Straight to the Heart
Heart disease rarely occurs in isolation. Learn about its common companions and what you can do to protect yourself.
Take Care of Your Ticker: Erskine James, M.D., medical director of the Cardiovascular Intensive Care Unit and Heart Failure Center at Navicent Health in Macon
Having one chronic disease is one too many, but when you have heart disease there’s a good chance you also have another – or others. By some estimates up to 75 percent of people with heart failure – a condition in which the heart does not pump efficiently – have at least one other chronic health condition. In one large study of Medicare recipients, more than half of those with chronic heart failure had five or more additional health conditions.
What gives? Doctors who study and treat heart disease offer several explanations. For one, heart disease is common – in fact, it’s the leading cause of death in Georgia, responsible for one in four deaths each year – so it’s not unlikely that a person with one disease might also have heart disease. Other explanations include the role of shared risk factors – such as smoking and obesity, which are associated with a number of diseases including heart disease, diabetes and even some cancers – as well as the propensity for some diseases to either trigger or exacerbate changes in the blood vessels that can lead to or worsen heart disease.
“Cardiovascular disease is largely due to endothelial disease – damage to the inner lining of the blood vessels,” says Erskine James, M.D., medical director of both the Cardiovascular Intensive Care Unit and Heart Failure Center at Navicent Health in Macon. “A lot of the diseases that people have make endothelial disease worse.” In some cases, those diseases can even precipitate heart disease, he says.
If you have one of these seven diseases, it becomes exceedingly important to take care of your heart.
Type 2 Diabetes
While heart disease is responsible for one in four deaths in the general population, among those with type 2 diabetes that number rises to two in three.
“If you look at patients with type 2 diabetes without any prior myocardial infarction [heart attack], they carry the same risk of cardiovascular [disease] as patients without diabetes who have a prior MI,” says Ismary DeCastro, M.D., assistant professor at Mercer University School of Medicine and a practicing endocrinologist affiliated with Memorial Health in Savannah.
The reason is related to a cascade of events that occur when someone has diabetes, she says. Blood glucose levels rise and cholesterol levels start to change; levels of triglycerides, the breakdown of fats from foods, become higher; levels of HDL, the good cholesterol, get lower. People with diabetes also tend to have a lot of small LDL (the so-called bad cholesterol) particles, which is problematic because they can penetrate the vessel wall and cause damage.
Fortunately, controlling diabetes can reduce the risk of cardiovascular death. Treatment goals should be individualized for each person, says Dr. DeCastro, and should include a discussion of the risk of cardiovascular disease along with a cholesterol panel, blood pressure check and an A1C – a blood test that provides information about a person’s average levels of blood glucose over the past 3 months – shooting for a score of 6.5 or lower.
“A lot of patients don’t realize the significant risk they have just because they are diabetics,” says Dr. DeCastro. “It is definitely something we need to increase awareness and talk about.”
While arthritis is primarily a disease of the joints, people with arthritis also face an increased risk of heart disease. The reason is different depending on the particular form of arthritis you have. For osteoarthritis – the most common form of arthritis where the joint cartilage breaks down over time – the main connection is shared risk factors, including advanced age and obesity. In addition, joint pain and stiffness can make it difficult to be active, which further increases the risk of cardiovascular disease and its progression.
For some other forms of arthritis, however, there is more to the connection. According to a 2013 study published in the American Heart Journal, people with rheumatoid arthritis (RA) have up to twice the risk of heart disease and heart failure compared to the general population. The culprit, doctors believe, is inflammation. In RA, inflammation causes destruction of the joint tissue, but inflammation associated with RA can also affect other parts of the body.
“What we are realizing is that there is an element of inflammation involved in coronary artery disease,” says Barry Mangel, M.D., chief cardiology officer of the WellStar Health System. “There is inflammation in the wall of the blood vessel.” Inflammation can damage the vessel wall and lead to the build-up of dangerous plaque, he says.
According to the Atlanta-based Arthritis Foundation, the wall of the heart in people with RA also can become inflamed, possibly contributing to heart failure; inflammation of the pericardium, the membrane that surrounds the heart, can cause sharp chest pain.
The greatest risk of cardiac events – such as heart attacks or angina – are among those in whom blood tests show the highest levels of inflammatory markers, says Dr. Mangel. While controlling the arthritis and its related inflammation are important to reducing heart risk, it is also important to reduce other risk factors by exercising, eating healthfully and not smoking.
The CDC estimates that close to half of American adults have gingivitis, an early form of gum disease that causes gums to become red, swollen and bleed easily. If not controlled, gingivitis can progress to periodontitis, a condition in which the gums pull away from the teeth and bacteria in the mouth invade the gums and underlying bone, leading to breakdown of the tissue that support the teeth. Bacteria also enter the bloodstream, triggering low-level inflammation that damages the blood vessels.
Although it is difficult to prove a direct causal effect between periodontal disease and heart disease in people, in animal models the introduction of periodontitis has been proven to accelerate atherosclerosis, says Christopher Cutler, DDS, Ph.D., associate dean for research at Augusta University’s Dental College of Georgia. Heart disease is 30 percent more common among people with periodontitis, even when other risk factors such as smoking are considered.
“You’ve got to remember that the oral mucosa in your mouth is part of your GI tract,” says Dr. Cutler. “If you have an infection in your oral cavity, it is not surprising it will cause problems in the rest of the body.
“To reduce the risk of periodontal disease and the potential risks it presents to your heart, it is important to practice good oral hygiene – flossing daily, brushing twice a day and having your teeth cleaned every six months,” says Dr. Cutler. “If you have been told you have gum disease and you have one other risk factor for heart disease – for example, if you smoke or you have elevated cholesterol – you should see a cardiologist, but also make sure to get your periodontal disease treated and maintained. See your hygienist every three months.”
Although their functions are much different, the kidneys and heart are strongly connected. Heart disease and kidney disease often go together, largely because the kidneys are responsible for regulating blood pressure – the force with which the blood travels through the vessels, says Dr. Mangel.
When the kidneys are damaged, they may release too much of an enzyme called renin, which increases blood pressure. Over time, this excessive blood force on the vessel walls causes damage. The result can be a heart attack, heart failure or aortic dissection, an often fatal tear in the wall of the aorta.
Damaged kidneys may also affect the heart in other negative ways. For example, they are less efficient at removing excess homocysteine, an amino acid, which in high levels can lead to cardiovascular disease and heart attacks. They may also produce insufficient amounts of erythropoietin, a hormone that signals the bone marrow to produce red blood cells. This can lead to deficiency of oxygen-carrying red blood cells, known as anemia, which can deprive the tissues of oxygen-rich blood and potentially lead to a heart attack.
Loud snoring can do more than irritate sleeping partners. It can be a sign of obstructive sleep apena, a condition in which an obstruction in the airways causes pauses in breathing during sleep. As a result you wake up many times a night – although you likely don’t remember it – gasping for air. In addition to leaving you feeling sleepy the next day, sleep apnea may increase your risk of heart disease, says Dr. Mangel.
The reason is that lapses in breathing cause oxygen levels in your blood to drop. When that happens, your sympathetic nervous system – which controls heart rate and blood pressure among other functions – is stimulated.
“Typically when you sleep, your heart rate goes down and your blood pressure goes down – it’s a time for your body to really shut down and relax,” says Dr. Mangel. “But when you have sleep apnea, you are constantly stressing your body because the oxygen level drops, the sympathetic nervous system is stimulated and your body never has a time for that relaxation.” The result, he says, can be high blood pressure, heart rhythm disturbances and worsening of congestive heart failure due to the increased load on the heart muscle.
In addition, says Dr. James, studies of people with sleep apnea have shown higher levels of markers of inflammation than people without sleep apnea. “It’s as if the body is fighting off some type of infection even though there is not an infection.”
The same sympathetic nervous system response that can stress the heart and blood vessels in people with obstructive sleep apnea can also cause damage in response to constant stress or emotional distress.
“If you are under a lot of stress, your sympathetic nervous system is stimulated or over stimulated, and that can lead to high blood pressure. And we know that can lead to heart attacks,” says Dr. Mangel. “We know that when there is a mass stress like an earthquake, we see a spike in heart attacks. You can imagine if a single high stress event can cause it, chronic lower level stressful events are also going to increase your risk.”
Activation of the stress response system can lead to anxiety, which, if not relieved, can affect the heart and blood vessels. Anxiety disorders – excessive anxiety about everyday life events – commonly occur with heart disease. Management of anxiety through exercise, counseling, relaxation techniques and/or medication can help protect the heart.
Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease is actually a group of diseases that block air flow in the lungs and make it difficult to breath, resulting in low levels of oxygen in the blood.
“If your oxygen level is chronically low, your body’s response to that is to increase your heart rate and try to pump more blood and more oxygen to your body,” says Dr. Mangel. “It’s a cyclical process – if your lung is damaged and your oxygen level drops, your heart has to work harder.
“Oftentimes when I see someone who has had bad lung disease and I measure their heart rate, it is going to be fast because the heart is trying to compensate for that low oxygen level,” he says.
It is widely known that severe COPD can lead to heart failure, but a 2010 study in The New England Journal of Medicine found that even mild cases of COPD can affect heart function. While COPD cannot be cured, it can be treated. The sooner it is identified and treated, the better for your lungs and heart.
Guard Your Heart
If you have one of these seven diseases, controlling it can often in itself help reduce the development or progression of cardiovascular disease, says Dr. James. “The body works in kind of a mysterious way. You don’t think that rheumatoid arthritis or gum disease should affect the heart, but they do. If a person is having some type of illness, they need to take care of it so they can hopefully protect their heart.”
If you have a chronic disease, ask your doctor how and if it might affect your heart and any tests you might need or precautions you should take.
Healthy lifestyle habits are also crucial – “managing all of the lifestyle things, like your weight, your cholesterol, not smoking, exercising, eating a diet that is lower in sodium,” says Dr. Mangel. “All of those things can modify your risk.”