Most of us have a family member or friend who has suffered a heart attack or a stroke. For some, this was fortunately a one-time event, but if one is not careful the probability is that it can happen again. Many would say: “That could have been me!” But there is a lot we can do to avoid this.
Cardiovascular diseases, which include heart disease – most commonly ischemic heart disease and heart failure, stroke and other vascular conditions – are the leading cause of death in Europe and worldwide.
Heart disease is a common condition in Malta as well and is claiming many lives. In 2015, over 38 per cent of all deaths among both men and women in Malta were related to diseases of the circulatory system, including ischaemic heart diseases, heart failure and stroke.
There are various risk factors linked to heart disease:
• Age (men over 40 and women over 45 are more prone);
• Gender (men are more susceptible);
• Having a family history of heart disease;
• Smoking;
• Hypertension;
• Diabetes;
• Overweight and obesity;
• Unhealthy cholesterol levels – high cholesterol, low HDL cholesterol, high LDL cholesterol, high triglycerides;
• Little physical activity;
• Much physical inactivity (long period of sitting down);
• Accumulation of abdominal fat (what is commonly called the ‘apple’ body shape).
Apart from risk factors that cannot be controlled, like genetics and age, there is a lot that can be done to prevent and manage the threat of heart disease. An important aspect of lowering the risk of heart disease is to manage health behaviours and biological risk factors, such as food quality and quantity, physical activity, physical inactivity level, smoking, body mass index, blood pressure, total cholesterol and blood glucose.
Many people are not aware of the risks of heart disease. In fact, few people maintain moderate levels of risk.
The first step to measure a person’s risk level is to identify the following risk factors so that one can start improving their health. Screening identifies those at risk of future disease of the heart and of other major body organs. It also identifies those with modifiable risk factors, which are reversible and reduce the risk of developing heart disease.
Blood pressure
Blood pressure is one of the most important parameters to be checked since high blood pressure usually has no symptoms – so it cannot be detected without being measured. High blood pressure, also known as hypertension, greatly increases the risk of heart disease and stroke.
A normal blood pressure is below 120/80 mm Hg. One needs to check it out at least once every two years, starting at the age of 20. If the blood pressure is higher, one needs to check it more often. High blood pressure can be controlled through lifestyle changes and/or medication.
Fasting lipoprotein profile (cholesterol)
Criteria for frequency of testing for cholesterol levels vary but most recommend that one should have a fasting lipoprotein profile taken every four to six years, starting at the age of 20.
Small changes done daily can add up to a much healthier life and decreased risk of developing heart disease
This blood test measures total cholesterol, LDL cholesterol (the bad cholesterol) and HDL cholesterol (the good cholesterol). If results are elevated or one has high risk for heart disease, then one will need to be tested more frequently. Similar to hypertension, high cholesterol levels can be controlled through lifestyle changes and/or medication.
Body weight
High Body Mass Index (BMI) and high waist circumference increase the risk of heart disease, stroke, atrial fibrillation and congestive heart failure. It is important to measure these to identify if a person has a healthy body weight.
Blood glucose
High blood glucose levels put a person at greater risk of developing insulin resistance, prediabetes and Type 2 diabetes. Untreated diabetes can lead to many serious medical problems, including heart disease and stroke. If a person is overweight and has at least one additional cardiovascular risk factor, it is recommended to check the blood sugar levels – which is usually done by fasting. Another test – glycated haemoglobin A1c levels (A1c percentage) – is useful to estimate risk of prediabetes or diabetes.
The American Diabetes Association recommends regular screening for diabetes risk at the age of 45, with repeated tests at least every three years.
Smoking, physical activity, diet
If you smoke, your healthcare provider can support you to quit. Eating a healthy Mediterranean diet and undertaking 30 minutes of daily physical activity can improve your lifestyle and decrease the risk of heart diseases.
Various evidence-based tools have been developed to evaluate cardiovascular disease risk. The best known global cardiovascular risk assessment tool is the Framingham Risk Score, whereby an asymptomatic individual is classified in accordance to the risk of having a vascular event (heart attack and coronary death) as follows:
• Low risk, corresponding to less than 10 per cent risk of vascular events over a 10-year period;
• Intermediate risk, corresponding to 10-20 per cent risk of vascular events over a 10-year period;• High risk, corresponding to more than 20 per cent risk of vascular events over a 10-year period.
This assessment should be done every five years, starting from the age of 18. More frequent assessment is recommended for people who are diabetic, chronic smokers or obese. This assessment is based on the various risk factors outlined.
Further screening tests may be required for people who are at moderate and high risk without any symptoms. These include a Resting Electrocardiogram (ECG), which is recommended for certain individuals, and cardiovascular screening in asymptomatic people with high blood pressure. An exercise stress test is recommended in individuals without symptoms – in men aged over 45 and women aged over 55 who plan to start vigorous exercise, and in men older than 45 and women over 55 who are at high risk due to concurrent diseases and in those with diabetes who plan to start vigorous exercise.
A coronary artery calcium score is recommended in patients who have atypical chest pain to rule out ischaemic heart disease. Cardiac stress imaging (stress echocardiography) is usually reserved for individuals with an abnormal exercise ECG. The use of CT coronary angiography as a screening test in asymptomatic individuals is still uncertain.
Small changes done daily can add up to a much healthier life and decreased risk of developing heart disease. Evidence shows that losing 10 per cent of excess body weight can dramatically lower the risk. Taking walk breaks at work, scheduling a walk with the family after work or during weekends, exercising with a friend or family member, actively playing with your pet and children and taking the stairs instead of the elevator are initial changes to the daily routine.
Aim for 30 minutes of physical activity on most days of the week and fit in strength and flexibility training on two days per week. Adding wholegrain foods to your diet can easily be done; eat red meats occasionally, eat white meat from chicken or fish in small portions, add nuts and avoid processed foods, sugar-sweetened beverages and sweets, and eat at least five servings of fruit and vegetables each day.
Early detection of risk factors prevents complications such as heart failure, stroke and kidney and artery disease. So, take action and work on reducing your risks. Advice and support on lifestyle is available from the Health Promotion and Disease Prevention Directorate and the Lifestyle Clinics in Primary Care.
Dr Charmaine Gauci is Superintendent of Public Health.