Learn About Your Heart...
Made Simple

By Nicolas Shammas, MD

A new, comprehensive sourcebook for
heart and vascular disease patients

Cardiovascular Health Topics

Statistics about Heart and Blood Vessel Diseases in the United States
Structure and Function of the Heart and Blood Vessels
Diseases of the Blood Vessels of the Heart
Surgical Therapies for the Cardiovascular Patient
Peripheral Vascular Disease
Diseases of the Blood Vessels of the Head and Neck
Strokes: How to Survive Them and How to Prevent Them
Valvular Heart Disease
Heart Rhythms: How to Recognize Them and Treat Them
Congestive Heart Failure
11. Understanding Cardiomyopathy, or Weak Heart Muscle
12. Children and Heart Disease
13. Diseases of the Pericardium
14. Systemic Illnesses, Infections and Drugs that Affect the Heart
15. Erectile Dysfunction: a Vascular Disease
16. Cardiovascular Disease Prevention
17. Heart Healthy Nutritional Tips
18. Cardiac Rehabilitation
19. Medications for Cardiovascular Disorders
20. Heart Tests You Need to Know
21. Learn What to Do in a Medical Emergency
22. How to Choose Your Doctor and Hospital
23. Medical Research and How You Can Get Involved
24. Taking the Next Step — A Few Community Resources to Help You Live More Healthfully
25. How Much Did You Learn from This Book: Take a Simple Test

Many drugs are available to treat hypertension. Your doctor has to weigh numerous aspects of your overall clinical picture in order to arrive at an appropriate choice of drug to reduce your blood pressure. ACE inhibitors, beta-blockers, calcium channel blockers, diuretics, and alpha-blockers are commonly used. Most patients require the combination of 2 or more of these drugs to achieve adequate control of blood pressure. People with diabetes require, on average, 3.5 medications to control blood pressure to target values.

The risk for hypertension increases continuously as we age. This is why it is important that your blood pressure be checked at least once or twice per year. The risk for death and disability from cardiovascular disease doubles for every 20/10 mmHg elevation in blood pressure. If your doctor wants to treat your blood pressure or add more types of medication to do it, be cooperative, since hypertension dramatically increases your risk for heart attack, stroke, sudden death, kidney disease, and blindness.

Only about 30% of patients reach their blood pressure goals. It is critically important that all patients form therapeutic alliances with their physicians and help to ensure that their blood pressure is lowered to appropriate levels. It is a good idea to invest in the purchase of a blood pressure measuring cuff and measure your blood pressure regularly. If it is creeping up, it is time to talk to your doctor. By the age of 50 years, approximately 30% of white men and 50% of black men have hypertension. The percentages are similar for white and black women. If you have isolated systolic hypertension (the upper number is above 140 but the lower number is "normal" at less than 90), you warrant therapy. Isolated systolic hypertension is particularly dangerous and magnifies risk for CHD and stroke. It is no longerbelieved that increased blood pressure in the elderly helps to preserve blood flow to critical organs. High blood pressure is bad for everyone.

How does diabetes affect CHD?

The prevalence of diabetes is growing at an alarming rate. This is a worldwide problem. The World Health Organization estimates that there will be 340 million people with diabetes throughout the world by the year 2025. The rising prevalence of obesity and sedentary lifestyle are largely to blame for this epidemic of diabetes. Diabetes is a vicious disease. It quadruples the risk for CHD and stroke and increases the risk for kidney failure, adult-onset blindness, and lower-limb amputation about 10-fold. If you have diabetes, studies have shown that it is safe to assume that you have CHD. Consequently, your risk factors must be managed extremely aggressively.

There are well-defined thresholds for the management of risk factors in people with diabetes.Your blood sugars before breakfast and supper should be less than 120. It is best to keep your hemoglobin A1c (a measure of blood sugar control over a 3month period) at 6.5 or less. Blood pressure should be less than 130/80 mmHg in the absence of kidney disease (diabetic nephropathy). However, if a patient has developed kidney damage from chronic diabetes, blood pressure should be less than 125/75 mmHg. Your urine should be checked every year for evidence of kidney damage. This typically manifests itself as a protein leak. A rising serum creatinine level (a measure of kidney filtration capacity) also warrants further evaluation. Make sure your eyes are checked every year by an ophthalmologist so that the earliest signs of eye and retina damage can be detected and appropriately treated. Your LDL should be less than 100, triglycerides less than 150, and your HDL should be greater than 40 (men) or greater than 50 (women).

Heart disease in a person with diabetes can be tricky to detect. Because of damage to the nerves of the heart, people with diabetes may not experience classical warning sings of heart attack. People with diabetes may have severe CHD and never experience chest pain. Consequently, if you have diabetes, and you are developing shortness of breath, lightheadedness, pain between your shoulder blades, or easily induced fatigue with minimal exertion, it is time to see you doctor for a heart evaluation.

What is metabolic syndrome?

Recently, physicians recognized an insidious problem that also increases risk for CHD: metabolic syndrome. Metabolic syndrome typically occurs in people who are overweight or obese. Like weight gain, metabolic syndrome creeps up on you.The fat around your waist (the so-called "android" distribution of fat) is metabolically active and drives the development of insulin resistance in your tissues. Produced by your pancreas, insulin is the hormone that helps you internalize glucose from your blood and into muscle and other cells where it is burned as fuel. When your cells and tissues become resistant to the effects of insulin, the levels of glucose in blood increase. This is a precursor to diabetes. High levels of blood glucose are highly toxic to blood vessels and accelerate the rate at which you develop atherosclerotic disease. In addition to having high blood sugar, patients with metabolic syndrome also develop hypertension, high triglycerides, and low HDL. This is a formula for disaster. Patients with metabolic syndrome have a 3–4-fold increased risk for developing CHD and diabetes compared to people who do not have metabolic syndrome.

If you develop metabolic syndrome, the most important first steps include weight loss, restriction of carbohydrate intake, and exercise. In the Diabetes Prevention Project, lifestyle modification with weight loss reduced the risk for progression to diabetes by almost 60%. Lifestyle modification reduces insulin resistance, improves blood pressure, and reverses abnormalities in lipid metabolism. Your physician may recommend that you take an ACE inhibitor or an ARB (angiotensin receptor blocker) for your blood pressure. These drugs have been shown to reduce risk for the development of diabetes by 20–34%, so taking them makes sense in the setting of metabolic syndrome and high blood pressure. You may also be advised to take a lipid lowering medication, such as a statin or fibrate. If you have metabolic syndrome, it is generally a good idea to take a daily aspirin in order to help mitigate the excess risk for heart attack and stroke.

How does smoking contribute to coronary heart disease?

Smoking is extremely detrimental to your heart and blood vessels. Cigarette smoke contains over 4,000 toxins. In addition to increasing risk for a variety of cancers, smoking accelerates the aging of your entire cardiovascular system. Women who develop CHD in their late 30s or early 40s are almost always smokers. Although smoking greatly increases the risk for lung cancer, it increases the risk for CHD even more. If you smoke, it is critical that you quit. Ninety percent of the battle to quit smoking is between your ears. If you want to quit smoking, you will. If you are half-hearted about smoking cessation, odds are you will fail.

Pharmacologic aids for smoking cessation are available. Nicorette gum and nicotine patches (Habitrol and Nicotrol) help provide the nicotine necessary to prevent symptoms of withdrawal. It is important to wean yourself from nicotine. If you use the patch, start at 21 mg per day for 1 month, then taper the dose and frequency to 14 mg per day for 1 month, then again to 7 mg per day for 1 month, and then stop. Zyban is a pill that helps to reduce the intensity of nicotine withdrawal. When taken at 150 mg twice daily, patients should decrease their cigarette consumption by 1 cigarette every other day until they quit. This way they reduce consumption at a slow but sustainable pace and limit the intensity of withdrawal. Some people simply have to "go cold turkey." The effort required to quit smoking is always worth it.

What is the relationship between hormone replacement therapy and CHD?

For many years, it was believed that estrogen replacement therapy would decrease risk for CHD. After all, women are highly protected from the development of CHD during the premenopausal years. Unfortunately, this has not turned out to be the case. Hormone replacement therapy (HRT) for postmenopausal women without CHD appears to slightly increase the risk for heart attack. Consequently, if a woman has low risk for CHD, the use of HRT may be largely an issue of quality of life. If she is having severe hot flashes and night sweats, pain with intercourse, or mood swings, a 3–5 year course of HRT is a reasonable choice to help her get through menopause. Where the issue appears to be particularly important is in women who have established CHD. Women with CHD should not take HRT, as multiple studies have shown that HRT significantly increases risk for heart attack in the face of established coronary artery disease.

How does alcohol consumption affect CHD?

Healthcare providers and the press generally discuss alcohol consumption in negative terms because of the risk for alcoholism. However, when consumed in moderation, wine (2–8 oz daily) can promote health rather than compromise it. Increased wine consumption appears to underlie the so-called French paradox: the people in France eat some of the richest foods on earth, yet their risk for CHD is the lowest in the Western hemisphere. Similar findings apply to people living in Italy.

Wine increases the levels of HDL in your blood by 2 mechanisms. First, it stimulates increased production of HDL by the liver. Second, alcohol helps to decrease the breakdown and clearance of HDL in your blood. Red wine appears to be particularly beneficial. If it has been stored and matured in oak barrels in wine cellars, it tends to contain high concentrations of potent, naturally occurring antioxidants, such a quercetin, catechin, and reservatrol. These antioxidants are protective to the cardiovascular system. However, remember, all things in moderation!

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