Show 1450: Beyond Cholesterol: Rethinking Your Risk of Heart Disease

Heart disease is still our number one killer, even though 50 million Americans have been prescribed a cholesterol-lowering statin. Cardiologists pay a lot of attention to cholesterol in all its variety: total cholesterol, LDL, HDL, VLDL. Even blood fats like triglycerides and lipoprotein a [Lp(a)] are getting some attention. What else do you need to know to reduce your risk of heart disease or stroke?

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What Factors Shape Your Risk of Heart Disease?

Our guest for this episode is a preventive cardiologist, a doctor whose practice is aimed at keeping people from getting heart disease. Even though heart disease ranks at the top of the list of reasons people die, it has been dropping. Dr. Michael Blaha points out that in some states heart disease has actually fallen below cancer as a cause of death. Presumably, that is not due to a dramatic increase in cancer mortality, but rather because we are successfully reducing the toll from cardiovascular disease. Cutting out smoking and removing trans fats from popular foods have helped a lot. Addressing obesity is also changing the equation.

Treating Obesity Helps the Heart:

We asked Dr. Blaha if the immensely popular GLP-1 drugs such as Ozempic, Wegovy, Mounjaro or Zepbound are making a difference in our risk of heart disease. He believes they are the biggest breakthrough since statins. Other medications that could help reduce obesity might also benefit the heart and cardiovascular system. Cardiologists have long been urging people to embrace physical activity and sensible diets. Now the medications can give them a head start on those efforts.

What Can We Do About Lp(a)?

About one-fifth of Americans have elevated levels of lipoprotein a, usually abbreviated Lp(a) and pronounced ell-pee-little-ay. This risk factor is considered stable and is an important predictor of cardiovascular complications. According to a meta-analysis of 18 studies, Lp(a) is an independent risk factor for calcified aortic valves (Frontiers in Cardiovascular Medicine, Oct. 13, 2025).

Several pharmaceutical firms are actively developing agents that could lower Lp(a). That would certainly be welcome, since statins actually raise levels of this potentially troublesome blood fat. This means that many heart patients are in the uncomfortable position of driving with their feet on both the brake and the gas pedals.

Getting Blood Pressure Right:

High blood pressure is a very common risk factor for heart disease and stroke. Doctors need to pay attention to balancing control of hypertension with potential side effects. Especially for older patients, the risk of orthostatic hypotension could be serious. This happens when blood pressure drops suddenly after a person stands from a sitting or reclining position. If they faint and fall, the results can be serious.

People with concerns about hypertension need to make sure their blood pressure is being measured correctly. Incorrect measurement techniques, possibly resulting in inaccurate readings, are shockingly common in busy clinics. Dr. Blaha discussed the correct procedures, along with the reasons that doctors may prescribe ACE inhibitors (such as lisinopril) or ARBs (such as losartan) as their first-line choice for blood pressure control.

Using the Risk Calculator to Estimate Your Risk of Heart Disease:

We asked Dr. Blaha about the new PREVENT risk calculator produced by the American Heart Association. The algorithms in this tool appear much less likely to overestimate a person’s risk of heart disease than those that cardiologists used previously. All of the cardiology guidelines now recommend its use. You can find it here, although you may not know all the numbers to plug in. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator

How Does CAC Score Illuminate Your Risk of Heart Disease?

Lately, cardiologists have been turning to the coronary artery calcium score, or CAC, to help estimate patients’ probability of developing circulatory problems. This is a CT scan of the heart that reveals the location of calcified plaque in the coronary arteries. In general, a higher CAC score indicates a higher level of cardiovascular risk. This measurement may be helpful in determining risk for people who aren’t clearly in a very high-risk category (or a very low-risk category) already. Dr. Blaha suggests it may also serve as a motivator for people who need to change their lifestyles to ward off serious cardiovascular consequences.

Can You Reduce Your Risk of Heart Disease?

Dr. Blaha suggests that everyone can benefit from paying attention to lifestyle recommendations. Getting adequate physical activity is crucial. So is consuming a diet rich in vegetables and fruits, minimizing highly processed foods. But these recommendations are overly general. People at higher risk of cardiovascular complications need more personalized advice from their doctors. How can you remove the barriers to exercise? Does the diet need more soluble fiber? What nutrients might be needed in addition?

Individuals with chronic infections such as HIV need even more personalized attention. For example, a person with high levels of inflammation may need an anti-inflammatory drug such as colchicine (American Heart Journal, Jan. 2025).

This Week’s Guest:

Michael J. Blaha, MD, MPH, is Professor of Cardiology and Epidemiology at Johns Hopkins School of Medicine. He is the Director of Clinical Research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Clinically, Dr.Blaha practices as a preventive cardiologist and in the interpretation of cardiac CT. Dr. Blaha has received multiple grant awards from the National Institutes of Health, FDA, American Heart Association, Amgen Foundation, and the Aetna Foundation.