“Ushmartem es nafshoseichem.” All of us are commanded to guard and protect our lives. This translates into taking care of our health to the best of our ability. As a cardiologist, I have the additional – and sacred – responsibility to treat and, whenever possible, cure illness. But even more important, in my opinion, is to prevent cardiovascular disease in the first place – a statement with which anyone who has experienced a frantic ride to the hospital in the midst of a heart attack would “heartily” agree.
We all know the elements of a healthy lifestyle: Diet and exercise are imperative, of course. Factors less often mentioned are improving one’s emotional health, continuing to learn about health and lifestyle, and regular medical checkups. In this article, I will discuss control of the traditional risk factors for heart disease – hypertension, diabetes, diet, and cholesterol – highlighting actions you can take on your own as well as interventions your doctor can use to reduce your risk and prevent heart disease. Indeed, I believe that good health is a partnership between you, your family, and a dedicated physician.
The Importance of an Active Lifestyle
Regular exercise is crucial, regardless of your age or overall physical condition. Even someone who is wheelchair-bound can do exercises designed for such people. Many excellent educational resources exist. In my office, we give our patients exercises entitled, “Growing Stronger as We Age,” by the Tufts Nutritional Institute.
Along with a regular exercise program, recent studies have shown the importance of being physically active throughout the day. If you have a sedentary job, for instance, even if you had an hour-long workout in the morning, periodically standing, using the stairs, and taking as many exercise breaks as possible is beneficial. Recent data from the Mayo Clinic shows that doing these simple activities can burn more than 500 additional calories per day.
The Importance of Diet
Diet is an area where we can make a major impact on our health. In our office, we recommend the Mediterranean diet, which consists of chicken, fish, and turkey (broiled, baked, or roasted, not fried), whole grain wheat products (not white bread), fruits and vegetables, and of course the generous use of olive oil. This way of eating is not really a “diet,” as it does not limit calories. Rather, it eliminates processed foods and changes the way we eat long term.
The key concept is to move away from the standard American diet, which promotes vascular inflammation, to one that is anti-inflammatory. When we are young, our blood vessels are like Teflon; nothing bad sticks to them. As we age, however, our blood vessels become sticky and have leaks in the lining. Material that once passed right by, now sticks to our blood vessels and infiltrates the wall, causing atherosclerosis or plaque. This process puts us at risk for clots, stroke, heart attack, and generalized vascular disease.
The Mediterranean Diet is an anti-inflammatory diet that helps return our blood vessels to the state they were in when we were young. Adhering to this diet is one of the easiest changes we can make to reduce our risk.
The Importance of Avoiding Diabetes
The prevalence of diabetes and pre-diabetes in the developed world is a true epidemic. Both these conditions lead to early onset vascular disease, including strokes, circulatory problems, and heart and renal failure. Adult-onset diabetes has an extremely strong association with obesity, especially central abdominal obesity. The good news is that a regular exercise program and changing to the Mediterranean diet can markedly decrease the chances of developing diabetes, as well as the morbidity and mortality associated with it. (A very important aspect of exercising is regular weight training to increase muscle mass and decrease the total amount of fat tissue,)
The Importance of Preventing Hypertension
Hypertension, or high blood pressure, is a true silent killer, causing the progression of vascular disease in all organs, especially the heart, kidney, and brain. Hypertension occurs without our knowledge and is often not discovered until it is too late: That is, we may not have any symptoms until we have a heart attack, stroke, or renal failure.
The key to prevention is a low-salt diet, less than two grams of sodium a day, coupled, again, with daily exercise and maintaining a healthy weight. Also, it is imperative to check your blood pressure at regular intervals: both during a visit to the doctor and at home with a home blood pressure monitor. Home monitors are inexpensive and quite accurate. It is more important to take your blood pressure at home regularly than at the physician’s office. This gives an accurate picture of “real world” blood pressure, while the office visit only captures one moment in time. We recommend strongly that you obtain blood pressure readings at various times over 24 hours, to get an idea of the fluctuations over the day.
This is important, because there are two patterns of blood pressure: a dipping pattern and a non-dipping pattern. The dipping pattern means that your blood pressure tends to rise before you get up and goes down slowly after noon. This is the normal pattern, regardless of whether one has hypertension or not. The patient who has a non-dipping pattern, where their blood pressure does not drop at noon but continues to rise over the course of the day is associated with a more malignant type of hypertension. Ascertaining whether a patient has a dipping or non-dipping pattern – which you can determine by simply measuring your blood pressure at home – determines how aggressively we treat the hypertension.
As a general rule, we say that the systolic blood pressure (the top number) should be between 120-140 mmHg. Diastolic blood pressure (the bottom number) is not as important as systolic blood pressure, especially as we age. The most important thing to be certain of when taking your blood pressure is to take it both sitting and standing. If the blood pressure drops significantly with standing, it can cause dizziness, lightheadedness, and possibly passing out and, G-d forbid, getting hurt. There are numerous medications that can control blood pressure if needed, but the most important things are diet control, salt control, and regular exercise.
The Importance of Lowering Cholesterol
Cholesterol is a necessary substance, present in every cell. However, when it builds up on the blood vessels, it promotes the development of atherosclerosis, leading to heart attack and strokes. There is good cholesterol, called HDL, and bad cholesterol, called LDL, as well as triglycerides, a marker of total body fat. When I am asked for the magic number for bad cholesterol, I generally say that LDL should be less than 100 mg/dl. The good cholesterol, or HDL, should be greater than 100 mg/dl, if possible, and triglycerides less than 100. The lower a person can get their bad cholesterol and triglycerides, the more they decrease their risk.
Although the body itself manufactures cholesterol, the levels in our blood are also affected by the fats we eat. Bad fats, like saturated fats (e.g., meat, poultry, cheese, etc.), can increase cholesterol. On the flip side, good fats, like polyunsaturated and mono-unsaturated fats can help lower cholesterol. There are diets available that target cholesterol levels, including the Mediterranean Diet. The general rule regarding food, however, is that if it does not look healthy, it probably is not, and should not be eaten.
Again, it is important to get the LDL and triglycerides down as much as we can. The first treatment is always diet and exercise. If those don’t work, we have excellent medicines that can truly help decrease mortality. A new type of medicine, a monoclonal antibody, is now available which decreases cholesterol by greater than 50 percent of what we have had previously been able to accomplish.
The Importance of Emotional Health
I do not want to leave out something very important that increases overall cardiac health. This is happiness and a good outlook on life. The Ramban writes in the Igeres HaTalmud about the importance of maintaining humility and self-esteem, and controlling anger. Working on our emotional health can truly promote an anti-inflammatory state, which decreases our risk of developing vascular disease. The concept of simchas hachaim, joy in life, is one of the most important things that we can do to improve our vascular health.
Imaging: a Remarkable Tool
Wouldn’t it be wonderful if we could gaze directly into the coronary arteries? There actually is procedure called a cardiac catheterization that views the arteries from within and implants a stent, if necessary. Since this is an invasive test, it is generally reserved for patients who have unfortunately already developed cardiovascular disease. For those in whom we are just managing risk, we always prefer non-invasive testing. Several such non-invasive imaging modalities can be used.
In our office, we do stress testing, which tells us if a patient develops a lack of blood flow when walking on a treadmill. (Actually, the most important predictive factor in a stress test is how long one can actually stay on the treadmill. The longer the patient can stay on the treadmill, regardless of whether or not he has blockages in the coronary vessels, is what determines a better prognosis for the patient.) While a positive stress test is an indicator of underlying coronary artery disease, it is not 100 percent accurate. Someone with a negative test may still have the disease. The classic example is an individual who has a negative stress test and goes on to have a myocardial infarction, or heart attack, the next day. This is due to an undetectable plaque that ruptured suddenly.
A novel test being done today goes beyond the limits of the stress test. This test, called a coronary calcium score, is a CT scan that looks at the amount of calcium in the three coronary arteries. If the test shows calcium in the arteries, this patient will already have vascular disease, even if he or she is asymptomatic. Another advantage of this test is that it is non-invasive; there is no dye and no IV, and it is not associated with any long-or short-term complications. It is a rapid test, the radiation dose is quite low, and it is inexpensive, costing about $75 dollars out-of-pocket.
There is an excellent dictum: Prevention is always better than treatment. I feel that this low-cost, non-invasive test should be done as a screening test on all adults on top of our routine exams and routine blood tests. It enables us to pick up early onset atherosclerosis in both high- and low-risk patients before they become symptomatic. The hope is that by managing the basic risk factors, with Hashem's help, we can prevent adverse events from occurring, rather than waiting for them to happen. We may even be able to possibly reverse the progression of early atherosclerosis.
Health: Our Most Important Resource
In conclusion, Hashem gives us one life, and we need to do the best we can to protect it. There are numerous risk factors we can and should modify: i.e., diet, exercise, obesity, diabetes, hypertension, and high cholesterol. It is equally important to try to maintain our emotional health. We must also realize that some risk factors are not modifiable, including age, gender, and genetics, with age being number one. But, as I have shown, it is in our hands to evaluate our risk factors and correct them to the best of our ability, in order to make the best use of the body we have been given. I have also described the coronary calcium score. This is a very valuable test, because it goes beneath the surface and lets us know where we stand in regards to early cardiovascular disease. Combining all this knowledge, you, together with your physician, can put into action a plan that will enable you, with G-d’s help, to avoid heart disease and remain healthy, active, and productive. Everything I have discussed can be achieved with hard work and dedication to the principle of “Ushmartem es nafshoseichem.” This will leave us with the greatest possible reward: a happy, healthy, and fulfilling life.
Dr. Jerald Insel and his staff service the community by seeing patients at both Quarry Lake and White Marsh. We will do our best to accommodate patients, including Sunday hours a couple of times a year. Call us today for an appointment: 410-933-4923.
