Learn the Basics about Heart Disease

T
he foundation of performance and longevity is good health. Yet, as
a nation, we have never been so unhealthy. Obesity, cardiovascular
disease, type 2 diabetes, hypertension, cancer, and many other seri-
ous diseases are rising at rates that have now reached epidemic pro-
portions.
The reason for this rise is that most people really do not know
what constitutes a healthy lifestyle. Our parents and our schoolteach-
ers never taught us—they don’t know either—and the great majority
of us do not have wellness programs in our workplace. Nor do we
understand how to monitor our health and our risk factors as we
grow older. Somehow we have developed the misconception that
staying vigorous and healthy is an intuitive process. But how can we
know what is true and what is not true when there is so much confus-
ing information about nutrition, exercise, and disease process out
there in the media? Who and what are we to believe?
That is why it is so important to have the proper tools for health
evaluation. During my twenty-five years of experience with thou-
sands of clients as a performance enhancement and fitness consult-
ant I have come to clearly understand the definitions of good health
and poor health because I have seen these scenarios played out so
many times over the decades. And the dozens of top medical pro-
fessionals I have worked with over the years and continue to work
with through my PEP (Performance Enhancement Program) and
through Ochsner Clinic Foundation have helped to acquaint me
intimately with the science behind state-of-the-art health care and
health evaluation.
To understand the care and attention your body requires at
every stage of life, it is important to know where you are at each
moment of your life continuum. What is your health age versus your
chronological age versus your performance age? Are you a thirty-
year-old with the health of a fifty-five-year-old? Or a fifty-year-old with
the body and cardiovascular system of a thirty-five-year-old? In the
pages that follow, I will offer you several important criteria that will
help you to evaluate accurately your health and whether you are at
risk for certain disease factors. These criteria include your cardiovas-
cular risk factors, your Body Mass Index (BMI), your waist measure-
ment, and your body composition.
Find Your Weak Link
It is not as easy as you think to ascertain your level of fitness because
the appearance of health is not always the same as true health. I
remember when Frank Warren, then a thirteen-year veteran with the
New Orleans Saints, dropped out of football to coach. After a while,
Frank decided to get back into the game because he felt that he was
better than most of the players he was coaching. When Frank came
to me for preseason training, he looked as if he were in decent
shape. But the in-depth health evaluation that I recommend for all
of my trainees showed that he had developed coronary problems
and needed angioplasty. If Frank had stepped onto the playing field
without assessing his health profile, there is a strong chance that he
would have died on the field.
Your career and your passion might be calling to you to put forth
your most energetic effort, but no one should ever jump into the
stresses of life’s battles without a clear understanding of whether or
not there is a weak link in your health chain—a point at which you
could literally break down. Following a recent decision by the office
of the commissioner of Major League Baseball to create a division
known as Umpire Medical Services to manage the health of their
umpires, my PEP program was hired as a consultant. I discovered
that one umpire, whose weight had soared to 357 pounds, didn’t
know that he had type 2 diabetes.
When this man didn’t want to consider the health ramifications
he was facing if he didn’t lose weight and begin eating and exercis-
ing right, I appealed to his better judgment. “How can you be calling
the balls and the strikes for every player when you won’t look at your
own score? Your body already has two strikes against it. The next one
could be your last.” I explained how easy—and even likely—it was for
him to develop complications such as heart disease that might lead
to premature death. Finally he took my suggestions seriously. He lost
weight and reduced his waist measurement, thereby getting his
blood sugar back to normal. Amazingly, he accomplished all this
without taking medication, just by following my nutrition, exercise,
and lifestyle management programs.
Many people are walking time bombs and don’t even know it. If
you don’t have the internal physical health to deal with the stresses,
demands, and performance standards of your personal life and
career, then it doesn’t matter if you look as if you are fine or even feel
relatively good.
Coronary Disease: The Number One
Cause of Death
I am going to focus on coronary disease in this chapter for two main
reasons: it’s the number one killer and it’s the most curable.
Reason 1: Heart Disease Is the Number One Killer
in the United States
Nearly 60 million Americans suffer from this illness, which accounts
for 41 percent of all deaths. Although most people think of it as a
man’s disease, coronary disease kills more than half a million women
per year. It just affects them ten to fifteen years later than the average
high-risk male, with risk levels gradually increasing following meno-
pause. Even though women have their first heart attacks later than
men, they are more likely to die from them. Within one year of hav-
ing an attack, 25 percent of men die, but 38 percent of women die.
According to the American Heart Association, if all major forms of
heart and blood vessel disease were eliminated, the average life
expectancy would be increased by seven years.
To understand the prevalence of this disease, and the amount of
money its treatment drains from our personal and health care
resources each year, let’s take a look at some of the facts and statistics
related to cardiovascular disease:
• By age sixty, one out of five men and one out of seventeen
women develop coronary disease.
• Nearly 15 million people have a history of heart attack and/or
angina (chest pain due to coronary artery disease).
• Each year, 1.5 million people have a new or recurrent heart
attack and, of these, one-third—500,000—die.
• Of those whose heart attacks are fatal, 50 to 60 percent die
within one hour of the onset of symptoms.
• Stroke is the leading cause of long-term disability.
• The leading cause of death in people with diabetes is heart dis-
ease. Therefore, if you have diabetes, you are at major risk for
coronary disease.
• In 1966, the estimated cost of heart disease in the United
States was $66 billion. By 2002, this yearly cost will be in the
$80 billion to $100 billion range.
• According to a recent article in the Wall Street Journal, an
employee’s share of company medical health care expenses is
expected to rise 19 percent within the next year, an average of
$38 per month for workers and $134 a month for families.
• For a substantial number of people, about 300,000 per year,
sudden cardiac death represents the first, last, and only mani-
festation of heart disease. The only way these unfortunate
people could have avoided this would be to have prevented
the disease from progressing in the first place.
Reason 2: Heart Disease Is the Most Curable Disease
In spite of these grim statistics, our ability to either improve or com-
pletely prevent heart disease is very great indeed. According to Dr.
Carl J. Lavie, codirector of the Cardiac Rehabilitation Program and
Preventive Cardiology and head of the exercise laboratory at Ochsner
Clinic Foundation:
Coronary heart disease is a very modifiable and, in many
cases, preventable disease. If most people followed a pro-
gram of eating a healthy diet, achieving and maintaining a
healthy weight, controlling their waist circumference, regu-
larly exercising, not smoking, and drinking alcohol in mod-
eration, I and my colleagues would have to look for another
job because we wouldn’t have enough business to practice.
That’s how much this disease is potentially modifiable. It
would become an old person’s disease as opposed to such a
prevalent problem in our society.
Identify Your Risk Factors
Sadly, many patients at risk are neither identified early enough nor
treated as vigorously as they should be—resulting in millions of
unnecessary deaths each year. For this reason, the first and most
important step in taking responsibility for evaluating the state of
your health should be learning if you are at risk for cardiovascular
disease. To help you to understand where you stand, what your risk
factors are, and whether or not you should seek further professional
evaluation, let’s take a look at factors that either lead directly or indi-
rectly to heart disease and other diseases such as type 2 diabetes and
some cancers. These factors include:
• Obesity
• The Body Mass Index (BMI)
• Waist circumference
• High LDL cholesterol and low HDL cholesterol
• Elevated triglycerides
• The cluster of health indicators known as Metabolic Syn-
drome X
Are You Overweight or Obese? Three Criteria
Weight gain has become a problem of epic proportions in our
society. In 1905, only 5 percent of the population was obese, but that
figure has been growing at an alarming rate. In the last decade alone
obesity has risen 8 percent. As of this writing, almost 60 percent of
those over the age of twenty, about 97 million people, are either
overweight or obese. Of that number, 12.5 million are severely over-
weight, and 2 million are morbidly obese. This means that they are at
great risk for serious and life-threatening health conditions such as
heart disease, stroke, diabetes, and some types of cancer.
Even though being overweight or obese is considered a health
risk, it is not always easy to define what those terms mean for you.
Scale weight alone is not an accurate indicator. Factors such as frame
size, body type, and the ratio of fat to lean muscle must also be taken
into consideration.
Let’s look at some of the most important tests and factors that
indicate whether you are overweight or obese and define your level
of risk.
1: The Ratio of Fat to Lean Muscle
I had a forty-four-year-old client who was five feet six inches and
weighed 158 pounds. She knew she wanted to lose about twenty
pounds, but she didn’t see herself as having a severe weight problem.
When she had a professional measure her fat to lean muscle ratio,
however, she found out that her body fat percentage was a whopping
34.5 percent. This made her technically obese. If nothing in her
lifestyle had changed as the years passed, she would most likely have
continued to gain weight and increase her health risks.
Once I placed her on a good nutrition and exercise program,
she lost 22 pounds of scale weight. In terms of body composition,
however, she actually lost 26.7 pounds of fat and gained 5.8 pounds
of lean muscle, since her body fat percentage dropped 14 points to
20.5 percent.
The following chart defines healthy and unhealthy body fat per-
centages for men and women.
BODY FAT PERCENTAGE
Level Men Women
Excellent, very lean <11 <14
Good/lean 11–14 14–17
Average 15–17 18–22
Fair/fat 18–22 23–27
Obese 22+ 27+

Three Techniques for Measuring Body Fat
There are several methods for measuring body fat. These include:
1. Hydrostatic weighing. This technique is the most accurate
and measures a person’s mass both in and out of a tank of
water. This test is based on the assumption that lean tissue is
denser than fat tissue. Lean tissue will sink and fat tissue will
float. This test costs between $100 and $150 and can be per-
formed at your local health club, hospital, university, or well-
ness center.
2. Skin fold measurement with a caliper. This involves measur-
ing subcutaneous (under-the-skin) fat with a caliper at certain
points on the body. Since this test has been around for quite
some time, you can get it done at YMCAs, health clubs, dieti-
cians’ offices, physical therapy centers, schools, and universities.
3. Anthropometric measurement. You can do this test at home.
This test is based on the assumption that fat is distributed at
certain sites on the body, such as the neck, wrist, and waist-
line. Muscle tissue is usually found at sites such as the biceps,
forearm, and calf.
The following two tests, one for males and the other for females,
will help you to ascertain your percentage of body fat to lean muscle.
These formulas are from Phil L. Goglia’s book Turn Up the Heat:
Unlock the Fat-Burning Power of Your Metabolism and have a plus or
minus error rate of 5 percent. All you need is a cloth tape measure
and a calculator.
AT-HOME BODY FAT TEST FOR MALES
Step 1: Taking Measurements
1. Height in inches _____________
2. Hips in inches_____________
3. Waist in inches_____________
4. Weight in pounds _____________
Step 2: Determining Your Percentage of Body Fat

1. Multiply your hips (inches) ____ × 1.4 = ____ minus 2 = ____ (A)
2. Multiply your waist (inches) ____ × 0.72 = ____ minus 4 = ____ (B)
3. Add A plus B = ________ (C)
4. Multiply your height (inches) _____ × 0.61 = _____ (D)
5. Subtract D from C, then subtract 10 more: C – D – 10 = _____ %
Your answer will be your approximate body fat percentage, if you
are a male.
AT-HOME BODY FAT TEST FOR FEMALES
Step 1: Taking Measurements
1. Height in inches _____________
2. Hips in inches
_____________
3. Waist in inches
_____________
4. Weight in pounds _____________
Step 2: Determining Your Percentage of Body Fat
1. Multiply your hips (inches) ____ × 1.4 = ____ minus 1 = _______ (A)
2. Multiply your waist (inches) ____ × 0.72 = ____ minus 2 = ______ (B)
3. Add A plus B = ________ (C)
4. Multiply your height (inches) ________ × 0.61 = ________ (D)
5. Subtract D from C, then subtract 10 more: C – D – 10 = ________%
Your answer will be your approximate body fat percentage, if you
are a female.
You do not necessarily have to get your body fat to lean muscle
ratio tested to know that your body composition is improving. If you
have been exercising and eating properly and your clothes begin to
feel looser, if you find yourself taking in your belt a notch or two, or if
you observe increased strength and muscularity, you will know that
you are losing fat and gaining lean muscle.
2: Body Mass Index
The Body Mass Index or BMI is another important criterion in ascer-
taining whether you are overweight or obese. While the BMI is not
an infallible standard for determining obesity and the risk of heart
disease, taken together with other factors, it is a useful tool for help-
ing to create an accurate health profile. BMI is defined as your
weight in kilograms divided by your height in meters squared. To
save you the trouble of converting pounds to kilograms and inches
to meters, I have done the math for you. Simply look up your BMI in
the table provided. Your height can be found in the left-hand col-
umn and your weight (in pounds) runs along the top of the chart.
Your BMI is where both points intersect. Because people between
five feet and five feet three inches have a generally lighter frame, we
have included a different chart for them.
100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280
5'0" 20 22 24 26 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55
5'1" 19 21 23 25 27 28 30 32 34 37 39 41 43 45 47 49 51 53 55
5'2" 19 20 22 24 26 28 29 31 33 35 36 37 39 41 43 44 46 48 50
120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300
5'3" 21 23 25 27 28 30 32 34 36 37 39 41 43 44 46 48 50 51 53
5'4" 21 22 24 26 28 29 31 33 34 36 38 40 41 43 45 46 48 50 52
5'5" 20 22 23 25 27 28 30 32 33 35 37 38 40 42 43 45 47 48 50
5'6" 19 21 23 24 26 27 29 31 32 34 36 37 39 40 42 44 45 47 49
5'7" 19 20 22 24 25 27 28 30 31 33 35 36 38 39 41 42 44 46 47
5'8" 18 20 21 23 24 26 27 29 30 32 34 35 37 38 40 41 43 44 46
5'9" 18 19 21 22 24 25 27 28 30 31 33 34 36 37 38 40 41 43 44
5'10" 17 19 20 22 23 24 26 27 29 30 32 33 35 36 37 39 40 42 43
5'11" 17 18 20 21 22 24 25 27 28 29 31 32 34 35 36 38 39 41 42
6'0" 16 18 19 20 22 23 24 26 27 29 30 31 33 34 35 37 38 39 41
6'1" 16 17 19 20 21 22 24 25 26 28 29 30 32 33 34 36 37 38 40
6'2" 15 17 18 19 21 22 23 24 26 27 28 30 31 32 33 35 36 37 39
6'3" 15 16 18 19 20 21 23 24 25 26 28 29 30 31 33 34 35 36 38
6'4" 15 16 17 18 20 21 22 23 24 26 27 28 29 30 32 33 34 35 37
6'5" 14 15 17 18 19 20 21 23 24 25 26 27 29 30 31 32 33 34 36
6'6" 14 15 16 17 19 20 21 22 23 24 25 27 28 29 30 31 32 34 35
Interpret Your BMI
• If your BMI is below 20. Unless you are an athlete with a very
high lean muscle to body fat ratio, a BMI this low might mean
that you are too thin and are possibly compromising your
immune system.
• If your BMI is between 20 and 22. This range is associated with
living the longest and having the lowest incidence of serious
illness.
• If your BMI is between 22 and 25. These numbers are still within
the acceptable range and are associated with good health.
• If your BMI is between 25 and 30. Now you are entering the zone
where there are serious health risks. A BMI this high puts you
at risk for developing heart disease, stroke, type 2 diabetes,
and some kinds of cancers. You should definitely lower your
weight through diet and exercise.
• If your BMI is over 30. This is the worst-case scenario where you
are definitely putting yourself at risk for all of the diseases
mentioned above. It is imperative that you begin to lose weight
and exercise.
Having a BMI over 25 may cause your life span to decrease signifi-
cantly, according to a study done in the New England Journal of Medi-
cine. If your BMI is higher than 30, your life span may decrease even
more sharply. Studies show that 59 percent of American men have a
BMI over 25 and almost as many women. For those who have a BMI
over 35, health care costs are likely to be more than twice that of indi-
viduals with a BMI between 20 and 25. Treatment of diabetes, hyper-
tension, and cardiovascular disease count for much of this spending.
3: Waist Circumference
One of the most important and accurate indicators of obesity, the
potential for cardiac disease, and other health risks is the circumfer-
ence of the waist. The reason for this is because an increased meas-
urement in the waist always indicates an increase in abdominal fat
(and the ratio of body fat to lean muscle in general). Since a pound
of fat is four times the volume of a pound of lean muscle tissue, it is
possible for someone’s scale weight and BMI to remain the same as
they get older, yet for their waist to increase as lean muscle is lost and
fat storage is increased through inactivity and poor nutritional habits.
Dr. J. Pervis Milnor III, one of the authors of the book It Can
Break Your Heart, addresses the fact that a waistline higher than 35
inches in a woman and 40 inches in a man puts one at greater risk
for developing not only higher cholesterol levels which leads to coro-
nary disease, but also type 2 diabetes. According to the National
Heart, Lung, and Blood Institute, a man whose waistline is 42 inches
or greater is more likely to have erectile dysfunction than his leaner
counterparts.
Of course, a waist measurement of 35 inches (female) or 40
inches (male) is not always an absolute indicator of health risks. You
should take into consideration factors such as height, body type, and
bone structure. A 35-inch waistline on a woman who is five foot
eleven inches with a large frame would represent less of a health risk
than the same waist circumference on a woman who is five foot four
inches with a medium frame.
The Connection between Waist Circumference and Diabetes
There is a direct correlation between fat in the abdominal region of
the body and diabetes. According to the American Diabetes Associa-
tion, as abdominal girth increases, so do the chances of contracting
type 2 diabetes. This is due to increasing insulin resistance. In fact,
88 to 97 percent of diabetes diagnosed is the direct result of obesity.
New research from Kaiser Permanente found that the fatter you are,
the more likely it is that you will contract type 2 diabetes before the
age of forty-five. The risk of contracting this disease rises 6 percent
for every five to eight pounds of extra body fat.
The number of people who have type 2 diabetes has increased 33
percent from 1990 to 1998. According to the New Orleans Times-
Picayune, what is most alarming about this increase is that 70 percent
of new cases are individuals in their thirties. The American Diabetes
Association used to suggest that people get their first diabetes test at
age forty-five but is now urging people to get this test earlier because
undiagnosed diabetes can cause serious damage to your eyes, kid-
neys, nerves, and arteries long before you realize you have the dis-
ease. According to the group’s new guidelines, people with any of
the following risks should get tested at age thirty if they:
• Have a relative with diabetes
• Have heart disease, high blood pressure, high triglycerides, or
low HDL
• Are a woman who had gestational diabetes during pregnancy
or delivered a baby weighing more than nine pounds
• Are a woman with a hormonal disorder called polycystic ovar-
ian syndrome
• Have had a previous blood sugar test that found impaired glu-
cose tolerance, a condition that leads to diabetes.
For a detailed analysis of how abdominal fat is related to health
risks, as well as nutritional and exercise programs targeted specifi-
cally for reducing fat in that area of the body, see my book Lose Your
Love Handles.
Cardiologist Carl J. Lavie warns that even if a patient has no prior
history of heart disease, if he contracts type 2 diabetes, he will have a
greater chance of dying from cardiovascular disease within the next
five to ten years than a patient without diabetes who has just had a
heart attack.
How to Interpret Your Full Lipid Profile
Before you fill out the Cardiovascular Risk Assessment Question-
naire later in this chapter, you should understand certain terms that
describe your blood chemistry. When your doctor draws blood and
does something called a “full lipid profile,” he or she is evaluating
five basic numbers:
1. HDL, or high-density lipid protein. HDL is the type of choles-
terol that we think of as “good” or protective. If small
amounts of plaque (LDL or “bad” cholesterol) have been laid
down in your blood vessels, if you have enough HDL, you will
be able to dissolve this plaque and use it as an energy source.
• A good HDL level is 40 mg/dl and above for a man.
• A good HDL level is 50 mg/dl and above for a woman.
2. LDL, or low-density lipid protein. This is the “bad” type of
cholesterol. It collects in your blood vessels as plaque and
clogs them if you have too much floating around in your
bloodstream, or if you don’t have sufficient HDL to dissolve
it. According to the new cholesterol standards recently pub-
lished by the Journal of the American Medical Association:
• An LDL of less than 100 mg/dl is optimal
• 100–129 mg/dl is near or above optimal
• 130–159 mg/dl is borderline high
• 160–189 mg/dl is high
• 190 mg/dl and up is very high
(These LDL figures are the same for both genders.)
3. Triglyceride level. Triglycerides are the fats that appear in the
blood immediately after a meal or snack. Normally, they are
stripped of their fatty acids when they pass through various
types of tissue, especially adipose (beneath-the-skin) fat and
skeletal muscle. When this happens, they are converted into
stored energy that is gradually released and metabolized
between meals according to the metabolic needs of your
body. Almost everyone loves sugars and other kinds of carbo-
hydrates. Unfortunately, if you are insulin sensitive and eat
more carbohydrates than you require daily, your triglyceride
level will elevate. When this happens, your disease risk for
hypoglycemia and type 2 diabetes can increase and you will
become more susceptible to coronary disease.
• A normal triglyceride level is 150 or below.
• 150–199 is borderline high.
• 200–499 is high.
• 500 or over is very high.
4. Total cholesterol. This number is found by adding your HDL
plus your LDL plus your triglycerides, then dividing that
sum by five. Ideally, your total cholesterol should be 100 plus
your age.
• A total cholesterol less than 200 mg/dl is desirable
• 200–239 mg/dl is borderline high
• 240 mg/dl or higher is considered high
5. Ratio between your total cholesterol and your HDL.
• The average male has a 3.5–1 ratio
• The average female has a 4.5–1 ratio
• The average athlete has a 2.1–1 to a 2.8–1 ratio
Assessing Cardiac Risk Factors
Now that you understand the basic vocabulary and health indicators,
you are ready to take the Cardiovascular Risk Assessment Question-
naire and the Metabolic Syndrome X Questionnaire. If after filling
out these questionnaires you find yourself in a moderate- to high-risk
group, I urge you to go to your doctor for a professional evaluation
and immediate care. Heart disease is too serious to ignore.
Cardiovascular Risk Assessment Questionnaire
To determine your major cardiovascular risk factors, add the num-
ber of positive risk factors and subtract the number of negative risk
factors to get a total.
• If you have only one of these risk factors, your risk of major
cardiovascular disease within the next ten years is slightly
increased (approximately 5 percent).
• If you have two major risk factors, your risk is moderately
increased (approximately 10 percent).
• If you have three major risk factors, your risk of major cardio-
vascular disease within the next ten years is markedly increased
(approximately 20 percent or higher).
Positive Risk Factors
1. Do you have a family history of major cardio-
vascular disease in first-degree relatives (parents
and grandparents) who are younger than fifty-five
years old if you are male or younger than sixty-five
years old if you are female?
2. Are you currently smoking, have you smoked within
the last three years, or do you smoke more than
twenty packs a year?
3. Hypertension—Is your blood pressure greater than
140/90 mmHg or are you taking antihypertensive
medication?
4. Obesity—Is your BMI greater than 25?
(See table for calculating BMI on page 89.)
5. Obesity—Is your waist circumference greater than
40 inches if you are male, or 35 inches if you are
female? (See page 90.)
6. Do you have high LDL (bad) cholesterol—greater
than 160 mg/dl?
7. Do you have low HDL cholesterol—less than
40 mg/dl in men and less than 50 mg/dl in
women?
8. Do you have elevated triglycerides greater than
200 mg/dl?
9. Are you physically inactive, that is, do you exercise
less than thirty minutes one time per week?
Total yes answers ____

Negative Risk Factors
1. Is your HDL (good) cholesterol greater than
60 mg/dl?
2. Do you exercise for thirty minutes at a time at
least four times per week?
Total yes answers ____

Metabolic Syndrome X Questionnaire
There are five main measurements that are listed as risk factors for
Metabolic Syndrome X. If you have three of the five following meta-
bolic syndrome risk factors, your risk of major cardiovascular disease
during the next ten years is at least moderately increased. Please
check off the ones that apply.
1. Do you have a waist circumference greater than
forty inches if you are a man or greater than
thirty-five inches if you are a woman?
2. Do you have hypertension that is being medically
treated or blood pressure greater than 135/
85 mm/Hg?
3. Are your triglycerides greater than 150 mg/dl?
4. Do you have a low HDL value, that is, less than
40 mg/dl if you are a man or less than 50 mg/dl
if you are a woman?
5. Do you have a fasting glucose greater than
110 mg/dl?
If you have diabetes mellitus that is under treatment or a fasting
blood sugar greater than 126 mg/dl, your risk of major cardiovascu-
lar disease during the next ten years is markedly increased, in excess
of 20 percent. In fact, a patient with diabetes who has no prior his-
tory of heart disease has a greater chance of dying from cardiovascu-
lar disease during the next five to ten years than a patient without
diabetes who has just had a heart attack. The risk of major events
related to heart disease is increased even further if the patient with
diabetes has two or more of the other major risk factors.
All of these factors are considered general and should be a part
of every standard risk assessment for adult patients. Tests for all of
these factors are covered by all insurance companies or health main-
tenance organizations.
Further Define Your Overall Cardiac Risk
There are additional tests you can request from your doctor that can
further define your overall cardiovascular risk. But since some of these
are not covered by health insurance plans, keep in mind that you will
likely have to pay for some of them yourself. These tests are discussed
in detail on Dr. Carl J. Lavie’s Web site www.myheartrisk.com, which
also provides a test that automatically calculates your risk of heart
disease.
The hs-CRP test. One of the newer risk factors to be discovered is
hs-CRP, which stands for high-sensitivity C-reactive protein. Hs-CRP
is measured by a blood test and is a very accurate maker for small
levels of inflammation in the body. Low levels of inflammation often
accompany atherosclerosis and are usually present to a greater degree
in individuals likely to develop future heart attacks and strokes. In
studies of healthy men and women, as well as those who already have
heart disease, hs-CRP has been shown to be at least as useful, if not
more useful, than cholesterol levels in predicting future heart attack
and stroke. When you combine measurements of cholesterol levels
with your hs-CRP score and your other risk factors, the ability to pre-
dict your risk of future heart attack increases markedly.
The low cost of this test, about $20 to $50 in most labs, makes it
a fairly common tool for additional risk assessment. It should be
covered by most health plans.
Lipoprotein(a) test. Lipoprotein(a) is a particle that is structurally very
similar to LDL, or bad cholesterol. Although your Lp(a) values are
influenced by your genetics, levels are generally higher in the eld-
erly, in African-Americans, and in women. Elevated levels of Lp(a)
may increase vascular disease risk by inhibiting the body’s ability to
dissolve clots, by playing a role in “foam cell” formation—an early
step in the atherosclerosis process—and in increasing oxidative
stress. Oxidative stress is often referred to as the body’s rust and can
be seen in the little brown “age marks” that you have on the back of
your hands.
Although most studies have shown that an elevated Lp(a) alone
is a risk factor for cardiovascular disease, your risk will be particularly
increased when you also have elevated total cholesterol or LDL levels.
While Lp(a) is not considered a standard lab test, it should be
covered by most standard health plans. Dr. Carl J. Lavie recommends
it to the following types of patients:
• Those who have symptoms of vascular disease without other
risk factors.
• Those who have symptoms of vascular disease out of propor-
tion to their risk factor profiles.
• Patients who are borderline for drug treatment for lipids
(cholesterol), meaning those who do not have a very good
profile, but are not quite bad enough to meet current guide-
lines for drug treatment.
• Patients who have not only a mildly increased LDL value but
also have a mildly increased triglyceride level and a mildly
reduced HDL value.
• Patients whose cholesterol shows only minimal improvement
when taking statin medications. Sometimes these individuals
are found to have very high Lp(a) values, greater than 100
mg/dl.
Homocysteine test. Elevated levels of homocysteine may increase the
risk of vascular disease. Elevated levels of homocysteine have been
associated with increased risk of venous thrombosis, pulmonary
embolism, peripheral vascular disease, cerebral vascular disease, and
coronary artery disease.
Although homocysteine levels may be determined by genetic fac-
tors, higher levels are associated with decreased fitness; a low intake
of vitamins B6 and B12, which contain folic acid; and renal failure.
A homocysteine test can cost as little as $50 or as much as $125.
Stress testing. According to the American Heart Association and the
American College of Cardiology (ACC), there are no absolute guide-
lines to doing a stress test in a patient unless he or she is showing
symptoms of chest pain or shortness of breath. Therefore, many
health plans may not pay for this unless symptoms appear. However,
many physicians recognize that a “positive” or abnormal stress test
can indicate a significant increase in risk when combined with sev-
eral other risk factors. This can range from four to eighty times an
increase in risk.
For this reason, many clinicians interested in preventive medi-
cine feel that a stress test is reasonable for:
• Men older than forty, and particularly men above fifty years of
age, especially with two or more risk factors
• Postmenopausal women who have two major risk factors
• Sedentary middle-aged individuals who are about to start an
exercise program more vigorous than regular walking
If your insurance does not cover this kind of test, it will cost you
$450 for a simple echocardiogram (ECG), $800 for a cardiopul-
monary test, $1,000 for an exercise echo, and $2,700 for a nuclear
stress test.
Coronary calcium scanning. Substantial research data indicate that an
electron beam CT scanning for coronary calcium deposits can be of
great use in identifying early atheriosclerosis and potential risk fac-
tors for CAD (coronary artery disease). Since the cost of this test is
high (between $400 and $800) and the American Heart Association
does not recommend its routine use, most insurance companies do
not pay for this test at the present time. However, if you decide to
have a coronary calcium scan performed, be aware that a value in
the 10 to 100 range is considered high and should be followed by
more vigorous risk factor modification and possibly treadmill testing
(especially for values greater than 100–200).
Should You Consider These Tests?
In general, cardiologist Carl J. Lavie recommends that any individual
who has two or more major risk factors, can afford the costs, and is
interested in reducing his or her major cardiovascular risk, might at
least consider getting the hs-CRP, Lp(a), and homocysteine tests, in
addition to other standard testing for cardiovascular disease.
Recently, a client named Susan signed up for my PEP program.
When we administered the standard health and screening portion of
my program, we discovered that she had a total cholesterol slightly
less than 200 and a borderline high LDL of 130. In the past, most
doctors would have just given her some dietary recommendations or
possibly put her on statin medications and then not worried about
her. However, when Dr. Lavie discovered that Susan had some his-
tory of early death from heart disease in her family, he recom-
mended that she be tested for these other three blood factors. When
the results came back, we discovered that Susan had elevated levels
of Lp(a), a hereditary factor that put her at greater risk for develop-
ing vascular disease. When Susan was given an angiogram after sev-
eral other tests including stress testing were abnormal, sure enough,
Dr. Lavie found blockages in her arteries. In other words, this test
quite possibly saved her life.
Take Ownership of Your Health
One question I ask all my clients is: “Do you live as if you rent your
body or as if you own it?” Far too many of us treat our bodies as if
they were rental apartments. And when you are merely renting a liv-
ing space, you will never take as much responsibility for its upkeep as
you would with a home you owned. If you want to achieve optimum
health, it is time to start taking ownership of your body, and not
treating it as a transient space that you rent.