What To Do If You Are At High Risk For Heart Disease

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So you've assessed your risk of developing heart disease, and it turns out to be high. What do you do now?

Step 1: Take This Seriously

If your risk factors for cardiac disease place you in a high-risk category, this means one of two things. Either your risk of developing heart disease within the next few years is quite high, or you already have heart disease and don't know it yet.

Unfortunately, a substantial proportion of individuals who learn they're in the "high risk" category turn out to already have significant coronary artery disease (CAD) - they just don't know about it because, so far, they are not having symptoms.

So having high cardiovascular risk is very serious stuff, and requires a very serious response.

Step 2: Make Sure Your Doctor Takes This Seriously

Finding that a patient is at high risk for a serious cardiac event, particularly one of the Acute Coronary Syndromes (ACS), ought to elicit a certain type of response from a doctor.

Your doctor should immediately do two things for you: a) Evaluate whether you may already have coronary artery disease, and if so, institute appropriate therapy, and b) Take steps to help you modify all the controllable risk factors you have.

Because some high-risk patients will already have significant CAD, a non-invasive evaluation ought to be strongly considered to rule out this possibility.

This evaluation will often include a cardiac calcium scan, and/or a stress/thallium study.

If the non-invasive evaluation strongly suggests CAD, then steps should be taken to treat it, and reduce the chances of developing ACS.

At the same time, your doctor should also lay out a clear plan for attacking all modifiable risk factors -- including diet, weight loss, smoking cessation, hypertension, and cholesterol -- and should initiate therapy immediately.

Your doctor should offer you all the resources at his/her disposal to encourage and assist you in adjusting your lifestyle to reduce your risk.

Your doctor should also display an especially aggressive attitude toward optimizing your LDL cholesterol and HDL cholesterol levels, and controlling your blood pressure and blood glucose (if necessary).

Your doctor should display the proper attitude toward your risk - your life is at stake here, and he or she ought to be taking this very seriously. This includes riding you pretty hard about making the needed lifestyle adjustments.

Also keep in mind that doctors are human, and human nature makes it difficult to pull out all the stops for a patient who is refusing to act in his/her own best interests. It's hard to motivate yourself as a doctor to go the extra mile for the patient who just won't make a genuine and persistent effort to exercise, lose weight, or stop smoking.

Step 3: Start Your Own Manhattan Project

While your doctor needs to help you reduce your cardiovascular risk, the most important part of the job is up to you.

Successfully reducing your risk is something that will happen only with your dedication, and it's not easy.

Doing what needs to be done often involves fundamental changes in both attitude and lifestyle of the sort that many people seem unable to accomplish.

The degree of effort required is akin to the effort the U.S. made to develop an atomic bomb during WWII. It was something that seemed to be barely possible, yet if we did not do it, the risk was high that either the Germans or the Japanese would beat us to the punch. So, against all the odds, we marshaled our resources and did the Manhattan Project.

This is exactly the kind of effort you need to make. Against the odds, you need to change your life. If you don't, you will suffer the consequences, perhaps many years earlier than you would like to think.

That the vast majority of patients who are in the high risk category end up making only half-hearted efforts to modify their risk may be related to the failure of primary care doctors and cardiologists to stress the utter life-and-death importance of changing their lifestyles.

Is there any group of doctors who have succeeded in getting their patients to stop whatever they're doing, to suddenly focus every ounce of energy on regaining their health?

Yes. It’s the oncologists. Patients who are told they have cancer often put everything else on hold and steel themselves to doing whatever is necessary (whether surgery, radiation, or chemotherapy, often painful, and often lasting for months or years) to attempt a cure. This is the same attitude that patients ought to adopt when told they are at high risk for heart attack, sudden death, or stroke.

After all, being told you are at high risk for a cardiac event is not all that much different than being told you have cancer. Heart disease is often no less disabling or fatal, and the outcome no less dependent on your attitude and your active participation in doing what's necessary. If anything, you have a much better chance of favorably altering the ultimate outcome than the average patient with cancer.

It’s that serious. And both you and your doctor should be marshaling all available resources to stop the disease that threatens to harm or kill you in the near future. Medications are important for reducing your risk, but exercise, diet, weight loss and smoking cessation are also critical.

Gradual Approach, Or All At Once?

Often, the high-risk people who are most successful are the ones who adopt a "change it all now" attitude - the ones who accept that a complete change in lifestyle is needed. They'll stop smoking, adopt an exercise program, and change their diet all at once. And they do it by making risk factor modification the central organizing theme of their lives. One day they're a high-risk-lifestyle kind of person, and the next day they're not. Getting rid of their risk factors becomes the chief focus of their lives, until the new lifestyle becomes an ingrained habit (and they are a different person). It sounds tough, and it is. Life and death is tough.

The more gradual approach to lifestyle changes, while seeming quite reasonable on its face, does not work for many people. If diet and exercise are postponed until smoking is stopped, for instance, think about what that means. You essentially will be living the same kind of life you always did, except you're trying to stop smoking. That’s hard. Somehow the smoking never really stops, and the diet and exercise never get addressed at all, and pretty soon a year or two or five go by -- and then it's too late.

Everyone is different, and the gradual approach may be the only feasible one for many people. Whatever works is the best approach. But in practice "gradualism" often reflects a constitutional failure to accept the deep-rooted changes that are really necessary. Gradualism, in other words, may be an indication that a person lacks the sort of battle-ready attitude that is needed to prevent a bad outcome.

Whether you opt for the gradual or all-at-once approach, make sure you get how critical it is to make the necessary changes.


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Record NB, Onion DK, Prior RE, et al. Community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970-2010. JAMA 2015; 313:147.

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