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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Healthy Heart Healthy Heart

Debunking the 50-50 Heart Disease Myth

June 27, 2013

By Thomas H. Lee M.D.

Harvard Medical School

Last reviewed by Faculty of Harvard Medical School June 27, 2013

One of the most common misconceptions in medicine is the 50-50 heart-disease myth. According to this myth, only about half of people who develop heart disease have any of the four major traditional "risk factors" — smoking, diabetes, hypertension or high cholesterol.

This myth is often quoted, and, if it were true, would have a frightening implication: Any of us, anytime, could be suddenly stricken down by a heart attack. For a generation of aging baby boomers, the logical next step is a search for further information that might provide reassurance that this is not going to happen to me!

The kind of "next steps" that many people are taking include getting electron-beam CT scans of the heart, exercise tests and echocardiograms and blood tests — all in search of that "clean bill of health." These tests are expensive, and rarely give that complete reassurance that is desired. In fact, they often lead to sleepless nights and even more tests.

Medical studies on several hundred thousand people have found that 80% to 90% of people who developed heart disease, and more than 95% of patients who died of heart disease, had at least one of the four major cardiac risk factors.

In other words, of people who "drop dead" from a heart attack, fewer than one out of 20 had no warning because they had none of these four risk factors. So if you do not smoke, do not have diabetes, have normal blood pressure, and your lipid levels are not at high-risk levels, your heart disease risk is really quite low.

C-reactive protein (CRP) appears to play a role in predicting increased risk of heart attack in people with normal cholesterol levels. Indeed, half of heart attacks occur to people with normal cholesterol levels. However, most people who have heart attacks with normal cholesterol happen to have hypertension, diabetes or histories of cigarette smoking.

While this information provides reassurance to the many people without any of the four risk factors, they should shift attention by others from "risk measurement" to "risk reduction." In short, we probably give too much energy to trying to measure our risk of heart disease these days, and not enough to actually lowering it through the hard work of weight loss, exercise and other lifestyle changes, along with careful monitoring of our chronic diseases if we have them. The debunking of the 50-50 myth about risk factors should mean a call to action for some, and a good night's sleep for others.

Thomas H. Lee, M.D. is the chief executive officer for Partners Community HealthCare Inc. He is a professor of medicine at Harvard Medical School. He is an internist and cardiologist at Brigham and Women's Hospital. Dr. Lee is the chairman of the Cardiovascular Measurement Assessment Panel of the National Committee for Quality Assurance.

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