I'll try to not be too verbose here, but I want to provide all the info about me to get a reasonable opinion about what to do at this point. I am being seen by the Preventative clinic at a well known university at this point. I'm just looking for some pointers as to what is a reasonable treatment/prevention path to follow.
As you will see, I've made some changes in diet and lifestyle that have modified my lipid numbers and BP. The current preventative clinic stance seems to be that this is sufficient for now. I'm curious if I should be pursing something more aggressive, and if so, how aggressive in preventative treatment.
I have a family history of early CHD on my father's side. Mother's side is unknown.
Family history: Father died of CHD -- MI @46, congestive HF @54
Grandfather on same side: MI in late 40's, stroke @55 as cause of death.
In Feb, of this year, I had what was probably a panic attack, but it drove me to the local university hospital. Troponin test was negative. They kept me over night. Did an echo stress test in the morning, and released me. Since this time I have had on and off on-going atypical chest pain. On admission to the hospital Total cholesterol: 235, LDL 181, HDL 35 (non-fasting). BP 170/90.
My current information:
Me: Caucasian Male -- 41.5 years old
6 feet tall, weight 160 lbs.
Resting blood pressure(morning/eve): ~115/74 mmHG : Daytime BP: ~130/80 mmHG
Latest lipid panel: Total: 178, LDL: 128, HDL: 35, Trig: 74; ratio 5.1
CRP: 0.9 mg/L
Homocysteine: 12.7 umol/L
Daytime HRsit: ~58 bpm.
I have never been on any BP or lipid lowering medications. I have never smoked.
Stress echo results from Feb:
Treadmill test. Achieved 106% of maximal predicted HR. Rest and exercise echo: normal resting wall motion and no stres-induced wall motion abnormality. Baseline ECG displays normal sinus rhythm. RAD. There was a maximum 1 mm ST seg. depression in the infero-lateral lead(s). The patient did not exhibit any symptoms during test. The patient exhibited a hypertensive response with stress. LV is normal in size. There is bordline LVH. LV ejection frac. is normal.
I've since had a separate echo that indicates: borderline concentric LVH (so unlikely this is due to my fine physical conditions, but rather a response to hypertension):
* Borderline concentric LVH; otherwise normal M-mode and 2-D study without evidence of organic heart disease.
* Doppler evidence of trace mitral and tricuspid regurg. In the face of anatomically normal valves, this is most likely represents a normal variant.
Ambulatory BP monitor:
* Daytime sys. range: 110-160 mmHg sys. with 13% > 140 mmHg.
* Daytime dia. range: 69-100 and 1 mmHg with 38% > 90 mmHg.
Average daytime: 130/86 mmHg.
* Nocturnal sys. range: 81-117 mmHg.
* Nocturnal dia. range: 46-86 mmHg with 11% > 80 mmHg.
Average noct.: 102/59 mmHg.
-- Conclusion: Mild diastolic hypertension noted during the daytime. Otherwise blood pressures were acceptable
I had a few brief periods of swallowing induced arrhythmia. I've seen a cardioelectrophysiologist and done a 24 hour holter. I don't have the report in front of me, but the result was essentially "normal". There was a very low rate of PVC (<.3%), even lower PAC rate, and 1 run of 3 or 4 beats of VTC in the 24 hours.
I do from time to time have PVCs and PACs that I can feel and that show up on my exercise HR monitor, FWTW. These seem to be rare, single ectopic beats.
Evaluation for GERD (endoscopy + BRAVO pH study) indicated mild GERD with no cell atypia in either my stomach or esophagus. Gastro conclusion: treat as-needed with over the counter antacids. Mostly, my stomach related issues seem to be resolved at this point.
Heart scan calcium score: 29
Separate chest CT was "essentially normal".
Current medications, etc:
81 mg ASA/day
multivitamin (includes folate)/day
1 gm fish oil/day
1000 IU vitamin D3/day
Previously, I was drinking no alcohol due to the GERD issues. I'm now back to 1/2 to 1 glass of wine every other day or so with dinner.
That said, I'm concerned about the following:
a) My low HDL. This is a chronic issue for me. I know it is an independent risk factor. Should I push for doing something to modify it? Niacin?
b) I've asked about having my lipid particle sizes tested as well as the HDL type distribution. I was told that it wouldn't really provide much more information. Also, all my LDL values are calculated versus measured. Should I have at least 1 real, full measurement done?
c) Depending on whose risk stratification calculator I use, I get wildly differing results as to what my risk is:
o ATP III (http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof): 1%
o Framingham total cholesterol: 5% (over 10 years)
o Framingham LDL: 7% (over 10 years)
o Calc. using Framingham + CAC: 7% (over 10 years)
Which do I believe? I'm inclined to believe the last the most: most specificity to me.
d) Given these factors, what is my risk stratification? Low? Moderate? What would be the general treatment/prevention plan? An aggressive one?
e) Any other testing that would be reasonable to have done that this point to have done for either baseline measures and/or risk/health evaluation?
f) I am a little concerned about the hypertensive response to stress that I had during the echo stress test. Comments about possibility of exercise induced hypertensive episodes? Is that worth pursing?
Obviously, I have a bit of an anxiety issue about my CA health.
Thanks for any input you can provide.