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Risk Factors for Heart Disease (Dr Hazen 9 25 12)

Tuesday, September 25, 2012 – Noon


According to the American Heart Association, over 7 million Americans have suffered a heart attack in their lifetime. There are many risk factors for heart disease; some are controllable, while others are not. Controllable risk factors include: smoking, high cholesterol, physical inactivity, high blood pressure, obesity, diabetes and stress. When people have uncontrollable risk factors such as family history or bio-markers for heart disease it is even more important to aggressively treat your risk factors. The more risk factors you have, the greater is the likelihood that you will have heart disease. By making changes in your lifestyle and when needed, taking medications, you can reduce your risk for heart disease.

Cleveland Clinic is recognized as the world leader in diagnosis and treatment of cardiovascular disease and has been ranked No. 1 in the nation for cardiac care by U.S. News & World Report every year since 1995. For National Cholesterol Education Month, Dr. Stanley Hazen, Section Head of Preventive Cardiology at Cleveland Clinic answers your questions about risk factors.

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National Cholesterol Education Month

Cleveland_Clinic_Host: Dr. Hazen, this month is National Cholesterol Education Month. Can you give our participants some guidelines they should follow regarding cholesterol screening and treatment?

Dr__Hazen: According to national guidelines, anyone with LDL (bad) cholesterol in excess of 160 is recommended for lipid lowering therapy. This is the minimum. The national guidelines recommend a minimal LDL goal of < 130 mg/dL in primary prevention subjects (those without known heart disease) and an ideal LDL goal of < 100. In preventive cardiology clinic at Cleveland Clinic, we routinely always shoot for the < 100 goal (at minimum) for those without known heart disease, and lower goals even in those at higher risk, and with known heart disease (secondary prevention). In those with CAD and at higher risk, the minimal goal is < 100, and the optimal goal is < 70 mg/dL for LDL.

Statins and Cardiovascular Disease

Irish: 34 yr old, mostly vegan (fish once a week), good BMI with father dying of CAD at 50. A year ago I was put on a 5mg of simvistatin for preventative treatment of a nmr test resulting in 1,086. Was tested 6 months later and had ladle of 67. Went off 5mg statin and got retested 6 months later and my LDL shot up to 99 and my nmr went up to 1168. Was this solely the result of the 5mg statin. My diet and exercise remained the same if not better. What could be some of the primary causes of this and should I be concerned.

Dr__Hazen: Sounds to me like you responded wonderfully to the statin - it is nothing to be concerned with - and that you may want to consider getting back on the statin!!

We get cholesterol from two locations - what we ingest from our diet and what we make. The latter, is what the statins work on. they block synthesis of new cholesterol. Each person is genetically wired to have a different balance of how much cholesterol we make. So statins can work quite well in some people - those that make most of the cholesterol in their LDL. With a strong family history of premature Coronary Artery Disease (CAD), I recommend you get screened also with a LPa. This is a risk marker that runs in families and is associated with premature CAD. If elevated, then an LDL < 70 may be more appropriate for you....with strong family history of premature CAD, we look for reasons for increased risks and to lower the LDL goals.

kitkat9982: I am a 50 year old female; not post menopause but 30 pounds overweight. I do not smoke, I could exercise more. My doctor wants to put me on a cholesterol drug for an LDL of 168 and total cholesterol of 230. My parents had heart disease but not until their 70s and 80s. Wondering what the risks of the drug would be or what my risk would be if I don't go on a medication. What if I diet first? How long do you wait if you try diet?

Dr__Hazen: I recommend diet first - and then the next day - lipid lowering medication too! The reasons are because at an LDL of 168, even the most rigorous of diets is unlikely to bring your LDL down to where it ought to be - <100. Most folks can bring about 10-20% change in LDL cholesterol with diet. A very large effect would be 30% and many simply can not achieve this even with very strict dietary efforts. That still would leave you a long way from reaching the minimal goal. Exercise is also an excellent idea. Cardiovascular fitness from a routine exercise program is ADDITIVE in terms of reducing cardiac risks. As a general goal, aim for 30-45 min of sustained exercise for at least 5 days per week. Walking at a brisk pace (at least 3.5 mph) or its equivalent in terms of exercise effort - is recommended. That doesn't have to be walking, but can be biking, swimming, jazzercise, racquetball - anything you like - just find the time and get moving! Activity is one of the best predictors of health and long life.

Statins and Diabetes

GailK: I am a 57 year old female weighing 112 lbs. at 5' 3". My lp(a) is 162--HDL is 55--LDL is 118--Total is 188--C-reactive protein was fine. I have tried Pravastatin and Crestor with both causing leg cramps. I am now on 2,000 mg. of fish oil daily, but my LDL is still too high. My paternal grandfather died of a heart attack at age 58. My father has peripheral artery disease but is 85 years old. His cholesterol has been controlled by diet and exercise. My A1C was 6.2 which I decreased to 5.7 through diet and exercise. Given that I have had problems taking statins, and that I have read that they can cause type 2 diabetes, what would be your recommendation for treatment? I also have concerns about the statins due to research being done to determine if there is a link between them and ALS--I have a friend with ALS. I also have a brother with Parkinson's and a paternal aunt with MS. Any suggestions would be appreciated. Thank you.

Dr__Hazen: LPa is an LDL associated protein that is genetically linked to increased cardiovascular risks. When elevated (> 30 mg/dL), it is associated with increased risks for MI, stroke and death (major adverse cardiovascular risks). While not yet part of national guidelines, within the Preventive Cardiology Clinic at Cleveland Clinic, we now lower LDL goals for subjects with high LPa and treat them like a high risk individual - so shoot for minimal LDL goal of <100 mg/dL, and optimal goal of < 70. We also recommend antiplatelet (low dose aspirin) therapy in subjects with high LPa because of increased risk for MI (thrombotic events – the LPa protein is related to clotting proteins in structure and function) and because it is highly inheritable, recommend screening of all first degree family members (even children - since known one has a high LPa in adolescence or older can help guide long term recommendations for where LDL ought to be …or so our expert opinion considers – again – this is not yet part of national guidelines in the US.

JonathanST: I am a diabetic, taking metformin. My doctor wants to put me on a statin for my LDL cholesterol. I am very concerned about taking the drug due to the affect on my sugars. I have heard Cleveland Clinic say that the benefits outweigh the risks - but what if you already have type 2 diabetes. What do you do with your patients?

Dr__Hazen: Diabetics are the patients who experience the greatest benefit from taking statins. I do not want to minimize your concerns, because it is reasonable to ask these questions especially with the headline seeking information that gets pumped out there... But it is my opinion that the worry about statins and diabetes is way out of control. The data is this - those taking a statin had diabetes diagnosed 2-3 months earlier than they otherwise would have. But they experience up to 50% reduced level of heart attack, stroke, need for bypass surgery, angioplasty - and - they live longer... Statins do not suddenly make someone need insulin or even diabetes medications or interventions that otherwise wouldn't have been needed. I hope this helps to alleviate any fears.

Statin Intolerance

marthaDL: Can you talk about any new drugs that may be available to people who have statin intolerance. I cannot take even the lowest dose of statin. My LDL is 110

Dr__Hazen: Statin intolerance is a slippery term. It doesn’t have a clear definition. We take the view of calling it anything that limits a subject’s ability to take the routine starting dose of statin daily. There are several drugs being evaluated (in clinical trials only) that show promise to lower LDL - but these are still investigational, and have not yet completed clinical trial stage and are not available for routine patient care.

We see subjects with statin intolerance in the Preventive Cardiology Clinic often at Cleveland Clinic, and on average can help lower LDL by an additional 30-40% in the "statin intolerant" patient. We often use pediatric sized doses, with less than daily regimens, of long half life statins. In addition, we also use alternative lipid lowering medications like Niacin, bile acid resins, cholesterol absorption blocking agents, and plant stanols, to help lower LDL. Over the counter approaches for helping to lower LDL include use of viscous fiber (e.g. 2gm starting dose of psyllium - the active ingredient in Metamucil) - to be taken immediately before the major meal of the day. This can help to lower LDL by 5-10%. Another example is the agent Cholest-Off - this is a plant stanol (a plant-based alternative to cholesterol) - it helps to block cholesterol absorption. It too is best taken with the major meal of the day, and can help to lower LDL by 7-10%.

Diet and Cardiovascular Disease

ShariG: What do Cleveland Clinic and the doctors participating in the September 24th chat think about Caldwell Esselstyn, Jr's method of treating heart disease, as outlined in his book "Prevent and Reverse Heart Disease"? Why isn't a plant-based diet mentioned in your website as a means of eliminating artery blockage and endothelium inflammation? Has any research been done to confirm Esselstyn's evidence-based findings?

Dr__Hazen: No – unfortunately many of the claims made with the diet are not yet supported with clinical studies. The plant-based diet has many good aspects, like reduction in cholesterol and fat in the diet, and higher fiber content. There are also some concerns, like deficiency of omega 3 fatty acids of cardiovascular benefit (DHA and EPA) and fat soluble vitamins. It also can be high in carbohydrate content. The name, “reverse heart disease” sounds quite attractive. I hope the diet lives up to its name – but at present we just don’t have the data needed. It is a very difficult diet for many to maintain. I recommend that the choice of one’s diet is something that should be enjoyed, a life-long change one can maintain, and optimally, for those at high cardiac risks, worked out in conjunction with a trained registered dietician.

Peppy: Carotids are both 50% blocked and they're watching annually. I'm on a statin and healthy vegetarian diet and exercise an hour a day. Can I reduce that blockage? Does significant weight loss reduce carotid blockage?

Dr__Hazen: Carotid artery blockage, known as peripheral artery disease (PAD) is considered a coronary artery disease (CAD) risk equivalent. In subjects with known PAD, we treat them as if they had already had one heart attack, and we are trying to prevent the second (in terms of risk profile). With aggressive lipid lowering therapy, the rate of blockage progression can be significantly retarded, and in some cases slow regression even, achieved.

Regression of atherosclerotic plaque (whether in coronaries or peripheral arteries like the carotids) is typically slow. But interestingly, regression of plaque in carotids seems to be a little faster to occur with low LDLc than that observed with coronary arteries. So being on a statin and maintaining a low LDL helps with PAD. Significant weight loss in of itself doesn’t reduce blockage - but it decreases likelihood of high blood pressure, improved cardiovascular health, and is an overall healthy thing to do.

sharig153: Thanks for your answer about the Esselstyn diet. But is it true that meat is inflammatory to our systems, specifically to the endothelium? How about dairy products? I've been thinking of reintroducing yogurt into my diet, to increase my gut bacteria and help with digestion, but wondered about the inflammation claims made by Esselstyn.

Dr__Hazen: A healthy balanced diet with fruits, vegetables, grains, and even low fat yogurt is fine. Stay away from yogurts with a lot of additives such as high sugared fruits and jams.

Family History of Heart Disease

AnnB: How much does family history affect your risk for developing heart disease. I am 34 years old and was diagnosed with high blood pressure after my mother had her 1st heart attack at 45. She smoked and was a little overweight. She has lost 3 siblings to heart disease in their 60's. My dad had bi-pass surgery at 67. Both parents are still alive (mother is 59 and father is 76 now.) What preventative measures should I be taking now to lower my risk factors? I currently am not on BP medicine, but on celexia which keeps my blood pressure at 96/60.

Dr__Hazen: Strong FHx for heart disease is something we look at closely. When seen, we focus on global aggressive preventive efforts, and screening, to ensure that all is ok. Lipid profile including apoB100 level (should be <100),and making sure LDL is < 100 is recommended. We also look at other risk markers like LPa, which often runs in families and if elevated, we then aim for LDL < 70 if feasible as outlined in a prior webchat answer. I also suggest seeing a preventive cardiology expert. In the Preventive Cardiology Clinic we also evaluate additional risk markers to see if there are any issues related to inflammation, or diabetes, thyroid, renal function, and other factors, that can globally contribute to higher cardiovascular risks.

Hormones and Cardiovascular Disease

web823673: A visit to my wife's OB/GYM revealed that I'm very low in testosterone. I'm a 58 year old male with a mitral valve prolapse, a fib and a calcium score of 384 with no narrowing on angiogram. 5'10" 170 lbs active ....low HDL is apparently genetic. My worry is if I start testosterone therapy, the hormone will soften the hard plaque and cause a cardiac or cerebral episode. However, I've not felt like myself for 2-3 years...profound fatigue, erectile dysfunction, memory issues...just a general unsteadiness. I take Crestor 40mg one a day. Flecanaide 50mg twice a day, a prostate supplement, fish oil and a multi.....I've been on statin therapy since 1990 so the calcium score was a surprise to all. Where would I look to determine risk factors, etc if I decide to begin testosterone therapy....Thank you

Dr__Hazen: Low testosterone makes you not only have the above symptoms, but also predisposes you to osteopenia (thinning of bones) and long term, increased risk for hip and other fractures. I recommend proceeding with testosterone supplementation. It is not a contraindication for your cardiac status (supplementing to replace low levels to normal levels). And should not adversely impact your cardiac status.

With a calcium score that is elevated as yours is, you fall into the category of having established coronary artery disease, and would be treated more aggressively for global preventive risk reduction efforts. This includes making sure the LDL is treated to goal of <70 is possible, low dose aspirin (unless there is contraindication like allergy, history of GI bleeding or other GI issues), closer attention to BP control, aggressive lifestyle (weight, diet and exercise) efforts, etc. Also, evaluation for pre-diabetes or diabetes, and thyroid function (other hormonal issues) are monitored as these too can impact on overall cardiovascular risks.

Menopause and Cardiovascular Disease Risk

CarolinaK28: I read an article in the NYT that women who have early menopause are at higher risk for heart disease. Are there additional recommendations you would have related to this?

Dr__Hazen: It is true that women, after menopause, are at increased risk for developing heart disease - in fact - age for age - women who are postmenopausal are at increased risk for heart disease relative to similar aged men. The best preventive efforts are global efforts aimed at lowering cardiovascular risks in general - not specific for post menopausal status - so weight reduction, monitoring lipid levels, blood pressure control, screening and treating diabetes, nutrition, exercise, getting a good 8 hours of sleep, etc.

Fish Oil – Omega 3 Fatty Acids

Char2209: Dr. Hazen, there has been a lot in the news the past couple weeks on fish oil and the lack of benefit. Are there any times when you would still prescribe it? What are you telling your patients who are taking fish oil?

Dr__Hazen: I still recommend fish oil. I don’t like calling it fish oil, because fish oil doesn’t always have the omega 3 fatty acids (DHA or EPA) that have the benefits. I recommend the supplements in two settings. The first is subjects with high plasma triglycerides (TG). The second is in secondary prevention (subjects with known cardiac disease – especially if TG are borderline or elevated, but this doesn’t have to be seen). Starting recommended dose is 1500 - 2000mg of EPA + DHA (be sure to add these up on the label, since not all “fish oil” has these. The blubber of a white fish doesn’t necessarily have DHA or EPA. For those with high TG that is resistant to dietary efforts to lower, the DHA+EPA supplement level can be increased to as much as 4000mg a day and can be taken at one time with major meal of day or split in two with lunch and dinner.

Gut Flora

HenryT: I would like to know more about what the next steps are for your gut flora studies? What is the next step for research?

Dr__Hazen: Next steps include:

  • Expanding the studies to larger clinical cohorts – showing that the gut flora metabolite linked to heart disease predicts risks in multiple low risk cohorts otherwise not identified by traditional risk factors/markers, like those whose LDL is <70, etc. 
  • Making the test available for clinical use, as a means of monitoring those at increased heart risk, and personalizing dietary recommendations/efforts.
  • Using this new information (the discovered pathway) to develop interventions for lowering cardiac disease progression/development – stay tuned…

samanthaM: thank you for the answer about your gut flora research. Do you think that there will changes in recommendations for food to include in our diets that will benefit us in the long run regarding cardiovascular disease risk. Are there types of foods we should especially include in our diet (not exclude) to make our blood vessels and heart more healthy?

Dr__Hazen: At this point in time, there are no new recommendations - other than things we already know....foods rich in lipids (cholesterol, fat) are the same foods that have high levels of phosphatidylcholine - the precursor that gut flora acts on to make the pro-atherosclerotic metabolite. So eating a heart healthy diet low in fat, saturated fatty acids, and cholesterol, will help lower the risk from this newly discovered risk factor. Increased consumption of whole grains and fiber also helps to shift the gut flora to a more heart healthy composition - again - nothing new in terms of dietary recommendations.

Obesity and Heart Disease Risk

george2257: Did you see the information about the healthy obese? How can that be that people can be healthy and overweight if obesity causes diabetes and blood pressure. But I saw on the news about people being overweight and fit?

Dr__Hazen: It is true that being obese, in of itself, does not mean one has to develop heart disease, diabetes, hypertension, or degenerative joint disease, etc. But obesity does predispose persons to these disorders. It is interesting to note that the risk calculators one can use to calculate heart disease risks often do not include weight or body mass index. This is because, obesity drops out of the risk formula when one includes the morbidities (complications) that arise from obesity like diabetes, hypertension, abnormal lipid levels, etc.

The take home message is NOT that obesity is not harmful. It is!!!

The single best way to help improve many heart related risks is to lose weight - and reduce the risk for diabetes, hypertension, lipid abnormalities, etc.


calisun36: I am a 38 year old male who is active - I walk and cycle every week. Taking a statin and my LDL is now 68, down from 136, my HDL is 38. I have yellow deposits under my eyes and my doctor said they can be xantoma or cholesterol deposits. What other testing should I have and is that something that can be controlled by cholesterol control? Are there additional tests I should have. I do not have heart disease but do have a family history - dad had MI at 58.

Dr__Hazen: Xanthelasthma - the lipid deposits/plaques you are describing that often occur on the lower eyelid, are difficult to get rid of - but they can very slowly over time recede if your lipids are lowered significantly. It is not routine to biopsy these since they are so common and readily diagnosed by visual inspection. It is important to keep not just the LDL , but also the VLDL and triglyceride levels low as these too can lead to the plaque deposits.

High Blood Pressure

McKelvey72: I am a 56 year old male who has exercised my whole life. My blood pressure has been 140/90- little higher or little less for the past year. Not quite hypertension. I am wondering if that puts me at risk and if I really need treatment if I am on the borderline of high blood pressure. Also - my heart rate is always in the 50s. Is that ok?

Dr__Hazen: "Not quite hypertension" - well - I respectfully disagree. 140/90 meets the diagnostic criterion for being called hypertension. That does not mean it requires medication though.

  • First, try lowering the salt (sodium) in your diet, as this can help lower blood pressure (BP).
  • Second, adopt a routine exercise program if you are not already doing so. A good regular exercise program can reduce SBP (systolic blood pressure - the top number) by 10 mm Hg - the same as a blood pressure medication. 
  • If these efforts don't work, then a blood pressure medication is recommended. There are so many different classes and kinds of BP meds, that one should be able to be identified that you can take without causing any side effects.

Keep in mind that most folks have BP that continues to creep up with age (our vessels get stiffer and less elastic with age) and a BP medication is likely in your future. High BP is a risk factor for heart attack and stroke. It is important to follow this - and not let it go without monitoring and, if needed, intervention, because the damage to your arteries from HTN is cumulative over time...good luck

McKelvey72: Another question. I saw on the American Heart website this week a study showing that sleep has an affect on hypertension. Do you think that could have an affect on my blood pressure? Are there other recommendations regarding sleep and heart disease?

Dr__Hazen: It is interesting that those who get a regular night sleep (at least 7-8h) have lower cardiovascular risks, and conversely, those who routinely sleep less (e.g. ~ 5-6 hours) or longer (I think >9hr per night) were at higher risks. As for the blood pressure (BP) connection to sleep - this is true. It also is true that obstructive sleep apnea is a risk factor for heart disease (can be up to 2-3 fold increased risk), and treating obstructive sleep apnea often improves BP control in hypertensive subjects.

Vitamin D, Calcium and Heart Disease

SusanOH: Thank you for answering these questions. I am hoping you can clear up the confusion that is still ongoing regarding Vitamin D and Calcium and heart disease risk? My doctor asked yesterday if I take calcium with vitamin D. I have had a stent a couple years ago and I am not sure with this risk of heart disease that I should be taking either.

Dr__Hazen: The connection between heart disease and supplemental calcium - if there is one - is incredibly modest. I say this because there are many studies where supplemental calcium was provided for attenuating osteoporosis, and hip fractures or compression fractures of the spine, and no significant increases in heart attack, stroke or death have been seen in these studies. These kind of studies (randomized placebo controlled trials) are the gold standard method of seeing a signal - and no significant one has been seen. However, some epidemiology studies, that sift through large databases, looking for associations, have seen associations between calcium supplement use and heart disease. These are less strong studies as they don't show cause and effect - just associations.

People who take calcium supplements are likely to be older, and thus have other degenerative diseases of aging - like heart disease. Sometimes the statistical analyses don't correct for confounding. A good example of my point is aspirin use - if one looks at subjects taking aspirin- one could come to conclusion that taking aspirin causes heart disease, because it is overwhelmingly associated with heart disease! Bottom line - having a stent has no bearing on whether you take calcium or not. If your doctor recommends taking calcium, because you have thin bones - I recommend you follow your doctor's advice.

Medications for Heart Disease

Peppy: How long do you have to stay on the beta blocker after a non-stemi and one artery DES in the diagonal artery 80% blocked? I find it makes me tired.

Dr__Hazen: The reasons we recommend beta blockers in subjects with known heart disease who have experienced an MI is that they prolong lives. If there is a second heart attack, the extent of damage to the heart also appears to be less. Of course, everything is a risk/benefit ratio - and one has to balance the benefits with adverse side effects. Often, side effects of fatigue, associated with beta blockers in some subjects, tend to dissipate over time. They also are dose related. Typically, beta blocker therapy is life long in the post MI setting (assuming one doesn't have adverse symptoms that limit taking the medication). I suggest you work with your cardiologist to see if you can find either an alternative regimen that works for you, while still gaining the benefit of the protection beta blockers provide.

Stress Test and Heart Disease

RayMC: I recently had a positive exercise stress test and previously have been diagnosed with moderate, asymptomatic heart disease. There is mild stenosis in my coronary and carotid arteries and I had a Branch Retinal Artery Occlusion 2 yrs ago. No history of high blood pressure. Cholesterol=178, hdl/ldl=48/78. I take Lipitor + low dose aspirin daily. I experience no discomfort with very vigorous exercise. My doctor has requested that I have an angiogram. He said that the likelihood of an angioplasty ensuing was 30%. I have declined the angiogram. I cannot discount the possibility of a false positive on the stress test nor can I ignore the low the probability for angioplasty. Do you feel there is an urgency for the angiogram or should I continue with the meds, modify my diet and monitor my lipids? What are your thoughts re: stenting? I am concerned that most stenting must be re-done within 5 yrs. That is not a lifelong process I would like to start. Thanks

Dr__Hazen: With a positive stress test there are concerns for underlying ischemia (lack of oxygen). Some subjects can have positive stress tests without symptoms. You have multiple examples of known cardiovascular disease. I would be concerned that your current regimen is not adequate, and would follow your doctor’s recommendations for obtaining a cath. And yes – there is a good possibility that you may end up with being recommended to have angioplasty. Stenting is better than open heart surgery…

Think of this as good fortune that you are lucky enough to have the possible warning sounded for more in depth evaluation BEFORE a potential catastrophic event… like a heart attack. Since some don’t survive such events.

Heart Rate Variability and Cardiovascular Risk

Francois: Is low Heart Rate Variability a heart disease risk factor? How is it measured? Some automatic home blood pressure monitors also measure heart rate. Would the difference of two such readings give an approximate value of Heart Rate Variability?

Dr__Hazen: Reduced ambulatory heart rate variability is associated with prospective risks for heart disease. This is not something that can be measured simply by visually watching the heart rate as suggested, but requires sophisticated instrumentation and monitoring, and is not routinely used in ambulatory setting (more of research tool or a prognostic tool during an exercise stress test and the recovery period).

Reviewed: 09/12

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