Right Decisions?

[CS64]

I am a 38 y.o. male, non-smoker, active, but  30 lbs overweight, blood pressure 140/90.  I have a hx of paroxysmal atrial fibrillation dating back to age 18 (approx 10 -12 episodes in 20 years, always at night).  My last episode occurred 18months ago, and i was placed on 25 mg. of atenolol.  I've also been taking an aspirin every day.  ECG is otherwise normal, and there are no structural abnormalities.  My cholesterol has always been low, but my hdl level has been too low (total:160s, HDL:28 - 36, LDL:100 -104).  Trilglycerides  ok.  I eat a primarily vegetarian, low-fat diet.   As I am adopted, I have no family medical hx to report.
  
At a recent physical, my lipid profile changed.  Total cholesterol  195, HDL 36, LDL 139.  Triglycerides ok (68).  Homocysteine 7.7.  Also screened cardio CRP, and the score was 1.8 mg/l.  Also, I had an ebct performed.  I had a "minimal" score (<10), but not "0".  Given all of this, my GP  said that he would feel comfortable with a "more aggressive" approach.  He doubled my atenolol to treat the blood pressure (50mg), and  suggested Lipitor, 10mg.  He also made clear that the extra weight had to come off.
I am comfortable with a more aggressive approach - it seems that there is already a disease process in motion and that I must begin fighting it now so it does not worsen.  As I'm basically a vegetarian now, I would like to give the "Ornish" program a try .

I would like to know if the approach outlined above sounds reasonable, if there is anything else I could add, or if there are other tests I should consider.  Thanks!

  

[bananagirl]

thought you might be interested in the fact that my mother (63) reduced her carb intake considerably (following the Atkins diet although with far less fat) and her bloodpressure dropped from 210/130 to 125/70. It made an amazing difference. the only carbs she now eats are whole food as opposed to refined. No sugar and no white flour or rice. she eats very lttle meat (semi-veg)

[CCF-M.D.-RCJ]

CS64,

Your question is interesting in that we are increasingly encountering patients like yourself in cardiology and internal medicine clinics -- and we don't have one right answer for what to do.

You are beginning to manifest criteria characteristic of the "metabolic syndrome":
(1) abdominal obesity (>40 in for men, 35 in for women)
(2) triglycerides > 150 mg/dl
(3) HDL <40 for men, < 50 for women
(4) Blood pressure > 130/85
(5) Fasting glucose > 110 mg/dl
When patients have 3 or more of these criteria, they can be labeled as having the metabolic syndrome. The more of the characteristics you have, the higher your risk for cardiovascular events.

You (probably) meet 3 of these criteri: obesity, HDL, blood pressure.  This means that you are likely relatively resistant to the effects of the insulin that your body produces.  

Excess fat and physical inactivity are the major lifestyle variables that have a bad effect on insulin action.  If you want to improve your prognosis, then get off the couch and lose that extra 30 pounds (assuming of course your doctor agrees that its ok for you to exercise).

I would be wary of the Ornish diet.  This diet emphasizes a low-fat, high carbohydrate approach.  A carbohydrate-based diet in a person who has insulin resistance leads to increased insulin levels, higher triglyceride concentrations, and lower HDL levels -- which can lead to increased cardiovascular risk.

Hope that helps.

Here are some references:
(1) ATP III. JAMA 2001; 285:2846-2497
(2) Reaven G, Metabolic Syndrome ..., Circulation 2002; 106:286-288.