An unexpected fatal heart attack, especially in a young or middle-aged person, is one of the most devastating experiences for the community and the relatives. Many decades of research and significant manpower have been dedicated to researching the cause of this disastrous tragedy with remarkable advances. Despite all this, cardiac diseases remain the number one killer of humans and sudden heart attacks, often fatal, continue to take a heavy toll.
Whenever a public figure passes unexpectedly from a heart attack, there is a surge of individuals in the same age bracket who decide to do whatever they can to “avoid” the same fate. Intuitively, there is nothing wrong with this decision, and I strongly recommend that. This wave, like any other, creates potential. Potential to do good or a possibility to destroy and create havoc. Some ride on this wave to propel their plan, making more waves and creating public anxiety.
We have witnessed two fatal heart attacks in the past three weeks. Since these events, media is riddled with headlines such as; “what is the best test to prevent heart attack”, or “A test that can eliminate the risk of a surprise heart attack”!
I strongly believe in preventive medicine as I have witnessed first-hand that many patients who choose to adopt a “healthy lifestyle” could entirely reverse their disease process or prevent it in the first place. But there is a delicate line between “disease prevention” and “overservicing”. With the advance of our knowledge of heart disease, many tests have proven valuable in predicting someone’s risk of a heart attack. However, it is crucial to remember that no holy grail test can entirely prevent a disease from happening but only “reduce the risk“. Many such tests do not require repetition unless specific criteria are met, like having a new symptom or complaint.
Some tests like coronary calcium score can undoubtedly help clarify someone’s risk of a heart attack. However, these are not “screening tests” and can not be applied to the mass population as they have many caveats that, if ignored, can result in harm. Many such unnecessary “tests”, if not interpreted correctly and ordered with disregarding the context, can result in unnecessary invasive interventions with potentially devastating complications.
Using a headline like “A test that can eliminate the risk of a surprise heart attack” by some experts in media is alarming and problematic. A heart attack could be a surprise any moment if one continues to smoke and lead an unhealthy lifestyle, regardless of any “test” they go through. The sudden passing of a public figure from a “likely” preventable heart attack should not be used to promote a “test”. Instead it is an opportunity, an unfortunate one, to promote a healthy lifestyle and raise awareness about heart attack risk factors. This will prevent far more heart attacks and unexpected deaths than any particular test, at a population level.
What is a Healthy Lifestyle?
Despite all the discoveries in medicine, leading a healthy lifestyle is the best way to reduce the risk of heart attack and stroke. I define a healthy lifestyle as;
A sensible and easy-to-follow diet:
A quick search online returns millions of pages about “the best diet.” The best diet is the one which is simple and at the same time enjoyable and rich in all nutrients. An old study called “The Seven Countries Study” (SCS) showed us a healthy diet is enjoyable and diverse in ingredients and certainly not restrictive. SCS showed us that people who live longer eat more fruits and vegetables, and fast food doesn’t have any place in their diet. They used plenty of Olive oil and tree nuts like walnut, almond and hazelnut. They drink, but in moderation. They DID NOT eliminate any specific nutrients like carbohydrates or add more of any ingredients like fat. More importantly, they didn’t “overeat” and had reasonable portions with frequent snacks in between their meals. After 7-8 pm, they didn’t eat anymore until the next day. This is a simple, healthy, and at the same time, enjoyable diet. Nothing fancy with no exotic name.
The minimum recommended exercise, delivering health benefits, is 150 minutes of brisk physical activity per week. Exercise should be simple as simplicity brings consistency which is the key. A “brisk” physical activity is an exercise that increases the heart rate and makes you sweat. This could be walking, jogging, swimming, dancing or bike-riding. Doing “any” amount of physical activity is better than nothing, even if it is a short stroll along the park. Walking is the most accessible and affordable exercise that someone can do. If you drive to work, park your car a bit further, walk 15 minutes to the office, or get off one station earlier, if you catch a bus. These short daily exercises slowly mount to a significant amount of physical activity during the week.
One of the most overlooked risk factors for any disease is having a stressful lifestyle. I have many young patients in my practice who have suffered from a heart attack by just going through very stressful events in their lives. One crucial factor overlooked in the Seven Countries Study is that people who lived longer, for example, on the Greek island of Crete, were happy. I believe it is not just about what they ate but also how they lived. They were “content” with their lives. They were not competing or striving to achieve more every day. They were not under the constant pressure of social media to change how they lived. As I spend more time in clinical practice, I realize the destructive power of stress on mental and physical health. Daily stress grinds you to the ground, mentally and physically, if not addressed promptly and efficiently.
Smoking undoubtedly is one of the strongest risk factors for a heart attack and and other vascular diseases (Peripheral Vascular Disease). Over the years, it has been proven that even a few cigarettes a day can substantially increase the risk of a heart attack. Apart from detrimental effects on the cardiovascular system, smoking is the leading cause of chronic airways disease like emphysema and certain types of cancer like lung and bladder cancers. Evidence has shown that one year after smoking cessation, the risk of cardiovascular disease would be equivalent to a non-smoker. Basically, It takes nearly one year for the toxic material to completely vanish from the body. Unfortunately, lung damage is irreversible, but smoking cessation will stop further damage at any time.
Alcohol in moderation:
Excessive alcohol intake is connected to many cardiac diseases, including Atrial Fibrillation (AF) and Heart Failure (Alcoholic Cardiomyopathy). However, alcohol in moderation, like one or two standard drinks a night, is not as harmful and may even be beneficial. There are suggestions that this could mainly be related to the anxiolytic (anti-stress) effects of alcohol rather than any specific effects of alcohol on the heart or the type of the alcohol.
What are the main risk factors for heart attack?
Research has shown that some conditions can accelerate “atherosclerosis”, which is a precursor for heart attack and stroke. These conditions are known as “risk factors”, which include:
- Hypertension (high blood pressure)
- Strong family history of heart attack (in first degree relatives, men <55 and women <65 years of age)
- Hypercholesterolemia (High cholesterol levels)
- History of inflammatory diseases like rheumatoid arthritis
- Sedentary lifestyle and obesity
If you have any of these risk factors, you would require a few additional tests to predict the risk of a sudden heart attack. The two tests that have gained significant popularity in this regard are the Coronary Artery Calcium Score (CAC score) and Lp(a) measurement. Both have shown that if significantly elevated, the risk of heart attack is considerably higher even in the absence of any symptoms or other risk factors.
Does any invasive cardiac intervention like stenting or bypass surgery reduce the risk of a heart attack?
During the past 30 years, there has been tremendous advancement in our knowledge of Coronary Artery Diseases (CAD). Enormous progress has been made in intervention techniques that have saved the lives of millions. However, most of this benefit has been in people who have suffered from acute myocardial infarction or heart attack. If someone with a heart attack is taken to Hospital urgently, there is a good chance that the blocked artery could be reopened. This intervention will be life-saving.
Yet, suppose we find CAD in someone by doing routine testing, like CT Coronary Angiogram, while this person has no chest pain or symptoms. In that case, the benefit of doing an intervention is in significant doubt. Many large trials have shown that Coronary interventions do not necessarily prevent heart attacks in this scenario and can be harmful. They can improve symptoms like chest pain or shortness of breath with exertion, but they don’t prevent a heart attack. Although there are exceptions, each case should be dealt with carefully.
In the presence of “asymptomatic” coronary artery disease, a healthy lifestyle and medical therapy are the most critical factors that prevent a heart attack. Medical therapy includes excellent control of risk factors like hypertension and diabetes and medications like statins and aspirin, when indicated.