Host: Abigail Trafford

Heart attacks can often happen to people who've tried everything to protect their heart — such as eating right, exercising regularly, drinking moderately. How that happens is the topic of this week's health discussion.

Dr. Marianne J. Legato, an academic physician, author and specialist in women's health, was our online guest Tuesday, May 11, from 2 to 3 p.m. EDT with Abigail Trafford, The Post's Health editor.

Dr. Legato has spent her research career doing cardiovascular research on the structure and function of the cardiac cell. She is the author of an award-winning book, "The Female Heart: The Truth About Women and Heart Disease."

Read the discussion below. Her comments are of an educational nature and should not be used for individual patient care. Consult a physician for individual treatment.

Abigail Trafford: Hello and Welcome to Health Talk. Today in the Health Section two people wrote about their experiences with heart disease. One man in his mid-fifites who was religious about exercise and followed a healthy diet had a sudden heart attack. He survived and is even more rigorous about diet and exercise. A woman in her seventies who also did everything right--exercise and diet--ended up with coronary bypass surgery. The question is why? Why do some people who follow a healthy lifestyle still develop heart disease. And what is the real value of a healthy life style? Today our guest, physician Marianne J. Legato is here to straighten all this out. Send us your questions.

Alexandria, VA: My mother has heart disease.
What should I do to prevent heart disease in my golden years....

Marianne J. Legato: Know your risk factors for coronary artery disease. Some of the most important are as follows:

Age: between 40 and 60, as many women die of CAD as die of breast cancer. By the age of 60, women are as likely to have a heart attack as is a man.

Menopausal state: premature menopause (before the age of 38) is a risk factor for CAD

Family history: if you have had a first degree relative younger than the age of 55 die of a heart attack, it increases your risk for CAD

Diseases that increase risk for CAD:
diabetes, hypertension, obesity

Life style factors that increase risk: diets high in fat, smoking, use of cocaine, lack of exercise

Dyslipidemia:
For women, Total cholesterol should be below 200, triglycerides below 200, HDL above 45 and LDL below 130.

Abigail Trafford: Dr. Legato, why is it that some people who do everything right and follow a healthy lifestyle still develop heart disease?

Marianne J. Legato: Presuming they have really done "everything right", including exercise, proper diet, being a non smoker, and controlling weight, failure to do well is usually the consequence of poor genes: they have low levels of HDL, for example, or other risk factors over which they have no control.

Abigail Trafford: What about people who do everything wrong--they don't exercise, they smoke, they eat anything they want--and they do NOT develop heart disease. Why is that?

Marianne J. Legato: Please refer to the article in the Washington Post this morning, which summarizes the information you need about these two questions.

Abigail Trafford: If they hadn't followed a healthy lifestyle, would they have developed symptoms of heart disease sooner? Would their heart disease have been more severe?

Marianne J. Legato: I think so, but I can't prove it. Certainly, patients should control whatever risk for CAD they have wherever possible to avoid premature and severe disease.

Washington, DC: From the two stories featured today, it's obvious that a healthy lifestyle isn't enough. Is there a sure-fire way to avoid heart problems?

Marianne J. Legato: Unfortunately, not everything about why we get sick --from any illness-- is entirely within our control. That's why its important not to blame yourself for things like cancer or mental illness: those diseases, like severe and/or premature coronary artery disease, may be due to things beyond your control.

Beltsville, MD: We see people like Arthur Ashe and Jim Fixe who were the model of fittness with their diet and exercise, yet both had heart attacks. Obviously there is more to this than just environment. What is it?

Marianne J. Legato: Diet and exercise might not have been able to overcome other vulnerabilities these men had to coronary artery disease: their genetic complement may have predisposed them to the illness in spite of all they could do. Furthermore, we don't know about other risk factors they might have had in spite of their lifestyle.

Beltsville, MD: You mentioned "poor genes"in an earlier answer. Can these "poor genes" be detected, and can anything be done about them?

Marianne J. Legato: The problem about genes is that (although we are making progress every day) we can't always identify which specific gene is at fault (or flawed) and is causing disease. The best way to assess genetic vulnerability is to make sure you know your family history: premature death from heart disease (before 55) in a first degree relative is a clue that your genetic equipment might work against you.

Alexandria, VA: Dr. Legato,

Thank you for this discussion! I'm a 27-year-old woman and my family has a history of heart disease on my mother's side. Both grandparents had multiple bypass operations, and an uncle died suddenly at age 42 from arteriosclerosis. I don't smoke, do exercise and try to eat healthy. Is there anything else I can do to be on the lookout for signs?

Marianne J. Legato: I outlined a short review of how to decide your risk factors for coronary artery disease; our host is reposting this answer for you. (Q&A With Dr. Legato)

Arlington, Va.: What causes clogged arteries?

Marianne J. Legato: "Clogged arteries" is a lay term for arteries which have accumulated deposits of fat, clot and other contaminants in their interior. These narrow the space through which blood travels to supply the heart muscle.

Washington, D.C.: Besides your book, can you suggest other books to read about the issues of heart disease?

Marianne J. Legato: Would suggest contacting a service like AMazon.com and ask them to supply you with a list.

Bethesda, Md.: You wrote a book called "The Female Heart" -- why did you choose to write about the female heart, in particular? What are the main ponits of your book?

Marianne J. Legato: The Female Heart was the first book to point out that women are not just small men, but that their normal physiology as well as the way in which women experience disease, is significantly different from that of men. Most cardiovascular research was done in men, and the results extrapolated to women without modification; this has not been optimal for women. The points of my book are those which outline important ways in which women have a unique experience with coronary disease; everything, from risk factors to optimal methods of testing, to presenting symptoms, to treatment choices and even to outcome--all differ as a function of gender.

Washington, DC: If exercise, a good diet and a healthy lifestyle are no guarantee against heart problems, then isn't the whole thing just a crap shoot? How do you keep motivated to adopt a healthy lifestyle when in the end it might not matter anyway?

Marianne J. Legato: Although some factors causing vulnerability to heart disease are immutable, we can control many of the things that make disease likely: i.e., levels of fat in our blood, our weight, whether or not we exercise and our personal lifestyle hazhards like cigarette smoking (the worst thing you can possibly do for your health with the exception of crack-cocaine)and excessive ingestion of alcohol. By the way, severe stress and feelings of hopelessness are also risk factors for coronary artery disease. I would urge you to control what you can, because risk factor reduction DEFINITELY lowers risk for CAD.

Washington, D.C.: Regarding your comments in the Post about the role of stress in heart disease:
People who appear to be stressed out often seem to be in denial about the level of stress they are living with -- like, "What? Me worry?" What questions can we ask ourselves or our doctors to decide whether our lives are too fast-paced or, to use your word, intolerable?

Abigail Trafford: All of us have stress in our lives. How can we distinguish between "good stress" and "bad stress." And how does stress increase the risks for heart disease?

Marianne J. Legato: The kind of stress that seems to predispose us to CAD is that from situations that cause us unbearable or very severe emotional distress for long periods of time,especially if the problems don't seem to be ones that we can solve and/or escape. A sense of hopelessness and despair, in particular, is a very important risk factor. "Good" stress (likely hoping I can answer all of your questions in a reasonable amount of time with good information) is probably a good thing--makes like seem more interesting and stimulates us to excell!

Silver Spring, MD: The 'Atlantic Monthly' recently ran an article about infection that seemed to suggest that clogged arteries may be caused by some unknown infectious agent rather than the genetic and environmental factors that conventional wisdom seems to attribute it to. The Post has highlighted heart disease in people who seemed to be doing all the right things - which would seem to support the 'infection' origin of heart-artery problems. What's you opinion on this issue ?

Marianne J. Legato: The idea of an infectious agent causing coronary artery disease is not only intriguing, it may turn out to be right, at least in some instances. You make an excellent point. An interesting parallel is in the science of the cause and treatment of peptic ulcer disease, where we found that an infectious agent (H. pylori) was causing the trouble. That does not negate the fact that hyperacidity and chronic stress seemed to provide a setting in which this illness was more likely to occur. Many things and factors combine to produce coronary artery disease; we may not yet understand them all, and thus can control or eliminat only a few. But a few (or almost all) are far better than taking no action.

Bethesda, Maryland: Do strict vegetarians have heart attacks?

Marianne J. Legato: Yes. Low fat diets are not the only defense against heart attacks and CAD.

Washington, DC: My parents both had heart operations in 1980. Back then the life expectancy of a bypass patient was five years or so, and it seemed to me that only really stringent diets and some exercise were part of the recovery program. I'm amazed at the difference in recovery regimen and life expectancy and quality has risen since then -My father is still with us-. What do you think have been the biggest improvements in how heart patients are treated in the past 20 years?

Marianne J. Legato: The biggest improvements are in the improvement of the accuracy and timeliness of how we make the diagnosis and in the expanding menu of therapies we have to offer patients; we have learned, for example, that beta blockers and ACE inhibitors are two classifications of medications that improve survival after a myocardial infarction. I also believe that the educational programs the AmericanHeart Association has put into place have helped patients and physicians alike prevent and ameliorate this disease.

Washington, D.C.: My husband has had two quadruple bypass operations and is not yet sixty. Heart disease is genetic; he was never overweight, smoked nor had high blood pressure. For more than 20 years we have been religiously following a low-fat-low cholesterol diet -Let me know if you need someone to co-author a cookbook on this subject!-. He is on a statin, regularly monitored, runs regularly. The question is what more? In that regard, what are your beliefs as to the usefulness of various vitamins and minerals in preventing-slowing down heart disease. I've got him taking a dietary supplement, Vitamin E and calcium. Anything else?

Marianne J. Legato: It sounds as though you and your husband have worked out a nearly ideal regimen for him. Is he reasonably happy and stress free? Even more important, are you paying close attention to your own health? As women, we all too often concentrate on the other members of our family and neglect ourselves. (I'd be interested in hearing your answer to my own question!)

Falls Church, VA: I am a 32 year old female
and just had my cholesterol
tested for the first time..
it was high..
Total=217
Triglycerides=73
HDL=57
LDL=145

What do I do to reduce my
cholesterol?
I weigh 130 and am 5'8"
and am active.

Marianne J. Legato: I would consult a nutritionist to review every aspect of what I actually eat over a two week period, and try to correct anything I am doing in my diet to produce higher than desirable levels of LDL and Total cholesterol. Also review what medications you are taking.

FORT WASHINGTON, MD: RECENTLY I HAVE FELT A WARM SENSATION DOWN MY RIGHT LEG. THIS LASTS ABOUT 40 SECONDS. IT IS ALMOST AS IF YOU WERE TO SPILL WARM WATER ON YOUR SKIN BUT I HAVEN'T. I AM 38 YEARS OLD AND NOT THE BEST DIETICIAN. IS THIS ONE OF THE SIGNS OF HEART PROBLEMS OR A POSSIBLE STROKE?

Marianne J. Legato: This is a "toughie". I'd ask your primary care physician to do a neurological examination and a good history to try to identify the possible causes of the problem.

Washington DC: Are the risk factors and steps possible for reducing their impact the same for CAD and for congestive heart failure?

Marianne J. Legato: This is a great question, because I get a chance to explain how to make an accurate and complete cardiac diagnosis:
It has several different components. The first is to decide what the CAUSE of the heart disease is; this is what doctors call "etiology"; coronary artery disease is a KIND or TYPE of heart disease. Congestive heart failure is not an etiology: it is a disturbance in heart function that happens as a result of heart disease of several types. We doctors call this "patho(sick)physiology(function)". Coronary artery disease is a type of disease; congestive heart failure is a malfunction of the heart muscle that results from a number of causes, coronary artery disease being only one of them. I wish doctors would stop saying congestive heart failure is a freestanding disease: it is only a PART of a cardiac diagnosis.

Atlanta, GA: I recently had routine blood work done, and my cholesterol level is 293. Over the past ten years, it's fluctuated between 210 and 300. Considering that I just turned 39, I'm very concerned as to what my next step should see be. I'm wondering if I should a specialist because heart disease runs in my family. Most doctors in the past have told me not to worry because I'm "pre-menopausal". Any advice would be greatly appreciated.

Abigail Trafford: We're always told women don't get heart disease before menopause. Is this a myth? And what happens at menopause to increase the risks for women?

Marianne J. Legato: I am so tired of health care providers reassuring women that risk factors aren't important for them because they are premenopausal!!! Your cholesterol is too high. Furthermore, you should also know three other values: your serum triglyceride level and your HDL and LDL levels. Then you should have a conference with your doctor about how to bring your values into control: what is your weight? What are the components of your diet? Don't allow anyone to tell you that because you are premenopausal, risk factors don't count.

Arlington: Hi, I'm a woman in my 30s and I've got heart history on my father's side -- both my father and grandmother died of heart attacks before the age of 60, my dad at 37. I exercise 4-5 times a week, eat well, don't smoke. How much of my risk is already pre-determined for me, considering my history? I know healthy life style is critical for a number of reasons, but there's no real guarantee of warding off the risk, is there?

Marianne J. Legato: My advice to everyone reading this page today is: don't give up before you start! We CAN and MUST reduce our individual risk for heart disease by correcting what we can to prevent it. You can exercise control over many factors that produce premature death from CAD: if this were not the case, we would not have seen the decrease in deaths from CAD over the past decade that we have been seeing. The decline in mortality rates have been less dramatic for women than for men, though, and so I spend a great deal of my life urging women to understand that they are not exempt from this disease, that cardiovascular disease kills more of them than ALL CANCERS COMBINED and that they must work to improve the statistics for women in particular.

Washington D.C.: I sometime wake up with this hard beating of my heart, it's so intense it makes my chest sink in and out. What causes this? It only last for a few seconds. I have mitual valve prolapse. Does this have anything to do with it?

Marianne J. Legato: Is the heart beat very fast when this happens?? Is it regular? Both are important to notice. If you simply have an unusually vigorous heart beat on awakening but it is at a reasonable rate and not irregular, I would not be particularly concerned. This may be due to a disturbing dream, a change in your position in bed, or a feeling of heightened anxiety. Ask you doctor about this one, so we can analyze your case more completely.

Falls Church, VA: How does one locate a good
nutritionist?

Thanks for your help!

Marianne J. Legato: A good nutritionist can usually be found through calling the Department of Medicine at the medical school/center nearest you. The best ones are invaluable in the fight against coronary artery disease and their advice, if you really work with them, helps improve health, vitality and well-being across the board. I use nutritionists all the time in my own practice.

Abigail Trafford: What are some specific ways in which women differ from men in terms of heart disease?

Marianne J. Legato: Risk factors:
diabetes increases women's risk for heart disease 4-6 fold, while for men it is only 2-4 fold.
Premature menopause increases risk for CAD in women; all who can should be on hormonal replacement therapy to minimize risk from this cause.
Presenting symptoms:
20% of women present with epigastric *upper abdominal) pain ,nausea and profuse sweating and profound shortness of breath rather than classic chest pain with an acute myocardial infarction. you can see how doctors might tell such a patient she is hysterical (valium for "hyperventilation") and having acute indigestion or a gall bladder attack( mylanta for this).
Outcomes:
White women are twice as likely to die within the first weeks after a heart attack as are white men, and are more likely to have a second attack within 4 years than are men.
Testing modalities:
the STRESS ECHOCARDIOGRAM is the optimal NONINVASIVE method (aside from tests that involve isotopes) to identify CAD in women; the stress test alone is not accurate enough for women, although it is for men.
Treatment:
Sadly, there is a real and amply documented difference in the treatment decisions made for women with CAD compared with men: women receive less aggressive treatment (fewer instances of clotbusting (or thrombolysis), angiopasty and bypass surgery) than do men with CAD>

Howard County, MD: You always hear about men getting stress tests as part of their physical--at what age should a woman without any particular risk factors be tested?

Marianne J. Legato: I begin to watch my patients for multiple risk factors and for signs of coronary artery disease in their forties, the beginning of what we call the "perimenopausal" period. This is a particularly interesting question, though, because even in my practice, I don't have an absolute rule for when I would order a stress echocardiogram as a routine test in the absence of any risk factors or of symptoms for coronary artery disease. I'd be interested to know what other specialists' opinions are about this. But then I don't test men simply because of age either. The fact that men and women are treated differently during, for example, an executive physical, may be yet another example of gender prejudice in the way we care for men and women.

Silver Spring, Md: In your opinion, has "placebo surgery" proven effective in cardiovascular disease? If so, in what ways?

Marianne J. Legato: We have found that simply opening the chest in some patients relieves angina pectoris--the reason for this isn't clear. Placebo surgery, though, doesn't open obstructed arteries.

Arlington, VA: I have heard that sleep apnea is particularly stressful on the heart. Recently, my father - 53, non-smoker - has had severe chest pains and was diagnosed with a arrythmia after two visits to the emergency room. No signs of heart disease or weakness. He does suffer from sleep apnea, but isn't undergoing any treatment for it. Is that something we should try to convince him to pay more attention to, or are the heart conditions I've described too vague to come to any conclusions?

Marianne J. Legato: Good call by you! Sleep apena is a risk factor for cardiac problems, including sudden cardiac arrest, and your father should be investigated and treated for this.

Washington, D.C.: In response to your question, my health is great--cross your fingers! Work out -gym four times a week - aerobics and weight maintenance. Eat the low fat-low cholesterol meals I prepare for my husband--with great enjoyment because they taste great. Practicing law is not stress free--but as you reach a certain age, you tend to put things into perspective. In the over 20 years with which we have lived with my husband's heart disease, I believe that the disease has to be looked at as a family problem and treated as a family problem. Everybody will benefit from that--Dad, Mom and the kids, some of whom likely have the same genetic predisposition as their dad.

Marianne J. Legato: I hope a wide audience reads your answer. Congratulations. You sound as if you should be helping families to learn how to protect their health across the board.

Middlefield, Ct. : Why do some people with high chloresterol have clear arteries with no evidence of
blockage? This seems to be counterintuitive. Is it just a matter of time before problems appear?

Marianne J. Legato: I can't answer your question completely, perhaps, but it's important to know more than just the number associated with your total cholesterol. Some women have higher than normal total cholesterol values, but it's all due to high levels of "good" cholesterol or HDL. So know all four numbers before you conclude you have a problem: total cholesterol, triglyceride levels, HDL and LDL.

Bethesda, MD: My brother just told me that he has been diagnosed with mitral valve prolapse, and suggested that I get screened for it as well. I have always been very active, including long distance running and biking. I do fit the profile of being a tall and thin woman -I'm 29 years old-. Is this something I should worry about?

Marianne J. Legato: In the vast majority of cases, mitral valve prolapse does not interfere with activity or general health. I your brother has it, you might ask for a good physical examination (sometimes your physician can tell just with a stethescope that you MIGHT have the problem); if his/her findings suggest MVP, an echocardiogram is in order as a baseline study for you.

Marianne J. Legato: Goodbye to all of you. You have been a marvelous group, with superb questions. Many of you can teach the rest of us how to fight coronary artery disease. Thank you for having me as your guest today.

Abigail Trafford: Dr. Legato, thank you very much for being on the show. You've given us all vital information. And thank you all for your questions. Join us again next week.