Category Archives: Cardiovascular Disease

What causes heart disease part XVI

When you start thinking about things in a new way it is funny where it takes you. You end up seeing connections, where you may previously only have seen confusion. You see links where they could not, or should not, seemingly exist before. In this blog, I am going to take you from migraine to sickle cell disease, and explain how they both cause CVD – and how they both do it through exactly the same underlying mechanisms.

Before reading on, perhaps you might like to think about how this can possibly work … It is always much more satisfying to work things out for yourself. Or maybe that’s just me.

To begin. As you will have picked up from this blog, I believe that cardiovascular disease (CVD) is, essentially, a disease created by endothelial damage and/or dysfunctional blood clotting. With a bit of impaired clot repair thrown in. I spend too much of my life tracking down anything, and everything, that may cause CVD to see if this hypothesis fits – or does not.

Which is why I was interested to see a headline that appeared very recently on Doctors Net (A website for doctors in the UK). It was entitled Migraine cardiovascular link examined’. Up to this point, I had not realised that migraine and CVD were related. So it was something new to me:

As the article, in the BMJ, went on to say:

Young women who suffer from regular migraine attacks appear to have an increased risk of cardiovascular disease, researchers warn today.

Women are three to four times more likely to experience regular migraines. The condition has previously been linked to an increased risk of stroke, but although the physiology of migraine has close links to the vascular system, the way in which migraine increases risk of stroke is unclear.

A team led by Professor Tobias Kurth of the Institute of Public Health in Berlin, Germany, looked at this association, and the link with cardiovascular disease in general.

They used details on 115,541 women aged 25 to 42 years at baseline, taking part in the US Nurses’ Health Study II, which began in 1989. Over the 20 years of follow-up, 15% of the women were diagnosed with migraine.

Cardiovascular disease was 50% more likely among the women with migraine. Heart attack was 39% more likely, stroke 62% more likely, and these women were 73% more likely to have a revascularization procedure.

In addition, women with migraine were 37% more likely to die from cardiovascular disease than women without migraine, and the risk was not significantly altered by age, smoking, high blood pressure, or use of hormone medications.1

So here is, yet another possible cause of CVD. There was no explanation put forward in this study, it was simply an observation. However, I find that unexplained observations are where the answers lie. These are the ghosts in the machine. Truths that occasionally emerge from the dark depths of the ocean, like oarfish, or giant squid, before slipping back into the abyss.

When I see a study like this, the first thing that I do is to look for an association with blood clotting, or endothelial damage, or both. If there is no association, then my hypothesis has suffered a serious blow. On the other hand…

So, taking a deep breath, I looked around the research done in this area. There has not been a great deal, but to my relief. [Yes, I know, a true scientist should never get too attached their own ideas. But, you know what, it’s hard not to….] To my relief I found that migraine is associated with, or causes, blood clotting abnormalities – and also damage to the endothelium.

Just to quote one short section from the Stroke Association:

Migraine-Related Stroke – There is evidence that patients with migraine, particularly migraine with aura, have an increased risk of stroke. The mechanism for this is unclear, although migraine is associated with abnormalities of platelet, coagulation and blood vessel inner lining function, and that may contribute to an increased risk of stroke.’ 2

Just to add further to the connections that potentially open up, I was interested to stumble across a case study where a patient’s migraines were ‘cured’ by using warfarin.

An unusual case report on the possible role of warfarin in migraine prophylaxis


Background: Migraine is a complex disease whose physiopathological mechanisms are still not completely revealed.

Findings: We describe an unusual case, not yet described in literature, of a patient who reported migraine remission, but still presented aura attacks, since starting a therapy with Warfarin.

Conclusions: This case report brings out new questions on the role of the coagulation, especially the blood coagulation pathway, in migraine with aura pathogenesis, and on the possibility to use vitamin K inhibitors, Warfarin or new generation drugs, as possible therapy to use in migraine prophylaxis.3

I must admit I never saw that one coming. Migraines can be treated with warfarin? Though, I suppose, had I thought things through, I might have worked it out. Or maybe not.

Anyway, pulling this information together, we now know that migraines increase the risk of CVD, – more often strokes than heart disease. When you look deeper, you find that migraines are also associated with endothelial dysfunction, and blood clotting abnormalities.

As should be pretty obvious, this all fits perfectly with the ‘CVD is all caused by blood clotting’ hypothesis. On the other hand, if you would like to try to explain how migraines cause CVD through any another process, please let me know. Of course, it could be that another deeper process causes both blood clotting abnormalities, and migraines, but that is for another day.

Of greater interest to me is that, whilst I was studying migraine and CVD, another condition kept popping up on the search criteria. Something that was, again, completely new to me. Which is that there is a very strong association between sickle cell disease (SCD), and CVD. I had never previously thought to link these conditions. However, a number of the migraine articles pointed me towards sickle cell disease (SCD).

Sickle cell disease is a genetic condition whereby red blood cells are malformed and have a sickle shape. This accounts for the name. It is a genetic mutation that, in milder forms, is thought to to protect against malaria, because mildly sickle shaped red blood cells are more difficult for the malaria parasite to enter. However, in its more severe forms, sickle cell disease is quite damaging. Sickle cells can burst, get stuck in smaller blood vessels, form clots in blood vessels in the eyes – leading to blindness, lung and kidney problems etc.

To cut a long story short, in sickle cell disease there are all sorts of ‘clotting’ problems. There is also the potential for significant endothelial damage due to the abnormal shape and function of the red blood cells. Given this, you might expect increased risk of CVD. Which there is, as covered in the paper ‘Atherosclerosis in sickle cell disease – a review:’

Ischemic (lack of oxygen) complications are the major causes of morbidity and mortality in patients with sickle cell disease (SCD). The pathogenesis (what causes these problems) of these complications is poorly understood. Ischemic events in these patients have been attributed to the effects of hemoglobin polymerization, resulting in rigid, dense and sickled cells trapped in the microcirculation. Therefore, vascular occlusion is often considered to be synonymous with occlusion of microvasculature by sickled red blood cells. Several observations suggest that other factors may also play a pathogenic role. Atherosclerosis is one of these factors and may affect many arteries all over the body.

It is fascinating what you find, when you decide to look at things from a different perspective. You start looking at the connection between migraine, CVD, and blood clotting, and end up studying sickle cell disease. I must admit that I get a great sense of satisfaction when I come across facts like this. Somewhat like completing a jigsaw puzzle. ‘Yes, hoorah, it all fits. In fact, it all fits perfectly.’

Indeed, the article on Atherosclerosis in sickle cell disease goes on to bring in Nitric Oxide and L-arginine. I have covered both of these factors in some in detail earlier on in this series. [Sorry this section a bit jargon filled]:

‘The sickling process leads to vascular occlusion, tissue hypoxia and subsequent reperfusion injury, thus inducing inflammation and endothelial injury. This causes a blunted response to nitric oxide (NO) synthase inhibition. In recent years, investigators’ attention has been attracted by the effects of chronic hemolysis on vascular bed integrity and function in patients with congenital hemolytic anemias. Hemolysis results in the release of free hemoglobin.

On one hand, it scavenges NO by oxidizing it to nitrate and releasing red blood cell arginase. On the other hand, it hydrolyzes L-arginine, the substrate of NO synthase. Because of these effects, NO bioavailability and its action is limited. All the previous mechanisms cause impairment of NO production. NO is an important vascular relaxing factor and its deficiency would lead to large artery stiffness. In addition, NO promotes general vascular homeostasis by decreasing endothelial expression of adhesion molecules, decreasing platelet activation, and inhibiting fibroblast, smooth muscle cell and endothelial cell mitogenesis and proliferation.

In one short section on SCD we have virtually everything I have been writing about in this series so far. There is:

  • Reduced NO synthesis
  • Damage to the endothelium
  • Increased risk of blood clotting in general
  • Increased platelet activation and adhesion
  • Inhibition of endothelial cell repair and proliferation
  • Increased risk of CVD and accelerated atherosclerotic plaque development

Another highly important point here is, as follows. You may recall that I said atherosclerosis almost never forms in the blood vessels in the lungs (pulmonary blood vessels). The only time it does is if you have pulmonary hypertension (high blood pressure in the blood vessels in the lungs).

Well, I just found out that if you have sickle cells disease, you are at high risk of developing atherosclerosis in the lungs:

The pulmonary artery is one of the common sites of atherosclerosis in sickle cell disease (SCD). Autopsy of the pulmonary artery in patients with SCD showed that approximately one-third of the patients had histological evidence of medial hypertrophy, intimal proliferation, and subintimal proliferation and fibrosis.’

Now you may not think this is particularly important, but to me it is a killer fact. Atherosclerosis in the pulmonary arteries is something so unusual that when you find it, you are looking at the mother lode. If you can cause atherosclerosis here, then you are gazing at a true underlying cause, with all other risk factors stripped out.

Here is the process (or processes) revealed. Deep joy. It is not often that I come across a fact that I had no idea existed before. Certainly not one that confirms so perfectly everything that I have been saying.

I realise that I have repeatedly stated that the primary purpose of science should be to contradict hypotheses. Here, all I have ended up doing, is providing more facts that support my own hypothesis. I would ask you to believe that I started out looking for a contradiction. I ended up with greater confirmation. Confirmation from places where I had never previously even thought to look.


1: BMJ 1 June 2016; doi: 10.1136/bmj.i2610




What causes heart disease part XV

Scientific hypotheses are easy. You can make up thirty a day if you want. In the arena of cardiovascular disease, I have watched many a hypothesis spring to life in the middle of a conversation. For example, I was at a meeting where an ‘expert’ was attempting to describe what foods cause CVD. Pizza was held up as a very unhealthy food.

I pointed out that there had only been one study done on pizza consumption and CVD. It showed, very clearly, that the more pizza you ate, the lower your risk of CVD. Quite a strong protective effect as a matter of fact. The study was done in Italy.

The moment the geographical location was mentioned, the expert simply replied. ‘Oh yes, but Italian Pizzas are far healthier than pizzas in the UK.’ Thus, ‘the healthy Italian Pizza hypothesis’, was simply plucked from thin air. It was based on no evidence whatsoever, but it seemed reasonable to the expert at the time I suppose. Who knows, it may even be true. Although I suspect not.

Now, I have nothing against the creation of any scientific hypothesis that anyone cares to put forward. Science progresses, primarily, through the development of new ideas. But if you are going to propose a new hypothesis it is beholden upon you to do something that few people then seem willing to do. You need to try and disprove it. There is no point looking for supporting data, you can find supportive data for almost any idea you decide to come up with.

There is a fairly well-known and humorous explanation for CVD (humorous the first fifty times you are told it anyway) that goes like this:

  • Japanese eat very little fat and suffer fewer heart attacks than us
  • Mexicans eat a lot of fat and suffer fewer heart attacks than us
  • Chinese drink very little red wine and suffer fewer heart attacks than us
  • Italians drink excessive amounts of red wine and suffer fewer heart attacks than us
  • Germans drink beer and eat lots of sausages and fats and sufferfewer heart attacks than us
  • The French eat foie-gras, full fat cheese and drink red wine and suffer fewer heart attacks than us

CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you

How would I disprove the ‘speaking English’ hypothesis? Assuming, that is, I could be bothered. I would point out that, currently, speaking Ukrainian kills you. Ukrainians have ten times the rate of CVD of the UK, and the US. Ergo, it is not speaking English that kills you. Next.

Moving to slightly more serious things. Disproving is where I started with in my long term search for a hypothesis about CVD. I did not start out with my own hypothesis. I started out trying to disprove other hypotheses.

Which inevitably meant that I started with the diet-heart/cholesterol hypothesis, as this was, and remains, the number one hypothesis in the area. I am not going to go through all the refutations again. Suffice to say that it failed in so many ways that it was clearly bunk.

Of course, this left me thinking, if CVD has nothing to do with saturated fat in diet, or cholesterol levels, it must be something else. What could that something else be? I began by looking at stress (I realise that the term stress is not remotely precise). I started with the thought that stress, whilst eating, could be a cause/the cause. If you are stressed you will be releasing stress hormones, these antagonise insulin, so when you eat blood sugar levels spike and VLDL levels spike etc.

I became interested in the idea that we measure almost all metabolic parameters e.g. blood sugar, VLDL, cortisol, glucagon in the fasting period. Yet, perhaps all the damage was being done within two hours of eating. So it seemed that we may, to use an analogy, be trying to understand football by visiting a football stadium only before and after the match is being played. ‘Blimey, nothing different ever happens here at all.’

I felt I was onto something, but thinking then moved on to a more general stress hypothesis. I felt that I got most of the way to creating a perfect scientific hypothesis. I had causes and pathways and a mass of supportive data. However, I could still find plenty people with an increased risk of CVD who were not in any way stressed. They had such things as antiphospholipid syndrome (Hughes syndrome). Or they were children with Kawasaki’s disease. Or they had type II diabetes, or they were taking drugs, such as non-steroidal anti-inflammatories, or Avastin. Or… the list went on.

Equally, I could find factors that reduced the risk of CVD, that had nothing to do with reducing stress. For example, aspirin (not a massive effect, but it does exist). Von Willibrand disease, omega-3 fatty acids, potassium, vitamin C. As with causal factors, the ‘nothing to do with stress’ list went on.

So, what did this mean? That stress did not cause CVD, or that it caused only one type of CVD. Or it caused CVD through a completely different process than other causes of CVD? It was at this point that I began to realise I was looking at things the wrong way round. There was no point in saying what things may, or may not, cause CVD – and compiling an ever-lengthening list of ‘risk’ factors.

I had to work out the process through which any factor may operate, both causal and protected. As some of you will know, in this series, I have pointed this out before… many times. But I think that it cannot be said often enough.

So I turned the entire thinking process inside out, and started again. I began by asking the question, what are atherosclerotic plaques? What do they consist of? What do they contain? It became very clear that they are primarily blood clots – in various stages of development and repair.

Having recognised this, I went further back, or forward, to look at the final event in CVD. This is, basically, the formation of a blood clot. Heart attacks occur when a blood clot blocks an artery supplying blood to the heart (there are caveats here, but I am not going into them at this point). Stokes occur when a blood clot blocks an artery in the brain (further caveats).

There is little disagreement that the blood clot is the final event in CVD. Most acute treatments for heart attacks and strokes are, essentially, ways of removing any clot that has formed. You can use aspirin, or more potent clot busters, or you can stick in a catheter to remove the clot/open it up/stick in a stent. You can do a bypass, diverting the blood round the clot… etc. Interventional cardiology could, pretty, accurately be described as ‘blood clot management.’

Many of the drugs used to prevent heart attacks and/or strokes are also anti-coagulants e.g. aspirin, Clopidogrel, warfarin, apixiban etc. [Statins are also potent anticoagulants]. Yet, and yet, no-one seemed willing even to countenance the possibility that blood clots also cause atherosclerotic plaque development. ‘Yes, blood clots kill you, but they have nothing to do with plaque formation.’

‘What, even when plaque contain such things as red blood cells, cholesterol crystals, fibrin, fibrinogen and Lp(a) and….’ the list of things found in both blood clots and plaques is very long.

But of course no expert can agree to this ‘blood clot’ hypothesis. To do so means that you have to discard the cholesterol hypothesis. Which ain’t going to happen anytime soon. So we currently have the dual hypothesis. Cholesterol causes plaques to form, then blood clots kill you. The ‘atherothrombosis’ hypothesis. Which can look as though the mainstream is agreeing about the importance of thrombosis, but is actually a way of keeping the cholesterol hypothesis alive.

For a while I half agreed with this atherothrombosis hypothesis, but the more I thought about it, the more it started to fall apart. I began to focus down on one thought. Can you explain CVD though the ‘abnormal’ development of blood clots alone? Can you link any and all factors, known to cause CVD by their impact on one of two things:

  • Endothelial damage (which triggers blood clot formation)
  • Increasing blood coagulability (making clots more like to form, become bigger and/or less easy to break down)

Then I started writing out a list of things that I knew did one, or both, of these things. There was no particular order to this:

  • Smoking
  • Cocaine use
  • Cortisol
  • Kawasaki’s disease
  • Diabetes
  • Rheumatoid Arthritis
  • Kidney failure
  • Non-steroidal anti-inflammatories e.g. brufen, naproxen
  • Biomechanical stress (within arteries)
  • Dehydration
  • Systemic Lupus Erythematosus
  • Antiphospholipid syndrome (Hughes syndrome)
  • Vitamin C deficiency
  • Raised fibrinogen levels (key clotting factor)
  • Homocysteine
  • Bacterial infections inc. gingivitis
  • Increased plasminogen activator inhibitor – (1 PAI-1) levels (critical factor in blood clot repair/breakdown)

I could have kept going, but that is enough for now. What do all of these things have in common. They increase the risk of atherosclerotic plaque formation, death from CVD. Most importantly, of course, they cause endothelial damage and/or increased blood coagulability. And I could not, and cannot, think of anything else that links them all together.

Then I started to think about factors that reduce the risk of CVD.

  • Exercise (overall, not whilst doing it)
  • Moderate alcohol consumption
  • Aspirin
  • Clopidogrel (expensive aspirin)
  • ACE- inhibitors (a blood pressure lowering agent)
  • Yoga
  • Haemophilia
  • Statins
  • Von Willibrand disease (lack of a specific clotting factor in platelets)
  • B vitamins (enough to reduce homocysteine)
  • Adequate Vit C (no idea what the correct intake should be)
  • Potassium (higher consumption reduces platelets sticking together)
  • Vitamin D
  • Nitric Oxide (through sunlight – and other nutrients e.g. l-arginine)
  • Magnesium (and other micronutrients)

Again, I could keep going. What do all of these things have in common. Well, once again, they either protect the endothelium, or they reduce blood clotting. And they all reduce the risk of CVD.

To my mind there was, and is, an almost perfect correlation. But, as I said earlier. Looking for supportive data is all very well. Can you find the black swan? Or black swans. Are there facts that completely contradict the ‘it’s all to do with blood clots’ hypothesis of CVD?

Warfarin could be one such black swan. Warfarin reduces the risk of stroke (in atrial fibrillation), but it does not really reduce the risk of heart attacks. It is a very powerful anti-coagulant, so surely it should do both. Yet it does not. Why not? Is this a black swan, or can it be explained?

My conjecture is, as follows.

Warfarin is a vitamin K antagonist. It is active in the liver, and interferes with the production of a number of clotting factors (mainly prothrombin and factor VII). This tends to inhibit clots forming, spontaneously, within the blood itself. Which is why warfarin is very effective in Atrial Fibrillation.

In Atrial Fibrillation, the upper chambers of the heart fibrillate (twitch rapidly) so some of the blood tends to get stuck in the upper chambers (the atria). Blood in stasis tends to start clotting. A clot forms, it is then ejected into the lower chamber (the ventricles) where it is then immediately pumped out into the rest of the body. These clots can get stuck anywhere the blood vessel narrows sufficiently – often in the brain, causing a stroke.

Warfarin also works well when you have blood stasis in the veins. For instance, if you break your leg, you will be put in a cast. At which point, due to physical immobility, the blood tends to stop flowing freely, if at all. At which point clots can form, a deep venous thrombosis – DVT. This can then break off and travel through your heart into your lungs causing a pulmonary embolus (PE), which can kill you. Warfarin tends to stop this ‘stasis’ blood clot formation. [Long distance flight and sitting anywhere for a long time can have the same effect]

So why does warfarin have little effect on the clots that cause myocardial infarction. This is probably because damage to the endothelium – the trigger for all the other downstream problems – exposes tissue factor (TF) to the blood. Tissue factor sits within the artery wall itself, and it is the big daddy of clotting.

As you can imagine, the body views damage to an arterial wall as a potential emergency situation that requires immediate and powerful clotting. A damaged artery wall exposes TF Once TF is in play, it will ride straight over such things as a lack of factor VII and prothrombin. TF will directly drive platelets to stick together, and form a plug over the area of damage. It can also directly activate thrombin etc.

Thus, whilst warfarin will prevent the slower ‘stasis’ clots from forming, it will have little effect on the emergency ‘damage to the artery wall’ clotting caused by exposure to TF. I am not going into any more detail on this, but it could be said that warfarin is a good ‘intrinsic’ anticoagulant. But has far less impact on the ‘extrinsic’ clotting system.

On the other hand aspirin, which prevents platelets sticking together, will have a more significant effect on reducing clot formation after activation of TF, as will Clopidogrel, as will a lack of von Willibrand factor (as found in Von Willibrand disease). This, to my mind at least, fits with the fact that ‘less potent’ anticoagulant factors can reduce risk of heart attacks (albeit by differing amounts), whereas warfarin does not.

So, the lack of effect of warfarin on heart attacks can be understood, in relation to where it actually acts in the coagulation system. In addition, because warfarin is a vitamin K antagonist, and vitamin K appears to protect against the build of calcium in various tissues, warfarin accelerates calcification in artery wall. Which could be a further problem in itself – leading to a higher rate of CVD.

Now, you could think this is all rather convoluted. An attempt to explain why an apparent contradiction is not a contradiction all. You could, of course, be right to think this. But firmly believe that the lack of effect on warfarin, on heart attacks, can be explained. Through a deeper understanding of the clotting system. In fact, the different effects of different anticoagulants on CVD risk supports rather than undermines the hypothesis.

Perhaps, now, you may gain an inkling as to why it has taken me so many, many, years to try and establish the true underlying cause of CVD. It did not take too long, at least once I got my thinking the right way round, to work out that blood clotting may be the underlying process that underpins CVD. What has really taken the time is looking for contradictions.

And, in the spirit of true scientific endeavour, I welcome as many attacks/contradictions as people can think of. What does not kill a scientific hypothesis can only make it stronger.

What causes heart disease part XIV

I have been much cheered by all the discussion on my series about what caused heart disease a.k.a. cardiovascular disease. Because of various comments, my series has gone off in a few different directions. I realise that not everyone agrees with everything (or anything?) I have to say, and that several issues I thought were clear, clearly are not. This is fine. Science should progress by discussion and debate and contradictions.

In this blog, in order to answer some of what people have written (albeit indirectly), I am going to look at two of the conventional risk factors for CVD in a bit more detail, and try to explain why they represent a major problem for conventional thinking.

As many of you may have discovered, if you go to see your GP – almost anywhere in the world – they will use a list of ‘standard’ risk factors to calculate your risk of a cardiovascular ‘event’ over the next five or ten years.

There are a few of these calculators, but two of most commonly used are probably QRISK2 and the ASCVD, created by the American College of Cardiology and American Heart Association. [ASCVD = atherosclerotic cardiovascular disease]. I cannot find out where the term QRISK comes from – perhaps someone can help me.

The ASCVD is a bit shorter than QRISK. It looks at:

  • Age
  • Gender
  • Race
  • Total Cholesterol
  • HDL
  • Systolic blood pressure
  • Diastolic blood pressure
  • Treatment for blood pressure
  • Diabetes
  • Smoker

The QRISK is a UK developed risk calculator. It is a bit bigger and more complicated than ASCVD. It looks at:

  • Age
  • Sex
  • Systolic blood pressure
  • Diastolic blood pressure
  • Total Cholesterol
  • Total Cholesterol/HDL ratio
  • Serum triglyceride
  • Smoking
  • Glucose Impaired glucose tolerance/diabetes
  • Left Ventricular hypertrophy
  • Central obesity
  • South Asian (South Asians, in the UK, have a far higher risk of CVD)
  • Family history of CVD

Now, there is no doubt that all of the factors on both lists are associated with CVD – to a greater or lesser degree. At least they are for the US and UK population currently living. It has to be pointed out thought, that if you use QRISK in France, you have to divide the risk by 4… ahem, slight problem.

A further problem is that it has been discovered that they both vastly over-estimate risk in US and UK population.

‘A widely recommended risk calculator for predicting a person’s chance of experiencing a cardiovascular disease event — such as heart attack, ischemic stroke or dying from coronary artery disease — has been found to substantially overestimate the actual five-year risk in adults overall and across all sociodemographic subgroups. The study by Kaiser Permanente was published today in the Journal of the American College of Cardiology.

The actual incidence of atherosclerotic cardiovascular disease events over five years was substantially lower than the predicted risk in each category of the ACC/AHA Pooled Cohort equation:

  • For predicted risk less than 2.5 percent, actual incidence was 0.2 percent
  • For predicted risk between 2.5 and 3.74 percent, actual incidence was 0.65 percent
  • For predicted risk between 3.75 and 4.99 percent, actual incidence was 0.9 percent
  • For predicted risk equal to or greater than 5 percent, actual incidence was 1.85 percent

“From a relative standpoint, the overestimation is approximately five- to six-fold,” explained Dr. Go. “Translating this, it would mean that we would be over-treating a good many people based on the risk calculator.”’1

So, you feed your risk factors in a risk calculator that took many years to create, using data carefully gathered by experts from the world of cardiology, and your true risk is overestimated five to six fold. Excellent. That mean millions upon millions of people have been told to take a statin based on a calculation that is so inaccurate as to be virtually meaningless. [This was always going to happen, because risk was established using clinical data from decades ago, since when, CVD rates have fallen dramatically]

Anyway, leaving the horrible inaccuracy of these risk factor calculators aside for the moment. What of the risk factors themselves? I am not going to look at all of them here, just two. Firstly, age. There is no doubt that age is the single most important risk for CVD. Your risk at 65 is around ten times as high as at age 35 – no matter what the overall risk may be in your particular country.

In fact, if you have no other factors at all, in the US, your future CVD risk at the age of 67 is so high (according to the calculator) it means that you are advised to go on a statin immediately, for the rest of your life. Ho hum. For women it is a few years later. ‘Here’s your first pension payment – with built in statin prescription.’

I find it fascinating that almost everyone seems to accept age as a risk factor for CVD, without really questioning why this should be so. Age does not necessarily increase the risk of diseases. There are many which are more common when you are younger, and the risk diminishes as you age.

The argument seems to be that CVD slowly progresses. Thus, as you get older, the risk increases. Yes, perhaps. However, if you have no conventional risk factors for CVD, why should it progress at all? At the risk of repeating myself, I shall repeat myself. You have no risk factors for CVD. Yet, as you grow older, your risk of CVD reaches the point where you are statinated. Because your future risk is so high.

But what is causing the atherosclerosis in your arteries to develop. Age? Through what process can age created atherosclerotic plaques, assuming no other risk factors? Raised cholesterol… well you don’t have raised cholesterol. Raised BP? Well, you don’t have raised BP. Smoking, well, you don’t smoke… etc.

The other major risk factor where we have an acceptance of a fact – without even an attempt at explanation is gender. In most populations younger men have a far higher risk of CVD than women. The different in risk varies greatly, but averages at about three to one. By which I mean, a women aged 55 women will have around one third the risk of a man aged 55 (living in the same country). Even if they have exactly the same risk factors.

For years it was stated, with great confidence, that this difference was due to female sex hormones. These hormones in some – never fully stated fashion – protected women against CVD. It has now been proven, beyond a molecule of doubt, that this is not true. Female sex hormones do not protect against CVD. Indeed, they probably accelerate it.

So, what does protect women against CVD. There is no explanation. It just is. Feed gender into the calculator and a different risk pops out for men and women. Why, because men and women, have a different risk of CVD. Why? Because they do. [BTW, the South Asian issue is much the same. Multiply the risk by 1.4. Why, because you do].

The reality is that age, and gender, are two of the most powerful risk factors for CVD. In that, if you use the ASCVD or QRISK calculator and change only age, and gender, the risk will go from close to zero, in a young woman to dark red – danger, danger, in an older man. Even if you set all other risk factors to zero.

It has always baffled me that experts in cardiology seem utterly unconcerned about this. They do not even consider that this is an issue. However, if the two most powerful risk factors you have for CVD, cannot be explained, are not explained, then you really have a major problem. Even if you cannot even comprehend that you do.

If you cannot explain why age, and gender, cause CVD… you cannot explain CVD.


What causes heart disease – part XIII

Heart disease and inflammation.

A few people have sent me links to a recent paper called ‘Inflammation and Atherosclerosis.’ This was published in Circulation, and the authors were: Peter Libby, MD; Paul M. Ridker, MD; Attilio Maseri, MD. Remember two of the names.

Here is a relatively long section of the abstract:

‘Atherosclerosis, formerly considered a bland lipid storage disease, actually involves an ongoing inflammatory response. Recent advances in basic science have established a fundamental role for inflammation in mediating all stages of this disease from initiation through progression and, ultimately, the thrombotic complications of atherosclerosis. These new findings provide important links between risk factors and the mechanisms of atherogenesis.

Clinical studies have shown that this emerging biology of inflammation in atherosclerosis applies directly to human patients. Elevation in markers of inflammation predicts outcomes of patients with acute coronary syndromes, independently of myocardial damage. In addition, low-grade chronic inflammation, as indicated by levels of the inflammatory marker C-reactive protein, prospectively defines risk of atherosclerotic complications, thus adding to prognostic information provided by traditional risk factors.

Moreover, certain treatments that reduce coronary risk also limit inflammation. In the case of lipid lowering with statins, this anti-inflammatory effect does not appear to correlate with reduction in low-density lipoprotein levels. These new insights into inflammation in atherosclerosis not only increase our understanding of this disease, but also have practical clinical applications in risk stratification and targeting of therapy for this scourge of growing worldwide importance.

This paper interested me for a number of reasons. I focused down for a few moments on the phrase ‘Atherosclerosis, formerly consider a bland lipid storage disease…’ Does this mean that the world is moving on… Atherosclerosis has nothing to do with lipids e.g. LDL a.k.a. ‘bad cholesterol’? Now that would be something. Especially as it was published in the mainstream CV journal ‘Circulation.’

It seems that these authors are trying to shift the thinking away from cholesterol to inflammation. However, before discussing anything else I wanted to point out something that most people may have missed – by looking at a bit of background on the authors. First, Paul Ridker, who ran the JUPITER study, and who is a hugely influential cardiologist.

It should be noted that Paul Ridker has a major interest in moving thinking about atherosclerosis from a lipid storage disorder to an inflammatory condition. Because he has patent on the high sensitivity CRP test (C-reactive protein).

‘Dr Ridker is named as a coinventor on patents filed by the Brigham and Women’s Hospital that relate to the use of inflammatory markers in cardiovascular disease.’

What this means is that every time someone uses a high sensitivity CRP test, Paul Ridker becomes a little bit richer. However, in this paper, this massive financial conflict of interest is not mentioned. Instead, we get Acknowledgements:

This work was supported in part by grants from the National Heart, Lung, and Blood Institute to Drs Libby (HL-34636, HL-48743, and HL-56985) and Ridker (HL-58755 and HL-63293), and by the Leducq Foundation (to Drs Libby and Ridker). Dr Ridker is also supported by a Distinguished Scientist Award from the Doris Duke Foundation. Dr Maseri is supported by a grant from Fondazione Internazionale di Ricerca Per il Cuore onlus

No conflicts Dr Ridker? Mind you, Paul Ridker does have considerable form in not disclosing his financial conflicts. Some years ago, the Journal of the American Medical Association JAMA, was forced to publish a statement on ‘Unreported Financial Disclosures’ that were spotted in paper ‘Associations of LDL, Cholesterol, Non-HDL Cholesterol, and Apolipoprotein B levels With Risk of Cardiovascular Events Among Patients Treated with Statins: A meta-analysis.’

This statement mentioned many, many conflicts that the authors had failed to mention at the time. The section on Dr Ridker reads thus:

‘…Dr Ridker reports board membership of Merck Sharp and Dohme and receipt of a grant or pending grant to his institution from Amgen.’ [Amgen, as you may know are pushing PCSK-9 inhibitors]. This is covered in my book Doctoring Data.

Just to spell this out in a little more detail, Paul Ridker was an author on a meta-analysis of statins, yet failed to report that he was a board member of a pharmaceutical company (Merck) that marketed statins.

In truth, the moment I saw a paper promoting the ‘new idea’ that atherosclerosis is all due to inflammation, my antennae started to twitch. Especially when I knew that Paul Ridker was involved. A man who holds patents on a test for the inflammatory marker that we should be using.

I then immediately wondered, Is Paul Ridker now running a clinical trial on behalf of a pharmaceutical company, looking at the use of an anti-inflammatory agent to treat CVD. So, I had a little look round the internet. And guess what. Paul Ridker is, indeed, running a trial on an ant inflammatory for the treatment of CVD. The CANTOS study If you look down the list those on the committee running this study, you will find that Peter Libby is also on the steering committee. A conflict that remained unmentioned in the Circulation paper either.

What is the drug, it is Canakinumab. Here, from Wiki:

Canakinumab (INN, trade name Ilaris, previously ACZ885) is a human monoclonal antibody targeted at interleukin-1 beta. It has no cross-reactivity with other members of the interleukin-1 family, including interleukin-1 alpha.

Canakinumab was approved for the treatment of cryopyrin-associated periodic syndromes (CAPS) by the U.S. Food and Drug Administration (FDA) on June 2009[4] and by the European Medicines Agency in October 2009.CAPS is a spectrum of autoinflammatory syndromes including familial cold autoinflammatory syndrome, Muckle–Wells syndrome, and neonatal-onset multisystem inflammatory disease.

Canakinumab was being developed by Novartis for the treatment of rheumatoid arthritis but this trial was completed in October 2009. Canakinumab is also in phase I clinical trials as a possible treatment for chronic obstructive pulmonary disease, gout and coronary artery disease. It is also in trials for Schizophrenia. In gout it may result in better outcomes than a low dose of a steroid but costs five thousand times more.

I thought I would highlight the final sentence, just to give you some idea of the potential cost of this drug, should it ever be marketed for the treatment of CVD.

I know that this may seem a diversion. However, I have been around the world of cardiovascular research for long enough to take nothing at face value. Here is a paper suggesting that atherosclerosis has little or nothing to do with lipids. It is primarily due to inflammation. Which is a reasonable hypothesis. But guess what, one of the authors has a patent for an inflammatory marker. He and another author are running a clinical study, funded by Novartis, on the use of an anti-inflammatory agent in CVD.

However, just because there is money in the background, it does not necessarily mean that everything written is wrong. Perhaps inflammation truly is the underlying cause of atherosclerosis. Many other people have been saying this for years. Some of them, I know, certainly believe it from a purely objective scientific perspective. For example, Duane Graveline – who writes a great deal about CVD on his blog, and is also a friend. He fully believes that atherosclerosis is an inflammatory condition, and he has no horse in the race.

My own take on this matter is slightly different. Yes, if you have a high C-reactive protein (CRP) level, this means that there is inflammation going on within the artery, and this is a sign of increased CVD risk. This is true, but what does it mean? Is the inflammation causing the CVD?

Whenever I see anyone stating that inflammation is a cause of anything I simply change the word inflammation to the word ‘healing,’ to see how sensible it then sounds. Inflammation is, in most cases, the way the body heals itself after injury. If you twist your ankle, it will become swollen and inflamed. The injury comes first, then you get the inflammation/healing. You would be hard pressed to state that inflammation causes twisted ankles.

Of course, there are some conditions where the inflammation itself can become greater than the original problem. Just to name three: Asthma, Crohn’s disease and Rheumatoid arthritis. In these diseases the body’s inflammatory/healing system becomes revved up, and starts attacking itself. This out of control inflammation can then lead to further problems downstream e.g. joint destruction. Such conditions are often ‘treated’ or controlled by anti-inflammatory agents e.g. steroids.

Equally, if you have Systemic Lupus Erythematosus (SLE), this is an ‘inflammatory’ disease, and you also have a severe vasculitis (inflammation of vasculature). As mentioned before SLE can raise the risk of CVD, in young women, by up to five thousand per cent. Case proven? Inflammation causes atherosclerosis?

No, I don’t think so. The sequence in SLE is that the vasculature is damaged (the endothelium is damaged). This stimulates the body to try and heal the damage. The healing is what we call inflammation and the C-reactive protein level goes up.

Get rid of the inflammation, and you will not be treating anything. You will simply be interfering with the healing process, and the CVD will, most likely, accelerate. Even if C-reactive protein levels go down, along with any observable inflammatory action.

If I may return for a moment or two to twisted ankles. To quote Dr Mirkin:

‘When I wrote my best-selling Sports medicine Book in 1978, I coined the term RICE (Rest, Ice, Compression, Elevation) for the treatment of athletic injuries. Ice has been a standard treatment for injuries and sore muscles because it helps to relieve pain caused by injured tissue. Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.’

As he goes on to say:

‘Anything That Reduces Inflammation Also Delays Healing [I cannot resist stating that, this is because inflammation is healing]

Anything that reduces your immune response will also delay muscle healing. Thus, healing is delayed by:

  • cortisone-type drugs,
  • almost all pain-relieving medicines, such as non-steroidal anti-inflammatory drugs like ibuprofen
  • immune suppressants that are often used to treat arthritis, cancer or psoriasis,
  • applying cold packs or ice, and
  • anything else that blocks the immune response to injury.’

At least Dr Mirkin has had the grace to admit that he was wrong. RICE reduces inflammation, but interferes with healing.

I am pretty certain that exactly the same thing will happen with ‘inflammation’ in CVD. I can state this with relative confidence, because the most powerful anti-inflammatory agent known to man are steroids/corticosteroids. Corticosteroids e.g. prednisolone, or hydrocortisone are potent anti-inflammatory agents, they are all based on the natural stress hormone cortisol – produced in the adrenal glands. Steroids = corticosteroids = cortisol (just about).

Cushing’s disease is a disease whereby too much cortisol is produce in the adrenal glands, usually due to a small tumour that overproduces the hormone. So, if you have Cushing’s disease, you have a powerful anti-inflammatory agent coursing through your blood vessels – at all times. And what is the effect of this on CVD?

‘In patients with Cushing’s syndrome (CS) cardiovascular complications determine a mortality rate four times higher than in an age- and gender-matched population.’

The same thing happens when you prescribe steroids, for various conditions:

‘Individuals who use glucocorticoids and exhibit iatrogenic (caused by the medicine) Cushing’s syndrome should be “aggressively” targeted for early screening of cardiovascular (CV) risk factors, say researchers.

Laurence Fardet (University College London, UK) and colleagues found that individuals with iatrogenic Cushing’s syndrome who were prescribed glucocorticoids had a significantly higher incidence of CV events (including coronary heart disease, heart failure, or ischemic cerebrovascular events) than individuals prescribed glucocorticoids without iatrogenic Cushing’s syndrome, or those not prescribed glucocorticoids.

Indeed, Cushing’s syndrome patients prescribed glucocorticoids had a CV incidence rate per 100 person-years at risk of 15.1 compared with 6.4 and 4.1 in those without Cushing’s but who were prescribed glucocorticoids and those not prescribed glucocorticoids, respectively.

Multivariate analysis revealed that iatrogenic Cushing’s patients had a 2.27-fold increased risk for coronary heart disease, a 3.77-fold increased risk for heart failure, and a 2.23-fold increased risk for ischemic cerebrovascular events.’

Proving a medical hypothesis is never that simple. However, if you believe that CVD is due to inflammation, then the world’s most potent anti-inflammatory agents ought to decrease CVD risk. Instead, it increases it by at least 400%. [Far more in some studies]

Other anti-inflammatory agents, known as Non-steroidal anti-inflammatories (NSAIDs) also greatly increase the risk of CVD. Vioxx (a potent NSAID), launched then pulled off the market, was estimated to have killed over one hundred thousand people in the US alone, from increasing CV risk.

In short, if CVD is primarily a disease of inflammation, then potent anti-inflammatory agents ought to reduce the risk. Instead they increase it massively. There is no doubt that inflammation is associated with CVD. Equally, if you measure C-reactive protein (a marker of inflammation), a high level is associated with a higher risk of CVD. However, it is not a cause, and if you try to reduce inflammation you will almost certainly increase the risk of CVD, not decrease it.

Ergo. Inflammation is sign of active CVD. That is all.

What causes heart disease part XII

Twelve parts and not finished yet. Oh well.

At this point I have an admission to make – having recently been thinking about things in a different way. Up to now I have been using a model which I have called the ‘four step’ process of cardiovascular disease.

  • Endothelial damage
  • Clot formation/dysfunctional clot formation
  • Clot repair/dysfunctional clot repair
  • The final, fatal, blood clot

I still think that all the parts of the model are correct. However, it is probably best to look at this more as overlapping sets, rather than steps. Whilst it is true that, until the endothelium is damaged, nothing else can happen in the process of atherosclerotic plaque development. Once endothelial damage has occurred we are not looking at step 2, step 3, step 4 – as a linear process. After the first episode of endothelial damage, all the processes can be going on, virtually simultaneously (apart from the final, fatal clot obviously).

So, the thought I wish to make at this point, is that we are looking at a dynamic process, where all processes overlap and interconnect. Endothelial damage can be going on, whilst dysfunctional clot repair is also happening, in addition to further clot formation.

I was trying to think of a good analogy. The best I could come up with was rust on paintwork on a car. Before you can get rust, you need some damage to the paintwork. After that other factors can come into play. Water, salt…. Um, water and a bit more salt…um. Well, I am sure that other things can make cars rust more quickly, but hope you get the general idea.

Thus, I have decided not to call this the four step process anymore. I shall call it the four process process. No, that is rather clumsy. I shall call it the…not sure. The quadrilateral process. The ‘four process clotting’ hypothesis of heart disease. Anyway. I hope you know what I am going on about (those that have read the previous eleven blogs may do).

The role of lipoproteins

Now I am going to take this discussion in a direction those who have followed my writing thus far, may not quite expect. I want to look at the role of lipoproteins in blood clotting. Mea Culpa. I have spent a great deal of time telling people that lipoproteins have nothing to do with CVD. This is not entirely true. They can, and do, play a role.

The reality is that virtually every substance that can be found in the blood has some influence on blood clotting – and there are an enormous number of substances in the blood. So, it should come as no real surprise to find that high density lipoprotein (HDL), low density lipoproteins (LDL) and very low density lipoproteins (VLDL) are also involved.

Just to recap on one lipoprotein, namely lipoprotein (a) (Lp(a). As I have discussed earlier Lp(a), is produced by the body to plug areas of damage to artery wall. It is found in animals that cannot synthesize vitamin C – and are therefore at high risk of scurvy. Scurvy is, primarily, a disease of connective tissue e.g. collagen (which needs vitamin C for its synthesis).

Breakdown of collagen leads to cracks in blood vessels, and Lp(a) plugs the gaps. Thus, here is one lipoprotein, the entire function of which, is to help form very strongly bound blood clots. What I wish to highlight here is that Lp(a) could also be called LDL(a). Because Lp(a) is LDL which has one different protein attached to it.

With LDL and Lp(a) being virtually identical, it should come as no surprise that LDL itself also has an impact on blood clotting, through a number of different mechanisms. Indeed, the interaction between LDL and blood clotting is mind-boggling in its complexity. I am not going into things here in too much detail, and I will just highlight one study. It has the catchy title: ‘LDL receptor cooperates with LDL receptor–related protein in regulating plasma levels of coagulation factor VIII in vivo.’ Here we go:

‘High levels of FVIII in plasma (greater than 1.5 U/mL) constitute a major risk factor for arterial and venous thrombosis in humans. Our observation that the up-regulation of hepatic LDLR protein expression in mice by gene transfer accelerated FVIII clearance from the circulation may be of therapeutic interest for patients who have elevated plasma FVIII levels. In humans, the up-regulation of LDLR protein is achieved by treatment with 3-hydroxy-3-methylglutaryl co-enzyme A (HMG-CoA) reductase inhibitors, also called statins. Statins are widely recognized in the treatment of hypercholesterolemia in humans.1

What is all this about? Basically if you have fewer LDL receptors (LDLR) there will be slower clearance of factor VIII (a key blood clotting factor) and the level in the blood rises. If you increase LDL receptors, by using statins, more factor VIII will be removed, and the risk of blood clotting will fall. So, here we have statins reducing the risk of cardiovascular disease by increasing the number of LDL receptors on the liver, which causes factor VIII (a blood clotting factor) to be removed from the blood.

In addition to this LDL interacts with platelets (the key blood cells involved in blood clotting) and the more LDL you have, the greater the tendency of platelets to clump together:

Platelets and lipoproteins are intimately involved in the pathogenesis of a wide variety of disease including atherosclerosis, thrombosis, and coronary heart disease. Evidence accumulated over the years suggests the possibility of a direct relationship between plasma lipoproteins and the hemostatic function of platelets. A number of studies demonstrated that native LDL enhanced the platelet sensitivity to stimulation and induced platelet activation.’2

In short, LDL activates platelets, and activate platelets are the starting point for blood clot formation.

The enormous complexity of the clotting system is further revealed when we look at High Density Lipoproteins (HDL) a.k.a. ‘good’ cholesterol. It is widely accepted that HDL is protective against death from CVD. It is generally believed that this protection comes through the process of reverse cholesterol transport i.e. HDL sucks cholesterol out of plaques. [Which I do not believe]

However, this is almost certainly not how HDL works. It has other important and potent effects on blood coagulation:

‘….Furthermore, HDL stimulates the endothelial production of nitric oxide and prostacyclin, which are potent inhibitors of platelet activation. Thus, HDL’s antithrombotic actions are multiple and therefore, raising HDL may be an important therapeutic strategy to reduce the risk of arterial and venous thrombosis.’3

VLDL (triglyceride)

Finally, for now, what to triglycerides do – with regard to blood clotting? More jargon here, but a very powerful statement linking VLDL/triglyceride levels to blood clotting.

‘Activation of platelets and the coagulation cascade are intertwined. VLDL and remnant lipoprotein concentrations are often increased with the metabolic syndrome. These lipoproteins have the capacity to activate platelets and the coagulation pathway, and to support the assembly of the prothrombinase complex. VLDL also upregulates expression of the plasminogen activator inhibitor-1 gene and plasminogen activator inhibitor-1 antigen and activity, a process accompanied by platelet aggregation and clot formation. The surface membrane of activated platelets also supports the assembly and activity of the prothrombinase complex, resulting in further thrombin generation and amplification of the coagulation cascade.’4

If you don’t like the jargon, I will simplify:

  • High levels of LDL increase the risk of blood clots forming
  • High levels of HDL reduce the risk of blood clots forming
  • VLDL/triglycerides increase the risk of blood clots forming

To this, I will just add that ‘oxidised’ LDL is particularly pro-coagulant. It reduces Nitric Oxide synthesis in the endothelium, triggers platelet activation and damages the endothelium. Thus the condition known as ‘dyslipidaemia’ is particularly dangerous. Dyslipidaemia consists of low HDL, high VLDL and more ‘oxidised’ LDL. It is usually caused by insulin resistance a.k.a. the metabolic syndrome a.k.a. pre-diabetes.

So, ahem yes, blood borne lipoproteins do have a role to play in CVD. The role is not key, but it is there. I thought I should get that off my chest.



2: Yashika Gupta, V. Mallika* and D.K. Srivastava: ‘INTERACTION OF LDL AND PLATELETS IN ISCHAEMIC AND ISCHAEMIC RISK SUBJECTS’ Indian Journal of Clinical Biochemistry, 2005, 20 (1) 97 – 92



Lowering cholesterol has no effect on heart disease

Yes, if anyone is interested, I enjoyed my holiday. Mountains, snow, skiing, food, France. What more could you ask for?

Whilst away I kept an eyes on a whole series of stories on cholesterol and statins and adverse effects of statins, and suchlike, unfold across various newspapers. Many of you were kind enough to send me said various articles and stories. Some of which were easy to follow. One, in particular, was completely incomprehensible.

HOPE-3, was a study done by Astra Zeneca looking at the use of rosuvastatin vs. placebo. Actually, it was a study done using rosuvastatin alone vs. antihypertensive medication vs. rosuvastatin and antihypertensive medicine vs. double placebo (a term I have never come across before). Double placebo has twice the power of a single placebo? Yes, its ‘Double Placeboman’ playing at a cinema near you.

I have read the HOPE-3 article, and given up several times. I just cannot understand it. Professor Michel de Lorgeril (who ran the Lyon heart health study) also had a go at making it easier to understand. Below is part of his simplification which (I am afraid) is not terribly simple. But it may give you some gist. There is a prize for anyone who gets to his final point:

  1. No effect on all-cause mortality.
  1. No effect on cardiovascular mortality.
  1. As cardiovascular disease is a serial killer, we could conclude that rosuvastatin is shown useless in that trial (as in the previous trials). We could stop the analysis at this point.
  1. Since the authors do suggest that rosuvastatin was protective, it means that these patients are as “deaths cured”’ or “death prevented”, which is probably not what they expected when taking the pills.
  1. All this despite the LDL reduction that was close to 30%.
  1. HOPE 3 investigators curiously examine the effects of rosuvastatin on two “combined primary endpoints” (called “first and second co-primary outcome” as shown on Table 2, below) suggesting that there were two primary hypotheses. This is not “in line” with basic Methods in clinical trial sciences [one trial, one primary hypothesis]. That strange and novel strategy should have been presented long before starting the trial. In any case, the probability of a difference between rosuvastatin and placebo for the first co-primary outcome [the only one to be considered] should have been adapted, a kind of Bonferroni correction; p should have been much lower than 0.05 to be significant; which is not “clinical significance”.
  1. HOPE 3 investigators present the comparison of rosuvastatin with placebo (Table 2, below) as if there were only two randomized groups. In fact, there were 4 groups as there was a second randomization to test an antihypertensive treatment; and also the combination of cholesterol lowering and blood pressure lowering. In summary, these investigators tested many more than two primary hypotheses. They say that they can pool the data from all the patients taking rosuvastatin (plus antihypertensive) to make the comparison with all the patients taking a placebo, including those taking antihypertensive; thus comparing two groups of about 6300 patients rather than 4 groups of about 3100 patients each) because there was no interaction between treatments. This is not exactly true as we see a clear interaction between treatments for at least two components (myocardial infarction and stroke) of the two co-primary outcomes (see Table S20 in the supplementary materials, below). It would have been therefore imperative to present data and full statistics for the 4 groups together to examine the effects of rosuvastatin vs. placebo. It is a mistake not to do that. 6- HOPE 3 investigator also say that there were fewer heart attacks; but after almost 6 years and with about 13,000 patients randomized, there were only 114 heart attacks (45 vs 69 in a simplistic analysis of 2 groups only, Table 2 below).
  1. In fact, things are not so clear when looking at Table 2: they report for the first co-primary outcome (CV deaths + myocardial infarction + stroke) 304 events in the placebo group and 235 in the rosuvastatin group, thus numbers different from the sum of 171+69+99 (total 339, placebo group) Michel de Lorgeril 2016 and 154+45+70 (total 269, rosuvastatin) according to the numbers given in Table 2. This means that they do not use the same numbers in the Table and in the statistics. This is a way of misleading the readers.

Ahem. Perhaps not as simple as you may expect, but I hope you get the general drift. All I did, rather than Lorgeril, was attempt to pull out the figures of greatest interest, to me. Which should be the figures of greatest interest to everyone taking rosuvastatin. The absolute difference in number of deaths between those taking rosuvastatin and double placebo.

  • After five years of treatment, in 3,181 people taking rosuvastatin, there were 171 deaths (of all causes)
  • After five years of taking double strength placebo, in 3,168 people, there were 178 deaths (of all causes)

This represents a difference of 7 deaths over 15,905 years of treatment. Or, one death delayed for every 2,272 years of treatment. This is both statistically, and clinically, insignificant. It is well within the limits of a chance finding. It is a difference that can simply be ignored.

Of course, it was hailed as a triumph, and further proof of the cholesterol hypothesis.

Of more interest, in many ways, and coming out at almost exactly the same time as HOPE-3 was the ACCELERATE trial. Which looked at the use of evacetrapib on lowering LDL (‘bad’ cholesterol), and raising HDL (‘good cholesterol) on the risk of CVD. It was reported thus…

‘Cleveland Clinic researchers studying evacetrapib have shown that despite reducing levels of low-density lipoprotein (LDL, or “bad” cholesterol) by 37 percent and raising levels of high-density lipoprotein (HDL, or “good” cholesterol) by 130 percent, the drug failed to reduce rates of major cardiovascular events, including heart attack, stroke, angina or cardiovascular death.

The phase 3, multi-center clinical trial was discontinued in October 2015, on the recommendation of the independent Data Monitoring Committee after preliminary data suggested the study would not meet its primary endpoint of a reduction in major cardiovascular events. The research is being presented at the American College of Cardiology’s 65th Annual Scientific Session

“Here we have a paradox. The drug more than doubled HDL and lowered LDL levels by as much as many statins, but had no effect on cardiac events,” said Steve Nissen, M.D., chairman of Cardiovascular Medicine at Cleveland Clinic. “These findings illustrate the importance of performing large, high-quality outcome trials. Just looking at the effects a therapy has on cholesterol levels doesn’t always translate into clinical benefits.”

The ACCELERATE trial involved more than 12,000 patients at more than 540 sites who were at high risk for serious cardiovascular problems. They were randomized to receive either 130 milligrams of evacetrapib or a placebo daily, along with standard medical therapy throughout the trial. Study participants either had an acute coronary syndrome 30 days to one year before enrolling, had cerebrovascular atherosclerotic disease, had peripheral vascular disease, or had both diabetes and coronary artery disease.’

In HOPE3, LDL was lowered 30%, had some (very slight) impact on CVD, and was hailed as a triumph for cholesterol lowering. In ACCELERATE LDL was lowered 37%, HDL raised 130%, with no effect whatsoever on CVD. Aha, but, there is an answer…

The ACCELERATE trials was, you’ve guessed it. A paradox. [Question, how many paradoxes can a hypothesis sustain before it collapses in a smoking ruin?]

Karl Popper would call such a thing a black swan. Which is a refutation of your hypothesis. Karl Popper, as we all – ahem – know ‘proposed falsification as a solution to the problem of induction. Popper noticed that although a singular existential statement such as ‘there is a white swan’ cannot be used to affirm a universal statement, it can be used to show that one is false: the singular existential observation of a black swan serves to show that the universal statement ‘all swans are white’ is false—in logic this is called modus tollens. ‘There is a black swan’ implies ‘there is a non-white swan,’ which, in turn, implies ‘there is something that is a swan and that is not white’, hence ‘all swans are white’ is false, because that is the same as ‘there is nothing that is a swan and that is not white’.

One notices a white swan. From this one can conclude:

At least one swan is white.

From this, one may wish to conjecture:

All swans are white.

It is impractical to observe all the swans in the world to verify that they are all white.

Even so, the statement all swans are white is testable by being falsifiable. For, if in testing many swans, the researcher finds a single black swan, then the statement all swans are white would be falsified by the counterexample of the single black swan.’2

Here is another ‘white swan’ hypothesis

Researchers, looking at those living in Framingham, in the US, found that younger men with high cholesterol levels were more likely to die from CVD. From this they concluded. Raised cholesterol causes CVD. ACCELERATE clearly falsifies their simplistic hypothesis. It is a black swan. Thank you, and goodnight.

Next, part XII as to what causes heart disease.



What causes heart disease part XI

This blog was going to be all about bringing together all of the strands about what causes heart disease. However, as often seems to happen, I was sent an article about a study that will be presented at the American College of Cardiology conference in Chicago. It led me down a slight detour, which is actually highly relevant to what I have been discussing.

At present I have no more details of this study than can be found in this press release.

Depressed CAD Patients May be at Higher Risk For MI, Death

Patients with coronary artery disease (CAD) who are depressed may have a much higher risk of myocardial infarction (MI) or death compared to those who are not depressed, according to research published March 23 which will be presented at ACC.16 in Chicago.

The study, conducted by Natalie Szpakowski, MD, and colleagues, included 22,917 patients who had been diagnosed with stable CAD following a coronary angiogram for chest pain. Results showed that the incidence of depression following a diagnosis of stable CAD was 18.8 percent. Patients who were female or who had more severe angina were more likely to be diagnosed with depression.

Further, depressed CAD patients were 83 percent more likely to die from any cause compared to those who were not depressed. They were also 36 percent more likely to present at a hospital for MI. Those who were diagnosed with depression 90 to 180 days following the diagnosis of CAD were at greatest risk.

According to the authors, these findings suggest that these patients may need to be screened for mood disorders, either by their family physician or their cardiologist.

“Based on these findings, there may be an opportunity to improve outcomes in people with coronary heart disease by screening for and treating mood disorders, but this needs to be further studied,” says Szpakowski. “Stable chronic angina due to narrowing of the coronary arteries is common, and our findings show that many of these patients struggle with depression. Our follow-up was at most five years, so many more might be affected.”1

Here, I thought, was an opportunity look at the process(es) by which depression can lead to heart disease. Up to now, the ‘experts’ in cardiology have stated that have heart disease causes depression…yawn. In this way they have dismissed the need to explain how, or why, depression could cause heart disease. Primarily, because this association cannot be explained using the currently accepted risk factors.

I thought this study represented a perfect opportunity to demonstrate exactly how, and why, depression will increase the risk of CVD, using the four step model for CVD (cardiovascular disease) which I have outlined in this series:

  • Endothelial damage
  • Clot formation/dysfunctional clot formation
  • Clot repair/dysfunctional clot repair
  • The final, fatal, blood clot

Your first thought may well be. How does depression damage the endothelium, or increase clot formation… or anything else in the four step process?

Well, clearly depression cannot directly damage the endothelium, or increase dysfunctional clot formation. However, the pathways that lead from depression to the four step process are easily defined, pretty straightforward, and supported by a mass of evidence, and they go like this.

Depression, from whatever cause, creates a dysfunction of the hypothalamic-pituitary-adrenal axis (HPA-axis). Sorry to bring in the jargon straight away. However, in an attempt to keep this is simple as possible, think of the HPA-axis as the ‘unconscious’ system of hormones, and nerves, that control how we react to stress. We are talking about hormones such as adrenaline, cortisol, glucagon and suchlike.

We are also talking about the sympathetic and parasympathetic nervous systems which control heart rate, pupil dilation, blood flow to muscles, contraction of the bladder – so just about involved in everything we do. The HPA-axis can also be thought of as the central management system for the ‘flight or fight’ response.

When I use the term, ‘dysfunctional HPA-axis’, what I mean that the HPA-axis has been knocked out of whack. Usually this means it is overproducing stress hormones (particularly cortisol), and is overdriving the sympathetic nervous system. [Yes, I know it is actually all far more complex than this – for those who will undoubtedly write in to tell me so].

The type of things that damage the HPA-axis are: episodes of extreme stress, leading to PTSD, anxiety, depression, schizophrenia. In fact, most mental disorders will be reflected in a dysfunctional HPA-axis – to one degree or another.

If you want more information on this, I suggest going to Google and typing in depression and HPA-axis and/or stress. Or PTSD and HPA-axis dysfunction etc. You will find that much information springs to life before your very eyes. Essentially, you will begin to see how stress, mental illness, depression, anxiety etc. can all be linked through the HPA-axis, to one degree or another.

In short, if you suffer from stress/anxiety/depression… etc, your HPA-axis will go wrong. It will go wrong in many, many, different ways. The complexities and interactions of HPA-axis dysfunction stretch as far as the eye can see – and further. Believe me, I have disappeared over the horizon in many different directions over the years.

However, for the sake of brevity, and understanding, I will look at focus on one hormone, Cortisol. Cortisol is quite easy to measure, and it usually the hormone used to diagnose HPA-axis dysfunction. If the levels of cortisol are high, or low, or do not go up and down in a flexible fashion during the day, you have HPA-axis dysfunction.

Yes, unfortunately, measuring cortisol levels can result in much confusion. I can guarantee that if you look into this area you will end up mind-boggled and mired in apparent contradictions. Just to give one example. Finding a low cortisol level in the morning does not mean that do not have a ‘stress’ related problems, which would normally lead to high cortisol levels.

It simply means that your neuro-hormonal system has ‘burnt-out,’ leading to low cortisol levels in the morning (but overall higher levels over 24 hours). Somewhat similar as to what happens in diabetes where the pancreas eventually gives up the effort of producing insulin to overcome insulin resistance, and ‘burns-out.’ At which point you may well be diagnosed with type II diabetes.

Is that a good analogy… yes, I think so. Because I have seen papers stating that raised cortisol/stress/anxiety/depression cannot be causes of CVD, because many people with CVD have low cortisol levels in the morning. Bong! Wrong answer. A low cortisol level in the morning is probably the single most powerful indication of HPA-axis dysfunction. [Look up Bjorntorp on Google]

Anyhoo. Getting back to depression. If you are depressed, your HPA-axis will become dysfunctional. You will have abnormal cortisol levels, and you will become insulin resistant (because cortisol is a direct antagonist to insulin at many sites). In fact, severe depression can actually cause type II diabetes. Yes, you can look that up too.

Even if you don’t develop frank diabetes, you will end up with a whole serious of metabolic abnormalities. For the sake of keeping this short, you will also end up with blood clotting abnormalities too. Just to give one example, depression increases fibrinogen level in the blood.

‘In cross-sectional analyses, a stepwise increase in fibrinogen percentile categories was associated with a stepwise increase in risk of psychological distress, use of antidepressant medication, and hospitalization with depression.’ 2

Another important clotting factor is Plasminogen Activator Inhibitor-1 (PAI-1). This stops blood clots getting broken down/repaired after they form. Another quick quote here from a paper called ‘Mental disorders and thrombotic risk.’

‘Patients with psychosis, severe depression, or chronic stress are at increased risk for thromboembolism. Evidence suggests that tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) imbalance may play an important role in pathophysiology of mental and thromboembolic disorders. tPA facilitates clot dissolution and participates in several brain functions, including response to stress, learning, and memory. Depression is characterized by high PAI-1 level.’ 3

Linking it together

I hope that, at this point, it has become very clear how depression can, should, and in fact does link directly to an increase in the risk of CVD. Depression causes creates HPA-axis dysfunction and abnormal cortisol secretion, leading to insulin resistance and even diabetes (in severe cases).

This, in turn, stimulates the over-production of various clotting factors, such as fibrinogen. In addition, there is an increase in PAI-1, which prevents the breakdown/repair of the blood clot. [It causes other things too, but I am trying to keep this as concise as possible]

Clearly all this links directly to the four step model. Diabetes/raised blood sugar levels are directly damaging to the endothelium. Raised fibrinogen and PAI-1 are very powerful risk factors for CVD, primarily because they make the blood more likely to clot, and the clot more difficult to clear up.

In short, it is extremely straightforward to link depression to CVD, through the four step process:

  • Endothelial damage
  • Clot formation/dysfunctional clot formation
  • Clot repair/dysfunctional clot repair
  • The final, fatal, blood clot

Next, I will try to demonstrate how a number of other apparently unrelated conditions link to CVD through the ‘four-step’ process. Finally, I will put together, what I believe, are the ten (or so) best things you can do to protect yourself from CVD. I suspect you will already have worked out a number of them for yourself.

Then, anyone who cares to, can attack the four step hypothesis of heart disease and, I trust, do their best to pull it apart. I welcome the debate.





P.S. For those who like this sort of thing. Here is a paper by Bjrontorp which outlines how the HPA-axis dysfunction actually happens, and how it can be measured.

P.P.S. Bjorntorp worked out the main cause of CVD many years ago

Sunbathing is good for you

News announcer: ‘We interrupt the series of blogs on ‘what causes heart disease’ to bring you (slightly delayed), breaking news from Sweden… Sunbathing is good for you. Shock horror etc.’

Someone sent me this news story today, and I thought I should share it with you. For many, many, years I have been telling people that lying in the sun, getting a nice tan, is one of the healthiest things you can do. Despite the howls of anguish from all dermatologists telling us that one photon of sunlight is one photon too many. ‘You will cause people to die from skin cancer.’ Ho hum:

Why do sunbathers live longer than those who avoid the sun?

New research looks into the paradox that women who sunbathe are likely to live longer than those who avoid the sun, even though sunbathers are at an increased risk of developing skin cancer.

An analysis of information on 29,518 Swedish women who were followed for 20 years revealed that longer life expectancy among women with active sun exposure habits was related to a decrease in heart disease and noncancer/non-heart disease deaths, causing the relative contribution of death due to cancer to increase.

Whether the positive effect of sun exposure demonstrated in this observational study is mediated by vitamin D, another mechanism related to UV radiation, or by unmeasured bias cannot be determined. Therefore, additional research is warranted.

“We found smokers in the highest sun exposure group were at a similar risk as non-smokers avoiding sun exposure, indicating avoidance of sun exposure to be a risk factor of the same magnitude as smoking,” said Dr. Pelle Lindqvist, lead author of the Journal of Internal Medicine study. “Guidelines being too restrictive regarding sun exposure may do more harm than good for health.”1

There is a point here I think I should repeat… avoiding the sun is as risky for your overall health and life expectancy, as smoking. Which is pretty damned amazing? It has been estimated that smoking reduces life expectancy by six, on average. Thus, if you sunbathe regularly, it seems you can expect to live six years longer.

If I may indulge myself by quoting from my book ‘Doctoring Data’ on this very topic:

‘How about frightening people to stay out of the sun, or slap on factor 50 cream at the first suspicion that a deadly photon may sneak through 10 layers of protective clothing. Not necessarily a good idea, because without vitamin D synthesis in the skin, from exposure to the sun, there is significant danger that we can become vitamin D deficient, which can lead to all sort of other problems.

Here are just two stand-out facts from a major study in the Annals of Epidemiology entitled ‘Vitamin D for Cancer prevention.’

  • Women with higher solar UVB exposure had only half the incidence of breast cancer as those with lower solar exposure
  • Men with higher residential solar exposure had only half the incidence rate of fatal prostate cancer

To put that in simple English. If you spend longer in the sun, you may be far less likely to die of breast and prostate cancer. But what about the increased risk of dying of skin cancer! I have you cry. Well, what of it. Around 2,000 people a year die of malignant melanoma in the UK each year. It increased sun exposure were to double this figure we would have 2000 more cases.

On the other hand, breast cancer kills around 20,00 a year, as does prostate cancer. If we managed to halve the rate of breast and prostate cancer, we would reduce cancer deaths by 20,000 a year. Which is ten times as great as any potential increase in deaths from malignant melanoma.’

To what I wrote in Doctoring Data, I would further add that sun exposure is the best known way of increasing NO synthesis throughout the body. This protects the endothelium and, as you would expect, lowers blood pressure (the natural way). So, you are far less likely to die from CVD.

What this study highlights, once again (as with all advice on diet), what we are told to do by mainstream medical research, turns out to be actively damaging to health. Will advice on sun exposure now change? There is not the slightest, tiniest, possibility of this happening. Evidence has no impact on the pronouncements of the medical profession (at least not over the average human lifespan).

The only possible change I can see is that, whilst we will continue be hectored to stay out of the sun, at all possible costs, we will be advised to take vitamin D supplementation to make up for lack of sun exposure (even though there is little or no evidence that it actually does any good).

My advice is, and has always been. Sunshine is good for you. I have been saying this for twenty years. Ten years ago, whilst writing for Pulse Magazine in the UK I wrote an article called ‘Sunshine is good for you.’ I finished with the following:

Ponder this

I shall leave you to ponder the results of a study looking at people diagnosed with malignant melanomas, and then followed for five years.

‘Results: Sunburn, high intermittent sun exposure, skin awareness histories and solar elastosis were statistically significantly inversely associated with death from melanoma’

‘Conclusion: Sun exposure is associated with increased survival from melanoma.2

Did I say that sunshine is good for you? It even prevents malignant melanoma.




The full study is: Avoidance of sun exposure as a risk factor for major causes of death: a competing risk analysis of the Melanoma in Southern Sweden cohort, P. G. Lindqvist, E. Epstein, K. Nielsen, M. Landin-Olsson, C. Ingvar and H. Olsson, Journal of Internal Medicine, doi: 10.1111/joim.12496, published online 16 March 2016.

2: Berwick M et al: Sun exposure and mortality from melanoma. J Natl Cancer Inst: 2005 Feb 2, 973(3):195-9

What causes heart disease part X


Yes, part X, and not at the end… yet. Before trying to sum up I thought I should discuss calcification of the arteries. This is an area I have tended to shy away from in the past, because I am not sure exactly where to place it. Association, end-result, cause… Ignore.

Firstly, what is calcification? It is generally accepted, and I think it is true, that calcification represents the final stage of atherosclerotic plaque development, or growth – or whatever word fits most accurately. The best way of looking at calcification, within the spectrum of CVD, would be to define it as the end stage of plaque development.

Having said that, this is not always the case. Not all plaques calcify. Some do, some don’t, and there are many other factors that have a key role in calcification. Various vitamins, such as Vitamin K(K2) and vitamin D are important. Warfarin, which blocks the effects of vitamin K, increases plaque calcification. The picture is complex.

You may have heard of a condition called fibrordysplasia ossificans progressiva, where muscle turns to bone. Not nice, but it does demonstrate that, in certain circumstances, various other tissues can also calcify – to one extent or another.

The main reason for mentioning calcification is that the Calcium artery score (CAC) has become the latest way of frightening people about CVD. You do a CT scan, count of the amount of calcium you can see, and score it. The more the calcium, the worse things are.

In truth, despite my slightly sceptical tone, measuring calcification seems to be one of the most accurate ways of assessing overall plaque burden, and your true risk of dying of CVD. Like everything else in this area, the CAC score is far from perfect. However, even with many provisos in place, if you have a high CAC then you are definitely at a higher risk of dying of CVD. Equally, if you have a zero calcium score, you can pretty much relax. So it is important.

I suppose you may be wondering, at this point, why would plaques calcify? What is the body doing here? Well, you might find these quotes interesting:

“Atherosclerotic calcification is an organized, regulated process similar to bone formation that occurs only when other aspects of atherosclerosis are present.” L Wexler, et al., American Heart Association Writing Group

In short – and, by the way, I fully agree with the above quote, calcification is not an accident, or an unwanted effect. It seems to be an organised, and regulated process. But organised, and regulated, for what purpose…

‘This chapter will show that vascular calcification is a physiologic defense against active, progressive atherosclerotic disease, that it is produced by physiologic mechanisms similar to those required for normal bone formation and that it is potentially reversible. 1

You might well then ask the following. If calcification is a physiologic defense mechanism… why would you want to reverse it? You might just be making things worse. It is certainly true that plaques pass through several different phases. The most dangerous of which seems to be the ‘unstable’ plaque. This is when the central core of the plaque is a kind of liquid goo which, if it ruptures, stimulates a massive – and potentially fatal – blood clot. Plaques in this state are sometimes called ‘vulnerable.’

On the other hand, once a plaque calcifies, it appears to become more stable, and less likely to rupture… and kill you. Which means that reversal of calcification may look good on a scan, and your doctor may smile with pleasure at your reduced CAC. But… it is all good? I have seen an argument used (by the pro-statin camp) that statins accelerate calcification – but this might be a good thing, because the plaque is less likely to rupture. Is this true? [It would by a nice irony].

Perhaps, here, you can see why I struggle a bit with the whole calcification thing. Is it a natural progression of the plaque? It is a way that the body closes down further damage, and stops further plaque progression. Does calcification help to strengthen the artery wall to prevent it rupturing? Should we be trying to reverse calcification… would we simple be turning a calcified plaque back into a vulnerable plaque?

Calcification is certainly not a new thing. CT scans of mummies – from a number of different cultures – have demonstrated that many/most mummified bodies have large areas of arterial calcification. Ergo, CVD is most certainly not a disease of modern humanity. The mummies from Egypt are well over two thousand years old.

As you can probably tell I am not sure exactly what to make of calcification. However, I think you can probably make the following statements:

  • If you do a CT scan and have no demonstrable calcification – after the age of about forty to fifty – you are at very low risk of dying of CVD
  • If you have a high CAC score this means that you have been developing plaques for quite a while, and therefore (unless you change something) you are at high risk of dying of CVD. [However, bear in mind that CAC represents your history, not necessarily your future].
  • Calcification can reverse. Vitamin K2s (Menaquinones) seem to be more protective/able to reverse calcification than Vitamin K1. Menaquinones are primarily found in meat and dairy-based foods and fermented soybeans (known as natto, commonly consumed in Japan)
  • Calcification is not a cause of CVD, it is (or seems to be) the final stage of plaque development. It may be a protective mechanism to stabilise plaques.
  • There is no evidence, that I am aware of, that if you reverse calcification you improve CVD risk. But it seems likely there would be benefit.

Sorry, I am not sure if that is very helpful, but I thought I had to discuss calcification in this series.


What causes heart disease part IX

Heart disease part IX? I think my little series is getting a bit like the Superbowl, with the ever increasing roman numerals. Oh well, it just started that way, now I’m stuck with it. Never mind.

I know people have been reading this series with different purposes in mind. Still, a number of people seem to be asking ‘OK, what’s the cause?’ In which case, I have failed rather miserably in my quest. My main theme is that there is no cause. I shall repeat. There is no cause. Or, perhaps to be more accurate – there is no single cause. There cannot be.

There is a process.

To reiterated what I have been trying to say up to now, you cannot identify real causes, unless you understand what is actually going on with CVD. Indeed, I firmly believe that the search for causes has been the main reason why we are in the current situation – a multifactorial mess. In 1981 the Journal Atherosclerosis searched for all the factors that had been identified as either causing CVD, or protecting against CVD. There were nearly three hundred. Some, such as copper in the diet, were simultaneously causal and protective.

If anyone were to try to scour all medical papers to carry out such a study today, there would be thousands more factors – this I can guarantee. Cholesterol alone itself has split and multiplied into good and bad, light and fluffy, small and dense LLD-C, LDL-P, eight subtractions of HDL (good cholesterol), dyslipidaemia, Lp(a)… Each one has somebody waving a flag furiously in support of it. New and expensive tests developed each and every day.

How could anyone possibly try to make sense of such a thing? Three thousand eight hundred and fifty causal factors, four thousand two hundred and eighty-six protective factors. Go figure. Get a super-computer and run it for the entire life-span of the rest of the Universe. You may be a trillionth of the way through working out how they all add and subtract, multiply, or divide risk.

I spent twenty-five years looking for a cause, or causes, and gave up. It was a fool’s errand. It was the transmutation of lead into the gold, the search for the missing chord, the creating of a perpetual motion machine, a discussion of how many angels can dance on the head of a pin – an attempt to fit planetary motion into a Geocentric model of the Universe (Everything rotates around the Earth). In short, impossible.

The first step to understanding CVD (and this happened for me, many years ago) was to strip cholesterol/LDL cholesterol out of the model. For so many people, then as now, Cholesterol was/is the Earth at the centre of the Geocentric model. It still represents the key jigsaw piece placed triumphantly in the middle of the puzzle. Hammered in, and decreed immovable by the likes of Ancel Keys, before anyone really knew what the picture looks like.

I have read paper after paper where people seem to be going in the right direction about heart disease, then they find they have to shoehorn cholesterol into the centre of their research. At which point everything distorts into a mess of twisted logic. A truth may be jumping up and down in front of them shouting ‘Me, me, me. Here. Look.’ But the truth is invisible. There are no so blind as those who will not see.

There is a process

The conclusion that I came to, eventually, is that we have to define the underlying process. As we should do with all diseases I suppose. However, the ‘disease’ model that medicine has become fixated with, as a way of thinking, was in major part started by a famous microbiologist Robert Koch in the late nineteenth century. His thinking was mainly directed microorganisms e.g. bacteria, viruses and suchlike. He decreed that for any microorganisms to be identified as a true cause of a disease, the following postulates must be fulfilled.

  • The microorganism must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms.
  • The microorganism must be isolated from a diseased organism and grown in pure culture.
  • The cultured microorganism should cause disease when introduced into a healthy organism.
  • The microorganism must be reisolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent.

Now, these are pretty tough criteria. If not just from an ethical perspective. You try putting a cultured microorganism into a healthily organism nowadays and see how far you get. ‘We are not sure that Ebola virus causes Ebola in humans. Let me isolate if from a patient and introduce into a healthy human.’ Good luck with that.

However, the main point I want to make here is the ‘single causal agent’ concept of medicine has become the meme. You start by looking for the cause of a disease. Once you believe you have it, all research, and all thinking starts to crystallize around that cause. It becomes the centre of all thinking, and dominates the landscape.

I see this in CVD researchers all the time. There are those who are still convinced that cholesterol causes heart disease. All facts are twisted and bent around to fit this central fact. Contradictions are ‘immunised’ against in various ways.

Me:                           ‘People with low cholesterol levels can still have plaques and an MI. So a raised cholesterol level is neither necessary, nor sufficient, to cause CVD.’ {See under Koch’s postulates}.

A.N. Expert:         ‘Actually the normal level of cholesterol in modern humans is far higher than the ‘healthy level.’ So, everyone actually has does have a high cholesterol level. Look at hunter gatherer’s, neonates and other animal species. Where cholesterol levels are much lower.’

The argument here is almost perfect. Everyone has a high cholesterol, so you cannot rule out a high cholesterol level as a cause of CVD- in anyone. [Total nonsense of course].

Me:                           ‘In the Framingham study, those whose cholesterol levels fell, in the first fourteen years of the study, had a greatly increased risk of CVD over the next eighteen years.’

A.N. Expert:         ‘The is reverse causality. A falling cholesterol is caused by an underlying disease, and it is the underlying disease causing the problem, not the low cholesterol.’

Me;                           ‘The French have higher cholesterol levels than the Russians and one tenth the rate of CVD

A.N. Expert:         ‘The French are protected by drinking red wine and eating lightly cooked vegetables and eating garlic.’

Me:                           ‘Asian Indians do not have high cholesterol levels, yet their rate of CVD is far higher than the surrounding population

A.N. Expert:         ‘The Asians are genetically susceptible to CVD.’

‘Ad-Hoc hypotheses – that is, at the time untestable auxiliary hypotheses – can save almost any theory from any particular refutation. But this does not mean that we can go on with an ad hoc hypothesis as long as we like. It may become testable; and a negative test may force us either to give it up or to introduce a new secondary ad hoc hypothesis, and on and on, ad infinitum.’ Karl Popper.

One of my favourite ad-hoc hypothesis, which covers the entire diet-heart/cholesterol hypothesis, rather than just the cholesterol hypothesis, was the use of teleoanlysis. Here, the authors looked at all the studies on using a low fat died and found they had no effect on CVD. However, they knew (and claimed as fact) that eating saturated fat raised cholesterol levels, and they knew (and claimed as fact) that raised cholesterol causes CVD. Ergo, eating saturated fat must cause CVD, so the trials must be wrong.

At which point, rather than relying on the published evidence, they decided that you simply make up studies in your head, and use them to prove that saturated fat does, actually, cause CVD. If you think I am making this up, here is the quote from the study, published in the BMJ

‘….teleoanalysis combines different categories of study to quantify the relation between a causative factor and the risk of disease. This is helpful in determining medical practice and public health policy. Put simply, meta-analysis is the analysis of many studies that have already been done; teleoanalysis provides the answer to questions that would be obtained from studies that have not been done and often, for ethical and financial reasons, could never be done.’

Yes, this was published in the BMJ, no less. I always enjoy this paper. It is so ludicrous that it goes well beyond despair and into surrealism. ‘Ceci n’est pas une Pipe.’ Ignore the evidence and, instead, rely on what you know to be true. This, of course, is the way high quality science should be done… not.

More recently we have equally mad studies on mendelian randomisation. Which may not immediately look like teleoanalysis, but at heart it is are exactly the same thing.

It has been found that older people with high cholesterol levels live longer than those with low cholesterol levels, and get less CVD. This does not fit well into a world where billions can be made lowering cholesterol levels – particularly in the elderly. The first attempt to refute this finding was to say that other diseases lead to low cholesterol levels (as mentioned earlier), and it is the other diseases causing the problem, not the low cholesterol. It was Iribarren who came up with this one.

This, so called ‘reverse causality hypothesis’, has been proven to be wrong in several major studies. So, a new attempt was made using ‘mendelian randomisation’ [Yes, genetics, after Gregor Mendel who proved the concept of genetic inheritance]. By using mendelian randomisation, you can identify people who would have had high cholesterol during most of their lifespan (they have genes associated with high cholesterol levels). So, their cholesterol may be low when you measured it, but it would have been high for most of their lifetime.

Ergo, people with low cholesterol levels, and higher mortality rates, actually had higher cholesterol levels when they were younger, and the lifetime effect of these high cholesterol levels will have caused them to die of CVD. Not, I repeat not, the low cholesterol levels they now have. Yes, this stuff gets published too, and rolled out to confuse the hell out of everyone. [Luckily, I have contact with people within the pharma industry who set up and run genetic studies. They tell me this stuff is simply smoke and mirrors].

I shall paraphrase mendelian randomisation studies. ‘Your cholesterol level is not your cholesterol level…. So there. It is whatever we decide it is.’

Believe me, attempts to refute contradictions to the cholesterol hypothesis get more complex than this. As you can see, in the world of CVD you can play the game of ad-hoc hypothesis, ad-infinitum. In the end there are so many ad-hoc hypothesis created that A.N. Expert can slip from one the other and back again without ever having to accept that any single fact represents a contradiction to the hypothesis. The final trick, when you are getting close to nailing them they just say ‘Oh well, CVD is multifactorial.’ This is not an answer. It is just a polite way of saying ‘shut up and do as I say.’

I ended up with a further realisation. There is no point attacking the cholesterol hypothesis. Those who believe in it have created a majestic Byzantine world of mind-numbing complexity where you can wonder the corridors of ad-hoc hypotheses forever, and never escape.

So, I made a decision, which I have just gone back on. Do not bother attacking the diet-heart/cholesterol (whatever you want to call it) hypothesis. You just get dragged onto a playing field that is not your own, chasing round and round in circles, trying to refute the latest made up ad-hoc hypothesis. It is like discussing the existence, or non-existence, of God with a Professor in theology. They can call on two thousand years of well-rehearsed arguments to confuse you with. You don’t stand a chance.

Instead I have spent, what I hope to be more productive, years and years, working out a hypothesis that actually fits the facts. There is no need for ad-hoc hypothesis, no need for teleoanalysis, or mendalian randomisation. No need for planets doing little circles in the sky, to support the Geocentric model of the Universe.

I could only do this by moving away from looking at causes, and trying to establish the underlying processes at work in CVD. I am not the first to attempt this. Rokitansky was first, Duguid had a good go, Ross also attempted to demonstrate the ‘response to injury hypothesis.’ Up to now, those who believe that CVD is, essentially, a disease of dysfunctional blood clotting have simply bounced off the well-guarded walls of the cholesterol citadel.

In the end, though, someone is going to break through. It is just a matter of time. You can stomp on the truth for many years. You can concrete it over. But the truth has a major advantage over sophistry. It is immortal. No matter how deep you try to bury it, It lies there, waiting to be discovered, pushing little green shoots up into the sunlight waiting to be discovered.

What causes heart disease part VIII

The healing process

Most people, when they think about atherosclerotic plaques, think of them as starting very small – as fatty streaks and suchlike. Then they inevitably get bigger and bigger over many years. However, this is not correct:

‘Atherosclerosis was originally considered to be an ongoing process that was inevitably associated with age. However, plaques are highly dynamic, and are able to progress, stabilize or regress depending on their surrounding milieu. A great deal of research attention has been focused on understanding the involvement of high-density lipoprotein in atherosclerotic plaque regression. However, atherosclerotic plaque regression encompasses a variety of processes that can be grouped into three main areas: removal of lipids and necrotic material; restoration of endothelial function and repair of denuded areas; and cessation of vascular smooth muscle cell proliferation and phenotype reversal.’ 1

In short, progression is not inevitable. Plaques can shrink down in size, the smooth muscle proliferation (often considered and irreversible components of plaques) reversed, and endothelial function restored. In truth, you will most likely not end up with a perfectly healed plaque with no signs it was ever there. You will be left with a bit of a ‘scar’ or some sort. However, the important point is that we are not looking at a one-way street. The body can heal plaques. (Probably not once calcified, but that is another issue).

This leads me onto the third part of the process of CVD. As I have been discussing in this series, the process of CVD has four basic components:

  • Endothelial damage
  • Clot formation/dysfunctional clot formation
  • Clot repair/dysfunctional clot repair
  • The final, fatal, blood clot

Up to now I have mainly talked about endothelial damage, and clot formation, which are plaque ‘growth’ factors. However, repair is also very important. Anything that can interfere with the repair process is going to make plaques grow, rather than regress.

The key players in repair are: monocytes, macrophages and Endothelial Progenitor Cells (EPCs). As mentioned several times before, once the endothelium is damaged, and a clot formed, EPCs are attracted to the area to form a new layer of endothelium. So, clearly EPCS are critical players. Just to quote one paper:

‘BACKGROUND: Cardiovascular risk factors contribute to atherogenesis by inducing endothelial-cell injury and dysfunction. We hypothesized that endothelial progenitor cells derived from bone marrow have a role in ongoing endothelial repair and that impaired mobilization or depletion of these cells contributes to endothelial dysfunction and cardiovascular disease progression.

CONCLUSIONS: In healthy men, levels of endothelial progenitor cells may be a surrogate biologic marker for vascular function and cumulative cardiovascular risk. These findings suggest that endothelial injury in the absence of sufficient circulating progenitor cells may affect the progression of cardiovascular disease.’2 Which means that with fewer EPCS, plaques grow faster.

The critical part that EPCs have to play is also seen in patients who have angioplasty, or stents. Immediately following the procedure, the bone marrow starts making more EPCs.

‘In conclusion, endothelial injury from angioplasty can lead to time-dependent mobilization or homing of EPCs; mature EPC subpopulations are actively mobilized, and may contribute more to endothelial reparation; and the mobilization amplitude of the main EPC subpopulations is significantly influenced by the degree of endothelial injury and certain clinical factors.’3

It follows that, if you have fewer EPCs the risk of CVD will be much higher. This is clearly seen in Systemic Lupus Erythematosus (mentioned a few times before). The paper quoted from below looked at SLE, and the number of EPCs, and also haematopoietic stem Cells (HSCs) – which are the precursor to EPCs – found in the bone marrow:

‘SLE patients have lower levels of circulating HSC and EPC, even during clinical remission. Our data suggest that increased HSC apoptosis (cell death) is the underlying cause for this depletion. These observations indicate that progenitor cell mediated endogenous vascular repair is impaired in SLE, which may contribute to the accelerated development of atherosclerosis.’4

Other conditions, or factors, that reduce EPC numbers include:

  • Type II diabetes
  • Avastin
  • Rheumatoid arthritis
  • Smoking

To name but four.

Of course there tends to be a tight association between factors that damage the endothelial cells, and factors that reduce EPC number. This appears to be primarily modulated by nitric oxide levels. Anything that increases NO levels in endothelial cells and also helps to protect them from damage appears to increase EPC production in the bone marrow.

A non-exhaustive list of things can do this this are:

  • Exercise
  • L-arginine/L-citrulline
  • ACE-inhibitors (used for BP reduction)
  • Statins

Yes, the dreaded statins… Boooo! In truth, for many years I have accepted (albeit with great reluctance), that statins do have some benefits in CVD. Not enough, in my opinion, to overcome the damage that they can do. However, the benefit is there, it is real.

I knew it could be nothing to do with the impact of statins on lowering LDL, as LDL has nothing to do with CVD (well, almost nothing). So there had to be another effect. And that effect is, in my opinion, almost entirely to do with the ability of statins to increase nitric oxide (NO) production:

‘Endothelial nitric oxide (eNO) bioavailability is severely reduced after myocardial infarction (MI) and in heart failure. Statins enhance eNO availability by both increasing eNO production and reducing NO inactivation. We therefore studied the effect of statin treatment on eNO availability after MI and tested its role for endothelial progenitor cell mobilization, myocardial neovascularization, left ventricular (LV) dysfunction, remodeling, and survival after MI….. These findings suggest that increased eNO availability is required for statin-induced improvement of endothelial progenitor cell mobilization, myocardial neovascularization, LV dysfunction, interstitial fibrosis, and survival after MI. eNO bioavailability after MI likely represents an important therapeutic target in heart failure after MI and mediates beneficial effects of statin treatment after MI.5

Yes, when you decide to look through a different prism, you can find that things you thought were one thing, turn out to be another thing entirely. Professor Michael Oliver – a trenchant critic of the cholesterol hypothesis before statins came along – changed his mind, once he saw that statins lowered LDL and lowered CVD risk. Case proven – he said.

No, case not proven. Instead, if you look at EPCs and nitric oxide (NO) and take the view of CVD that it is all due to endothelial dysfunction, blood clotting and impaired repair, you can see exactly where statins may fit into the picture.

Next: The final event.







What causes heart disease part VII

For over thirty years I have been studying heart disease, or Cardiovascular Disease (CVD). I don’t think that I have Obsessive Compulsive Disorder…but maybe I have. I must admit that, at times there seemed to be no answers, at least no answers that did not have at least one Mount Everest sized contradiction.

At one point I simply decided that CVD was just a manifestation of ageing. It happened to everyone, at different rates. There was no cause – no causes. CVD was simply something humanity suffered from, get over it.

However, deep down, I knew that this could not actually be true. There were populations with almost zero rates of CVD, and others where the rates were extremely high. Just to give one example. Russia vs. Japan. In 2006 Russian men under the age of 65 suffered eighteen times the rate of CHD of men in Japan. I don’t think this ratio has changed this much.

I knew that Japanese men did not have any genetic protection. When they emigrated to other countries, their rate of CHD rose rapidly to match that of the surrounding population. Not always, but almost always. So it was obvious that something, or somethings, was causing massive differences in the rate. It wasn’t just fate, or genetics, it wasn’t just the ‘way it is.’ [By the way, the average cholesterol level in Russian men in 2006 was 5.1mmol/l, in Japanese men it was startlingly different at….. 5.1mmol/l]

Long, long ago I worked out that cholesterol, or LDL cholesterol has nothing much to do with CVD. Well, if two populations have exactly the same cholesterol levels and an eighteen-fold difference in the rate of CVD, cholesterol could only be causing 1/18th of the overall risk – absolute max. This figure assumes that the entire of the rate of CVD in Japan was caused by cholesterol, with no other factor playing any part. I don’t think I need bother telling what I think of that as a concept.

For a number of years, I pursued the alternative hypothesis that CVD was primarily caused by stress. There was a great deal of evidence to support this, and of course there still is. I still believe that stress (a concept which does need a bit of explanation) is the single most important cause of CVD. However, there were still many cases of death from heart disease and strokes where it was clear that stress had nothing (or nothing that I could see), to do with it.

For example, as mentioned before in this series of blogs. Systemic Lupus Erythematosus (SLE), where the increased (relative risk) rate of CVD in young women is up to 5,000% higher than the surrounding population. Now that is a proper increase in risk. In fact, it is the sort of increase that tells you that you are looking at a ‘true’ cause of CVD. Not some very wobbly and weak association.

I was also interested in Kawasaki’s disease. This is a vasculitis (inflammation of the blood vessels) that affects young children, who can then suffer heart attacks aged four, or five. Not exactly the same mechanism that causes heart attacks in adults, but very nearly. Again, this is highly significant. A condition that can kill children aged four from CVD is not just some anomaly that can be ignored. I knew I was looking at another true cause.

Later, my attention turned to Avastin. A cancer drug that was almost pulled from the market as it rapidly accelerated atherosclerotic plaque development, and death from CVD. No other risk factors needed to be present.

But how to link SLE, Kawasaki’s, and Avastin, through stress and other important risk factors such as smoking, or diabetes? When I discussed such things with ‘experts’ in cardiology, they would just end up saying that CVD was multifactorial. However, this has always seemed the ultimate cop out. ‘Yes of course, it is multifactorial.’ I would reply. ‘But how do this multiple factors actually fit together. Do they all create different diseases, or the same disease… through completely different process?’

In the end, if you are going to understand CVD you must be able to link all true causes of CVD into a single coherent process that fits all of the facts. If you cannot do this, you are really just stumbling about in the dark. Simply muttering ‘multifactorial’ whenever anyone asks you a question you cannot answer adds nothing to understanding.

Over the years, I found myself drawn back to the Scottish Heart Health study, for one very important reason. Which was that, in this study, fibrinogen emerged as the single most important risk factor for CVD. A fact that seemed to have popped out of nowhere. Never to be mentioned again. As a quick aside, in this same study it was found that the cholesterol was not a risk factor for heart disease. Another fact never to be mentioned again.

Was the Scottish ‘fibrinogen factor’ just an anomaly. A single observation, never to be replicated? I needed to find out. So I shifted my attention away from stress, to a focus on blood clotting factors. When I did so, I kept finding the same thing over and over again. Factors that increase blood clotting were always associated with a higher risk of CVD. Factors that reduced blood clotting always reduced the risk of CVD.

Just to give one specific example. High Density Lipoprotein (HDL cholesterol), so-called good cholesterol. Conventional thinking is that HDL sucks cholesterol out of atherosclerotic plaques and transports this back to the liver via the ‘reverse cholesterol transport’ system. A concept which has always seemed to me to look like a most desperate clutching at straws.


‘The antithrombotic properties of native HDL are also related to the suppression of the coagulation cascade and stimulation of clot fibrinolysis. Furthermore, HDL stimulates the endothelial production of nitric oxide and prostacyclin, which are potent inhibitors of platelet activation. Thus, HDL’s antithrombotic actions are multiple and therefore, raising HDL may be an important therapeutic strategy to reduce the risk of arterial and venous thrombosis.’1

Yes, HDL is actually a potent anticoagulant. In addition, it protects the endothelium and increases NO synthesis in endothelial cells. So, we don’t need a reverse cholesterol transport conjecture. HDL can be looked in a completely different way. I found it fascinating that the moment you decide to look at things from another direction a very different picture emerges.

Once I had my ‘clotting’ goggles on I began to ask myself: Is CVD simply the end result of dysfunctional (and I use the word dysfunctional in the broadest sense here) blood clotting?

Of course, for this to be true, atherosclerotic plaques have to be, at their core, blood clots. Well, are they? In 1856 Karl Von Rokitansky examined atherosclerotic plaques and declared them to be blood clots – in various stages of repair – or degeneration (depending on your point of view). They contained everything you find in blood clots, platelets, red blood cells, lipoproteins, fibrin and all the rest.

Karl Von Rokitansky’s problem? He could not explain how a blood clot could form within the arterial wall itself, underneath the endothelial cells. The reason why he could not explain this is that he did not know that Endothelial Progenitor Cells (EPCs), cover over clots that form in blood vessels. This, effectively, draws them into the artery wall.

Because he had never heard of EPCs, and could not counter the central criticism of his hypothesis, Rokitansky’s ideas never took off, and the cholesterol hypothesis filled the void. The rest, as they say, is history.

A few weeks ago I was presenting on CVD and I was asked, whilst waiting in the coffee line, ‘Come on then, what does cause CVD?’ The man who asked was a doctor, a pathologist, just retired, who had spent his life doing autopsies, and examining many, many, people who had died of heart attacks. I said to him. ‘Plaques are clots, and clots are plaques. It is all due to blood clotting.

He was not in the slightest surprised. He just nodded in affirmation. ‘I thought so.’ He said. ‘I have always thought that plaques were blood clots.’ Well, what else could they be? There is little else that they could be.

For example, if you start looking at platelets and plaques, a whole new world of information opens up. Platelets are, if you remember, small blood cells that are the key ingredient of all blood clots (thrombi). They are attracted to the site of arterial damage, they clump together and then stimulate the ‘clotting cascade’ which creates clots that are tightly bound together by fibrin.

If clots are plaques, and plaques are clots, you would expect to find that platelets are intimately involved in the entire process of plaque formation. Here, I quote a long section from a book called ‘Platelets in Thrombotic and Non-Thrombotic Disorders.’ For some, this may be a big technical, but I suggest a read, and re-read.

In this section it is pointed out that clots/thrombi form at areas of endothelial damage/stress. In addition, platelet rich thrombi are incorporated into the vessel wall at sites of injury…. Yes, the whole process is outlined here. Including the fact that platelets contain a substance that causes smooth muscles to grow and proliferate (a key finding in all plaques).

Where is cholesterol in all this…nowhere. Please read and inwardly digest:

‘von Rokitanksy and Virchow were early investigators who reported that in some instances, the development of atherosclerosis involved early vessel wall injury, thrombosis, and the incorporation of thrombi into the vessel wall. In 1887, Welch gave a clear description of arterial thrombi based on the experiments of a number of investigators, showing that they began as platelet-rich thrombi and are then transformed into masses rich in fibrin. Much later, these observations were reinforced by Duguid, Morgan, More and Haust and French.

In the 1960s, we observed that platelets were deposited on, and interacted with, the walls of arteries in regions of disturbed blood flow. These are the sites where atherosclerotic lesions develop and increased vessel permeability is demonstrable.

In 1973, Moore induced ‘thromobathererosclerosis’ in rabbits by continuous damage of the endothelium of the aorta with an indwelling catheter, and in 1976, he and his group showed that prior administration of anti-platelet serum to induce thrombocytopenia (very few platelets in the blood) prevented the development of these lesions. The finding by Ross and his colleagues in 1974 that stimulated platelets release a mitogen for smooth muscle cells (platelet derived growth factor PDGF) arose from a chance observation.

They noticed that serum prepared from platelet-free plasma did not support the proliferation of smooth muscle cells in culture, but when they prepared serum by blotting platelet rich plasma, the serum supported cell growth as effectively as serum prepared from whole blood. These results gave even more credence to the theory that platelets are involved in the development of atherosclerotic plaques because they promote the proliferation of smooth muscle cells.

The progression of atherosclerotic plaques also involved platelets since platelet rich thrombi have been shown to be incorporated into the vessel wall at sites of injury. Platelet rich thrombi that form on ruptured atherosclerotic plaque may occlude the lumen of the vessel, or may embolize (break off and travel down the artery).

When the thomboemboli impact in smaller downstream vessels, organ damage occurs. These concepts about platelets and atherosclerosis have stood the test of time. The picture developed by Ross of the development of an atherosclerotic plaque is not well known, and the signalling pathways, PGDF activated are being explored. The importance of platelet interaction with the components of ruptured atherosclerotic plaque in the thromboembolic complications of atherosclerosis is now generally accepted.2

When I read stuff like this I think. Come on guys, you know that plaques are clots and clots are plaques. It is staring you in the face. It has been staring humanity in the face for over a hundred and sixty years. Ever since Rokitansky and Virchow started to look closely.

Next: Impaired plaque repair


2: ‘Platelets in Thrombotic and Non-Thrombotic Disorders.’ Edited by Paolo Gresele. Page 5.

What causes heart disease part VI

A summary up to now

Heart disease is really a disease of the larger arteries in the body. Essentially it is a build-up of atherosclerotic plaques (thickenings and narrowings) in the arteries. This could more accurately defined as cardiovascular disease (CVD), in that it can affect all large arteries, not just the arteries in the heart, or neck.

The final stage of plaque formation is complete blockage of an artery due a large blood clot forming, usually, over an existing plaque. This is the underlying cause of most heart attacks. In the case of an ischaemic stroke, the clot breaks off the main artery in the neck (carotid artery) and gets stuck in a smaller artery in the brain.

Other forms of ‘heart attacks’ and strokes can occur due to different mechanisms e.g. atrial fibrillation causes a clot to form in the atria before breaking of and travelling into the brain. Or, sudden acute stress on the heart can lead to catastrophic ischaemia, causing a ‘heart attack’ – without any underlying plaque. These type of stroke and ‘heart attack’ are not covered in this series of blogs.

When it comes to CVD, the cholesterol hypothesis holds sway over the medical profession i.e. when the cholesterol level is high it is deposited on/in the artery creating the thickenings and narrowings.

I have long argued that this hypothesis makes no sense from any perspective, and that CVD is actually caused by another process that that has little, or nothing, to do with cholesterol (in whatever form cholesterol is described). Instead CVD is a four step process:

  • Endothelial damage
  • Clot formation/dysfunctional clot formation
  • Clot repair/dysfunctional clot repair
  • The final, fatal, blood clot

In short, plaques are simply blood clots – in various states of repair. The final event (heart attack or stroke) is simply one part of exactly the same process that caused the plaques to form in the first place. Just bigger and more deadly.

In this series, up to now, I have mainly focussed on the process of damaging the endothelium, and explained how this inevitably results in a blood clot forming over the area of damage. Repair of the clot consists of forming a new layer of endothelium over the blood clot, thereby drawing it into the arterial wall. At which point it is attacked and broken down by monocytes and macrophages – amongst other things.

However, if the endothelium is repeatedly and rapidly damaged – at the same spot – the repair systems become overwhelmed and the clot/plaque, rather than being broken down and removed, starts to grow and turn into a dangerous ‘vulnerable’ plaque. I am now going to look at the process of clot formation itself – ‘thrombogenesis’. (Thrombo = clot, genesis = starting)

Clot formation

Clot formation is complicated, very complicated. However, I am going to try and make it as simple as possible by looking at three main players. At least I will to start with.

  • Tissue factor
  • Platelets
  • Fibrinogen/Fibrin

As mentioned earlier, tissue factor (TF) sits within artery walls (and vein walls). It is the key trigger factor for most blood clots. Normally the blood is protected from contact with TF by the endothelium. However, if you damage the endothelium, TF is exposed to blood. This fires the starting gun for a massive and explosive cascade of blood clotting. This is known as the ‘extrinsic pathway.’ By extrinsic I mean basically factors that sit outside the bloodstream. And by this I basically mean TF (at least I do for the purposes of this discussion).

Having said this, it is possible to have blood clots form without TF involvement. This occurs primarily in veins, and is usually due to blood flow stasis i.e. the blood stops flowing in a blood vessel. This happens if you cross your legs, lie in bed, have a plaster cast on, or take a long haul flight, or suchlike. If the stasis lasts too long, the blood can slowly start to form a clot. A big one usually. This is usually referred to as a DVT (deep vein thrombosis).

The other place this can happen is, as described before, in the atria, when you have atrial fibrillation. Rather than the blood being rapidly ejected with each heart beat, when the atria fibrillate, the blood can become trapped in eddies, not moving. Then clotting, then escaping, then stroke.

Blood clots which are created mainly through the action of the intrinsic pathway are, usually, far less strongly bound together – because fibrin is not created to the same extent. Therefore, a DVT that forms in a large vein in your leg can easily break off, travel up the vein and into your heart. It can get stuck there – instant death. Or it can pass straight though the heart and into the lungs, where it gets stuck. Causing a pulmonary embolism. Can be fatal, but not always.

Intrinsic pathway clots are stimulated by all the clotting factors you may have heard of. Factor X, factor IX, factor VIII, prothrombin, and suchlike. If you want to stop these clots forming you can use various anticoagulants such as warfarin, or heparin, or the new oral anticoagulants (NOACs). These block various intrinsic factors making the blood ‘thinner’ and less likely to clot.

Warfarin, for example, interferes the action of vitamin K, which is needed by the liver to synthesize several clotting factors. Indeed, warfarin is often referred to as a vitamin K antagonist. Practically, this means that you can rapidly reverse the actions of warfarin by giving a massive dose of vitamin K.

Sorry, I said I was only going to talk about tissue factor, platelets and fibrinogen. But I think the fact that blood clotting has different pathways can help to explain why, for example, warfarin is very poor at preventing CVD, but very good at preventing stokes caused by atrial fibrillation, and can prevent dearth from DVT.

At times I am just staggered by the amazing ingenuity of human physiology. How the hell, I think to myself, did all of this evolve? Blood clotting is just one physiological system, one small part of how the body works, and just this one part is frighteningly complex.

Anyway, moving on. In the arteries, if you want to get a blood clot to form, you need expose the blood to TF and the clotting system then fires into action. The first part of the process is that platelets are attracted to the site of damage. Platelets are small blood cells which, when ‘activated’ become very sticky and start to clump together. They then release a massive family of different factors, including clotting factors, that stimulate the rest of the clotting cascade. [Platelets also contain quite a lot of TF, which is transferred to them by circulating monocytes – a tale for another day].

The final step of the clotting cascade is to join lots of small fibrinogen stands together. Fibrinogen consists of short thin strands of protein. If you stick hundreds of strands together, end to end, you get fibrin. This is a bit like fishing line. Long, tangly, sticky and extremely strong. It binds platelets together into a furiously strong clot.

At the same time, fibrin drags in almost everything else into the blood stream, and binds it into the clot. White blood cells, red blood cells, lipoproteins etc. Some of these may, or may not, be innocent bystanders in the clotting process. Although, the closer you look, the more you will find that almost all blood elements are actually players in the process.

Just to look at one example here, very low density lipoproteins (VLDLs), also known as ‘triglycerides’. These lipoproteins have significant effects on clotting. To understand how this happens I need to move sideways for a moment, and bring in something that most of you will never have heard of. Plasminogen activation inhibitor 1 (PAI-1).

To explain. Blood clots, when they form, incorporate within them an enzyme called plasminogen. This enzyme, when activated, can slice strands of fibrin apart and, thus, break down blood clots into tiny bits. After a heart attack, or stroke, you can be given tissue plasminogen activator (tPa) – or something very similar. This activates plasminogen within the blood clot, and causes the clot to disintegrate. Thus, a blocked artery will be reopened.

Now, as with everything else to do with blood clots, we have yin and yang. On one side we have plasminogen; on the other side we have plasminogen activator inhibitor – 1 (PAI-1). This does exactly what you would expect. It inhibits the action of plasminogen. This is not surprising. In all parts of the clotting system, for every factor that reduces blood clotting tendency, there is an equal and opposite factor increasing blood clotting. All is in balance.

Plasminogen slices clots apart, PAI-1 prevent this from happening. Clearly, therefore, the more PAI-1 you have, the more difficult it is for a clot to be broken apart. So any factor that increases PAI-1, will make any blood clot that forms bigger and more difficult to shift. Which brings us back to VLDL – a.k.a. triglycerides.

‘In vitro data have shown that triglyceride-rich very low density lipoprotein (VLDL) particles enhance PAI-1 secretion from endothelial cells and liver cells Furthermore, it has been shown that VLDL stimulation of PAI-1 expression in endothelial cells is mediated through transcriptional activation of the PAI-1 gene, and a VLDL response element has been identified in the promoter region.’ 1

Or, to put this more simply. If you have lots of VLDL in your blood, you will stimulate the production of PAI-1. So, you will have impaired breakdown of blood clots (impaired fibrinolytic activity). Which means that (from the same paper):

Hypertriglyceridemia is associated with an increased risk of coronary heart disease (CHD). Impaired endogenous fibrinolytic function is a frequent finding in subjects with hypertriglyceridemia.’

The most common condition where you are most likely to find high VLDL levels is type II diabetes. In type II diabetes there is, always, a high PAI-1 level. I am not sure if this needs a reference, but you are getting one anyway, with regard to type II diabetes:

‘The combination of hypertriglyceridemia, glucose intolerance and inflammation is linked with increased production of the primary inhibitor of endogenous thrombolysis, plasminogen activator inhibitor-1 (PAI-1). Recent data suggest that PAI-1 contributes directly to the complications of obesity, including type 2 diabetes, coronary arterial thrombi, and may even influence the accumulation of visceral fat.2

The bigger picture – other factors

I think, as always, I have become in danger of heading off down a narrow channel here. Time to drag the discussion back to the main process. The point I want to make clear, in this part of the argument, is that after you have damaged the endothelium a clot will form. This is quite natural.

However, if you have factors in the blood that make any clot that forms bigger, or more difficult to break down, the chances are that any clot that forms will end up within the artery wall as a bigger plaque. Or the clot may simply block the artery altogether, first time.

Some of the other factors that make blood clots likely to be bigger, and/or more difficult to clear up, in addition to type II diabetes and high VLDL levels, are:

  • Raised fibrinogen levels
  • Raised Lp(a) levels
  • Antiphospholipid syndrome (Hughes syndrome)
  • Smoking
  • Raised homocysteine levels

Not an exhaustive list by any manner of means, and I am only going to look at two of these in this blog. Fibrinogen and Lp(a) levels.


It would seem common sense that raised fibrinogen levels would make blood clots bigger when they form, and thus more difficult to clear up, as they are a key component of any blood clot.

The importance of a high fibrinogen level was something I first saw in the Scottish Heart Health Study. This was a major study that lasted ten years and included thousands of people. The researchers looked at many different factors which were thought to be involved with causing heart disease (and death from all causes). Raised cholesterol was found to have no effect. Instead they found that:

‘Fibrinogen is a strong predictor of coronary heart disease, fatal or non-fatal, new or recurrent, and of death from an unspecified cause, for both men and women. Its effect is only partially attributable to other coronary risk factors, the most important of which is smoking.’  

The increase in (relative risk) between the highest and lowest fibrinogen levels was:

  • 301% for men and 342% for women (CVD death)
  • 259% for men and 220% for women (Death from any cause)

In fact, a high fibrinogen level was the single most important risk factor they found – just beneath already suffering a previous heart attack. A raised fibrinogen was an even more powerful risk factor than smoking (although smoking can raise fibrinogen levels, which complicates this picture somewhat).

This finding was reinforced by the Prospective Cardiovascular Münster (PROCAM) study.

The incidence of coronary events in the upper tertile (top third) of the plasma fibrinogen distribution was 2.4-fold higher than in the lower tertile (bottom third)… plasma fibrinogen was found to be an independent risk indicator for CHD (P < .05). Individuals in the high serum low-density lipoprotein (LDL) cholesterol tertile who also showed high plasma fibrinogen concentrations had a 6.1-fold increase in coronary risk. Unexpectedly, individuals with low plasma fibrinogen had a low incidence of coronary events even when serum LDL cholesterol was high.’ 3

[Ah yes, the old ‘high cholesterol low rate of heart disease conundrum.’ It must be, let me see, a paradox. I do love the word unexpectedly. Mainly, because, here is where scientific truths hide]

I feel the need to add that a 2.4-fold increase in coronary events = relative risk increase of 240%, which is in the same ball park as the Scottish Heart Health study. Some of the things that can raise your fibrinogen levels are:

  • Smoking
  • Stress (physical or psychological)
  • Type II diabetes
  • Depression
  • Cushing’s disease
  • Post-traumatic stress disorder (PTSD)
  • Obstructive sleep apnoea

Of course, all of these things are also associated with a greatly increased risk of CVD. You can have hours of fun by typing CVD raised fibrinogen and… (insert favourite risk factor for CVD of your choice here).

Lipoprotein (a) (Lp(a))

There has been much discussion of Lp(a) of late. What it is, what does it do, why does it matter? The first thing to point out about Lp(a) is that it is, essentially, LDL a.k.a. LDL-cholesterol a.k.a. ‘bad cholesterol.’ However, it differs in one way. It has a special strand of protein attached to it, known as apolipoprotein A.

This protein is very interesting, from a blood clotting perspective, in that it is chemically identical to plasminogen. Yes, the one and only clot busting enzyme, switched on by tissue plasminogen activator.

But, big but. Apolipoprotein A is folded into a slightly different structure than plasminogen. Let us say it has a right handed thread, instead of left handed thread. (This is not fully accurate, but it is close enough).

This is important because almost of the receptors in the body have a symmetry to them, as do most of the molecules that nature provides, and most of them are left handed (levo-rotated). If you aim a right handed molecule at a left handed receptor very little happens – or strange and unpleasant things can happen. Thalidomide for example The L handed version causes no problems, but the R handed version causes serious birth defects – or was it the other way round. Remove one, or the other, version and you could give thalidomide perfectly safely in pregnancy. I would dare you to try.

As it is, thalidomide has been relegated to a cancer treatment, under the brand name Immunoporin. How does it work? It works by stopping angiogenesis (formation of new blood vessels) which cancer cells need to grow into a larger tumour mass.

The way that Thalidomide does this is that it damages endothelial cells, and endothelial progenitor cells (EPCs), as discovered in this study: ‘Thalidomide attenuates nitric oxide mediated angiogenesis by blocking migration of endothelial cells.’

‘….thalidomide interferes with nitric oxide-induced migration of endothelial cells at the initial phase of angiogenesis before cells co-ordinate themselves to form organized tubes in endothelial cells and thereby inhibits angiogenesis.4

Okay, maybe that means nothing to you. What it means is that thalidomide stops new blood vessels forming, by blocking the action of NO on both endothelial cells and endothelial progenitor cells (EPCs). Whilst this is a good thing in cancer treatment, it is not so great in the developing fetus.

A pregnant women taking thalidomide will find that new blood vessels do not form properly in her baby. This means that arms and legs cannot get blood supply, so they don’t develop, so you are left with a severely deformed baby, often with missing limbs.

It would be interesting to know what impact thalidomide has on CVD risk? We already know what impact Avastin has on CVD risk. It increases it massively. Avastin, like thalidomide, works primarily by inhibiting endothelial cell growth and EPC production. Whilst this stops tumours growing, it also greatly accelerates CVD. Oooh, I do love the way everything is connected.

Anyway. To return to apolipoprotein A again. If you incorporate Lp(a), and thus apolipoprotein A, into a blood clot, it cannot be broken down. This is because tissue plasminogen activator cannot activate it, because it is right handed. Effectively, therefore, apoliporotein A blocks the enzymatic destruction of fibrin, thus protecting the clot from destruction. Why, you may ask, would the body create such a stupid thing?

Well, as with everything the body does, it is not stupid. It is very, very, clever. Lp(a) is only made in animals that cannot synthesize vitamin C. Guinea pigs, fruit bats, great apes and…humans. The reason for this is that, if you are vitamin C deficient, the body cannot manufacture certain important support materials/connective tissue, the most important of which is collagen.

Without collagen, your blood vessels start to crack apart. When this happens, blood escapes, so you start bleeding from the gums, and suchlike. This condition is known as scurvy. In scurvy you start bleeding all over the place and, in the end, you die from blood loss. It is what killed many sailors of in the olden days.

Along to the rescue comes Lp(a).. well, it can rescue you for a bit. Lp(a) sticks to cracks in blood vessel walls and forms, impossible to break up blood clots that ‘plug’ the gaps created by collagen deficiency. So you can see that Lp(a) is actually evolution’s way of protecting animals, that cannot synthesize vitamin C, from the early stages of scurvy.

All of which means that if you don’t eat enough vitamin C, and you have a high level of Lp(a), you will end up with a multitude of very difficult to break up blood clots scattered all over your arterial walls, and inside your arterial walls too. Thus, you are going to develop CVD at a rapid rate.

This, the ‘vitamin C deficiency’ theory of CVD was proposed by Linus Pauling (double Nobel prize winner) and Matthias Rath (and you can look him up too – but be prepared for some interesting information). Here is a short section from their modestly entitled paper ‘A Unified Theory of Human Cardiovascular Disease Leading the Way to the Abolition of This Disease as a Cause for Human Mortality.’

We have recently presented ascorbate (Vitamin C) deficiency as the primary cause of human CVD. We proposed that the most frequent patho-mechanism (think of this term as the ‘process) leading to the development of atherosclerotic plaques is the deposition of Lp(a) and fibrinogen/fibrin in the ascorbate-deficient vascular wall. In the course of this work we discovered that virtually every patho-mechanism for human CVD known today can be induced by ascorbate deficiency.’

So there you go, vitamin C deficiency is the answer to CVD? No, it is not THE answer, but it is an answer, or a part of an answer. There is no doubt that a low level vitamin C is a bad thing. There is equally no doubt that a low vitamin C level, associated with a high Lp(a) is a double bad thing. Furthermore, there is absolutely and completely no doubt that taking extra vitamin C would be a good thing for everyone – just in case.

However, Pauling and Rath, brilliant though their thinking was, made the number one error in medicine. They looked for the single cause, and the single cure of a disease. They became so certain they were right, that they stopped looking elsewhere.

Having said this, their ideas about the process of CVD were, in my opinion, absolutely right. They realised that the essential underlying process was: arterial wall damage, followed by blood clots, followed by the development of atherosclerotic plaques. But they thought it could all be explained by a single factor, Vitamin C deficiency. In this they were wrong. It is a great shame they did not look at the wider picture.

However, I hope you can now see what Lp(a) is, what it does, and why it is important in the whole CVD argument. It is not a clotting factor per se, but it has a huge impact on the clots that do form. Unfortunately, it seems that Lp(a) levels are genetically determined and there seems little you can do to alter them. I would suggest that, if you decided to get your Lp(a) level tested, and it is high, you should make sure you get plenty of vitamin C in your diet.


I realise that you may think I have taken you off on a couple of wide detours in this blog. More than a couple actually. However, my cunning plan was to give a sense of how everything in the physiology of endothelial health and blood clotting can be fitted together. Also, how it can be seen that any factor which has an impact on the development of blood clots (following endothelial damage), will have an impact on CVD through mechanisms that can be easily understood.

Looking at an even wider picture I hope that you can now see, why drugs such as thalidomide – which may seem a million miles away from CVD – are actuallly closely related. How Lp(a), which at first glance may appear to have nothing to do with the four step process of CVD, can be brought into the picture. In addition, where, and how, such things as VLDL and PAI-1 fit in…. to name only a few. Over the years I have followed the story down a million different pathways. Each fascinating, but there are far too many to discuss them all here.

Yes, it is a complex story. Did you really think it would be easy? Did you really think there would be ONE factor that caused everything, and ONE factor that cured everything? CVD is not binary, it is about propensity, chaos theory. It is about changing the odds here and there. It is about the weighting of the dice. You can improve the odds in your favour, but you will never make them zero.

Next….the repair process.





What causes heart disease part V

The first stage of cardiovascular disease is damage to the endothelium. The single layer of cells lining the arteries. After this, we need to look at what then happens? Before looking at this more closely, I would like to take you back in time around one hundred and sixty years. This was when the first scientific debates about plaque development were taking place.

Rudolf Virchow and Karl von Rokitansky were the proponents of different hypotheses at this time. I am grateful to Professor Paul Rosch for providing the information on Virchow’s ideas. He provided this description in one of his newsletter.

Rudolph Virchow was the first to demonstrate the presence of cholesterol in atheroma in 1856. He described atherosclerosis as “endarteritis deformans” The suffix “itis” emphasized that it resulted from an inflammatory process that injured the inner lining of the arteries, and that the cholesterol deposits started to appear subsequently

Virchow was very specific about this when he wrote. ‘We cannot help regarding the process as one which has arisen out of irritation of the parts, stimulating them to new, formative actions; so far therefore it comes under our ideas of inflammation, or at least of those processes which are extremely nearly allied to inflammation.

We can distinguish a stage of irritation preceding the fatty metamorphosis, comparable to the stage of swelling, cloudiness, and enlargement which we see in other inflamed parts. I have therefore felt no hesitation in siding with the old view in this matter, and in admitting an inflammation of the inner arterial coat to be the starting point of the so-called atheromatous degeneration and the cholesterol deposits came later.’

So, even one hundred and sixty years ago, eminent professors recognised that atherosclerotic plaques started with ‘inflammation of the inner arterial coat’ a.k.a…the endothelium. The cholesterol deposits came later. Quite so. Or to put this another way, the cholesterol was not the cause of the plaque, the appearance of cholesterol in a plaque was part of the second stage of plaque development.

However, whilst agreeing on this observation, Karl Von Rokitansky had a further hypothesis.

‘Rokitansky proposed that the deposits observed in the inner layer of the arterial wall were derived primarily from fibrin and other blood elements rather than being the result of a purulent process. Subsequently, the atheroma resulted from the degeneration of the fibrin and other blood proteins and finally these deposits were modified toward a pulpy mass containing cholesterol crystals and fatty globules.’

Or, to put it another way. He believed that plaques were, in fact, blood clots, in various stages of repair. He believed this because plaques looked exactly like blood clots, and contained everything that you can see in a blood clot. Perhaps most critically, a great deal of fibrin, which is the key component of all blood clots.

However, Virchow objected to this idea on the simple basis. ‘How can a blood clot form within the arterial wall?’ Or, how can a blood clot form under the endothelium. A good point, and Rokitansky had no effective response. So he lost.

However, there is a very simple explanation as to exactly how a blood clot can be found beneath the endothelium. And this is, because the endothelium wasn’t there when the clot formed. It grew over the top of the clot afterwards. Which takes us to Endothelial Progenitor Cells (EPCs).

After my last blog, a poster made the following comment.

‘And then… the clot, now trapped under the new endothelium, becomes plaque? If true, seems a stupidly “designed” 🙂 healing process.’

Well, superficially, this is a good point. Simply incorporating clot into arterial wall, where is forms a plaque and then kills you, does not seem a great idea. However, I would ask you to consider what would happen to a blood clot, lying on an artery wall, that simply broke off and travelled down the artery. What would happen?

The answer is simple; it would jam up as the artery narrowed. This could cause a stroke, or a heart attack, or suchlike. Exactly as happens with atrial fibrillation. Where small clots that break off from the atria travel into the brain and get jammed. The body does not like blood clots floating about in the arterial system.

So this does not happen/is not allowed to happen. When the endothelium is damaged, a clot forms on top of it. It is true that a certain amount/a great deal of this clot will be shaved away into very small (not stroke creating sized) pieces, but a ‘core’ will be left. This has to be got rid of in some way.

How are you going to do this? There is only one possible way. Firstly, you cover it over with another layer of endothelium, then you attack it, break it down, and destroy it. And this is exactly and precisely what the body does.

Once a blood clot has stabilized, Endothelial Progenitor Cells (EPCs), that are manufactured in the bone marrow, and float around in the bloodstream, are attracted to the clot. They stick to it, then they grow into fully mature endothelial cells, forming a new layer of endothelium, effectively drawing the clot inside the arterial wall. Then the clot is attacked and got rid of. How?

Well, a critical fact to add in here is that. EPCs do not always become endothelial cells, they can go down another developmental pathway as well. They can become monocytes, which in turn become macrophages. Macrophages are the ‘clear up’ cells of the immune system. They attack alien material and then engulf/ingest it. After this they either exit back into the blood stream or travel directly into the lymphatic system. Whereupon they are transported to lymph glands where they are broken down and all the ‘alien material’ is disposed of.

The body is amazingly clever is it not? After endothelium is damaged, and a clot forms, EPCs not only cover over the area of damage, they can also turn into the very cells that can clear up the clot/plaque and get rid of it. So, not a stupidly designed healing process at all. One of absolute brilliance. In fact, this is probably happening inside your artery walls right now.

The problems start to occur when the process of endothelial damage is occurring too rapidly for the healing system to clear up the mess. Repeated endothelial damage and clot formation over the same spot, time and time again. At which point, instead of having clot/plaque healing we end up with clot/plaque growth and development. Or as Rokitansky put it so eloquently

‘Subsequently, the atheroma resulted from the degeneration of the fibrin and other blood proteins and finally these deposits were modified toward a pulpy mass containing cholesterol crystals and fatty globules.’

Next, clot formation and associated problems.

What causes heart disease – part III

In most diseases it is best to start at the beginning and work forwards. This should be the case with cardiovascular disease (CVD) too. However, for complex reasons I found myself starting at the end, and working backwards. The main reason for this is that I had to start with certainty. Yet, almost everywhere I looked there was mush. For example, the epidemiology of CVD.

Now you would think that there would be agreement about how many people actually die from CVD in different countries and at different times. Not a bit of it.

A researcher:                                    ‘The French have a low rate of CVD.’

A N Other researcher:            ‘Oh well the French, they don’t agree with the normal definitions, they don’t classify CVD properly. Who knows what the true rate may be?’

True? False? A bit true? Taking another example. I have looked at the figures from the US and, you know what. Not a single person died of Ischaemic Heart Disease before 1948. Amazing. What was protecting them? [Dying from IHD is what you would also call a heart attack, or MI]. What was protecting them was the fact that IHD did not exist in the US as a disease classification, before 1948.

This then changed. In 1948 the World Health Organisation was created, and one of the first things they did was to create an International Disease Classification system (ICD). Heart disease is 1. Cancer is 2. (example for illustrative purposes only). Of course it is a bit more complex than that. Just to look in more detail at Ischaemic Heart Disease: [See box]:


Not every country took up the ICD system. Until 1968 the French did not use the ICD codes (so I am told, which no doubt means this is not true). Therefore, in France, statistics on deaths from IHD in France, before this date, are completely unreliable.

It goes without saying that, before 1948, no-one else used the ICD system either, because it did not exist. So, what can we tell about the epidemiology of CVD before 1948? Nothing. Or at least nothing you could hang your hat on. IHD would have been mixed within a much broader ‘Heart Disease’ in the death certificate statistics. And heart disease could mean almost anything, from cardiomyopathy to pericarditis, to atrial fibrillation.

Even after the ICD system was introduced, and even after France came on board, many countries clearly did not use it in the same way. Which is why the WHO set up the MONICA study.

‘The MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) Project was established in the early 1980s in many Centres around the world to monitor trends in cardiovascular diseases, and to relate these to risk factor changes in the population over a ten year period. It was set up to explain the diverse trends in cardiovascular disease mortality which were observed from the 1970s onwards. There were total of 32 MONICA Collaborating Centres in 21 countries. The total population age 25-64 years monitored was ten million men and women. The ten year data collection was completed in the late 1990s, and the main results were published in the following years. The data are still being used for analysis.’

It was also an attempt to see if different countries were actually looking at the same diseases, and classifying them in the same way. Even after that, the data was still not absolutely clear cut, as further studies were then set up to see if the US system ARIC, and MONICA, actually matched each other. This was 1984.

‘To foster collaboration between the World Health Organization MONICA Project and the NHLBI Study of Atherosclerosis Risk in Communities (ARIC). To ensure that valid comparisons could made between findings in MONICA and ARIC by supporting activities to standardize coding, classification, and analysis of coronary and stroke events, risk factors, and medical care according to MONICA protocol.’

In simple terms, the US has its system, ARIC, and Europe had its system MONICA. Do they actually match? In short we can see that, even as late as 1984, there was clear uncertainty about how diagnoses were being made and how data were being gathered around the world. Did it all match, or not.

Given such uncertainly on both definition and diagnosis, can we say that the US epidemic of CVD in the 1960s actually happened. Or were doctors just putting IHD on death certificates when they didn’t really know what killed the patient. Personally, I think the epidemic did occur. Actually I think it happened a bit earlier. It is my belief that it took a while for US doctors to start using the new-fangled WHO ICD system.

Anyway, the point I am trying to make is that it is incredibly difficult to find the ‘bedrock.’ By which I mean facts that are inarguable. Things you can base your thinking on that are absolutely true, or that are as close to absolutely true, as possible.

Which is why I ended up at the end, the formation of the final, often fatal, blood clot. A blood clot which, generally, forms over an existing atherosclerotic plaque. There is widespread agreement that this is the case. So we can, I think safely, start here.

[There are, undoubtedly other things going on, such as sympathetic stress, mitochondrial damage and acidosis with heart muscle. that play a hugely important role. But the clot is, usually the final event

It is also widely agreed that factors which increase blood clot formation (thrombophilc factors) increase the risk of dying from CVD, and that things that reduce blood clotting reduce the rate of death from CVD. Here are a few things that increase the risk of blood clots forming, in no particular order:

  • Dehydration
  • Waking up in the morning/getting up in the morning
  • Acute physical stress
  • Acute psychological stress
  • Having a high fibrinogen level
  • Diabetes
  • Cocaine use
  • Smoking
  • Cushing’s disease

Here are some of the things that reduce the risk of blood clots

  • Haemophilia
  • Von Willibrand Disease
  • Aspirin
  • Moderate alcohol consumption
  • Clopidogrel
  • Yoga
  • Regular exercise

I suppose I should add that all of the things that increase the risk of blood clotting also increase the risk of death from CVD, and vice versa.

This is hardly a complete surprise. If blood clots kill you, things that reduce blood clots will prevent you from dying, and vice-versa. Let us not fall to the ground in stunned amazement over this statement of the bleeding obvious.

At this point, and slightly out of sequence, I would like to introduce statins to the list of factors that reduce the risk of blood clots

Readers of this blog know that I am not keen on statins, to say the least. However, if the studies are to be believed, they do reduce the risk of CVD. Not to any great extent, but the effect certainly does exist. Many people use this fact to attack my view that raised cholesterol does not cause CVD. ‘Well, what about statins,’ they bellow in delight. ‘They lower cholesterol and reduce the risk of CVD. Case proven…next’

Well, as with all drugs, statins do many other things than lower cholesterol levels. For example:

‘Recent studies have shown that statins reduce thrombosis via multiple pathways, including inhibiting platelet activation and reducing the pathologic expression of the procoagulant protein tissue factor.’1

So, as they say, there. In fact, one could quite sensibly propose that statins work pretty much the same as aspirin. They are anti-coagulants, and lowering blood cholesterol is simply a nasty and unfortunate side-effect of statins.

In reality, statins have a far more important effect on CVD (through other actions also related to clot formation) that I will get to later. I just thought I would pop that statin fact in. I even provided a reference. I have not really done much referencing in this series up to now. I believe that it is very simple to type, for example, ‘regular exercise and reduced thrombus formation’ into Google and see what you get. Or ‘Yoga and reduced blood coagulation.’

Where was I? Oh yes. Things that increase blood clot formation are more likely to kill you from CVD, and vice versa. Nothing controversial here. But the potentially controversial bit starts right here.

Are there two processes or one?

Currently, whilst conventional thinking on CVD accepts that blood clot formation is almost always the final event in CVD. This represents a completely separate process to the development of the atherosclerotic plaque itself. In short, we have two unrelated physiological processes:

  • Plaque formation
  • Clot formation on top of plaque

I apologize for saying, essentially, the same thing in different ways. But I think it is important.

Strange then, is it not, that plaque formation and clot formation share so many risk factors? Smoking, for example. Diabetes, for example. In fact, you could say (with certain provisos) that the risk factors for plaque formation and blood clot formation, are exactly the same.

Which gives one to think. Well it certainly gave me to think. Could it be that plaque formation, and blood clot formation, are simply two different manifestations of exactly the same underlying disease process. From a pure scientific perspective, I liked the idea. I liked it because it seems clumsy to have a disease, CVD, that is made up of two, essentially unelated processes

In medicine, as in all of science, one single disease process always looks much better, much cleaner, and much more likely to be right. This is the principle of Occam’s razor:

‘The principle in philosophy and science that assumptions introduced to explain a thing must not be multiplied beyond necessity, and hence the simplest of several hypotheses is always the best in accounting for unexplained facts.

Next: The four step process of CVD


What causes heart disease – part II

[By heart disease I mean, the development of atherosclerotic plaques in large arteries. Mainly the coronary arteries (supplying blood to the heart) and carotid arteries (supplying blood to the brain). This, I will refer to as Cardiovascular Disease CVD. Not entirely accurate, but language never is.]

At this point, I am going to start at the end. What kills people? (Or what causes myocardial and cerebral infarctions). You might think that this was clear cut, but of course it is not, far from it. For example, there is a major cause of death from ischaemic strokes that has nothing whatsoever to do with CVD. This is Atrial Fibrillation.

Atrial fibrillation (AF), is a condition where the upper chambers in the heart (atria) do not contract in a regular and co-ordinated fashion. Instead, they fibrillate – AF definition : ‘(of a muscle, especially in the heart) make a quivering movement due to uncoordinated contraction of the individual fibrils.’ AF is pretty common.

People who have AF tend to develop blood clots in the atria. These can break loose, and are then ejected from the heart into other parts of the body. Quite commonly these clots travel into the brain. As the artery the clot is traveling down narrows, the clot gets stuck, and blood supply is cut off, leading to an area of ‘ischaemia’ (no oxygen) and a stroke. A cerebral infarction.

Which means that it is perfectly possible to have strokes (cerebral infarctions) that are unrelated to CVD. If, that is, you define CVD as the development of atherosclerotic plaques. You can also have strokes where an artery in the brain bursts, causing bleeding into brain tissue, which is called a haemorrhagic stroke. This is clinically indistinguishable from an ischaemic stroke. You need a brain scan to see what type of stroke has happened.

Ergo, whist death from a stroke is clearly a form of cardiovascular disease, many strokes have nothing whatsoever to do with atherosclerotic plaques – which is what I am calling CVD.

Equally you can die from something commonly defined as a ‘heart attack’ which has nothing to do with atherosclerotic plaque development either. You can, for example, develop a fatal arrhythmia. This is where the conduction system in the heart goes wonky, the heart stops contracting regularly, and you die. [Of course, quite often this happens as part of a myocardial infarction].

If we put aside these forms of dying of strokes and heart attacks, we can then focus more clearly on the event that kills you with CVD? Which is, in general, a clot forming on a vulnerable plaque, and blocking an artery, leading to a myocardial infarction (heart attack).

Looking at strokes. If a clot forms in a carotid artery, it does not tend to block the artery completely. Instead, a part of the clot breaks off, and travels up into the brain where is gets stuck – causing a stroke (as per AF).

But… there are those who disagree with this simple model. Mainly with regard to heart attacks. I am fully aware of a growing movement which states that the myocardial infarction (heart attack) happens first, then the clot forms afterwards. (Incidentally, this concept is not new; it was first proposed over eighty years ago. You may think that is seems completely mad. However, there is strong evidence that would appear to support this ‘reverse’ hypothesis’ (infarction first, then the blood clot forming in the artery).

For example, in many cases after a confirmed and accurately diagnosed myocardial infarction, you cannot find any blood clot in the artery leading to the infarcted area. In other cases, you can find a blood clot that is several days, or weeks old. This age of the clot can be established because of the ‘evolved’ state of the thrombus. In short, there is no ‘temporal’ connection between the blood clot forming and the heart attack occurring.

On the other hand, you can find an acute blockage of a coronary artery that has not caused any symptoms, let alone a myocardial infarction.

Anyway, if you try to bring these facts together you find that:

  • Myocardial infarctions can occur without any clot being found in an artery
  • A clot can form in coronary artery days, or weeks, before any symptoms of an MI
  • A clot can fully obstruct the coronary artery, without causing a myocardial infarction

Given these facts (facts which, incidentally, are not in dispute), you can make a pretty strong case that there is no causal association between a blood clot blocking a coronary artery, and an MI taking place. Instead people can, and indeed do, argue that the process is the other way around. Infarction first, then clot.

Perhaps, now, you can begin to understand why it has taken me thirty years to try and work out the underlying process of CVD. At times I have thought that there isn’t any… but that is another story, for another place

The reverse hypothesis – why it is not correct

I have studied the ‘reverse hypothesis’ – if that is a reasonable term for it – for many years, and I believe that it is wrong. The primary cause of a heart attack is simply a blood clot blocking a coronary artery. However, there are two major complications that lead to the apparent contradictions listed above. In no particular order they are the following:

  • An infarction does not mean that heart muscle dies
  • Collateral circulation develops

What is an infarction?

Cardiology is, unfortunately, dominated by highly simplistic thinking. Namely, plaque develops, clot forms, infarction occurs. The infarction occurring within minutes of the clot formation.

But this is nothing like the reality of what actually happens. Heart muscle, like all tissues in the body, is enormously complicated. If you suddenly reduce the blood supply, it can do several different things. It can infarct, it can hibernate, or it can do nothing much.

Just to look at infarction. The dictionary definition is… ‘obstruction of the blood supply to an organ or region of tissue, typically by a thrombus or embolus, causing local death of the tissue.’ Well, I’ve got news for you, heart muscle does not die (not unless the organism surrounding it dies).

Infarction, in the case of myocardial infarction, does not mean death of the tissue. Instead, the heart muscle undergoes a complex transformation into a different cell type. One that needs far less oxygen to survive and one that cannot do the contracting thing. But it is not dead. Because dead cells become necrotic and necrotic cells disintegrate. After a heart attack do you see disintegrated areas of the heart? No, you most certainly do not. You see a form of scar tissue developing.

There is also a halfway house that lies between infarction, and nothing happening. This is ‘hibernation’, a state whereby heart muscle simply decides to stop contracting/beating (to save oxygen use). If you do MRI scans on the heart, in those with known heart disease, such ‘silent’ regions are a relatively common finding. Sometimes these regions wake up and start beating again, sometimes they do not. Sometimes they go on to infarct.

Adding further to the complication, if a coronary artery starts to narrow, the heart will create small ‘collateral’ blood vessels to get round the narrowing, and keep the blood supply up. When, and if, the artery fully blocks, the collateral circulation will maintain the blood flow, and so nothing very much will happen, even if the coronary artery is fully blocked. Many people survive on collateral circulation alone.

All of which means that, after an artery blocks, one of three things can happen:

  • There is a sudden infarction (could be large enough to be fatal)
  • The heart muscle decides to hibernate, if there is sufficient collateral circulation to keep things ticking along
  • Nothing much happens. If there is high level of collateral circulation, the heart just carries on much as before.

Only in the first case will the obstructive blood clot closely precede the heart attack. In case two the hibernating heart muscle may later decide to infarct, if the circulation does not improve. This can happen under periods of high physical or psychological stress. Thus the formation of the blood clot can precede the infarction by days, weeks or months. Indeed, the clot may have been fully cleared away by the time infarction occurs.

In short, the apparent contradictions to the: clot → blockage → infarct hypothesis can be explained, reasonably easily. So long as you realise that what happens inside the heart is not a case of simple pipe-work, where there a fixed number of tubes (arteries) supply oxygen to a pump (the heart). If you block one tube, the pump is immediately damaged.

Heart attacks and strokes

However, my main reason for disbelieving the ‘reverse hypothesis’ is that the standard model works for both heart attacks and (most) ischaemic strokes.

In ischaemic strokes, as mentioned before, a blood clot forms over a plaque in a carotid artery. This rarely blocks the artery; as carotid arteries are much wider bore than coronary arteries. However, what happens next – after a variable time period – is that the clot breaks off and travels into the brain.

This is, essentially, exactly the same process as a heart attack – except the clot lodges further down the vascular tree. Not only are the processes of stroke and heart attack virtually identical, the risk factors for both are virtually identical. Perhaps most telling is the fact that people with plaques in their coronary arteries almost always have plaque in their carotid arteries, and vice-versa. For example, here is the title of a paper on this topc: ‘Tight relations between coronary calcification and atherosclerotic lesions in the carotid artery in chronic dialysis patients.’1

This is further supported by a study that has just come out, and published in BMJ open. Key points were:

  • We studied the risk of heart disease following a stroke in those patients with no cardiac history. This study is the largest of its kind and, by bringing together multiple data sets, robustly quantifies the risk of heart disease following stroke. As with all meta-analyses, the main limitation of this work relates to publication bias.
  • Most patients with stroke die of heart disease.
  • One in three patients with ischaemic stroke with no cardiac history have more than 50% coronary stenosis.
  • 3% are at risk of developing myocardial infarction within a year of their stroke.
  • Patients with stroke need to be screened for silent heart disease and appropriate and aggressive management of total cardiovascular risk factors is required2.

In short, the two conditions are the same. It is beyond any reasonable doubt that with ischaemic stroke, and myocardial infarctions, we are looking at the same underlying disease. To be frank I don’t think may people would disagree with this. But it does lead to a critical point. Namely has anyone, ever, argued that cerebral infarctions (strokes) happen before the blood clot blocks an artery in the brain?

No they have not. Because to do so would, quite frankly, be bonkers. We can be absolutely certain that blood clots cause infarctions in the brain. Yet many people quite strongly argue that with myocardial infarction it is the other way around. For the reasons outlined above I do not, and cannot, believe this. There is only one process, and no need to start searching for another.

You may wonder why I have gone off in such a wide detour here? There are two reasons. First to make it clear that this area is gigantically complex. Secondly, to reinforce the point that wherever and however you look at CVD, alternative hypotheses have been proposed. Until you have tracked them down, and examined them fully, you cannot really move on.

Next: Some answers.



What causes heart disease?

I have been somewhat silent on this blog for a while. Mainly because I have been putting together ten thousand words on the true cause of heart disease. Of course, by heart disease I mean the thickenings and narrowings in the larger arteries in the body (atherosclerotic plaques). I am also focussing almost entirely on the arteries supplying blood to the heart (coronary arteries), and the main arteries that supply blood to the brain (carotid arteries).

Whilst atherosclerotic plaques can develop in other arteries that supply, for example, the kidneys, or the bowels, problems here are generally less common, and less severe – although not always. In general, however, the main killers in ‘heart disease’ are heart attacks and strokes (not all strokes, only the most common form of stroke, an ischaemic stroke). So, at the risk of becoming over-pedantic, and simultaneously sloppily inaccurate, I am calling heart disease Cardiovascular Disease (CVD), and looking at heart attacks and strokes.

With that out of the way, what causes cardiovascular disease (CVD)? Whilst it took me only a few days of research, many years ago, to realise that the diet-heart/cholesterol hypothesis was clearly nonsense. It has taken over thirty years to work out what is actually going on. In truth I could not truly progress until it suddenly dawned on me that I should not be looking for causes. For that is a mugs game.

Once you start looking for causes, you find that there is almost nothing that a human can ingest, or do, that has not been claimed to be a cause of CVD, or a cure for CVD. In many cases both… simultaneously. In 1981 a paper was published in the journal Atherosclerosis which outlined several hundred possible ‘factors’ involved in causing or preventing CVD. Today, if you hit Google, or Pubmed, I can guarantee that you could find several thousand different factors. If, that is, you could be bothered.

If you could be bothered, what could you possibly make of ten thousand different things involved in CVD in one way or another? Can they all be true risk factors? Some of them are certainly only associations, not causes. A few are simply statistical aberrations, found in one study and contradicted in another. Even removing them, there are so many, so very very many. Pick your favourite and trumpet it to the world. Vitamin K, Vitamin D, coffee, leafy green vegetables, omega 3 fatty acids, intermediate chain monounsaturated fats, HDL raising agents, selenium, lowering homocysteine…. on and on it goes.

Is there any other hypothesis where you have to fit in ten thousand different factors? No, there is not. Yet no one has been put off identifying more and more things. This is why, I believe, we have such a terrible mess. I amuse myself sometimes looking at the knots the cholesterol hypothesis ties itself into to.

Just to give one example. We have had ‘good’ cholesterol and ‘bad’ cholesterol for some time now. More recently we have ‘bad good’ cholesterol (raised HDL increasing CVD risk during the menopause), and ‘good bad’ cholesterol (light and fluffy LDL that protects against CVD). Now, that’s what I call a non-disprovable hypothesis. A risk factor that can be good, or bad. Or ‘Good bad’ and ‘bad good’.

Whilst contemplating such nonsense it came to me, in a moment of the blindingly obvious, that in order to understand CVD I had to move away from trying to fit ten thousand factors into the biggest intellectual jigsaw known to man, and move on. I had to know what the actual process is. What is actually happening in the arteries.

Once you start to look at CVD through this window, you suddenly realise that very little is ever written on this topic. The world famous cardiology bible ‘Braunwald’s Heart Disease’ is virtually silent on the matter. Or at least it was when I looked through it a few years ago.

In a massive book on heart disease, the process of CVD development is covered in less than half a page. The cholesterol hypothesis itself is usually left completely unexplained. Or there are gaping holes, and bits that you just have to take on faith. Raised LDL leaks/travels/gets into the artery wall where it creates inflammation and plaques develop. The end.

Then you start to ask, so why do plaques never develop in veins? Same structure as arteries, same level of LDL. Why do plaques never develop in the blood vessels in the lungs (pulmonary arteries and veins?). What has oxidised LDL got to do with it? Where does oxidation occur? How does LDL leak into coronary arteries, and carotid arteries, but cannot leak into arteries within the brain itself?

Questions, questions, questions and almost no decent answers. There is a kind of collective brouhaha noise with a lot of ‘well it just does’ thrown in when you start to ask. ‘Explain again, how does LDL get into the arterial wall. Each step please?’. You are usually met with perfect anti-Popparin logic. We know that raised cholesterol causes heart disease, so it must get into the arterial wall using some mechanism or other. And look, there is cholesterol in atherosclerotic plaques. So it must get through.

Of course, it is true you can find cholesterol in atherosclerotic plaques. No-one is going to deny that. But you can also find, for example, red blood cells (RBCs). Now, you might be able to explain how LDL can pass through endothelial cells (the cells that line the arteries) in some fashion. Although I would argue that, if so, why does LDL not pass through endothelial cells in veins. And why cannot it pass through, or between, endothelial cells in the arteries with the brain?

LDL molecules, after all, are minute in comparison to an endothelial cell. However, RBCs and endothelial cells are pretty much the same size. So, please try to explain to me how a RBC finds itself within the artery wall, underneath the endothelium? Try getting one cell, virtually the same size as another, to pass through it. A very clever trick indeed.

Then, if you start exploring further, you find that the cholesterol you find in atherosclerotic plaques almost certainly comes from the cholesterol rich membranes of RBCs.

The view that apoptotic macrophages (dead macrophages) are the predominant source of cholesterol in progressive (atherosclerotic) lesions is being challenged as new lines of evidence suggest erythrocyte membranes contribute to a significant amount of free cholesterol in plaques.’1

Oh look, it seems that the cholesterol does not come from LDL. Anyway, I am jumping ahead of myself here, and getting dragged back into explaining why the cholesterol hypothesis is nonsense. Which is playing the game on the opponents’ pitch, under their rules.

The simple fact is that, to replace the Cholesterol hypothesis, there is a need to come up with something better, which actually fits all the facts. That, of course, is rather trickier as – boy – there are a lot of facts. Also, some of them may seem utterly disconnected.

My simple credo is that, if your hypothesis cannot explain everything about CVD you cannot explain anything. Attempting to do otherwise means that you are left suggesting that there are many different causes, and many different processes, all of which end up causing CVD through non-connected mechanisms. Well if that is true, then we just have to give up. Smoking causes CVD like this, LDL causes it like that, diabetes in a completely different way.

This is why I get so frustrated when people simply shrug their shoulders in a debate on CVD, and retreat to the position of inarguable logic when they tell me that CVD is ‘mutifactorial.’ To which I agree that of course it is bleeding mutlfactorial (as are all diseases). But that the statement itself is meaningless, unless you can then tell me how all the ‘multi’ factors fit together within a single, unified process.

In short, with CVD, if you are going to explain it, you need to be able to explain how, for example, the following factors increase risk, and through what single mechanism, or process. [This is not an exhaustive list by any means, but these are all definite, and potent, causes]:

  • Rheumatoid arthritis
  • Steroid use
  • Systemic Lupus Erythematosus
  • Smoking
  • Kawasaki’s disease
  • Use of Non-steroidal anti-inflammatory drugs e.g. ibuprofen, naproxen and suchlike.
  • Being a deep coal miner – especially in Russia
  • Using cocaine
  • Getting older
  • Getting up in the morning – especially on Mondays
  • Type II diabetes
  • Raised fibrinogen level
  • Cushing’s disease
  • Air pollution
  • Acute physical or psychological stress
  • Chronic kidney disease
  • Avastin – a cancer drug

Looking at one of these risk factors, System Lupus Erythematosus. Young women with this condition have, in some studies, an increased risk of CVD of 5,500%. Compare that with, for example, raised LDL. Even if you believe that it raises the risk of CVD, which is debatable, the increase in risk (as defined by mainstream research) is 66% for a 3mmol/l increase in the LDL level2. Changing the LDL level by this much takes you from low risk, to Familial Hypercholesterolaemia (FH).

If we accept that the 66% figure is, indeed, correct, we can see that SLE increases the risk 83 times more than having a very high LDL level. Or, to frame this differently. SLE increases the risk of CVD 8,300% more. Clearly, therefore, SLE has far more to tell us about what really causes CVD than raised LDL ever could. Deep coal miners in Russia have their final, fatal, heart attack aged 42, on average. Children with Kawasaki’s disease can die of a heart attack aged 3.

Here, therefore, are the real causes of CVD. Super accelerated CVD with death at a young age. No need for statistical games. This is the where the answers truly lie. Now comes the difficult bit. How can you fit them all together within a single disease process, without finding anything contradictory?

Ladies and gentlemen, it took me thirty years.



Cholesterol goes up heart disease goes down

As readers of this blog will know well, I do not believe that cholesterol levels have anything to do with heart disease, which would more accurately called coronary artery disease (CAD) or coronary heart disease (CHD). This is not a view that is widely accepted in the medical community, nor in society as a whole. In fact, this view places me very firmly in the ‘nut job’ category. I have been told that my views mean that I feature on several quack watch sites. Hoorah, fame – of a kind – at last.

So when I come across information that supports my position, I am always keen to make as much noise about it as possible. Today, or at least today as I write this, someone sent me an article entitled ‘Continuous decline in mortality from coronary heart disease in Japan despite a continuous and marked rise in total cholesterol: Japanese experience after the Seven Countries Study.

Now, that’s the kind of thing that I like to see. Cholesterol levels go up; heart disease rates go down. Here is the abstract of the paper, published in the International Journal of Epidemiology:

The Seven Countries Study in the 1960s showed very low mortality from coronary heart disease (CHD) in Japan, which was attributed to very low levels of total cholesterol. Studies of migrant Japanese to the USA in the 1970s documented increase in CHD rates, thus CHD mortality in Japan was expected to increase as their lifestyle became Westernized, yet CHD mortality has continued to decline since 1970. This study describes trends in CHD mortality and its risk factors since 1980 in Japan, contrasting those in other selected developed countries.

We selected Australia, Canada, France, Japan, Spain, Sweden, the UK and the USA. CHD mortality between 1980 and 2007 was obtained from WHO Statistical Information System. National data on traditional risk factors during the same period were obtained from literature and national surveys.

Age-adjusted CHD mortality continuously declined between 1980 and 2007 in all these countries. The decline was accompanied by a constant fall in total cholesterol except Japan where total cholesterol continuously rose. In the birth cohort of individuals currently aged 50–69 years, levels of total cholesterol have been higher in Japan than in the USA, yet CHD mortality in Japan remained the lowest: >67% lower in men and >75% lower in women compared with the USA. The direction and magnitude of changes in other risk factors were generally similar between Japan and the other countries.

Conclusions: Decline in CHD mortality despite a continuous rise in total cholesterol is unique. The observation may suggest some protective factors unique to Japanese.’1

This paper was actually published in July, but I missed it until now. I have to say that I like everything about the abstract (and the entire paper) apart from the last ten words. ‘The observation may suggest some protective factors unique to Japanese.’ You may be thinking, what’s wrong with that suggestion. It seems completely reasonable.

I put it to you, members of the jury, that we have a situation whereby we see continuously rising cholesterol levels in a population, whilst the rate of heart disease in that population (already very low), falls even lower. This, despite the fact that their other risk factors are just as high, if not higher than in all the other countries studied. Just to compare and contrast Japan with the USA and the UK. These figures are from the latest year 2008 where all figures are available (figures for men).

% WHO SMOKE 35.4% 23% 17.2%
AVERAGE BP (SYSTOLIC) 130.5mmHg 131.2mmHg 123.3mmHg
CHOLESTEROL LEVEL 5.2mmol/l 5.4mmol/l 5.1mmol/l
RATE OF CHD/100,000/year 45.8 143.7 150.7

Perhaps most important thing in this study is that the rate of CHD in men in Japan was 62.4 (per 100,000/year) in the years 1980 – 83, when their average total cholesterol level was 4.8. Since then cholesterol has risen 9% to 5.2mmol/l; meanwhile the CHD rate has fallen by 27%. In fact, this trend of rising cholesterol and falling CHD has been going on since the 1960 – which is also mentioned in this paper2.

More dramatically, the rate of stroke in Japan, which was once the highest in the industrialized world, has dropped by more than 80% over the last fifty years, or so. Most people bring together deaths from coronary heart disease, and stroke, under the overall banner of cardiovascular disease (CVD). Raised cholesterol is considered a major risk factor for both, and statins are prescribed for both. Yet, as cholesterol levels have steadily risen in Japan, deaths from both major forms of CVD have fallen massively.

Where was I. Oh yes, I was putting it to the jury that the evidence from Japan utterly and completely contradicts the cholesterol hypothesis. Utterly and completely. Facts like these should leave the hypothesis as a smoking ruin. But of course, this has not happened, as it never does.

Karl Popper, the famous scientific philosopher, would say that such a finding represents a black swan. If your hypothesis is that all swans are white, finding more and more white swans slightly strengthens the likelihood that your hypothesis is correct. However, if you find one single black swan, your hypothesis is wrong and must be discarded.

Unfortunately, a recurring theme in medical research is that, when someone does discover a black swan, the medical experts immediately come out and tell you that this black swan is not, in fact a black swan at all. It is a swan that may look black but it will, in time, turn out to be have been white all along. A more bullish tactic is to state that, as all swans are white, a black swan cannot be a swan at all. It is a member of a different class. ‘The black bird that looks exactly like a white swan.’

Both approaches come under the banner of ‘Our hypothesis is right, we absolutely know that it is right, so any evidence that contradicts our hypothesis must be wrong.’ Or can be explained away. Otherwise known as painting the black swan white.

Explaining away also comprises a few other, well established, techniques. Firstly, to denigrate the researchers, or their research. They didn’t measure this correctly, the ignored that, they can’t be trusted, this is rubbish work – please ignore. I call this technique ‘kill the unbeliever.’

The next form of explaining is to call your finding a paradox. i.e. we know that this looks just like a black swan, but an explanation will be found at some time for its apparent blackness. Let us simply ignore this finding until the correct explanation comes along to explain it. I call this technique ‘Hide the black swan away in a cupboard and hope everyone forgets it was ever there.’

Fortunately, or unfortunately, depending on your position on the cholesterol hypothesis, these techniques won’t really work here. This study was funded by the National Institutes for Health, which makes it difficult to rubbish the results, or the researchers. Also, the data have been gathered by the WHO under the MONICA study. A massive and high quality data set which I have never seen anyone argue with. It was also published in the International Journal of Epidemiology. Generally considered a high quality medical journal.

Equally, it is rather difficult to call the Japanese data a paradox. We are not looking at a sudden, one-off finding. What we have in Japan is over sixty years of data, all pointing exactly the same way, year after year. The Japanese cholesterol levels have gone up, year on year, and there has been a steady (yet massive overall) reduction in the rate of heart disease and stroke. This data comes from a population of over one hundred million. Sorry guys, this Paradox hasn’t gone away.

It is also exceedingly difficult for mainstream researchers to attack this current data, as the Japanese were once held up as poster boys for the cholesterol hypothesis. ‘Look at the Japanese’ the researchers shouted loudly in the 1960s. ‘Very low cholesterol levels and very low rates of heart disease… case proven.’ In fact, the Japanese data were one of the strongest drivers of the cholesterol hypothesis. It is entirely possible that, without the Japanese data, the cholesterol hypothesis would never have been accepted in the first place.

Well, look at the Japanese today. Not shouting about them from the rooftops now, are we chaps? Sorry, what was that…couldn’t quite hear you. You may be thinking, at this point. Ah, so the Japanese must be genetically protected against heart disease. Well, this is not correct. To quote from the paper again:

‘Studies of migrant Japanese to the USA in the 1970s reported a dramatic increase in CHD rates within one generation of migration. It was thus expected that exposures to more a Westernized lifestyle among native Japanese after World War II (WWII), for example increase in dietary intake of saturated fat, would cause sizeable rise in blood total cholesterol, leading to a considerable increase in CHD rates in Japan. Between 1960 and 1990, dietary intake of fat and cholesterol in Japan more than doubled. The current levels of blood total cholesterol in Japan, especially among individuals born after WWII, are comparable to those in other developed countries, very different from the 2-mmol/l difference in total cholesterol at the time of the Seven Countries Study.

Moreover, age adjusted mortality from other diseases related to Westernized lifestyle, such as colon, breast and prostate cancers, more than doubled during this period. Very surprisingly, age-adjusted CHD mortality in Japan started to decline in 1970 as in Western countries, and has remained one of the lowest in developed countries: >67% lower in men and >75% lower in women compared with the USA, accounting partly for the greatest longevity in the world among Japanese.’

I liked the words ‘very surprisingly’ in that section. There is only one reason why you should be very surprised in science. That is, when everything you thought you knew about something proves to be wrong.

Just to summarize here. The data from Japan are robust, the researchers free from commercial bias. We are not looking at poor quality research, nor are we looking at a paradox, it is a pure black swan. Yes, of course, the researchers tried to find something, anything, that could explain away this finding. They looked at salt intake. Ooops, the Japanese have way higher salt intake than every other country they looked at. Sorry, ignore.

They did find that the Japanese ate more fish than in most other countries and that, my friends, was that. In fact, even they didn’t believe that this provided any explanation. For we are left with this statement at the end of the discussion section:

The lower CHD mortality in Japan compared with the USA is very unlikely to be due to the difference in trends in other CHD risk factors, cohort effects, misclassification of causes of death, competing risk with other diseases or genetics. The observation may suggest some protective factors unique to Japanese which merit further research.’

I shall give you a different conclusion from this study. One that actually fits the facts that these researchers round.

‘A raised cholesterol level is not a cause of CHD/CVD. ‘

There you are, nice and simple. There is no need for the creation of unknown and undiscovered ‘unique’ protective factors. It just fits. And when a hypothesis fits all the facts, without the need for any fancy adaptations, you know that it is right. That, my friends, is called science.


1:  Continuous decline in mortality from coronary heart disease in Japan despite a continuous and marked rise in total cholesterol: Japanese experience after the Seven Countries Study’ International Journal of Epidemiology, 2015, 1614–1624 due: 10.1093/ije/dyv143

2:   Ueshima H, Sekikawa A, Miura K et al. Cardiovascular disease and risk factors in Asia: a selected review. Circulation 2008;118:2702–09.

Four legs better

I spend far too much of my life reading about heart disease and heart disease research and suchlike. As a consequence of this I also consider myself something a ‘Kremlin watcher’. I am always on the lookout for the subtle, carefully crafted and coded messages that are allowed to escape into the outside world from the inner enclaves of power in the medical establishment.

Once something interesting appears, I then try to work out what game is afoot. What you have to recognise is that even the most apparently innocent announcement is crammed with hidden meaning:

Statement:                   ‘Comrade Yushkin has been promoted to the Department of Internal Affairs.’

Interpretation:              ‘Comrade Yushkin has made too many enemies and he has been stabbed in the back by those he thought were friends and kicked out of the Politburo. He is now going to languish in a backwater for the rest of his miserable, pointless, political career. So, for those who thought Yushkin was a rising star…tough.’

Try this one for size:

‘Some prominent cardiologists have questioned the 2013 guidelines, but the ACC and AHA have shown little appetite to return to LDL targets. “LDL may or may not correlate to cardiovascular outcomes,” Dr. Kim Allan Williams, president of the ACC, told Reuters last week1.’

This little nugget was part of a news story about the dreaded PCSK-9 inhibitors, carried by the Reuters news agency. These are blockbuster cholesterol lowering drugs that are descending upon humanity.

However, that is a side issue for the moment. I think we need to return to the comment. ‘LDL may or may not correlate to cardiovascular outcomes.’ Nine little words that you could pass over without really noticing they were there. I would, however, suggest you paid them a little more heed.

The American College of Cardiology (ACC) is at the very epicentre of conventional thinking about heart disease. Now the president…. Kim Williams, el Presidenté himself, has made this statement. “LDL may or may not correlate to cardiovascular outcomes,”

You may think, oh well, little slip of the tongue, nothing to see here, move along. Oh no, absolutely not. Whilst I would be amongst the first to criticise and castigate the ‘experts’ in charge of cardiovascular disease research. There is one thing I would never accuse them of, and that is of being careless.

There is no way on earth that this comment would have been made by mistake. It would have been thought about very carefully indeed. Equally, if Kim Allan Williams had thought he was being quoted in error, he would have asked the journalist to obliterate that statement. Before any interview he would almost certainly demand editorial control over copy. I know I always do.

So, what are we looking at here? I believe that what we are looking at here, ladies and gentlemen, is a major repositioning manoeuvre. For year after year we have been told that a raised LDL is the most important causal risk factor for heart disease.

However, when the latest ACC/AHA (American Heart Association) guidelines came out in 2013 there were no longer any targets for LDL lowering. If someone was at high risk for cardiovascular disease suddenly, lo and behold, you just gave a high dose statin. You did not need to measure what happened to the LDL level, you just prescribed the statin and that was that.

In one way this changed nothing at all, in another way it changed everything. What we had here was an admission, though no-one will admit it, that statins reduce the risk of cardiovascular disease through mechanisms other than LDL lowering. This was shortly followed by the AHA admitting that cholesterol in the diet has nothing to do with raising cholesterol and/or causing heart disease.

More recently several papers have come out clearly demonstrating that saturated fat in the diet has nothing to do with cardiovascular disease. In case you missed it, this paper was in the BMJ last week….

‘Russell J. De Souza, ScD, RD, from McMaster University, Hamilton, Ontario, Canada, and colleagues published their synthesis of observational evidence online August 11 in the BMJ.

Consumption of saturated fats is not associated with all-cause mortality, cardiovascular disease, coronary heart disease (CHD), ischemic stroke, or diabetes2.’

Now the president of the ACC is telling us that LDL may or may not correlate to cardiovascular outcomes. You would have to say that the diet-heart/cholesterol hypothesis is beginning to look a little threadbare right now. One might even say it is dead. However, like the biggest, stupidest dinosaurs, it will stumble about crushing people underfoot for several years before it finally crashes to the ground.

When it does, finally, expire we will have found something very interesting has happened. The ‘experts’ who ruthlessly promoted the diet/heart cholesterol hypothesis a.k.a ‘absolute bollocks’ for the last ‘few decades will have moved their position completely. They will no longer be coaching us all to chant ‘four legs good, two legs bad’. We shall have a new slogan:

‘Four legs good, two legs better.’

Those in power will remain in power. Thus endeth today’s lesson.




Hats off to the Japanese

(Raised cholesterol is good for you)

For many years I have told anyone who will listen that, if you have a high cholesterol level, you will live longer. Equally, if you have a low cholesterol level, you will die younger. This, ladies and gentlemen, is a fact. The older you become the more beneficial it is to have a high cholesterol level.

This fact has become more difficult to demonstrate recently as so many people have been put on statins that the association between cholesterol levels and mortality has been twisted, bent and pumelled into the weirdest shapes imaginable. However, Japan, provides some very interesting data. Japan has always had a very low rate of heart disease, an enviable life expectancy, and… generally low cholesterol levels. Aha!, surely this means that low cholesterol levels are good for you? Well….

Well, here is the introduction to a one hundred and sixteen page review of the cholesterol hypothesis published in the Annals of Nutrition and Metabolism. It was published on April 30th 2015. I have just finished reading it for the first time. I thought I would share the Introduction, in full:

High cholesterol levels are recognized as a major cause of atherosclerosis. However, for more than half a century some have challenged this notion. But which side is correct, and why can’t we come to a definitive conclusion after all this time and with more and more scientific data available? We believe the answer is very simple: for the side defending this so-called cholesterol theory, the amount of money at stake is too much to lose the fight.

The issue of cholesterol is one of the biggest issues in medicine where the law of economy governs. Moreover, advocates of the theory take the notion to be a simple, irrefutable ‘fact’ and self-explanatory. They may well think that those who argue against the cholesterol theory—actually, the cholesterol ‘hypothesis’— are mere eccentrics.

We, as those on the side opposing the hypothesis, understand their argument very well. Indeed, the first author of this supplementary issue (TH) had been a very strong believer and advocate of the cholesterol hypothesis up until a couple of years after the Scandinavian Simvastatin Survival Study (4S) reported the benefits of statin therapy in The Lancet in 1994. To be honest with the readers, he used to persuade people with high cholesterol levels to take statins. He even gave a talk or two to general physicians promoting the benefits of statins. Terrible, unforgivable mistakes given what we came to know and clearly know now.

In this supplementary issue, we explore the background to the cholesterol hypothesis utilizing data obtained mainly from Japan—the country where anti-cholesterol theory campaigns can be conducted more easily than in any other countries. But why is this? Is it because the Japanese researchers defending the hypothesis receive less support from pharmaceutical companies than researchers overseas do? Not at all. Because Japanese researchers are indolent and weak? No, of course not. Because the Japanese public is skeptical about the benefits of medical therapy? No, they generally accept everything physicians say; unfortunately, this is also complicated by the fact that physicians don’t have enough time to study the cholesterol issue by themselves, leaving them simply to accept the information provided by the pharmaceutical industry.

Reading through this supplementary issue, it will become clear why Japan can be the starting point for the anti-cholesterol theory campaign. The relationship between all-cause mortality and serum cholesterol levels in Japan is a very interesting one: mortality actually goes down with higher total or low density lipoprotein (LDL) cholesterol levels, as reported by most Japanese epidemiological studies of the general population. This relationship cannot be observed as easily in other countries, except in elderly populations where the same relationship exists worldwide.

The mortality from coronary heart disease in Japan has accounted for around just 7% of all cause mortality for decades; a much lower rate than seen in Western countries. The theory that the lower the cholesterol levels are, the better is completely wrong in the case of Japan—in fact, the exact opposite is true. Because Japan is unique in terms of cholesterol-related phenomena, it is easy to find flaws in the cholesterol hypothesis.

Based on data from Japan, we propose a new direction in the use of cholesterol medications for global health promotion; namely, recognizing that cholesterol is a negative risk factor for all-cause mortality and re-examining our use of cholesterol medications accordingly. This, we believe, marks the starting point of a paradigm shift in not only how we understand the role cholesterol plays in health, but also how we provide cholesterol treatment.

The guidelines for cholesterol are thus another area of great importance. Indeed, the major portion of this supplementary issue (from Chapter 4 onward) is given over to our detailed examination and critique of guidelines published by the Japan Atherosclerosis Society. We dedicate a large portion of this work to these guidelines because they are generally held in high regard in Japan, and the country’s public health administration mechanism complies with them without question. Physicians, too, tend to simply obey the guidelines; their workloads often don’t allow them to explore the issue rigorously enough to learn the background truth and they are afraid of litigation if they don’t follow the guidelines in daily practice.

These chapters clearly describe some of the flaws in the guidelines—flaws which are so serious that it becomes clear that times must change and the guidelines must be updated. Our purpose in writing this supplementary issue is to help everyone understand the issue of cholesterol better than before, and we hope that we lay out the case for why a paradigm shift in cholesterol treatment is needed, and sooner rather than later. We would like to stress in closing that we have received no funding in support of writing or publishing this supplementary issue and our conflicts of interest statements are given in full at the end.

Here is the introduction to the chapter on cholesterol and mortality:

All-cause mortality is the most appropriate outcome to use when investigating risk factors for life threatening disease. Section 1 discusses all-cause mortality according to cholesterol levels, as determined by large epidemiological studies in Japan. Overall, an inverse trend is found between all-cause mortality and total (or low density lipoprotein [LDL]) cholesterol levels: mortality is highest in the lowest cholesterol group without exception. If limited to elderly people, this trend is universal. As discussed in Section 2, elderly people with the highest cholesterol levels have the highest survival rates irrespective of where they live in the world.

I don’t think that I really need to say anything else, other than to repeat this fact. If you have a high cholesterol (LDL) level, you will live longer. This is especially true of the elderly.

Ann Nutr Metab 2015;66(suppl 4):1–116 DOI: 10.1159/000381654