Genetics and Heart Disease: What you Need to Know

Interviewer: Can you talk about genetics?  We hear a lot about that if your father or mother has heart conditions an we watch you closely is that fair, is that accurate? 

Dr. Bradley Bale: Yes, genetics can have a huge influence on the risk.  And we've been doing genetic testing with our patients for over a decade.  One of the ones we found extremely useful, and it's been available for a long time.  It's called the APOE gene, determines to a large degree how you break down what you ingest, what you put in your body.  And there are three basic different forms of the APOE gene two, three, and four and you can mix and match them, because you get one from one parent one from the other.  Just to try and keep it simple if you inherit the APOE four gene you have a lot of difficulty breaking down fats, digesting the fats.  So if you're on a higher fat diet you're probably in trouble.  

The APOE 2's tend to have a little more trouble with the carbohydrates and alcohol for example.  The APOE 2's tend to break that down pretty well, and it will usually raise the good a little bit and lower the bad.  APOE 4's are just the opposite tend to have more trouble metabolizing the alcohol so in a lot of those patients it will actually increase the bad and decrease the good.  So of course all the studies show a little bit of alcohol appears to be beneficial the APO-E 4's are only 20 percent of a population as a rule.   

So 80 percent are either two or three's which  usually do pretty well metabolizing alcohol so the data always shows well that's always a little beneficial to drink alcohol.   Well if you're a four it may  not be it may actually be harmful.  So that's just one simple example of how we utilize that genetic information to guide one of the most important therapies to reduce risk, and that's diet.   Should you avoid fats more, the carbohydrates more, is alcohol beneficial or not beneficial.   

And we always point out with our female patients even if they're an APO-E 2, where alcohol, you can argue well it could be beneficial, they need to know we've got excellent data now showing that even one alcoholic beverage a day for females significantly increases risks of cancer.  For the number one cancer it increases risk of breast cancer, then rectal cancer, and then liver cancer.  So they need to be aware of that, so and then there are lots of other genes that we look at. 

One of the ones we've been measuring for quite some time now is called 9P21 and it's nicknamed the heart attack gene.  If you inherit that gene from both parents so your home is homozygous for it. You have a 100 percent increase risk of having a heart attack a young age.  And a 75 percent increase risk of developing an abdominal aortic aneurism.  So those are individuals that if you know they're homozygous for that gene you may choose to be a little more aggressive at a younger age.  

They try to control they're cholesterol making sure they sleep well.  Making sure they understand the psychosocial issues can drive inflammation of the arteries.  They might want to go through some bio feedback if they have trouble with anger or anxiety.  They certainly need to make sure they get into the dentist on a regular basis and get a thorough check ups for oral disease. 

So those, that type of genetic information can make a difference in aggressiveness in management for example.  But a large part of the future of medicine certainly is genetics and we all know people who wow, they were the picture of health and they had a heart attack.  And a lot of those people will find out they inherited a gene that increases a cholesterol particle called lipoprotein-A.  And lipoprotein-A is an inherited cholesterol problem.

Really has nothing to do with what you eat or how much you exercise.  And when it's  elevated we have definite data now through genetic studies, definitely is a cause of heart attacks and it's found in about a third of the people who have heart attacks when it's measured.  It amazes us because you may be aware we started guaranteeing our work for heart attack and [??] strokes several years ago, so that kinds of skews our patient population. 

So that we get a lot of patients now who come to us after they've had their heart attack or their bypass or stints.  So they've seen specialists, they've seen other health care providers, and we're amazed at how many of those patients we see in that cholesterol measurement has never been done.  Because you can effect it with certain therapies, one of which is vitamin B3.  But if you don't know you have the problem you're not going to know to put the patient on that medication.

As a matter of fact the European Cardiovascular Society several years ago came out with a guideline statement saying look, people need to have lipoprotein-A measured and when it's elevated they should be placed on Niacin.  Europeans are way ahead of us in that regard.  In fairness to this country when that study was published it really unequivocally told us Lipoprotein-A causes heart attacks.  Dr. Michael Lauer [SP] who at the time was the  head of the National Institute of Health did come out with a statement.  It went out to all health care providers.  Look, Lipoprotein-A causes heart attacks. 

Basically you're saying would you please measure it, maybe do something about it when you find it's elevated, but it's still not in the formal guideline.  A lot of people have already suffered a heart attack.  And it also increases the risk of stroke.  Haven't even had it measured which is amazing.  We have a long way to go with prevention.  Unfortunately this country's health care system really was established on a platform of taking care of emergencies, end stage disease.  And that's lead to the bankruptcy of our healthcare system.  

The Chinese had it right over 4000 years ago.   They actually stated that back then superior health care providers prevent disease.  Mediocre providers treat disease before it's full blown.  Inferior providers treat the full blown disease.  In our system is set up to reward treating the full blown disease and we have to migrate over to a platform of preventing disease or certainly at least if you have disease find out about it before it's full blown and treat it so it doesn't become full blown, and that can be done.