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10. Other Risk Factors for Coronary Heart Disease

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10.1 Being overweight – obesity

 Question: I don’t feel overweight but the doctor says I am. Have I got more chance of developing heart disease because of this?

Answer: Very overweight (obese) people do have more chance of developing heart disease and this has been mentioned earlier.

Being fat increases the work the heart has to do, causes high blood pressure and leads to abnormal blood lipids (hypercholesterolaemia). It can also lead to you developing diabetes. You should try to reduce your weight. Big bellies are bad for your heart!

10.2 Stress

 Question: I have a very stressful job. Am I more likely to get heart problems?

Answer: There is no proof that stresses actually cause’s heart disease but it can contribute to the symptoms. It is like a trigger, setting things off. Stress is a state of mind, not an illness, so it is difficult to obtain a precise measurement of it. We all feel stress but it affects us in different ways and we respond differently. Under stress people may smoke or drink more, overeat for comfort or have slightly higher blood pressures. Stress can be fun as well as unpleasant, for example watching a close team match or taking part yourself in team games. A sudden acute stressful incident is the most dangerous (such as a near-miss on the motorway) but usually cannot be avoided. Stress interacts with your chances of developing heart disease and can make them worse.

Question: Will I be able to recognise the symptoms of dangerous levels of stress?

Answer: Symptoms will vary but, in general, when stress is detrimental, you will become tense, nervous and often afraid; you may sleep badly, wake early and have tension pains in the muscles of the neck or back.

Question: Is there any way I can reduce my stress levels?

Answer: Yes, there are various ways you can help yourself.

• Try to remove yourself from a stressful environment for some of the day. If work is stressful, go for a walk at lunch time. Keep physically active.

• Don’t rely on caffeine or alcohol and don’t smoke.

• Learn that you cannot solve all life’s problems alone and that they are not all caused by you.

• Try relaxation tapes, yoga or deep breathing exercises. These work well for some people.

• Spend less time with people who irritate you.

• Try to avoid rush-hour travel (leave for work earlier and walk the last mile or so).

• Talk through any problems at work or with friends (don’t repress them and let them fester).

• Avoid over-commitment – be positive but don’t be afraid to turn things down.

• Don’t rush about; take your time, plan what you are going to do and follow it through – again be positive and don’t be deflected.

• Most of all, keep life in perspective – yesterday is gone, tomorrow hasn’t happened, just get on with today and enjoy it.

The most important therapy is your own. Look at what you are doing and ask what your priorities are. If you had one day left in your life, would you shout and yell in traffic, or swear at the railway guard because the train is late (again!), or would you spend time with your loved ones, telling them how much they mean to you. Take deep breaths and keep the world in proportion. If you must do something, punch a pillow but laugh at yourself as you do it!

Really stressed people usually have other psychological problems which benefit from counselling or a support group. If you are unlucky enough to have a heart attack, a ‘cardiac rehabilitation programme’ is invariably helpful. It provides expert help and support as well as guidance on exercise and a healthy lifestyle. It is usually run by nurses who understand your fears and worries, and can help you regain your confidence.

Diffuse your feelings by using art, music, dance and exercise as a relief valve. There are many videos, tapes and books on stress man - agement which people have found useful. Any relaxation technique will help. Yoga is a very useful exercise and is an ideal way to wind down and relax. Take evening classes which will allow you to meet others and get away from your normal daily routine. Above all else, remember that by bringing stress under control you will not only benefit your heart but also improve your outlook on life, allowing better and more complete relationships with loved ones, friends and colleagues at work.

Question: Why is so much emphasis placed on stress in the media?

Answer: There is a lot of money in stress management and it is an easy diagnostic dustbin. If you have a funny illness, it’s ‘a virus’; if you can’t explain something, it’s ‘stress’!

Question: I have read about type ‘A’ and ‘B’ personalities having an effect on the heart. What is the difference between them?

Answer: Some psychiatrists divide the world into two groups, type A and type B people. Type A people are competitive, intense and driven by success. Type B is relaxed, unhurried and content with their lives and achievements. Type A personality has been linked to heart disease but several studies have failed to establish a direct connection. It may well be the consequences of a type A personality that establish a relationship with heart problems, reflecting the degree of anger and frustration that these people feel rather than their attitudes and activities alone.

Question: Do different emotions affect the heart adversely?

Answer: Anger appears to be the most dangerous emotion, increasing heart strain by raising blood pressure and increasing heart rate. If you are angry, write a letter about the person or problem, expressing your anger, and then tear it up. (Don’t send it!) Yell and shout at a mirror, then laugh at yourself as you regain perspective. Learn to count to 10 slowly, while breathing deeply.

Question: I feel that I am stressed at the end of the day. What can I do?

Answer: You are probably overdoing things and overcommitted. Look at your day: can you organise it better? 

• Does anyone or any issue stress you more? If so, bring it into the open.

• Walk some of the way to work and try to get out at lunch time.

• If you feel trapped in your home all day, make the effort to go out – go window shopping, walk round a shopping mall if it is raining; walk in the park if it’s fine.

• Complete the day with deep breathing exercises, have a warm soak in the bath, clean your teeth and freshen up.

• Read a book, do crosswords, work on a hobby project, or ‘surf the net’ and think about your priorities.

• If you have a pet, pat it or stroke it – play with the cat, or walk the dog.

Stress is usually present when emotions are bottled up and everything gets out of perspective.

10.3 Diabetes

 Question: I have had diabetes for 30 years. What is the effect of diabetes on heart disease?

Answer: People with diabetes do have more heart disease than those without. Whilst very good and strict sugar control may reduce some of the risk, this is undone by an increased number of hypoglycaemic attacks. Although you can’t help having diabetes and, unfortunately, it cannot yet be cured, you can help the other factors that cause heart disease. Do not smoke, keep as fit as you can and avoid getting overweight; keep your cholesterol in check and aim for a normal blood pressure.

Many doctors routinely put people with diabetes on statins to reduce the risk no matter what their cholesterol level is.

Question: I have diabetes and have now been told that I have insulin resistance and am at risk of heart disease – what is insulin resistance?

 Answer: Normally, when you eat food, your blood sugar (glucose) levels go up; your body produces insulin as a response; insulin helps glucose to be taken up by the tissues, the glucose in your blood falls, and then your insulin level falls. It is called a negative feedback mechanism. If you are insulin-resistant the action of insulin in the tissues is less effective than it should be and glucose (sugar) is not used properly, so the sugar and insulin levels remain raised because the feedback is interrupted. Insulin in high levels can raise the blood pressure, cause salt and water retention and raise LDL (‘bad’) cholesterol and lower HDL (‘good’) cholesterol. Therefore, yes, insulin resistance can increase your risks of developing heart disease. Being overweight, particularly abdominal obesity (a fat belly), is associated with or causes insulin resistance and Type 2 diabetes. By reducing weight, both diabetes and insulin resistance can be controlled or even overcome. It is more common among Indo-Asian people. Besides reducing your weight, you can also take medications to lower insulin resistance such as metformin or other anti-diabetic drugs.

10.4 Illegal drugs

 Question: I worry that my teenage daughter might have access to drugs. Do illegal drugs affect young people’s chances of heart problems?

Answer: Cannabis (or ‘pot’ or marijuana) increases the heart rate and blood pressure as well as body temperature. It also contains carbon monoxide in the smoke. Although it can help some medical problems, for example, the nausea of cancer therapy, severe pain and multiplesclerosis, heart problems is not one of them and it is therefore not recommended.

Cocaine (‘crack’) is a powerful addictive drug which can cause blood vessels to shut down go into spasm. It can raise blood pressure, cause strokes and lead to severe heart disease, provoking irregular heartbeats, inflaming heart muscle and causing heart attacks. Just one ‘fix’ can do it – my advice is don’t try it.

You may have heard that morphine helps the heart. It is not that simple. Children may begin with the idea of taking heroin (related to morphine) in small amounts and keeping it under control, but the addiction takes over, infection risks rise (from dirty needles or impure products), the heart valves can become severely damaged and the heart, overwhelmed by disease, gives up functioning properly. This leads to heart failure, resulting in a rapid and inevitable premature death. If you think your child may be addicted, seek help. Help is available for recovery but an addict needs to admit to addiction, want to end it and accept help from professionals.

Ecstasy has been very much in the news. Taking even one ecstasy tablet is akin to committing suicide. It may cause a very high fever, irreversible brain damage and heart failure.

 10.5 Women and coronary heart disease

 Question: I am a mother aged 53. I am concerned to read that coronary heart disease is a major risk for me. Isn’t this a man’s disease?

Answer: Of the deaths from heart attacks each year, nearly half are in women. All forms of heart and blood vessel diseases added together claim twice as many women’s lives as do all forms of cancer. Although fewer women have heart disease than men at the age of 50, they have caught up by 65–70 years of age. The main difference between men and women as regards heart disease is not if they are going to get coronary disease, but when; the difference in its timing is about 10 years.

Coronary heart disease is therefore your – and other women’s – biggest problem too. It is becoming more of a woman’s disease as women tend to live longer; coronary disease is partly a problem of getting older, so more women will eventually develop it. The problem is going to increase as the population ages in general. More men and women are now surviving heart attacks, so they are likely to encounter heart problems later – an increased chance of angina or a further heart attack, unless they try to reduce their risks. Women are more vulnerable to the risks of cigarette smoking and high blood pressure but less so to that of cholesterol. Having diabetes sadly wipes out any advantages that women may have had over men.

Question: My father had heart disease and I am concerned that my daughter might develop heart disease also. I know that she smokes. How can I help her avoid heart disease?

Answer: Your daughter may have an increased risk of heart disease if it runs in your family but one of the best ways to help prevent coronary heart disease is to get her to stop smoking. It is well known that there has been an increase in the numbers of young women smoking; their chances of heart disease in later life consequently are rising. If your daughter smokes, she should stop now. If she is thinking about starting, she should think again!

Question: I have read that women’s natural hormones protect us from heart disease. Is this true?

Answer: To a degree they do, but if you smoke, have high blood pressure or have diabetes, women lose a lot of this protection. Following the menopause, the normal protection that oestrogen gives disappears anyway. “Hormone Replacement Therapy” (HRT) unfortunately does not appear to help.

Question: I have been taking the pill on and off since I was 18. I have just been through the menopause. Am I at any greater risk of heart disease because I have been using oral contraceptives?

Answer: Very few women on the pill (taking oral contraceptives) develop heart disease and the low hormone dose pills do not increase the coronary risk. So long as you do not smoke, the low dose pill may actually protect you against heart problems. In women under 35 years of age we do not know what the risk is from taking the pill, nor do we know about its long-term use (over 5 years), although it is unlikely you will be harmed. Cigarette smoking and also taking the pill is not a good combination and should be avoided at all costs. In general the low dose pills are safe, but smokers should preferably stop smoking, or use alternative contraception.

Question: I have felt well since being on HRT but I am worried about its effect on my heart and the risk of breast cancer – what should I do?

Answer: There is no doubt that HRT helps with the distressing symptom of menopausal flushes and protects against thinning of the bones (osteoporosis). Initial enthusiasm regarding HRT and heart disease has been replaced with sound scientific evidence of a lack of benefit. Currently HRT is not recommended as a treatment to prevent heart disease developing or to benefit women who have heart disease already. If coronary disease has been diagnosed, other protective treatments should be used – for example statin therapy. Some studies have suggested HRT can actually increase the risk of heart disease, but this risk does not appear to be present if the cholesterol is normal or a statin is also being taken.

A very big study – “The Million Women Study” – has identified an increased risk of breast cancer if HRT is taken for 5 years or more. We are looking at 1 extra case of breast cancer in 166 women treated for 5 years or 1 extra case in 53 women treated for 10 years. There is no need to panic about these figures, but clearly women on HRT for many years should see their family doctor about discontinuing.

The HRT story is a sad journey from the belief of benefit to the proof of potential harm. There is no role for HRT in women who do not have menopausal symptoms (such as flushes). When flushes are a problem (this happens in 10–20% of women), the risks must be weighed against the benefit, and HRT used for as short a time as possible.

Most women are on combined medications of oestrogen and progestogen but, if they have had a hysterectomy (removal of the womb), they will be on oestrogen alone. All increase the breast cancer risk. With regard to the heart, we are not sure about oestrogen alone but, with all the information we have, HRT cannot be considered a treatment for heart disease.

Whether this advice will change when we know more about raloxifene (see next question) is debatable, but it is obviously important to continue research in this area and advise women on upto-date scientific facts.

Question: I have read in the paper about a new drug called raloxifene – what advantage does this have?

Answer: Raloxifene is one of a class of drugs called “Selective Estrogen (American spelling) Receptor Modulators, or SERMS”. Tamoxifen is the one we already have but tamoxifen can sometimes, as a side effect, cause the uterus (womb) lining to overgrow and become troublesome. Raloxifene acts the same as tamoxifen in benefiting the heart and bones, avoids breast cancer risks and does not affect the womb. It is an important drug but like tamoxifen does not reduce hot flushes. It may be an important advance in HRT for women because it looks to have the major benefits without the major risks. A lot of research is taking place to determine how valuable it will be to the heart – proof is not yet available, but early results do not show any harm.

Question: Does HRT have any side effects?

Answer: All medication can give side effects and HRT is no exception. You may feel nauseous but it usually goes after 2 weeks or so – taking tablets after a meal can help this. Breast tenderness and swelling may occur and, again, wear off. If they are persistent, you may be given a different form of HRT to try.

Women worry about gaining weight whilst on HRT. The many research trials do not report weight gain but you should remember that everyone is an individual and if you gain weight, it is you that matters, not the statistics. It is probably due to eating more as you feel better on HRT! Watching your weight is important anyway, so at this time take note of what you are eating and make sure that you take plenty of exercise.

On average, women take 3 months to settle into their HRT therapy.

Question: Does HRT raise blood pressure?

Answer: Very rarely. Your doctor or nurse will always check your blood pressure when HRT is prescribed. If you have high blood pressure, you can still take HRT because the chances of your control being upset are so small.

 Question: I have breast cancer which is now controlled, and I have also had a heart attack – will HRT help me?

Answer: It will not obviously help the heart and it could make the breast cancer worse, so it is not recommended. HRT is not an alternative to proven heart attack treatments.

 Question: What sort of HRT therapy is available?

Answer: The choice of therapy is best discussed with your doctor. There are two sorts: the first is oestrogen only and this type is for women who have had a hysterectomy (removal of the womb) – this is known as ‘unopposed oestrogen’. The second type is ‘combined’ HRT (containing oestrogen and progesterone) for women who still have a womb, because oestrogen alone in these women will cause excess stimulation of the lining of the womb.

Question: I have been advised to go on HRT but I am resisting as I have read that it doubles your chances of getting blood clots in the legs – is this true?

Answer: Yes, this is true. Your normal risk of getting a dangerous blood clot is 1 in 10 000 and it increases to 2 in 10 000 on HRT. So the risk is very small and remains very small on HRT. The risk is higher in those over 60 years of age, but HRT is rarely started in this age group. Smoking and being overweight increase the risk. Talk to your doctor about this, if you think that you may be at risk.

Question: I’m fit and active with no risk factors for heart disease – will I benefit from HRT?

Answer: If you have no risks for heart disease, HRT will not improve this as your risk is very low anyway, but you may benefit from HRT by avoiding osteoporosis (thin bones). This is more common in slim women. HRT also helps to relieve hot flushes. Check with your doctor about the possibility of having a bone density scan if you think you may be at risk for osteoporosis.

Question: From the point of view of heart health, who will benefit most from taking HRT?

Answer: No one.

Question: I have been taking HRT for 7 years and I think that it is wonderful – I now feel a new woman! However, my doctor says that I should stop it soon. How long should I continue taking HRT?

Answer: HRT is usually taken for hot flushes for up to 5 years. Bone benefits continue on beyond 10 years, but the breast cancer risk increases. So, at present, we recommend HRT is stopped.

Question: I’m on HRT at the moment. Do I need regular check-ups?

Answer: It is very important that you attend for regular check-ups at first every 3 months and then 6-monthly, and follow your doctor’s instructions. For these check-ups, make a note of any queries or concerns that you might have and discuss them with your doctor.

Question: I have been on oral HRT for some months and my doctor has arranged for me to have a lipid test. Why?

 Answer: The doctor is checking to make sure that you are not at risk of heart disease, which is good medical practice. Up to the menopause, women usually have a raised high density lipoprotein level (HDL) (greater than 1.3) which helps protect them from coronary disease.

This HDL gradually falls after the menopause unless HRT is taken. It is important that women should always have a ‘full lipid profile’ taken (HDL as well as LDL) because a high total cholesterol may reflect good (HDL) rather than bad (LDL) cholesterol levels. Reducing your total cholesterol in this situation might reduce the protective HDL and be counter -productive.

A full lipid profile will also tell you about your triglycerides. Oral HRT can raise triglycerides, but HRT patches have no effect on triglyceride levels. A high triglyceride level is more of a risk in women than in men; the best means of lowering it is by weight loss and regular exercise, along with a low saturated fat diet. An underactive thyroid and too much alcohol can also be a cause.

Question: I do find the advice on HRT confusing – can you clarify it for me?

Answer: I’ll try, but we doctors find it confusing too!

• HRT definitely helps menopausal symptoms, e.g. hot flushes.

• It definitely helps prevent thin bones (osteoporosis).

• It does not protect against heart disease developing.

• In those with coronary disease, it does not benefit them, so it is not a treatment for heart disease.

• In those with heart disease, it still helps menopausal symptoms and osteoporosis.

• HRT increases the risk of breast cancer.

• Overall, HRT is indicated only if menopausal symptoms are severe and intolerable. It is then given for as short a time as possible and at as low a dose as possible.

Question:  I’m concerned that my wife is at risk of heart disease and I want her to take it seriously; she smokes and is rather well padded! However, her doctor does not seem to be bothering either. What should I tell her?

Answer: You should point out that women are just as vulnerable to coronary disease as men. Some women don’t recognise this and play down any symptoms of chest discomfort. They usually put their family first. Sometimes they might hide things from the doctor, which makes diagnosis difficult for both angina and a heart attack. Your wife and every other woman should take heart disease seriously and her doctor, like all doctors, should recognise that women with a mixture of symptoms need taking seriously. Women may be reassured too easily because most women believe themselves to be less likely to have heart disease than men. Post-menopausal women are at more risk and, even when the symptoms are not typical, these should be discussed and heart disease ruled in or out.

Women are just as likely as men to develop coronary disease if they smoke and just as likely to benefit if they stop. Keeping to a sensible weight and taking regular exercise are also important preventative measures. Tell her that heart disease is an equal opportunity killer and that she should do her best to avoid it for her sake and that of her family.

Each year in the each country of EU around 350 000 people visit their doctor for angina. Over six million people in America and two million in the United Kingdom are affected. Angina (pronounced ‘ann-jy-na’) is a symptom of a problem, not a disease in itself. It is usually caused by narrowing of the coronary arteries by atheroma. It can also be caused by a high blood pressure, disease of the aortic valve, severe anaemia, and rapid palpitations or a mixture of conditions. Far and away the commonest cause is coronary artery disease.

The coronary arteries supply oxygen to the heart and the heart gets this supply between its beats, when it is refuelling itself. This means that the faster your heart beats, the less oxygen there is for the heart.

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