Is Your Heart Older Than Your Actual Age?

February is “American Heart Month,” which the CDC calls in the “Strong Men Put Their Health First” post as “a great time to commit to a healthy lifestyle and make small changes that can lead to a lifetime of heart health.”

While I agree making changes that can lead to a lifetime of heart health is important, why the CDC wrote this post about men is beyond me. Especially because heart disease is THE NUMBER 1 KILLER OF WOMEN in the US. Though this is frustrating, I provided a link to the CDC male-oriented page because there’s useful general info there. And here’s a link to About Heart Disease In Women – and as a reminder, heart attack symptoms can be different for women – jaw pain or heartburn in women as opposed to crushing chest pain, for example!  Read more in my blog post, Heart Attack Symptoms In Women.

The CDC also has an initiative called “Million Hearts” (@MillionHearts) and their main online page has a great “Additional Resources and Events” section with links to info on preventing heart disease, physical activity, and heart-healthy recipes. There are Facebook and Twitter links to follow, and something called HOW OLD IS YOUR HEART in both video and online calculator form.

This ‘How Old Is Your Heart’ thing intrigued me, so I clicked on the video which explains that your heart can be older than your actual age. While slightly amusing, the more important bit, IMHO, is the CDC’s actual ‘heart health calculator.’ (Note, the calculator is only for people 30-74 with no history of heart disease.)

I was surprised that to use the CDC’s Heart Health Calculator you need only two inputs: your systolic blood pressure (the top number) and your BMI. No cholesterol input at all! And, not to worry that you don’t know your BMI – you can quickly calculate it with the simple online BMI calculator (this is the official one from the National Heart Lung and Blood Institute – frankly, googling ‘BMI calculator’ nets one that’s easier to view.)

As I said, I was stunned to see not one mention of cholesterol.

OK, I thought. Let me give it a go anyway – even with no cholesterol input. Given that I am not a smoker, and don’t have diabetes (the other inputs on this heart age calculator), I expected that my calculated heart age would be lower than my actual age, because I’m fit, with normal blood pressure.

I was stunned to find heart age using this calculator exactly equalled my actual age.

How could that be? If my all-pretty-positive inputs into the calculator resulted in a ‘same as age’ heart age result, that must mean that many (most?) using this calculator must end up with a calculated heart age OLDER than their actual age.

Really?  Could that be true?

And why isn’t cholesterol figured into the ‘heart age’ equation?

Puzzled, I played with the inputs to see what causes the heart to ‘age’ most in this calculator.  It’s not the BMI (mine is a pretty low/normal 22) – changing that a few points didn’t affect heart age much. Turns out, the key measure must be blood pressure because changing the systolic blood pressure by just a few points had a pretty drastic effect on heart age. Thus, it seems that – at least for this ‘heart age calculator’ – high blood pressure is the most dangerous condition / ages your heart the most. Certainly more than the not-even-mentioned cholesterol.

Maybe cholesterol is missing because the medical community is still at odds over the changed 2013 Guidelines for Cholesterol Treatment (and the faction who is behind this calculator doesn’t believe cholesterol is a big deal?) Or maybe I’m reading too much into all this…

Net, while I’m not entirely positive what the key takeaway here is, it does seem prudent to continue to monitor cholesterol along with blood pressure. Because frankly, a lo-co lifestyle – exercise and diet to lower cholesterol – will also help keep blood pressure down!

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Statin Guidelines – The Fight Continues

It’s startling how much debate and disagreement exists about the guidelines for statin use.

Back in November 2013, new guidelines were published by the American Heart Association and the American College of Cardiology. The 2013 guidelines represented a significant shift in cholesterol management: essentially moving away from targeting/treating to a specific cholesterol level and instead encouraging treatment of all individuals with a 10-year risk of heart disease of 7.5% or higher (for specifics, see my post, The NEW guidelines for cholesterol-lowering statin meds).

There then ensued heated arguments over the published Risk Calculator that yields that all-important 10-year level of heart disease risk. Indeed, clicking the AHA’s Heart Attack Risk Assessment page right now yields this frustrating error:

“We’re sorry, but this tool is currently unavailable. The Heart Attack Risk Calculator is being updated and will be available soon. Please check back!”

Luckily, the AHA’s Prevention Guidelines page with a link to the original calculator still exists, so you can still calculate your 10-year risk. (Note: if these links fail, try my RESOURCES page: I’ll try to keep the risk calculator links up-to-date there.)

Assuming one believes at least directionally in the AHA’s risk calculator (and I do), it’s important for those who can use the calculator* and assess your personal level of heart disease risk over the next 10 years. (* You cannot use the calculator if you have heart disease or take statins already. Read more about calculators here.)

Until yesterday, it was clear what to do with your resulting risk: if someone between 40-75** gets a 10-year risk of heart disease of 7.5% or more, statin therapy should be considered and discussed with a doctor. (** See full 11/2013 recommendations below.)

But yesterday, things got a little tricky for anyone whose risk is between 7.5% and 10%.

Because yesterday, the U.S. Preventive Services Task Force issued new guidance for the use of statins which is not exactly the same as the AHA 2013 guidelines. (The USPSTF guidelines were published in the Journal of the American Medical Association; read/download a PDF here).

  • On the plus side, the new USPSTF guidelines support the November 2013 AHA decision in that the new guidelines are also based on the 10-year risk calculator. So the USPSTF added weight to the argument for using 10-year risk calculator, and not treating by managing to a particular LDL cholesterol level.
  • On the tricky side, the new USPSTF guidelines increased the risk of heart disease cutoff from 7.5% to 10%.

So now it’s not entirely clear what someone with a risk rate of 7.5%-10% should do. And whether insurance will cover statins for those individuals.

That’s because, as Ariana Eunjung Cha of The Washington Post astutely points out in her excellent article, New Statin Guidelines: Everyone 40 and older should be considered for the drug therapy, both Medicare and the Affordable Care Act use USPSTF recommendations to guide drug coverage plans. So that MAY call into question whether insurance companies will cover statin drugs for those in the 7.5% to 10% risk group.

In the end, what’s important is this: calculate your 10-year risk of heart disease. Use the calculator, and:

  • If you’re below 7.5%, make sure to keep pursuing a lo-co lifestyle with frequent exercise and a healthy, low-fat, low-sugar, plant-based diet.
  • If your risk is over 10%, get thee to a doctor and discuss statins.
  • If your risk is between 7.5% and 10%, talk to your doctor or cardiologist about what next steps are right for you.

It all starts with your risk: calculate it!  It’s so easy – all you need is your latest cholesterol results and systolic blood pressure (the first number).  Then review your personal results and make a plan with your doctor.

Supplement:
** November 2013 AHA recommendation: if you are in one of the following four groups, you have elevated heart disease risk and should take statins:

  1. those who already have cardiovascular disease
  2. anyone with LDL (bad) cholesterol of 190 mg/dL or higher
  3. anyone between 40 and 75 years of age who has Type 2 diabetes
  4. people between 40 and 75 who have an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher.

The USPSTF November 2016 recommendation:
“The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.”

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How Much Exercise For Boosting Heart Health?

Exercise is one of the key methods for lowering cholesterol – and blood pressure, my new concern — without medications. So to reduce my blood pressure and to continue to keep my cholesterol in check without any meds, I’ve been wondering just how much, how hard, and how often I need to exercise.

In researching, I found this nifty chart from the American Heart Association. It’s a little busy, but the key is the bottom-most graphic, which is for lowering cholesterol and blood pressure (how handy that they are together goal-wise!)

Apparently, to lower cholesterol and blood pressure, one needs to exercise for an average of 40 minutes at a ‘moderate-to-vigorous-intensity aerobic activity’ 3-4 days each week.

AHA Exercise Guidelines

Which sounds like kind of a lot, people.

I mean, I can jog for 20 minutes before my knees hurt – but certainly not 40 minutes (I was awed when my 21 year old son ran the Chicago marathon in 3 hours and 49 minutes. I still can’t believe he did that / that anyone can run for that long!).  So, um, 40 minutes of ‘moderate-to-vigorous’ exercise 3-4 times a week sounds like a LOT to me.

So obviously, the key question is – what is ‘moderate-to-vigorous-intensity’ aerobic activity?

To me, moderate-vigorous seems like it’d be exercise that gets my heart rate to hit at about 70-85% of my Max Heart Rate (for me, that’s 140-154 or so). If you want to know more about setting a personal heart rate goal, read How To Set A Simple Heart Rate Goal. But is that moderate or is that vigorous?

Luckily, the American Heart Association had a post that answered that exact question: Moderate to Vigorous – What is your level of intensity?  The AHA defines moderate and vigorous exercise as follows (link to the article for more detailed, pretty interesting info):

Examples of Moderate Intensity:

  • Walking briskly (3 miles per hour or faster, but not race-walking)
  • Water aerobics
  • Bicycling slower than 10 miles per hour
  • Tennis (doubles)
  • Ballroom dancing
  • General gardening

Examples of Vigorous Intensity:

  • Race walking, jogging, or running
  • Swimming laps
  • Tennis (singles)
  • Aerobic dancing
  • Bicycling 10 miles per hour or faster
  • Jumping rope
  • Heavy gardening (continuous digging or hoeing)
  • Hiking uphill or with a heavy backpack

Whew. I can walk quickly for 40 minutes to count as heart-healthy exercise. Yay – that’s one I can actually do!  But walking is kind of boring to me – and 40 minutes still feels like a lot of time.

So I need another option. One that’s vigorous but doesn’t eat into my day. Which is why I’m intrigued by High-Intensity Interval Training. In fact, this explanation of HIIT from Karen Reed of Positive Health Wellness was music to my ears, “Thanks to the non-stop, high-intensity pace of the workout, you can fit in both aerobic (cardio) and anaerobic (resistance training) exercise in just 15 to 25 minutes.” For more details, read her article, “All The Benefits of High Intensity Interval Training Workouts.”

I’d rather ramp up my exercise plan than go on blood pressure or cholesterol meds, so I’m looking at trying out High-Intensity Interval Training and/or scheduling more – or longer – aerobic exercise into my week. How about you?

 

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New Study Suggests Statins For Those at Low Risk

A new study published in March 2016 by McGill University’s George Thanassoulis, MD in the Circulation journal of the American Heart Association suggests that many identified as ‘Low Risk’ by the latest cholesterol treatment guidelines should be taking cholesterol-lowering statins.

The current guidelines for treating cholesterol, published with much fanfare and controversy in November 2013, moved away from targeting treatment to reach a specific cholesterol level and instead include a ‘calculator’ that measures risk. If a person’s risk is lower than 7.5% chance of heart disease in 10 years, statins are NOT recommended. (Details, including a link to the calculator, found in my post: The NEW Guidelines for Cholesterol-Lowering Statin Meds.)

Personally, I fall into the ‘do not take statins’ pool using this calculator as:  a) I do not already have cardiovascular disease; b) my LDL (bad) cholesterol is less than 190; c) I do not have diabetes; and d) my 10-year risk is lower than 7.5%.

But according to this NEW March 2016 study, “Individualized Statin Benefit for Determining Statin Eligibility in the Primary Prevention of Cardiovascular Disease,” I might be one of the many at ‘low risk’ who should be taking statins!

Yikes.

The new study recommends “an INDIVIDUALIZED statin benefit approach” rather than relying on the calculator; using this approach, thousands who are currently at ‘low risk’ and not treated with statins would instead be treated with statins. According to the study authors, “Statin treatment in this group would be expected to prevent an additional 266,508 cardiovascular events over 10 years.”

Yikes times two.

And it was a large study. The study, “included 2134 participants representing 71.8 million American residents potentially eligible for statins in primary prevention from the National Health and Nutrition Examination Survey for the years 2005 to 2010.”  The study “compared statin eligibilities using 2 separate approaches: a 10-year risk-based approach (≥7.5% 10-year risk) and an individualized benefit approach (ie, based on predicted absolute risk reduction over 10 years [ARR10] ≥2.3% from randomized, controlled trial data).”

The risk-based approach (the ‘new’ 2013 guidelines that doctors are currently using) identified 15.0 million Americans who should take statins, versus 24.6 million Americans who should take statins according to the benefit-based approach. Thus, “the benefit-based approach identified 9.5 million lower-risk (<7.5% 10-year risk) Americans not currently eligible for statin treatment who had the same or greater expected benefit from statins (≥2.3% ARR10) compared with higher-risk individuals.

That’s 10 million Americans who should be taking statins who right now are not.

And I’m probably one of them!  Because the study goes on to say, “This lower-risk/acceptable-benefit group includes younger individuals (mean age, 55.2 versus 62.5 years) with higher low-density lipoprotein cholesterol (140 versus 133 mg/dL). Statin treatment in this group would be expected to prevent an additional 266,508 cardiovascular events over 10 years.

Yikes times three!  As this describes me: I’m under 55 and my LDL is 145.

I guess it’s time to put in a call to my cardiologist and ask what he thinks of this study.  I do not want to go on a statin medication, but I do want to understand his thoughts on both this study and what an “individualized benefit approach” to treating my high cholesterol looks like.

 

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Is the New Class of Cholesterol-Lowering Drugs For You?

The quick answer to ‘Am I a candidate for one of the two new PCSK9 cholesterol-lowering drugs?’ is Probably Not (unless you have FH or have heart disease / have had a heart attack.)

The reason? Two, actually. First, this totally new class of (injectable) cholesterol-lowering drugs is approved ONLY for those with high cardiac risk. And secondly, clinical study results with key safety data won’t be available for YEARS.

The two new drugs, Praluent and Repatha, were approved this past summer by the FDA only for those with a serious, genetically inherited disease that causes very high LDL (bad) cholesterol called Familial Hypercholsterolemia (FH) and/or for those who have heart disease / have suffered a heart attack. Said differently, this new class of drugs is NOT for those with “regular” high cholesterol — and that’s key because these drugs have potentially serious (neurological and other) side effects which won’t be fully known until clinical results are released in 2017.

As reported by CNN’s FDA Approves Second In New Class of Cholesterol Lowering Drugs:

“Repatha provides another treatment option in this new class of drugs for patients with familial hypercholesterolemia or with known cardiovascular disease who have not been able to lower their LDL cholesterol enough with statins,” Dr. John Jenkins, director of the FDA Office of New Drugs, Center for Drug Evaluation and Research, said in a news release.”

A similar CNN article, FDA Approves New Cholesterol Lowering Drug, explains:

“It focuses on those who’ve truly had clinical disease or those who start out with such high levels of LDL they can’t get anywhere near where they should be and I think those are the most at-risk people,” said Dr. Donald A. Smith, associate professor of medicine and cardiology at Mount Sinai Hospital in New York.”

So, yes, this new class of drugs is amazing news for those with FH and those with cardiac disease who cannot tolerate statins. These folks should run, not walk, to their cardiologists. But for the rest of us, Repatha and Praluent are drugs we can ask our internists and cardiologists about at our next appointments, not race there with questions now.

What’s fascinating frustrating to me about these new drugs is that there is a lack of clarity from the American Heart Association (AHA) and the American College of Cardiologists about how this new class of drugs fits in with their 2013 “New Guidelines” for treating high cholesterol.  Indeed, in ‘Understanding The New Guidelines,’ the new class of drugs is not even mentioned. I find this exasperating – this is an ONLINE instrument and should be current. I found exactly one article on AHA’s site (their blog, actually) called FDA Approves New Cholesterol Drug. In a nutshell, what the AHA said about the new class of drugs is that MAYBE WE SHOULD THINK ABOUT IT VIS-A-VIS OUR GUIDELINES? (emphasis mine, obviously.)

Seriously? That’s it, AHA? Very disappointing. Here’s a quote from that article:

“The AHA revised its scientific guidelines about cholesterol in 2013. They de-emphasize the setting of specific LDL targets and recommend statin use for all at-risk patients with elevated LDL. The recommendations also suggest statin treatment for people who don’t have cardiovascular disease but who by using an at-risk estimator tool are determined to have at least a 7.5 percent risk of developing it over a decade.

Now with the possibility of having ultra-low levels of LDL, Eckel, who sat on that guideline-writing panel, said it is unclear whether there will be a move soon to rewrite the guideline to take into account the developments with PCSK9 inhibitors.

“Some people feel the guideline could be re-written now and others believe it should wait until the PCSK9 outcome trials are completed,” he said.”

(NOTE: ‘he’ refers to “Dr. Robert H. Eckel, an endocrinologist and professor at the University of Colorado Anschutz Medical Campus and director of the medical school’s Lipid Treatment Clinic” who sat on the AHA/ACC new guidelines panel.) 

This equivocating statement (and no real guidance at all) is the sum total of what I could find in terms of opinion from the American Heart Association about this new class of drugs. One can only hope they are providing more to doctors and cardiologists, but I doubt it. Which leaves doctors deciding on treatment based on information presented by (necessarily biased) drug companies. Because you can be sure reps from Amgen and Sanofi are banging down the doors of US cardiologists.

Personally, I’m confused. Every single adult in my family takes statins to lower cholesterol. ALL of them.  But I’m trying not to; I’m trying to manage my risk with lifestyle and diet. And following the American Heart Association’s guidance, I should not be taking statins (my results from the AHA ‘risk calculator’ are below. And clearly I’m not a candidate for the PCSK9 drugs as I don’t have FH nor have had a heart disease event, yet. And further, my advanced lipid panel testing also confirms I am not at great cardiac risk.

But what if they’re wrong? What if the AHA changes the guidelines again and I waste two years not taking statins? Or find out that everyone should be taking PCSK9 to lower cholesterol dramatically?

Dr. Mercola doesn’t think that will happen. In his FDA Approves Potentially Disastrous Cholesterol-Lowering Drug, he argues this new class of drugs is likely to be widely prescribed before it’s safety is known, and that there are early indicators of safety issues.

But I’m left wondering.  Luckily I have a follow up appointment with my cardiologist in December, so I’ll ask him what he thinks of the 2013 Guidelines now that two PCSK9 drugs have been approved. I plan to ask if he thinks I should continue to follow AHA/ACC guidelines or consider further tests or treatment.

**************

RESOURCE: CALCULATING YOUR CARDIOVASCULAR RISK:

If you haven’t used the AHA/ACC’s  2013 CV Risk Calculator, you should. It’s free, online (or an app) and is simple to use – all you need are your cholesterol results and your blood pressure (both my internist and my cardiologist used this app during my appointment). Click on the link and fill in the very few boxes and you’ll get a personalized result.

For reference, here’s a summary of my personal inputs and result/recommendation.

“Based on the data entered (assuming no clinical ASCVD and LDL-C 70-189 mg/dL):

  • “Total Cholesterol: 240
  • HDL-Cholesterol: 88
  • Systolic Blood Pressure: 130
  • Hypertension Treatment: No
  • Diabetes: No
  • Smoker: No

Not In Statin Benefit Group Due To 10-Year ASCVD Risk <5%   (THIS IS MY RECO)

In individuals for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. These factors may include primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first degree male relative or <65 years of age in a first degree female relative, high-sensitivity C-reactive protein ≥2 mg/L, CAC score ≥300 Agatston units or ≥75 percentile for age, sex, and ethnicity, ankle-brachial index <0.9, or elevated lifetime risk of ASCVD. Additional factors may be identified in the future. (IIb C)

Lifestyle Recommendations

AHA/ACC guidelines stress the importance of lifestyle modifications to lower cardiovascular disease risk. This includes eating a heart-healthy diet, regular aerobic exercises, maintenance of desirable body weight and avoidance of tobacco products.”

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