By
Bradley A. Radwaner, M.D., F.A.C.C.

In the ambulance on the way to the hospital, a diagnosis of coronary heart disease can be ominously exact. Almost half of Americans suffering a heart attack die before they reach the hospital; another 15 percent do not survive hospitalization.
While a heart attack is an emergency that often gives little or no warning, the disease that causes it is progressive, often starting during the teen years. Over the past two decades the heart attack death rate has been nearly halved for men and significantly reduced for women, thanks not just to improved therapies and more sophisticated technology at the hospital but also to earlier and better diagnosis. We also now know that the majority of heart attacks occur from cholesterol deposits that suddenly rupture into the bloodstream, causing clots that obstruct the blood flow completely.

THE HISTORY AND PHYSICAL

Your family physician can get a fairly good idea of your cardiovascular health through a history and physical. Many things can go wrong with the heart, but the most common cause of a heart attack is insufficient blood flow due to narrowing or blockage of one or more coronary arteries.
Without adequate blood flow, the body cries for oxygen, often through pain in the chest area or shortness of breath that comes with exertion but goes away with rest.
Other signs of a problem include coughing up blood or blood-streaked sputum: palpitations; swelling; faintness or dizziness, and bluish discoloration (cyanosis) of the skin or mucus membranes.
If you’re having shortness of breath or chest pain, your physician can learn a lot by talking to you about when your symptoms appear and exactly where and how you feel discomfort.
The physician may also note signs of physical appearance, including clubbing or other changes in the fingers or thumbs, an abnormal gait, a head bob or exaggerated pulsations of arteries in the neck. The physician can measure venous and arterial pressure and pulse, feel for abnormalities in the chest, listen to the heart through a stethoscope and perhaps order tests, including chest X-rays and an electrocardiogram (EKG).
Chest X-rays can rule out non-cardiovascular causes of the symptoms as well as provide information about the size of heart chambers and major blood vessels. The most widely used non-invasive diagnostic procedure, the EKG depicts the electrical activity produced by the heart. Certain abnormalities in the rhythm, pumping action or blood flow can be detected even at rest.
New advanced lipid analysis not only identifies LDL (bad) and HDL (good) cholesterol levels, but also looks at particle size. We now know that those patients who make a predominance of small LDL particles have a 300% greater risk of developing coronary blockages than those who predominantly make large LDL particles. Large HDL particles are involves in reverse cholesterol transport, moving cholesterol away from the heart and storing it safely in the liver. With exercise and certain medications, the particle size can be dramatically improved.

SPECIALIZED TESTS

The definitive approach has been cardiac catheterization, usually prescribed to determine if surgery or balloon angioplasty is necessary. Typically on an outpatient basis, a flexible tube (catheter) is inserted into a blood vessel in the arm and then threaded through the body to reach the openings of the major arteries near the heart. In terms of discomfort, one patient compared it to “getting a tooth drilled under novocaine.”
The films, produced within a matter of hours, give a detailed picture of the location and extent of obstructions, providing an excellent guide for future procedures.
A narrowing in your left main coronary artery (which is the major supplier of blood to the heart) or in three other primary arteries usually indicates bypass surgery. If obstruction is less extensive, angioplasty or other procedures may offer just as much chance of prolonging life.
While the technology is available to diagnose and treat even the most advanced cases of coronary artery disease, the most highly trained and advanced cardiologists, i.e., Dr. Radwaner, prefer to prevent coronary artery heart disease before it is present and reverse the disease when it has already taken hold.

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HEART DISEASE Endorses Equal Opportunity

If you ask a group of women in their 40s and 50s about their major health concerns for the next 10 or 20 years, most are likely to list breast cancer, osteoporosis and, if they smoke, lung cancer. While these are all legitimate concerns, many women fail to recognize the single biggest killer of American women – heart disease. Every year heart disease kills about a quarter of a million American women, compared to 40,500 for breast cancer and 41,600 for lung cancer. In recent decades, Americans have become more aware of the dangers of heart disease, and have made some important changes in lifestyle. Over the past decade, the death rate from heart disease has declined seven percent every year – for white males. In the same period, however, women and black males have experienced only a slight decline. If women want to achieve equal opportunity in this matter of life and death, it’s necessary to reexamine some long-held assumptions. One myth is central to all the others – that heart disease is a uniquely male problem. In fact, almost equal numbers of men and women die from atherosclerosis, or hardening of the arteries. The difference is that women tend to develop the disease about 10 years later than men. By age 70 women develop cardiovascular disease at a rate equal to that of men. Many women (and even the medical community) are lulled into a false sense of complacency because they feel they have a built-in protection against heart disease. Most pre-menopausal women do, in fact, have a relatively low risk of heart attack, possibly because of the protective effect of the female hormone estrogen. When a woman’s estrogen level drops after menopause, however, the risk rises sharply, catching most women unprepared. Even during the pre-menopausal years, m any women give up some of their natural protection by choosing to smoke. At least two-thirds of heart attacks in women can be attributed directly to smoking. Women who smoke 35 cigarettes a day or more have 10 times the risk of non-smokers. Long-term use of birth control pills also tends to increase a pre-menopausal woman’s risk of heart disease. A woman who takes birth control pills and smokes compounds this risk.

BIGGER THREAT TO WOMEN

Contrary to popular belief, heart disease is usually more severe and more life-threatening in women. A woman’s chances of surviving a heart attack are about 5 to 10 percent lower than a man’s. Women are twice as likely as men to die in the first few weeks after a heart attack and they also have a higher risk of death following open heart surgery or balloon dilation. The reasons for the increased risk are not fully understood, but some researchers believe that the smaller size of a woman’s arteries may make her more susceptible to clots. The authors of another study carried out at Cedars-Sinai Hospital in Los Angeles found that the women in their study were not only older than the men, but also sicker. They were referred much later in the course of the disease. Men were more likely to have heart surgery after a screening examination; women, after a life-threatening emergency. In the mistaken belief the heart disease is a male malady, women, and often their doctors, ignore the early symptoms until the disease has progressed to a dangerous level. Often the symptoms of a heart attack or angina are atypical in woman, not the usual crushing mid-chest pain, but rather nausea, shortness of breath or other less classic symptoms.

MANAGING THE RISKS

For a woman, the most important risk factor is age. But heart disease is not a normal part of aging. People who have strokes and heart attacks in their 60s and 70s are not dying of “old age”. Atherosclerosis is brought on by a combination of genetics and lifestyle. We can control our lifestyle. Age controls the way risk factors interact with each other. A 55-year-old man, for example, who combines three risk factors such as smoking, high blood pressure and high cholesterol doubles his risk of heart disease, but a woman the same age will find her risk tripled. Blood cholesterol should be under 200, but even more important than total cholesterol – is high density lipoprotein or HDL, the “good cholesterol”. A low level of HDL, under 40, is the second most important predictor of heart disease for a woman. Recent studies from Harvard indicate that an elevated C-reactive protein, a marker of inflammation, is an even more important predictor of heart attack and stroke risk than levels cholesterol in woman. It is important for women to get a blood cholesterol reading that breaks down the levels of HDL and LDL (low density protein) and gives the ratio of total cholesterol to HDL. Ideally your ratio should be less than 3.5; if it’s about 5.0, that’s a sign of danger. Smoking greatly increases the risk for heart attack in women of any age. But the damage can be undone. If you quit, within two to three years your risk will be about the same as someone who has never smoked. High blood pressure is a major health risk, even at mildly elevated levels. If you have readings higher than 140/90, your blood pressure is too high. When a woman combines high blood pressure with smoking, high cholesterol and use of birth control pills, she becomes a walking time bomb. Obesity and a sedentary lifestyle are two risk factors that often go hand in hand. Research shows that those at the greatest risk of heart disease are apple-shaped, with excess weight on the abdomen, rather than pear-shaped, with weight distributed on the hips and thighs. Whatever your shape, a diet that focuses on low-fat foods and a regular exercise program will promote a healthy heart as well as help with weight loss. After menopause or a hysterectomy, when the ovaries stop their production of estrogen, a woman’s risk of having a heart attack increases two-to-three-fold and by ten years after menopause, a woman and man’s risk is the same. Recognizing that heart disease is a major killer of women as well as men is the first step in fighting back. As a woman, you need to know what is unique about the disease as it affects women, and what you can do for prevention. Know y our pressure and work on lifestyle changes that will give you the heart to enjoy your post-menopausal years.

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CHOLESTEROL: NOT THE FATTEST CAT

Cholesterol, the fat with the greatest name recognition, is technically not a fat all but a fat-related compound that has an ability to combine with fatty acids. Cholesterol is found in every animal cell (lean as well as fat meat),…but never in fruits, vegetables or any plant derivatives -even peanut butter or vegetable oil. Egg yolks and organ meats such as liver and kidney are particularly rich in cholesterol. Cholesterol is a primary ingredient of the crust-like plaque that forms in the walls of arteries, eventually obstructing the flow of blood and leading to a heart attack. Cardiologists now feel there is no safe level of cholesterol above 180 mg/dL of blood, and every one percent increase in blood cholesterol results in a two percent increase in the risk of a heart attack. The human body is capable of manufacturing all the cholesterol it needs so there's no danger in eliminating all dietary cholesterol…although there's no reason to do so. The American Heart Association now recommends a daily intake of about 300 milligrams of cholesterol a day - a little more than that found in one egg yolk. The relationship between blood cholesterol and dietary cholesterol is, however, not as direct or simple as many believe. A person's serum cholesterol level is determined by many factors, including heredity, age and sex. Obesity, caused by excess calories of any kind, can also cause high blood cholesterol. Even considering dietary factors alone, cholesterol is not as crucial as total saturated fats - whether the source be animal or vegetable. As a result, eliminating all foods containing cholesterol will not assure either a low-fat nor a heart-healthy diet.

SATURATED VERSUS UNSATURATED

All fat-containing foods are made up of a variety of fatty acids classified according to their chemical structure as either saturated or unsaturated. Generally speaking, a saturated fat is solid at room temperature; an unsaturated one is liquid. Foods high in saturated fatty acids include meat fat, lard, butter, milk, cheese, ice cream and the oils most commonly used in commercial baked cookies, cakes and doughnuts - cocoa fat, coconut oil, palm oil and palm kernel oil. Because saturated fats are less likely to turn rancid, they are also useful in processed foods that must sit on the shelf for extended periods. Foods containing more unsaturated than saturated fatty acids include fish, the white meat of poultry, nuts, grains and most liquid vegetable oils. Through a process called hydrogenation, a liquid unsaturated oil can be made more solid and usable as a spreadable margarine. The process also makes the fat more saturated.

POLY-VERSUS MONO-UNSATURATED

Another important distinction is between polyunsaturated (safflower, sunflower, soybean) and mono-unsaturated (olive, avocado, canola, walnut and peanut) oils. Whereas saturated fats increase blood cholesterol, unsaturated ones tend to decrease it or at least displace some of the saturated fats. In comparison, mono-unsaturates reduce only the LDL, thereby tending to increase the ratio of "good cholesterol". Trying to improve your blood cholesterol profile by over-dosing on olive oil is, of course, not recommended. All food contains a mixture of fats in varying proportions; along with mono-unsaturated fatty acids, you'll also be getting an unhealthy dose of saturated fats and calories. The gain in weight from too much or any oil will greatly increase the cholesterol. With understanding of the differences between saturated, polyunsaturated and mono-unsaturated fats, it is possible to make sensible use of the information available on food labels. As far as your heart is concerned, saturated fats are worst, followed by cholesterol. Mono-unsaturates are probably preferred over polyunsaturates. Some studies have suggested that omega-3 fatty acids (found in fatty fish and marketed widely in fish oil capsules) may offer some protection from heart disease. As for cancer and other disorders, the formula is similar. A diet high in fat has been associated with a higher risk of breast and colon cancer. And all fats are culprits when it comes to weight control. Fat has nine calories per gram compared to four per gram for protein and carbohydrate.

LEAVE THE FAT

For Americans, the safest approach is basically what the U.S. Senate Committee recommended, then rescinded, 25 years ago. Fat is an essential nutrient and source of energy that cannot and should not be eliminated completely, but affluent Americans eat far more than is necessary or prudent. In China, where the diet is traditionally low fat, blood cholesterol levels typically range from 90 to 180, heart disease is rare and life expectancy exceeds 70 years. That is until the Chinese immigrate to America, adopt the American high fat diet and then develop the same degree of heart disease. Keeping total fat under 30 percent can be accomplished with a little vigilance. While most Americans know the danger of making a steady diet of steak, shake and fries, they tend to overlook the less obvious sources of fat: the blue cheese dressing that smothers the green salad, the buttery croissant that cradles the tuna, the four teaspoons of saturated fat use to make the oat bran muffins. Whether a food has cholesterol is less important that the percentage of calories derived from fat and whether that fat is saturated, polyunsaturated or mono-unsaturated. When looking at food labels make sure that the percentage of calories from fat is less than 1/3 of the total calories. That is the official legal definition of "low-fat" and these are the food to be favored.

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HIDDEN DANGERS IN THE SUPERMARKET

As we walk through the aisles of the supermarket making selections for meals with family members returning from school or on vacation, we are bombarded with screaming labels: LOW CHOLESTEROL, CHOLESTEROL LITE, NO CHOLESTEROL. Assured that we have once again saved our families and ourselves from a future of certain hardened arteries, strokes and heart attacks, we confidently reach for these products. Some of us, still suspicious, turn the package over to look at the labels. Schooled in the post-Watergate era of seeing is believing, we adjust our glasses, or toy with bifocals to read labels clearly written for Lilliputians. Aha! There is it: 0 mg cholesterol. Once again assured that we have triumphed over evil cholesterol, we place the food in our supermarket cart and move on. We have provided our family with food low in cholesterol, confident that years of clean arteries lie ahead? But do they?

SATURATED FATS: THE HIDDEN DANGER

Although Madison Avenue has created a boon for new labels regarding the cholesterol content of food, little if any attention is paid to a far worse enemy: saturated fat. Gram for gram, the serum cholesterol will rise more from the ingestion of saturated fat than it will from an equal amount of cholesterol. More people will develop hardening of the coronary arteries, coronary atherosclerosis, from diets unknowingly filled with saturated fats, and increase the risk of heart attacks and strokes. While eating a diet high in saturated fats will raise your serum cholesterol greatly and put you at risk for heart disease, a diet high in polyunsaturated fats will lower cholesterol and reduce your risk.

DON'T PASS THE BUTTER

Saturated fats are a type of fat different from cholesterol that is naturally found in animal fat and certain vegetable products. Saturated fats harden and solidify at room temperature, while unsaturated fats are liquid. The difference, chemically, is that saturated fats contain more hydrogen molecules than unsaturated fats. Which foods contain saturated fats? Dairy (milk-based) products such as cream and butter, generally contain saturated fats. Beef, lamb and porkt have a higher percentage of saturated fats than veal, chicken or turkey (except for the poultry's skin). Coconut, palm and palm kernel oil also have a larger amount of saturated fats than many others; moreover, many processed foods used these vegetable oils to provide a palatable taste and longer shelf life. On the other hand, olive oil is monosaturated, and corn, safflower and sunflower oils are primarily polyunsaturated. Fish, which can contain anywhere from 1 to 20 percent fat, is also predominantly unsaturated.

PICTURE THIS

The problem is not only that fat is pervasive is in our diet, but it is often what makes our food seem tasty. Indeed, a frankfurter gets 80 percent of its calories from mostly saturated fat, and a donut get about 60 percent of its calories from fat, mainly in the form of saturated vegetable oil. So, how do we stop eating this fat? Well, picture the white layer of a fat on top of gravy or stew after it has been refrigerated. Then picture this within your coronary arteries, which are only one-quarter-inch wide to begin with.

KEEP THE PERCENT DOWN

Now that you know that saturated fat is the enemy, you can enter the supermarket as an informed, intelligent consumer. Processed and canned foods should have their labels scrutinized for the total fat content and the amount of saturated versus polyunsaturated fat. As you read the label, fat should be listed as one of the last ingredients: If it is among the first three, then the product is probably high in saturated fat. As a general goal, you should reduce the amount of fat in your diet to about 30 percent of your daily calories (for example, if you eat 1800 calories, you should have no more than 60 grams of fat); of that amount, only one-third (in our example, 20 grams) should be saturated fats. Someday, hopefully, you may be able to enter the supermarket and see labels screaming: NO SATURATED FATS, LOW IN SATURATED FATS. Until then, you must be on your guard to protect you and your family from the unseen dangers of saturated fats.

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MENTAL STRESS AND HEART DISEASE: It's All in the Mind

By Bradley A. Radwaner, M.D., F.A.C.C.

If you think you're always in the wrong line at the grocery store or the bank, the problem may not be the service. Stress fills modern life-our feet hit the floor running when the alarm goes off in the morning; we idle on the expressway knowing we'll be late for the tension-filled "team" meeting at work; the hectic stop at the store to pick up something for dinner means we're already five minutes late for Jimmy's baseball practice. No wonder we got in the wrong line. Our bodies were built to handle stress. When danger threatens, a rush of adrenaline floods the system, the heart beats faster and the breathing rate increases. We become hyper-alert, ready to do battle or flee. This sophisticated fight-or flight mechanism served our ancestors well when they were faced with short-term threats such as an attack from a sabre-toothed tiger. Chronic rather than short-term stress is the order of modern life, however. Our fight-or-flight response is on constant low as we struggle to meet the many demands of a modern lifestyle. A response that developed as a protective mechanism, when chronically activated can become lethal. If we are surrounded by stress, we also create our own. Just as we can activate our salivary glands at the mere thought of biting into a lemon, so too can we start our adrenaline pumping as we lie in bed fretting over real or imagined problems. Yet not all stress is bad. Exercise stresses our bodies causing a surge of adrenalin and an increase in heart rate and respiration. Regular, sustained exercise actually makes our bodies more capable of handling mental stress. Healthy individuals are better able to handle stress than those who already have heart disease. For patients with diagnosed coronary artery disease, mental stress is known to bring on angina and reduce the flow of oxygen-rich blood to the heart. A study published in the New England Journal of Medicine (November 28, 1991) found that when patients were subjected to mental stress, those whose arteries were free of atherosclerotic plaque either experienced no change or their arteries dilated (widened) in response. Patients diagnosed with atherosclerosis, on the other hand, had abnormal constriction in their arteries in stressful situations.

PERSONALITY AND MENTAL STRESS

In the 1950s Drs. Meyer Friedman and Ray Rosenman identified a personality type, classified as Type A, as being more likely than others to suffer heart attacks. Type A persons tended to be hostile, impatient, self-involved and always in a hurry. Recent research has zeroed in on more specific aspects of the Type A syndrome and its link to heart disease. The aspects most related to heart disease are self-involvement, hostility and cynicism. One study concluded that it was possible to predict the likelihood of a heart attack by the frequency with which a person referred to him/herself, i.e., using the words "I", "me", "my" and "mine". Those who are overly self-involved, tend to alienate themselves from others, becoming socially isolated. Another study based on interviews with 2,320 male survivors of heart attacks showed that those who were socially isolated and had a high level of life stress had more than a fourfold risk of death from heart disease and all other causes compared with men with low levels of stress and frequent social contacts.

CHANGING OUR RESPONSE TO STRESS

If your heart disease can be traced to diet, you can measure and eliminate grams of fat from your diet. If you suffer from chronic stress, your solutions are much less tangible. Mental stress is personal and idiosyncratic. Your colleague might see a new sales goal as an exciting challenge, while you see it as an unreasonable demand. The potential for stress is everywhere and may follow even if you flee to a mountaintop in the Himalayas. A more reasonable approach is to learn to handle stress. Stress management is an essential component of a program developed by Dr. Dean Ornish. Based on research conducted over 13 years, Dr. Ornish believes that heart disease can be halted or reversed without bypass surgery or angioplasty, simply by making lifestyle changes. The program combines a low-fat diet, regular exercise at a safe level, group therapy, yoga and meditation. Participants work on improving communication skills in a group setting as a way of overcoming isolation and hostility; on an individual basis, they practice yoga and meditation in an effort to slow pulse and breathing rates and allow the individual to remove him/herself physically and psychologically from surrounding stress. It is not certain that stress alone causes heart disease, but stress is known to aggravate existing heart disease and is implicated in many other diseases. Learning to deal with the stress in our lives - whether by meditation, biofeedback or relaxation methods - may allow us to transcend the daily turmoil and achieve, not just better health, but a sense of inner peace.

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GETTING FIT AND STAYING THERE

By Bradley A. Radwaner, M.D., F.A.C.C.

Of all the changeable factors influencing health, physical fitness may be the most important. Even though that view is widely publicized, the majority of Americans would admit that, for one reason or another, fitness has eluded them.
Resolutions simply to "get a little more exercise" usually get buried in the face of other obligations. Any activity is better than none at all, but fitness involves more than an afternoon of softball at the company picnic or an occasional golf outing. As defined by the American College of Sports Medicine, it includes not just an increased capacity of the heart and lungs but muscular strength and endurance, flexibility and a favorable percentage of lean body mass to fat. While that ideal may sound intimidating, it can be achieved by anyone with a little persistence.
Fitness does not require any special athletic talents. You don't have to look like the Fitness Pros or be able to run and jump like Michael Jordan. But you do have to be willing to work up a sweat several days a week…and do it on a regular basis.

FIRST STEP: GET A PHYSICAL

The first step, particularly if you're over 40 or have been inactive for a number of years, is a physical examination. If you have heart disease, diabetes or arthritis, your doctor will give you an exercise prescription appropriate to your condition; otherwise, the task is up to you.
The principles are fairly simple: 1) gradually build a base of muscular strength and endurance; 2) keep your muscles and joints supple with regular warm-ups and stretching; and 3) develop cardiovascular fitness through activities vigorous enough to elevate your heart rate for an extended period three to five days a week. Eventually your body composition will begin to reflect your efforts, but if you're overweight, you also need to adjust your eating habits. Athletes thrive on a diet that's low in fats and high in complex carbohydrates such as fruits and vegetables.
No matter what activities you ultimately choose, brisk walking or jogging may be a good starting point. At least keep the intensity of your workout low at first while you gradually increase the duration. This allows the body to lay down supply lines to feed the muscles and prepare them for handling the increased work load. It also encourages some early weight loss that helps reduce stress on joints and muscles.
It's important to stretch the muscles you use both before and after exercise. As muscles get stronger, they tend to contract; stretching relaxes and lengthens them, preventing injuries and reducing next-day muscle soreness. Warm-ups also help loosen muscles and prevent injury by slowly increasing body and muscle temperature.
For total fitness, muscles ordinarily not used in the chosen activity (such as those in the upper body) should be strengthened through weight training.

AEROBIC ACTIVITIES

Strong, supple muscles are essential, but the ultimate goal of a fitness program is to strengthen the heart and improve the efficiency of the cardiovascular and respiratory systems. To accomplish cardiorespiratory fitness, the American College of Sports Medicine recommends 20 to 60 minutes of aerobic exercise three to five times a week. An aerobic activity is one that produces rhythmic contractions of large muscle groups for 20 to 40 minutes at a time with sufficient supplies of oxygen present. Exercise should be vigorous enough to make you breathe harder (a heart rate 60 to 90 percent of maximum is recommended) but not so much that you have to stop to catch your breath.
The stop and go action of softball is not vigorous or extended enough to be aerobic. Other competitive sports such as basketball and hockey are aerobic but can be risky for those who do not maintain proper conditioning. Activities most commonly recommended are those that can be performed regularly at a controlled level of intensity: walking, running, cycling, stair climbing, skating, aerobic dance and cross country skiing.
Fitness develops gradually over six weeks or more relative to the frequency, intensity and duration of the exercise. Increased intensity will bring about impressive results…but with an increased risk of injury. For most individuals, I recommend exercise of low to moderate intensity with an emphasis on total calories expended. Mileage or duration should be increased by no more than about 10 percent every few weeks up to an expenditure of about 2000 to 3500 calories a week (20 to 35 miles of running or walking).
Rest is an important part of any fitness program. Sessions of high intensity or long duration should be alternated with relatively easy sessions, and at least one or two rest days each week are required to allow muscles to recover fully.
As the body adapts to training, the changes that take place are dramatic: the heart becomes stronger and pumps blood more efficiently to all parts of the body. Blood pressure usually declines, and the heart beats more slowly but the greater force, allowing greater force, allowing greater capacity for work with less effort. The body also becomes more efficient at metabolizing fuel and eventually reshapes itself with a reduced proportion of body fat.

MAINTAINING FITNESS

Even the most dedicated person faces the challenge of maintaining fitness through illness, injury, vacations, family upheavals and exercise burnout. Generally speaking, three sessions a week are needed to maintain a fitness level. Four or five sessions will likely bring about improvement while one or two sessions may lead to a slight decline. Muscle strength, on the other hand, can be maintained with only one day a week of resistance training.
Many individuals become obsessive about not missing an exercise session, and that may not be all bad. For the sake of mental as well as physical health, however, it's wiser to be concerned about the overall trend rather than short-term ups and downs. If you find yourself cutting back to one session a week over a month or so, you should realize that your fitness level is eroding and that you cannot immediately go back to the intensity and duration that was previously comfortable. It's also important to watch what you eat whenever you slack off a bit on your exercise program. Even a few extra pounds will put an extra burden on the body when you resume.
Two consecutive weeks of inactivity will result in a reduction of some aspects of your cardiovascular fitness. It takes several months of inaction, however, to reverse all you've accomplished, and even after eight months you won't be totally back to square one…although nearly so. Sometimes a prolonged rest is necessary, but it's important not to jump back into vigorous activity without undergoing the long, slow process of re-training.
To prevent burn-out, runners may turn to cross country skiing during the winter; walkers occasionally switch to swimming or cycling. Many fitness athletes choose a regular program of cross training, not just to prevent boredom but to avoid overuse injuries and keep all parts of the body conditioned.

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DIABETES IS A HEARTFELT PROBLEM

By Bradley A. Radwaner, M.D., F.A.C.C.

Diabetics face a special risk of heart disease, at least double that of the general population. Poorly controlled blood sugar over the long term exacts a toll on the entire circulatory system, from the large arteries that supply the heart and brain, to the tiny capillaries that deliver nutrients to the body's individual cells.
When control is poor, the interior walls of blood vessels become bathed in high concentrations of blood sugar. This sets the stage for atherosclerosis, a build-up of fatty plaque that can clog arteries and eventually lead to heart attacks and strokes.
Heart disease seems to act in slightly different ways in diabetics. Coronary artery disease is usually more marked with a greater build-up of atherosclerotic plaque and other debris on arterial walls. The heart muscle itself is more likely to be affected by disease in the person with diabetes.
As a result, diabetics suffer a higher-than-normal death rate from heart disease and are less likely to survive a heart attack. They also experience more silent or undiagnosed heart attacks. In fact, heart attacks and strokes are by far the leading cause of death in diabetics.
Although the prognosis may sound grim, heart disease is not inevitable for those with diabetes. Patients with knowledge of their disease and its effect on the cardiovascular system can make choices that will make a difference on risk and quality of life.

PREVENTIVE STRATEGIES

Except for the damage done by high blood sugar, the heart disease risk factors faced by diabetics are the same as those facing the rest of the population: high cholesterol and triglyceride levels; hypertension; smoking; and obesity.
Physicians now know that it's not only total cholesterol levels that count, but the high density lipoprotein (HDL, the good cholesterol), and low density lipoprotein (LDL, the bad cholesterol). Studies show that those with high levels of HDL and low levels of LDL have the fewest heart attacks. Many diabetics have the Metabolic Syndrome which consists of three of these components: obesity, hypertension, diabetes or insulin resistance or low HDL levels and is a strong predictor of coronary artery disease. Many diabetics have a high level of smaller sized dense LDL particles, the type most likely to build up blockages in the coronary and carotid arteries.
Analysis of data from the Framingham heart study shows that women with diabetes tend to have very low HDL and abnormally high levels of LDL.
Heart disease is considered rare in women who have not yet reached menopause. Women enjoy the protective benefit of female hormones during the child bearing years.
Unfortunately women with diabetes face a particularly high risk of heart disease, even before reaching menopause. The increased risk can probably be attributed to high levels of LDL, a powerful indicator of heart disease.
There are a number of ways diabetics can improve their HDL and LDL levels. Recent studies indicate that good blood sugar control appears to increase the level of HDL. Exercise is also known to improve the level of HDL and significant weight loss will greatly lower the bad LDL cholesterol.
Eating a diet low in cholesterol and saturated fats will also help keep LDL cholesterol in check. This can pose a special challenge to diabetics since the diabetic diet tends to be lower in sugar and carbohydrates and higher in fat than the diet recommended for the general population. As a result, diabetics need to be vigilant about the types of fat they eat, concentrating on polyunsaturated fats found in most vegetable oils and some fish, and avoiding saturated fats, including animal fats, coconut and palm oils.

KEEP BLOOD PRESSURE UNDER CONTROL

People with diabetes are more likely than others to develop hypertension. This factor shows up in the higher rate of deaths from heart attacks and strokes and the increased risk of kidney and eye problems faced by diabetics. One study found that people who had suffered from diabetes for 30 years or more were twice as likely to suffer from hypertension as their peers.
Lifestyle changes are known to have a positive effect on high blood pressure. Patients are advised to restrict the amount of salt consumed, to maintain normal weight, to avoid unnecessary stress and to exercise regularly.
Diabetics who smoke, especially diabetic women, simply compound their risk of heart disease. Smoking constricts blood vessels and restricts available oxygen in a circulatory system already at risk because of diabetes.
Obesity is not usually a problem for Type I diabetics, who have to carefully balance food intake and insulin doses from meal to meal, but is a major factor in Type II, or adult onset diabetes. Obesity itself is a risk factor for cardiovascular disease and is associated with high cholesterol levels. An epidemic of obesity now exists in the U.S. with one-third of the population now obese, as defined by about 30 lbs overweight.

LOOKING TO THE FUTURE

There is now very strong evidence that aggressive control of lipid abnormalities and hypertension can prevent many of the heart attacks and strokes that diabetics would otherwise suffer. Tight control of their blood sugar will help prevent the kidney and eye complications that develop in the smallest blood vessels of diabetics.
Innovations in the diagnosis of heart disease (for example, the wide-spread use of echocardiography that allows earlier diagnosis) along with new classes of medications such as ACE-inhibitors, offer diabetics better opportunity for successful treatment.
Aggressive use of statins and other cholesterol lowering medications can reduce the risk of the greatest threat to diabetics, heart attacks and strokes.
We are all at risk for heart disease. The fact that a diabetic is at increased risk need not be cause for fear but should encourage vigilance in controlling risk factors. As knowledge increases about the way diabetes acts on specific areas of the body, diabetics will be better able to make the necessary lifestyle changes.

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CONGESTIVE HEART FAILURE: AN ONGOING BATTLE

By Bradley A. Radwaner, M.D., F.A.C.C.

IT'S EASY TO TAKE FOR GRANTED the rhythmic beating of the heart, constantly renewing the body as it pumps 2,000 gallons of blood each day.
With the central pumping system in good working order, like the bunny in the battery ad, we keep going and going and going….When the pump begins to fail, however, it's like working on a run-down battery. Energy levels drop, and even the slightest exertion can cause breathlessness and exhaustion.
Congestive heart failure (CHF) is a chronic condition that affects between two and three million Americans. Most often seen in those over 50, CHF is directly responsible for up to 40,000 deaths and contributes to another 230,000 deaths annually. CHF is a major health problem that has increased by 30 percent since 1970. The increase is due in part to an aging population and in part to higher survival rates from heart attack and stroke.
As more Americans survive these potentially fatal episodes, they add to the number of those with weakened or impaired heart muscles. By age 70, about 10 percent of the population suffers from CHF, a disease that drains seniors of their energy and vitality and seriously detracts from their quality of life.
Congestive heart failure occurs when the heart fails to pump effectively, decreasing blood flow throughout the body and allowing blood to back up into the veins. The heart tries to compensate by beating faster and stretching to increase its capacity. The result is a large, baggy heart with poor pumping action.
The heart is actually two pumps working in tandem. CHF can affect both sides of the heart or just one. Left-sided CHF is the most common, causing fluid to back up into the lungs.
A number of factors can cause CHF. A heart attack or coronary artery disease can damage the heart muscle and lessen its effectiveness as a pump. Defective heart valves also impair pumping ability. Chronic high blood pressure can cause the heart muscle to thicken and become stiff. Alcohol or drug abuse can also cause the heart muscle to deteriorate.

SYMPTOMS OF CHF

Symptoms of congestive heart failure may vary depending on which side of the heart is involved and the severity of the condition.

If you have any of these symptoms, see a doctor right away. Although there is no outright cure for this condition, treatment will slow the progression of the disease and greatly enhance your quality of life. Delaying treatment may damage the heart muscle and lead to life-threatening consequences.

TREATMENTS, OLD AND NEW

In the recent past, a diagnosis of CHF promised a gloomy outcome. While it's still a chronic disease, advances in medication and surgical techniques offer patients a better chance of a productive life. Early diagnosis holds out the hope of treating CHF before it becomes too severe.
Digitalis, diuretics and vasodilators are the drugs most commonly used to treat CHF. Digitalis, obtained from the foxglove plant, has been used in medicine for over 200 years. Digitalis, usually prescribed under the name digoxin, improves the pumping action of the heart.
Diuretics help the body get rid of excess sodium and water, both of which are excreted in the urine.
Vasodilators have been used in the treatment of CHF for 20 years. They work by dilating or expanding blood vessels, lessening the pressure and allowing blood to flow more easily. The most commonly prescribed of the vasodilators, also known as the ACE inhibitors, are captopril, enalapril and lisinopril.
A study published in the New England Journal of Medicine concluded that the ACE inhibitor, enalapril, when used in conjunction with conventional therapies for CHF, significantly reduces mortality, even among those patients with mild to moderate CHF. In the past the drug had been used to treat only the most serious cases of CHF. As well as saving lives, the drug also reduced the number of hospitalizations in the study group. Mortality was reduced by 16 percent, and hospitalizations were reduced by 37 percent.
According to Deeb N. Salem, M.D., chief of cardiology at New England Medical Center in Boston, "in the United States and other Western countries, use of an ACE inhibitor as standard therapy in symptomatic patients could prevent a few thousand premature deaths and avoid several tens of thousands of hospitalizations annually."
Recently the use of beta blockers have been found to be very beneficial in CHF. Medications block the deleterious effect of adrenaline on the heart and slow the pulse rate, often too fast in patients with CHF. Beta blockers, once thought to be unsafe in patients with weakened hearts, has now been shown to dramatically improve survival when used in combination with ACE inhibitors.
Surgical options exist to treat advanced cases of CHF. An implantable pump, known as left-ventricular assist device, can be inserted into the chest to help the heart's pumping action. ICD's or iimplantable cardio-defibrillators help prevent sudden death from potentially lethal heart arrhythmias, which patients with weakened hearts are often at risk for.
Heart transplants are becoming more common to give a new chance at life for those with severe CHF. Approximately 2,000 heart transplants were performed last year. Heart transplantation now has a one-year survival rate of 85 percent and five-year survival rates of more than 50 percent.
Cardiomyoplasty is an experimental surgical technique in which a surgeon takes muscle from the patient's back, wraps it forward around the heart and then, with the help of a pacemaker, retrains the muscle to contract with the heart.
New drug therapies and surgical techniques offer hope for continued improvements in the treatment of CHF. Early diagnosis and treatment give patients the best chance of a longer and more productive life.

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SMALL DENSE LDL

What is LDL and how is it related to atherosclerosis? - LDL or low density lipoprotein is unquestionably a very powerful marker for the development of an atherosclerotic vascular event. LDL is directly involved in the atherosclerotic process and is felt to be directly toxic to the vascular endothelium. LDL, at increased concentrations in the blood stream, enters the blood vessel wall and in the appropriate circumstances the LDL particle changes and becomes oxidized. Oxidized LDL is a major trigger of the atherosclerotic process that ultimately culminates in plaque build up and obstruction of the blood vessel and all of the consequences thereafter.
Individuals with an abundance of small LDL have 300 percent more heart disease risk than people with large LDL. We know that at any level of LDL, having a significant amount of small LDL particles raises the risk of heart disease greatly. This helps explain the approximately 50% of people who suffer a heart attack yet have "normal" blood cholesterol levels.

What is Small Dense LDL? - All LDL is not created equal. There are different types of LDL. What has been clear is that all people with markedly elevated LDL do not get atherosclerotic vascular disease while other individuals with modest elevations in LDL get severe disease. This can be explained by the quality of the LDL particle. Small dense LDL is more atherogenic or more toxic to the endothelium. It is more likely to enter the vessel wall, become oxidized and trigger the atherosclerotic process. Small dense LDL is a single type of LDL; another type is large buoyant LDL. Large buoyant LDL is not as toxic to the blood vessel wall and much less prone to trigger the atherosclerosis development.

How is Small Dense LDL measured? - Determining whether small dense LDL is present can be done on both clinical grounds as well as in the laboratory. There are basically two types of assays involving blood samples to determine particle size or the presence of small dense LDL. One is the Nuclear Magnetic Resonance (NMR) particle analysis and the other is the Gradient Gel electrophoresis. Both can separate the quality and quantity of the respective types of LDL.

What are the Clinical Predictors for the Presence of Small Dense LDL? - Presence of small dense LDL can be predicted by clinical parameters. Although not as accurate as laboratory assessment certain clinical factors predict the presence of small dense LDL to a reasonable degree of accuracy. These markers include diabetes, HDL below 35, and triglycerides above 250. In the presence of any one of the above, there is about a 90% chance that small dense LDL is present.

What Causes Small Dense LDL? - Causes of small dense LDL are multiple. There is a genetic pre-disposition to have small dense LDL. An atherogenic lifestyle involving minimal activity or exercise along with a typical American diet high in saturated fat is another cause. Insulin resistance or pre-diabetes is the last major cause of small dense LDL.

How is Small Dense LDL Treated? - There are multiple therapies that can affect small dense LDL. The goal of therapy is to shift small dense LDL to large buoyant LDL, in particular an adequate exercise regimen associated with a diet restricting saturated fat. Simple weight loss can effect particle composition. Treatment of diabetes is also very important in the presence of small dense LDL and certain anti-diabetic medications are capable of this. Certain, but not all, cholesterol lowering drugs will promote a shift in particle composition. Cholesterol lowering drugs that impact small dense LDL are nicotinic acid and the fibric acid derivatives. Of note, are the statin drugs - they do not affect particle size, but they do strongly affect the LDL concentration. In combination with therapy to alter LDL size, statin therapy to lower overall LDL concentration is felt to be a very powerful intervention in terms of lowering atherosclerosis risks and preventing atherosclerotic events. Studies done by Greg Brown, M.D. at the University of Washington in Seattle have shown up to a 90% reduction of cardiac events in overall studies of combination medications that lower overall LDL, raise HDL and increase LDL particle size. This is the future of preventive cardiology.

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