Cardiac testing for an integrative practitioner: What you need to know

By Regina Druz

As a practicing and board-certified cardiologist, I find that many of my integrative colleagues are often unaware of the multitude of cardiac tests and their significance in care of their patient. While this article is not aiming to present a comprehensive review of cardiac testing modalities, it profiles a situation frequently encountered in the integrative and holistic cardiac practice.

I recently evaluated a patient seeking a holistic cardiology consult. This patient is a 47-year-old woman who has no chronic medical issues other than a long history of elevated cholesterol. As per her account, she was diagnosed with elevated cholesterol in childhood at the age of two. In her late 20s, she was treated with statin medications, but developed muscle soreness and discontinued. She is asymptomatic, physically active, not under high stress. Her father sustained a myocardial infraction in his 30s and is presently alive although suffering from congestive heart failure. Her paternal grandmother had tendon xanthomas.

Based both on the personal and family history, and baseline screening cholesterol levels, this patient was given a diagnosis of heterozygous familial hypercholesterolemia. She was also determined to be a compound heterozygote for methylenetetrahydrofolate reductase (MTHFR) single-nucleotide polymorphism (SNP).

Her laboratories over the past few years consistently revealed total cholesterol levels greater than 260 mg/dl, with LDL cholesterol of 190 mg/dl or higher. Her most recent high sensitivity c-reactive protein (hsCRP) was less than 0.2 mg/dl and there was no advanced lipid profiles or additional inflammatory markers available.

This patient presented seeking a functional medicine evaluation to multiple practitioners and an integrative cardiologist out of state. She had multiple tests, including stool testing, food sensitivity testing, saliva cortisol testing to address recurrent episodes of itchy rash, felt to be due to a histamine reaction. At various time points, her elevated lipids prompted re-testing and recommendations for berberine, bergamot, phytosterols, red yeast rice on top of the foundational regimen of fatty acids, probiotics, and activated B vitamins. She follows a gluten-free and low-histamine/low Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAPS) nutritional plan.

Along the way, none of the functional medicine physicians advised her to have a formal cardiac evaluation or testing. This patient, who is a physician herself, consulted her medical colleagues and was advised to have a coronary artery calcium (CAC) score. The test revealed a total coronary artery calcium of 386 Agatson units, putting her in the upper ninetieth percentile for age and gender. Most of the calcium deposits were located in the left anterior descending (LAD) coronary artery, so called “widow-maker” artery. She was then evaluated by an integrative cardiologist out of state and no additional testing was advised.

To understand why this patient appears to be over-tested and undertreated, it is important to put her test findings in context.

For coronary artery disease, the most common testing is focused on identification of obstructive coronary disease, where stenoses in the one or several of the coronary arteries are equal or greater to 70 percent of the luminal diameter. Notice that this is often an “eyeball” estimate obtained visually although recent advancements in optical coherence tomography and vessel ultrasound, both intravascular techniques available during an invasive coronary angiography as well as flow measurements have refined the ability to measure. In clinical practice, such patients often have exercise-related chest pain, shortness of breath, or palpitations and exertional fatigue.

However, this patient never had symptoms suggestive of obstructive coronary artery disease. She does have a nearly 45-year history of exposure to high LDL, and to assess the impact of that CAC score is a useful test. It allows to identify subclinical coronary artery disease which is prognostically significant. In the best-case scenario, a CAC score of zero portends a disease free state with the probability of any coronary artery disease related event at 0.1 percent per year. Thus, there is a 99.9 percent chance that if a CAC is zero, there will be no cardiac event.

Once the CAC is equal to or greater than 400, the probability of events rises sharply, and further investigations might be warranted.

In practice, I almost always couple CAC scoring with the non-invasive coronary artery angiography. While it adds radiation exposure and intravenous contrast, the identification of soft or mixed plaques, lacking calcium deposits, is a valuable piece of information, pointing to potentially unstable coronary vascular situation. This is where advanced inflammatory markers are key to determine a possible time course and urgency of treatment. Imaging for sub-clinical disease, when put in the appropriate context allows to focus the decision making and redefines treatment goals. It also allows a patient to be a part of the decision-making, providing an objective measure to their metabolic and other concerns.

In this patient, evidence supports using moderate to high intensity statins and she was agreeable to that with revised supplementation. She is also progressing in the holistic cardiology program focused on metabolic, hereditary, hormonal, inflammatory, infectious, immune, toxic, stress, and sleep facets that initiate and promote vascular dysfunction.

In my opinion, integrative practitioners need to incorporate appropriate referrals into their practice and collaborate with cardiology colleagues to best personalize patient vascular risk assessment. If we just throw a few supplements into the mix, we will not be any different from a pharmaceutical company approach to dyslipidemia.