Non-modifiable risk factors

Non-modifiable risk factors are factors, that if present, increase your risk for heart disease and there is no intervention that will change them.

A positive family history includes having a first degree relative with heart disease. A first-degree relative is a parent, sibling or child. It is considered a particularly strong risk factor if your family member had an onset of disease before age 50.

Males have a higher risk for heart disease at a younger age. The risk balances out and men and women are at equal risk for heart disease at the age of 70 and beyond.

Age is the last non-modifiable risk factor. The older one becomes the more at risk he or she is for heart disease.

Modifiable risk factors

Modifiable risk factors are factors you can change to reduce your risk of heart disease.Cholesterol: Controlling blood fats reduces death, heart disease and strokes. Cholesterol and smoking are considered the top two cardiovascular risk factors. Optimizing cholesterol levels delays heart disease and reduces its complications.

Three subtypes of cholesterol are reported on a lipid panel. Total cholesterol should be less than 200 mg/dl. The low-density lipoprotein (LDL) cholesterol is the most damaging cholesterol particle. This is the one that can result in the most benefit from lowering – the lower the LDL the better. Most recent guidelines recommend if you have heart disease or are at high risk for heart disease that values should be less than 100 mg/dl and patients who are very high risk should have values less than 70 mg/dl.

The high-density lipoprotein (HDL) is considered the good cholesterol. The HDL cholesterol takes the LDL cholesterol away from the vessel where it does the most damage. The minimum number that should be achieved is 50 mg/dl – the higher the better.

When assessing cholesterol it is important to look at the LDL and HDL cholesterol to determine risk of disease. The total cholesterol is not correlated with heart disease as well as the components of cholesterol.

Triglycerides are another number reported on the lipid panel. The role of triglycerides is less clear in the development of heart disease. It is recommended that the people strive to achieve triglyceride levels less than 150 mg/dl.


Diabetes: Having diabetes puts you at increased risk for heart disease. Diabetes is a condition where high levels of sugar are in the blood. Blood sugar is high because the body is unable to use insulin or does not create enough insulin. Both high levels of blood sugar and levels of insulin can damage the blood vessels in the body contributing to the development of heart disease

Hypertension: High blood pressure puts you at increased risk for heart disease. Optimal goals include reducing the blood pressure to less than 120/80 mm Hg. Elevated systolic blood pressure (top number), which is more common in the older population, is correlated more with heart disease than increases in the diastolic blood pressure (bottom number).

Physical inactivity: Lack of exercise is a clear risk for heart disease. Exercise can affect a variety of other risk factors. Regular exercise has been shown to decrease blood pressure, raise HDL cholesterol and decrease insulin resistance (a factor associated with diabetes).

Smoking:  Cigarette smoking is a strong risk factor for heart disease. Toxins in cigarette smoke have been shown to damage the vascular wall and may precipitate plaque formation. Smoking only one cigarette a day significantly increasing the risk of heart attack over a non-smoker.

Stress: Chronic daily stress increases your risk for heart disease.

Abdominal obesity: A waist circumference of greater than 32 inches in females and 34 inches in men is a predicator of heart attack. Weight gain negatively affects many of the other risk factors for heart diseases. The direct effect of obesity on the risk for heart disease is a question of debate but weight gain increases the risk of insulin resistance, blood pressure, diabetes and cholesterol.

Eating few fruits and vegetables: Fruits and vegetables have antioxidants and fiber that are protective against heart disease.

Drinking too much alcohol: It is believed that drinking 1 drink a day for the female and 2 per day for men reduces the risk of heart disease. Drinking more than this amount has the potential to increase you risk of not only heart disease but many other diseases.

High level of blood homocysteine: This is a relatively new risk factor. High levels of this chemical have been shown to increase the risk of vascular events. These levels can be reduced with the addition of folic acid, vitamins B6 and B12. Homocysteine levels are higher in patients with cardiovascular disease and they may damage the vascular wall making it more likely to develop plaque.

Inflammation: Another relatively new risk factor, high levels of inflammation can increase you risk for heart disease. A test that is often run to detect this is the high sensitivity C-reactive protein (hs-CRP).Signs and Symptoms

The most common scenario for patients with heart disease is chest discomfort on exertion, which is relieved by rest. Angina is another term for chest pain and is typically describes as a squeezing pain or pressure in the chest. These pains are caused by a blockage of the arteries that supply blood to the heart. The discomfort is often described as pain, tightness, burning, pressure, aching, gas, indigestion or an ill-defined discomfort. It is often brought on by exercise, eating a heavy meal or becoming excited. The discomfort is usually located in the chest but it can radiate to the jaw, arms or back. The attacks usually last less than 3 minutes but can last up to 15-20 minutes. If the pain lasts longer than 30 minutes it could indicate a heart attack.

Stable angina is chest pain that comes on with a certain level of activity and goes away with rest. Unstable angina is the term used to describe a pattern of discomfort that is noticed with less exertion or at rest and is a more ominous sign. Angina, while always a worrisome symptom, is more dangerous in someone who has not had it before or is having more episodes with less exertion or at rest. Another sign or great concern is when the pain does not go away after rest or taking the medicine nitroglycerine. In these situations the patient should go to the emergency room.

Older individuals often have significant heart disease and never have chest pain. Fatigue or shortness of breath on exertion without chest pain are common symptoms in older patients with heart disease. This is common in older individuals and diabetics. Diabetes can damages nerves, including nerves in the chest, which decreases the ability to feel chest pain.







Diagnosis

The first step in testing for heart disease is a history and physical exam by your health care provider, which includes screening for risk factors of heart disease. Screening for cardiac risk factors includes a laboratory assessment of cholesterol, blood counts, kidney function, and diabetes and sometimes testing for homocysteine and inflammation. If the history and physical exam is highly suggestive of heart disease than more extensive testing is indicated to help evaluate for the presence of heart disease.

The next step is running a battery of diagnostic tests. The first test commonly run is an electrocardiogram (EKG), which is performed to help diagnose any electrical abnormalities or any areas of the heart that have blocked blood flow. This test does not pick up on all cases of heart disease and further testing is frequently required.

The next line of testing is a stress test, which is a more sensitive indicator of heart disease. Stress testing is unable to accurately rule in or rule out heart disease and is typically preformed on patients who are at moderate risk for heart disease. If the doctor feels that the patient is at high risk for heart disease, a cardiac catheterization will be performed which is a much more accurate way to diagnose heart disease.

During a stress test the patient performs progressive exercise on a treadmill or bike with a continuous EKG monitoring the heart. Blockage in any of the coronary arteries can be detected. To improve the ability of this test to diagnose heart disease it is often combined with a nuclear medicine injection or a picture of the heart called an echocardiogram. When these tests are positive the patient is referred on for more definitive testing such as cardiac catheterization.

Some computerized axial tomography (CAT) scans of the heart detect calcium levels in the coronary vessels. This type of testing has been shown to detect coronary heart disease, which was missed by stress testing.

The gold standard test for detecting heart disease is angiography. This test involves placing a catheter into the groin and threading it up to the heart and getting an accurate picture of the coronary arteries. While this is the most risky procedure it is the best way to tell if there are blockages in the arteries around the heart and how severe they are. While this is the best way to diagnose disease, it is not without risk. Complications of this procedure include heart attack, stroke, bleeding or nerve damage.

Physicians often perform diagnostic tests – typically stress tests – on patients with multiple risk factors for heart disease even if they do not have typical signs or symptoms. Routine use of stress tests is not recommended in individuals at low risk for heart disease.

The routine use of testing on individuals who are at low risk for disease puts the patient at risk because of the high number of false positive results. A false positive result is a test that shows disease is present when in reality disease is not present. Based on the positive results, patients are required to undergo more invasive and dangerous testing such as a cardiac catheterization.

For individuals with medium risk, an exercise test is warranted in men over 45 and women over 55 who are starting an exercise program or have established cardiovascular disease, diabetes, another type of vascular disease (such as peripheral vascular disease or stroke) or kidney disease.

Treatment

Treatment options for heart disease always include lifestyle modification and risk reduction. Lifestyle modification techniques shown to treat and prevent heart disease are weight loss, reducing saturated fat in the diet, stopping smoking and exercise.

Most people know that they need to involve themselves in lifestyle modifications but few do a good job at following this recommendation. A lifetime of habits is difficult to break even when diagnosed with a serious disease. Lifestyle modification involves starting an exercise program and changing eating habits and can be very difficult to maintain over the long haul.

Therefore, medical treatment is the mainstay of treatment for the heart patient. The method of treatment depends on the severity of disease and the patient characteristics. Medical therapy consists of using medicines to control the symptoms of disease and decrease risk. In older individuals with chest pain attributed to cardiovascular disease, medical treatment is as effective as surgery at reducing death and cardiovascular events in patients over 75 years old (1).

Surgery is often the treatment of choice for heart disease but some patients are not candidates. Frail, older patients who are not candidates for surgical intervention are treated with medical therapy. Patients with less severe symptoms and no evidence of severe blockage are also candidates for medical therapy. Patients who have signs and symptoms of stable angina are also candidates for medical therapy.

Risk Reduction

Reducing risk factors for heart disease decreases the risk of future cardiovascular events and is a vital component to treating established heart disease. Unfortunately, it is unknown if years of exposure to risk factors for heart disease can be reversed. Risk reduction is done through a combination of lifestyle modifications and medications. For those with established heart disease, risk factors should be treated with specific medicines known to not only treat the risk factor but also heart disease itself.

High blood pressure: This needs to be treated aggressively because increased blood pressure increases the strain on the heart. Continued stain on the heart increases the risk of damage. Beta-blockers, which are discussed below, are one medication that should be used to treat high blood pressure – unless there is a contraindication – in patients with heart disease

Cholesterol: Reduction in cholesterol, specifically LDL cholesterol, decreases the progression of heart disease and may reduce established disease. Cholesterol reduction is accomplished through lifestyle changes – mainly diet and exercise – and with certain medications. Evidence points to the possibility that reversal of plaque around the heart is possible with intensive cholesterol lowering.

Diabetes: Anyone with established heart disease or risks for heart disease should be screened for diabetes. High levels of blood sugar and insulin damage the heart and vascular system.

Exercise: Physical inactivity is major contributor to heart disease. Become more physically active.

Smoking: Stop smoking – it has many negative effects on heart disease. It increases hormones that put extra stress on the heart. It decreases the ability of the blood vessels to dilate resulting in a decreased ability of the body to get oxygen. It also lowers the good cholesterol and makes the body more prone to blood clots.

Homocysteine: A newer risk factor is high levels of homocysteine. This is an amino acid found in the blood. Some doctors test for and treat high levels of homocysteine. High levels of homocysteine are treated with the vitamin folic acid, which is found in green leafy vegetables as well as vitamin pills. Some clinicians recommend that patients at risk for or diagnosed with heart disease take a supplement of folic acid, as there is little risk and may provide significant benefit in lowering homocysteine levels.

Dietary changes: Many dietary changes can have a beneficial effect on heart disease. Those who eat fatty fish (which are high in Omega-3 fatty acids) including salmon are at lower risk for heart disease. Diets high in fruits and vegetables also decrease risk.

Medical Therapy

Medical science has found many medicines that attack the defects that are associated with heart disease. Nitroglycerin is a medicine that dilates the vessels around the heart and allows more oxygen to get to the heart. It can be given in a variety of forms including oral, patch or under the tongue. The under the tongue formulation (sublingual) comes in pill or spray form. It is used for relief of an acute attack and should be carried by anyone with established heart disease in the event of an acute onset of chest pain.

The sublingual form of nitroglycerine provides relieve of pain from an acute attack. Three doses can be given five minutes apart. If three pills are unable to relieve the pain, then 911 should be called immediately.

Nitroglycerine can also be given in a long acting form – either pills, given 1-3 times a day or a patch. Side effects often limit the use of this medicine. Major side effects include headache, low blood pressure, light-headedness and nausea.

Beta-Blockers, which are pills used to control blood pressure, decrease input from the nervous system, slow down the heart rate and increase the amount of oxygen that gets to the heart. This class of drugs has been shown to decrease death rates in coronary heart disease. Side effects include fatigue, slow heart rate, dizziness, depression and low blood pressure.

Calcium Channel Blockers (Verapamil and diltiazem) are used in coronary heart disease to improve the amount of oxygen that gets to the heart. There are more potential complications with this class of medicines compared with nitroglycerin and beta-blockers and they have not been shown to decrease death rates in coronary disease like beta-blockers. This class of drugs should be used with caution in patients with congestive heart failure because they have the potential to decrease the amount of blood that the heart can pump out.

Side effects include constipation, swelling, low blood pressure, low heart rate and dizziness. The incidence of low heart rate and blood pressure is increased when calcium channel blockers are combined with beta-blockers.

Platelet inhibitors: Heart attacks and some types of chest pain are strongly associated with platelets sticking together. Platelets are part of the blood associated with the blood clotting process. Platelet inhibitors reduce death rates and recurrent cardiac events in patients with coronary disease. Medicines in this class include aspirin and clopidogrel (Plavix).Cholesterol:

Lowering cholesterol is one of the primary goals in managing heart disease. The number one priority is to lower the LDL cholesterol to less than 100 mg/dl and less than 70 mg/dl in those at high risk. Secondary goals include raising the HDL cholesterol and lowering the triglyceride levels. If cholesterol levels are not controlled with lifestyle interventions then they are controlled with a class of drug called statins.

Statins inhibit an enzyme that is responsible for making cholesterol. In addition to lowering cholesterol, statins are believed to improve the stability of the plaques. Plaque stability reduces the likelihood a piece of the plaque will break off, and clog up a blood vessel – causing a heart attack.

While there are many benefits to this drug they are not without risk. Statins have many side effects including muscle weakness, liver disease, diarrhea, abdominal pain, muscle cramps and joint pain. Examples of statins include: atorvastatin (Lipitor), simvastatin (Zocor), and lovastatin (Mevacor).




Surgical Treatment

Surgical treatments used to treat heart disease are considered when medical therapy cannot control disease, disease becomes severe or quality of life is impaired on maximal medical therapy. Treatment options include: angioplasty, stent placement or bypass surgery. The goal of surgical therapy is to relieve symptoms, increase quality of life and decrease death rates.

If a patient is found to have severe disease – blockages in three vessels or a blockage in a major vessel – and is a surgical candidate, then open heart surgery is the option of choice. Some patients have more localized disease – blockage in one or two vessels – and are candidates for localized therapy such as angioplasty or stent placement.

Angioplasty entails placing a balloon tipped catheter into the blocked blood vessel. The balloon is blown up and the plaque is smashed down in the blood vessel. Angioplasty carries the risk of the blood vessel closing up after the procedure. This risk can be reduced with the use of stents. A stent is a wire mesh tube that is put into the artery where the blockage was to hold the artery open and improve blood flow to the heart.Health Care Responsibility

1. Know the answers to the questions listed below.
2. Use the risk factor tracking form to assure that all of your risk factors are controlled.
3. Utilize any forms in other chapters that are related to your heart disease. For example, if you have high blood pressure use the blood pressure tracking form or if you have diabetes use the diabetes forms.

   Questions to ask your health care provider:

   What type of heart disease do I have? Is there a blockage in the coronary arteries around the heart or do I have another type of heart disease?

   How did you diagnosis my disease? Was disease diagnosed based on a medical history and physical exam, stress test or coronary angiography?

   How severe is my disease/How fast will it progress/Can I expect any improvement?

   What testing should I have to assess for heart disease? Should I have an EKG, CAT scan, stress test, stress test with echocardiogram, stress test with nuclear imaging or angiography?

   How can I prevent heart disease? This involves treating risk factors for heart disease as listed below.

   Is my blood pressure at goal?

   Is my cholesterol at goal?

   Have I been checked for diabetes?

   Should I be exercising? How?

   Do I need a stress test prior to starting an exercise program?

   Should I be on an aspirin?

   Is their any indication that I have had a heart attack? Changes in the EKG can indicate if you have had any damage to your heart, which may indicate a previous heart attack.

   Should we check an hs - CRP level? This is a marker of inflammation and has associated with heart disease.

   Should we check a homocysteine level? High levels of homocysteine levels are associated with increased risk of vascular events. This level can be treated with a combination of B-vitamins including folic acid, B-6 and B-12.

   If you have known heart disease.

   How are we going to treat my disease? Is it going to be treated with surgery, angioplasty, stents, or medicines.

   Reference

   1. Pfisterer M. Long-term outcomes in elderly patients with chronic angina managed invasively versus by optimized medical therapy Circulation 2004; 110(10): 1213-128.