Long-Term Love for Your Heart

Michael Ayers, MD, is Assistant Professor of Medicine in the Division of Cardiology at the Hospital of the University of Virginia. He is the Co-Director of the Hypertrophic Cardiomyopathy Center of Excellence and serves as the Principal Investigator for numerous trials. He also has advanced training in preventive cardiology, inherited cholesterol disorders, sports cardiology, and advanced cardiac imaging. He serves as the System Leader for cardiovascular medical education at the UVA School of Medicine and recently won the Dean's Award for Excellence in Teaching at UVA as well as the Harvey Proctor Award for Outstanding Educator for the American College of Cardiology.

An American dies of heart disease every 33 seconds. A third of these deaths are avoidable. The most common preventable contributors are tobacco use, physical inactivity, diabetes, high cholesterol, and high blood pressure. These “feared five” are extremely common; 1 in 2 American adults has abnormal blood pressure, 2 in 5 have high cholesterol, 1 in 10 has diabetes, 1 in 10 uses tobacco, and 1 in 2 do not get the recommended amount of exercise. They are silent killers, requiring purposeful vigilance. We often do not know we have a problem until it is too late.

The Main Intervention

When it comes to blood cholesterol levels, the mantra is simple: lower, for longer, is better. Low-density lipoprotein (LDL), or “bad cholesterol,” will not flag as abnormal on lab reports until it is greater than 130 mg/dL. In most mammals, normal LDLs are in the 30-70 mg/dL range. There is nothing “normal” about an LDL of 129 mg/dL! Cumulative lifetime exposure to cholesterol drives the formation of fat buildup in the walls of blood vessels in a process called atherosclerosis. When these fatty plaques rupture, blood clots form within the blood vessels and cause heart attacks or strokes. Blockages do not cause symptoms until the blood vessel is more than 70 percent obstructed. Still, tests like coronary calcium scans can detect smaller plaques to identify patients at higher short-term risk for events.

Additional Major Risk Factors

Obesity is a well-known risk factor for atherosclerosis and accelerates the process. A common misconception is that obesity is a disease of limited motivation. Obesity causes measurable changes in neurohormone levels, modifying the way our brains operate. These changes persist throughout life, even after weight loss has occurred. Recent medicinal advances have leveled the playing field by finally addressing the biology driving obesity at a chemical level. Also, our armamentarium of medications for treating diabetes and hypertension has expanded. These treatments can normalize blood sugars and lower blood pressures to less than 130/80 mmHg. We have never had more pharmaceutical options at our disposal.

Risk Modification's Future

Even after optimization of these conditions, there are residual risk factors for cardiovascular disease. For example, a particularly problematic and highly heritable form of cholesterol called lipoprotein(a) is responsible for around 5% of heart attacks in the US. Current cholesterol therapies like statins do not lower lipoprotein(a) levels. Pharmaceutical companies are racing to develop lipoprotein(a)-specific therapies and multiple major trials should be completed within the next few years. 

Next-generation therapies take aim at inflammation, another known accelerant of cardiovascular disease. When modifying the immune system, a delicate balance must be struck to decrease cardiovascular risk without increasing the risk of infections.

Heart disease runs stronger in some families than others. Most of our genetic risk comes from the accumulation of many low to intermediate-risk genes rather than a few high-risk genes. The American Heart Association recently endorsed polygenic risk scores to help assess an individual’s genetic predisposition to heart disease. The goal of polygenic risk scores is to get the right treatment to the right patient at the right time. 

Lifestyle Modifications

One of the most common questions I get in the clinic is, “What can I do to improve my health besides taking medications?” The answer is… quite a lot! 

• If you use tobacco, stop. This is the single most important first step. 
• Beyond smoking, the two primary areas of focus are diet and exercise.

Randomized control trials are the bedrock of modern medicine guidelines, and admittedly, it is very challenging to perform high-quality research on lifestyle interventions. That said, through many smaller trials and larger retrospective studies, themes emerge. When it comes to diet, avoid red or fatty meats, sugary drinks, and sweet desserts, and limit salt intake. Eat more vegetables, fruits, whole grains, fish, poultry, and nuts. Use vegetable oils like olive oil in cooking rather than animal fats. For exercise, the CDC recommends 150 minutes of moderate-intensity exercise a week. An often-overlooked fact, however, is that the biggest benefit of exercise comes in just the first 30 minutes each week. Those first minutes have a major impact on reducing risk!

Please do not wait until it is too late. Discuss your risk profile with your primary care team to determine the right approach for you. Are your blood sugar, blood cholesterol, and blood pressure optimized? Would a coronary calcium scan or blood tests to look at inflammation clarify your risk? Are you doing everything you can do with respect to stopping smoking, making smarter nutritional choices, and exercising? Together, we can work to live longer, healthier lives.