Heart Disease Prevention
By Eric Felber, DO
This is the first place winner of the 2008 Namey/Burnett Writing Award.
The Namey/Burnett Writing Award is implemented by the ACOFP Preventive Medicine and Medical Preparedness Committee to honor the best preventive medicine papers submitted by osteopathic family practice residents, interns, and osteopathic medical students.
Heart disease is the number one cause of death in the United States according to the Centers for Disease Control.1 In 2004, heart disease accounted for 652,486 deaths out of a total of 2,397,615 deaths.1 Twenty-seven percent of all deaths are caused by heart disease. Interestingly, the number of deaths from heart disease has decreased since 2000 when there were 710,760.1 The next most common causes of death are cancer (553,888),stroke (150,074), chronic lower respiratory diseases (121,987), accidents (112,012), and diabetes (73,138).1
The incidence of heart disease increases with age and is increased with several risk factors. The number of cardiac deaths is greater than the third, fourth, fifth, and sixth most common causes of death combined.
In the worldwide INTERHEART study of patients from 52 countries, nine potentially modifiable factors accounted for over 90 percent of the attributable risk of a first heart attack.2 These factors include smoking, dyslipidemia, hypertension, diabetes, abdominal obesity, psychosocial factors, daily consumption of fruits and vegetables, alcohol consumption, and physical activity.
Fortunately, there are several ways to reduce the chances of suffering from heart disease: maintain a healthy weight and normal blood pressure, avoid smoking, exercise regularly, eat plenty of fruits and vegetables, get tested and treated (if necessary) for diabetes, and abnormal cholesterol and triglycerides. It is important for patients to work together along with their primary care provider to achieve these goals.
An osteopathic family physician utilizes a holistic approach to achieve optimal health so that the body and mind are healthy and are able to be cared for by promoting ideal blood and lymphatic flow. To minimize the chance of heart disease, one should have regularly scheduled preventive exams that include risk factor modification, labwork, and osteopathic manipulation.
Many causes of heart disease are preventable and thus it is crucial to make these lifestyle changes to prevent the leading cause of death and disability in the United States. The Nurses’ Health Study (2000) found that among women, maintaining a desirable body weight, eating a healthy diet, performing regular exercise, and not smoking could account for an 84 percent reduction in their cardiovascular risk.3
U.S. Mortality from Coronary Heart Disease
The most powerful and the most preventable risk factor for heart disease is smoking, according to MayoClinic.com.4 One must avoid all tobacco products. One year after quitting, the risk of heart attack and death from chronic heart disease is reduced by one-half, and after several years begins to approach that of nonsmokers.5 The nicotine in cigarette smoke makes the heart work harder by constricting blood vessels and increasing heart rate and blood pressure. The carbon monoxide in cigarette smoke replaces some of the oxygen in the blood. This increases the blood pressure by forcing the heart to work harder to supply oxygen. Tobacco contains 4,800 chemicals, many of which cause atherosclerosis and heart disease.4 Second-hand smoke, especially over a long period of time, can carry the same risks due to the inhalation of the same harmful chemicals.
The good news, though, is that when someone quits smoking, their risk of heart disease drops dramatically within just one year.4 Many therapies are currently available to help one stop smoking including a relatively new prescription aid called varenicline (Chantix) that mimics nicotine receptor action in the brain without having to ingest the harmful nicotine chemical.
Physical activity is imperative. Federal guidelines recommend “at least 30 to 60 minutes of moderately intense physical activity most days of the week.”4 People don’t have to exercise strenuously; although, constant aerobic activity that produces a sweat is recommended. Not only does physical activity directly reduce the chance of heart disease, but it greatly assists in modifying other risk factors such as weight reduction, blood pressure control, and stress reduction.
A heart-healthy diet is the next step. Consistently eating a diet rich in fruits, vegetables, whole grains, and low-fat dairy products can protect the heart.6 Limiting the intake of certain fats is crucial. Saturated fats and trans-fats increase the risk of heart disease by increasing cholesterol levels. Trans-fat may be worse than saturated fat because trans-fat raises LDL (bad cholesterol) and lowers HDL (good cholesterol). Saturated fats include beef, butter, cheese, and milk. The more-maligned trans-fats are found in deep fried fast foods, bakery products, packaged snack foods, and margarine.
Substantial evidence from the Journal of the American Medical Association (JAMA) indicates that diets using nonhydrogenated unsaturated fats as the predominant form of dietary fat, whole grains as the main form of carbohydrates, an abundance of fruits and vegetables, and adequate omage-3 fatty acids can offer significant protection against CHD.6 Alcohol in moderation can protect the heart although alcohol in excess can be hazardous to the heart. The average male should drink no more than two drinks a day; the average female should drink no more than one drink a day.
A healthy weight must be maintained. In order to find out one’s healthy weight, he or she can calculate their body mass index (BMI).
A BMI greater than 25 is associated with a higher risk of heart disease. BMIs do have drawbacks in that muscle weighs more than fat and may falsely elevate one’s BMI. In this case, waist measurement is a good indicator. A waist size greater than 40 inches in males and 35 inches in females is associated with higher risk of heart disease.6 Furthermore, weight reductions have been proven to lower blood pressure and cholesterol while decreasing the risk of diabetes.
A high-fiber diet has many benefits that include lowering blood cholesterol and controlling blood sugar levels. Soluble fiber found in beans, oats, flaxseed and oat bran may help lower LDL cholesterol. Also, soluble fiber can slow the absorption of sugar, which for people with diabetes can help improve blood sugar levels. Men 50 years old or younger should receive at least 38 grams of fiber a day, men older than 50 should receive 30 grams a day, women 50 years or younger should receive 25 grams a day and women older than 50 should receive 21 grams a day.6 Fiber can be found in grains, whole-wheat products, fruits, vegetables, beans, legumes, nuts and seeds.
Antioxidant vitamins have been a focus of research in cardiovascular disease. At this time, the American Heart Association does not recommend using antioxidant vitamin supplements until more complete data are available. The scientific evidence supports a diet high in food sources of antioxidants and other heart-protecting nutrients, such as fruits, vegetables, whole grains and nuts instead of antioxidant supplements to reduce risk of CVD. Some recent studies have even shown harmful effects from antioxidant supplements.6
Minimizing stress also appears to reduce heart disease. The link between stress and heart disease is not completely clear, but what is known is that stress accelerates the heart rate. People with heart disease are more likely to have a heart attack during times of stress.7 Minimizing stress is included in the holistic care of medicine which incorporates the integrated care of mind and body.
Nuclear radiographic tests also are an aid in preventing heart disease. Nuclear stress tests can identify areas of the heart that are not getting optimally oxygenated. This can predict cardiac events and thus enable a patient to undergo procedures to open diseased coronary vessels before harmful events occur. Also, on the frontiers of medicine are CT and MRI scanning techniques that directly visualize coronary vessels and can measure blockages and calcifications that may cause heart disease.
Medicines can also treat heart disease. The U.S. Food and Drug Administration recognizes aspirin, with its anti-clotting abilities, as safe and effective in helping to lower the risk of a second heart attack. The American Heart Association recommends low-dose aspirin (75-160mg/day) in people at higher risk of coronary heart disease.7
ngiotensin-converting enzyme (ACE) inhibitors help the heart pump blood better, and beta blockers slow the heart down. Nitrates and calcium channel blockers relax blood vessels and relieve chest pain. Diuretics decrease fluid in the body. Patients should carefully review their medical history with their family physicians to determine which medicines are most appropriate for improving their health.
Angioplasty and stents are an invasive way to open diseased vessels in the heart. Angioplasty is the insertion of a balloon to widen a vessel and a stent may be placed to hold the vessel open. In 2003, drug-coated stents were first used with the goal of reducing the risk that the artery will re-clog. Coronary bypass is performed to replace a diseased vessel in the heart with another vessel in the body that is free from atherosclerotic disease. These invasive procedures are performed once the above risk factor modification has failed, and heart disease has taken hold.
Studies have shown that even a “splurge” of saturated fat can cause heart disease. The Journal of American Cardiology reported that when study participants ate just one piece of high-fat carrot cake and drank a milkshake, the ability of their arteries to accommodate increased blood flow was diminished.8 The sudden boost in what’s known as saturated fat prevented “good” cholesterol, or HDL, from doing its job, which is to protect the inner lining of the arteries from inflammatory agents that promote the build-up of fatty plaques.8 The effects may be temporary. However, there is still a concern because the effect may recur each time a person eats a high-fat meal.
High levels of “good” HDL cholesterol protect against heart disease and stroke no matter what the blood levels of “bad” LDL cholesterol, according to a new study in the New England Journal of Medicine.9 In a major trial, the incidence of heart attack, stroke, and other cardiovascular problems was 40 percent lower in the one-fifth of participants who had the highest HDL cholesterol levels, regardless of their LDL cholesterol levels.9 A medication that increases HDL would likely greatly decrease heart diseases according to this data. In 2006, Pfizer withdrew its HDL-increasing medication Torcetrapib because patients who took the medicine had a higher death rate.
Other lab tests are available to assess the risk of heart disease. One test detects homocysteine, a protein that may be better than cholesterol for predicting heart disease and stroke. Lipoprotein a, Lp(a), is similar to LDL but does not respond to diet, exercise, and medications. Lp(a) seems to be a marker of genetic disease and may show which patients are candidates for more aggressive lipid-lowering therapy.
Another test is hypersensitive C-reactive protein (hsCRP) that may predict a coronary event even in patients having normal cholesterol levels. These different markers are currently speculative and the lipid profile, fasting glucose, and triglycerides remain the gold-standard for assessing the risk of heart disease. Studies of patients with CHD suggest that serum triglycerides are an independent predictor of risk.10
Regular health screenings with an osteopathic family physician are imperative in accomplishing the above goals. High blood pressure and high cholesterol can damage the heart but without getting those levels tested, one would not know they are elevated. Data from the American Heart Association states that about 38 percent of people who experience a heart attack in a given year die from it.11 Thus, prevention of heart disease is crucial.
Regular preventive exams are economical in addition to the positive health benefits they provide. A cardiac catheterization or bypass can cost tens of thousands of dollars or more depending if hospitalization is required. Thus, regularly scheduled preventive exams can allow a person to enjoy many more healthy and active years.
Dr. Felber is a 2005 graduate of Philadelphia College of Osteopathic Medicine. He is currently a third year family medicine resident at Frankford Hospitals in Philadelphia, Pennsylvania.
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