— Henry, Massachusetts As a preventive cardiologist, one of the questions I get asked on a regular basis is: How do I know if I will develop heart disease? While there are no easy answers, the procedure that you’re referring to is one of the simplest and most effective tests I can do to help predict and ultimately improve a person’s cardiovascular outlook. Called an EndoPAT (Endothelial Peripheral Arterial Tone), this fingertip test can painlessly and noninvasively measure the health of your blood vessels. The key to its success are sensors resembling thimbles that can instantaneously gauge the blood flow in your lower arms and fingers. The EndoPAT works as follows: First, the sensors are placed on your right and left index fingers and a blood pressure cuff is wrapped around one of your arms. The cuff is then inflated, stopping blood flow to that arm and hand. The finger sensor on the affected arm will now show no blood flow, while the sensor on the opposite index finger will continue to display your normal blood flow level. After several minutes, the blood pressure cuff is released, allowing blood to flow back into the affected lower arm. If the finger sensor on the affected arm shows a rush of blood, your vessels are functioning normally. If the blood flow return is sluggish, however, your vessels are unhealthy. The reason this finger test is so beneficial is because the arteries in your heart (your coronary arteries) react to stress the same way blood vessels in your arm react to constriction of the blood pressure cuff. If your arm vessels are sluggish, then your coronary arteries are likely to be sluggish as well. And this can lead to the buildup of atherosclerosis and increase your risk of a heart attack. The good news is this type of vascular dysfunction can now be detected early. Diabetic teenagers, for instance, often have unhealthy readings even before there is an accumulation of atherosclerotic plaques in their arteries. If your arteries are unhealthy, treating key cardiac risk factors, such as high cholesterol and high blood pressure, can transform your vessels and bring them back to normal health in a matter of months. And during this process the fingertip test is again very useful to me and rewarding to my patients: We can clearly see their vascular health improving as they adopt a healthier lifestyle and get a handle on their risk factors. Although the EndoPAT test is still quite new, it is increasingly available at cardiologists’ offices and major medical centers — but it may not be covered by all insurance carriers. Check with your insurer to find out. Either way, it’s a quick, easy, and valuable way see where you stand. Q2. I am a 44-year-old woman who had a pacemaker put in about a month ago for sick sinus syndrome. Problem is . . . I don’t feel better. Shouldn’t I feel something different by now, or is it still too soon? — Janet, Ohio I’m sorry that you’re not feeling great, Janet. There could be a number of reasons for this. Sick sinus syndrome is the name for a group of heart rhythm problems that stem from the sinus node — the little bundle of specialized cells in the upper-right chamber of the heart (the atrium) that generate the electrical impulse that makes your heart contract. In other words, the sinus node is your heart’s natural pacemaker. When it doesn’t work properly, you may experience a slower than normal heart rate (bradycardia) or a faster than normal heart rate (tachycardia), a heart rate that alternates between fast and slow (bradycardia-tachycardia syndrome), or even extra (premature) heartbeats or missed heartbeats. The thing to know about a standard man-made pacemaker, however, is that it will only increase a slow heart rate, not slow down a fast one. So, when a doctor implants a pacemaker for sick sinus syndrome, it means that you were likely diagnosed with a slow heart rate. That said, a patient with fast-heartbeat symptoms may get a pacemaker because the medications that would slow their heart rate to normal simply slow it down too much. In such cases, a pacemaker is put in to counteract the medications. Another reason that you might not be feeling well is that sick sinus syndrome can sometimes be due to heart defects. Scar tissue from a previous heart surgery or from structural problems due to heart disease could affect the electrical system of the heart and cause uncomfortable abnormal heart rhythms. In addition, certain medications, such as calcium channel blockers or beta-blockers prescribed to treat high blood pressure (or to slow fast heart rates, as noted above) can cause bradycardia. Furthermore, how you are feeling could depend on the type of pacemaker you have. Some heart rhythm problems are treated with a single-chamber pacemaker, which uses one wire lead to stimulate one chamber of the heart (the atrium). But other rhythm problems — such as those involving the atrioventricular (AV) node, for example — could require a dual-chamber pacemaker, in which one lead paces the atrium and another paces the ventricle. More likely, the reason you aren’t feeling well is that it has only been about a month since your procedure. It takes about that long for the incision to heal, and you may feel numbness or fullness in the area around the pacemaker for a few months longer. I hope this is the case — that your issues are due to how recently you had the procedure. But since I don’t know exactly what you mean when you say you’re not feeling better, I urge you to call your doctor to discuss your symptoms and to perhaps inquire about some of the things I have addressed above. You should also get checked out for other problems not related to the heart that may be contributing to the way you feel. Q3. I read that doctors may start prescribing the statin drug Crestor for people whose cholesterol is normal but who have some sort of inflammation in their bodies that might put them at risk of a heart attack. Should everyone be taking a statin like this to prevent heart troubles? — Oscar, Colorado No. Not everyone should take a statin to prevent a heart attack or stroke, especially if inflammation is the only known risk factor. Inflammation as indicated by a high level of C-reactive protein (CRP) is a risk factor for heart disease and many other chronic diseases. But just because you have inflammation and a high CRP level doesn’t mean you need to take a statin. Even when inflammation is present, we can’t be sure it’s heart-related until advanced tests are performed. C-reactive protein is just one factor that needs to be considered, along with many others, in assessing cardiac risk. Before an elevated level of C-reactive protein is truly diagnosed, a blood test called the hs-CRP should be repeated three times with at least several weeks in between. That’s because a cold, a flare-up of arthritis, or some other infection or injury can raise CRP levels. As the media is currently pointing out in its articles and ads about Crestor, we have moved well beyond elevated cholesterol as the primary focus for risk factor evaluation for heart disease (roughly half of all heart attacks and strokes occur in people without high cholesterol). We now know that cardiovascular risk, including preclinical disease, should be determined not just by looking at cholesterol and other conventional risk factors such as weight (belly fat), smoking, blood pressure, and blood sugar, but by assessing more subtle factors such as LDL and HDL particle size and density, carotid artery wall thickness, buildup of coronary calcium (which we determine from a noninvasive heart scan), inflammation, and your genetics. Yes, family history is an important determinant for heart disease that has been underestimated for years. If advanced testing shows you are at high risk for a heart attack or stroke, then you should probably be on a statin (like Crestor) or a combination of a statin and niacin along with other medications and lifestyle modifications. But if you are at low risk, then at $3.50 a day Crestor is certainly not a cost-effective treatment. Q4. What is heart-scan imaging and why is it beneficial? According to the National Heart, Lung, and Blood Institute, about 1.1 million Americans experience heart attacks each year. I believe that number could be greatly reduced if we took more aggressive steps toward preventing heart disease. Often, the usual prescription of improving diet and exercise is not enough. That’s why I recommend that most men (over the age of 40) and women (over the age of 50) work with their doctor to undergo a noninvasive heart scan. A heart scan (also known as computed tomography, CT, or CAT scan) uses a combination of X-rays and computer imaging to provide a picture of the heart’s arteries. Using new, fast CT scanners is currently one of the best methods to detect the buildup of arterial plaque years before it causes symptoms of heart disease. Fast CT scans can detect even the slightest buildup of calcium on the artery walls, and can be used to diagnose early coronary artery disease in people with no symptoms. The higher the calcium buildup score, the greater the risk of a future heart attack or stroke. Early detection is the key to heart attack and stroke prevention. Fast CT scans are best used in people with some risk factors of heart disease, such as high cholesterol, pre-diabetes, diabetes, smoking, high blood pressure, obesity, and/or a family history of heart attack and stroke. Keep in mind, however, that the procedure is fairly expensive and may not be covered by all health insurance providers. Check with your insurance company and physician before undergoing a CT scan. Q5. My doctor says my triglycerides are a bit high, but my cholesterol is within the normal range. Are triglycerides something I should worry about? Yes, you need to keep an eye on triglycerides, which are the most common type of fat found in the body. When you eat, any calories not used immediately for energy are converted into triglycerides and stored in fat cells. Triglycerides also circulate in your bloodstream. High triglycerides combined with low HDL (“good”) cholesterol are a risk factor for heart disease and type 2 diabetes. A normal triglyceride level is below 150; 150 to 199 is borderline high; levels above 200 are considered high. For high-risk patients, my goal is a triglyceride level of less than 100 mg/dL. I call triglycerides and HDL lifestyle lipids because they are both very sensitive to changes in diet and exercise. Losing weight, taking prescription niacin and fish oil supplements, and avoiding starchy and sugary carbohydrates as well as saturated fat and trans fats are all effective ways of reducing elevated levels of this bad type of blood fat. Q6. I have an irregular heartbeat. Recently, after I missed a dose of medication (atenolol), my heart was pounding for about an hour. Could there be damage? No doubt your heart rate did go up after you missed a dose of your beta-blocker medication (beta-blockers work, in part, by slowing the heart rate). But it’s extremely unlikely that missing one dose would cause damage to your heart. That’s because there would still be plenty of atenolol in your system, assuming you’ve been taking the drug for a while. If you have a structurally normal heart, then palpitations, even if they continued for a period of time, would not cause damage. That said, if your heart palpitations are sustained for any length of time when you are taking your medicine, or if they are associated with other symptoms such as chest pain or light-headedness, contact your doctor and then relax. Most of the time, heart palpitations are nothing to worry about. Q7. I live in an area with poor air quality, and I have asthma. Should I be worried that this will affect my heart? — Samuel, Alabama Unless you already have heart disease, Samuel, I would be more concerned about how an asthma attack is affecting your lungs rather than what it is doing to your heart. When you have asthma, your immune system overreacts to substances in the environment, including smog, and this triggers a full-scale alarm, or an asthma attack. When this happens, immune system defenders called mast cells, located in tiny passageways in your lungs, release chemicals, including histamines. Your airways then become inflamed and constricted, causing your breathing tubes to produce extra mucous and making it even more difficult for air to get through. While it would seem like an asthma attack, with its attendant coughing and wheezing, would be hard on your heart, asthma is not a risk factor per se for heart disease. In fact, some pulmonary specialists believe that the histaminic response that your body has to such an attack can actually help protect the heart, because the histamines may counter the release of excessive amounts of the neurotransmitter noradrenaline. This is the “fight or flight” chemical that your body produces when under stress, including the stress of a heart attack. That said, a few studies that have found a possible association between asthma and stroke, and there have been associations made between compromised lung function and coronary heart disease (mainly in women). But more research is needed in both of these areas, so I wouldn’t be too concerned. For someone who already has heart disease, however, it is possible that certain drugs used to treat asthma could precipitate an acute coronary event. Beta-agonist drugs that are commonly used as quick-acting bronchodilators tend to have stimulatory side effects similar to those of adrenaline. Generally, these effects are slight, but occasionally, people with certain types of heart disease, such as angina or arrhythmia, are sensitive to even these minor effects. On the flip side, certain beta-blockers, such as Inderal (propranolol), which are used to treat high blood pressure, can have particularly strong effects on the bronchial tubes, causing constriction and triggering an asthma attack. Since I don’t know your personal situation, I suggest that you discuss any concerns you have with your own physician. Q8. What if you find disease on a calcium heart scan? What then? — Ed, West Virginia Once coronary heart disease is identified on a calcium heart scan, advanced blood tests that go beyond conventional cholesterol screening can determine the causes of the plaque buildup and the best treatments to halt its progression. Such tests include the hs-CRP test, which measures C-reactive protein, a particle that when elevated signifies inflammation, and a test for Lp(a), a type of cholesterol particle that facilitates the penetration of bad LDL cholesterol into vessel walls. With the additional information provided by such tests, treatment can be tailored to each individual and typically includes lifestyle changes (such as diet and exercise as well as stress reduction), one or more medications, or all of these. One of the best-kept secrets in this country is that doctors who employ the prevention strategy of advanced testing and aggressive treatment have been seeing heart attacks and strokes all but disappear from their practices. Q9. My husband had a heart attack last year, and since then, he barely leaves the house. He doesn’t want to do anything active and spends all of his time watching TV or surfing the Internet. How can I help him participate in life again? — Gail, New York Although you didn’t use the term, your husband’s lack of action is a classic sign of depression, which is very common after a heart attack or stroke. I’m glad that you are determined to help him. Depression after a heart attack has been linked to abnormal heart rhythms, inflammation, increased blood pressure, high cholesterol levels, and increased plaque buildup, all of which significantly increase the risk of another heart attack. There are certainly plenty of reasons why your husband might be depressed. Worrying about having another heart attack and fear of dying are probably paramount, but he may also be concerned about caring for you and the rest family, when he can return to work, or if he can ever play full-out basketball or 18 holes of golf again. It’s very common for depressed people to lose interest in their self-care and to give up the activities that once made them happy. Just like your husband, those who are depressed are more likely to be sedentary, eat poorly, and start smoking and/or drinking alcohol. They may also skip their medications. The good news is that treatment helps between 80 and 90 percent of people with depression. The place to start is with your husband’s cardiologist to discuss the problem and re-evaluate the medications he’s on (sometimes beta-blockers, which are often given after a heart attack to slow heart rate, can cause or aggravate depression). Depending on the depth of his depression, it may be that he will need to be prescribed an antidepressant. Beginning talk therapy with a psychotherapist or family counselor can also help. I would also recommend that your husband get back to exercising (in consultation with his doctor, of course). Many people fear that exercising will cause another heart attack, but it’s actually beneficial. Begin with short daily walks and gradually work up to longer walks and more strenuous cardiovascular and core-strengthening exercises if his doctor permits. Not only will regular exercise stimulate the mood-boosting brain chemicals called endorphins, it will also boost his energy and strengthen his heart muscle. Interacting with supportive people outside the home can also help. Consider contacting a support group for heart attack survivors and their families, such as Mended Hearts, which is sponsored by the American Heart Association and has chapters in communities throughout the United States and Canada. Q10. I’m trying to avoid trans fats, as you suggest, but I don’t know how to determine which foods they’re in. How do I read and interpret the food label to find trans fats? The U.S. Food and Drug Administration (FDA) requires food manufacturers to display the amount of trans fats on all of their product labels. You’ll see this number listed on the Nutritional Facts panel after Total Fat and Saturated Fat. Dietary supplements (such as energy and nutritional bars) will also list trans fats on their Supplement Facts panel if the product contains 0.5 grams or more of trans fat. Trans fats are created when manufacturers turn liquid oils into solid fats through a process called hydrogenation, which was originally done to increase the shelf life of foods. But we now know that consuming trans fats contributes to clogged arteries – which can lead to heart disease or stroke. Besides listing the amounts of trans fats, these labels will also tell you the amounts of saturated fats and cholesterol so you can compare products and choose the ones with the lowest amounts. Why should you be concerned about these numbers? Consuming trans fats raises your LDL (“bad”) cholesterol levels, which in turn increases your risk for heart disease, stroke, obesity, and other conditions. These fats also lower your HDL, the good, protective form of lipids. Foods high in saturated fats and cholesterol can also increase your risk for heart disease, but since trans fats have a negative effect on both HDL and LDL, they probably pose an even greater risk than saturated fats. Try to minimize your intake of trans fats as much as possible, and instead focus on eating products containing the “good” fats, such as extra-virgin olive and canola oils. Q11. What is your best advice when it comes to heart disease prevention? Frequently, coronary artery disease has a significant genetic component and requires more than just lifestyle changes of diet and exercise to treat. In my cardiology practice of high-risk patients (those who experienced a heart attack at a young age or who never had a heart attack but are at risk of one), it is usually necessary to use a combination of diet, exercise, and often several medications to prevent heart attack or stroke. In my experience, I have seen that patients can develop significant arteriosclerosis, or blockages, in the heart arteries and still have negative stress testing (often interpreted by doctors as a positive indicator of heart health). This is because stress testing predicts the adequacy of blood flow to heart muscle during exercise; it does not tell us what is happening in the vessel walls. Many so-called “obstructed arteries” have their own collateral vessels (natural bypasses), and this is why an exercise test can be normal despite even significant blockages. The point is that stress testing alone is not sufficient to predict whether someone is at risk for a heart attack. It is also important to understand that cholesterol levels and other risk factors cannot accurately predict the presence and extent of heart arteriosclerosis in any individual. Each of us has our own threshold of cholesterol and other risk factors where cholesterol actually gets into the vessel wall and causes arteriosclerotic plaques. The best method to detect the buildup of plaque years before it causes symptoms is by a heart scan that uses ultrafast CT technology and by advanced lipid (blood) testing. By incorporating heart-scan technology and advanced blood testing, the buildup of plaque can be detected five, 10, or even 15 years before it becomes a major risk factor. With that knowledge, aggressive preventive strategies can be instituted in time to prevent angioplasties and bypass surgery. I believe that people could avoid advanced heart disease or a heart attack if they follow aggressive preventive measures. Specifically, I typically recommend that all men over 40 and women over 50 work with their cardiologists and follow four major steps: The use of statins (cholesterol-lowering drugs) decreases the risk of a coronary event by only 20 to 40 percent. With aggressive prevention, we can prevent nearly all the heart disease and heart attacks in this country. Q12. My husband has a high-pressure job and works long hours. I’m worried that his work, combined with a less-than-ideal diet, may lead him to have a heart attack. What can I do to get him to make his health a priority? — Annabelle, California Your husband’s case sounds familiar. I see it all the time. In my book The South Beach Heart Health Revolution (now available in paperback), I tell a story about a wife who literally drags her overweight and sedentary husband into my office for tests because she’s worried he’s at high risk for heart attack or stroke. She wants me to read him the riot act about his health. But, while dragging a workaholic husband into a doctor’s office might seem like a great way get him to focus on his health, it isn’t ideal because the patient is basically against the idea from the get-go. Even so, for many couples, visiting a doctor is the only way to start the process, and I would highly recommend that they see a preventive cardiologist. For some resistant patients, I’ve found that “shock and awe” is the only thing that works; for others, it may be instituting a series of small steps toward better health. When I say shock and awe, I mean that one of the quickest ways to get a person to understand his or her risk for heart attack is to do a heart scan for coronary calcium (which I typically do after some advanced blood work and a carotid ultrasound). This noninvasive procedure shows the amount of calcified plaque in the person’s coronary arteries. If there’s a lot of plaque, the arteries will light up like an airport runway at night on the scan. Seeing this firsthand can often shock the person into wanting to take immediate action to improve matters. I’ve found that putting the scan up on the fridge is also a potent reminder. For people who prefer not to have such a test or who turn out to have a moderate amount of plaque after the scan is done, I typically recommend changes in diet and exercise. It’s unrealistic to tell a person who enjoys his work to cut back, but you can tell him that simply getting 20 minutes of vigorous aerobic exercise every other day — either before or after he heads for the office or during his lunch hour — can go a long way toward beating stress, strengthening the heart muscle, and preventing a heart attack or stroke. Since most workaholics won’t go to the gym (no time), I tell them to buy the most expensive treadmill or elliptical machine available, since they’re more likely to use it if it costs a lot of money! Making simple dietary changes like eating more antioxidant-rich, high-fiber fruits, vegetables, whole grains, and legumes, and eating at least two nutritious snacks a day at the office (rather than chowing down on empty-calorie fast food) can also help. And if your husband smokes (which many workaholics do), I would definitely read him the riot act. I tell my patients who smoke that I think they’ll be lucky if they do die quickly from a heart attack, because a long and lingering death from emphysema or lung cancer is far worse! Q13. I had a few cups of black coffee (no cream or sugar) before a cholesterol test. Will it affect the results, and if so, how? Can I have any liquids besides water before this test? — Vicki, Michigan Knowing your total cholesterol number and the values of its two components (HDL and LDL) can help you understand your risk for cardiovascular disease and allow you to make lifestyle changes before any adverse events occur. In order to get the most accurate results, fasting for a minimum of eight hours — preferentially 12 hours — is recommended. While total cholesterol and HDL (good cholesterol) can be fairly accurately determined in a non-fasting sample, getting the values for triglycerides and LDL (bad cholesterol) requires fasting. And because treatment regimens are determined for the most part by risk factors in conjunction with the LDL level, an accurate reading of this component is critical. Are you doing everything you can to manage your heart condition? Find out with our interactive checkup. Drinking water before your cholesterol test will not affect the results, but whether coffee significantly affects cholesterol testing has been debated for years. A 2005 study in The Annals of Pharmacotherapy looked at the effect on cholesterol test results of a single six-ounce cup of coffee without sugar or cream, drunk one hour before testing. The good news is that the study found very small, clinically insignificant changes. The message then is that it is probably acceptable to have that single cup of black coffee, but if the results are borderline, I would consider repeating the test without the coffee. It may be prudent just to skip the cup for one day and not have the debate! Learn more in the Everyday Health Heart Health Center.
