Raising Awareness: A Q&A With the American Heart Association

Bhatt: In more recent years, heart disease has become more prevalent in younger people. I think that has a variety of different reasons, one of which is that risk factors for heart disease have been increasing in younger people. By that, I mean high blood pressure, diabetes—in large part driven by higher rates of obesity than has historically been the case—high cholesterol. But what might be really driving a lot of that is, in fact, obesity more than any one thing, because obesity itself increases the risk for diabetes, high blood pressure, high cholesterol, which in turn increases the risk for heart attack, stroke and cardiovascular disease.

It certainly has been the case in the U.S.—this isn't true in every part of the world—that rates of smoking cigarettes have gone markedly down in the past couple of decades. But the rate of vaping has been going up, and that's been going up really quickly among younger people.

Maybe smoking cigarettes isn't as cool as it used to be, but vaping is certainly perceived by younger folks as being cool. I think risk factors like that are also driving some of what's going on in terms of younger people having more heart disease in perhaps the recent past.

There are risk factors as well that aren't commonly appreciated that are maybe more common in younger people, like marijuana smoking. There is a clear association between smoking marijuana and heart attacks.

Some portion of young people that are having heart attacks—it's like, 'Oh, wow, that person was young, they were active, they looked healthy and they had a heart attack'—it was due to drugs like marijuana; drugs like cocaine. There, the association with heart attacks is even stronger, where a single use can trigger a heart attack. When young people come in with heart attacks, we think about cocaine, crack, methamphetamines.

Really, the key factors, many are in our control. But not everything. There are some genetic predispositions to heart disease. But as far as a common form of heart disease, things like heart attacks and strokes, there's no question diet contributes. The most important thing is don't smoke. By don't smoke, I mean no cigarettes, no cigars, no vaping, no marijuana, no cocaine, no tobacco, none of it.

For people who aren't [smoking], the next most important thing is weight control. This used to be my advice: The weight you are at the end of high school, you don't want to weigh any more than that. Now, of course, if you were obese in high school, then that doesn't apply. In general, one doesn't want to gain weight as one ages. That's the natural tendency. There's arguments as to what's the best metric, weight or body mass index [BMI]. I think the best is waist circumference. If there's extra fat around the belly, it's not good for health. Any extra fat on the belly, even if a person's weight is normal, is still a problem in terms of risk for heart disease and diabetes.

So controlling weight is important, and the best ways to control weight are through diet. The most important thing is to control the amount of calories going in. Nothing beats calorie control. If someone is controlling the amount of calories going in, then it's important to look at what those calories are. Sometimes people put the second part of that equation first, that is, they are focused so much on what those calories are, but they're just eating a lot of it. So you could be on a vegan diet but eating an enormous amount of calories a day. That's extremely unhealthy.

So the most important first step is to control calories such that it matches the calories you're burning, [through] whatever work you do during the day plus whatever exercise you do. If those things are matching, then you won't gain weight. The general tendency over time is calorie intake goes up, exercise goes down, people become more sedentary, and weight is gained. So maintaining an ideal body weight and an ideal waist circumference is very important.

I recommend, specifically, calorie control, but then specifically in terms of those calories, a plant-based diet. But even for people who aren't doing that, the more fresh fruit, vegetables and whole grain intake in the diet, the better. That's in part because those are very healthy foods with nutrients, vitamins and more that are good. So a healthy diet is the way to do it. And a healthy diet is good because it crowds out eating other things. The foods I mention themselves have intrinsic health value, and beyond that, if you're eating that stuff, then you're not eating a lot of red meat, which is clearly bad in terms of cardiovascular and cancer risk.

Daily exercise is good, and by exercise I mean at least 30 minutes of daily activity. Even if it's not going to the gym, it could include things like brisk walking, gardening, anything that works up a sweat. Something is better than nothing. Ten minutes a day is better than zero minutes a day, even if it's not 30 minutes a day.

I think there's the mistaken belief that young people can't have heart disease. Yes, heart disease in general, especially common forms like coronary and heart attack, is less frequent in young people. But there certainly are folks who have heart attacks in their 30s, 40s and 50s.

I think there is some misconception out there that heart disease doesn't affect women. And, of course, it does. I think there's a lot of attention that's been given through the years to breast cancer affecting women, which is an important problem, but for Americans, heart disease kills a lot more women than breast cancer. So I think while the word "cancer" can cause a lot of fear in women and men, it's important to remember heart disease is still more likely to kill men and women at some point in their lives.

About 80 percent of what causes heart disease is preventable. Things like I discussed: weight control, proper diet, regular physical activity, avoiding bad things like tobacco, marijuana and other things. There are a few other things that are good to do. I'll add to the list: A regular good night's sleep seems to prevent a variety of illnesses and also does seem to promote heart health. Alcohol. Our thinking has changed on that. It used to be that some cardiologists would recommend a glass of wine a day. It's not that drinking a glass of wine a day is making you healthier, it's that the person who was drinking the glass of wine was healthier than the person who was not drinking.

If someone chooses to drink because they enjoy it, then they should limit that quantity to one drink a day. Even one drink a day actually is associated with some heart diseases. In particular, the most common, heart arrhythmia, or abnormal heart rhythm, and atrial fibrillation [are] clearly associated with alcohol intake. The lowest associated risk is with zero drinks a day. That's what the data supports. Above zero, the risk of other diseases goes up.

I think that's important. That's why I specifically mentioned adequate sleep. I think that goes a long way to reducing stress. If someone is stressed out, they're probably not getting a good night's sleep. Or the quantity or quality is impaired. I think if someone is getting a good night's sleep, they're eating well, they're exercising regularly, I think their stress levels will be down.

The reality of modern life is that people are really stressed out and that's contributing to poor diet, not exercising and bad sleep. So it's a bit of a vicious circle where one bad habit is feeding into another, and then things can kind of spiral out of control. So I do think as part of an overall healthy lifestyle, as far as cardiovascular health, stress reduction strategies can be useful. That can vary person to person. Some people may find exercise relaxing. Some people might find meditation relaxing. I think that's actually a very good, even evidence-based strategy.

Yoga can be very good even if somebody is very out of shape. Tai chi is another one that is very safe. Again, if someone is severely out of shape, it may be good to get professional instruction, but that can be free off legitimate sites off the internet. For some people, it might be listening to music. Music can have a lot of benefits in terms of calming the mind and just elevating the mood. Reading a book, some people find that helpful in terms of stress reduction.

Sometimes people say, 'I have heart disease because I have a really stressful job.' That's probably not true. Stress is likely contributing to everything I mentioned, like diet, being overweight, not sleeping, etcetera. But everybody is under some degree of chronic stress. So it's not directly causing heart disease, but rather indirectly through the ways I mentioned.

We could do a better job in terms of public health with actionable things. So even if someone can't exercise, park the car farther from the office. Take the stairs instead of the elevator. Simple things like that done every day add up in terms of calories. Maybe cut out the coffee with all the sugar in it. Or cut out the coffee altogether and save a couple bucks.

There's a lot of things like that that are actually actionable. And I think part of the message is we sort of have people strive for perfection, which usually doesn't work and then demoralizes folks. So even if all you're doing is five or 10 minutes of vigorous activity, that's better than doing nothing. Same with diet. Maybe someone can't become entirely vegetarian, but at least try to cut down on red meat. I think the message that gets out is oversimplified by just saying eat right and exercise and you'll be fine.

For both men and women, they should be aware in themselves and their partner that sexual dysfunction may be a manifestation of cardiovascular disease. That link is strongest in erectile dysfunction in men where there is at this point in time a ton of data supporting that cardiovascular disease, in many cases, is contributing to erectile dysfunction. And, in many cases, erectile dysfunction might be the first sign of cardiovascular disease.

Of course, there are many causes of erectile dysfunction. Sometimes there can be psychogenic causes, but more often than psychogenic is a physical cause. And a good chunk of that is due to cardiovascular health being impaired. So if a man has erectile dysfunction, it may be time to start thinking, 'Hmm, do I also have high blood pressure or high cholesterol?' A lot of times, if a man has erectile dysfunction, that will actually make him go to the doctor when he's not going to the doctor otherwise. It's an opportunity to get a full cardiovascular checkup.

Whenever I see a man with erectile dysfunction, if that's the only medical problem he has, I worry: Does he have other risk factors for heart disease? Is his blood pressure out of control? Is his cholesterol too high? There's some that even say if someone has erectile dysfunction, it should be treated almost as you would treat someone who has known cardiovascular disease, because it possibly means the small arteries that supply blood to the genitalia are starting to clog up, and that means it might be only a matter of time that the slightly larger arteries in the heart or the brain start to clog up. That's kind of a simplification of the science, but it is oftentimes a canary in the coal mine.

With respect to women and sexual dysfunction, the research is much more in its infancy. But there probably are linkages there. When a woman is postmenopausal, her risk of cardiovascular disease, independent of any sort of sexual dysfunction issues that may arise, has gone up. The risk, premenopause, of women having heart disease is much lower than men in terms of common forms of heart disease, such as heart attacks. But after menopause, that risk rapidly escalates. So it's important, especially in the perimenopausal period and even before, to be aware that their risk for heart disease is going up.

As well, something that is relatively recent knowledge, when women have had certain problems during pregnancy, that is actually a harbinger of cardiovascular problems to come. Things like eclampsia and preeclampsia or hypertension or diabetes that manifested during pregnancy and went away? Doctors used to say, 'Oh, it's just because you're pregnant. You're fine, the child's fine, everything's OK.' That's good, but that's not entirely true. Actually, I wrote an editorial about this in the past and titled it, "Pregnancy: Cardiac Stress Test." It is a cardiac stress test. If a woman struggles to get through a pregnancy at, presumably, a time when she's younger and healthier, then maybe that means her heart and cardiovascular system aren't in as good shape as she was thinking otherwise.

So even though a 50- or 60-year-old woman might not think of her pregnancy history as something to tell her doctor when she's 50 or 60, in fact, it's probably relevant. It probably is a risk factor for heart disease. Bottom line: If a woman has had trouble with her pregnancy, convey that to physicians even decades down the road. As silly and unrelated as it may otherwise seem, it turns out, it's all related.