Living Well with Heart Disease

Last Editorial Review: 2/22/2005

WebMD Live Events Transcript

The key to living with heart disease is to become educated and involved in your own care, says Harlan M. Krumholz, MD, author of The Expert Guide to Beating Heart Disease. Krumholz joined WebMD Live on Feb. 15 to answer your questions.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Welcome to WebMD Live, Dr. Krumholz. Cardiovascular disease is a leading cause of death for both men and women in the U.S. But because of advances in treatment the number of Americans living long-term with heart disease is increasing. Can those who are living with heart disease do it well -- have a good quality of life, not just wait for "the big one?"

I don't think there's any question that we have within our reach today the ability to help people live long and healthy lives, even after the diagnosis of such a threatening disease like heart disease. One of our challenges is to help people take advantage of the progress and breakthroughs that we've had in medicine so that they can live these long healthy lives.

One of the great problems we have in medicine today is in spite of our great gains in knowledge, many people are being left behind. That is, the knowledge that we have is not always made available to all the people who could benefit from it. I wrote this book to put the critical, most essential information in people's hands and to make that information easily understandable and available to them so that they can use it to get the very best care and give themselves the best chance of beating heart disease.

"Although there are many talented, dedicated health care professionals who are delivering the very best care, it is actually imperative patients take charge of their own health, educate themselves about their own health care issues and participate actively with their physician and nurses in their care."

In your book, you reference seven key strategies for "taking charge" of heart disease. Could you explain please?

In this book I've tried to do two things. First, encourage and motivate people to get involved in their health care. Many people are used to a relationship with the health care system where they are taking orders or handed prescriptions and often do not understand the relationship between the strategies that are being recommended to them and their health. There are also generational differences in relationship to health care. Many older patients were raised in an era in which they were taught never to question physicians and nurses. Too often people feel discouraged or inhibited from taking an active role.

Although there are many talented, dedicated health care professionals who are delivering the very best care, it is actually imperative patients take charge of their own health, educate themselves about their own health care issues and participate actively with their physician and nurses in their care. The idea of this book was first and foremost to equip patients with heart disease and those who care about them with the very essential information that can help them.

So, the first part regarding the book is about a philosophy and approach, but the second part is about content. And in that respect, I recognized a need to cut through the avalanche of overwhelming health care information that exists for patients with heart disease. To cut through the hype, through inflated claims that exist for many pet strategies and treatments. I felt that patients and their families need to understand that among the various strategies and treatments that are available, the amount of evidence that's available to support them is not all equal.

There are some strategies for which the amount of evidence is enormous, evidence which indicates that people can benefit themselves tremendously, and for which there is little controversy. There are other treatments and strategies for which the evidence is much less strong, and for which there is some controversy.

Someone may choose to pursue a strategy that is not yet well established, but they need to know that decision is a bit of a gamble. It may turn out when all is known and more studies are performed that the decision was a good one. Someone who, for example, decided to take aspirin before the evidence was definitive would have been fortunate to have made that decision. But someone who makes a decision before the evidence is firm, may also pay a penalty. For example, a woman who decided to take estrogen therapy before the trials were completed would have actually put herself at greater risk.

So what I tried to do in the book was distill the most important information in cardiology, express it to patients in a way they would understand and sort out what we know for sure and what knowledge is still evolving. I tried to give these patients some information about how to interpret new information that might be appearing on the news. The book also includes information about how patients should prepare for their visits with their physicians and the kinds of questions they should ask and tools to help them monitor their care.

How did the seven strategies evolve?

The seven strategies that are highlighted in the book derive from national guidelines that have been written by a large number of experts in cardiology. I have had the pleasure of participating on such a panel. We get many experts together and spend time going through the entire medical literature and identifying the strategies for which there is the most evidence and translating that evidence into recommendations to physicians for the care of patients with heart disease. Time and time again, these seven strategies are highlighted as the most important approaches to reducing risk for patients with heart disease. By the way, these strategies are also excellent for helping avoid heart disease in the first place.

What is remarkable is that despite the importance of these strategies, and the strength of evidence that exists regarding their benefit, there remain vast numbers of people who are not taking advantage of them. One of my goals in writing the book was to highlight these strategies -- make sure that people understand their importance and answer many frequent questions that people have about them. These strategies, in my mind, should be a checklist for each person who can go down the list and assess where they stand with respect to each one. People who pay attention to these seven strategies have done a remarkable service for themselves in reducing their risk of heart disease.

One thing to note in the book is that each of the strategies is framed in the book by the words "Take Charge." This is a call to the reader to get engaged and take control.

"Of the people with high blood pressure, only about 1 in 3 have a blood pressure that is at the target that has been identified by national experts. That is, only 1 in 3 is truly under control with respect to their blood pressure."

Let's go through the seven strategies, one by one.

The first strategy is take charge of your blood pressure.

It's remarkable that even though we have known about the potential hazards of high blood pressure, for many, many years, there remain a large number of people whose blood pressure puts them at substantial risk; that is, it is too high. Overall, about 1 in 3 adults have high blood pressure. Of those with high blood pressure, only about two-thirds have been told that their blood pressure is high. Among those with high blood pressure only about half have been treated with a medication to lower their blood pressure.

This is the amazing fact: Of the people with high blood pressure, only about 1 in 3 have a blood pressure that is at the target that has been identified by national experts. That is, only 1 in 3 is truly under control with respect to their blood pressure.

When I say take care of your blood pressure, I'm telling patients they need to know what their numbers are, they need to know whether their blood pressure is under control, and if it's not, they need to be talking to their doctor about what it takes to get their blood pressure to the target level that has been recommended.

The second strategy takes a similar approach with cholesterol levels. There are a third of people in this country who have never had their cholesterol tested. Just like blood pressure, there are only about 1 in 3 people who have high cholesterol who know it, a small percentage of them are on treatment, and a considerable proportion are not at the recommended target levels. Again, the thing that is important here is that patients know their cholesterol numbers and that they work with their physicians to reach the proper target.

Didn't the target numbers change within the last year for both cholesterol and blood pressure?

For both cholesterol and blood pressure, there is an increasing appreciation that the lower the levels, the lower the risk.

For blood pressure, at some point a low level can cause symptoms. People may feel light-headed, or dizzy or unsteady. For an older person, a fall can be catastrophic. So we try to be careful in treating blood pressure. Recently what is being called normal blood pressure was redefined a bit. But the numbers I have mentioned, that is, the large numbers of people who are not at target levels does not even take into account these lower targets. So even with the more traditional target, of a blood pressure of 140/90, many people are not reaching it.

With regard to cholesterol, there are also studies now that are suggesting the lower the LDL or bad cholesterol levels, the better. The target for people with heart disease has been 100 milligrams per deciliter, a number that should be easy to remember.

A recent national expert panel from the National Institutes of Health (NIH) indicated that a target of 70 might be beneficial, but they labeled that an optional target, acknowledging that the evidence that we should go down that far is not yet definitive. These discussions in the medical community should not confuse the patient. There are far too many people who are not below the target level of 100, a level for which there is strong consensus. If a patient working with their doctor would like to be more aggressive and gamble that going to 70 would be even better, then there would be evidence to support them, even though the jury is not in yet.

"The benefits of increasing physical activity, even a regular routine, of walking, can pay remarkable benefits."

You've described the first two strategies. What are steps three through seven?

In the next list of strategies I talk about:

  • Taking charge of your fitness
  • Taking charge of your weight
  • Taking charge of your blood sugar
  • Taking charge of your smoking (obviously for smokers only)
  • Taking charge of your medications
Each of these strategies has a potential to confer substantial benefits.

In talking about fitness, I explain how physical activity can have a powerful effect on reducing risk and at the same time, provide considerable benefits with regard to quality of life and functioning. I urge people to think about fitness and weight as if they were a pill; that is, if these strategies were a pill, they would be miracle pills because of their abundance of benefits and virtual absence of side effects. Of course, making changes in lifestyle, which is really what is being suggested by these two strategies, can be challenging, but I tried to convey how their lives can be changed for the better.

How do you define fitness?

Let me say that in this strategy, I am not talking about training for the Olympics, but talking about increasing physical activity. The benefits of increasing physical activity, even a regular routine, of walking, can pay remarkable benefits. And, it seems that both the duration and intensity of exercise can be important. But, maybe even the word exercise can be off-putting to some people. This is really about moving, getting your heart beating, moving your muscles and getting into a routine and lifestyle where physical activity is part of every day. It does not need to be strenuous, but there seem to be clear evidence if it becomes part of your regular daily habit.

Walking the dog, dancing to the radio, taking that after-dinner stroll through the neighborhood with your partner -- just get active.

Can you explain the role of C-reactive protein (CRP) in heart disease? It has been reported that reducing the level of CRP is as important as reducing the level of cholesterol.

Our understanding of heart disease has undergone remarkable change in the last 10 to 20 years. We now appreciate that inflammation plays an important role in heart disease. Inflammation is really the body's own defense system in this case, working against us and placing us at risk.

C-reactive protein is a substance in the blood that indicates whether there is inflammation in the body and has turned out to be a good predictor of the risk of heart disease.

Now people are asking the question, can you lower risk by lowering CRP (C-reactive protein)? Some studies are suggesting that statin drugs, which are used to lower LDL cholesterol, may be useful in quieting inflammation and reducing the risk of heart disease. To this point, we lack a definitive study that proves the effectiveness of that strategy.

There is a large randomized trial that is currently underway in which patients with normal cholesterol levels, but elevated C-reactive protein levels, are being randomized to a statin drug or placebo. That study may help us understand whether the treatment of an elevated C-reactive protein should become, one day, a key strategy for the treatment of heart disease. But, for right now, it is uncertain whether treatment of C-reactive protein in that way is beneficial.

"I have known many patients who were the healthiest they ever were in their lives after their surgery and once they recognized what they needed to do to stay healthy."

What do you think of supplements such as polycosanol to lower cholesterol? If the cholesterol is naturally high due to heredity, can the polycosanol be used along with a lower dose of statin (to reduce likelihood of dangerous side effects)? Also, what are your thoughts about the long-term efficacy of relying on statins?

I believe strongly in sticking with the best scientific evidence. For now, the best approach to lowering cholesterol is with the statin medications at doses that are known to reduce LDL. The risks of adverse effects are small. I'm not suggesting there are no risks, but they are small. Rather than trying a strategy for which there's much less evidence, I strongly recommend people stick with what has been demonstrated in the medical literature.

If you follow the diet and exercise guidelines after bypass surgery what are the chances of new blockage occurring?

There's nothing more important after bypass surgery than realizing heart disease cannot be cured by surgical procedure. Some people have the misunderstanding that once they've had surgery they are cured. Your question suggests to me that you understand that the work in preventing future problems begins immediately and will continue for the rest of your life. Adopting a good diet and finding ways to increase your physical activity appropriately can be good strategies in helping you avoid ever having to undergo surgery again.

All of the key strategies that I mention in the book should be required reading for anyone who has had to undergo bypass surgery. I have known many patients who were the healthiest they ever were in their lives after their surgery and once they recognized what they needed to do to stay healthy.

My blood pressure is very high (174/118). I have no other risk factors for heart disease except chronic illness and meds (Rheumatoid Arthritis). Which do you recommend giving higher priority to -- the care of the disease and subsequent heart damaging drugs, or protecting my heart and taking fewer meds?

This is an important question. People rarely have only one medical condition to address. And often need to balance one or more conditions in order to find the best approach for them. Fortunately, with many of the strategies we have today, more than one condition can be addressed at the same time.

For high blood pressure there are strategies that do not require medications. Even if your blood pressure is very high, these strategies can help make it so you require less medication to control it. Elevated blood pressure puts you at risk for heart disease and stroke. You should not have to be in a position where you need to ignore the blood pressure in order to treat another condition.

You should work with your doctor to make sure both conditions are adequately addressed.

"For people who wish to live a long and healthy life, even after a diagnosis of heart disease, there are clear strategies that will help them."

We are almost out of time, Dr. Krumholz. Before we wrap things up for today, do you have any final words for us?

My greatest hope is that this book will help people chart a course for themselves that will lead to a longer and healthier life without the sense that the course requires sacrifice. What it does require is that they take charge of their health, take responsibility for their health, and make decisions that are most aligned with their goals and values.

For people who wish to live a long and healthy life, even after a diagnosis of heart disease, there are clear strategies that will help them. This book is an attempt to put the information in their hands that they need to pursue these strategies.

We are out of time. Our thanks to Harlan Krumholz, MD, for joining us today. And thanks to you, members, for your great questions. I'm sorry we couldn't get to all of them. For more information, please read Dr. Krumholz's book, The Expert Guide to Beating Heart Disease: What You Absolutely Must Know . For more discussion on this topic, be sure to visit the WebMD message boards to ask questions of our online health professionals, and to share questions, comments, and support with other WebMD members.

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