Homocysteine is known to be a vascular toxin.
Here is how it works.
Hyperhomocysteinemia and autoimmunity. Homocysteine thiolactone, the reactive cyclic anhydride of homocysteine, reacts with free amino groups of protein to form peptide-bound homocysteine [68]. The process of homocysteinylation of proteins is termed thiolation, because this reaction produces a free sulfhydryl group within the peptide-bound homocysteine molecule.
Homocysteine thiolactone reacts with the free amino groups of apoB protein of LDL [69]. When an increased concentration of homocysteine thiolactone reacts with human LDL, the thiolated LDL becomes aggregated and subject to spontaneous precipitation [18]. LDL aggregates are phagocytosed by cultured human macrophages, forming foam cells with greatly increased cholesterol and cholesterol ester content.
It was suggested [18] that thiolation of LDL would also alter its antigenic properties and lead to autoantibody formation. Ferguson et al showed that thiolated LDL is immunogenic in rabbits, producing a polyclonal antibody recognizing thiolated LDL [70].
Antibodies to N-thiolated serum albumin were demonstrated in patients with coronary heart disease [71,72]. Thiolated LDL is present in human serum at low concentration (0.04-0.1%), but autoantibodies to human thiolated LDL have not been reported [73].
The possibility that autoantibodies against thiolated LDL may play a role in the creation of atherosclerosis is suggested by other observations. Hyperhomocysteinemia, a potent risk factor for atherosclerosis, is found in autoimmune diseases, such as lupus erythematosus, rheumatoid arthritis, Behcet’s disease, inflammatory bowel disease, and myelodysplastic syndrome [74]. These diseases all are characterized by increased susceptibility to vascular disease and activation of immunity and inflammation.
Homocysteine activates cytokines and pro-inflammatory molecules, such as IL-1beta, IL-6, IL-12, IL-18, IL-1 receptor antagonist, Creactive protein (CRP), adhesion molecules (Pselectin, E-selectin, ICAM-1), and metalloproteinases (MMP-9). Homocysteine up-regulates reactive oxygen species, leading to NF-kappaB activation [74]. CRP binds oxidized LDL and oxidized phospholipids, enhancing phagocytosis to form foam cells [75].
Best Medical Paper Ever Written - 6
The lipoprotein immune system - continued
For those inclined to look at pictures, here is the table that explains the results below.
Also, if you find the reading too heavy - please go to the end and look at the images. It will show you something I GUARANTEE YOU HAVE NEVER HEARD BEFORE!
Most investigators have identified the immunoprotective role of the lipoproteins by demonstrating inhibition of the biological effects of various microorganisms and endotoxins, such as hemagglutination, hemolysis, the cytokine response of human monocytes, and virus replication. Skarnes first suggested that the lipoproteins also form complexes with microbial products [39].
By using immunodiffusion with anti-endotoxin and serum from various rodents that had been injected with Salmonella enteridis endotoxin, he demonstrated lipoprotein-positive staining and esterase activity on the precipitation lines. Using crossed immunoelectrophoresis, Freudenberg et al found that the HDL peak of rat plasma changed position after injection with various lipopolysaccharides (LPS); they concluded that the effect was due to the formation of a complex between LPS and HDL [42]. By separating a mixture of rabbit plasma and LPS from Salmonella minnesota by column chromatography with sepharose linked with LPS antibody, Ulevitch et al found that the eluate from the bound material contained both LPS and apoprotein A1, the major protein of rabbit HDL [43]. There is strong evidence that human lipoproteins complex with microbial components as well. By electron microscopy (EM) Bhakdi et al found that the inactivation of Staphylococcus aureus alpha-toxin by purified human LDL led to oligomerization of 3S native toxin molecules into ring structures of 11S hexamers that adhered to the LDL molecules [44].
Lipoproteins also form complexes with viruses. Huemer et al found that all lipoprotein subclasses were able to bind purified Herpes simplex virus, as demonstrated by EM, enzyme-linked immunoabsorbence assay, and column chromatography [47]. Superti et al confirmed that all human subclasses of lipoproteins were able to inhibit the infectivity and hemagglutination by SA-11 rotavirus, and complex formation was visualized by EM [51].
The lipoprotein immune system may be particularly important in early childhood as, in contrast to antibody-producing cells, this system works immediately and with high efficiency. For instance, human LDL inactivated up to 90% of Staphylococcus aureus alpha-toxin [44], and it inactivated an even larger fraction of bacterial lipopolysaccharide (LPS) [48].
LEWIS NOTE: The antibody-producing immune system of the very young is immature and only develops upon exposures - thus this lipoprotein immunity is an essential part of innate immunity.
In agreement with these findings, hypocholesterolemic (low LDL levels) rats injected with LPS had a markedly increased mortality compared with normal rats, which could be ameliorated by injecting purified human LDL [54]. On the other hand, hypercholesterolemic mice challenged with LPS or live bacteria had an eightfold increase of LD50, (Lewis - a higher LD50 means it take much more infection to be lethal) compared with normal mice [55].
Hudgins et al demonstrated that high molecular weight lipoproteins (the ones found in the lymphatic system) not only bind LPS, but lipoproteins disappear from the general circulation in infected human beings [56]. They injected a small dose of LPS in normal volunteers and demonstrated the expected rise of the usual inflammatory markers and a fall of total cholesterol, LDL-cholesterol and apo-B, whereas concentrations of HDL-cholesterol and apo-A1 were unchanged. The formation of complexes between lipoproteins and microbial products may lead to aggregation of lipoprotein particles.
In case of a massive invasion of microorganisms, the size of such aggregates, especially those composed of the high-molecular weight VLDL and LDL, may impede their passage through capillary networks, in particular the vasa vasorum of the artery walls, because of high extra-capillary tissue pressure. Indeed, aggregated lipid structures similar to the size of LDL have been demonstrated by electron microscopy in the extracellular space beneath fatty streaks [57].
Recent reviews [58,59] summarized the evidence that both LPS and lipoteichoic acid (the Grampositive counterpart of LPS) form aggregates in solution. In addition, sphingolipids interact with bacterial toxins, and all lipoproteins isolated from animals treated with LPS contain high levels of sphingolipids (ceramide), which promote lipoprotein aggregation.
An unsettled question concerns the nature of the process that converts macrophages into lipid-laden foam cells, one of the main factors in production of atherosclerotic lesions. Normally excess cellular uptake of cholesterol is counteracted by down-regulation of the LDL receptor, indicating that another pathway must be responsible for foam cell formation. According to the current view, oxidized LDL cholesterol in the arterial wall is taken up by the scavenger receptor of macrophages, allowing an unlimited uptake of cholesterol, independent of the LDL receptor. However, macrophages also take up aggregated LDL by phagocytosis after modification by vortexing or by digestion with phospholipase C [60].
LDL that is modified by complex binding with microbial products is also taken up by the same process, because in vitro experiments have shown that LPS from Chlamydia pneumoniae [61] and also from several periodontal pathogens [62] is able to convert macrophages to foam cells in the presence of human LDL.
A direct attack of microorganisms or their products on the endothelium, as often suggested, seems unlikely, as demonstrated by Madjid et al [63]. In a post-mortem study of 27 patients with coronary atherosclerosis, 14 of whom had had a systemic infection within two weeks before death, luminal coronary thromboses and myocardial infarction were found in 5 of the infected patients. They found that the number of macrophages in the infected group was much greater in the adventitia than around the plaques, whereas no difference was noted in the uninfected control group, which suggests that the microbes arrive via vasa vasorum.
In agreement with this view, Guyton et al found that extracellular lipid deposits are almost entirely located deep within the intima, close to the vasa vasorum and well below most of the foam cell lipid [57]. This finding opposes the view that the lipid-rich core region of plaques originates primarily from the debris of dead intimal foam cells, but the finding agrees with the spontaneous atherothrombosis observed in genetic double-knockout mice [64].
These thrombi were demonstrated on the surface of atherosclerotic lesions similar to human vulnerable plaques, accompanied by marked medial degeneration and invasion of inflammatory cells into the adventitia. During the oxidative breakdown of microbial material inside macrophages, cholesterol is partially oxidized and returned to the liver by HDL, and the cholesterol content of fibrous plaques is not higher than in normal arterial tissue [65]. Indeed, several HDL processes that are able to convert oxidized LDL cholesterol to free cholesterol have been identified [66]. Also, esterified cholesterol may be converted to free cholesterol by microbial processes [67] and deposited as extracellular cholesterol crystals found deep within the intima [57].
Congratulations is you read through to here. This paper is the work of a true thinker who looks deep into mechanisms - ignoring dogma. That doesn't mean that everything states is absolute. For example, Drs. McCully and Ravnskov state,
LEWIS COMMENTS
"cholesterol may be converted to free cholesterol by microbial processes."
Based on current knowledge, I suggest a slight word change to make this more accurate.
"cholesterol may be converted to free cholesterol because of microbial processes."
Why the change from "by" to "because of?"
Cholesterol is an antibiotic substance, among other things. Thus, free cholesterol is produced "as a result" of microbial process, and not "by" microbial processes. This a a subtle but important difference.
Look at what is shown in this paper.
The cholesterol molecule itself is an antibiotic. This may explain the antibiotic effects of LDL and HDL, which are rich in the actual cholesterol molecule. The scribblings on the images above are by Dr. Trempe. Dr. McCully was NOT aware of this paper - and its findings - until after the paper discussed in this blog was written.
Best Medical Paper Ever Written - 5
The microbial hypothesis.
A century ago, bacteria and viruses were considered as the main cause of atherosclerosis, a view that was based mainly on post-mortem observations. Thus, Thayer reported a high frequency of arterial lesions in patients who died from typhoid fever and a high prevalence of hardened radial arteries in those who survived [19].
Wiesel found an association between the degree of atherosclerosis in people who had died from an infectious disease and the length of the preceding infection [20], and Osler described the vulnerable plaque as an atherosclerotic pustule [21].
The following statement by Klotz and Manning is typical for the general view at that time: “There is every indication that the production of tissue in the intima is the result of a direct irritation of that tissue by the presence of infection or toxins” [22].
The molecular mechanisms were unknown and because of the chemical composition of advanced atherosclerotic plaques, more recent research has instead focused on cholesterol. (Indeed, cholesterol is at the site of plaques - as a healing agent for tissue damaged by inflammation and infection.)
However, in addition to and in accordance with the older findings, much epidemiological, clinical, laboratory, and experimental evidence has more recently been reported, suggesting that infectious processes may play a role in cardiovascular disease [23–27].
Cardiovascular mortality increases during influenza epidemics [28]. A third of patients with acute myocardial infarction or stroke have had an infectious disease immediately before onset [29].
Bacteriemia and periodontal infections are associated with an increased risk of cardiovascular disease [30,31].
Serological markers of infection are often elevated in patients with cardiovascular disease and are also risk factors for such diseases [32].
A role of infectious agents is suggested by the narrowing of the coronary arteries seen in children who died from an infectious disease [33] and from thickening of carotid intima-media on high-resolution ultrasound in those who survived [34].
The lipoprotein immune system.
LEWIS COMMENT: This section may be a little unclear if you are not familiar with infectious species testing. However, the highlighted text below explains it well. That is, lipoproteins are part of the immune response and are NEVER a treatment target.
A normal serum factor is able to neutralize the hemolytic effects of streptolysin-S, and, for this reason, the factor was named antistreptolysin-S and was previously considered to be an antibody. However, this concept was questioned in 1939 by Todd et al, who found that this serum factor did not behave as a normal antibody because its titer fell below normal values in patients with rheumatic fever at the peak of the clinical symptoms [35]. A few years later, Stollerman and Bernheimer also found that, in contrast to the antistreptococcal antibodies, the antistreptolysin-S titer did not rise above its normal level during convalescence [36]. At the same time, Humphrey discovered that antistreptolysin-S was located within the lipid fraction of the blood [37].
Stollerman et al identified antistreptolysin-S as a phospholipoprotein complex [38]. Since then, at least a dozen research groups have established that antistreptolysin-S is identical with the lipoproteins and constitutes a nonspecific host defense system, able to bind and inactivate not only streptolysin-S, but also other endotoxins and several virus species [39–55] (Table 1⇓). In rodents, cholesterol is mostly transported by high-density lipoprotein (HDL), and in these species HDL has the main protective effect [42,43], whereas human studies have generally found that all lipoproteins participate in the nonspecific defense system.
Now it's time to "hear" Dr. McCully's overview by way of the introduction to the paper.
Vulnerable Plaque Formation from Obstruction of Vasa Vasorum by Homocysteinylated and Oxidized Lipoprotein Aggregates Complexed with Microbial Remnants and LDL Autoantibodies
Introduction.
There is general agreement that atherosclerosis begins as an inflammatory process in the arterial wall, and also that rupture of a vulnerable plaque is the starting point for the creation of the occluding thrombus in myocardial infarction and ischemic stroke [1,2].
Therefore, any hypothesis about the cause of atherosclerosis and its consequences must necessarily be able to point to the origin of the inflammation and explain how a vulnerable plaque is created [3].
and
According to the current view, the first step is endothelial dysfunction or damage caused by hypercholesterolemia, hyperhomocysteinemia, or other toxic factors in the circulation, allowing the migration of LDL, cholesterol, and monocytes into the arterial wall. LDL is modified by oxidation, leading to an accumulation of T-cells and the production of LDL autoantibodies.
LEWIS: Why would T-cells and monocytes be present? They are part of the immune system that MAINLY fight infection or repair the damage caused by infection.
Monocytes are a type of white blood cell that perform a variety of functions in the body, including:
Fighting infection: Monocytes are produced in the bone marrow and enter the blood, where they destroy bacteria, viruses, fungi, and protozoa.
Helping other white blood cells: Monocytes call on other white blood cells to help treat injuries and prevent infection. They also help remove dead or damaged tissues and destroy cancer cells.
Regulating immunity: Monocytes regulate innate and adaptive immune responses.
Healing and repair: Monocytes help support the removal of infected cells and aid in healing and repair of the body.
Influencing organ formation: Monocytes have also shown to influence the formation of some organs.
T cells, also known as T lymphocytes, are white blood cells that are a crucial part of the immune system, primarily responsible for fighting infections by directly attacking infected cells and coordinating the immune response by signaling other immune cells to join the fight against pathogens like viruses and bacteria; essentially, they help protect the body from disease by identifying and eliminating infected or cancerous cells.
Key points about T cells:
Function:
T cells recognize and destroy cells that are infected with viruses or have become cancerous, contributing to cell-mediated immunity.
Types of T cells:
Helper T cells (CD4+): These cells act as "commanders" by signaling other immune cells, like B cells and cytotoxic T cells, to activate and attack pathogens.
Cytotoxic T cells (CD8+): These cells directly kill infected or cancerous cells by releasing toxic substances.
Regulatory T cells (Tregs): These cells help suppress the immune response to prevent overreaction and autoimmune diseases.
BACK TO MCCULLY:
Modified LDL is taken up by macrophages that are converted to lipid-laden foam cells, considered as the early lesion of atherosclerosis. The inflammatory process, probably aggravated by antigens from microbes such as Chlamydia, Herpes simplex and Cytomegalo-virus, is followed by smooth muscle cell proliferation and the synthesis of extracellular matrix. The macrophages may become overloaded with lipids and die, resulting in the creation of a vulnerable plaque that by rupturing initiates the formation of an occluding thrombus [4].
This suggested chain of events is based mainly on epidemiological observations and experimental models, where vascular changes similar to human atherosclerosis have been produced in rodents with inherited or dietary hypercholesterolemia. However, THE CHOLESTEROL HYPOTHESIS conflicts with many clinical, epidemiological, pathological, and experimental observations. There are in particular six disturbing facts:
HOW THE CHOLESTEROL HYPOTHESIS OF CARDIOVASCULAR DISEASE IS WRONG.
The concept that high LDL cholesterol causes endothelial dysfunction is unlikely because there is no association between the concentration of LDL cholesterol in the blood and the degree of endothelial dysfunction [5].
The concept that endothelial damage leads to influx of LDL cholesterol is unlikely as well, because the atherosclerotic plaques seen in extreme hyper-homocysteinemia caused by inborn errors of methionine metabolism do not contain any lipids in spite of pronounced endothelial damage [6,7].
No study of unselected individuals has found an association between the concentration of LDL or total cholesterol in the blood and the degree of atherosclerosis at autopsy [8].
In studies of women and the elderly, hypercholesterolemia is a weak risk factor for cardiovascular disease, or, in most cases, not a risk factor at all [9], although the large majority of cardiovascular deaths occur in people above 65 years of age.
Among individuals with familial hypercholesterolemia (FH) there is no association between LDL-cholesterol and the prevalence or the progress of cardiovascular disease [10–15]. The higher coronary mortality in young people with FH may instead be due to inherited abnormalities of the coagulation system, often seen in FH and a strong risk factor for coronary heart disease in this population [15,16].
With one exception [17], an occluding coronary thrombus has never been produced experimentally in rodents by hypercholesterolemia alone [3], indicating that the pathological process in these models may differ from that in human beings.
Origin of vulnerable plaques.
In the following discussion we present a new interpretation of the origin of vulnerable plaques that we think is in better agreement with presently available evidence.
This interpretation is based on the fact that the lipoproteins function as a nonspecific immune system that binds and inactivates microorganisms and their toxins by complex formation.
In the case of a massive microbial invasion, these complexes may aggregate, in particular in the presence of hyperhomocysteinemia, because homocysteine thiolactone causes aggregation and precipitation of thiolated LDL [18].
Complex formation and aggregation may also be enhanced by autoantibodies against thiolated LDL and oxidized LDL. Because of high extra-capillary tissue pressure, the aggregates may be trapped in arterial vasa vasorum, resulting in local vascular ischemia, intramural cell death, and the creation of vulnerable plaques.
Such plaques have many characteristics of a micro-abscess, which, by rupturing, initiates the occluding thrombosis and releases its content of infectious material into the circulation and the myocardium.
This suggested chain of events explains why many of the clinical symptoms and laboratory findings in acute myocardial infarction are similar to those seen in infectious diseases.
It also explains the frequent presence of microbial remnants in atherosclerotic plaques, the many associations between infections and cardiovascular disease, the similarities between myocarditis and myocardial infarction, and why cholesterol accumulates in the arterial wall.
REFERENCES
References
Hansson GK, Nilsson J. Introduction: atherosclerosis as inflammation: a controversial concept becomes accepted. J Int Med 2008;263:462–463.
Lusis AJ. Atherosclerosis. Nature 2000;407:233–241.
Hansson GK, Heistad DD. Two views on plaque rupture. Arterioscler Thromb Vasc Biol 2007;27:697.
Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. NEJM 2005;352:1685–1695.
Reis SE, Holubkov R, Conrad-Smith AJ, Kelsey SF, Sharaf BL, Reichek N, Rogers WJ, Merz CN, Sopko G, Pepine CJ. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J 2001;141:735–741.
McCully KS. Vascular pathology of homocysteinemia: implications for the pathogenesis of arteriosclerosis. Am J Pathol 1969;56:111–128.
McCully KS. Hyperhomocysteinemia and arteriosclerosis: historical perspectives. Clin Chem Lab Med 2005;43:980–986.
Ravnskov U. Is atherosclerosis caused by high cholesterol? Q J Med 2002;95:397–403.
Ravnskov U. High cholesterol may protect against infections and atherosclerosis. Q J Med 2003;96:927–934.
Miettinen TA, Gylling H. Mortality and cholesterol metabolism in familial hypercholesterolemia. Long-term follow-up of 96 patients. Arteriosclerosis 1988;8:163–167.
Hopkins PN, Stephenson S, Wu LL, Riley WA, Xin Y, Hunt SE. Evaluation of coronary risk factors in patients with heterozygous familial hypercholesterolemia. Am J Cardiol 2001;87:547–453.
Hill JS, Hayden MR, Frohlich J, Pritchard PH. Genetic and environmental factors affecting the incidence of coronary artery disease in heterozygous familial hypercholesterolemia. Arterioscler Thromb 1991;11:290–297.
Ferrières J, Lambert J, Lussier-Cacan S, Davignon J. Coronary artery disease in heterozygous familial hypercholesterolemia patients with the same LDL receptor gene mutation. Circulation 1995;92:290–295.
Neil HAW, Seagroatt V, Betteridge DJ, Cooper MP, Durrington PN, Miller JP, Seed M, Naoumova RP, Thompson GR, Huxley R, Humphries SE. Established and emerging coronary risk factors in patients with heterozygous familial hypercholesterolaemia. Heart 2004; 90:1431–1437.
Jansen AC, van Aalst-Cohen ES, Tanck MW, Cheng S, Fontecha MR, Li J, Defesche JC, Kastelein JJ. Genetic determinants of cardiovascular disease risk in familial hyper-cholesterolemia. Arterioscler Thromb Vasc Biol 2005;25:1475–1481.
Sugrue DD, Trayner I, Thompson GR, Vere TV, Dimeson J, Stirling Y, Meade TW. Coronary artery disease and haemostatic variables in heterozygous familial hypercholesterolaemia. Br Heart J 1985;53:265–268.
Calara F, Silvestre M, Casanada F, Yean N, Napoli C, Palinski W. Spontaneous plaque rupture and secondary thrombosis in apolipoprotein E-deficient and LDL receptor-deficient mice. J Pathol 2001;195:257–263.
Naruszewicz M, Mirkiewicz E, Olszewski AJ, McCully KS. Thiolation of low-density lipoprotein by homocysteine thiolactone causes increased aggregation and altered interaction with cultured macrophages. Nutr Metab Cardiovas Dis 1994;4:70–77.
Best Medical Paper Ever Written -3
In the last blog, I "unpacked" the paper's title. Keep in mind, this paper was published in 2009 and led to myself and Dr. Trempe contacting Dr. McCully. Subsequently, this led to a 10-year relationship where we hashed over this paper and disease mechanisms. In the comments below, I attempt to update Dr. McCully's conclusions, but not much has really changed because he never writes papers like this on a hunch.
Review and Hypothesis: Vulnerable plaque formation from obstruction of Vasa vasorum by homocysteinylated and oxidized lipoprotein aggregates complexed with microbial remnants and LDL autoantibodies
Now, it's time to review and decipher the abstract.
Here is the abstract in all its complicated glory.
1. Little attention has been paid to the function of lipoproteins as part of a nonspecific immune defense system that effectively binds and inactivates microbes and their toxins by complex formation.
LEWIS: LDL and HDL are soap molecules that absorb and transport fats. This includes "lipophilic toxins." Hopefully, you know that tartar in your mouth is a biofilm and that the otter structure is fat (lipid) based. Biofilms may be substances that LDL and, probably more likely, HDL, bind and inactivate.
Be aware that the authors are a little confused about lipoproteins - as a most doctors - but what I captured below is completely consistent with what Dr. McCully presents.
Fentoglu et al. reported that serum and gingival cervical fluid (GCF) levels of TNF-α, IL-1β and IL-6 seem to be related factors between periodontal disease and high serum lipid levels (3). Several studies have shown that there is a relationship between periodontitis and high serum lipid levels (4-9). (See the article for the references)
Additionally, here is how HDL acts as part of the "non-specific" immune defense.
"The dynamic binding interactions between AMPs and HDL were mediated through the hydrophobic interactions (HDL is a soap that binds fats just like your dish soap!) rather than by ionic strength. Interestingly, some AMPs, such as SMAP29, dissociated from the AMP-HDL complex and translocated to bacteria upon contact (that is, exerted its antimicrobial properties on the buggers), while some AMPs, such as LL37, remained in the complex with HDL. These results suggest that HDL binds AMPs and facilitates their translocation to the bacteria.
2. Because of high extra-capillary tissue pressure, aggregates of such complexes may be trapped in vasa vasorum of the major arteries. This complex formation and aggregation may be enhanced by hyperhomocysteinemia, because homocysteine thiolactone reacts with the free amino groups of apo-B to form homocysteinylated low-density lipoprotein (LDL), which is subject to spontaneous precipitation in vitro.
LEWIS: I'm not sure they are "trapped." So often, I hear "experts" explaining how the disease is caused by the body doing something wrong. I doubt that is ever the case, but collateral damage can certainly occur. This morning, I was listening to a lecture on mast cell activation, and the "expert" claimed that the body was doing something wrong. IMHO, if that is the case, and this happens a lot, how did we survive as a species?
Dr. McCully explains that lipoproteins are there just like a cleaning crew appears after a fire (inflammation in our body). This was explained in 1. above.
3. Obstruction of the circulation in vasa vasorum, caused by the aggregated complexes, may result in local ischemia in the arterial wall, intramural cell death, bursting of the capillary, and escape of microorganisms into the intima, all of which lead to inflammation and creation of vulnerable plaques.
Local ischemia is the loss of blood flow. Certainly, cleanup crews get in the way of traffic flow after an accident. However, what is really happening is the deterioration of the capillaries in the vasa vasorum followed by upregulation of the Vascular Endothelium Growth Factor (VEGF). What Dr. McCully wasn't aware of at the time was the connection between macular degeneration, cardiovascular disease, and early mortality risk. Dr. Trempe, as an ophthalmologist, understood this well as he saw it in his practice daily - for 47 YEARS!
When VEGF is activated, it means only one thing, the original vessels have deteriorated and can no longer supply adequate blood flow, so new ones are produced by the action of VEGF.
This chart show the Age-Related Eye Disease study (AREDS) and how macular disease is DEADLY. The reason is, what is happening in the eye is happening in the rest of the body. What Dr. McCully is describing as occuring in the Vasa Vasorum is exactly what is happening in the capillaries of the retina.
As you can see from the date of this article (2004), Dr. Trempe was well aware of this concept of ischemia long before Dr. McCully's paper was published in 2009. And, Dr. Trempe was probably aware of this in the 1970s or 1980s - he was that far ahead of his time - and still is post mortem.
4. The presence of homocysteinylated LDL and oxidized LDL stimulates the production of LDL autoantibodies, which may start a vicious circle by increasing the complex formation and aggregation of lipoproteins.
LEWIS: I believe a couple of intelligent researchers at UCSF explain this well, excluding their recommendations for drug therapy. Oxidation (of LDL or anything) involves the loss of electrons. Obligate intracellular infections are obliged to their host (your body) for electrons. LDL, being in the area of infection, is attacked by the infection, which steals electrons from the membrane, leading to oxidation / inflammation.
WARNING - They still think lowering a protective substance like LDL or HDL is ok. Thus, even though they understand the mechanism by which LDL increases, they are stuck in statin dogma. After all, who do you think funds their research, disclosed or otherwise?
5. The content of necrotic debris and leukocytes and the higher temperature than its surroundings give the vulnerable plaque some characteristics of a micro-abscess that by rupturing may initiate an occluding thrombosis.
LEWIS: Nothing to add here. It's obvious today that a vulnerable plaque is a micro-abscess.
6. This suggested chain of events explains why many of the clinical symptoms and laboratory findings in acute myocardial infarction are similar to those seen in infectious diseases.
LEWIS: Dr. McCully now understands that these are one in the same!
2003: It is just 17 years since Chlamydia pneumoniae was first described and 14 years since the first observational evidence of a possible association of the organism with coronary heart disease (CHD). For 5 years, there was little interest in this association, but it has subsequently attracted an increasing number of investigators. The question of an association was settled by the frequent demonstration of C. pneumoniae in atherosclerotic lesions.
LEWIS: There is a strong and well-known link between periodontal spirochetes, bacteria associated with gum disease, and an increased risk of myocardial infarction (heart attack), as these bacteria can enter the bloodstream and contribute to inflammation within the arteries, potentially promoting the development of atherosclerotic plaques which can lead to coronary artery blockage and heart attack; essentially, severe gum disease may be considered a risk factor for myocardial infarction due to the presence of these spirochetes
Periodontitis Increases the Risk of a First Myocardial Infarction: A Report From the PAROKRANK Study
A pathobiont is a microorganism that is normally part of a host's microbiome but can become pathogenic and cause disease under certain conditions. H pylori may be an example as indicated in this blog.
LEWIS: This is explained in many of the sections above.
9. Some risk factors may not cause vascular disease directly, but they may impair the immune system, promote microbial growth, or cause hyperhomocysteinemia, leading to vulnerable plaques.
LEWIS: This is a broad topic that includes: diet, micronutrient intake, exercise, sunlight exposure, toxins, and other factors that impact our overall health.
Many of the pathogenic bacteria are correctly termed as pathobionts. Their job is to decompose us when we die. At that point, our immune system is at zero (0). However, everyone with a chronic condition has a compromised immune system and their effective immune activity is, say, 50%. At that point, some organisms that are "beneficial" or "commensal" get told by some elaborate signaling mechansims, to start doing their job - decomposing "dead" tissue.
"We resist the organisms that might break us down and we regenerate our tissues faster than we decompose. However, yes, people can absolutely begin to decompose before they die, if they are susceptible."
This is one factor leading to chronic disease and early mortality.
Best Medical Paper Ever Written - 2
Unpacking the title of this magnificent paper.
Review and Hypothesis: Vulnerable plaque formation from obstruction of Vasa vasorum by homocysteinylated and oxidized lipoprotein aggregates complexed with microbial remnants and LDL autoantibodies
Review and Hypothesis:
The "review" part indicates many other peer-reviewed papers supporting his paper's thesis. The "hypothesis" part indicates that he is bringing a new and fresh perspective to that which has been previously presented.
Vulnerable plaque formation:
Nothing is more debilitating or deadly than vulnerable plaque formation. A healthy longevity is all about the integrity of your vascular system. The Japanese outlive us by 10 years, and they consume sea vegetables and fish with substances scientifically proven to enhance vessel health.
"vulnerable plaques can be deadly because they are prone to rupturing, which can lead to blood clots that block blood flow to vital organs like the heart, potentially causing a heart attack or sudden death; essentially, a vulnerable plaque is considered the primary culprit behind most acute coronary syndromes like myocardial infarction."
from obstruction of Vasa vasorum:
Heart attacks and strokes are the result of the deterioration of large vessels, right?
Wrong
The disease of the large vessel is a disease of the "small vessel feeding the large vessel."
Wait! When did this thinking change?
Here is what I wrote on this topic in my book "Health Freedom Lost."
In 2009, along with his co-author, Uffe Ravnskov, he authored a “Review and
Hypothesis” on how infection contributes to heart disease. Here, he explains that
vulnerable plaques, the type that kills or debilitates us by way of heart attack or
stroke, do NOT form from inside a blood vessel as stated by the U.S. Federal
Government, as depicted on TV and in your doctor’s office. Instead, they start
outside the vessel and work their way inside. Dr. McCully does not get
full credit for this discovery as he was scooped by at least 140 years by a German
doctor by the name of Koester. 54
54 Koester W. Endarteritis and arteritis. Berl Klin Wochenschr. 1876;13:454–5.
Dr. Trempe explains this correct description of heart disease this way:
“Heart disease is a disease of the small vessels of the large vessel.”
Say this fast three times and then give it some deep thought! This means that large
vessel walls are big enough to require their own blood supply. The smaller vessels
that support the structure of large vessels become diseased first and lead to the
disease of the larger vessels - and eventually to heart attacks and stroke. Figure
5.16 shows the incorrect and correct depiction of the heart and vascular disease
Yes, every depiction of heart disease in every medical office is completely wrong!
by homocysteinylated and oxidized lipoprotein aggregates
What causes a lipoprotein to oxidize.
What is a lipoprotein? We commonly hear that LDL and HDL are lipoproteins - NOT cholesterol, by the way.
What really is a lipoprotein? Please erase dogma and understand what LDL and HDL genuinely are.
Here is a blog I wrote that goes into the details of the actual structure and function of lipoproteins - including but not limited to LDL and HDL.
Here is the summary from that blog.
Now back to the question, how do lipoproteins oxidize? The answer is simple - the same way anything oxidizes. The answer to how this happens is the answer to how essentially all chronic diseases manifest. To quote Dr. Thomas Levy, M.D., J.D.
"All healing is the gain of electrons - while all deterioration is the loss of electrons."
Here is an AI overview that is surprisingly informative.
LDL (low-density lipoprotein) becomes oxidized when it encounters reactive oxygen species (free radicals) in the bloodstream, primarily within the artery lining, causing a chemical reaction that damages the LDL molecule, modifying its lipids and proteins, and transforming it into "oxidized LDL" (oxLDL) which is considered more atherogenic (plaque-forming) than native LDL; this process often happens due to factors like inflammation,
Wait, wait - I thought LDL was toxic, that's why we take drugs to reduce it!
It seems like we are being told that there is an underlying process of oxidation - or loss of electrons. This can only mean one thing.
LDL (foolishly referred to as cholesterol) is NOT THE CAUSE OF HEART DISEASE - IT'S AN INNOCENT VICTIM OF A DEEPER FREE RADICAL PROCESS.
Who would have thunk it!!!!!!!!
So if ("cholesterol") lipoproteins is/are the cause of disease, how do they oxidize? What is stealing electrons? Find that answer and you will know the real cause of heart disease.
complexed with microbial remnants
I'm beginning to like AI (just a little bit). You might even get the right answer if you know how to ask the right question. Here is an example.
Hmmm... "effectively damaging host cells and tissue through oxidative stress."
Could this mean??? No, it couldn't... But that data shows... I don't believe it. It can't be that heart disease is not caused by LDL (cholesterol, for those of you who still don't understand that the dogma has duped you).
Son of a gun - it's infection - but of the chronic ilk. That's too simple of an idea - and how would big pharma make money off of this????? That's the biggest question.
This information is well appreciated, as indicated by the 200+ other papers that cite this work. We are not alone, but Mammon is muting our voice.
Here is more information that stealth infectious species are creating oxidation in the area of tissue damage because they are "obliged" to you - the organism - for their energy.
What is the energy of the cell? Ultimately it is ATP, but the pathway to the production of ATP is the electron transport chain within the mitochondria. Thus, obligate organisms are "eating" electrons - thus they are CREATING OXIDATION!
and LDL autoantibodies
Some in vitro studies suggest that antibodies to oxidised LDL may have an atherogenic effect by enhancing the lipid accumulation into macrophages in the atherosclerotic vessels. These antibodies can be considered as markers of the pathogenic determinants of atherosclerosis, such as enhanced lipid oxidation, proinflammatory stage and impaired vasodilatation.
Conclusions:
Our study proves an association between human oxLDL markers and chronic infections.
Moreover, in this population-based study, neither IgG nor IgM OxLDL autoantibodies were independently predictive of atherosclerosis progression in the carotid arteries.
INTERESTING NOTE - THE AMERICAN COLLEGE OF CARDIOLOGY WANTS YOUR LDL BELOW 70 OR EVEN 50 - WHICH PUTS YOU AT GREAT STROKE RISK.
Here, they are saying that LDL is NOT the target.
All praise goes to Dr. McCully - one of my 2 mentors for 15 years.
Best Medical Paper Ever Written - 1 Reproduced
Dr. Kilmer S. McCully is a dear friend and a brilliant medical scientist who has published more peer-reviewed papers on disease mechanisms than anyone else. Some doctors
Some authors have many more papers attributable to their names, but in most cases, they did not write them.
Here is a link to his best work. I will present and dissect this paper in subsequent blogs. Today is all about describing the life and times of Dr. McCully.
"Science advances one funeral at a time."
--Max Planck
"Eine neue wissenschaftliche Wahrheit pflegt sich nicht in der Weise durchzusetzen, daß ihre Gegner überzeugt werden und sich als belehrt erklären, sondern vielmehr dadurch, daß ihre Gegner allmählich aussterben und daß die heranwachsende Generation von vornherein mit der Wahrheit vertraut gemacht ist."
A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.
Written in 1997
In summary, Dr. McCully did not receive tenure at Harvard because he eschewed the cholesterol theory of cardiovascular disease. A man of integrity, he didn't back down. Not only was he fired, he was blacklisted and could not get a job in Boston, so he wound up commuting 90 minutes to Providence beyond the despicable reach of Harvard.
Here are a couple of excerpts.
The current chief of pathology at Mass. General Robert Colvin agrees with his predecessor that ''the main issue was that nobody could fund McCully's research,'' but he emphasizes the funders' short-sightedness.
''McCully was so far advanced in his thinking about the biochemistry,'' Colvin says.
''And N.I.H. is not very good at funding very innovative, creative research. They're better at funding natural extensions of existing theories.''
Since Mass. General and Harvard appointments go hand in hand, and McCully had not been recommended for tenure at Harvard; both jobs formally ended in January 1979. At about the same time, a former classmate at Harvard who became the director of the Arteriosclerosis Center at M.I.T. attacked his ideas as ''errant nonsense'' and a ''hoax that is being perpetrated on the public.'' McCully says that when he was interviewed on Canadian television after he left Harvard, he received a call from the public affairs director of Mass. General. ''He told me to shut up,'' McCully recalls. ''He said he didn't want the names of Harvard and Mass. General associated with my theories.''
McCully stresses that his ideas do not dismiss cholesterol as a risk indicator, but they do question its hegemony. ''Cholesterol is important, certainly,'' McCully says. ''But the cholesterol theory isn't really a theory -- it's a collection of observations.'' He says his own theory suggests that ''homocysteine might be the underlying cause of arteriosclerosis, that
"homocysteine damage sets the stage for cholesterol buildup in the arteries."
I think altered homocysteine metabolism and biochemistry is at the heart of vascular disease.
Of course, he was right - it is now widely known - except by those making "bank" on the cholesterol theory that it is the fire trucks at the fire - helping to save your vessels, not destroy them.
The full NY Times article is below, so you don't have to visit that "rag's" website. The fewer "hits" they get, the better.
Fall and Rise of Kilmer McCully - Full Article. Written in 1997
In 1981, when Kilmer McCully started commuting from his home in a Boston suburb to a new job in Providence, R.I., he would drive past the domed Rhode Island Capitol. High atop the dome stands a statue called ''The Independent Man'' -- a representation of Roger Williams, the Puritan founder of Providence. ''Because of Williams's religious beliefs, he was thrown out of Boston,'' McCully says now. ''It sounded familiar.'' McCully, too, felt like an outcast when he went to Providence from Boston, though he was a scientific rather than a religious infidel. He had left appointments at Harvard Medical School and Massachusetts General Hospital under a cloud, told that his research had dead-ended. He had been denounced by some fellow scientists and ignored by others. His research grants had withered away. He took refuge in a pathology job far from the fast track at the Providence Veterans Administration Medical Center.
These are distinctly better days for McCully, who is now 63. His lifetime's study of a little-understood trigger for heart disease is suddenly at the forefront of cardiac research. His theory -- the same one that came close to scuttling his career -- holds that homocysteine, an amino acid in the blood, damages artery walls and causes heart attacks, and that in most cases homocysteine can easily be lowered to safe levels by taking certain common vitamins. If he's right, homocysteine could join cholesterol, smoking and high blood pressure as a major culprit of heart disease, accounting for (and perhaps someday preventing) upward of 10 to 15 percent of all cases. For an illness that kills nearly 1,500 Americans a day, these are serious numbers.
Homocysteine is the theory of the moment in a notoriously competitive field, and McCully's name is inextricably tied to its ascent. He has been called ''the father of homocysteine'' at meetings of leading international figures in cardiology and epidemiology. His book, ''The Homocysteine Revolution: Medicine for the New Millennium,'' was published in May. Where once McCully's was almost a lone voice in homocysteine research, now dozens of articles have appeared in scientific journals, including one a few weeks ago in The New England Journal of Medicine. Where once the theory was shunned by the grant-giving powers that be, the National Institutes of Health recently put out a request for applications for further research, and at least one large-scale study of homocysteine in humans is already under way.
While McCully says he is ''grateful'' and ''thrilled'' that his work is being appreciated, there is a bittersweet quality to his current success and to his anointment as an innovator. A personality more prone to might-have-beens would find it easy to dwell on the contrast between his present situation and that of more than 20 years ago -- another moment when accolades and recognition seemed almost within reach. But beyond the issue of McCully's halted career, those concerned about heart disease -- the nation's No. 1 cause of death -- might wonder, what took so long?
The son of two schoolteachers, McCully grew up in Colorado as a self-described ''boy scientist.'' After graduating from Harvard College and Harvard Medical School, he embarked on a series of research fellowships. In the mid-60's, as a young pathology instructor at Harvard, McCully made the scientific observation that would define his career. He became intrigued by two different cases of children with homocystinuria, a rare genetic disease in which the levels of homocysteine in the blood are unnaturally high. In both cases, the cause of death was severe arteriosclerosis, a narrowing and loss of elasticity in arteries that is normally seen only in the elderly. By re-examining the autopsy tissues of both children and drawing on previous animal research, McCully emerged with two linked and provocative suggestions: perhaps homocysteine directly damages the cells and tissues of the arteries, in much the way that cholesterol is thought to do, and perhaps that damage occurs not just in these rare genetic cases but in the population at large, in any people with elevated homocysteine levels.
He soon expanded his theory to include a probable cause of elevated levels of homocysteine: a deficiency of vitamins B6, B12 and folic acid. When these vitamins were administered to animals with high homocysteine levels, those levels plummeted, often within hours. Once McCully started extrapolating from his cellular-tissue and animal studies to the human situation, he says, ''it all began to fit together.''
Homocysteine in the body derives from methionine, an essential amino acid present in large amounts in protein from animal sources like meat, eggs and milk. If there are adequate levels of vitamins B6, B12 and folic acid in the body, the homocysteine is broken down into harmless waste products or protein building blocks. But if there's a deficiency of those vitamins, the homocysteine begins its ravages on the blood vessels.
What, then, is the diet most likely to lead to heart disease, according to the homocysteine theory? One high in animal protein and low in B-vitamins, which occur in many foods but are very easily destroyed by processing -- a diet of meat, cheese, milk, white flour and foods that are canned, boxed, refined, processed or preserved. The American diet, in other words.
Here was a strong connection between diet and heart disease, but one that took a different path from cholesterol. The homocysteine theory considers arteriosclerosis a disease of what McCully calls ''protein intoxication.'' The cholesterol theory (sometimes called the lipid theory) instead demonizes fats. Since proteins and fats often occur in the same foods, the potential dietary treatments for high homocysteine and high cholesterol are similar, with this distinction: the anti-homocysteine diet focuses on what should be eaten, as a preventive, while the anti-cholesterol diet focuses on what should be avoided, as a precipitator. Thus, a diet of lower homocysteine would include many natural sources of B-vitamins like fresh fruits and vegetables and would limit animal protein. The cholesterol-reducing diet would limit foods high in saturated fats and cholesterol, like eggs, meat and butter.
But dietary intervention often fails to lower cholesterol levels, and the next step is drug therapy. A new class of drugs called statins has been more effective than previous drugs at lowering cholesterol with few side effects, but questions have been raised about the safety of long-term use. No clinical consensus on how to treat high homocysteine has yet emerged, but most researchers say that the logical course is simply to take a multivitamin. Studies suggest an optimal daily intake of 3 to 3.5 milligrams of B6, 350 to 400 micrograms of folic acid and 5 to 15 micrograms of B12; many multivitamins contain these amounts.
''For the first few years, everywhere I turned I got evidence that the basic idea was correct,'' McCully recalls. He injected rabbits with homocysteine and within weeks found arteriosclerotic plaques in their coronary arteries. If the animals were also given a diet deficient in vitamin B6, the plaques were more widespread. While others conducted similar experiments with baboons, McCully examined and manipulated cell cultures from children with homocystinuria. Two Australian researchers, Bridget and David Wilcken, published the first human study in 1976, showing a possible connection between coronary heart disease and high elevations of blood homocysteine.
Then, in the mid-70's, the homocysteine theory began to lose momentum. McCully believes that his support at Harvard and Mass. General began to flag after his department chief and mentor, Benjamin Castleman, retired in 1974. Castleman, who died in 1982, had helped review McCully's findings, sponsored him for lectures and showcased his work before a prestigious panel of experts.
Under the new chief, Robert T. McCluskey, this backing eroded. He was moved to an inferior laboratory in the basement, he lost staffers and his N.I.H. funding was running out. ''With the changes in my lab and the loss of some key collaborators, it was difficult to come up with new ideas,'' he says. ''I felt very cut off from everybody, and there was no encouragement. Then they told me that if I didn't renew my grant, I would definitely be out. Their view, I suppose, was that I was no longer productive. My view was that I was being discouraged at every turn.''
McCluskey, who is no longer the department head, now says that the key issue was money. ''It's certainly true that, perhaps because his idea at that time wasn't generally accepted, he wasn't able to get funding for research after his grants ran out,'' he says. ''There was some uncertainty at the time about how important his work was. Anyone doing research at Mass. General has to apply for and eventually succeed in getting outside funding, and McCully was unable -- in fact, unwilling -- to do that. He wanted the department to support him, which wasn't possible on a long-term basis. So he was asked to either attempt to get further support or to leave.''
McCully acknowledges that he eventually did give up on obtaining another N.I.H. grant. ''My enthusiasm had been drained,'' he says. ''In that atmosphere, and because I hadn't generated a lot of new information, I felt it was hopeless to apply for a new grant -- that I wouldn't get it.'' But he denies that he asked the pathology department to support his research. ''I'd already been told by the director of the hospital that it was felt at Harvard that I had not proven my theory,'' he says. ''In fact, when I left he told me never to come back.''
The current chief of pathology at Mass. General, Robert Colvin, agrees with his predecessor that ''the main issue was that nobody could fund McCully's research,'' but he emphasizes the funders' short-sightedness. ''McCully was so far advanced in his thinking about the biochemistry,'' Colvin says. ''And N.I.H. is not very good at funding very innovative, creative research. They're better at funding natural extensions of existing theories.''
Since Mass. General and Harvard appointments go hand in hand and McCully had not been recommended for tenure at Harvard, both jobs formally ended in January 1979. At about the same time, a former classmate at Harvard who went on to become the director of the Arteriosclerosis Center at M.I.T. attacked his ideas as ''errant nonsense'' and a ''hoax that is being perpetrated on the public.'' McCully says that when he was interviewed on Canadian television after he left Harvard, he received a call from the public-affairs director of Mass. General. ''He told me to shut up,'' McCully recalls. ''He said he didn't want the names of Harvard and Mass. General associated with my theories.''
In retrospect, it seems clear that McCully was a man ahead of his time when the times were all about cholesterol. ''Kilmer McCully's hypothesis seemed to challenge the cholesterol-heart hypothesis, which was riding high,'' says Irwin Rosenberg, director of the U.S.D.A. Human Nutrition Research Center on Aging at Tufts University. Rosenberg was a medical-school classmate of McCully's and, briefly, a physician in Mass. General's department of medicine when McCully was in the department of pathology. ''Because his work was not in vogue,'' Rosenberg says, ''his insistence on what he was doing contributed to costing him his job.''
Thomas N. James, a cardiologist and president of the University of Texas Medical Branch who was also the president of the American Heart Association in 1979 and '80, is even harsher. ''It was worse than that you couldn't get ideas funded that went in other directions than cholesterol,'' he says. ''You were intentionally discouraged from pursuing alternative questions. I've never dealt with a subject in my life that elicited such an immediate hostile response.''
It took two years for McCully to find a new research job. His children were reaching college age; he and his wife refinanced their house and borrowed from her parents. McCully says that his job search developed a pattern: he would hear of an opening, go for interviews and then the process would grind to a stop. Finally, he heard rumors of what he calls ''poison phone calls'' from Harvard. ''It smelled to high heaven,'' he says. ''Eventually I went to an attorney friend of mine, someone quite prominent in Boston. He made a few phone calls and it was all over. Then this job came through.''
The story of those two scary, free-fall years -- McCully can still recite the exact dates, Jan. 1, 1979, to March 15, 1981 -- emerges in small details, teased out by questioning. This is not a man who eagerly lays his grievances on the table. ''My daughter told me recently that she still gets nightmares about that time,'' he says. Later, describing his son's and daughter's careers as, respectively, Wall Street banker and magazine editor, he remarks: ''They both had been interested in chemistry when they were younger. Then they saw what happened to me'' -- he barks a laugh -- ''and that was the last I ever heard about that.''
McCully also laughs with seeming good grace about the contrast between his present position and that of medical-school classmates like Irwin Rosenberg, ''the director of the nutrition institute at Tufts, with a multimillion-dollar budget and all these projects.'' But from his much more modest perch at the Providence V.A. lab, he says, ''I've been able to develop my own approach, which might not have been possible at a high-powered place.''
When McCully landed in Providence, he continued testing his theories, inducing arteriosclerosis in rabbits, observing homocysteine's effect on cancer cells and publishing his first monograph, an overview of the homocysteine theory. At the same time, a study at Cornell and several others in Europe -- in Sweden, Norway, the Netherlands and Ireland -- explored the workings of homocysteine in humans. By 1990, some of those results were beginning to pique fresh interest in the United States, and Meir Stampfer, a professor of epidemiology and nutrition at the Harvard School of Public Health, decided to take a look at homocysteine in members of the Physicians Health Study, an ongoing survey of almost 15,000 doctors. Stampfer's findings helped start the current surge in homocysteine research.
Using blood samples taken years before any of the physicians in the study developed heart disease, Stampfer and his colleagues found that homocysteine levels were directly correlated to heart-disease risk. ''The study represented something of a turning point in the field,'' Stampfer says, ''because it was the first time we had prospective data -- the men were healthy at the time the blood was drawn and some later became ill -- and also because the homocysteine levels were all basically in the normal range. Even within that range, being at the top was strongly predictive of heart disease.''
Other powerful evidence soon followed. Jacob Selhub, a senior scientist and colleague of Irwin Rosenberg's at Tufts, looked at another large ongoing human sample, the Framingham Study, which has documented the population of Framingham, Mass., for nearly 50 years. Selhub found a strong association between homocysteine in the blood and insufficient levels of vitamins B6, B12 and folic acid. ''We showed that 30 percent of the American population is not taking in enough folic acid,'' Selhub says. ''And, at least in Framingham, close to 30 percent of the population has high homocysteine.'' Next, Selhub observed the relationship between homocysteine levels and narrowing, or stenosis, of the carotid artery. He found another correlation.
''The higher the homocysteine in the blood, the higher the prevalence of stenosis,'' Selhub says. ''We also showed that people with low intake of folic acid and vitamin B6 have a higher chance of having stenosis in the carotid artery. That was very important and exciting -- that practically tells you that we might be able to prevent this if our folic acid intake was sufficient.'' Both of Selhub's articles on these landmark studies, which appeared in The Journal of the American Medical Association and The New England Journal of Medicine in 1993 and 1995 respectively, cited McCully's original 1969 article on homocysteine and arteriosclerosis in the very first sentence.
The homocysteine theory was back in business, and McCully with it. Even old-line supporters of the cholesterol theory now acknowledge that homocysteine is, if not entirely proven, an extremely promising area of research. ''There's no question that homocysteine is a very important issue,'' says Claude Lenfant, director of the National Heart, Lung and Blood Institute, which some scientists consider a kind of ground zero for the cholesterol camp.
''Even if only 10 percent of the risk of heart disease is explained by homocysteine,'' Rosenberg says, ''you're talking about a huge element of the process of the disease -- and a lot of people. Forty-plus studies have so far observed a relationship between higher homocysteine levels and the risk of different kinds of vascular disease.''
McCully appears to be enjoying the flowering of homocysteine with a minimum of bitterness. ''Any scientist wants to have his work confirmed, wants to make a place for himself in the scientific literature,'' he says. ''I thought it was great that these big shots were paying attention to it.'' Lenfant suggests that perhaps they would have paid more attention earlier if the cholesterol theory had been less divisive. ''Twenty-five years ago, not everybody was accepting the cholesterol business,'' he says. ''So who wanted to hear about something that perhaps would weaken the argument for cholesterol?''
The cholesterol theory of heart disease, Thomas James says, ''has been a favorite theory for 50 years.'' It holds, essentially, that high levels of cholesterol in the blood cause arteriosclerosis and heart disease and that lowering those levels will lower the risk of heart disease. But while it was easy to show that very high cholesterol was associated with a high risk of heart disease, it was harder to show how it caused heart disease, or whether reducing it would reduce heart disease. Recent studies have firmed up those relationships, according to Lenfant, who says, ''Now the cholesterol story is as solid as the Rock of Gibraltar.''
But there continue to be indications that the cholesterol story is extremely complex and sometimes contradictory. For instance, Stampfer says, ''the majority of heart attacks occur in individuals with 'normal' cholesterol. That does not mean that cholesterol is not important, but it tells us that there are other mechanisms.''
It has not always been easy to propose other mechanisms, perhaps because the cholesterol proponents themselves felt somewhat embattled. Throughout the 70's and early 80's, agencies like the National Heart, Lung and Blood Institute and the American Heart Association were gearing up for major public health initiatives that culminated in the National Cholesterol Education Program begun in 1985, and the advocates for those agencies felt that a united front was essential.
Even as recently as last year, Alan Garber, an associate professor of medicine at Stanford University, was stunned after he and a colleague, Warren Browner, proposed that healthy young men and women need not be screened for cholesterol, since treatment at young ages has not been shown to be useful or cost effective. ''The American Heart Association and the National Heart, Lung and Blood Institute issued press releases and had a big campaign to discredit our work,'' Garber says.
McCully stresses that his ideas do not dismiss cholesterol as a risk factor, but they do question its hegemony. ''Cholesterol is important, certainly,'' McCully says. ''But the cholesterol theory isn't really a theory -- it's a collection of observations.'' He says his own theory suggests that ''homocysteine might be the underlying cause of arteriosclerosis, that homocysteine damage sets the stage for cholesterol buildup in the arteries. I think altered homocysteine metabolism and biochemistry is at the heart of vascular disease.
''But,'' he adds with a laugh and a flash of self-knowledge, ''working in this field all these years, naturally I feel that way.''
As McCully knows well, history is crowded with examples of ostrich-like behavior among medical researchers. There was strong resistance for years to the idea that many ulcers are caused by a bacteria rather than stress -- a theory that was ridiculed until the evidence finally became too strong to dismiss.
The American scientific establishment's answer to such human foibles as stubbornness, arrogance and the unwillingness to let go of favored theories has been peer review. The peer-review system in research tries to be equitable by having panels of experts judge grant proposals and articles submitted to the medical journals. But even a process that has objectivity as its goal is vulnerable to the pitfalls of committee-think.
''For instance,'' Rosenberg says, ''if most of the people on the National Heart, Lung and Blood Institute's advisory council come out of the lipid-fat-cholesterol camp and there's no one from, say, a nutritional orientation, it's not as likely that an expensive study will get the same hearing if it's looking at a homocysteine-lowering intervention versus a cholesterol-lowering intervention.''
James believes that as long as the management of the Heart, Lung and Blood Institute espouses the cholesterol line, ''then the review committees, the other evaluating bodies, are going to be influenced -- not by written memoranda but by the environment and by word of mouth.''
But James sees an even bigger reason for cholesterol's dominance of the heart-disease debate: ''It's the money that's the problem. Look at the colorful advertisements in general-interest publications, explaining to grandfather that his grandchildren want him to stay alive using these drugs. The anti-cholesterol medications are multibillion-dollar industries now, and they have a huge stake in fanning the flames of the cholesterol mission.''
Charles Hennekens, a professor at Harvard Medical School and chief of preventive medicine at Brigham and Women's Hospital, cites the example of aspirin. ''For years now, we've known about these large benefits of aspirin in treating acute heart attacks and survivors of heart attacks, and yet we have underutilization of it,'' he says. ''At an F.D.A. advisory committee meeting recently, I joked that if aspirin were half as effective, 10 times as expensive and on prescription, maybe people would take it more seriously.''
Like aspirin, the vitamins that control homocysteine levels are readily available, inexpensive and nonexclusive. ''It's inescapable that there's just not the commercial interest for supporting research in homocysteine,'' Stampfer says, ''because nobody's going to make money on it.''
McCully takes this follow-the-money approach to its logical conclusion: who stands to gain? ''The most dramatic improvements in longevity over the last couple of hundred years have been through public health, not through medicine,'' he says. ''But public health is notoriously unprofitable. People don't make a profit preventing disease. They make a profit through medicine -- treating critical, advanced stages of disease.''
Although there's not much money to be made from doctors prescribing vitamins and offering dietary guidelines to heart-disease patients, corporate wheels are already turning to make homocysteine levels the latest, hottest measure of optimal health. A new TV commericial for Centrum multivitamins singles out folic acid because it ''may help reduce homocysteine levels in the blood, an emerging risk factor for heart disease.'' McCully says that Abbott Laboratories has developed a test for homocysteine, though he feels it is inadequate. ''Once we develop a better test,'' he says, ''I would like to think that the vast majority of heart patients, far greater than the current estimates of 10 to 15 percent, will show this striking elevation in homocysteine.''
Such confirmation may come years from now, and McCully realizes that he may not play a role in it. ''Generally speaking, a scientist makes one contribution and then everybody else takes over and it becomes extremely competitive,'' he says. It is only when pressed about the past that McCully reveals, briefly, the shadow of disappointment that must have loomed larger two decades ago. ''Last October,'' he says, ''the pathology department at Mass. General had a reunion and invited me, and I saw one of the people involved in my leaving the department. 'Well,' he said to me, 'it looks like you were right after all.' It's 20 years later. My career is almost over. There's really not much that can be done about 20 lost years, is there?''
Worse, the political and economic forces that undid McCully back then may be more intense today. Last April, The New England Journal of Medicine published an article titled ''The Messenger Under Attack -- Intimidation of Researchers by Special-Interest Groups,'' which detailed three cases of harassment by advocacy groups, physicians' associations or academic consultants who often failed to disclose their ties to drug companies. With more and more pressure groups weighing in on what research gets financed and promoted, the article said, ''such attacks may become more frequent and acrimonious.''
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