Heart: health and life

Dr. Valentí Fuster

 director of the Cardiovascular Institute at Mount Sinai Hospital in New York and the Carlos III National Center for Cardiovascular Research in Madrid

Opinion

Over the coming years we will have to address three great challenges in order to face a highly complex disease like that of the heart. The first challenge is economic, as we have a significant population with important cardiovascular illnesses and this is very expensive to deal with.

We must bring about a paradigm shift: take the leap from treating a complex disease to promoting health. The second challenge is integrating heart and brain pathologies because there is no doubt that certain brain diseases are caused by the same factors as heart disease. And the third challenge we are facing is the use of new, cutting-edge technology like imaging, regenerative and genetic therapies.

Myocardial and cerebral infarctions are an epidemic and the leading cause of death in the world, and 95% of these occur in people with, at least, two of the seven established risk factors. Two factors are mechanical in nature, obesity and high blood pressure; two are chemical, high cholesterol and diabetes; two involve lifestyle, whether or not the person smokes, whether or not they exercise; and the final factor is age. The most vulnerable age is over 55 for men and over 65 for women.

When we speak of myocardial infarction we mean the death of heart muscle due to occlusion of the arteries that bring oxygen to the myocardia or heart muscle. If we analyze this in more detail we will see that two types of incidents can occur in a coronary artery: the first is a buildup of cholesterol, which takes years to develop, and the second, which is more acute, is blockage due to a blood clot. Myocardial infarction is the acute moment; the disease develops silently over time, leading the patient to wonder why they had a heart attack if they felt fine. The answer is simple: the person felt fine because their arteries were blocked but not severely enough to cause cardiac symptoms.

The body has a number of defense mechanisms to avoid or prevent this type of attack.  One of the systems involves cells from the bone marrow, which attempt to move to the site of the problem and substitute the endothelium. Age and ageing are key factors in this process. A cell moving and going where it is needed requires activity, and a number of factors influence this activity, one of which is very important: telomere activity. Telomeres are found at the end of the chromosomes, long filaments inside cells that provide them with the energy to move to where they are needed. Various studies are researching telomere behavior because it seems that how quickly a person ages, regardless of their age, depends on the length of this substance. If telomeres are shorter and there is less cell activity, we age faster and our defenses are lower. Thus, to have long telomeres and age more slowly we must exercise, quit smoking and follow a low-calorie diet.

The body’s second defense mechanism is made up of vessels that tend to eliminate cholesterol. Our coronary arteries recognize that cholesterol is present and these vessels expel it. This defense is highly vulnerable because the vessels break easily and this leads to hemorrhaging inside the artery. At the same time all the inflammatory cells eliminate the detached red blood cells. This process is very aggressive because it gives off substances that break part of the artery, leaving us with a coronary artery with cholesterol that is beginning to fracture. A time comes when this creates an ulcer, the blood clots and can't flow, the heart doesn’t get enough oxygen and there a myocardial infarction occurs.

We have carried out a study, with 7,000 healthy women between the ages of 60 and 64 in Florida and Chicago, in order to find out whether or not we can identify people who are going to have a heart attack before it happens. Using five cutting-edge imaging techniques, we have been able to see inside the arteries. The result was that 35% of these women already had two affected carotid arteries. How is it possible that these women felt fine but were already developing this disease? Well, because they displayed two of the seven possible risk factors.

At the beginning of this symposium, I spoke of another challenge: integrating heart and brain diseases. If we identify disease in the arteries that go to the brain it is almost 100% sure that we will find it the arteries that connect to the heart. It is a diffuse disease and, thus, although it is found in one area, the explosion may occur in another. For example, if we take Alzheimer’s, we can see this relationship clearly. If pressure increases with age and isn’t treated, cognitive function decreases. This is not only caused by high blood pressure, but also high cholesterol, diabetes, smoking, etc. The same factors that are causing disease in coronary arteries are doing the same in the small arteries of the brain. This means that the same risk factors that can lead to a heart attack also cause us to lose intellectual capacity because the small vessels are obstructed by the same risk factors.

All of this brings us to the need to promote health and stop discussing disease, because there comes a time when we can't continue treating a disease as costly as heart disease if we haven’t worked on prevention and on promoting health. This is one of the reasons that led us to create the International Foundation for Science, Health & Education (SHE). The name of the foundation exactly expresses the goals we have set: we want to stop speaking about disease and start speaking about health; we want to work with people who are sick and those who are apparently healthy taking into account the scientifically proven risk factors; and, finally, we want to speak about education because we are all responsible for educating.

We still have a long road ahead. We will have to work hard and do so with all segments of the population. If we want to stop this invisible pandemic, we must lower childhood obesity rates starting between the ages of 3 and 6, working in their immediate environment, with their families and teachers. We must change the elderly’s health habits and we must take care of the elderly because it isn’t as important that they live many years as that they do so with the right quality of life. In order to achieve this, we must bring about behavioral changes, preventing degenerative heart disease before it manifests itself. And to do this will require the complete collaboration of the entire population because heart attacks are a behavioral problem: people must take care of themselves by quitting smoking, lowering their cholesterol and controlling their blood pressure.