Test, Medicine, and Procedures
- What is Your Risk of Heart Disease
- Other Lifestyle Risk Factors
- Additional Blood Tests that Go Beyond Routine Cholesterol Checks
- Role of Heart Tests
- Role of Medication
The following information is provided for background only. Please consult with your own health care professional before making any health decisions.
Your risk is determined by both your medical history and your lifestyle choices. Conditions that determine your risk include:
- Family history of heart disease: The more family members with a history of heart disease, and the younger they were at the time of their diagnosis-the greater your “inherited” risk. For example, your risk due to family history is much greater if your parent or sibling had heart disease at age 40 than if your grandparent had a heart problem at age 72.
- Diabetes is an especially strong risk factor-so much so that a diabetic’s risk of a future heart problem is considered the same as someone who has previously suffered a heart attack. Diabetes is diagnosed when the fasting sugar (glucose) level is 126 or greater on more than one day.
- High blood pressure: defined as repeated readings of 140 or greater for the top number (systolic) or 90 or greater for the lower number (diastolic
- High level of the “bad” LDL: LDL is the fat most responsible for plaque build up in the arteries. Levels under 130 are best for most people, with tighter control needed for those with diabetes or history of blocked arteries (when LDL should be at least under 100 and best under 70).
- Low level of the “good” HDL: HDL is your body’s garbage collector, scooping up the excess LDL and eliminating it. You want to have enough garbage collectors to keep the “pavement” of your arteries clean-levels should be above 40 for men and above 50 for women.
- Smoking: smoking is the strongest controllable risk factor. If you smoke and want to
concentrate on only one area-make quitting your #1 goal.
- Large Waist Circumference: over 35 inches for women and 40 inches for men puts you at increased risk. To make the measurement, circle a tape measure around your waist just over your hip bone. Not only does the extra weight pose a burden to your heart because your heart has to pump harder, but excess belly fat is actually a ‘factory” of inflammatory chemicals that irritate the blood vessels.
- Lack of Sleep: Too little sleep (varies from person to person, but generally less than 7 hours/night) puts excess strain on your body, and contributes to weight gain, high blood pressure, and an increased risk of heart attacks. Those with sleep apnea are at especially high risk. Signs of sleep apnea include: excessive snoring, always feeling tired even after a long period of sleep, and falling asleep during the day when you are not trying to sleep. If you have these symptoms, your doctor may order a sleep study to confirm the diagnosis.
Everyone should have standard tests for the ‘good” and “bad” cholesterol (referred to as a “lipid panel”) at the time of their regular doctor check-up. For individuals with reason for special concern, especially those with a strong family history of heart disease, additional testing may be helpful to test for inherited risks.
LDL Particle Size and Particle Number
LDL is the ‘bad” cholesterol that clogs blood vessels. LDL comes in different sizes-either small and dense or large and fluffy. Although you might imagine that the larger particles are a bigger problem-the opposite is true. The small, dense LDL particles are more risky because they are better able to penetrate into the lining of arteries to cause plaque buildup. Small dense LDL particles are like compact cars and more of them are needed to carry a given cargo of cholesterol. A high number of LDL particles is a strong risk, even if your standard cholesterol tests look “normal”.
LDL size is mostly determined by your genes, but is also affected by your diet, weight, and exercise level. Excess weight, lack of cardio exercise, and diets high in sugar can increase your chance of having the small, more risky LDL.
Think of Lp(a) as an “LDL with attitude” because of its dual role as a fat and blood clotting stimulant. Lp(a) is unusual because levels are determined by almost entirely by inheritance and not much affected by diet or lifestyle. High levels are suspected in those with a very strong family history of early heart disease.
Treatment of high Lp(a) is controversial. The risk from high levels of Lp(a) may be reduced by lowering the level of other fats in the blood. Treatment may include standard cholesterol lowering medicine (statins) with or without niacin, which is the only agent that significantly lowers Lp(a) levels directly.
High sensitivity CRP
High sensitivity CRP is a measure of inflammation and high levels may increase the risk of heart disease. Anything that irritates the body will boost CRP levels, including extra belly weight, smoking, and trans fats. Optimal levels are under 1.0, neutral levels are between 1.0 and 2.0, and high levels are over 2.0. Blood tests drawn at the time of an infection or allergic reaction may not be reliable and should be repeated. There is no direct treatment for CRP apart from control of the irritants-including smoking cessation, weight loss, and good nutrition.
Exercise Stress Tests
Exercise stress tests are widely used to check for strain on the heart caused by blocked arteries. The oldest type of stress test involves monitoring with an ECG (heart tracing) while running on a treadmill. Strain on the heart during exercise can provoke changes in the shape of the ECG tracing that signals the possibility of a blocked artery.
More recently, stress tests include pictures of the heart during exercise taken either with ultrasound (stress echo) or with a small amount of a radioactive dye (nuclear stress test). Stress tests with either of these pictures are much more accurate than those that rely on the ECG alone, although they are also much more expensive.
The risk of having a heart attack or other serious problem during a stress test is very small. However, stress tests can lead to other problems by triggering a spiral of additional, unnecessary tests. Unfortunately, about 1 or 2 of every 10 abnormal stress tests are a “false alarm”, an abnormal result when the heart is really fine. These misleading results are a problem because they often lead to more invasive testing with an angiogram (heart catheterization).
When is a stress test most appropriate? Stress tests can help determine if symptoms of discomfort, shortness of breath, fatigue, or heart beat irregularities are related to heart strain from a blocked artery.
Another good use for a stress test is to check the heart in sedentary people with many risk factors for heart disease who are about to begin an exercise program.
Routine stress testing for people without symptoms or multiple risk factors is generally not recommended. Abnormal tests in such people are more likely to be a false alarm that lead to unnecessary invasive testing.
An angiogram (heart catheterization) is a more definitive test to look for blockages in the arteries of the heart. It costs several thousand dollars and is generally safe-although it carries a small but real risk of very serious problems-including stroke, heart attack, damage to the arteries, and death.
An angiogram should be reserved for more serious situations such as patients in the midst of a heart attack or those with unstable heart symptoms. An angiogram may also be helpful when a stress test is very abnormal, suggesting that a large part of the heart is under strain from poor blood flow.
An angioplasty is a procedure to open up a blocked artery in which a small balloon is thread through the blockage and inflated to push the plaque aside and create a larger space for blood to flow. Most often, it is combined with placement of a stent, a mesh used to further prop open the artery after the balloon procedure. In most cases, the angioplasty and stent procedures are done in the same session as the angiogram.
Except for critical situations including a heart attack in progress, or unstable heart symptoms, angioplasties and stents have not been shown to prevent heart attacks or save lives. They are, however, effective for relieving heart pain when lifestyle changes and medication are ineffective.
Heart Scans (CT Scans)
There are two types of heart scans: one that does not use dye and checks for calcium buildups in the arteries and a second test, a CT angiogram, that requires dye and can give an estimate of the amount of blockage (with exceptions).
The CT scan without dye measures calcium inside the artery. Think of this as an indicator of how “rusty” the arteries are. Generally, the higher the calcium score, the more “rust’, or plaque in the arteries. However, it is impossible to know the amount of blockage from this test (despite some confusing advertising to the contrary).
A “zero” score for calcium is favorable, but does not absolutely eliminate the possibility of a blockage. High calcium scores are linked to a higher risk of heart attacks-but not enough is known to chart the best course of action based on the scan results. Often, patients with high calcium scores are advised on stringent prevention measures that may include aspirin and cholesterol lowering medicine-possibly in addition to stress testing.
A heart CT scan without dye is often ordered in people who have some risk for heart disease, but not clearly in need of intensive prevention efforts with cholesterol medication. A low calcium score might argue for a less aggressive approach, and a high calcium score may tip the scale toward starting cholesterol medicine.
The CT scan with dye can give important information about blockages-but this insight comes at a cost-both financial and medical. The charge is usually over $1,000 and carries the risk of side-effects from the dye (allergy and kidney problems) as well as a significant level of radiation exposure. This type of test is often used to follow-up questionable stress test results instead of proceeding directly to an angiogram and, in some settings, as an initial test in the Emergency Room for individuals with chest pain.
An integrative approach clearly holds a place for medication-given judiciously and in the lowest possible dose to accomplish the goals. But even in those situations, it is clear that good health can not be maintained by taking pills alone. No pills can replace the benefits of nutrition and a healthy lifestyle.
Blood pressure: An ideal blood pressure is 120/80 or less. Medication is generally required when repeated readings are 140/90 (or less for diabetics) despite lifestyle changes.
Natural methods to keep your blood pressure lower include: cardio exercise and healthy eating with low salt intake and a diet rich in fruit, vegetables, whole grains and yogurt. Don’t be fooled: only 10% of the salt in your diet comes from using the salt shaker, most salt is built into convenience food (ie. fast food, soups, salty snacks). Mind/body can also help lower blood pressure include breathing exercises, biofeedback, and acupuncture.
Cholesterol: Those with a history of blocked arteries, as well as diabetics, are at highest risk of heart disease and benefit most from cholesterol control. For other individuals, the decision to take cholesterol medication needs to be individualized-based on the likelihood of further lifestyle changes, risk factors for heart disease, family history, other medical conditions, age, and personal philosophy regarding healthcare.
For those in need of cholesterol management beyond lifestyle measures, a wide range of prescription cholesterol medication is available-including many potent and low cost generics . Although many patients fear liver side-effects, serious liver problems are uncommon. Much more frequent side-effects from statin medicine are muscle and joint pain.
Side-effects from cholesterol medicine can often be eliminated by reducing the dose or changing brands of medicine. Interestingly, cutting the dose of a statin by 50% will generally cut the potency by only 7%, but will often reduce the side-effects more significantly. Another option is red yeast rice, an over the counter product that contains a small dose of a prescription type of statin but is better tolerated in some people than the prescription version. But red yeast rice is a form of a statin and, like all statins, should be taken only under a doctor’s supervision. Any changes to your medical program need to be made in consultation with your health care provider.
Other serious heart issues, including heart failure and heart beat irregularities, often call for prescription medication based on good scientific evidence. Remember, an integrative approach includes all of the best in conventional medicine, combined with maximizing the impact from natural strategies.