Before you can reduce your chance of being diagnosed with CAD, you need to understand the elements that make you vulnerable to the disease. While some risk factors are unavoidable—family history, your age, and gender, for example—others are relatively easy to modify.
Problem is, many people with CAD are unaware they’re living with the disorder because they aren’t suffering from identifiable symptoms. Even if you have a robust family heart history, no link to diabetes, and a healthy diet and exercise regime, you may have underlying atherosclerosis to which you’re oblivious, especially if you’re over 55. Since your chance of having a heart attack increases with every risk factor you have, it’s important to get each one under control.
To complicate matters, there’s no definitive assessment for confirming CAD. Tests such as stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging haven’t been shown to improve outcomes. In fact, the high rate of false positive results produced by these tests has caused many to undergo unnecessary cardiac catheterization.
So, what’s a heart-conscious person to do?
Be proactive. It’s always best to prevent a heart attack rather than attempt to treat it after symptoms appear. Try altering your diet and exercise regimes. Quit smoking. If you have a family history or other un-modifiable risk factors, see a doctor to determine your best medical approaches. With the right treatment, you may be able to reduce the possibility of developing CAD or a heart attack before they strike.
Luckily, the same steps you need to take to prevent CAD also are effective at helping you avoid a heart attack. But beware: Certain go-to measures like a daily aspirin regimen are no longer recommended as a primary prevention method for everyone. (See “The Great Aspirin Debate.”)
The best way to stay heart healthy is by using a combination approach to your treatment. Talk to your doctor about coupling lifestyle modifications with medicine and/or surgical therapies to increase your chance of success.
Types of CAD Risk Factors
Some people, because of non-modifiable (unchangeable) risk factors, have a high chance of developing CAD despite their best efforts to stay healthy. Others can blame their increased risk on modifiable elements that are within their control.
Unmodifiable Risk Factors
Certain CAD risk factors may be part of our makeup. Below are four examples.
Genetics. CAD has a strong genetic component, and those with close family members who suffer from the disease (or other risk factors such as diabetes, high cholesterol, and increased blood pressure) have an even larger chance of developing the condition.
If your father or brother had heart disease before age 55, or your mother or sister had it before age 65, for instance, your chance of developing CAD spikes dramatically. Women with this type of risk may even have a heart attack in their 20s, 30s, or 40s. If one or more CAD risk factors run in your family, however, you may be able to reduce your likelihood of getting the disease with lifestyle modifications including dietary improvements and moderate exercise.
Age. The older you get, the higher the chance you’ll develop CAD or have a heart attack, especially if you’re over 55. Another troubling stat: If you suffer a heart attack at 75, you’re twice as likely to die from it than you are if you have a heart attack at 65.
Gender. Men and women are at equal risk of developing coronary artery disease. That said, a man is 2½ times more likely than a woman to die from heart disease in his 40s. As for heart attacks, the average age for a first occurrence is 65 for men and 70 for women. Females, however, are more likely to die from their first heart attack. The reason for the age difference? Women are blessed with protective effects from estrogen. After going through menopause, however, the effects disappear, causing their heart attack risk to skyrocket and quickly equal that of men.
Women who undergo menopause early are twice as likely to suffer from CAD, regardless of ethnicity or other traditional cardiovascular disease risk factors. The negative impact of early menopause is similar whether a woman reaches it naturally or through surgical removal of her reproductive organs in a hysterectomy. Unfortunately, efforts to stave off heart disease with estrogen replacement therapy haven’t been successful.
Ethnicity. Heart disease is the leading cause of death regardless of race. However, African-Americans are more likely than Caucasians to die from heart disease, while Hispanics, East Asians, and Native Americans are less likely to have a heart attack than Caucasians. South Asians have a particularly high risk of heart attack. A new study also found that certain ethnicities carry higher levels of lipoprotein (a), or Lp(a), a type of cholesterol that increases the risk of heart attack.
Modifiable Risk Factors
No matter your age, race, gender, and family history, there are things you can do to reduce or, better yet, eliminate modifiable risk factors. These include:
Smoking. Nothing good comes from smoking. Need proof? Smokers are two to three times more likely than nonsmokers to develop CAD, and they develop the disease about 10 years earlier. And smokers are two to four times more likely to die suddenly from a heart attack. Research also shows that stroke survivors who smoke are at a greater risk for a heart attack. Now for the good news: Quitting smoking can reduce the risk of heart attack or stroke, even if you quit after age 60. (Note: Merely cutting back on the number of cigarettes you smoke won’t have the same effect; it’s best to cut all ties with nicotine.)
Unfavorable Levels of Cholesterol and Triglycerides. Cholesterol and triglycerides are fat-soluble substances necessary for normal cellular functions. Excess amounts, however, mean bad news for your heart. In addition to contributing to the development of atherosclerosis, higher levels of LDL cholesterol or triglycerides and lower levels of HDL cholesterol can elevate your risk of developing CAD. These factors also can boost your chances of having a heart attack or developing aortic valve disease.
Since the development of atherosclerosis is a gradual process, everyone should have a cholesterol check at age 20 and every five years thereafter. Those with a family history of heart disease should have a full cholesterol profile test yearly starting at age 20 to delineate levels of total cholesterol, LDL, HDL, and triglycerides. New research suggests we should be aiming for lower cholesterol levels than originally thought.
High Blood Pressure. It’s called “the silent killer” for good reason: High blood pressure doesn’t always make itself known and can lead to death if left untreated. Having uncontrolled hypertension more than doubles the risk of heart attack. According to the American Heart Association, hypertension (blood pressure higher than 130/80 millimeters of mercury, [mmHg]) is found in 51 percent of people with CAD, 69 percent of people who have a first heart attack, 77 percent of people who have a first stroke, and 74 percent of people with heart failure. Nearly 75 million Americans suffer from high blood pressure—nearly one in three adults.
If everyone with hypertension could maintain normal blood pressure and LDL and HDL levels, the number of coronary events in the United States would drop by 75 percent. Instead, only half of those with high blood pressure have their condition under control.
Diabetes. Having diabetes doubles or triples the risk of a heart attack. Plus, having type 2 (adult-onset) diabetes, being overweight, and having high blood pressure and cholesterol are three of the most major risk factors for CAD.
Obesity. A person is considered obese when he tips the scales at 20 percent or more than the recommended weight on a standard height-weight table. At this point, many regular bodily functions become strained, leaving an obese person twice as likely to have high blood pressure and diabetes. The higher your body mass index (BMI), the greater your risk of heart attack at a younger age.
Being Sedentary. Everyone knows that exercise is essential to good heart health. Being active strengthens the heart muscles, lowers blood pressure and cholesterol, and helps control weight. Not surprisingly, couch potatoes are almost two times more likely to have a heart attack.
Environment. Pollution is bad for your heart, especially if it’s in the form of particulate matter (for example vehicle exhaust, or smoke from burning wood). Colder weather also may wreak havoc on your health. Research suggests that cool temperatures may increase blood vessel constriction and raise blood pressure. Other research found that a heat wave or cold snap lasting two or more days could lead to premature death from a heart attack. The dramatic temperature change likely triggers differences in blood pressure, blood thickness, cholesterol, and heart rate.
Additional CAD Risk Factors
Other CAD risk factors include endometriosis, low estrogen levels occurring in menopause, low testosterone levels, the amount of specific proteins in the blood, previous treatment for certain cancers, and diseases such as pneumonia. Check with your doctor about having a pneumonia vaccine (or booster).
Psychological stresses such as depression and loneliness also can worsen heart health. Bacterial infection was once believed to be a causal factor as well; however, this theory has largely been disproved. Antibiotic therapy has failed to impact plaque buildup on the rate of heart attacks even though certain bacteria are sometimes found in plaques.
Reduce Your Risk
You’ve heard this advice before, but now it’s time to heed it: Quit smoking, exercise regularly, maintain a healthy weight, lower your cholesterol levels, control your blood pressure, and, if you have diabetes, keep on top of your blood sugar. If you already have CAD, following those tips can help prevent a future heart attack.
Even small changes, like cutting back on sugar, can make a big impact. The American Heart Association recommends limiting added sugar (sugar not naturally occurring in fruit and fruit juice) to 100 calories a day for women and 150 calories a day for men.
Although these measures have been proven to lower a person’s CAD risk, 25 to 50 percent of those who follow them will still develop the disease. The reason? Physicians have long suspected other risk factors to be involved, several of which have now been identified. While some are genetic in origin, others are caused by inflammation. That’s why it’s necessary to identify the individual factors that influence your risk.
Smoking
Although any amount of smoking raises the chance of a heart attack, risk increases in proportion to the number of cigarettes smoked. Those who smoke two or more packs a day, for instance, are at least three times as likely to develop CAD as nonsmokers. Those who smoke a pack a day have more than twice the risk. The longer you smoke, the greater your risk. Even “part-time” smoking is dangerous.
One study published in The BMJ online in January 2018 reported that smoking only one cigarette a day increases cardiovascular risk by 50 percent for a man and 75 percent for a woman. Women who smoke—even those without a history of heart disease or stroke—have nearly 2½ times the risk of sudden cardiac death, compared with healthy nonsmokers. For every five years of continued smoking, the risk climbs by 8 percent.
The risk of a heart attack begins to decrease after you smoke your last cigarette. Of all the modifiable risk factors, quitting smoking has the greatest effect on lowering risk. Once you quit smoking, your risk will drop by 50 percent over the next two to four years. That said, you’ll remain at increased risk for 10 years or longer.
Yes, quitting is hard, but it’s not impossible. These suggestions can get you started:
- Quitters are twice as likely to succeed when using a nicotine-replacement product such as a nicotine patch, gum, nasal spray, or inhaler.
- A study published in JAMA Internal Medicine in April 2018 confirmed the safety of smoking-cessation drugs varenicline (Chantix) and buproprion (Wellbutrin, Zyban). Researchers found no evidence that these therapies increased the risk of serious cardiovascular events for typical smokers at no risk for heart disease.
- Combining treatments has been proven to work best. Research shows that using three stop-smoking aids simultaneously is the most effective route to success.
- Avoid second-hand smoke—it can up your risk of CAD by 30 percent. This tip is true for non-smokers, too. Exposure to passive smoke is almost as dangerous as actively smoking.
- Be wary of alternatives. It may be tempting to turn to an e-cigarette when your craving peaks, but don’t. E-cigarettes typically contain nicotine in addition to a flavoring agent and solvent. Nicotine is addictive no matter the form. And while the flavoring agents are safe to eat, their safety when inhaled is unknown. Some vaping liquids also contain undesirable products such as anabasine, principally used as an insecticide.
If at first you don’t succeed, try again! Your chance of success improves with each attempt. Don’t get discouraged. Most smokers try to quit five to seven times before they succeed.
Unhealthy Levels of Cholesterol and Triglycerides
Cholesterol and fats are vital to our survival. While we gain fat from various foods, cholesterol is made in the liver and ingested as animal products such as meat and dairy. Triglycerides are an important type of fat found in the blood.
When we overeat, our bodies convert excess calories into triglycerides and store them in fat cells. Fats are released and processed in our cells to produce energy, when needed, in response to hormonal triggers. Most of us know the dangers of high levels of “bad” LDL cholesterol, but many are less familiar with the damage that can be caused by skyrocketing triglycerides.
Triglyceride and cholesterol molecules are wrapped in tiny, protein-
covered spheres that move easily through the bloodstream. These particles are called lipoproteins. Low-density lipoproteins (LDL) and high-density lipoproteins (HDL) contain high concentrations of cholesterol. Very-low-density lipoproteins (VLDL) and larger particles called chylomicrons contain a higher proportion of triglycerides.
In general, LDL (“bad cholesterol”), VLDL, and chylomicrons move fats from the gut and liver into the circulation and to the rest of the body. HDL—“good cholesterol”—moves fats from the body to the liver, where they are packaged for excretion. VLDL plus LDL plus HDL equals your total cholesterol, which is measured after fasting. Chylomicrons appear only after a meal.
When the different lipoproteins exist in normal proportions, they don’t pose a health risk. However, when total cholesterol or LDL levels rise, or the amount of HDL drops, the body tends to deposit cholesterol in the arteries.
Although triglycerides don’t accumulate in arteries like cholesterol does, abnormally high levels of triglycerides also are associated with an increased risk of heart attack and stroke.
Cut Cholesterol. Although low levels of HDL increase cardiovascular risk, efforts to raise HDL haven’t proven beneficial. That’s why physicians promote taking action against LDL cholesterol and triglycerides. Lowering levels of these lipids has a positive impact on the heart.
Cardiologists recommend healthy LDL levels under 100 milligrams per deciliter (mg/dL) for those who haven’t had a heart attack and 70 mg/dL or less for those who have. These are lower than previous recommendations because clinical trials have confirmed that the lower your level of LDL, the lower your risk of having a heart attack or stroke, developing unstable angina, or needing stenting or CABG.
To make matters more confusing, new research has proven that even lower levels of LDL can be beneficial.
Accumulations of plaque start at a young age and grow over time. Since even slightly elevated cholesterol levels in adults ages 35 to 55 lay the foundation for developing heart disease, you shouldn’t wait until you’re older to pay attention to your cholesterol.
Lowering LDL early is more effective in reducing risk than lowering LDL with a statin later in life. The increased benefit appears to be independent from how LDL is lowered. This means that diet and exercise are probably as effective as statins or other medications at reducing the risk of CAD when started early.
After quitting smoking, the next-best thing you can do to prevent a heart attack is to get your cholesterol down to recommended levels. Start by eating a diet low in saturated and trans fats. Saturated fats raise LDL. Trans fats raise LDL and total cholesterol while lowering your healthy HDL. Trans fats (or trans fatty acids) are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid. They’re found in hydrogenated fats, including shortening, margarine, and partially hydrogenated cooking oils.
Fried foods and highly processed bakery goods and snack foods typically contain high amounts of trans fats.
Adding nuts and fish to your diet is a healthy way to lower cholesterol. Those with high triglyceride levels may want to take high-dose supplements of the omega-3 known as eicosapentaenoic acid (EPA)—especially if they have cardiovascular disease or diabetes and one additional risk factor.
While this fatty acid has long been touted for its heart-boosting benefits, new research shows that it may not be as helpful as once thought in reducing the risk of CAD, although they are thought to have other health benefits.
High Blood Pressure
High blood pressure causes nearly 1,000 deaths every day. It also greatly increases the risk of stroke, heart attack, heart failure, and kidney failure at any age.
Widely fluctuating blood pressure may be as dangerous as stable high blood pressure, emphasizing the need to keep your readings under control. Hypertension is dangerous because it forces the heart to pump harder to push blood into and through the arteries. When it pumps so hard for a long time, the heart muscle initially compensates by growing thicker, like a weightlifter’s biceps. However, this adaptation works for only so long. The heart eventually becomes an increasingly ineffective pump.
High blood pressure also is believed to damage the lining of the coronary arteries and those throughout the entire body, providing sites where fatty plaques can form and cause atherosclerosis.
Lowering blood pressure by modifying diet or taking medication gives the arteries a chance to heal and return to their normal, healthy state. Blood pressure-lowering treatment can reduce the risk of stroke or transient ischemic attack (TIA, or “mini-stroke”) by 30 percent, death from stroke by 39 percent, death from any cause by 21 percent, death from heart attack by 23 percent, and risk of heart failure by 64 percent.
In 2017, the American Heart Association and the American College of Cardiology developed new hypertension guidelines, dividing at-risk patients into four categories:
- Normal (less than 120/80 mmHg)
- Elevated (120 to 129/90 mmHg)
- Stage 1 hypertension (130 to 139/
80–89 mmHg) - Stage 2 hypertension (140 and above/90 and above mm Hg)
By lowering the number for Stage 1 (it was 140/90mm Hg previously), the new recommendations are designed to encourage people to take action to lower their blood pressure earlier.
However, only one in five of the additional adults now classified as having hypertension are expected to need antihypertension medications.
Not all doctors agree with the new guidelines. The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have expressed concerns that the altered recommendations will lead to significant over-diagnosis and treatment—which is not without risks. Your doctor will be able to advise you based not only on your blood pressure readings, but also on your other health indicators.
How to Lower Blood Pressure. How do you get your blood pressure numbers down? The most effective suggestions:
- Improve your diet. (The DASH diet is one option; it includes restricting sodium intake, increasing dietary potassium, and moderating alcohol consumption.)
- Incorporate regular physical activity.
- Lose weight.
By incorporating all three lifestyle changes, you can be successful at maintaining normal blood pressure and cholesterol levels, even if you have Stage 1 hypertension.
Those who also have CVD, diabetes, chronic kidney disease or an estimated CVD risk of more than 10 percent over a period of 10 years, however, may need to add antihypertension medication into the mix.
Medication is a must for those with Stage 2 hypertension, regardless of risk or CVD diagnosis.
Other ways to reduce blood pressure include:
- Limit alcohol consumption.
- Consume enough potassium, calcium, and magnesium in your diet by eating dairy products, bananas, sweet potatoes, green vegetables, and nuts.
- Drink low-calorie cranberry juice and ingest flaxseed. They may have a beneficial effect on blood pressure.
- Restrict sodium intake. The average American diet contains the equivalent of two to four teaspoons of salt per day. Reducing that amount to one teaspoon normalizes blood pressure for many with mild hypertension and may prevent or delay the development of this condition in healthy people. Anyone diagnosed with hypertension, all African Americans, and those ages 50 and older should strive to reduce sodium intake to no more than a teaspoon, or 1,500 mg, a day.
Beware of how often you use pain-relieving medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin), naproxen (Aleve), diclofenac (Voltaren), and celecoxib (Celebrex). Daily use increases the risk of developing hypertension. Aspirin can be used as an occasional pain reliever, but it shouldn’t be taken to prevent a first heart attack or stroke without first discussing it with your doctor. It may, however, help you prevent a second heart attack if you’ve had one already.
Looking for a more novel way to lower blood pressure? Try acupuncture. A recent study found it could have positive benefits.
Diabetes
Diabetes mellitus and CAD tend to go hand in hand, meaning if you have diabetes and don’t control your risk factors, you’ll likely develop the disease.
Diabetes is a chronic disorder that affects your body’s ability to metabolize carbohydrates, specifically sugar. Glucose (the sugar formed when our body breaks downs sugars and carbs) is an essential source of energy for our body’s cells. It travels through the bloodstream and requires insulin, a hormone, to regulate its production.
Insulin is created in the pancreas, a gland located next to the stomach, when blood sugar levels increase after a meal. Insulin acts on the cells of your body to facilitate the process of removing sugar from the blood and moving it into cells. Diabetics are unable either to make enough insulin or use the insulin it has produced. For reasons not completely understood, cells stop responding to insulin, no matter how much the pancreas makes. This is called insulin resistance.
Type 1 Diabetes. Type 1 diabetes also is known as insulin-dependent diabetes and often starts during childhood. Those with a fasting blood glucose level between 110 and 126 mg/dL are considered insulin resistant. In type 1 diabetes, the immune system mistakenly attacks pancreatic cells that make insulin. This prevents the pancreas from making enough (or any) insulin. The result: Those with type 1 diabetes need insulin injections under the skin.
Most studies on the impact of diabetes on the heart have made no distinction between type 1 and type 2—participants were lumped together as “having diabetes.” Recent research, however, found type 1 diabetics to be at very high risk for heart problems.
Even when controlled well with insulin, type 1 diabetes was found to increase the risk of heart failure four times. Poorly controlled type 1 diabetes raised the risk 10 times. Once kidney damage occurred, the risk of heart failure increased 18 times. The take-home: People with type 1 diabetes should take steps to lower all cardiovascular risk factors in addition to controlling their blood sugar.
Type 2 Diabetes. The most common form of the disease, type 2 diabetes is a milder variety also known as non-insulin-dependent diabetes. Those with a fasting blood glucose level above 126 mg/dL have type 2 diabetes. While it used to be diagnosed mainly in adults, the obesity epidemic has led to a greater number of children and teens to be diagnosed. Type 2 diabetes increases a person’s risk of heart disease, which is likely linked to obesity, high blood pressure, and high cholesterol.
Drugs that control blood sugar can reduce some of the complications from type 2 diabetes, but heart attack and stroke remain responsible for 65 percent of deaths in people with type 1 diabetes. These drugs, called insulin-sensitizing agents or anti-hyperglycemic agents, enhance insulin sensitivity. By doing so, they enable cells to remove sugar from the bloodstream with less insulin. Attaining just the right blood sugar level is important, as very low blood sugar levels (hypoglycemia) that result in hospitalization are a risk factor for cardiac death.
Since people with type 2 diabetes are especially prone to developing CAD, they must be treated aggressively, particularly if they also have high cholesterol or high blood pressure. Losing weight—as little as 10 pounds—can stop or reverse insulin resistance. High blood pressure, high cholesterol levels, and high triglyceride levels often disappear along with the pounds.
Conversely, most people with type 2 diabetes who don’t make the necessary lifestyle adjustments will eventually require insulin therapy.
Three medications that have been shown to reduce cardiovascular risk in people with type 2 diabetes include:
➧ Empagliflozin (Jardiance): A daily pill approved by the Food & Drug Administration in December 2016. Clinical trials showed it reduced cardiovascular mortality in diabetics.
➧ Liraglutide (Victoza): A daily pre-filled injector pen approved in August 2017. It reduces the risk of heart attack, stroke, and cardiovascular death by 13 percent.
➧ Canagliflozen (Invokana): An oral medication approved in October 2018. It reduces the risk of a cardiovascular event or death by 14 percent in the overall diabetes population and 18 percent in diabetic patients with cardiovascular disease. It’s also is available in fixed-dose combinations with metformin (Invokamet) and metformin extended-release (Invokamet XR).
Metabolic Syndrome
The higher your number of risk factors, the larger your chance of developing CAD. As such, having metabolic syndrome puts you at an increased risk. According to the National Heart, Lung, & Blood Institute, metabolic syndrome is defined as the presence of three or more of the following five risk factors:
- High triglyceride level
- Large waistline
- Low HDL cholesterol level
- High blood pressure
- High fasting blood sugar
The risk of heart attack and other cardiac events compounds with the addition of each risk factor, as they contribute to the formation of atherosclerosis. Those with the greatest chance of developing metabolic syndrome have abdominal obesity, insulin resistance, and a sedentary lifestyle. Other contributing factors include gender (women are more likely to suffer from this condition than men), polycystic ovarian syndrome, and a personal or family history of diabetes. A whopping 50 million Americans suffer from metabolic syndrome.
The best way to lower cardiac risk is to treat the individual components of metabolic syndrome by losing weight, eating a diet low in saturated fat and cholesterol and high in fiber (recommended: 30 grams a day), increasing physical activity, quitting smoking, and taking blood pressure medication, if required. Reducing stress through activities such as meditation or exercise also may help. Studies have shown that bad habits adopted in stressful times, rather than stress itself, may be responsible for an increased risk.
Obesity
Being overweight is dangerous regardless of your shape—be it pear, apple, or big all over. Obesity is now considered by many to be the second-most-preventable cause of death in this country after smoking. More than 68 percent of U.S. adults and 31.8 percent of children ages 2 to 19 are overweight or obese.
Not only does obesity increase your chance of getting CAD, but it puts you at risk of developing high blood pressure, type 2 diabetes, stroke, gallbladder disease, and cancer of the breast, prostate, and colon. High blood pressure accounts for more than 30 percent of excess heart attack risk and 65 percent of excess stroke risk.
A good way to figure out if you’re obese is to calculate your body mass index (BMI). If you fall into the overweight or obese categories, consider modifying your lifestyle by changing and restricting your diet and increasing exercise to lose weight safely and keep it off.
If you’re morbidly obese (100 pounds over your ideal weight if you’re a man; 80 pounds if you’re a woman), a weight-loss drug might be needed. These drugs also are useful for people who can’t exercise due to physical limitations or for “jump-starting” the weight-loss process. Be sure to discuss this option with your physician since some diet drugs can increase the risk of heart attack.
It is important to note that even normal-weight people who carry fat in their belly have a higher death risk than obese individuals. And a new study shows that while being obese can preclude you to developing CAD, it may not increase your risk of stroke.
The primary cause of obesity is the consumption of more calories than the amount burned through exercise. Between 1972 and 2004, the average calorie consumption jumped by 22 percent in women and 10 percent in men. One factor: larger portion sizes.
The source of calories matters, too; avoid carbohydrates (starches, refined grains, and sugars), fast foods, and sugar-sweetened beverages and snacks. Equally concerning, the American Heart Association reports that 30 percent of adults do not engage in any physical activity at all.
Your Diet. Carrying extra weight isn’t healthy, but losing it can be tough. The good news: Dropping 10 percent of your body weight—a “doable” goal—can help your heart risk plummet from high to medium or from medium to low.
In this weight-obsessed society, we’re bombarded with plenty of diet options. From Atkins to South Beach to Keto diets, there’s no shortage of plans to choose from. Many have a scientific basis, while others are mere fads that may do more harm than good. Which one is best? The American Heart Association and the National Cholesterol Education Program recommend a diet in which only 8 to 10 percent of calories come from saturated fats, 10 percent or less from polyunsaturated fats, and 15 percent or less from monounsaturated fats.
Get advice from your doctor and other reputable sources such as the American Heart Association (AHA), the National Heart, Lung, and Blood Institute (NHLBI), and the U.S. Department of Agriculture (USDA).
If dieting on your own doesn’t work, consider joining a weight-loss program or find a registered dietitian to create a plan just for you.
Even if you aren’t overweight, improving your diet can lower your risk of CAD. Depending on your eating habits, a complete dietary overhaul may be necessary, especially if you’re a fan of fried, sugary, and salty foods.
Mediterranean Diet. A heart-healthy Mediterranean diet is known to protect the heart from cardiovascular disease and may reduce the risk of stroke in women. Rich in fish, olive oil, fruits, and vegetables and low in animal fats, this plan will help keep atherosclerosis at bay.
This diet contains about 30 percent fewer calories from saturated fat and 50 percent less cholesterol than the average Western diet. It’s also higher in fiber and antioxidants such as omega-3 and omega-6, which, when consumed in foods, may safely slow the development of atherosclerosis in the coronary arteries and elsewhere. (See “Reduce Stroke Risk with a Mediterranean Diet.”)
A 17-year study of 23,232 men and women ages 40 to 77 in the U.K. found that adherence to a Mediterranean-style diet reduced strokes by 17 percent in women and 6 percent in men. The diet’s overall effect was greater than the impact of any individual food within the diet.
This suggests the components of a Mediterranean-style diet may have a synergistic effect. Why the diet isn’t as protective against stroke in men as in women couldn’t be explained and will require additional research.
DASH Diet. A major government study called Dietary Approaches to Stop Hypertension (DASH) found that people who emphasized fruits, vegetables, and low-fat dairy products in their diets reduced saturated and total fat consumption and significantly cut back on sodium. Research on this diet has been so positive that some experts regard it as one of the most important non-drug measures for controlling hypertension.
The DASH eating plan was developed for people with a systolic blood pressure of 160 mmHg or less and a diastolic blood pressure of 80 to 95 mmHg, but it’s now considered an appropriate heart-healthy diet for anyone.
Other Heart-Friendly Diets. Diets high in certain types of seafood also appear to be protective. Fatty fish contain omega-3 unsaturated fatty acids, which don’t raise blood cholesterol levels. These fatty acids thin the blood and make it less “sticky,” reducing the risk of blood clots and inflammation that are thought to facilitate plaque growth. Eating as little as one meal a week of a fatty fish, such as fresh or canned tuna, salmon, mackerel, trout, or halibut, may reduce the risk of heart attack by 50 to 70 percent. Prepare fresh fish by baking or broiling since frying negates any cardiovascular benefits.
A vegetarian diet also can lower a person’s risk of heart disease by one-third. In the largest study to compare cardiovascular disease rates between vegetarians and carnivores, vegetarians had a 32 percent lower risk of hospitalization or death from cardiovascular disease than those who consumed meat or fish. Researchers also have found that daily doses of probiotics, typically found in some yogurt and other dietary supplements, may lower cholesterol.
A diet that includes ample antioxidants also is thought to help protect against heart disease. Coenzyme Q10 has recently been touted as a cholesterol-lowering superstar.
Antioxidants neutralize certain highly toxic molecules called oxygen-free radicals, which are produced by cells and consume oxygen while metabolizing sugars for energy. Free radicals aren’t all bad—they attack bacteria and help prevent infections. Yet if they aren’t neutralized by antioxidants, they attack healthy cells and tissues, causing extensive damage that fosters atherosclerosis. Smoking, consuming excessive quantities of alcohol, eating a high-fat diet, getting too much sun, and being exposed to polluted air all promote the release of free radicals in our bodies.
Foods naturally high in antioxidants include yellow and orange vegetables and fruits (e.g., carrots, sweet potatoes, apricots, peaches, and strawberries), dark green leafy vegetables (e.g., broccoli and spinach), vegetable oils, citrus fruits, tomatoes, garlic, nuts, and olives. Unfortunately, antioxidant vitamins are no substitute for healthy food. They don’t help lower the risk of heart disease and, in fact, may increase mortality risk.
Certain flavonoids in purple grape juice and red wine also are powerful antioxidants. Several studies have suggested that drinking alcohol in moderation (no more than two drinks for men and one for women per day) may reduce the risk of a heart attack. The benefit was first noted with red wine, but any alcoholic drink appears to afford similar protection. That said, possible benefits must be weighed against known risks, and most cardiologists would not encourage nondrinkers to take up alcohol given the adverse health effects of overuse. If you don’t drink alcohol, purple grape juice may help protect your heart health.
Weight loss occurs more quickly when calories are burned through regular exercise. The heavier you are, however, the more difficult it may be to start an exercise program. If you’re struggling, aim for long, slow walks. Any little bit counts.When diet and exercise aren’t enough, try:
- Structured weight-loss programs
- Regular meetings with a physician, dietitian, or weight-loss coach
- Keeping track of exactly what to eat and avoid
- Receiving prepared meals or shopping lists
- Bariatric surgery
Sedentary Lifestyle
The risk of developing CAD from physical inactivity is comparable to that associated with high blood pressure, high cholesterol levels, and cigarette smoking, according to the AHA. Adopting a regular exercise program is a good way to eliminate this threat. Aim for a minimum of 30 minutes of light to moderate exercise five days a week, or 20 minutes of vigorous exercise three days a week.
Aerobic exercise helps prevent age-related thickening and stiffening of the arteries, as well as impairment of vascular function. Fitness also:
- Enhances the ability of individual heart muscle cells to process calcium, improving the heart’s ability to pump and reducing the risk of deadly arrhythmias.
- Increases blood flow, in turn increasing the production of beneficial nitric oxide, reducing the number of harmful free radicals, and boosting the production of antioxidants.
- Causes stem cells known as endothelial progenitor cells to migrate from bone marrow to the circulation system, where they promote the growth of small blood vessels throughout the heart and repair damaged endothelium.
- Slows heart failure and muscle breakdown from aging, thereby decelerating the aging process.
How often you exercise is more important than the intensity of the workout. You don’t have to train for a marathon, although the more intense your workout, the better when it comes to longevity, found a recent study. Not a fan of the gym? Yard work and housecleaning count as exercise. So too do enjoyable activities like walking and biking. As long as you do them regularly (five to seven times a week) your heart will reap the benefits.
Researchers of a UK-based study of more than 500,000 participants found that those who were fitter and stronger also noticed lower risks of cardiovascular events and atrial fibrillation in every genetic risk category. In fact, those considered to be at high risk for heart attack or stroke, but who were the most physically fit, had a 49 percent lower risk of CAD and 60 percent lower risk of atrial fibrillation than their peers. Those with a stronger grip were also 31 percent less likely to develop CAD and 39 percent less likely to develop atrial fibrillation.
Still overwhelmed by the prospect of a regular and consistent exercise routine? Start with a modest exercise program and build up gradually to at least 30 minutes a day. The greater your capacity to exercise, the less likely you are to have a heart attack. And if you have one, you’re more likely to survive it, as physical fitness lessens the amount of permanent damage done to the heart.
A study published in the American Journal of Preventative Medicine online found that walking for two hours a week can reduce the risk of death by all causes. Those who walked or participated in 150 minutes of moderate exercise each week experienced a 20 percent lower mortality risk than those who exercised for less time.
If you have CAD or any risk factor for heart disease, ask your doctor for advice on the type and intensity of exercise that’s ideal for you.
Newly Discovered Risk Factors
You learned about the modifiable and unmodifiable risk factors responsible for 80 to 90 percent of CAD cases. Now it’s time to delve into lesser-known issues that also may cause the disease. While more research is needed on these conditions, the following could raise your CAD risk.
Not Enough HDL Cholesterol
Low levels of “good” HDL cholesterol can cause CAD despite the absence of other risk factors. The landmark Framingham Heart Study showed the risk of heart attack to be higher in those with lower HDL levels. In fact, very low levels of this good cholesterol may negate the benefits of a low LDL.
What perplexes physicians is that raising HDL with medications, such as niacin or fibrates, doesn’t lessen cardiac risk. Two large clinical trials found no benefit in raising HDL when LDL was optimally treated.
Keep in mind that the quality of HDL is more important than the quantity. Inflammation and oxidation can hinder its ability to remove cholesterol from artery walls and return it to the liver. Also, when high levels of high-sensitivity C-reactive protein (hsCRP)—a marker of inflammation—are present in the blood, the risk of heart attack is high, even in people with high levels of HDL.
Too Much Calcium in Coronary Arteries
Calcium buildup in the coronary arteries can help predict the risk for developing serious CAD and cardiovascular events in women who are otherwise thought to be at low risk. A coronary artery calcium score (CACS) can be obtained with computed tomography (CT), which is a cross-sectional x-ray technique. In a research effort known as the Multi-Ethnic Study of Atherosclerosis (MESA), the risk of a serious cardiovascular event was directly correlated with CACS. Women with the highest scores had six times the risk
of those with no detectable coronary artery calcium.
Do you take a calcium supplement? Don’t worry. An expert panel concluded that taking these supplements for bone health can be done without increasing the risk for cardiovascular disease, despite the medical community’s worry about additional calcium buildup in the arteries.
Where you live may affect the amount of calcium in your arteries. Those who reside in an urban area may be twice as likely to have coronary artery calcification (CAC) than others who live in less polluted urban and rural areas. Although air pollution is suspected in the development of CAC, the mechanisms by which air pollution may contribute to CAC are not well understood.
A genetic variant for lipoprotein(a), or Lp(a)—a cholesterol-rich particle that circulates in the blood—may increase the risk of heart attack and stroke. It also may play a role in calcium buildup in the heart’s aortic valve (aortic stenosis), which can result in heart failure, stroke, and sudden cardiac death. A 10-fold elevation in Lp(a) due to a genetic variation can raise the risk of aortic valve stenosis by 60 percent. More severe elevations can double or even triple the risk.
Psychological Aspects
Depression, isolation, and anger appear to be serious factors in the development of a heart attack. Depression heightens the risk of atherosclerosis, heart attack, and death from heart disease.
In 2014, after an extensive review of literature, a 12-person panel of experts recommended to the American Heart Association that depression be added to the list of risk factors associated with heart failure.
Anxiety appears to be equally risky. In fact, anxious men have four times the chance of dying suddenly from a heart attack. And new research found that caregivers for family members with cardiovascular disease may unintentionally raise their own risk for heart disease by neglecting their health.
As of now, researchers haven’t been able to prove these emotions cause plaque formation in the arteries. But they suspect that depression, isolation, and anger cause chemical changes in the body that cause platelets to clump together and form blood clots.
Research conducted on those suffering from post-traumatic stress disorder, or PTSD, identified the amygdala (the section of the brain responsible for processing emotions) as the area accountable for the reaction and connects it with heart attack and stroke.
Having a good support system reduces your likelihood of suffering a heart attack. Research suggests that those with a strong group of family and friends fare better after a heart attack or surgery for heart disease than those who lack sturdy ties.
Pollution
Long-term exposure to pollution may increase the risk of death for heart attack survivors. In a European study, researchers were able to assess the impact that pollution had on death rates by linking the records of 154,204 heart attack survivors between 2004 to 2007, with air pollution data from 2004 to 2010. They found deaths increased by 20 percent in people exposed to higher levels of tiny air pollutants (measuring 2.5 micrometers in diameter, which is about 30 times smaller than a human hair). The mortality rate among heart attack survivors exposed to lower levels of air pollutants declined by 12 percent.
Sleep
Getting too little or too much sleep can lead to heart problems, including cardiovascular disease, according to findings from the National Health and Nutrition Examination Survey (NHANES).
Adults who get less than six hours of sleep a night are at a significantly greater risk of stroke, heart attack, and congestive heart failure. Those who sleep more than eight hours a night, on the other hand, have a higher prevalence of heart problems such as chest pain and CAD. The reason for this is still unknown. According to the National Sleep Foundation, we should aim for a minimum of seven hours of sleep every night.
Obstructive sleep apnea (OSA) also can lead to serious heart problems. OSA is characterized by abnormal pauses in breathing during sleep, which can last from 10 seconds to minutes and may occur five to 30 times or more an hour. One study of women with OSA showed that 31 percent had abnormal electrocardiograms.
The Flu Factor
Having the flu increases the risk of hospitalization and death from cardiovascular disease (CVD). Between 2015 and 2016, 41 percent of those hospitalized with the flu had heart disease. And those who test positive for influenza are six times more likely to have a heart attack the week after their flu diagnosis despite their history with heart disease.
Luckily, CVD events triggered by the flu are potentially preventable—and prevention is as simple as having a flu vaccination. A 2013 analysis of six studies reported that flu shots reduced major CVD events by 55 percent in those who’d suffered a recent heart attack or stroke. Also, a 2018 study reported a 50 percent reduction in flu-season deaths among heart failure patients who received the flu vaccine.
The AHA, American College of Cardiology (ACC), Heart Failure Society of America (HFSA), and other organizations recommend yearly flu shots for people with, or at high risk for, CVD. Even if the vaccine isn’t fully effective, it can reduce the severity of symptoms and lessen the likelihood of a CVD event.
Various Blood Markers
Modifying risk factors such as smoking, high cholesterol levels, and increased blood pressure and taking medications to reduce the impact of these elements can lower a person’s chance of having a heart attack.
Since these measures reduce heart attacks only by about 50 percent, researchers are searching for additional ways to improve risk prediction. Among them is the idea of testing certain substances within the blood. While only a small number of these biomarkers have been proven useful enough to be widely adopted, there is hope. Today, abnormally high levels of six substances in the blood are used to help identify people who remain at risk, so they can be treated more aggressively:
High-sensitivity C-Reactive Protein. C-reactive protein (CRP) is a marker of inflammation in the body. When measured by a high-sensitivity (hs) laboratory test, high levels of CRP are associated with a higher risk of CAD and heart attack, even in people with normal cholesterol levels. The test can identify a person whose elevated risk was not discovered with traditional tests, who remains in danger despite statin therapy, or who may require more aggressive therapy to prevent a heart attack.
Lipoprotein(a). Abnormally high blood levels of a lipoprotein related to LDL called lipoprotein(a), or Lp(a), appear to confer an increased risk of CAD and heart attack in men under 55 and in all women, especially those over 55. High levels of Lp(a) are genetically determined, so increased Lp(a) levels indicate higher risk in people with a strong family history of CAD. Because Lp(a) is attached to LDL cholesterol, aggressive LDL lowering is necessary to lower the chance of heart attack.
Homocysteine. Homocysteine is an amino acid necessary for normal cell function. It also contributes to the development of heart attack and stroke in those with no recognized risk factors. Every 10 percent increase in homocysteine levels increases the risk of CAD by 10 percent. Under certain circumstances, excess homocysteine leaks out of cells and into the blood, where it may damage the endothelial cells lining the arteries, providing a site for atherosclerosis to develop.
Currently, homocysteine is used primarily to identify patients with chronic kidney disease who are in more danger of having a cardiac event and require aggressive blood pressure and cholesterol reduction.
Myeloperoxidase (MPO). A protein secreted by white blood cells to kill bacteria, MPO is also a marker of inflammation in the blood vessels. High MPO levels signify an increased risk of heart attack, even when HDL, LDL, and hsCRP levels are normal.
Its presence inflames arteries, changes LDL into a form that causes plaque formation, and prevents HDL from doing its beneficial job. MPO also releases a type of “bleach” that kills cells in the artery lining, causing plaque to become unstable, and reducing the ability of nitric oxide to relax blood vessels. High levels of MPO in those with heart disease or chest pain indicate a very high risk of heart attack. High MPO levels are treated with aggressive antiplatelet and LDL-lowering therapy.
Trimethylamine N-Oxide (TMAO). TMAO is a compound produced when bacteria in the gut digest certain nutrients found in meat, egg yolks, and high-fat dairy. TMAO makes blood platelets prone to clotting. High levels of TMAO are known to be a strong predictor of increased risk for heart attack or stroke caused by a blood clot. Fortunately, a new class of drugs with exciting potential to counteract TMAO is being tested in clinical trials.
N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP). NT-proBNP is a hormone causing blood pressure to rise and the body to retain sodium and water. High levels of NT-proBNP indicate worsening left ventricular ejection fraction, making the test valuable for diagnosing heart failure in asymptomatic patients. High NT-proBNP levels require blood pressure to be tightly controlled.
Be Proactive
Worried about your heart? The best way to protect it (i.e., to reduce the effects of CAD, prevent a heart attack, and eliminate your risk of serious cardiovascular issues) is to be proactive. Cut the excuses and make a commitment to your health. While changing years of bad habits won’t happen overnight, the benefits you’ll reap from a new, healthier lifestyle will last for decades.
Think you’re too old to start? Think again. Multiple studies prove that the more heart-healthy habits you adopt (quitting smoking, for example, and choosing a salad over fries), the lower your risk of heart problems. The longer you stick to these good habits, the better you’ll feel—no matter how old you are when you start to improve your lifestyle.
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