A heart attack after the age of 80 is an act of God
but a heart attached before age 80 is a failure of the medical system.

In 2015, I wrote the book entitled, “Dead Execs Don’t Get Bonuses.” I plead with the readers to arrange to have a more comprehensive assessment of their heart health. I encourage all health professionals to provide this same level of care. 

4 Steps for Preventative Heart Health

Step 1: Determining arterial age-coronary artery calcium scan (CACS)

The concept of “arterial age” to predict longevity goes back to the 1600s when a leading English physician, Thomas Sydenham, MD, wrote that “a man is as old as his arteries.” Think of a CACS as a preventative screening for the heart, the same way colonoscopies and mammograms are recommended for preventative care. 

The American Heart Association updated its guidelines for managing cholesterol to consider CACS to determine the proper course of therapy. It is considered the most important step to assess the risk of a heart attack (1,2). CACS is a CT scan of the heart that is highly accurate, takes under one minute, uses no dye or needles, has a very low radiation exposure (equivalent to a mammogram), and costs about $125 at most hospitals and some larger clinics (3). It is the only way to see heart arteries in a painless and simple manner. This test will reveal hard plaque or calcification to be present. Soft plaque, which can also threaten heart health, will not be detected with this test. The ideal result identified in about 50% of those tested is a CACS score of zero. A zero indicates the absence of calcium in the arteries, including the left anterior descending (LAD) artery, sometimes called the “widowmaker.” Blockage in the LAD results in sudden closure, massive heart attacks, or sudden death and is the most frequent location of the narrowing of all arteries of the heart. Even a slight elevation in the CACS raises the risk for a future heart attack and therefore, referring to or working on collaboration with a preventative cardiologist would be recommended. 

If a patient has a stent, has undergone heart bypass surgery, or has a known heart blockage or previous heart attack, generally, the CACS is not necessary as the details of your patient’s heart disease are already known. Otherwise, a CACS may be repeated every 5-10 years. 

A digital carotid ultrasound called a carotid intimal-medial thickness (CIMT) can show hard and soft carotid plaque years before an event (4). A CIMT is a 20-minute ultrasound of the neck that uses advanced software measurements to examine carotid arteries for plaque and measures the thickness of arteries, another sign of aging. The biggest drawback of the CIMT is finding a quality center that offers it. 

Step 2: Arrange for advanced labs

In general, the same lab studies done during a physical exam in the 1980s are ordered today; however, there have been major advances in laboratory testing. Relying on the “old way of doing it” isn’t just outdated, it’s unacceptable.

Advanced cholesterol panel: The “calculated” LDL cholesterol level found in routine panels can be quite inaccurate in the presence of excess weight, elevated blood sugar or diabetes, and a sedentary lifestyle, all common in today’s society. 

An advanced cholesterol panel measures the LDL particle number and size. These numbers are more accurate in predicting future heart and stroke events (5). Two patients can have the same total cholesterol levels but have different patterns and sizes and, therefore, different risk potential (6).

These tests are widely available (i.e., NMR LipoProfile®) and relatively inexpensive (~$150). 

Lipoprotein (a): Some comprehensive lipid panels will include this biomarker, but it deserves its own attention. Lipoprotein (a) is a genetic form of cholesterol that’s elevated in about 20% of the public and is unaffected by most lifestyle measures and statin medications. It’s rarely drawn even though hundreds of research studies indicate that if it’s high, the risk of heart attack and stroke skyrocket (7). There is even a foundation dedicated to educating the public about the risk. This test only needs to be conducted once since it is a genetic test.

ApoA/ApoB: Like lipoprotein(a), apolipoprotein A1 (ApoA1) and apolipoprotein B (ApoB) may be included in a comprehensive panel. ApoA1 is the apolipoprotein associated with high-density lipoprotein (HDL), providing anti-atherogenic effects. ApoB is an atherogenic lipoprotein particle found in very low-density lipoprotein (VLDL) and low-density lipoprotein (LDL). The ApoB/ApoA1 ratio can be calculated. The higher the ratio, the greater the risk for CHD (8,9). The higher the ratio, the greater the risk for CHD (8,9), however, this ratio is considered outdated based on the newest research.

ApoE: This is a genetic marker related to cholesterol metabolism measured from a blood sample. A pattern called apoE 4/4, found in 5 percent of the public, greatly increases the risk of atherosclerosis and future Alzheimer’s disease (10). Knowing this can permit time to optimize lifestyle and overall health. Some nutritional genomic tests include this as part of their panel. 

Trimethylamine N-Oxide (TMAO): This marker of heart and kidney health becomes elevated after eating meat- and egg-heavy diets with an altered gut microbiome. It has been shown to cause heart and kidney damage and is associated with worsened prognosis (11).

Hs-CRP: The high sensitivity C-reactive protein is a blood test patented by Harvard Medical School to measure inflammation, or the “fire,” that results from an irritated immune system. The higher the hs-CRP, the greater the risk for a future heart attack, stroke, and even other conditions such as cancer and dementia (12). Other inflammatory markers may include 1) myeloperoxidase (MPO), when elevated, can be indicative of an increased risk of cardiovascular disease (13) and 2) lipoprotein-associated phospholipase A2 (Lp-PLA2) to aid in determining the risk factor of cardiovascular disease in patients with metabolic diseases (14).

Homocysteine: This amino acid is produced by the process called methylation. It can injure arteries when elevated. It may be due to a genetic defect in the methylenetethydrofolate reductase (MTHFR) gene, which is easily measured. It can be addressed using (methylated) B-complex vitamins (15).

Step 3: Calculate an Astro-CHARM Score.

A major advance in 2018 was the publication of the application called the Astro-CHARM score (16). The online risk calculator is a collaboration of NASA and the University of Texas Southwestern Medical Center and is the most advanced tool available. It permits entering the CACS, hs-CRP, and more traditional measures (age, smoking status, total cholesterol, HDL-cholesterol, and blood pressure) to predict the 10-year risk of fatal and non-fatal MI and stroke.

Step 4: Never leave an emergency room (ER) visit without a complete evaluation 

Please share this information with your patients (A patient friendly handout is available in the Clinical Toolkit ): If, by some misfortune, your patient ends up in an ER with chest discomfort, a blackout spell, shortness of breath, or a racing heartbeat, please don’t let your patient go home without a thorough evaluation. 

1. Have your patients ask for “serial” cardiac enzymes (sometimes called cardiac biomarkers). This test is repeated two or three times every four to six hours. Troponin and CPK levels rise for up to 12 hours following heart damage. Elevated levels of any of the enzymes can be indicative of a heart attack or another heart problem, such as myocardial ischemia or acute coronary syndrome. 
2. Have your patients ask for repeat electrocardiogram (ECG) to compare to the one done within the first few minutes of arrival. The patient should have had an ECG performed within 10 minutes of arrival, in alignment with the American College of Cardiology recommendations. ECGs can evolve quickly in the setting of myocardial ischemia and repeat tracings can offer a critical diagnosis of impending myocardial infarction. 
3. Have your patients ask for a definitive test before discharge. Many ERs offer an even more advanced test than the CACS, called a coronary CT angiogram (CCTA). This test is by far the most accurate way to be sure the arteries are clean and free of the risk before discharge, providing 3D imaging of the heart and arteries. This test will use dye and expose the patient to low radiation levels, similar to a mammogram. 

We must do better as clinicians...It is time to protect our patients’ hearts.

References

1. Mitchell JD, Fergestrom N, Gage BF, Paisley R, Moon P, Novak E, et al. Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring. J Am Coll Cardiol. 2018;72(25). 

2. Rubenfire M. American College of Cardiology. 2018 [cited 2024 Jan 24]. 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol. Available from: https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2018/11/09/14/28/2018-Guideline-on-Management-of-Blood-Cholesterol

3. Neves PO, Andrade J, Monção H. Coronary artery calcium score: current status. Radiol Bras. 2017;50(3). 

4. Abbasi MR, Abbaszadeh SH, Rokni-Yazdi H, Lessan-Pezeshki M, Khatami MR, Mahdavi-Mazdeh M, et al. Carotid intima-media thickness as a marker of atherosclerosis in hemodialysis patients. Indian J Nephrol. 2016;26(2). 

5. Urbina EM, McCoy CE, Gao Z, Khoury PR, Shah AS, Dolan LM, et al. Lipoprotein particle number and size predict vascular structure and function better than traditional lipids in adolescents and young adults. J Clin Lipidol. 2017;11(4). 

6. Otvos JD, Mora S, Shalaurova I, Greenland P, Mackey RH, Goff DCJr. Clinical Implications of Discordance Between LDL Cholesterol and LDL Particle Number. J Clin Lipidol. 2011;5(2). 

7. Scipione CA, Koschinsky ML, Boffa MB. Lipoprotein(a) in clinical practice: New perspectives from basic and translational science. Vol. 55, Critical Reviews in Clinical Laboratory Sciences. 2018. 

8. Lu M, Lu Q, Zhang Y, Tian G. ApoB/apoA1 is an effective predictor of coronary heart disease risk in overweight and obesity. J Biomed Res. 2011;25(4). 

9. Yaseen RI, El-Leboudy MH, El-Deeb HM. The relation between ApoB/ApoA-1 ratio and the severity of coronary artery disease in patients with acute coronary syndrome. Egyptian Heart Journal. 2021;73(1). 

10. Mahley RW. Apolipoprotein E: from cardiovascular disease to neurodegenerative disorders. Vol. 94, Journal of Molecular Medicine. 2016. 

11. Tang WHW, Wang Z, Kennedy DJ, Wu Y, Buffa JA, Agatisa-Boyle B, et al. Gut microbiota-dependent trimethylamine N-oxide (TMAO) pathway contributes to both development of renal insufficiency and mortality risk in chronic kidney disease. Circ Res. 2014;116(3). 

12. Kamath DY, Xavier D, Sigamani A, Pais P. High sensitivity C-reactive protein (hsCRP) & cardiovascular disease: An Indian perspective. Vol. 142, Indian Journal of Medical Research. 2015. 

13. Khan AA, Alsahli MA, Rahmani AH. Myeloperoxidase as an Active Disease Biomarker: Recent Biochemical and Pathological Perspectives. Vol. 6, Medical sciences (Basel, Switzerland). 2018. 

14. de Stefano A, Mannucci L, Tamburi F, Cardillo C, Schinzari F, Rovella V, et al. Lp-PLA 2 , a new biomarker of vascular disorders in metabolic diseases. Vol. 33, International Journal of Immunopathology and Pharmacology. 2019. 

15. Ganguly P, Alam SF. Role of homocysteine in the development of cardiovascular disease. Vol. 14, Nutrition Journal. 2015. 

16. Khera A, Budoff MJ, O’Donnell CJ, Ayers CA, Locke J, De Lemos JA, et al. Astronaut cardiovascular health and risk modification (Astro-CHARM) coronary calcium atherosclerotic cardiovascular disease risk calculator. Circulation. 2018;138(17).