What You Need to Know
About Heart Disease
By Dr. Alan Kronhaus, Health and Wellness Editor

When people speak of heart disease, they usually mean the condition more accurately described as coronary artery disease. This is a narrowing of the coronary arteries that reduces blood flow to the heart muscle, which can cause chest pain (angina) or a heart attack (myocardial infarction). Coronary artery disease is by far the most common type of cardiovascular disease. It’s also the most preventable.

The coronary arteries play a vital role by supplying the heart with oxygen-rich blood. The heart muscle depends on two main arteries, the right and left coronary arteries, for its entire supply of blood and oxygen. Like the branches of a tree, each main artery divides into progressively smaller channels that carry blood to the heart muscle cells. Either of these arteries or any of their branches can be narrowed by a buildup of fatty plaque, known medically as atherosclerosis. In atherosclerosis, the artery walls become filled with soft, mushy deposits that eventually make the artery hard, stiff, and narrow.

These deposits can restrict blood flow, resulting in ischemia, or oxygen deprivation. A partial or temporary interruption in blood supply, causing mild ischemia, will injure the heart muscle and can produce angina. Complete or prolonged interruption of blood flow, causing severe or prolonged ischemia, leads to the death of heart muscle cells that constitutes a heart attack. Ischemia can impair the heart’s ability to pump blood, interrupt its normal pumping rhythm, or even produce a heart attack.

Coronary artery disease can also produce congestive heart failure and abnormal heart rhythms (arrhythmias). Congestive heart failure occurs when the heart can’t pump sufficient blood, producing shortness of breath, fatigue, and fluid accumulation known as edema. Arrhythmias can produce palpitations, fainting, and even sudden death.

Heart Disease in America

• About 65 million people have high blood pressure.
• More than 7 million have had a heart attack.
• More than 6 million experience angina (chest pain).
• Another 11 million have some other type of cardiovascular disease:
• Nearly 5 million have congestive heart failure.
• More than 5 million have had a stroke.
• About 1 million are born with heart defects.
• Every minute, someone dies from a heart attack or some other coronary event.

Recognizing and Reducing Risk Factors
Most but not all people who develop coronary artery disease have at least one major risk factor. (See accompanying article in this month’s issue!) Fortunately most of the risk factors for coronary artery disease can be modified or avoided. By addressing the risk factors that you can modify, at least to some extent, you can significantly reduce your vulnerability to coronary artery disease.

Diagnosing Heart Disease
Doctors use several techniques to diagnose heart disease. These include learning your medical history, performing a physical exam, and doing routine laboratory tests and an electrocardiogram. Depending on the results of this initial evaluation, the doctor may recommend more specialized tests — for example, an exercise tolerance test, nuclear imaging, or coronary arteriography (also known as coronary angiography).

By far, the most important “test” in the diagnosis of coronary artery disease is a detailed conversation between you and your doctor. Your medical history — that is, your description of your medical background and symptoms — usually provides enough information for a physician to make or exclude this diagnosis with a high degree of certainty. The doctor should ask about such things as smoking, diet, and exercise; whether your parents or other family members have had heart problems; and whether you have a history of other medical problems, such as hypertension, high cholesterol levels, or diabetes.

What Is a Heart Attack?
A heart attack, known medically as a myocardial infarction, occurs when a blood clot blocks one of the coronary arteries. Each coronary artery supplies blood to a specific part of the heart’s muscular wall, so a blocked artery causes pain and malfunction in the area it supplies. Depending on the location and the amount of heart muscle involved, this malfunction can seriously interfere with the heart’s ability to pump blood. Also, some of the coronary arteries supply areas of the heart that regulate heartbeat, so a blockage sometimes causes potentially fatal abnormal heartbeats called cardiac arrhythmias.
Most people are familiar with the classic description of a heart attack: crushing chest pressure; pain radiating to the neck, jaw, back, or arm; sweating and shortness of breath; sudden "indigestion" that isn’t relieved by antacids. If you experience these symptoms or others that indicate you may be having a heart attack, call your doctor immediately and go to the nearest emergency room. Chew an aspirin on the way to help reduce your blood’s tendency to clot.

Every second counts. In one landmark study, people who received treatment within one to two hours were only half as likely to die as those who were treated four to six hours after the onset of symptoms. The primary goal in treating a heart attack is to unblock the artery and restore blood flow to the heart as fast as possible with medication or surgery. Doing so will minimize the damage to the heart tissue.

Medications for Heart Disease
Although lifestyle changes are an essential first step in treating coronary artery disease (see accompanying article), you may need to take medications to reach your cholesterol and blood pressure goals and otherwise reduce your risk. In fact, most people with heart disease need to take more than one medication. The specific combination of drugs will depend on your particular symptoms and risk factors.

Blood Pressure Medications -- Antihypertensives
For many years, doctors used diuretics — sometimes known as water pills — to treat high blood pressure. Although diuretics remain a mainstay of blood pressure treatment because they are cheap and effective, a flood of other drugs have become available since the 1980s. Work with your doctor to determine the best type of medication for you.
It is important to keep in mind, though, that most people with hypertension do not get their blood pressure under control with the starting dose of the first drug chosen. At that point, two philosophies exist about what to try next. Some doctors increase the dosage of the first drug to see if it will bring blood pressure down to target levels. The advantage of this approach is simplicity, as the person being treated takes one pill per day. A second approach is to use low doses of two or more blood pressure drugs that work in different ways. This approach minimizes the likelihood of side effects, but may be harder to follow, as it requires taking two or more pills per day. It may also be more expensive for the person being treated, as he or she may face additional co-payments or out-of-pocket expenses for the drugs. A compromise approach is to use combination medicines that include, for example, both an ACE inhibitor and a low-dose diuretic. This is convenient, but many combinations are available only in brand-name forms and are thus more expensive.

Cholesterol Medications
Since statins were first introduced in the late 1980s, they have become the treatment of choice for lowering cholesterol, simply because they are so effective. Even so, they don’t work for everyone. Although some newer cholesterol-lowering drugs block the absorptions of cholesterol into the body, most cholesterol-lowering drugs work by preventing the liver from making cholesterol, and by forcing the liver to draw LDL -- the “bad” cholesterol -- from the blood. These medications not only significantly lower LDL levels but also improve your overall cholesterol profile by lowering total cholesterol, slightly boosting HDL – the “good” cholesterol -- and slightly lowering triglycerides — although by differing amounts. What’s more, studies have revealed that these medications have other benefits: They stabilize cholesterol-filled plaque in artery walls, promote the growth of new blood vessels, and calm inflammation. All of these actions help to reduce the risk for coronary artery disease and heart attack or stroke. Small wonder that statins are considered one of the most important advances in drug therapy since the 1970s.

But statins are not miracle pills, and they’re not for everyone. They don’t always lower cholesterol enough, and they cause troubling side effects in some people. It’s also important to remember that eating healthy foods, exercising regularly, and losing weight if necessary are the best — and should be the first — approaches to treating high cholesterol and reducing the risk for heart attack or stroke. Consider the options carefully and talk with your doctor about whether to take a statin and, if so, which one to take.

Avoiding Common Pitfalls
One of the great medical success stories of our time is the ability to diagnose and treat heart disease and to gauge a person’s risk of developing it in the future. But preventive measures and therapies can only be successful if people use them. A continuing medical challenge is helping people avoid a variety of common pitfalls: ignoring key symptoms, deferring recommended tests, or neglecting to take medications as prescribed. Any or all of these things can keep you from reaping the full benefit of decades of medical research and practice.

“I’m having side effects.”
Tell your doctor about side effects that you find bothersome. Chances are, you can use a different medication that’s more bearable. One of the best ways to minimize unpleasant side effects from heart medications is to avoid taking other drugs that interact adversely with them. Many drugs commonly prescribed for the prevention or treatment of heart disease should not be taken with other medications.

“The drugs worked. Can I stop now?”
If you’ve reached your target blood pressure or cholesterol level, it’s tempting to stop taking your medicine. But doing so can cause your blood pressure or cholesterol to rise again — along with your risk for heart disease. Check with your doctor before deciding to cut back or eliminate any medication.

“It must be heartburn.”
Ignoring chest pain is another common pitfall. Most people know that it might be a sign of angina or heart attack — or of nothing more than indigestion. But anyone having chest pain should err on the side of caution by calling the doctor and having an evaluation for heart disease. If you disregard chest pain or pretend it’s not that big a deal, you could be denying yourself the chance for early — and potentially lifesaving — treatment.

Dr. Kronhaus is a recognized expert in the medical field and the owner of Doctors Making Housecalls, 919.932.5700, www.doctorsmakinghousecalls.com

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