Urgent Action Needed: Coronary Heart Disease in the Shadows of Arrhythmias

Coronary artery disease (CAD) and arrhythmias, such as atrial fibrillation, are significant health issues. In the U.S., heart disease accounted for about 702,880 deaths in 2022, which translates to one death every 33 seconds from cardiovascular disease. This makes it the leading cause of death in the country. Heart arrhythmias and CAD often coexist, presenting a complex challenge in cardiology due to their shared risk factors. The prevalence of coronary disease in patients presenting with a primary rhythm problem is high.

Diagnostic Tools for CAD

Diagnosing CAD is crucial when dealing with arrhythmias. Coronary Artery Calcium (CAC) and CT Angiogram (CTA) scanning is simple, inexpensive, and an excellent way to start the process. When patients present with arrhythmia, diagnosing underlying coronary artery disease becomes crucial. Direct imaging tests like CAC scanning offer a simple, cost-effective initial assessment. For more detailed analysis, technologies like CTA with AI-driven software such as ‘Cleerly’ provide hard and soft insights into plaque morphology.

Evidence-Based Medicine (EBM)

The critique on EBM often focuses on singular biomarkers like LDL cholesterol for risk reduction, which certainly overlooks broader health aspects. For example, ignoring insulin resistance can lead to incomplete treatment plans for CAD and arrhythmias. The most accepted approach to lowering CV risk is decreasing LDL cholesterol to as low as possible. This is all good, but we are missing a big part of the problem by focusing solely on EBM. There’s a growing debate about the reliance on guidelines and evidence-based medicine, especially when they might overlook holistic health aspects and anecdotal cases. For instance, ignoring insulin resistance in favor of more traditional metrics can lead to incomplete treatment plans.

I’ve written quite a bit about EBM in previous Substack articles -

Insulin Resistance and Heart Health

Research has clearly linked Insulin Resistance with Heart Disease. Insulin resistance is relevant to both CAD and arrhythmias. Insulin resistance plays a pivotal role in heart health and is often underestimated in slender individuals with arrhythmias. The concept of ‘skinny fat,’ where subcutaneous fat is minimal but visceral fat accumulation is high, highlights why conventional assessments miss these individuals.

External appearance doesn’t tell anything about this particular kind of insulin resistance. This is new epidemic, the so-called “skinny fat,” is a condition where a person appears to be of normal weight or even underweight, but has a high percentage of body fat and a low percentage of muscle mass. We don’t have great tools for diagnosing ectopic fat except through MRI, and even that’s like looking at shadows and guessing what’s there. Most healthcare professionals assume that such a person is healthy. The problem with guidelines and these glucose-centric metrics is that you will miss insulin resistance in these individuals. Most healthcare professionals seldom check fasting insulin levels.

The Heart’s Electrical System

The heart's electrical system is like its own internal pacemaker, allowing it to beat in a coordinated rhythm. It starts with the sinoatrial (SA) node, located in the right atrium, which acts as the natural pacemaker by sending out electrical impulses that initiate each heartbeat. These signals spread across the atria, causing them to contract and push blood into the ventricles. The electrical impulse then travels to the atrioventricular (AV) node, which delays the signal slightly to ensure the ventricles fill with blood. From there, the signal is passed through the bundle of His and Purkinje fibers, which distribute the electrical impulse throughout the ventricular muscle, leading to their contraction and the pumping of blood out of the heart. This precise, timed electrical activity ensures the heart pumps blood efficiently throughout the body thousands of times each day.

The essence of medicine is to evolve and develop new theories. Our task is to identify a problem; in this case, the problem lies in our inadequate treatment of heart disease. Our goal is to devise innovative solutions to solve this problem. For instance, the idea that fat around the heart affects the electrical system that governs our heartbeats is intriguing. If this is the case, insulin resistance, fatty liver disease, and diabetes become far more critical. Future imaging modalities might focus on detailing the amount of fat around the heart and how it might affect our heartbeats.

Emphasizing the Need for Holistic Approaches

If you don’t fix this root cause, you’ll be back in a couple of years, so the goal has to be to adopt a preventative mindset to help with progression, along with any therapy that modern medicine still might be able to deliver.

In the case of heart disease, one thing is clear: improving insulin resistance is the key. It just makes perfect sense. We have demonstrated this biological and biochemical chemistry problem, and let’s see if fixing that problem will cure heart disease.

We need to get back to the concept of the terrain, where we try to do things to heal the internal environment, Which is what modern medicine is missing. I talk about the terrain in my book Stopping Pain.

Healing is done by Moving Energy

Albert Szent Gyorgyi, the famous Hungarian physiologist who discovered vitamin C, once said that in every culture before ours, healing was done through the movement of energy. This is the medicine we need to start thinking about holistically and broadly. It’s about homeostasis and creating the conditions for healing. In many traditional cultures, health was viewed as a balance of energy within the body. The concept of 'movement of energy' in healing refers to the balance and flow of vital energy within the body, a key principle in many traditional healing practices.

Modern medicine might benefit from revisiting the concept of the terrain, focusing on the body’s internal environment. healing, as traditionally understood, involves restoring homeostasis, not just symptom management.”

Debate on RCTs

Nick Noritz’s salient quote, “absence of evidence is not evidence of absence,’ underscores this debate.”

While critics argue for RCTs to validate the impact of managing insulin resistance on heart disease outcomes, proponents counter that fundamental physiological corrections should inherently improve health. Critics will respond that there is no data that measuring insulin resistance has any favorable impact on outcomes and that outcomes are greater than anecdotes. We must have RCTs to examine the outcomes of fixing insulin resistance and its effect on heart disease.

The broader approach to healing connects back to the earlier points on traditional medicine’s shortcomings. You can certainly go back to the 1970s, and there are no randomized controlled trials manipulating LDL cholesterol showing it has any effect on heart disease. We can also argue about the subsequent trials that were conducted. We don’t need an RCT to know that fixing broken biology or physiology will have a favorable impact on outcomes. You have broken physiology because your cells are dysfunctional, and these cells cause disease.

We don’t need an RCT to know that fixing broken biology or physiology is going to have a favorable impact on outcomes. You have broken physiology because your cells are dysfunctional, and these cells cause disease. We don’t need an RCT for that. We’re never going to RCT because you know parachutes are good when you’re jumping out of airplanes.

Dietary Interventions

We need to tie this back to real-world implications and patient care. When discussing dietary interventions, we’ve genuinely yet to see a patient harmed. For example, if they use a low-carb diet to improve their insulin resistance. It doesn’t work for some patients, and for others, they can’t adhere. What should be guiding us is that there’s a problem. There’s a mechanism for the problem that has been identified, and we have ways of addressing that mechanism. Trying to change the problem through diet doesn’t appear to have any harm associated with it. So why not give it a try?

Dietary interventions, particularly those aimed at reducing insulin resistance, like low-carb diets, show promise. While not universally applicable due to adherence issues, these approaches represent a low-risk strategy potentially beneficial in managing heart health.”

Conclusion: Future Directions and Closing Thoughts

The potential research and clinical applications around the interaction between fat accumulation, particularly around the heart, and its effect on cardiac nerve function suggest that metabolic health should be at the forefront of heart disease management. Future research should explore these connections to refining treatment strategies and potentially integrating dietary and lifestyle changes with traditional medical interventions.

References

Stary Off My Operating Table – Heath Rhythm Problems? Your Insulin Levels May Be the Key – Dr. Phillip Ovadia and Dr. Ryan Cooley