These articles are presented as a source of information only and can not be used as medical advise.
Please note that there are some risk factors to be aware of when dealing with heart disease.
Common Risk Factors
- Major coronary risk factors include:
- a family of heart disease
- high blood pressure
- elevated cholesterol
- cigarette smoking
The modification of these risk factors is an essential element in preventing the development or progression of heart disease. The Articles listed to the left provide information regarding heart disease and these risks.
AN INTERVIEW WITH DR. BRADLEY RADWANER, FOUNDER OF THE NEW YORK CENTER FOR THE PREVENTION OF HEART DISEASE
You exercise, you eat right, and you feel terrific.
But - whether you are a man or a woman - you still may be at risk of heart disease, the nation's leading cause of death.
If you eat a diet high in saturated fats, or if you've inherited a tendency to accumulate cholesterol, you may develop fatty deposits along the walls of your arteries. And if you are a woman, you actually have a five times greater risk of dying from a heart attack than from breast cancer.
Dr. Radwaner is a graduate of Cornell University Medical College, completed his post-doctoral training in internal medicine at Lenox Hill Hospital, and cardiology training at Columbia University and NYU Medical Center.
An experienced invasive cardiologist, Dr. Radwaner had performed cardiac catheterization and balloon angioplasty on over 5,000 patients but now focuses on preventing heart disease. In 2001 he established The New York Center for the Prevention of Heart Disease dedicated to early detection, prevention and treatment. He is affiliated with Lenox Hill Hospital and New York Presbyterian Hospital. Dr. Radwaner is Assistant Clinical Professor of Medicine at Weil-Cornell Medical College.
Published in many medical journals, he is highly articulate, and knows how to get your attention. "Nearly one-quarter of all heart attacks are not recognized when they occur", he tells me. They are silent heart attacks, with no pain. But they're potentially even more serious than what we commonly recognize as a heart attack - because the unknowing victim has not been warned to examine his or her lifestyle, and to get appropriate medical attention."
A person can exercise, eat well, have low stress, and still have the potential for heart disease.
Dr. Radwaner: Yes. Unfortunately, a lot of people have silent ischemia, a problem with blood flow to the heart muscle.
Radwaner: It's 'silent', because though there is a problem, the heart doesn't signal the body by having chest pains. These people are unaware they have a serious problem.
People may be running for cabs, walking up stairs, or doing heavy labor at work, and not even know they're stressing their heart and doing damage to it.
Studies from John Hopkins University show that people who had silent ischemia did worse than those people who had chest pain and sought medical attention. Those with painful ischemia, or lack of blood flow to the heart, know when to stop performing a physical activity, or to avoid a situation of stress, because they feel chest pain or pressure. This is classic angina, the heart's signal it's under duress, not receiving enough oxygen.
It's the same as when you're running and get a cramp in your calf. Angina is a cramp in the heart muscle, when it's not getting enough oxygen to supply the demand.
At what age should someone get concerned about this?
Radwaner: The American Heart Association in general recommends that men and women over the age of 40 should have a stress test prior to beginning an exercise program. Certainly if they are going to engage in strenuous physical activity, like hiking or jogging, they should consider a stress test.
In the absence of chest pain or discomfort, patients with multiple risk factors for coronary heart disease should consider having a stress test to look for silent ischemia.
Each year about 350,000 Americans die suddenly with no chest pain - and at autopsy, the vast majority are discovered to have severe coronary heart disease, which has been symptom-free.
Examples of this include Dave DeBuschere, the professional basketball player and the former baseball commissioner, Bart Giametti. Neither had a history of angina or chest pain, and at ages 59 and 51 they both died suddenly of a heart attack.
Autopsy studies from the Vietnam War showed that 18 and 19 year old soldiers killed in action already had early cholesterol buildup in their arteries.
What are the risk factors?
Radwaner: They include high blood pressure, cigarette smoking, high cholesterol, diabetes, being just 30% above your ideal weight, and a family history of heart attacks before age 55 in men and before age 65 in women.
Men and women who have some of these risk factors should be looked at as candidates for hardening of the arteries. Clearly, those who have multiple risk factors, even in the absence of symptoms, should have these tests.
What tests are given?
Radwaner: One key test is the exercise stress, usually on a treadmill, but it also can be with a bicycle. On the treadmill, a patient is hooked up to an electrocardiogram while he or she goes through a graduated program of walking at different speeds and different elevations.
We watch the electrocardiogram for a response that indicates the heart is under strain, and whether or not it is receiving enough oxygen.
The second type of stress test is a nuclear stress test, where the cardiologist, often in combination with the radiologist, looks at images of the heart obtained by injecting a
radioisotope during exercise and rest. This technology gives us very good pictures of the heart and its functional capabilities.
Interestingly, what we learn from the stress test does not necessarily depend on how long you exercise on the treadmill. It's more a function of what the cardiologist sees while you're exercising. A person who is in shape could still have unsuspected silent ischemia.
Recently we have found that more than 50% of the 1.5 million people who have a heart attack each year, have normal levels of cholesterol. Using an advanced lipid analysis which I do in my office through the Berkley Heart Lab in California, we can identify many of the otherwise hidden risk factors that do not show up on standard cholesterol tests, including small LDL, HDL size, CRP, LPA and homocysteine. Studies at Stanford, Emory and Quebec have shown that the size of the LDL particle, which is determined genetically for the most part is a major coronary risk factor. Small, dense LDL infiltrates more easily than larger particles into the lining of the arteries and builds up cholesterol blockages very quickly. Medication and exercise addressed against small LDL excesses can save lives.
Are there any other tests?
Radwaner: Yes. We now have ultrafast CAT scans that can measure the amount of calcium in the coronary arteries, a marker for cholesterol buildup. Patients who have higher calcium scores have been shown to have a higher probability of heart attacks over the next 4 years independent of their cholesterol level. In addition, 3D CT angiography, a new technology, allows us to noninvasively image the coronary to see the earliest blockages. Before this technology, an invasive angiogram would have been needed. Soon 70% of angiograms will be replaced by 3D CT angiograms done noninvasively.
People know men are at risk, but women above a certain age also are at risk.
Radwaner: By far, heart disease is the leading cause of death for women: 247,000 women die of heart attacks each year. By comparison, about 40,000 women die each year from breast cancer, about 41,000 from lung cancer.
In addition, women who have heart attacks are twice as likely as men to die within the first few weeks.
Unfortunately, most studies done in the lat 25 years were based only on men. But now, doctors have been giving more emphasis to heart disease in women.
Women are less at risk before menopause, because their estrogen seems to raise 'good' HDL cholesterol to protective levels, preventing development of coronary heart
disease. So, though a lot of women who are pre-menopausal might have high cholesterol levels, they also have high HDL, and therefore, are at less risk.
Cigarette smoking remains the major risk for coronary disease in pre-menopausal women. Whereas one in nine women aged 45 to 64 has some form of heart or blood vessel disease, this rate rises to one in three by age 65 and over.
Once women lose their estrogen, they rapidly catch up with men over a 10-year period. In fact, the incidence of heart attacks in post-menopausal women, and in men of the same age, rapidly becomes similar within several years.
What about diet?
Radwaner: Saturated fats are pervasive in the foods we buy in markets and especially what we eat in most restaurants. These fats are primarily found in animal foods and in some vegetable products, such as avocados and tropical oils, like coconut and palm.
Also, dairy products contain predominantly saturated fats. These fats actually raise your serum cholesterol, contributing more to coronary artery disease than eating an equal amount of cholesterol.
Polyunsaturated fats are predominantly found in vegetable and fish products. They do not contribute to hardening of the arteries. And the good news is that there is a lot of evidence that diets high in polyunsaturated fats can actually lower your serum cholesterol, slowing the development of coronary artery disease.
In reality, every fat is usually some combination of saturated and polyunsaturated, so you have to look at the ratio. You want to have more polyunsaturated relative to saturated fats. The higher the ratio, the better it is.
Certain oils, like sunflower and safflower, are higher in polyunsaturated fats than say, corn oil, while olive oil is a monosaturated fat.
Most evidence on monosaturated fat seems to indicate it is either neutral or actually lowers serum cholesterol, thus contributing less to hardening of the arteries.
What about cholesterol?
Radwaner: In addition to determining the level of cholesterol, we need to break it down, determining how much is 'good' and how much is 'bad'. LDL cholesterol levels above
100 are clearly now associated with a higher risk of heart disease. Recent studies have shown that in patients with coronary disease, LDL levels in the 60s or lower brought down with medication have the best survival and lowest incidence of new events.
New advanced lipid analysis not only identified LDL (bad) and HDL (good) cholesterol levels, but also looks at particle size. We 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 cholesterol particles. Large HDL particles are involved 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.
I thought all cholesterol was bad.
Radwaner: No, not really. HDL is the good cholesterol. It removes cholesterol from the lining of the coronary arteries, particularly the large HDL particles.
Remember that the arteries are less than one-half inch in diameter, and some are as small as one-quarter inch. So over 40 or 50 years, it doesn't take much to block off an artery and reduce the blood flow.
But the HDL acts as a scavenger, a 'scrubber', taking the cholesterol away from the arteries, and putting it in the liver. When you have a high level of LDL, the bad cholesterol, it ends up deposited in the lining of the coronary arteries. Small LDL is the worst.
In the Framingham, Massachusetts heart study, where they followed thousands of men and women for over 30 years, high triglycerides also were found to be an independent cardiac risk factor. In particular, someone with a high triglyceride level, and a low HDL, is in the group we've observed as having the greatest number of heart attacks. We now need to also pay close attention to triglyceride levels and particle size.
The Metabolic Syndrome is a very common and very high risk syndrome for heart attacks that consists of obesity, hypertension, latent or actual diabetes, high triglycerides and a predominance of small LDL particles.
In 1999 - 2000 the National Health and Nutrition Examination Survey estimated that 64% of U.S. adults are either overweight or obese (more than 30 lbs above their ideal weight). This obesity epidemic is strongly linked to the increasing incidence of adult onset diabetes in America.
What can a person do?
Radwaner: Unfortunately, the strongest risk factor, genetics, you can't do anything about. In terms of foods, you can avoid saturated fats and cholesterol - butter, egg yolks and red meat.
Of course, one problem with saturated fats is that they taste good. That's why we love French fries, potato chips, hamburgers, and hot dogs. They're filled with saturated fats, and to the American palate, that's very tasty. You have to retrain your palate away from wanting all that fat, and instead learn to love vegetables, fruits, fish, grains and pastas.
In addition, there are now excellent, safe medications to dramatically lower cholesterol, which a cardiologist can prescribe. For every 1% reduction in your blood cholesterol, you reduce your risk of having a heart attack over the next five years by 2%. With combination medication directed by the Advanced Lipid Analysis and a 3D CAT scan, I can now prevent 90% of cardiac events over a 10 year period of time.
Also, regular exercise, such as jogging or bicycling at least 20 minutes three times a week, has been shown to both raise HDL cholesterol and also to lower the risk of heart disease. Weight loss through eating a healthy, low-fat diet and regular exercise is key in reducing cholesterol levels.
What about stress?
Radwaner: We all live with stress, particularly in New York, and there is really no good evidence that it alone can cause coronary artery disease. But if you already have coronary disease, with cholesterol-filled vessels, and are then under stress, you clearly run a higher risk of having your coronary artery close off completely, causing a heart attack.
The key is prevention. Here at The New York Center for the Prevention of Heart Disease, we would much rather identify the person at risk before they have a heart attack or stroke and prevent it from ever occurring.
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.
To get an idea of how your heart performs in action, the physician may ask you to wear a Holter Monitor, a portable EKG device that is carried throughout the day, or undergo a full scale exercise stress test on a treadmill.
Performed under the supervision of a physician, the treadmill stress test proceeds slowly and gradually through several levels. It is designed not to push you to your limits but to determine exactly what level of exercise your heart can safely withstand.
If necessary, additional tests such as a thallium scan (injection of a radioactive dye into your blood that can be traced during an exercise EKG to indicate trouble spots) can pinpoint the location and cause of the problem.
Other specialized tests include:
•Echocardiography: using sound waves to evaluate the structure and motion of the heart.
•Radionuclide imaging: computer-generated pictures that track radionuclides in the blood stream in order to determine how well the heart muscle is supplied with blood and how the chambers are functioning.
•Magnetic Resonance Imaging (MRI): these detailed images can detect damage from a previous heart attack, identify congenital defects and evaluate blockage of larger blood vessels.
• Calcium is a marker for atherosclerosis development. If someone has calcium deposits already present, this is an indication that the process of cholesterol building in the arteries has begun. Recent studies have shown that a high calcium score indicates a high risk of a heart attack in the next 4 years and is a predictor independent of your cholesterol level.
•CT angiography also uses ultrafast, CAT scans to get noninvasive 3D images of the coronary arteries that before could only be obtained by cardiac catheterization. This noninvasive test will likely replace 75% of diagnostic cardiac cath over the next 10 years. Ultrafast CAT scans providing a reading of the amount of calcium in the coronary arteries.
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.
By Bradley A. Radwaner, M.D., F.A.C.C.
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.
By Bradley A. Radwaner, M.D., F.A.C.C.
The amount and nature of fat in the American diet has long been a matter of public debate. As early as 1977, the U.S. Senate Committee on Nutrition and Human Health recommended that Americans limit their fat consumption to 30 percent of total daily calories, made up of 10 percent saturated fat, 10 percent unsaturated fat and 10 percent cholesterol. These early guidelines are close to what most dietitians and cardiologists would recommend today; yet, at the time, they sparked enough controversy to cause the government, in a 1980 revision, to eliminate all specific percentages. Over the past 25 years, researchers have confirmed that blood cholesterol is an important risk factor for heart disease and have clarified the effect of various dietary fats on blood cholesterol. In addition, some research has implicated a high-fat diet as a possible factor in the development of some forms of cancer, and there is no question that fat is more calorie-dense than other foods and, as a result, contributes to weight problems. Even though the average American still gets about 45 percent of his or her calories from fat, increasing n umbers are becoming aware of the health hazards and would like to reduce the amount of fat in