Heart Care for Life: Developing the Program That Works Best for Youby Barry L. Zaret
More than 70 million Americans have some form of heart disease. For each of them, obtaining accurate information about the disease and the many options for dealing with it can be both empowering and life saving. In this book, cardiologist Dr. Barry L. Zaret and Genell Subak-Sharpe offer up-to-date facts about the best treatments available and an innovative
More than 70 million Americans have some form of heart disease. For each of them, obtaining accurate information about the disease and the many options for dealing with it can be both empowering and life saving. In this book, cardiologist Dr. Barry L. Zaret and Genell Subak-Sharpe offer up-to-date facts about the best treatments available and an innovative approach that shows how treatment programs can be tailored to meet the needs of each unique patient.
There are no short-term fixes and no one-size-fitsall programs, explain Zaret and Subak-Sharpe. Although certain characteristics are common to each form of heart disease and its treatments,these constants must be tempered against individual variables. The authors outline the constants for the full range of cardiovascular conditions, from angina and heart attacks to high blood pressure and cardiac arrhythmias. They then guide readers through the process of assessing personal variables to develop an individual treatment and life-style program.
Written in a warmly reassuring style, this indispensable guide to heart care offers realistic hope and specific directions for designing a lifelong heart care program. Filled with practical advice, instructional case histories, a philosophy for controlling your health, self-tests to assess risk, and questions to ask your doctor, it looks toward an even better future for those with heart disease.
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HEART CARE FOR LIFEDeveloping the Program That Works Best for You
By Barry L. Zaret Genell J. Subak-Sharpe
YALE UNIVERSITY PRESSCopyright © 2006 Barry L. Zaret and Genell J. Subak-Sharpe
All right reserved.
Chapter OneA Personalized Plan: The Key to a Lifelong Heart Program
Although people often think of heart disease as a single, well-defined problem that affects all patients similarly, nothing could be further from sreality. Just as no two people are exactly alike, heart disease (and its risk factors, symptoms, and successful treatments) varies greatly from one person to another. In our experience, a one-plan-fits-all approach-be it diet, medication, or lifestyle modification-simply does not work. Thus, an essential first step toward developing your lifelong heart health regimen is to identify what makes you different from your parents, siblings, neighbors, and the other patients in your doctor's office. This is why the concept of constants and individual variables is so important.
Many scientific studies have identified the constants, the core medical values that guide physicians in the diagnosis of cardiovascular disease. Large population studies, such as the Framingham Heart Study, pinpoint the risk factors doctors look for in identifying patients who may have orare likely to develop heart disease. The Framingham study, an ongoing exhaustive research project, was started in 1948 and over the decades has followed the health status of thousands of residents of Framingham, Massachusetts, over several generations. As a result of such studies, doctors now have solid evidence linking a number of lifestyle, hereditary, and health factors to an increased risk of a heart attack. The Framingham study also demonstrates that eliminating or modifying these risk factors reduces the likelihood of a heart attack. For example, your doctor should always check your cholesterol levels. This is a constant. But he must also account for your variability. Can elevated levels be treated with diet or is medicine necessary? Which medicine? How often should it be checked? What happens as you get older? What happens if you exercise more? The same applies to high blood pressure and the other major risk factors.
Such large-scale population studies form the basis of much of our current medical knowledge. But there are always exceptions; we all have known or heard about individuals who smoke three packs a day, never exercise, eat fat-laden red meat every day, ignore doctors' advice (if they even go to a doctor at all), and still live long lives. Clearly, such people defy the odds. Yet playing such odds is a very risky business. A much wiser approach involves optimizing your chances for a healthful future by defining your personal risk profile (constants or core medical values) and then working with your doctor to define your individual variables and devise a long-term plan to minimize risk. This makes your lifelong treatment or preventive program different from other seemingly similar individuals. And this is where your individual variables come into play.
Some risk factors-your age, blood pressure, cholesterol, and so forth-are obvious or easily identified. Others are more subtle yet may be equally fundamental in determining the long-term success of your treatment. Only you can home in on many of these individual variables. What is your mindset? Are you in a state of denial, ignoring clear warning signs? In contrast, do you (or your spouse) obsess over every little twinge? Helping you answer such questions is a focus of this book.
In this chapter, we first describe the various cardiovascular risk factors (the constants) and briefly outline some of the more common variables that doctors should consider in working with you to develop a realistic and effective management program. We also list common warning signs and symptoms, again taking into consideration important individual variables. Finally, we offer guidelines for finding a doctor who will become your partner in managing your health care.
Let's start by considering the risk factors that increase your chances of developing some form of heart or blood vessel disease. The fewer of these you have, the lower your chances of developing heart disease. Similarly, your chances are improved by reducing or eliminating as many risk factors as possible.
INBORN OR GENETIC RISK FACTORS
First, let's consider those risk factors that are beyond your control. Remember, however, that even if you have one or more of these risk factors, you need not sit back and await your fate. First of all, the differences between your genes and those of family members can change the odds. And even though you can't change inborn risk factors, there is a good deal you can do to modulate their presumed effects. Within each of the following categories are many variables that you can alter as part of your individualized treatment and preventive program.
Although it would be a huge mistake to assume you're somehow immune to heart disease because you're still in your thirties, forties, or fifties, it is clear that cardiovascular risk rises with advancing age. More than half of all heart attacks occur in persons over the age of sixty-five, and 80 percent of those who die of heart disease are in this age bracket. But given that cardiovascular disease claims as many as a million people each year, a huge number of younger people are also at risk.
Obviously, you can't turn back or stop the clock, but lifestyle factors-such as diet, exercise, and stress management-certainly minimize the adverse effects of advancing age. How you modify your lifestyle also varies greatly depending on your age. For example, exercise is important at any age, but a regimen that works well for a forty-year-old may be difficult or impossible for an eighty-year-old to maintain. Cholesterol levels and blood pressure rise naturally with increasing age, so what's dangerous for a thirty-year-old may well be acceptable for an eighty-five-year-old and not require treatment. This is a controversial area. In contrast, systolic blood pressure-the first (higher) of the two numbers in a blood-pressure reading-often rises to unacceptably high levels in older people, even though the diastolic pressure (the second, or lower, number) may be normal. This type of systolic hypertension requires treatment to reduce the risk of a heart attack or stroke (see Chapter 7).
Symptoms also can vary with age; for example, irregular heartbeats that are benign in a young person may signal a serious problem in someone who is older. In addition, older people are more likely to have other diseases that increase the risk or compound the effects of heart disease.
Age also affects which treatments will work best. Medications that work well in a young person, for example, may be inappropriate or prescribed in a different dosage for someone a few decades older. (See Chapter 10 for a more detailed discussion of older patients' specific needs.)
Heart disease is by far the leading cause of death in both men and women, but there are important gender differences in risk, diagnosis, and treatment. The reasons for these differences are not fully understood, although anatomy and hormones undoubtedly play important roles. For example, women have smaller coronary arteries than men-a consideration when treating coronary artery disease. In addition, women with heart disease often experience symptoms different from those of their male counterparts. When a woman has a heart attack, she may experience little or no pain, and when pain occurs, it may be centered more in the back and abdomen than in the mid-chest. As a result, many women delay seeking medical attention or assume the problem is indigestion or a backache rather than a heart attack. In contrast, men are more likely to experience crushing or severe chest pain, which leaves little doubt that something is wrong with the heart.
Women face an increasing risk of a heart attack after menopause, when estrogen production falls dramatically. Until the last few years, doctors attributed the increased risk to a lack of estrogen and many prescribed hormone replacement therapy (HRT) as a preventive measure. But we now know that estrogen alone is not the whole story. A 2004 report by the Women's Health Initiative Study, a long-term research project coordinated by the National Institutes of Health, showed that estrogen replacement after menopause may actually raise the risk of a heart attack or stroke. This finding differed from earlier studies, including the 1989 report on the Nurses' Health Study (see Chapter 9 for a more detailed discussion).
Heart disease tends to develop at a younger age in men than women, and men are more vulnerable to sudden cardiac death. But after menopause, women begin to "catch up" with men, and overall, more women than men die of heart disease each year. Still, many people-both doctors and patients-mistakenly think that women are somehow immune to heart disease and tend to discount early warning signs and symptoms until a woman's condition reaches an advanced stage. All too many women still mistakenly think that breast cancer is their number one health risk. In reality, the risk of suffering a fatal heart attack is many times higher than that of succumbing to breast cancer. Obviously, this does not mean that women should ignore the risk of breast cancer. But periodic assessment of cardiovascular risk is just as important for a woman as getting a mammogram every year or two.
explain their increased vulnerability. Some Native Americans have a very high incidence of diabetes, which also increases their cardiovascular risk. Other factors that may play a role include unidentified genetic differences, diet, stress, low income, and limited access to health care. Again, early intervention and extra attention to a heart-healthy lifestyle can go a long way toward dealing with these risk factors in all populations. (See Chapter 11 for a more detailed discussion.)
ACQUIRED RISK FACTORS
The list of acquired risk factors, which can be changed or prevented, is much longer than those that are beyond our control. Reducing or eliminating these risk factors is key to achieving and maintaining heart health, so they deserve special attention.
Elevated Blood Cholesterol and Other Lipids
Cholesterol is a fatty substance (lipid) that circulates in the blood and is essential to maintaining life. Indeed, every cell in the body must have a certain amount of cholesterol in order to function properly. The body can make all of the cholesterol it needs; it is also found in all animal products, especially eggs, whole milk, and fatty meats. Thus, a diet high in such foods can raise blood cholesterol levels. In addition, foods that include tropical oils (palm, palm kernel, and coconut oils) and transfatty acids (fats that have been artificially hardened) raise cholesterol, and reducing intake of these foods can help lower elevated cholesterol.
Cholesterol becomes a problem when too much circulates in the blood. This may be due to diet, or to the tendency for cholesterol to rise with age, but sometimes the body simply makes too much cholesterol, perhaps due to genetic differences. Regardless of the underlying cause, high blood cholesterol can lead to atherosclerosis, the buildup of fatty deposits (plaque) in the coronary arteries and other blood vessels. But the story is more complicated than simply having too much cholesterol circulating in the blood. Because cholesterol and other lipids are fats and blood is mostly water (and fats and water don't mix), in order for cholesterol to circulate in the blood it must be attached to water-soluble substances. These are proteins, which when combined with cholesterol are called lipoproteins. The type of lipoprotein is a key factor in determining the degree of potential harm from high cholesterol. Low-density lipoproteins, or LDL cholesterol, form the so-called "bad" cholesterol. This is because high LDL levels can form fatty deposits in the arteries. In time, this plaque can narrow the coronary arteries, setting the stage for coronary artery disease and a heart attack.
In contrast, high-density lipoprotein, or HDL cholesterol-the so-called "good" cholesterol-prevents the buildup of fatty plaque by carrying lipids away from the artery walls and returning it to the liver to be reprocessed or eliminated from the body. In general, experts agree the ratio of HDL to LDL cholesterol is a prime predictor of coronary artery disease, heart attack, and stroke. But how high or low each should be is still open to debate. It has long been accepted that a total cholesterol of less than 200 mg/dl (milligrams per deciliter) should be the goal for most people. More important, however, is the level of LDL cholesterol, which should be below 100 mg/dl in people free of heart disease and 80 mg/dl or less in people who have been diagnosed as having coronary artery disease. In addition, the higher the levels of HDL cholesterol, the better. At a minimum, your HDL should be 40 mg/dl.
In determining the best approach to lowering high blood cholesterol, a doctor will look at a number of variables: diet, weight, exercise habits, genetics, the existence of diabetes and other diseases, age, and gender, among others. For people with high LDL cholesterol, drugs called statins are especially beneficial because they lower LDL cholesterol while promoting a higher level of the protective HDL cholesterol. Elevated triglycerides, another lipid that is a factor in increased cardiovascular risk, can usually be controlled by diet and possibly exercise. If these measures are inadequate, other medication may be prescribed. (See Chapter 7 for a more in-depth discussion.)
High Blood Pressure
Often called the silent killer, high blood pressure (or "hypertension") produces no obvious symptoms until it reaches the advanced stage and damages organs, especially the kidneys, heart, brain, and blood vessels. It is one of the most common risk factors for heart attack, stroke, kidney failure, peripheral vascular disease, atherosclerosis, and heart failure, defined as an inability of the heart to pump enough blood to meet the body's needs. Untreated, it can also lead to left ventricular hypertrophy (LVH), an enlargement and thickening of the walls of the heart's main pumping chamber. LVH is an independent risk factor for heart failure.
In general, high blood pressure is defined as consistent blood pressure readings above 140/90, although 120/80 is the goal. Although hypertension is bad for everyone, African Americans are especially vulnerable to developing it and to suffering its complications. Reasons for this include the increased salt sensitivity and greater incidence of obesity and diabetes in this population group. Regardless of the underlying cause, when compared to other racial and ethnic populations, African Americans are more likely to suffer severe consequences from high blood pressure, including kidney failure, congestive heart failure, and stroke.
Women also have an increased risk of developing high blood pressure, especially if they are overweight, have a family history of the disease, or are over the age of fifty. Some studies have found that nearly three out of four American women over the age of sixty-five have high blood pressure. Fortunately, most high blood pressure can be controlled with a combination of lifestyle factors (diet, exercise, weight control) and antihypertensive medication. (See Chapter 7 for treatment guidelines.)
Metabolic syndrome is a constellation of risk factors that tend to occur together. Although it is very common, affecting more than 40 percent of Americans over age sixty, it has only recently been defined as a major cardiovascular risk factor. Diagnosis is based on a patient's having three or more of the following risk factors: abdominal obesity (a waist circumference greater than forty inches in a man and thirty-five inches in a woman), elevated triglycerides (a blood level of 150 mg/dl or higher), low HDL cholesterol (blood levels lower than 40 mg/dl in men and 50 mg/dl in women), high blood pressure (more than 130/85), and insulin resistance (defined as a fasting blood sugar of 100 mg/dl or higher along with elevated insulin levels).
Metabolic syndrome poses a double risk because it not only increases your chances of developing cardiovascular disease but is also strongly linked to the development of type II diabetes. Consequently, doctors now pay more attention to the syndrome when developing a treatment program. For example, moderately elevated cholesterol may be treated more vigorously in a person with other components of metabolic syndrome than in someone without them. In addition to treating individual components of the syndrome, doctors work with patients to institute lifestyle changes to halt progression to heart disease and/or diabetes. Important variables that should be considered include weight, age, racial and ethnic background, and the status of any of the individual components of metabolic syndrome.
Diabetes and Insulin Resistance
There is no doubt that persons with diabetes mellitus,both type I and type II, have an increased risk of heart attacks, stroke, and other cardiovascular diseases. Even persons who do not have established diabetes but have slightly elevated levels of blood sugar and circulating insulin-the hormone that maintains normal blood sugar-are at increased risk. The risk is further increased in persons with metabolic syndrome, in which other risk factors are present (see earlier). This accumulation of risk is increasingly worrisome given the current epidemic of obesity and a skyrocketing incidence of type II, or insulin-resistant, diabetes among young adults and even teenagers.
Excerpted from HEART CARE FOR LIFE by Barry L. Zaret Genell J. Subak-Sharpe Copyright © 2006 by Barry L. Zaret and Genell J. Subak-Sharpe. Excerpted by permission.
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Meet the Author
Barry L. Zaret, M.D. is Robert W. Berliner Professor of Medicine and professor of radiology, Yale University School of Medicine. Dr. Zaret served as chief of the section of cardiology at Yale from 1978 - 2004 and has been a pioneer in developing the field of noninvasive diagnosis in cardiovascular disease, with an emphasis on nuclear cardiology. Genell Subaksharpe, M.S., is president of G. S. Sharpe Communications, Inc. and has produced or collaborated on more than forty books in health and medicine.
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