Gambling with Cardiovascular Risk: Picking the Winners and Losers
Having just undergone your annual physical examination, you are now sitting in your doctor’s office hearing for the first time that your blood pressure or cholesterol level is elevated. Your doctor strongly recommends that you do something to correct this situation, either through lifestyle changes, such as losing weight and going on a low saturated fat or low salt diet, or by starting one or more medications. You have never been sick and have viewed yourself as a healthy individual. Your doctor is now suggesting that you have a problem that must be corrected.
The issue is not the elevated cholesterol level or the blood pressure level per se. It is the fact that there is an increased risk of cardiovascular disease (CVD) associated with both of these factors. Accordingly, after your physician has told you just how high your cholesterol or blood pressure is, he/she should also inform you of what this means in terms of your overall risk of CVD. This assessment should be based on the wide variety of established risk factors, including, among others, your age, sex, physical activity level, weight, and family history of premature coronary heart disease. The word “premature” is important in that you are only considered to have a positive family history if a direct family member suffered from angina, a heart attack, stroke, etc. before the age of 60. If a parent or grandparent died of a heart attack at the age 80, this does not mean that your family is prone to premature CVD.
The risk of developing cardiovascular disease is associated, in varying degrees of importance, with the presence or absence of these specific risk factors. While it is important to understand which risk factors are present in your specific situation, their presence does not represent an early death sentence, a medical emergency, or sufficient reason to avoid most of the pleasures that life has to offer. On the other hand, treatment is often proposed for a period of years to a lifetime. Accordingly, there is usually plenty of time to repeat the measurements, to be re-evaluated by your physician, and to seek a second opinion if you remain unconvinced that the benefits of treatment outweigh its costs and potential complications in your particular situation. An appropriate evaluation of this type should take three to twelve months to complete, following which the various treatment options available to you should be weighed.
The Risk Factors in Cardiovascular Disease (CVD)
(To be considered individually in future issues of Lay Medix)
1. Family history of premature (before the age of 55) CVD
2. High blood pressure
3. Cigarette smoking
4. Elevated blood levels of cholesterol and other ‘fatty materials’ (related to genetics, age, sex, degree of elevation, etc.)
5. Diabetes Mellitus
6. Obesity (of major degree)
7. Enlargement of the left ventricle of the heart
8. Highly sedentary lifestyle
As an educated consumer of health care services, how should a patient approach cardiovascular health promotion and disease prevention? First, ask your physician if the identified risk factor has been measured in the past, and whether or not it was noted at the time. If this is the first time, for example, that an elevation in cholesterol has been noted, it is possible that it simply represents a random variation that may occur throughout your lifetime, and in three to ime, and in threesix months this abnormal value may well return to normal spontaneously. Another possibility is that changes in your present lifestyle (weight gain, inactivity, change in diet, etc.) have resulted in this acute change in your risk profile. A reversal of lifestyle may well simultaneously reverse the risk factor.
Finally, the test may simply be wrong. Blood pressure measurement is not as simple as it sometimes appears to be; close attention must be paid to details such as the size of the blood pressure cuuff and the positioning of the patient. Several readings should be taken at rest to ensure that the final measurement of pressure is accurate.
The same is true for blood cholesterol measurements. Accuracy of determination varies significantly from labboratory to laboratory. No decision should be made regarding the reality of elevated cholesterol levels until two or more measurements have been completed and the results are reasonably consistent. When convincingly accurate data has been obtained and your other potential risk factors have been determined from your medical history, it is then reasonable to develop a personalized CVD prevention strategy.
Having a specific risk factor is not the same as having a specific disease. Risk assessment issisnt is like predicting the weather or the stock market. The predictions are based on probabilities. When the probability of disease becomes sufficiently high so that the potential benefits of treatment outweigh the risks and costs of therapy, it is then appropriate to consider starting treatment.
If your physician cannot address these questions to your satis- faction, it is sensible for you to ask for a referral for a second opinion from an appropriate specialist. Do not be rushed or intimidated into acceptting a new treatment plan. A wise medical professor is said to have observed that, “The practice of medicine is rarely black or white. Any practitioner who tells you it is, is either a fool or takes you for one.” The same can be said for the practice of preventive medicine – it is rarely black or white. Careful consideration of all risk factors is necessary to arrive at a treatment plan that is practical, acceptable to the patient, and has a high probability of success.