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Life After Cancer A Roadmap for Cancer Survivors

Heart Disease
Gary F. Milechman, MD, FACC and Jay S. Luxenberg, MD

The Causes and the Cures
Risk Factors and Strategic Solutions

Heart disease is the number one reason people don't live as long and as healthy lives as they might want. The two most common causes of early death and debility are heart attacks and heart failure. As you are probably aware, coronary atherosclerosis is the number one killer in America. You may not be aware that 2.5 to 3 million Americans have heart failure, a disease with a mortality rate worse than most cancers. The good news is, these diseases are very much preventable. The power is in your hands to change the odds of your being afflicted with heart disease.

The Causes and the Cures
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The heart is actually a pump. Its job is pumping the blood that carries oxygen from your lungs to the rest of your body - brain, muscles, kidneys, intestines, etc. When the pump fails, major trouble results. The waste products build up, and the vital tissues are starved for food and oxygen. The failing pump causes a build up of salty fluid in the body, resulting in swollen ankles and often fluid in the lungs, which causes shortness of breath. When the heart fails to pump blood adequately, we call it congestive heart failure. When people with congestive heart failure attempt physical work (for example lifting groceries or doing housework) they can get short of breath and fatigued. You can do several things that can minimize your chances of developing this problem.

Congestive heart failure in older people can also be caused by damage to the heart from heart attacks and long-standing high blood pressure. Fortunately, there are a variety of ways of preventing and treating high blood pressure. By avoiding obesity, smoking, and alcohol, and with physical exercise you will help prevent high blood pressure. If high blood pressure does develop, then avoiding excess sodium in the diet will help control it. If these measures fail, then adding one of the many safe and tolerable blood pressure medications will allow control of blood pressure elevation, preventing the heart failure down the road. Congestive heart failure is a disabling and often ultimately fatal form of heart disease, and now you know a strategy for preventing it.

Another potentially preventable form of heart disease is coronary artery atherosclerosis. This is the process that leads to heart attacks, chest pain with activity (called angina) and even sudden death. Atherosclerosis refers to fatty deposits in the walls of blood vessels. If this occurs in the fairly small blood vessels that supply the heart muscle, we call this coronary artery disease. If the blood flow in these blood vessels is only partially blocked, then under conditions of low energy usage such as resting or minimal physical activity, all is well. When you try to perform more activity, such as walking or lifting, the heart muscle can't get enough blood flow and pain or angina may result. This disorder can be so severe that you can lose the ability to work or perform the activities that provide pleasure in life.

If the blockage to blood flow in the arteries supplying the heart muscle becomes more severe, then all blood flow to a portion of the heart may stop. The heart muscle without blood supply dies. This is what is generally called a heart attack, and in about 25% of cases the person dies before reaching the hospital. If the initial attack is survived, then the dead heart muscle tissue slowly turns into a scar. If enough of the heart muscle is damaged, the heart can't pump well and congestive heart failure develops.

There are a number of very effective high tech treatments for blocked coronary arteries. Angioplasty is a technique that opens up an artery non-surgically with a balloon. Stenting is performed by having a slotted metal tube, sometimes impregnated with medication, mounted on a balloon and placed in the narrowed coronary artery, then the balloon is expanded, the tube expands and the balloon is deflated and removed, leaving the stent to hold the artery open. Bypass surgery places new conduits or pipes around the blocked arteries, bringing fresh blood to starved myocardial tissue. These procedures can be very useful and lifesaving, but they do not address the underlying pathologic process.

Our goal is to prevent these serious heart problems from ever developing. Fortunately, over the last few decades we have learned much about what causes these problems, and how we can prevent them. A major clue was the fact that heart disease is very uncommon in developing societies, where diets are much higher in fiber, fruits and vegetables and much lower in animal fats. Physical activity is greater, and in most cases certain types of emotional stress are much less that in developed societies. By changing our dietary habits, increasing physical activity and reducing stress, we can lower our own risk of developing heart disease and the atherosclerotic process.

Risk Factors and Strategic Solutions
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Risk factors associated with atherosclerosis have been known for years. These are cigarette smoking, high blood pressure, high cholesterol, diabetes, age, being male, family history, and probably stress and Type A behavior. Much has been learned recently in ways in which significant modifications can be made to retard or even reverse atherosclerosis.

Stopping smoking is a most critical and very obvious step. Treating high blood pressure will help. Common sense ways, such as lowering salt intake, getting to a reasonable weight, reducing stress, and exercising, should be your first choices.

Easy, regular exercise has multiple benefits. A regular walking regimen will help you control your weight, your blood pressure, aid in the control of diabetes, help with reducing stress, and has been shown to improve your cholesterol profile.

Cholesterol has received much well-deserved attention in both the media and the scientific community. Total cholesterol is divided into good (HDL or High Density Lipoprotein) and bad (LDL or Low Density Lipoprotein) cholesterol. HDL acts as a scavenger to remove cholesterol deposits from vessel walls while LDL encourages cholesterol deposition. High HDL is protective whereas low HDL is associated with a significant risk for coronary disease. Your HDL level is largely hereditary although exercise is the safest way to increase your level. Eating foods high in mono-unsaturated fats (such as olive, canola, and nut oils, plant sterols, as well as avocados and walnuts) and low in saturated fats can significantly raise your HDL. Partially hydrogenated oils (frequently in packaged and processed foods) promote arteriosclerosis and should be avoided, so read the labels. Red wine (in moderation) and the vitamins Niacin or Nicotinic Acid in pharmacological doses (which has potentially significant side effects and should not be done except under medical supervision) are two other ways of increasing your good cholesterol.

Bad cholesterol (LDL) is somewhat hereditary as well, but is much more responsive to simple interventions. A low fat diet by its nature is low in calories and the best way to get you back to your fighting weight. There is increasing evidence that simple carbs (things high is sugars or starches that are quickly broken down by the body) promote diabetes, weight gain, and the atherosclerotic process. Avoiding sugars and simple starches such as white bread, potatoes, and white rice, while increasing your consumption of high fiber brown breads and brown rice will help with weight loss, help prevent diabetes, and improve your lipid profile.

It had been thought that atherosclerosis was an inevitable part of aging. Aggressive treatment of high cholesterol levels in patients with documented and quantified coronary narrowing has shown that many people can reverse the atherosclerotic process and fatty plaques can melt away. There are many very effective and safe medications for lowering high LDL that is not responsive to diet alone.

A group of medicines called statins (Lipitor, Zocor, Crestor, Lescol, and Pravachol) can dramatically lower LDL levels, promote regression, and have been proven to prevent progression, heart attacks, and strokes. Side effects, such as muscle aches or liver problems, are quite rare. Lower LDL levels are better for your health; as low as 60 seems to be optimal for people with established disease or risk factors such as diabetes. Most people cannot get their cholesterol levels that low with lifestyle modifications only. Niacin, fibrates, or Zetia can be added to a statin to optimize your lipids and lessen the chance of progressive atherosclerosis causing big problems.

People who eat more fish tend to have fewer coronary events. Certain fats in fish (omega-3 fatty acids) are felt to be protective, although the exact mechanism is not clear. Sardines, herring and wild salmon are a good main fish source.

One of the exciting implications of the human trials attempting to prevent and regress atherosclerosis is that some of the biggest improvements were found in patients with the most severe fatty deposits in the walls of their blood vessels. In other words, it may never be too late to make lifestyle changes and, if needed, use cholesterol lowering medication to decrease your chances of having a heart attack or stroke.

Fatty deposits in blood vessels can be reduced with improvement in diet, exercise and stress reduction. Both men and women will benefit from these lifestyle choices. Another important finding is that even moderate decreases in the amount of fatty deposits seem to produce a much greater decrease in the number of deaths and heart attacks.

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There is now overwhelming evidence that we are not limited by our heredity - by taking charge of our health we can eliminate much of the death and disability caused by heart disease. The ways to prevent heart disease and improve the quality and enjoyment in your life are apparent.
Get regular aerobic exercise. Walking 30 to 40 minutes three or four times a week is all that is needed.
Avoid deconditioning. The cardiovascular condition most likely to hinder recovery from cancer is not actually a disease - it is deconditioning. It helps to think of the difference between an athlete and a sedentary couch potato. The athlete's heart, lungs and muscles work more efficiently and allow the athlete to dramatically increase the work his or her muscles do under conditions of challenge - such as running a race or running for a bus. Unfortunately, most of us are closer to the couch potato than the athlete, and the deconditioning of our cardiovascular system limits our ability to compensate for stresses both physical and emotional. Fortunately, an exercise program that gradually becomes more rigorous as our muscles strengthen can allow us to regain such lost conditioning.
Be sure your blood pressure is within the normal range. If not, get it there with whatever works for you.
Stop smoking, obviously.
Eat healthy food. Stay away from red meat, chicken skin, dark meat poultry, eggs, fried foods, tropical oils, and any hydrogenated oils. Do eat plenty of the right kind of fish, white meat chicken or turkey, high fiber bread, brown rice, beans, vegetables, and fruit.

If you have strong risk factors for coronary disease such as family history, high cholesterol, and/or being a former smoker, and your cholesterol is not in a good range despite a good diet, strongly consider medications to get your total cholesterol down under 200 and increase your HDL while lowering your LDL.

Consider stress reduction. It may be in the form of a support group, yoga, running, swimming, Type A behavior modification, changing your work environment or schedule, or spending more real time with your family. Think about what causes stress in your life. Lessening stress can certainly make your life more enjoyable, and probably longer, too!

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