is realistic.

The Next 18 Months

You've read about the current situation in the previous post. I had a thalium stress test this past week in order to assess further the results of the calcium heart scan. I'll be meeting with the specialist in early February. I'll likely schedule a second calcium heart scan in the summer of 1011 to see whether my efforts have stabilized calcium build up.

All of these tests are indirect measures used to determing heart risk. In fact, right now I am asymptomatic. My O2Max is excellent for my age (41); morning heart rate (52); good heart rate variability (HRM); no chest pains, shortness of breath; dizzyness, etc. The challenge is to make the most of these indicators and others to manage risk prudently. For example, I didn't train enough for the last Cycle Oregon and "blew it out" when I did the ride -- probably not the most prudent approach. At the very least I'll increase my training mileage before the race so that there is not a big discontinuity between the race milage and my average race mileage.

So it's helpful to know the real state of my vascular system before emabarking on some demanding exercise adventures (Cycle Oregon, hiking across England, doing the Grand Canyon Rim to Rim to Rim again).

None of the tests I've mentioned actually involve looking into my vascular system. So they are "indirect". (An angiogram would provide a view, but that is invasive and not without its own risk.)

The calcium heart scan can "slice" the heart into 60 cross-sections and build up a view of the calcium in your major heart arteries. You are not looking at the plaque directly, only the calcium which is very highly correllated with plaque. On this test it showed that I have a one in five chance of a major heart incident soon if no changes occur. Some studies show that I am 21 times more likely within a specified time (say a year) to have a major heart incident if I don't do anything. I take this seriously.

There are other indicators, blood pressure is a good one. 130/80 is the new standard (Pre-hypertension). Another is the CRP (C-Reactive Protein) test which tests for inflamation, where inflamation is highly correlated with plaque build up.

The thalium stress test is probably not going to tell me anything more than the calcium heart scan. I'll let you know about this when I see the specialist in February. It does show blood flow under modest stress. It compares, as I understand it, blood flow in a relaxed state with blood flow under modest exercise. A different color dye is injected when you are on the treadmill. The key is to see which arteries are totally blocked, or blocked in one state (relaxed) and not in another. The calcium heart scan theoretically can show this, but the "real-life" blood flow situation perhaps can show more. We'll see.

During my debriefing after the heart scan, the nurse said that "70% is in the genes." If change is to be made, it has to occur in the remaining 30%. There are two areas 1) Lifestyle and 2)Medication.

Lifestyle consists of diet and exercise. I'm working on the former and have lost about 4 pounds since the summer. I plan to continue losing slowly and have a goal of a total of 8 pounds by March when I take the next lipid panel.

In terms of exercise, I plan to up my mileage for the September, 2010, Cycle Oregon. Also it should be possible to do something each day, including stretching, some (new) elliptical work, and some running cross-training. These are "tweaks" that might help. It's possible I might be able to up my O2Max (Polar version) to 44 by March and perhaps higher in the summer as my bike milage rises.

But the re-take of the calcium heart scan wouldn't occur until a year from this summer, so I would not have a smaller scan number to reinforce my efforts (if it happens at all) until then. So I'll have to make do with weight loss, cycle and other miles, maybe calories, higher O2Max, etc.

Seeking the Perfect Lipid Profile -- The Situation Now

Friends have asked about the ups and downs of my attempts over the years to control cholesterol and thereby lessen the risk of heart attack and stroke from the build up of plaque in my circulatory system. I got a good report earlier this month on my "lipid profile" and thought this might be a time to put it in context. The next eighteen months will be a crucial time during which I'll be looking for indications that my plaque build-up is stabilized or perhaps (happy thought) reveresed slightly.

On January 8, I took at standard lipid panel (not a VAP or Berkeley Heart Labs panel). Total Cholesterol: 140 mg/dL. This is the second lowest score in the past five years, which is when I started following my lipids closely. In fact it has been nearly five years since I scored 132 in July of 05.

My LDL-Cholesterol is 77, is cut in half from my last test in March of this year. This is good news. LDL-Cholesterol is a better predictor of heart incident than Overall (or Total) cholesterol. My goal is to lower this to below 70. Important here is the fact that my recent HBCT heart scan showed considerable placque build-up in the heart and that without changes (lifestyle, medication) I have (or had at the time of the test) about a 1 in 5 risk of a heart attack soon. Also important here is that I have the dreaded "Small-LDL Trait" which is also closely correlated with heart attack and stroke.

I will be talking about this later, but this means that I have smaller, denser, grittier LDLs (Low Density Lipoproteins) than normal. These are well-adapted to create plaque build-up. They fit into crevices in your ateries and ratchet up the plaque like gangbusters. It is possible, however, to make them less dense and even bouyant through medication. Doing so means moving from "Type B" to "Type A" in this aspect of our lipid inventory. I've made it in the past almost to the "A" range of the spectrum. Typically, though, I've been mired in the gritty end ("B"). My last lipid panel was a standard one which doesn't test this. VAP or Berkeley Heart Labs panels do test this, so I will looking closely for results in this area when I take a VAP test in March. In fact, the size/bouyancy dimension extends over the range of lipids, including High-Density-Lipoproteins (HDL-the "good" cholesterol). Increasing the bouyancy of all lipids protects against heart incident.

My "good" cholesterol - HDL - is 45 on my last test. This is good for me, but because of a familial pre-disposition, not what it could/should be given my level of exercise. That is, all things considered, it should be about 70. My brother shares my anomalous tendency for 1) slightly elevated overall chosterol, 2) elevated triglycerides (typically >150 mg/dL standard), and 3) diminished HDL, often <>60"]

The final difference is taking Rx Omega3 consistently and in large quantities - 3 to 4 grams a day.

More about VAP tests and key indicators (CRP test, calcium heart-scan, thalium stress test, and others) in subsequent posts.