The rewarding feeling that I receive from the practice of vascular surgery is tremendous. The field is quite challenging but the rapid evolution in technology allows us to treat a greater percentage of disease in a minimally invasive fashion.

Still, my research focus is squarely on increasing awareness of cardiovascular disease with an emphasis on educating children, adolescents and adults about the lifestyle changes that we can make that would make cardiovascular disease an uncommon event.

Cardiovascular disease (including stroke and heart attack) is the number one cause of death among Americans. Greater than combined death from all cancers. But we are not born with CVD. Poor dietary behaviors, lifestyle choices like smoking, increased stress and a sendentary lifestyle all contribute to our high incidence of CVD.

For those individuals with "bad genes", new highly sensitive genetic testing and cholesterol fractionation can help doctors determine which patients are at highest risk for disease formation. In these patients, prompt alterations in diet and aggressive cholesterol treatment can decrease the risk of stroke and heart attack

My new book, Your Guide To Optimal Health: Creating Your Personal Wellness Wheel, presents an eight step program focused on dimishing the risk of developing chronic diseases such as hypertension, diabetes, cardiovascular disease and obesity. For people with chronic disease, the program can make the management of these diseases easier by decreasing or eliminating medication dosages

For people who have no obvious illness and are striving to prevent these diseases by living a life of wellness, "Your Guide To Optimal Health" program provides a strategy for achieving this lofty goal. Visit www.personalwellneswheel. to learn more about the program and how to order your book

I encourage everyone to make sure that you observe PAD awareness Month by encouraging those around you over the age of 50 to have their ABI (Ankle Brachial Index) checked. The Ankle Brachial Index is a comparison of the blood pressure at the ankle to the blood pressure at the elbow. Its very simple and anyone that is capable of measuring a regular blood pressure can perform the test, it does not necessarily require a medical professional. Lets do a sample calculation:

Mrs Smith has an ankle blood pressure of 60/20. Her brachial (elbow) pressure measures 120/80.
60 divided by 120 = .50 . Mrs Smith's ABI is .50. The Normal ABI is>1.0, mild decrease .9-.75, moderate decrease .74-.50, severe decrease <.49

At least one in fifteen people over the age of 55 have PAD which can lead to stroke, limb loss and heart attack.
Importantly more than have the people that are affected have no symptoms for various reasons including the presence of diabetes and limited activity.

Early diagnosis can permit effective treatment.

For more information, visit www.beatpad.org

My non profit organization The PAD Coalition (www.beatpad.org) kicked off the season with a visit to a local church recently. After several years of campaigning to increase public awareness about Cardiovascular disease, I am always surprised at the number of people who have a poor understanding of the process. As a healthcare system, we clearly do a very poor job of educating people about identifying the symptoms of disease. We are stuck in a "Medical Treatment Model" instead of a disease prevention model

Peripheral Arterial Disease or PAD is a subset of Cardiovascular disease. PAD is the term for blockages that occur outside of the  heart including the blood vessels of the neck (carotid) responsible for strokes; the blood vessels of the legs that are responsible for pain with ambulation (claudication) , gangrene and amputations; the blood vessels of the kidneys responsible for hypertension and kidney failure just to name a few

Of these groups, the legs are by far the most easily diagnosed by patient's complaints, physician examination and very easily performed tests like the ABI (Ankle Brachial Index). This is important for several reasons. One, if we identify developing blood vessel blockages in the legs, we can become more aggressive in treating the medical factors of blood pressure, lipids and diabetes as well as smoking cessation. If these fail to improve the symptoms, then many procedures are available to improve the situation

More importantly, if a patient has abnormal circulation in the arteries of the legs, there is an 80% chance that they will have significant blockages in the blood vessels of the heart. By identifying this process by a patient complaints of pain in the legs with ambulation or more sever symptoms of ulceration; we are alerted to be very aggressive in treating the identical risk factors for heart disease. If patients and primary care doctors were aware of this very simple premise and applied it every day, we would make a significant impact on the prevention, identification and treatment of heart disease.

The problem is that although vascular specialists are familiar with this 5-10 minute evaluation,  the familiarity of non specialist is much less. That's why it is just as important to improve awareness among PCP's, nurses, NP's as it is for patients. In fact, if one can measure their blood pressure, you can measure your ABI

photo source www.cardiovascularsystemsinc.com

There are always a lot of questions about the "art" or treating cholesterol. It's a good time to refresh everyone's minds about some common guidelines. Remember that they are just that...Guidelines. Discuss the options with your physician. Most of all, remember that a health lifestyle specifically a low fat diet can reverse many of these issues.

What can cause high cholesterol?

Elevated cholesterol levels can be caused by several factors, including heredity, poor diet, obesity, sedentary lifestyle, age, and gender (premenopausal women have lower cholesterol levels than men.) Of these causative factors, only heredity, age and gender cannot be controlled.

"Secondary" elevation of cholesterol

Some people have elevated cholesterol levels as a result of specific medical conditions, including diabetes, hypothyroidism (low thyroid,) obstructive liver disease, chronic renal (kidney) failure, and drugs (anabolic steroids, progesterone drugs, and corticosteroids.) In these patients, treating the underlying disorder often improves cholesterol levels.

Who needs to be treated for elevated cholesterol?

Deciding when to treat can be based on two factors: lipid levels (total cholesterol, LDL, and HDL,) and the presence of additional risk factors, as follows.

Desirable lipid levels:
Total cholesterol: Desirable levels are below 200 mg/dL. Total cholesterol is considered "borderline high risk" at levels between 200 and 239, and "high risk" at levels above 240. LDL cholesterol: Optimal LDL levels are less than 100 mg/dL. Near optimal levels are between 100 and 129 mg/dL. Levels between 130 and 159 are considered "borderline high risk;" and levels between 160 and 189 are considered "high-risk;" and levels of 190 and above are considered "very high risk." HDL cholesterol: HDL cholesterol levels below 41 mg/dL are considered too low.

Additional risk factors that modify cholesterol goals:
cigarette smoking
diabetes
hypertension (high blood pressure)
low HDL cholesterol
family history of premature heart disease
age greater than 45 in men, or greater than 55 in women
10-year risk of heart attack greater than 20% The 10-year risk is calculated from a formula that takes into account the individual's the lipid levels and other risk factors. Click here for the NIH's on-line version of the 10-year risk calculator.

Based on these two items (i.e., lipid levels and presence of additional risk factors) treatment is recommended as follows:
For those with 0 - 1 risk factors:LDL target: 160 or lower. Lifestyle changes should be initiated for LDL > 159, and ************** for LDL > 189.
For those with 2 or more risk factors:LDL target: 130 or lower. Lifestyle changes should be initiated for LDL > 129, and ************** for LDL > 159.

If heart disease is present or 10-year risk > 20%, or diabetes is present:LDL target: 100 or lower. Lifestyle changes should be initiated for LDL > 100, and ************** for LDL > 129.


What about treatment for high triglycerides?
The latest guidelines for the first time, recommend treating patients who have elevated triglyceride levels. This recommendation is based on recent analyses strongly suggesting that triglycerides are indeed an independent risk factor for coronary artery disease. The decision to treat is generally based on the triglyceride levels themselves. Normal triglyceride levels are less than 150 mg/dL. Borderline high levels are 150-199 mg/dl. High levels are 200 - 499 mg/dL, and very high triglyceride levels are greater than 500 mg/dL.  For people with borderline or high triglyceride levels, treatment should emphasize weight reduction and exercise. Drugs are recommended for people with very high triglyceride levels. Most people who need treatment for high triglyceride levels have metabolic syndrome X.

What other "special circumstances" deserve attention?
Patients with very high LDL cholesterol levels (greater than 189 mg/dL): These patients often have a genetic form of lipid disorder. Not only do they have a high risk of premature heart disease without aggressive therapy, but also their family members should be screened for elevated cholesterol levels, and those with high cholesterol levels also need to be treated. Patients with low HDL cholesterol levels (less than 40 mg/dL):  The latest guidelines recognize low HDL levels as a strong independent risk factor for coronary artery disease. Many of patients with low HDL will have diabetes or "metabolic syndrome x." They are often overweight and physically inactive. Other causes of low HDL levels are smoking, very high carbohydrate diets (greater than 60% of calories), and drugs (anabolic steroids, progesterone, and beta blockers). Unfortunately, current drug therapy usually does not markedly increase HDL levels. Treatment for patients with low HDL levels is usually aimed at weight reduction, smoking cessation, exercise, and controlling other risk factors (such as hypertension, LDL cholesterol, and triglycerides.)