What doctors wish patients knew about heart-disease prevention

One person dies every 34 seconds in the U.S. from heart disease with about 697,000 deaths in 2020. On top of that, heart disease cost the U.S. about $229 billion each year from 2017 to 2018. This includes the cost of health care services, medicines and lost productivity due to death, according to the Centers for Disease Control and Prevention. Yet heart disease is not inevitable—there are ways to reduce your risk for cardiovascular disease.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, Brent M. Egan, MD, an internist and vice president of cardiovascular health at the AMA, took time to discuss what patients need to know about preventing heart disease.

“There is certainly a family history component and the earlier it strikes in the family, the greater the family-related risk,” said Dr. Egan, noting that “if people in your family are having heart attacks and strokes in their 70s, 80s, 90s, it is not nearly as important as the 40s and 50s. So, the earlier it’s occurring in your family, the more concerned you need to be.”

“The closer the genetic relationship, the stronger the risk, so certainly father, mother, brother, sisters. But if it’s also grandparents, there could be a significant concern,” he said. “Because for some younger people, their parents may not yet quite be to that 60-year age.

“So, particularly women under the age of 50 and men under the age of 60 in your family who are having heart disease or stroke problems increase your risk,” Dr. Egan added, noting that other traditional risk factors for heart disease include high blood pressure and cholesterol, smoking, diabetes, obesity, unhealthy diet and physical inactivity.

“The whole concept of ‘life’s simple seven’ is really to make heart-disease prevention very simple so that it would be easy for individuals and their physicians to think about and implement,” said Dr. Egan. “Then while the focus was on reducing heart disease and stroke, what they found over time is that there’s substantially less lung disease, kidney disease, liver disease and cancer when following these seven items for prevention.”

“There’s both medical and lifestyle variables. On the medical side, we have drugs to manage it with drugs for blood pressure, cholesterol and diabetes,” he said. “Then we have nutrition, physical activity, smoking on the lifestyle side and weight, which fits in between the two.”

“In terms of physical activity, what the American Heart Association generally recommends is 75 minutes per week of high intensity physical activity, which means you’re typically getting your heart rate up around 70% of maximum, 15 minutes a day at least five days a week,” Dr. Egan said. “And then 150 minutes per week of moderate intensity physical activity. That’s probably more in the 50% to 60% of maximum capacity range.”

“What is also important, though, is low-intensity physical activity because there are a lot of sedentary people who would find it very difficult to do moderate and high intensity physical activity,” he said. “What we know is that if you get up and move around at all, and the data suggests if you move 10% of the time or six minutes per hour, it has very important health benefits.”

For example, “if you take a completely sedentary individual and have them move six minutes an hour, it lowers blood pressure 10 millimeters of mercury or more—and it also improves cholesterol and reduces risk for diabetes,” Dr. Egan explained. “That’s an important concept because when we start talking about moderate or high intensity physical activity, a lot of people tune out. It’s just too much for them.”

“Data suggests that each additional serving of fruit and vegetables reduces your risk for cardiovascular disease by 5%,” said Dr. Egan. “So, if you go from three to seven per day, you potentially can reduce your risk for heart disease and stroke by 20% or more.”

“When we think about the value of an extra fruit or vegetable per day, it adds up. And a lot of folks unfortunately are stuck at two and three,” he said, emphasizing “if we can get them moving toward that seven, each incremental fruit or vegetable lowers your risk for heart disease and stroke about 5%, which is really pretty good.”

“In terms of cigarette smoking, that’s pretty self-evident—a lot of people are aware of that. But you can really reduce your risk very rapidly if you stop smoking,” Dr. Egan said. “The American Heart Association considers if you’ve quit for a year or more to be a nonsmoker.”

That’s because “if you quit for a year or more, you’ve reduced a lot of the heart disease and stroke risk that’s associated with smoking,” he said. “Within a year, you get the maximum points for that, so it doesn’t necessarily take a long time to see the benefit.”

But remember, “even smoking a few cigarettes a day has a lot of adverse effects or damage to the heart and vascular system, so it’s not linear,” Dr. Egan explained. “A lot of the risk is at low levels and that’s why passive smoking is such a risk for heart disease—you don’t have to smoke a lot to actually acquire the risk.”

“When I’m working with patients, a lot of times they’ll say: Well, wasn’t my blood pressure OK a couple of visits ago?” said Dr. Egan. But “the key is consistent control. The blood pressure consistently needs to be less than 140/90. By consistently, I’m saying 80% or more.”

“Having blood pressure normal half the time is not good, so it makes it difficult for physicians sometimes to get the appropriate treatment because the patient will focus on those occasional normal values and what we want to do is to see the blood pressure less than 140/90 most of the time,” he said. “you’re going to do better if your blood pressure is not elevated most of the time.”

“The other thing that is important for physicians and their patients to know about is the value of single pill combinations,” Dr. Egan said, adding “most patients don’t want to take another pill and they’re more concerned about taking another pill than another medication.”

“We have a number of good single pill combinations that put two and three blood pressure medicines into a single pill, so it’s possible to increase the number of medications without increasing the number of pills,” he said. “Less than 10% of patients are prescribed single pill combination blood pressure medications in the United States.”

But “it would make it easier for the physicians and patients to get the blood pressure to control if we use more single pill combinations,” Dr. Egan said. “And a lot of times they’re not more expensive. In some cases, you save money, and you get better blood pressure control.

“Seventy percent of people with high blood pressure have an indication to take something to lower their cholesterol. Most often that’s a statin medication and a lot of patients are concerned about taking statins,” said Dr. Egan. “We understand that the risk with low-and moderate-intensity statins is quite low for developing diabetes. Now, there is some risk with high-intensity, but we recommend the high intensity to people who are very high risk for heart disease.

“So, high-intensity statins increase the risk for diabetes by about 1%, but you’re reducing your risk for heart disease much more than that. Again, it’s a trade-off,” he added, noting that moderate-intensity statin medications “reduce cholesterol 30% to 50% and risk for heart attack 30% to 40%.”

“Americans are getting two hours less of sleep per day than they were 100 years ago,” Dr. Egan said. “And we know that getting less than six to seven hours of sleep per night increases risk for obesity, hypertension and diabetes.”

“A lot of people are trying to pack more and more into their 24 hours and it’s just not healthy,” he said, noting that “under the age of 60, getting at least seven hours of sleep per night seems to be associated with lower risk of obesity, hypertension and diabetes, which are things that lead to the heart disease that we’re trying to prevent.”

“There’s a lot of sleep hygiene things to follow, such as don’t take caffeine before you go to bed, decrease blue light, don’t have a lot of extra stimulation going on,” Dr. Egan explained. “But also, don’t try to go to bed later and get up earlier so you can do more. It actually takes a big toll on your health and that’s not the best thing to do.”

“Optimism. Resilience. Hope. There are a lot of things that are closely related, but we have some control over whether we view the world in a positive or negative way,” Dr. Egan said. “And most of us have some internal dialogue going most of the time, so let’s keep that internal dialogue positive.

“The whole world isn’t against us. The sky is not falling. We may have a bad day, but tomorrow is likely to be a better day,” he added. “That hope and optimism, as silly as it sounds, reduces your risk for cardiovascular disease by about 30%. It’s significant.”

“If individuals have a good exam, good report and are doing well in following these prevention steps, visiting your doctor annually is good,” Dr. Egan said. “If some of these risk factors are borderline, then perhaps a little more often is needed, depending on the levels.”

“But in general, if your labs are really good, every year is adequate for following up with your physician,” he said.