7 Things You Can Do To Reduce Your Risk Even If You Already Have Heart Disease.
People with existing heart disease often feel like they have 'missed the boat', but they haven't.
This newsletter focuses on prevention.
A common feedback I get is that people with existing coronary artery disease feel like it doesn’t apply to them.
They feel like they have ‘missed the boat’.
They have not.
And I will explain why.
Arguably, applying the principles of prevention offers more bang for buck in the short term for people WITH coronary artery disease than those without coronary artery disease.
Yes. Preventing or delaying the onset of coronary artery disease is a great strategy for living longer.
The challenge is that the things you do to prevent heart disease are unlikely to pay dividends for a very long time—many years if not decades.
But that is our goal. We are thinking long-term.
For those WITH coronary artery disease, the risk reduction often happens much sooner.
This is why applying the principles outlined here can mean substantial reductions in risk.
The Many Faces Of Prevention
Typically, when discussing prevention, we are talking about two types of prevention: primordial and primary.
Primordial prevention is changing the environment around you so you do not develop the risk factors for heart disease and, by extension, do not get the disease early in life.
Think better cycling infrastructure or food laws that limit trans fats.
Primary prevention is the management of the risk factors, e.g. high blood pressure, early in life to prevent complications of the condition, i.e. coronary artery disease.
But there is another type of prevention. Secondary prevention.
This refers to all the steps necessary to reduce the odds of a subsequent event, such as a second heart attack or stroke.
So, let’s cover seven things that reduce the risk of a subsequent heart attack.
Just because you have heart disease or have had a heart attack does not mean there is a lot that can be done.
Cardiac Rehabilitation.
This is a program that starts the day of your heart attack.
It’s a multidisciplinary approach involving nurses, doctors, physiotherapists, dieticians, psychologists and many others.
It is a structured education and exercise program that helps people understand what has just happened to them and helps them get all the lifestyle and medical pieces together to reduce the future risk of a major heart event.
But does it work?
The answer is a resounding yes!
Those who attend cardiac rehab have 44% fewer major heart events than those who do not complete cardiac rehab1.
The big problem is that only about one-third of all patients who have a heart attack attend cardiac rehab.
This is a massive missed opportunity, and I think cardiac rehabilitation gets the least recognition for the degree of benefit it provides2.
Reverse Coronary Artery Disease.
We cannot entirely eliminate coronary artery disease.
But we can reverse or regress it to an extent.
Regular exercise and hitting LDL-C targets of <1.4 mmol/l (55 mg/dl) have been repeatedly shown to regress coronary artery disease345.
Aggressively lipid-lowering therapy is also known to significantly reduce the likelihood of future cardiovascular events6.
Anti-Platelets.
Anti-platelets are medications including aspirin, clopidogrel, prasugrel and ticagrelor.
All of these have proven effective at reducing subsequent major heart events7.
These can be used in combination or in isolation depending on each person’s circumstance and how recent their heart attack was.
Any decisions related to anti-platelets MUST be made in consultation with your doctor, as stopping these prematurely can cause serious issues.
Exercise
Exercise is one of the best tools we have for living longer.
But the benefits also apply to those who have already had a heart attack.
Compared to those who do not exercise, those who continue or increase their exercise have a 45 to 50% reduction in future subsequent heart events8.
Many of my patients who have had a heart attack are afraid to exercise. This is why cardiac rehabilitation is so important.
What is important is you start slow and work up.
If you have any concerning symptoms at higher workloads, you should always pull back and chat with your doctor.
Optimise Weight
Excess weight, particularly excess visceral fat, is a major driver of cardiovascular risk.
Reducing weight back to normal ranges is a useful strategy for reducing future cardiovascular risk. This is a key part of the nutrition guidance provided during cardiac rehab.
New obesity medications such as GLP-1 agonists have shown significant reductions in weight in those with a prior heart attack.
But more importantly, with that weight reduction was a 20% reduction in future heart events9.
Blood Pressure Control
High blood pressure is the risk factor associated with the greatest number of deaths worldwide.
High blood pressure is a major risk factor for heart attack.
Even a 5 mmHg reduction in systolic blood pressure after a heart attack is linked to an 11% reduction in future heart events10.
We do a poor job of identifying and treating those with high blood pressure.
It is an easy win, frequently missed.
Inflammation
A more recent addition to the secondary prevention toolkit has been colchicine.
Traditionally used as an anti-inflammatory for pericarditis (inflammation of the lining of the heart), it has recently been shown to result in fewer major heart events in those with a recent heart attack.
Low-dose colchicine of 0.5mg daily resulted in a 23% reduction in future heart events11.
It isn’t as widely used as the other therapies mentioned here but in select patients it has its place
You have not ‘Missed The Boat’.
It is understandably frustrating to discover the potential benefits of prevention after a heart attack, but that does not mean you have lost the opportunity to reduce future risk.
If anything, people in this group should be the most committed to focusing on prevention as they have already declared themselves at higher risk.
But the most important thing to note is that you have not missed the opportunity to focus on prevention.
It might not be primordial prevention and delaying the onset of heart disease.
But it is a prevention strategy that can significantly decrease your risk of a subsequent heart event.
And that matters a lot!
Some Housekeeping.
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Dose of Cardiac Rehabilitation to Reduce Mortality and Morbidity: A Population-Based Study. J Am Heart Assoc. 2021 Oct 19;10(20):e021356.
Trends and Predictors of Participation in Cardiac Rehabilitation Following Acute Myocardial Infarction: Data From the Behavioral Risk Factor Surveillance System. J Am Heart Assoc. 2017 Dec 29;7(1):e007664.
REVERSAL Investigators. Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial. JAMA. 2004 Mar 3;291(9):1071-80.
ASTEROID Investigators. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA. 2006 Apr 5;295(13):1556-65.
High intensity interval training induces beneficial effects on coronary atheromatous plaques – a randomized trial, European Journal of Preventive Cardiology, 2022;, zwac309,
FOURIER Steering Committee and Investigators. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. N Engl J Med. 2017 May 4;376(18):1713-1722.
Secondary prevention following myocardial infarction: a clinical update. Br J Gen Pract. 2018 Mar;68(668):151-152.
Systematic Review of Physical Activity Trajectories and Mortality in Patients With Coronary Artery Disease. JACC Volume 79, Issue 17, 3 May 2022, Pages 1690-1700
Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med. 2023 Nov 11.
Blood Pressure Lowering Treatment Trialists' Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis. Lancet. 2021 May 1;397(10285):1625-1636.
Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. N Engl J Med. 2019 Dec 26;381(26):2497-2505.
I often cut and paste your details in when I have patients who could do with reading your articles! Thank you
Great article, thank you. I did cardiac rehab after an MI and it was the best! Having my heart monitored during exercise with nurses and therapists watching greatly reduced my anxiety about starting exercise again. Also, walking the treadmill gave the nutritionist the opportunity to talk to me while I was a captive audience.