Thursday, March 11, 2010

Assessing Your Risk of a Heart Attack - Consults Blog - NYTimes.com

arch 10, 2010, 3:54 pm




Assessing Your Risk of a Heart Attack

What tests can determine your risk for cardiovascular disease? Michelle from Cleveland asks the Consults blog:

My family, on my mother’s side, is at risk for heart disease. My grandfather died of a massive heart attack in the steel mill where he worked at the age of 45. My mother has had two strokes and several transient ischemic attacks (T.I.A.’s) beginning at the age of 45. Her brother had quadruple bypass at age 73, and her sister had a triple bypass at 71. My father has also had two stress-related heart attacks.

I was wondering if you could recommend any tests to monitor my cardiovascular health, in order to prevent the events that have plagued my family from happening to me.


Dr. Peter Libby

 chief of cardiovascular medicine  responds:


The issue of risk prediction in people without known cardiovascular disease is an area of considerable current controversy. The surest place to start is with the tried and true conventional risk factors.

The Framingham Heart Study, which began in 1948 in Framingham, Mass., defined high cholesterol, high blood pressure, age and male sex as risk factors for coronary heart disease in the mid-20th century. You can plug your own values into a risk calculator available on a government Web site to estimate your 10-year risk of having a heart attack or dying from heart disease, based on these risk factors. The tool asks for your age, gender, cholesterol levels and whether you are a smoker or on blood pressure medicines.

You don’t give your age or sex, but I’m guessing from your name and student status that you are a young woman. The Framingham Risk Calculator, which does not take family history into account directly, would almost assuredly classify you as having a low 10-year risk of a cardiovascular event, particularly if you’re not a smoker.

The main concern for someone like you is more about lifetime risk of a cardiovascular event, rather than just for the next 10 years. The Framingham algorithm doesn’t really help you in this respect. Moreover, I share your concern about elevated cardiovascular risk, given the extensive family history of premature cardiovascular disease that you describe.

You ask about emerging markers of risk. Of the emerging biomarkers that add information to the traditional Framingham risk factors, many experts, but not all of them, consider that the high sensitivity C reactive protein, or hsCRP, furnishes the most clinically useful tool for this purpose today. (Disclosure: my employer — but not me — holds a patent on the use of hsCRP in cardiovascular diagnosis.) A risk calculator called the Reynold Risk Score, derived from long-term follow-up of a group of apparently healthy women, adds hsCRP and family history to the Framingham variables. The hsCRP test is widely available and relatively inexpensive; your doctor can order it on a routine blood draw. The use of this risk score helps to sharpen the risk prediction afforded by the Framingham tool.

No matter what calculator you use for cardiovascular risk  a healthy lifestyle is certainly in order. You should not smoke, and you should eat a healthy diet  In addition, avoid excess weight and make physical activity part of your daily life. Consider alternatives to oral contraceptives, especially if you have high blood pressure or smoke, since these medications may raise cardiovascular risk. If your Reynolds Risk Score computes an intermediate or high risk (that is, more than a 5 percent chance of a heart attack or other cardiovascular event in 10 years), consult with your doctor regarding the need for measures beyond a healthy lifestyle to minimize your cardiov