3 days ago
Cardiovascular disease — are you in the danger zone?
One of the disadvantages of being an older doctor is that your work starts to bleed into your personal life. I was reminded of this over the weekend when chatting to a friend about his coronary artery bypass surgery. He's one of six of my, mostly, clean-living peers to have had major heart problems in their fifties and sixties. Welcome to sniper's alley: the period in middle age when people (mainly men) get picked off by something they never saw coming.
Cardiovascular disease (CVD) isn't the only threat but it's the main one. And it doesn't just shorten lives: most people who have a heart attack or stroke will survive, but many of those who do will be left with some sort of long-term disability. Sniper's alley maims more often than it kills. So just how risky is it?
According to the CVD calculator favoured by most British doctors — QRISK3 (see below) — an average healthy non-smoking 55-year-old white man living in my patch (Gloucestershire) has a 1 in 16 chance of having a stroke or heart attack before his 65th birthday. It is 1 in 34 for a similar woman.
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Add in a family history of CVD and that increases to 1 in 11 and 1 in 25 respectively. If they also have high cholesterol, the odds rise to 1 in 7 and 1 in 15. And if their blood pressure is high too, the chances are 1 in 5 and 1 in 10.
The sniper analogy isn't a pleasant one, but given that the above risk factors are often silent and/or missed, it has some relevance because people don't see what's coming. If you are very overweight, smoke or have diabetes, you should be aware that you are at much higher risk of an early heart attack or stroke.
However, you may not know that your father's angina (chest pain on exertion) was significant, and have no idea what your blood pressure or cholesterol levels are because you have never been tested.
A worrying family history, defined in QRISK3 as a first-degree relative who developed angina or had a heart attack before the age of 60, can affect your odds in two ways. First, it is often due to inheritable glitches in cholesterol metabolism that lead to very high levels, or unhealthy mixes (typically low 'good' HDL and high 'bad' LDL). Second, even if you have normal blood fats, there are other, less well-understood inheritable factors that mean you are still at higher risk than people with no such family history. Or, to put it another way, according to QRISK3, having a positive family history can carry a similar degree of risk to smoking ten a day.
Of course, we don't get to choose our parents and can't (yet) alter the genetic hand they have dealt us, but we can take steps to mitigate any additional risk, which is why it is important to 'know your numbers'. At the very least, I believe everyone over 35 should know what their cholesterol profile looks like and what their blood pressure is.
You can request a cholesterol test at your GP surgery, and you don't need to fast for a basic screening one, though I advise avoiding drinking coffee as this can result in higher readings. Levels do rise with age but tend to tail off after 60, so if yours is OK after a one-off testing, and nothing else changes, there is often no need to have multiple repeat blood tests.
Blood pressure checks are typically best done at home as they tend to be more accurate than a one-off reading in your surgery when you may be nervous. It is estimated that as many as one in three adults in the UK now have high blood pressure, a third of whom remain undiagnosed. And measuring it is the only way to be sure you are not one of them.
Accurate machines now cost as little as £20-30 and you can borrow one if you don't have your own. If your readings are healthy (an average under 135/80 for most people), put the machine away for 6-12 months. If they are borderline, check again in 3-6 months. And if they are up, send/take your readings to your GP.
A quick word about diabetes. Although most people will be all too aware that they have it, and what the implications are, there are thought to be about a million people in the UK with undiagnosed type 2, putting them at even higher risk of complications such as an early stroke or heart attack. The Diabetes UK risk calculator ( will help to determine if you may be one of them and advises on how to get tested.
Finally, based on recent experience, you may want to avoid joining my social circle.
QRISK3 is the preferred risk calculator for most doctors. It is designed to be used with a healthcare professional but there is no reason why you can't try it on your own. You will need to have some data to hand, such as blood pressure, height, weight, cholesterol levels etc but you can leave bits blank if unsure and QRISK will substitute an average reading for you. Results are only estimates and do not consider all risk factors, but if your heart age is significantly higher than your chronological age, you should look to mitigate modifiable ones such as blood pressure, weight and cholesterol levels.
