Persons with LDL cholesterol pattern A have large, buoyant LDL cholesterol particles. Individuals with pattern A are more likely to have normal blood levels of LDL cholesterol, HDL cholesterol, and triglycerides. Pattern A is usually not associated with an increased likelihood of atherosclerosis.

Persons with LDL cholesterol pattern B have predominantly small and dense LDL cholesterol particles. Pattern B is frequently associated with low HDL cholesterol levels, elevated triglyceride levels, and the tendency to develop high blood sugar levels and type II diabetes mellitus.

Individuals with pattern B are also more likely to develop high blood triglyceride levels after a fatty meal (postprandial hyperlipidemia). Pattern B is associated with accelerated atherosclerosis and a 3 to 5- fold increase in heart attack risk. Pattern B is believed to be the most important cause of atherosclerosis in people with normal or near normal total and LDL cholesterol levels.

Some scientists believe that the smaller LDL particles are more dangerous than the larger ones because they can more easily squeeze through the tiny gaps between the cells in the endothelium to reach inside the artery walls. The endothelium is a thin layer of cells which covers the inner wall of the arteries. The cells making up the endothelium have tiny gaps between them. Others postulate that the smaller LDL cholesterol particles are more easily oxidized. Oxidation of cholesterol is significant in the formation of cholesterol plaques.

How can LDL cholesterol size be enlarged?

Even though LDL cholesterol particle size is mainly genetically inherited, individuals who have small LDL particles (pattern B) can increase their particle size through diet, exercise, and medications.

Diets that are low in saturated fat and cholesterol, regular aerobic exercise, and loss of excess body fat have been determined to decrease the number of small LDL particles and increase the number of large LDL particles in the blood. In other words, lifestyle modifications can change pattern B to pattern A.

When lifestyle changes alone are unsuccessful, medications can be used. Even though the statin medications (discussed above) are effective in lowering the absolute levels of LDL cholesterol, they appear to have a limited effect on LDL cholesterol size pattern. Medications such as nicotinic acid (niacin) and gemfibrozil (Lopid) have been found effective in many instances in increasing the size of LDL cholesterol particles.

Lipoprotein (a) (Lp(a)) is an LDL cholesterol particle that is attached to a special protein called apo(a). In large part, a person’s level of Lp(a) in the blood is genetically inherited. Elevated levels of Lp(a) (higher than 20 mg/dl to 30 mg/dl) in the blood are linked to a greater likelihood of atherosclerosis and heart attacks in both men and women. The risk is even more significant if the Lp(a) cholesterol elevation is accompanied by high LDL/HDL ratios.

Certain diseases are associated with elevated Lp(a) levels. Patients on chronic kidney dialysis and those with nephrotic syndromes (kidney diseases that cause leakage of blood proteins into the urine) tend to have high levels of Lp(a).

There are many theories as to how Lp(a) causes atherosclerosis although exactly how Lp(a) accumulates cholesterol plaques on the artery walls has not been well defined. Clinical trials conclusively proving that lowering Lp(a) reduces atherosclerosis and the risk of heart attacks have not been conducted. Currently, there is no international standard for determining Lp(a) cholesterol levels and commercial sources of Lp(a) testing may not have the same accuracy as research laboratories. Therefore, specifically measuring and treating elevated Lp(a) cholesterol levels are not widely performed in this country.

How can Lp(a) cholesterol levels be reduced?

Most lipid-lowering medications such as statins, Lopid, and cholestyramine have a limited effect in lowering Lp(a) cholesterol levels. Estrogen has been shown to lower Lp(a) cholesterol levels by approximately 20% in women with elevated Lp(a) cholesterol. Estrogen can also increase HDL cholesterol levels when given to postmenopausal women. Additionally, nicotinic acid (Niacin or Niaspan) in high doses has been found to be effective in lowering Lp(a) cholesterol levels by approximately 30%.

The carotid intima-media thickness test (CIMT) is a measure used to diagnose the extent of carotid atherosclerotic vascular disease. The test measures the thickness of the inner two layers of the carotid artery – the intima and media – and alerts physicians to any thickening when patients are still asymptomatic. Early detection may indicate the need for a more aggressive approach to managing the risk factors associated with heart disease and stroke.

Aging is a contributing factor to increased carotid intima-media thickness. Other risk factors include high lipoprotein levels, high blood pressure, smoking, diabetes, obesity and a sedentary lifestyle.

Physicians use CIMT testing to determine the “age” of the carotid arteries. Knowing that patients may not be experiencing the symptoms of artherosclerosis, there still may be subtle changes in artery thickness. Armed with this information, physicians may develop an aggressive medical approach by prescribing medications such blood pressure and cholesterol lowering agents and aspirin, and patients may be encouraged make lifestyle and dietary improvements.

What to Expect During the Carotid Intima-Media Thickness Test

• No preparation is required for the CIMT test. Patients may resume normal activities immediately following the test unless otherwise instructed.
• A physician or a diagnostic medical sonographer will perform the test.
• A thick gel, the same consistency as hairstyling gel, is applied to the skin of the neck. With the use of a transducer (a small microphone-like device), the gel helps the sound waves to get from the machine into the body.
• Sound waves bounce off the carotid arteries. This creates “echoes” that are reflected back to the transducer, which converts them to electronic signals. A computer then processes the signals into pictures and shows them on a computer monitor.

The test generates a CIMT measurement and a report identifying the patient’s risk profile.

Her report emphasizes smoking’s immediate, powerful effects on lungs, heart

As little as one cigarette a day, or even just inhaling smoke from someone else’s cigarette, could be enough to cause a heart attack and even death, warns a report released Thursday by U.S. Surgeon General Dr. Regina M. Benjamin.

“The chemicals in tobacco smoke reach your lungs quickly every time you inhale, causing damage immediately,” Benjamin said in a statement. “Inhaling even the smallest amount of tobacco smoke can also damage your DNA, which can lead to cancer.”

And the more you’re exposed, the harder it is for your body to repair the damage.

Smoking also weakens the immune system and makes it harder for the body to respond to treatment if a smoking-linked cancer does arise.

“It’s a really good thing when the Surgeon General comes out and gives a wide scope to the dangers of smoking,” said Dr. Len Horovitz, a pulmonary specialist with Lenox Hill Hospital in New York City. “They’re looking at very small amounts of smoke and this is dramatic. It’s showing the effect is immediate and doesn’t take very much concentration. In other words, there’s no safe level of smoking. It’s a zero-tolerance issue.”

A Report of the Surgeon General: How Tobacco Smoke Causes Disease – The Biology and Behavioral Basis for Smoking-Attributable Disease, is the first tobacco report from Surgeon General Benjamin and the 30th since the landmark 1964 Surgeon General’s report that first linked smoking to lung cancer.

More so than previous reports, this one focused on specific pathways by which smoking does its damage.

Some 70 of the 7,000 chemicals and compounds in cigarettes can cause cancer, while hundreds of the others are toxic, inflaming the lining of the airways and potentially leading to chronic obstructive pulmonary disease (COPD), a major killer in the United States. The chemicals also corrode blood vessels and increase the likelihood of blood clots, upping the risk for heart conditions.

Smoking is responsible for about 85 percent of lung cancers in the United States. But this report puts more emphasis on the link between smoking and the nation’s no. 1 killer, heart disease.

“This report went way beyond pulmonary issues, which people are all too familiar with, but got into cardiovascular risks,” Horovitz said. “We’ve known that even a few cigarettes a day could triple your risk of heart disease. If you have a 3 percent risk of cardiac issues, as a light smoker you could have 9 or 10 percent. That’s significant. It’s a little Russian Roulette.”

And the problems don’t stop there, the reported stated. Smoking cigarettes can interfere with blood-sugar control for diabetes and can help spur a range of pregnancy and birth-related problems such as miscarriage, low birth weight and sudden infant death syndrome (SIDS).

Cigarettes are also getting more addictive, the report stated, with newer formulations getting the nicotine more quickly and efficiently from the lungs — where it first enters the body — to the heart and brain. Compounds other than nicotine that are added to cigarettes also help hook people in, the report said.

“The evidence clearly states that tobacco products are lethal weapons capable of shortening the lifespans of smokers and nonsmokers alike,” American Heart Association CEO Nancy Brown said in a statement. “However, tobacco companies will stop at nothing to addict a new generation of smokers.”

“We strongly believe the findings will support implementation of new federal tobacco regulations, including the development of graphic warning labels for cigarette packages,” she continued. “We also urge state officials to fund smoking prevention and cessation programs at CDC- recommended levels, enact strong smoke-free policies and boost tobacco excise taxes. Policymakers must not allow complacency to rule in the fight against tobacco. Bold, aggressive measures are needed to save lives, reduce the burden of disease and improve quality of life.”

More information

View the new report at the Office of the U.S. Surgeon General.

SOURCES: Len Horovitz, M.D., pulmonary specialist, Lenox Hill Hospital, New York City; Dec. 9, 2010, Report of the Surgeon General: How Tobacco Smoke Causes Disease-The Biology and Behavioral Basis for Smoking-Attributable Disease

Congestive heart failure (CHF) is a condition in which the heart’s function as a pump to deliver oxygen rich blood to the body is inadequate to meet the body’s needs. Congestive heart failure can be caused by:

1. diseases that weaken the heart muscle,
2. diseases that cause stiffening of the heart muscles, or
3. diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver.

The heart has two atria (right atrium and left atrium) that make up the upper chambers of the heart, and two ventricles (left ventricle and right ventricle) that make up the lower chambers of the heart. The ventricles are muscular chambers that pump blood when the muscles contract (the contraction of the ventricle muscles is called systole).

Many diseases can impair the pumping action of the ventricles. For example, the muscles of the ventricles can be weakened by heart attacks or infections (myocarditis). The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole.

Diseases such as hemochromatosis or amyloidosis can cause stiffening of the heart muscle and impair the ventricles’ capacity to relax and fill; this is referred to as diastolic dysfunction. The most common cause of this is longstanding high blood pressure resulting in a thickened (hypertrophied) heart. Additionally, in some patients, although the pumping action and filling capacity of the heart may be normal, abnormally high oxygen demand by the body’s tissues (for example, with hyperthyroidism) may make it difficult for the heart to supply an adequate blood flow (called high output heart failure).

In some patients one or more of these factors can be present to cause congestive heart failure. The remainder of this article will focus primarily on congestive heart failure that is due to heart muscle weakness, systolic dysfunction.

Congestive heart failure can affect many organs of the body. For example, the weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their normal ability to excrete salt (sodium) and water. This diminished kidney function can cause to body to retain more fluid. The lungs may become congested with fluid (pulmonary edema) and the person’s ability to exercise is decreased. Fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins. The intestines may become less efficient in absorbing nutrients and medicines. Over time, untreated, worsening congestive heart failure will affect virtually every organ in the body.

If you are having severe pain, crushing, squeezing, or pressure in your chest that lasts more than a few minutes, or if the pain moves into your neck, left shoulder, arm, or jaw, go immediately to a hospital emergency department. Do not drive yourself. Call 911 for emergency transport.

Chest pain is one of the most frightening symptoms a person can have. It is sometimes difficult even for a doctor or other medical professional to tell what is causing chest pain and whether it is life-threatening.

• Any part of the chest can be the cause of the pain including the heart, lungs, esophagus, muscle, bone, and skin.
• Because of the complex nerve distribution in the body, chest pain may actually originate from another part of the body.
• The stomach or other organs in the belly (abdomen), for example, can cause chest pain.

Potentially life-threatening causes of chest pain are as follows:

• Heart attack (acute myocardial infarction): A heart attack occurs when blood flow to the arteries that supply the heart (coronary arteries) becomes blocked. With decreased blood flow, the muscle of the heart does not receive enough oxygen. This can cause damage, deterioration, and death of the heart muscle.
• Angina: Angina is chest pain related to an imbalance between the oxygen demand of the heart and the amount of oxygen delivered via the blood. It is caused by blockage or narrowing of the blood vessels that supply blood to the heart. Angina is different from a heart attack in that the arteries are not completely blocked, and it causes little or no permanent damage to the heart. “Stable” angina occurs repetitively and predictably while exercising and goes away with rest. “Unstable” angina results in unusual and unpredictable pain not relieved totally by rest, or pain that actually occurs at rest.
• Aortic dissection: The aorta is the main artery that supplies blood to the vital organs of the body, such as the brain, heart, kidneys, lungs, and intestines. Dissection means a tear in the inner lining of the aorta. This can cause massive internal bleeding and interrupt blood flow to the vital organs.
• Pulmonary embolism: A pulmonary embolus is a blood clot in one of the major blood vessels that supplies the lungs. It is a potentially life-threatening cause of chest pain but is not associated with the heart.
• Spontaneous pneumothorax: Often called a collapsed lung, this condition occurs when air enters the saclike space between the chest wall and the lung tissue. Normally, negative pressure in the chest cavity allows the lungs to expand. When a spontaneous pneumothorax occurs, air enters the chest cavity. When the pressure balance is lost, the lung is unable to re-expand. This cuts off the normal oxygen supply in the body.
• Perforated viscus: A perforated viscus is a hole or tear in the wall of any area of the gastrointestinal tract. This allows air to enter the abdominal cavity, which irritates the diaphragm, and can cause chest pain.
• Cocaine-induced chest pain: Cocaine causes the blood vessels in the body to constrict. This can decrease blood flow to the heart, causing chest pain. Cocaine also accelerates the progression of atherosclerosis, a risk factor for a heart attack.

Causes of chest pain that are not immediately life-threatening include the following:

• Acute pericarditis: This is an inflammation of the pericardium, which is the sac that covers the heart.
• Mitral valve prolapse: Mitral valve prolapse is an abnormality of one of the heart valves in which the “leaves” of the valve bulge into the upper heart chamber during contraction. When this occurs, a small amount of blood flows backward in the heart. This is believed by some to be a cause of chest pain in certain people, although this has not been proven with certainty.
• Pneumonia: Pneumonia is an infection of the lung tissue. Chest pain occurs because of inflammation to the lining of the lungs.
• Disorders of the esophagus: Chest pain from esophageal disorders can be an alarming symptom because it often mimics chest pain from a heart attack.
  • Acid reflux disease (gastroesophageal reflux disease, GERD, heartburn) occurs when acidic digestive juices flow backward from the stomach into the esophagus. The resulting heartburn is sometimes experienced as chest pain.
  • Esophagitis is an inflammation of the esophagus.
  • Esophageal spasm is defined as excessive, intensified, or uncoordinated contractions of the smooth muscle of the esophagus.
• Costochondritis: This is an inflammation of the cartilage between the ribs. Pain is typically located in the mid-chest, with intermittently dull and sharp pain that may be increased with deep breaths, movement, and deep touch.
• Herpes zoster: Also known as shingles, this is a reactivation of the viral infection that causes chickenpox. With shingles, a rash occurs, usually only on one small part of the body. The pain, often very severe, is usually confined to the area of the rash. The pain may precede the rash by 4-7 days. Risk factors include any condition in which the immune system is compromised, such as advanced age, HIV, or cancer. Herpes zoster is highly contagious to people who have not had chickenpox or have not been vaccinated against chickenpox for the five days before and the five days after the appearance of the rash.

High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called “pre-hypertension”, and a blood pressure of 140/90 or above is considered high.

The top number, the systolic blood pressure, corresponds to the pressure in the arteries as the heart contracts and pumps blood forward into the arteries. The bottom number, the diastolic pressure, represents the pressure in the arteries as the heart relaxes after the contraction. The diastolic pressure reflects the lowest pressure to which the arteries are exposed.

An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications.

It was previously thought that rises in diastolic blood pressure were a more important risk factor than systolic elevations, but it is now known that in people 50 years or older systolic hypertension represents a greater risk.

The American Heart Association estimates high blood pressure affects approximately one in three adults in the United States – 73 million people. High blood pressure is also estimated to affect about two million American teens and children, and the Journal of the American Medical Association reports that many are under-diagnosed. Hypertension is clearly a major public health problem.

These are the guidelines for cholesterol levels presented by the American Heart Association. You can compare your cholesterol to these guidelines. When determining your risk for heart disease, in addition to your cholesterol levels, your doctor will take into consideration other risk factors, such as age, family history, smoking and high blood pressure. Discuss your cholesterol levels and other heart disease risk factors with your doctor to determine a treatment plan that is right for you.

American Heart Association Classification: