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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Healthy Heart Healthy Heart
 

Taking An Individualized Approach To Your Heart Care


June 27, 2013

By Thomas H. Lee M.D.

Harvard Medical School

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

In this information age, it's nearly impossible to avoid health advice, especially when it comes to heart disease. Whether from books, magazines and television, or talking with friends and families, we are bound to see and hear many recommendations for leading a healthy life and preventing cardiovascular disease. With such a flow of information, it's not surprising that people have a lot of questions about their heart health. For example, should I take aspirin to lessen my risk of heart disease? Should I take a statin? Should I get an exercise test?

With heart disease, like most areas of medicine, one size does not fit all. The health-promoting interventions that are right for you require a personalized approach, because most interventions that can reduce your risk of heart problems have risks as well as benefits. You and your doctor need to determine your overall risk of heart problems before deciding whether specific preventive measures are wise.

The idea that various preventive measures make sense for some people but not others shouldn't seem too foreign. If you live directly on the ocean, you need homeowners insurance that provides more protection from storm damage than if you live further inland. The same principle applies to protecting yourself from heart disease; you need to assess your individual risk for feared problems.

Assessing Your Overall Risk of Heart Disease

You can do this using tools like the Framingham risk index to get a quick assessment of whether you are at low, medium or high risk. For people who have no heart disease and one or no risk factors for heart disease, the risk is usually pretty low. For these people, even taking aspirin may not be wise. As gentle a drug as aspirin may seem, it raises your risk of bleeding problems, including strokes caused by bleeding in the brain. Taken over a long period of time, the risks may well exceed the benefits.

For people who are at high risk, such as those with diabetes or multiple other risk factors for heart disease, taking aspirin and a statin often is advisable. In fact, one of the major trends in medicine today is toward deciding whether or not to use statins based upon overall risk, not just cholesterol level. Statins seem to reduce the risk of heart problems by about one-third in everyone — but they do have real risks (and costs) of their own. Recent medical studies suggest that a statin should be considered when risk of heart disease is elevated — even if the cholesterol level is fine.

Developing a personalized approach is reflected in new guidelines for women for preventing heart disease just issued by the American Heart Association, and in most other guidelines for use of preventive strategies. This approach also applies to use of tests, like exercise tests. Every test has its own potential risks. A false positive test can send you down a road to getting invasive procedures to “settle the question,” and invasive procedures can cause complications.

Every doctor can recall patients with a low risk of heart disease who got a screening exercise test, and eventually had a cardiac catheterization because the exercise test raised the question of heart disease. And every cardiologist can recall patients who had a cardiac catheterization who had a stroke, heart attack, or sudden death as a result of the procedure — even though their hearts were normal.

So, just because your neighbor or cousin had an exercise test, or is on aspirin or a statin, doesn't mean you should, too. If you have known heart disease, these types of interventions are almost surely a good idea for you. But if not, you should make an overall assessment of your own risk of heart disease.

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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