Spokane family-practice physician Dr. Bradley F. Bale, who has been an outspoken advocate of attacking heart disease preemptively, has started a heart-attack prevention clinic at his office here.


Bale began seeing patients earlier this month at the new clinic, on the third floor of the Deaconess Physicians Building, at 801 W. Fifth.


The longtime Spokane doctor says that with the combination of physical examination, radiological imaging, and blood and urine work, the clinic can determine whether a patient is at risk for heart diseaseor what he calls in the heart attack zoneand if so, what preventive treatment would be best.


With the screening, all people who are in danger of suffering from heart disease can be identified as being at risk before they suffer a heart attack, Bale asserts.


I do sincerely believe all heart attacks are preventable, he says.


Dr. Pierre Leimgruber, an interventional cardiologist with Spokane Cardiology PS, says that preventing all heart attacks is an ambitious endeavor. Regardless, he says, Bale is on the right track with the clinic.


I think Brad is on the cutting edge of what preventive measures will have to take place, Leimgruber says. From a scientific point, hes very sound in what he does.


He adds, Im an interventional cardiologist, but the future is not stents and balloons. Its prevention of the diseases we treat.


Leimgruber is referring to stents and balloons that are used to reopen coronary arteries that are occluded.


Bale has developed expertise in heart-disease prevention during the last five years and gives presentations on the subject to physician and medical groups across the country.Before Bale started the clinic, a cardiologist came to his family practice as a patient seeking heart-attack risk assessment similar to whats offered through the new clinic now. Currently, Bale has two cardiologists and a number of additional physicians as patients for heart-disease prevention.


Its another thing that spurred me on to do this clinic, he says.


Bale is seeing roughly a patient a day at the new clinic, in addition to tending to his regular, general-practice patients. The primary-care practice has hired a nurse practitioner to see some patients, and thereby free up Bale for heart-attack prevention work. The new clinic is staffed by the general practices employees.


Bale says he believes the clinics preventive heart-care approach fills a gap in Spokanes health-care market. The mortality rate from heart attacks has decreased because of the excellence of our cardiologists, but the incidence of heart attack hasnt dropped at all, he says.


We have some excellent cardiologists, but they are too busy putting out fires to prevent them, Bale says. We need more emphasis on education and prevention.


Multiple assessments


To evaluate whether patients are candidates for a heart attack, Bale uses several tools, including: the National Cholesterol Education Panel Guidelines on several risk factors, coronary-calcification imaging tests, insulin-resistance testing, and a series of blood tests that identify emerging risk factors. Each of those assessment methods on its own wouldnt catch all heart-attack risks, but when used together, they could identify virtually everyone at risk, Bale contends.


The cholesterol panels guidelines are used to evaluate a group of basic risk factors: age, family history, smoking history, blood pressure, and cholesterol levels. When more than one of those factors is present or above a certain threshold, the risk of heart attack increases.


Coronary-calcification imaging detects calcium deposits in the coronary arteries. Such deposits are a potential sign of atherosclerosis, or hardening of the arteries, a precursor to heart disease. Computed tomography scanners at Deaconess Medical Center and Inland Imaging LLC have the capability to perform coronary-calcification imaging, and Bale sends his patients to those facilities.


Bale says both the guidelines and the coronary-calcification tests are good indicators of potential heart disease, but at-risk patients can slip through both screenings unnoticed. A portion of the at-risk populationabout 30 percent, Bale saysdoesnt have high cholesterol or the related signs in the cholesterol panels guidelines, and wont detect coronary calcification in younger patients, who dont have calcified plaque in the coronary arteries yet.


To catch those patients, a series of specialized blood tests and a specific urine test are necessary, and those tests can yield such useful information that Bale will use them for all cases.


For example, one blood test, called an Apolipoprotein E gene type test, determines how a person metabolizes, or breaks down, food. A person with an Apo E type 4 has difficulty breaking down harmful cholesterol and is more likely to develop coronary disease. Such a person should be on a strict low-fat diet.


Also, despite well-publicized reports that moderate consumption of alcohol helps reduce heart disease, a patient with Apo E type 4 could increase his or her risk of getting heart disease by drinking alcohol, Bale says.


Other blood work tests for subparticles of high-density lipoprotein, known as good cholesterol, and low-density lipoprotein, or bad cholesterol.


Bale says LDLs include seven subparticles, three of which are very bad and if prevalent, increase the risk of heart disease. HDLs, he says, are composed of five subparticles, one of which is good for you.


A urine test also is administered to check for a certain type of protein that signifies a patient is prone to atherosclerosis.


Only a few laboratories in the U.S. perform these specific blood and urine tests. Bale says his heart-disease prevention clinic uses the Berkeley Heart Laboratory, in Berkeley, Calif., to do the tests.


Also, the clinic tests for insulin resistance. Those who are insulin resistant, even if they havent developed diabetes, have an increased risk of heart disease.


Because some health insurance companies routinely dont cover such testing and consultation, the clinic doesnt bill insurers, and patients are required to pay for heart-attack prevention tests and visits to the clinic up front. Patients then can submit their bills to an insurance company and typically will be reimbursed for a portion of the cost, Bale says.


Bale says the cost of the testing, including lab work and coronary-calcification testing, can range into the hundreds of dollars for each patient, approaching and possibly exceeding $1,000.


If a patient has risk of heart disease, treatments include specific lifestyle advice and a variety of pharmaceutical options.


Bale expects the clinic to draw patients who inquire on their own and those who are referred by other physicians, including cardiologists. Leimgruber says heart specialists often dont have time to answer all of an inquisitive patients questions about heart disease and detailed preventive measures. Such patients can benefit from visiting such a prevention clinic.


Bale says, This is for any patients who want to take an active, preventive approach to heart care.