Tag Archives: HDL

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.

However…

‘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

References:
1: http://cardiovascres.oxfordjournals.org/content/103/3/362

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

A farewell to statins – part one

In the end I knew that statins would be overthrown. Their time, like the dinosaurs would come to an end.  I also knew it would be nothing to do with me, or any of the other critics. Nor would it have anything to do with the fact that their terrible burden of adverse effects finally came to light.

No, it would be because their patents ran out, which meant that the big pharmaceutical companies could not make eye-watering profits from them anymore. Inevitably, therefore, they would be replaced. Indeed, for years I have watched, with varying degrees of amusement, the unending efforts to unearth the ‘new’ statins. The wonder drugs to be taken by everyone, for the rest of their lives. The ones that will make billions for the pharmaceutical companies, and several millions for the key opinion leaders promoting them.

Steven Nissen had a go with apoA-1 Milano. This is a little story you may want to look up on Wikipedia.  Basically, a small village was found in Italy (near Milan) where people had very low rates of heart disease, and they also had very low levels of HDL ‘good’ cholesterol.

Turning science on its head, it was therefore decreed that their HDL must be especially ‘good’ at preventing heart disease. [Rather than accept that HDL had bugger all to do with heart disease]. So attempts were made to synthesize their form of HDL, then inject it into patients. This was done in small scale clinical studies.

So brilliantly did Nissen sell the results of these studies that a start-up company called Esperion, which funded the trials, was sold to Pfizer for over a billion dollars on the back of the results. If you want to find out more, the HDL synthesized was called ETC-216, not apoA-1 Milano.

This is what Steven Nissen had to say about the trials.

The fact that you can actually pull major amounts of plaque out of the artery in five or six weeks is an epiphany,” Nissen says. H. Bryan Brewer, chief of the molecular disease branch at the National Heart, Blood & Lung Institute, adds: “Quite to everyone’s surprise, this indicates that we might be able to be much more successful in a shorter period of time than we thought possible.”

By golly it all sounds very exciting, does it not.  Pulling significant amounts of plaque out of artery walls, in six weeks! This is quite amazing, what a brilliant drug. In truth, though, that quote was from 2003. Has anything since happened since to this magical plaque munching HDL? Is it now on the market, saving lives? Well, as you ask, the answer is no.

However, several other HDL raising agents have also been developed in the last few years. Unfortunately, they also raised the risk of heart attacks and strokes – then disappeared. Torcetrapib, dalcetrapib, anacetrapib…. A yes, anacetrapib, not quite gone yet.

Anacetrapib has a knock-your-socks-off effect on HDL and a jaw-dropping effect on LDL,” said Chris Cannon in an AHA press release.  He also said “The lipid effects are jaw dropping in both directions,” Yes, indeed, they were.  Although I am not sure that ‘jaw dropping’ and ‘knock your socks-off’ are truly scientific terms.

But then Forbes ran this headline on the 22nd October

Merck Heart Drug Runs Into New Worry.’ 1

As an aside, you can find out far more about drugs in development by reading Forbes magazine than you will ever get from the scientific journals.

Anyway, I wouldn’t bet the house on anacetrapib as I suspect it will soon follow the other ‘trapibs’ into an early grave. But never mind, Lilly has yet another HDL raising agent waiting in the pipeline, evacetrapib. What is it with these unpronounceable names, and why don’t these companies just give up? However, perhaps this one has a better shot than most, because as Steven Nissen said of dalcetrapib…

Dalcetrapib was always a long shot,” said Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic. “The worry all along was that it wouldn’t have enough effect to produce a benefit,”

Then, as he went on to say of evacetrapib

We got everything we could hope for from this drug, and maybe more,” remarked study co-author Steven Nissen, adding that “we are going to move evacetrapib forward as rapidly as possible” into a late-stage trial.” Gosh, he is running a study on evacetrapib too.  He was also lead investigator for Torcetrapib2.

That Steven Nissen, what a busy chap he is?  Wasn’t he the one who said about the new cardiovascular prevention guidelines.  “The evidence was never there” for the LDL targets, he said. Past committees “made them up out of thin air,” he added.  Why yes, I think he was.

Anyway. They have tried raising HDL…fail. They have tried a different way of lowering LDL using ezetimibe. It lowered LDL, and has had absolutely no effect on cardiovascular disease…fail. They have tried combing different HDL raising agents with statins….fail.

You know, you might even begin to think that raising HDL wasn’t that good an idea. Billions have been thrown this target, everything has miserably failed. It is also interesting that LDL lowering agents, other than statins, have failed to have any impact on cardiovascular disease. Has this had any effect on the lipid hypothesis? You must be joking.

Given this litany of disastrous drugs trials, why do I now believe that statins are about to be overthrown? What agents could be out there that are going to sweep them into the dustbin of history.

Clearly it cannot be an agent that lowers LDL even more than statins. Can it? Well, Steven Nissen has recently said the following about LDL lowering. This quote is in connection to new drugs being developed3.

 “….it matters how you lower cholesterol, not just by how much.”

It matters how you lower cholesterol, not just by how much….. Interesting.  Well, if cholesterol does cause heart disease, then it doesn’t really matter how you lower it, does it? The only question is, by how much? Or is Steven Nissen trying to say something else?

As a further aside, if you want to know where the really big bucks are being spent in cardiovascular research, and what is in the pipeline, all you need to do is follow Steven Nissen’s pronouncements. He is the weather vane. You don’t need to be a weather man to know which way the wind is blowing.

…… (to be continued)

 

1: http://www.forbes.com/sites/matthewherper/2013/10/22/merck-heart-drug-runs-into-new-worry/

2: http://online.wsj.com/news/articles/SB10001424052702304363104577389353232022644

3: http://www.forbes.com/sites/johnlamattina/2013/09/05/esperions-novel-approach-to-lowering-cholesterol-will-it-be-successful/

Sweden gets it right

I sometimes think that I should go and live in a Scandinavian country. They get so many things right about how to run healthy, equitable, societies. In addition, the people who live there seem more balanced and, well, frankly, more grown up. So it comes as no surprise to me that if a nation was to turn round and begin the process of rejecting the absolute nonsense that a high fat diet is bad for you, then it would be a country in Scandinavia.

That Scandinavian country is Sweden1.

Now, I have been aware that there has been a movement towards a high fat low carb diet (HFLC) going on in Sweden for some years. This has been led recently by the heroic Dr Annika Dahlqvist, a General Practitioner who had been advising her diabetic patients to eat a low carb high fat diet (LCHF).

She was, of course, attacked by the idiots…sorry experts:

‘In 2007, the controversy began when two dieticians pointed out to Sweden’s National Board of Health and Welfare that LCHF dietary advice recommended to diabetic patients by general practitioner Dr Annika Dahlqvist was not compatible with either scientific evidence or conventional practice. However, following a report by diabetologist Dr Christian Berne, Dahlqvist was cleared.’

Cleared of what, exactly? Advising diabetic patients not to eat sugar. The mere fact that anyone could be dragged in front of the authorities for advising this just shows had completely mad the world of dietary advice has become. How entrenched the idiotic anti-fat dogma now is. How utterly divorced from reality and science.

As I have pointed out many times on this blog, and elsewhere, carbohydrates, at least all the carbohydrates humans can digest, are converted to sugar(s) in the GI system. They must be, because all that carbohydrates consist of are different number of sugar molecules bonded together in different ways. When you break them to bits in the digestive system, they become simple sugars.

As we all know, people with diabetes have problems with high blood sugar levels. So, dum de dum….let me think. Should diabetics eat carbohydrates/sugar, or should they eat fats. Yes, you are right, they should eat fats. This is a complete no brainer.

But, of course, the argument goes that diabetics are more likely to die of cardiovascular disease and eating fat increases cholesterol levels, and this increases your risk of cardiovascular disease. Well, this could obviously be a problem if any part of that causal chain were true. But it is all nonsense. As the latest Swedish report from the SBU (Swedish Council on Health Technology Assessment) makes clear (after reviewing 13,000 studies), a low carb diet leads to the terrible dangers of

‘…a greater increase in HDL cholesterol (“the good cholesterol”) without having any adverse effects on LDL cholesterol (“the bad cholesterol”). This applies to both the moderate low-carbohydrate intake of less than 40 percent of the total energy intake, as well as to the stricter low-carbohydrate diet, where carbohydrate intake is less than 20 percent of the total energy intake. In addition, the stricter low-carbohydrate diet will lead to improved glucose levels for individuals with obesity and diabetes, and to marginally decreased levels of triglycerides.’2

In short, when they looked at all the evidence, they found that low carb/high fat diets raise HDL cholesterol (the so-called ‘good’ cholesterol). They have no effect on LDL levels; they also lower blood sugar levels and triglyceride (VLDL) levels. All good and healthy, and all of which bascially means that insulin resistance has been reduced – the underlying cause of diabetes.

In reality all that the Swedes really ‘discovered’ is the quite astonishing fact that eating a high carbohydrate diet is bad for you, and worse for you if you are a diabetic. Well, blow me down with a feather. They have found exactly what a working knowledge of human biology/physiology would tell you would happen.

But we live in a wold controlled by entrenched stupidity, dogma, and the financial interests of massive companies who are making billions selling tasteless low fat mush. These companies know that the only way you can make low fat food, e.g. low fat yoghurt, taste like anything half palatable is to stuff it with sugar. Cheap, nasty, and damaging to health – also driving the ever increasing weight gain and diabetes in the Western World.

Why is everyone in the Western World becoming obese? Because we are replacing fat with sugar in many foodstuffs. The obesity ‘epidemic’ started at exactly the same time as the idiots, sorry experts, decreed that a healthy diet was a diet full of carbs. Which was, and remains, the exact and complete opposite of the truth.

However, anyone who dares to stand up and state the truth, gets dragged in from of organisations such as the National Board of health and Welfare. Eventually, however, the truth does emerge, as it must. Because the truth never dies. It can be stomped on, squashed, concreted over and napalmed. However, it lives on, taunting those who do everything in their power to deny its existence.

The truth is that all of the dietary advice we have been bombarded with for the last forty years about the dangers of fat consumption has been utterly and completely and damagingly wrong. Of course there will be a backlash against the Swedish report – there always is. Various powerful idiots, sorry experts, will be pushed in front of cameras to make various denunciations of the Swedes and their damaging and dangerous conclusions. The strings of these idiots will be jerked in unison by faceless marketers in companies that promote low fat spreads, and the like. Yes, you know who you are.

And yes, this stuff does make me angry. It is killing people prematurely, millions of people, all around the world.

1: http://coconutoil.com/sweden-becomes-first-western-nation-to-reject-low-fat-diet-dogma-in-favor-of-low-carb-high-fat-nutrition/

2: http://www.dietdoctor.com/swedish-expert-committee-low-carb-diet-effective-weight-loss

P.S:

Question:            ‘What do you call five hundred dieticians lying at the bottom of the ocean?’
Answer:               ‘A good start.’