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Men's Health

Article: "Are You at Risk for Sudden Death?"

The Killer Exposed:

Every man carries deadly forms of cholesterol. A standard test won't tell if you have them.

Back when researchers first discovered the correlation between cholesterol levels and heart disease, many of us thought we'd discovered the root cause of coronary heart problems. We thought that doctors were finally in a position to intervene and save patients from a pernicious and deadly disease. Those on the front line felt on top of the world--or at least on top of the summit they had been scaling for so many years.

The researchers were wrong. How do I know? Because I was one of them. In fact, I participated in one of the original studies to determine the effects of lowering cholesterol on heart-disease risk. Over the course of the study, we met with patients periodically to review their progress. Since that study included only male participants, I was surprised one afternoon to see a woman waiting for me. Her question was simple: "My husband's cholesterol numbers were perfect, and you told him that based on those numbers he was at low risk of heart disease. So why did he drop dead suddenly of a massive heart attack?"

As you can imagine, I was devastated, but at the time I didn't have an answer to give her. Almost 20 years have passed since that day, and I now believe that I can finally offer her--and the many others who have lost husbands and wives, fathers and mothers, sons and daughters to an unexpected heart attack--an answer to that question.

It's certainly true that the correlation between heart disease and cholesterol was a discovery of critical importance, and the standard cholesterol blood test--total cholesterol, LDL, HDL, and triglycerides--became (and remains) routine at every physical. Our mistake was in thinking that it gave us all we needed in a blood test for heart disease.

The sheer, horrifying frequency of "surprise" heart attacks was the tip-off that the cholesterol breakthrough was a false summit. For anyone not yet convinced, here's an ice-cold wake-up call: If we use the total-cholesterol test as our sole predictor of heart-disease risk, we miss eight out of 10 cases. That's a shocking percentage, and it means that--contrary to what you've heard and read--normal cholesterol results aren't necessarily reliable measures of your risk.

The good news is we now have the ability to go beyond basic cholesterol and screen for a far broader spectrum of risk factors that show up in your blood. While there are a number of these "metabolic markers," one of the most important--and deadly--is an especially small, dense form of LDL. If you have it--and one study indicates that 50 percent of men with heart disease do have it--you're three times more likely to have coronary artery disease, even if everything else (such as your body weight and your standard-cholesterol-test results) is perfect. And, that risk doubles to six times if you have a lot of these LDL particles.

Scary? Yes. But, fortunately, we know that small LDL responds remarkably well to lifestyle changes such as diet and exercise. This means that many of those stealth heart attacks are preventable. Maybe even yours.

A Bad Pattern:
If the LDL in your blood consists of predominantly small, dense LDL particles, we say that you're LDL pattern B (people whose LDL is predominantly large are called LDL pattern A). Why is this tiny lipoprotein such a big deal? First of all, the size of these particles makes it easier for them to weasel their way into the artery walls, where they cause all kinds of damage. And the presence of small LDL also implies the presence of a truly nasty metabolic stew. The stew includes rapid progression of partially blocked arteries; arteries that are more prone to sudden spasm; an increased number of blood fats after a meal; lousy removal of cholesterol from the blood supply; platelet stickiness that increases the likelihood of a heart attack caused by a blood clot; insulin resistance; plaque instability; and more.

You may not have all of these things if you have small LDL, but all of them are associated with it. People with small LDL are also more likely to have low HDL, or "good" cholesterol, which means that cholesterol isn't taken out of blood vessels as well and as fast as it might be. Low HDL is also associated with an increased risk of cardiovascular disease.

So these are some of the very good reasons why we worry so much about catching and treating small LDL.

The Small-LDL Paradox
There's another danger to being LDL pattern B: If you have small LDL and have heart disease, the disease will get worse twice as fast as it will in someone who doesn't have small LDL. But if you treat it, you can seriously retard the further development of the blockages and, in many cases, stop the progression of the disease more easily than a person without these small particles could. In fact, in a small percentage of cases, you can actually cause the disease to regress. In other words, LDL-pattern-B patients have the most rapidly progressive disease, but they are also the patients who respond best to treatment.

Bad Odds, Made Worse
Still not convinced you should be tested for small LDL? Consider this: People with small LDL may also have elevated levels of the metabolic marker apo B, the combination of which may increase the risk of coronary artery disease increases by six times. Worse, the presence of small LDL, elevated apo B, and high insulin ratchets your risk up to an alarming 20 times normal.

A Happy Ending
Here's some good news: Although the size of your LDL particles is genetically linked, your risk can be modified through treatment.

In fact, we can actually convert you from a high-risk LDL pattern B to a low-risk LDL pattern A. And the treatment isn't complicated or expensive. Weight control, a diet relatively low in saturated fat and simple sugars, and an adequate amount of exercise will often do the trick. So if you have this risk factor, don't despair. Just get busy.

Are You at Risk for Sudden Death?

Why being young and fit may not protect you from a heart attack:
Heart attacks aren't just for older, overweight men with high cholesterol and high blood pressure. Northwestern's football coach Randy Walker, a fit 52, recently dropped dead from a heart attack, and doctors are seeing patients in their 40's come in with heart disease, due to self-inflicted risk factors, according to Ilan Wittstein, M.D., an assistant professor at The Johns Hopkins University School of Medicine and its Heart Institute. Middle-aged men need to be on guard. Even if you work out and eat healthy, you could still be at risk.

Beware of Risk Factors
"In half of the cases of heart attacks, the heart attack is the first time the patient finds out about heart disease," says Richard A. Stein, director of preventive cardiology at Beth Israel Medical Center and spokesperson for the American Heart Association. More than 60 percent of heart attacks have to do with simple lifestyle issues, such as diet, exercise and cigarette smoking, and easy to detect and treat medical issues such as high blood pressure and high cholesterol. "Men need to know about the risk factors that predict the majority of heart disease cases," Stein says.

Stress Less
Research shows that not only do you have to watch your diet, exercise, and avoid smoking and excessive alcohol to prevent a heart attack, it's imperative to be aware of your family history and to manage your stress level. According to the 2004 INTERHEART study in the Lancet, stress is one of three main risk factors for coronary artery disease, and is responsible for a fifth of heart attacks worldwide.

Stress played a very important role in what may have caused the heart attack of Ken Lay, the founder of Enron Corp, saysWittstein. Convicted of conspiracy and fraud, Lay faced 25 to 40 years in prison before his untimely death. "If we look at medical literature over time, we find many good examples of how stress can have a profound affect on the heart," says Wittstein, who co-authored last year's study on "broken heart syndrome" in The New England Journal of Medicine. "We can't prove that heart attacks can be caused by stress, but we know that people who are under higher stress, have a greater risk of developing heart disease," Whittstein adds.

Release the Pressure
But it's possible to lessen your risk of heart disease by using calming stress management techniques, say these experts. Duke University Medical researchers conducted a study with 107 patients who had a history of heart problems. To lower the risk of future heart attacks, researchers divided the patients into three treatment groups; a third of the group exercised, another third received standard care, and the last third learned stress management techniques through 4 months of therapy and training. The stress management group fared the best with a 74% reduction in cardiac events over the 5-year analysis.

Stress management techniques can include getting therapy, or be as simple as taking up yoga, practicing tai chi or using meditation techniques for five minutes every day. "It's proven that relaxation techniques lower blood pressure and improve bloodflow," Dr. Wittsetin says.

Modify Your Lifestyle
Below we'll provide you with risk factors to be aware of and simple modifications you can make to your lifestyle today, to lessen the probability of a heart attack down the road.

Starting in your mid-to-late 30's, take measures to prevent heart disease by doing the following:

1. Be aware of major risk factors: Hypertension, high cholesterol, cigarette smoking, having a family history of heart disease, and diabetes are all major risk factors that could increase your probability of having a heart attack.

2. Make a lifestyle change: Think of the things that are in your power to change, like improving your diet, getting exercise, and quitting smoking. Eat 7 to 9 fruits and vegetables each day, says Dr. Stein, who recommends the Dash Diet, a Mediterranean, fruit-and-vegetable-based diet that can be downloaded online for free here. Get at least two hours of moderately intensive exercise each week, recommends Dr. Stein.

3. Make an appointment to be evaluated: If you have a family history of heart attacks, or you think you're at risk, spend 45-minutes to an hour with a preventive cardiologist at your local hospital. The evaluation and blood test will reveal your HDL and LDL cholesterol, triglycerides, fasting lipid profile, blood pressure, and family history. "Don't wait until you are in your 50s to get a formal assessment," Dr. Wittstein says. From this checkup, the doctor will be able to determine if you need to have a non-invasive scan of your heart to look for problems, or if you need to be prescribed medication like statins.

4. Don't deny cardiac symptoms: If you're experiencing "shortness of breath or chest pains from exertion, get to the hospital right away," warns Dr. Stein, who had a friend die from a heart attack last year, after experiencing chest pains while riding his bike.

5. Use medication: "If a physician recommends it, get started on medication, like statins, that can help you modify your risk factor," Dr. Wittstein says. If you have a family history or believe you are at risk, also take a 81-160 mg aspirin tablet each day as a precaution. "For a 40-year-old man with a strong family history of heart attacks, a baby aspirin would be reasonable," he says.

Extra: If you're under high stress, take up meditation, yoga, tai chi, or practice any other relaxation technique for five minutes every day. "Exercise can relieve a lot of stress for people," Wittstein says. "People who exercise on a regular basis, are less likely to have heart disease or die from a heart attack later in life."

Cancer Proof Your Prostate

Ten ways to defuse a potential gland mine
For a walnut-sized organ, the prostate is the source of a lot of misery. Apparently, it has only two jobs: Producing the fluid in which semen travels and providing fertile ground for cancer cells--talk about your love-hate relationships.

This organ is the second most common cause of cancer in men (skin is the first), and one in six men will develop prostate cancer in his life. This year alone some 230,000 will get diagnosed with the disease. That's more than lung, colon, and brain cancers combined. Some 30,000 will die.

Grim statistics, yes, but there are plenty of reasons to be optimistic. If caught and treated early, chances of survival are nearly 100%. And for the guys who find out the cancer has spread, the news is getting better. This past February, researchers at the University of California, San Francisco, announced they have a vaccine called Provenge that can treat severe forms of the disease. It doesn't prevent the disease; the vaccine combines a protein found in prostate cancer cells with a substance that stimulates the immune system. Doctors collect immune cells from the patient's blood, mix them with the vaccine, and then inject the mixture in three doses over 2 months. The goal is to prompt the patient's immune system to recognize the cancer cells for the intruders that they are.

In a study of 127 men with advanced prostate cancer, 34% of those who got the vaccine survived beyond 3 years; only 11% of the placebo group made it that far. And side effects were limited to a few days of cold-like symptoms, such as fevers and chills, says study author Eric Small, MD. Provenge is currently being fast-tracked through the FDA's approval process and could be ready by 2006. If the vaccine continues to succeed against difficult cases--the men in the study had failed to respond to standard treatment--doctors will try it in patients with less advanced forms of the disease.

While it's nice to know science is developing prostate solutions should you need them, the following advice can help reduce the likelihood you'll suffer anything more than the indignity of a gloved finger. Putting this science into action (read: more sex, more wine) won't confer immunity, but it will make your prostate one tough nut to crack

PREVENTION

Rev up your sex life
A happy man makes for a healthy man, especially when it comes to regular orgasms and your prostate. In a report from last year, National Cancer Institute researchers quizzed nearly 30,000 middle-aged men about their sex lives and discovered that those who averaged 21 ejaculations a month ran a 33% lower risk of prostate cancer than those who have four to seven ejaculations a month.

Researchers say it's the ejaculation--not sex--that protects the prostate. In fact, a recent Australian study showed masturbating five or more times a week offered the same amount of prostate defense. "Seminal fluid contains substances that are carcinogenic," says Graham Giles, PhD, the lead study author. "Regular ejaculation may help flush them out."

If you're not in a monogamous relationship, make sure that you and your partner are tested for sexually transmitted diseases. Human papillomavirus (HPV), cytomegalovirus (a type of herpes), and gonorrhea can infect the prostate, which ups your risk for prostate cancer.

Consider switching hair-loss treatments
Turns out the hair-loss drug Propecia has one impressive side effect. In a National Cancer Institute study of 18,882 men, researchers found that the men who took 5 mg of Propecia, aka finasteride, daily for 7 years had a 25% lower risk of prostate cancer than those taking a placebo. Finasteride blocks production of dihydrotestosterone, a hormone that triggers hair loss and prostate growth.

"It's the first study to prove that prostate cancer is preventable," says Peter Greenwald, MD, the National Cancer Institute's director of cancer prevention--and one of those 18,882 men. "My prostate's normal," he adds. One caution: Men on finasteride had a slightly greater chance of being diagnosed with a more aggressive form of the disease than did the placebo takers. More research on the drug is needed, but if you're concerned about prostate cancer, discuss these findings with your doctor.

Go Mediterranean
There's a good reason Western European men have lower prostate-cancer rates than we do. New research suggests that certain staples of the Mediterranean diet contain prostate cancer- fighting properties. For starters, a recent study published in the Journal of the National Cancer Institute shows that men who eat more than 10 g of garlic or scallions (about three cloves of garlic or 2 tablespoons of scallions) daily have a 50% lower risk of prostate cancer than those who eat less than 2 g. (Give credit to organosulfur compounds, which are common to both vegetables.)

Then there's pasta sauce: In 2004, a University of California, San Francisco study revealed that men who ate at least two servings of tomato sauce a week were 28% less likely to develop prostate cancer. Tomatoes contain the antioxidant lycopene, which helps protect against cell damage that leads to tumor growth. Bonus points if you use whole-wheat pasta; eating plenty soluble fiber has been shown to reduce levels of testosterone, which promotes tumor growth, and prostate-specific antigens (PSA), a cancer marker.

Drink wine and tea
Drinking a glass of wine a day can cut your cancer risk in half, finds a study from the Fred Hutchinson Cancer Research Center in Seattle that was released in January. Wine is rich in resveratrol, an antioxidant found in the skin of red grapes that may help inhibit the growth of prostate cancer. "But too much alcohol can neutralize wine's beneficial effects," says study author Janet L. Stanford, PhD, head of the center's program in prostate cancer research. "Stick to four to eight glasses a week."

If you have wine with your meal, sip on some tea afterward. The antioxidants in black and green tea may inhibit tumor growth, finds a study from October 2004 that was done by the Center for Human Nutrition in UCLA. Researchers had prostate cancer patients drink five cups of tea or soda for 5 days. After examining tissue samples, they found tea drinkers had the least amount of cancer growth, as well as lower levels of polyamines (a chemical associated with malignant prostate cancer cells).

DETECTION

Take an imperfect test
One of the more maddening cancer screens around is the one for your prostate. This blood test looks for prostate-specific antigens (PSA), proteins associated with a growing prostate gland. The problem is that routine testing has never conclusively been shown to save lives. Thomas A. Stamey, MD, and professor of urology at Stanford University, is the man credited with inventing the test, and he's now arguing that men shouldn't get it unless their doctor detects a lump. That's because his new study suggests that routinely administering the test causes needless surgeries and alarm. Stamey and his Stanford colleagues studied 1,317 men who had their prostate removed and found that only 2% actually had aggressive cancer that required surgery. The rest had benign prostatic hyperplasia, a mostly harmless increase in prostate size that can drive up PSA scores.

At the heart of the PSA conundrum is the fact that by the age of 70, three out of four men will have cancer cells in their prostate. But these cancer cases are progressing so slowly that they pose no major danger, says Stamey. "More men die with prostate cancer than they do from prostate cancer," he says.

A crucial distinction, but how can a man be sure he's not among the 2% with an aggressive case? He can't. There's a screaming need for a test that can distinguish slow-growing cancers from those that kill. In its absence, most patients with a high score and a positive biopsy opt for surgery and radiation. The only problem with that approach is a man's quality of life can go sharply downhill after the removal of the prostate. Incontinence, impotence--the results of treatment aren't pretty.

So you'll find this even more confusing: Some researchers want to lower the current PSA standards to catch even more cancers. Doctors usually request biopsies for those with a score of 4.1 or greater, but a recent study of 6,691 men published in the New England Journal of Medicine showed that this traditional threshold for ordering a follow-up biopsy may be missing 82% of prostate-cancer diagnoses in men under 60. According to the study, using a score of 2.6, especially under age 60, doubled the cancer-detection rate, from 18% to 36%. But if, as Stamey suggests, 98% of those cancers aren't a threat, does the lower threshold make any sense at all?

It does for men who are overweight or obese. Men with more body fat have lower PSA scores, finds a University of Texas at San Antonio study. Researchers believe this could be why obese men are more likely to die of prostate cancer than men with healthy a healthy BMI, or body mass index--a measure that takes into account one's weight-to-height ratio.

So where does this leave you? Currently, the National Cancer Institute is studying whether the PSA screen does in fact save lives. In the meantime, the Centers for Disease Control and Prevention are sticking with the recommendation that all men get a yearly PSA after age 50 (45 if you have a family history or are African-American).

Calculate your risk
Let's say your PSA is 2.6. One way to get a better read on your need for a biopsy is with a nomogram. This needle-free analysis turns a patient's age, PSA density (PSA divided by the volume of the prostate), digital-rectal-exam result, and transrectal-ultrasound result into a score that helps determine whether a biopsy is really warranted. "We can say whether or not, for your prostate, that's a high PSA," says Mark Garzotto, MD, director of urologic oncology at the Portland VA Medical Center. In a study of 1,200 men, Garzotto found that if a nomogram had been used in every case, it would have spared 24% of the men from unnecessary biopsies. If your doctor can't crunch the numbers, ask for copies of your test results; you can find the same nomogram at www.prevention.com/nomogram and do the math yourself.

TREATMENT

Hit the spice rack
Researchers at the Center for Holistic Urology at Columbia-Presbyterian Medical Center in New York City reported in 2004 that a blend of herbs including ginger, oregano, rosemary, and green tea reduced prostate-cancer cell growth by 78% in the lab. Sold as Zyflamend, it's thought to inhibit the activity of COX-2, a protein linked to the progression of the disease.

"We're using it with promising results in some of our patients," says Aaron Katz, MD, the center director. Another herbal option is FBL 101. When researchers at the National Cancer Institute gave FBL 101 to mice with prostate cancer, they found that it decreased a tumor blood-vessel growth factor called VEGF to undetectable levels. Crimp the blood supply and cancer can't survive, says William Figg, PharmD, the principal investigator. "Men who want to delay the time before they begin traditional treatment should check this out," he says. You can order FBL 101 at www.fblsciences .com and find retailers of Zyflamend at www.new-chapter.com (about $25 for a bottle containing 60 pills). Get your doctor's okay before starting on either one.

Choose a computer-assisted doctor
If you're headed for the cutting table, you'll be happy to know that the radical prostatectomy recently became a lot less radical. Using a new robotic device known as the da Vinci system, doctors can watch a three-dimensional image of the prostate while directing two nimble robotic hands through a few small slits in the patient's abdomen to remove the cancerous prostate. According to data from the Vattikuti Urology Institute at the Henry Ford Health System in Detroit, 90% fewer men became incontinent and 50% fewer became impotent with the da Vinci system than with manual gland removal. "It's like playing golf with a titanium driver versus a wooden driver," says chief of urology Mani Menon, MD. Another plus: Patients spent an average of 1.5 days in the hospital, compared with 2.3 days for open surgery. To find a list of da Vinci-equipped hospitals, go to www.intuitivesurgical.com/patients/maps.

Ask about hormone therapy
About half of all prostate cancer cases that need treatment have yet to spread to other parts the body. These patients often get radiation alone or radiation combined with drugs that suppress male hormone production. Radiation treatment is getting more sophisticated--radioactive seeds can target the prostate, preserving surrounding tissues. But taking hormone drugs for an extended period can cause thinning bones, anemia, and heart problems. Now, a Harvard study from August 2004 suggests that just 6 months of hormones may be enough. Researchers followed 206 prostate cancer patients; half of them got radiation plus and 6 months of hormone therapy, and half of whom underwent radiation alone. After 5 years, they found 88% of men who received the combined treatment were still alive, compared with 78% who had only radiation. The survival rate for men on short-term therapy is similar to that of patients who undergo long-term therapy, says study author Anthony D'Amico, MD, PhD.

Restart your sex life
Unless you're David Beckham, this one's a no-brainer: Take a nerve graft from your ankle and save your sex life. The cavernous nerves of the crotch--they trigger erections--are often a casualty of prostate removal if the cancer has (or might) spread outside the gland. But by replacing them with the sural nerve that runs along the ankle, as many as 9,000 men a year could recover erectile function, says Peter Scardino, MD, one of the developers of the procedure and chairman of neurology at Memorial Sloan-Kettering Cancer Center in New York City. "If you've got only one nerve left, you're firing on four cylinders, but if I do a graft, it's like you're firing on seven out of eight." And don't worry; a slight numbness in your foot is the only side effect. Talk to your urologist about where to find a surgeon experienced in sural-nerve grafting.