16 April, 2024

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The South Asian Enigma: Why We Die More & Die Early From Heart Disease

By Ariaratnam Gobikrishna

Ariaratnam Gobikrishna MD

Across all ethnicities, heart disease is a common threat, but South Asians seem to bear a particularly heavy burden, experiencing it disproportionately more and at a younger age. This vulnerability went largely unnoticed due to the lack of tracking systems and long-term observational studies. However, through the observation of South Asian migrants compared to native populations in Western countries and subsequent comparisons with those back home, we’ve uncovered the fact that we pose the highest vulnerability to heart disease.

Fortunately, strides are being made. In 2010, the first large prospective population study began in the USA, The MASALA Study( the Mediators of Atherosclerosis in South Asians Living in America) initially focusing on professionals on the west coast but now including people from all walks of life on the East coast.

Before delving into potential explanations for this phenomenon among South Asians, it’s crucial to assess established principles for mitigating heart disease severity. We need to understand their origins, the evidence supporting interventions, and their repeated effectiveness. Without this foundation, efforts to combat the issue may inadvertently lead to confusion and chaos.

Heart attacks have been recognized since ancient civilizations, from the Egyptians and Greeks to Islamic times. However, it wasn’t until the Renaissance, particularly with Leonardo Da Vinci’s cadaver dissections (1506), that the correlation between calcium deposits in the arteries, and this malady became apparent. Until the early 1900s, the malady itself and these changes in particular were often attributed to fate, aging, and providence.

True investigation began with Anitchkov’s feeding of pure cholesterol to rabbits (1913), revealing arterial changes. While cholesterol was already identified in bile salts, its abundance in diseased arteries was a revelation. Initially, not all animals exhibited the fat hypothesis; dogs, for instance, showed high cholesterol clearance capacities, leading to little cholesterol deposition in their arteries. This raised the question: What about humans?

As an attempt towards answers, Ancel Keys’ landmark Seven Countries Study  (1952) observed that nations with predominantly Mediterranean diets—less saturated fat and more unsaturated fat—tended to have fewer heart attacks. This finding was confirmed by ongoing studies like the Framingham Heart Study, which initially observed higher total cholesterol correlating with increased heart attacks, later refining into LDL/HDL fractions and most recently into Apo B 100 levels.

The significance of LDL cholesterol emerged when its excess was linked to premature heart attack deaths, notably in children. Brown and Goldstein’s groundbreaking work (1973), which earned them the Nobel Prize, illuminated the mechanism by which cells absorb LDL cholesterol through LDL receptors. Their pivotal discovery came into sharper focus when they compared normal skin cells with biopsies from afflicted children, revealing a notable deficiency in absorption capability of LDL among those children, leading to significantly elevated LDL levels in their blood. Conversely, Individuals with genetically lower LDL levels from birth demonstrate a reduced incidence of heart disease, even in the presence of other risk factors acquired over their lifetime.

While observations pointed to a link between high LDL levels and heart attacks, causation remained unproven, particularly in those falling in the middle range of cholesterol levels. This spurred investigations into cholesterol reduction through various means, including dietary interventions, medications, and surgery—all with the aim of reducing LDL cholesterol. The common theme across these interventions was the correlation between lower LDL cholesterol levels and reduced heart attack rates, eventually substantiated by numerous randomized placebo-controlled double-blinded studies.

In addition to cholesterol, factors such as high blood pressure, diabetes, smoking, high-fat diets, and physical inactivity — initially identified by the Framingham Heart Study (FHS)— contribute to the development of cardiovascular disease. As scientific knowledge evolves, more risk factors are continually added. The presence of multiple risk factors increases the likelihood of adverse events. However, trial after trial, LDL cholesterol stands out as an independent risk factor for heart attacks, consistently observed at the population level.

On an individual basis though, the role of elevated LDL becomes more subtle and complex. It interacts with various genetic and environmental factors, making predictions challenging. While science effectively predicts outcomes at very low and very high LDL levels, it encounters uncertainty at intermediate levels. This is where the risk calculators come into play, incorporating factors such as age, sex, and other conventional risk factors identified by FHS. In addition, risk modifiers are in use as well, like coronary calcium scoring, ethnicity (such as South Asian) and many others to categorize individual risk.

When it comes to treating individuals, lifestyle modifications take precedence for individuals without a history of heart attack or stroke, challenging the common belief that all elevated LDL levels are prescribed statin therapy. Lifestyle changes such as dietary modifications, weight loss, and exercise can make a significant impact, rendering medication unnecessary for many. However, genetics can sometimes override these efforts. For those with borderline to intermediate calculated risk, especially non-diabetic non-smokers of middle age, a CT scan of the heart for calcium scoring may be offered to further stratify risk. A calcium score of 0 in a middle-aged individual downgrades her or him as low risk for at least the next 5 years, with risk stratification repeated thereafter. The medications will be the last resort for this category.

Before we dive deeper into the subject of why LDL is the main culprit, it’s important to understand the typical blood chemistry results we encounter regularly. What we see on paper doesn’t always reflect what’s happening within our arterial walls, and this discrepancy is where much of the confusion arises and persists.

In an ideal scenario, interpreting blood lipid results should be simple: we would focus on the number of LDL, HDL, IDL and VLDL. Instead, the laboratories report measured total cholesterol, triglycerides and HDL, while LDL cholesterol is estimated, giving rise to confusion. In reality, fats—both cholesterol and triglycerides—are always carried in these vehicles. These lipoprotein vehicles play crucial roles in the transportation of fats in and out of arterial walls. LDL, IDL and VLDL are responsible for ferrying cholesterol into the arterial walls, where it can contribute to plaque formation. On the other hand, HDL works to remove excess cholesterol from arterial walls, facilitating its disposal by the liver. However, there’s a silver lining amidst the confusion: each vehicle capable of penetrating and causing depositions(LDL, IDL and VLDL) in the arterial walls carries a protein on its surface called Apo B 100. By measuring Apo B levels, we can sidestep the need to count LDL, IDL, and VLDL vehicles separately, providing a clearer picture of atherogenic particle concentration in the bloodstream.

Hopefully, Apo B 100 levels may become a universal standard. However, until then, we must work within our current reporting system, which often assumes that high total cholesterol or LDL cholesterol corresponds to a higher number of LDL particles and that high triglyceride levels indicate a higher number of IDL and VLDL particles and vice versa. Unfortunately, this assumption is not always accurate and can lead to misinterpretation of lipid profiles.

About LDLs culpability, LDL’s extended circulation time, lasting days compared to hours for IDL and VLDL, makes it the primary culprit in atherosclerosis. Roughly 90% of Apo B-carrying particles in the bloodstream are LDL, driving cholesterol transport and plaque formation in arterial walls. Unlike LDL of any size, only small size VLDL can penetrate artery walls, rendering VLDLs contribution inconsequential, with IDL quickly cleared from circulation, making its contribution not noteworthy as well. Rare genetic mutations may impair IDL clearance, but such cases are rare exceptions.

Having established LDL’s role in plaque formation, it’s crucial to examine the specific mechanisms at play. Two key steps, penetration and retention, drive this process. The ideal milieu for penetration is a high pressure blood stream — arteries,not veins — with abundance of LDL, sloshing around for prolonged periods, aided by known factors such as high blood pressure, diabetes and smoking along with unknown factors — genetic or otherwise. Retention is aided by oxidation of LDL and attachment to proteoglycans exacerbated by inflammation and impaired functionality of HDL. Once the oxidized LDL is retained, it is engulfed by white cells and the vicious cycle of inflammation ensues. Thus, studies unequivocally demonstrate the importance of reducing LDL levels at the outset to mitigate plaque formation, alongside efforts to address other risk factors.  However, some individuals may tolerate high LDL levels due to unknown factors, but preemptive identification is not possible. At this time they can only be identified retrospectively, for example by periodic coronary scans.

Now we know how the plaques are formed, next we need to know why they cause heart attacks. Plaques within arteries can trigger heart attacks through two primary mechanisms. First, they can gradually grow over time, narrowing the artery and ultimately obstructing blood flow. This process can lead to chest pain (angina) and, in severe cases, tissue death (myocardial infarction).

Secondly, plaques can suddenly rupture, triggering the formation of blood clots that rapidly block the artery, resulting in an acute and often fatal heart attack. This process, known as plaque rupture, is particularly dangerous as it can occur with minimal warning signs. Swift intervention to open fully blocked arteries within 90 minutes due to sudden clot formation is life-saving. This forms the basis for emergency medical services and catheterization labs in the West, albeit impractical in many developing countries. Bystander resuscitation and on-site defibrillator use further enhance these protocols in the West.

Our central theme of this article as to why South Asians are more prone to heart disease remains elusive, but several theories have emerged. A central hypothesis revolves around visceral adiposity—the accumulation of fat around internal organs. It’s proposed that due to limited fat storage capacity among South Asians, excess fat accumulates around organs, leading to multi organ inflammation triggered by the slow release of harmful adipokines — in contrast to the fast release of cytokines (cytokine storm) responsible for multi organ failure in Covid-19 deaths.

This chronic inflammation damages arterial linings and promotes insulin resistance in muscles and the liver, perpetuating the inflammatory cycle. Insulin resistance in turn results in a distinctive cholesterol profile called atherogenic dyslipidemia, characterized by low levels of protective HDL, high triglycerides, and dense LDL particles—known for their heightened plaque-forming potential.

These plaques, fueled by a highly inflammatory environment, become prone to rupture, culminating in premature heart attacks and deaths—a risk compounded by the smaller caliber of arteries in the South Asian population.

While these hypotheses shed light on potential mechanisms, further research is needed to validate their significance in South Asian cardiovascular health.

While we await conclusive research on causation, there are proactive steps we can take to mitigate our risk of cardiovascular disease.

The body stores excess calories as fat, primarily from simple carbohydrates and fats. While saturated fats can reduce LDL absorption by cells, especially in the liver, polyunsaturated fats have the opposite effect. Dietary intervention studies on cardiovascular outcomes consistently favor the Mediterranean diet, rich in polyunsaturated and monounsaturated fats, whole-food carbohydrates, fish, vegetables, and less processed foods and red meat. Emulating this composition, tailored to local palates, is prudent, while avoiding our usual high consumption of processed carbohydrates, whole milk, butter (ghee), deep-fried foods and our practices of prolonged cooking times, and reuse of cooking oil. Additionally, caution is advised regarding coconut oil’s safety, as evidence remains inconclusive. Moreover, it is a saturated fat known to elevate LDL while elevating HDL as well.

Engaging in physical activity is pivotal for shedding unnecessary fat and promoting overall health.

Interpreting health metrics may require a nuance from Western standards. Considerations such as a lower (body weight) normal BMI (e.g., 23 instead of 25), reduced waist circumference, and aiming for lower LDL levels may be prudent. Individuals with a strong family history of cardiovascular disease should commence screening early and adopt healthy lifestyles promptly. They should be screened for Apolipoprotein (a), a known transmissible cholesterol from parents, as well. Middle-aged individuals should consider coronary calcium scoring and elevated results may necessitate aggressive lifestyle changes and medication to lower LDL levels.

Expanding population-based prospective studies to include Asian nations could illuminate unknown factors. Public awareness is crucial, as many genetic predispositions require environmental triggers or epigenetic influences to manifest as diseases. Hence, lifelong adherence to a healthy lifestyle is paramount.

While uncertainties abound, optimism is warranted, as advancing technology holds promise for affordable solutions to seemingly intractable health challenges.

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Latest comments

  • 53
    17

    An awesomely informative article!

    Ariaratnam Gobikrishna, MD, just swiftly mentioned about the “smaller caliber of arteries” in the South Asian population. That too has been well studied and established that us South Asians have narrower coronary arterial lumen compared to other ethnicities.

    • 59
      30

      Yes a comprehensive informative article. If I may add , what was thought benign , sleep deprivation including sleep apnea ( snoring) is a risk factor in causing heart attack and stroke. ( uncontrolled pressure and sugar levels). One more to consider is hard water or excess indirect calcium intake may play a role. Consumption of FRESHvegetables and fruits , ( part of Mediterranean diet) adequate water intake/ hydration and fiber intake can help in cutting down risk.

      • 46
        0

        Hello Chiv,
        I have noticed a number of differences in Diet between Sri Lankans and Europeans. I have Cereal or Oats (Porridge) and some fruit for breakfast. I do not use Palm-oil or Coconut-oil for cooking, instead I use Sunflower-oil and sometimes Olive-oil. I try to eat a range of vegetables and proteins (Chicken, Fish, Shrimps and Crabs). I drink coffee with milk and eat a portion or so of Yogurt. I like Pol Rotti, Malu rolls, Dosa, Dal Vada but limit my consumption of them. Sri Lankan consumption of Sugar based cakes and sweets is also very high
        Sri Lankans have a high consumption of Fats, Salt and Carbohydrates. Most of my relations in my age group (upper 60s and low 70s) and younger suffer from High Blood Pressure, High Cholestorol, Type 2 Diabetes (some Type 1), Severe Arthritis and various Gastric problems. Among the younger population around here (CentralProvince) alcohol consumption is a big problem. Four of my Sri Lankan relations have died in the past 2 years of heart related issues – 2 were heavy drinkers. Scotland had similar Heart Disease problems in the mid-20th Century due to a poor diet.
        Best regards

        • 35
          19

          LS , along with healthy diet , nutritional balance, physical activity, adequate sleep, hydration, moderate drinking ( if at all ) avoid smoking , preventive care, …. …. .. age old practices still seem to hold up. I believe with change in life style ( work , finance, ……….other pressures) we ended up sacrificing healthy habits and with that our health. I will like to stress on preventive health care like regular check ups, The reason being, a common condition like thyroid abnormality if untreated can lead to multiple systemic problems. , including elevated cholesterol levels.

        • 12
          0

          Dear LS,
          .
          “Sri Lankans consume too much fat, salt and carbohydrates.”

          Many people do not know that adding too much salt is a threat to high blood pressure. Last November, when I was buying some fruits for a friend in Wellawatte, the big-bellied seller told me, “Gentlemen, I eat 2 large plates of rice at a time, and the little children do the same.” Rates of disproportionate obesity and diabetes are on the rise rapidly in our country today..

          To be honest, Sri Lankans tend towards fast food and convenience eating habits rather than preparing their meals at home. Derana TV, Swarnavahini TV, HIRU TV and few other YOUUTBER are heavily involved in false propaganda through their TELEDRAMA series and many women, wives and many others are involved in wasting time for watching TELEDRAMA. So housewives do not spend time much for preparing a good meal as our elderly mothers did then. All good habbits of cooking are vanishing..
          :
          Tbd

          • 12
            0

            cont.
            .
            In the 80s, if I say so, my mother never allowed us to buy packeted or canned food, even if there was fresh fish even 3-4 km away from our ancestral home. SOUTHERN province.
            However, the new generation depended on buying meals outside today… but they women could prepare their good and healthy food rather than buying “string hoppers or hoppers” outside. Most of them do not have minimum knowledge about the nutritional levels their daily diet.They overcook some vegetables. Dahl curry is prepared destroying all the proteins in it.
            I’m a biochemist and I know how and when food intolerance could mislead many of the consumers. And our people are big eaters… they eat RUWANVALISAY sized plate of rice for their lunch and dinner. Nor do they listen to anyone today, people are so addicted not only to drug use but also to fast food. Every time I visit them I rely on good vegetables, fruits and fish.

      • 45
        4

        Chiv, prolonged stress too is a risk factor. Prolonged elevated levels of stress hormone is said to be a risk factor for the other risk factors (cholesterol, diabetes, bp) for heart disease, as well a direct factor causing higher levels of inflammation.

        https://www.yalemedicine.org/news/stress-affects-your-heart#

        https://www.hopkinsmedicine.org/health/wellness-and-prevention/risk-factors-for-heart-disease-dont-underestimate-stress

        Stress is one’s own reaction to situations, and so it is in one’s own control in how they react.

        • 36
          17

          Stress is one’s own reaction to situation and so it is one’s own control.. CBT ( cognitive behavioral therapy) is based on that. Thoughts influence emotions ( feelings) and behaviors ( actions) You can refer to any ” self help CBT ” ( there are mamy ) . Very useful tool and dosen’t cost any.

      • 44
        2

        Must add tobacco smoking to the list of risk factors;
        “ Smoking is a major risk factor for heart disease. The chemicals you inhale when you smoke cause damage to your heart and blood vessels that makes you more likely to develop atherosclerosis, or plaque buildup in the arteries.”

        Ref:
        https://www.nhlbi.nih.gov/health/heart/smoking#:~:text=Smoking%20is%20a%20major%20risk,plaque%20buildup%20in%20the%20arteries.

        • 36
          18

          Sugandh , you’re absolutely right. I was about to add stress and mental health issues mainly mood disorders ( depression and anxiety) which are highly prevalent among elderly and when not addressed will significantly impact one’s physical health. Recent studies show beimg lonely is as significant or more , as in smoking . Another area to pay attention is Environmental pollution . There are plenty studies showing pulmonary damages but few recentl ones show cardiac related problems. Not explained by dyslipidemia / hyperlipidemia but still causing inflammation or damaging inner most layers of arteries.( kind of arteritis) .Stress is explained by higher corticosteroid levels which inturn in combination with multiple other factors can worsen cardiac health.

          • 35
            19

            Initially I was about to include mental health / mood issues but avoided due to limited space and time. Being lonely, stress, and mental health issues can either trigger or exacerbate physical problems including cardiac, and memory / cognitive decline.

            • 35
              19

              Sugandh , According to latest WHO studies mental illness is now prevalent anywhere from one in five to soon going to be, one in three among all age groups ( life time prevalence). Recent pandemic just made matters worse. This is one area still there are many barriers starting from stigma, denial, poor insight, lack of access …… currently in India, there is only one mental heal provider and clinical psychologist for more than one thousand population.

              • 30
                0

                Emotional stress is increasing as a result of fast changing life styles and rising external pressures.
                The stigma attached to mental illness is a factor in reluctance to seek psychiatric assistance in time. Individuals and families tend to cover-up issues rather than face them.

              • 33
                19

                Sorry, one doctor and therapist for more than 100, 000 population. In general elderly (> 65 years ) are vulnerable in many ways 1) being alone, widowed, separated, 2) lacking family / social support, mostly in West 3) having chronic medical issues like Diabetes, blood pressure to many others 4) disabilities due to ageing and illness, like visual , hearing, gait impairment 5) In west on an average they are on minimum 3 to 5 medicines 6) lacking independence , access to health services , socialization 7) needing assistance with mobilization, wheel chair bound 8) chronic pain , frequent falls, loss of bladder / bowel control 9 ) high prevalence of elderly depression 10 ) hormonal changes, 11) neglect . . . . . . . ……..

        • 27
          0

          Hello Sugandh,
          I haven’t seen many women smoking here where I live in Central province. Have any studies researched this difference between men and women regarding Heart Disease?
          Best regards

          • 27
            1

            LS, as long I know there is no difference in morbidity or mortality among both sexes. Smoking is harmful to all. Whereas alcohol may vary. For example the metabolizing enzyme called alcohol dehydrogenase levels it self can vary among both sexes.

          • 25
            1

            Hello LankaScot, great question. Hadn’t explored the topic before.

            Please take a look at this 2021 article;
            https://www.nature.com/articles/nrcardio.2011.134#:~:text=The%20risk%20of%20coronary%20heart%20disease%20(CHD)%20is%2025%25,than%202.4%20million%20people%20worldwide.

            So it seems women smokers are at substantially higher risk for coronary heart disease.

            • 18
              0

              Obviously I’m still a learner. A big thank you to Dr. Andy Somesan for the valuable information on Insulin resistance and risk of atherosclerosis. Also to Sugandh for reproducing the research study, on smoking and high risk of CHD/CAD in women.

    • 29
      0

      True,
      But the rise in incidence of heart problems has to do with change in our way of life.
      Modernism brought with it a decline in exercise and some bad food habits.
      Asian living abroad are particularly more vulnerable I think.

      • 34
        19

        SJ, agree , in search of knowledge, wealth, comforts, rights ….. among many other things , ended up sacrificing, healthy habits.

      • 35
        2

        SJ,
        “Asian living abroad are particularly more vulnerable I think.”
        Yes, South Asians in the US have the highest risk. But don’t the others eat more starch and fat?

    • 8
      1

      An excellent piece of work for the public. That’s the norm based on the thousands of years of diet and strength. It is perfectly ok by knowing that a billion of us are around. Most of the heart diseases corresponds with winding down with old age.

      The other side of the coin is that we all have to go one day. Prolonging the lifespan without corresponding ability to have strong and healthy mind, and by suffering with Alzheimer, etc., is not worth living. A visit to partially cared seniors’ residences will confirm it.

      Let’s ensure that young are taken care of well. Older South Asians have a balanced way of going out until now. Going out is not a bad thing, it is living with bad health is difficult to handle for the patient and the relatives. Not all the people are rich either to pay for private health for marginal increase in lifespan.

  • 38
    0

    An excellent and instructive essay that incorporates recent research and observations. This kind of article is refreshing and sorely needed in a forum where the usual engagements are quite pathetic. I see from comments above, that there are good inputs from commenters who seem knowledgeable of health issues and medical matters. One’s mental state and levels of stress, sleep and relationships, social engagement are all critically important for a healthy life in addition to regular monitoring of investigative data. We must encourage this writer to share more information, as he also has an excellent command of the language and articulates with much dexterity.

    • 38
      2

      “Dr. Ariaratnam Gobikrishna, MD is a cardiology specialist in Bronx, NY and has over 34 years of experience in the medical field. He graduated from Thanjavur Med Coll-Madras University in 1989. He is affiliated with Montefiore Medical Center. “
      I think Dr. AG isn’t Chiv, but I wonder what the crypto-fascists on this forum have to say about his qualifications? 🤣🤣🤣

  • 35
    0

    I know bugger all about any of these medical research …….. there are some Japanese islands where some of the taxi drivers are over 100 …… and the most of the inhabitants as well …… https://edition.cnn.com/2019/04/05/health/japan-okinawa-food-diet-hara-hachi-bu-chasing-life-gupta/index.html

    But we overlook a group right among us …….. Lanka’s geriatric politicians ……. why they last so long ……. and the rest don’t.

    And don’t let Old Codger be bashful about the secret of his longevity: the book he wrote …….. ” The Joy of Sex.”

  • 38
    0

    Thank you Dr. Gobikrishna, it was an excellent attempt to convey your knowledge on coronary artery disease especially affecting prematurely the South Asians.

    As we all know insulin is the most arthrogenic hormone known to us. Unfortunately we all focus insulin into carbohydrate metabolism. Apparently it plays a major role in fat metabolism too.

    In Southeast Asians insulin resistance is a major factor in premature coronary artery disease. In this condition insulin levels are several folds higher than normal range which promotes all your LDL particle going across endothelial cells causing the most dreaded inflammation and eventually arthrogenic plaques.

    Anything promoting to reduce insulin resistance (serum insulin level) will help improve atherosclerotic coronary artery disease. This include cutting down carbohydrates especially the processed foods, reducing stress, regular aerobic exercise, alcohol in moderation, any food or medicine improves insulin resistance, stopping smoking etc.

    In any situation the genetic vulnerability with environmental trigger factors play a major role in any disease process. Premature atherosclerotic disease in South Asian also obeys the same rules. Our traditional diet and lifestyle, protected us from this dangerous disease but unfortunately introduction of Western processed food and sedentary lifestyle had played major roles in promoting this disease.

    Thank you
    Dr. Andy Somesan

    • 0
      42

      Dr. Somesan,
      .
      Where did you find these ‘arthrogenic plaques’? Can you enlighten us about them, the less fortunate?
      .
      I want to post a few smiley comments here and make a big joke out of you, in the same spirit of some other commenters here, but, I am restraining myself.
      .
      Still please let us know about your discovery – arthrogenic plaques.
      .
      Thank you.

      • 25
        0

        Ruchira, looks like you have finally completely lost your mind. Nit picking on a typo??? “Arthrogenic” instead of “Atherogenic”.

        Perhaps you are indeed unfortunate and ignorant of Atherogenesis and don’t know where one can find an “Atherogenic plaque”. If so, please check out these links and tell us where you can find an atherogenic plaque? Specifically, could atherogenic plaques form in coronary arteries?:
        https://www.sciencedirect.com/topics/medicine-and-dentistry/atherogenesis
        https://pubmed.ncbi.nlm.nih.gov/37494987/

        • 2
          16

          Not exactly a nitpicking. Word got cross-used for plaque. Correction is good.

          “Arthrogenic muscle inhibition (AMI) is a common impairment in individuals who sustain an anterior cruciate ligament (ACL) injury. The AMI causes decreased muscle activation, which impairs muscle strength, leading to aberrant movement biomechanics.”

          “Atherogenesis (the formation of atherosclerosis from the root “gen,” meaning to form) is a disorder of the artery wall that may be the result of a chronic inflammatory fibroproliferative process that has become excessive and in its excess this protective response becomes the disease state, a maladaptive response.”

          • 13
            0

            The author of the original comment has stated that it was an inadvertent error due auto correction. It was not an unintended cross use of terminology.

            There was no room for confusion about the location of the plaques to which Dr. Somesan referred.

      • 30
        0

        Webmd Doctor
        https://doctor.webmd.com › doctor
        Dr. Andy Somesan, MD, Geriatric Medicine | Pensacola, FL
        Dr. Andy Somesan, MD, is a Geriatric Medicine specialist practicing in Pensacola, FL with 40 years of experience.

      • 21
        0

        Thanks for pointing out the error. Welcome to auto correction era. Unfortunately without my knowledge it twisted the word. Besides I am not publishing this article for a strict spelling check. Apparently the comment made was unfair and low level..

        • 21
          0

          Andy,
          “the comment made was unfair and low level”
          That particular commenter suffers from a non-medical allergy to people who are smarter than him.

          • 18
            0

            OC , what a PITTY isn’t it.

          • 15
            0

            Thank You.

            • 0
              18

              Dr. Somesan,
              .
              Glad to be of help and thank you for acknowledging such comments are low level. That was precisely the reason it was made.

        • 0
          18

          Dr. Somesan,
          .
          Glad to be of help and thank you for acknowledging such comments are low level. That was precisely the reason it was made.

          • 16
            0

            Who are you trying to fool, Ruchira?

            Instead of accepting you were ignorant of the terminology (aethrogenesis, aethrogenic) because you are only familiar with the widely used term ‘Atherosclerosis’, and being your usual self, launched an insult at Dr. Somesan ridiculing with the question, “Where did you find these ‘arthrogenic plaques’? Can you enlighten us about them, the less fortunate?”…. Yet again launched another insult at him.

            Disgusting behaviour, Ruchira.

            • 0
              5

              I am not trying to fool anyone. You are free to make your own judgements. Unlike you I have no issues with it. But I don’t need your character certifications. I’ve got better references for my behaviour. Have a good day. Given your attitude I am not interested in interacting with you here.

              • 5
                0

                Perhaps, you need to work on your written communication skills so that when you’re ridiculing anyone on this forum, in actuality, it comes across as being decent and respectful. Then you too can be a smooth operator!

                This is a public forum. Be prepared to face the consequences of what you write. Please learn to value feedback, and take ownership when you muck up.

            • 0
              5

              And just FYI this whole piece is nothing but an advertorial for lipid lowering drugs on the pretext of promoting heart health. Not that I have any issue with them. They play a vital role in the management of heart disease. But one should learn to read inbetween the lines and learn to identify a spade for what it is. That’s it nothing more to say to you.

              • 5
                0

                Poor Ruchira baba gets more whiny by the day.
                Poor Ruchi must improve his “making friends and influencing people ” skills as I told him long ago.

    • 0
      4

      Hello Dr. Somesan – on a more serious note I think you are probably on the right track by highlighting the role of insulin in the pathophysiology of coronary artery diseases (CAD). I never kept abreast with the latest developments but I am sure being based in the US you may have heard of the alleged scandal involving the sugar industry and the American Heart Association (AHA). It is alleged that sugar was known to be a bigger culprit than fat in the formation of heart diseases or CADs to be precise, but the sugar industry allegedly ‘paid off’ the AHA to look the other way an implicate lipids, based I think on the famous, often quoted Framingham study, which some seem to think was ill designed, and does not provide adequate level of evidence to support the conclusions and recommendations made based on its findings. If I can remember right specially wrt to CAD in females. Something perhaps to do with sample size?

      • 0
        4

        Continued from above in case the comment get truncated for word limit…
        .
        There was a meta analysis published few years back around the same time the news of the alleged scandal received media attention that somewhat supported this claim. That is evidence to implicate ‘fats’ in CAD is low – or some such argument. But it was a meta analysis and concluded that further studies may need to ascertain the truth. Not sure what happened after that. I think it was even suggested that fats in fact are cardioprotective! Not sure of this last claim either but I’m sure you either are already aware of this or could easily find it out. Cheers!

  • 10
    0

    what he has omitted is stress.Stress is a killer.To lead a stress free life follow the Lord bhuddha’s teachings.If you are a worrier(not warrior) then you are likely to die of a heart attack.Stop worrying.

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