Q&A with Cardiologist Richard Fleming
April 20, 2004 -- Dr. Richard M. Fleming, a nuclear cardiologist and founder of the Fleming Heart and Health Institute in Omaha, Neb., routinely uses a C-RP test, a simple blood test to scan patients' blood for signs of inflammation in coronary arteries that may lead to heart attacks. The test can raise the red flag early in heart disease — while you still have time to prevent serious damage.
Dr. Fleming spoke with ABCNEWS' medical editor Dr. Tim Johnson on 20/20 and answers viewers' questions below.
Denise Davis asks:I am a 48-year-old female with rheumatoid arthritis. I have been advised, due to the arthritis, that my CRP will be higher than normal. My CRP has ranged from 5 to 17. My cholesterol rate is in the normal range. Should I be on a statin drug to reduce my chances of heart attack, or can diet alone produce the same results?
Dr. Richard Fleming:
There are many causes of inflammation that can lead to an elevated C-RP level. With "arthritis", you definitely have a reason for C-RP to be elevated. But it's important to remember that having "arthritis" doesn't make you immune to heart disease, nor does it mean you have heart disease. There are several other tests that we talk about that may be important to you. These include your triglyceride level, homocysteine, lipoprotein (a), fibrinogen, and interleukin-6 (see discussion in subsequent questions). Rather than discuss each of these here, suffice it to say that many of these respond to proper exercise and nutrition. I frequently recommend that people have these blood tests to see where they are starting at and then make the appropriate changes in diet and lifestyle. After several weeks I then suggest people have their abnormal tests (those which are high to begin with) repeated to determine how well they are doing. Many people report that their "arthritis" has improved after changing their diet and lifestyle and most doctors will be delighted that you are making these healthy lifestyle changes.
Judy Tindall asks:Hello,I just watched 20/20 where I was very interested about the blood test. I learned so much from that segment that I didn't know. I have had the test twice so far & my # was high. Off hand I don't the exact # but my Dr. said she wants to watch keep a eye on it. The only thing is she said she would do the test again later to see how I'm doing. I didn't realize the danger was that high. Even thought my cholesterol is normal she had me take the test because of my family history. My mother died of a heart attack. Also, my brother, who was only 47, died in his sleep. I'm very interested in two things, what was that test called were it gave more information about the heart after you have the blood test. Also, how can I find out information about the diet your guest is on. I did just recently start the Ultimate Food Plan (by Dr. Phil) because I am overweight.
Also are there any trigger-foods to avoid?
Thank you for your time & take care, Judy
Dr. Richard Fleming:
The study showing improvement in the blood flow to her heart as well as evidence of reduced inflammation is a "myocardial perfusion imaging" (MPI) study. This is a special type of study used by Nuclear Cardiologists like myself to determine if your have coronary artery disease. We do these studies in a way that allows us to look for evidence of both heart damage and inflammation. The different diet regimens we use are presented in the book "Stop Inflammation Now!" and can be obtained through bookstores or the Internet. There are several weeks worth of recipes and menus in addition to explaining the role of inflammation in heart disease. These recipes and menus can not only help you improve you health but lose weight too.
Ajay Patel asks:What are the symptoms of heart inflammation. How can I get my CRP test done?
Dr. Richard Fleming:
Inflammation is the result of your bodies immunologic system recognizing something as wrong and trying to correct it. Our immunologic system has evolved over thousands of years and responds to everything going on in your body. When something occurs to damage your body, the cells of your immunological system (white blood cells, aka. Interleukins) come to your defense. The change includes redness, tenderness, pain and swelling. When this happens on your skin because you stepped on a nail, you can see this and feel it. But inside the walls of your arteries, this swelling isn't seen and there aren't nerves on the inner lining of your arteries to alert you to the pain. This means that this inflammation can go unnoticed inside the walls of the arteries of your heart, until this damaged "vulnerable inflammatory plaque" ruptures like a volcano into the inside of the artery where a blood clot forms, causing a heart attack. An excellent article was written by Mr. Mark Andersen and published in the Lincoln Journal Star (STAT Medicine-Health section) on January 13, 2004. The article is called "The Dynamic Duo". The CRP test can be done or ordered anywhere blood tests are done, including hospitals, clinics, and doctors offices.
Anne Guerrant asks:Can the C-Reactive Protein test distinguish heart and arterial inflammation from inflammation in other areas such as the elbow or shoulder? I am a national age group tennis champion (55 yrs old)in great shape with excellent eating and workout habits, but I have a 2.8 CRP. I went to the Arizona Heart Institute but was told not to worry about it because my other numbers and lifestyle are very good. It seems like I am always nursing some type of inflammation in my elbow, shoulder, knees, back, etc. Thanks
Dr. Richard Fleming:
C-reactive protein is a non-specific blood test, which can tell you if there is inflammation occurring somewhere within your body regardless of your cholesterol level. It is a clear indication that you have a problem which needs to be addressed; however, this inflammation could be anywhere in your body. When we see an elevated C-RP value, I then look to determine the cause. Some of these tests look for evidence of infection, while others look for evidence of artery inflammation. Since 1995, many researchers like myself have been looking for other tests, which could determine whether the inflammation is coming from the arteries of the heart. The blood flow (myocardial perfusion imaging/MPI) study that we showed on 20/20 can find problems with blood flow to the heart even when other tests may miss the disease. The reason for this, is that other tests are looking for evidence of a change in structure (anatomy) of the artery, while the MPI study looks for problems with the function (physiology) of the arteries of the heart, showing coronary artery disease even in its early stages. Another useful test, which can see within the walls of the arteries (intravascular ultrasound/IVUS), can detect these early anatomic changes of "vulnerable inflammatory plaque" within the walls of the artery. When the C-RP level is high, I check an even more specific blood test called interleukin-6 (IL-6), which can be drawn at the same time as the C-RP level. "Interleukins" mean "inter" (between) "leukins" (white blood cells). "Interleukins" are the "Internet" of the body — they are the means by which the body defenses (white blood cells) communicate with each other to defend and protect the body. This Internet of the body allows us to wage war on the damage to our body. The WMDs of this war are those foods high in saturated fat and refined, processed foods high in calories, which lead to the inflammation which our bodies Internet battles. Everyday these WMDs of our diet assault our bodies rendering countless damage and causalities to our bodies defenses yielding more and more inflammation and damage. As our white blood cells confront the enemy of saturated fat, excess calories and the other causes of inflammation we talk about in our book Stop Inflammation Now!, they release these "interleukins" to call in reinforcements in the battle against inflammation. The success of that battle is determined by what we eat and how we live, since we are the ones releasing the WMDs on our bodies and overloading our Internet system of survival.
Marion Rush asks:
My father's family have heart problems and I want to cover all bases! Would the CRP test replace any tests that show plaque build-up? (Like Heart Check America).
Dr. Richard Fleming:
The use of specialized CT scanners to look for evidence of calcium build up in the arteries of the heart (the test to which you are referring) is an interesting form of non-invasive testing of the body. While work is being done in the field to investigate this type of testing, the absence of calcium on these studies, like the absence of an elevated cholesterol level, does not mean that you are free of the inflammation, which produces coronary artery disease. Getting a CRP test would add useful information to understanding whether you have inflammation and possible coronary artery disease. Considering the cost of a CRP blood test, this is money well spent!
Sandra Wojtaszek asks:My son, 45, had a massive heart attack five months ago. To date he is doing quite well with medication. My question: Should he have a CRP test done? If so when? I've read where a lot of people experience another heart attack within a year after having a had one. Thank you.
Dr. Richard Fleming:
First, let me say I am glad to hear your son survived the heart attack and that he is doing well. Everyone tends to look at numbers and forget that when it happens to someone near to us, that impact is much more than a just number. It is someone we love and care about. There are several tests you son could have to allow him to focus on reducing his risk of inflammation and heart disease. A CRP test could easily be done today and would give important information about underlying inflammation and heart disease in his body.
Karen asks:
Could you tell me which foods fight inflammation of the heart arteries? Please list foods. Does exercise reduce inflammation of the arteries?
Dr. Richard Fleming:
Exercise is a key component to any efforts at improving health. Exercise on a regular basis reduces inflammation in addition to other causes of heart disease (eg. Fibrinogen). As I discuss in the book "Stop Inflammation Now!" it is important that this exercise be something you are interested in. No one exercises for a prolonged period of time without enjoying it and the goal is neither to turn you into an Olympic athlete, nor to injure your body from the exercise. Walking, bicycling, and swimming are all forms of aerobic exercise, which is important for you. When you include other sports (golf, tennis, bowling, etc.) you not only improve your health, but reduce the inflammation too. Foods which are anti-inflammatory, include those foods which are high in the substances (phytochemicals, vitamins, minerals, anti-oxidants) which help the body fight infection, inflammation and damage. An easy way to remember these is to remember that foods rich in color are rich in these beneficial substances. For example, cranberries, blueberries, oranges, cherries, broccoli, spinach, peppers (red, orange, yellow and green), strawberries, etc., are all high in these nutrients. As you probably already noticed, many of these foods are fruits and vegetables. These same foods provide fiber, which we all know are important. Foods that are pro-inflammatory and have been associated with increasing fats, cholesterol and homocysteine in the blood include those foods which are high in saturated fat and high in refined sugars. Most people don't know it, but heart disease was a significant problem in Europe immediately prior to World War II. When WWII began, heart disease dramatically disappeared as the diets changed from excess to reduced fat and calories. When Ancel Keys traveled after WWII he noticed that individuals in Scandinavian countries who consumed large amounts of saturated fat (according to Keys, they actually put butter on their cheese) had very high cholesterol levels and heart disease, while those people in Japan who ate diets high in complex carbohydrates and low in saturated fat had low levels of cholesterol and heart disease. This insight into the role of saturated fat and excess calories and high levels of cholesterol and heart disease began our understanding of the effect of these foods on heart disease. It has only been during the last ten years that some of us have tried to point out the role of inflammation and heart disease, as well as how our diets and lifestyles affect this inflammation.
Angela Hardin asks:Is this a newly developed test? Why haven't the public been made aware of this test before?
Dr. Richard Fleming:
Unfortunately, progress is not always fast, nor steady. In 1995-1996, I developed a theory (explanation) establishing the role of inflammation and heart disease and you don't hear much about this either. We showed that inflammation could result from many causes and began working on what could be done to reduce the inflammation. In fact, many people (physicians and researchers alike) have been trying to explain and then educate others on the causes of this inflammation and problems with conventional tests finding the underlying inflammation. Unfortunately, as Dr. Topol so eloquently pointed out, not everyone embraces new ideas, even when the scientific proof is there. But as you can see from the 20/20 program, Drs. Topol, Ridker, Libby, and myself have been trying to get the word out and thanks to Dr. Timothy Johnson, Barbara Walters and Susan Wagner (who produced the piece), the word is beginning to get out,
Elizabeth Perrone asks:How do you contact your web site? I would like to buy your book, Stop Inflammation Now.
Dr. Richard Fleming:
Stop Inflammation Now! is available in bookstores and can be ordered on line through Amazon.com or Barnesandnoble.com. I do not sell the books, even to my own patients. I firmly believe that selling books in my office represents a conflict of interest and that if people are convinced about what I am trying to explain and do for them, they will go and purchase the book on their own without feeling pressure from me to do so. Please recognize that I am not making a statement regarding others who chose to sell their books directly to people, I am simply stating what I personally believe and am comfortable with.
Dr. Benson Duff asks:Your information is compelling. As you undoubtably know, there has been a significant amount of interest and research into the potential relationship between cardiovascular disease and periodontal disease (ie gingivitis and periodontitis). Since periodontal disease, which is of course an inflammatory reaction to local factors in the mouth, is so prevalent (up to 80 percent of adult population has it), the mouth must be considered one of the most common sources of inflammation intravascularly. I'm curious why, in evaluating your patients and looking to reduce systemic inflammation, you aren't evaluating their periodontal health and making certain that is treated as part of your protocol. At least you didn't mention it in your report.
Thanks,Benson C. Duff, DDS, MS, MS, FICD
Dr. Richard Fleming:
Thank you, Dr. Duff. When C-RP is elevated, there are several tests we do to determine the cause of the inflammation. One of these tests, as I mentioned in one of the other questions, is interleukin-6, which is a part of the "Internet of the body". The other tests we run are related to antibody titers, which look for evidence of bacterial infection in the body. When this infection involves the arteries of the heart, I refer to it as "Bacterially Aggravated Atherosclerosis" (BAA). When we find a bacterial cause of this infection, we treat the person with appropriate antibiotics and have shown considerable improvement in the persons inflammation and heart disease. This research was published in the Journal of the American College of Angiology in 2003 (Using C-reactive protein as a marker for bacterially aggravated atherosclerosis in acute coronary syndromes. J Amer Coll Angiol 2003:1:165-71.) The medical community owes a debt of gratitude to the dental community who first suggested a link between periodontal disease and possible heart disease.
Leonora Arteaga asks:Is stress a contributing factor for blood vessel inflammation?
Dr. Richard Fleming:
Stress is an interesting contributor to most disease including inflammation and heart disease. When someone is stressed for a long enough period of time, changes in the hormones (eg. Cortisol) of your body can influence your health. One of the most interesting blood tests we have seen increase, in response to sustained physical stress is "homocysteine" (Hcy). Hcy can increase when your diet is deficient in plant foods or when there is excess methionine (from protein) in your body. It is important for your body to have sufficient folate (folic acid/vitamin B9), vitamin B6 and B12 and that you not overload or stress your body. This explains one of the benefits of exercise and problems associated with smoking and excess alcohol intake. Many years ago, a book was written about type A personality and your heart. This suggested that people who were highly competitive (Type A behavior) were at an increased risk of heart disease while those who were more relaxed and laid back (Type B behavior) were at less risk. In the end we discovered, that it wasn't so much the type of behavior you exhibited, but whether you were "wired" to exhibit that behavior. By that I mean, if you are "wired" to be laid back (Type B) but you are forced to be Type A, then you are not behaving the way your body was intended to, and you are "stressed". Likewise, those who are "wired" to be Type A and are for whatever reason forced to be type B, are living opposite of their design. This explains why some people do well under stress and others do better under more relaxed environments. In the end, the combination of how we live and what we are eating, determines our "true Stress level" and its impact on our bodies and health.
Monica asks:What causes the inflammation, and can it be prevented? Will my doctor know what diet I need to follow? If not, how can I find it?
Dr. Richard Fleming:
Inflammation within the arteries of your heart results from the build up of saturated fats, cholesterol, oxidative damage, infection, insufficient vitamins and minerals to deal with the toxic effect of these injuries and numerous other concerns which we talk about in the type of depth you are looking for in the book Stop Inflammation Now! This can be ordered through you local bookstore or through the Internet, whichever approach you feel most comfortable with, potentially even through your public library. This is not just a diet book because it's focus is on the health of your body. If you follow a dietary program and lifestyle, which is healthy for you body, you will not only lose weight (if that is a goal for you) but improve your health as well. While obesity is a major concern for many, obesity is not a disease, but the result of poor diet and lifestyle. You can treat weight problems by reducing the number of calories you eat and still have health problems. Your goal is to improve your health by reducing the inflammation within your body through reducing the cause(s) of the inflammation and, if it is your goal, to lose weight too.
Denise Johnson asks:I have Rheumatoid arthritis and when the disease is in its active stage, the CRP is elevated. Am I to assume that patients like myself run a higher risk of heart disease? I am on prescription drugs to control the inflammation however, will a diet of fruits and vegetables help patients like myself as well?
Dr. Richard Fleming:
I have several individuals who have told me that by changing their diet and lifestyle to that which we discuss in the book, that they have had a significant improvement in their rheumatoid arthritis. As always, check it out with your doctor. I'm sure he/she would be delighted with anything that improves your overall health. Regarding your specific risk of heart disease, further blood work, like the IL-6 discussed earlier, could help answer this question for you.