"I Just Didn't Think I Was At Risk"

Even former President Bill Clinton, treated by some of the best doctors in America when he was in the White House, didn't know he was a heart attack waiting to happen. How could that be, and what does it say for the rest of us? Determining heart-attack risk is a tricky thing: Each of us has a different susceptibility to cardiovascular disease. Some people will live to be 100 on burgers and milk shakes, while a few vegetarian marathon runners will have heart attacks at 35. Your fitness level and what you eat play a role, of course, and so do genes and gender. But gender helps only for a while. Women have fewer heart attacks than men before they reach menopause. They catch up within a few years, however, and heart disease is an equal- opportunity killer after that. Nearly a quarter of the population -- 64 million Americans -- have cardiovascular disease. And here's the shocker: As much as 40 percent of those who have a heart attack have no symptoms at all.

One obstacle to diagnosis is denial. In a TV interview with Diane Sawyer after his bypass procedure, Clinton said that before his surgery, he had been experiencing tightness in his chest after exercising. "I'd have to stop and catch my breath," he said. But he thought he was just tired, working too much, and out of shape. He was convinced it was nothing serious. Sadly, this is a common story.

It never occurred to Dennis Higgins, 56, a freelance product designer in New York City, that he was at risk for a heart attack, either, but it should have. He'd "lived a wild, crazy life," as he describes it, including smoking since he was 12, drinking a lot, eating a diet high in saturated fat and not exercising regularly. At six-foot-two and 238 pounds, he was overweight. He also had a catastrophic family history: Five of his mother's six brothers, and two of their sons, had all died before age 60 of heart-related problems. "I knew all that," says Higgins, "but I just didn't think I was at risk." He had no symptoms, he says, except for some occasional shortness of breath, usually in the middle of the night.

But one day he logged on to a website where an interactive tool calculated that he was going to die at age 68. That did it. "I said, 'Oh, my God!' I have two children, five and six, and I want to be around for them," says Higgins. So he went to a doctor for the first time in 30 years and, after several tests, learned that he had two arteries with blockages. The treatment? Two stents to hold open the arteries, several medications including a statin and a blood thinner -- and a total change in lifestyle.

The Future of Heart Disease Prevention

If Higgins hadn't happened upon that website, he might never have gone to his doctor. But even those who do go might not know their risk. Cholesterol scores can't always tell us who will be at risk. Screening tests catch only half of the population. For patients with symptoms, angiograms (in which a catheter is threaded through an artery into the heart for a look around) can provide good information on plaque buildup, blockages and heart damage -- after the fact. Still, these tests are too expensive and invasive to be used in patients with no symptoms.

And there are millions more like Higgins. In fact, John Postley, MD, an internist on the faculty of Columbia University Medical Center in New York City, says that blood vessels may start to show signs of lifestyle damage at an alarmingly young age. One study reports that the arteries of obese nine-year-olds are measurably stiffer than those of their peers. With the proper diet and exercise, their arteries can return to normal. By our mid-30s, the stiffening often progresses to hardening of the arteries, characterized by the buildup of plaque, which, if ruptured, can result in a heart attack -- within hours. But all plaque may not be equally dangerous. Calcified plaque is considered relatively stable and can indicate healing after a rupture has occurred. Fatty plaque is more susceptible to the cracking and clotting that lead to heart attacks. But most tests cannot detect this kind of plaque. And therein lies the problem: Until recently, doctors simply didn't have the tools to diagnose heart disease in time to prevent heart attacks.

Now, a new generation of noninvasive technology may change that. By looking directly into a patient's arterial walls using CT scanning, high-resolution ultrasound and MRI, doctors can see plaque building up years before it gets to the critical stage. Because risk factors can be as hard to read as tea leaves, Postley believes in proactively using the new diagnostic tools to predict and prevent arterial damage. The results? While we may not have a crystal ball to prevent heart disease, we may someday have the ability to eliminate most killer heart attacks well before they happen.

3 Tests to Stop Your Heart Attack Before It Starts

CT scans
What's your calcium score? Coronary CT scanning has become a widely recognized, noninvasive tool to identify plaque buildup. The newest and most highly detailed types, electron beam (EBCT) and multidetector CT, cost around $500 to $700, compared to as much as $4,000 for an angiogram. A patient can be scanned in ten minutes and have a good idea of the state of his arteries. While choles-terol can't be visualized on a CT, the inflammation in the plaque draws in calcium, which shows clearly on the scan. The amount of calcium correlates fairly well with the amount of plaque. But there are drawbacks. CT scans can't detect fatty plaque, they require radiation and, until recently, the results were too unreliable for the screening to be used routinely. For many doctors, the percentage of "false negatives" is still too high: 5 to 10 percent of people with clean scans will actually have heart disease.

Ultrasound
Six arteries tell the story. High-resolution ultrasound has a number of advantages over other imaging techniques. It involves no radiation, is noninvasive, fast (about 12 minutes), costs much less than a CT or MRI using portable, relatively inexpensive units, and physicians can be trained to do screenings in a short time (as opposed to diagnostic ultrasound, which requires years of specialty training).

Postley has been using external vascular ultrasound as part of the routine annual checkup in his office for two years, tracking plaque in the six major arteries in the body. A high-frequency probe is placed on the neck and groin to view the arteries from the outside in, as opposed to the tunnel-like view achieved from angiograms. Ultrasound allows doctors to see the thickening of the arterial walls as plaque accumulates within. Because the procedure is simple, noninvasive and safe, it can be repeated frequently to monitor plaque buildup.

Since a number of studies have shown that ultrasound can gauge arterial plaque from moderate to severe, patients can be treated over time: The patient with lowest risk could be treated with lifestyle changes alone. If ongoing ultrasound screening revealed moderate plaque formation, cholesterol-lowering or other drugs would be added to the regimen. If severe plaque developed, more aggressive therapy, such as angioplasty or bypass surgery, would be called for. All this would happen years before the fatal heart attack, often the first and only sign of trouble.

Postley cautions that high-resolution ultrasound still needs more definitive studies to prove its efficacy as a predictor. And while it gives exceptionally accurate readings of more superficial arteries, it cannot look at the actual heart (as CT and MRI can). Moreover, while ultrasound can identify fatty plaque, it can't identify calcified plaque because it can't see through calcium deposits or bone.

MRI
Analyzing the chemistry of plaque. The newest generation of MRI can give detailed images of the actual blood vessel wall as well as plaque. This high-resolution MRI can analyze plaque to a degree that none of the other diagnostics can. But studies of this type of MRI are still underway, and it's not readily available to the public. Postley uses it as a progressive diagnostic for patients who need greater clarification than the ultrasound or CT scan can provide. The bottom line? Along with the increasing numbers and types of cholesterol-lowering medications, blood thinners and new treatments such as drug-coated coronary stents coming onto the market, these tools can help wage war on heart disease. And with these diagnostic techniques, patients may get help before they ever become symptomatic.

As for Dennis Higgins, he quit smoking and gave up hard liquor (but still enjoys an occasional glass of wine). He now eats a Mediterranean-style diet, with lots of vegetables, legumes, whole grains, nuts and a bit of fish. He's kept off 30 pounds by riding his bike, walking, playing with his kids and doing yoga. He's never felt better, he says. He and his wife are thrilled that his projected lifespan has increased to 89. "The most important message I can give another person," he says, "is to go to the doctor. Go check it out. Then get fit, get healthy -- and get on with your life."