Dr. Evan L Lipkis, MD

Generally no symptoms of blackout, near blackout, palpitations, etc. Common causes of lower pressure are dehydration, weight loss, and blood pressure meds and a variety of other medicines.

1 out of every 500-1000 people have an intolerance to gluten, which can be associated with iron deficiency anemia, intestinal lymphoma, skin rashes, and elevated liver tests. It is often genetic and is diagnosed by a small intestinal biopsy through a scope or via a blood test called tissue transglutaminase. A gluten-free diet can be curative but not easy to follow.

Best,

Dr Lipkis

Smoking is the biggest risk factor, but if there is a family history or COPD happens at 50 or so, get an alpha 1 antitrypsin level on a blood test as this genetic form can be helped.

Best,

Dr. Lipkis

Here’s an article I wrote:

Weight Loss—Why is it so hard to do and what can be done?
Obesity is a disease located in the hypothalamus of the brain. Unfortunately, it’s like treating high blood pressure in the 1960s, we understand the lifestyle changes but only have a few medicines. Many drugs are in the pipeline.

The problem is that 70% of the nation is either overweight or obese. Arthritis, diabetes and sleep apnea are sky-rocketing due to obesity. Obesity is an actual disease as evidenced by inflammation in the hypothalamus of the brain. The brain fails to receive the hormonal input that causes one to feel full.
It is hard to lose weight because metabolism slows and the hunger hormone, ghrelin, increases.

The key to losing weight is taking action by setting up follow-up appointments with your physician, dietician and/or weight loss psychologist. Form the team and stick with it! Portion control works better than exercise but both are important factors.

Weight Watchers remains the most successful weight loss program according to clinical studies. The power of the group is motivating.

Remember to keep a food journal, exercise daily or every other day, weigh each day and wear a pedometer. Aim for 10,000 steps daily, bring the right foods into your house and eat only when you’re hungry. A great snack is air popped popcorn (not microwave or theater popcorn) with a little olive oil. It is a whole grain, gluten free and quite filling and can even be used as a meal substitute (no more than once a day).

The MyPlate approach increases satiety and decreases waist circumference even at 1 year. Essentially, you have a plate of food that is divided into quarters and includes whole grains, vegetables, fruits and proteins.

What is the best lifestyle change to lengthen your life?
It’s the Mediterranean diet which consists of lower carbs, olive oil, fruits, vegetables, fish, whole grains and a little alcohol. Basically, you are reducing white rice pasta, white potatoes, sweets, chips and bread.

Sugar and processed foods increase weight, elevate the risk for cardiovascular disease, double the cancer risk and heighten the risk of dementia.

This approach reduces dementia, cancer and heart disease!
Wow, so the father of medicine, Hipoccrates, was right. The best medicine is at the end of your fork. Ok, maybe they didn’t have forks back in those days but you get the idea.

Losing weight can preserve your memory, reduce arthritis, cure sleep apnea, prevent diabetes, decrease cancer and lessen heart attacks.

Interestingly, a Nov. 17th 2005 NEJM study showed in a 1 year study that a weight loss drug alone resulted in an 11 pound weight loss. An intensive lifestyle modification program consisting of 30 meetings added to a drug yielded nearly a 15 pound weight loss.

The drug plus eight 15 minute counseling sessions done by an MD helped patients to lose 16.5 pounds. Finally, the combo of intensive lifestyle modification plus the drug resulted in over a 26.5 pound weight loss.

If we extrapolate, perhaps Weight Watchers plus a medicine can be an effective strategy.

Another interesting strategy is just add fiber to your diet. Fiber can have many beneficial effects upon the body. In a small 8 week study from Nutrition Journal 201615:86, 10.5 grams of soluble fiber or psyllium reduced HbA1C by 1% (as good as a drug to lower sugar), improved the cholesterol and resulted in nearly a 7 pound weight loss.

So you could take a teaspoon of Metamucil=psyllium 3 times daily and lose weight. At the very least, you’ll likely improve blood sugar and cholesterol. A medicine called Gelesis100 (Plenity, Gelesis) is FDA cleared for weight loss. 25% of patients will lose 10% or more of their weight and it can be used in people who have a BMI of 25-30.

Let’s debunk a myth for just a moment. You must eat breakfast, it is the healthiest meal of the day. Breakfast doesn’t help you lose weight or help you live longer. It is your option if you wish to eat breakfast. See BMJ Jan. 30th 2019.

Newer medications (Belviq, Qsymia, Saxenda and Contrave) and surgical procedures can also be beneficial. All of these weight loss medicines create a sense of fullness and help one lose about 5% of total body weight, but the results can vary. The chart gives a quick overview.

The side effect profiles are low, but these agents can be expensive so utilize the coupons provided by your health provider.

Such medicines are indicated if you are obese (a BMI of 30 or higher) or if you are overweight (a BMI of 27-30) with a cardiovascular risk factor such as diabetes, smoking, high cholesterol or high blood pressure. BMI stands for body mass index and charts are numerous on the internet.

If you have a BMI of 35 or more (morbid obesity), then you may need to consider a procedure.

Commonly, gastric sleeves are being performed. By simply making the stomach smaller with this laparoscopic, surgical procedure, significant weight loss can be realized. This surgery carries the same or less risk than a gall bladder operation. It is indicated for individuals who are obese, especially if there are additional cardiac risk factors.

You can lose up to 50% of your excess body weight. So if you should weigh 200 pounds but you actually weigh 300, then a gastric sleeve procedure can help you lose an additional 50 pounds. According to Ann Intern Med. 2018;169(11):741-750, here are the percent weight loss for gastric bypass, gastric banding and gastric sleeve procedures:

1 yr. 31% 25% 14%

5 yrs. 25% 20% 10%

Gastric bypass has more side effects, but results in more weight loss. Also, gastric surgery likely reduces cardiovascular death in half according to JAMA 2018 Oct 16; 320:1545. Additionally, according to JAMA 2018 319 (3) 279-290, the overall mortality is significantly lower in each surgical group compared to no surgery.

Best,

Dr. Lipkis

Get an X-ray. Could be wear and tear arthritis. Gout is highly inflammatory. It hurts like hell and often gets red and swollen. Usually, the uric acid is high and crystals can be aspirated from the affected joint.

Best,

Dr. Lipkis

Fatigue, hair loss, weight gain, abnormal menstrual periods, and elevated cholesterol can occur. A blood test call a TSH will help to let you know.

Best,

Dr. Lipkis

It all depends upon the extent of the heart attack. But yes, it is certainly possible. Think of our vessels as an organ. If you were to open up all the vessels in our body they would contain the same surface area as the football field. So, once you have coronary disease, which causes heart attacks, you also have disease in other vessels in the body. Here are some suggestions:

—-Follow a Mediterranean Diet....it prevents heart disease.

—-Get the LDL low. Below 55 would be great but at least below 70

—Obtain an actual LDL measurement called the LDLp—-see the article from my book.

—Regular exercise per the doc

—Control other risk factors including diabetes, blood pressure (goal is 130/80), smoking (quit), kidney disease etc.

—Reduce stress thru meditation

Best,

Evan L. Lipkis, MD


Cholesterol. What are the guidelines? Is a stress test worthwhile? What do you think of the coronary calcium score?
Most reduction in cardiac risk occurs with lowering the LDL down to 100. So 100 is a great goal. With more risk factors and cardiac events, go even lower.

Basically, the higher your risk, the more aggressive, the doc should be. And the Feb. 2nd 2019 Lancet showed that ALL ages benefit from statins even if you are older than 75! The earlier a statin is started, the less damage that is done. So initially it was thought that statins didn’t help the elderly. This probably had to do with less time for the drug to work. Certainly some elderly people with lower cardiac risk might consider stopping their statin, but what if that elderly person lives to be 105? Cholesterol plaque builds up over time. Now that people are living longer, statins have a place in reducing heart disease and strokes in the older population.

The 2017 AACE guidelines are complex but easier to understand than most of the other guidelines. The ACC or American College of Cardiology has their 2018 guidelines as well. Ok, here we go!

Determine your risk factors. The major risk factors are high blood pressure, age, diabetes, smoking, family history of early heart disease, advanced kidney disease, elevated LDL or bad cholesterol etc. Keep it simple and just look at these risk factors. So let’s say Joe had a father who had early heart disease (under age 55 for males and under age 65 for females). Additionally, Joe has elevated LDL cholesterol.

2. Figure out your risk based upon the risk factors:

EXTREME RISK

having progressive heart disease even with an LDL less than 70 or
established heart disease with diabetes and advanced kidney disease and/or heterozygous, familial high cholesterol (a genetic syndrome) or
a personal history of heart disease (male under 55, female under 65).

VERY HIGH RISK

established or recent history of coronary disease, stroke or vascular disease in the lower extremities or
either diabetes or advanced kidney disease with one or more additional risk factors or
heterozygous, familial high cholesterol (genetic syndrome)

HIGH RISK

2 risk factors or more or diabetes or advanced kidney disease or 10-year risk of heart disease between 10-20%-http://www.cvriskcalculator.com

MODERATE RISK

2 risk factors or more or diabetes or advanced kidney disease or 10-year risk of heart disease less than 10%-http://www.cvriskcalculator.com

LOW RISK

Zero risk factors

So, Joe is EXTREME RISK. Why? Because he has a family history of early heart disease.

3. Establish your category which will tell you your LDL goal. In Joe’s case, he is at extreme risk and his LDL needs to be lowered to less than 55.

4. Use lifestyle modification and medicines (if necessary) in order to meet the standards set forth in the above chart. If you are at low risk (no risk factors), keep the LDL below 130. On the other hand if you are at extreme risk, keep the LDL below 55.

We have boiled down many pages of guidelines into just a few paragraphs. Let’s say you had a heart attack only. Your risk is very high and the LDL goal is less than 70.

What if you are 65 and have 2 risk factors such as high blood pressure and hyperlipidemia (elevated LDL cholesterol) you go to http://www.cvriskcalculator.com and find out that your risk is 15% in 10 years of having a cardiac event. You are at high risk and the goal is an LDL less than 100.

The good cholesterol or HDL remains a black box. People can have elevated HDLs and still get heart disease because the HDLs might be lazy and not remove plaque from our arteries. Right now, LDL is the most important value in the cholesterol profile and does not require fasting. I have a patient with an HDL of 120 yet she developed vascular disease in her legs. What gives? Well, her HDLs were lazy and didn’t do the job of clearing out bad cholesterol in the arteries.

Admittedly, per the April 17th edition of JAMA, 2018 the most benefit comes from getting the LDL down to 100 and then smaller benefits are realized with further lowering. Statins are cheap and reduce heart attacks, strokes and coronary bypass surgery. They can lower LDL by up to 50%.

Unfortunately, there are many naysayers regarding statins and that is really sad because I have seen people die rather than take a statin. Interestingly, the risk of dying in a car is 1 in 6000 while the risk of dying from a statin is less than 1 in 30 million. The chance of being struck by lightning s 1 in 500,000 just to add some perspective. All I can do is provide the truth as we know it based upon the evidence today. And knowledge is a precious commodity.

Now certainly some statins can raise the blood sugar mildly but the benefits far exceed the risks. Statins may cause muscle spasms but so does age. A trial off the statin can be useful so one can tell if the statin is the culprit. Amazingly, after a statin break, the same statin can be tried again and often there are no longer muscle side effects. Switching to a statin that doesn’t get in the muscle very much can be helpful. Examples include Livalo or Zypitamag (pitavastatin). Sometimes raising vitamin D levels over 40 or taking coenzyme Q-10 can be useful. I firmly believe that after vaccines and antibiotics, statins are the greatest drug class of the 20th century.

Ezetimibe (Zetia) has been shown to reduce heart attacks in high risk patients who have coronary heart disease and lowers the LDL by an additional 25% per the Improve-It trial. In the Ewtopia trial it reduced the first cardiovascular events in a senior Japanese population. This is a great add on medicine if a statin doesn’t get you to goal. It blocks the absorption of cholesterol while a statin blocks the production of cholesterol by the liver. It is a great 1-2 punch!

Newer agents called PCS-K9s (Repatha and Prauluent) are costly but can reduce plaque and cardiac events as well. They are injected every 2-4 weeks and are easy to use. These agents can lower LDL by 60% when added to a statin. Generally they reduce cardiac events by 20%. I often hear people worry that they will be left without a memory because the cholesterol goes very low. Actually we are born with an LDL or bad cholesterol of 35-40 and babies learn just fine at these levels. Additionally, patients on the above agents can have LDLs of 15-20 and there is no change in memory.

In fact, fast foods can impair memory plus most of the risk factors for dementia are the same for heart disease so keep the lipids well controlled.

If you are already on a statin and your triglycerides (fats) are borderline or high, the Reduce It study shows a 25% reduction in heart attacks and a 30% reduction in sudden death by adding pharmaceutical grade fish oil such as Vascepa (icosapent ethyl) which contains only EPA or one type of fish oil. 70% of the patients already had heart disease and the other 30% had diabetes with 1 additional risk factor. Therefore this was a high risk group.

The real question is, why did fish oil work in this trial, but in the VITAL study, fish oil and vitamin D did not reduce heart attacks or cancer. Possible explanations include:

—The people in the VITAL study were healthier so fish oil didn’t make much difference.

—The REDUCE it trial patients received 4 fish pills a day as opposed to 1 fish pill a day in the VITAL study and the pills were pharmaceutical grade (unoxidized and high quality). More trials are forthcoming.

—Finally, there are 2 ingredients in fish oil supplements, EPA and DHA. It seems to me that EPA is more protective for the heart because it doesn’t raise bad cholesterol like DHA. A study in the Jan 3rd 2019 edition of Stroke showed that patients who had higher levels of EPA in their fat tissue had less strokes. Some patients were on fish oil supplements and some just ate fish.

There is little controversy that eating fish cuts heart attacks, strokes, and peripheral vascular disease. So, go eat fish!

Sometimes it’s hard to decide what your actual risk of heart disease really is. And many people just won’t take a statin. Under these circumstances, one can do a coronary calcium score as seen below or look at a few other inflammatory biomarkers such as HS-CRP or LP-PLA2 in the blood. High values in any of these tests would warrant more aggressive treatment. There is also a gene for heart disease called Lp(a) and this usually warrants more aggressive treatment.

We also like to measure the direct LDL particle count. 50% of patients have a normal LDL concentration with the usual measurement that your doc performs, but the LDL particle count or LDLp can be high and lead to increased cardiac risk. There are many studies that verify this point.

Here is an example of why this is so important. Tim Russert was the host for ‘Meet The Press’ for many years but died of a heart attack back in 2008. His regular LDL concentration was 67, which was amazingly good. So, why did he die? Post-mortem, his blood was measured for LDLp or the actual number of bad particles. Turns out that this value was nearly 3000, which was sky high. We like to see an LDLp under 1000 in patients with higher cardiovascular risk.

So many people have cardiac risk factors such as smoking, high blood pressure, obesity, early family history of heart disease, kidney disease, sleep apnea, diabetes or pre-diabetes, elevated LDL cholesterol, and even depression/stress, yet they won’t take a medicine or change their lifestyle to reduce that risk. Ok, there I go again but noncompliance is the biggest risk factor for heart disease outside of age.

Consider basing your beliefs on overwhelming medical evidence because it’s all we have right now. Once again, knowledge is a precious commodity but we live in an emotional world. And emotions are far less mature than reasoning. But that topic is for another day.

If you refuse to believe that you are at moderate or high risk for vascular diseases (stroke, heart attack, kidneys disease, eye vessel diseases), then in addition to the above biomarkers, get a rapid coronary CAT scan.

This test takes about 5 minutes and only costs $50 at some hospitals. It will tell you how much cholesterol plaque you have in the coronary arteries of your heart compared to people of your own age. If you have a lot of age-adjusted plaque, then maybe this will serve as a visible indicator to treat your vessel problem with more aggressive lifestyle interventions or a specific medicine. If it is zero, that is great news and your risk for heart disease is much lower but not gone.

In fact, a significantly abnormal rapid coronary CAT scan is an independent risk factor for heart disease. So this test is very useful but usually not necessary.

If you already know your risk category as seen in the above chart, and you’re willing to take action, then this test is just superfluous. But if you just cannot accept that you are at high risk or just don’t want cholesterol lowering medications, then the coronary calcium score may help you to decide in an objective manner. The ACC came out with 2018 recommendations for cholesterol management but it is similar to the guideline I have provided. Basically, more risk means more aggressive treatment.

A stress test is a poor screen for coronary disease. In fact, it only detects blockages of 80% or more. And a heart attack can occur with a 30% blockage because cholesterol plaque can suddenly rupture, bleed and then form an obstructing clot. So the best way to prevent a heart attack is to reduce the risk factors which include smoking, stress, obesity, elevated sugars, high LDL cholesterol and high blood pressure.

Certainly diet (especially the Mediterranean diet) and exercise can lower LDL by 10% but in most cases it is just not enough.

Statins fortunately reduce heart disease, stroke, bypass surgery and help to protect the kidneys.

According to Lancet Feb. 2nd 2019, statins even help people over age 75 which is a point of controversy as I stated earlier.

But statins especially help in this age group if there is evidence of coronary disease.

Drs. Rx: A few pills and lifestyle changes beats catheters and scalpels! Use logic and reasoning when it comes to your own health. Hit the right LDL number based upon your risk.


Evan L. Lipkis, MD

There are so many reasons for hives or urticaria:

Recent illness (eg, fever, sore throat, cough, rhinorrhea, vomiting, diarrhea, headache)
Medication use including penicillins, cephalosporins, sulfas, diuretics, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), iodides, bromides, quinidine, chloroquine, vancomycin, isoniazid, antiepileptic agents, and other agents
Intravenous radiocontrast media
Travel (amebiasis, ascariasis, strongyloidiasis, trichinosis, malaria)
Foods (eg, shellfish, fish, eggs, cheese, chocolate, nuts, berries, tomatoes)
New perfumes, hair dyes, detergents, lotions, creams, or clothes
Exposure to new pets (dander), dust, mold, chemicals, or plants
Pregnancy (usually occurs in last trimester and typically resolves spontaneously soon after delivery)
Sun or cold exposure
Exercise


So the history is everything. Avoidance of the precipitating factor is key. Loratadine, montelukast and ranitidine are a few agents that can be used. For more help, see a dermatologist or allergist.

It all depends how much you drank when you were young. One of the better tests to determine scarring (cirrhosis), is a Fibroscan. It’s a noninvasive vibrational device that can tell if the liver is flexible or stiff and cirrhotic. If any cirrhosis was detected, I would avoid alcohol completely, get the proper vaccinations against hep A and B and further eval. Start with your primary care physician and show him or her my response.

Good health,

Dr Lipkis