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Catching heart disease early is crucial

ALBUQUERQUE, N.M. — A 58-year-old man with no history or symptoms of heart disease came to my office at the New Mexico Heart Institute for cardiac evaluation after one of his friends died suddenly.

The patient – we’ll call him MB – did absolutely no exercise, was overweight by 30 pounds, with a BMI of 32.7 (obese is greater than 30). (To calculate your BMI, go to nhlbisupport.com/bmi/.) His blood pressure, he said, “was a little high,” but he said he felt fine. On examination, it was elevated at 145/80. He drank a glass of wine a day, proudly explaining, “red for my heart.”

Even though he told me his cholesterol was normal, it was not, with total cholesterol of 210 mg/dl, LDL 130 mg/dl, HDL 38 mg/dl and triglycerides 170 mg/dl. His LDL should be less than 100, HDL 40 or higher and triglycerides less than 150. A high-sensitivity CRP, a measure of inflammation, was 3.0 (high). His EKG was normal.

Establishing risk

Because 50 percent of the time the first symptom of coronary artery disease is a heart attack or sudden death, we wanted to establish his risk for a heart attack or dying in the next 10 years. With my iPad, I went to the Reynolds Risk Score site (www.reynoldsriskscore.org/home.aspx). His risk for having a heart attack or dying in the next 10 years was 12 percent, placing him in an intermediate risk group (high is more than 20 percent and low is less than 10 percent). The score also tells what happens if the risk factors like weight, cholesterol and hypertension are controlled and the person quits smoking.

High-risk patients usually have symptoms, and so their evaluation often includes stress testing and possibly coronary angiography. Low-risk patients usually do not require further testing, but intermediate-risk patients require a very individualized approach to testing.

The score caught MB’s attention. He wanted every possible test.

Tests that help

The American Heart Association published evidence-based guidelines in 2010 (circ.ahajournals.org/content/122/25/2748) to help decide what testing will assist in more precisely defining risk and directing the patient to therapy different from what is gleaned from the Reynolds or Framingham scores.

So any further studies would be directed toward finding evidence of preclinical coronary artery disease or evidence of inflammation. The CRP was helpful in MB’s case, where the guidelines say it is reasonable for men 50 years of age or older or women 60 years of age or older with LDL cholesterol less than 130 mg/dl. CRP can be useful in the selection of patients for statin therapy.

Two non-invasive tests can be used to look for preclinical coronary artery disease: an ultrasound measure of the lining of the carotid arteries and a coronary calcium score. I prefer the latter, which is a low-radiation-exposure CT scan of the coronary arteries to look for calcium. The finding of calcium in plaque lining the coronary arteries meant MB had coronary artery disease. An ideal score is 0 but his was 220. That does not mean the arteries are narrowed, it just means they have plaque and that puts his risk of a heart attack much higher. The higher the calcium score is, the greater the risk for a coronary-related event. These findings directed my recommendations.

Healthy heart program

Because MB wanted to go to New Heart, the center for wellness, fitness and cardiac rehabilitation in Albuquerque, for a vigorous exercise program, we performed an exercise stress test. Not surprisingly, he was in terrible shape but did not show any worrisome EKG changes with exercise. Most people like MB who have no symptoms do not need a stress test.

More sophisticated imaging using echocardiography or nuclear stress testing in patients is usually not indicated, but sometimes we study people with diabetes, a strong family history or a high calcium score above 400.

MB was placed on a healthy heart program and in my next column, I will tell you what that was and how MB fared.

Dr. Barry Ramo is a cardiologist with the New Mexico Heart Institute and medical editor for KOAT-TV. Send questions for him to Albuquerque Journal Live Well, P.O. Drawer J, Albuquerque, NM 87103, or email them to htaylor@abqjournal.com.

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