The Smart Heart-- Peter Salgo, MD-- 02/19/04
By Peter Salgo
WebMD Live Events Transcript
You don't have to be smart to understand that heart disease is the No. 1 killer of both men and women in the U.S. But if you're feeling not so smart when it comes to taking care of your heart, discover the simple steps you can take now to prevent heart disease. Our guest was Peter Salgo, MD, author of The Heart of the Matter.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome to WebMD Live, Dr. Salgo. Please start us out with an introduction to your book and the "three key breakthroughs" mentioned in the title.
Salgo: This book was written because for the first time we understand what causes heart attacks. Now it may surprise you to learn that we didn't know what caused heart attacks until very recently, but that's true. When I was in medical school, back when dinosaurs roamed the earth, we were taught that you got plaque in your coronary arteries, the arteries that feed blood to the heart. This plaque slowly obstructed the arteries, leading to heart pain, or angina, and eventually, heart death or heart attack. It was a very simple explanation. The only problem was, it didn't work.
It does not and did not explain why 50% of people who have heart attacks have no plaque. It did not explain why you could be feeling fine without angina one day and have a catastrophic life-threatening heart attack the next. It also failed to explain why cholesterol was bad for you, why aspirin was good for you, and lots of other facts that simply didn't fit.
However, over the past few years our understanding of heart attack has shown us that heart attack is not the same disease as angina, that the mechanism that causes heart attack differs significantly from the mechanism that causes angina. In this difference lies hope, because for the first time we know how to turn off the heart attack mechanism.
I wrote in my book, The Heart of the Matter , that we are, with regard to heart attack today, where we were with regard to polio on the eve of the Salk vaccine, where we were with infectious disease just before penicillin, where the dentists were with dental cavities just before fluoridation. We have within our grasp the ability to turn off the heart attack mechanism and end death caused by premature heart attack once and for all.
The Heart of the Matter proposes a three-part attack on heart attacks:
- First, it proposes that everyone take aspirin. This is not surprising. We know that aspirin can prevent a second heart attack if you've already had your first. However, the literature strongly supports taking aspirin before your first heart attack, so you never have a heart attack at all.
- The second part of the program recommends that everyone in this country and everyone, for that matter, in the world, consider taking a statin drug. These drugs lower your serum cholesterol much more effectively and powerfully than the effect you can get using diet and exercise alone. Recent studies suggest strongly that even people with so-called normal cholesterols need those cholesterols lower than we ever thought before.
- The third part of The Heart of the Matter program is the most surprising of all. It recommends that everybody, at some point around middle age or earlier, consider taking an antibiotic to treat a common bacterium known as chlamydia pneumoniae.
And if you think that I am suggesting that heart attacks are caused by an infectious agent, a bacterium that you can catch, you're right. Before you dismiss this idea, check the back of my book. The bibliography is enormous, filled with scientific proposition that you can catch a heart attack. A generation ago if I had told you that ulcer disease was caused by a bacterium that you could treat with antibiotics, you would not have believed me, but in fact it's true. The infectious disease heart attack connection is profound, important, and is critical in our understanding of the way to prevent death.
I wrote this book because it's time for the American public to know what physicians already know, and it's time for the American public to have the choice to do those things to protect their health that many doctors are already doing themselves but not talking about in public. To paraphrase Groucho Marx: You should ask your doctor if she's taking an aspirin a day and a statin, and if she says no, find another doctor.
Moderator: This sounds like nothing short of a medical sea change you're describing. What is the timeline you see for this becoming standard practice for everyone?
Salgo: I think the timeline, with history as our guide, will show us that five years from now people will be doing this routinely. But you can save your own life by starting now. There are many reasons to delay the initiation of any new therapy. Most of the time, you need to look at the risks and benefits of any new treatment. But what The Heart of the Matter is recommending is very low risk.
The benefits are enormous. This treatment promises prolonged life and life of good quality. With the benefits and stakes as high as they are and the risks as low as they are, the time for you to know about this advance is now, not five years from now, not 10 years from now. The drugs are available, some are over the counter, and others should be.
I think you're correct, this represents a sea change, or in a phrase that has been overused of late, this represents a paradigm shift in the way we think about heart attack and what we intend to do about it. I've been not only on the front lines of the heart attack wars, as an associate director of the Open Heart ICU at Columbia Presbyterian Medical Center in New York City, but also as an Emmy award-winning journalist for CBS, I have watched the development of this story over the past decade. It is time for this news to reach the people who need to hear it, hence The Heart of the Matter .
Member question: I'm concerned about your statement regarding antibiotics. We have heard so much about the overuse of them and the eventual development of superbugs that are antibiotic resistant. Don't you think you are overstating your point by saying that everyone should go on these drugs? What about testing first to see if you have an infection before you start passing out the pills?
Salgo: An excellent question, and one that deserves a detailed answer. First, I'm not recommending that we put people on antibiotics indefinitely; I am suggesting a brief course of a specific antibiotic to treat a specific infection. The bacterium we are treating is ubiquitous. More than half of Americans have been exposed to it by middle age. By the age of 70, more than three-quarters of Americans have been exposed.
There is no doubt that testing an individual for the evidence of exposure makes logical sense, and an individual may want to be tested, but if you were to treat every American 70 years of age or older as if that person had been exposed to chlamydia pneumoniae, you would only be wrong 25% of the time.
As in intriguing side note there is no question that we have, as a nation, been overusing antibiotics for generations. This has produced significant bacterial resistance, but if you look at the heart attack rate over time in this country, it is slowly declining. The shape of this curve, heart attack rate over time, resembles nothing more, nor less, than the curve of a partly treated bacterial epidemic. The evidence that bacteria are involved is powerful. Treating bacteria that cause disease with antibiotics is not only a good idea, it is good medicine, it is good public policy, and it will save lives.
By the way, if somewhere in the past few years someone has been treated already with an antibiotic that will kill chlamydia pneumoniae, he or she will not have to repeat the process. Antibiotics make sense; dying of heart disease because we're afraid to use them, does not. We have an indication, we have a target, and we have a benefit. These criteria work.
Member question: How did you determine this particular infectious agent was the culprit? What does it do to the heart? (And I assume that this isn't the STD chlamydia)
Salgo: The $64,000 question I was waiting for someone to ask; thank you. I didn't discover anything. Researchers all over the world have been working with this question for decades. Check the bibliography in the back of my book; you will find scores of research papers looking into the relationship between chlamydia pneumoniae and heart attack. This is not a story that people have been suddenly made aware of; it has been based upon a rapidly mounting pile of scientific evidence.
With regard to the chlamydia name, don't let it frighten you. You are absolutely correct; chlamydia pneumoniae is not the same bug that causes the STD. The mechanism by which this bacteria causes heart attack is fascinating. It seems to go something like this:
First, you have an infection with chlamydia; it is a respiratory infection, which may produce symptoms or it may not. The bacteria, once established in your lungs, find their way to your coronary arteries, where they decide to chow down on cholesterol (his is where a cholesterol heart attack connection becomes clear). The body then recognizes it has unwelcome guests in the walls of the coronary arteries and sends in the troops, i.e., inflammatory cells, to attack the bacteria. This war smolders on for days, weeks, months, and years. The collateral damage of this war is damage to the coronary arteries themselves. When these arteries are sufficiently damaged to cause holes to appear (or ulcerations), the debris of the chlamydia wars is exposed to the blood traveling in the coronary arteries. This leads to blood clots and coronary artery blockage. With the coronary arteries suddenly obstructed, blood cannot get to the heart muscle, and the heart muscle dies. This is a heart attack.
Looking at it in this way the three-point program outlined in The Heart of the Matter makes perfect sense:
- First, get rid of the bacteria.
- Second, get rid of the food the bacteria eat, i.e., get rid of the excess cholesterol in your blood.
- And last, turn off the inflammatory response. Stop the war before it damages your arteries, and that's what aspirin does. Seen in this light it is clear that aspirin is working as an anti-inflammatory agent and that's how it prevents heart attacks.
Member question: So you can have this chlamydia pneumonia and not know it? What are the symptoms? How is one exposed to this form of chlamydia?
Salgo: Yes, you can have it and not know it. The symptoms are respiratory symptoms, such as a common cold. You are exposed the same as you are to other respiratory agents, through the air.
Moderator: For those who are aspirin intolerant (my asthmatic husband), are there alternatives to take that would also help?
Salgo: Unfortunately, aspirin seems to be unique; however, there may be hope. Research continues. I cannot give you advice of course, individually, that would help your husband, but stay tuned to this space.
Member question: Prevention is a tough sell, even if it involves easy steps. How do you convince people they need to do this? It seems most of us tend to fix a problem after it happens, instead of warding off the problem in the first place.
Salgo: You're right. I don't have a complete answer. All I can do is lay out a road map for those who want to follow it. The trail of death and destruction that this disease creates is there for everyone to see.
One of the reasons I think this particular program has such great promise is that it doesn't necessarily require enormous changes in lifestyle for it to work. I'm not insisting people turn into latter day monks; they don't have to eat celery and tofu, chant every morning, and exercise 10 hours a day. Statins will lower your cholesterol if you put them to work. Aspirin will keep you safe if you take it. A course of antibiotics will help.
Don't get me wrong; I'm not giving you a free pass. You must, must improve your lifestyle as much as you can. You must lose weight if you are too heavy. Stop smoking, unequivocally. Exercise. But this program will make whatever you do much more effective.
Member question: A British study published in The Lancet back in 2002 suggested that a much wider range of people should be given statin drugs, based on risk of heart disease rather than cholesterol levels. This supports your theory on the use of statins. But have you seen any change in how physicians are prescribing statin drugs? Is anyone listening? And who will pay for these medications? How do you get the attention of the medical community and the insurance industry? The general public is notoriously slow to deal with prevention issues unless they are mandated or vigorously promoted by government, the medical community and the pharmaceutical industry.
Salgo: Let's start with the last part first. How do you promote change? That's what I'm doing today. That's why I wrote the book. That's why I appeared on the Today show. That's why I'm doing interviews to everyone who asked. I'm doing everything in my power to tell people the truth: We have a radical new, powerful, effective way to save their lives.
The evidence that you site in The Lancet is only one of hundreds of articles that support the use of statins. Doctors know this, and over the years have been giving more and more statins to people whose cholesterols are lower and lower. There is now evidence to suggest that even people at so-called low cardiac risk will benefit from statins. Doctors recognize the entire concept of "normal cholesterol" needs to be re-evaluated. After all, we are a nation dying of heart disease. In that sense we are a nation dying of cholesterol poisoning. Who would want to be "normal" in that group?
LDL cholesterols can be dropped with statins and must be dropped to levels we never expected to reach if we are to maximize the benefits of this program for everyone. The insurance companies, for their part, have given a silent wink and a nod to the use of statins in people whose cholesterols are otherwise normal. Most of my colleagues who prescribe statins for patients with so-called normal cholesterols get no opposition from the insurance companies.
I propose that we make statins available to the public over the counter. Although insurance companies typically do not pay for over the counter medication, my expectation is that the volume of sales of over the counter statins will drive their price down.
I think this program can work; further, I think it must work. We have a right to live longer and live better and we have a right to the information that will let us do so, which brings us back to promoting heart health. It is every doctor's mandate to tell people what they should do if they want to live longer, better, and healthier. In fulfilling that mandate I wrote The Heart of the Matter. I will continue to speak to anyone who wants to listen about this issue. It's that important, that timely, that powerful a message.
Member question: So you are doing all you can. But how do we get other physicians on board? If I went to my doctor today and asked to be put on statins, I'm sure she would say "no" even though I have a strong family history of heart disease and need to lose weight. She would tell me that my cholesterol levels are good and I don't need statins.
Salgo: Don't be so sure. You might be surprised at the answer, if you asked her about statins. Still, you're right, many physicians haven't gotten the message. They still believe that it is better to take conservative measures first, i.e., lose weight, change your diet, and then see what needs to be done. This approach to heart disease doesn't work. It hasn't worked because it can't work, given the nature of human beings. We will not, we cannot, as a society, it seems, change our lifestyle and our behavior that has been engrained in us our entire lives, at the drop of a hat.
Further, even if we could change everything overnight, we would not see the dramatic improvements in cholesterol levels that the statins can produce. Twenty percent of the cholesterol in your blood is related to your diet. The other 80% is manufactured in your liver. At best, your diet will only wiggle 20% of your cholesterol. That's why statins are so effective. If changing your diet is like taking a hammer to your cholesterol level and beating it down, taking a statin is slamming your cholesterol level with a sledgehammer.
We know one other painful truth about diets and Americans: We don't stay on diets. That's why in the chapter in The Heart of the Matter regarding diet, I point out it really doesn't matter whether you follow the Atkins diet, the Pritikin diet, or the Ornish diet, you'll be off it within a year and back to square one. More than 95% of people who start statin therapy tolerate it and stay on it for over a year. That's dramatic.
I'm glad you asked me this question because it gives me the opportunity to stand on my soapbox. There is a school of thought that says pills are bad, medicines are bad, and only "natural" approaches are good. Dr. Dean Ornish has gone so far as to write in medical journals that using statins have cost us the soul of American medicine. That's balderdash.
The entire history of the human race and medical science has led us to this moment in time, where we have for the first time medications that can help people live longer and live better. Americans deserve access to these medications. We are not talking about religion, we are not talking about a cult of behavior and diet; we are talking about average people who want to live better and longer. We have the opportunity to give that life to them. Holding back that boon is unconscionable, unethical, and will indeed cost us our soul.
Member question: How do we get access to the statins and antibiotics if physicians haven't accepted this as standard practice yet?
Salgo: Antibiotics should always be controlled. Our previous questioner, who raised the specter of superbugs, had a very good point. I propose that we rotate the antibiotics we use against chlamydia pneumoniae, so that we never have the chance of developing a resistant species.
The statins, on the other hand, should be available over the counter, and one of them already is. You can find a drug called Cholestin. It's sold as a health food, and it has had an on-again-off-again relationship with the FDA. What's fascinating about the statins is that they are, in fact, natural products. The first ones were made in nature by fungi seeking to defend themselves from bacteria (it's a dangerous world out there for fungi). Cholestin appears to be a naturally occurring statin.
Whether you can find it in your community or not probably depends on where the FDA battle is at any moment. I would prefer, however, that instead of going to a health food store and purchasing a product about which I know very little regarding its purity and consistency, dose after dose, to be able to go to a pharmacy and get pharmaceutical-grade statins of known potency and purity over the counter.
Still, there have been very few reports that have reached me of problems using health food-grade statins. This implies the drugs must be relatively safe.
Moderator: You mentioned proposing statins be made over-the-counter. How long a process is that, and do you think it will happen?
Salgo: Yes. I don't know how long.
Moderator: Dr. Salgo, do you have any final comments for us?
Salgo: This is an exciting time. We now have the information we need to keep heart attacks from happening and the tools we need to use that information. These tools are easy to use, safe to use, and must be made available to anyone who wants them.
The Heart of the Matter will show you the evidence behind the recommendations and show you what you need to do to save your own life. Read the book. Discuss the book with your doctor. Even buy the book for your doctor. The choice is yours. Free choice is what we all need and expect, but we should all demand the information we need to make our choices intelligent choices. That's why I wrote The Heart of the Matter.
Moderator: Thanks to Peter Salgo, MD, for sharing his expertise with us. For more information on everything he discussed today, pick up a copy of his book, The Heart of the Matter: The Three Key Breakthroughs to Preventing Heart Attacks .
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