Happy Father’s Day!
If you watch this week’s video, you’ll notice I’m somewhat hoarser and deeper-voiced, thanks to a highly irritating viral infection that has been doing the rounds at work. I’m on the mend, but combined with a whole week on-call has left me very weary! I’ve not been able to exercise too which has been a source of immense frustration, but I’ve been a good patient and listened to my own advice.
Welcome to week 3 of my series on prevention, where I’m taking what I consider to be the major health conditions and giving you my take on the medical evidence for reducing risk. This week I’m moving on to the topic I probably should have started with: cardiovascular disease. Heart attacks, strokes, heart failure and rhythm problems are the core of my working life, and if there is one area where prevention can make an enormous difference, this is it. There are two reasons I thought this was a good week to tackle it.
The first is that I gave a public talk earlier this week on heart health, heart attacks and heart failure prevention. Thank you to everyone who came along. It was lovely to see such a good turnout and to speak to people who are clearly interested in taking their health seriously. The second is that Jeremy Clarkson has been in the news again. He has been speaking about being treated for prostate cancer, but of course last year he also underwent urgent heart treatment, including stenting, after what sounds like a very close call. I do not mention this to have a go at him, far from it. I actually think he has been very open and useful in talking about health in a way that reaches people who might not usually listen to doctors. By his own admission, he had not historically led what most of us would call a textbook healthy lifestyle! However what I found interesting was his apparent change in tone: being willing to change what he eats, to take his tablets, and to accept that sometimes the doctor probably does know what they are talking about. He used an analogy I rather liked: if you take your car to a mechanic, you do not usually stand over them questioning every adjustment. You accept that they probably know more about cars than you do, and he knows more about cars than most!
Now, I would never want patients to follow medical advice blindly. Questions are good. Understanding is good. Shared decision-making is good. A well-informed patient is likely to fare better than not, but there is also something to be said for recognising expertise, especially when the alternative is ignoring risk until it declares itself as an emergency. One of the reasons I have become so passionate about primary prevention of cardiovascular disease is that I see patients week in, week out who are sitting in front of me after a heart attack, with heart failure, or with advanced vascular disease, where I cannot help thinking: if more attention had been paid to prevention ten or twenty years earlier, perhaps they would not be here today.
That is not about blame. It is about missed opportunity.
Why cardiovascular disease matters
Despite enormous medical advances, cardiovascular disease remains one of the biggest causes of illness and death the world over. It includes heart attacks, strokes, heart failure, peripheral vascular disease and many rhythm problems. It is common, serious, and often develops silently over many years before the first obvious symptom. A heart attack can appear to come out of nowhere, but in many cases the underlying process has been building for decades: cholesterol accumulating in artery walls, blood pressure damaging blood vessels, diabetes and smoking accelerating vascular injury, inflammation, weight gain, poor sleep and inactivity all adding to the overall burden.
Heart failure is similar. Sometimes it develops suddenly, but more often it is the end result of years of high blood pressure, coronary artery disease, diabetes, obesity, valve disease, rhythm disturbance or inherited risk. The reason cardiovascular prevention matters so much is that many of these risks are measurable and modifiable. We cannot prevent everything, but this is one of the areas in medicine where acting earlier can make a very real difference.
What we cannot control
There are some aspects of cardiovascular risk we cannot control. We cannot change our age. We cannot change the genes we were born with. We cannot change our family history. Some people have inherited conditions that affect the heart muscle, the heart rhythm or cholesterol handling. Others have a strong family tendency to early coronary disease despite doing many things “right”. There are also social and environmental factors that are not evenly distributed: access to healthy food, safe places to exercise, education, stress, deprivation, shift work and the demands of modern life will all vary from one individual to another. Again, as with cancer and dementia, prevention is not about blame. It is not about pretending that everyone starts from the same place or that everyone has the same level of control, but it is also not true in many cases that cardiovascular disease is simply bad luck.
What we can influence
This is where cardiovascular disease is so important, because we can influence a great deal through the way we live our lives, and the choices we make. In my view, there are some main areas to consider. This is a long list, but remember there is considerable overlap. By that I mean, the person who sleeps well, maintains a normal weight and doesn’t smoke is more likely on average to have better blood pressure, cholesterol and so on.
- Blood pressure control
- Cholesterol, ApoB and Lp(a) where appropriate
- Not smoking
- Diabetes prevention and glucose control
- Exercise: both aerobic fitness and strength
- Healthy weight, metabolic health and diet quality
- Sleep, alcohol and stress
- Treating atrial fibrillation or other rhythm problems where present
- Recognising family history and inherited risk
- Imaging such as coronary calcium scoring or CT coronary angiography in selected people
The point is not that everyone needs every test. The point is that modern prevention should be more thoughtful than simply waiting for symptoms. Blood pressure is a good example. During my week on call, I field a great many of what we call ‘advice and guidance requests’ from GPs via an online portal. I’ve noticed in recent times how many of these relate to raised blood pressure in ‘younger’ people. High blood pressure often causes no symptoms at all, but over time it increases the risk of stroke, heart failure, kidney disease, atrial fibrillation and coronary disease. It is one of the most important numbers to know, and one of the most treatable risk factors in medicine. It’s therefore especially important that we pick it up early.
Cholesterol is another. For years we have focused mainly on LDL cholesterol, which remains very important. Increasingly, I also think about ApoB, which gives a measure of the number of atherogenic particles in the blood. In simple terms, the more of these particles circulating over time, the greater the opportunity for them to enter the artery wall and contribute to plaque. Lp(a) is another useful marker in selected people. It is largely genetically determined, often runs in families, and can increase the risk of premature coronary disease and aortic valve disease. It is not something most people will have had checked routinely, but in the right context it can be very informative.
Lifestyle matters too, of course. But I do not think we should reduce cardiovascular prevention to vague advice to “eat better and move more”. That may be true, but it is not specific enough. A useful goal is to build a life that supports vascular health: regular movement, some exercise that gets you out of breath (and sweaty!), some resistance training to preserve muscle, a diet based mostly on minimally processed foods, enough protein and fibre, not smoking, sensible alcohol intake, and sleep that is treated as a pillar of health rather than an optional extra.
Screening and early detection: why it is complicated
Compared with cancer and dementia, cardiovascular screening is in some ways more straightforward because so many risk factors are easy to measure: blood pressure, cholesterol, glucose, kidney function, weight, waist circumference and smoking status. However, it is still not always simple.
Some people have apparently “normal” cholesterol but a strong family history or high Lp(a). Some have reassuring short-term risk scores because they are young, but very high lifetime risk. Some have no symptoms, but significant coronary plaque on imaging. Others have abnormal tests that may not need aggressive treatment but do need sensible interpretation.
Risk calculators (the commonest being the QRISK) can be useful, but they are not the whole story. I still recognise their role, but in my own practice I increasingly find them too blunt for many of the people I see. They often estimate 10-year risk, which can underestimate the importance of prevention in younger people. A 45-year-old may have a low 10-year risk but a very different lifetime risk if blood pressure, cholesterol, weight or family history are unfavourable.
This is where I think prevention is heading: not blanket testing for everyone, but more personalised risk assessment. That may include standard blood tests and blood pressure. It may include ApoB or Lp(a). It may include CT coronary calcium scoring or CT coronary angiography in selected people. It may include genetic information in the future, including polygenic risk scores.
The aim is not to medicalise everyone. The aim is to identify the people who would benefit from earlier, more intelligent intervention.
Key takeaways
Cardiovascular disease is common, serious and often develops silently over many years.
Many of the major risk factors are measurable and modifiable.
Blood pressure is one of the most important numbers to know.
LDL cholesterol matters, and ApoB and Lp(a) may add useful information in selected people.
Prevention is especially important before symptoms appear.
Lifestyle matters, but medication is not failure. In the right person, tablets can be genuinely life-saving.
Family history should be taken seriously.
The goal is not perfection. The goal is to stack the odds in favour of a longer, healthier life.
For those who want to go deeper
One of the most important concepts in cardiovascular prevention is cumulative exposure. It is not simply what your blood pressure or cholesterol is on one day. It is the total exposure of your arteries to high blood pressure, high ApoB-containing particles, smoking, diabetes and inflammation over many years. This is why earlier prevention can be so powerful. Lowering risk in your 40s or 50s is not just about avoiding a heart attack next year. It is about reducing the total burden of vascular injury over decades. If someone has high blood pressure or high cholesterol for 30 years, the arteries have been exposed to that risk for a long time. If we identify and treat it earlier, we reduce that lifetime exposure. This is also why I think the phrase “I feel fine” can be misleading. Most people with high blood pressure feel fine. Most people with high cholesterol feel fine. Many people with early coronary plaque feel fine. The first symptom can be chest pain, a heart attack, heart failure or a stroke. That is exactly what prevention is trying to avoid.
I also think we need to get away from the idea that needing medication is somehow a personal failure. If someone has high blood pressure, high cholesterol, diabetes or high inherited risk, medication may be the right thing to do. Lifestyle remains foundational, but tablets are not a defeat. They are one of the tools we have to reduce risk. Many of my friends, for example, are already on medication for cholesterol in their early 40s.
Looking ahead, this is exactly the sort of area I am interested in for future preventive health and healthspan work. A proper cardiovascular prevention assessment should not simply be a quick cholesterol check. We can do so, so much more these days.
This is not about making everyone anxious. It is about being honest that cardiovascular disease often develops quietly and that if we look earlier, we may be able to act earlier.
If you have not checked your blood pressure recently, do me a favour and check it this week. If you do not know your cholesterol, find out. If you have a strong family history of early heart disease, do not ignore it. And if you smoke, stopping remains one of the most powerful things you can do for your heart and blood vessels.
A final thought. In medicine we often meet people after the event: after the heart attack, after the stroke, after the diagnosis of heart failure. Modern treatment can do amazing things, but I would much rather help someone avoid that first event in the first place.
That, to me, is the whole point of prevention.