Keeping Your Heart Healthy

CBS News Chief Medical Correspondent Dr. Jon LaPook shares words to the wise about avoiding heart disease

Cardiovascular disease (e.g., heart attack, heart failure, stroke, angina, high blood pressure) is by far the No. 1 killer in the United States. Heart attacks alone claim about 450,000 lives a year, strokes about 150,000. Over the past two decades, we've definitely made strides, but we still have a long way to go. One reason is that we don't pay enough attention to prevention. Many studies have shown that coronary atherosclerosis ("hardening" of the arteries supplying the heart) begins decades before symptoms start to show. Although chest pain usually doesn't begin until after 40, those arteries can start to deteriorate before the age of 20. In one dramatic study, coronary atherosclerosis was found in one-in-six teenagers! The message is clear: By the time you develop symptoms, the underlying cardiovascular disease has usually been smoldering for many years -- time that should have been spent reducing your risk factors.

For two weeks, I will blog daily with tips for cardiovascular health. I'll try to dispel some common myths while pointing out what we know, what we think we know, and what we definitely don't know!

Friday, Feb. 20, 2009

That seems to be the question these days - with two studies from the New England Journal of Medicine out this past week to help clarify the situation.

But first some background. When doctors suspect that there may be narrowing in the coronary arteries (the arteries that supply blood to the heart muscle), they will sometimes suggest a coronary angiogram ("coronary angiography").

During this test, a tiny catheter is inserted - usually through an artery in the groin - and threaded up into the arteries of the heart. A special dye (contrast material) is injected so that areas of narrowing become apparent.

When a narrowed segment is identified, it can be opened up with a small balloon; this process is called angioplasty. Then a tiny coil called a stent can be inserted to try to keep the arteries open. These days, when angioplasty is performed, a stent is almost always inserted because past experience has shown that coronary arteries often block up again after angioplasty alone. The term "percutaneous coronary intervention" (PCI for short) is often used synonymously with "angioplasty with stenting."

The hard part has been figuring out when to put in a stent.

Cardiologists used to think that an open artery was always better than a closed one. That turns out to not always be true. Opening the artery is clearly beneficial during the early hours after a heart attack, but not if the artery has been blocked for several days. Stents have been shown to save lives when used during a heart attack or near heart attack. And they may help relieve angina (e.g., chest pain from lack of blood flow to the heart muscle) in patients whose symptoms were not relieved by medication and lifestyle alone.

But a major study in 2006 found that stable patients who had 100 percent blocked arteries opened up using stents from three to 28 days after a heart attack were no less likely to have another heart attack or die than patients treated with medicine alone. And the same researchers published another study two days ago reporting no difference in quality of life, including the chances of having angina.

How could this be true? Shouldn't an open artery be better than a closed one? Not necessarily true - especially if, as is now felt to be the case, second heart attacks often come from the rupturing of small, fatty plaques that are usually too small to be treated with stents.

When these plaques rupture, a blood clot may form that totally blocks the artery. In that case, preventing a second heart attack may best be achieved by aggressive medical therapy that includes lowering the LDL ("bad cholesterol") to less than 70, controlling hypertension, decreasing inflammation that is felt to contribute to plaque rupture, lowering the stickiness of platelets so they're not as likely to contribute to the clogging of arteries, and addressing lifestyle changes to improve diet, increase exercise, and lower stress.

A second article in this week's New England Journal of Medicine tackled the issue of what to do in cases where patients have certain types of severe blockages involving the "left main" coronary artery (that supplies two-thirds of the heart muscle) or when there are blockages in all 3 of the heart's arteries, so-called "triple vessel" disease.

Open heart surgery called "coronary artery bypass and graft" (CABG for short) has been shown to prolong the lives of patients with these types of blockages. But open heart surgery is more involved than an angioplasty with stenting; after all, with CABG the chest wall has to be opened up.

So over the last decade, as angiography has become safer, interventional cardiologists have wondered if placing stents could offer just as good an outcome with a less invasive approach. But this week's study found that stenting resulted in more than twice the need for repeat procedures and concluded that "CABG remains the standard of care for patients with three-vessel or left main disease … ." Of interest, patients undergoing CABG had a 2.2 percent chance of stroke - 1.6 percent higher than the risk of stroke in patients receiving stents.

There's a very enlightening video discussion of the study by three physicians: Dr. Thomas Lee, Dr. David Hillis, and Dr. Elizabeth Nabel, Director of the National Heart, Lung and Blood Institute (NHLBI). They point out that there are still many unanswered questions and that physicians and patients need to weigh the entire clinical picture very carefully in order to decide which procedure makes sense in any one particular case.

Another important study has been the COURAGE trial, which compared angioplasty with stenting with medical therapy in patients with stable coronary artery disease. Although stenting provided some initial benefit in terms of relief from angina, that difference had disappeared by 36 months and there was no difference in the chance of having a heart attack or dying after almost five years.

So where does that leave us? It's clear that stents are very helpful in the early phase of heart attack, and after that - they may be helpful in patients who have symptoms of angina. But in many situations, aggressive medical treatment may be the way to go - and that means not just taking pills but addressing lifestyle issues such as diet, exercise, and stress.

We're learning more and more that one size does not fit all. Increasingly, personalized medicine is becoming the name of the game.

Thursday, Feb. 19, 2009

We are in the midst of a health crisis of immense proportions, literally and figuratively. Childhood obesity is threatening the health of millions.

From 1980 to 2006, the percentage of obese children increased from five percent to twelve-point-four percent in two-to-five-year-olds and from six-point-five percent to 17 percent in six-to-eleven-year-olds. It more than tripled in adolescents 12-17-years-old, rocketing from five percent all the way up to 17.6 percent. For more on these numbers, click here.

Childhood obesity increases the risk of all sorts of adult illnesses, including heart disease, stroke, diabetes, and even cancer.

This is one of the toughest health problems we've ever faced. Multiple government and professional organizations have sounded the alarm and launched programs. In addition, I'm encouraged to see health experts from all part of the country using imaginative, innovative approaches. My good friend, Dr. Mehmet Oz, is a cardiac surgeon, best-selling author, and health expert on the "Oprah Winfrey Show." He's founded an organization called HealthCorps to fight childhood obesity by going to the belly of the beast: school cafeterias and local communities, especially underserved populations. HealthCorps uses peer mentoring to teach young students about diet, exercise, and mental resilience. As Dr. Oz explains, "Our goal is to get one kid in a family to understand what healthy food and exercise is about. Once one kid gets the story, it becomes cool, because knowledge is power, and the rest of the family follows."

And the latest news on the childhood obesity front is encouraging. The Alliance for a Healthier Generation, a joint initiative of the American Heart Association and the William J. Clinton Foundation, launched the Alliance Healthcare Initiative, a collaboration of national medical associations, insurers and employers that will offer health benefits to children and families for the prevention, assessment, and treatment of childhood obesity.

As with so many health problems, much of the solution lies in better education and comprehensive, well-conceived programs -- and they cost money. Efforts like HealthCorps and The Alliance for a Healthier Generation realize it will take more than brochures and public service announcements to get the message through. It will take hands-on efforts that provide close, one-on-one interaction with children. It will take financial support for families that can't afford adequate health coverage, not to mention healthy meals.

Those programs cost money, but I can think of no better investment. We need to dig deep. When it comes to childhood obesity, empty words just lead to empty calories.

Wednesday, Feb. 18, 2009

With the advent of statins (e.g., Lipitor, Crestor, Pravachol, Mevacor, Zocor, Lescol), doctors can now almost dial your "bad cholesterol" (LDL) to whatever number they want. The questions are: What should that number be, and can you reach it without medication?

The ideal target LDL has been a moving target, edging lower and lower over the years.

The National Heart, Lung, and Blood Institute (NHLBI) is a wonderful source of information about everything having to do with heart health. Its Web site contains the latest government guidelines and is very helpful for both patients and physicians; I visit it often for guidance.

I asked Dr. Elizabeth Nabel, the Director of NHLBI, for the best patient reference for understanding cholesterol guidelines. She suggested this page.

Dr. Chris Cannon, a cardiologist and expert in cardiovascular risk, has written an easy-to-understand article about cholesterol that can be accessed by clicking here. He points out that, for patients with prior heart attacks, going even lower for LDL is beneficial, based on the most recent studies.

For those wanting a deeper dive, click here for the full text of the latest guidelines.

To determine your risk for heart disease using the Framingham Risk Score, click here.

If you can't reach your target LDL with diet and exercise alone, your physician may recommend treatment with a cholesterol-lowering medication, such as a statin.

But don't fall into the trap of thinking that taking a pill is all you need to do to lower your risk of heart disease. Yes, you may dramatically lower your LDL. But don't let the medication lull you into a false sense of security.

If taking a statin lulls you into doing no exercise, eating poorly, and gaining weight, then the sum total may actually be an increase in your risk, even though your LDL is nice and low. Obesity, poor diet, and lack of exercise all contribute to hypertension (high blood pressure) and diabetes -- each a strong risk factor for cardiovascular disease. So, if you do need medication, make sure you talk to your doctor about diet and lifestyle, too.

Tuesday, Feb. 17, 2009

Reducing risk factors is the name of the game when it comes to cardiovascular health. Your doctor should be specifically asking you about risk factors and discussing proper diet and exercise.

Modifiable risk factors for heart attack include: smoking, hypertension (high blood pressure), high cholesterol, diabetes, being overweight or obese, lack of physical activity, and stress.

(CBS)

A similar tool from the American College of Cardiology can be accessed by clicking here.

There's also excellent general information at HeartHub.org.

Risk assessment tools aren't perfect. They don't take into account all your personal information and can only give you a rough statistical idea of your risk. Their value is mainly in educating you and, especially if you are at increased risk, getting your head in the game. If you wait until you develop chest pain before you start thinking about lowering your risk factors, you are asking for trouble.