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