15 Factors Other Than Cholesterol Leading to Heart Disease

Welcome to the Healthy Aging Newsletter, a free publication translating trustworthy medical research into simple habits to age well, free of chronic disease. I’m Dr. Ashori, a family medicine doctor turned health coach.

Oversimplifying heart disease down to digits on a lipid panel leads to bad outcomes. A different way to think about heart disease is to consider all the cumulative factors necessary for this event to happen.

I’ll help you think through how to prioritize the right lifestyle choices that will help you avoid heart disease.

1. Arterial Pressure

High blood pressure is a far more common risk factor for heart attacks than high cholesterol. Supposedly, it damages the delicate lining of the arteries, allowing cholesterol to deposit there, building plaque.

Lower Your Risk: Monitor your blood pressure every 1-2 years. Fortunately, there are effective lifestyle ways to lower blood pressure. If that fails, safe medications are available.

I like using an 24-hr ambulatory blood pressure cuff if my patient has numbers all over the place. Don’t forget night-time spikes if you have hidden sleep apnea.

2. Diet & Nutrition

Excess salt, added sugar, excess calories, and not enough vegetables and fruits independently increase the risk of cardiovascular disease.

Lowering Your Risk: Consider the quantity of healthy fat to saturated fat, unprocessed carbs to ultraprocessed carbs, and lean proteins to processed meats.

Adding more carbs to your diet always helps because it tends to crowd out the less desirable foods.

3. Environmental Chemicals

Tiny sized particulate matter in air pollution seem to add to the damage of vessels.

Lowering Risk: You’re definitely not doomed to develop heart disease just because you live in a city with poor air quality. Fortunately we have air quality meters and air filtration devices.

4. Societal Factors

Low income, poor health literacy, limited access to medical care, unsafe neighborhoods, and food insecurity are factors that can raise heart disease risk by 30%, Social Determinants of Health (SoDH).

Lowering Risk: Find a caring physician, understanding your body, learning to navigate the healthcare system, and choose your meals intentionally.

Most of us think that health literacy is a problem for the ‘illiterate’. Not so! The US has seen declining health literacy year after year in all socioeconomic levels.

5. Tissue Oxygenation & Exercise

In my practice we call it “movement” or “activity” and not exercise. While blockage affects the big heart vessels, the best way to prevent microvascular disease is with adequate aerobic activity.

Lowering Risk: Try walking regularly. Consistency is more important than intensity. Monitoring zone-based training and VO2max, HRV, and resting heart rate (RHR) is too boring for most and is downstream of exercise.

6. Metabolic Health

Whatever your baseline cardiovascular disease risk is, metabolic disease such as diabetes or insulin resistance can double or triple it.

Lower Your Risk: It’s not hard to spot insulin resistance without any lab tests. But it’s nice to confirm it, if you are at high risk.

Usually a slight dietary modification with a consistent activity routine can help reverse it.

7. Obesity

Obesity is a medical term that refers to that point when excess fat has damaged adipose tissue and spilled into our internal organs such as the liver (fatty liver), heart, and omentum. There are better tools available than BMI, such as DEXA scans and body impedance measurements.

Lowering Risk: Fortunately, any weight loss will favor visceral fat loss before any muscle or subcutaneous fat loss. While some will achieve this with exercise alone, others may need to have a slight calorie deficit or change in dietary composition.

8. Physical Inactivity

Physical inactivity refers to someone who is incredibly sedentary, whether because of their job, habits, or due to other health factors. This includes someone who goes for a bike ride on weekends but spends the other 100+ hours in the week barely moving.

Lowering Risk: Don’t worry, you can still sit, lay down, enjoy a scenic car ride. The goal is to break up consistent, extended sedentary time with some movement and stretching.

9. Adherence

Adherence and compliance refer to someone’s ability to stick to a necessary health routine. It’s often something we grow up developing or it may be inherent. Either way, it can also be learned. But without it, the fact that we live in a Westernized society increases our risk of heart disease.

Lowering Risk: Since society is based around comfort and abundance, saying no, making intentional decisions, meal planning, and structuring our weeks is a helpful antidote. And if a nutrition/exercise or prescription is advised by your doctor, sticking to it can make a big difference.

10. Stress

Chronic stress increases the risk of developing a heart attack.

Lowering Risk: Stress may not be avoidable, but coping mechanisms and stress-reduction techniques such as walking, meditation, and journaling help offset the negative effects of physiologic stress.

11. Perspective on Life & Living

Pessimistic, negative, catastrophizing, and critical personality types have more risk of cardiovascular disease.

Lowering Risk: You don’t need to be Mr. Rogers, but witnessing the negative thoughts and perspectives can help create a little more balance, which balances the stress hormones in the bloodstream.

12. Restorative Sleep

Good sleep = good cardiovascular health. But just because you deal with insomnia, don’t worry, it doesn’t mean you’re doomed to build plaque on your arteries.

Lowering Risk: When it comes to good quality sleep, sleep hygiene is the biggest driving factor. It’s how well you protect your sleep time and well-rested you feel after you sleep, even if it is interrupted.

13. Hidden Inflammation

People with higher CRP blood levels are more likely to have heart attacks and strokes. That’s true even if their cholesterol and blood pressure are fine. Just because serum inflammatory markers are elevated it doesn’t mean someone will have a heart attack but it’s worth considering in the overall risk of a person.

Lowering Risk: For most people a small shift in dietary pattern, exercise, and sleep will improve their inflammation, and with it the risk of plaque development.

14. Microbiome’s Protection

It might be premature to say that an unhealthy gut microbiome increases the risk of cardiovascular disease, but a healthy one certainly may be protective.

Lowering Risk: Avoiding unnecessary antibiotics and eating a varied diet of less-processed foods seems to help improve gut flora diversity.

15. Our Family History & Genetics

We know that in Familial Hypercholesterolemia patients can develop heart attacks at shockingly young ages. We also know about APOE4, PCSK9 loss-of-function, and 9p21 gene variant.

Lowering Risk: Family history is quite telling. Some of my patients have had multiple heart attacks in their geneology while others have none. Testing is helpful when the prevalence is quite high.

A Better Approach to Prevent Cardiovascular Disease

Instead of focusing on one pathway, one medication, and one treatment strategy, it’s best that we look at a patient holistically. Cardiovascular risk can be lowered through several strategies at the same time, without hyperfocusing on just blood pressure or lipid numbers.

Assess your baseline risk with your doctor and see where you have some wiggle room for improvement. There is a time for lifestyle intervention and there is a time for medications. The good news is that we understand the pathophysiology of ASCVD and have effective strategies for each patient type.