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Coronary Risk Factors and Risk Modification

Coronary Risk Factors

When your physician told you that you had a heart attack, probably one of the first questions to cross your mind was "WHY ME?" Medical science has not yet discovered the answer to your question. Right now we cannot predict who will have a heart attack, nor do we know exactly why certain individuals have heart attacks and others do not. But even though we don't have these answers, research has provided some clues about the occurrence of heart disease. For example, research has shown us that people with certain habits, attributes, and lifestyles have an increased risk of having a heart attack. These specific habits, attributes, and lifestyles are called "coronary risk factors".

Now is the time for you and your health team to identify your risk factors and take steps toward modifying or eliminating the risk factors that you can control. Your goal should be to minimize your risk of future heart problems.

FAMILY HISTORY OF HEART DISEASE: Do you have close relatives (parents, grandparents, or siblings) who have had heart attacks, high blood pressure, or strokes?

MALE SEX: Males between the ages 35 and 55 have a greater risk than do women of the same age. After the age of 55, women quickly rise to the same risk level as men.

HIGH BLOOD PRESSURE: High blood pressure is called hypertension, and is defined as a blood pressure greater than 140/90.

CIGARETTE SMOKING: Smoking reduces oxygen in your blood and accelerates the development of plaque in your coronary arteries.

OVERWEIGHT: If you're overweight, your heart has to work harder to pump blood through your body.

HIGH LEVELS OF BLOOD FATS: Elevated levels of cholesterol and triglycerides will predispose to earlier development of plaque in your coronary arteries.

DIABETES MELLITUS: Diabetes is an elevation of the level of sugar in your blood. Diabetes can damage your blood vessels and raise your blood cholesterol levels.

LACK OF EXERCISE: If you do little or no aerobic exercise, you may be more likely to have heart problems.

HIGH STRESS: When you're under stress, your heart beats faster and raises your blood pressure.


RISK MODIFICATION:

Hypertension

Blood pressure is the force of blood pushing against the walls of the blood vessels. When your blood pressure is measured, you will notice that the measurement is given in two separate numbers, 110/70 for instance. The top number refers to the pressure in your arteries when your heart is pumping (systolic pressure). The lower number refers to the pressure in your arteries when the heart is resting (diastolic). Blood pressure changes throughout the day depending on your activity, stress level, diet, and other factors.

High blood pressure or hypertension is usually defined as blood pressure greater than 140/90 that fails to come down regardless of your activity.

Too much sodium (commonly found in table salt) can aggravate high blood pressure by causing your body to retain fluid. This fluid can make it harder for the heart to pump effectively. If you suffer from hypertension, you will probably be advised to cut down on added salt and avoid high sodium foods.

Regular aerobic exercise has been shown to help lower blood pressure as well as raise levels of "protective" HDL cholesterol (the kind that carries artery clogging cholesterol out of the blood).

If you smoke, STOP! Smoking not only raises blood pressure, but also damages arterial walls. Smoking is also linked to higher levels of artery-clogging cholesterol.

The importance of regular blood pressure screenings can not be over emphasized. For those who suffer from high blood pressure, check-ups can help track your progress, evaluate your treatment, and motivate you to continue your blood pressure control program.

If other lifestyle changes fail to lower your blood pressure to safe levels, your doctor may prescribe daily medication. Take your medication faithfully. If you experience side effects, do not stop your medication. Instead, notify your physician who can recommend an alternate type of medication.


Stress

Stress in itself is not unhealthy. It's your body's response to any physical or emotional demand. But too much unrelieved stress can lower your body's resistance to disease, contribute to disorders such as stomach ailments and insomnia, and cause changes in the body's chemistry that can directly affect your heart's health.

The "stress response" is your body's physical reaction to a stressful situation. It is commonly called the "fight or flight" response. The physical changes which occur are designed to help your body to fight, or to flee from the threat. When your body reacts to stress it produces more adrenaline which acts as a stimulant to increase your heart and respiratory rate as well as your blood pressure. Fatty acids and cholesterol are emptied into the blood stream, and the blood becomes "thicker'. Muscles tense and prepare for action. When the stressful situation is relieved, your body relaxes and these processes reverse. The key to reducing stress is not in eliminating all stress, but rather in learning to manage your response to stressful situations. Its also means learning how to relax following stressful periods so that your body has a chance to recover. Begin by identifying the stressful situations in your life. Can you avoid them? Can you learn to accept the situations you can not change? Can you respond differently to them? When you find yourself in a stressful situation, try one of the stress-reduction techniques listed below.

Consider how you will handle a potentially stressful situation before it happens. Often stress results from fear of the unknown. By "rehearsing" your response, you can help yourself deal with the situation and defuse your stress.

One time-honored technique that virtually anyone can do is deep breathing. Practice deep breathing whenever you feel "stressed out." Inhale deeply through your nose, hold for a count of five, then exhale slowly through pursed lips. Repeat three or four times until you feel more relaxed.

Take time to relax. Go to a movie, take a warm bath, walk around the park, listen to soothing music, read a novel, put your feet up and close your eyes, or take up a relaxing hobby.

It is not stressful situations themselves, but rather our responses to them that can cause physical and emotional distress. Learn to accept that some things are beyond your control and are not worth worrying about. When you learn to manage stress you'll be happier, and your heart will be healthier. If you need help in learning to manage stress, speak with your physician.


Cigarettes

The nicotine in cigarette smoke is a stimulant that elevates heart rate and blood pressure. Nicotine also causes arteries to constrict making it more difficult for blood to flow, thereby placing a greater strain on an already overworked heart.

Carbon monoxide, also present in cigarette smoke, reduces the oxygen-carrying capacity of the blood. The heart must work harder to supply the body with needed oxygen.

Smoking causes changes in the blood. Platelets (blood cells needed for normal clotting) become abnormally sticky, blood becomes "thicker," and your risk of developing blood clots increases.

Smoking also causes changes in the inner lining of the arteries, and this is a factor in the development of coronary artery disease (the build-up of fatty substances in the arteries that nourish the heart).

There are a variety of methods to quitting cigarettes. But no method will work without motivation. You already have quit if you have been admitted to the hospital. Now commit yourself to a new habit by remaining smoke-free!

There are circumstances or events which will trigger the urge to smoke such as drinking coffee, feeling edgy, watching TV, and so on. Research has shown that the most difficult place to resist the urge to smoke is in your home. The key is to learn to deal with these urges without giving in to them.

Listed below are several major coping skills to assist you in remaining smoke-free:

Review your reasons for quitting, for example, "smoking is bad for my heart," or, "smoking makes my clothes and hair smell". Everyone has different reasons for quitting. List them and review them when you have the urge to smoke.

Be on guard for making or finding excuses to smoke again.

Anticipate triggers and prepare in advance ways you can avoid them.

Do an activity with your hands that make smoking difficult such as gardening, meditating, knitting, or playing cards.

Put sugarless gum or a low fat snack in your mouth instead of a cigarette.

Engage in an exercise program such as walking or biking and do it regularly. This will make you feel healthy and leave you feeling less inclined to smoke.

Change some habits. If a cigarette was associated with a cup of coffee, switch to tea for a while. Instead of lighting up after a meal, get up as soon as a meal is over and wash the dishes, brush your teeth, or walk the dog.

Avoid smoking areas and smoking people.

Limit alcohol consumption. Too much alcohol may weaken your commitment. Better yet, switch to juice, soda, or mineral water.

Brush your teeth several times during the day to keep your mouth fresh and clean.

Reward yourself for not smoking. Place the money you would have spent smoking aside and reward yourself on a weekly basis for committing to remain smoke-free.

Use positive thoughts. Remind yourself how far you have come and the benefits of not smoking.

Use relaxation techniques. Deep breathing helps reduce tension and overcome the urge to smoke. Instead of a cigarette, take a long deep breath, hold it momentarily, and release it. Repeat this several times.

Seek social support. It is easier to remain committed with the encouragement and support of friends and family members.


Diet

Poor nutrition is an important risk factor in the development of coronary artery disease. Your diet should be modified to control weight, blood sugar and cholesterol.

The USDA’s Food Guide Pyramid makes it easy to choose a balanced diet from the five major food groups. The base of the pyramid contains the largest portion of food in the form of grains: bread, cereal, rice, and pasta. Add the recommended number of servings from the fruit, vegetable, milk, and meat groups for a balanced diet. It is important to eat a variety of food from each group. The chart shows examples of serving sizes. Please note! This is a general guide for people without dietary restrictions and may be modified by your physician or dietitian.
USDA Food Guide Pyramid

Bread, Cereal, Rice and Pasta Group
1 Slice Bread
3 to 4 small crackers
1 oz. of ready-to-eat cereal
1/2 cup of cooked cereal, rice or pasta/
Vegetable Group
1 cup of raw leafy vegetables
3/4 cup of vegetable juice
1/2 cup of other vegetables, cooked or chopped raw/
Fruit Group
1 medium apple, banana, orange
3/4 cup of fruit juice
1/2 cup of chopped, cooked, or canned fruit
Milk, Yogurt and Cheese Group
1+1/2 ounces of natural cheese
2 ounces of process cheese
1 cup of milk or yogurt
Meat. Poultry, Fish, Dry Beans, Eggs, and Nuts Group
2-3 ounces of cooked lean meat, poultry, or fish
1/2 cup of cooked dry beans, 1 egg, 1/3 cup nuts, or 2 tablespoons of peanut butter count as 1 ounce of lean meat



DIETARY FAT

Fat is an essential nutrient used by the body for many functions including energy, thermal insulation, vital organ protection, cell structure and function. It is recommended that less than 30% of food calories come from dietary fats. Below are some explanations of the different categories of fat and cholesterol. It is important to make smart choices based on these explanations.

Cholesterol: A waxy, fat related compound in the body tissues and organs of man and animal, cholesterol plays a vital role in metabolism. However, cholesterol is a key part in the creation of fatty deposits in the arterial walls and an increased blood cholesterol is a risk factor in coronary artery disease. Cholesterol is found only in foods of animal origin. It is recommended that the daily intake of dietary cholesterol be no more than 200 - 300 mg. per day.

Low Density Lipoprotein (LDL): A type of cholesterol carrier which deposits cholesterol on the walls of blood vessels.

High Density Lipoprotein (HDL): A type of cholesterol carrier which helps remove cholesterol from the bloodstream.

Saturated Fat: Fat that is usually solid or semi-solid at room temperature and can be found in animal as well as vegetable sources. A diet high in saturated fat frequently increases blood cholesterol and LDL.

Polyunsaturated Fat: Fats primarily from vegetable sources which are generally liquid at room temperature. When used in moderation, they tend not to effect blood cholesterol levels.

Monounsaturated Fat: Fats which help to lower blood cholesterol when used in place of saturated fat in the diet.

Omega-3 Fatty Acids: Fats found in fish sources which help to lower LDL cholesterol.


REDUCING DIETARY CHOLESTEROL

Protein is essential for good health. But many protein-rich foods are animal products which are also high in saturated fats and cholesterol. Fatty cuts of “red” meat, and organ meats are the worst offenders. In order to obtain the best protein with the least amount of fat and cholesterol, eat more fresh water fish, legumes (dried peas, beans, and grains), and skinless poultry. When you do eat meat, trim all visible fat before cooking and limit the portion size to three ounces/day (the size of a pack of cards).

Skim milk, yogurt, and skim milk cheeses are the best dairy choices. When buying cheese (which is traditionally high in saturated fat), look for low fat varieties such as farmer’s cheese, pot cheese, uncreamed cottage cheese, or part-skim ricotta.

Whole grain breads, cereals, and pastas are your best choices. When buying baked products, such as muffins, read labels carefully. Many obtain half their calories from saturated fats such as palm and coconut oil.

With few exceptions, fresh fruits and vegetables are naturally low in saturated fat. Palm oil, palm kernel oil, coconut oil, and hydrogenated vegetable oils are highly saturated.

When you must use fats, use poly or monounsaturated vegetable oils.

FOOD SOURCES OF FAT IN THE DIET

POLYUNSATURATED MONOUNSATURATED SATURATED
corn oil canola oil lard/
safflower oil peanuts butter
sunflower oil peanut oil egg yolk
soybean oil olives whole milk
tub margarine olive oil cream
pumpkin seed avocado meats
sunflower seed cashews/pecans organ meats
walnuts filberts palm
almonds coconut oil


SODIUM

Frequently, cardiac patients are on a restricted sodium or salt diet. This is intended to minimize fluid retention and so reduce the workload of the heart. In general, a low salt diet should be one that contains 2000mg.. or less of sodium per day. All the sodium you need can be found naturally in balanced meals excluding the use of preprocessed foods or adding salt at the table.

It is important as you embark on your heart healthy dietary regimen to get accustomed to reading food labels. The government requires that all packaged food be labeled including serving size and nutrition consult. Sodium occurs in all foods, and you will likely be surprised once you begin checking labels.


Exercise

The benefit of exercise in the treatment and prevention of heart disease should not be underestimated. Physical inactivity is known to increase the risk of heart disease. Physical activity combats this risk by:

1. Reducing blood cholesterol, triglycerides and low density lipoproteins (LDL) while increasing high density lipoproteins (HDL).
2. Reducing blood pressure and resting heart rate which decreases the workload on the heart.
3. Alleviating stress and anxiety.
4. Assisting with weight loss.

For the average adult, fitness is the ability to: (1) perform daily activities without undue fatigue; and (2) be able to respond to sudden physical and emotional stress without overtaxing the heart. Fitness relies upon a healthy heart to deliver oxygen to the body, thereby supplying endurance and stamina.

There are two basic types of exercise: isotonic and isometric. Isometric exercise is a sustained contraction of large muscles, such as weight lifting, and puts a disproportional workload on the heart and limits the amount of oxygen delivered to the heart. Isotonic or aerobic exercise, on the other hand, is accomplished by alternate contraction and relaxation of large muscles. This form of exercise promotes cardiovascular fitness by strengthening the heart muscle. Excellent examples of this form of exercise are walking, biking, cross-country skiing, and swimming. The effects of conditioning last only as long as you continue to exercise, therefore it must be included as a lifetime process for the results to be lasting.

Aerobic exercise is the type recommended to strengthen the heart and cardiovascular system. Studies show that exercising aerobically 3-4 times a week for at least 30 minutes is enough to accomplish this.

Please remember that if you have suffered a recent cardiac event you must discuss your exercise program with your cardiologist. The intensity and frequency of your aerobic exercise will probably need to be modified to insure safety. In general, a low level exercise program during recovery would consist of walking several times a day. You may gradually increase the pace and distance of your walks and include some inclines as you recover and your stamina increases.

As with all exercising, your program should include a warm-up and cool down period. The warm-up and cool down are important because they prepare the body for a change of activity level by slowly altering body temperature, blood pressure, heart rate, and respiration. The warm-up and cool-down are a minimum of five minutes in duration and consist of slow walking.


ENVIRONMENTAL CONSIDERATIONS

1. Exercising in hot weather:
Heat and humidity decrease exercise tolerance by adding an extra demand on the heart to cool the body. Therefore, it is best to exercise in the coolest times of the day, early morning or evening. If the temperature is above 80-85 degrees F and/or the humidity is high, consider exercising in an environmentally controlled area such as a mall or using a stationary bike in an air-conditioned room. Be sure to wear loose, light weight clothing to aid in the elimination of body heat. Drink plenty of water before and after exercise in order to replace fluid lost through respiration and perspiration.

2. Exercising in cold weather: Be sure to exercise in the warmest part of the day, layering your clothing to control heat loss. Forty percent of body heat is lost through the head, therefore a hat is indicated. Wearing a scarf across the nose and mouth is helpful as it warms the air momentarily before it is inhaled into the lungs. If the weather is inclement or the temperature is cold (below 32 degrees F), consider exercising indoors in an environmentally controlled area.

3. Air pollution: The carbon dioxide released from cars replaces the oxygen taken into the lungs. Therefore, avoid heavily traveled roads, especially during rush hour. Utilize side roads or bike/walking paths in your local park.


SIGNS AND SYMPTOMS OF EXERCISE INTOLERANCE

It is normal to feel pleasantly tired when first beginning an exercise program. Mild muscle fatigue or soreness may occur due to unaccustomed exercise. These minor complaints should go away as you progress through the program.

If you should experience excessive shortness of breath, muscle cramps, pain, or extreme fatigue, follow the steps below to modify your program:

1. Stop and rest until these symptoms subside.
2. Return home at slower pace and take a short-cut.
3. Over the next several days, walk more slowly or for a shorter distance, then gradually increase your distance and pace.

If you experience chest pain while walking follow these steps:

1. Stop your activity and sit down. Rest will often relieve chest pain. To return home, take a short cut, walking at a slower pace.

2. Unrelieved chest pain after rest requires nitroglycerine if prescribed by your physician. If you continue to have chest pain unrelieved by rest, you must call your cardiologist immediately and get to an emergency room promptly.

REMEMBER: ALWAYS CHECK WITH YOUR PHYSICIAN BEFORE STARTING AN EXERCISE PROGRAM.


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