How do I know if I have heart disease?
It’s a simple question, but difficult to answer. That’s because the damage to coronary arteries that leads to plaque growth, or atherosclerosis, is generally for a long time a silent disease.
For years, indeed, decades, most of us feel no pain. Nothing is telling us that the walls of our arteries are suffering from inflammation and injury, and filling up with plaque.
For many people, the first time they learn they’re in trouble is when they have a heart attack or stroke.
That’s why it is so important to attempt to identify and evaluate the presence of atherosclerosis in the coronary arterial circulation.
There are several ways to do so, which this article describes. All have pros and cons.
The simplest way is the evaluation of the risk factors for the development of coronary artery disease. These risk factors include those we have no control over, such as family history, as well as those that we are able to modify and improve, and in doing so, decrease heart disease risk.
There are many modifiable risk factors, including:
High LDL cholesterol
Atherosclerosis is caused by the long-term deposition of circulating blood cholesterol (primarily low-density lipoprotein or LDL, also known as “bad or “lousy” cholesterol) in the artery wall, resulting in inflammation and plaque build-up. The higher the LDL cholesterol concentration in your blood, the more plaque you are likely to have, and the more inflamed your artery walls become, leading to progressive vessel blockage and weakness. Chemical oxidation of the LDL particle (which means the LDL particle turns rancid) makes it more toxic to cells and speeds up the damaging process.
High glucose (blood sugar) can also accelerate injury to our artery walls.
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Other risk factors that damage the artery wall and increase the risk of a heart attack or stroke include:
- High blood pressure (hypertension)
- Carbon monoxide from cigarette smoke
- Increased tendency towards blood clotting
- Remnants of triglycerides, called VLDL and chylomicrons, that flood the blood right after a fatty meal and promote the growth of cholesterol-filled plaques
- Increased clotting Factor VII (increased by dietary fat)
- Increased fibrinogen, a precursor of fibrin that traps red blood cells to form clots
- Elevated platelet counts
- Elevated CRP levels, which are associated with inflammation that weakens and destabilizes plaques, leading to plaque rupture and a heart attack
- Excess weight, especially abdominal (belly) fat
- Stress associated with anger and hostility, both external (by directed) or internalized (known as depression)
- Sedentary lifestyle
Assessment of key risk factors can be applied to a computerized score regarding the probability of a coronary event occurring over a defined period of time. For the most accurate assessment, make an appointment with your cardiologist.
As a prelude to your consultation with your physician, consider taking the “Heart Attack Risk Calculator,” created by the American Heart Association, which estimates your 10-year risk of heart attack or dying from coronary artery disease.
The Pritikin Program for Risk Modification
The Pritikin Program of diet and exercise works to improve modifiable risk factors and prevent atherosclerosis and heart attacks and strokes in many different ways.
The Pritikin Eating Plan is:
- Very low in saturated fatty acids, trans fatty acids, and dietary cholesterol. All three tend to raise LDL cholesterol,
- High in water-soluble fiber (such as pectin and gums) that lowers LDL cholesterol,
- Rich in a variety of plant-based substances that slow the oxidation of the LDL cholesterol particles,
- Effective in reducing platelet aggregation (the clumping together of platelets) and clotting,
- Helpful, in combination with exercise, in lowering blood sugar in insulin-resistant diabetics and reducing the tendency for blood to clot,
- Helpful, combined with exercise, in lowering triglycerides and other blood fats that promote heart disease, and concomitantly raising the high-density lipoprotein level, HDL, or so-called “good” cholesterol,
- Effective in reducing CRP levels and other inflammatory markers.
The pros of risk factor evaluations are the noninvasive computation of probability. The cons: Risk factor evaluations obviously lack the specific imaging of the arteries themselves.
A reasonably accurate assessment for the presence of atherosclerosis in the arteries of the heart is a radiographic study called the Calcium Scoring CT scan of the coronary arteries.
If the scan is positive, it identifies the presence of plaque in the arteries. Plaque, as it matures, absorbs calcium from the blood stream, permitting imaging by X ray.
Unfortunately, CT scans may not identify the most dangerous form of plaque: young and unstable “soft” plaque. This tender plaque (often described as “vulnerable” plaque) is the type most likely to rupture, triggering an acute clot and closure in an artery of the heart. The older, calcified plaques are much less likely to burst.
However, if your CT scan is positive, it does identify the presence of atherosclerosis. Chances are that where there are calcified plaques, there are also younger, softer plaques in the artery walls. A positive scan, in short, indicates aggressive management of risk factors, and possibly, medication.
Another benefit of the CT scan is that it has minimal radiation exposure.
Additional technologies to assess the presence of atherosclerosis exist, including a more detailed radiographic study called a Computerized Tomography Angiography of the coronary arteries.
A Computerized Tomography Angiography combines a CT scan with an infusion of an iodine dye, called contrast material, that produces pictures of the inner walls of the arteries. The contrast is injected through an intravenous line (IV) started in your hand or arm.
A Computerized Tomography Angiography involves significant radiation exposure. Other risks include allergic reactions to the contrast material, as well as tissue damage if a large amount of contrast material leaks around your IV site. Angiography contrast material may also damage kidneys, so you may not be able to have this test if you have diabetes or kidney disease.
A variety of new and more exotic technologies, including Positron Emission Tomography (PET) scans, are also available.
A PET scan is an imaging test that uses a radioactive substance called a tracer to determine whether areas of your heart muscle are receiving enough blood, or if there is damage and/or scar tissue in the heart.
Most of these technologies, unfortunately, include significant radiation exposure.
Many people are aware of or have undergone a graded exercise test (GXT), often called the treadmill stress test. This test evaluates functional work capacity and monitors changes in blood pressure and the heart’s rate and rhythm when exercising at progressively increasing workloads. Your electrocardiogram (EKG) is continuously monitored for changes. A GXT may also reveal cardiac abnormalities that may not be apparent at rest.
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Other options also exist, such as nuclear stress testing. Nuclear stress testing is similar to the GXT, but in addition, it involves injection of a radioisotope (a radioactive substance) that absorbs into the muscle of the heart in relation to its circulation (perfusion). It provides images that may reveal areas of low blood flow through the heart as well as damaged heart muscle.
Another form of stress testing is stress echocardiography. It uses ultrasound imaging to show the motion of the contracting heart muscle, and, in doing so, helps determine how well your heart muscle is working to pump blood to your body. Like nuclear stress testing, stress echocardiography is often used to detect a decrease in blood flow to the heart, the result of atherosclerosis.
There are also studies that stimulate the heart chemically rather than by exercise.
“How do I know if I have heart disease?” | Summing Up…
Ultimately, the decision regarding specific testing should be made after discussion with your physician. There is no substitute for thoughtful assessment of the effect the test’s results would have in both lifestyle improvements and possible use of medication.