In my last post, we talked a lot about the mechanism of heart disease. From there, in an Instagram Reel and TikTok, I explained the three main risk factors in this process: smoking, high blood pressure, and high cholesterol. Now that our variables to work with have been established, let’s look into how we can modulate each to minimize risk.
Before we get into preventive strategies, I’ll give a quick recap of the disease process (if you have already seen the minute-long video explaining this, you can skip this paragraph). Since cholesterol does not dissolve in water, it has to be transported in blood with special proteins called lipoproteins. Problems can arise when these lipoprotein particles deposit a cholesterol molecule into the wall of the blood vessel, in a layer of cells called the endothelium. This will kick off the inflammatory process of the body that initiates atherosclerosis, the most common mechanism of cardiovascular disease. Therefore, it makes sense that we want to lower our total exposure to lipoproteins through low cholesterol numbers (note, we call this lab value “cholesterol,” but we are actually measuring the cholesterol-carrying lipoproteins). It also makes sense that we want to eliminate anything that would cause damage to the endothelium, making it more vulnerable. Smoking causes chemical damage to the endothelium, while high blood pressure does mechanical damage. Thus, we want to focus on moving these three factors in the other direction to prevent atherosclerotic cardiovascular disease (ASCVD). Here’s how to do it:
Figure 1: Smoking-induced chemical damage to the endothelium. Note that this inflammatory mechanism of damage results in decreased endothelial integrity, and increased susceptibility) to lipid deposits from lipoprotein particles. (Image: Dahdah et al., 2022)
Smoking
The advice here is pretty straightforward: don’t smoke. Many will ask the question if it matters between smoking cigarettes and marijuana, and the answer seems to be that we do not entirely know. Intuition would suggest that neither is good for cardiovascular disease, because either way you are introducing toxic particulates from the smoke into the bloodstream, which will damage the endothelium. Even if it turns out that smoking marijuana is less harmful for ASCVD than smoking cigarettes, it is important to note that both are still harmful. If one thing is “better for you” than something else, that does not mean it is at all good or safe. For ASCVD preventive purposes, it is best to avoid all forms of smoking or vaping, so as to remain clear of potential chemical threats to blood vessel integrity.
High blood pressure
Blood pressure is an area where guidelines continue to evolve, but the latest work is pretty convincing and intriguing. For the longest time, it was thought that hypertension (another term for high blood pressure) was largely due to a high-salt (or high-sodium) diet. While it is undoubtedly true that high salt intake can raise blood pressure, it of course turns out that there’s far more nuance to this.
First off, with regards to salt intake, the total amount of salt you eat does not matter nearly as much as the concentration of salt. The key message here is that you can balance out your salt intake by drinking a lot of water. Critically, if you are going to have a high-salt meal, you want to drink a lot of water before the meal so your blood salt concentration never gets high enough to cause major problems. As University of Colorado nephrologist Rick Johnson says, if you start to feel thirsty, you’re already at a pretty high salt concentration. You want to hydrate enough ahead of time that you never get to that point.
Another point Johnson makes is that high blood uric acid is also a major culprit in high blood pressure. While uric acid is often thought of in gout as a product of eating a lot of purines (components of DNA) and protein, Johnson highlights a link between fructose consumption and uric acid that actually appears to be far more significant. We have previously harped on the importance of restricting fructose consumption–largely by avoiding added sugars and sugary beverages–for prevention of non-alcoholic fatty liver disease (NAFLD). Blood pressure maintenance provides yet another motivation to do so.
Lastly, it is clear that both exercise and weight management have a significant impact on blood pressure. Lifestyle plays a major role in blood pressure, so if one stays in good cardiorespiratory fitness and keeps off excess weight, that will go a long way to keeping blood pressure low.
Figure 2: Initial stages in the pathophysiology of atherosclerosis. Note that LDL penetrates the endothelium and becomes oxidized, leading to an immune response driven by macrophages and foam cells. (Image: Jebari-Benslaimin et al., 2022)
High cholesterol
When doctors say “high cholesterol,” they are actually referring to high levels of cholesterol-carrying lipoproteins in the blood. In particular, we often focus on levels of low-density lipoprotein (LDL), which is an especially bad actor that tends to kick off this process. Note: standard practice in the U.S. is still (inexplicably) to use LDL-C (LDL cholesterol) as the metric for LDL, despite the fact that LDL-P and ApoB (LDL particle counts) appear to be far better predictors of risk. If you are able to get an LDL-P or ApoB measurement from your doctor, definitely take advantage of that opportunity.
Regardless of what measure you are using, though, there are ways to lower LDL. For the most part, it is far less malleable with lifestyle modifications than blood pressure. Though many express concern over consuming cholesterol, it is quite apparent that dietary cholesterol does not have much bearing on one’s blood level of cholesterol. This is because our bodies absorb and excrete different amounts of cholesterol in the gut based on demand. While dietary cholesterol does not have much impact on this, saturated fat intake does, thus it is important to generally keep saturated fat in the diet in moderation.
Finally, there are several excellent, safe pharmaceutical options to lower cholesterol. Last post, I mentioned that I am prophylactically taking a statin despite normal numbers, solely because I have a family history and chronic condition that put me at increased risk. Especially if you start to see any elevations in LDL, have any additional risk factors or family history for heart disease, I would highly recommend asking your doctor about proactively using these agents as a means of prevention.
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