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Cardiovascular disease might be the leading cause of death, but after my conversation with Dr. Mark Houston, I’m more convinced than ever that we have the power to change that narrative. We delved into the power of diet and lifestyle changes, the essential role of nitric oxide and the impressive results of innovative supplements like Vascanox HP by Calroy Health Sciences in managing blood pressure and cardiovascular disease risk. Dr. Houston’s passion for prevention and the practical tips he shared made me feel hopeful and empowered. From understanding key tests to making everyday changes, this episode is all about giving you the tools to protect your heart health. Let’s dive in and explore how we can all live longer, healthier lives. ~DrKF
In this episode of New Frontiers, Dr. Fitzgerald and Dr. Mark Houston explore the latest insights into cardiovascular health. They discuss the critical role of nitric oxide in vascular function, its decline after age 40, and how factors like common medications and the oral microbiome impact its production. Dr. Houston shares his expertise on managing hypertension, including current and emerging therapies and the importance of comprehensive blood tests, including advanced lipid profiles. The episode also covers practical tips for cardiovascular function screening, preventive strategies across all life stages, and the use of supplements like Arterosil and Vascanox from Calroy Health Sciences for vascular support. For practitioners, this episode provides actionable insights into assessing cardiovascular risk and optimizing patient care.
In this episode of New Frontiers, learn about:
- The Critical Role of Nitric Oxide: Discover why maintaining optimal nitric oxide levels is crucial for vascular health and the challenges faced, especially after age 40.
- The Impact of Common Medications: Understand how medications like PPIs and H2 blockers, and personal care products such as mouthwash can affect nitric oxide production and vascular health.
- Oral Microbiome’s Contribution: Explore how the health of the oral microbiome influences nitric oxide production and overall cardiovascular well-being.
- Essential Non-Invasive Cardiovascular Tests: Get insights into key non-invasive tests, such as coronary calcium scoring and HDI profiling, that help assess cardiovascular risk and monitor health.
- Critical Blood Tests for Cardiovascular Health: Learn which blood tests, including advanced lipid profiles and inflammation markers, are vital for evaluating cardiovascular risk.
- Target Reference Ranges for Biomarkers: Discover the recommended reference ranges for biomarkers like C-reactive protein, LDL, and ApoB to guide effective treatment and monitoring.
- The Importance of Genetic Testing: Understand the role of genetic testing in assessing cardiovascular risk, particularly for patients with a family history of heart disease.
- Managing Elevated Lp(a): Learn about the challenges of treating elevated Lp(a) and current and emerging therapies, including PCSK9 inhibitors.
- 24-Hour Blood Pressure Monitoring: Discover why monitoring blood pressure over a full day is crucial, with a focus on the impact of dipping status and nocturnal blood pressure as key drivers of stroke, heart attack, heart failure, and kidney failure.
- Preventive Measures Across the Lifespan: Explore strategies for early and aggressive prevention of cardiovascular disease, starting from adolescence or even earlier.
- Integrative Vascular Health Strategies: Discover the benefits of combining vascular health supplements like Arterosil and Vascanox to improve arterial health and prevent cardiovascular events.
- Expert Health Practices: Get practical tips on maintaining personal health, including sleep, exercise, diet, and avoiding tobacco, as a model for patients.
- Personal Health Habits of Leading Experts: Find out how leading experts maintain their health and longevity through specific lifestyle practices and routines.
Dr. KF SPONSORED CONTENT
I am eternally grateful to our sponsors who, by blogging, podcasting and advertising with us, enable me and my team to devote energy and time to writing and publication. All the companies who sponsor us are companies that I trust for myself and my patients and use regularly in my clinical practice. Please check out their websites! – Dr. KF
Dr. Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine, where we are interviewing the best minds in functional medicine. And of course today is no exception. If you’re joining me here on YouTube and you can see who I’m with, of course, you know this human being—he is just a treasure in the functional and integrative community. He’s a mentor to me as he is to many, many, many of us and I’m just delighted to be talking to him today. I’m with Dr. Mark Houston. Dr. Houston is a clinical instructor at George Washington University. He’s also the director of the Hypertension Institute and Vascular Biology, and medical director of the Division of Human Nutrition at Saint Thomas Medical Group, Saint Thomas Hospital, and Health Services in Nashville.
Dr. Kara Fitzgerald: He is on faculty at A4M (The American Academy of Anti-Aging Medicine), the FAARM (the Fellowship competent to practice Anti-Aging, Regenerative, and Functional Medicine), and the Metabolic Medicine Institute (MMI), and George Washington University, and he directs the cardiovascular modules. He’s also published seven bestselling books on vascular function. Dr. Houston has an active clinical practice. He teaches all the time. He does clinical research at Saint Thomas Medical Group and Hospital, and he founded the Hypertension Institute in 2000. Dr. Houston, welcome to New Frontiers.
Dr. Mark Houston: Thank you Kara. It’s a pleasure to be with you today.
Dr. Kara Fitzgerald: It’s always great to spend time listening and being educated by you Dr. Houston. I’m excited to be talking about cardiovascular disease, of course something that you’re incredibly well-versed on, and you’ve been at the forefront of teaching us in integrative and functional medicine. What determines our risk for cardiovascular disease?
Dr. Mark Houston: Well, everybody points to the fact that genetics are important, and they are. But I think environmental influences can actually trump genetics if you know how to manage what’s called gene expression.
Dr. Mark Houston: The usual things we talk about are lifestyle, dietary, nutrition, exercise. The typical risk factors like blood pressure, cholesterol, diabetes, smoking, etc. But I think if we just make it simple and say that genetics can now be measured. You’re not stuck with your genetics, so you’re not doomed to whatever they say you have because we can turn the genes on and off and modify cardiovascular risk. Most risk factors that we have now are easy to treat. We have good drugs and nutritional supplements. The integrative approach, which is what we use at the institute, has really allowed us to manage anything in cardiovascular disease to, I think, to an optimal degree.
Dr. Kara Fitzgerald: That’s such an incredibly optimistic outlook. I mean, I love it. It’s very uplifting. It’s powerful. So, in your mind, it shouldn’t be a leading killer by any stretch.
Dr. Mark Houston: Not at all. I mean, we know that it is right now in both the United States and worldwide.
Dr. Mark Houston: CVD (cardiovascular disease) is the number one cause of death. Stroke and MI (myocardial infarction) are the top cardiovascular reasons for death. But the point I want to make is that if we identify patients early—I’m talking about pediatrics here for sure, maybe even earlier than that. I don’t see a lot of pediatrics, but when they’re teenagers, I’m starting a very aggressive identification program, prevention program, and treatment program. I really believe if we do the things that we’re going to talk about today, we could reduce the risk of cardiovascular events in this country by, and I’m being optimistic, but 70 to 80%.
Dr. Kara Fitzgerald: Extraordinary. What’s the best predictor for a cardiovascular event?
Dr. Mark Houston: The two best ones that we use at the Hypertension Institute for coronary heart disease risk, which is the precursor for myocardial infarction, would be coronary artery calcium scoring and another test we do that measures arterial elasticity. So we’re looking at both a function and a structural issue. There are a lot of other things to do, but if you did just those two things in patients, you could really pick up early disease and start treating it.
Dr. Kara Fitzgerald: Awesome. Awesome. All right. Well, let’s get into how we want to address early disease. Actually, we can talk about disease across the spectrum. But specifically, I want to talk about the 2023 paper that you published, looking at nitric oxide. So, just introduce the use of nitric oxide, its benefits, utility, efficacy, and then what you guys looked at and why what you did was really something different. You demonstrated something pretty cool.
Dr. Mark Houston: Yeah. So one of the very basic molecules that drives cardiovascular disease is nitric oxide. Don’t get that confused with nitrous oxide, which is what you get in the dental office. Nitric oxide is a gas, and it doesn’t last very long. You can store it in your body and then pull the banked nitric oxide out when you need it.
Dr. Mark Houston: It won the Nobel Prize in 1996 and it’s related to anything you can think of related to cardiovascular disease, whether it’s myocardial infarction, coronary heart disease, stroke, congestive heart failure, renal disease, and other things. The primary role of nitric oxide is to vasodilate the arteries. It has antioxidant effects, anti-inflammatory effects, immune function, and a host of other things and maintaining a good nitric oxide level is one of the key things to prevent CVD. It’s one of the things that we measure in the office, that test I mentioned, where we’re measuring arterial elasticity. And there are other ways you can do it. There are strips you can use under your tongue, and there are blood tests that measure it as well. But the functional test for nitric oxide, which is called pulse wave velocity, arterial elasticity, is one of the best ways to identify adequate levels of nitric oxide that are, in fact, bioavailable.
Dr. Kara Fitzgerald: And so, in your population, do people generally have adequate nitric oxide? I’m going to guess probably not.
Dr. Mark Houston: No, you’re right Kara. Almost no one has adequate nitric oxide levels unless they’re taking a nutritional supplement that raises nitric oxide. There are a few drugs that do it, but they don’t do it as much actually as the nutritional supplements do. When we measure that, I would say 95% of the people that come into my office have very low nitric oxide levels.
Dr. Kara Fitzgerald: That’s extraordinary. And does it track with hypertension, or do you see it drop initially?
Dr. Mark Houston: It tracks with hypertension particularly, because the earliest finding in hypertension is stiff small arteries. It’s called the C2 compliance. If you have stiff small arteries, almost all of those patients are hypertensive. Then the larger arteries are next to go. And when you have those two arterial systems in a stiff format, the risk for all those CVD problems will go up dramatically.
Dr. Kara Fitzgerald: Even in a healthy diet, there’s inadequate nitric oxide?
Dr. Mark Houston: Yeah, it’s very difficult to get nitric oxide levels up just with dietary means, although you can do it. But it requires a lot of dark green leafy vegetables like kale, spinach, beets, grapes, and other things like that. If you eat a really good diet like that, then your nitric oxide levels may in fact be normal. But most people, as you know, don’t follow that kind of nutrition program.
Dr. Kara Fitzgerald: You need to be eating, when you say a good amount, it’s substantial servings.
Dr. Mark Houston: Yeah, we’re talking ten servings a day of fruits and vegetables.
Dr. Kara Fitzgerald: So even those of us who are mindful are not going to be hitting that all the time. We’re just not going to be hitting it. So I guess that could explain the fact that I think 50% of Americans are hypertensive.
Dr. Mark Houston: Yeah, that’s about the right number. If you look at 140/90 as the break point between normotensive and hypertensive, it’s right at 50% of the US population that has high blood pressure.
Dr. Kara Fitzgerald: Extraordinary. All right, that’s extraordinary. Well, I want to bring us back to the study. There are a ton of questions I could ask, and we’ll circle back to that a little bit later on, just thinking about nutrition more broadly. But let’s talk about what you did in the study. You used a product called Vascanox HP. You noticed, actually, extraordinarily enough, that Vascanox immediately increased nitric oxide, and it actually hung around for a while. So walk us through what you did in the study, what the findings were, and the intervention that you used.
Dr. Mark Houston: We took a group of mild hypertensive patients, gave them Vascanox, two capsules in the morning. The patients who got Vascanox had an immediate increase in their nitric oxide levels, as measured with a strip and they had immediate reductions in blood pressure, both systolic and diastolic. Those reductions were persistent for a full 24 hours. And then we re-dosed it and over a period of time, the blood pressure actually continued to decrease to a significant level. It was actually similar to what we would see with a single drug therapy for hypertension.
Dr. Mark Houston: It was highly significant. What was interesting is that the higher the blood pressure was at the start of the study, the greater the reduction. The importance of that is if you have, for example, normal blood pressure and take the Vascanox, you probably won’t see much of a change in blood pressure, which is good because you don’t want to drop it if it’s already normal. We didn’t see anyone with high blood pressure drop to a level that would cause hypotension or clinical symptoms of low blood pressure. It seems to modulate the blood pressure into a very safe range, but the reductions that occur were very significant.
Dr. Kara Fitzgerald: That’s extraordinary. And to your point, it’s a single dose. Other nitric oxide-stimulating or producing products— Talk about the half-life of nitric oxide and why it’s remarkable that this worked in a single dose and why it did. What’s the mechanism that allows that sustained activation?
Dr. Mark Houston: Your question is exactly correct. Most of the previous nitric oxide promoters were very short-lived. They would peak at a high level, perhaps, but then they were gone very quickly. In fact, most of them would be gone in four hours, dropping below the therapeutic threshold of nitric oxide. However, when we compared Vascanox to other nitric oxide promoters, the peak level of Vascanox was about four times greater than any of the others and its half-life, or the level at which it maintained above a certain threshold for nitric oxide, lasted a full 24 hours. It did not drop off quickly. In fact, the end of the 24-hour level of Vascanox was higher than a lot of the four-hour dosing of some of the other nitric oxide promoters.
Dr. Kara Fitzgerald: That’s incredible. I just want to link that to the earlier statement you made that despite this pretty extraordinary spike, it didn’t cause hypotension. These were mild hypertensives, so some people were on the higher side and some were pretty close to normal. Those close to normal folks didn’t become hypotensive even though they had measurable, good amounts of nitric oxide present.
Dr. Mark Houston: There basically were no side effects at all during our study.
Dr. Kara Fitzgerald: That’s awesome. That’s so interesting to me. What are the ingredients in this product that allow it to hang around for a while?
Dr. Mark Houston: Yeah, it’s a very unique combination. We can talk about the two primary ingredients that make it work. It does have a lot of things in it though that increase its effectiveness. You’ve got the nitric oxide promotion, and then you have a substance that blocks the breakdown of the nitric oxide. That’s a hydrogen sulfide compound which is derived from a form of garlic. It’s so unique. It’s the only nitric oxide supplement on the market with that combination.
Dr. Kara Fitzgerald: So then, would this be appropriate in erectile dysfunction? Might we consider using it?
Dr. Mark Houston: Yeah, in clinical practice and also in the study, there was an actual improvement in sexual dysfunction.
Dr. Kara Fitzgerald: That’s really interesting. So, some of the folks in this study had diastolic hypertension, some did not. Vascanox effects were different in these two groups. It was actually an interesting population. Some were closer to normotensive and their diastolic BP was decent. There was someone who was a bit treatment-resistant. I’d be curious about your thoughts on that individual who didn’t appear to respond. So, diastolic normotensive, diastolic hypertensive, you know, just the population group. What are some of the interesting things that you found? Walk us through that.
Dr. Mark Houston: Systolic and diastolic hypertension are totally different animals. Diastolic hypertension generally is an abnormality of the small resistance arteries, which we can measure with this machine I mentioned. Systolic hypertension tends to occur as you get older, and that’s when the large arteries tend to get stiff, like the aorta. So both of them are important in reducing cardiovascular risk and what we found in the study, is if we took the hypertensive higher end versus those that were more borderline, there was a huge difference in the response rate. I alluded to that earlier that the higher the pressure at the initiation, the more reduction we had in both systolic and diastolic. Whereas if you looked at those who were in the very mild range, there could be a difference between systolic and diastolic blood pressure. It’s not so much a resistance effect as it is, I think, the level of blood pressure when you start the Vascanox and how it’s going to respond, depending on arterial resistance and probably age.
Dr. Kara Fitzgerald: There was one person who didn’t respond at all. I’m curious about your thoughts on that individual.
Dr. Mark Houston: There can be a rare patient with an arterial system so stiff it takes them 3 or 4 months to correct it. Whereas most people’s arteries respond quicker. If you get the large and small arteries corrected at the same time, you get the most dramatic reductions in both systolic and diastolic. But there are those cases, and I have a lot of them in the office, we call them vasculopaths, meaning that their arteries are so stiff they just take longer for things to become more elastic.
Dr. Kara Fitzgerald: Okay. And you would still do a lifestyle approach, but you’re going to be using medication as appropriate and more aggressive interventions.
Dr. Mark Houston: Absolutely. I think you have to always integrate your antihypertensive program. You want to use nutrition and lifestyle combined with good supplements and drugs to get the maximum effect.
Dr. Kara Fitzgerald: You’ve talked about two of the tools that you’re using in the office to evaluate blood pressure. What else are you looking at? And where do you start? How do you evaluate blood pressure in your patients?
Dr. Mark Houston: We have a whole host of non-invasive cardiovascular tests. We have the EndoPAT for endothelial dysfunction, we have the CVProfilor, which is for small and large artery arterial compliance, and plethysmography for overall cardiac function related to coronary heart disease, residual blood volume in the coronary arteries, and elasticity. We use 2D echos, carotid duplex, and of course the typical stress test. But we use a test called CPET, which is the cardiopulmonary exercise test, which measures both cardiac and pulmonary function at the same time. Coronary calcium scoring, which tells you how much calcium you have in the entire arterial system. And then we do more sophisticated tests, but this is the baseline that almost everyone gets. Depending what those show, we might go to more sophisticated testing later.
Dr. Mark Houston: One of the newest tests we’re using, once you identify high-risk patients, is called CCTA, coronary CTA with FFR, which is a fractional flow reserve, and Cleerly, which is an AI analysis of soft plaque and hard plaque, and the degree of stenosis in the coronary arteries. It’s almost as good, if not better, than a coronary arteriogram.
Dr. Kara Fitzgerald: That’s incredible. It’s a very robust analysis. I’m excited about the use of AI in imaging. Cleerly is something we’re bringing into our practice as well. Who needs this kind of investigation? I would imagine that probably all of us at a certain point, actually, you’re starting in some cases with adolescents… Should everybody get this evaluation regardless of what their blood pressure is? And when should we get it? Who is an appropriate candidate for this?
Dr. Mark Houston: That’s a great question. Of course, I might answer that differently than most because I’m very aggressive in cardiovascular testing and early detection. I think the cost-benefit of doing these tests, even in a very early population, is very good because if the results are all normal, hallelujah, you don’t have to worry for a while. But if you have a 17 or 18-year-old person in your office and any of those tests are showing abnormalities, those people are at high risk and you’ve identified them at a stage where you can actually start to do something to prevent them from developing hypertension, or coronary heart disease, or some other complication.
Dr. Kara Fitzgerald: Yeah. It could be highly motivating. It just seems to me as we put more and more attention into prevention and optimal wellness, etc, that this kind of investigation would be fabulous to do in younger individuals, but at least in the 40s and 50s for a start. It would be a nice evaluation.
Dr. Mark Houston: And I think one of the take-home points I would want to leave with your audience is that aggressive early detection and early aggressive prevention and treatment is the only way we’re ever going to reduce cardiovascular illness in this country and worldwide.
Dr. Kara Fitzgerald: Amen to that. All right, let’s go back specifically to blood pressure. There’s a concept called nocturnal dipping and we actually want to see it. Let me back up from that. The gold standard for evaluating blood pressure is 24-hour monitoring. Talk about how you do that specifically, and the variation we might see through that 24-hour cycle. What’s normal and what’s not normal?
Dr. Mark Houston: Typically, when you have your blood pressure checked, it’s in the office by a nurse or physician, and then you may do home monitoring with one of the automated cuffs. Those are great for that reading at that time, however those do not evaluate things that are important over 24 hours. The gold standard, as you mentioned, for hypertension evaluation and treatment, is a 24-hour ambulatory blood pressure monitor. So what things do you get that you don’t with a regular, routine, single office testing? Well, you get what’s called nocturnal dipping, which you mentioned. You also get nocturnal blood pressure, lability of blood pressure, and you get AM rises, which refers to how quickly the pressure increases and to what level in the early morning hours, which is when most people have strokes.
Dr. Mark Houston: Nocturnal dipping means your average daytime pressure is 10% different from your average nighttime pressure. So that means you have a 10% dipping at night, which is important to allow the arteries to relax and get the pressure off the arterial wall. So dipping is important, but also the actual level is important. And that is what you would call the nocturnal blood pressure. They are two different things, but both are important. So the actual level and the 10% dipping are the two things that drive the risk for heart disease. And that’s why you have to do a 24-hour ambulatory blood pressure monitor (24-hour ABPM). You can do all the other things in your office but the number one driving force for stroke, heart attack, heart failure, and kidney failure is dipping status and nocturnal blood pressure.
Dr. Kara Fitzgerald: Fascinating.That’s associated with an AM spike?
Dr. Mark Houston: Well, the AM spike is important, but if you look at all the criteria that you get with a 24-hour ABPM, number one is nocturnal blood pressure and number two is dipping status.
Dr. Kara Fitzgerald: That’s fascinating. If we’re not doing this kind of investigation in-office with our hypertensive patients, we should be referring them. But barring being able to do that, what do you suggest?
Dr. Mark Houston: If you’re measuring blood pressure a lot in your office and you want to really find out how bad it is and how to treat it, you can purchase a 24-hour ABPM for a reasonable price. You can get used ones online for probably $1000-$1200 and they’re reimbursable through insurance. The other important thing about the 24-hour ABPM is not only does it help you diagnose nocturnal dipping and nocturnal hypertension, but it also tells you how to treat.
Dr. Mark Houston: For example, how would you know when to give their antihypertensive medications? Well you don’t unless you know their dipping status. And here’s the example: If your dipping status is abnormal—in other words they don’t have that 10% dip at night—what time of day should you give your blood pressure meds? Well, you should give it at night. However, if you’re a normal dipper, you would prefer to give it in the morning so you don’t drop their pressure too low at night. So, the two most important benefits of the 24-hour ABPM are the diagnosis of blood pressure issues related to dipping status and the second is what is the timing for medications. What is the diurnal rhythm, circadian rhythm when you give medication?
Dr. Kara Fitzgerald: I’m imagining we’re going to miss a lot of these nocturnal shifts just by taking an in-office pressure.
Dr. Mark Houston: You can’t. There’s no other way to get it. If you really want to practice state-of-the-art hypertension management, you have to use a 24-hour ABPM in your patients.
Dr. Kara Fitzgerald: Right. Just out of curiosity, how many PP (pulse pressure) patients would we miss by only doing in-office measurements? How many of those extremely–
Dr. Mark Houston: Lack of nocturnal dipping is very common. Just looking at my practice, at least 50% of the patients don’t dip. So, you would miss a lot of people.
Dr. Kara Fitzgerald: And that’s not going to improve if you miss them. I think it will just worsen over time, I would imagine.
Dr. Mark Houston: It won’t get better because you might not give the right medication or get the right time of day.
Dr. Kara Fitzgerald: Yeah. So, clearly, many prescriptions are going to be indicated for a lot of the pathological changes you’re describing. But we’re also going to be thinking about lifestyle interventions too. You’ve talked about Vascanox. What are some other lifestyle interventions you think about?
Dr. Mark Houston: I want to say one important thing that people need to recognize, because it’s not emphasized enough in the literature. When you have recognized hypertension that’s defined as sustained or chronic, you must start a drug immediately to get their pressure under control. Because there’s clinical studies that show that the longer you wait, the more adverse events you’ll have, and you never catch up. You don’t say, “Well, your blood pressure is 140/90 and we’re going to give you 6 months of natural lifestyle changes to see what happens.” You don’t. You start them on drug therapy immediately and then add lifestyle changes to that regimen to add to the blood pressure reduction effect. These lifestyle changes are things including low-sodium, and high potassium and magnesium diet, a supervised exercise program, weight reduction, tobacco cessation, and controlling of inflammation and oxidative stress. You also monitor levels of markers in the blood like homocysteine and C-reactive protein.
Dr. Mark Houston: Then you do a physiological measurement of what’s causing their blood pressure issues, and of course measure their elasticity issues. All these factors must be addressed as part of the composite program that you integrate to manage hypertension. There are two goals in treating hypertension: one is to get the blood pressure to 120/80 or less, and the second is to change the function and structure of the arterial system to make it healthy. These two goals can be independent of each other, depending on what you’re using for drugs and supplements.
Dr. Kara Fitzgerald: What’s an optimal blood pressure, in your opinion?
Dr. Mark Houston: You would want it at 120/80 most of the time, with appropriate nocturnal dipping and appropriate nocturnal blood pressure. You can go lower, 110/70 would probably bring it to the flat line, but that’s a hard goal to reach in most patients. I’m perfectly happy when I can get a pretty good sustained 120/80 with a 24-hour ABPM with good dipping status.
Dr. Kara Fitzgerald: And what do you expect to see as a good dipping status?
Dr. Mark Houston: You try to get as close to 10% as you can, not go over that and not go under it. Obviously, it’s very hard to hit 10% every time, but if you can get as close to 10% as possible and then look at the nocturnal blood pressure at the same time, it’s pretty easy to identify with the ABM exactly where you need to be and then adjust your medicines and supplements around that.
Dr. Kara Fitzgerald: Are you layering Vascanox into the care program for most of the patients that you’re seeing?
Dr. Mark Houston: Yeah, we do. What we do is we measure their nitric oxide levels with a strip and we measure it with a machine, and then we measure through the blood something called ADMA, asymmetric dimethylarginine, and those three will tell you exactly where you are with your nitric oxide. As I said, almost everybody is low, so it’s important to go ahead and give them Vascanox as part of the usual regimen, which you start on day one along with the drugs. Because that way you hit the blood pressure level and you also hit the arterial elasticity issues at the same time.
Dr. Mark Houston: So, the drugs are going to lower blood pressure. Certain drugs will include nitric oxide, but they’re not as strong, actually, as Vascanox. Vascanox will improve the arterial elasticity, and it will also help support the blood pressure.
Dr. Kara Fitzgerald: It’s a really interesting product. Again, just to hit home, adherence is easy with it because you only need to take it once and you’ll have that sustained benefit over time, as we described in your study outline. Incidentally folks, on our show notes page we will be linking to the study. It’s a free full text so you can check it out yourself.
Dr. Kara Fitzgerald: You know, I eat a pretty plant-dense diet. I’ve got a big bowl of greens here to tuck into after we’re done recording, and when I did my salivary nitric oxide it wasn’t right. I expected to see it nice and purple, you know, a nice strong nitric oxide. It was there. I had some, but I didn’t have a lot. So to your point, I think some of us eating what we would consider a pretty impactful diet may need some extra support.
Dr. Mark Houston: Yeah, which brings up another good point, which we hadn’t talked about. After age forty the regular system by which you make nitric oxide through arginine and citrulline is not working well with the eNOS enzyme (endothelial nitric oxide synthase). Most of your dietary nitric oxide is through food after age forty, so you’ve got to get the dark green leafy vegetables, the beets and other things to get your nitric oxide levels up.
Dr. Mark Houston: But here’s the problem, even with a good diet, if you’re using mouthwash or taking a PPI or an H2 blocker, you’re knocking out the entire nitric oxide. You’ve got a bad microbiome in your mouth, a bad microbiome in your gut, you don’t make nitric oxide. If you don’t have gastric acid, you don’t make nitric oxide. It’s a very complicated pathway. That’s one reason many people don’t have good levels. Even if they’re eating well, if they’re taking certain medications that will adversely affect their NO levels.
Dr. Kara Fitzgerald: Yeah, of course. And who doesn’t have some degree of dysbiosis these days. And I’m measuring the oral microbiome more and more as well and so I really appreciate your discussion in the paper on the key players in the oral microbiome that are helping us produce nitric oxide.
Dr. Mark Houston: Yeah, if you swish Listerine once a day, you’re done with your oral microbiome.
Dr. Kara Fitzgerald: Yeah. And I would not be surprised if those of us not using Listerine haven’t damaged it in some other way. It’s just fascinating how essential the oral microbiome is. And PPIs are the top drug in this country. Many of our patients are on them so down the line we can see how it interrupts…What about just using arginine or citrulline? Do you use those in practice these days?
Dr. Mark Houston: No. I have totally gotten away from using arginine and citrulline for a lot of reasons. Most people are not arginine deficient and if you give arginine, you’ve already saturated the enzyme. It doesn’t do anything. In fact, it can give you a bad pathway called peroxynitrite, by taking too much arginine. You don’t usually get that with citrulline because you’re kind of going in the back way. But I don’t usually find those to be effective in patients, even before age forty, so I don’t typically use those anymore. I’m going to go straight to the Vascanox if I want their nitric oxide levels up at any age, actually.
Dr. Kara Fitzgerald: Yeah. I remember there was a sustained release arginine out around the time we started using ADMA as a measure and we were thinking about arginine and sustained release arginine. But I’m with you. It wasn’t the success that I was hoping that it would be. Arterosil HP is another cool product from Calroy Health Sciences. I know that you’re a medical board member of Calroy Health Sciences and that you’re really familiar with the products and researching them. Why don’t you tell me a little bit about Arterosil and how you’re using this product.
Dr. Mark Houston: Arterosil is a glycocalyx promotor. Glycocalyx is the layer outside the endothelium that protects the endothelial lining. Glycocalyx is very similar, actually, to the endothelium. It’s got nitric oxide and it’s got antioxidants, all kinds of great things that help to improve vascular health. In our clinical trial, Arterosil was also great in supporting blood pressure. It’s a great add on to use with Vascanox in patients who need an extra boost in their nitric oxide levels, or an extra boost in their overall prevention for cardiovascular events and health and we use them together all the time. It’s easy for me because I have this machine that measures the arterial resistance so I can say if they come back in 3-4 months and arterial elasticity is better, but not where it should be, we keep them on the Vasconox and add the Arterosil to it. Almost everybody, I would say close to 98% of people will respond to the two together to get the arterial system under control.
Dr. Kara Fitzgerald: Are they long term? Do you keep most of your patients on them long term?
Dr. Mark Houston: Typically yes. I would recommend long term use of both. The reason for that is most patients, as they get older, are going to lose nitric oxide levels, their arteries get stiffer, and their risk for CVD goes up. So, you’re better off taking something that’s going to help prevent cardiovascular disease by keeping your arteries healthy. And by doing that you’re going to maintain good arterial and vascular health without having a lot of side effects.
Dr. Kara Fitzgerald: That’s what I was just going to bring in. For long term use there’s no downside.
Dr. Mark Houston: And you can use Vascanox and Arterosil routinely with virtually any drug. There are hardly any contraindications or drug interactions.
Dr. Kara Fitzgerald: And then, to the earlier point, we’re not worried about hypotension. You haven’t seen that?
Dr. Mark Houston: No. You don’t get hypotension in patients, even though they’re normotensive to begin with.
Dr. Kara Fitzgerald: Okay. You’ve talked a lot about the tests you’re doing, including blood tests, imaging, and functional tests. If you only have three – and you may have already covered this, but I’m going to ask again – what would be your top three? For those of us in clinical practice without access to a Vascular Institute at the University of Tennessee. For those of us in clinical practice who want to do a good job, who want to do right by our patients, but have more modest tools?
Dr. Mark Houston: If you’re talking about the top three non-invasive vascular tests, I’d recommend the Coronary Calcium Scoring – which you can get done anywhere for about $50. Second would be the HDI Profiler, which measures arterial compliance. There’s a lot of ways to do that. You can purchase or lease this machine. It was developed at the University of Minnesota, it’s still available, and is very highly effective. And that one, actually, not only measures arterial compliance, but it can indirectly give you a good effect on endothelial function.
Dr. Mark Houston: The third option would be an EndoPAT which is going to measure endothelial function directly, or you could do a plethysmography, which measures the overall cardiovascular function indirectly and gives you some really great information. Those machines are not that expensive either.
Dr. Kara Fitzgerald: What about a carotid intima-media thickness (CIMT) scan?
Dr. Mark Houston: You can do those. I recommend them. The problem is, by the time carotid intima-media thickness or plaque is detected, you’re way past the prevention stage. You’ve already developed structural disease in your carotid arteries. So I would do it, and again it could be a close third or fourth to the things I’ve mentioned. Any office can do those by contracting with another company, so you don’t have to buy the machine yourself.
Dr. Mark Houston: Another useful test is a 2D Echo (2D echocardiography) which you can contract with a company so you don’t have to buy an echo machine or become an echo reader. You can always farm those out. So, those two can be done easily, while the others would probably need to have in your office.
Dr. Kara Fitzgerald: And we’ve actually created some nice partnerships in our practice. We’re in Connecticut, so there are decent providers relatively close by. Clinicians can do that as well. All right. What about blood tests then? Same question. Give me your top three.
Dr. Mark Houston: For blood tests, I would say, number one would be an Advanced Lipid Profile where you’re getting particle size and particle number. And then you definitely want to measure inflammation in some form. C-reactive protein (CRP) is probably the easiest to do. And then a good chemistry profile where you’re going to be measuring renal function, with microalbuminuria with urine, for example. Blood tests of creatinine and blood sugar to make sure they’re not diabetic, homocysteine levels… All of those can be included in a nice Chem 12 Profile.
Dr. Kara Fitzgerald: Are you getting asymmetric dimethylarginine (ADMA) levels routinely in your patients?
Dr. Mark Houston: Yes, I do. I get it routinely through Cleveland HeartLab as part of the routine initial profile. I have an oxidative stress, immune function, and inflammation profile that I organized through Cleveland HeartLab, specified to what I want. It’s unique to my practice and we measure about 15 different things, including ADMA.
Dr. Kara Fitzgerald: Okay, good. We might be able to actually just plug in to Cleveland HeartLab and ask them to pull your panel out for us.
Dr. Mark Houston: Yeah, you can do that. Of course.
Dr. Kara Fitzgerald: If we wanted to, and see what you’re doing. It would be a whole other conversation. I’m dying to ask you about reference ranges and what you’re aiming for. Do you want to make a quick comment on that? I know it’s on people’s minds.
Dr. Mark Houston: Sure, I can give you some easy ones to remember. For C-reactive protein, aim for less than one. That’s a good marker for inflammation. For LDL in a patient who has not had a heart attack, aim for 100 and then we measure the particle number, which should be less than 1,000, maintaining a 10:1 ratio. If you measure microalbumin in the urine, it should be zero. This is a great marker for future cardiovascular events, but also kidney failure.
Dr. Kara Fitzgerald: Yeah, and what about apolipoprotein B (apoB)? Clinicians and patients alike are talking about it.
Dr. Mark Houston: ApoB is one of the things you get on the advanced lipid profile. It’s a composite measure of all the advanced cholesterologenic, atherogenic particles in your system. But with the advanced lipid test, the ApoB should probably be less than 70, but it correlates very well with LDL particle number, but the particle number is actually a little bit better than ApoB. You’ll get both on the advanced lipid test.
Dr. Kara Fitzgerald: What about lipoprotein(a) [Lp(a)]? If you’re seeing someone with elevated Lp(a)—I know I’m diverging here, Mark—but if you see somebody with Lp(a) – half of my family has pretty elevated levels of Lp(a). I’m fortunate that I escaped that, but my dad and two of my siblings do. And so we’re going pretty aggressively after everything else we can. I’m curious about your thoughts.
Dr. Mark Houston: Lp(a) is also measured on the advanced lipid test. You won’t get it with a routine profile. You’ll miss it so it’s important that you measure advanced lipids. Lp(a), as you pointed out, is genetic. We’re not sure of the actual incidence in the population, but it’s probably around 20-25%. It’s pretty high and it causes both thrombosis and plaque formation. It’s very hard to treat. The only thing that treats it well right now is the PCSK9 inhibitors, which can drop it about 30%. Niacin, maybe 15%-30%, depending on the dose. Outside of that we don’t have anything yet, but there are several new drugs in development that could reduce Lp(a) by up to 98%, which are supposed to be out by 2024.
Dr. Kara Fitzgerald: Incredible. Okay. We’ll be paying attention to those. For this population when you’re looking at a lipids panel and you see Lp(a), of course you need to go after them with drugs. And we’re not saying we don’t, but Arterosil in this population strikes me as a no-brainer, and Vascanox as well.
Dr. Mark Houston: Both of those would improve arterial health, but neither have been shown to reduce Lp(a).
Dr. Kara Fitzgerald: Right. I realize that we’re not changing Lp(a), but we’re addressing everything around it.
Dr. Mark Houston: Right. I think your point is well taken that when you have vascular disease and you have something that’s hard to treat like Lp(a), you do your best with that one, but you also support all the other vascular issues that could contribute to a heart attack and try to minimize those.
Dr. Kara Fitzgerald: That’s right. So, coming full circle in the question, it’s good that we ended with the conundrum of Lp(a). It’s the top cause of death in cardiovascular disease. We can’t understate how extraordinary the risk is. And I see it directly in my family. My grandfather died of a massive heart attack. I’m certain he had elevated Lp(a), as my dad does and I see it in my siblings. And we’re really paying attention as best we can. You started our conversation by giving some positive thoughts around how this does not have to be our cause of death. So even though it is everywhere and it is the number one cause of death, this doesn’t have to be what kills us. There are plenty of nutritional and lifestyle interventions. There are things we can do, to your point, in adolescence – even with our newborns and on. The cycle of life. What do we need to be doing so that we absolutely not have this be our death sentence?
Dr. Mark Houston: For me, as an adult internal medicine cardiologist, obviously I wouldn’t be seeing patients until the age of 13 or so, but I would be doing the tests that we’ve talked about in those patients. Then I would start aggressive non-invasive cardiovascular testing with all the different things we’ve talked about, with the extensive blood panel, etc. and based on their family history, I would get some genetics as well. Once I have that, I know exactly where they’re heading. Are they in trouble now? Or will they get in trouble soon? That way you know when you need to start seeing them. Do I need to start seeing them every three months or every year to make sure that we start treatment of something before it gets out of hand.
Dr. Mark Houston: If you’re a pediatrician, that’s not to say you shouldn’t also be doing some of these things because you may have somebody who’s eight years old who has a horrible family history and you need to start treating them early. Because they may already have problems that are beginning to cause vascular disease. One of the old adages that I throw out – people laugh at me when I say this – is, when does vascular disease start? It starts in utero.
Dr. Kara Fitzgerald: As does dementia. I was interviewing David Perlmutter and that was his answer — it starts in utero as well. Right. So we actually need to start before. Preconception.
Dr. Mark Houston: Exactly.
Dr. Kara Fitzgerald: Well listen, I’ve known you for my entire career, and you walk the talk. You’re advocating pretty aggressive interventions and testing, and you’re one of the healthiest people who shows up at a conference. It’s true. Before we hit record you told me that you’re about to go teach 24 hours of content to physicians at A4M in December, as you’ve been doing for years. What are some of the practices you adhere to in your life to stay healthy and strong?
Dr. Mark Houston: If you want to pick a few things that would keep you as healthy as possible, I focus on getting eight hours of quality sleep every night, an hour of both aerobic and resistance exercise daily, following a Mediterranean, PREDIMED type diet (Prevención con Dieta Mediterránea), which is going to be 10 to 12 servings of mixed colored fruits and vegetables every day, maintaining an ideal body weight with 16% body fat for males and 22% for females, and then doing all things I recommend for everyone else – to track my cardiovascular measurements and get all my cardiovascular risk factors under control. And obviously, don’t use any tobacco products at all.
Dr. Mark Houston:If you did those things, you could probably make it to 123 years or so, which is what Jeanne Calment, a little French lady, was able to make it to.
Dr. Kara Fitzgerald: You’re not going to Starbucks and having one of those giant purple, green, and yellow frappuccino ultra processed, yada yadas…
Dr. Mark Houston: I don’t drink any caffeine whatsoever, except maybe for occasional herbal tea.
Dr. Kara Fitzgerald: That’s as risky as you go. I have to say, it’s just been a real delight talking with you.
Dr. Mark Houston: You too, Dr. Kara. I appreciate you having me on your show.
Dr. Kara Fitzgerald: I look forward to seeing you in person and giving you a real, live in-person hug.
Dr. Mark Houston: There we go. Look forward to it. We’ll get Andy to set something up for us maybe.
Dr. Kara Fitzgerald: Yeah, absolutely.
Dr. Mark Houston: Awesome.
Dr. Kara Fitzgerald: Thank you so much.
Dr. Mark Houston: Thanks, Kara. Have a great day. Bye bye.
Dr. Kara Fitzgerald: You too.
Dr. Mark Houston is a Clinical Instructor at George Washington University. He is also Director of the Hypertension Institute and Vascular Biology and Medical Director of the division of Human Nutrition at St. Thomas Medical Group, St. Thomas Hospital and Health Services in Nashville, TN. He is on the faculty of A4M, for the FAARM and the Metabolic Medicine Institute (MMI) and George Washington University, and directs the Cardiovascular modules. He has also published seven best-selling books on vascular function. Dr. Houston has an active clinical practice, teaches, and does clinical research at St. Thomas Medical Group and Hospital. He founded the Hypertension Institute in 2000.
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Metabolic Medicine Institute (MMI)
Dr. Houston’s Study: Effects of S-Allylcysteine-Rich Garlic Extract and Dietary Inorganic Nitrate Formula on Blood Pressure and Salivary Nitric Oxide: An Open-Label Clinical Trial Among Hypertensive Subjects
Ovationlab Vascular Support Protocol
Study: Prevalence and Factors Associated With Circadian Blood Pressure Patterns in Hypertensive Patients
Article: Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association
Study: Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes
Study: Nighttime Blood Pressure Phenotype and Cardiovascular Prognosis: Practitioner-Based Nationwide
Cleerly Health: AI-based digital care platform
Podcast: Mastering Cardiovascular Longevity: Glycocalyx & Biohacking for Optimal Heart Health
Podcast: How to Fix the Vascular Health Crisis: The Endothelial Glycocalyx
DrKF Clinic: Patient consults with DrKF physicians including Younger You Concierge
Better Broths and Healing Tonics book
Podcast: Mastering Cardiovascular Longevity: Glycocalyx & Biohacking for Optimal Heart Health
Podcast: How to Fix the Vascular Health Crisis: The Endothelial Glycocalyx
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Thank you for this interesting episode. I see many individuals with hypertension in my practice. Vascanox seems to be an interesting product to watch. However, are you not concerned about the dose of B12 at >4,000 X the RDA? The majority of my clients who take high doses of B12 over the medium-term (and long-term) seem to end up with elevated serum B12 and their GP quite understandably then directs them to stop taking B12. I’m also concerned about the studies reporting elevated serum B12 correlating with increased risk of hip fracture. If a version of Vascanox could be created without this B12 megadose, it would be a far more accessible product in my view. I’d be extremely grateful for your expert opinion on this please. Many thanks.
I started a trial of Vasconox last year. I unfortunately experienced episodes 3-4 hours after taking my usual morning supplements (including Arterosil) plus 2 Vasconox.
These consisted of a sudden onset of dizziness (not lightheadedness) and queasiness. I had to lay down in quiet room and wait for it to pass….which it does in about 15-20 minutes. My heart is not racing nor do i feel any palpitations. When I feel well enough to check my blood pressure is normal. When I check my blood nitric oxide it is in the bright pink (optimal) range as compared to barely pink (depleted) when I wake up and measure it. I experienced the same episodes even at 1 pill a day.
I reported this symptom of taking Vascanox to Calroy. They advised I discontinue. Could it be a sudden boost in nitro oxide and too much arterial relaxation?
I have no history of migraines but I do have very elevated lp(a) and carotid atherosclerosis as per CIMT. I am a WFPB eater and do get 10 servings of fruit and veg a day.