Measure Your Risk
with
Dr. Robert Roth, Columbia St. Mary's
It's never too soon to test for risks
If you have high triglyceride levels but your
cholesterol levels are normal, you may think you're in the clear. You might be surprised when your doctor hands you a laundry list of lifestyle changes to correct those triglyceride levels.
New guidelines on cholesterol management, including high triglyercide levels as a special concern, are one of the ways doctors are improving early detection of risk of cardiovascular disease.
Another is routinely assessing patients' general risk beginning at age 20, and calculating the risk of developing heart disease in the next 10 years for people age 40 and older or for anyone who has multiple risk factors.
Risk factor screening includes having blood pressure, body mass index, waist circumference and pulse recorded at least every two years and cholesterol and glucose testing at least every five years beginning at age 20.
Most people are referred to a specialist, such as a cardiologist, through risk factor screening done by the primary doctor, says Dr. Robert Roth, cardiologist, with Columbia St. Mary's. "The main symptom we are asked to evaluate is chest pain, along with shortness of breath, heart palpations and skipping or irregular heartbeat."
People often ignore or rationalize the symptoms, Dr. Roth continued. "They don't want to think it's their heart, and so the first thing we assess is the likelihood that they have heart disease by looking at their risk factors."
The first risk factor is gender, he said. Heart disease is generally thought to affect men more than women, and prevention efforts have typically been targeted at middle-aged men because they were seen as the prime candidates for heart attack. However, the heart attack rate for women increased by 36 percent during the 1980s and '90s, a time when heart attacks among men were declining by eight percent.
"We can't really ignore or not ask women about it, and we need to start asking earlier," Dr. Roth said, despite the fact that women typically get the disease eight to 10 years later than men. "Six to seven years after menopause, all else being equal, the risks for women are the same as they are for men. We need to screen post-menopausal and even pre-menopausal women very carefully."
Next, a cardiologist will look at family history of heart disease. "The fact that your grandmother died at age 80 of heart disease is not as indicative as if a first generation relative had early stage heart disease at age 45 and above for men or age 55 and above for women," Dr. Roth said.
A personal history of hypertension, high cholesterol or diabetes may indicate a course of treatment as if the person already had coronary artery disease, Dr. Roth said. High blood cholesterol levels are a standard indicator of risk for heart disease, but Dr. Roth advises patients with normal cholesterol levels who have diabetes to be very cautious. "The management of their lipid levels are the same as someone who has already had a heart attack."
Specialists, such as Dr. Roth, use tests to get a better picture of a patient's true cholesterol-related heart disease risk. While standard tests measure HDL (the so-called "good cholesterol") LDL (the "bad cholesterol") and triglycerides, the expanded tests give information about the exact composition of the cholesterol and a possibly more accurate picture of risk.
"After we assess the likelihood that they are at risk for heart disease, we ask what they are feeling," Dr. Roth said. "Don't wait until you have the classic "Hollywood heart attack" symptoms - especially if you are diabetic or female."
Symptoms in diabetics and women are much more subtle or not noticed at all. "If we can pick up on these in advance, if we're more aggressive with risk factors, we can treat it before it becomes a real problem," Dr. Roth said.
Such things as stress tests on treadmills measure exercise capacity and heart capacity, and electrocardiograms measure changes caused by blocked arteries. In some cases, heart scans can be helpful, Dr. Roth said. "They are expensive and insurance doesn't often cover it, but if someone goes in for a heart scan and finds he has 95 percent more calcium buildup that the average person his age, he might be motivated to get more aggressive with managing the risk factors he can control."
Prevention of cardiovascular disease is a two-way street. Patients can be more attuned to symptoms and risk and have regular follow-ups with their cardiologist, who, in turn, will monitor smoking, diet and cholesterol charts as well as ongoing stress tests and other more aggressive risk factor management in patients who have previously had a heart attack.
"For some patients the really hard facts have an impact while other patients just go into denial and don't do anything. Therefore, it's important to individualize treatment and gain the confidence of patients. Primary care physicians can be excellent at this kind of thing if they have the opportunity to do it," Dr. Roth said.
