Heart attacks are preventable, but for reasons discussed in previous columns in this series they remain the number one killer in the United States. This is another column based on the effective Bale Doneen Method (BDM) of heart attack prevention.

To review, the cause of diseased arteries is oxidation, which results in inflammation of the inner lining of arteries called the endothelium. Bale and Doneen call this inflammation “fire in the arteries.” Let’s say you have an imaging study such as carotid IMT that shows plaque in your arteries, and lab tests indicate inflammation. What can you do to “put the fire out?”

First of all, Bale and Doneen point out in their 2022 book “Healthy Heart, Healthy Brain” that “study after study has proven that an optimal lifestyle is the most powerful defense against chronic inflammation and the devastating diseases it can spark.” They recommend the following lifestyle measures: 1) Devote 10 minutes a day to mindful meditation, which can boost heart health by decreasing anxiety, stress, and depression. 2) Engage in daily physical activity, which has been shown not only to reduce blood pressure, cholesterol, and weight, but also inflammation. 3) “Eat the rainbow,” which means consume a variety of colorful fruits and vegetables, which are loaded with antioxidants and other micronutrients that promote arterial wellness. 4) Avoid sugary drinks and other refined foods, because they cause inflammation and increase the risk of heart attacks, strokes, cancer, obesity, and prediabetes/diabetes.

Second, your doctor needs to look for and help you control any contributing risk factors for heart disease: 1) Blood pressure should by < 120/80 in most cases; 2) Lipid levels (total cholesterol, HDL, LDL, triglycerides) and especially ApoB (a measure of all the “bad cholesterol”) should all be brought to optimal levels; 3) Sleep apnea should be looked for and treated if present; 4) Tobacco should be avoided; 5) Insulin resistance, which is involved in prediabetes and type 2 diabetes, drives 70% of heart disease in this country and should be screened for using a 1 and 2-hour glucose tolerance test —and reversed by measures such as losing belly fat; 6) Non-apnea sleep problems should be addressed; 7) Obesity should be treated; 8) Inflammatory diseases such as asthma should be treated; 9) Tooth and gum disease should be searched for, which includes a saliva test for high-risk oral bacteria — and treated when present. 10) Low vitamin D levels should be treated with D3 supplementation.

Third, the BDM recommends the following medications and supplements to treat fire in the arteries:

· STATIN DRUGS are advised regardless of cholesterol levels, due to their proven anti-inflammatory, anti-oxidant, and anti-platelet effect (platelets are blood cells that cause clotting). Atorvastatin and pravastatin should only be prescribed for the 60% of Americans who are positive for the KIF6 genetic variant. Furthermore, Bale and Doneen cite evidence that that atorvastatin has poor outcome data in women, and in diabetics of either sex.

· ACE INHIBITORS, usually used to treat hypertension, help stabilize arterial plaque and are recommended by Bale and Doneen for anyone who shown to have it. Occasionally, people experience a dry, hacky cough with ACE inhibitors, in which case second-line ARB drugs such as losartan should be considered.

· ASPIRIN helps prevent an artery-blocking blood clot from forming if plaque ruptures (the cause of heart attacks and most strokes). The downside of aspirin is that it can cause dangerous bleeding, and it should be avoided in people who have not been proven to have plaque — which Bale and Doneen call primary prevention. The BDM method considers anyone with plaque to qualify for secondary prevention — in these people the benefit of low-dose aspirin (81 mg.) outweighs the risk. Anyone who has had a cardiovascular event (heart attack or stroke) qualifies as what the BDM call tertiary prevention, and these patients need aspirin. The BDM recommends that all patients who need aspirin for heart attack prevention be checked for aspirin resistance through an inexpensive and widely-available urine test such as AspirinWorks, because some patients need a dose higher than 81 mg.

· PIOGLITAZONE (ACTOS) should be considered in patients with insulin resistance/prediabetes/diabetes who do not respond to diet and exercise–the mainstays of treatment for these conditions. This drug halts the progression of cardiovascular disease and helps prevent new-onset diabetes.

· COENZYME Q10 (CoQ10) in the form of ubiquinol is a useful supplement for people who have muscle aching with statin drugs. (Low thyroid and low vitamin D levels can also contribute to this statin side effect and should be ruled out prior to starting a statin).

· BERBERINE is a natural compound found in several plants, and is available in supplement form. It has anti-inflammatory effects, improves insulin resistance, lowers cholesterol and blood sugar, and reduces fatty liver.

· CINNAMON reduces blood sugar, lipid levels, and insulin resistance.