Detect It Early, Hit It Hard
Sometimes life isn't fair, and if you're a guy, heart disease is one of those times. Sorry, but just being male automatically makes your risk of developing and dying from heart disease higher than it is for women--a lot higher. And the stakes are big. In 2002 heart disease caused more than 1 in every 4 deaths of American men, snuffing out nearly 341,000 lives. Usually the first symptom is a heart attack.
But new ways to detect risk early are being developed, along with new risk factors to look for. To begin, those whose high risk is known are treated as if they already have heart disease, so, to change that fate, doctors are hammering hard at those risk factors that can be modified. "As we get better at assessing risk, we take the highest-risk people and we really treat them aggressively," says Daniel Rader, a cardiologist at the University of Pennsylvania School of Medicine.
Beyond identifying high-risk patients, there is more emphasis on catching those at intermediate risk, who have a 10 to 20 percent chance of developing heart disease within the next decade. In the past, such people were generally told to wait and see if things got worse. That's now considered russian roulette.
An initial evaluation for heart disease is surprisingly simple, no more than providing a medical history, giving a little blood, and submitting to a quick physical. That's because the major flags are well known: high blood pressure; elevated levels of LDL, the bad cholesterol; smoking; diabetes; a family history of heart problems; and, as noted depressingly, simply being a man.
New flags. It's no longer enough, for one thing, to keep track of your total cholesterol (which should be below 200 milligrams per deciliter). "Every man, regardless of age, should know not only his total cholesterol but his LDL and HDL cholesterol level as well," says Rader. (HDL is the good cholesterol, which reduces risk.) Moreover, any man at intermediate risk or higher needs to have his cholesterol checked regularly.
The notion of what levels to shoot for has also changed over the years. The current thinking is that a man with a couple of major risk factors--say a smoker in his 50s--should strive for an LDL level below 100 mg/dL. Every point cut from the LDL number means a 1-point drop in heart disease risk. A man's HDL should be no less than 40 mg/dL.
How do you achieve these numbers? Expect your doctor to plead with you or lecture you to improve your diet (more produce and fiber, less saturated fat) and exercise regularly. Even if lifestyle changes can't lower your LDL and raise your HDL to ideal levels, stick with it. "If a person only makes small changes, that might mean that you need to take less medication," says Mary Frank, a family physician in Rohnert Park, Calif.
These days medication is virtually synonymous with statins, a class of drugs that can slash LDL levels by more than half and also bump up HDL a bit. Lipitor, one of the most potent statins available, is the top-selling drug in the nation.
But it's a drug class that doesn't lack for controversy. How often statins should be prescribed, what dosage to start and keep patients on, and whether statins are as safe as their advocates claim are all up for grabs. A recent study has shown that Crestor, a powerful, recently introduced statin, has caused twice the rate of side effects, such as kidney and muscle damage, as other statins. But only days after it was released, authors of another study concluded that statins are not being prescribed enough. If you're on a statin, especially a high dose, you should alert your doctor to muscle soreness or pain and go every six months or so for a check of certain liver enzymes.
Doctors are also working on medications to raise HDL levels, though they are not on the market yet (box). "Many people think that increasing HDL will be to this millennium what statins were to the 1990s," says Steven Nissen, a Cleveland Clinic cardiologist.
Diabetes, which has become an epidemic, is now considered such a risk for heart disease that diabetics are felt to face the same threat as do those with established heart disease. And diabetics, says Raymond Gibbons, a cardiologist at the Mayo Clinic and president-elect of the American Heart Association, do not respond as well to most heart treatments. People who are overweight should try to trim a few pounds. "If we can get them to lose 5 percent of their body weight, that will decrease their risk of diabetes by 50 percent," says Gibbons. For a 200-pound individual, that's just 10 pounds.
What doctors would love to be able to do is to look right into the coronary arteries to see if blockages are building up, but the current technology is expensive, invasive, or both. Many blockages are lined with calcium deposits, so some researchers are promoting calcium ct scans. MRI scans also hold promise. The images from these scans are impressive, and some doctors swear by them. The AHA does not consider them ready for widespread use, however. The ct scans don't always reveal buildup of "soft" plaques, and they carry some risk from the radiation used. MRI scans aren't quite detailed enough. The scans cost hundreds of dollars, and insurance does not usually pay for them. But the biggest question is whether those getting the scans really benefit; most scan patients either have been diagnosed with heart disease or are at high risk and are being treated aggressively anyway. "We need a lot more research before this is ready for prime time," says Nissen.
Tolerating stress. Another screening tool, the tried-and-true exercise stress test, may be ready for an upgrade. Patients walk or jog on a treadmill with increasing intensity while their heart is monitored. The tests have a tendency to identify patients--women in particular--as being at risk when they're not. Yet a just published study shows that measuring the heart's tolerance for exercise in other ways, such as how quickly it recovers its normal beat, could be a more reliable predictor.
Some men score very low on traditional measures of risk but still develop heart disease. For them, doctors are looking beyond traditional risk factors. One increasingly used measure is the blood level of C-reactive protein--an indicator of inflammation, which is now believed to be part of the heart-disease process. CRP tests are done regularly at larger heart centers, but they are not routine in most primary-care practices. Men who could benefit most from the test are those about whom their doctor isn't quite certain. They may have only a few risk factors or cholesterol and blood-pressure numbers just on the cusp. They're the ones Mary Frank wants to treat right away. "We used to say, 'That's high normal--see you next year.'" Not anymore.
On the Horizon
Heartwise, the not-too-distant future is likely to see more medications and less surgery.
Good cholesterol, or HDL, can't be raised as readily as bad cholesterol can be lowered. Individuals blessed with naturally low blood levels of a protein called CETP have remarkably high levels of HDL. CETP inhibitors, a new class of drugs, would confer the same benefits to those less genetically fortunate. Current trials are promising, but the drugs probably won't be on the market for several years.
Combo therapy, consisting of two or more heart drugs in one pill, is being tested. Typically one drug is a statin, for LDL-lowering, and others raise HDL or complement the statin in some other way.
Replacing heart valves without surgery is being tried out by interventional cardiologists. Instead of open-heart surgery, a dysfunctional valve is replaced or fixed through small tubes inserted into a blood vessel and pushed into the heart.
Accompli is the first diet drug to inhibit the brain's cannabinoid receptors, the same that are stimulated when smoking marijuana. It could help obese individuals, whose weight increases their heart risk, to drop enough pounds to make a difference. -B.Q
This story appears in the September 26, 2005 print edition of U.S. News & World Report.