What Puts You at Risk for a Heart Attack?

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Your likelihood of having a myocardial infarction (heart attack) can be estimated by tabulating the risk factors you have for coronary artery disease (CAD), or atherosclerosis of the coronary arteries.

The bad news is that there are several risk factors for CAD, and most of them are common in Western societies. The good news is that most of these risk factors are things that are in our power to control.

This means that each of us has a lot to say about how likely we are to have a heart attack.

The risk factors for heart attack can be divided into two general groups: those which we have no control over, and those which we can control.

Non-Controllable Risk Factors

Non-controllable risk factors are the ones we can’t do much about. That is, we cannot get rid of them with lifestyle choices or medication.

Generally, the non-controllable risk factors are related to age, sex and genes. These risk factors are:

  • A history of close relatives who have had premature CAD (generally, CAD that has occurred in male relatives before the age of 50, or in female relatives before the age of 60.)
  • Age 55 or older (men), or 65 or older (women)
  • For women, being post-menopausal, or having your ovaries removed.
  • Chronic kidney disease.

For those of us who have non-controllable risk factors, it is even more important to focus on our controllable risk factors, since reducing those will still have a major impact on our overall risk.

Controllable Risk Factors

Controllable risk factors are the ones we can do something about. We can greatly diminish our risk of heart attack and cardiac death by paying careful attention to the following risk factors:

  • Smoking. While smoking is the chief cause of heart attacks in people under the age of 40, it is a strong risk factor at any age.
  • High cholesterol and triglycerides. High LDL cholesterol, total cholesterol, and triglycerides, and low HDL cholesterol levels, are associated with a significantly increased risk of heart attack.
  • Obesity. Being overweight, and especially having a big belly, has been associated with an increased risk of heart attack.
  • Lack of exercise. People who exercise regularly have a reduced risk of heart attack.
  • Hypertension. High blood pressure is a major risk factor for heart attack, and especially stroke. Hypertension is very common in Americans over the age of 55, but is commonly inadequately treated.
  • Diabetes. Diabetes is becoming much more frequent in the U.S., as the population becomes more overweight. Diabetes, specifically, the elevated blood sugars and the other metabolic abnormalities that accompany this disease, greatly accelerates the development of atherosclerosis.
  • Metabolic syndrome. Metabolic syndrome, or pre-diabetes, is also strongly associated with increased cardiac risk.
  • Increased C-reactive protein (CRP). CRP is a relatively "new" risk factor. Increased levels of CRP indicate active inflammation somewhere in the body, and unless some obvious source of inflammation is seen elsewhere (such as active arthritis), elevated CRP is thought to reflect inflammation in the blood vessels - which goes along with atherosclerosis.
  • Lack of moderate alcohol intake. Several studies suggest that moderate alcohol intake (one to two drinks per day, or in some studies, one to two drinks per week) is associated with a reduced risk of heart attack. The reason doctors are reluctant to recommend alcohol for cardiac risk reduction is that, when people drink more than about two drinks per day, their overall risk of death (from liver disease, heart disease, breast cancer, trauma, and other causes) rises very quickly. And as we all know, for many people it's hard to stop with one or two.
  • Psychological stress. Stress has been linked to heart attacks for many years. But some stress in life is unavoidable and is even a good thing in many cases.

    Additional Risk Factors in Women

    Here are two more risk factors that are specific to women:

    • Taking birth control pills, especially among smokers. Birth control pills have been associated with a small increase in the risk of early heart attack in women. But when birth control pills are combined with smoking, there is a very large increase in risk. In fact, it is now clear that women who smoke simply should not take birth control pills.
    • Complicated pregnancy. Women who develop certain complications during pregnancy, specifically, women who develop high blood pressure (a condition called preeclampsia) or gestational diabetes (diabetes during pregnancy), or who deliver low-birth-weight babies, have an increased risk of early heart attack. Because complicated pregnancies identify women who are at increased risk, these women should manage all their controllable risk factors very aggressively.

    Sources:

    Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:S49.

    Lloyd-Jones, DM, Larson, MG, Beiser, A, et al. Lifetime Risk of Developing Coronary Heart Disease. Lancet 1999; 353:89.

    Wilson, PW, D'Agostino, RB, Levy, D, et al. Prediction of Coronary Heart Disease Using Risk Factor Categories. Circulation 1998; 97:1837.

    Yusuf, S, Hawken, S, Ounpuu, S, et al. Effect of Potentially Modifiable Risk Factors Associated With Myocardial Infarction in 52 Countries (The INTERHEART Study): Case-Control Study. Lancet 2004; 364:937.

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