How to Keep Your Heart Healthy
Sixty-two-year-old Jack Andre says having a heart attack
in March 2003 was like getting hit in the head with a baseball
bat. "It brought a lot of things to my attention that
I never thought about before," he says. He was overweight,
didn't exercise, and often ate high-fat foods. But he never
connected his lifestyle to his heart.
"Six months before the heart attack, my doctor told
me I had borderline high cholesterol and high blood pressure,"
says Andre, of Rockville, Md. "But I didn't think much
That all changed after he experienced heart attack symptoms--extreme
fatigue, dizziness, and back pain. Tests revealed that Andre
had three clogged coronary arteries. "Now I walk every
day at lunch, eat smaller portions, and I'm a food label reader,"
Bonnie Brown, 50, of Baltimore, says she also didn't change
her life until she had a heart attack in 1997. "I used
to smoke, ate cold-cut subs for breakfast, and had lots of
fried foods, all the time, any time," Brown says. But
her heart attack--which she initially mistook for a bad case
of indigestion--led her to give up cigarettes, improve her
diet, and sign up for weekly water aerobics and line dancing
"There's nothing that motivates people like having
a heart attack or bypass surgery," says Christopher Cates,
M.D., director of vascular intervention at the Emory Heart
Center in Atlanta. "I've found that people think that
heart disease always happens to someone else, until it happens
to them." Experts say that until Americans change their
way of thinking from one of damage control to one of proactive
prevention, heart disease will remain the No.1 killer of men
and women in the United States.
"In many ways, I think we've become insulated by high-tech
care," Cates says. "As physicians, we are partners
in the health care of our patients, which means we need to
educate them about their risk factors for heart disease. And
they need to have some sense of ownership about what they
can control. They can't simply look to their doctors or to
the FDA or to Medicine, and say, 'Cure me, but I'm going to
eat fatty foods, smoke, and be sedentary.'"
One of the reasons that some people may shrug off the possibility
of developing heart disease is that it's a gradual, lifelong
process that people can't see or feel. About the size of a
fist, the heart muscle relies on oxygen and nutrients to continually
pump blood through the circulatory system. In coronary artery
disease, the most common type of heart disease, plaque builds
up in the coronary arteries, the vessels that bring oxygen
and nutrients to the heart muscle. As the walls of the arteries
get clogged, the space through which blood flows narrows.
This decreases or cuts off the supply of oxygen and nutrients,
which can result in chest pain or a heart attack. Damage can
result when the supply is cut off for more than a few minutes.
It's called a heart attack when prolonged chest pain or symptoms
(20 minutes or more) are associated with permanent damage
to the heart muscle.
Every year, more than 1 million people have heart attacks,
according to the National Heart, Lung, and Blood Institute
(NHLBI). About 13 million Americans have coronary heart disease,
and about half a million people die from it each year.
What's Your Risk Profile?
Risk factors for heart disease are typically labeled "uncontrollable"
or "controllable." The main uncontrollable risk
factors are age, gender, and a family history of heart disease,
especially at an early age.
The risk of heart disease rises as people age, and men tend
to develop it earlier. Specifically, men ages 45 and older
are at increased risk of heart disease, while women 55 and
older are at increased risk. A woman's natural hormones give
some level of protection from heart disease before menopause.
"Heart disease presents in women an average of seven
to 10 years later than in men," says Patrice Desvigne-Nickens,
M.D., leader of cardiovascular medicine at the NHLBI. "But
after menopause, women develop heart disease as often as men,
and women who have a heart attack don't fare as well as men."
Women are more likely than men to die from a heart attack.
Though heart disease is the leading cause of death for both
men and women in this country, surveys have shown that many
women don't know it, and that they are more worried about
cancer, especially breast cancer. "We want women to know
that heart disease is not a man's disease. Rather, heart disease
is the leading cause of death for women, and heart disease
is preventable and treatable," says Desvigne-Nickens.
The NHLBI defines having a family history of early heart
disease this way: A father or brother who had heart disease
before 55, or a mother or sister who had heart disease before
65. Be sure to tell your doctor if any of your family members
have had heart disease. Andre says it was only after he had
a heart attack that he learned that he had four uncles who
had been diagnosed with coronary artery disease.
Even if you have uncontrollable risk factors for heart disease,
it doesn't mean that you can't take steps to limit your risk.
Researchers say that controllable risk factors--physical inactivity,
smoking, overweight or obesity, high blood pressure, high
blood cholesterol, and diabetes--are all major influences
on the development and severity of heart disease.
According to Cynthia Tracy, M.D., chief of cardiology at
Georgetown University Hospital in Washington, D.C., the best
way to combat heart disease is to know the risk factors, "own"
the risk factors that apply to you, and address the ones that
are controllable. "I think many people can rattle off
risk factors, but then they don't internalize them to say:
'That's a risk factor for me. I am at risk for heart disease.
And now I'm going to do something about it,'" Tracy says.
Taking Charge of Your Health
Because of advances in medicine and technology, people with
heart disease are living longer, more productive lives than
ever before. But prevention is still the best weapon in the
fight against heart disease. As with anything in life, there
are no guarantees. You could do all the right things and still
develop heart disease because there are so many factors involved.
But by living a healthier life, you could delay heart disease
for years or minimize its damage. Whether you are already
healthy, are at high risk for heart disease, or have survived
a heart attack, the advice to protect your heart is the same.
Get moving and maintain a healthy weight. Exercise
improves heart function, lowers blood pressure and blood cholesterol,
and boosts energy. And being overweight forces the heart to
work harder. But about 1 in 4 U.S. adults are sedentary.
The general recommendation from the NHLBI is to get at least
30 minutes of moderate physical activity on most, and preferably
all, days of the week. And you don't need to run a marathon
or buy an expensive gym club membership to do it. The 30 minutes
also don't have to be done all at once, but can be broken
up into 10-minute intervals throughout your day.
"Exercising is like taking the pennies from under the
couch cushions and putting them into your piggybank,"
says Ann Bolger, M.D., a spokeswoman for the American Heart
Association (AHA) and a cardiologist in San Francisco. "Every
little bit counts."
Vigorous exercise like running or doing aerobics brings
more health benefits than lighter intensity activities, but
walking is a great form of exercise. Brisk walking can get
your heart rate up and give you a solid workout. Walking at
a comfortable pace can work well for many people, too. "The
best exercise is the one you feel good about and can do over
and over again," Bolger says. And it's easier to work
exercise into your everyday routine than you might think.
For example, Bolger suggests parking farther away when you
go to the grocery store or to your office to create a longer
walk, taking the stairs, walking all the way around a mall
the next time you go shopping, and walking around your neighborhood.
Getting support from a walking buddy or a walking group can
be a good way to keep you motivated.
Talk with your doctor about what form of exercise is best
for you. Those with severe heart disease, for example, are
advised against strenuous exercise.
Desvigne-Nickens suggests that you teach your children early
that exercise is fun and good for them. Families can walk
together, ride bikes, and chase after balls in a park. "But
we have to show them," she says. "Our children are
exercising their thumbs with computers and video games, and
obesity in childhood is epidemic."
Stick to a nutritious, well-balanced diet. This
advice might make you groan if your usual lunch consists of
cheeseburgers with french fries or pizza slices topped with
sausage. But the good news is that diet isn't an all-or-nothing
A heart-healthy diet means a diet that's low in fat, cholesterol,
and salt, and high in fruits, vegetables, grains, and fiber.
"But it doesn't mean that you can never have pizza or
ice cream again," Bolger says. You could start by telling
yourself that you will eat a big leafy green salad first,
and then you will have one slice of cheese pizza, not three
slices with sausage. "Or if you must have a burger, don't
get your usual order of french fries," Bolger suggests.
"That alone cuts hundreds of calories."
Experts point out that a heart-healthy diet should be the
routine. That way, when you have high-fat food every now and
then, you're still on track. Making a high-fat diet the routine
is asking for trouble.
Bolger teaches people about the AHA's Simple Solutions program,
which helps women--often the ones who do the cooking and grocery
shopping--adopt simple ways to improve eating habits for the
whole family. For example, it's wise to make a grocery list
so that you can carefully plan your meals. "You have
to make a conscious decision to make your snack a bag of grapes
instead of a candy bar or cookies," Bolger says.
Bolger also asks her patients to tell her the food or food
group that gets them into trouble. If you pin that down you
can start to make healthy substitutions. Tell Bolger that
overloading on ice cream is your downfall and she'll tell
you about her recipe for a berry dessert: Use nonfat yogurt,
sweeten it up as much as you want with a sugar substitute,
add a drop of vanilla extract, microwave frozen strawberries
briefly to soften them up, add the berries, stir it all around,
Like exercise, good eating habits need to start early. "Teaching
your children to eat well is one of the most loving things
you can do for them," Bolger says. Your children tend
to follow your lead, eat what you eat, and eat what you put
in front of them. It's up to you how often you put a banana
in front of them instead of high-fat cookies.
Look at the Nutrition Facts label on the foods you buy for
guidance. The general rule of thumb is that foods that provide
5 percent of the daily value (DV) of fat or less are low in
fat, and foods that are labeled as providing 20 percent or
more of the daily value are high in fat.
Control your blood pressure. About 50 million
American adults have high blood pressure, also called hypertension.
The top number of a blood pressure reading, called the systolic
pressure, represents the force of blood in the arteries as
the heart beats. The bottom number, called diastolic pressure,
is the force of blood in the arteries as the heart relaxes
between beats. High blood pressure makes the heart work extra
hard and hardens artery walls, increasing the risk of heart
disease and stroke.
A blood pressure level of 140 over 90 mm Hg (millimeters
of mercury) or higher is considered high. The NHLBI recently
set a new "prehypertension" level of any reading
above 120 over 80 mm Hg.
Poor eating habits and physical inactivity both contribute
to high blood pressure. According to the NHLBI, table salt
increases average levels of blood pressure, and this effect
is greater in some people than in others.
The National Institutes of Health's DASH diet (Dietary Approaches
to Stop Hypertension) is rich in fruits, vegetables, and low-fat
dairy foods, and low in total and saturated fat. The DASH
diet also reduces red meat, sweets, and sugary drinks, and
it's rich in potassium, calcium, magnesium, fiber, and protein.
It's important to keep on top of your blood pressure levels
through regular doctor visits. High blood pressure disproportionately
affects racial and ethnic minority groups, including blacks,
Hispanics, and American Indians/Alaska Natives. The condition
is known as a silent killer because there are no symptoms.
If lifestyle changes alone don't bring your blood pressure
within the normal range, medications may also be needed.
Recent NHLBI research has shown that older, less costly
diuretics work better than newer medicines to treat high blood
pressure. These findings, part of the Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),
were published in the Dec. 18, 2002, issue of the Journal
of the American Medical Association.
Control blood cholesterol. Cholesterol is
a fat-like substance in the blood. High levels of triglycerides,
another form of fat in the blood, can also indicate heart
As with blood pressure, eating a low-fat, low-cholesterol
diet and engaging in physical activity can lower cholesterol
levels. Your body turns saturated fats into cholesterol. And
the higher your cholesterol level, the more likely it is that
the substance will build up and stick to artery walls.
The only way to find out your cholesterol levels is to go
to a doctor and have a blood test after fasting for nine to
12 hours. A lipoprotein profile will reveal your total cholesterol,
which is measured in milligrams (mg) of cholesterol per deciliter
(dL) of blood. Total cholesterol less than 200 mg/dL is desirable,
200-239 mg/dL is borderline high, and 240 mg/dL or more is
Low-density lipoprotein (LDL), also known as "bad cholesterol,"
should be less than 100 mg/dL. A level of 100-129 mg/dL is
near optimal/above optimal, 130-159 mg/dL is borderline high,
160-189 mg/dL is high, and 190 mg/dL and above is very high.
High-density lipoprotein (HDL), also known as "good
cholesterol," protects the arteries from bad cholesterol
buildup, so the higher the HDL, the better. HDL levels of
60 mg/dL or more help lower heart disease risk, and an HDL
level of less than 40 mg/dL is considered low.
People ages 20 and older should have cholesterol measured
at least once every five years. If lifestyle changes alone
don't adequately budge cholesterol levels, medications may
Experts say the drug class known as "statins"
marks a significant advance in preventing heart disease. These
drugs work by partially blocking the synthesis of cholesterol
in the liver, which helps remove cholesterol from the blood.
Along with lowering cholesterol, statins help stabilize blood
vessel membranes. Examples include Lescol (fluvastatin), Pravachol
(pravastatin), Zocor (simvastatin), and Lipitor (atorvastatin).
The most recent addition to this class, AstraZeneca Pharmaceuticals'
Crestor (rosuvastatin), was approved by the Food and Drug
Administration in August 2003. Even with drug treatment, a
cholesterol-lowering diet and exercise are still recommended.
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||eat baked, steamed, boiled, broiled, or
|lard, butter, palm and coconut oils
||cook with unsaturated vegetable oils such
as corn, olive, canola, safflower, sesame, soybean, sunflower,
|fatty cuts of meat
||eat lean cuts of meat or cut off the fatty
|one whole egg in recipes
||use two egg whites
|sauces, butter, and salt
||season vegetables with herbs and spices
|regular hard and processed cheeses
||eat low-fat, low-sodium cheeses
|salted potato chips
||choose low-fat, unsalted tortilla and potato
chips and unsalted pretzels and popcorn
|sour cream and mayonnaise
||use plain low-fat yogurt, low-fat cottage
cheese, or low-fat or "light" sour cream
Prevent and manage diabetes. About 17 million
people in the United States have diabetes, and heart disease
is the leading cause of death of those with the disease. According
to the American Diabetes Association (ADA), 2 out of 3 people
with diabetes die from heart disease or stroke.
Diabetes is a disease in which the body does not properly
produce or use insulin. Insulin is a hormone needed to convert
sugar, starches, and other nutrients into energy. Another
16 million Americans have pre-diabetes, a condition in which
blood glucose levels are higher than normal, but not high
enough to be diagnosed as diabetes. Genetics and lifestyle
factors such as obesity and physical inactivity can lead to
One in three people who have diabetes don't know they have
it. See a doctor if you have any diabetes symptoms, which
include frequent urination, excessive thirst, extreme hunger,
unusual weight loss, increased fatigue, irritability, and
Quit smoking. Ditch the cigarettes and you'll
dramatically lower your heart attack risk. And if you don't
smoke, don't start. Along with raising your risk of lung cancer
and other diseases, the mixture of tar, nicotine, and carbon
monoxide in tobacco smoke increases the risk that your arteries
will harden, which restricts blood flow to the heart.
Smokers have more than twice the risk of having a heart
attack as non-smokers. According to the AHA, smoking is the
biggest risk factor for sudden cardiac death, and smokers
who have a heart attack are more likely to die than non-smokers
who have a heart attack.
In the first year that you stop smoking, your risk of coronary
heart disease drops sharply, according to the NHLBI. And over
time, your risk will gradually return to that of someone who
has never smoked.
Minimize stress. After having a heart attack
in 1987, Dennis Everett, 61, retired early from a high-stress
job and moved with his wife, Joyce, from Vienna, Va., to Berkeley
Springs, W.Va.--a rural resort town that gives Everett a relaxing
Stress management was a major part of Everett's recovery,
which also included improving his diet, going for daily walks,
and giving up smoking. "I couldn't have done it without
the support of my wife," he says. "Spouses also
have a big adjustment."
The link between stress and heart disease isn't completely
clear, but what's known for sure is that stress speeds up
the heart rate. And people with heart disease are more likely
to have a heart attack during times of stress.
Everett was serving as coach for a girls' softball team
when the pain he had been experiencing in his left arm for
a few days became unbearable. "It hurt so bad that I
had to hold my left arm up with my right one," he says.
He happened to mention his symptoms to a player's father,
a dentist. "He told me, 'I hate to tell you this, but
those are the signs of a heart attack,'" Everett says.
"That's when we called 911."
Heart Attack Symptoms
Research has shown that people typically wait two hours
or more before seeking emergency care for heart attack symptoms.
It could be because they are uncertain about their symptoms
or concerned that it might be a false alarm. But clot-busting
medications and other effective treatments that restore blood
flow and save heart muscle are most effective in the first
hour following a heart attack.
Symptoms of heart attack include chest discomfort or pain,
discomfort in the arm(s), back, neck, jaw, or stomach, shortness
of breath, breaking out in a cold sweat, nausea, and lightheadedness.
Most heart attacks don't involve someone clutching the chest
and dropping to the floor like you might see on TV. It's also
important to know that heart attack symptoms for men can be
different than symptoms for women.
"The classic sign is when someone comes into the emergency
room, puts their fist on their chest, and says it feels like
a squeezing pressure," says Cynthia Tracy, M.D., chief
of cardiology at Georgetown University Hospital in Washington,
D.C. "But it's not always like that. For women, it may
present as back pain, flu-like symptoms, or a sense of impending
"We need women to be aware of their symptoms, and we
need doctors to put the pieces together and say, 'This woman
is postmenopausal and her mother died of a heart attack at
47. So even though her symptoms don't sound classic, I need
to investigate her for coronary disease.'"
When Bonnie Brown, 50, of Baltimore, felt a sharp pain in
the middle of her chest in 1997, she thought it was indigestion
and assumed the feeling would pass. But something made her
tell her sister, Joan Hamilton, 53, who lived with her at
the time. Joan noticed how pale Bonnie looked and insisted
they call an ambulance. Soon after, doctors confirmed that
she was having a heart attack.
Then, amazingly enough, Joan also had a heart attack--two
weeks after Bonnie did. For Joan, her main symptom was persistent
pain in the left arm. "I thought it was from lifting
boxes," Joan says, "but I don't tolerate pain too
well so I checked it out."
Both Bonnie and Joan used to think heart disease was only
for men. Both women are part of the Red Dress Project, the
centerpiece of the Heart Truth campaign, sponsored by the
National Institutes of Health. The Red Dress Project features
a collection of 19 red dresses from America's most prestigious
designers, with the dresses symbolizing the fact that heart
disease is a women's issue too.
Treating Heart Disease
Once doctors determine that you have clogged coronary arteries,
the treatment plan typically involves a combination of drugs,
lifestyle changes, and procedures that open up the arteries.
Drugs: Thrombolytic drugs, also referred
to as "clot-busting drugs," are given during a heart
attack to dissolve blood clots in coronary arteries and restore
blood flow to the heart.
Because of its anti-clotting abilities, aspirin is recognized
by the Food and Drug Administration as safe and effective
to help lower the risk of having a second heart attack.
Other drugs commonly used to treat people with heart disease
include drugs that lower blood pressure, angiotensin-converting
enzyme (ACE) inhibitors, which help the heart pump blood better,
and beta blockers, which slow the heart down. Nitrates and
calcium channel blockers relax blood vessels and relieve chest
pain. Diuretics decrease fluid in the body. Blood cholesterol-lowering
drugs reduce levels of low-density lipoproteins (LDL), the
"bad cholesterol," in the blood and increase high-density
lipoproteins (HDL), the "good cholesterol."
Catheter-based treatments: Angioplasty is
a procedure in which a thin tube called a catheter is put
into an artery in the groin and threaded up to the narrowed
artery in the heart. The catheter, which has a balloon at
the tip, is used to widen the artery. Routinely, tiny mesh
wire tubes called stents are then inserted into the artery
to hold it open permanently. But a major challenge is restenosis,
which is the reclogging or renarrowing of an artery after
angioplasty or stenting.
Maureen Magoon, 67, of Blairsville, Ga., who was diagnosed
with heart disease in 1999, has experienced problems with
restenosis since receiving angioplasty. So when her doctors
at the Emory Heart Center in Atlanta recently discovered that
another one of her arteries was clogged, they determined that
she was a good candidate to receive the Cypher Stent from
Cordis Corp., the first drug-eluting stent.
The new stent, approved by the FDA in May 2003, releases
the drug sirolimus, which reduces the risk that the artery
will reclog. As part of its conditions for approving the Cypher
Stent, the FDA is requiring Cordis to conduct a post-approval
study of 2,000 patients to assess the long-term safety and
effectiveness of the new device. The agency is monitoring
reports of problems with the stent, as it does with all medical
A process called intravascular radiation therapy, which
uses radiation to kill cells that are clogging an artery,
is sometimes used during angioplasty procedures. Also known
as brachytherapy, this treatment is not approved for use with
the placement of a stent for a vessel that has never been
treated, says Jonette Foy, Ph.D., a biomedical engineer in
the FDA's Center for Devices and Radiological Health. "Brachytherapy
is approved for vessels that have been previously stented,
but reoccluded over time."
Coronary bypass surgery: In cases of severe
blockages or when someone is unresponsive to medications or
not a candidate for angioplasty, doctors may perform coronary
bypass surgery. This involves taking a blood vessel from the
leg or chest and grafting it onto the blocked artery to bypass
In the last few years, the FDA has approved several devices
that improve heart disease diagnosis and treatment. For example,
after a person has received coronary bypass surgery, devices
are used to catch loose particles that could potentially float
downstream and clog another artery. This process is known
as embolic protection.
C-reactive Protein: A New Risk Factor
Among the new risk factors that may be linked to increased
risk of cardiovascular disease is C-reactive protein (CRP).
It's produced by the liver as a response to injury or infection
and is a sign of inflammation in the body. Research correlates
high levels of CRP with an increased risk of heart attack
and stroke. Though the evidence is conflicting, some researchers
believe that CRP itself is not a risk factor, but elevated
levels of CRP could mean that some part of the cardiovascular
system is inflamed, which can lead to stroke or heart attack.
Information about CRP and other new risk factors is still