Coronary Artery Disease: 11 Ways to Cut Your Risk
The more risk factors you have for coronary artery disease, the greater your chance of developing it. While you can't control every factor, such as having a family history of the condition, there are many elements you can do something about. Here are 11 ways you can cut your risk of developing coronary artery disease.
1. Quit smoking
Cigarette smoking is a dangerous risk factor not only for lung cancer but also for coronary artery disease. Smoking decreases high-density lipoprotein (HDL, or good) cholesterol levels. It also damages arteries and promotes atherosclerosis and blood clot formation.
Fortunately, if you stop smoking, you can dramatically decrease your coronary artery disease risk. Even if you have smoked for many years, if you quit, you can cut your chances of having a coronary heart disease event (such as a heart attack) in half within a year or two of quitting.
Even if you’re a nonsmoker, inhaling secondhand cigarette smoke makes blood platelets stickier and more likely to form blood clots—after only brief exposure. Some studies show that secondhand smoke also damages the endothelial cells lining the arterial walls, which promotes atherosclerosis.
2. Control high blood pressure
High blood pressure (also called hypertension) affects nearly one in three adults. It is called a silent killer because it usually has no warning symptoms—at least initially—but it can wreak havoc on your body nonetheless, damaging blood vessels and making your heart work harder.
For this reason, you need to have your blood pressure checked regularly by a doctor so that high blood pressure can be detected before it causes serious damage.
A recent government study estimated that of the 77 million Americans with hypertension, more than half did not have their condition under control—and some weren’t even aware they had hypertension.
Blood pressure is normal if it is less than 120/80 mmHg (millimeters of mercury). The top number (120) is your systolic blood pressure; it is the pressure in the arteries while the heart is pumping blood. The bottom number (80) is your diastolic blood pressure; it indicates pressure in the arteries while the heart relaxes between beats.
If your blood pressure is above normal, you have a greater risk of developing coronary artery disease. There are two types of above-normal blood pressure: prehypertension and hypertension. Prehypertension is systolic pressure between 120 and 139 mmHg or diastolic pressure between 80 and 89 mm Hg. People with prehypertension are more likely to develop high blood pressure. Hypertension is diagnosed when systolic blood pressure is 140 mmHg or above or diastolic blood pressure is 90 mm Hg or above.
Whether you have prehypertension or hypertension, lowering your blood pressure not only will reduce your likelihood of developing coronary artery disease but also can lower your risk of having a heart attack or stroke, or developing heart failure. Lowering high blood pressure can also slow the progression of kidney disease.
If you are over age 50, you should pay particular attention to your systolic blood pressure. Research shows that elevated systolic blood pressure is a significant threat to heart health.
The Systolic Blood Pressure Intervention Trial (SPRINT) found that maintaining systolic blood pressure in the 120 to 125 mm Hg range was associated with significantly fewer atherosclerotic cardiovascular disease events (such as heart attack or stroke) than keeping it in the 135 to 140 mm Hg range.
3. Manage high cholesterol
Your doctor has probably measured your blood levels of cholesterol and triglycerides. These substances are lipids (fats) carried through your bloodstream on proteins called lipoproteins. The two types of lipoproteins that carry cholesterol to and from cells are low-density lipoprotein, or LDL, and high-density lipoprotein, or HDL. LDL is considered the "bad" cholesterol because it contributes to plaque, while HDL cholesterol is considered “good” cholesterol because it helps remove LDL from the arteries.
Blood cholesterol is transported primarily on LDL, but a small amount is transported on HDL; blood triglycerides are mainly carried on very-low-density lipoprotein (VLDL). High blood levels of total cholesterol, LDL cholesterol, and triglycerides and low levels of HDL cholesterol increase your risk of coronary heart disease.
The American Heart Association and the American College of Cardiology issued updated guidelines in 2013 for managing high cholesterol. These guidelines have moved away from starting cholesterol-lowering statin therapy primarily based on baseline and target LDL levels.
Statin therapy is now based on overall cardiovascular risk for heart attack or stroke. This represents a major shift from previous guidelines, which set specific levels of total, LDL, and HDL cholesterol to be reached in order to reduce heart attack risk. In addition, the previous guidelines did not include an assessment for stroke risk.
If you have diabetes or a history of cardiovascular disease, you should be on a statin. Here are other components to consider for coronary artery disease treatment.
• Total and LDL cholesterol. High levels of total and LDL cholesterol increase the likelihood that cholesterol will be deposited within the artery walls. The previous recommendation was to keep your total cholesterol level at less than 200 mg/dL to reduce the risk of coronary heart disease. More than 40 percent of Americans have levels of 200 mg/dL or higher; long-term observational studies suggest that even a 10 percent decline—for example, from 220 mg/dL to 198 mg/dL—may decrease the risk of a heart attack by about 20 percent.
With the latest guidelines, if you have no known history of cardiovascular disease, your total cholesterol level is one factor taken into account when your doctor calculates your overall risk for a heart attack or stroke over the next 10 years. An individual whose risk is 7.5 percent or greater is likely to be placed on a cholesterol-lowering statin after a detailed discussion with his or her doctor, regardless of the patient’s initial LDL level.
Statins are also recommended for people whose LDL cholesterol level is unusually high. The guidelines specify statin use for adults over age 21 with an LDL cholesterol level of 190 mg/dL or higher. The dosage prescribed will depend on an individual’s risk level.
• HDL cholesterol. Since HDL removes cholesterol from artery walls, a high—rather than a low—level helps protect against heart attacks. An HDL cholesterol level below 40 mg/dL in men or less than 50 mg/dL in women is a risk factor for a heart attack. Your HDL level will be taken into consideration when your doctor calculates your risk for a heart attack or stroke.
A risk assessment calculator included with the guidelines also takes into account your age, gender, race, blood pressure, use of blood pressure medication, and whether or not you have diabetes or smoke.
• Triglycerides. The optimal level for triglycerides, as defined by a 2011 statement from the American Heart Association, is less than 100 mg/dL. A desirable goal for triglycerides is to keep them below 150 mg/dL.
Triglyceride levels between 150 and 199 mg/dL are borderline high, levels between 200 and 499 mg/dL are high, and levels of 500 mg/dL or greater are very high. The recent guidelines recommend further evaluation in people with very high triglyceride levels to determine whether a secondary cause, such as untreated diabetes, is responsible.
High triglycerides pose a greater risk in women than in men, and the coronary heart disease risk of elevated triglycerides is even higher if you also have low levels of HDL cholesterol and a predominance of small, dense LDL particles or abnormally high blood levels of insulin (hyperinsulinemia). Excess triglycerides in the blood may interfere with the normal widening of coronary arteries that occurs during physical exertion and may increase the risk of blood clots.
• Small, dense LDL particles. The size and density of LDL particles can affect your coronary artery disease risk. People with high blood levels of small, dense particles have a higher risk of coronary artery disease than those with mostly large LDL particles.
• High lipoprotein(a) levels. High levels of this lipoprotein, also known as Lp(a), are another risk factor for coronary artery disease. Lp(a) has a structure similar to LDL, but on its surface is a protein called apolipoprotein(a) that resembles the blood protein plasminogen. Because of this similarity, Lp(a) may interfere with the conversion of plasminogen to plasmin, an enzyme that helps dissolve blood clots by breaking down fibrin (a major component of blood clots).
Elevated levels of Lp(a) are of particular concern for people who also have high LDL cholesterol levels. Unfortunately, Lp(a) levels are difficult to lower, although some individuals are able to achieve modest reductions with high doses of niacin. An aggressive lowering of LDL cholesterol is generally advised to neutralize the risk of having a high Lp(a).
• High apolipoprotein B levels. Apolipoprotein B (apo B) is a protein present on the surface of LDL and VLDL particles. Studies suggest that high apo B levels are even more strongly linked to a risk of heart attacks than high LDL cholesterol when the triglycerides are elevated or the HDL cholesterol is low.
4. Lose weight
An estimated 69 percent of adults in the United States are either overweight or obese, and their excess weight increases their coronary artery disease risk. Additionally, as weight rises, blood pressure and triglyceride levels increase and HDL cholesterol levels decrease, further increasing the risk of coronary artery disease.
One way to determine if you’re overweight is to calculate your body mass index (BMI). You are overweight if your BMI is between 25 and 29.9 and obese if it is 30 or more.
An even better way to assess the effect of your weight on coronary artery disease risk is to measure your waist circumference. The adverse effects of obesity depend not only on the total amount of body fat but also on how that fat is distributed in your body.
Excess weight concentrated in your abdomen is particularly dangerous because it leads to a condition called insulin resistance (a reduced ability to respond to insulin, a hormone that helps the body use glucose as a source of energy).
People with insulin resistance tend to also have high triglyceride levels, low levels of HDL cholesterol, and high blood pressure. In addition, people with insulin resistance are more likely to develop diabetes, another risk factor for coronary artery disease.
To measure your waist circumference, place a tape measure around your waist, just above the top of your hip bones. The tape should feel snug without compressing your skin. You should measure after a normal exhale. A waist circumference of greater than 40 inches in men and more than 35 inches in women indicates abdominal obesity and a heightened coronary artery disease risk.
If you are overweight, take sensible steps (such as eating fewer calories and exercising more often) to lose those excess pounds. Dropping even a few pounds and keeping them off can make a significant difference in your blood pressure, blood sugar, cholesterol values, and other risk factors for coronary artery disease.
5. Treat metabolic syndrome
A collection of health characteristics called metabolic syndrome raises the risk of having a heart attack or stroke or developing diabetes. The risk of a heart attack or dying of cardiovascular disease is three to four times more likely for people with metabolic syndrome than it is for those without the syndrome.
Women with metabolic syndrome are particularly at risk, having nearly three times the risk of heart attack or death than women without the syndrome. Some doctors diagnose metabolic syndrome when someone has at least three of the following five findings:
• Abdominal obesity (waist circumference greater than 40 inches in men or greater than 35 inches in women)
• Elevated fasting triglyceride level (150 mg/dL or higher) or taking medication to lower triglycerides
• Low HDL cholesterol level (less than 40 mg/dL in men or less than 50 mg/dL in women)
• Blood pressure of 130/85 mm Hg or higher or
taking blood pressure-lowering medication
• Fasting blood glucose level of 100 mg/dL or greater or
taking medication for diabetes
While it’s clear that the individual components of metabolic syndrome increase the risk of heart disease, strokes and/or type 2 diabetes, there are questions about whether, in combination, they form a distinct syndrome. And if they do, does the concept help in the diagnosis or treatment of people who have it? Some researchers no longer think so.
In practical terms, it may not matter whether metabolic syndrome is a distinct condition or not. There’s no magic pill for it. If your doctor says you have it, you simply have to treat the individual risk factors.
The key steps involve lifestyle measures such as weight loss, exercise, a fiber-rich diet and smoking
cessation. Medications to improve lipid levels, lower blood pressure, control blood glucose, and prevent blood clots also may be needed.
6. Treat diabetes
About 21 million Americans have diagnosed diabetes (a fasting blood glucose level of 126 mg/dL or more), and they are two to four times more likely to develop coronary artery disease than the general population.
One reason is that coronary artery disease risk factors (such as elevated triglycerides, low HDL cholesterol, high blood pressure, and obesity) are more common in people with diabetes. In addition, diabetes itself increases the risk of coronary artery disease by contributing to dysfunction in the arteries.
People with prediabetes (fasting blood glucose levels between 100 and 125 mg/dL) also have an increased risk of coronary artery disease. It’s estimated that 35 percent of Americans have prediabetes.
If you have diabetes or prediabetes, it’s important to make lifestyle changes to control your other coronary artery disease risk factors. Your doctor may prescribe a statin to lower your LDL cholesterol level. In addition, you should aim to keep your blood pressure below 130/80 mm Hg, your triglycerides under 150 mg/dL, and your HDL cholesterol above 50 mg/dL for women and above 40 mg/dL for men.
7. Get some exercise
Regular physical activity helps prevent coronary artery disease and its complications, such as heart attacks. It also helps to control weight, lower blood pressure, and improve blood lipid levels.
Despite these beneficial effects, too many Americans are content with a sedentary lifestyle. Only about 47 percent of adult Americans participate in moderate or vigorous leisure-time physical activity on a regular basis, and 30 percent of adults do not participate in any leisure-time physical activity at all.
In addition, physical activity tends to decline as people get older. About 43 percent of 18- to 44-year-olds fail to participate in at least 20 minutes of moderate physical activity three or more days a week—and that proportion rises to 75 percent among adults age 75 and older.
8. Control stress
Mental stress contributes to coronary artery disease. When under stress, your body responds by releasing epinephrine and other hormones that speed heart rate, raise blood pressure, and may even cause a spasm or constriction of the coronary arteries.
If the coronary arteries are already narrowed by plaque, a spasm can cause further narrowing, leading to unstable angina or a heart attack.
9. Treat depression
Many studies link depression with an elevated risk of coronary artery disease and its progression. Some experts believe the connection is indirect. For example, depression can make it difficult to stick with a heart medication regimen or to commit to healthy lifestyle changes.
Another possibility is that depression has more direct effects on the heart by increasing blood pressure and blood cholesterol; promoting clot formation, inflammation and endothelial dysfunction; and reducing heart rate variability (the normal changes in heart rate that occur throughout the day).
To reduce the effects of depression on the heart, the American Heart Association now recommends that all people with coronary artery disease undergo screening for depression. In addition, don’t hesitate to talk with your cardiologist if you think you might be suffering from depression.
Fortunately, like many of the other coronary artery disease risk factors, depression is a treatable condition. The available treatments include psychotherapy and sometimes antidepressant drugs. Regular brisk physical activity also helps relieve the symptoms of depression.
10. Treat sleep apnea
Breathing interruptions that occur throughout the night, lowering oxygen levels in the blood, mark this disorder. Sleep apnea is associated with high blood pressure and abnormal heart rhythms that can raise your risk of a heart attack and cardiac arrest.
Symptoms include loud snoring or choking and gasping during sleep, sleepiness throughout the day, morning headaches, dry throat upon waking, and frequent nighttime urination.
Proper treatment can help minimize and even eliminate the symptoms of sleep apnea. It can also reduce the high blood pressure and heart problems that often accompany sleep apnea.
Your doctor may recommend lifestyle changes, such as losing weight. Or you may need specialized treatment, such as a continuous positive airway pressure (CPAP) machine, which helps keep airways open during sleep.
11. Avoid air pollution
A position paper from the American Heart Association confirms evidence that air pollution can contribute to and exacerbate coronary artery disease. This is especially true if you are exposed to the pollution over long periods of time and have other susceptibilities, such as diabetes, preexisting coronary artery disease, or advanced age.
Air pollution, especially the small particle type emitted by traffic, can contribute to atherosclerosis and increase your likelihood of a heart attack. Researchers also now believe that air pollution can affect blood vessel function, increase blood clotting, raise blood pressure, and disrupt the electrical activity of the heart.
If you live in a place where there’s a lot of air pollution, you can take steps to reduce the risks. For example, limit your time outside when the Air Quality Index is high (151 to 200), try to travel during non-rush hours and opt to exercise indoors.
When you do venture outside, reduce your level of exertion on days when the air pollution is high. This advice is especially important if you already have coronary artery disease or have several risk factors for it.
What else to consider
• High-sensitivity C-reactive protein (hsCRP). This protein is produced by the liver in response to inflammation or infection. A blood hsCRP level of more than 3 mg/L increases coronary artery disease risk, regardless of age, gender, or the presence of other risk factors.
Some experts believe that hsCRP injures arteries, which in turn contributes to plaque development and blood clot formation that can lead to a heart attack.
The current leading theory is that hsCRP is simply a marker for blood vessel inflammation and the events that follow.
• High levels of homocysteine. High blood levels of the amino acid homocysteine may increase the risk of coronary artery disease by damaging artery walls and contributing to atherosclerosis. Researchers are uncertain exactly how homocysteine adversely affects the arteries, but elevated levels may damage the endothelium (the cells lining the artery walls) and may contribute to the development of blood clots that could lead to a heart attack.
Deficiencies in certain B vitamins—particularly vitamins B6, B12, and folic acid—contribute to high levels of homocysteine. Although taking supplements of these B vitamins (particularly folic acid) helps lower homocysteine, there is no evidence that these vitamins lower the risk of coronary artery disease. The American Heart Association does not recommend vitamin B supplements to reduce the risk of coronary artery disease.