TO: John Warner, MD, President, American Heart Association TOPIC: Speedy Recovery

Dear Dr. Warner,

I hope this letter finds you in good spirits and on a path of speedy recovery. The news reports are very encouraging. I am sure serving as President of the American Heart Association and requiring a coronary stent just hours after delivering the Presidential Address at the national meeting of the AHA is a lot to digest. Best wishes for a full return to health and activities. The world needs your efforts to curb the #1 killer of men and women.

Although we have not met, we share several things in common. The first is that I trained as a fellow in cardiology at UT Southwestern back in the day that Drs. Willerson and Hillis were in charge. You now lead that same program in Dallas. Those 3 years were transformative and I decided to concentrate in interventional cardiology, just like you did. I spent a year with Geoffrey Hartzler, MD at the Mid-America Heart Institute treating acute cardiac conditions with urgent angioplasties. Finally, like you, I have a family history of early coronary heart disease and have concentrated my practice to an aggressive preventive and heart disease reversal program.

Dr. Warner, upon your full recovery, you have the opportunity to position the American Heart Association to lead cardiologists to a new standard of early detection and prevention of heart disease not currently practiced universally. I may be overstepping my bounds but I would like to suggest a few steps I have found useful in my clinic practice.

1) Institute Mandatory Training About Heart Disease Reversal Diets in Cardiology Fellowships

I was taught in fellowship that coronary artery disease (CAD) progresses from minor “fatty streaks” in youth, to plaques or early narrowings in young adulthood, and on to complicated plaques later in life that may require stents to resolve. The arrows always pointed towards the disease advancing and never reversing. This one-way street was shown to be incorrect in 1990 by Dean Ornish, M.D. He prescribed a plant-based diet to patients with heart blockages. He also recommended walking, social support and stress management to help their hearts. He demonstrated that the patients who adhered to the lifestyle program felt better and showed reductions in the amount of narrowing in their arteries. Since those first reports, the data that heart disease can be reversed by intensive lifestyle changes using a plant based diet naturally low in fats has become so robust that the Ornish Lifestyle program was recognized by Medicare in 2010 for reimbursement as a therapy of CAD. Another similar program, based out of the Pritikin Longevity Center in southern Florida, received the same Medicare designation for intensive therapy and reversal of heart disease with dietary therapy. Similar research findings have been reported from the program at the Cleveland Clinic Foundation led by Dr. Caldwell Esselstyn. He monitored patients with advanced heart disease who adopted a plant based diet without added oils and reported the same types of clinical improvements with documented reversal of heart blockages. It is unfortunate that so many cardiology trainees do not know of these groundbreaking studies, now approved by Medicare for secondary prevention of heart disease, and do not recommend them. This has been noted as a problem by other leaders in our field. Please see that mandatory education is built into the medical training and board certification of cardiology fellows.

2) Endorse routine screening with coronary artery calcium scan (CACS)

As you know, studies show that CACS is by far the most accurate way to determine if heart arteries are developing calcified plaques at an early and asymptomatic stage. In Detroit as an example this widely available scan costs as little as $75 and in some cities it is offered for $50 or less. It’s far more accurate for screening for silent CAD than a stress test and the prognostic impact of an elevated score is well established. Instituting a strong recommendation for routine use of the CACS at age 45 or 50, as is available as a benefit in your state of Texas but not nationwide, would permit those with a CACS score above zero to institute a more aggressive diet and lifestyle preventive program.

3) Institute Training in Cardiology Fellowships on Advanced Lab Tests

Although there have been so many advances in the field of cardiology, most patients in primary care and cardiology offices still get the same “Framingham” style lab assessments I ordered at UT Southwestern in the 1980s. My years of practice indicate the utility of advanced testing and cardiology fellows would provide better care if they routinely added some of the following to their assessments:

Advanced lipid profile: Advanced lipid panels measure LDL particle number and size, which are more predictive of future heart and stroke events than routine assessments. They also do not need to be done in a fasting state.

Lipoprotein a: This genetic form of cholesterol is elevated in about 20% of those tested or 63 million Americans and contributes to the development of CAD. There’s even a foundation dedicated to educating the public of the risk.

Homocysteine: This amino acid is produced by a process called methylation. It’s important for artery and brain health, and when elevated, it causes endothelial dysfunction leading to atherosclerosis and clotting. It may be due to a genetic defect in the MTHFR gene, which is easily measured. It can be treated with B complex vitamins, and the level will return to normal.

TMAO: This marker of heart and kidney health is elevated after eating meat- and egg-heavy diets with an altered gut microbiome. It has been shown to cause heart and kidney damage, and is associated with worsened prognosis that can be resolved with a plant based diet.

ApoE genotype: This blood test can indicate whether you inherited low risk genes for heart disease and Alzheimer’s dementia, such as ApoE 3/3, or very high risk genes for these conditions like ApoE 4/4. Furthermore, carriers of even one ApoE 4 allele are wise to greatly reduce their dietary saturated fat intake such as meats, cheeses, eggs, and full fat dairy.

4) Expand the availability of Intensive Cardiac Rehabilitation Programs (ICR)

There are 2 insurance covered versions of ICR. One is called the Pritikin ICR program and the other is called the Ornish ICR. These programs permit more hours of teaching plant based diets shown to reverse heart disease to patients recovering from heart events. They also teach exercise, cooking classes and strategies for stress management like yoga. In my state of Michigan there is only one hospital with one of these ICR programs leaving the majority of heart patients unable to access this superior training and lifestyle change.

5) Upgrade Hospital Food and Ban Processed Meats

I remember fondly the ubiquitous fried okra served at the Dallas VA hospital in the 1980s but as I was already eating plant based, I never wandered to Sonny Bryan BBQ across from Parkland Hospital. With the WHO announcement equating processed meats and carcinogens, it is time for the AHA to join the American Medical Association and the American College of Cardiology in calling for a complete ban in hospitals on sugar sweetened beverages and processed meats. We cannot train a new generation of prevention minded cardiology fellows if they are eating sausage muffins, bacon and hot dogs and hospital celebrations and cardiology cath lab conferences.

Dr. Warner, we have come so far in the field of cardiology and I am sure you feel as energized as I do about the future of our field for the prevention of this serious health problem. An aggressive stance focusing on enhanced public education and mandatory training of cardiology fellows as experts in cardiac nutrition and in the tools of early identification of cardiac risk and atherosclerotic disease can hasten the end of heart disease. Be bold and use your position to speed the introduction for such measures. May your days be long and full of practicing our beloved shared field of medicine.

Sincerely,

Joel Kahn, MD, FACC

Former Chair, AHA Walk Detroit