Your friend just turned 50 and after seeing his doctor was told his physical exam was fine and he appeared to be in good health. Two days later he was in the hospital with a heart attack. This is a nightmare scenario for doctors as well as the patient with the heart attack. So how do we do better in predicting and preventing heart attacks and stroke?
Heart attacks and strokes are caused by blockages in coronary arteries (heart) or cerebral arteries (stroke). These are caused by a build up of cholesterol plaque that eventually deprives the organ of blood. When this happens the tissue dies and heart attack or stroke occurs. Some people have a family history of heart disease that suggests a genetic component and is a strong predictor of heart attack. There are other risks than family history that contribute which include cigarette smoking, obesity, high blood pressure, diabetes, high cholesterol and inactivity.
We now have a number of tests that can be done to help better predict stroke and heart attack and decide if medication is indicated. First of all is blood cholesterol. In my preventive concierge practice of Internal Medicine I start with a complete physical. Included is an advanced cholesterol profile. This test looks at the bad (LDL) and good (HDL) cholesterols to determine risk. If the LDL is too high or the HDL is too low you are at increased risk. We also do a CRP blood test. This is a test of inflammation. If there is a high level of CRP then heart attack risk is high. Tests for diabetes include A1c and fasting blood sugar. If these are high then heart attack risk is high. If you have elevated triglycerides, low HDL and elevated blood sugar, you have the METABOLIC SYNDROME. This further drives risk. Just add obesity to that and you are a heart attack waiting to happen.
During the physical exam I listen over several arteries: the carotids, femoral, and aorta. If I hear a bruit (a noise indicating obstruction of the artery) I will ask you to get additional testing to check for blockages in these arteries. As part of the regular wellness exam we also check the circulation in your legs. We do this by measuring the ABIs (Ankle Brachial Indices) by using a Doppler and blood pressure cuffs on your legs. If the ABIs indicate obstruction we consider treatment to lower cholesterol.
At the end of the physical exam there is a coronary risk calculation done based on your blood pressure and cholesterol, your age and gender, and whether or not you are a smoker or diabetic. This calculates the risk of heart attack in the next 10 years and is accepted by the American Heart Association and the American College of Cardiology. If the risk is greater than 7.5% then you are at high risk and treatment is indicated. So what do we do if the tests thus far are borderline. Further testing may be indicated including a Vascular Screen of your carotids and aorta. (This is available for $29 at a local hospital outpatient department, is non-invasive and takes only 20 minutes to do). If the test is abnormal, treatment is indicated. An even better test for $99, called the CT CORONARY CALCIUM SCORE looks directly at calcium in the coronary arteries using a 10 minute low radiation CAT scan to check for cholesterol plaque build up. If this result is high you need treatment and may need an exercise test.
In my preventive concierge practice of internal medicine we take the time to assess your risk for heart attack. We alot 2 hours of time to go through the complete physical and assess your cardiac risk. Could your 50 year old friend have prevented his heart attack…Maybe, maybe not. But isn’t it worth your time to see what your risk truly is?
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