Chasing life, p.13
Chasing Life, page 13
Good advice? Yes and no. An angiogram is the gold standard of heart tests, and in Clinton’s case, it picked up a problem that all his previous stress tests and EKGs had missed. But an angiogram is not something to be taken lightly. It involves injecting a dye directly into the blood vessels of your heart through a catheter that has been threaded into your chest from an artery in your groin. By taking X-ray images of the dye, doctors can get a pretty clear picture of where blood is flowing freely and where there are constrictions.
But angiograms are not risk-free. In about one case out of one thousand, according to Dr. Richard Stein, associate chairman of medicine at Beth Israel Medical Center in New York City, there are complications—including, in rare cases, strokes. For patients who have never had any symptoms (such as the chest pains and shortness of breath that Clinton experienced) and whose stress tests are normal, the risks outweigh the benefits, says Stein.
That’s why there has been so much attention given lately to a noninvasive test called electron beam computed tomography (EBCT). It uses a burst of X-rays to show how much calcium has been deposited in the coronary arteries—a good measure of how much plaque has accumulated there. In a study published in the Journal of the American College of Cardiology, more than half of 1,119 patients who passed their stress tests had high calcium scores in subsequent EBCTs, suggesting significant hardening of the arteries.
Getting an EBCT is not the end of the story. If you get a high calcium count, you will still need an angiogram so your doctor can tell precisely where your arteries are blocked. But EBCTs are spotting a lot of hidden heart disease. Although some insurance companies are reluctant to pay for this new test, its use is growing rapidly, and it may eventually become part of the standard heart workup. This is something you may want to talk to your doctor about if you have a strong family history of heart disease or have other reasons for concern.
There has also been a lot of interest in a new sort of blood test called C-reactive protein (CRP). President Bush has his checked regularly, and it is extraordinarily low, which means to him (and his doctors) that he is at very low risk of having a heart attack. At medical cocktail parties nowadays, it seems cardiologists are talking about CRP the way they used to talk about high-density lipoprotein (HDL) and low-density lipoprotein (LDL), and for good reason. Two recent reports from the New England Journal of Medicine suggest that CRP may be just as important a risk factor for coronary artery disease and heart attacks as LDL—and maybe more so. CRP is a protein secreted by the liver in response to inflammation, and over the past several years, it has become apparent to experts that inflammation is a big part of heart disease. CRP seems to play a role in damaging artery walls, making them more prone to the buildup of fatty plaques that can rupture and block the vessels that feed the heart. Sure enough, studies have shown that high CRP levels, signaling active inflammation, are significantly associated with heart problems. So what can you do about it? Well, doctors know statins can reduce inflammation. So cardiologists from Brigham and Women’s Hospital in Boston put 3,745 patients who had experienced heart attacks or severe chest pain on statins and later measured their levels of both LDL and CRP. It turned out that patients who ended up with low CRP levels were less likely to have heart attacks or die than were those whose CRP levels stayed high—whether or not their LDL levels went down. This was in many ways a landmark study, showing that CRP reduction is at least as important as cholesterol reduction. The second study, performed at the Cleveland Clinic Heart Center, also tracked cardiac patients, but instead of looking at heart attacks, the researchers measured actual plaque buildup. The patients whose CRP level dropped the most while taking statins saw their plaques get smaller—again, independent of what happened to their LDL level. There is no question that CRP will continue to become increasingly important, and it now makes sense for anyone who’s at risk for heart disease to be evaluated. It’s a simple blood test that any lab can do, and while it might not be covered by all insurance companies, it costs $15 at most.
Still, for us life chasers, I want to start with the basics so we may never need these medications, tests, or operations. It comes down to working out harder, sleeping more soundly, and being very particular about what and how much you eat.
Exercise
Exercising is the first simple step toward lowering your risk of heart disease. If you become leaner and fitter, your risk of heart disease and stroke goes down. It’s that simple. Not exercising raises your risk of coronary artery disease as much as high blood pressure, high cholesterol, or smoking, according to a study published in the Journal of the American Medical Association. You also know that focusing on losing that abdominal fat makes a world of difference. So in addition to such aerobic activities as running, stair climbing, or perhaps walking on a treadmill, you want to do some targeted, core exercises to work off that abdominal fat. As you gradually add even small amounts of weight training to your program, you will start to see the abdominal fat melt away. And here is an added benefit: it will also likely help you get critically important, quality sleep at night.
Sleep
Chronic lack of sleep has been linked with heart disease, among other health problems. A number of studies have linked sleep with appetite and weight control. One study, involving more than one thousand people between the ages of forty-five and seventy-five, found the body mass index (BMI) of participants actually increased as their sleep time decreased. I know it seems counterintuitive, but it turns out the less you sleep, the more your overall metabolism changes, conserving energy and fat. So lack of sleep makes your fat that much harder to lose and thus contributes to heart disease. In another study, researchers restricted young, healthy adults to four hours of sleep a night for six days and found some remarkable, measurable hormonal changes that could lead to overeating. The study subjects actually developed decreased levels of leptin, an appetite suppressant. And to make matters even worse, they had increased levels of ghrelin, a hormone that stimulates appetite.
Smoking
If you smoke, you should stop. If you don’t smoke, please don’t start. It’s amazing that with all the information out there about the horrible health consequences of breathing in cigarette smoke, an estimated 1.4 million Americans start smoking each year (half of them under eighteen). You must know the association between smoking and cancer, but those nasty nicotine-delivery devices also result in an estimated doubling or tripling of your risk of dying from coronary artery disease, according to the American Heart Association. I am not going to preach about cigarettes, although I recently learned not enough doctors counsel their patients to quit. Let me simply say that everything else in this book is null and void if you continue to smoke or ever start.
Nutrition
There are certain foods that appear to help protect against heart disease. I call them “power foods,” and you should try to incorporate as many as you can every day into your diet. A large-scale study found a diet high in fruits and vegetables and low-fat dairy products; with moderate amounts of fish, poultry, and nuts; and low in red meats, sweets, and sugary drinks lowered blood pressure by as much as seventeen points in people with high blood pressure. And that was within just two weeks. In case you ever thought simple changes to your diet wouldn’t amount to much, think again. Cholesterol also dropped within that same time period.
Despite this straightforward antidote, the statistics collected by the American Heart Association are extremely worrisome. For example, four in five men and nearly three in four women do not get the recommended five servings of fruits and vegetables a day. A third of our calories come from fat, and our diets are low in whole grains. Our daily fat consumption is about 75 grams, the equivalent of three McDonald’s Quarter Pounders with cheese. In a very real way, we are by and large what we eat—fat.
Eating a fatty diet is so easy in the United States. Fast food restaurants, vending machines, and gas station marts offer up food that is high in fat. Even hospitals are offering fatty fare. A study commissioned by the Center for Science in the Public Interest found cafeterias at eighteen of the nation’s top hospitals were serving foods prepared with partially hydrogenated vegetable oil, the biggest source of artery-clogging trans fat in the American diet.
Heart Disease Power Foods
• Fruits, especially strawberries, blueberries, and bananas
• Vegetables, including tomatoes, spinach, eggplant, and okra
• Low-fat dairy
• Legumes such as lentils, chickpeas, and lima beans
• Fish, especially such oily fish as tuna, mackerel, and herring
• Poultry
• Nuts, including almonds and walnuts
• Whole grains
Here are some heart-healthy foods: such oily fish as tuna, mackerel, and herring, which contain omega-3 fatty acids, can significantly lower the risk of dying of heart disease, according to the American College of Cardiology.
Eating foods containing soluble fiber, such as oat bran and legumes, has been shown to lower total cholesterol and LDL (bad) cholesterol. Blueberries may have a similar effect. Lycopene, found in tomatoes and tomato products, such as ketchup and tomato juice, may also lower cholesterol and reduce the risk of heart attack, although results from a number of studies are not consistent. Okra and eggplant have also been shown to lower cholesterol, as long as they are not fried. Adding strawberries to your diet could lower your systolic blood pressure.
One study found eating cereal fibers later in life lowered the risk of cardiovascular disease. This is one area in which Americans really fall short. The recommended daily intake is 25 grams, but we are averaging about 15.
A heart risk you don’t often hear about comes from the amino acid homocysteine. Elevated levels of homocysteine in the blood increase the risk for such cardiovascular diseases as coronary artery disease, stroke, and blood clots. That’s true even for people with normal cholesterol levels. In fact, high homocysteine levels account for an estimated 10 to 20 percent of cases of coronary artery disease and pose as big a threat as high blood pressure and hypertension. Fortunately, there appears to be a simple dietary fix.
Adding folic acid, or folate, to your diet decreases the homocysteine levels in the blood, which should in turn lower the risk of heart disease and stroke. How do you increase your folic acid intake? The simplest sources of folic acid are fortified breakfast cereals and folic acid supplements. Green, leafy vegetables, such as spinach, are rich in folic acid, as are citrus juices and legumes, such as lentils, chickpeas, and lima beans. In addition, heavy drinkers, cancer patients, and pregnant women all need extra folic acid in their diets.
The minerals we get in our food also affect our heart health. The National Health and Nutrition Examination Surveys, which involved nearly ten thousand men and women whose eating habits were charted for two decades, revealed that those who had the lowest potassium levels in their diet had a 28 percent greater risk of stroke than those who consumed more potassium-rich foods. The Honolulu Heart Program, which studied seven thousand men, found those with the highest magnesium intake had a 45 percent lower risk of heart disease than did those who consumed the least.
Good sources of potassium include bananas, baked potatoes, orange juice, raisins, prunes, and spinach. Sources of magnesium include bran cereal, oat bran, shredded wheat, brown rice, almonds, hazelnuts, almonds, spinach, okra, lima beans, and bananas.
In a year-long study conducted by the University of Toronto, something called the portfolio diet showed cholesterol-lowering properties that rivaled the blockbuster cholesterol drugs known as statins. The diet allowed for no meat, eggs, poultry, fish, or dairy. Foods were picked based on their ability to lower cholesterol a little. Together, they lowered cholesterol a lot. What was it? Participants in the study ate a mostly vegetarian diet also rich in soy foods, almonds, and fruit. They also ate whole grains and beans, and they used healthy oils and margarine made from plants.
Another study found omega-3 fatty acids, which I talked about in chapter 5, reduced the chance of dying of heart disease more than statins.
STATINS, SUPPLEMENTS, AND OTHER DRUGS
Dr. Steve Nissen, a cardiologist at the Cleveland Clinic, told me we are almost to the point in the United States where we should put the class of cholesterol-lowering medications called statins in the drinking water. “The medications are that good,” he added. I am pretty sure he was exaggerating somewhat, but not that much. Nissen is not alone. Many doctors consider statins a true wonder drug.
Truth is, most people do not rely on dietary changes, but instead take drugs to lower their cholesterol. An estimated 20 million Americans now take cholesterol-lowering statins. One of these drugs, atorvastatin (Lipitor), is the best-selling drug in the world. Despite their popularity and their effectiveness at lowering cholesterol, you should try lowering your cholesterol through dietary changes before you take one of these drugs—unless you’re cholesterol is dangerously high.
Not everyone is enthusiastic about the widespread use of statins to prevent heart disease. Dr. John Abramson, who teaches primary care at Harvard Medical School, argues in his book Overdo$ed America that statins are widely overprescribed, thanks to a recommendation made in 2001 by an influential panel of experts. The guidelines they published suggested increasing the number of Americans who qualify as having cholesterol levels high enough to warrant statins from 13 million to 36 million, and doctors have largely followed these recommendations. But Abramson argues that the gradual buildup of plaque in the arteries caused by cholesterol is not the main cause of heart attacks. Rather, he says, it is when a small area of plaque breaks open, triggering first a blood clot and then a heart attack. The cause of these “fractures” is not known.
Abramson recommends prescribing statins for people who already have coronary artery disease, but not for patients with only moderately elevated cholesterol levels, and he says a number of large trials back him up. Despite his criticisms, there appears to be no letup in the number of prescriptions written for statins.
Before you start taking statins, be aware that the drugs have rare but significant side effects. The drugs can cause muscle weakness and raise liver enzymes.
More than 20 million Americans take aspirin to help prevent heart attacks and strokes. Aspirin’s benefits as an anticlotting drug have been known for decades, but the latest research suggests that the situation is not as clear-cut as once believed.
For starters, recent studies suggest from 1 million to more than 8 million of these aspirin users do not get the drug’s anticlotting benefits. They are aspirin-resistant and will not reduce their chances of heart attack or stroke by taking the drug. The findings do not affect people who take aspirin for inflammation or pain.
Most doctors who advise their patients to take aspirin do not test for aspirin resistance, although new tests make it easier than ever to do so. The alternative to aspirin to lower the risk of heart attack or stroke is a popular antistroke drug called clopidogrel bisulphate (Plavix), which is far more expensive.
In addition to resistance, there appear to be some differences in the way men and women respond to aspirin. A ten-year study of healthy women found taking low-dose aspirin did not prevent first heart attacks in women younger than sixty-five. Aspirin does help men under sixty-five. In fact, one study of healthy men showed taking an aspirin pill every other day reduced their risk of heart attack by 44 percent.
Because aspirin can cause bleeding, doctors recommend only men and women at risk for heart disease take aspirin for this purpose. Risks include a family history of heart disease, high blood pressure, or diabetes. Anyone over sixty-five is also considered at risk for heart disease.
Even with its potential to cause bleeding, aspirin is less likely to cause ulcers than Plavix, a recent study published in the New England Journal of Medicine found. Patients on Plavix suffered from ulcers more than twelve times as often as did people who took aspirin plus a heartburn pill. This countered the conventional wisdom that Plavix was safer for the stomach than aspirin.
An estimated 23 million Americans take vitamin E, many of them no doubt in an effort to prevent heart disease. As I noted in chapter 3, studies have not backed up the efficacy of this behavior.
