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Every 40 seconds, someone in the U.S. has a heart attack.
The American Heart Association has led the effort to educate women about their risk of heart disease, stressing that more women die of heart related problems (1 in 4) than of breast cancer. In fact, the AHA has stated that “Every minute in the United States, someone’s wife, mother, daughter or sister dies from heart disease, stroke or another form of cardiovascular disease.”
Each year, more than 30,000 women younger than 55 years old are hospitalized with an acute heart attack. Importantly, women may be more likely than men to experience lesser-known heart attack symptoms such as chest pressure, tightness, or discomfort, in addition to chest pain. The pain and discomfort can be in the jaw, neck, arms, or between the shoulder blades. Heart attack symptoms unrelated to chest pain can include shortness of breath, a cold sweat, nausea or lightheadedness. Misinterpreting such heart attack symptoms can put women at a greater risk of death.
Young women with an acute heart attack may have more health conditions such as congestive heart failure, hypertension, renal failure, chronic obstructive pulmonary disease, and diabetes mellitus. They may also experience a longer length of stay in the hospital and have higher in-hospital mortality than men. Women with a history of autoimmune diseases such as lupus, rheumatoid arthritis, or psoriatic arthritis, as well as a history of preeclampsia, hypertension during pregnancy, and gestational diabetes, have increased risk for heart disease.
Some women may not have obstructions in the large coronary arteries that men exhibit but rather have involvement of small coronary arteries that may escape notice but are still able to cause a heart attack.
Women undergoing procedures such as coronary artery stent placement or coronary artery bypass surgery may experience worse outcomes than men, a finding possibly related to other health conditions and increased surgery-related complications.
Women need to be aware of their heart disease risk, how symptoms can present, and the potential outcome. Prevention is the fundamental order of the day, which can be impacted by healthy lifestyle choices such as a proper diet, exercise, blood pressure control, and smoking cessation. A happy marriage helps.
Finally, if you suspect you are having heart problems, do not hesitate to call your health care professional, or 911 if it’s an emergency. Do not worry about false alarms. It is better to be safe than sorry.
By the 1960s, research was already showing that the typical American diet increased the risk of heart attack. This article from the January 25, 1964, issue of the Post shared new studies about attempts to reduce the risk.
The great hope and challenge lie in the facts that any man can control the risks of heart attack by controlling his living habits. There is no guarantee that by reducing each risk he can escape or postpone a heart attack, but there is a mounting mass of evidence that he can build some protection. Controlling even one of these hazards should boost the chances for longer life. Control them all, and your heart, in a sense, gets nine lives.
This article is featured in the July/August 2017 issue of The Saturday Evening Post. Subscribe to the magazine for more art, inspiring stories, fiction, humor, and features from our archives.
Soon after Stan Hattaway woke from the fog of quadruple bypass surgery, he vowed to forever change his old eating and lifestyle habits. “It used to be that I never saw a cheeseburger I didn’t like, and if there was barbecue, well, just bar the door,” says Hattaway, who runs a marketing and advertising agency with his wife, Cathy, in Scottsdale, Arizona.
“Now, I just don’t have the desire to eat like that anymore. I exercise regularly and am probably in the best shape of my entire life.” Indeed, since suffering a heart attack and undergoing the ensuing surgery in October 2011, Hattaway has stuck closely to a plant-based diet rich in beans, vegetables, and fruits. He typically exercises every day of the week, and takes a coenzyme Q10 (CoQ10) supplement, which has been shown to benefit heart patients, plus a low-dose prescription statin.
Hattaway’s situation has prompted him to take what some may view as drastic measures in his quest to reverse heart disease, and new research affirms that many elements of his approach have relevance for anyone seeking to keep heart disease at bay, ward off a heart attack, or reverse the effects of heart disease.
And plenty of people fit the profile. Heart disease is the number one killer in the United States. The Centers for Disease Control and Prevention estimates that each year 715,000 Americans suffer a heart attack, while heart disease kills about 600,000 people annually, accounting for 25 percent of all recorded deaths. The CDC estimates the total annual price tag for coronary heart disease in the U.S. at $108.9 billion.
Though the statistics are daunting, there is also guarded optimism. Past generations were armed with only sketchy information about how to prevent heart disease, but now we live in an era in which highly advanced research is capable of providing new insights into how factors such as inflammation, diet, exercise, stress, sleep, and even a positive outlook might impact heart health. What is emerging is an increasingly clear blueprint for living a heart-healthy lifestyle.
For the five major (and simple!) steps to improving your heart health and reducing the risk of heart disease, pick up the Jan/Feb 2014 issue of The Saturday Evening Post on newsstands, or
Foods naturally red, blue, and purple contain powerful anthocyanin antioxidants widely believed to benefit the heart and blood vessels. And now there’s proof that eating three or more servings of strawberries and blueberries per week may help women reduce their risk of a heart attack by one-third—according to a large study of women aged between 25 and 42 registered with the Nurses’ Health Study II. Scientists from the University of East Anglia in collaboration with the Harvard School of Public Health say anthocyanins in berries may help dilate arteries and counter the build-up of plaque. “We have shown that even at an early age, eating more of these fruits may reduce risk of a heart attack later in life. This is the first study to look at the impact of diet in younger and middle-aged women,” says the lead researcher.
The American Heart Association recommends at least 4.5 cups per day of fruits and vegetables as part of a healthy lifestyle that can help avoid risks for heart disease and stroke. Eating enough fruits and vegetables also has other benefits: the recommendation to reduce cancer risk is the same.
An interview with Dr. William Thies, chief medical and scientific officer for the Alzheimer’s Association.
In the spring of 2011, the National Institute on Aging and the Alzheimer’s Association announced a new pre-clinical stage of Alzheimer’s Disease, marking the first change in the definition of the illness in 27 years. The announcement grows out of evidence that plaques and tangles characteristic of Alzheimer’s Disease begin to form in the brain years before the patient shows any symptoms. The new definition raises the tantalizing possibility of developing treatments that could delay or halt the progression of the illness before the brain is compromised. BeClose.com spoke with Dr. William Thies, chief medical and scientific officer for the Alzheimer’s Association, about the impact of this new definition both today and in the future.
Q: If there are no symptoms, why is it important to identify this very early phase of Alzheimer’s?
A: There is the feeling in the field that by the time someone has become demented, it’s too late to treat them. What we’re beginning to see is the evolution of a picture that is a lot like that of other diseases with a long onset. For example, at one time, people defined heart attack as the event that happened when the coronary artery was blocked. But the real success in treatment came when it was realized that the pathology for heart attack appeared many years before a heart attack occurred. We now know that if you treat the sclerosis that underlies the problem, you can prevent a heart attack from ever occurring.
Q: Can you get tested for pre-clinical Alzheimer’s at this point?
A: No, you can’t go to your local doc and say, I’d like to get this particular cerebro-spinal fluid test; it’s just not commercially available. That said, it may be possible that amyloid imaging, which is a way of using a PET scanner to take a picture of the amount of beta amyloid in an individual’s brain, will become publicly available in a relatively short period of time. A few months maybe. However, for consumers, there’s no point in doing the testing unless there are good treatment options.
Q: What are some of the most promising avenues of research into future treatments?
A: Many of the therapies being tested have the potential to limit the accumulation of beta amyloid. This is a polypeptide chain that exists naturally in the brain, but develops two extra amino acids as some people age. This substance starts to accumulate in the brain. We know from experiments that beta amyloid is toxic to brain cells. Many feel that if you could limit that accumulation of toxin, you could limit the course of Alzheimer’s Disease.
Q: How would a potential drug work?
A: You can either get the brain to make less amyloid or get rid of more. It’s not exactly rocket science. Two drugs are currently being tested at phase III level—these are the big trials necessary to get permission from the FDA to sell the drug. Being in phase III doesn’t mean that the drug is effective. Still, we can at least imagine a time when they might be available in your medicine cabinet. So that’s one promising area.
Q: Any others?
A: Some data says that if you drink more red wine you tend to have less Alzheimer’s Disease disease, so that track of epidemiological information has led us to resveratrol, an antioxidant found in grape skins. There’s also a blood product called IVIG (intravenous immunoglobin), which is being tested at phase III level. All of those are promising.
Q: But all this is far off. Without a cure, what’s the benefit of knowing you have this devastating illness in your future?
A: The Alzheimer’s Association has encouraged early diagnosis for years, not so much for the medical care you can receive, but rather for your ability to learn about the disease and prepare for the future. If you have a goal to travel around the world, for example, and if we have an effective biomarker that could let you know years in advance, you might want to take that trip a bit sooner while you’re still able. You’d certainly want to create powers of attorney so that your healthcare and estate planning would be handled as you wish.
Q: What about the impact for family members and potential caregivers?
A: It’s a chance for education. One of the things people don’t recognize is that people in early stage dementia get victimized by society. For example, they don’t remember they just bought a new car, so they go out and buy another one. Family members can help protect them from harm. Another benefit is understanding that Alzheimer’s changes peoples’ personality. This can be devastating to family members who mistakenly believe that mom or dad, in expressing hostility or anger, is revealing true opinions they’d been hiding for years. So the value of an early diagnosis will be able to stand on its own even with the limits of what we know today. And certainly knowing that better medications are coming, it takes on an even greater purpose.
Steven Slon is the Editorial Director for The Saturday Evening Post. He writes a regular column about aging and caregiving for http://www.BeClose.com, in which this article first appeared.
Dr. Nortin Hadler refuses to let anyone measure his cholesterol. An avid cyclist who adheres to a healthy diet, does not smoke, and doesn’t have heart disease, Hadler, a professor of medicine at the University of North Carolina, knows that a reading above 200 for total cholesterol and/or above 130 for LDL (“bad”) cholesterol is likely to make his internist whip out the prescription pad and send him to the pharmacy for a statin, one of the widely prescribed drugs that lower cholesterol. And that doesn’t sit well with Hadler. More than a dozen studies, he points out, have shown that in an otherwise healthy person with no history or symptoms of heart disease, taking statins provides zero benefit.
That’s right. Zero. Statins—Lipitor, Crestor, Pravachol, Mevacor, Zocor, and their generic equivalents—today reside in the pill dispensers of a huge segment of the population over 45, but for heart-healthy patients, statins will not increase longevity, prevent a fatal heart attack, or avoid a life-ending stroke.
So if taking statins won’t keep you alive and healthy any longer than not taking the pills, Hadler asks—especially when you consider possible side effects ranging from muscle pain and fatigue to liver damage to increased risk of diabetes and even memory loss—what’s the point in knowing your cholesterol numbers?
Cardiologist Eric Topol is equally scathing about statins. Chief academic officer of Scripps Health, a nonprofit health care system based in San Diego, Topol has long believed that medicine must become personalized with treatments tailored to a patient’s DNA and other characteristics. Yet statins are the poster child of taking a drug that benefits some people and then prescribing it to many more. In his new book, The Creative Destruction of Medicine, Topol points out that only one or two out of 100 patients “without prior heart disease but at risk for developing such a condition will actually benefit” from a statin. To which he asks, “how about the 98 out of 100 patients who don’t benefit?”
To put these views in perspective, statins are associated with one of the greatest public health triumphs of the past 30 years: halving America’s death rate from coronary heart disease. From 543 per 100,000 men in 1980 the death rate fell to 267 deaths per 100,000 (adjusted for the aging of the population) in 2000. From 263 deaths per 100,000 women in 1980 it fell to 134 per 100,000 in 2000, data from the U.S. Centers for Disease Control and Prevention show.
Looking at it another way: As a result of the lower death rate from coronary heart disease, 341,745 fewer Americans died in 2000 alone.
That sounds pretty spectacular, but the crux of the debate lies in whether statins have a benefit in primary prevention—reducing heart attacks and strokes in patients without known heart disease. There’s no argument about the benefits of statins for secondary prevention—averting a heart attack or stroke in people who have already had one. For example, the 1994 Scandinavian Simvastatin Survival Study—still considered the definitive statin study—showed that treating patients with pre-existing heart disease decreased their chance of dying over five years from 12 percent without statins to eight percent with the drugs; their chance of cardiac death, heart attack, or needing heart surgery fell from about 30 percent without statins to about 20 percent with them also over five years. “If you’re in this category, you would definitely want to take a drug that decreased your chance of dying or having a major cardiac event by a third,” says Dr. Eli Farhi, an assistant professor of cardiology at the University at Buffalo School of Medicine and Biomedical Sciences.
Primary prevention is another matter, however. These are the people Hadler, Topol, and other critics focus on when they discuss the statin problem. Consider two of the most rigorous and widely cited clinical trials of statins: In one, three people of every 100 without pre-existing heart disease but with high cholesterol who took a placebo pill suffered a heart attack; two of every 100 such people taking the best-selling Lipitor did. In the other trial, four of every 100 volunteers taking placebo had a non-fatal heart attack or stroke while two of every 100 taking Crestor did. These results are typical of the findings of other studies. As Topol notes, the bottom line is that the most popular statins reduce the risk of having a heart attack or stroke from three or four percent to two percent.
That’s not very significant. A 2011 analysis that reviewed 14 randomized trials and over 34,000 patients compared the tiny benefit with the very real risks of diabetes and muscle pain or weakness the drugs pose and concluded, “there was no net overall benefit of statins for patients without pre-existing heart disease,” notes Topol.
The key phrase here is “without pre-existing heart disease.” But most general practitioners take their cue from cardiovascular specialists, and many of these experts believe that statins save lives, period. Theirs is a straightforward argument: Cholesterol is bad; therefore, lowering cholesterol is good. “If someone has high LDL as well as high blood pressure or a history of smoking or other risk factors such as age and gender, let’s take that one risk factor [elevated cholesterol] out of the equation,” says Cleveland Clinic’s Dr. Marc Gillinov, co-author of the new book Heart 411. (Indeed, Topol himself, once one of the fiercest advocates of statin drugs, wrote in The New England Journal of Medicine as recently as 2004 that “statin drugs have already surpassed all other classes of medicines in reducing the incidence of the major adverse outcomes of death, heart attack, and stroke” caused by atherosclerotic vascular disease.)
Statins, first introduced in 1987, lower blood cholesterol levels by affecting how much of the substance the liver produces, how much the intestines absorb, or how much circulates. Study after study, going back to the late 1980s, has concluded that statins lower the risk of heart disease, heart attacks, and stroke. Research into statins won the 1985 Nobel Prize in Medicine for Michael Brown and Joseph Goldstein. No wonder statins rang up U.S. sales of $14.3 billion in 2009. One-fourth of Americans 45 and older take statins according to the National Center for Health Statistics.
“Statins clearly decrease one’s chance” of having a heart attack or stroke, agrees Buffalo’s Farhi. But the real-life importance of the decrease depends on how high your risk is in the first place. If your 10-year risk is extremely slim—a value judgment, but many clinicians regard anything under 10 percent as low—then “it would be of minimal benefit to take a statin,” says Farhi. “You could treat thousands of such people without preventing a single event.”
One useful way to look at the data is to consider something called “number needed to treat” (NNT). NNT simply means how many people must be given a medication, undergo surgery, have a diagnostic test, or have any other medical intervention in order for a single one of them to benefit from it. That number can be surprisingly high even for interventions with unquestioned benefits. For instance, 16 people with open fractures need to receive antibiotics for one to benefit; eight people need to take inhaled steroids during an asthma attack to prevent one from going to the hospital. In each case the vast majority of people would not have developed infections or needed a trip to the ER, respectively, even without the intervention. The NNT in these cases is 16 and eight.
Statins for primary prevention have a stratospherically higher NNT. Sixty people would have to take a statin for five years for one to avoid a heart attack; 60 is the NNT for avoiding this outcome. And 268 people without heart disease would need to take a statin for five years for one person to be saved from a stroke; 268 is therefore the NNT for avoiding this outcome, explains Dr. David Newman of Mount Sinai Medical Center in New York, who maintains an NNT database at thennt.com.
It’s one thing to talk about population-wide research. The challenge, of course, is determining the risks or benefits to any individual. To use an extreme example, a person riding in an airplane that’s headed for the side of a mountain is at very low risk of dying from heart disease. On the other extreme, “If you’re a 50-year-old smoker with very high cholesterol and everyone in your family has died of a heart attack before the age of 40, you would probably be very interested in something that decreases the risk of a heart attack,” says Farhi. Most people fall between these two extremes. You can gauge your risk of having a heart attack in the next 10 years by visiting hp2010.nhlbihin.net/atpiii/calculator.asp.
The National Cholesterol Education Program calculator cited above can also be used to show why lowering cholesterol, as statins indisputably do, fails to make much difference in whether or not you will develop cardiovascular disease. After you’ve typed in your actual cholesterol, blood pressure, and other data, notice what happens if you change the cholesterol: In many cases, it alters the risk of a heart attack by little or nothing. A 55-year-old non-smoking woman with total cholesterol of 240 (high enough to make most physicians prescribe a statin), HDL (good cholesterol) of 50 (which is quite low), and systolic blood pressure of 110 has a 1 percent chance of having a heart attack over the next decade, for instance. Now change her total cholesterol to 190—a huge decline. Her risk is still 1 percent. A 65-year-old man with those first numbers has an 11 percent chance of having a heart attack over the next decade; lowering his cholesterol to 190 brings that down to 9 percent.
In other words, cholesterol levels are not as strongly predictive of cardiovascular disease as once thought. “This has shocked everyone,” says Newman. “Cholesterol levels are actually a fairly weak predictor of who will have a heart attack.”
Might statins provide benefits unrelated to cholesterol reduction? There is some evidence that they also decrease inflammation. (When inflammation occurs in the arteries, it is thought to increase the risk of heart disease.) A 2008 study called the JUPITER trial tested statins in about 18,000 people with normal LDLs but elevated C-reactive protein, a measure of inflammation. Statins reduced the risks of heart attack and stroke. That led proponents to conclude that by working through an additional mechanism—lowering inflammation, not just LDL—statins were helping even people with normal LDL levels. Critics of the study note that it was halted earlier than planned (when people on statins were having fewer cardiovascular events than those not taking the drugs), which can produce a misleading result.
Whether cutting your risk of having a heart attack over the next 10 years from 11 percent to 9 percent, as in our hypothetical 65-year-old man who slashed his cholesterol, is meaningful depends on your perspective. But physicians who question the benefit of statins note that no medication is without risk—and statins are no exception. One known side effect is muscle pain or weakness. About five percent of people taking statins develop this, though in most it goes away when they stop taking the drugs. Another is diabetes. One person in 167 who take a statin for five years will develop diabetes. Newman points out that among people taking statins for primary prevention, the risk of diabetes is greater than the benefit in stroke reduction. Indeed, a 2012 study by the Mayo Clinic as reported in the Archives of Internal Medicine found that the use of statins in postmenopausal women is linked to an increased risk of new-onset diabetes of 71 percent. And in February, the FDA announced what it called “important safety changes” in the labels required on statins. Beginning immediately, the labels will have to warn patients that the drugs have been reported to cause certain cognitive effects in some patients, including memory loss and confusion; when patients stopped taking statins, these problems disappeared. The labels will also have to warn that increases in blood sugar (hyperglycemia) have also been reported, and that the FDA is aware of studies showing that statins may increase the risk of type 2 diabetes.
As we were going to press, a new study was reported in The New York Times suggesting that taking statins makes it harder to exercise. The study, by French scientists, found that lab animals taking statins couldn’t run as far as a control group on a placebo. And a 2005 study that looked at human subjects had similar findings: “It seems possible that statins increase muscle damage” during and after exercise “and also interfere somewhat with the body’s ability to repair that damage,” Dr. Paul Thompson, the chief of cardiology at Hartford Hospital in Connecticut and senior author of the study, told the Times.
How many people might be taking statins despite having only a slim chance of benefiting? Experts can give only rough estimates, but the numbers are clearly in the millions. No one currently taking a statin should stop the medication without talking to his or her doctor, of course, but “it doesn’t make sense to treat all these low-risk people with statins,” says Farhi. “The effect is indeed ‘cosmetic,’ improving their cholesterol numbers without producing any measurable difference in clinical outcome.”
He adds: “Doctors who put everyone on a statin without considering whether they’re likely to benefit are doing their patients a disservice.”