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Coronary Heart Disease, Part 1
June 6, 2017
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July 13, 2017

Coronary Heart Disease, Part 2

Coronary Heart Disease

(How to Modify your Risk and Prevent Heart Attack)

By: Dr Eugene Nwosu MBBS, FACC, FACP, FAHA Chief Medical Director

In our part 1 series of Heart Matters, we outlined the major traditional risk factors for coronary artery disease (CAD). These are family history of premature death from heart attack, increased age, male sex, high Cholesterol, hypertension, diabetes, obesity, smoking, poor diet, sedentary life style, and vascular inflammation. We obviously can do little to change our sex, age or family history. The other risk factors can be modified to decrease heart attack risk.

 1.Poor Diet (High Fat, high Cholesterol diet.): Eat right and take note of what you eat. Hippocrates stated in 400BC; “Let food be your medicine and medicine be your food.” Food is the single most important factor influencing your health. With knowledge and discipline you have full control over it. Certain Foods (Mediterranean diet) are healing and decrease inflammation while others (traditional America diet) promote inflammation. CAD also known as atherosclerosis is an inflammatory process.

Traditional western diets promote inflammation and are toxic to our bodies. There are high in salt, simple sugars, processed food with preservatives, bad fat and low on magnesium and potassium. Our consumption of such diet has a lot to do with increased trend of obesity, hypertension, diabetes, stroke, heart disease and death.

The best diet proven to decrease heart attack and CAD is Mediterranean diet. The Mediterranean diet is not really a diet; it is rather a life style that includes food (Colorful fruits, Vegetables, Whole grain bread and Pasta, Omega-3- rich Seafood) activities, meals with friends and family and wine in moderation with meals.

Several studies have shown that those following a traditional Mediterranean diet suffer significantly less heart disease and death from heart attack compared to those following traditional American diet.

  • Anatomy of Mediterranean Diet: Mediterranean diet is very low in saturated fat and contains no trans-fat. It consist of fruits, vegetables, olive oil, whole-grains, legumes, nuts, fish, poultry and red wine in moderation. It is plentiful in vitamins, fiber and antioxidant. Red meat is eaten twice a month and refined sugar and processed foods are avoided. It decreases inflammation and lowers the risk of heart attack, cancer, diabetes and other disease linked to chronic low grade inflammation.

Consumption of Mediterranean diet results in sustained weight loss and improvement in overall health. It lowers the risk of metabolic syndrome, diabetes, HTN, Alzheimer’s disease, cancer and other diseases.

  • Food to Avoid: sugar cereal, potato chips, French fries, grilled steak, cheese cake, butter, soda, and high omega-6 fat diet. Omega-6 fat is bad fat and is found in vegetable oil and red meat. It promotes inflammation whereas omega-3 fat found in walnuts, flaxseed, and fish is good fat and anti-inflammatory. The optimal Omega -6 / Omega-3 ratio in our diet is 2:1 and Mediterranean diet makes this ratio a reality. For many people on traditional Western diet that ratio is between 10/1 to 20/1.
  • Avoid heavy drinking; Drink just before or with your evening meal. Take not more than one drink for a woman or two drinks for a man in 24 hour period. One drink equals 12 fluid ounces of beer (355ml), 5 fluid ounces of wine (144ml), or 1.5 fluid ounces of Spirits (44ml).
  • Avoid processed foods; these have been stripped of their healthful ingredients and are loaded with artificial preservatives. They contain excessive amounts of unhealthy fats, refined sugar and sodium.
  • Avoid high fructose corn syrup used in many foods including diet soda and baked food.
  • Avoid Red meat. Limit to twice a month but not more than once a week. Red meat is high in saturated fats which raise bad (LDL) cholesterol and is high in Omega 6 fatty acid which promotes inflammation. Cooking red meat generates cancer causing compounds. Red meat is high in iron which is also believed to promote cancer. Processed meat contain substances known as nitrosamines which have been linked to cancer.

Eating well done meat increases the risk of certain cancers including lung, bladder, colorectal, stomach, pancreatic cancers and others.

Meat cooked at high temperature generates cancer causing chemicals called heterocyclic amines (HCAS).

  • Eating processed meat must be avoided. Many researchers define processed meat as meat that is preserved by smoking, curing, salting or addition of chemical preservatives.


Advice on Red meat Consumption.

  1. Avoid regular red meat consumption, limit intake to 4 ounces(114gm) 2 to 4 times a month
  2. Avoid processed meat entirely
  • Consume Fish, Poultry or Turkey several times per week.


Avoid Dairy Milk. It has high saturated fat content increasing cholesterol and has high calories contributing to obesity and diabetes. Excellent milk alternatives are soy and almond milk.


Mediterranean Diet Pyramid

2.Sedentary Lifestyle: is a significant risk for CAD. Exercise is medicine and is the key to heart health. Practically every cardiac risk factor can be countered by exercise. Physical inactivity is directly linked to poor health including obesity, diabetes, heart attack, stroke, cancer and others. Exercise stimulates blood circulation throughout the body and to all our organs, helping to remove toxins through sweating and other filtration methods, as well as improving the efficiency of our lungs and heart.

Exercise is not just an essential behavioral contribution to longevity, it is the most essential. There is a close relationship between the amount of physical exercise, longevity and the risk for heart disease. Studies have shown that expending 500Kcal per week in exercise produced modest improvements in risk, whereas expending 2000Kcal per week had very significant reductions in heart disease risk. This benefit was dose dependent up to a level of 3500Kcal a week, then it leveled off. It has been calculated that for every hour you exercise you add two hours to your life span.

  • Studies have shown that heart disease is low in populations that walk an average of 10,000 steps per day and is hardly existent in those that average 17,000 steps daily
  • Walking 10,000 steps each day is considered to be equivalent of 6o minutes of moderate intensity exercise.
  • Recent study showed that those who walk 10,000 steps or more each day reduce their odd of developing metabolic syndrome by 72%.
  • British Medical Journal Study showed that 10,000 steps daily help control weight and may reduce diabetes risk.
  • Australian Study found that walking 10,000 steps per day had a lower body mass index, less belly fat and better insulin sensitivity.
  • The kind and amount of exercise that is best for you depends on your risk profile which is different from someone else.

There are three considerations to exercise.

  • Frequency refers to how often you exercise.
  • Intensify refers to how hard you exercise.
  • Time or Duration refers to how long you exercise.


The American Heart Association (AHA) created the “FIT Formula”; Frequency, intensity and Time. They recommend frequency of 3 to 5 times per week, intensity to break a sweat but able to carry on a conversation and time/duration of 30 to 40 minutes.


Exercise benefit occurs in two distinct ways, First Muscular or Mechanical benefits. This type of exercise changes the size and density of all muscles including the heart. Exercising to the point of muscle fiber exhaustion or overload of the muscle causes it to become thicker and denser so that the next time the same load won’t fatigue it. For this kind of mechanical benefit, higher intensity, shorter duration and less frequency are optimal.

The second benefit of exercise is the metabolic state of the body. It changes how the muscles process fuel, which in turn changes the chemistry of the blood.

The changes produced affect almost all of the circulating risk factors for cardiovascular disease. The metabolic benefit of exercise occurs with lower intensity, longer duration and increased frequency.


The Exercise Continuum.


The exercise continuum in the diagram is based on maximum heart rate. Heart rate closely corresponds to oxygen consumption and the amount of energy you are expending while exercising. A fair accurate estimate of your maximum heart rate (MHR) is 220 minus your age. MHR roughly corresponds to your maximum exercise capacity – that is the maximum amount of energy you can consume in a given amount of time.

The Mechanical benefits begin at about 60% of your MHR. Above 80% of MHR you get full benefits of mechanical conditioning and the more intense the exercise the better.

The metabolic benefits on the exercise continuum do not increase in a straight line with the intensity of exercise. Peak benefit is between 70 to 75% of MHR. It starts to fall off after 80% of MHR.

The key to reducing metabolic risk factors is to exercise at the level of intensity that will deplete the muscle cells internal supply of fat (Triglycerides). Between 70% and 75% of your maximum Heart Rate (which corresponds to level 2 exercise) is the perfect intensity level for metabolic benefits.

At about 75% MHR point, there is an overlap of the mechanical and metabolic conditioning zones. If your need for reducing risk factors require equal portion of both kind of exercise, this is the optimum level intensity around which you should build your workout.

Low level intensity exercise is also effective in decreasing cardiovascular risk. Recent research shows that moving at moderately brisk pace for 45min three times per week at about 60% of your MHR significantly increases cardiovascular fitness and can decrease BP, plasma triglyceride, cholesterol and bad (LDL) cholesterol levels, while increasing good (HDL)

cholesterol concentrations. Participants in this study also lost body weight and fat stores and even decreased their waist size.

Most cardiologists will recommend having a stress test before starting an exercise program for certain category of patients.


Who Should Have a Stress Test.?

  • Males over 40 years old who do not exercise
  • Females over 50 years old who do not exercise
  • Anyone who while doing any kind of physical activity develops chest pain or unusual shortness of breath
  • Anyone with a family history of premature coronary artery disease
  • Diabetes
  • Smokers
  • Asthmatics, or people with chronic lung disease
  • Anyone with abnormal resting electrocardiograms, heart murmurs, or congenital heart problems
  • Anyone with any kind of known heart disease.


The Cardiovascular Benefits of Regular Exercise:

  • Lowers body weight
  • Improves lipid profile: lowers triglyceride and LDL (bad) cholesterol particles, and raises HDL (good) cholesterol. Increase LDL particle size making it less likely to clog up the artery.
  • Lowers insulin levels
  • Raises insulin sensitivity
  • Lowers blood sugar
  • Lowers inflammation
  • Lowers risk of blood clots
  • Lowers stress hormones (e.g. Adrenalin)
  • Lowers blood pressure and heart rate
  • Increases volume of blood pumped for every level of energy used by heart muscle
  • Dilates the coronary arteries
  • Improves collateral circulation.


Non Cardiac Benefits of Exercise.

  • Increases muscle mass and strength.
  • Blocks age related decline in muscle mass.
  • Decrease anxiety and depression.
  • Decrease body fat.
  • Decreases craving to smoke.
  • Improves lung function.
  • Improves arthritis and joint flexibility.
  • Improves sleep quality.
  • Improves memory.
  • Reduces signs of aging
  • Improves bone health and conservation of bone mass.
  • Lowers risk of cancer, especially colon and breast.
  • Increases immune function.
  • Increases brain activity and facilitates neuron transmission.






 3.  Hypertension: Hypertension is a known risk factor for CAD and is very common in people of African descent.  Natural means to control blood pressure includes;

  • Limit sodium (< 1500mg/day)
  • Consume a wide variety of fruits and vegetables
  • Drink grape and pomegranate juice
  • Exercise daily
  • Stop smoking
  • Avoid trans fat
  • Avoid excess alcohol
  • Avoid excess caffeine
  • Manage stress
  • Achieve an ideal body weight
  • Treat sleep apnea if present

American Heart Association recommends that average person limit their sodium intake to less than 2300mg per day and less than 1500mg per day for those at increased risk of cardiovascular disease. One teaspoon of tablet salt has 2000 mg of sodium.

  • Dash diet: DASH stands for Dietary Approaches to Stop Hypertension. The diet is simple: Eat more fruits, vegetables, and low-fat dairy foods. Cut back on foods that are high in saturated fat, cholesterol, and Trans fats.












 4.  Smoking: there is nothing good about smoking and there is no question that smoking is dangerous to your health. Smokers are 2 to 3 times likely to die from CAD than non-smokers. Smoking just 1 to 4 cigarettes daily increases your risk and each additional cigarettes you smoke per day increases your risk further. Your cardiovascular risk will decrease significantly within the first 2years of smoking cessation compared to patients who continued to smoke. Those who quit smoking before their first heart attack had a 50% lower mortality rate, and those who quit after their first heart attack lowered their risk by 37%.

Smoking increases blood pressure, decrease exercise tolerance, increases the risk of recurrent CAD after bypass surgery and decreases HDL good cholesterol. Quitting Smoking and Aerobic exercise will counter all these adverse effect of smoking.

5.  Age: Increasing age causes the dysfunction of the arteries by decreasing endothelial function and increasing arterial stuffiness. This results in cardiovascular disease (CVD). Aerobic exercise blocks the dysfunction of the arteries caused by aging thereby preventing CVD.







 6.  Create a Stress- Free Lifestyle: Stress and anger increase the release of stress hormones such as adrenaline and cortisol. These have the natural effects of increasing blood pressure, cholesterol, and blood sugars; causing the heart beat to become rapid and increasing the “Stickiness” of platelets, which raises the likelihood of a blood clot. Practice the relaxation response. Actively find ways to manage your stress. Practice meditation and yoga. Get more nighttime sleep: – some studies found that people who reported sleeping less than 5hrs per night were twice as likely to develop cardiovascular disease compared with those who slept 7hrs.

Spend time with friends. Laugh: Deep heart felt laughter is good medicine. With laughter, it appears that serum cortisol, which is hormone that is secreted when under stress, is decreased; laughter improved arterial stiffness in healthy individuals. It may be as beneficial as exercise in relaxing arteries and increasing blood flow.

 7.   Address Lipid Profile: Get a complete lipid profile including total cholesterol, LDL (bad) cholesterol, HDL (good) cholesterol, LDL particle numbers, triglyceride level, and lipoprotein (a) level. One third of people who develop CAD have elevated Lipoprotein (a). Lipoprotein (a) is an LDL particle with an attachment called Apoprotein(a). Elevated levels of Lipoprotein (a) increase the risk of heart attack and stroke.

The Framingham study showed that the optimal total cholesterol is less than 150mg/dl. Other studies found that populations around the world with practically non existent CAD/Heart attack had average total cholesterol between 120mg/dl and 150mg/dl. Mediterranean diet can lower your cholesterol levels by 25%. It has been proven to lower LDL cholesterol, lower LDL particle numbers, raise HDL cholesterol, and lower triglyceride levels.

A study found that women who ate on apple a day for a year lowered their LDL cholesterol by 23% and raised their HDL cholesterol by 4%. Also daily apple consumption lowered inflammation and free radicals, thereby lowering heart attack risk.

Exercise has been shown to lower total cholesterol, lower LDL particle number, raise HDL cholesterol, and lower triglyceride, as well as make LDL cholesterol particles larger and potentially less dangerous.


 8.  Diabetes: Diabetes Mellitus: is a significant risk for CAD and the risk is considered heart attack equivalent. Proper treatment of diabetes aims to control blood sugar, and hemoglobin A1C blood levels with diet, weight loss when appropriate and exercise. Diagnosis of diabetes can be made when fasting blood sugar is more than 126mg/dl or Hgb A1C level is greater than or equal to 6.5%. Optimal Hg A1C level is less than 5.7%.

People who follow Mediterranean diet are 83% less likely to develop new onset diabetes.










 9.   Obesity: obesity is associated with high cholesterol high triglycerides, hypertension, diabetes and sedentary life style.  A body mass index (BMI) is a measure of your body fat. A BMI of 18 to 24.9 is normal, 25 to 29.9 is overweight, and a BMI greater than 30 is obese. BMI of 35 or more carries high risk for CAD.  Abdominal girth (waist circumference) predicts heart disease better than BMI. Abdominal girth of greater than 102cm (40in) for men carries high risk for CAD and that greater than 88cm (35in) carries high risk for women. A 10% gain in body weight increases your risk of heart attack by 25%.

Diets that contribute to obesity include:

  1. Toxic pro-inflammatory American diet. These are heavy on processed foods, artificial preservatives, and excessive amounts of unhealthy fats, refined sugar and sodium. Unhealthy fats are saturated fat found in butter, meat and cheese, and trans-fat found in packaged cookies, chips and pastries.
  2. Food that contain high fructose corn syrup. They are found in many beverages and food including soft drinks, sports drinks, packaged cookies, and other baked goods.

Exercise and Mediterranean diet are effective ways to lose weight resulting in decreased cardiovascular risk.


  10.    Get Rid of Inflammatory States: Vascular inflammation is a risk factor for CAD (atherosclerosis). The process of atherosclerosis begins with damage to the endothelium. Coronary artery disease is an inflammatory disease and inflammation begets inflammation.

 Ways to get rid of Inflammation includes:

I.   Get a dental checkup: your oral health can directly impact your heart health. Regular dental cleaning reduces the risk of heart attack. Inflammation in your gums from periodontal disease increases the risk of cardiovascular disease: – heart attack and stroke. A study that followed more than 100,000 people with no history of heart attack or stroke for seven years found that those who had their teeth cleaned by a dentist or dental hygienist at least twice a year for 2 years had a 24% lower risk for heart attack and 13% lower risk for stroke compared to those who never went to the dentist or only went once in two years.

II.  Get rid of the traditional American diet which promotes inflammation.

III.  Limit environmental toxins which promote inflammation. Exposure to toxins every day and over time causes our bodies to mount inflammation response. These toxins include cigarette smoke, pesticides, chemicals, food additives and pollution.

Key life style changes to limit inflammation are regular dental cleaning, heart healthy diet such as a Mediterranean diet, regular exercise, smoking cessation and weight control.

IV.  Limit conditions/Toxins that lead to increase free radical generation and oxidative stress. Increased free radical state will promote inflammation, increase oxidized LDL cholesterol and accelerate CAD (atherosclerosis). Free radical is the term used for any molecule with an uneven number of electrons. They are very unstable and they will do whatever they can to get or steal another electron so they can have an even number. This theft by free radicals is referred to as oxidation. The oxidation of LDL (bad) cholesterol causes intense inflammatory response because the body now views the oxidized cholesterol as foreign. Toxins that increase free radical release include air pollutants, cigarette smoke, excess ultraviolent rays from the sun, pesticides, radiation (especially CAT scans, unless absolutely needed), excessive alcohol, preservatives in foods and food packaging, industrial chemicals and household cleaners.

Antidote to the free radicals is antioxidants. Mediterranean diet is a powerful source because it includes so many foods that are antioxidant rich.


Some advanced Cardiovascular Diagnostic Tests & Risk:

  1. Elevated LDL cholesterol/ Elevated LDL particle.

Relative risk: 2 -3x increase risk of CVD

  1. Elevated small dense LDL particles.

Relative risk: 3x increased risk of heart attack and stroke

  1. Low HDL cholesterol.

Relative risk:

a. 2.5 increased risk of CVD (if HDL-C <35mg/dl and total chol <200mg/dl).

b. 5x increased risk of CVD (if HDL-c <35mg/dl and total  chol 200 to 300 mg/dl)

  1. Elevated Triglyceride.

Relative risk: 2 -3x increased of CVD

  1. Elevated Lipoprotein(a) also known as LP(a).

Relative risk:  3 -5x increased risk of CVD

  1. Elevated high sensitivity C- reactive protein (hs – CRP).

Relative risk:  2 -3x increased of CVD

  1. Elevated fibrinogen. Fibrinogen is a protein that coverts to fibrin in forming clots. It also responds to any inflammatory process including CAD.

Relative risk:  2-3x increased risk of CAD.

  1. Elevated homocysteine. Homocysteine is an amino acid intermediate in methionine and cysteine metabolism which requires Vitamin B12 and folic acid.  Elevation of Homocysteine is often the result of Vitamin B12 and folic acid deficiency.
  • High level cause endothelial dysfunction, vascular injury, smooth muscle proliferation, and thrombogenicity (Increased blood clothing)
  • Augments the production of oxidized LDL-C
  • Commonly used as a screen for patients at risk for CVD and stroke especially if there is no other risk factors except family history.

Relative risk 2 -3x increased risk of CVD.

  1. Low 25-Hydroxy-Vitamins D. Deficiency of 25-hydroxy-vit D is associated with atherosclerosis (CAD), hypertension, up regulation of renin- angiotensin- aldosterone systems involved in hypertension and cardiovascular disease, insulin resistance, diabetes, metabolic syndrome, low calcium and low phosphorus and associated with incidence of cardiovascular events, cancer, osteoporosis and all-cause mortality.

Relatively risk: 2x increased risk of CVD ( if <10ng/ml )

  1. Elevated Lipoprotein associated phospholipase A2 (LP- PLA2): Lp-PLA2 is an enzyme associated with atherosclerotic lessons and primary carried on LDL and LP (a) in the circulation.

It is an indicator of arterial inflammation that has been associated with increased risk of CAD and especially high risk for ischemic stroke. It is a risk factor for CVD independent of LDL- C. High levels are found in circulation when vulnerable, inflamed, rupture prone plaque are present.

It cleaves oxidized LDL-C in endothelium and attracts inflammatory cells (macrophages). Macrophages then engulf LDL-C particles forming foam cells

Relative risk;

2x increased risk of CVD

5.5x increase risk of stroke,

11.4x increased risk of stroke when hs- CRP and Lp-PLA2 are elevated.

6.4x increased risk of stroke when systolic BP is elevated.

11. Elevated Myeloperoxidase (MPO):

Myeloperoxidase is an enzyme synthesized and stored within polymorphonuclear  leukocytes and monocytes which are white blood cells.

MPO is a marker of free radical and oxidative stress

MPO reduces bioavailability of nitric oxide, thereby promoting endothelial dysfunction.

It catalyze the oxidation of HDL – C impairing its ability to perform reverse cholesterol transport that removes plaque buildup from the arteries to the liver.

It catalyzes the oxidation of LDL-C contributing to foam cell formation and plaque progression.

Elevated MPO levels predict risk for developing CAD in healthy individuals independent of traditional CVD risk factors.

Elevated MPO levels contribute to plaque instability and are associated with increased risk of CVD events.

Related risk:

20x increased risk of CAD

5x increased risk of MI/heart attack (when negative for troponin T)

2 x increases in all-cause mortality.



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