This month, even as volunteers raise money and doctors renew efforts to spread information about cardiovascular disease as part of American Heart Month, the disease will continue to extract a dire toll.

In just those 28 days, nearly 35,000 Americans will die from heart disease and strokes. Some $35 billion will be spent fighting the illness, the nation’s leading cause of death. An increasing number of Americans will be diagnosed with some form of the condition — ranging from high blood pressure to coronary artery disease, from heart attacks to strokes.

Sadly, doctors say, the vast majority of cases could be easily avoided with information already widely known. “It’s disheartening,” remarks Dr. Lynne Wagoner, a cardiologist with Greater Cincinnati Cardiovascular Consultants. “Most of the patients we see are predictable. They’re the patients that still smoke, they have diabetes, they won’t take medications even though they really need it. It all comes down to how much the patient is willing to do.”
Annual physical exams, when primary care physicians monitor basic cardiovascular assessments, such as weight and blood pressure, remain a frontline defense. After age 40, doctors will pay closer attention to your family history. High LDL cholesterol (commonly referred to as “bad cholesterol”) levels and diabetes become more important. Post-menopausal women become more susceptible to high LDL levels and resulting cardiovascular problems.

“It’s not just about age, it’s not just about individual risk factors,” explains cardiologist Dr. Robert Toltzis of the Cincinnati Heart Group. “You have to take all the factors into consideration.”

People tend to misunderstand genetic factors, Wagoner adds. “I have patients who think, despite the family history, they’re managing their risk factors, but that piece of the puzzle doesn’t go away,” she explains. “They may push heart disease to later in life, maybe 20 years later than family members who didn’t take care of themselves, but they still need to be careful when they’re 55 or 65.”

For patients at greater risk, an evaluation by a cardiologist may be in order. An electrocardiogram (EKG) is considered essential. Initial findings could lead to echocardiogram ultrasound, stress tests or computed tomography (CT) scans.

Newer screening tools may prove to be bellwethers for patients who don’t yet show symptoms. Chief among those is a simple blood test for C-Reactive Protein (CRP), which detects substances produced by inflammation. More precise versions, known as high-sensitivity CRP tests, focus on inflammation from arterial swelling that has been linked to increased risk of heart disease, heart attacks and strokes. Although CRP testing has been in limited use for years, it’s now getting more attention as a predictor of cardiovascular problems.

Dr. James A. Kong of the Ohio Heart & Vascular Center and Christ Hospital is one cardiologist who favors employing these techniques selectively. “By the time I use the CRP, I’m already worried about a patient and I’m going to be treating them anyway. But if they’re concerned about taking medication or other treatments, you can point to the CRP and say, ‘Look, your risk is high,’ and that might motivate them. It’s had a niche role in my practice, used for very specific applications like this.”
•Cardiovascular diseases have been the leading cause of death in the United States every year since 1900, except during the 1918 flu epidemic.

• In the most recent annual statistics (2004), cardiovascular disease accounted for 869,724 deaths in America — almost one in every three.

• The estimated direct and indirect costs of CVD in the United States rose to $448 billion last year, up from $274.5 billion a decade ago.
In November, the New England Journal of Medicine published a study conducted by Harvard cardiologists that Time magazine ranked as the No. 2 medical breakthrough for 2008.

Called the Jupiter Study, researchers found that people who have normal cholesterol but high CRP levels could lower their heart attack risk by more than 50 percent by going on statin drug therapy. Their conclusion: The fatty plaque inside blood vessels, formed by excess cholesterol, is still a main culprit in cardiovascular disease, but inflammation can make those plaques more likely to rupture, actually triggering a heart attack or stroke.

“CRP is kind of where cholesterol tests were 20 years ago — we had identified a link between a high CRP result and heart disease, but we didn’t know if treating it really made a difference until the Jupiter trial,” Wagoner says. “That was the first real study that showed it did seem to make a big difference. If someone has a favorable cholesterol profile but a high CRP, we’re realizing now that these are patients we want to get into treatment.”

University Hospital cardiologist Dr. Massaoud Leesar says the Jupiter Study has already changed his practice: He now includes the CRP test for all his patients.

“In the past, if we had a 40-year-old guy come in with slightly high cholesterol, or some other risk factor that was slightly elevated, we would tell him to change his diet, get more exercise, those kind of things,” Leesar says. “We can still do that as well, but if I get his CRP and it comes back high we can start treatment right away.”

For others, the Jupiter results confirmed long-held beliefs. Dr. D.P. Suresh, St. Luke Hospitals’ chief of cardiology, has included high-sensitivity CRP testing along with patients’ cholesterol screening for four years because early studies suggested its benefits. The Jupiter study was “the icing on the cake,” he says. “If doctors are doing lipid panels [to check cholesterol levels] without a CRP, that’s not actually the current standard of care,” Suresh asserts.

Nonetheless, universal consensus on CRP testing is still on hold. The American Heart Association says other CRP studies indicate only a small advantage, perhaps not enough to justify widespread, routine CRP screening. The American College of Cardiology is waiting to update its recommendations.

Toltzis says the test is simple and inexpensive, “So why not do it and get more information?”

Others, like Kong, note that by the time patients are referred to cardiologists, they’ve already been diagnosed with risk factors that lead to much the same treatment.

“It’s a great example of technology,” Kong admits, “but sometimes we miss the forest for the trees, looking for that 101st patient with a high CRP but no other symptoms when we have that huge swath of people that are overweight, continuing to smoke and not getting the message.”
The Jupiter Study and other research also add to the debate over prescribing statin drugs more widely to lower-risk patients.

Doctors openly disagree about the cost-to-benefit ratio for drugs that can be expensive, especially when tallied as a lifelong medication. Nonetheless, these drugs have earned near-unanimous praise for significantly lowering cardiovascular-related deaths.

“I never tell patients that I’m putting them on medicine to lower their cholesterol. I tell them I’m giving them something that will prevent them from having a heart attack or stroke,” Suresh notes.

Many Tristate doctors say the possible side effects of statins, such as liver damage and muscle aches, have received inordinate attention — especially on the internet — and spook some patients.

“While it’s true there are side effects [from statins], they’re rare and they’re far outweighed by the benefits,” Kong says.