Personalized Medicine

“Tim Russert’s death from a heart attack at age 58 is a stark reminder of our vulnerability to the ravages of cardiovascular disease even in the face of major advances in understanding its causes and how to prevent its consequences. Some 300,000 Americans die of sudden cardiac arrest outside the hospital each year. Russert was one of those who at least was aware that he was at risk.

Russert’s doctor Michael Newman said the tough-questioning but congenial host of NBC’s “Meet the Press” had been under treatment for asymptomatic coronary disease. He was carrying excess weight, Newman observed, but he got regular exercise and he performed well on an exercise stress test in April.

None of that prevented a cholesterol-laden plaque from rupturing on Friday morning. The resulting clot, an autopsy indicated, apparently caused his heart to go into ventricular fibrillation which led to cardiac arrest. The autopsy also showed he had an enlarged heart–a manifestation of coronary disease.”

Wall Street Journal Health Blog

June 13, 2008

Coronary artery disease can take one or both of two forms:

1) Hard plaque – years of calcium plaque build-up in blood vessels cause artery blockage, preventing flow of blood. It is gradual and can be measured with a CT Calcium Score.

2) Soft plaque – non-calcified, the plaque erodes the walls of blood vessels and causes rupturing, suddenly preventing flow of blood. A stress test is completely unhelpful in detecting the risk. A CT Angiogram will detect soft plaque and allow the physician to visualize overall plaque load and its locations.

Tim Russert most likely died as a result of a ruptured aneurysm in an artery containing soft plaque build-up.

Mr. Russert’s personal physician spoke on CNN of his having completed a stress test and being on cholesterol-reducing drugs. Neither (of these traditional measures) was adequate to detect and reduce his risk.

Indeed, to quote two eminent cardiologists:

Sidney Smith … at University of North Carolina Charlotte and past president of the American Heart Association: “Russert’s death underscores a major shortcoming in cardiac prevention: protecting people at immediate risk of a heart attack.”

Prediman K. Shah, director of cardiology at Cedars-Sinai Heart Institute, Los Angeles: “It was a classic episode, the way 80% of cases of sudden cardiac arrest occur.” He wasn’t impressed with the report of Russert’s recent successful treadmill test. Even if a test is normal, “You can still have plaque and be at risk,” he tells us. It wasn’t clear whether Russert had been taking a cholesterol-lowering statin, but even if his LDL, or bad cholesterol, was under control, that wouldn’t assure protection against a heart attack. “Statins do stabilize plaque (and thus reduce chances of rupture), but they haven’t eliminated every heart attack or sudden death,” Shah says. “We have to look for other means.”

Unfortunately, what happened here is common in the medical community. The approach ostensibly is to seek “cost effective” methods in managing patients and to stay within the “standard (‘traditional’) protocol”. Unfortunately, these are inadequate.

What’s even more concerning is that his physician knew he had high cholesterol “controlled” with a drug, was overweight but “working out”, and lived a highly stressful work life … all the more reason to take extra precautions.

What should we learn from this tragic story? Inflammation is at the root of cellular damage and plaque formation in the first place. We need to do all we can to prevent inflammation.

What contributes to inflammation? Stress, lack of exercise, poor diet, inadequate sleep and infections that lead to:

· High blood sugar

· Inflammatory protein in the blood

· Presence of the enzyme lipid peroxidise that erodes vessel wall

· Existing plaque burden

How do you prevent or reduce inflammation and repair the damage done?

· Natural anti-inflammatories – Omega 3 fatty acids

· Anti-oxidant factors – CoQ10 (dosage of which must be increased when accompanied by statin drugs) and Vitamin E

· Repair agents – amino acids such as arginine, glutathione, carnitine

What should you have tested?

· Insulin level and insulin resistance

· Inflammation markers (C-reactive protein, aracidonic acid, homocysteine)

· Lipid peroxidase

· CT Calcium Scoring & CT Angiography

· Genetic factors affecting inflammation, elevated cholesterol, plaque formation and spontaneous clotting tendencies.

· Pharmacogenetics – effective metabolism of medications

Genetic testing is also valuable in determining appropriate use of potent prescription medications.

Unfortunately, the world has to lose an amazing talent at a young age in order to show the sharp contrast – between traditional “disease care” and true “healthcare” made possible by science that has existed for a few years already.  Managing his risks in the “traditional” manner killed him. Russert’s heart attack was predictable and, quite possibly, preventable.

Elaine Chin, MD

Chief Medical Officer