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With heart disease, the biggest risk factor is that it can be hidden

TV pitchman and Tampa resident Billy Mays died unexpectedly on Sunday at age 50. The suspect: heart disease, according to the Hillsborough County medical examiner. Yet Mays reportedly had no idea he had a problem.

The same day, Jeff Swanagan, who turned around the financially foundering Florida Aquarium, died of an apparent heart attack at age 51.

Last week, local lawyer Glenn Burton died at 51 of cardiac arrest after collapsing at the wheel of his car. And of course, Michael Jackson died one week ago today at 50, from cardiac arrest. Autopsy results, including whether he was abusing prescription drugs, are pending.

It may seem shocking to you and me when a man's heart gives out so young. But physicians say they see it all the time.

Dr. Peter Wassmer, a St. Petersburg cardiologist with the Heart and Vascular Institute of Florida, answered questions a lot of us have been asking.

What causes a sudden cardiac death in someone who had no symptoms?

"We've known for years that in a lot of cases the first symptom of heart disease is death. In 20 percent of those cases it's the younger men, less than 60, that this happens to, not the older men, in their 70s and 80s. These younger men probably had a lot of risk factors. What really happens is there's plaque in the coronary vessels that ruptures. The body tries to seal up that rupture with blood clots. That blocks the vessel, and the heart suddenly goes into a bad rhythm, known as fibrillation, and that's what they die from.''

What triggers the rupture?

Stress and nicotine use are just two possibilities, Wassmer said.

A report from Harvard University medical school says anger, heavy physical exertion, sexual activity, grief, natural disasters or simply waking from sleep can trigger a heart attack, cardiac arrest or stroke.

When does plaque start forming? Can you have it and not know it?

"We know from autopsies done on Korean War GIs in their 20s that they already had significant blockages in their vessels."

How do you know if you are at risk?

"Most important is checking cholesterol. That gives you a good idea if you are at risk for early heart attacks. You should get it done in your 20s, especially if there's a family history of early heart attacks. Then check it every five years until you reach age 40, then every year or two. If you have high cholesterol, address it. Treat it. Don't ignore it.

"Also check your family history; parents, brothers, sisters who had a heart attack before age 60 or 65 increases your risk. So does smoking, uncontrolled high blood pressure, diabetes, obesity, inactivity and, of course, poor diet."

How does high blood pressure cause death?

"Hypertension causes plaque to rupture. Imagine 50-year-old plumbing in your kitchen sink. There's probably some crud in the pipes. Turn on the water slowly and you probably won't disrupt the crud, but turn it on full force and it's going to crack open that crud and move it along. If you have high blood pressure, you're creating stress on that crud, that plaque, making it prone to rupturing."

(High blood pressure also means the heart is working too hard, which can cause the ventricular wall to thicken, as the coroner noted in Mays' case.)

How bad does blood pressure have to be to kill you?

"A lot of patients don't feel it until it's extremely high. That's the problem. 130 over 80, or less, is recommended by the American Heart Association and the American College of Cardiology. At 140 over 90 it ought to be treated. You're at increased risk for heart attack and stroke. Above 160 over 100 or 110 and you're talking stroke or congestive heart failure."

What do you do to protect yourself, besides a diet low in saturated fat and salt, and regular exercise?

"First prevent it from happening. Prevention is key. If you smoke, you are a walking time bomb. Quit. If you are a diabetic, you need to be treated early and aggressively. If your cholesterol is bad, try changing your diet and exercising for three months. If it doesn't budge, you need to be on a statin (a cholesterol-lowering drug). We now know we must be aggressive early on to prevent a heart attack or stroke. A lot of people don't like to take medication, but if you have risk factors, you should. Statins stabilize plaque, making it less prone to rupture and reduce first heart attack risk by 40 percent.

"I recommend for my patients with risk factors for coronary artery disease a baby aspirin a day. With women the benefit is less clear, but for men, at least a baby aspirin a day may lower their risk for heart attack or stroke. Talk to your doctor first, definitely."

Are there screening tests we should be asking for?

"It depends on their risk factors and symptoms. A lot of guys who die of a heart attack wouldn't have shown a problem on a stress test. So routine stress tests are usually not indicated without risk factors. But consider an hs-CRP (high sensitivity C-reactive protein) blood test. It looks for markers for inflammation in the body. It can help determine your risk for heart disease."

Any others?

"I would also get a CT scan or MRI of the coronary blood vessels because it can help identify asymptomatic patients. Anybody who has a significant family history and risk factors for heart disease may benefit. The downside is there's a certain amount of radiation exposure, like having 60 chest X-rays, but the newer machines have less radiation and can scan you in 10 to 20 seconds. Also, cost can be a factor. It can be $400 to $500 out of pocket. But it picks up plaques that are small and new. If you ask me, it's well worth the expense and some insurance plans will cover it."

If you do that test and find plaque, what's the next step?

"That's the dilemma. I would be very aggressive and put patients on aspirin, get them on a statin, make sure they stop smoking, change their diet and exercise. If the blockage is over 70 percent maybe we would do angioplasty and a stent to prevent a heart attack."

Irene Maher can be reached at imaher@sptimes.com or (813) 226-3416.

By the numbers

865,000

Annual U.S. heart attacks, defined as a blockage in the blood supply to part of the heart muscle.

300,000

Americans treated by EMS for cardiac arrest, defined as a sudden loss of heart function when electrical impulses in the heart become rapid or chaotic. (Note: A heart attack can cause cardiac arrest, but the two are not the same thing.)

5.7 million

Americans living with congestive heart failure, a chronic condition in which the heart doesn't pump blood as it should.

670,000

New cases of heart failure diagnosed every year.

911

The number to dial if you experience symptoms of a heart attack, typically chest discomfort, shortness of breath, nausea, discomfort in the arm, neck or jaw. Atypical symptoms can include a cold sweat, back pain and lightheadedness.

Source: American Heart Association

More on heart scans

We also talked to Dr. Vibhuti Singh, director of cardiology and cardiac catheterization at Bayfront Medical Center in St. Petersburg about the idea of using CT scans to screen young men for early heart disease:

"The official guidelines from the American Heart Association and the American College of Cardiology haven't said to use it as screening tool, it might be too expensive,'' Singh said.

"But the scan picks up calcium and blockages with 90 to 95 percent accuracy. My feeling is, if you have two risk factors for heart disease, then it may be good to use it as a screening tool. Being a man is considered one risk factor,'' along with smoking, being overweight, inactivity, diabetes, high blood pressure, high cholesterol or family history of heart disease.

"It appears to be a very good diagnostic test and only misses 10 percent of the time."

Bottom line?

"For a man in his early 50s, with two risk factors, insurance might even pay for the scan. With no risk factors, I would say if he's worried enough, paying out of pocket — and it could be as high as $1,000 in some of Tampa Bay — it's still doable."


For further information

With heart disease, the biggest risk factor is that it can be hidden 07/01/09 [Last modified: Saturday, July 4, 2009 1:44pm]

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