- Heart Attack
- Causes of a Heart Attack
- Who is at risk for a heart attack?
- Inherited (genetic) factors: Who is most at risk?
- Acquired risk factors: Who is most at risk?
- Managing heart attack risk factors
- Prevention of Heart Attacks
- Symptoms of a Heart Attack
- Responding to heart attack warning signs
- Treatment for a heart attack
- Coronary angioplasty
- Coronary artery bypass
- Heart Health Tips
- A: Assess Your Risk of Heart Disease
- A: Aspirin
- B: Blood Pressure
- C: Cholesterol
- C: Cigarette/Tobacco Cessation
- D: Diabetes Prevention and Treatment
- D: Diet and Weight Management
- E: Exercise
- Can Coronavirus Cause Heart Damage?
- If I’ve had COVID-19, should I follow up with a cardiologist?
- History | Johns Hopkins Heart and Vascular Institute
- Heart Failure
- Six Years of Exercise — or Lack of It — May Be Enough to Change Heart Failure Risk
- The Ciccarone Center | Heart and Vascular Institute
- Our Tripartite Mission
- Research Interests
- Treatment Approach
- Fellowship Program
- History of the Ciccarone Center
A heart attack (myocardial infarction) happens when one or more areas of the heart muscle don't get enough oxygen. This happens when blood flow to the heart muscle is blocked.
Causes of a Heart Attack
The blockage is caused by a buildup of plaque in the arteries (atherosclerosis). Plaque is made up of deposits, cholesterol, and other substances. When a plaque breaks (ruptures), a blood clot quickly forms. The blood clot is the actual cause of the heart attack.
If the blood and oxygen supply is cut off, muscle cells of the heart begin to suffer damage and start to die. Irreversible damage begins within 30 minutes of blockage. The result is heart muscle affected by the lack of oxygen no longer works as it should.
Who is at risk for a heart attack?
There are two types of risk factors for heart attack.
|Inherited or genetic risk factors are risk factors you are born with that cannot be changed, but can be improved with medical management and lifestyle changes.||Acquired risk factors are caused by activities that we choose to include in our lives that can be managed through lifestyle changes and clinical care.|
Inherited (genetic) factors: Who is most at risk?
These groups are most at risk:
- People with inherited high blood pressure (hypertension)
- People with inherited low levels of HDL cholesterol, high levels of LDL cholesterol, or high levels of triglycerides
- People with a family history of heart disease. This is especially true if the heart disease started before age 55.
- Older men and women
- People with type 1 diabetes
- Women who have gone through menopause. Generally, men are at risk at a younger age than women. After menopause, women are equally at risk.
Acquired risk factors: Who is most at risk?
These groups are most at risk:
- People with acquired high blood pressure (hypertension)
- People with acquired low levels of HDL cholesterol, high levels of LDL cholesterol, or high levels of triglycerides
- Cigarette smokers
- People who are under a lot of stress
- People who drink too much alcohol
- People who lead a sedentary lifestyle
- People overweight by 30% or more
- People who eat a diet high in saturated fat
- People with type 2 diabetes
A heart attack can happen to anyone. When you take the time to learn which risk factors apply to you, you can take steps to eliminate or reduce them.
Managing heart attack risk factors
Here are ways to manage your risks for a heart attack:
- Look at which risk factors apply to you, then take steps to eliminate or reduce them.
- Learn about high blood pressure and high cholesterol levels. These may be “silent killers.”
- Change risk factors that aren't inherited by making lifestyle changes. Talk with your healthcare provider to find out how to do so.
- Talk with your healthcare provider to find out if you have risk factors that can't be changed. These can be managed with medicine and lifestyle changes.
Prevention of Heart Attacks
You can help prevent a heart attack by knowing your risk factors for coronary artery disease and heart attack and taking action to lower those risks. Even if you’ve already had a heart attack or are told that your chances of having a heart attack are high, you can still lower your risk, most ly by making a few lifestyle changes that promote better health.
- Don’t smoke. Your doctor may recommend methods for quitting, including nicotine replacement.
- Eat a diet low in fat, cholesterol and salt.
- See your doctor regularly for blood pressure and cholesterol monitoring.
- Pursue a program of moderate, regular aerobic exercise. People over age 50 who have led a sedentary lifestyle should check with a doctor before beginning an exercise program.
- Lose weight if you are overweight.
- Your doctor may advise you to take a low dose of aspirin regularly. Aspirin reduces the tendency for the blood to clot, thereby decreasing the risk of heart attack. However, such a regimen should only be initiated under a doctor’s expressed recommendation.
- Women at or approaching menopause should discuss the possible cardio-protective benefits of estrogen replacement therapy with their doctor.
Symptoms of a Heart Attack
The following are the most common symptoms of a heart attack. But each person may have slightly different symptoms.
- Severe pressure, fullness, squeezing, pain, or discomfort in the center of the chest that lasts for more than a few minutes
- Pain or discomfort that spreads to the shoulders, neck, arms, or jaw
- Chest pain that gets worse
- Chest pain that doesn't get better with rest or by taking nitroglycerin
- Chest pain that happens along with any of these symptoms:
- Sweating, cool, clammy skin, or paleness
- Shortness of breath
- Nausea or vomiting
- Dizziness or fainting
- Unexplained weakness or fatigue
- Rapid or irregular pulse
Although chest pain is the key warning sign of a heart attack, it may be confused with other conditions. These include indigestion, pleurisy, pneumonia, tenderness of the cartilage that attaches the front of the ribs to the breastbone, and heartburn. Always see your healthcare provider for a diagnosis.
Responding to heart attack warning signs
If you or someone you know has any of the above warning signs, act right away. Call 911, or your local emergency number.
Treatment for a heart attack
The goal of treatment for a heart attack is to relieve pain, preserve the heart muscle function, and prevent death.
Treatment in the emergency department may include:
- Intravenous therapy, such as nitroglycerin and morphine
- Continuous monitoring of the heart and vital signs
- Oxygen therapy to improve oxygenation to the damaged heart muscle
- Pain medicine to decrease pain. This, in turn, decreases the workload of the heart. The oxygen demand of the heart decreases.
- Cardiac medicine such as beta-blockers to promote blood flow to the heart, improve the blood supply, prevent arrhythmias, and decrease heart rate and blood pressure
- Fibrinolytic therapy. This is the intravenous infusion of a medicine that dissolves the blood clot, restoring blood flow.
- Antithrombin or antiplatelet therapy with aspirin or clopidogrel. This is used to prevent further blood clotting.
- Antihyperlipidemics. These medicines lower lipids (fats) in the blood, particularly low density lipid (LDL) cholesterol. Statins are a group of antihyperlipidemic medicines. They include simvastatin, atorvastatin, and pravastatin. Bile acid sequestrants—colesevelam, cholestyramine, and colestipol—and nicotinic acid (niacin) are two other types of medicines that may be used to lower cholesterol levels.
You may need other procedures to restore blood flow to the heart. Those procedures are described below.
With this procedure, a balloon is used to create a bigger opening in the vessel to increase blood flow. This is often followed by inserting a stent into the coronary artery to help keep the vessel open.
Although angioplasty is done in other blood vessels elsewhere in the body, percutaneous coronary intervention (PCI) refers to angioplasty in the coronary arteries. This lets more blood flow into the heart.
PCI is also called percutaneous transluminal coronary angioplasty (PTCA). There are several types of PTCA procedures:
- Balloon angioplasty. A small balloon is inflated inside the blocked artery to open the blocked area.
- Coronary artery stent. A tiny coil is expanded inside the blocked artery to open the blocked area. The stent is left in place to keep the artery open.
- Atherectomy. The blocked area inside the artery is cut away by a tiny device on the end of a catheter.
- Laser angioplasty. A laser used to “vaporize” the blockage in the artery.
Coronary artery bypass
This surgery is most commonly referred to as simply bypass surgery or CABG (pronounced “cabbage”). It is often done in people who have chest pain (angina) and coronary artery disease. Coronary artery disease is when plaque has built up in the arteries.
During the surgery, the surgeon makes a bypass by grafting a piece of a vein above and below the blocked area of a coronary artery. This lets blood flow around the blockage. The surgeon usually takes veins from a leg, but he or she may also use arteries from the chest or an arm.
Sometimes, you may need more than one bypass surgery to restore blood flow to all areas of the heart.
Heart Health Tips
The causes of heart disease are often complex — but preventing heart disease doesn’t have to be. Many of those factors are within your control. Johns Hopkins cardiologist Michael J. Blaha, M.D., M.P.H.
, director of clinical research at the Ciccarone Center for the Prevention of Heart Disease, explains how heart disease prevention is as easy as A-B-C-D-E.
“This helps us make sure we hit all the elements of preventive care,” Blaha says.
A: Assess Your Risk of Heart Disease
To prevent heart disease, it first helps to know whether you’re at high risk. Try an online calculator to determine the lihood that you’ll experience a heart disease event in the next 10 years.
“That’s a great first step,” Blaha says.
But it’s also a good idea to get checked by your primary care doctor, who can track factors such as blood pressure and cholesterol levels and help you make sense of the numbers.
A small daily dose of aspirin can lower the risk of heart attack or stroke in many patients who are at increased risk of heart disease, including those with diabetes or narrowing of the arteries. Talk to your doctor to find out if daily aspirin is a good idea.
B: Blood Pressure
High blood pressure (defined as 140/90 or higher) is a significant cause of heart attack, stroke, kidney disease and dementia. You can help keep blood pressure low by maintaining a healthy weight, getting regular aerobic exercise, eating a diet low in salt and high in fruits and vegetables, and reducing alcohol intake. Medications can also keep high blood pressure in check.
So-called “bad” cholesterol, also known as low-density lipoprotein (LDL) cholesterol, builds up in the arteries over time, reducing blood flow to the heart and increasing the risk of heart attack and stroke.
“We generally aim to keep LDL cholesterol levels below 100 mg/dL,” Blaha says. As with blood pressure, a healthy diet and regular exercise can help keep cholesterol levels low. Medications such as statins can also help lower cholesterol and reduce heart disease risk.
Talk to your doctor to find out if statins are right for you.
C: Cigarette/Tobacco Cessation
Tobacco use increases the risk of heart attack and stroke and is linked to several cancers as well. If you smoke, quitting is the best first step to slashing your heart disease risk, Blaha says. A number of resources are available to help you quit, including nicotine replacement products, prescription medicines and classes.
D: Diabetes Prevention and Treatment
Both diabetes and prediabetes can lead to heart disease, stroke, kidney failure, blindness and amputations.
“If you’re trending toward diabetes, you should make an effort to prevent it through diet and exercise,” says Blaha.
If you already have diabetes, keeping it in control through healthy lifestyle changes and/or medications will lower your risk of serious complications, including heart disease.
D: Diet and Weight Management
A nutritious diet is a key piece of good health. Experts recommend a diet rich in fruits, vegetables and whole grains, as well as low-fat dairy products, poultry, fish, legumes and nuts.
Minimize or avoid sweets, sugar-sweetened beverages, red meats and refined carbohydrates, such as those in white bread, white rice and pasta. For people who are overweight (with a body mass index or BMI from 25–29.
9) or obese (with a BMI of more than 30), even modest weight loss can improve heart disease risk.
Exercise helps you maintain a healthy weight and lowers your risk of a wide range of diseases.
The American Heart Association recommends 150 minutes of moderate activity per week. Thirty minutes a day, five days a week is a great goal. But don’t stop there, Blaha says: “Think of exercise as general activity, including things less sitting, less screen time and more walking, as well as the type of moderate to vigorous activity that gets you to break a sweat.”
Can Coronavirus Cause Heart Damage?
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Can COVID-19 damage the heart? Yes: Although COVID-19 — the disease caused by the coronavirus that’s led to the global pandemic — is primarily a respiratory or lung disease, the heart can also suffer.
Early reports coming China and Italy, two areas where COVID-19 took hold earlier in the pandemic, show that up to 1 in 5 patients with the illness end up with heart damage. Heart failure has been the cause of death in COVID-19 patients, even those without severe breathing problems such as acute respiratory distress syndrome, or ARDS.
Not all heart problems related to this coronavirus — officially called SARS-CoV-2—are a, however. Cardiologist Erin Michos, M.D., M.H.S., explains the different ways the virus — and the body’s response to it — can cause heart damage.
Michos explains that cells in the lung and heart are both covered with protein molecules called angiotensin-converting enzyme 2, or ACE-2. The ACE-2 protein is the doorway that the new coronavirus uses to enter cells and multiply.
ACE-2 normally plays a favorable role in protecting tissue by being anti-inflammatory. But if the new coronavirus somehow disables those molecules, these cells may be left unprotected when the immune system springs into action.
“There are multiple mechanisms for heart damage in COVID-19, and not everyone is the same,” Michos says. Temporary or lasting damage to heart tissue can be due to several factors:
Lack of oxygen. As the virus causes inflammation and fluid to fill up the air sacs in the lungs, less oxygen can reach the bloodstream.
The heart has to work harder to pump blood through the body, which can be dangerous in people with pre-existing heart disease.
The heart can fail from overwork, or insufficient oxygen can cause cell death and tissue damage in the heart and other organs.
Myocarditis: inflammation of the heart. The coronavirus may infect and damage the heart’s muscle tissue directly, as is possible with other viral infections, including some strains of the flu. The heart may also become damaged and inflamed indirectly by the body’s own immune system response.
Stress cardiomyopathy. Viral infections can cause cardiomyopathy, a heart muscle disorder that affects the heart’s ability to pump blood effectively. When attacked by a virus, the body undergoes stress and releases a surge of chemicals called catecholamines that can stun the heart. “Once the infection resolves, the stressor has ended and the heart can recover,” Michos says.
Cardiologist Erin Michos discusses who is at higher risk for complications due to COVID-19, how COVID-19 impacts the heart, supportive therapies for patients with the virus and infection prevention strategies.
Most serious of all, Michos says, is the possibility of the immune system launching an attack on the invading virus that is so severe that it destroys healthy tissues.
When responding to infection with the new coronavirus, the body releases a flood of proteins called cytokines that help cells communicate with one another and fight the invaders.
In some people, perhaps due to a genetic difference, this normal defensive event is exaggerated, leaving them vulnerable to a cytokine storm. In a cytokine storm, the immune system response causes inflammation that can overwhelm the body, destroying healthy tissue and damaging organs such as the kidneys, liver and heart.
A cytokine storm and its resulting heart damage can also affect the heart’s rhythm. “Serious ventricular arrhythmias due to a cytokine storm can be catastrophic,” Michos says.
A cytokine storm is difficult to survive. Current research is exploring the possible benefit of using immune-suppressing drugs to treat patients with COVID-19 who experience this serious complication.
Check symptoms. Protect yourself. Get information.
Yes. Michos says people with COVID-19 can have symptoms similar to those of a heart attack, including chest pain, shortness of breath and changes on their echocardiogram (ultrasound of the heart), or EKG.
“In many of these COVID-19 cases when these patients are given an angiogram, there is no evidence of a major blockage in the heart’s blood vessels, which would indicate a heart attack in progress,” she says.
Symptoms of myocarditis can also mimic those of a heart attack. Additionally, Michos says that viral infections such as COVID-19 can cause very small blood clots to form, which can block tiny blood vessels and cause pain.
She notes that before the coronavirus pandemic, patients with these signs and symptoms might go directly to the catheterization lab for treatment.
But now, emergency room doctors and cardiologists have to consider these COVID-19 “mimickers” first, and perform additional testing such as EKGs. Performing a heart catheterization on a patient with symptoms caused solely by COVID-19 doesn’t address the underlying problem, and puts both the patient and health care practitioners at risk.
However, Michos stresses, even in the pandemic, real heart attacks can still occur, and patients with signs and symptoms of a heart attack should still seek urgent medical attention and not manage these symptoms at home.
“There is growing concern that people are delaying receiving prompt care for heart attacks due to fear of contracting COVID-19 at the hospital, and untreated heart attacks can lead to long-term serious complications,” she says.
If I’ve had COVID-19, should I follow up with a cardiologist?
Michos says that people living with heart disease should stay in close touch with their doctors during the pandemic, and take care to comply with medication to manage their heart condition. If they catch COVID-19, they should request a follow-up examination after they recover to detect any further heart damage from the virus.
Patients without known heart disease who get COVID-19 should follow up with their primary care doctor. Tests may be recommended if symptoms such as weakness, shortness of breath or chest pain persist after recovery, since these problems could be due to COVID-19-related damage to the lungs or heart.
What you need to know from Johns Hopkins Medicine.
History | Johns Hopkins Heart and Vascular Institute
One of the photographic studies done by Yousuf Karsh to mark the official “1000 blue baby” procedure performed by Dr. Alfred Blalock. Portrait by Yousuf Karsh, ©Karsh
In 1944 doctors at Johns Hopkins performed the surgery that opened the door to today's heart surgery.
Working together, The Johns Hopkins Hospital's chief surgeon, Dr. Alfred Blalock, and pediatric cardiologist Dr. Helen Taussig devised a means for improving the flow of oxygen into the blood by connecting one of the heart's major arteries with another feeding into the lungs.
Known as the Blue Baby Operation, it brought relief to a young girl plagued with a combination of heart defects that kept her blood so starved for oxygen that her skin was literally blue.
In time the procedure not only helped save the lives of thousands of similarly afflicted children around the world, but also opened the door to now-familiar procedures coronary bypass surgery.
In the 1950s doctors and scientists at Hopkins developed the first cardiac defibrillator and discovered cardiopulmonary resuscitation or CPR. While defibrillators today with their metal paddles are a familiar feature of hospital emergency rooms and ambulances almost everywhere, CPR has been credited with saving hundreds of thousands of lives.
In the 1970s researchers at Hopkins helped refine pacemaker technology when they invented the first implantable device that could actually be recharged inside the body. A decade later they developed the first implantable defibrillator to help those with unpredictable and potentially fatal irregularities in their heartbeat.
Known today as an ICD, the tiny devices have been credited with saving thousands of lives.
Dr. Helen Taussig examines an infant. Portrait of Helen B. Taussig by Yousuf Karsh, ©Karsh
Over that same time period other research at Hopkins helped improve the diagnosis and treatment of heart disease by working not just outside the heart, but inside it as well.
Small probes that could be threaded through veins and arteries gave heart doctors a way to actually look and work inside the heart, making a whole range of new diagnoses and new treatments possible.
Known as cardiac catheterization, the technique created a new field in cardiology known today as interventional radiology.
In the 1980s cardiac specialists at Hopkins working with children developed balloon angioplasty — inserting a balloon-tipped probe into the arteries feeding the heart and then inflating it to clear blockages. the first open heart surgery pioneered at Hopkins during the Second World War, this new technique quickly became a common procedure for the treatment of adult heart problems as well.
Dr. Blalock and his surgical team, performing one of the first shunts.
Heart doctors at Johns Hopkins also played an important role in developing the field of clinical genetics.
Intrigued by the clustering of abnormalities he saw in heart patients, particularly those with Marfan's syndrome, a genetic disorder that stretches the body's connective tissues and often damages the aorta, Victor McKusick began studying genetics and mapping the locations of genes, tracking how their abnormalities expressed themselves and caused disease. In time his research at Hopkins expanded to include not just Marfan's syndrome, but hundreds of other genetic disorders as well. By establishing a clear link between genetic disorders and certain medical problems, his work helped open the door to modern gene therapy. Rather than just treating the symptoms of inherited diseases — including some forms of heart disease — doctors today are working to actually cure them through techniques such as gene therapy and gene replacement.
That tradition of pioneering work continues at Johns Hopkins with physicians and researchers working in almost every field related to cardiovascular disorders, from transplant surgery to prevention.
The hospital receives more federal research funding than other medical institution in the country and its cardiology department has been specially recognized for its work. Each year the National Institute of Health awards just ten SCORE (Specialized Center Of Research Excellence) grants to medical institutions nationwide.
Cardiologists at Johns Hopkins have managed to win two of those ten awards for their studies of coronary artery disease and the causes of sudden cardiac death.
Linkedin Pinterest Heart and Vascular
Heart failure is a condition in which the heart can’t pump enoughoxygenated blood to meet the body’s needs.
The heart keeps pumping, but notas efficiently as a healthy heart. Heart failure does not mean the heartstops. Rather, it means the heart fails to pump as well as it should.
Heartfailure generally results from some other underlying condition.
What You Need to Know
- Cardiomyopathy, a name for any disease of the heart muscle, is one condition that often leads to heart failure.
- Symptoms of heart failure include shortness of breath, swelling in the legs and feet, and abdominal pain or nausea.
- Diagnosis includes tests for the existence of heart failure, followed by tests to evaluate the cause of the heart failure.
- Treatment for heart failure begins with lifestyle changes and medications. In more advanced cases, surgery may be needed.
- People can and do live with heart failure. Close self-monitoring and sticking to the doctor’s recommended diet, medication and exercise plans are essential to improving quality of life.
The following are the most common symptoms of heart failure. However, each person may experience symptoms differently. Symptoms may include:
- shortness of breath during rest or exercise, or while lying flat
- weight gain
- visible swelling of the legs, ankles and sometimes the abdomen, due to a buildup of fluid
- fatigue and weakness
- nausea, abdominal pain, loss of appetite
- persistent cough that can cause blood-tinged sputum
Broadly speaking, some people will develop symptoms because they can’t get blood to the body (fatigue and weakness, shortness of breath with activity), and some will develop symptoms because blood and fluid become congested prior to reaching the heart (shortness of breath lying down, weight gain, persistent cough, abdominal congestion, nausea, abdominal pain, poor appetite, leg swelling). Some may have symptoms from both groups. And yet some may not have any symptoms at all.
The severity of the condition and symptoms depends on how much of the heart’s pumping capacity has been affected.
Symptoms of heart failure may resemble those of other conditions or medical problems. Always consult your health care provider for a diagnosis.
In addition to a complete medical history and physical examination, diagnostic procedures for heart failure may include some combination of the following:
- chest X-ray: a process that produces pictures of internal tissues, bones and organs
- echocardiogram (also called echo): an ultrasound of the heart
- electrocardiogram (ECG or EKG): wires taped to various parts of your body to create a graph of your heart’s electrical rhythm
- BNP testing: B-type natriuretic peptide (BNP) is a hormone released from the ventricles in response to increased wall tension (stress) that occurs with heart failure. BNP levels rise as wall stress increases. BNP levels are useful in the rapid evaluation of heart failure. In general, the higher the BNP levels, the worse the heart failure.
The goal of heart failure treatment is to improve quality of life by addressing the underlying causes, reducing symptoms and managing overall health. Education plays a crucial role. Patients and their families who learn to recognize and respond to small changes, such as swelling or weight gain, can help slow the progression of heart failure.
- Treating underlying conditions
- Controlling risk factors
- quitting smoking
- losing weight (if overweight) and increasing moderate exercise
- switching to a heart-healthy diet
- avoiding alcohol
- getting proper rest
- controlling blood sugar (if diabetic)
- controlling blood pressure — which also means controlling the amount of sodium (salt) in your diet
- limiting fluids
- These medications have been shown to prolong life in heart failure patients:
- angiotensin converting enzyme (ACE) inhibitors: This medication decreases the pressure inside the blood vessels and reduces the resistance against which the heart pumps.
- angiotensin receptor blockers (ARBs): This is an alternative medication for reducing the workload on the heart if ACE inhibitors are not tolerated. An ACE inhibitor or ARB blocker will often be recommended, but not both.
- beta blockers: These reduce the heart's tendency to beat faster and reduce its workload by blocking specific receptors on heart cells.
- aldosterone blockers: This medication blocks the effects of the hormone aldosterone, which causes sodium and water retention.
- angiotensin receptor-neprilysin inhibitors (ARNIs) : This is a relatively new class of medication that for some people has been shown to be a better alternative than ACE inhibitors or ARB blockers.
These medications have been shown to reduce symptoms:
- diuretics: These reduce the amount of fluid in the body.
- vasodilators: These dilate the blood vessels and reduce workload on the heart.
- digoxin: This medication helps the heart beat stronger with a more regular rhythm.
- anti-arrhythmia medications: These help maintain normal heart rhythm and help prevent sudden cardiac death. However, some anti-arrhythmics may actually cause heart failure.
- These medications have been shown to prolong life in heart failure patients:
Implanted devices that help the heart function more effectively
- biventricular pacing/cardiac resynchronization therapy : This new type of pacemaker paces both sides of the left ventricle simultaneously to coordinate contractions and improve the heart's function. Some heart failure patients are candidates for this therapy.
- implantable cardioverter defibrillator (ICD) : A device similar to a pacemaker, it senses when the heart is beating too fast and delivers an electrical shock to convert the fast rhythm to a normal rhythm.
- ventricular assist device (VAD): This mechanical device takes over the pumping function for one or both of the heart’s ventricles, or pumping chambers. A VAD may be necessary when heart failure progresses to the point that medications and other treatments are no longer effective.
- heart transplantation: For select patients, replacing the heart with a donated heart is a last resort for those who do not improve despite all other treatments.
Six Years of Exercise — or Lack of It — May Be Enough to Change Heart Failure Risk
By analyzing reported physical activity levels over time in more than 11,000 American adults, Johns Hopkins Medicine researchers conclude that increasing physical activity to recommended levels over as few as six years in middle age is associated with a significantly decreased risk of heart failure, a condition that affects an estimated 5 million to 6 million Americans.
The same analysis found that as little as six years without physical activity in middle age was linked to an increased risk of the disorder.
Un heart attack, in which heart muscle dies, heart failure is marked by a long-term, chronic inability of the heart to pump enough blood, or pump it hard enough, to bring needed oxygen to the body. The leading cause of hospitalizations in those over 65, the disorder’s risk factors include high blood pressure, high cholesterol, diabetes, smoking and a family history.
“In everyday terms our findings suggest that consistently participating in the recommended 150 minutes of moderate to vigorous activity each week, such as brisk walking or biking, in middle age may be enough to reduce your heart failure risk by 31 percent,” says Chiadi Ndumele, M.D., M.H.S.
, the Robert E. Meyerhoff Assistant Professor of Medicine at the Johns Hopkins University School of Medicine, and the senior author of a report on the study. “Additionally, going from no exercise to recommended activity levels over six years in middle age may reduce heart failure risk by 23 percent.
The researchers caution that their study, described in the May 15 edition of the journal Circulation, was observational, meaning the results can’t and don’t show a direct cause-and-effect link between exercise and heart failure. But they say the trends observed in data gathered on middle-aged adults suggest that it may never be too late to reduce the risk of heart failure with moderate exercise.
“The population of people with heart failure is growing because people are living longer and surviving heart attacks and other forms of heart disease,” says Roberta Florido, M.D., cardiology fellow at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease.
“Un other heart disease risk factors high blood pressure or high cholesterol, we don’t have specifically effective drugs to prevent heart failure, so we need to identify and verify effective strategies for prevention and emphasize these to the public.
” There are drugs used to treat heart failure, such as beta blockers and ACE inhibitors, but they are essentially “secondary” prevention drugs, working to reduce the heart’s workload after dysfunction is already there.
Several studies, Florido says, suggest that in general people who are more physically active have lower risks of heart failure than those who are less active, but little was known about the impact of changes in exercise levels over time on heart failure risk.
For example, if you are sedentary most of your life but then start exercising in middle age, does that decrease your risk of heart failure? Or, if you are active much of your life but then stop being active at middle age, will that increase your risk?
To address those questions, the researchers used data already gathered from 11,351 participants in the federally funded, long term Atherosclerosis Risk in Communities (ARIC) study, recruited from 1987 to 1989 in Forsyth County, North Carolina; Jackson, Mississippi; greater Minneapolis, Minnesota; and Washington County, Maryland.
The participants’ average age was 60, 57 percent were women and most were either white or African-American.
Participants were monitored annually for an average of 19 years for cardiovascular disease events such as heart attack, stroke and heart failure using telephone interviews, hospital records and death certificates. Over the course of the study there were 1,693 hospitalizations and 57 deaths due to heart failure.
In addition to those measures, at the first and third ARIC study visits (six years apart), each participant filled out a questionnaire, which asked them to evaluate their physical activity levels, which were then categorized as poor, intermediate or “recommended,” in alignment with guidelines issued by the American Heart Association.
The “recommended” amount is at least 75 minutes per week of vigorous intensity or at least 150 minutes per week of moderate intensity exercise. One to 74 minutes per week of vigorous intensity or one to 149 minutes per week of moderate exercise per week counted as intermediate level activity. And physical activity qualified as “poor” if there was no exercise at all.
After the third visit, 42 percent of participants (4,733 people) said they performed recommended levels of exercise; 23 percent (2,594 people) said they performed intermediate levels; and 35 percent (4,024 people) said they had poor levels of activity. From the first to the third visit over about six years, 24 percent of participants increased their physical activity, 22 percent decreased it and 54 percent stayed in the same category.
Those with recommended activity levels at both the first and third visits showed the highest associated heart failure risk decrease, at 31 percent compared with those with consistently poor activity levels.
Heart failure risk decreased by about 12 percent in the 2,702 participants who increased their physical activity category from poor to intermediate or recommended, or from intermediate to recommended, compared with those with consistently poor or intermediate activity ratings.
Conversely, heart failure risk increased by 18 percent in the 2,530 participants who reported decreased physical activity from visit one to visit three, compared with those with consistently recommended or intermediate activity levels.
Next, the researchers determined how much of an increase in exercise, among those initially doing no exercise, was needed to reduce the risk of future heart failure.
Exercise was calculated as METs (metabolic equivalents), where one MET is 1 kilocalorie per kilogram per hour. Essentially, sitting watching television is 1 MET, fast walking is 3 METs, jogging is 7 METs and jumping rope is 10 METs.
The researchers calculated outcomes in METs times the number of minutes of exercise.
The researchers found that each 750 MET minutes per week increase in exercise over six years reduced heart failure risk by 16 percent. And each 1,000 MET minutes per week increase in exercise was linked to a reduction in heart failure risk by 21 percent.
According to the American Heart Association, fewer than 50 percent of Americans get recommended activity levels.
Other authors on the study include Lucia Kwak, Mariana Lazo, Gary Gerstenblith, Roger Blumenthal, Elizabeth Selvin and Josef Coresh of Johns Hopkins; Vijay Nambi and Christie Ballantyne of Baylor College of Medicine; Haitham Ahmed of Cleveland Clinic; Sheila Hegde of Brigham and Women’s Hospital and Aaron Folsom of University of Minnesota.
The research was funded by a Robert E. Meyerhoff Professorship, a Robert Wood Johnson Amos Medical Faculty Development Award, a JHU Catalyst Award and grants from the National Heart, Lung, and Blood Institute (K23HL12247) and the National Institute of Diabetes and Digestive and Kidney Diseases (K24DK106414).
The Ciccarone Center | Heart and Vascular Institute
Read the Ciccarone Center's latest Annual Report
The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease works with adults at high risk for cardiovascular disease.
Through education, research and a comprehensive approach to heart disease prevention, we work to reduce the lihood of heart attack, stroke, bypass surgery and angioplasty in patients with risk factors such as:
- Hypertension (high blood pressure)
- Hyperlipidemia/dyslipidemia (high cholesterol, elevated triglycerides, low HDL cholesterol)
- Cigarette smoking
- Sedentary lifestyle
- Excess weight
- Existing cardiovascular or peripheral arterial disease
- Family history of cardiovascular or peripheral arterial disease at an early age
Our Tripartite Mission
- Create excellent clinical care for people at risk of developing heart disease or other types of atherosclerotic vascular disease.
- Educate health care practitioners to better identify and treat patients at risk of developing heart disease, peripheral arterial disease or stroke.
- Establish rigorous research programs to study heart disease and stroke prevention.
We are particularly interested in factors contributing to heart disease clusters in families and in adults younger than 65 with cardiovascular disease. We are also interested in patients who have family members with premature atherosclerotic disease but who don’t yet show symptoms.
Other research areas include:
- Accelerated atherosclerosis
- Estrogen replacement therapy
- Noninvasive cardiovascular imaging
- Use of mobile health (mHealth)
- Physical activity/exercise
- Use of testing in risk assessment
- Preventive medication
We have developed a comprehensive approach to preventive cardiology, performing advanced screening tests to identify patients at risk and to examine lifestyle habits, medical history and family history. Our team consists of cardiologists as well as an endocrinologist and a nurse practitioner, who create a plan to significantly reduce patients’ risk and slow the progression of cardiovascular disease.
Along with medication changes suggested by the doctors, our nurse practitioner/health educator helps patients develop a healthier diet, maintain a prudent body weight, stop smoking, create a regular aerobic exercise program and cope better with stress.
All cardiology postdoctoral clinical fellows rotate with our faculty. Those fellows and residents interested in pursuing research in the field of preventive cardiology attend biweekly research meetings led by Dr. Michael Blaha, our clinical research director. Opportunities also exist to earn a master's degree from the Bloomberg School of Public Health.
History of the Ciccarone Center
Learn how the Ciccarone Center united the proud traditions of Johns Hopkins lacrosse and Johns Hopkins Medicine.
Make an appointment with our team at one of the Ciccarone Center’s locations.