8 Risk Factors for Heart Disease—and What to Do About Them

(Illustration by Barron’s)

The deadliest disease in the U.S. is one of the most preventable.

Cardiovascular disease kills more than 900,000 Americans a year. Over recent decades, powerful new drugs and other medical interventions have slashed these deaths. Doctors say it may take broader lifestyle changes to keep reducing mortality rates. By some measures, including the prevalence of obesity and diabetes, Americans are as sick as ever.

“Heart disease is by far the leading killer of men and women in the U.S.,” says cardiologist James Rippe, who wrote the book Heart Disease for Dummies. “And people don’t pay enough attention to it.”

The irony is that cardiologists have a good idea of what it would take to dramatically lower death rates from cardiovascular disease. They point to the so-called Life’s Essential 8 from the American Heart Association: eat better, be more active, quit tobacco, get healthy sleep, manage weight, control cholesterol, manage hypertension, and manage blood sugar.

Meeting those guidelines could slash heart disease deaths by 80% to 90%, doctors say.

Cardiologist Ashish Sarraju of the Cleveland Clinic says every American should be looking at those eight factors and grading themselves. “Part of it is looking at which of these risk factors are you getting an A on, or a B on, or an F,” and gradually replacing all the lower grades with As, he says.

The two biggest risk factors are smoking and not exercising, cardiologists say. When you smoke, you don’t just inhale harmful nicotine. You also bring chemicals produced by burning into your veins, increasing arteriolosclerosis or clogging of the veins, Dr. Sarraju says.

“Smoking has a number of adverse effects on health,” he says. “It’s a very significant risk factor for blockages and heart disease.”

Exercise is equally important. Americans should aim for 150 minutes of moderate exercise or 75 minutes of vigorous exercise a week. Being sedentary has the same effect on your mortality as smoking a pack of cigarettes a day, says Dr. Rippe. “[People who didn’t exercise] doubled their risk of heart disease compared to active people.”

The next important factor is diet. Numerous studies have shown that some variant of the Mediterranean dietThat) produces significant improvements in health. That entails consuming lots of vegetables, fruits, whole grains, nuts, legumes, fish, and lean meat. The DASH diet for high blood pressure is similar in most aspects, but it also recommends reducing salt consumption, eating less fat, and consuming low-fat or nonfat dairy. Some studies have found that a vegan diet, with no animal products, can be even healthier than the Mediterranean diet.

Obesity is yet another risk factor linked to heart disease, cancer, diabetes, and other diseases. Ideally, people should try to keep a body mass index (BMI) under 25. For example, if you’re five feet, six inches tall, you should weigh no more than 156 pounds. Here is a BMI calculator, and here is a Barron’s article on how to understand your BMI reading. While losing weight is tough for many people, new GLP-1 drugs such as Ozempic are helping millions of Americans lose weight.

“We are seeing more and more people who had struggled to lose weight, but since the availability of GLP-1s, they have had a lot of success in weight loss,” says cardiologist Nino Isakadze of Johns Hopkins.

Sleep is an often forgotten risk factor. When we sleep, our bodies and brains repair themselves, getting rid of waste products. When people are sleep-deprived, their cortisol levels tend to rise, which can raise blood pressure. Individual needs vary, but sleeping at least 7 hours a night is a good goal for most people.

The final three risk factors are also worth paying attention to. High blood pressure plays a role in everything from heart disease to kidney disease to dementia. Ideally, you should keep your blood pressure under 120/80. A level below 130/80, particularly for seniors, is still acceptable.

“High blood pressure is similar to smoking. When the blood pressure is high, the blood has to pump against thick vessels. The heart gets thicker, and eventually people develop weak heart muscles because of the work the heart has to do,” Dr. Isakadze says.

High blood sugar levels wreak havoc on your entire body, particularly your cardiovascular system. You want your fasting blood sugar level to be under 100. If you can’t get it there through diet and exercise, there are drugs, including metformin, that will help you get it there. Don’t forget that the new GLP-1 drugs, which are being used as weight-loss drugs, were originally designed to combat diabetes and are good at it.

High cholesterol levels contribute to arteriosclerosis. You want your non-HDL cholesterol to be under 130. The lower the better. With powerful statins and other drugs that lower cholesterol, most Americans can now easily keep their blood lipids at healthy levels.

“Nowadays, there’s really no excuse not to have very low LDL (bad cholesterol) numbers, because we have very powerful medicines,” Dr. Isakadze says.

Modifying these health risks will stop the progression of heart disease. And there is some evidence that taking action can reverse heart disease, particularly the aggressive use of statins. You need to get your LDL cholesterol under 70 to see regression, says Dr. Sarraju.

Beyond these eight measures, add one other test to your list: the calcium score, which measures the level of calcification (a measure of arteriosclerosis) in your veins. Cardiologist Michael McConnell of Stanford thinks even healthy men should be tested starting at age 60 if they have an ASCVD (atherosclerotic cardiovascular disease) risk of more than 5%. Organizations like the American Heart Association and the American College of Cardiology provide ASCVD calculators. Those who don’t get a zero (which indicates no calcification) should begin treating themselves for cardiovascular disease, even if they have no other symptoms, he says. The higher the number, the more aggressive the treatment.

“It’s a very strong predictor of risk,” Dr. McConnell says of the calcium score.

Developing cardiovascular disease takes decades. Most of the treatments used today focus on older adults. In the future, doctors may start treating young adults or even children before heart disease has a chance to get established.

“Our healthcare system is amazing at treating sick people,” says Erica Spatz, a Yale cardiologist. “We are pretty lousy at preventing illness.”

Dr. Spatz says a series of policy changes are needed to really arrest heart disease, such as building walkable cities or making healthy food affordable.

“We’ve made healthy choices challenging to access and expensive,” she says. “Walk into a grocery store and put together a shopping list that will be healthy. It’s really hard to afford it.”

Write to Neal Templin at neal.templin@barrons.com