Heart Disease: Getting Serious About Prevention

Here’s one more way men and women are equal: neither sex should have heart disease.

New data:

Last year, Finnish investigators showed that 4 of 5 heart attacks in men could be avoided. All the men had to do were five things: be modestly active, eat a good diet, not smoke, drink alcohol moderately and maintain a normal body weight.  The findings of this robust study made an impression on the cardiology community. But it was a study of just men.

This year, a group of American researchers reported similar results in women. In the Nurses’ Health Study, women had to do six things to avoid heart disease: not smoke, keep a normal body weight, exercise 2.5 hours per week, eat a good diet, drink less than 1 alcoholic drink per day and watch less than 7 hours of TV each week. In this 20-year study, the 23-44 year-old nurses who made those basic choices were 73% less likely to get heart disease. These were nearly the same odds as the Finnish men.

There was a bonus in the Nurses Health Study. The same six lifestyle factors prevented 93% of diabetes and 57% of high blood pressure in women.


A note on watching too much TV: three studies published this month showed inactivity—sitting for long periods–was linked to higher rates of heart disease and even death. Although regular exercise lowered the risk,  it did not eliminate it. (Athletes with desk jobs pay attention to that.)

Although the research on “sitting disease” is still early, not sitting in one place for hours at a time may be an important way to live longer and better.

Changing the language:

Perhaps the most important thing about this new research is its effect on the language of heart disease prevention. Rather than treating diseases like high blood pressure and high cholesterol, doctors are looking at the basic and fundamental things that keep us from getting heart disease. Moving our bodies, making wise food and drink choices, not smoking and getting away from white screens will deliver far more health than any pill or capsule.

I know what you may be thinking: This is not new.

That’s partly true. But what’s different is that these studies are changing the way doctors think. They may now emphasize lifestyle changes before drugs. More doctors are writing prescriptions for exercise.

Remember these numbers: four out of five.

For four out of five men or women, heart disease need not happen. It is not necessary. It is not normal to let heart disease do this to us.

How to Get a Handle on Your High Blood Pressure

High blood pressure is a condition that patients tend to dangerously underestimate – many people just don’t take it very seriously. But they should. It’s a leading cause of death and disability; in fact, it’s been estimated that high blood pressure is a primary or contributing cause of over 400,000 deaths per year – that amounts to more than 1,100 deaths per day.

So why aren’t we more afraid of it?

I think the answer is a mix of familiarity and treatability. The recent statistics show that roughly 50% of adults have it – so most of us probably know someone with high blood pressure. And most of us are aware that it is treatable – we can take medications and make lifestyle to keep it under control.

The problem is, we’re not keeping it under control.

According to the CDC, only about ½ of those with high blood pressure are adequately controlling their condition. Some people are unaware that they have high blood pressure. Others are reluctant to take high blood pressure medications because of real or perceived side effects; or maybe they don’t want to (or can’t) make the needed lifestyle changes. But one of the biggest reasons people aren’t controlling their blood pressure is that they’re having trouble getting an accurate view of what their blood pressure numbers are exactly.

In the past, high blood pressure was determined by the blood pressure reading your get in your doctor’s office. But data has shown that blood pressures in the doctor’s office are often not accurate – even up to up to 65% of the time.

So, if you have, or are concerned that you have, high blood pressure, monitoring your readings away from your doctor’s office is crucial.

Here are the recommendations I give to my patients about monitoring blood pressure at home:

  1. Get a monitor where the cuff goes on your upper arm.  And make sure it’s the right size for you. Well-rated devices cost between $25 and $100.
  2. Sit quietly for at least 5 minutes before you take your blood pressure.  Make sure the cuff is on your bare arm and not over clothes.
  3. Vary the time of day that you check your blood pressure. Record your results and bring them with you to your next doctor’s appointment.

Blood pressure greater than 180/120 mm Hg is called a hypertensive crisis.  If you aren’t having any symptoms, it may be reasonable to wait 5 minutes and check it again before contacting your health care professional. If you are having any concerning symptoms (at any level of blood pressure), such as chest or back pain, shortness of breath, numbness or weakness or difficulty with your vision or speaking, you should call 911 immediately. 

Appropriately monitoring your blood pressure is an important opportunity for you and your doctor to work together to make sure you get the best treatment for your blood pressure.

Not All Blocked Arteries Should Be Fixed. Here’s Why

If you think all heart artery blockages should be fixed, you’re not alone. For years, cardiologists also thought if we can open a blocked artery with a stent or a balloon, we should.

It makes sense, but in some cases, it’s wrong. Let me explain.

Reviewed by James Beckerman on 9/9/2019

Doug is a 67-year-old man who came to see me because he feels like he’s a little slower during vigorous exercise than he should be. He doesn’t have chest pain or shortness of breath, and his endurance is good, but he’s not able to keep up as well as he wants. Part of the investigation into his symptoms included an exercise treadmill test – a stress test – which indicated ischemia, meaning it showed the possibility of blockages in his heart arteries.

An exercise stress test is useful, but isn’t highly accurate. So, to confirm a positive stress test, we usually run an additional test to look at the arteries themselves. In Doug’s case, I recommended a CT coronary angiogram, which is an x-ray test that directly evaluates the heart arteries to assess for blockages. Doug’s study showed a highly narrowed artery in his heart. Importantly, this artery was a minor one that provided blood to a relatively small area of his heart. When I told him the results, he was initially surprised I didn’t recommend fixing this blockage with a stent.

Who Needs a Heart Artery Stent?

There are almost one million heart artery procedures (called PCI’s or percutaneous interventions) done each year in the U.S., making them among the most common surgeries performed. But, recent research suggests some of these surgeries may not be necessary.

In broad terms, heart artery stents are performed in two situations. One is during a heart attack or an impending heart attack. This is called acute heart disease. The other is when stress tests or other heart artery tests discover blockages. This is called stable heart disease.

During a heart attack, it is well accepted that opening the heart artery with a stent procedure is beneficial. There is solid research evidence that opening the artery lowers the risk of death, further damage to the heart, and future heart failure.

However, the same is NOT true for most blocked heart arteries discovered by stress-testing when the patient is not having a heart attack.

While it seems logical that opening blocked heart arteries would be helpful, multiple research trials have not shown a benefit to fixing blocked arteries in stable patients.

One of the first large research studies that showed opening blocked heart arteries in stable patients did not save lives was the COURAGE trial. This study compared people who had heart artery blockages treated with stents and medications to those treated with just medications. After following these individuals for almost five years on average, there was no difference in death rates or heart attack rates between the two groups.

The result was a surprise for many cardiologists, and the study was criticized for several potential flaws.

However, a more recent trial showed the same lack of benefit for stents in stable patients.

The ISCHEMIA trial of over 5,000 people with a blockage in a major heart artery were randomized to fixing the blockage and medications or just medications. Just like the COURAGE trial, the study found no differences in death, heart attack, heart failure, or hospitalization between the two groups.

It is now generally accepted that stents in blocked heart arteries in patients who are not having a heart attack do not lower the risk of death or future heart attack. However, the COURAGE and ISCHEMIA trials did show a decrease in chest pain for those who had stents compared to medical treatment alone, but even this benefit is controversial

The decision to perform a stent in a heart artery involves weighing the risks and benefits. In the case of heart artery stents, the risks of the procedure are known. While infrequent, serious complications such as heart attack, stroke, or even death can occur in less than 1% of cases. Bleeding complications, kidney damage, or an allergic reaction are more common, although still infrequent.

However, if there is no benefit to the procedure, ANY risk is unacceptable.

The decision to perform a stent procedure is a complex one. There are numerous factors to consider, too many to explain in a single article. So, to decide the best course for you, have a thoughtful discussion with your doctor to explore the medical risks, benefits, and alternatives, balanced with your values and goals.

After I reviewed the medical information with Doug, we decided that his symptoms were unlikely due to his heart artery blockage. Since a stent was probably not going to help him feel better, and we knew it would not lower his risk for death or heart attack, we decided on treating his heart artery disease medically. We started an aggressive prevention treatment regimen that included excellent blood pressure and cholesterol control, along with his healthy lifestyle.

One year later, he continues to do well.

High Blood Pressure? These 3 Things Could Save Your Life

If you’re concerned about your high blood pressure, you’re right to be. High blood pressure is called the silent killer for a reason.Although high blood pressure typically doesn’t cause symptoms, it has a devastating effect on our health. High blood pressure is the primary or contributing cause of more than 1,300 deaths every day in the U.S. That’s someone dying almost every minute. It’s one of the leading causes of two of our most feared diseases, heart attack and stroke, and also increases the risk for dementia and kidney failure.

How to Check Your Blood Pressure

Roll up your sleeve and slide on that blood pressure cuff. It’s important to check how well your heart pumps blood.


These numbers are frightening, but here is something even more striking.

Almost all the deaths, diseases, and disabilities caused by high blood pressure are preventable.

We just aren’t doing it.

The Surgeon General’s Call To Action To Control Hypertension notes that only 1 in 4 people with high blood pressure have it under control.

As a cardiologist, I think this is unacceptable, so I have come up with the three most important things I want all my patients to know about lowering their blood pressure — and possibly saving their lives.

1. Know your numbers.

If possible, check your blood pressure at home. Reliable automatic blood pressure cuffs (get the ones that wrap around your upper arm) are inexpensive and widely available.

Although it is tempting to rely on the blood pressure from your doctor’s visits, the reality is these blood pressures are more likely to be inaccurate than not. Regularly checking your blood pressure at home — it’s critically important to sit quietly for 5 minutes before taking it — will set you up to be your own blood pressure expert and help guide your doctor in the best treatment options for your blood pressure. Talk to your doctor about how often to check your blood pressure and when. Empty your bladder beforehand, and wait at least 30 minutes after exercise, smoking, or drinking caffeine.

2. Treat the cause of your high blood pressure.

If you had a continuously running kitchen faucet, you wouldn’t treat it by bringing a mop. You would turn the faucet off. The same logic applies when treating your blood pressure. If you have a cause, the best treatment will be eliminating the cause.

Common causes of high blood pressure include:

  • Sedentary lifestyle — Even modest levels of activity can lower your blood pressure and minimize medications.
  • Eating highly processed food — Particularly if high in sodium
  • Being at an unhealthy weight — Losing 5%-10% of your weight can lower your blood pressure as much or more than any medication.
  • Excess alcohol — More than a drink a day can increase your blood pressure.
  • Untreated sleep apnea — Experts estimate 30%-50% of people with high blood pressure have sleep apnea, most untreated. If you snore, don’t wake up feeling rested, or your partner notices you periodically stop breathing while asleep, ask your doctor if you should be checked for sleep apnea.
  • Primary aldosteronism — This is a hormone problem once thought to be quite rare, but recent research has shown it to be relatively common. If your blood pressure is not well controlled on several medications, ask your doctor if high aldosterone levels could be the cause.

Talk to your doctor about what may be causing your high blood pressure. Certainly genetics are important, but experts estimate half or more of high blood pressure is caused by factors we have control over.

3. Take your medications.

Nobody wants to take medications. I get it. And I’m a firm believer we all should be selective about any medicines we take (including supplements) and know the benefits and risks.

However, if you know your blood pressure is regularly over 130/80 — even after doing all you can to treat high blood pressure causes — not taking your blood pressure medications puts you at higher risk of heart attack, stroke, and early death. The first-line blood pressure medications are effective, inexpensive, and have a low risk for side effects. It is critically important to work with your doctor to have a strategy for treating your blood pressure that makes sense to you and controls your blood pressure.

Although high blood pressure often doesn’t cause symptoms, its effects on our health are potentially devastating. But you have more control than you may have realized to lower your risk for heart attack, stroke, and early death. By following the three steps above, you are well on your way to controlling your blood pressure — and not becoming a statistic.

6 Simple Rules to Heart Healthy Eating

What is a heart healthy diet?

When I first became a cardiologist about 15 years ago, the answer to this question seemed simple. It was a low-cholesterol, low-fat diet. Unfortunately, that answer ended up falling apart. Turns out, eating foods with cholesterol probably doesn’t have much influence on your cholesterol levels; but eating processed, packaged foods with a “low fat” label has been terrible for our health.

Today, the answer to the heart healthy diet question is more controversial. Is it low carb? Plant-based, vegan, Mediterranean, gluten free, DASH? The list goes on, and each diet has their advocates.

But who is right? Unfortunately, the “experts” haven’t been very helpful. Each one seems to have research and reasons “proving” why their diet is best (and why you should buy their book).

There was a time when I wasn’t sure what to tell my patients about a heart healthy diet.  So I did my own research. I read the important papers, attended conferences, talked to the experts and my patients to see if I could cut through the noise to come to a simple message I could share with my patients.

In the beginning, the more I learned, the more confusing it was. Research findings were often conflicting and seemed to change weekly. Each diet had testimonials of success –  even the ones that seemed to directly contradict each other. In the end though, I came to see that we have been overcomplicating the task of eating well.

Here are the tips I give to my patients who are looking for a heart healthy diet (and by diet I mean the type of foods you usually eat, not restrictive eating to lose weight).

6 Simple Rules to Heart Healthy Eating

1. There is no one “right” diet for everyone

The beauty – and challenge – of medicine is how different we are and how the same treatment can lead to different responses in different people. A medication that saves one person’s life can cause a life-threatening side effect in another.

The same principle applies to diet. While one person may have amazing results with a certain diet, that does not mean you will have those same results. And just because a diet doesn’t work for you, doesn’t mean you failed – it may just mean that diet wasn’t right for you.

2. You should like it (even better if you love it)

Even if we had research that proved that one diet is best (and we don’t), if you won’t eat it, it won’t do you any good. We don’t do well when we feel deprived, and if you’re eating food you don’t like, you’re setting yourself up to fail.

Find a healthy eating style you love and that loves you back. There are too many great tasting and healthy options to settle for food you don’t like.

3. Avoid highly processed foods

If you only follow one of these 6 rules, make it this one. About 70% of the US diet is highly processed foods and it’s a major contributor to the obesity, diabetes and high blood pressure epidemics.

What are highly processed foods? There are several definitions, but here is one I like. Processed food is manufactured food, typically high in added sugars (like high fructose corn syrup) or refined grains (for example, white flour or white rice).  These foods often contain many ingredients you would not recognize as food such as preservatives and other chemicals.

4. Include vegetables and other plant based foods

Mom was right. Eat your vegetables. Every reputable expert recommends that vegetables and other plant based foods should be a big part of your diet.

This doesn’t mean you need to be vegetarian (I’m not), but the simple act of getting planet-based foods into most of your meals can do wonders for your heart health.

5. Portion size still counts

Even if it’s healthy food, eating too much is still, well, too much.

Slowing down, eating mindfully, and serving your meals on smaller plates are all proven strategies to decrease the amount you eat without feeling like you are going hungry.

6. Eat at home

Who has time to cook anymore? YOU do! Cooking at home can be quicker than going out, and the benefits are indisputable. Better quality food, lower cost, a stronger connection with loved ones, and a healthier weight are just some of the benefits of home cooked meals.

You don’t have to be a master chef to put good quality, nutritious food on your table. Start with one or 2 “go to” meals that you enjoy and can prepare quickly.  Or you could try one of the many meal delivery services that are available.

Eating heart healthy is not one size fits all, nor is it written in stone. For most of us, it’s a constant process of trying new things and judging the response. To make things easier, you can start with one of the major diets (i.e. Mediterranean, DASH, vegan, Paleo, etc.) and adapt it to your tastes and needs, or you can start with your own creation.

As long as you follow the 6 rules, you will be able to find YOUR best heart healthy diet!

Could COVID-19 Be Causing Strokes? Know the Signs

A new, and frightening, expression of COVID-19 infection has surfaced. Numerous physicians around the world are reporting a possibly increased risk for blood clots in patients with COVID-19.

Blood clots (what doctors call thrombosis) are particularly worrisome because of the potential consequences. Blood clots in the veins can travel to the lungs (which is called pulmonary embolus), a potentially life-threatening problem. Blood clots in the arterial system are even more alarming because these can lead to heart attacks, strokes, and amputations.

COVID-19 appears to increase blood clots in both the arteries and the veins. Although all of the studies are small and observational at this point, one study from the Netherlands showed that 31% of subjects with COVID-19 in the ICU developed blood clots despite usual measures to prevent clotting. Another small study from China showed that 25% of the COVID-19 patients developed blood clots in the veins. These are shockingly high numbers.

Physicians are particularly troubled by this possible blood clotting issue for several reasons. One is that the usual treatments (such as blood thinner medications) aren’t working for some patients. Another reason is the report of COVID-19 positive people as young as their 30’s experiencing large strokes that are more typically seen in a much older population.

More information is needed to understand if this is a true correlation between COVID-19 and blood clotting disorder, what the mechanism is, and, most importantly, how to prevent and treat it. 

For now, be aware that there’s reason to suspect that COVID-19 could possibly put any of us at risk for stroke.

So, be alert for stroke symptoms – sudden weakness, numbness, trouble speaking, seeing, or the onset of a severe headache without other explanation – even if you wouldn’t ordinarily need to be concerned about stroke risk, and even without other signs of COVID-19 infection.

If you do experience symptoms that may be stroke-related, it is critically important to seek urgent medical attention. Timing is crucial because the best treatments for these types of stroke need to be delivered in the first 3 hours of symptoms to be most effective. As stroke neurologists like to say, “Time is brain.”

And if you suspect a stroke in someone else, act F.A.S.T.:

F.A.S.T. stands for:

F—Face: Ask the person to smile. Does one side of the face droop?

A—Arms: Ask the person to raise both arms. Does one arm drift downward?

S—Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange?

T—Time: If you see any of these signs, call 9-1-1 right away.

Understandably, some are reluctant to go to the hospital during the COVID-19 pandemic, but when it comes to a stroke, the consequences of delaying medical treatment could be devastating. Do not delay. Call 911 if anyone has these symptoms.

How to Avoid the Diabetes/Heart Disease Connection

If you have diabetes, is it inevitable that you’ll end up with heart disease as well? Traditional teaching suggested that it was, or at least highly likely – if you were diagnosed with diabetes, you were automatically categorized at “high risk.” But more recent data suggest that, with a little work, you can stay out of that high risk category – even with diabetes.

This research not only provides hope, but also a road map to lowering your risk for heart disease.

John’s Story

John had been told for years that diabetes increases his risk for heart disease, but he didn’t take the risk very seriously until chest pain and pressure led to the discovery of a blocked artery. We inserted a stent that opened his artery and relieved his pain, but the experience left John deeply concerned about his future health. He worried that he had missed his chance, that the damage was already done because he didn’t pay attention to his health when he was younger.

John’s new interest in his health resulted in some big changes. He started participating in cardiac rehab and exercising every day. He is eating nutritious food and has already lost 10 pounds! He is taking his medications and his blood sugar and cholesterol numbers are much improved.

But he is wondering if that is enough? Does he need to do more, or will his efforts even make a difference?

Diabetes and Heart Disease

One of the first major research studies to show that people with diabetes were at very high risk for heart disease was published in 1998. This was eye-opening to the medical community and led to a change in the way doctors treat patients with diabetes. Based on the recommendations from researchers, we began taking an aggressive preventive approach for all patients with diabetes, emphasizing lower blood pressure, improved blood sugar and statin medications. Around ten years later, a small study looked at the effects of this “multifactorial” approach to prevention and found that it does, in fact, lower the risk of death and heart disease in patients with diabetes. And now we have evidence in large populations that death rates and heart disease rates are falling in patients with diabetes.

These research findings are important because they show that heart disease is not inevitable if you have diabetes. A recent study goes a step further, not only showing that some people with diabetes can lower their risk for heart disease and stroke to the same levels as those without diabetes, but also provides a 5-step road map on how to do it.

(Lots of) Hope for People with Diabetes

A recently published study in the New England Journal of Medicine of over 1.6 million people showed that if 5 good health targets are met, those with diabetes have a similar risk for death, heart attack and stroke as those without.

Those 5 good health targets are:

  • Good blood sugar control (Hemoglobin A1C < 7.0%)
  • Good blood pressure control (Systolic blood pressure < 140 mm Hg, Diastolic < 80 mm Hg)
  • No protein in the urine
  • Not smoking
  • Good LDL cholesterol (LDL < 97 mg/dL)

We now have good evidence that if you have diabetes, you have a lot of control over your risk for heart disease. John was very happy to hear the news that his recent efforts are likely to pay big dividends for his future health. If you have diabetes, work with your doctor to identify the ways you can manage your diabetes and not let it manage you.

Would You Recognize the Symptoms of a Heart Attack?

Someone dies of heart disease in the United States about every 40 seconds. And more than one in three of those deaths occur suddenly – something doctors call “sudden cardiac death.”

Here’s why this is important. Most of the people with sudden cardiac death had symptoms in the hours and days before dying; they either just didn’t recognize the signs as worrisome or ignored them. Many of these people missed the signs because they didn’t think they could be at risk for heart disease – they were fit, they exercised, they felt strong.

Just like Rob.

Rob was training for his 4th Iron Man when he started to notice his throat felt dry during strenuous parts of his training. He ignored it at first, but it was getting worse. Rob began to feel the throat dryness earlier in his bike rides and even started to feel it when he wasn’t training. When he mentioned his symptoms to his wife, she insisted that he seek medical attention.

Ultimately, Rob ended up in the emergency room, where it was confirmed that he was having a heart attack. He had an urgent heart catheterization, which found not one, but two blocked heart arteries. He had stents put in to open the arteries, and fortunately only had mild damage to his heart.

Rob had never considered the possibility that he could have a heart problem. Sure, he had a family history of heart disease, and his cholesterol wasn’t great, but people with heart problems had chest pain – and they weren’t Ironmen!

Rob was fortunate that he wasn’t one of the 300,000 people who die each year in the US from sudden cardiac death. I have several patients with similar stories. They had symptoms that were recognized too late to prevent significant heart damage. But unlike many others, at least these patients were able to tell their story.

The message is that symptoms of heart disease are complex. It’s not just chest pain or pressure that radiates to the left arm. There is a lot of individual variation in how heart disease presents, making it a challenge for all of us, including doctors, to determine when symptoms are heart-related.

Here is the information I want everyone to know about possible heart symptoms.

  1. Symptoms that occur with physical activity or emotional stress and go away with rest – like what Rob experienced – need to be evaluated by a medical professional.
  2. Symptoms such as chest pain or pressure, nausea, indigestion, or heartburn that aren’t going away – particularly if associated with shortness of breath, sweating, palpitations, or feeling like you will pass out need to be evaluated by a medical professional urgently. Don’t drive yourself to the hospital, but call 911.
  3. If you’re concerned, I’m concerned. Be safe and have your symptoms evaluated by a medical professional. It’s much better to be told it isn’t your heart than to find out too late that it is.

Rob’s story was a success because it ended well. He has resumed participating in Ironman competitions, although he doesn’t push himself to the limits anymore. More importantly, he has continued his duties as a loving father and husband.

Recognize the possible symptoms of heart disease. Don’t become a statistic.