Matters of the Heart

Monday, February 1, 2010

Illustration by Stephen Sauer.

Illustration by Stephen Sauer.

Illustration by Stephen Sauer.

More Information

American Heart Association: www.americanheart.org, (603) 669-5833

Catholic Medical Center: www.catholicmedicalcenter.org

Elliot Hospital: www.elliothospital.com

Dartmouth-Hitchcock Medical Center: www.dhmc.org

When it comes to health, our cardiovascular system plays a starring role, with the survival of every organ hinging on the continuous, pulsating beats of our heart. Is it somewhat ironic, then, that heart disease is the leading cause of death in the United States, or just a testament to the crucial power of our rhythmic cardiac muscle? The fulcrum of our well-being, which we should pay particular attention to, is all too often neglected until it is panicked over.

Statistics indicate that it’s high time we show our hearts a little love. In 2006, heart disease caused more than one in every four deaths in the U.S. according to the Centers for Disease Control and Prevention.

Heart disease is an umbrella term that is used to describe a range of conditions affecting the heart. In the United States, the most common type of heart disease is coronary artery disease, which occurs when coronary arteries become clogged with plaque, a combination of cholesterol, fat, and other substances.

Men have a greater risk of developing heart disease than women, and at an earlier age, but after menopause, a woman’s risk quickly increases, says David C. Charlesworth, M.D., F.A.C.S., a cardiothoracic surgeon with Cardiothoracic Surgical Associates and Catholic Medical Center, both in Manchester. With heart disease killing more than 430,000 women in 2006, according to the American Heart Association, it’s clear that it is not only a “man’s disease,” as some people continue to mistakenly believe.

Getting a handle on heart trouble

As is the case with so many medical conditions, early recognition of heart disease can be life-saving. “There’s a sizable percentage, maybe 20 percent, of people whose very first manifestation of heart disease is a heart attack,” says Bruce W. Andrus, M.D., F.A.C.C., director, Preventive Cardiology at Dartmouth-Hitchcock Medical Center in Lebanon and assistant professor of medicine at Dartmouth Medical School. But diagnosing heart disease can be tricky, experts say. Not all patients experience the textbook symptoms of discomfort in the center of their chest that radiates into their jaw or their arm with physical exertion, Andrus says.

As doctors try to pinpoint a cardiac problem, they can choose from an array of diagnostic tools, such as stress tests and coronary angiography, which involves injecting a dye into blood vessels to highlight blockages. Other diagnostic advances involve non-invasive imaging technology, particularly computerized tomography (CT) scanning to measure coronary calcium, and carotid intima-media thickness measurement, related to the carotid artery walls. The imaging methods “have been promoted as a means of detecting early disease, before the patient has any symptoms at all,” Andrus says.

But the role of tests and imaging studies to detect disease can be controversial, Andrus says. The CT scans involve radiation exposure. Critics say the value of some of the methods hasn’t been proven through long-term study, and each of the methods involves expense, says Andrus.

In addition, testing can sometimes create a Pandora’s box of worries, says Robert M. Lavery, M.D., F.A.C.C., chief of cardiology at Elliot Hospital in Manchester. Test results that reveal an abnormality can lead to sleepless nights for the patient. The physician, meanwhile, must decide whether to pursue additional tests, with all their inherent risks and cost.

“If the test is equivocal, it creates more anxiety,” Lavery says, possibly leading to more testing and radiation exposure.

It’s a dilemma as big as they come: Will testing a particular patient bring worthwhile reassurance, information, risk and expense, or not?

Mending hearts

There aren’t any blockbuster medications that can cure heart disease, Lavery says, but some of the drugs that help lower cholesterol or prevent clot formation in arteries can be helpful, although they do sometimes trigger side effects.

Some heart disease patients are prescribed a combination of medication plus some sort of procedure, such as angioplasty and stenting to open and maintain blocked arteries, or coronary artery bypass grafting, says Charlesworth. The number of performed stent treatments now surpasses bypass surgeries, he says. But even for patients who undergo bypass surgery, efforts to maintain a healthy heart should be never-ending. Coronary artery disease, for example, “is like a video that lasts for a lifetime, and bypass surgery is a snapshot,” Charlesworth says. “Coronary artery disease doesn’t stop the day that we do the bypass surgery; it has to be mitigated and ameliorated by drug therapy, exercise, lifestyle changes, diet and so on,” he says.

Maximizing heart health for minimal dollars

Want to keep your heart healthy? Some risk factors for heart disease are out of our control, such as family history, age and gender. A number of risk factors, however, stem from lifestyle choices, including a lack of exercise, smoking and high cholesterol brought on by a poor diet. “A huge percentage” of heart disease is preventable, Andrus says, and there’s growing appreciation of quantifying risk, he says, as heart-related numbers such as cholesterol and blood pressure measurements can help classify patients as being at low, medium or high risk of developing heart disease.

It’s a step in the right direction because for doctors in the age of healthcare reform one of the big challenges is diagnosing heart disease patients without breaking the budget, says Lavery. “We still don’t have the Star Trek scanner, where we put every patient in and they come out with a little ticker tape that says what is wrong.” Some patients have classic symptoms, others do not. Still others really don’t have any symptoms, but they are worried about their risk, often because of a parent who died prematurely of heart disease. Physicians must determine which patients are at risk and need further testing, and at what level, eliminating unnecessary testing while still providing the same high level of care as always, Lavery says.

As for patients, they would do well to follow the old health axioms, Andrus says. To a large extent, he says, “the foundation of prevention is really within the reach of all of us, just simply by eating more wisely, eating less, exercising more, not smoking and getting our blood pressure treated.”

What’s Your Risk?

For a quick measure of your cardiovascular health risk, visit the Web sites for Framingham Risk Score (www.framinghamheartstudy.org) or the newer Reynolds Risk Score (www.reynoldsriskscore.org), says Dr. Bruce W. Andrus, director of Preventive Cardiology at Dartmouth-Hitchcock Medical Center in Lebanon and assistant professor of medicine at Dartmouth Medical School. The Reynolds score incorporates family history, which is not part of the Framingham score, and C-reactive protein, an indication of vascular inflammation. The two scoring systems can give patients and their care providers a rough estimate of heart disease probabilities.

More Help

For more information on heart disease, consider checking out CardioSmart (www.cardiosmart.org), created by the American College of Cardiology, says Dr. Robert M. Lavery, chief of cardiology at Elliot Hospital in Manchester. The Web site includes information about heart disease, tests and treatments.