Heart Health, Part Two:Your Questions Answered Q & A with David Funt, MD
Updated: Nov 14, 2019
Dr. David Funt has been practicing cardiology for more than 30 years in Boca Raton, Florida. As a board-certified physician in both internal medicine and cardiology, his interests include clinical, general and preventive cardiology. Although the average age of his patients is 65 years old, they range in age from 25-100. He graciously allowed me to interview him concerning heart health.
This post continues the Heart Health discussion begun last week in our Q & A with David Funt, in honor of Heart Health Month.
Can you explain a bit about cholesterol, age and how you assess cardiovascular risk? One of the most important factors in terms of risk for heart disease is age. A 65-year-old with the same blood pressure, same cholesterol and same weight as a 45-year-old will have five to six times the risk of a heart problem in the next 10 years. We are more aggressive in treating cholesterol and elevated blood pressure as people get older.
Another essential factor in cardiovascular risk assessment is cholesterol.
The lower the HDL, the higher the risk.
The higher the LDL, the higher the risk.
In addition to all that we have discussed so far, I spend a lot of time deciding who should go on a cholesterol-lowering medication called a statin.
Assessing risk I use the CV risk calculator to estimate the risk of a CV event in the next 10 years. Based on this risk evaluation, I can determine how aggressive I should be in treating a patient's various risk factors (blood pressure, cholesterol, etc.). Often, I will study a blood test called CRP-hs (C-reactive protein-high sensitivity; it is a general measure of inflammation in the body). If a patient is borderline on the CV risk calculator, the CRP-hs helps me to determine whether I will treat with a statin. I need to be certain there is no other inflammation present in the body, such as an active infection and/or gum disease (the CRP-hs will be elevated if there is inflammation present). I will repeat the CRP-hs again a few weeks later to see if there has been any change in this inflammatory marker. In addition to the CV risk calculator, I may order a coronary calcium score (ccs). These are also sometimes called heart scans. This radiological study—a low-dose radiation cat scan—helps me sort out someone’s risk of a CV event by looking at the amount of calcium in a patient’s coronary arteries. It is a surrogate marker for the amount of plaque that might be present, which signifies a future risk of cardiac disease. The more calcium present, the more plaque present and the higher the risk of a CV event. Heart scans can only be ordered on patients who haven't started statins, as they alter the calcium composition in the arteries and invalidate the test's findings.
Are there any noninvasive studies that you recommend?
EKG. I recommend that everyone have a baseline EKG, which can be used for future comparison, if needed. The EKG is a good indicator for unusual disease if it is abnormal. I don’t do yearly EKGs or on any schedule unless there is a reason.
Echocardiogram (AKA an echo, or ultrasound of the heart). Often performed on a patient’s first visit, it gives a lot of information in terms of the patient’s heart valves, ventricular wall thickness, ventricular function and overall heart function. It also becomes a baseline for future comparison. Echos allow us to evaluate patients with heart murmurs, a history of fainting, palpitations and known cardiomyopathies.
Stress echocardiograms. This is a good diagnostic test that provides immediate results. It involves no ionizing radiation exposure, no need for an intravenous catheter, it is inexpensive, performed in the office, and it is especially helpful with patients who have experienced chest pain. The test determines how well the heart tolerates activity. Patients who have a stress echocardiogram first have an echocardiogram, an EKG and their blood pressure evaluated prior to exercise. Then they start exercising and gradually increase the intensity until the patient is exhausted. Then, the echocardiogram is performed again. The two studies are compared to one another and an assessment of wall motion is made. If the patient is unable to complete the exercise, we order a pharmacologic nuclear stress test instead.
If there is a strong family history of heart disease, what general surveillance do you do and what recommendations do you make?
Most importantly I look closely at their lipid/cholesterol levels. With a strong family history, I have a lower threshold for prescribing a statin medication. I may order a coronary calcium score to help with the decision of instituting a statin.I pay careful attention to blood pressure. If it is elevated, I treat it aggressively.I stress the importance of a well-balanced diet (this is even more essential for people with a family history) and exercise.
Are there any genetic tests that you recommend? No. As of now, there are no genetic tests available that will determine increased cardiac risk. I only recommend genetic testing if a patient has a history of prolonged QT syndrome or hypertrophic cardiomyopathy because these conditions pose an increased risk of inheritance for their family members.
Do you recommend any supplements?
Aspirin (81 mg)–If the risk calculator indicates a 10% or greater risk of a CV event in 10 years, I recommend an aspirin/day. Also, anyone with established vascular disease (transient ischemic attacks, peripheral vascular disease or any vascular disease from head to toe) should be taking an aspirin daily. However, I instruct my patients not to use aspirin if they have a history of bleeding because aspirin increases the risk of hemorrhage.
Omega-3 fatty acids–I would prefer that people eat fatty fish 2-3x/week (salmon, mackerel, anchovies, sardines, herring) rather than take a supplement, however, in patients with high triglycerides, I recommend Omega-3 supplementation (2 grams/day).
Vitamin D–I do not recommend it for cardiac health, but it may be helpful for general overall health. I will check a patient’s vitamin D levels, and if they are low, then I recommend supplementation (usually 2000 IU/day).
B vitamins–I will check the B12 level, especially if patients have dementia and/or neuropathy and anemia. I am not necessarily checking B12 for heart issues. I recommend supplementation if their levels are less than 400ng/L. If a patient has a high homocysteine level, then I will check both folate and vitamin B12 levels. (If patients drink a lot of alcohol or are on Dilantin, I will often recommend a folic acid supplement.)
Multivitamin–I do not recommend these unless the patient shows signs of being malnourished or cachectic.
ASCVD Risk Estimator Plus, American College of Cardiology: http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
"Cholesterol Guidelines: What's New?" Berkeley Wellness Letter: http://bit.ly/2USf43I
"The Aspirin-a-Day Quandary. Do the Benefits Outweigh the Risks?" Berkeley Wellness Letter: http://bit.ly/2TDuZCA
"The Truth about Four Popular Heart Health Supplements," Johns Hopkins Medicine: http://bit.ly/2GwOmJT
"Vitamin B12 Assay, Serum," Mayo Clinic: www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/9154
David Funt, MD
Dr. David Funt received his undergraduate degree from Emory University, where he was a member of Phi Beta Kappa. He graduated from the NYU School of Medicine and completed his internship and residency in Internal Medicine at the University of Miami-Jackson Memorial Hospital. He then completed his Cardiology Fellowship at Boston University and Boston City Hospital. David is on staff at West Boca Medical Center and Delray Medical Center. He has been Chief of Medicine at West Boca Medical Center and has served on the Board of Governors. David volunteers his time at the Caridad Center for migrant workers. He was born and raised in Long Island, New York. He is married and has three sons. David Funt Davef1027@gmail.com
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