Heart Disease: A guide to preventing and treating coronary artery disease
/ Sep 23, 2013 / By / No Comments

Dear Reader,

Over the past few decades, advances in diagnosis and treatment have led to dramatic drops in the rate of deaths from heart disease. Still, this disease is often feared, and with good reason: it remains the leading cause of death for both men and women, killing about one in six people. In the United States, someone dies from a heart attack or other cardiovascular problem every 39 seconds.

Most heart attacks result from atherosclerosis — the hardening and narrowing of arteries that supply the heart. This progressive condition starts early in life and is influenced by a wide range of factors, especially your family history. By that, I mean not just your genes but also the environment in which you grew up and the lifestyle habits (such as diet and exercise) that you picked up from your parents or other adults.

But there’s plenty you can do to change those habits — and your heart health — for the better. Most people who develop heart disease — at least eight in every 10 — have at least one major risk factor that’s within their power to change, such as lack of exercise, high blood pressure, or abnormal cholesterol levels. Surefire ways to lessen your risk of heart disease include maintaining a healthy weight, getting regular exercise, and making sure you eat plenty of colorful fruits, vegetables, and fiber-rich whole-grain foods.

These and other heart-healthy habits are described in a chapter about cardiac rehabilitation programs. These underused but often helpful programs are designed to help you heal and regain strength following a heart attack or heart-related procedure.

This report also features a risk calculator to help predict your odds of developing heart disease over a 10-year period, descriptions of what to expect from various diagnostic tests and procedures for heart problems, and a detailed guide to medications for the heart.

Finally, there’s a growing awareness that the risk of heart disease rises with stress. My own patients struggle with a range of stressors; the most common are concerns about money, taking care of children and elderly parents, and discrimination. The special section of this report describes how some of these challenges spell trouble for your heart and offers a number of ways to cope.

To successful longevity,

Michelle Albert, M.D.
Medical Editor

What is heart disease?

When people speak of heart disease, they usually mean the condition more accurately described as coronary artery disease — a narrowing of the coronary arteries that reduces blood flow to the heart muscle. Chest pain (angina) and heart attack (myocardial infarction) are the most common manifestations. In the United States, coronary artery disease is by far the most prevalent type of life-threatening cardiovascular disease. It’s also the most preventable.

The coronary arteries play a vital role by supplying the heart with oxygen-rich blood. The heart muscle depends on two main arteries, the right and left coronary arteries, for its entire supply of blood and oxygen. Like the branches of a tree, each main artery divides into progressively smaller channels that carry blood to the heart muscle cells (see Figure 1). Either of these arteries or any of their branches can be narrowed by a buildup of fatty plaque, known medically as atherosclerosis. This term combines two Greek words, athere (porridge) and sclerosis (hardening). The name is accurate: in atherosclerosis, the artery walls become filled with soft, mushy deposits that eventually make the artery hard, stiff, and narrow. Inflammation — the process by which the body responds to injury or infection — triggers a release of chemicals and cells thought to contribute to the development and rupture of plaques.

Figure 1: Supplying the heart

It’s often said that the heart is the size of your fist, but it’s actually closer to the size of two fists. The aorta, the body’s largest blood vessel, is almost the diameter of a garden hose. A network of coronary arteries, each about as thick as a strand of spaghetti, emerges from the aorta. These arteries branch into smaller and smaller vessels that eventually penetrate the heart muscle, supplying it with oxygen and nutrients. This illustration shows the main coronary arteries (for simplicity’s sake, the veins are not pictured). The lighter-shaded vessels represent those that wrap around the back of the heart.

These deposits can restrict blood flow, resulting in ischemia, or oxygen deprivation. Ischemia can impair the heart’s ability to pump blood, interrupt its normal pumping rhythm, or even cause a heart attack. A partial or temporary interruption in blood supply, causing mild ischemia, injures the heart muscle and can produce angina. A heart attack results from complete or prolonged interruption of blood flow from plaque — or more precisely, from the interplay between plaque rupture, cholesterol buildup, blood clotting, and inflammation, which causes severe or prolonged ischemia that leads to the death of heart muscle cells (see Figure 2).

Figure 2: From healthy artery to heart attack

Heart attacks aren’t just the result of a buildup of fatty plaque in the arteries. Inflammation triggered by damage or stress in the inner lining of an artery sets off the steady growth of atherosclerotic plaque, which can suddenly erupt, causing a heart attack.

Stage 1: Excess LDL passes through the artery

Cholesterol travels in the bloodstream within spherical particles called lipoproteins. About two-thirds of blood cholesterol is in the form of low-density lipoprotein (LDL), often called “bad” cholesterol, because excess LDL leaves the blood and lodges in the artery walls. The higher your LDL, the greater your risk for atherosclerosis. So-called “good cholesterol,” or high-density lipoprotein (HDL), carries cholesterol away from the arteries to the liver, where it’s eventually eliminated from the body via the digestive tract. HDL also helps keep blood vessels dilated and fights inflammation, minimizing blood vessel injury caused by LDL.

Stage 2: Plaque builds up and the artery narrows

LDL cholesterol lodges in the artery wall, where it triggers a harmful sequence of events. Any injury to the inner layer of cells lining the artery (caused by high blood pressure, smoking, or diabetes, for example) speeds this process. White blood cells arrive on the scene and engulf LDL cholesterol in the artery wall. These cells then enlarge and transform into fat-laden foam cells.

Stage 3: A fibrous cap tops the plaque

As foam cells die, they release soft, fatty gruel that provokes further inflammation. Smooth muscle cells in the artery wall enlarge and multiply, forming a cap over the whole mess and adding to the bulk of the plaque.

Stage 4: The plaque ruptures

Large plaques block blood flow more than small plaques, but they tend to be covered by thick, fibrous caps that can resist breaking apart. Smaller plaques may be too small to block blood flow, but still can be dangerous, as they are active, dynamic lesions teeming with inflammatory cells. And they sometimes have very thin, underdeveloped caps that rupture easily. About three of every four heart attacks occur because of plaque rupture.

Stage 5: A clot blocks the artery

Once a plaque ruptures, a protein called tissue factor is released into the bloodstream, where it attracts platelets. The platelets stick to the disrupted plaque, triggering proteins in the blood to start clotting. The result is a thrombus — a clot of red blood cells, platelets, and other material — that completes the blockage and prevents blood from reaching the heart cells downstream. Deprived of blood and oxygen, a portion of the heart muscle dies.

Coronary artery disease can also independently lead to heart failure, abnormal heart rhythms (arrhythmias), or cardiac arrest. Heart failure occurs when the heart can’t pump sufficient blood, producing shortness of breath, fatigue, and fluid accumulation. Arrhythmias can cause palpitations, shortness of breath, and fainting. Cardiac arrest — when the heart suddenly stops, usually due to an electrical disturbance in the heart — suspends both consciousness and breathing and is fatal without immediate, appropriate medical care.


Recognizing and reducing risk factors

The vast majority of people who develop coronary artery disease have at least one major risk factor. Although you can’t change some of them (namely, your age, gender, and genes), you can control most of them by making positive lifestyle choices like eating a healthy diet, exercising regularly, and not smoking. All of those habits will also help address other health problems (such as diabetes and high blood pressure) that raise your risk of heart disease.

There’s yet another range of issues that falls somewhere in between: psychological factors, which include stress, depression, anxiety, neuroticism, and anger. On one hand, it might be difficult to control many of the events in your life that cause stress or hardship. On the other hand, you do have a certain degree of control over how you respond to those stresses. The special section, “Hearts and minds: How stress and negative emotions affect the heart,” explores the latest findings on this topic.

What you can’t control: Age, gender, and genes

Some risk factors for coronary artery disease are unavoidable. But it’s good to be aware of them and to know that addressing factors you can control can still lower your risk.

Age

Heart disease becomes more prevalent with age in both men and women (see Figure 3). More than four in five people who die from heart attacks are over age 65. In men, risk begins to mount beyond age 45, whereas women’s risk rises after age 55.

Figure 3: Heart disease: Men vs. women

1

By middle age, almost 40% of men and women have cardiovascular disease, which includes coronary artery disease, heart failure, stroke, and hypertension. By age 80, the percentage rises to about 80% in men and 87% in women.

Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute.


Gender

Although heart disease remains the leading killer of both women and men in the United States, there are differences between the genders when it comes to symptoms and prognosis. Men are more likely than women to develop coronary artery disease, and usually at younger ages. Moreover, the average age for a first heart attack in men is 65; for women, it is 70.

Women also differ from men in terms of cardiac health outcomes. Although women tend to be better than men at describing medical symptoms and seeking help, women have a 50% greater chance of dying from heart disease than men do. At ages 40 and older, about 26% of women who’ve had heart attacks die within a year, compared with 19% of men. What’s more, women are almost twice as likely as men to have a second heart attack within six years of the first. Women are also more likely to die in the hospital after coronary artery bypass surgery or angioplasty.

What might explain these disparities? A leading theory is that women are more likely to die because they tend to develop heart disease and have heart attacks at a later age compared with men, and are thus more frail when their heart attacks occur. Women also are more likely than men to have other illnesses, such as diabetes, by the time they undergo heart surgery. Another problem is anatomy: women’s hearts tend to be smaller than men’s, making it more difficult for surgeons to stitch arteries together during surgery or keep them open after angioplasty. A condition called coronary microvascular disease (see “What is coronary microvascular disease?”) could be another reason.

Some research suggests that women with heart problems may not be diagnosed as early or treated as aggressively as men. For instance, women with heart attack symptoms are less likely than men to be admitted to the intensive care or coronary care unit and to get electrocardiograms, clot-busting drugs, or cardiac catheterization. After leaving the hospital, they are less likely to be directed to a cardiac rehabilitation program (or to finish one), or to get counseling about nutrition, exercise, and weight loss.

The classic symptoms of a heart attack were identified largely in studies of white, middle-aged men. But these symptoms do not always occur in women, which may contribute to delays in diagnosis and treatment. For instance, one study of heart attack symptoms reported that an astounding 43% of women who had heart attacks did not recall any type of chest pain, usually considered the hallmark symptom. Instead, the women reported shortness of breath, weakness, unusual fatigue, cold sweat, and dizziness.

What should you do to protect your heart if you’re a woman? Perhaps most important, focus on steps you can take to prevent heart disease, and take medications if necessary to lower blood pressure and cholesterol (see “Medications for heart disease”). Second, learn more about what types of symptoms indicate you may be having a heart attack (see Table 7).

Hormones were once considered a possible explanation for the gender differences seen in heart disease. But teasing out the effects of testosterone and estrogen and their relationship to heart disease risk has proven complicated. Men with low testosterone levels appear to have a higher risk of heart disease, type 2 diabetes, and other long-term conditions. But there’s no evidence that boosting testosterone levels (via injections, gels, or lozenges of the hormone) can lessen that risk. What’s more, athletes who abuse testosterone and other male hormones have a clearly higher risk for high blood pressure, heart attack, and stroke.

Estrogen raises HDL cholesterol and lowers LDL cholesterol. But when estrogen declines at menopause, typically around age 50, so do its protective effects, causing a sharp increase in the risk for heart disease. Women who have gone through menopause are two to three times as likely to develop heart disease as women the same age who are still menstruating. Yet, as two major studies showed, hormone replacement therapy not only does not prevent heart disease, it may actually increase heart disease risk in some cases.

Fast fact

Most women don’t realize that heart disease is the No. 1 killer of women in the United States, according to an American Heart Association survey. In 2007, heart disease claimed the lives of more than 190,000 women, compared with about 41,000 deaths from breast cancer and 70,000 from lung cancer.


Family history, race, and ethnicity

Coronary artery disease runs in families, and certain racial and ethnic groups are more at risk than others. Latinos, Asian Americans, and American Indians are less likely to have coronary artery disease than whites and blacks. Are certain families and ethnic groups more at risk because of shared environmental and lifestyle characteristics such as smoking, diet, inactivity, or psychological stress? Or does this situation reflect genetics, which may underlie risk factors such as high cholesterol, blood pressure, and blood sugar? The answer is both.

Family history. The genes you inherit are certainly important. Many studies have shown that people with a parent who developed coronary artery disease before age 55 face a much higher risk than others of developing heart disease themselves. Estimates of the magnitude vary, but this type of family history is clearly on par with other major risk factors such as high blood pressure and cholesterol.

However, it’s important to keep two things in mind. First, not every family history is equally worrisome; it takes a strong history (for example, a father or brother afflicted before age 55 or a mother or sister stricken before age 65) to increase your risk. Second, genetic research into heart disease remains in its infancy, and many questions remain, particularly about which genes are most important in making people susceptible to heart disease and how these genes interact with other genes and lifestyle factors to affect risk.

Many studies are now under way to better understand the genetics of heart disease. The hope is that genetic testing will one day enable doctors to identify people at high risk for heart problems and perhaps help them avoid those problems with preventive treatment. In the meantime, if you have a family history of heart disease, it’s vital to address risk factors such as high blood pressure and elevated cholesterol and adopt a heart-healthy lifestyle as soon as possible.

Race and ethnicity. Blacks are more likely to develop heart disease and to die from it than whites, Latinos, and Asian Americans. In fact, when adjusted for age, death rates from heart disease are 30% higher in black men than white men, and 40% higher in black women than in white women. One reason behind these trends may be the high rates of high blood pressure among blacks. Experts also believe that a number of other factors may explain the disparity, such as education and economic differences, both of which can affect access to appropriate medical care, and unique stressors such as discrimination. (For more on stress and heart disease, see the special section, “Hearts and minds: How stress and negative emotions affect the heart.”) As a result, despite advances in medical treatments for heart disease, life expectancy remains approximately five years higher in whites than in blacks.

What is coronary microvascular disease?

Unlike typical coronary artery disease, which affects the heart’s largest arteries, microvascular disease affects the heart’s smallest arteries. Instead of growing inside the artery, plaque limits blood flow by growing evenly around the artery, or bulging outward. In addition, these tiny arteries can spasm and tighten, preventing adequate blood flow. Standard tests such as a coronary angiogram don’t always detect microvascular disease, which is more likely to occur in women than men.



Lifestyle habits that raise your risk

Eating an unhealthy diet, not exercising, and smoking can all conspire to raise your risk of heart disease. The same factors increase your odds of developing high blood pressure and diabetes.

Unhealthy diet

When it comes to heart disease risk, you are what you eat. As noted above, a poor diet contributes to elevated cholesterol and triglycerides, high blood pressure, diabetes, and obesity. A number of major studies provide compelling evidence that diet also affects the likelihood of progressing to full-blown coronary artery disease and having a heart attack. The Lyon Diet Heart Study, for instance, reported that people who regularly adhere to a Mediterranean-style diet are 50% to 70% less likely to have a heart attack, stroke, or other type of cardiovascular problem or to die from heart disease. This type of diet includes eating plenty of fruits, vegetables, beans, whole grains, and nuts; using olive oil and other types of unsaturated fats for cooking; eating more fish and poultry and less red meat; and drinking wine in moderation. Other research shows that consuming more omega-3 fats, found in certain fish, nuts, and other foods, as well as in supplements, may be particularly heart-healthy (see “Healthy fats”).

Just about everyone can benefit from a heart-healthy diet. Be aware, however, that while some foods, such as soy products and cereals, come with labels identifying them as “heart-healthy,” no one food will prevent or reverse heart disease. Instead, decades of research have provided the basis for some general guidelines (see “Eat healthy foods”) that, if followed, can go a long way toward preventing heart disease.


Sedentary lifestyle

Only one in three American adults regularly engages in any kind of leisure-time physical activity. The reasons are many, but certainly the advent of labor-saving devices and the lure of television and the Internet are taking their toll — along with harried lives that leave little time for exercise. Yet it is clear that physical activity is a good investment of time when it comes to protecting your heart. Sedentary living roughly doubles the risk for coronary artery disease, making it as risky as smoking, high cholesterol, or high blood pressure.

More than 50 years of research shows that the people who are the most physically active are only half as likely to develop coronary artery disease as the most sedentary people. And the benefits accrue in a dose-response manner: the more physically active you are, the lower your risk for heart disease. What’s more, regular physical activity raises HDL cholesterol levels, reduces triglycerides, lowers blood pressure, burns body fat, and lowers blood sugar levels. When combined with weight loss, exercise can also lower LDL levels. It also helps alleviate mental stress, which can be a trigger for heart problems. Following a heart attack, an exercise-based rehabilitation program can reduce the likelihood of dying from heart disease by one-third. (For tips on how to add exercise to your life, see “Get active.”)


Tobacco use and exposure

Everyone knows that smoking is a major health hazard: it’s the leading preventable cause of death in the United States. But some people may be surprised to learn that smoking is not only a cause of cancer, but also one of the most significant risk factors for heart disease. People who smoke are two to four times as likely to die from heart disease as nonsmokers.

Passive exposure to other people’s smoke also puts you at risk. A report issued by the U.S. Surgeon General in 2006 warned that nonsmokers exposed to secondhand smoke at home or work increased their risk of developing heart disease by 25% to 30%.

In all, about one in three smoking-related deaths is from coronary artery disease. But quitting smoking can significantly reduce the risk. Within a year of quitting, smokers can cut their heart disease risk in half. In 15 years, the coronary artery disease risk for a former smoker is very close to that of a person who never smoked. One possible reason for this decrease in risk is that smoking probably contributes to blood vessel inflammation; removing that irritant should slow the inflammatory process. (For tips on how to kick the habit, see “Stop smoking.”)



Health conditions that raise your risk

The two most prevalent conditions linked to heart disease, diabetes and high blood pressure, are also more common among people who are overweight or obese. If you’re among the majority of Americans who are carrying extra pounds, losing weight is the most critical step toward resolving your risks for these common and potentially dangerous health problems.

Overweight and obesity

Because obesity is so closely linked to high blood pressure, unfavorable cholesterol levels, lack of exercise, and diabetes, scientists took a long time to figure out whether obesity itself is a cardiac risk factor. Experts now agree that it is. Excess weight increases your risk for heart disease independent of these other conditions.

There are two ways to estimate body fat. One is waist measurement. An increase in waist size is an indicator of increased body fat. As you grow older, you may find that your waist size increases even though you have not gained pounds. That’s because people tend to lose muscle mass and gain fat with age. Any increase in waist size is a signal that your percentage of body fat is increasing. In the past, experts thought that carrying most of your fat above the waist in your upper body (the “apple shape”) was more dangerous to the heart than fat stored lower in the body, in the hips and thighs (the “pear shape”). But evidence suggests that the location of excess weight doesn’t seem to make a difference — extra pounds harm the heart regardless of where they accumulate.

Body mass index (BMI), which takes both height and weight into consideration, provides another way to estimate body fat (go online to www.nhlbisupport.com/bmi for a calculator, or see Table 1). You should aim for a BMI of 19 to 24, the range that’s considered normal and poses minimal risk for heart disease and other health problems. A BMI of 25 to 29 is considered overweight (moderate risk), and a value of 30 or over is defined as obese (high risk).

A 2011 report in The Lancet pooled findings from 58 studies involving more than 220,000 people to better understand how to use body fat measurements to help assess heart disease risk. The investigators concluded that BMI, waist circumference, and waist-to-hip ratio (another way to gauge body size) were equal in terms of predicting heart disease risk. Given that it’s simpler to look up your BMI than to correctly measure your waist or hip circumference, it makes sense to focus on BMI. If you’re overweight or obese, it’s worth noting that losing even modest amounts — just 5% to 10% of your weight — can help lower blood pressure and improve cholesterol levels.

Table 1: Normal, overweight, or obese?

The body mass index (BMI) is an index of weight by height. The definitions of normal, overweight, and obese were established after researchers examined the BMIs of millions of people and correlated them with rates of illness and death. These studies identified the normal BMI range as that associated with the lowest rates of illness and death.

Height

Body weight in pounds

4’10”

91–115

119–138

143–162

167–186

191+

4’11”

94–119

124–143

148–168

173–193

198+

5’0″

97–123

128–148

153–174

179–199

204+

5’1″

100–127

132–153

158–180

185–206

211+

5’2″

104–131

136–158

164–186

191–213

218+

5’3″

107–135

141–163

169–191

197–220

225+

5’4″

110–140

145–169

174–197

204–227

232+

5’5″

114–144

150–174

180–204

210–234

240+

5’6″

118–148

155–179

186–210

216–241

247+

5’7″

121–153

159–185

191–217

223–249

255+

5’8″

125–158

164–190

197–223

230–256

262+

5’9″

128–162

169–196

203–230

236–263

270+

5’10”

132–167

174–202

209–236

243–271

278+

5’11”

136–172

179–208

215–243

250–279

286+

6’0″

140–177

184–213

221–250

258–287

294+

6’1″

144–182

189–219

227–257

265–295

302+

6’2″

148–186

194–225

233–264

272–303

311+

6’3″

152–192

200–232

240–272

279–311

319+

6’4″

156–197

205–238

246–279

287–320

328+

BMI

19–24

25–29

30–34

35–39

40+

 

Normal

Overweight

Class I obesity

Class II obesity

Class III obesity


Diabetes

This chronic disorder is marked by high levels of sugar in the blood. Most of the 24 million Americans with this condition have type 2 diabetes, which occurs when the body becomes resistant to the effects of insulin (the hormone made by the pancreas that enables cells to draw sugar from the blood for energy) and does not produce enough insulin to overcome the resistance. Although the exact cause of type 2 diabetes isn’t clear, one thing is certain: excess body fat is the No. 1 risk factor. The other, far less common form of diabetes, type 1, is an autoimmune disorder that occurs when the immune system attacks the pancreas, destroying its insulin-producing cells.

The link between diabetes and heart disease is very strong. An adult diagnosed with diabetes has the same high cardiac risk as someone who has already had a heart attack. Everyone with diabetes, regardless of type or when it was diagnosed, has reason for concern. At least 65% of people with diabetes will die from some type of cardiovascular disease — a death rate that is two to four times that of the general population.

Many experts suspect that the long-term elevated blood sugar and low-grade inflammation seen in diabetes damage the coronary arteries, speeding the process of atherosclerosis. Heart attacks and other cardiovascular problems are not only more common in people with diabetes, but they occur earlier in life and are more likely to be fatal than in people without diabetes.

If you have diabetes, do your best to keep your cholesterol levels and blood pressure under control. People with diabetes should aim for LDL cholesterol levels of less than 100 milligrams per deciliter (mg/dL) and a blood pressure of less than 130/80 (ideally, less than 120/80; see next section for more information on blood pressure measurements). Also keep your blood sugar levels as close to normal as possible. However, tight blood sugar control doesn’t protect against heart attack as much as it helps to prevent other complications of diabetes, such as eye and kidney disease. Ask your doctor for a specific goal, as the target level depends on the blood test used to assess it.

Like everyone at risk, practice a healthy lifestyle: watch your weight, eat a heart-healthy diet, and exercise regularly (see “Lifestyle changes to protect your heart”). Talk to your doctor about taking a cholesterol-lowering statin if you can’t achieve your cholesterol goal through lifestyle changes, if you already have heart disease, or if you have one or more substantial risk factors for heart disease, such as being over age 55 or having elevated levels of C-reactive protein (see “Beyond blood lipids: Other biomarkers for heart disease”). You may also need one or more drugs to help you keep your blood pressure in check (see “Medications for heart disease”).

Yet another link between diabetes and cardiovascular disease should give you pause: diabetes can cause chronic kidney disease, which, in turn, can increase the risk of cardiovascular disease even more. Larger-than-normal amounts of a protein called albumin in the urine — a condition known as microalbuminuria — is an early sign of chronic kidney disease. Make sure your doctor orders a urine test for microalbumin at least once a year. And continue to do your part by controlling your blood sugar and blood pressure. Certain drugs used to treat blood pressure can help curb kidney damage.


High blood pressure

Your blood pressure reading has two parts. The first and higher number (systolic blood pressure) represents the pressure while the heart is beating and shows how hard the heart works to push blood through the arteries. The second and lower number (diastolic blood pressure) represents the pressure when the heart is relaxing and refilling with blood between beats and shows how forcefully arteries are being stretched most of the time.

The higher your blood pressure, the greater your risk of suffering a heart attack, heart failure, stroke, or kidney disease. Yet too many people ignore the risk posed by high blood pressure. Recognizing this fact, a federal report — the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7, for short) — urged Americans to take blood pressure more seriously and control it more aggressively.

Treating high blood pressure really pays off. Clinical trials have shown that treating hypertension reduces the incidence of stroke by 35% to 40%, the incidence of heart attack by 20% to 25%, and the incidence of heart failure by more than 50%.

Blood pressure goals. Given the evidence, the JNC7 guidelines not only defined normal (meaning “optimal”) blood pressure as anything under 120/80 millimeters of mercury (mm Hg), but also introduced a new category, prehypertension, to identify people who might prevent or at least slow the onset of hypertension by adopting a healthier lifestyle (see Table 2).

Table 2: Blood pressure guidelines

The guidelines listed in this table are for adults ages 18 and older, based on the average of two or more seated blood pressure (BP) readings on each of two or more office visits.

Category

Systolic BP (mm Hg)

Diastolic BP (mm Hg)

Treatment recommendations

Normal

Less than 120

Less than 80

Lifestyle changes encouraged

Prehypertension

120–139

80–89

Lifestyle changes necessary

Drugs for compelling indications*

Stage 1 hypertension

140–159

90–99

Lifestyle changes necessary

Thiazide diuretic for most people

May also consider other blood pressure drugs alone or in combination

Drugs for compelling indications*

Stage 2 hypertension

160 or higher

100 or higher

Lifestyle changes necessary

Two or more blood pressure drugs for most people

Drugs for compelling indications*

*Compelling indications: diabetes, chronic kidney disease, previous heart attack, heart failure, previous stroke, high cardiac risk.

Note: When systolic and diastolic pressures fall into different categories, physicians rate overall blood pressure by the higher category. For example, 150/85 mm Hg is classified as stage 1 hypertension, not prehypertension.

Source: Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), December 2003.

About 60% of American adults have high blood pressure (either prehypertension or hypertension). And data from the Framingham Heart Study indicate that people who are 55 years old and have normal blood pressure face a 90% chance of developing high blood pressure as they get older, unless they take preventive steps.

When to be tested. Because hypertension usually begins gradually between ages 20 and 50, all adults should have their blood pressure checked regularly. Blood pressure checks every two years might suffice for people with normal levels. But people with elevated blood pressure need more frequent measurement — once a year for those with prehypertension, and sometimes even more frequently in people with hypertension.

How low to go. For people with hypertension, JNC7 defines good control as getting your blood pressure under 140/90 mm Hg — but people with diabetes or chronic kidney disease should aim for an even lower level, below 130/80 mm Hg. The American Heart Association (AHA) recommends that people with coronary artery disease or other forms of atherosclerosis, or who are at high risk for heart disease, also lower their blood pressure below 130/80 mm Hg. However, this advice has been questioned, in light of research showing that blood pressure values below 130/80 did not result in fewer cardiovascular events.

To prevent or treat hypertension, the first step is to adopt healthier habits (see “Lifestyle changes to protect your heart”). Even with lifestyle changes, however, many people with hypertension also need medications to treat the disorder (see “Blood pressure medications”).


Unfavorable blood lipids

Many different forms of lipids, or fats, circulate through your bloodstream, including various forms of cholesterol and triglycerides. About one in five Americans has high total cholesterol, defined as 240 mg/dL or higher. But the chance of having a heart attack drops by 20% to 30% for each 10% drop in your total cholesterol level. The National Cholesterol Education Program (NCEP), part of the National Institutes of Health, has created guidelines that provide an easy way to set your cholesterol goal based on your risk for heart disease, and then to take steps to achieve your goal. The NCEP guidelines are periodically updated on the basis of new evidence. The 2004 guidelines are summarized in Table 3.

Table 3: LDL cholesterol treatment goals and options

Use this table to get an overview of your goals and options for treatment. See Table 6 to determine your risk category.

Risk category

Your LDL cholesterol goal (mg/dL)

When to start lifestyle changes (mg/dL)

When to consider drug therapy (mg/dL)

Very high risk

below 70*

at or above 100

at or above 100 (optional: below 100*)

High risk

below 100 (optional: below 70*)

at or above 100

at or above 100 (optional: below 100*)

Moderately high risk

below 130 (optional: below 100*)

at or above 130

at or above 130 (optional: 100–129*)

Moderate risk

below 130

at or above 130

at or above 160

Low risk

below 160

at or above 160

at or above 190 (optional: 160–189*)

*Optional goal. Many experts anticipate revision of the NCEP guidelines and the possibility of lower LDL targets in some settings. If treatment brings your lipid levels substantially below the values listed above, you shouldn’t worry about being overtreated unless you’re having adverse side effects from the medication.

Although total cholesterol levels are important, it’s even more important to look at levels of different types of cholesterol, particularly LDL and HDL. That is why the NCEP recommends that everyone age 20 or older undergo a fasting lipid profile test (also called a full lipid profile or lipoprotein analysis) every five years. This test measures not only total cholesterol, but also LDL, HDL, and triglyceride levels.

Total cholesterol. This number is the sum of cholesterol carried in all cholesterol-bearing particles in the blood, including HDL, LDL, and very-low-density lipoprotein (VLDL). Although the total cholesterol level closely parallels the LDL level in most people, there are enough exceptions to that rule to make it useful to test separately for LDL, HDL, and triglycerides. The NCEP guidelines advise aiming for a total cholesterol level below 200 mg/dL.

LDL. No specific cholesterol level guarantees that you will — or won’t — develop heart disease. However, LDL is clearly the bad element in terms of raising your risk for heart disease, so lowering elevated LDL should be the primary target of therapy. In making its 2004 recommendations, the NCEP cited data from clinical studies indicating that for every 1% reduction in LDL levels, there is a corresponding 1% drop in the chance of suffering a heart attack, stroke, or some other type of cardiac event. This is significant given that the proper combination of lifestyle changes and heart medications can help lower LDL levels by 30% to 40% in many people at risk for heart disease (and in some people, lower it even further), creating a corresponding drop in the risk for cardiac events.

So how low do you go? In a nutshell, if you have had a heart attack or are at very high risk of having one, the answer is lower than before, and probably as low as possible. Your particular LDL target depends on your cardiovascular health and your odds of having a heart attack in the next 10 years. Targets range from below 70 mg/dL for those at very high risk up to 160 mg/dL for people with the least overall risk (see Table 3). See “What’s my risk?” to determine your personal risk.

You can lower LDL levels by reducing the amount of saturated fat, trans fat, and cholesterol in your diet; eating more complex carbohydrates, such as fruits and vegetables; eating more fiber; reducing body fat; and exercising regularly (see “Lifestyle changes to protect your heart”). When these good habits aren’t sufficient to reach your cholesterol goal, cholesterol-lowering medications are recommended.

HDL. The more HDL in your bloodstream, the lower your chances of having a heart attack. Results from the Framingham Heart Study (a long-running, landmark study of factors contributing to heart disease) and elsewhere suggest that every one-point rise in HDL lowers the risk for heart attack by 2% to 3%. The NCEP guidelines consider levels of 60 mg/dL or above protective against heart disease, while levels of less than 40 mg/dL are regarded as too low and increase your risk. To boost your HDL, your best bets are to lose weight, eat well (paying particular attention to minimizing unhealthy fats and consuming more heart-healthy fats, as explained in “Healthy fats”), engage in more physical activity, stop smoking, and drink alcohol in moderation (no more than one drink a day for women and two for men). Certain medications can also help to raise HDL levels (see “Cholesterol medications”).

Ratio of total cholesterol to HDL. Some clinicians use the ratio of total cholesterol to HDL cholesterol to help identify people who need cholesterol-lowering therapy. As a general rule of thumb, the lower the ratio, the better. To determine your ratio, simply divide total cholesterol by HDL cholesterol. Reports from the Framingham Heart Study suggest that for men, a total cholesterol–to-HDL ratio of 5 signifies average heart disease risk; for women, average risk is signified by a ratio of 4.4.

Triglycerides. The main form of stored fat — both in the food we eat and in the body’s adipose (fat) tissue — is triglycerides. The chylomicron, the largest and least dense of the lipoprotein particles, carries most of the triglycerides in the bloodstream. In general, triglyceride levels have less impact on heart disease risk than LDL or HDL levels. However, when triglyceride levels are very high, risk for heart disease does increase. Often people with low HDL cholesterol levels also have high triglycerides, and this combination seems an especially important predictor of heart disease risk.

Table 4: Triglyceride levels

Triglyceride level

Triglyceride category

Less than 150 mg/dL

Normal

150–199 mg/dL

Borderline high

200–499 mg/dL

High

500 mg/dL and above

Very high

The NCEP guidelines define normal fasting triglyceride levels as below 150 mg/dL (see Table 4). High triglyceride levels can result from obesity, physical inactivity, tobacco exposure, alcohol abuse, uncontrolled diabetes, and even certain medications, as well as some genetic disorders. Often, triglycerides can be lowered using the same steps that help bring down LDL cholesterol: choosing healthful foods, exercising more often, losing weight, avoiding tobacco in all its forms, and, if necessary, taking medications.

Beyond blood lipids: Other biomarkers for heart disease

Biomarkers are substances that can be measured as possible indicators of the risk or progression of a specific health condition. For heart disease, several biomarkers have been studied for their potential to improve early diagnosis of heart disease. The two best known are C-reactive protein and homocysteine.

C-reactive protein (CRP) is a protein produced by the liver in response to infection, inflammation, or tissue injury anywhere in the body. For years, doctors have measured blood CRP levels to monitor diseases such as pneumonia, rheumatoid arthritis, and lupus. Mounting evidence that inflammation is an integral part of atherosclerosis led researchers to develop a new, more sensitive test to measure CRP, called the high-sensitivity CRP (hsCRP) or cardiac CRP (cCRP) test, which measures blood vessel inflammation.

Studies show that people with the highest CRP levels are about twice as likely to develop coronary artery disease and suffer a heart attack or other cardiac event as people with the lowest levels. As a result, CRP is now used along with other markers (such as cholesterol and blood pressure) to estimate cardiovascular risk. In 2008, a Harvard study showed that people without a history of heart disease who had average LDL cholesterol levels (less than 130 mg/dL) but elevated CRP (equal to or greater than 2 mg/L) who received a cholesterol-lowering statin medication had a 54% decrease in their risk of heart attacks, a 48% reduction in stroke risk, and a 43% decrease in venous blood clots compared with their counterparts who got a placebo pill.

Standards for using CRP in clinical practice are still evolving. For example, it is not yet clear what CRP target levels should be for healthy men and women of different racial and ethnic groups. For now, risk assessment is based on the following three levels of CRP:

  • Below 1 mg/L = Low risk

  • 1–3 mg/L = Average risk

  • Above 3 mg/L = High risk

The high-sensitivity CRP (hsCRP) test is recommended to ensure that you get the most accurate reading.

If you are already being treated for heart disease or are considered at high risk for cardiovascular disease (greater than 20% in the next 10 years, based on the calculations in Table 6 or an online risk calculator), a CRP test is not necessary. The results won’t change how you and your doctor manage your condition.

If you have a moderate risk of heart attack (10% to 20% in the next 10 years), an hsCRP test might help to more accurately place you in a high- or low-risk category. Studies indicate that people at moderate risk based on the conventional risk factors might move into the high-risk category if they also have elevated CRP. Such people might need more aggressive treatment to prevent a heart attack. In particular, your doctor may recommend a lower LDL goal — under 100 mg/dL rather than under 130 mg/dL.

If your cholesterol levels are fine but you have other risk factors (such as diabetes, high blood pressure, or a family history of heart disease), ask your doctor whether an hsCRP test would help to better assess your risk and decide how to reduce it. Think of the results as a “tiebreaker” to help you decide whether to take medications, if you’re on the fence about doing so.

Homocysteine. Starting in the mid-1980s, numerous studies noted a link between high blood levels of homocysteine (an amino acid found in everyone’s blood) and an increased risk of cardiovascular disease. Research also reveals that many people with high homocysteine levels are deficient in certain B vitamins: folic acid, B6, and B12. Supplements of these vitamins can reduce homocysteine levels within weeks.

But here’s the rub: lowering homocysteine levels does not appear to benefit people with normal homocysteine levels who already have heart disease. Two large studies found that B vitamin treatment in heart disease patients did not reduce the risk of heart attacks or other forms of cardiovascular disease, even though homocysteine levels in patients taking B vitamins dropped by 27%. The bottom line: while it’s still a good idea to get plenty of B vitamins in your diet (fruits and vegetables — especially dark leafy greens — are good sources) for overall health, there’s no reason to take B vitamin supplements to stave off heart disease.




Special section: Hearts and minds

How stress and negative emotions affect the heart

The links between the heart and the mind are harder to measure than those between the heart and the waistline. But a growing body of evidence suggests that psychological factors are — literally — heartfelt, and can contribute to cardiac risk. Stress from all sorts of challenging situations and events plays a significant role in cardiovascular symptoms and outcome, particularly heart attack risk. The same is true for depression, anxiety, anger, and hostility, as well for social isolation. Acting alone, each of these factors heightens your chances of developing heart problems. But emotional issues are often intertwined: people who have one commonly have another. For example, psychological stress often leads to anxiety, depression can lead to social isolation, and so on. When combined, their influence is compounded.

In some cases, you can make changes to ease your burdens — by changing jobs or relationships, for example. But some of the stress in our lives is simply impossible to avoid, and a moderate amount of stress can act as a positive, motivating force. The question is this: does reducing stress, or changing how you respond to it, actually lower your cardiac risk and the likelihood of having a heart attack? The answer isn’t entirely clear, although some preliminary results suggest yes (see “Relaxation and your health”). The uncertainty reflects the challenge of doing research into psychological stress, which is so often accompanied by behaviors that are risky in their own right, such as smoking and overeating. It also reflects the challenge of persuading people to make changes in the way they think and behave.

The stress response

Your body reacts to life-threatening stress (“The house is on fire!”) with a “fight-or-flight” response. The brain triggers a cascade of chemicals and hormones that speed the heart rate, quicken breathing, increase blood pressure, and boost the amount of energy (sugar) supplied to muscles. All of these changes enable your body to respond to an impending threat. Unfortunately, the body does a poor job of discriminating between grave, imminent dangers and less momentous, ongoing sources of stress. When the fight-or-flight response is chronically in the “on” position, the body suffers. This chronic stress response can occur if your body is persistently exposed to stressors that overwhelm its adaptive ability. Think of it as your body in a constant state of “short-circuiting.”

The release of stress hormones also activates the blood’s clotting system. And long-term mental stress appears to stimulate the body’s production of LDL and triglycerides, to interfere with blood pressure regulation, and to activate molecules that fuel inflammation (see Figure 4).

Figure 4: The stress response

The hypothalamus, pituitary gland, and adrenal glands make up the HPA axis, which plays a pivotal role in triggering the stress response. By releasing certain chemicals, such as adrenocorticotropic hormone (ACTH) and cortisol, the HPA axis rouses the body for action when it’s faced with a stressor. As the illustration reveals, the effect of this release of hormones is widespread. Senses become sharper, muscles tighten, the heart beats faster, blood pressure rises, and breathing quickens. All of this prepares you to fight or flee in the face of danger.


Stressors that harm the heart: What’s the evidence?

Everyone knows that particular events, such as the death of a spouse or being fired from a job, are extremely stressful. Yet research indicates that less dramatic but more constant types of stress may also harm your heart. In 2004, The Lancet published a study that involved over 24,000 participants from 52 countries. Roughly 11,000 patients who had just had a first heart attack were asked, as they left the hospital, about various forms of stress they had experienced in the preceding 12 months. The questions probed reactions to job and home stress, financial problems, and major life events. Members of a control group, who were matched to the patients for age and gender but had no history of heart disease, underwent similar assessments. Despite variations in the prevalence of stress across countries and racial or ethnic groups, increased stress levels conferred a greater risk for heart attack than did hypertension, abdominal obesity, diabetes, and several other risk factors.

Many other studies have also documented that various forms of stress can take a toll on the heart:

Workplace stress. Women whose work is highly stressful have a 40% increased risk of heart disease (including heart attacks and the need for coronary artery surgery) compared with their less-stressed colleagues. These findings come from the Women’s Health Study (WHS), which included more than 17,000 female health professionals. For the study, researchers defined job strain as a combination of demand (the amount, pace, and difficulty of the work) and control (the ability to make work-related decisions or be creative at work). Earlier studies found similar trends among men: one documented a twofold higher risk of newly diagnosed heart disease among men who felt the rewards they received at work weren’t compatible with their effort. Finally, working overtime hours seems to overtax the heart, as evidenced by a study that found a nearly 70% higher risk of heart disease among people who worked an average of 11 hours per weekday, compared with those who worked normal working hours (seven to eight hours per day). The study, which followed nearly 7,100 people (none of whom had heart disease at the outset) for just over 12 years, was published in Annals of Internal Medicine in 2011.

Financial stress. Heart attacks rose as the stock market crashed, according to a 2010 report in The American Journal of Cardiology. Researchers at Duke University reviewed medical records for 11,590 people who had undergone testing for heart disease during a three-year period, and then compared monthly heart attack rates with stock market levels. Heart attacks increased steadily during one eight-month period — September 2008 to March 2009 — that was particularly bad for the stock market (see Figure 5).

Figure 5: Heart attacks rise as stocks crash

Heart attacks increased steadily during one eight-month period that was particularly bad for the stock market.

Caregiver stress. Women who cared for a disabled spouse for at least nine hours a week were significantly more at risk of having a heart attack or dying from heart disease compared with women who had no caregiving duties, according to findings from the Nurses’ Health Study. This large study followed more than 54,000 female nurses over a four-year period.

Disaster-related stress. Following the terrorist attacks of Sept. 11, 2001, researchers asked 2,700 American adults to complete an online survey of physical and mental health. People who had high levels of stress immediately after the attacks were nearly twice as likely to develop high blood pressure and more than three times as likely to develop heart problems during the following two years compared with those who had low stress levels.

Earthquakes also trigger stress-related heart problems — not just in their immediate wake but for years afterward, some research has shown. Sudden cardiac deaths rose sharply immediately after the 1994 earthquake in the Los Angeles area, and hospitalization for heart attacks jumped on the day of the 1995 temblor near Kobe, Japan. A longer-term follow-up of another major earthquake in Japan (Niigata-Chuetsu in 2004) revealed that death rates from heart attacks rose during the three years after the quake compared with rates during the five years prior to the disaster. The property damage, loss of livelihood, social disruption, and other stressful events resulting from the quakes probably explain this trend, say the study authors, who published their findings in the journal Heart in 2009.

Researchers are also beginning to study the effects of other stressors on heart health, including neighborhood-related stressors such as violence or growing up in a disadvantaged environment marked by adversity and discrimination.


Other mental health concerns

Given the widespread prevalence of both heart disease and mental health problems such as depression and anxiety, it’s not surprising that they often occur together. Understanding how they interact — and, more importantly, how they can be prevented, minimized, or treated — may help people feel better both emotionally and physically.

Depression. The relationship between depression and heart disease is a two-way street. Not only does depression appear to promote heart disease, but it can also result from a heart attack. Studies suggest that people who are depressed are about twice as likely to develop coronary artery disease, and that people who already have heart disease are three times as likely to be depressed as other people. For as many as one in five people, depression follows a heart attack. Finally, depression is an independent risk factor for a subsequent heart attack in people who’ve already had one. This may be in part because people who are depressed are less likely to take proper care of themselves — they might continue to smoke, fail to take their medications regularly, or not exercise enough.

Whether you’ve had a heart attack or not, if you feel depressed, tell your doctor. Depression can be treated successfully with antidepressants, psychotherapy, or both. Treating depression can make you feel better and decrease your heart attack risk.

Anxiety. Between 24% and 31% of people with heart disease have symptoms of anxiety, according to various studies. But these findings are somewhat questionable, as some of the research relied on participants’ recollections or single objective “snapshot” assessments rather than using structured interviews to diagnose anxiety. Many studies have also lacked controls for factors such as lifestyle that could affect heart disease risk.

However, two studies that followed large numbers of participants over time addressed some of those weaknesses, such as controlling for confounding factors such as major depression (which often occurs in conjunction with anxiety). The results showed that generalized anxiety disorder — characterized by constant and pervasive anxiety, even about mundane matters — appears to increase the risk of heart attacks.

It’s also worth noting that severe anxiety — which may manifest as a panic attack — can mimic a heart attack (see Table 5). One analysis of studies involving people admitted to emergency rooms for chest pain found that 22% of those who underwent cardiovascular testing had panic disorder rather than heart disease. Another extremely common symptom related to anxiety, particularly in women, are palpitations — the sensation that your heart is racing or beating too fast.

As with depression, medications and therapy can help treat anxiety. Because anxiety often stems from stress, techniques that aim to quell the stress response can also be effective for easing anxiety.

Table 5: A panic attack or a heart attack?

Both a panic (anxiety) attack and a heart attack can cause shortness of breath, sweating, or dizziness. Below are some of the factors that help to differentiate a panic attack from a heart attack. (Note that anyone having these symptoms should seek immediate medical help.)

More likely a panic attack

More likely a heart attack

Sudden onset of fear or terror in conjunction with heart palpitations or chest pain

Gradual onset (over several minutes) of pain, pressure, or tightness in chest and upper body

Pain and discomfort tend to occur in the center of the chest

Pain may occur in center of chest but may also radiate to upper body (arms, shoulders, or jaw)

Chest pain and other symptoms subside after 5 to 30 minutes

Symptoms last at least 15 minutes without subsiding in intensity and may continue for hours


Stress-easing strategies

It’s nearly impossible to avoid all sources of stress in your life. While you can’t change the world around you, you can try to change your reactions and to manage your stress. Try the following to minimize your stress level:

Get enough sleep. Lack of sound sleep can affect your mood, mental alertness, energy level, and physical health.

Exercise. Physical activity alleviates stress and reduces your risk of becoming depressed.

Learn relaxation techniques. Meditation, progressive muscle relaxation, guided imagery, deep breathing exercises, and yoga are mainstays of stress relief. Your local hospital or community center may offer meditation or yoga classes, or you can learn about these techniques from books or videos. To get started, try a quick relaxation exercise (see “Quick stress-relief exercises”).

Quick stress-relief exercises

When you’ve got one minute. Place your hand just beneath your navel so you can feel the gentle rise and fall of your belly as you breathe. Breathe in. Pause for a count of three. Breathe out. Pause for a count of three. Continue to breathe deeply for one minute, pausing for a count of three after each inhalation and exhalation.

When you’ve got three minutes. While sitting down, take a break from whatever you’re doing and check your body for tension. Relax your facial muscles and allow your jaw to fall open slightly. Let your shoulders drop. Let your arms fall to your sides. Allow your hands to loosen so that there are spaces between your fingers. Uncross your legs or ankles. Feel your thighs sink into your chair, letting your legs fall comfortably apart. Feel your shins and calves become heavier and your feet grow roots into the floor. Now breathe in slowly and breathe out slowly. Each time you breathe out, try to relax even more.

When you’ve got 10 minutes. Try imagery. Start by sitting comfortably in a quiet room. Breathe deeply and evenly for a few minutes. Now picture yourself in a special place. Choose an image that conjures up good memories. What do you smell — the heavy scent of roses on a hot day, crisp fall air, the aroma of baking bread? What do you hear? Drink in the colors and shapes that surround you. Focus on sensory pleasures: the swoosh of a gentle wind, the soft, cool grass tickling your feet, the tranquility of watching or listening to flowing water. Passively observe intrusive thoughts and then gently disengage from them to return to the world you’ve created.

Learn time-management skills. These skills can help you juggle work and family demands.

Confront stressful situations head-on. Don’t let stressful situations fester. Hold family problem-solving sessions and use negotiation skills at work.

Nurture yourself. Treat yourself to a massage. Truly savor an experience: eat slowly, focusing on each bite of that orange, or soak up the warm rays of the sun or the scent of blooming flowers during a walk outdoors. Take a nap. Enjoy the sounds of music you find calming.

Cultivate friendships. Having a core group of friends that you can do relaxing activities with and talk to can be extremely helpful in blowing off steam. Remember that friends are the family that you get to choose!

Talk to your doctor. Discuss with your doctor why you think that you might be stressed or anxious. Your doctor can give you strategic tips to help you or refer you to a specialist. If stress and anxiety persist, ask your doctor whether anti-anxiety medications could be helpful.

Are you a mean one, Mr. Grinch?

If your demeanor is more like the Grinch or Mr. Scrooge than Mary Poppins, you’re more likely to experience heart trouble. So says the literature on personality traits and heart disease, which has linked hostility, anger, and social isolation to a higher risk of cardiac woes.

The notion that personality can affect heart disease risk dates to the 1950s, when two cardiologists first observed that people with “Type A” personalities, who are hard-charging, competitive, and aggressive, are more at risk for heart disease than others. It turns out that’s not entirely true. Some Type A people are happy and healthy, while others are not. As research has continued into specific elements of the Type A personality that put people at risk, one trait in particular — anger — seems to be very toxic to the heart. People who are angry or hostile are two to three times as likely to have a heart attack or other cardiac event as others, according to one review article. Taming your rage with an anger-management program could help, however (see “Relaxation and your health”).

More recently, doctors have turned their attention to people with “Type D” personalities, who tend to have negative emotions, suppress these emotions, and avoid social contact. Although Type D’s appear to have poorer outcomes from heart disease, a 2011 study found no evidence of compromised heart function in people with Type D personality without documented heart disease.

Other research shows that men and women who live alone are more likely to have a heart attack or die suddenly from one. Adults who live alone are also more likely to smoke, be obese, and have high cholesterol levels than those who do not live alone, and they tend to see the doctor less often. On the flip side, older adults with a strong network of friends and family are significantly less likely to die over a 10-year period than those with a smaller network of friends. Friends and family, it seems, can inspire (or nag) you to take better care of your health. Divorce, loss of a spouse or companion, retirement, and relocation can all contribute to your becoming isolated from friends and family.

It’s possible that these personality traits and tendencies make people more vulnerable to stress, depression, and anxiety, which could explain the cardiac link. If that’s true, addressing those problems might help and certainly won’t hurt. And if your social isolation stems largely from circumstance, it’s worth making an effort to enrich your life by connecting with people. Take an adult education class, pursue a volunteer opportunity, join a book club, or take a walk around the neighborhood. Who knows, maybe you’ll experience a transformation like the Grinch, whose “heart didn’t feel quite so tight” at the end of the classic holiday story by Dr. Seuss.


Relaxation and your health

A modest but encouraging body of work shows some benefits to managing stress and anger. One study found that elderly people with hard-to-treat isolated systolic hypertension who underwent relaxation response training (see “Learn relaxation techniques”) were more likely to be able to effectively control their blood pressure to the point where they could eliminate their antihypertensive medications.

If anger is an issue for you, an anger-management program might help. An analysis of 50 studies that included almost 2,000 volunteers found that such programs help people tone down their anger, respond to threatening situations less aggressively, and use positive behaviors such as relaxation techniques or better communication skills. Other studies have demonstrated that improvements like these translate into lower blood pressure and better blood flow to the heart during exercise and stress. It’s not yet known, however, whether anger management can prevent coronary artery disease and reduce the likelihood of heart attacks, strokes, and other cardiac events.

An evaluation by the Centers for Medicare and Medicaid Services examined two programs aimed at improving cardiovascular health through lifestyle modifications, including stress management, exercise, and nutrition counseling. The study, which ran from 1999 through 2007 and involved 589 patients who already had heart disease, evaluated two nationally recognized programs: one from the Benson-Henry Institute for Mind Body Medicine and one developed by Dr. Dean Ornish.

Both programs had a beneficial effect on cardiac risk factors; for example, participants lost weight, reduced their blood pressure levels, improved cholesterol levels, and reported greater psychological well-being. Participants in both programs also appeared to have better cardiac function. Moreover, participants in the Benson-Henry program had lower death rates and were less likely to be hospitalized for heart problems, compared with controls. The study concluded that these kinds of intensive lifestyle modification programs are clinically effective. While this study is good news for those with heart disease, more studies are needed to confirm these results.



What’s my risk?

In the past, physicians gave people ballpark assessments of their heart disease risk based on their total cholesterol level. People were told that their risk was “low,” “medium,” or “high.” But these rough estimates meant different things to different people. Clinical and epidemiological studies have helped to refine these estimates in several ways. First of all, it’s now possible to predict who is most likely to develop heart disease and its complications. Second, treatment is tailored to your particular risk profile, and often involves a multiprong strategy of diet, exercise, and medication.

Although there is no one-size-fits-all solution, in general, the higher your risk, the more aggressive the treatment. If you have already been diagnosed with heart disease, diabetes, or chronic kidney disease, you are considered high or very high risk (see “Risk treatment categories,” below). Table 3 summarizes treatment goals and recommendations based on your LDL and risk category.

Risk treatment categories

The following five categories are used to guide treatment for cholesterol levels (see Table 3) as well as other types of heart disease treatment. To determine your 10-year risk of cardiovascular disease, see Table 6.

Category 1: Very high risk

  • Cardiovascular disease (such as detection of narrowed or partially blocked arteries in your heart, neck, legs, or elsewhere; or a history of stable or unstable angina, heart attack, or stroke; or a heart procedure such as angioplasty or bypass surgery)

and one or more of the following:

  • Diabetes or kidney disease

  • Severe and poorly controlled risk factors (especially cigarette smoking, but also uncontrolled high blood pressure or family history of heart disease)

  • Multiple risk factors, especially high triglycerides (200 mg/dL or above) and low HDL (below 40 mg/dL)

  • A recent heart attack or hospitalization for unstable angina.

Category 2: High risk

  • A history of heart disease (such as heart attack, stable or unstable angina, or a heart procedure such as angioplasty or bypass surgery)

or

  • A heart disease “risk equivalent” (such as diabetes, kidney disease, peripheral artery disease, blocked carotid arteries, or transient ischemic attacks), along with two or more major risk factors (such as smoking, high blood pressure, or family history of heart disease)

and

  • A 10-year cardiovascular disease risk of more than 20% (see Table 6).

Category 3: Moderately high risk

  • Two or more major risk factors

and

  • A 10-year cardiovascular disease risk of 10% to 20%.

Category 4 Moderate risk

  • Two or more major risk factors

and

  • A 10-year cardiovascular disease risk of less than 10%.

Category 5: Low risk

  • One major risk factor or none.

If you don’t have a history of heart disease, you can estimate your 10-year risk of cardiovascular disease using the risk calculator in Table 6. You’ll need to know your LDL, HDL, and total cholesterol values, as well as your systolic blood pressure reading, before and after you started taking blood pressure medications, if applicable. This risk calculator was developed by researchers with the Framingham Heart Study. To use it, add up the number of points that apply to you. Points are given to different risk factors for heart disease (age, total cholesterol, smoking, and so on). Protective factors, such as young age and high HDL, reduce your total. The higher the total points, the greater your risk and the more aggressive the recommended treatment.

Table 6: What’s your 10-year risk of cardiovascular disease (CVD)?

Step 1: Calculate your cardiovascular risk points

Tally up your points from the six categories below.

Risk factor

Points

Men

Women

1. Age

30 – 34

0

0

35 – 39

2

2

40 – 44

5

4

45 – 49

6

5

50 – 54

8

7

55 – 59

10

8

60 – 64

11

9

65 – 69

12

10

70 – 74

14

11

75+

15

12

2. Total cholesterol

<160

0

0

160 – 199

1

1

200 – 239

2

3

240 – 279

3

4

280+

4

5

3. HDL cholesterol

<35

2

2

35 – 44

1

1

45 – 49

0

0

50 – 59

–1

–1

60+

–2

–2

4. Choose A or B.

A. Systolic blood pressure (not treated)

<120

–2

–3

120 – 129

0

0

130 – 139

1

1

140 – 149

2

2

150 – 159

2

4

160+

3

5

B. Systolic blood pressure (treated)

<120

0

–1

120 – 129

2

2

130 – 139

3

3

140 – 149

4

5

150 – 159

4

6

160+

5

7

5. Smoker?

No

0

0

Yes

4

3

6. Diabetes?

No

0

0

Yes

3

4

Your total

 

 

Step 2: Convert points to risk

Find your total points in the left column of the appropriate gender table below to find your 10-year risk of CVD and your vascular age.

Points for men

10-year risk of CVD

Vascular age (years)

–3 or below

Less than 1 %

Under 30

–2

1.1 %

Under 30

–1

1.4 %

Under 30

0

1.6 %

30

1

1.9 %

32

2

2.3 %

34

3

2.8 %

36

4

3.3 %

38

5

3.9 %

40

6

4.7 %

42

7

5.6 %

45

8

6.7 %

48

9

7.9 %

51

10

9.4 %

54

11

11.2 %

57

12

13.2 %

60

13

15.6 %

64

14

18.4 %

68

15

21.6 %

72

16

25.3 %

76

17

29.4 %

80+

18+

Above 30%

80+

Points for women

10-year risk of CVD

Vascular age (years)

–2 or below

Less than 1 %

Under 30

–1

1.0 %

Under 30

0

1.2 %

Under 30

1

1.5 %

31

2

1.7 %

34

3

2.0 %

36

4

2.4 %

39

5

2.8 %

42

6

3.3 %

45

7

3.9 %

48

8

4.5 %

51

9

5.3 %

55

10

6.3 %

59

11

7.3 %

64

12

8.6 %

68

13

10.0 %

73

14

11.7 %

79

15

13.7 %

80+

16

15.9 %

80+

17

18.5 %

80+

18

21.5 %

80+

19

24.8 %

80+

20

28.5 %

80+

21+

Above 30%

80+

Note that a 3% risk means that three out of 100 people with your risk profile will have a heart attack in the next 10 years, a 10% risk means that 10 out of 100 people with your risk profile will have one in the next 10 years, and so on. This risk calculator also presents risk in a new way; it gives an estimate of your “vascular age” — how old your arteries are, regardless of how old you are.

Fast fact

Your heart beats about 100,000 times each day. That adds up to more than 2.5 billion times in a 70-year lifetime.

You can also use various online calculators; you type in your information to have your risk calculated automatically. Here are three:

  • The most commonly used calculator, based on the Framingham information, is from the National Heart, Lung, and Blood Institute: go to http://hp2010.nhlbihin.net/atpiii/calculator.asp.

  • The most comprehensive one is in the heart disease section of the Web site “Your Disease Risk,” created by the Harvard School of Public Health and now hosted by Washington University School of Medicine, at www.yourdiseaserisk.wustl.edu.

  • Yet another tool, the Reynolds Risk Score, developed by researchers at Harvard Medical School and Brigham and Women’s Hospital, considers traditional risk factors as well as CRP levels and parental history (mother or father having a heart attack before age 60). It is available at www.reynoldsriskscore.org.


Diagnosing heart disease

Doctors use a variety of techniques to diagnose heart disease. They range from tried-and-true standards like taking a medical history, performing a physical exam, and ordering an electrocardiogram (ECG) to high-tech strategies such as nuclear imaging and computed tomography (CT) scanning or invasive tests such as coronary angiography. So what tests are best? The answer depends on your condition and your doctor’s level of concern. If you have mild, stable, or atypical symptoms (for instance, fleeting episodes of stabbing pain), an experienced clinician might not go further than a history, examination, and ECG. On the other hand, if your symptoms are threatening (for example, a squeezing sensation in your chest, with breathlessness when walking more than a few yards and an abnormal ECG), your doctor might skip the preliminaries and go straight to an angiogram. In practice, most people fall between these two extremes, and they often benefit from a stepwise approach that begins with easy tests, followed by more sophisticated tests as needed, until the diagnosis becomes clear.

Your medical history

By far, the most important “test” in the diagnosis of coronary artery disease is a detailed conversation between you and your doctor. Your medical history — that is, your description of your medical background and symptoms — usually provides enough information for a physician to predict the general likelihood of coronary artery disease. The doctor should ask about such things as smoking, diet, and exercise; whether your parents or other family members have had heart problems; and whether you have a history of other medical problems, such as hypertension, high cholesterol levels, or diabetes.

The clinician will probably ask about two common symptoms: chest pain and palpitations.

Chest pain

The most common symptom of heart disease is angina, or pain in the chest that’s often described as a feeling of pressure, heaviness, or tightness. Some people complain of a burning or aching sensation; relatively few describe the pain as sharp or stabbing. The discomfort often spreads to the shoulders, arms, neck, or jaw, and is often accompanied by shortness of breath or sweating. Pain that is very short-lived or is limited to a small area (a couple of inches) is probably not from the heart.

Angina often occurs in response to a number of everyday stressors, both physical and emotional. Angina that lasts just a few minutes and goes away quickly when you rest or take medication is considered stable angina. A more serious form, unstable angina, builds in intensity, lasts several minutes to hours, and doesn’t subside with rest.

Why it happens: Angina occurs when plaque in the coronary arteries partially blocks blood flow and the heart muscle isn’t getting enough blood (see “Common angina triggers”).

How it’s treated: Stable angina is commonly treated with nitroglycerin, a drug that widens blood vessels. Your doctor will probably also prescribe other drugs used to treat heart disease (see “Medications for heart disease”). But unstable angina demands urgent medical care. If the blockage in your coronary arteries is severe, you may need angioplasty.

Common angina triggers

  • Walking briskly outside on a cold, windy, or humid day

  • Hurrying with a heavy load

  • Exerting after a heavy meal

  • Working under a deadline

  • Speaking in public

  • Engaging in sexual activity

  • Being worried, tense, or angry


Palpitations

Often described as feeling like the heart is skipping, racing, or fluttering, palpitations are not necessarily a sign of heart disease. Most people experience them at least occasionally. But they may be a symptom of a more serious heart condition, such as an irregular heartbeat (arrhythmia).

Why they happen: Common causes of palpitations include stress or anxiety, strenuous exercise, fever, hormonal changes that occur with menstruation or menopause, or certain stimulant-type drugs, including caffeine, nicotine, weight-loss drugs, or pseudoephedrine (found in some over-the-counter cold and cough medications). But they can also result from an irregular heartbeat or other electrical abnormality in the heart.

How they’re treated: If palpitations occur in response to a known trigger, try to avoid it. Your doctor may ask you to check your resting pulse regularly. To do so, place your forefinger on your wrist near the base of your thumb to feel the pulse of the radial artery as it supplies blood to the hand. Count the number of pulses during 15 seconds and multiply by four. Most people have heart rates of 60 to 80 beats per minute. Some well-conditioned athletes have rates in the 40s and 50s. But a resting heart rate of 100 or more beats per minute may mean the heart is working extra hard because of some underlying problem. If your heartbeat is irregular (for example, you experience a series of rapid heartbeats that start and stop suddenly), your doctor will probably order an electrocardiogram.

Other causes of chest pain that may mimic angina

The heart isn’t the only organ in the chest, and other medical problems can cause chest discomfort, including these:

  • Acid reflux or heartburn. When acid from the stomach flows up into the esophagus, it can cause a burning sensation in the chest that’s often mistaken for angina or a heart attack.

  • Lung conditions. Pneumonia or blood clots in the vessels supplying the lungs tend to cause shortness of breath and sharp pains that intensify with a deep breath.

  • Pericarditis. Inflammation of the tissues around the heart (pericarditis) can cause a sharp pain that often worsens when you lie down.

  • Costochondritis. This condition, caused by inflammation in the chest wall between the ribs and the breastbone, can also trigger pain that’s often mistaken for a heart attack. The stabbing, aching pain may be caused by trauma or an overuse injury, or it may accompany arthritis.

  • Esophageal spasm. This refers to the narrowing and opening of the esophagus, the muscular tube between the mouth and the stomach. Like angina, this pain is also relieved by nitroglycerin. However, only your doctor can conclusively make this diagnosis.



Physical examination

During a routine examination, your doctor will check your blood pressure, pulse rate, and breathing rate. He or she will also listen to your chest for extra sounds called gallops that may result from damage to or abnormal function of the heart. Gallops are abnormal, soft, thudding noises that the heart makes when it fills with blood. These sounds are not always a sign of coronary artery disease, but they indicate a stiffness of the heart’s main pumping chamber. Gallops are extremely common among older people, particularly if they have hypertension. Although gallops are usually nothing to worry about, if you have them, get checked periodically by your doctor for signs of heart trouble.

Your doctor will also listen for a heart murmur, a sound caused by increased or turbulent flow of blood through heart chambers or valves. Some heart murmurs do not indicate heart problems, but others do. For example, certain heart murmurs can be normal when a woman is pregnant. But a heart murmur can also be caused indirectly by coronary artery disease if inadequate blood flow deprives the muscles controlling the heart’s mitral valve of needed oxygen. The mitral valve may also have problems closing correctly if the heart has enlarged because of damage from a heart attack or other medical problem. If the valve fails to close completely during each contraction, blood can be squeezed backward through the valve — a syndrome called mitral regurgitation. Unless the amount of mitral regurgitation is very minor or very pronounced, it will produce a murmur that can be detected with a stethoscope. Other valves in your heart — the aortic, tricuspid, and pulmonary valves — can also malfunction, causing murmurs. Valvular murmurs can result from regurgitation (leaky valve), stenosis (a tight valve, usually due to calcium or infection), or tears in the valve tissue.

Your doctor may feel the pulse in your feet (see “Checking artery health beyond the heart: The ankle-brachial index,” below), which may be weakened if there is severe atherosclerosis in the major arteries feeding the legs, a condition known as peripheral artery disease. Sometimes, by looking into your eye with an ophthalmoscope, your doctor can see abnormalities in the small vessels of the retina. If atherosclerosis exists in these vessels, there’s an above-average chance that you also have coronary artery disease. A ring around the iris of your eye or fat-filled nodules just under your skin, particularly on your elbows, hands, and heels, are symptoms of high blood cholesterol levels.

Finally, your doctor will most likely order a blood test to measure your cholesterol and triglyceride levels. A urine microalbumin test and a blood chemistry test can detect diabetes or kidney disease, which are sometimes linked to atherosclerosis.

Checking artery health beyond the heart: The ankle-brachial index

Arteries that deliver blood to parts of the body below the heart don’t get nearly as much attention as the coronary arteries that supply the heart or the carotid arteries that supply the brain. These so-called peripheral arteries are also prone to the same damaging processes that stiffen and clog coronary arteries. A key test for problems in these arteries is the ankle-brachial index (ABI), which compares blood pressure readings from the ankle and the brachial artery in the arm, using a blood pressure cuff and an ultrasound probe. A large difference between the two can signal the presence of peripheral artery disease.

The ABI is the highest pressure recorded at the ankle divided by the highest pressure recorded at the brachial artery. The normal range is between 0.90 and 1.30. An index under 0.90 means that blood is having a hard time getting to the legs and feet: 0.41 to 0.90 indicates mild to moderate peripheral artery disease; 0.40 and lower indicates severe disease. The lower the index, the higher the chances of leg pain while exercising or of limb-threatening low blood flow. An ABI over 1.30 is usually a sign of stiff, calcium-encrusted arteries. These often occur in people with diabetes or chronic kidney disease. In such cases, blood pressure should be measured at the toe, where arteries are less likely to be rigid.

The ABI also offers information about general cardiovascular health. A 2008 analysis in The Journal of the American Medical Association of studies involving nearly 50,000 men and women showed that a low index (under 0.90) doubled the chances of having a heart attack or stroke or dying of heart disease over a 10-year period. The researchers suggested that the ABI could improve the accuracy of the widely used Framingham risk score (see “What’s my risk?”).


Electrocardiogram

The single most widely used test for detecting heart problems is the electrocardiogram, which is abbreviated as ECG (or EKG, from the German spelling of electrocardiogram). The ECG provides a picture of the electrical activity that regulates the heart’s cycle of contraction and relaxation (see Figure 6). Every person with suspected or diagnosed coronary artery disease should have an ECG as part of an initial evaluation. This test is likely to be repeated periodically to detect whether a heart attack occurred between examinations.

Figure 6: Electrical waves of the heart

An ECG produces a diagram, called a tracing, that corresponds with each phase of a heartbeat.

Cardiac contractions begin when the sinoatrial node sends a wave of electrical impulses through both upper chambers of the heart, known as the atria. This activity can be seen on the ECG in the form of a blip, called the P wave. As the wave moves through the atrioventricular node and stimulates both lower chambers, or ventricles, it generates the QRS complex, the tallest segment of the tracing. Once the ventricles have contracted, the heart relaxes for a moment as it prepares to repeat the cycle. This last phase produces a gentle rise and fall in the tracing, known as the T wave.

If you are middle-aged or elderly and have risk factors for a heart attack — such as high blood pressure, high LDL cholesterol, or diabetes — you should probably have the test yearly, even if you’re feeling fine. Also, because there are wide ranges of what’s considered a “normal” ECG, it’s helpful to have a baseline ECG to compare against future tests, to spot any abnormal changes.

The ECG gives a reading, or tracing, of the electrical activity that occurs with each heartbeat. This simple, painless test reveals a lot about your heart. By evaluating the tracings of your heart’s electrical activity, doctors can spot an irregular heartbeat (an arrhythmia), find out whether your heart is enlarged, or even detect the telltale signs of damage from an old heart attack. The ECG is crucial for evaluating chest pain. ECG abnormalities are often enough to enable emergency department physicians to establish a definitive diagnosis of a heart attack in progress.

In the standard technique, you lie down as the technician applies four electrodes, or leads, to your skin — one on each arm and one on each leg — with a special paste or adhesive pads. These limb leads permit the recording of cardiac electrical activity from different angles. Six additional electrodes are usually placed across your chest to detect activity at the front and left side of your heart. The routine ECG provides information from many different areas, enabling doctors to find the location of possible heart damage.

Sometimes, people who have suspected heart rhythm abnormalities need to wear a Holter monitor or an event recorder, which are, in essence, portable electrocardiogram devices (see “Holter monitoring”).

Holter monitoring

A Holter monitor is a portable ECG device that records your heart rhythm over a sustained period of time — usually a 24- to 48-hour period — while you go about your daily activities and even while you sleep. You can fit the monitor into a purse or jacket pocket or wear it over your shoulder by its strap and then continue your normal routine, with two exceptions. First, you can’t take a shower or bath during the period in which you’re wearing the monitor. Second, you are given a small diary in which to note any worrisome symptoms you feel, along with the time they occur. The doctor will later review both your diary and data about your heart’s activity from the monitor, to see if any symptoms you experienced were caused by some underlying heart problem. There are no side effects from the testing.

Another type of monitor, known as an event recorder, can be activated by the person wearing it to capture the heart rhythm during symptoms. Cardiologists commonly order these devices for people who experience infrequent palpitations (once a week or so) that cause bothersome or potentially dangerous symptoms. Most are worn for one to two months. If you are wearing an event recorder and experience symptoms, you simply press a button, which prompts the device to record your heart rhythm. This information is then transmitted via telephone to the device maker, and from there to your physician.


Exercise stress test

An exercise stress test, also called an exercise tolerance test, indicates whether your heart gets enough blood flow and oxygen when it’s working its hardest. The test is most commonly ordered if you have symptoms of coronary artery disease or if your doctor wants to assess the effectiveness of your treatment. It is not recommended as a screening test or for people without symptoms, except in people in high-risk professions, such as airplane pilots. For this test, doctors do an ECG and take blood pressure readings as you walk on a treadmill. You will typically begin walking on a slight incline at a slow pace. If you have had a recent heart attack or are otherwise physically limited, you may be asked to exert yourself even less. Every few minutes, the physician checks your ECG and blood pressure.

If all is well and you feel up to it, treadmill speed and degree of incline are increased until you need to stop because you feel short of breath, lightheaded, or otherwise uncomfortable. In other cases, the physician may end the test if your blood pressure drops (or rises too high) or abnormalities appear on the ECG. If you are not accustomed to marked physical exertion or have recently had a heart attack, the physician might stop the test after a predetermined period, or after a certain heart rate is reached. When the exercise is over, you are helped to a nearby bed while the ECG continues to record data. Often, the information obtained while you are recovering is the most revealing.

Many people worry that this test could be dangerous to someone with coronary artery disease, possibly even inducing a heart attack. But even though people are asked to push themselves to the limit, the screening is extremely safe if physicians examine you beforehand to make sure that you are healthy enough for it. Fatal complications are rare.

If walking on the treadmill produces symptoms such as chest discomfort, shortness of breath, or dizziness, and if these symptoms are accompanied by ECG changes, the test strongly suggests coronary artery disease. A test is considered negative if you can perform a normal amount of exercise without symptoms or ECG changes.

However, many people have chest discomfort but no ECG changes, or vice versa. In these cases, the exercise test is of less help and the result will be interpreted as consistent with coronary artery disease, but not definitive. Furthermore, some people with coronary artery disease don’t show any evidence of ischemia in exercise testing because other medical conditions, such as arthritis, prevent them from walking long enough or fast enough to stress their hearts. (For them, other test options exist. See “Nuclear stress test” and “Echocardiography.”)

In addition, exercise testing is less sensitive and possibly less accurate in women. Some doctors believe that women may benefit more from a pharmacologic stress test (see below), which uses medications instead of exercise to make the heart work harder. It’s also possible that women’s breast tissue keeps the leads farther from the heart, distorting the findings and making them harder to interpret.

Finally, almost every physician has heard of someone who had a negative exercise test one week and a heart attack the next, but this is a rare event. Sometimes a negative result may provide false reassurance to someone who had been unable to exercise enough to trigger ischemia during the test. In other instances, a negative result may be accurate, but a heart attack could still occur. For example, an atherosclerotic plaque might not be large enough to cause significant obstruction of a coronary artery during the test, but later suddenly ruptures and leads to the formation of a clot that blocks blood flow.

Stress tests, like all tests, are not foolproof. When the results are unclear, a nuclear stress test can help clarify a person’s diagnosis and risk status.


Pharmacologic stress test

People who are older or out of shape and those with arthritis, lung disease, vascular disease, certain baseline ECG abnormalities, or other medical conditions typically cannot exercise enough to undergo the traditional exercise tolerance test. In such situations, a pharmacologic stress test, which substitutes medication for exercise, provides another option. The medication increases the heart’s need for blood, allowing doctors to detect blockages that obstruct the supply of blood.

Two strategies are commonly used in pharmacologic stress tests. In one, the medication used — dobutamine, which acts like adrenaline and is sometimes combined with atropine — increases the amount of work the heart does, thereby increasing its need for oxygen-rich blood, much as exercise does. Echocardiography is generally used to monitor abnormalities induced by dobutamine. A second strategy is to give dipyridamole (Persantine) or adenosine (Adenocard), medications that cause the coronary arteries to widen, producing a fourfold increase in blood flow. Blood flow does not increase normally in blocked arteries. Nuclear imaging (see next section) is usually used to detect blockages revealed by dipyridamole or adenosine.

Pharmacologic stress tests aren’t for everyone. People with asthma, emphysema, carotid artery disease, or aortic stenosis should not take dipyridamole or adenosine, while anyone with uncontrolled hypertension or abnormal heart rhythms should not take dobutamine. But for many people, pharmacologic stress testing is safe.


Nuclear stress test

Nuclear stress tests are similar to the other exercise stress tests, but the images are usually taken with single-photon emission computed tomography (SPECT), in which a camera that records x-ray images circles around the heart, taking pictures from many angles. A computer uses this information to build a more detailed and precise image of the heart.

Because nuclear imaging is more expensive and invasive and takes longer than a traditional exercise tolerance test, it’s not usually the first test used for diagnosing coronary artery disease. It’s used primarily for people with abnormal ECGs who either have inconclusive exercise test results or can’t do a conventional exercise test because arthritis, stroke, lung disease, or other ailments restrict their mobility.

During a nuclear imaging test, you will either exercise on a treadmill to make your heart work harder (see “Exercise stress test”) or be injected with a medication that can induce ischemia (see “Pharmacologic stress test”). You also get an injection of a tracer, a slightly radioactive substance (technetium or thallium) that circulates in the bloodstream (see “Radiation risks from heart tests”). The SPECT scanner tracks blood flow through the heart by detecting these radioactive particles in the bloodstream. The tracers concentrate in areas of the heart muscle that have a good blood supply, while areas with no blood supply, such as scars from a previous heart attack, won’t collect the radioactive particles.

You wait a short time for the tracers to reach your heart, then lie down as the scanner rotates around you taking pictures. A second series of images is taken later on, when the heart is at rest. When comparing the two sets of images, doctors look to see whether abnormalities present under stress disappear once the stress has passed. This difference would suggest that the heart muscle is in danger from coronary artery disease. In people with coronary artery disease, ischemia occurs under periods of stress, but not otherwise. Any abnormalities that appear on both sets of images indicate old heart damage, perhaps from an earlier heart attack.

Radiation risks from heart tests

Many tests used to diagnose heart disease involve radiation exposure, which is measured in millisieverts (mSv), a designation that reflects the biological effect of radiation on tissues. Radiation offers extraordinary benefits for diagnosing heart disease and other ailments, but it can cause damage to cells that may trigger cancer. Each year, the average person receives about 3 mSv of so-called background radiation from naturally occurring sources of radiation from the Earth and cosmos. This tiny amount has little effect on health. But since the 1980s, the amount of radiation used in medicine has grown so much it now rivals background radiation, adding an average 3 mSv per person each year, says the National Council on Radiation Protection and Measurement. Much of this growth comes from computed tomography (CT) scans (see “Computed tomography”).

The amount of radiation from these scans varies widely, according to a 2009 report in The Journal of the American Medical Association (JAMA). Researchers estimated exposures from CT scans at 50 hospitals worldwide and found levels at the highest-dose sites to be six times as high as those at the lowest doses. The variability stemmed from differences in scanner models, how the machine was operated, and whether radiation-reducing techniques were used. The average radiation exposure from a single new-generation test was equal to the exposure from 600 conventional chest x-rays.

The following are estimated amounts of radiation exposure from some common heart tests:

  • coronary calcium scan, 1–3 mSv

  • 64-slice cardiac CT, 7–23 mSv

  • 320-slice cardiac CT, 10–18 mSv

  • technetium stress test, 6–15 mSv

  • thallium stress test, 17 mSv

  • dual isotope stress test, 18–38 mSv

  • angiogram, 2–23 mSv.

Just how dangerous are these levels? A 2009 scientific advisory on the topic from the AHA offers some perspective. Your risk of developing some type of cancer during your lifetime is 41%, and the risk of dying as a result is 21%. The relative risk of dying of cancer from radiation due to a heart CT scan is very small in comparison — an estimated increase of about 0.05% above the 21% background risk. In addition, radiation-induced cancers don’t occur until decades after exposure, making the cancer risk even less concerning for older people, who are likely to die from other causes (including heart disease) before developing cancer.

However, a 2010 study in JAMA that looked at heart imaging tests on patients at a New York teaching hospital found that many received “alarming and probably unsafe” levels of medical radiation from the tests. About one-third of the tests were done in people without symptoms of heart disease and therefore would not prompt changes in treatment. The findings underscore the AHA’s recommendation that tests involving radiation exposure should be ordered only after “thoughtful consideration,” including whether an alternative test might do instead. Don’t request or agree to any type of medical test unless it will give you and your doctor important information about your health or body. And ask about receiving the lowest dose of radiation possible.


Echocardiography

Some cardiologists use echocardiography instead of nuclear imaging to detect ischemia during a cardiac stress test. As with nuclear imaging, echocardiography (sometimes referred to as a stress echo or ultrasound) is appropriate for people at high risk for a heart attack who can’t have an exercise tolerance test or whose exercise test was inconclusive.

With echocardiography, sound waves provide a video image of the beating heart (see Figure 7). After exercise or an injection of one of the ischemia-inducing drugs, the portion of the heart muscle with inadequate blood supply contracts abnormally.

It’s difficult to compare echocardiography with nuclear imaging because studies show that their accuracy and effectiveness vary considerably from one imaging laboratory to the next. Therefore, when making the choice, you and your doctor should take into account which test is preferred and used most often by the institution where you’ll be evaluated.

Figure 7: Echocardiogram

Echocardiography uses sound waves to create still and moving pictures of the heart. These images show the size, shape, and structure of the heart and give important clues about how it is working.


Coronary arteriography (angiogram)

The “gold standard” test used in diagnosing coronary artery disease is coronary arteriography (also called coronary angiography). Coronary arteriography is used to confirm a diagnosis in people who are suspected of having coronary artery disease on the basis of noninvasive tests, such as the exercise tolerance test, or whose tests were inconclusive. It’s also recommended for some people known to have coronary artery disease, to determine the location and extent of arterial blockages, and for those being considered for angioplasty or coronary artery bypass surgery.

Coronary arteriography is a type of cardiac catheterization (a procedure in which a thin tube called a catheter is inserted into a coronary artery). About 1.3 million cardiac catheterizations are performed in the United States each year — mostly in hospitals with special laboratories designed for this purpose.

In coronary arteriography, the cardiologist inserts the catheter into a blood vessel elsewhere in the body (usually an arm or leg) and threads it deeper into the circulatory system until it reaches the coronary arteries. The physician then squirts a dye that can be seen on x-rays into the coronary arteries. A technician takes x-ray films during the procedure, and these films help reveal whether and how severely the coronary arteries are narrowed (see Figure 8).

Although the catheterization itself usually takes an hour or less, health care personnel must keep you under observation for several hours after the procedure to make sure that there is no internal bleeding where the catheter was inserted. If a leg vessel was the point of entry, you must lie down for about four to six hours, usually with a weight compressing the catheterization site. If you don’t have angina, internal bleeding, or other complications, you may be able to go home later that day.

Coronary arteriography should not be painful and is remarkably safe when performed by experienced physicians. However, it involves some risks. The most common complications are bleeding where the catheter was inserted or the formation of blood clots in the vessel. Other possible complications include heart rhythm abnormalities, infections, and allergic or kidney reactions from exposure to the contrast dye. Stroke, heart attack, and major bleeding are uncommon.

Half or more of women who have alarming stress tests have what look to be clear coronary arteries on an angiogram. Technically, this is not because coronary arteriography has missed an atherosclerotic plaque. Rather, these women may have coronary microvascular disease (see “What is coronary microvascular disease?”). On an angiogram, the arteries register as open, and the test result may lead to a false sense of security.

Figure 8: Coronary angiogram

This angiogram shows a narrowing (see arrow) in the left anterior descending coronary artery.


Computed tomography

Traditional computed tomography (CT) devices are doughnut-shaped machines that house rotating x-ray tubes that take pictures of thin “slices” of your anatomy. A computer assembles these images into a three-dimensional picture. Older CT scans weren’t fast enough to capture the beating heart, since the heart’s movement blurred the images of the arteries on most scans. It was like trying to take a photograph of a speeding car with a slow shutter speed.

Two developments now make it possible to get images sharp enough to actually see blockages inside the coronary arteries. First, beta blockers, such as atenolol (Tenormin) and metoprolol (Lopressor, Toprol XL), can slow down the heart, so doctors can get a better look.

Second, technology has improved, providing the equivalent of much faster film to photograph that speeding car. Traditional CT devices typically had four internal scanners. Now, 64 scanners have become standard, and devices with 256 or even 320 scanners are used at some institutions. The greater the number of scanners, the better the resulting image. In a process called multidetector computed tomography (MDCT), these devices simultaneously take dozens of snapshots from different angles. These snapshots are then used to reconstruct a complete image of the inner workings of the arteries. A different technology, electron beam CT (EBCT), takes pictures with a rotating beam of electrons that circles the body far faster than an x-ray camera.

The advantage of CT is that it can show whether someone has coronary artery blockages without subjecting them to a coronary angiogram. (That’s why these scans are sometimes referred to as “CT angiograms.”) Although coronary angiograms are generally safe, they carry a low but real risk for complications such as stroke, heart attack, kidney problems, and even death.

Even so, there are several issues to consider before undergoing a CT angiogram. First, not all CT scanners are created equal. If you opt for a CT angiogram, make sure the device is the latest generation. Second, although the scans are noninvasive, they do carry risks (see “Radiation risks from heart tests”). Perhaps the most significant issue, though, is that the scans may reveal partial blockages that might not otherwise have been visible. While this may seem like a good thing, it’s not clear that it is. Some people will want to “fix” these with angioplasty and coronary artery bypass surgery rather than trying lifestyle changes and medications. This can lead to greater expense and greater risk for complications, and it is not clear that going after these narrowings in people who have no symptoms helps them avoid heart attacks or live longer. Nor is it clear yet whether using CT scans in place of angiograms will improve health outcomes — ultimately the most important consideration. For these reasons, many insurance companies do not pay for CT angiograms, and they are not routinely used.

Coronary artery calcium tests

MDCT and EBCT can also be used to measure the amount of calcium in the coronary arteries. Calcium is an elemental part of the body’s response to the cycle of inflammation, damage, and repair that results in atherosclerotic plaque. Calcium scores indicate whether a person has calcium-laden plaque in the coronary arteries.

Guidelines from the AHA advise coronary artery calcium scans only for people who fall into the gray zone of intermediate risk for heart disease. For these people, a low calcium score (0–99) could calm worries about having a heart attack, while a high score (400 and over) might tilt the scales in favor of stepping up prevention efforts. Beware, however, that calcium scores may be less reliable for people in certain racial groups. An African American, for example, may receive a low calcium score, but that doesn’t necessarily mean he or she is at low risk for a heart attack.

The guidelines warn against coronary artery calcium scans in people at low risk for heart disease. The scans also aren’t useful for people at high risk or who have already been diagnosed with heart disease, since the results wouldn’t change prevention or treatment strategies. The scans are sometimes not covered by insurers. Finally, the next generation of CT scanners, with ever-improving image quality, may make coronary calcium scanning obsolete.




Coping with a heart attack

A heart attack, known medically as a myocardial infarction, occurs when a blood clot blocks one of the coronary arteries (see Figure 9). Each coronary artery supplies blood to a specific part of the heart’s muscular wall, so a blockage causes pain and malfunction in the area that the affected artery serves. Depending on the location and the amount of heart muscle involved, this malfunction can seriously interfere with the heart’s ability to pump blood. Also, some of the coronary arteries supply areas of the heart that regulate heartbeat, so a blockage sometimes causes potentially fatal abnormal heartbeats called cardiac arrhythmias.

Most people are familiar with the classic description of a heart attack: crushing chest pressure; pain radiating to the neck, jaw, back, or arm; sweating and shortness of breath; sudden “indigestion” that isn’t relieved by antacids. While some women do experience these classic symptoms, the warning signs of a heart attack may be significantly different in women than in men (see Table 7).

If you experience these symptoms or others that indicate you may be having a heart attack, call your doctor immediately and go to the nearest emergency room. Chew an aspirin on the way to help reduce your blood’s tendency to clot. Every second counts. In one landmark study, people who received treatment within one to two hours were only half as likely to die as those who were treated four to six hours after the onset of symptoms. The primary goal in treating most heart attacks is to unblock the artery and restore blood flow to the heart as fast as possible with medication or surgery. Doing so will minimize the damage to the heart tissue.

Figure 9: Your heart’s “weakest links”

Blockage can occur in any of your coronary arteries. Two common sites are the right coronary artery (A) and the left anterior descending artery (B). When blockages occur in these locations, heart damage can result in the adjoining areas (shown shaded).

Is it a heart attack?

Physicians or emergency room staff must first determine whether you are having a heart attack, an episode of angina, or something completely unrelated to the heart (see “Chest pain”). The American College of Cardiology recommends that a diagnosis of heart attack be made when two of the following three criteria are met:

  • compatible symptoms (see Table 7)

  • suggestive ECG abnormalities

  • blood tests that reveal elevated levels of the blood chemicals troponin or creatine kinase-MB (see “Blood tests”).

Because heart attacks are sometimes hard to distinguish from other causes of chest pain, your physician may also order additional tests, such as echocardiography, nuclear scans, and cardiac catheterization, before making a diagnosis.

Table 7: Common symptoms of a heart attack

Learn the symptoms of a heart attack and seek help immediately if you think you are having one. Although the most common sign of a heart attack in both men and women is chest pain or discomfort, other symptoms tend to vary depending on your gender.

Men

Women

  • Pain or discomfort in the center of the chest

  • Pain or discomfort that radiates to the upper body, especially shoulders or arms and neck

  • Sweating

  • Dizziness

  • Pressure, aching, or tightness in the center of the chest (although not as frequently as in men)

  • Shortness of breath

  • Weakness; unusual fatigue

  • Nausea or vomiting

  • Dizziness

  • Back or jaw pain

ECG patterns

Emergency room staff often do an immediate ECG; sometimes this is even done in the ambulance during the ride to the hospital. In many cases (but not all), the ECG helps to determine whether you are having a heart attack, and if so, what type of heart attack.

One such type is a full-thickness or transmural heart attack, meaning it involves the full thickness of the heart’s muscular wall. Generally, this type of heart attack produces an injury current that shows up on an ECG as an ST segment elevation (see Figure 10). Cardiologists call this kind of attack an ST-elevation myocardial infarction, or STEMI.

A partial-thickness heart attack, or non-ST-elevation myocardial infarction (non-STEMI), produces different ECG changes — or at least, it should. Instead of becoming elevated, the ST segment is depressed, or lowered.

To complicate matters, angina often produces exactly the same changes as a partial-thickness heart attack, and it can sometimes mimic a full-thickness heart attack. More often, however, the ECG abnormalities that accompany a heart attack are atypical, subtle, or even absent. That’s why doctors always use blood tests to confirm a heart attack diagnosis.

Figure 10: Types of heart attacks

Doctors analyze ECG patterns to help determine what type of heart attack you are having. In an ST-elevation heart attack, which requires the most aggressive treatment, the ST segment is usually above the baseline (middle). In a non-ST-elevation heart attack, the ST segment is below the baseline (right). However, ECG patterns are seldom so clear, and blood tests and other indicators will confirm a diagnosis.


Blood tests

When heart cells die, they release enzymes, the chemicals that trigger vital tissue functions. Some of these enzymes are specific to the heart and aren’t produced in any other tissue in large quantities. Doctors measure the blood levels of these enzymes at intervals over time. Because dying heart cells release different enzymes at different rates, the blood tests can help pinpoint the time the heart attack occurred — information that is particularly useful when symptoms are vague. In addition, the more cells that die, the higher the blood levels of these different enzymes. Doctors can use this information to estimate the amount of heart tissue that has been destroyed.

If doctors suspect that you are having a heart attack, they will probably test your blood for either troponin I or troponin T, which are proteins that begin to rise within minutes to hours after a heart attack. Troponin levels usually increase sharply about four to six hours after heart muscle has been damaged, reach peak levels in 10 to 24 hours, and return to normal 10 to 14 days later. Another protein in the blood, creatine kinase-MB, also rises in response to heart tissue damage within six hours of a heart attack. It reaches peak levels at about 18 hours and returns to normal in two to three days. Troponin has emerged as the preferred test for heart attacks at most hospitals. Compared to creatine kinase-MB, it is less likely to cause false positives (that is, to mistakenly identify a heart attack when one has not occurred), and it remains elevated for a longer period of time.

Fast fact

Two-thirds of Americans can’t identify the signs of a heart attack and say what needs to be done when one strikes.



Treating a heart attack

If you have a heart attack and reach the hospital in time, chances are very good that you will walk out of the hospital within a week or even sooner.

First, you’ll probably go to an intensive care unit (or coronary care unit), where there are nurses and doctors with specialized training and equipment to monitor your condition and treat emergencies. For the first few days after a heart attack, you’ll probably need to rest in bed and have your heartbeat continuously monitored to make sure that no dangerous rhythms develop. You may need supplementary oxygen to fuel your heart muscle and an intravenous (IV) line in your hand or arm so you can receive medications.

Treatment of a heart attack involves several strategies, some of them conducted almost simultaneously:

  • reopening the blocked artery (reperfusion)

  • preventing further blood clots from developing

  • reducing the oxygen needs of the heart muscle

  • monitoring for and controlling complications

  • treating any complications that develop

  • assessing short- and long-term risk.

Immediate treatment

During the early stages of a heart attack, heart cells are dying rapidly from a lack of oxygen. Therefore, the immediate goal of treatment for most people is to restore blood flow to the heart, by reopening the blocked artery and preventing further blood clots from developing. Such reperfusion therapy can restore the flow of oxygen-rich blood to the heart muscle, sometimes before any serious damage occurs.

There are two main ways to restore blood flow: with angioplasty (with or without stenting), or with thrombolytic agents, medications known as “clot busters” because they help break down clots in blood vessels. (Coronary artery bypass surgery is used much less frequently.) In general, the treatment of choice is now angioplasty, simply because it saves more lives than clot-busting drugs and is less likely to cause complications. But if a cardiac team is not available or the hospital is not equipped to do angioplasty, clot-busting drugs provide another lifesaving option.

Time is of the essence in all cases, however: the faster blood flow is restored to the heart, the greater your chances of surviving and recovering. Experts recommend that people diagnosed with STEMI receive clot-busting drugs within 30 minutes of arrival at the hospital, or, even better, that they undergo angioplasty with stent insertion within 90 minutes.

Results from a large international trial further emphasize the need to act quickly, suggesting that even for patients with stable chest pain after a heart attack, angioplasty may be beneficial only if performed within 24 hours after symptoms begin. In this trial, patients who had angioplasty plus optimal medical therapy (at least aspirin, an ACE inhibitor, a beta blocker, and a statin) more than 24 hours after the start of symptoms had only slightly fewer second heart attacks, cases of heart failure, or deaths than patients who received optimal medical therapy alone. This trial reinforces the importance of recognizing heart attack symptoms quickly and getting to the hospital as fast as you can.

In people diagnosed with non-STEMI or angina, the situation is not quite so dire in the short term, and you may be monitored for a longer period before your doctors recommend a particular treatment. However, early, invasive treatment seems to result in better outcomes for people with these diagnoses.

Medications given to open blocked arteries include clot-dissolving drugs known as thrombolytics, such as alteplase (Activase) and several others, as well as drugs that prevent new blood clots, such as aspirin and heparin (see “Medications for heart disease”). On the other hand, these drugs (especially the thrombolytics) can cause bleeding complications in people over age 70, people with severe high blood pressure (greater than or equal to 180/100), and people with a history of strokes or certain other conditions.


Minimizing the heart’s oxygen needs

At the same time that blood flow is being restored, doctors take steps to minimize the heart’s oxygen needs. During the first few hours after a heart attack, bed rest helps reduce the heart’s oxygen requirements. In addition, medications are given to reduce the heart’s workload in several ways. These medications include beta blockers, nitrates, analgesics, sedatives, angiotensin-converting–enzyme (ACE) inhibitors, and angiotensin-receptor blockers (ARBs). For a discussion of these drugs, see “Medications for heart disease.”


Monitoring and follow-up

After the immediate treatment for heart attack, doctors monitor your heart for rhythm abnormalities and other heart problems. In the coronary care unit, nurses are highly trained to recognize electrical disorders and to administer heart drugs. An array of devices and machines — defibrillators, ventilators, pacemaker equipment, and other tools for monitoring and maintaining heart function — stand at the ready.

Most people don’t have major problems after a heart attack and can leave the coronary care unit for a step-down unit, or intermediate care, within a day or two. Intermediate care units have much of the same monitoring equipment as coronary care units do; the difference is in the ratio of nurses to patients. In intermediate care, each nurse cares for three to five patients, compared with only two in coronary care.

The last step in the hospital phase of treatment is evaluating your risk of having another heart attack — and teaching you how to minimize that risk. This risk assessment involves several types of tests.

Some people who have uneventful recoveries may undergo a low-level exercise tolerance test before leaving the hospital. You might get one if you did not have angioplasty or if you have several blocked arteries of unknown severity. The low-level test differs from the conventional exercise tolerance test in that you stop exercising after a predetermined number of minutes of low-level exercise on a treadmill, even if you show no problems or symptoms. The goal of this limited exercise test is to determine whether you are sufficiently stable to resume a reduced level of physical activity at home. If the test is negative — that is, it reveals no problems — you’ll be able to go home. The exercise test can also help you learn how much exertion is safe and appropriate during the next phase of the healing period. Most people are reassured to learn that the period of imminent danger has passed and that they can resume a fairly normal life over a period of several weeks.

A low-level exercise test that reveals abnormalities — such as chest pain, fluctuations in heart rhythms, or changes in blood pressure — generally indicates that parts of the heart remain at risk for further damage. In such cases, cardiologists may suggest cardiac catheterization, which can reveal whether angioplasty or coronary artery bypass surgery might improve blood flow to the heart and reduce the chances of another heart attack.




Healing your heart: Cardiac rehabilitation

Right after having a heart attack or undergoing angioplasty or bypass surgery, you’ll need time to recuperate. In addition to the emotional impact of a brush with mortality, you’ll feel run-down and physically depleted. Even short periods of bed rest and inactivity weaken the muscles, heart, and lungs. Blood loss from surgery, angioplasty, and multiple blood tests can leave you with low blood levels of iron (anemia), a common cause of fatigue. Your appetite may have flagged, and not eating and drinking saps your energy. Finally, your body may be adjusting to a new regimen of medications, which can also cause weakness.

Not that long ago, rest was what the doctor ordered after a heart attack or heart trouble. Taking it easy, the thinking went, wouldn’t stress the heart and would help it heal more quickly. Now, doctors know that inactivity doesn’t help your heart or the rest of your body. Exercise not only strengthens your heart, it helps your muscles use oxygen more efficiently, easing the heart’s workload.

A month or so after a heart attack or bypass surgery, and sooner after angioplasty, you should start cardiac rehabilitation, a medically supervised program designed to help you heal your heart and keep it healthy. The centerpiece of cardiac rehabilitation is usually a structured and supervised exercise program. Rehab programs also teach people about heart disease and how to manage it. Many also offer classes or information on weight management, nutrition education, stress reduction, smoking cessation, and returning to work. The staff typically includes doctors, nurses, exercise specialists, physical and occupational therapists, nutritionists, and psychologists. (For more detailed information about stress reduction, see the special section, “Hearts and minds: How stress and negative emotions harm the heart.”) This chapter explains why and how to choose a rehabilitation program and outlines some of the practical information you’re likely to receive. It also features a profile of a physician’s successful recovery following bypass surgery and cardiac rehabilitation (see “One doctor’s story: From ‘heartburn’ to surgery and rehabilitation”).

Why rehab?

Cardiac rehabilitation programs have been shown to reduce deaths by up to 25% during the few years following the heart attack or procedure. That’s at least as good as taking aspirin, a beta blocker, a statin, or a combination of these. Participating in rehab can also improve your quality of life. For one thing, you’ll have peace of mind when you exercise, knowing that you’ll be closely monitored for any potential problems. Some people also enjoy the shared camaraderie of working out with people who understand what they’ve been through. Others benefit from group sessions or classes (whether focused on nutrition or relaxation), where they’re able to ask questions and learn from one another. Some rehab programs also offer support groups for family members, who may benefit from personal sharing, as well.

Doctors sometimes overlook the importance of referring their patients to cardiac rehab, so if you qualify (see “Is cardiac rehab for you?” below), ask your physician about local facilities. Despite the benefits, fewer than 30% of eligible patients take part in rehab. For people 65 and older, participation is even lower — just 14%. A shortage of programs nationwide and accessibility issues (for instance, some facilities aren’t near public transportation or the classes are at inconvenient times) may explain these low figures. Private insurers or Medicare usually cover the cost, although you may have a copayment. Schedules vary among different programs, but people usually come to the facility at least once a week and up to three times a week, from one to several hours. Some people attend for just a few weeks, while others continue for months.

Is cardiac rehab for you?

Anyone can sign up for cardiac rehab; the catch is that insurers will typically pay for it only if

  • you’ve had a heart attack

  • you’ve undergone angioplasty, with or without a stent

  • you’ve had bypass surgery

  • you have stable angina

  • you’ve had a heart valve repaired or replaced

  • you’ve undergone a heart or lung transplant.


Choosing a facility

First, check to see that the program is certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR; see “Resources”). There are about 2,600 cardiac rehab centers nationwide, and about 1,400 have been certified by the AACVPR. The following list of questions can help you decide on a facility:

  • Does the staff include trained cardiac nurses, exercise specialists, dietitians, and mental health specialists?

  • Is there a doctor on the premises?

  • Is the staff ratio at least one to every four patients?

  • Is the staff certified in basic and advanced life support skills?

  • Does the program offer workshops and counseling?

  • Are assessments and treatment plans individualized?

  • Will someone on staff file your insurance claim?

  • Will the staff stay in regular contact with your cardiologist?

  • Is there a post-rehab program available that would allow you to continue to exercise at the facility for a fee?

While visiting a facility, look for these features:

  • a variety of exercise equipment such as treadmills, elliptical trainers, stationary bikes, and step machines

  • equipment that’s modified for elderly or disabled patients

  • free weights, wall pulleys, and rowing machines.

One doctor’s story: From “heartburn” to surgery and rehabilitation

A Harvard Medical School physician shares his experience as a cardiac patient.

Early one spring, I noticed a burning sensation high in my abdomen whenever I walked up a hill or worked out on the treadmill. It felt like heartburn (also known as acid reflux). But that usually comes on after a big meal or when you lie down to sleep. I took powerful acid-suppressing pills before walking up the hill, but that didn’t help.

I felt perfectly healthy otherwise — I had lots of energy and could do high-level exercise on the treadmill after the burning sensation went away without becoming short of breath. But I was well aware of my risk for heart disease, since it runs in my family. My father, his father, and his sister all died from the disease in their late 40s or early 50s. My father did not have the usual risk factors for coronary artery disease, such as high blood pressure, high cholesterol, or diabetes. He exercised regularly, was not overweight, never smoked, and ate a fairly healthy diet.

For me, this was not good news; it meant that my father probably had some unknown genetic or hereditary factor that made him (and possibly me) vulnerable to coronary artery disease. In terms of other factors, my record was mixed. Until about age 20, I ate lots of foods filled with saturated fats, like most Americans at the time. After my father’s heart attack, I improved my diet (although I still ate too much ice cream). For the last 20 years, I’ve eaten a heart-healthy diet, and jogged or (more recently) walked briskly for 30 minutes, at least five times a week. With my doctor’s agreement, I started taking low-dose aspirin each day — even before the famous Harvard study that showed that, in men like me, aspirin protects against coronary artery disease.

I had been checking my weight, blood pressure, and cholesterol regularly since my mid-20s. As I approached the age of 60, they all started to rise. Eating even more carefully, taking medications for cholesterol and blood pressure, and increasing my exercise lowered them all.

The burning sensation I felt from time to time gave me a lot to think about. I remembered an old saying to the effect that “A doctor who takes care of himself has a fool for a patient.” Still, I hesitated; I didn’t want to waste the time of a cardiologist if all I had was acid reflux.

One morning, as I walked across the street from the garage to my office in the hospital, the burning sensation returned with a vengeance. When I got to the front door of the hospital, I was completely out of breath and couldn’t take another step. At that moment, the game was up: I knew I had heart disease and that it was becoming worse.

I called my doctor. He ordered an exercise stress test that day. It was abnormal. The next day I had a cardiac catheterization. As I lay on the table, I watched the face of the cardiologist, a colleague of mine, as he performed the test. I saw him nod several times, and clench his jaw. Then he turned the video screen around so that I could see it. There, clear as day, was an ugly picture. Three different coronary arteries had blockages, and one showed an unstable, vulnerable plaque: a blood clot was forming at the site of the blockage, threatening to shut down blood flow in the artery and cause a heart attack. I had seen such pictures many times before, but this time it was a picture of me.

The next day I underwent coronary artery bypass surgery. I was in superb hands, at a top hospital, and experienced no complications. Most important, although the vessels that supplied the heart with blood were diseased, we had caught the problem before a heart attack had injured my heart. My heart still pumps today as strongly as it did when I was 20. The surgery had defused three time bombs. I participated in a cardiac rehabilitation program, gradually increasing my level of exercise while my heart was carefully monitored. My family, friends, and colleagues were always there, with love and affection and a willingness to help. Because my health is otherwise excellent, I was back at work in two weeks and back to my usual level of exercise in six weeks.

The experience helped me realize that it’s better knowing that you have a real problem — and have done everything you can to fix it — than living every day with the fear that you might have a problem, as I had done for 40 years.


Lifestyle changes to protect your heart

Whether or not you attend a cardiac rehab program, you can rehabilitate at home. The following section highlights some of the changes you can make on your own.

Stop smoking

Smokers who want to quit the habit can choose from a variety of tools that double or triple their chances of succeeding. The best approach uses medication to quell cravings for nicotine along with some sort of support or counseling to break the patterns that make a smoker reach for a cigarette. In the meantime, a few tips may help:

Know the enemy. List all the hazards of smoking. Then write down why you want to quit.

Make a date. Pick a date to quit and prepare yourself by figuring out how you will deal with cravings. The day before, throw away all cigarettes, ashtrays, and lighters — anything that may tempt you.

Talk with your doctor. Smoking changes the way your body processes some medications, so talk with your doctor about how to manage doses. Ask about nicotine replacement (available as patches, gum, and inhalers) and bupropion (Wellbutrin, Zyban) to ease cravings. In May 2006, the FDA approved varenicline (Chantix) for smoking cessation. Varenicline packs a one-two punch: by binding to the same receptors in the brain as nicotine, it can help ease withdrawal symptoms and also make smoking less pleasurable if you do slip up and resume smoking.

Avoid temptation. Avoid smoke-filled bars and social situations that may tempt you until you feel stronger in your resolve.

Find alternatives. Start exercising or find ways to relax.

Keep trying. If you don’t succeed on your first try, try again. It usually takes several attempts to quit smoking completely.


Get active

Your first exercise after a heart attack or procedure should take place in a medical setting during the first few weeks of your recovery. Your heart rate will be monitored to make sure you don’t develop any dangerous heart rhythms. If you don’t attend rehab, you should have a pre-exercise stress test, which can help set the guidelines for your exercise prescription.

What kind of exercise is best, and how much should you do? Aim for 30 minutes or more of moderate activity per day as a good initial goal (and if you want to build up from there, all the better). Aerobic exercise, which employs large muscle groups in a rhythmic, repetitive fashion for prolonged periods of time, has long been considered the best type of exercise for the heart. (For suggestions, see “Examples of moderate activity.”) But flexibility exercises (those that stretch muscles) and resistance exercises (which strengthen them) are also good. What follows is a quick guide to exercise for cardiac rehabilitation.

Get started. If you aren’t doing much physically, then mild exercise a few times a week will cut your heart disease risk in half. Even mild activity, like walking at a reasonable pace, can make a big difference in the health of your blood vessels. Raising your heart rate and dilating arteries modestly can help to lower your blood pressure and prevent atherosclerosis. Start with 20- to 30-minute walks three days a week, then build up to 30 minutes or more nearly every day. Or try three 10-minute walks every day, which is just as effective. If you feel chest pressure, lightheadedness, or marked shortness of breath, see your doctor right away.

Keep going. Daily exercise will help you to burn more calories, and that will have a whole range of beneficial health effects.

Pump up the volume. If you can do mild or moderate physical activity daily, start doing short bursts of more intense activity. You can walk five miles every day at the same slow clip, and you will burn plenty of calories. But short bursts of intense activity — 30 to 60 seconds of really pushing yourself — can help take the health of your blood vessels to a new level. If you walk for exercise, for instance, increase your pace, try a slow jog, or try walking in a pool (the water provides resistance, making you work harder). This type of moderate physical stress on the arteries helps to keep them younger.

Examples of moderate activity

  • Bicycle riding (leisurely pace)

  • Gardening

  • Golf (walking the course)

  • Housework

  • Mowing the lawn (power mower)

  • Raking leaves

  • Swimming (slow pace)

  • Walking (3 to 4 mph)


Eat healthy foods

The AHA dietary guidelines recommend a “big picture” approach, encouraging people to establish a healthy eating pattern over an extended period rather than simply counting calories or avoiding particular foods. The following is advice on major food groups and other dietary components.

Complex carbohydrates. Carbohydrates are the major component of bread, pasta, cereal, fruit, milk, vegetables, and beans. Simple carbohydrates are sugars; complex carbohydrates include starches and fiber. Although carbohydrates have been demonized in some popular diets, the right types of complex carbohydrates are good for your heart. That means eating lots of fruits, vegetables, and whole grains, while avoiding sugar, white bread, and other refined starches.

  • Vegetables and fruits. Diets that include multiple servings of vegetables and fruits lower the risk for hypertension, heart disease, and stroke. Whole fruits and those dark in color tend to be high in fiber, nutrients, and antioxidants — all of which are good for health. Aim for five or more servings of a variety of fruits and vegetables per day.

  • Grain products. You can find grains in cereal, pasta, and bread. The best strategy is to avoid highly refined grains (white bread, white rice, and the like) and instead opt for whole-grain foods, such as whole-wheat bread and brown rice. First of all, the highly refined carbohydrates are digested quickly and tend to have a high rating on the glycemic index, a measure of the rate at which blood sugar rises after you eat a particular food. High-glycemic foods create a spike in blood sugar, or glucose, that triggers a surge of insulin to help cells use this nutrient. As glucose is metabolized, your blood sugar levels plummet, making you want to eat again. This “blood sugar roller coaster” boosts triglycerides, lowers helpful HDL cholesterol, and increases the risk for heart attack in people who are overweight. Whole grains, on the other hand, take longer to digest and tend to be low on the glycemic index; they cause blood sugar levels to rise and fall more slowly. As a result, you will feel full longer while obtaining more nutrients. Aim for six or more servings of healthy grains per day.

  • Fiber. Slowly digested carbohydrates also tend to be high in fiber, a form of indigestible carbohydrate found mainly in plant foods. Fiber can produce a slight decrease in both total and LDL cholesterol. Perhaps more significantly, a number of studies show that fiber helps to prevent heart disease and reduce the risk for a heart attack. The Institute of Medicine recommends 38 grams of fiber per day for men and 25 grams for women ages 50 and younger; men and women over 50 should get 30 and 21 grams per day, respectively.

Proteins. Your body needs protein to build and repair muscles, skin, and cells. Protein is found primarily in meat, fish, poultry, dairy products, and nuts, as well as beans and other legumes. Some protein sources are better than others when it comes to your heart. Red meat and dairy products made from whole milk are high in saturated fat, which can boost your cholesterol. The AHA recommends that you eat other sources of protein, such as fish, skinless lean poultry, nuts, and legumes.

Healthy fats. One of the biggest dietary developments since the 1990s has been the understanding that not all fats are bad. Some fats are better than others — and some are actually good for you.

  • Avoid saturated fats and trans fats. Saturated fat, derived primarily from animal products, does indeed clog your arteries and raise your risk for coronary artery disease. Even worse are trans fats, which pack a double whammy by raising LDL cholesterol and lowering HDL cholesterol. Trans fats can be found in margarines, crackers, cookies, snack foods, and other foods made with or fried in partially hydrogenated oils. Since January 2006, the FDA has required that trans fats be listed in the “Nutrition Facts” label on food packages. The AHA recommends limiting your trans fat intake to less than 1% of your total calories.

  • Choose monounsaturated and polyunsaturated fats. Monounsaturated fats (found in olive and canola oils, nuts, and avocados, for example) and polyunsaturated fats (found in fatty fish, corn, soybean, safflower, and cottonseed oils) actually protect your health by improving your cholesterol profile. Based on data from more than 80,000 women enrolled in the Nurses’ Health Study, researchers estimated that replacing 5% of calories from saturated fat with unsaturated fats would reduce the risk of heart disease by 42%, and replacing just 2% of calories from trans fats with unsaturated fats would reduce risk by 53%.

  • Include fish, omega-3 fats, and fish oil supplements. Omega-3 fats, a type of polyunsaturated fat found in fatty fish, nuts, and other foods, are particularly heart-healthy. The main omega-3 fats in fish are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Studies show that fish and omega-3 fats reduce your risk for heart disease, heart attack, and sudden cardiac death. Omega-3s also decrease triglyceride levels.

The AHA recommends eating fish, especially oily fish, at least twice per week. Men and women with heart disease are advised to consume about 1 gram of EPA and DHA per day through a variety of high– omega-3 seafood or by taking fish oil supplements.

A common concern about eating fish is that fish can contain mercury and other toxins, including PCBs and dioxins. The FDA recommends that children and pregnant women avoid eating shark, swordfish, king mackerel, and tilefish, which contain a higher level of contaminants. For most other people, however, the benefits of eating fish far outweigh the risks. If you’re still concerned, choose from the following, which are high in omega-3 fats and low in contaminants: anchovies, Atlantic herring, Atlantic mackerel, scallops, wild salmon, canned salmon, sardines, trout, and mussels.

Fish oil capsules, which are rich in omega-3 fats and contain little, if any, mercury or PCBs, provide another option. The AHA recommends that people with heart disease consider taking a fish oil supplement if they are unable to consume 1 gram of EPA and DHA daily by eating seafood. For people with high triglycerides, the AHA suggests fish oil capsules containing 2 to 4 grams of EPA and DHA per day. Remember to talk with your doctor ahead of time about whether you should take supplements. This is especially important if you are taking blood-thinning medications such as warfarin (Coumadin), since taking omega-3 supplements may lead to bleeding problems. Consider, however, that you may need to eat fish rather than just fish oil to enjoy its heart-healthy benefits.

Alcohol. Dozens of studies have suggested that moderate consumption of alcohol reduces the risk for heart disease. Although a few have found that wine is more beneficial than beer or hard liquor, most have found that any type of alcohol in moderation may help. It is not entirely clear why moderate alcohol consumption helps the heart, but it may raise helpful HDL levels, quell inflammation, and decrease the risk for blood clots. The key is moderation, however. Drinking more than two drinks of alcohol per day on a regular basis increases the risk of developing hypertension, while having more than three per day raises the risk for stroke, arrhythmia, and sudden death. Another factor to consider is that alcohol is addictive. So if you don’t drink, don’t start just to help your heart; eating healthier food and exercising are better lifestyle strategies. If you do drink, do so in moderation (no more than one drink a day for women and two for men). A drink is defined as 1.5 ounces of hard liquor, 5 ounces of wine, or a 12-ounce beer.

Salt. You need only about one-eighth of a teaspoon of salt — 300 milligrams (mg) of sodium — to meet your body’s daily requirement. The average American consumes about one-and-a-half teaspoons (3,400 mg of sodium) a day. Eating too much salt raises blood pressure (see “High blood pressure”), while cutting back on salt lowers blood pressure to greater or lesser degrees, depending on your genes, your age, and your medical conditions. Reducing salt intake is most effective at lowering blood pressure in blacks, middle-aged and older people, and individuals with high blood pressure, diabetes, and chronic kidney disease.

The AHA has become more strict about salt, recommending that Americans reduce their salt intake to only 1,500 mg per day, an amount that has been shown to lower blood pressure in people with or without hypertension. However, taking into consideration the high-sodium foods available on supermarket shelves and in fast-food restaurants, the AHA concedes that a target of 2,300 mg of sodium per day might be a more realistic place to start.

More than 75% of the salt consumed in the United States comes from processed foods such as cold cuts, canned soups, and commercially prepared baked goods. Fast foods also pack a salty punch. To reduce the sodium in your diet, limit the amount of canned, processed, and frozen food you eat. Also, read food labels and choose foods low in sodium.

Sugar. Average sugar consumption in the United States increased from about 120 pounds per person annually in 1970 to 150 pounds per person annually (almost half a pound per day) in 1995. High sugar intake lowers helpful HDL cholesterol and can elevate triglyceride levels, as well as increase the risk for type 2 diabetes and contribute to weight gain and obesity. Studies dating back to the 1960s have shown that increased sugar intake raises the risk of developing coronary artery disease. The AHA recommends limiting intake of sugar as much as possible. This means not only doing the obvious (not adding heaping teaspoons of sugar to your coffee every morning), but also avoiding foods with added sugars (such as sweetened soft drinks) and foods with a high glycemic index (see “Grain products”).

What about vitamins?

Over the past few decades, various vitamins have been touted for their alleged ability to stave off heart disease. First came E, then C, then beta carotene (a vitamin A precursor), then the B vitamins (see “Beyond blood lipids: Other biomarkers for heart disease”). It would be nice if popping a daily multivitamin helped — they’re inexpensive and virtually risk-free. But while numerous observational studies have shown links between higher vitamin intakes and heart health, the more rigorous research that compares people who take specific vitamins with those who take placebos has come up short. In fact, the American Heart Association guidelines specifically state that vitamins E, C, beta carotene, and three B vitamins (folic acid, B6, and B12) should not be used to prevent heart disease. Not only do they not help, there’s even some suggestion that taking vitamin E supplements may slightly raise the risk of heart failure and hemorrhagic (bleeding) strokes.

As for vitamin D, a handful of observational studies suggest that people with low levels of the so-called sunshine vitamin face a higher risk of heart disease. People with dark skin (especially African Americans) and those who live in colder climates are particularly susceptible to vitamin D deficiency. So far, two large trials of vitamin D supplementation showed no benefit in reducing the likelihood of heart disease or stroke. Another one, involving some 20,000 people who are taking vitamin D either alone or in combination with fish oil, is under way, but results aren’t expected until 2016.


Sleep soundly

Two sleep-related problems that plague many people — sleep apnea and lack of sufficient sleep — have been linked to a higher risk of heart disease.

Sleep apnea. A common cause of loud, disruptive snoring, sleep apnea makes people temporarily stop breathing many times during the night. In those with the most common form, obstructive sleep apnea, soft tissue in the upper part of the mouth or back of the throat completely blocks the airway. The resulting drop in oxygen prompts the brain to send a “Breathe now!” signal that briefly awakens the sleeper and makes him or her gasp for air. That signal also jolts the same stress hormone and nerve pathways that are stimulated when you are angry or frightened. As a result, the heart beats faster and blood pressure rises — along with other factors that drive up heart disease risk, such as inflammation and a propensity for blood clot formation. Daytime drowsiness often occurs with sleep apnea, which affects one in 10 people ages 65 and older.

Research documents the dangers of sleep apnea: in one study, people with severe sleep apnea were three times more likely to have died of cardiovascular disease during 18 years of follow-up than those without apnea. When researchers excluded those who used a breathing machine (a common apnea treatment), the risk jumped to more than five times higher. Apnea spells can trigger arrhythmias (irregular heartbeats), and the condition also increases the risk of stroke and heart failure. Studies are now under way to see if treating sleep apnea with specialized breathing machines that can help prevent heart disease deaths.

In the meantime, experts advise people with high blood pressure, angina, heart failure, peripheral vascular disease, a past heart attack or stroke, or other types of cardiovascular disease to consider getting checked for sleep apnea.

Sleep deprivation. Most people need between seven and nine hours of sleep per night, but one in five Americans sleeps less than six hours per night — a trend that can have serious personal and public health consequences. Insufficient sleep can make you too tired to work efficiently, to exercise, or to eat healthfully. Over time, sleep deprivation increases the risk for a number of chronic health problems, including heart disease.

A number of studies have linked short-term sleep deprivation with several well-known risk factors for heart disease, including higher cholesterol levels, higher triglyceride levels, and higher blood pressure. One such report, published in a 2009 issue of Sleep, included more than 98,000 Japanese men and women ages 40 to 79 who were followed for just over 14 years. Compared with women who snoozed for seven hours, women who got no more than four hours of shut-eye were twice as likely to die from heart disease, the researchers found.

A shut-eye shortfall has been linked to increased calcium deposits in the heart’s arteries, according to a 2008 study in The Journal of the American Medical Association. Sleep deprivation boosts blood pressure, inflammation, and stress hormones, which may explain the association.




Medications for heart disease

Although lifestyle changes are an essential first step in treating coronary artery disease, most people need at least two medications to reach their cholesterol and blood pressure goals and keep the blood flowing freely through their arteries. The specific combination of drugs will depend on your particular symptoms and risk factors. Figure 12 shows each of the major classes of medications typically prescribed to people with heart disease and how they work in the body. The following summaries feature additional information about the most commonly prescribed medications.

Figure 11: Aspirin’s balancing act

Taking aspirin to prevent a heart attack or stroke isn’t for everyone. It makes the most sense if your chance of having a heart attack or stroke (see “What’s my risk?”) is greater than the odds of it causing a problem. For example, a 65-year-old woman with a 20% chance of having a stroke over the next 10 years is a good candidate for aspirin, since her potential for having a problem with aspirin is low (about 8%).

Aspirin

This common, inexpensive drug helps protect survivors of heart attack and stroke from subsequent heart attacks and death, and even helps reduce the number of deaths that occur within the first hours following a heart attack. Dozens of studies involving tens of thousands of people have shown that low-dose aspirin reduces the risk for heart disease and stroke by about 25%. But determining who benefits from aspirin — and how much to take — has been uncertain.

In 2009, updated guidelines from the U.S. Preventive Services Task Force (USPSTF) helped clarify these questions. In general, you should consider taking aspirin if its benefits outweigh its risks. For men, the main benefit is preventing a heart attack; for women, it is preventing an ischemic stroke (the type caused by a blockage in an artery feeding the brain). See “What’s my risk?” to figure out your heart disease or stroke risk.

For both men and women, aspirin’s main risks are gastrointestinal bleeding and hemorrhagic (bleeding) stroke. As with heart disease, the risk of bleeding complications rises with age. The USPSTF has set several tipping points, based on age and gender (see Figure 11). To get a sense of your own tipping point, compare your 10-year risk of heart attack or stroke with the likelihood that you’ll experience a hazard from taking aspirin. Notice that the risks are higher in men, because men are about twice as likely as women to have gastrointestinal bleeding.

Aspirin resistance

Some people — perhaps as many as 40% — may not experience all or any of the anticlotting benefit from taking aspirin. Several factors may explain this so-called aspirin resistance. For instance, the body’s response to aspirin may change over time. Some people have trouble absorbing aspirin from the digestive tract. Smoking blunts the effect of aspirin on platelets, as do being overweight and having high cholesterol or high blood pressure. A variety of genes influence how the body responds to aspirin. Finally, a few studies have indicated that a common nonsteroidal anti-inflammatory drug (NSAID), ibuprofen, may block aspirin’s protective effects. The occasional dose of ibuprofen isn’t likely to do this, but daily use could.

Although two laboratory tests are available to measure how well aspirin may be working for you, the idea of aspirin resistance is so new that many doctors either aren’t aware of it or are waiting for more evidence that it’s real before ordering these tests. So what do you do in the meantime? First, talk with your doctor about being tested for aspirin responsiveness. Second, if you need to take an NSAID for arthritis or some other condition, pick one that doesn’t interfere with aspirin, such as naproxen (Aleve, Naprosyn) or diclofenac (Cataflam, Voltaren). Third, don’t stop taking aspirin — regardless of whether you can get tested or what the results are. Aspirin probably works in several ways to prevent heart attacks. If you do find you are aspirin resistant, talk with your doctor about other antiplatelet medications.

Still, it’s best to get input on your decision from a trusted physician, especially if you face a higher-than-average risk of bleeding because of your medical history. Aspirin-induced bleeding is more likely to occur in people who have a history of uncontrolled high blood pressure, ulcers, or bleeding problems and those who regularly take ibuprofen (Advil, Motrin, generic), another nonsteroidal anti-inflammatory drug, or warfarin (Coumadin, Jantoven, generic).

The task force recommends a dose of 81 mg a day, the amount in a baby aspirin, which seems to work just as well as higher doses, with fewer bleeding problems. In theory, taking aspirin with a protective coating, known as enteric-coated aspirin, should help avoid ulcers and other stomach-related side effects, as the coating allows the aspirin to pass through the stomach to the intestine before dissolving. But aspirin in the bloodstream irritates the stomach just as much. In addition, there’s some evidence that not all the aspirin in a coated pill gets into the circulation.

Figure 12: Medications for treating heart disease and how they work

People with heart disease typically take at least two (and often more) different types of medication to manage their condition. This figure summarizes the major types of medications and how they work in the body. Note that most of these drugs work throughout the entire body — in particular, those that affect the blood or blood vessels, including aspirin, anticlotting and clot-busting drugs, and some blood pressure–lowering drugs. Other drugs to treat high blood pressure act in the kidneys, while cholesterol-lowering drugs work primarily in the liver. The medication tables below give examples of commonly used drugs in each of these major classes.


Blood pressure medications

The five categories of drugs used to treat high blood pressure (see Table 8) are equally effective for most people. But keep in mind that most people do not get their blood pressure under control with the starting dose of the first drug chosen. Some doctors increase the dosage of the first drug to see if it will bring blood pressure down to target levels. A second approach is to use low doses of two or more blood pressure drugs that work in different ways. This approach minimizes the likelihood of side effects, but may be harder to follow, as it requires taking two or more pills per day. It may also be more expensive for the person being treated, as he or she may face additional copayments or out-of-pocket expenses for the drugs. A compromise approach is to use combination medicines that include, for example, both an ACE inhibitor and a low-dose diuretic (see “Combination medications”). This is convenient, but many combinations are available only in brand-name forms and are thus more expensive.

Table 8: Blood pressure medications

Generic name
(brand name)

Side effects

Comments

Thiazide diuretics

chlorothiazide* (Diuril)

Weakness, confusion, potassium depletion, gout, fatigue, thirst, frequent urination, lightheadedness, muscle cramps, diarrhea or constipation, increased sensitivity to sunlight, allergic reaction in people allergic to sulfa drugs, erectile dysfunction.

Inexpensive, generally well-tolerated; often the first-line treatment for high blood pressure. Can cause low potassium levels and may require the use of potassium supplements.

chlorthalidone* (Hygroton)

hydrochlorothiazide* (Esidrix, HydroDiuril, Microzide)

indapamide* (Lozol)

metolazone* (Mykrox, Zaroxolyn)

ACE inhibitors

benazepril* (Lotensin)

Persistent dry cough, altered taste sensation, rash and other allergic reactions; may cause kidney damage and, rarely, decrease white blood cells.

ACE inhibitors are usually taken once or twice a day; may be used alone or in combination with other medications.

Captopril may take several weeks to achieve the full effect; kidney function should be monitored; usually taken two or three times per day.

captopril* (Capoten, Capozide)

enalapril* (Vaseretic, Vasotec)

fosinopril* (Monopril)

lisinopril* (Prinivil, Zestril)

moexipril* (Univasc)

quinapril* (Accupril)

ramipril* (Altace)

trandolapril* (Mavik)

Angiotensin-receptor blockers (ARBs)

candesartan (Atacand)

Persistent cough, elevated potassium levels, dizziness, headache, drowsiness, diarrhea, abnormal taste sensation, rash.

May be an alternative for people who can’t take ACE inhibitors.

eprosartan (Teveten)

irbesartan* (Avapro)

losartan* (Cozaar)

olmesartan (Benicar)

telmisartan (Micardis)

valsartan (Diovan)

Beta blockers

atenolol* (Tenormin)

Less likely than propranolol to cause wheezing and spasm of arteries outside of the heart.

Atenolol and metoprolol are “cardioselective” beta blockers, which means they can be used with caution by people with asthma, although they can still cause side effects.

metoprolol* (Lopressor, Toprol XL)

nadolol* (Corgard)

Can worsen or provoke asthma or pain in legs due to narrowed arteries; can worsen heart failure; can provoke Raynaud’s phenomenon (spasm of blood vessels to hands); sometimes cause fatigue or depression, impotence, hallucinations, or bad dreams (elderly people are more prone to these latter side effects).

Nadolol is a long-acting drug usually taken once per day; do not stop taking suddenly.

propranolol* (Inderal, Inderide)

Propranolol is available in short-acting and extended-release forms.

timolol (Blocadren, Timolide)

Timolol is usually taken twice per day.

Other beta blockers not included in this table include pindolol (Visken), acebutolol (Sectral), labetalol (Normodyne, Trandate, others), penbutolol (Levatol), carteolol (Cartrol), betaxolol (Kerlone), bisoprolol (Zebeta), and combination medications with a beta blocker as one ingredient. Although most of these medications are often used to treat hypertension, not all of them have been evaluated in large, randomized trials for their ability to help people who have coronary artery disease.

Calcium-channel blockers

amlodipine* (Caduet, Lotrel, Norvasc)

Higher doses cause similar side effects to those caused by nifedipine.

Can be taken once daily; with less than the highest doses, possibly fewer side effects than from nifedipine.

felodipine* (Plendil)

diltiazem* (Cardizem, Dilacor XR, others)

Headache, flushing, nausea, weakness, drowsiness, fluid retention, constipation, excessively slow heart rate.

Low rate of side effects in most people; available in long-acting preparations.

nifedipine* (Adalat, Nifedical XL, Procardia)

Headache, swelling of legs (edema), flushing, palpitations, dizziness, constipation.

Long-acting preparation may reduce side effects, but swelling of legs and ankles remains a problem with both short- and long-acting formulations.

nicardipine* (Cardene)

verapamil* (Calan, Verelan, others)

Constipation, excessively slow heart rate, worsened heart failure.

Available in long-acting preparations; constipation limits use in some people.

*An asterisk indicates the drug is available in a generic version or is expected to be within the near future.


Cholesterol medications

Among the medications used to lower cholesterol, statins are by far the most effective and therefore most widely used. Results from large trials show that taking a statin reduces the chances of having a heart attack or stroke, needing bypass surgery or angioplasty, or dying of heart disease. Overall, for every 40-point reduction in LDL achieved with a statin, the risk drops by 20%. The greater your chances of having a heart attack or stroke or dying of cardiovascular disease, the more a statin can help. In addition to lowering LDL, these drugs also help stabilize cholesterol-filled plaque in artery walls, promote the growth of new blood vessels, and calm inflammation.

Table 9: Cholesterol-lowering medications

Generic name (brand name)

Side effects

Comments

Statins

atorvastatin (Lipitor)

Abdominal pain, constipation, diarrhea, indigestion, nausea, flatulence, heartburn, dizziness, fatigue, headache, rash, blurred vision, muscle pains, damage to muscle or liver, sleep disturbances.

Do not take if you drink heavily or have liver disease. Use with caution if you take gemfibrozil, cyclosporine, clofibrate, erythromycin, or niacin. Can increase the effect of warfarin.

For Crestor: Take the lowest starting dose if you are over 65, have hypothyroidism or kidney disease, or are Asian American.

(Also see “Getting the most from your statin.”)

fluvastatin (Lescol)

lovastatin* (Altoprev, Mevacor)

pitavastatin (Livalo)

pravastatin* (Pravachol, Pravigard PAC)

rosuvastatin (Crestor)

simvastatin* (Zocor)

Bile acid binders

cholestyramine* (LoCholest, Questran)

Constipation, heartburn, “bloated” feeling, nausea, flatulence, tendency to bleed easily; decreased absorption of certain drugs and vitamins A, D, and K. May elevate triglycerides.

Do not take if you have familial dysbetalipoproteinemia (a very high triglyceride level) or a history of severe constipation. Use with caution if you have moderately elevated triglycerides. Take any other medications at least one hour before or four hours afterward. Vitamin supplementation may be necessary. Colesevelam also helps lower blood sugar levels, and is less likely to cause side effects than the other two medications.

colestipol* (Colestid)

colesevelam (WelChol)

Ezetimibe

ezetimibe (Zetia)

Uncommon but may include fatigue, gastrointestinal problems, muscle pain, fever, headache, runny nose, sore throat.

Helpful for people who have not responded to statins. Boosts LDL-lowering effect of statins, but no evidence for heart disease protection.

Cholesterol-lowering combination

ezetimibe plus simvastatin (Vytorin)

Headaches, muscle pain, allergic reaction, liver problems, inflammation of the pancreas, nausea, gallstones, inflammation of the gallbladder.

Unclear whether this combination strategy will prevent more heart attacks and deaths than other treatment approaches.

Fibric acid derivatives (fibrates)

fenofibrate* (Lofibra, Tricor)

Nausea, vomiting, diarrhea, indigestion, flatulence, abdominal pain, headache, cardiac arrhythmias, dizziness, fatigue, muscle pain and weakness, rash, hair loss, abnormal liver or muscle enzymes.

Do not take if you have liver problems, severe kidney problems, or gallbladder disease. Avoid if in combination with statins. Can increase the effects of warfarin. Liver functions and blood counts should be checked before and throughout therapy.

gemfibrozil* (Lopid)

Niacin

Niacin/nicotinic acid* (Advicor, Niacor, Niaspan)

Flushing (especially with crystalline preparations), rash, headache, nausea, vomiting, diarrhea, flatulence, indigestion, low blood pressure, elevated uric acid blood levels, high blood sugar, peptic ulcer activation, cardiac arrhythmias, dry skin, abnormal liver enzymes (especially with sustained-release preparations).

Especially effective in combination with bile acid binders. Do not take if you have chronic liver disease, active peptic ulcer, or arterial bleeding. Use with great caution if you have gallbladder disease, diabetes, severe gout, or high blood levels of uric acid. Tests of blood glucose, uric acid, and liver functions need to be performed regularly.

*An asterisk indicates the drug is available in a generic version or is expected to be within the near future.

Other cholesterol-lowering medications (see Table 9) may be as beneficial for you, depending on your circumstances. Bile acid binders lower LDL cholesterol by 15% to 30%, depending on the daily dose and whether they are combined with a statin. If you have high triglycerides in addition to high LDL, fibric acid derivatives may help. They reduce triglycerides by 20% to 50% and raise HDL levels by 10% to 15%, but have only a modest effect on LDL. If you have low HDL cholesterol, niacin is an option. Niacin alone can reduce LDL levels by 15% or so, lower triglycerides even more, and boost HDL by as much as 20%. Taken in addition to a statin, niacin lowers LDL another 10%. Another drug in a class of its own is ezetimibe (Zetia), which lowers LDL cholesterol by about 20%. Vytorin, a drug that combines ezetimibe with simvastatin, lowers LDL levels another 15% to 23%.

Getting the most from your statin

You can do several things to make sure your particular statin is working as well as it can.

  • Take lovastatin with food. This almost doubles the amount of medication that gets into your bloodstream.

  • It’s best to take lovastatin, simvastatin, or fluvastatin with your evening meal. That’s because these statins block a key cholesterol-making enzyme in the liver that is most active at night. Atorvastatin, pravastatin, and rosuvastatin last long enough in the body that it doesn’t matter when you take them.

  • Grapefruit juice increases blood levels of lovastatin, simvastatin, and atorvastatin, but doesn’t usually affect the other statins.

  • Beware of drug interactions. Mention all other medications you are taking when talking with your doctor about a statin to avoid potentially harmful interactions. If you are on other medications, you may want to try pravastatin, which is less likely than the other statins to interact with other medications.


Nitrates

One of the oldest classes of drugs used to treat heart problems, nitrates (see Table 10) have been used for more than a century to treat angina. One common form, nitroglycerin (Nitrostat), is best known as the little white pills that people carry with them and slip under the tongue when they have bouts of chest pain. The drug also comes in different forms, including a short-acting liquid spray as well as long-acting ointments and patches. People who take the long-acting forms run the risk of developing nitrate tolerance, which means the body no longer responds to the drug’s effects. Removing the patch at night can minimize this risk.

Table 10: Nitroglycerin and long-acting nitrates

Generic name (brand name)

Side effects

Comments

nitroglycerin (Nitrostat)

Headache, flushing, low blood pressure.

Placed under tongue to provide relief from or to prevent angina attack; a short-acting preparation.

nitroglycerin spray (Nitrolingual Pump spray, NitroMist)

One to two squirts onto or under the tongue to treat or prevent angina.

isosorbide mononitrate* (Imdur, Ismo, others)

Long-acting nitrate pill; taken at regular prescribed intervals to decrease the frequency of angina.

nitroglycerin ointment (Nitro-Bid)

Placed on the skin and covered with a dressing, allowing slow absorption of the medication over several hours; removal of ointment for several hours each day recommended to provide a period without exposure to nitroglycerin.

nitroglycerin patch* (Minitran, Nitro-Dur, others)

Convenient; removal of patch for several hours each day recommended to provide a period without exposure to nitroglycerin.

Special caution for all nitrate medications: Do not use if you are taking medications to treat erectile dysfunction, such as tadalafil (Cialis), vardenafil (Levitra), or sildenafil (Viagra). These medications can cause a life-threatening drop in blood pressure when used in addition to a nitrate. If you are taking nitroglycerin and are experiencing erectile dysfunction, talk with your doctor about alternatives.

*An asterisk indicates the drug is available in a generic version or is expected to be within the near future.

Other nitrate delivery systems, including long-acting isosorbide mononitrates (Imdur, Ismo), accomplish the same thing with a single dose each day. One risk with this approach is that you might be left unprotected during the first hour or so after awakening — a high-risk time for heart attacks. This problem is often addressed by using other long-acting anti-anginal medications in conjunction with the nitrates.

Cautions about COX-2 inhibitors and traditional NSAIDs

Many people take medications for both heart disease and arthritis. Typically, nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve the pain and inflammation of arthritis. This class of medications includes aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and celecoxib (Celebrex), a COX-2 inhibitor. Celebrex carries a warning because there is a risk to inhibiting only the COX-2 enzyme: an increased chance of having a heart attack or stroke.

Emerging research suggests that most NSAIDs, not just the COX-2s, increase risk for heart attacks and strokes. Ibuprofen and diclofenac (Cataflam, Voltaren), for example, appear to increase the risk of cardiovascular disease. An exception is low-dose aspirin, which helps prevent blood clots but may also increase risk for gastrointestinal bleeding. Naproxen does not appear to increase cardiovascular risk, but it also does not protect against heart attacks, as it was once thought to do. NSAIDs also increase the risk of developing high blood pressure.

It is still possible to treat your arthritis pain even if you have heart disease. But a few common-sense precautions — and perspective — may help. The following strategy should help most people:

  1. Start with aspirin or acetaminophen (Tylenol). If these medications cannot control your pain, consider using codeine or another narcotic agent on a short-term basis, although it’s always important to work with your doctor to identify the cause of your pain so you can treat it definitively.

  2. If aspirin or acetaminophen doesn’t provide sufficient relief, try naproxen, which appears to have a neutral effect on the heart.

  3. Ibuprofen or another NSAID should be tried next. Just remember to mention this to your doctor, so your blood pressure can be monitored. If taking these drugs in the past caused gastrointestinal bleeding or gave you an ulcer, ask your doctor for advice. Sometimes taking an NSAID with a meal, or taking another medication to protect your stomach, such as omeprazole (Prilosec), which is available over-the-counter, can quell gastric distress.

  4. The COX-2 inhibitor Celebrex should be used as a last resort because it can increase the risk of having a heart attack. Remember, many people turned to the COX-2s because these drugs were marketed as providing better pain and inflammation relief than other NSAIDs. In fact, the older NSAIDs are just as effective in many cases; the main advantage of COX-2s is that they aren’t as likely to cause bleeding ulcers.

  5. If you take any NSAID, try to do so at the lowest dose possible and only as needed.


Anticlotting medications

In addition to aspirin, a number of drugs are prescribed to prevent blood clots. The oldest one, warfarin (Coumadin and others; see Table 11), has been the mainstay “blood thinner” used by millions of people to lessen the chances of developing a harmful, or possibly fatal, blood clot. But many things can affect how the drug works, including what you eat and drink, your health, and a number of drugs, vitamins, supplements, and herbal remedies. As a result, people taking warfarin need routine blood tests for their international normalized ratio (INR), a measure of the time it takes blood to clot. The results tell your doctor if your warfarin dosage needs adjusting.

In 2010, the FDA approved dabigatran (Pradaxa), which works similarly to warfarin but has several advantages. In clinical trials, it decreased the risk of stroke or death more than warfarin, with fewer episodes of major bleeding. It isn’t affected by diet and doesn’t require routine blood tests. But as with all newly approved drugs, the full extent of dabigatran’s efficacy, side effects, and safety won’t be apparent until after hundreds of thousands of people have taken it for long periods of time. The situation that occurred with COX-2 inhibitors in the 1990s (see “Cautions about COX-2 inhibitors and traditional NSAIDs,” below) underscores why it makes sense to be cautious whenever a new medication hits the market.

Table 11 lists other anticlotting medications that doctors may prescribe for people who have unstable angina or who have had a heart attack, and either before or after angioplasty with a stent.

Table 11: Anticlotting medications

Generic name (brand name)

Side effects

Comments

warfarin* (Coumadin, Jantoven)

Bleeding from any tissue or organ.

Not recommended for people who have active ulcers. Requires routine blood testing. Certain medications including antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and barbiturates may boost the bleeding effect of warfarin.

dabigatran (Pradaxa)

Stomach pain, heartburn, nausea. Serious side effects include bleeding, joint pain or swelling, headache, swelling of the arms or lower legs.

Useful alternative to warfarin for people with atrial fibrillation who are at risk of stroke. Not for use in people with certain kidney diseases, liver disease, or those with a mechanical heart valve.

clopidogrel* (Plavix)

Stomach pain, nausea, headache, dizziness. Serious side effects include bleeding, hives, rash, liver dysfunction, and swelling of the face, hands, and feet.

May be less effective in people taking heartburn drugs such as omeprazole (Prilosec) and esomeprazole (Nexium). About 3% of whites and blacks and up to 20% of East Asians have a genetic variation that diminishes the drug’s effectiveness. Genetic tests are available to identify people with this variant, and information about who should get this test should become available by 2012.

prasugrel (Effient)

Dizziness, excessive tiredness, headache, or pain in the back, arms, or legs. Serious side effects include shortness of breath and a slow, fast, or irregular heartbeat.

Should not be taken by people who have a history of ulcers or other internal bleeding, or who have had recent surgery, a stroke or a mini-stroke, or liver disease.

Glycoprotein inhibitors: These medications are given intravenously in the hospital to people who have unstable angina or who have had certain types of heart attacks, as well as those undergoing angioplasty or other invasive heart procedures.

abciximab (ReoPro)

Bleeding, dizziness, nausea, vomiting, headache, back pain, slow heart rate.

Unsafe for people with recent bleeding episodes, bleeding problems, who have had recent surgery, or who have had a stroke within two years.

tirofiban (Aggrastat)

Unsafe for people with kidney problems.

eptifibatide (Integrilin)

Dosage should be monitored and adjusted carefully in people with kidney problems.


Clot-busting medications

Your chances of surviving and recovering from a heart attack increase if you receive a thrombolytic drug within 12 hours — and ideally within the first 90 minutes — after the heart attack starts. These drugs help restore blood flow by dissolving blood clots. Alteplase is the most common one; Table 12 lists additional options.

Table 12: Clot-busting medications

Generic name (brand name)

Side effects

Comments

recombinant tissue-plasminogen activator (tPA), also called alteplase (Activase)

Bleeding from any tissue or organ.

Must be given intravenously within a few hours of when heart attack symptoms begin. Can be life-threatening for people who have had a hemorrhagic stroke. Unsafe for people who’ve had a previous stroke or head injury or who have uncontrolled hypertension, a bleeding disorder, an aneurysm, or an arteriovenous malformation.

reteplase (Retavase)

May be delivered via a catheter directly to the blood clot. Unsafe for people who’ve had a previous stroke or head injury or who have uncontrolled hypertension or a bleeding disorder.

streptokinase (Streptase)

tenecteplase (TNKase)

urokinase (Abbokinase)

*An asterisk indicates the drug is available in a generic version or is expected to be within the near future.


Combination medications

A number of combination medications are available to treat coronary artery disease. Most aim to control high blood pressure by combining a diuretic with a beta blocker, calcium-channel blocker, ACE inhibitor, ARB, or a different type of diuretic.

Is a combination drug right for you? It depends on your situation. Many people take more than one drug to control blood pressure or cholesterol, for instance. If you find you routinely miss doses or get confused about which medications you have taken, it may make sense to take a combination pill.

Cost is another consideration, especially if you have to make a copayment each time you purchase a medication. Using a combination drug means you would make one copayment instead of two. But if you pay for your medication yourself, or if your health plan charges a higher copayment for brand-name drugs than for generics (as is often the case), a combination could prove more expensive, as some combination drugs include one or more brand-name drugs for which less expensive generic versions are available. Indeed, combination drugs represent a growth industry for drug makers: they can help a company extend high-profit sales of a drug whose patent is about to expire.

Another drawback to combination medications is that it is hard to adjust the dose, and changing dosage is a fact of life for people using cardiovascular drugs. Doctors often start patients on low doses of particular medications and then increase specific ones as needed to control one or more factors such as blood pressure, cholesterol, or blood sugar. But in a combination drug, the doses are paired: you can’t increase one medication without increasing the other.

So what do you do? Combination drugs probably aren’t a good idea if you are just starting drug therapy for a condition, or if your doctor needs to change the dose often. On the other hand, if you have been taking two well-established medications at stable doses for some time, a combination that delivers both of them at the right doses is worth looking into, especially if it contains generic versions of the drugs.



Heart procedures

With the help of medications, most people with coronary artery disease can live normal lives with few limitations. However, some people benefit from revascularization procedures, which restore blood flow to areas of the heart muscle that have been affected by the blocked artery. The two main procedures are angioplasty and coronary artery bypass surgery. Doctors often refer to angioplasty as PCI, which stands for percutaneous (through the skin) coronary intervention. A nonsurgical procedure, PCI encompasses both angioplasty and stent placement (see below).

If your doctor has recommended a cardiac procedure, seek out a cardiac specialist at a medical center where bypass surgery and angioplasty are frequently performed. As you might expect, research has shown that outcomes are best at the institutions with the most experience. You may also want to do research about your surgeon’s track record (see “Report cards for cardiac surgery”). But in an emergency situation, the closest facility is often your best option.

Angioplasty

Percutaneous transluminal coronary angioplasty (PTCA), better known as angioplasty, revolutionized cardiology. The technique enables doctors to open narrowed or blocked coronary arteries with special catheters that carry inflatable balloons. The term angioplasty refers to the reshaping of the narrowed segment of a blood vessel in the course of the procedure. Most angioplasty procedures also involve the placement of stents, which are metal mesh tubes that serve as scaffolds to help hold arteries open (see “Why use a stent?”).

Angioplasty is often appropriate following a heart attack. It is the most effective way to treat people with ST-elevation heart attacks (see “ECG patterns”). To be effective, angioplasty must be done early — ideally within 90 minutes of the start of symptoms, but certainly within 24 hours.

But the decision to use angioplasty to alleviate angina and other heart problems should be made on an individual basis. Angioplasty can treat narrowing at curves in coronary arteries, disease in several vessels, and even narrowing in coronary artery bypass grafts. Because of technical advances in angioplasty, doctors are now willing to perform it on some people for whom it used to be considered too risky.

Angioplasty does not solve the underlying problem of atherosclerosis. The procedure may open one or more narrowed arteries, but it is likely that atherosclerotic plaques lurk elsewhere. Even after people undergo angioplasty, they still have to take other steps to reduce their risk for heart attack, such as eating better, getting more exercise, and taking medications as prescribed.

And if you have stable angina (or no symptoms at all) from a narrowed coronary artery, medical therapy alone is a better option than more aggressive treatment, according to the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, which was published in 2007. And, contrary to what many people believe, angioplasty done for mild or no symptoms does not protect you from having a heart attack in the future.

However, if you are having a heart attack or an episode of unstable angina, angioplasty is definitely better than drug treatment at preventing a second heart attack and improving survival.

Figure 13: Radial artery angioplasty

Starting artery-opening angioplasty at the radial artery in the wrist is a safe alternative to starting it at the femoral artery in the groin.

Angioplasty, step by step

A person undergoing angioplasty remains awake during the procedure, but receives local anesthesia. As in routine coronary arteriography, angioplasty starts with the physician inserting a catheter into an artery in an arm or leg and guiding it through the blood vessels to the openings of the coronary arteries. Inside this catheter is a thinner catheter, which has an inflatable balloon near its tip. And inside that catheter is an even thinner wire with a soft tip that can snake through tight narrowings and punch through clots, but is unlikely to damage the wall of the coronary artery.

Although most angioplasties are done via the femoral artery in the groin, a small percentage are done through the radial artery in the wrist (see Figure 13). A major study involving more than 7,000 patients in 32 countries found the two approaches to be nearly identical in terms of serious complications such as death or heart attack during the month following the procedure. But there were fewer cases of bleeding around the angioplasty entry site with the radial approach. And it also appeared to be more effective than the femoral approach for treating people in the midst of a heart attack, as reported in a 2011 article in The Lancet. Another advantage of the wrist entry: you don’t need to lie still for several hours after the procedure to make sure the bleeding has stopped.

Once the catheter reaches the heart, the cardiologist guides the wire gently down the artery until the tip is beyond the narrowing. (If the coronary artery is completely blocked, the physician may try to push the wire through the obstruction.) Once the wire has crossed the stenosis (blockage), the catheter with the balloon slides down the wire until the balloon is adjacent to the atherosclerotic plaque (see Figure 14). From outside the body, the physician inflates the balloon, which cracks and compresses the atherosclerotic plaque, stretches the underlying normal artery wall, and widens the artery.

Figure 14: Balloon angioplasty

To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).

Stent placement is also done with the balloon catheter. The stent is made of a springy, collapsible metal mesh (see Figure 15). During angioplasty, the doctor places the collapsed stent over the balloon catheter. When the balloon is inflated at the site of the blockage, the stent also expands. The doctor withdraws the catheter and the deflated balloon and leaves the expanded stent in place.

Figure 15: Angioplasty with drug-coated stent

One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).

Following a stent procedure, you take medications to prevent blood clots that could lead to restenosis, or renarrowing of the artery (see “Why use a stent?”). To prevent this problem, doctors may use a stent coated with medication. Aspirin must be taken indefinitely, no matter what type of stent is used. In addition, clopidogrel (Plavix) or prasugrel (Effient) is prescribed for at least one month if an uncoated stent is inserted, and for at least one year if a drug-coated stent is used.

Angioplasty triggers minor heart attacks in about four in 100 people, and just fewer than one in 100 die from complications of the procedure. Even with the drug-coated stents, about five in 100 people will eventually need to repeat the procedure because the reopened artery narrows again.

There are two main ways to tell if a stent has collapsed or if it is being overgrown with tissue: symptoms such as chest pain, and heart function tests. If you start experiencing chest pain or other symptoms of angina, call your cardiologist and ask for an evaluation. But if you feel fine, it is safe to assume that the stented artery remains open.

Why use a stent?

Angioplasty has one troubling complication: restenosis, a renarrowing of an artery in the same spot that angioplasty had cleared. Restenosis usually happens within three to six months of the original procedure and may occur for several reasons. One cause is elastic recoil — that is, the vessel stretched by angioplasty gradually returns to its original size. A second reason is intimal hyperplasia, which involves a vigorous growth of cells lining the vessel wall. Intimal hyperplasia can occur as part of the healing process following angioplasty.

In the 1990s, cardiologists began using devices called stents to prop open arteries after angioplasty. A stent looks like a miniature chain-link fence rolled into a tube. By placing a stent inside the treated blood vessel, cardiologists were able to keep arteries from recoiling, thus preventing one serious complication of angioplasty. But the early stents did not stop restenosis.

Drug-coated stents, first introduced in 2003, helped solve the problem. The first, the Cypher stent, is coated with sirolimus, a substance that cools inflammation and stops muscle cells in the artery wall from growing and dividing. Trials comparing these stents with the older ones showed a clear advantage for the sirolimus-coated stent. Only about one in 20 people who get angioplasty plus a Cypher stent has enough regrowth in the artery wall to again limit blood flow, compared with one in three who get a bare-metal stent. The second drug-coated stent, Taxus (which is coated with paclitaxel), hit the U.S. market in 2004. By early 2007, drug-coated stents accounted for almost 85% of all stents placed.

But drug-coated stents have problems of their own. The drugs they exude prevent cells in the artery wall from covering the stent. Without this protective sheath, clots can form on the stent. Early studies suggested that this problem, known as stent thrombosis, was twice as likely to happen with drug-coated stents as with bare-metal stents. However, a long-term follow-up showed no significant difference in deaths and heart attacks among 19,000 people three years after receiving a drug-coated or bare-metal stent.



Coronary artery bypass surgery

The principle behind coronary artery bypass surgery is to construct a new channel so blood can get around blockages in the coronary arteries. The cardiac surgeon takes a length of blood vessel from elsewhere in the body and places it so that it can shunt blood around the narrowed or blocked coronary artery. The grafted vessel thus permits blood to bypass the blockage, so the heart muscle ordinarily supplied by that coronary artery can once more receive nourishment.

Coronary artery bypass surgery may be a better choice than angioplasty for patients with blockages in multiple arteries; clinical trials have shown that it also relieves the pain of angina more effectively on a long-term basis than angioplasty alone or angioplasty with stent insertion. And, in light of the safety concerns about stents, doctors may be more likely to recommend bypass surgery for some patients who might have otherwise undergone angioplasty with stent insertion. One thing to keep in mind, however, is that bypass surgery does not cure the underlying disease — atherosclerosis — and so angina may return five to 10 years after the operation, as arteries again become clogged with plaque. (This is why it’s so important to adhere to a strategy of diet, exercise, and medication; see “Recognizing and reducing risk factors.”)

Several options in bypass surgery now exist. The old standby is conventional open-heart surgery, known medically as coronary artery bypass grafting. In addition, two so-called minimally invasive procedures are also sometimes used: beating-heart surgery and minimally invasive bypass surgery. The procedure you undergo will depend largely on the nature and extent of your heart disease, your overall health, and your surgeon’s expertise.

What happens during bypass surgery

In most forms of bypass surgery, you receive general anesthesia. The surgeon makes a large incision and cuts through the breastbone to gain access to the heart. The beating of the heart is usually stopped so that the surgeon doesn’t have to operate on a heart that’s constantly moving. A heart-lung machine pumps oxygen-rich blood through the body, temporarily substituting for the heart.

The surgeon takes a vein or an artery from another part of your body and sutures that vessel into place to reroute blood around the blocked artery. The replacement vessel might be an internal mammary artery taken from your chest, a saphenous vein taken from your leg, or even a radial artery from your arm. Whatever artery or vein is used is a “spare” vessel. You will suffer no ill effects from the removal of that piece of artery or vein.

If the grafted vessel is a vein from a leg or arm, one end is attached to the aorta and the other is sewn onto the diseased coronary artery, beyond the blockage. When a mammary artery is used, the upper end is usually left in place at the aorta and the lower open end is attached to the diseased coronary artery, below the blockage. After the surgery is completed, your heart is started again, and you are taken off the heart-lung machine.

Some people stay in the hospital for just four to five days, but many stay six to 10 days or, if they have complications, even longer. Within a day or two of surgery, the doctor will probably ask you to get up and walk. You might also be scheduled for a cardiac rehabilitation program, which you will attend after leaving the hospital. Cardiac rehabilitation helps you and your heart gain strength. It also teaches you heart-healthy practices that will help protect you from future heart disease, such as following a low-fat diet and exercising regularly (see “Healing your heart: Cardiac rehabilitation”).

If your job doesn’t require much exertion, you can probably return to work in about two months. However, people who do heavy labor must wait longer or, in some cases, find jobs that aren’t as physically demanding.


Keeping vessels clear after surgery

Bypass surgery is very effective in controlling the symptoms of coronary artery disease. After surgery, people often feel as if they’ve been given a new lease on life. But bypass surgery doesn’t cure coronary artery disease. Angina can recur, either from the buildup of plaque in arteries that weren’t bypassed or because blockages form in the grafts. Combating such problems requires dietary and lifestyle changes, such as exercising regularly and not smoking, as well as aggressive efforts to control cholesterol through medication. To maximize your chances of recovery, the experts recommend these steps:

A daily aspirin. You should begin taking a daily aspirin within 48 hours of your bypass operation in order to reduce the risk of your grafted vein closing, as well as to lower your chance of heart attack, stroke, kidney failure, or death. Dosage varies from 81 to 325 mg per day. If you are unable to tolerate or respond to aspirin, your doctor will recommend an alternative antiplatelet therapy, but aspirin is the treatment of choice.

Statin therapy. Almost everyone undergoing a bypass operation should take a statin to lower LDL cholesterol. The only exceptions are people who cannot take statins for some other reason; in that case, work with your doctor to find another way to lower LDL.

People undergoing a bypass operation (and all others at high risk for heart attacks) should aim for LDL levels less than 70 mg/dL, based on recommendations by the NCEP for people at very high risk for heart attacks and on findings from other studies. Talk with your doctor to determine the LDL goals that will maximize your own recovery.

Treat all other risk factors. Even if your LDL levels are within the target range, you may also have to use medication and make lifestyle changes to boost your healthy HDL cholesterol level and lower harmful triglycerides.

Report cards for cardiac surgery

When choosing a surgeon to perform your upcoming bypass surgery or angioplasty, you probably want to know which surgeon has the lowest mortality rates. Some states, including New York, New Jersey, Pennsylvania, and Massachusetts, post report cards online that rate cardiac surgeons based on the outcomes of their patients.

While the report cards certainly merit a look, it’s important to keep a few precautions in mind. For one thing, the ratings are based on very small numbers. A busy cardiac surgeon may perform 200 bypass operations a year. The average death rate for bypass surgery is 2%. That means that a difference of one or two deaths in a year can make a surgeon look very bad or very good. Mortality rates can also be skewed by how sick a patient was before the surgery. Surgeons who operate on sicker patients may end up looking bad, even if their surgical skills are excellent.

An important factor to consider when evaluating a surgeon is how many procedures of a certain type the doctor performs every year. Choose a physician with relatively more experience, especially if you have health issues that could cause problems during the surgery or recovery.

Finally, the quality of the hospital where you have your surgery is just as important as the quality of the surgeon. The best hospitals have key diagnostic tools, clear-cut safety systems to minimize medication mistakes and surgical errors, and a favorable nurse-to-patient ratio.


Complications and risks

Bypass surgery is recommended only for people who can’t be helped enough by heart medications or angioplasty, because it is riskier than these other treatments and requires a longer recovery time. Possible complications of conventional bypass surgery include heart attack, bleeding, and stroke. Stroke may occur if blood clots develop and travel to the brain, or if bleeding or periods of low blood pressure deprive the brain of oxygen during the surgery. About 3% to 5% of people who undergo bypass surgery have a stroke. About 5% suffer a heart attack. The risk for death from conventional bypass surgery is about 1% to 2%.

As surgical techniques improve, these numbers may go down. It is important to understand that the risk for complications or death from bypass surgery is lowest at hospitals that perform the most bypass operations. Once again, for the best results, find an experienced heart surgeon working at a hospital with a high-volume cardiac surgery unit.


Memory and concentration problems

Studies indicate that a significant number of people experience mild memory problems or trouble concentrating following a bypass operation. Although many of these impairments are subtle, showing up only on a battery of mental status tests, the prospect of cognitive difficulties is a complication that worries many patients.

An often-cited study found that about half of the people who underwent bypass surgery experienced memory impairment and cognitive decline immediately afterward; about six months later, about one in four people continued to experience cognitive decline. What’s going on is not clear. Time on the heart-lung machine during traditional bypass surgery is believed to be especially risky for the brain because blood can collect atherosclerotic particles while passing through the heart-lung machine and then deposit them in the brain.

On the other hand, the problem may not be the surgery. Some research has suggested that some of the biological processes involved in coronary artery disease also contribute to Alzheimer’s disease and other types of dementia — raising the possibility that it is the underlying disease, and not bypass surgery, that may contribute to cognitive problems.

Researchers continue to look into this issue. In the meantime, if you are preparing for a bypass operation, talk with your surgeon ahead of time about what strategies are available to minimize the chances of memory and thinking problems. After the operation, mention any problems with attention or concentration you may be having.


Off-pump coronary artery bypass surgery

One less-invasive innovation in coronary artery bypass surgery is a procedure called off-pump bypass, or beating-heart surgery, because the operating team doesn’t stop your heart and place you on a heart-lung machine. Instead, the surgeon uses special equipment to hold the heart steady, enabling surgeons to operate on it while it continues beating.

Early studies of the surgery, which was first introduced in the mid-1990s, suggested that off-pump bypass lowers the need for blood transfusions and leads to less short-term cognitive decline. But more recent evidence hasn’t upheld the cognition advantage. And some data show that grafts placed during off-pump surgery are more likely to become blocked, which probably reflects the technical difficulty of sewing grafts onto a beating heart.

Over all, in terms of effectiveness and safety, off-pump and conventional bypass surgery seem to be equal. The risks for two of the biggest long-term complications of bypass surgery, cognitive problems and cardiac events (subsequent heart attack or the need for a follow-up procedure), are similar for off-pump and conventional surgery. For now, the skill of the surgeon and the quality of the hospital are more likely to affect the outcome than whether your surgery is performed on-pump or off-pump.


Minimally invasive coronary artery bypass surgery

In minimally invasive coronary artery bypass surgery, the surgeon operates without making a large incision and splitting the breastbone, so recovery times are faster and risks are generally lower. This procedure can also be used either with or without the heart-lung machine. However, this procedure can only be used on people with one or two blocked arteries located at the front of the heart.

During the operation, the surgeon makes an incision of 2.5 to 4 inches on the left front side of the chest. To access the heart, the surgeon separates the pectoral muscles and removes a small portion of the front of a rib. Usually a mechanical stabilizer steadies the heart, so that it continues beating while the surgeon performs the bypass operation. However, sometimes it is better to stop the heart. If a heart-lung machine is used, the surgeon operates with the help of a videoscope to see inside the chest even though it has not been opened.

Compared with conventional bypass surgery, minimally invasive direct bypass causes less postoperative pain and reduces hospital stays to about three days on average. It is not yet known whether this procedure is as safe and effective (in both the short and long term) as conventional bypass surgery.




Resources

Organizations

American Association of Cardiovascular and Pulmonary Rehabilitation
401 N. Michigan Ave., Suite 2200
Chicago, IL 60611
312-321-5146
www.aacvpr.org

Dedicated to reducing death and disability from heart and lung disease through education, rehabilitation, research, and disease management. The AACVPR certifies cardiac and pulmonary rehabilitation facilities to ensure they meet essential standards of care. The Web site includes a searchable directory of certified programs.

American Diabetes Association
1701 N. Beauregard St.
Alexandria, VA 22311
800-342-2383 (toll-free)
www.diabetes.org

Funds research into diabetes and serves as a prime resource for diabetes news, health information, legislative action, and advocacy efforts. Annual membership includes a subscription to the magazine Diabetes Forecast.

American Heart Association
7272 Greenville Ave.
Dallas, TX 75231
800-242-8721 (toll-free)
www.americanheart.org

Operates a consumer hotline to answer questions on general heart health, and offers educational pamphlets, posters, and audiovisual material, all at no charge or for a nominal fee. Its Web site has news on heart disease research, as well as background information on prevention and treatments.

National Heart, Lung, and Blood Institute
NHLBI Health Information Center
P.O. Box 30105
Bethesda, MD 20824
301-592-8573
www.nhlbi.nih.gov

Offers educational pamphlets on heart disease, blood pressure, cholesterol, obesity, and physical activity at no charge or for a nominal fee. These pamphlets are available on the Web site, or you can order them by phone.


Books

Eat, Drink, and Be Healthy
Walter C. Willett, M.D., with P.J. Skerrett
(Simon and Schuster, 2005)

This easy-to-understand book by a Harvard Medical School expert presents state-of-the-art information about the links between diet and health, including coronary artery disease. It also provides a practical approach to healthy eating.

Mind Your Heart: A Mind/Body Approach to Stress Management, Exercise, and Nutrition for Heart Health
Aggie Casey, R.N., and Herbert Benson, M.D., with Ann MacDonald
(Simon and Schuster, 2004)

This book provides a complete mind-body approach to stress management, exercise, and nutrition in order to improve heart health. The advice is based on the Cardiac Wellness Program offered at the Benson-Henry Institute, founded by Dr. Benson, a Harvard Medical School physician.

The No Sweat Exercise Plan: Lose Weight, Get Healthy, and Live Longer
Harvey B. Simon, M.D.
(McGraw-Hill, 2006)

Written by a founding member of the Harvard Cardiovascular Health Center, this book introduces an innovative exercise plan that shows how to be healthy and lose weight through day-to-day activities.


Harvard Health Publications

Harvard Heart Letter

Edited by Harvard Medical School cardiologist Thomas H. Lee, this monthly newsletter provides timely, practical information on heart health.

Harvard Medical School Special Health Reports:

Healthy Eating for a Healthy Heart

Hypertension: Controlling the “Silent Killer”

Lose Weight and Keep it Off

What to Do About High Cholesterol

To receive these or other Harvard Medical School publications, contact:

Harvard Medical School
P.O. Box 9306
Big Sandy, TX 75755
877-649-9457 (toll-free)
www.health.harvard.edu/subinfo



Glossary

angina: Chest pain or discomfort that develops when the heart muscle isn’t getting enough oxygen and blood; also known as angina pectoris.

atherosclerosis: The buildup of fatty deposits in the walls of arteries; the disease responsible for most heart attacks and many strokes.

cholesterol: A waxy, fatlike substance that is present in animal tissues and produced by the liver. Excess levels can build up in artery walls.

coronary arteries: The small blood vessels that carry oxygen-rich blood to the heart muscle.

coronary artery disease: The most important form of heart disease, caused by the buildup of fatty plaques in the coronary arteries.

diastolic blood pressure: The pressure in the arteries while the heart is refilling with blood between beats; the second and lower of the two numbers obtained when blood pressure is measured.

electrocardiogram (ECG): A graph recording the electrical activity responsible for the contraction and relaxation of the heart.

heart attack: Damage to, or death of, heart muscle because of insufficient blood supply; the medical term is myocardial infarction.

high blood pressure: A longstanding increase in blood pressure above the normal range — that is, abnormally high pressure of blood flow against the artery walls; also called hypertension.

high-density lipoprotein (HDL): A lipoprotein that transports cholesterol from body cells to the liver and other sites for elimination; called “good” cholesterol.

lipoprotein: A combination of fat (lipid) molecules and protein molecules bound together as packages that enable other fats and cholesterol to move easily through the blood. See low-density lipoprotein and high-density lipoprotein.

low-density lipoprotein (LDL): Spherical particles that transport cholesterol in the blood; called “bad” cholesterol because high levels are associated with a high risk for heart attack.

myocardial infarction: Heart attack.

plaque: Deposits of cholesterol and fatty and fibrous substances in the walls of the arteries.

platelets: Small, fragmentary blood cells that initiate the clotting process.

prehypertension: A condition that increases the risk of developing high blood pressure; defined as systolic pressure between 120 and 139 mm Hg or diastolic pressure between 80 and 89 mm Hg.

restenosis: Renarrowing of a blood vessel that has been widened (with or without stents) during angioplasty.

stent: A wire mesh device inserted into a coronary artery to prop it open once a blockage has been cleared by angioplasty.

systolic blood pressure: The pressure in the arteries at the point when the heart pumps; the first and higher of the two numbers obtained when blood pressure is measured.

triglycerides: Particles that transport fats through the bloodstream.


Credits

Medical Editor
Michelle Albert, M.D., M.P.H.
Director of Behavioral and Neurocardiovasular Cardiology Associate Physician, Brigham and Women’s Hospital
Assistant Professor of Medicine, Harvard Medical School

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Julie Corliss

Editor, Special Health Reports
Kathleen Cahill Allison

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Heather Derocher

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Melissa Rico

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Scott Leighton
Michael Linkinhoker

Published by Harvard Medical School
Anthony L. Komaroff, M.D., Editor in Chief
Edward Coburn, Publishing Director

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Robert Englander, Chairman and CEO
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