I puff up. Or maybe a slope. Furious, I fall onto the bench. My partner Mike looks at me nervously. “You should examine your heart,” he says bluntly.
I chase away his worries. I walk 30 miles and swim three times a week, climb escalators, do Pilates. I just hate the hills – they have taken my breath away since childhood.
My friends tell me not to panic. Nobody likes middle-aged hills. And Mike, a wiry Yorkshireman, can be a bit bossy when it comes to walking.
It’s true, my diet has flaws. I live alone and during the lockdown I was giving myself two sweet treats a day (plus alcohol and my late-night Bombay Mix – I’m a child of the 70s, after all).
So I’m fit, but a little fat. In this positive age body, that’s definitely okay, right?
But something is tempting. My family’s heart health is terrible. My father and all my grandparents died of a heart attack early in life. I assumed that would be my fate. Not now, of course – there’s nothing to see here – but years later. It may even be a nicer alternative to a long illness.
But when I do the calculations, it doesn’t look right. A family history of heart disease is defined by having a first-degree relative (father, brother) who had a heart attack before the age of 55 or a first-degree relative (mother, sister) before the age of 65.
Then it would be me. My poor father first had angina in his forties. He had a heart attack while on holiday in Spain at the age of 54. A triple bypass gave him a new lease of life. He quit smoking and started exercising. But 20 years later, he died of a heart attack after going out for afternoon tea and booking a holiday.
I never knew my paternal grandfather, who died at the age of 45 in 1953 (after participating in the D-Day landings). It was devastating for my father, then 17, and his 19-year-old brother who were at the cinema. My grandmother, widowed at 41, lived alone until she had a heart attack herself at 79, with her suitcase packed under her bed ready for her next vacation. A symbol of delayed gratification that breaks my heart.
On my mother’s side, my grandmother had a stroke at the age of 70. This left her half paralyzed (terrible for a strong woman). She lived half her life until she died of heart failure at the age of 92, seven years after her husband, my grandfather, who died of heart disease at the age of 85.
I denied it for years. It’s just our genetic lottery, I told myself. My loved ones lived life to the fullest (mostly) and still planned treats to the end. But really, when you’re approaching your milestone birthday (I was 60 in August), dying at 74 doesn’t seem far away.
My mother is slim and elegant at 86 years old. But my middle sister (I’m the eldest of three children) in her 30s was diagnosed with cardiac arrhythmia and takes her meds diligently every day. Should I be doing more to reduce my risk? When I look at the family album, the gaps are painful.
Coronary artery disease is the leading cause of death worldwide. Statistics show that deaths from heart attacks have risen sharply in the UK since the pandemic, with limited access to emergency services. Sir Chris Whitty, the government’s chief medical adviser, is concerned that too many people are dying of strokes and heart attacks because they missed treatment for high blood pressure.
And it’s not just about treating blood pressure. You must be assessed for other risk factors for an early stroke or heart attack, such as age, cholesterol levels, and family history, using a calculator like QRISK3, which calculates a person’s risk of having a heart attack or stroke over the next 10 years.
I visit my GP who takes my shortness of breath seriously. My blood pressure is only slightly elevated, but she sends me to King’s College Hospital for a basic health checkup – everything from an EKG to cholesterol, liver and thyroid tests. “Everyone should have them by the age of 60,” she says energetically.
In the hospital, I feel cheated when I sit among really sick people.
The results come back. Apart from skyrocketing vitamin D levels (Covid!), my surgery is not worried. Still, I insist on notes – and a telephone consultation. GP says my EKG was fine, my bad cholesterol (LDL) is a bit high but this is offset by good cholesterol (HDL).
However, my GP adds that my HbA1c reading (a blood test that measures blood sugar) is 41, one step away from pre-diabetes (a reading above 42).
It’s a shock. My dad had type 2 diabetes before he died, my slim mom is pre-diabetic.
But my overall QRISK is 8.4 (should be below 10). So all good. “Nothing to worry about,” I tell Mike.
But when I consult Prof. Kausik Ray, a leading consultant cardiologist and president of the European Atherosclerosis Society, is less impressed. My EKG only tells him I haven’t had a heart attack or an arrhythmia.
“You’re younger and you’re female, so your QRISK of a heart attack or stroke will be 8.4 percent in 10 years, but in five years, with your diet and lifestyle, your risk will be over 10, and you’re advised to switch to statins because the risk is more than 10 percent over 10 years.”
If I don’t act now, it could mean years of ill health, Prof. Ray. He’s happy that I’m exercising, but to burn off what I eat, “I’m going to have to exercise a lot.”
And the villain is the cholesterol in the blood vessel walls, a process that begins in the first decade of life and progresses over time. My total cholesterol level (serum) is 6.7 mmol/l (ideally it should be 5 mmol/l). Yes, I have high levels of good cholesterol (it’s higher in women), but that doesn’t necessarily compensate for other risk factors.
Statins help lower the level of bad cholesterol (LDL) in the blood. They reduce the amount of cholesterol deposited in the wall and stabilize atherosclerotic plaques and glue arteries. But they cannot immediately reverse a process that has been going on for decades.
The heart is like a cauldron. “You may have a problem with your pump [the muscle] and you may have various valve problems [leaking or narrowing] straining the heart muscle. This can be a problem with the pipes, they can flake off and become covered in fur. But if we narrow it down to heart attack risk, basically the process that leads to part of the attack is the formation of a blood clot on the lining of one of the three main blood vessels that supply the heart.
“And that doesn’t happen overnight. We consider age to be a risk factor, but it’s just the number of years you’ve been exposed to everything else, against the backdrop of inherited susceptibility to everything you’re exposed to.” Ray.
The key is to target and slow down the lifelong accumulation of cholesterol in the walls of our blood vessels. We return to the hydraulic metaphors. “When it gets clogged, this is not the time to put in drain cleaner,” he admonishes. “Time to call the plumber. That’s what happens with a heart attack. You go to the hospital and someone unlocks it. But whether it gets blocked again depends on how much drain cleaner – i.e. drugs and a low-fat diet – you keep putting it off.”
The good news is that for every unit of LDL cholesterol, the risk of a heart attack drops by 22 percent. Losing weight would lower triglycerides (a fatty substance similar to bad cholesterol) and raise good cholesterol, and blood pressure would drop even more.
“So you’re compensating for some of the causal factors that speed up the blood vessels from collapsing,” says Prof. Ray. Although technically all cholesterol is bad.
My Bombay Mix and weekly chips habit needs rethinking. He tells me that the main factor in prediabetes is weight. Waist size matters. In post-menopausal women, when the sex advantage slowly disappears, the risk of a heart attack increases dramatically. Over time, high blood sugar levels can damage blood vessels, directly the heart muscle, and also the kidneys.
“Your body becomes insulin resistant as you gain weight, so even if you have normal blood sugar levels, your pancreas pumps out more insulin. This keeps your blood sugar at a relatively normal level, but when the level rises, the pancreas cannot produce enough, and you drift towards diabetes. The only way, really, is to lose weight, preferably with a change in diet and lifestyle, but with medication if necessary.
Putting in work
The hard work begins. I eliminated sugar and learned to love non-alcoholic beer. In addition to downloading hypnosis apps to target my binge eating, I now cook from scratch. I also invested in an Omron M4 Intelli IT blood pressure monitor that connects to my phone and speeds up horribly when I’m drinking a bottle of wine with a friend in a restaurant.
The more alcohol you drink, the greater your risk of developing hypertension (high blood pressure). He even admonishes me after a cookie. Sugar not only helps you gain weight, but independently affects blood pressure.
Professor Ray still thinks I should still check the root cause of my shortness of breath. She advises me to ask my GP for an echocardiogram (an ultrasound that will tell me if the heart muscle and valves are fine, but will need a CT scan to see if I have fur in the arteries that supply the heart).
“As oxygen demand increases during exercise, the heart muscle has to work harder. If blood vessels are constricted, oxygen supply does not match demand during exercise.”
I will always have a greater predisposition to heart attacks. I can’t change the genes, but I can change the environment and offset that vulnerability. “It’s like being on top of a mountain ski slope,” says metaphor-loving Prof. Ray. “You see the danger at the bottom. If you correct your course early, you’ll miss it by a mile. If you only see it with 10 meters to go, you’ll have to make a lot of course corrections.”
Speaking of slopes, with my improved diet, it’s easier for me to find hills. If I’ve learned anything, it’s not burying my head in the sand. Mike was frustrated with me because he wanted me to stay alive.
I owe it to my loved ones to be more adults. They’d be delighted to have my choice.