From the Publisher

Millions of people -- many of them younger than we care to believe -- are living in the aftermath of a heart attack, and it is vital for them to learn how to reduce the risk factors for subsequent heart problems. This unique and important book offers advice to survivors of a heart attack and also to those trying to prevent the onset of a heart attack. Contributors include not only distinguished medical professionals but also eleven individuals who either participated in a cardiac rehabilitation program or designed a program of their own. The patients -- men and women of varied ages and ethnic backgrounds -- relate their own histories, providing insight into the many faces of heart disease and inspiration and hope for other heart attack survivors.

Booklist

[An] informative book on the current state of the diagnosis and treatment of heart attacks.

Nanette K. Wenger

This eminently readable book offers a new and valuable perspective to patients with coronary disease.

Philip R. Lee

A wonderful book that should be invaluable for patients and their physicians.

Library Journal

What distinguishes this title from other guides on preventing and treating heart disease is its down-to-earth sharing of individual stories. Besides a chapter on diagnosis, treatment, and rehabilitation written by Berra (clinical trial director, Stanford Ctr. for Research in Disease Prevention), Gerald W. Friedland (emeritus, radiology, Stanford Univ. Sch. of Medicine), and Francis H. Koch (consulting cardiologist, Cardiac Therapy Fdn. of the Midpeninsula), the book features 11 other chapters authored by heart attack survivors. These men and women from across the country, of all ages and ethnicities, end their narratives with a bulleted list of what they have learned from their experiences. The section on diet and nutrition by Christopher Gardner (director, nutrition studies, Stanford Ctr. for Research in Disease Prevention) looks at the most recent research and compares the most popular and well-known diets. Berra also contributes a chapter that stresses the benefit of cardiac rehabilitation programs for patients with or at risk for heart disease; in fact, this work was initiated by four participants in the same program, the Cardiac Therapy Foundation of the Midpeninsula, Palo Alto, CA. So many of us tend to believe erroneously that heart attacks won't affect us, but these stories prove otherwise and bring the issue home in a way that a more detached style of writing can't achieve. Every public library and consumer health collection should purchase a copy. Eris Weaver, Redwood Health Lib., Petaluma, CA Copyright 2001 Cahners Business Information.

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HEART ATTACK!

YALE UNIVERSITY PRESS

Chapter One

Kathleen Berra and Gerald W. Friedland

Did you know that, worldwide, twenty-three people each minute have a heart attack? This adds up to about 12 million heart attacks a year. More than 1 million Americans will have a heart attack each year, and 14 million Americans now living have had a heart attack or angina. In fact, if you live in an industrialized country, heart disease is either the number one killer there or a major cause of death.

Even when heart disease does not kill, it maims, so if you have had a heart attack, you may well find yourself attending a cardiac rehabilitation program to help in your recovery. If you do, remember that millions of people just like you are in similar programs all over the world.

But there is also good news: your chances of dying from a heart attack grow less and less. In fact, the United States Centers for Disease Control and Prevention, in Atlanta, Georgia, report that in the past fifty years there has been a stunning 60 percent reduction in mortality from heart attacks. If, for example, the death rate in 1963 from heart attacks had continued unchanged, an additional 621,000 Americans would have died in 1996 alone.

The Centers for Disease Control and Prevention found that this dramatic result was due in part to the systematic reduction of risk factors for heart attacks. In fact, if you have had a heart attack, one of the very best ways to learn how to reduce your risk factors is by enrolling in a cardiac rehabilitation program, which will provide a warm, nurturing, and supportive environment.

Fortunately, cardiac rehabilitation programs now exist wherever heart attacks are common, so if you have had a heart attack, help is likely to be at hand. If you happen to live in Western Europe, where the first such programs were established, probably you will automatically join a program after your heart attack. Other locations, unfortunately, lag behind Western Europe in this regard.

The goals and techniques of cardiac rehabilitation programs are similar all over the world, since they all follow similar published guidelines. (As you might expect, there are differences related to cultural and other factors, but the similarities between programs are far more significant than the differences.)

Unhappily, fewer than 40 percent of heart attack victims in the United States actually attend a cardiac rehabilitation program. In recognition of this statistic, a number of home-based rehabilitation programs are under way, in which the participant is monitored via telephone or by other means. These programs are discussed in detail in Chapter 16. Despite these ongoing efforts, many heart attack victims in the United States are not involved in any program, home based or not. Typically, these individuals construct their own, unmonitored rehabilitation program, which is why we have included one such story in this book (Chapter 3).

What Is a Heart Attack?

A heart attack occurs when an artery feeding blood to a section of heart muscle becomes completely blocked. If the blockage lasts long enough, the section involved will die. This process is called a heart attack, or myocardial infarction (MI). Scientists have discovered that when arteries are exposed to high levels of cholesterol, high blood pressure, high blood sugar, cigarette smoking, a diet high in saturated fats and cholesterol, and other risk factors, atherosclerosis often develops, followed by a process that results in blockage of the arteries and a heart attack if uncontrolled. The signs and symptoms of a heart attack should not be ignored; immediate medical care can, in some cases, restore blood flow and prevent permanent damage. In addition, the risk factors for heart disease (atherosclerosis) need to be aggressively managed to avoid developing disease in the heart arteries and throughout the body.

When someone has had a heart attack, the damage to the heart muscle is permanent. The best medicine can do is improve the patient's condition and help prevent a future heart attack or other heart problems. In addition, reducing risk factors for a heart attack also reduces the risk of a stroke. That is why it is crucial to know what factors put people at risk for a heart attack or a stroke in the first place-and what can be done to change these risk factors.

Risk Factors

Typically, the risk factors for a heart attack and stroke include one or more of the following:

Smoking or the use of other tobacco products

High LDL "bad" cholesterol (levels greater than 100 mg/dL if you have atherosclerosis and/or diabetes)

Low HDL "good" cholesterol (levels lower than 40 mg/dL)

High triglycerides (levels greater than 150 mg/dL)

High blood pressure (levels greater than 135/85 mm/Hg)

Diabetes (high blood sugar levels, greater than 110 mg/dL)

Sedentary lifestyle (exercising less than thirty minutes three or four times weekly) (Chapter 16)

Obesity (being more than zo percent over your ideal body weight or having a body mass index greater than 25)

Negative emotional states (such as depression and/or high levels of anger and hostility) (Chapter 16)

Lacking social support (being socially isolated)

A diet high in saturated fat and lacking adequate plant-based foods such as nuts, grains, vegetables, and fruits (Chapter 13).

Here and in later chapters, we shall discuss these risk factors so that you can see how they influence your risk in and of themselves, and how they relate to greater risk when several occur together.

Smoking

Smoking affects the heart in many ways. A major cause of cancer and of diseases of the heart and lungs, it also blocks blood flow in the leg arteries. Particles of low-density lipoproteins (LDL) are very damaging to the artery walls. Smoking interferes with important actions of vitamin C, thereby allowing the LDL particles to become oxidized and even more damaging. Once oxidized, LDL particles generate an inflammatory reaction in the walls of the arteries, leading in turn to atherosclerosis. In addition, the nicotine in cigarette smoke can cause arteries, including the coronary arteries, to spasm (tighten up). The heart muscle will therefore receive less blood. Cigarettes also cause the blood pressure to go up, which increases the amount of work the heart has to do. And chronic high blood pressure leads to heart damage.

Other life-threatening complications of smoking include lung cancer and chronic obstructive pulmonary disease. Normally, oxygen and carbon dioxide are exchanged in the blood in air sacs within the lungs. With cigarette smoking, the walls of the air sacs break down; they become enlarged, and inadequate gas exchange results. This process is the notorious emphysema and it is not reversible. Once emphysema reaches a certain stage, individuals find themselves chronically short of breath even at low levels of physical activity. People with emphysema often have chronic bronchitis as well. The combination of chronic inflammation of the bronchial tubes and emphysema is known as chronic obstructive pulmonary disease (COPD). What is this like from the patient's point of view? Living with advanced COPD was absolute hell for Jerry Fox (Chapter 12); he found it "like being continuously tortured."

Smoking is by far the most serious risk factor for a heart attack. The best thing for smokers to do is to quit-the sooner the better. It is never too late to stop and it is crucial not to give up trying. Fortunately, nicotine replacements are available now, as well as new medications that make it easier than ever to stop smoking.

Quitting was easy for Verne Peters (Chapter 9), because he was extremely disciplined. For most people quitting is very difficult. Hans Forsell (Chapter 3) managed to reduce his smoking from two packs a day to one, but recent studies show you have to stop completely in order to derive any benefit at all. Some people require a major shock to quit: for Peter Jones (Chapter 6) it was the death from cancer of his father and many close friends. For David Moses (Chapter 7), who could not stop smoking for eleven years after developing angina, the shock was more personal: he developed cancer on the roof of his mouth. Jerry Fox (Chapter 12) had the most difficult time; he was hooked twice in his life by a cigarette offered at a party, once at age 24, then again at age 59. Each time he turned into a three-pack-a-day smoker. Consult the American Heart Association, the American Lung Association, the American Cancer Society (or the appropriate organization in the country in which you live), as well as your local cardiac rehabilitation program or your health care provider, for additional advice.

Elevated Cholesterol and Triglycerides

It is vital to regulate cholesterol levels. Everyone needs to know the results of their laboratory tests, including total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels. Data collected from an enormous number of studies now irrefutably show that a person who has coronary artery disease or diabetes should make every effort to achieve at least the following levels:

Total cholesterol less than 200 mg/dL (5.2 mmol/L)

LDL cholesterol less than 100 mg/dL (2.6 mmol/L)

HDL cholesterol greater than 40 mg/dL (1.0 mmol/L), the higher the better

Triglycerides less than 150 mg/dL (3.9 mmol/L); lower is probably even better (< 120 mg/dL).

There are many ways to achieve these levels, including exercise, diet, and weight loss. Some people are genetically inclined to produce too much cholesterol within their bodies, or are not able to clear it properly. New and truly excellent medicines are available to deal with these kinds of cholesterol problems. Regardless of the cause of the abnormal lipid values, weight control, appropriate nutrition, and exercise will benefit a person's health in remarkable ways in terms of heart disease, stroke, and certain cancers.

A number of other abnormalities are now emerging as potential risk factors. These include small, dense LDL particles; high levels of Lp(a), a particle with a protein called apo(a) stuck to its surface; high levels of an amino acid called homocysteine; or high levels of a protein called highly sensitive C-reactive protein (CRP). Any number of these abnormalities can occur within the same person. Both Jacob Gershon (Chapter 8) and Sonny Adams (Chapter 10), for example, had high blood levels of homocysteine and Lp(a), together with small, dense LDL particles.

Small, dense LDL particles can pass easily through the arterial wall. There they are particularly susceptible to oxidation and can readily injure the arteries. They generally occur in the presence of high levels of triglycerides.

Elevated Lp(a) levels have an effect similar to that of elevated LDL cholesterol, but they also increase the likelihood of clot formation in blood vessels and can augment the risk of a heart attack. Your Lp(a) level is inherited, and if you have heart disease and a high Lp(a), you are potentially at high risk for a future heart attack and/or stroke. What we know today is that the best treatment for a high Lp(a) level is to keep your LDL and triglyceride levels as low as possible and your HDL level as high as possible.

Another new and interesting risk factor is a high homocysteine level. Researchers have found that a high level of homocysteine increases the susceptibility of arteries to developing atherosclerosis.

Elevated levels of highly sensitive C-reactive protein (measured in the blood as hs CRP) is also being carefully evaluated as a coronary risk factor. C-reactive protein indicates that an inflammatory process is occurring in the arteries, which appears to be related to an increased risk of a heart attack.

One of the problems with these emergent risk factors is that although data exist showing that they are related to the development of coronary artery disease and atherosclerosis in general, at present no data demonstrate unequivocally that changing levels of homocysteine, Lp(a), or hs CRP makes any difference in long-term outcomes. Some few data indicate that increasing the size and buoyancy of the LDL particles can help prevent worsening atherosclerosis. Interestingly, the size of the LDL particle can be changed through weight control and dietary management to lower triglycerides below 120 mg/dL.

Current advice regarding the new factors is controversial. If you have a strong family history of coronary artery disease (especially if it has occurred in your father under the age of 55 or your mother under the age of 65), you might consider having yourself tested for these risk factors. The presence of these new risk factors was crucial in the cases of Jacob Gershon and Sonny Adams, both of whom had heart attacks early (Gershon at 51, Adams at 39), as well as a family history of coronary artery disease. If your homocysteine, Lp(a), or hs CRP levels are high, the decision about whether to try to lower them will be up to you and your doctor. The real point is to use the deepening knowledge of our body chemistry to minimize all risk factors for coronary artery disease.

If your homocysteine levels are high, consider taking a multivitamin tablet each day, one that contains 400 micrograms of folic acid. If your levels are extremely high, your doctor may prescribe heavy doses of folic acid.

Niacin can lower Lp(a) in men and women, as can estrogen in women. Once again, however, only your own doctor can discuss the pros and cons of these treatments. The best way to increase LDL particle size and make the particles more buoyant (and less likely to cause atherosclerosis) is to lower triglycerides and keep HDL levels up. The lower the triglycerides, the larger and more buoyant the LDL particles will become.

Restricting intake of alcohol and simple sugars, losing weight if necessary, and regular exercise are outstanding ways to lower triglycerides and increase the size and buoyancy of LDL particles. Exercise, by the way, also helps to raise HDL levels. Both Jacob Gershon and Sonny Adams take folic acid for elevated homocysteine levels, and niacin for elevated Lp(a) levels and small dense LDL particles. Neither drinks alcohol, both avoid simple sugars, and both exercise regularly. Gershon, in addition, is on the Mediterranean diet (Chapter 13), which has raised his HDL levels and lowered his triglycerides.

High Blood Pressure

Lowering blood pressure to normal will dramatically decrease the chances of having a heart attack or stroke and will go a long way toward protecting the kidneys.

Many Americans feel that a blood pressure of 135/85 and sometimes even higher is "okay."

Continues...

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Excerpted from HEART ATTACK! by Kathleen Berra Gerald W. Friedland Christopher Gardner Francis H. Koch Donna Louie Nancy Houston Miller Robin Wedell Barton Thurber Copyright © 2002 by Cardiac Therapy Foundation of the Midpeninsula. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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