Beyond Heart-health Basics

Research is uncovering a broad range of risk factors for heart disease.
Georgia Trend Feb 2023 Heart Health Dr Arora 082
New Threat to Hearts: Dr. Vishal Arora, interventional cardiologist at Augusta University Cardiology Center Photo: Hillary Kay

Even if we don’t always heed them, most of us know the traditional risk factors for heart disease and what we can do to minimize at least some of them. A few years ago, the American Heart Association summed up the risk factors we can change and called them Life’s Simple Seven: cigarette smoking, obesity, hypertension or high blood pressure, high cholesterol, physical inactivity, poor diet and diabetes.

While the concept of prevention is simple, the role of these risk factors in heart disease and their connection to one another is complex. Research – and experience – continues to uncover additional factors that increase the risk of heart disease and add to the understanding of the underlying mechanisms like inflammation that play a role in its development.

Representatives of the Metro Atlanta American Heart Association and cardiologists from around the state weighed in on the latest in cardiovascular risk factors and what we all can do protect ourselves – and each other.

Inadequate Sleep

Fast-paced lifestyles, screen time that stretches into the night and medical conditions ranging from obesity to sleep apnea are affecting our ability to get good sleep, and our hearts are paying the price.

Research shows that, for adults, seven to nine hours of sleep nightly is best for healthy hearts. Yet according to a 2021 joint report by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, 38.3% of Georgians average less than seven hours a night, making Georgia one of the most sleep-deprived states in the U.S.

Inadequate sleep can affect cardiovascular health in a number of ways, including raising levels of the stress hormone cortisol and affecting the body’s ability to regulate blood sugar or glucose, says Dr. Marcus Brown, an interventional cardiologist with Northside Heart in Atlanta and president of the Metro Atlanta American Heart Association board. (Interventional cardiologists perform procedures like angiogram, catheterization, angioplasty and stenting.)

“[Poor sleep] increases risk-enhancing factors such as high blood pressure, elevated cholesterol and build-up of plaque,” says Dr. Vishal Arora, an interventional cardiologist at Augusta University Cardiology Center. “By increasing blood pressure and cholesterol, it certainly leads to more heart disease.”

In 2022 the American Heart Association recognized the role of sleep in heart health by replacing Life’s Simple Seven with Life’s Essential Eight. The new measures add sleep along with updates to some of the other traditional risk factors. It also makes them more about actions one can take (such as “manage weight” and “be more active”).

“As the science develops, we want to be able to add more information so that individuals know what the potential risk factors are for heart disease and stroke and how to improve their heart health – what things that they can do,” says Shana Scott, vice president of health strategies for the Metro Atlanta American Heart Association.

For most people, getting better sleep is a matter of adopting better sleep habits, Brown says. He recommends people go to bed and get up at the same time each day, ban electronics from the bedroom at night, skip caffeine and alcohol close to bedtime and get plenty of physical activity.

If sleep problems persist, Brown says it’s time to see a doctor who will screen for a sleep disorder and provide a referral to a sleep disorder clinic for evaluation and treatment if needed.

The COVID-19 Effect

Although poor sleep has likely plagued humans since the dawn of time, a new threat to our hearts was unheard of until just three years ago – COVID-19.

“What we have learned from the pandemic is that COVID-19 by itself does predispose our patients to certain kinds of heart disease,” says Arora.

The most common way it does this is by causing inflammation of the inner lining of the coronary arteries, which then causes clots to form and block blood flow, says Arora. “The other thing it can do is cause inflammation of the heart muscle, called myocarditis,” he says.

People who get COVID pneumonia are also at risk for developing cardiomyopathy, or weakness of the heart muscle, says Dr. Nima Ghasemzadeh, an interventional cardiologist with Northeast Georgia Health System (NGHS). NGHS is a major contributor to a registry of COVID patients across the U.S. and Canada who were also found to have acute myocardial infarction (heart attack), he says.

Using data from the registry, Ghasemzadeh and his colleagues examined how these patients did while they were in the hospital and how they did compared to their clinical counterparts who did not have COVID pneumonia.

Among the findings are that people with COVID pneumonia who are admitted to the hospital with a heart attack tended to have longer hospitalizations and longer ICU stays and were more likely to die in the hospital, according to Ghasemzadeh.

Doctors have also used data from the registry to create a scoring system that helps them identify patients who at higher risk of dying in the hospital so they can treat them earlier and more aggressively, Ghasemzadeh says.

“Because of the increased risk of developing an acute myocardial infarction, people with COVID pneumonia need to be vigilant about symptoms such as chest pain and shortness of breath and if they have any of those symptoms, or passing out spells, they need to seek medical attention,” says Ghasemzadeh.

Taking steps to reduce your risk of COVID and, thereby, the damage that can result from it is important, says Arora. “I think it is really, really important as we are coming out of this pandemic that we take all of the precautions make sure that we are immunized against COVID-19 so we can prevent some of these long-term consequences of infection,” he says.

Infections and Inflammatory Diseases

COVID may be the latest disease to be linked with heart disease, but it is one of many. Problems as diverse as gum disease, inflammatory bowel disease (IBD) and rheumatoid arthritis have all been linked to heart problems. The common denominator in these diseases: inflammation.

“We know for certain that increased inflammation directly leads to damage to the vascular system, which means more heart attacks and strokes,” says Arora.

For some people, inflammation is related to an autoimmune process, says Dr. Rachel Harris, a cardiologist certified in advanced cardiac imaging with the Phoebe Putney Health System in Albany. Autoimmune diseases are those in which the immune system fights the body’s own tissues. Several forms of arthritis, including rheumatoid arthritis, fall into that category.

“Basically the immune system is treating your body like it is under attack, so it triggers inflammation,” Harris says. The inflammation causes familiar symptoms such as joint swelling, stiffness and pain, but it can affect the cardiac system as well, she says. It can cause inflammation of the heart muscle (called myocarditis) or of the sac that surrounds the heart (called pericarditis). It can also put people at greater risk of narrowing of the arteries or even heart failure.

Chronic inflammatory diseases can also contribute to heart disease in other ways, such as making it hard to be physically active or get enough sleep. Ironically, the medications often used to control inflammation – corticosteroids (steroids, for short) – may make the risk of heart disease worse, by raising cholesterol and making the body less sensitive to insulin, which means that blood glucose levels rise. “For that reason, we try to recommend that these patients don’t need to be on steroids long-term,” Harris says.

Other kinds of drugs used to treat inflammatory diseases – drugs called biologic agents and disease-modifying antirheumatic drugs – help protect the heart, she says.

Vaping and Marijuana Use

Two of the biggest lifestyle trends in recent years – marijuana use and vaping, or e-cigarettes – are emerging as threats to heart health. Both habits are particularly dangerous for younger people, research shows.

Vaping, which is often promoted as a healthier alternative to smoking, probably isn’t, says Dr. Erskine James, a cardiologist affiliated with Atrium Health Navicent Medical Center in Macon. “I firmly believe that vaping will be just as bad as regular type of tobacco use,” he says.

In its Life’s Essential Eight, the American Heart Association renamed the section on cigarette smoking to nicotine exposure, including e-cigarettes and exposure to secondhand smoke, to highlight those risks.

According to the Georgia Department of Public Health’s Georgia Youth Tobacco Surveillance Report, in 2018 one in four (26.1% or 120,000) Georgia high school students reported that they had ever used e-cigarettes. Studies have found that young adults who use e-cigarettes experience damage to the blood vessels and have higher blood pressure and heart rates, the report states. This suggests that the damaging effects of using e-cigarettes may accumulate over time, increasing the risk of cardiovascular disease in people who use them long-term.

Because vaping is relatively new, Brown says more research is needed to fully understand its effects, adding that breathing in the chemicals in e-cigarettes appears to cause inflammation of the airways. “Probably the best thing is not to put anything into your lungs, if you can follow that advice,” he says.

“Anything,” Brown and other cardiologists agree, includes marijuana.

Because of its widespread use – even for medicinal purposes – people to tend to think it is benign, says Harris. “And that’s really not what we are seeing at all.”

Harris points to the findings of a number of studies examining the cardiovascular risks of marijuana. The most notable was a large 2022 U.K. study which found that those who smoked marijuana at least once a month were more likely to have a first heart attack before age 50 compared to those who didn’t.

A separate U.S. study found that among 18- to 49-year-olds who were hospitalized for heart attacks between 2007 and 2018, 4.1% also had cannabis use disorder. Cannabis use disorder is the continued use of marijuana even when it impairs psychological, physical or social functioning. Harris says she has observed the trend in her own practice, adding that she always suspects marijuana as factor when a young patient comes in with a heart attack and doesn’t have a family history of early coronary artery disease or the traditional risk factors, such as obesity, high blood pressure or tobacco use.

Harris says it is not completely clear how marijuana may cause heart disease, but that THC – the substance that makes you high – may lead to inflammation in blood vessels. This can, in turn, hasten a buildup of plaque in the arteries and potentially lead to a heart attack.

“There is a lot more data that need to be obtained, but it is clear an association is there,”she says.

Discrimination and Stress

While sexual orientation doesn’t likely have direct effects on the heart, the stress that comes with being part of a sexual minority appears to take a toll on heart health, research has begun to show.

In late 2020, the American Heart Association issued a scientific statement that found that LGBTQ people have worse cardiovascular health than their heterosexual and cisgender peers and asked healthcare providers to do more to recognize and make efforts to reduce those risks.

“Being a member of the LGBTQ community, these adults experience a lot of interrelated psychological and social stressors and more exposure to discrimination and violence,” says Brown. “Data has shown that these stressors actually affect cardiovascular health because the stress itself leads to increased inflammation, increased blood pressure and increased heart rate, so we do know that being in a subgroup that faces discrimination actually puts you at higher risk.”

Perhaps the group facing discrimination that is most studied and at greatest risk is African Americans. In 2018, African Americans were 30% more likely to die from heart disease than non-Hispanic Whites, according to the U.S. Department of Health and Human Services Office of Minority Health. African American adults as a whole are 40% more likely to have high blood pressure – a risk factor for heart disease – than non-Hispanic Whites. African American women are nearly 60% more likely to have high blood pressure, as compared to non-Hispanic White women.

“I believe that lack of sleep [and] increased mental stress all play a role in increasing the inflammatory markers in our body,” Brown says. “Potentially they worsen cholesterol markers as well as increase inflammation that damages the inner vascular lining of the cardiovascular system. That is why all of those things work together.”

In addition to the direct effect of the stress response on the body, the habits people sometimes adopt to cope with stress – for example, smoking, overeating, using alcohol or recreational drugs – can cause their own damage.

“Everyone has stress in life,” says James. “You can’t grow as a person without stressors, don’t get me wrong, but having overactive stress is harmful to somebody.”

Treating that stress in productive ways – a meditation program, exercise or counseling, for example – is essential.

New Findings Offer Hope

The good news is that a better understanding of what makes us more likely to develop heart disease also offers new clues for prevention:

• Maintaining a consistent bedtime and making sleep a priority

• Using clot-dissolving drugs for COVID-19 patients

• Improving control of inflammatory diseases with disease-modifying drugs and biologic agents

• Increasing awareness of the dangers of vaping and marijuana use

• Improving attitudes toward and acceptance of sexual and other minorities

• Using meditation and better coping strategies for stress, regardless of the cause.

Research continues to show the benefits of paying attention to the traditional risk factors for cardiovascular disease that made up Life’s Simple Seven. Many are risk factors people can change, and even those that can’t be eliminated – like a family history of heart disease – can be reduced with a healthy lifestyle, a 2022 study published in the American Heart Aassociation journal Circulation shows. “In the past, I would just tell patients it is kind of something you were born with, a bad hand dealt, but now we know from some new data that by living a healthy lifestyle you can actually offset some of the risk that comes from genetic predisposition,” says Arora. “Now I am stressing to my patients that regardless of what their family history is, regardless of what their genetic makeup is, by adhering to some good, healthy lifestyle changes, they can definitely decrease that risk.”

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