MDAdvisor Spring 2022

Medical Risk Factors

Hypertension

Obviously, the medical community has major concerns surrounding the global COVID pandemic, but there’s another pandemic going on right now as well: hypertension. Hypertension is a multifactorial, complex disorder estimated to affect one in three adults in the United States. Worldwide, 1.3 billion people live with hypertension¹; this number is expected to rise to 1.6 billion by 2025.² Unfortunately, fewer than one in four individuals have their blood pressure under control.³

These numbers put all primary care physicians on high alert when monitoring the risk of heart disease in patients with hypertension. Hypertension increases the workload on the heart, inducing structural and functional changes in the myocardium. It is one of the predominant risk factors for the development of several cardiovascular diseases such as coronary artery disease, congestive heart failure, atrial fibrillation, cerebrovascular disease, peripheral arterial disease, aortic aneurysm and chronic kidney disease.⁴ Unfortunately, our ability to control hypertension is actually declining along with the rise in obesity, which is making management of risk factors much more difficult.

Ideally, the goal is to get blood pressure down to at least 115/75.⁵ However, more realistically, in 2021, the International Society of Hypertension published guidelines calling for an average threshold of 140/90 mm Hg for office diagnosis of hypertension; 135/85 mm Hg for home; and 130/80 mm Hg for 24-hour ambulatory monitoring.⁶ A 10 mm drop in systolic blood pressure reduces the risk of major cardiovascular disease events by 20 percent, coronary heart disease by 17 percent, stroke by 27 percent, heart failure by 28 percent.⁷ Given this impressive opportunity to prevent heart disease events, primary care physicians should follow aggressive guidelines and directed medical therapy with at-risk patients.

“As the most common, modifiable risk factor for premature cardiovascular disease,⁴ early detection and management of hypertension is incredibly important.”

As the most common, modifiable risk factor for premature cardiovascular disease,⁴ early detection and management of hypertension is incredibly important. The primary care physician is in a unique position to monitor the chronic progression of hypertension as it develops over many years and to play a vital role in offering education in the risks of uncontrolled blood pressure.

Approaches for managing hypertension commonly involve lifestyle modification (as later discussed in this article) along with antihypertensive medications. Start with a diuretic and standard medical therapy. If you find that the numbers are resistant to the initial medication dosage, rather than add an additional low-dose medication, which is unlikely at this homeopathic level to get the patient to where they need to be, increase the dosage of the initially prescribed medication to the guideline maximum.

Additionally, routine measurement of blood pressure has been shown to improve compliance and allows for more patient involvement in the management of their disease.⁴ Automatic blood pressure cuffs are widely available and inexpensive and should be recommended to every at-risk patient for home monitoring of their blood pressure.

Patients should keep daily logs of their blood pressure; this is especially important for those at higher risk of disease progressions such as treatment-resistant hypertension or those with multiple concomitant risk factors for cardiovascular disease.

Diabetes

The relationship between heart disease and diabetes is well established. The risk of death from heart disease for adults with diabetes is higher than for adults who do not have diabetes.⁸ In fact, according the Centers for Disease Control & Prevention, if you have diabetes, you’re twice as likely to have heart disease or a stroke than someone who does not—and at a younger age. The longer you have diabetes, the more likely you are to have heart disease.⁹

Given that 37.3 million people have diabetes (11.3 percent of the U.S. population) and 8.5 million of those people are undiagnosed,⁹ it is vital that all healthcare workers protect the heart health of those at risk for or diagnosed with diabetes.

The behavioral strategies discussed later in the article will benefit the diabetic in addition to strategies targeted to specifically keep blood sugar levels within a target range.

Specific medical strategies to manage diabetes rely on routine and consistent monitoring by the primary care physician⁹:

• Monitor patient’s ability and willingness to monitor blood sugar levels at home.
• Monitor compliance with prescribed medication and blood sugar response to medication. Adjust dosage, type of insulin and timing as needed.
• Monitor compliance with the meal plan and refer to a dietitian if patient has trouble following the guidelines.

In addition to monitoring compliance with a recommended meal plan, your patients also need dietary education. They need help in understanding what a “low sugar/ low salt” diet means. It does not mean merely breaking the habit of adding extra salt to their food if they are already consuming a diet high in sodium. It does not even mean adding a “healthy” food like yogurt to the diet when the yogurt choice is one that contains 14 to 16 grams of sugar in one serving. Your patients need to understand how to read food labels, to look for the salt level in canned soups, to understand the high-salt levels found in processed meats. They need guidance before you can expect them to become compliant.

Hyperlipidemia

The statistics reported by the CDC associated with hyperlipidemia¹⁰ are quite astounding:

• In 2015–2018, nearly 12 percent of adults age 20 and older had total cholesterol higher than 240 mg/dL, and about 17 percent had high-density lipoprotein (HDL, or “good”) cholesterol levels less than 40 mg/dL.
• Slightly more than half of U.S. adults (54.5 percent, or 47 million) who could benefit from cholesterol medicine are currently taking it.
• Nearly 94 million U.S. adults age 20 or older have total cholesterol levels higher than 200 mg/dL. Twenty-eight million adults in the United States have total cholesterol levels higher than 240 mg/dL.
• Seven percent of U.S. children and adolescents ages 6 to 19 have high total cholesterol.

“Given these numbers, it is clear that cholesterol management is an important part of reducing cardiovascular disease.”

Given these numbers, it is clear that cholesterol management is an important part of reducing cardiovascular disease. In the primary care setting, individuals can learn early on about the relationship between high LDL cholesterol levels and clogged arteries that prevent blood from reaching the heart, brain or other organs, leading to stroke, heart attack or heart failure.

Additionally, primary care physicians who take the time to make informed decisions regarding treatment protocols for their patients with high cholesterol levels can substantially reduce the risk of heart attacks.

For people with high LDL cholesterol levels, patient education regarding lifestyle changes (as discussed later in this article) is an important first step.

For some, cholesterol-lowering medications may be indicated. Statins, or HMG-CoA reductase inhibitors, lower LDL cholesterol by reducing the liver’s production of cholesterol. They also improve the liver’s ability to remove LDL cholesterol that is already in the blood.¹¹

Based on the 2013 American College of Cardiology/AHA guidelines for the management of blood cholesterol, 56.0 million (48.6 percent) U.S. adults ≥40 years of age are eligible for statin therapy; however, even after the guidelines were published, statin use and mean low-density lipoprotein cholesterol level remained unchanged.¹² In fact, data from 2013–2014 indicate that only about half (54.5 percent) of U.S. adults (over age 21) who might benefit from statin use are taking them.¹³

These numbers indicate that increased efforts to understand and implement these guidelines are needed to get LDL cholesterol down under 70. If your patients who are candidates for statin therapy do not want them or do not take them as prescribed, because of the side effects or other factors that cause resistance, move quickly to alternative treatments. You might, for example, recommend niacin or high-quality fish oil. You might also refer the patient to a lipid specialist for long-acting injectables.

Obesity

Obesity, a complex and costly condition, raises the risk of morbidity from heart disease and is a major cause of preventable death. Hyperlipidemia, hypertension and diabetes, which (as just discussed) all raise the risk of heart attack, are all exacerbated by obesity.

According to the CDC, obesity numbers are rising to include nearly half of the U.S. population¹⁴:

• From 1999 – 2000 through 2017 – 2018, U.S. obesity prevalence increased from 30.5 percent to 42.4 percent. During the same time, the prevalence of severe obesity increased from 4.7 percent to 9.2 percent.
• Non-Hispanic Black adults (49.6 percent) had the highest age-adjusted prevalence of obesity, followed by Hispanic adults (44.8 percent), non-Hispanic white adults (42.2 percent) and non-Hispanic Asian adults (17.4 percent).
• The obesity prevalence was 40.0 percent among adults aged 20 to 39 years, 44.8 percent among adults aged 40 to 59 years and 42.8 percent among adults aged 60 and older.

These numbers are staggering, calling for more patient education at the primary care level to help patients fully understand the relationship between body weight and heart disease. Research from CDC’s National Center for Health Statistics (NCHS), Division of Health Care Statistics found that while health education is offered relatively more often at visits for obesity, overall, it is offered at less than one-half of these visits.¹⁵

The primary care physician is in the ideal position to help all patients achieve and maintain a healthy weight. Spending time during office visits to discuss the role of healthy eating and regular physical activity (rather than only short-term dietary changes) in controlling body weight is absolutely vital to establishing the relationship between weight and health issues, such as high blood pressure, stroke, heart disease, diabetes, ulcers, arthritic problems, joint issues, and more. Additionally, measurement of BMI and waist circumference are two screening tools that can be part of routine checkups to estimate weight status and potential disease risk when indicated.

Aspirin Use For Cardiovascular Disease Prevention

Nearly all major heart health organizations have made recommendations regarding aspirin use for CVD prevention, including the American Heart Association/American Stroke Association, American College of Chest Physicians and the American College of Cardiology. Organizational guidelines are in relative agreement for secondary prevention with life-long, low-dose aspirin therapy recommended following a CVD event. Even so, the American College of Cardiology and American Heart Association guidelines for secondary prevention have remained without a definitive stance on aspirin dosage.¹⁶

The guidelines for primary CVD prevention are more variable. The American College of Cardiology and American Heart Association guidelines recommend that low-dose aspirin use might be considered for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) among select adults aged 40 to 70 years at higher CVD risk but not at increased risk of bleeding. Low-dose aspirin use is not recommended on a routine basis for primary prevention of CVD in adults older than 70 years or among adults of any age who are at increased risk of bleeding.¹⁷

The latest recommendations from the US Preventive Services Task Force (USPSTF) note that the decision to initiate low-dose aspirin use for the primary prevention of CVD in adults aged 40 to 59 years who have a 10 percent or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small, and people who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. For patients initiating aspirin use, it would be reasonable to use a dose of 81 mg/d. However, the USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older. For persons who have initiated aspirin use, the net benefits continue to accrue over time in the absence of a bleeding event. The net benefits, however, generally become progressively smaller with advancing age. Data suggest that it may be reasonable to consider stopping aspirin use around age 75 years.¹⁸ As always, patient care has to be individualized based on risk factors. The American College of Cardiology offers an ASCVD Risk Estimator on its website.

COVID-19

The medical community is gathering data regarding the relationship between COVID-19 and heart health. At this time, however, there is a lot we don’t know about COVID-19 and the direct or indirect cardiovascular effects.

Early in the pandemic, the focus was on the effect of SARS-CoV-2 on the respiratory system, as the virus spread through the air and infected the lungs and airways. But it soon became apparent that the virus moved throughout the body affecting many organs, including the heart.

The damage to the heart can be indirect—the heart muscle can become stressed when it must work harder as the virus attacks body organs such as the kidneys, lungs and liver. Also, the body’s natural response to the virus is to create inflammation. In some people, the inflammation is excessive and can damage the heart. In children and teens, a high level of inflammation is called multisystem inflammatory syndrome (MIS-C), and it can particularly affect the heart.¹⁹

“The COVID-19 virus can also directly infect heart muscle cells, which can lead to complications such as myocarditis, arrhythmias, cardiomyopathy and heart failure.”

The COVID-19 virus can also directly infect heart muscle cells, which can lead to complications such as myocarditis, arrhythmias, cardiomyopathy and heart failure. Additionally, it has been found that the virus damages blood vessels, including those that supply the heart, which can lead to small blood clots and inflammation of the heart. This can increase the risk of heart failure, causing long-term damage such as fibrosis and heart muscle damage.²⁰

Major cardiac events following COVID virus are generally quickly referred to cardiac specialists. It is the primary care physician who must be alert to the cardiac complications now being found in often young, otherwise healthy, people who have had COVID with only mild, or even no, symptoms. They are now presenting with myocarditis, heart failure and arrhythmias. And to make the COVID-heart connection even more difficult to detect, physicians are now seeing heart abnormalities that appear months after the person has completed recovered from COVID.²⁰

It is also important to know that the CDC is monitoring reports of myocarditis and pericarditis, especially in adolescents and young adult males, within the week after mRNA COVID-19 vaccination (Pfizer-BioNTech or Moderna). Fortunately, most of these patients have responded well to medicine and rest.²¹

The COVID-heart connection is complex and reciprocal. Just as COVID can damage the heart and its vessels, having heart disease can exacerbate COVID. Having cardiovascular disease, or any of its risk factors (hypertension, diabetes, high cholesterol and/or obesity) puts a person at high risk for severe illness and/or death from COVID-19.²⁰

These facts make it clear that routine physicals and checkup can no longer be delayed as they have been during this pandemic. The negative effects of delayed cardiovascular care on patients who have been afraid to seek medical help during the COVID outbreak are evident on a grand scale. At least one in five expected emergency department visits for heart attack or stroke did not occur during the initial months of the COVID-19 pandemic, according to the CDC.²²

There were 43.4 percent fewer estimated daily hospitalizations in March 2020 compared with March 2019.²³ While the number of patients with acute myocardial infarction (AMI) seeking care at hospitals dropped during the pandemic, those that did receive care experienced more severe symptoms because of delays in seeking emergency services.²⁴ Now, some patients presenting with coronary disease or peripheral vascular disease seem to be in more advanced stages of diseases. Going forward, a large percentage of those patients who have avoided medical care are likely to end up with larger myocardial infarctions and chronic heart failure.

It is vital for all physicians to recognize the relationship between COVID and heart disease as we know it at this time.

Demographic Factors Affecting Cardiovascular Disease

Gender

Heart disease does not discriminate based on gender. It is the leading cause of death in both males and females. In 2019, heart disease accounted for 24.3 percent of all deaths in males and 21.8 percent of all deaths in females.¹² Meaning, approximately one in every four males and one in every four females will die of heart disease.

“Unfortunately, the diagnosis of cardiovascular disease is often missed in women because of the idea that women don’t get heart disease and because they don’t present with the typical symptoms.”

Unfortunately, the diagnosis of cardiovascular disease is often missed in women because of the idea that women don’t get heart disease and because they don’t present with the typical symptoms. Their symptoms may be milder or atypical, so their cardiovascular disease may be attributed to some other diagnosis unrelated to the heart. Another reason for the missed diagnosis is that when we look at things like obstructive disease, in particular, or nonobstructive disease like aneurysms, we forget that women’s vessels, in general, are smaller, so, very often, women will present with more advanced coronary disease because they’re diagnosed later.

For example, if you have a six-foot-five gentleman with a normal 2cm aorta, the cutoff to address an aneurysm is at 5cm. When you look at a smaller woman who has a normal 1cm aorta, with a 3cm aneurysm, she’s under the 5cm cutoff, but her aneurysm is three times the size of her aorta. There are physiologic differences, and structural differences and size differences that matter; these should make us have a higher index of suspicion in women than we normally do, and they should help us be more objective about deciding when to intervene on women.

Race

Heart disease is the leading cause of death among most racial and ethnic groups in the United States, including African Americans, American Indians or Alaska Natives, Hispanics and whites. For Asian American or Pacific Islander men, heart disease is second only to cancer.¹²

Black men and Hispanic men, however, have coronary heart disease in greater numbers than white men.²⁵ The relationship between cardiovascular disease and race can be a matter of access to healthcare, particularly in the inner cities. Compliance becomes difficult in lower socioeconomic groups, too often comprised of people of color. Beyond the inequities in healthcare, lack of access to healthy foods is another factor in the development of cardiovascular disease. Lack of education regarding the risks for the development of cardiovascular disease is also a contributing factor to cardiovascular disease in underserved communities.

This is a key area where primary care physicians can make a major impact on cardiac health. Talking about the risk factors, distributing educational materials and making sure there is no language barrier to health education are all actions that can be taken during routine visits to ensure the patient never ends up in the cardiac surgeon’s office.

Age

For the population aged 65 and over, heart disease is the leading cause of death, accounting for 25.1 percent of deaths. It is also the leading cause of death for the population aged 85 and over, accounting for 28.7 percent of deaths. It is the second leading cause for age group 45 – 64 (20.9 percent of deaths). The mortality rate from heart disease then decreases among younger individuals, dropping to the fourth leading cause for age group 25 – 44 (9.8 percent of deaths), and dropping to the fifth leading cause for age groups 10 – 24 (2.9 percent) and 1 – 9 (3.7 percent of deaths).¹²

“If we can address the risk factors at early stages in a patient’s healthcare through primary care routine visits, we can have a strong impact on delaying the onset of cardiac problems.”

Of course, the age at which someone develops heart problems is dependent on the number of risk factors present in each person. Obviously, a person with many risk factors (such as obesity, alcoholism, diabetes, a history of smoking, etc.) may present at a younger age than someone without those factors. Also, with improvements in healthcare and medical technology, patients are living longer, so cardiologists see a lot of patients now presenting in their 80s and even 90s, not with coronary disease but with other issues such as structural heart disease or valvular heart disease.

Although there is no one specific age of risk, we are starting to see a lot of younger patients, likely in large part, due to the pandemic of obesity.

If we can address the risk factors at early stages in a patient’s healthcare through primary care routine visits, we can have a strong impact on delaying the onset of cardiac problems.

Lifestyle Risk Factors

The primary care physician can have a major impact on heart health in the general population as well as in those patients with known heart disease. This impact occurs when office visits include discussion and education regarding the lifestyle risk factors that are directly under the control of the individual.²⁶ Learning how to modify these factors through behavioral strategies is crucial to reducing the high mortality rate of heart disease.

The following discussion of the relationship between lifestyle risk factors and heart disease are well known to physicians, but we need to do a better job in relaying this information to our patients and offering them resources to support their efforts to make changes.

Smoking cessation. Nicotine raises blood pressure. Carbon monoxide from cigarette smoke reduces the amount of oxygen that the blood can carry. Both can damage the heart and blood vessels, increasing the risk for heart conditions such as atherosclerosis and heart attack.

Obviously, patients vulnerable to heart disease should stop smoking, but this can be the most difficult risk factor to modify. Nicotine can be more addicting than narcotics, causing actual structural changes in the brain that make it extremely difficult to stop. These patients need constant support, education and incentive.

Healthy eating habits. Eating a diet low in saturated fats, trans fats, cholesterol and sodium reduces the risk of heart disease and many of the risk factors (hypertension, high cholesterol, obesity) associated with it.

However, these recommendations are not always easy to follow—especially for patients with limited access to grocery stores and limited funds who often have trouble making good food choices. Socioeconomic factors that limit resources must also be a part of this conversation with our patients.

Physical activity: Lack of exercise can lead to heart disease because it increases the likelihood of other medical conditions that are known risk factors, including obesity, hypertension, hyperlipidemia and diabetes.

However, the recommendation to increase exercise levels must to tailored to the abilities of the patient. “Exercise” is not always about going to the gym every day. Simple aerobic activities like walking regularly—perhaps even just by parking in the spot furthest from the store—can increase conditioning on a daily basis.

Reduction of alcohol intake. Too much alcohol can raise blood pressure and increase levels of triglycerides, which can increase the risk of heart disease. So, what does “reduction” of intake look like? That’s a conversation to have with your patients. “Normal” amounts mean different things to different people. If one glass of red wine is good for me (as some recommended), then several glasses must be great! Help your patients define and acknowledge “reasonable” alcohol intake.

Stress reduction. Stress can raise blood pressure and can also lead to unhealthy behaviors such as drinking too much alcohol or overeating. True. But we are living in exceptionally stressful times. To guide your patients to a calmer place, you can talk with them about how they might turn their focus away from the things they find stressful. What do they enjoy? What hobby, exercise or other activity can keep them mentally active and focused on the joy of daily living? This simple conversation can reap major benefits.

So much of the primary care physician’s role in combating heart disease centers on conversation and education. As the frontline healthcare provider who sees patients first and most often, you can have a powerful impact on the lives of your patients when you explain the why and the how of your recommendations. This is where improved health for all begins.