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 Questions on this page:
- Does having a healthy lifestyle mean that I won't get heart
disease?
- What are the best ways to find out if I am at risk for heart
disease?
- What are some of the blood tests that can tell me if I am at
risk?
- Does taking medication to lower cholesterol really prevent
heart attacks?
- Last time my cholesterol was checked it was less than 200,
but my "good cholesterol" (HDL) was less than 35. Is this anything to worry
about and if so, what should I do?
- Should I drink a glass or two of wine with dinner to prevent
heart disease?
- I keep hearing about taking antioxidant vitamins, like beta
carotene and vitamin E, as a way to prevent heart disease. Is there any truth to this, and
if so, why isn't everybody recommending them?
- I've heard that the vitamin nicotinic acid is used to lower
cholesterol and treat heart disease. Should I start taking it?
- My cholesterol is high but no one in my family has heart
disease. Does this mean that I don't need to worry about my cholesterol?
- I heard that some people in Italy have a gene that protects
them from really high cholesterol. Can I receive treatment with this to make my heart
disease get better?
- Can cholesterol medication affect your liver and even cause
cancer?
- Can't I just prevent heart disease by taking the right
vitamins?
- Is is true that just taking one aspirin a day helps to prevent
heart attacks?
- How can I make my heart disease go away?
- Can't I just wait until I get heart disease and then have a
balloon or bypass surgery to fix it?
- Does the Dr. Dean Ornish Program for Reversal of Heart
Disease apply for situations where there is significant calcification of coronary artery
blockage?
- What are the scientifically proven ways that I can reduce my
chances of getting heart disease?
- What is heart failure?
- What is hypertension?
Q. I try to watch my diet, get a reasonable
amount of exercise, and have a cholesterol level under 200. Does this mean that I won't
get heart disease?
A. Not necessarily. Many people have genetic (inherited) factors
that increase their risk of heart disease despite a healthy lifestyle. One clue to this is
your family history: if one of your parents or another close relative has early heart
disease, you could also be at risk. Only more detailed tests can fully determine your risk
and help you know how to decrease that risk.
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Q. What are the best ways to find out if I am
at risk for heart disease? I heard that having a stress test might be important.
A. If you haven't ever had any evidence of heart disease and
don't have any symptoms of heart disease, stress testing is not a very good way to
determine your risk. It can only detect very significant blockages in the vessels.
Instead, there are newer ways to find out if you are at risk. One way is through special
blood and gene tests that help to predict risk. In addition, a specialized type of CAT
scan, called Ultrafast CT, can detect evidence of plaque buildup in the heart vessels as a
marker for your risk of heart disease. Ultrafast CT was recently mentioned by the American
Heart Association as a very promising method to help predict risk of heart disease.
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Q. What are some of the blood tests that can
tell me if I am at risk? Isn't it enough to know my cholesterol level?
A. No, knowing your cholesterol is not enough, especially if you
have a family history for early heart disease. For example, the breakdown of the good
cholesterol (HDL) and the bad cholesterol (LDL) is very important. You want to have a lot
of the good stuff and less of the bad stuff. In addition, there are some newer tests that
have been shown to help in predicting risk. These have strange names like Lp(a),
homocysteine, fibrinogen, and apoE. The bottom line is that if you are not sure about
whether to take medication for your cholesterol level, these other tests can help you and
your doctor figure out if you are likely to develop early heart disease.
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Q. Last time my cholesterol was checked it
was less than 200, but my "good cholesterol" (HDL) was less than 35. Is this
anything to worry about and if so, what should I do?
A. Low HDL is a risk factor for heart disease, but not all
persons with low HDL are at increased risk. Although it sounds paradoxical, low fat diets
tend to lower HDL levels (in fact vegetarians often have low HDL levels). But in this
situation the LDL ("bad cholesterol") is also usually low and people like this
are usually not at increased risk of heart disease. On the other hand, if you eat a normal
diet and especially if you have other risk factors such as a family history for early
heart disease, your low HDL could be sign of increased risk. It would be worth getting a
full lipid profile after a 12 hour overnight fast in order to determine your triglycerides
and LDL, then talk with your doctor about the results. There is no proof that raising HDL
prevents heart disease, but you should consider the following ways to raise your HDL:
- stop smoking if you smoke;
- lose weight if you are overweight;
- get more aerobic exercise.
Although alcohol raises HDL levels, it is not recommended that you begin drinking just
to raise your HDL. Niacin can raise HDL but this is not usually recommended and niacin
should always be taken under a doctor's care. Finally, your low HDL may be a sign that
your should work harder to lower your LDL, even if it requires medication.
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Q. Should I drink a glass or two of wine
with dinner to prevent heart disease?
A. This is truly a frequently asked question, and most doctors
have developed their own response to this question. First, what are the facts? The facts
are that moderate alcohol intake (1-2 drinks/day) is strongly associated with decreased
incidence of coronary heart disease and heart attacks. This is apparently true of all
types of alcohol (beer, white and red wine, liquors) and not just red wine. (The mystique
surrounding red wine involves its content of flavenoids, antioxidants which have been
speculated to decrease heart disease risk). Although alcohol raises HDL, it is not clear
that this is the way in which alcohol decreases risk of heart attacks. Alcohol should
never be used simply as a "medication" to raise HDL or to prevent heart disease.
There are certainly abundant risks associated with drinking alcohol, from driving under
its influence to the risk that use could escalate and cause liver disease. However, the
fact remains that moderate alcohol use appears to decrease risk of heart attacks. This is
one of those questions that once armed with the information, everyone has to make his or
her own decision.
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Q. I keep hearing about taking antioxidant
vitamins, like beta carotene and vitamin E, as a way to prevent heart disease. Is there
any truth to this, and if so, why isn't everybody recommending them?
A. We have all been inundated with hype surrounding antioxidants
and heart disease. Again, before jumping onto the bandwagon, let's pause a second to look
at the data. The infatuation with antioxidants comes from two sources:
- LDL may get oxidized before it can cause heart disease and antioxidants may prevent this
from happening; and
- survey studies suggest that people who take in more antioxidants get less heart disease.
The problem is that until controlled studies are done, we can't really be sure. A case
in point is beta carotene: two large studies were recently reported showing that beta
carotene did not prevent heart disease and in fact may have been associated with an
increased risk of cancer! At this point, there seems to be no reason to take beta carotene
supplements. So far, we only have one small study with vitamin E which was not definitive.
Several more studies are on their way. In the meantime, what should people do? Although
taking vitamin E is probably not harmful, most experts feel it makes sense to wait until
we have proof that it really works.
See:
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Q. I've heard that the vitamin nicotinic
acid is used to lower cholesterol and treat heart disease. Should I start taking it?
A. Niacin is a very effective mediation for treating high
cholesterol and triglycerides, and it also raises levels of HDL (see
article on niacin on HeartInfo). However, although it is a vitamin in low doses, it
should be taken for cholesterol only under the care of a doctor. Its most common side
effect is flushing, a warm sensation soon after taking the niacin that can be associated
with redness and itching and can be bothersome. The body adapts fairly quickly to niacin
and usually the flushing will go away over time. To avoid flushing, the starting dose
should be 100 mg 3 times per day and it should always be taken after meals. The dose can
gradually be increased over weeks to at least 500 mg 3 times per day, and in some cases to
1000 mg 3 times per day. Niacin can also make diabetes worse, elevate uric acid (a cause
of gout), and elevate the liver enzymes. However, for the right person it can be extremely
effective. You should discuss with your doctor whether you should consider niacin.
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Q. My cholesterol is high but no one in my
family has heart disease. Does this mean that I don't need to worry about my cholesterol?
A. Not everyone with high cholesterol is destined to develop
early coronary heart disease. First, a breakdown into the LDL (bad) and HDL (good)
cholesterol should always be done. Some people with high cholesterol have normal LDL but
high HDL (which is a good situation to be in!). Second, there may be other inherited
factors which help to offset the effects of high LDL cholesterol. Third, some people are
just lucky and defy the odds. In any case, the lack of a family history, though a good
sign, does not make anyone immune to the effects of a high cholesterol. In any case,
watching your diet, exercising regularly, and taking an aspirin a day would make sense as
ways of decreasing risk. Whether medication is advisable would depend on how high the
cholesterol is and on your age and the presence of other risk factors.
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Q. I heard that some people in Italy have a
gene that protects them from really high cholesterol. Can I receive treatment with this to
make my heart disease get better?
A. Many people have heard or read about the small town in Italy
with a supposedly "magic" gene that protects against heart disease. What are the
facts? As so often, the truth is not as exciting as the press makes it seem. Several
people in this small Italian town have a very low level of HDL and relatively high
triglycerides, but no heart disease. Initially, it was thought that people with this
genetic condition (called apoA-I Milano) lived longer than other Italians, but it was
later realized that all people in this small town live longer than other Italians in
general! There is no direct evidence that this gene protects against heart disease or
causes it to improve. Nevertheless, this story has been publicized widely, leading many to
go in search of treatment based on this gene. Studies are underway which should eventually
provide more information about whether apoA-I Milano has any clinical benefit in
preventing or treating heart disease.
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Q. Does taking medication to lower
cholesterol really prevent heart attacks?
A. Thanks to lots of studies over the past 20 years, we now have
proof that medication to lower cholesterol can prevent heart attacks and actually save
lives in people who are at high risk for a heart attack. That's why people who have
already had one heart attack almost always need to be treated to lower their cholesterol
in order to prevent another one. If you don't have any heart problems right now, it's
harder to decide whether medication is needed. However, a major recent study showed that
men without any heart disease who took a medication called pravastatin for five years had
far fewer heart attacks than the men who took a sugar pill. Therefore, if you are at
higher than average risk and your cholesterol is elevated, you will probably benefit from
taking mediation. Your doctor can help you make this decision.
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Q. I heard that cholesterol medication
affects your liver and might even cause cancer. Is this true?
A. We always monitor blood tests for the liver in people taking
cholesterol medication. However, problems with the liver are actually very rare and almost
never serious. In particular, the class of medications called statins have been associated
with almost no liver problems, and so the medical community is now much less concerned
about this possibility. Regarding cancer, there was a recent report about laboratory
animals getting mostly benign tumors at extremely high doses of some cholesterol
medications. Actually, this has been known for years, but the Food and Drug Administration
and many other experts had long since concluded that these medications do not represent a
risk of cancer in people at the doses we use.
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Q. Can't I just prevent heart disease by
taking the right vitamins?
A. The concept of taking vitamins to prevent heart disease is a
great one--the problem is that we don't have any proof that they really do. Our only
evidence is based on nutritional surveys that suggest that people who eat foods richer in
vitamin E, vitamin C, and others are less likely to have heart disease. However, these
same people could be getting more exercise and watching their health in many other ways,
so these studies don't prove that it's the vitamins that make the difference. Quite a few
studies are going on right now to try to investigate this question. Until we have more
information it's hard to recommend any vitamins on a routine basis. However, your doctor
may have specific reasons for recommending certain vitamin supplements.
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Q. Is is true that just taking one aspirin a
day helps to prevent heart attacks?
A. Yes, amazing but true: aspirin has been proven in many
studies to help prevent both heart attacks and strokes. Aspirin thins the blood a little
in a way that decreases heart disease risk. Acetominophen and ibuprofen will not do the
same thing. Aspirin should be a routine part of any effort to decrease the risk of
developing heart disease, but talk with your doctor before starting it.
See:
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Q. I had a heart attack five months ago and I
don't want to have another one. How can I make my heart disease go away?
A. You are asking about the potential for
"regression," the process by which heart blockages can be made to partially get
better. There is now evidence that this is possible in some people through a combination
of lifestyle changes, exercise, diet, and when needed, cholesterol lowering. However, in
general the major issue is not making heart blockages go away, rather just making sure
that they don't get worse or cause another heart attack. We now have tremendous evidence
that future heart attacks can be prevented, especially by aggressive treatment to lower
the cholesterol level.
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Q. Instead of eating better, exercising, and
taking cholesterol medication, can't I just wait until I get heart disease and then have a
balloon or bypass surgery to fix it?
A. If only things were that easy! First, having a heart
catheterization and bypass surgery is no fun and to be avoided if at all possible. But
even more importantly, almost half of the people who have heart attacks die of their first
heart attack before they ever have the chance of having things fixed. Therefore, it's
better to try to figure out if you're at risk and to try to decrease your risk to prevent
heart disease.
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Q. Does the Dr. Dean Ornish Program for
Reversal of Heart Disease apply for situations where there is significant calcification of
coronary artery blockage?
A. The Dean Ornish program is a lifestyle modification program
that reduces risk of heart disease. Several of Dr. Ornish's studies were performed in
people with definite blockages, but the same lifestyle changes are probably beneficial for
anyone at risk of having a heart attack in the future. Of course, some people are at such
high risk that lifestyle changes are not enough; high blood pressure, diabetes, and high
cholesterol should always be addressed, even if they require medication. In addition,
aspirin is an easy and safe way to further decrease risk.
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Q. Remind me once more: what are the
scientifically proven ways that I can reduce my chances of getting heart disease?
A. Here are the things that are proven to help prevent heart
disease:
- Diet low in total and saturated fat
- Frequent aerobic exercise
- Quit smoking - if you are a smoker
- Treatment to lower elevated cholesterol
- Treatment to lower elevated blood pressure
- Treatment for diabetes
- Aspirin at least once every other day
- Hormone replacement therapy in post-menopausal women
The great thing about heart disease is that it can be prevented. If you think you might
be at risk for heart disease, talk to your doctor about ways that you can reduce your
risk.
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Q. What is heart failure? A. The earliest descriptions of heart failure date back to the ancient
Egyptian, Greek and Roman medical literature. In the last two centuries as our knowledge
of the structure and function of the heart has advanced, so has our understanding of the
abnormal or diseased function of the heart advanced. Currently we define heart failure as
the inability of the heart to pump out sufficient blood to meet the needs of the body. The
mechanisms behind this are incredibly complex and we continue to make significant strides
in the unraveling of these processes. The pumping function of the heart is divided into
two phases - firstly the ability of the heart to relax properly so that blood can return
into the relaxed heart to be secondly actively pumped out to the body. The first phase is
called diastole and the second is called systole. When the heart begins to malfunction
almost always both of these function become abnormal - the issue in treatment is what are
the relative percentages of diastolic or systolic dysfunction in each particular person
with heart failure!
We know the most about the systolic mechanisms of heart failure and less about diastolic
mechanisms of heart failure. This is heavily reflected in our ability to treat heart
failure, with the most known treatments directed to systolic dysfunction and the least
known treatments for diastolic dysfunction. Probably the most significant advances
recently have been in our understanding of how the rest of the body adapts to the
dysfunction of the heart in an attempt to correct and counteract these changes. These
adaptations which initially keep things functioning the same eventually become
maladaptations and actually worsen the situation. This new knowledge has translated into
the most important improvements in therapy.
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Q. What is hypertension?
A. The control of blood pressure involves incredibly
sophisticated and complex checks and balances. Blood pressure represents a measure of the
amount of blood pumped out by the heart and then the vessels into which this blood is in
turn pumped. The amount of blood pumped out by the heart is controlled by two factors -
firstly the volume of blood returning to the heart from the rest of the body and secondly
the actual muscular pumping of the heart itself. The vessels into which this blood in turn
is pumped are also controlled by two major mechanisms - firstly the sympathetic nervous
system (central control by the brain) and secondly by the inner lining of the actual
vessel (called endothelium), which produces an enormous quantity of chemical substances
which in turn control the tone of the vessel (either dilating or constricting the vessel).
It is thus obvious that anything going wrong with any of the above mechanisms can and in
fact will result in abnormalities of the blood pressure. Most people with elevated blood
pressure - hypertension, have some abnormality with more than one of the above mechanisms
and often have two, three or more reasons why pressure is up! This explains why many
people with hypertension need two or more therapeutic agents to treat their hypertension.
As we learn more about blood pressure and its mechanism of control it becomes more
compelling than ever to try to counteract the various abnormalities for maximal protection
against the ravages of elevated pressure - such as stroke, heart attack, heart and kidney
failure and the development of vascular disease generically.
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