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  • Writer's pictureRyan Allen

Proactivity with heart disease prevention

Recently, I began taking a class of drug called a statin, which is very well-established in the medical community as a strategy for lowering blood cholesterol. Now, let’s be clear on my circumstances right now as a patient: I am in my 20s, and so far, I have not seen any concerning elevations in my cholesterol numbers. Of course, I am a type 1 diabetic, which increases risk of cardiovascular disease (CVD) in a manner distinct from that of lipids, and this condition does drive me to be more proactive in disease prevention across the board. However, I would likely be pushing my doctor to put me on this drug or something similar even if I were not diabetic.


Why is that? I am young, and presumably every factor of my “risk calculator” for a heart attack or cardiac event would suggest I am at very low risk of anything happening anytime soon. The misconception, though, is that this is a disease of older people. The reality is that it is not binary; we do not get a heart attack one day, and all of a sudden go from having no CVD, to having CVD. Rather, like many chronic conditions, it exists on a spectrum. It is a life course disease that starts incredibly early on, even in childhood and adolescence. To understand why this is the case, and why it requires such early management, we need to think about how atherosclerosis–the primary mechanism of cardiovascular disease–kills strikingly more people in the U.S. and worldwide than any other disease.


Lining the walls of our blood vessels exists a protective layer of cells called the endothelium. You can think of the endothelium as a barrier between our bloodstream and surrounding tissue, largely determining what can cross in either direction. While a critical component of our circulatory system, the endothelium appears to be the primary place where long-term trouble can originate. That is because particles known as lipoproteins, which carry cholesterol through the blood, can stick to the endothelium and hang around longer than they should. Oftentimes, if they stick around long enough, they can undergo an unfavorable chemical reaction known as oxidation. The accumulation of these oxidized molecules in the endothelium can kick off an inflammatory response from the body which, in an effort to heal itself, actually makes matters worse in the long-term by forming plaques. Eventually, enough of this process will result in obstruction of blood flow to various tissues, which is the source of major problems like heart attacks or strokes.


With that primer, it might not be hard to envision that heart disease is largely a matter of total exposure to lipoprotein particles. How they get stuck in the endothelium is largely random, and thus the goal is to hammer down the sheer quantity of potentially harmful lipoproteins over the entire course of our lives. One reason to start this early (as I have) is that we are not necessarily any “less likely” to have them lodge into our artery walls when we’re young versus when we’re old. Instead, CVD is tightly associated with age because it’s a matter of accumulation and odds. As you age, you are constantly exposed to lipoproteins, and with enough exposure you accumulate more and more plaques, increasing the odds of one such plaque resulting in vessel obstruction and an adverse event.


There’s a reason why cardiologists in the Netherlands will start treating certain children at age 6, though, and that is because lipoprotein deposition does not wait to start. In fact, in autopsies of teenagers who have tragically died of other unrelated causes such as trauma or accidents, researchers can already observe evident atherosclerotic lesions. That is to say, as an adolescent, one can already start accumulating this cardiovascular damage from lipoproteins. Yes, at this early point in life, the odds of a major event are low, but as long as there are lesions and plaques, the odds are definitely never zero. If our goal, then, is to keep these odds as close to zero as possible, we must start early to minimize lipoprotein burden, and thus minimize risk of vessel damage.


In my next post, I will detail the steps by which we can alleviate this burden from an early age, as well as other factors we can monitor and control in CVD risk. In the meantime, I would like to leave you with this final plea for prevention. As I have mentioned, CVD (like many chronic diseases) is an odds game. We’re always playing with probabilities; it’s simply a matter of keeping our risk at a comfortably low percentage. That said, because it is an odds game, we never truly have a sense of when this disease will catch up with us.


A medical school professor used to tell his students that the most common presentation, or symptom, of a first heart attack was sudden death. In other words, the majority of patients who had their first cardiac event, most likely having no idea they even had disease, just died. Personally, a beloved dean at my high school recently passed away in this manner. At 60 years old, he had his first heart attack, and overnight he went from a lively, positive, ever-present figure around campus, to a loving memory of our community that had been lost far too soon. Even though heart disease might not be something that’s outwardly apparent to us, not right there staring us in the face, it is always there. By the time one really faces the consequences and perhaps starts to take it more seriously, it is often already too late. I urge you: start managing this condition now, no matter what stage of life you are in, and you will stand a far greater chance of increasing your length and quality of life.





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