These tests could have prevented your parent's heart attack.
What to discuss with your doctor and extra tests to consider that may save your life.
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We often don’t believe a heart attack will affect us.
Statistically it’s much more likely this will kill you than any other condition. And people don’t know their real risk.
It appears with the sudden heart attack, but has been sitting in the sidelines for years, possibly decades.
A brief look at statistics.
In Australia, it’s the second leading cause of death. In the UK, it remains the single biggest cause as with the rest of the globe.
Cardiovascular disease accounts for 27% of all deaths in Australia.
Around 1.2 million Australians are living with one or more heart or vascular conditions.
In the UK, an estimated 7 million people are living with cardiovascular disease.
Heart attacks are not inevitable.
Heart attacks are never far from home.
My father had a heart attack at the age of 60.
He was a smoker, his diet consisted of a mix of healthy but also highly processed foods. He wasn’t particularly active.
He had high cholesterol and diabetes; both managed with medication.
It looks obvious in hindsight, but 60 is early.
Nobody sat him down and properly explained his overall risk.
His doctors would stay that they treated appropriately. It was ‘ok’. But we could have done so much better.
We’re disease focused as a medical system, so we don’t give enough time to prevention.
Prevention isn’t glamorous. You can’t see the immediate impact of saving someone’s life. There’s no celebration to avoiding an illness.
Major life threatening events lead to change.
It was only when he had the heart attack that he stopped smoking.
Men are more likely to change their behaviours long term after witnessing or experiencing a life-changing event.
Lifestyle changes that stick will significantly alter your risk.
My father changed his lifestyle. Increased activity with cycling cutting stress at work, better dietary habits and now a non smoker.
But even now, years later, he still doesn’t have the clear follow-up he should have had.
He won’t have any further reviews with a cardiologist. We’re genuinely unclear as to how his arteries are actually functioning today, so we’ll just have to hope there isn’t another.
But what if the heart attack didn’t need to happen?
Better risk assessment earlier, a proper qualification of all his risk factors, possibly earlier involvement of a cardiology team could have prevented the heart attack.
This experience has contributed to how I practice. And it’s why I believe we can all do better, both as doctors and as patients taking ownership of our health.
“I’m fit, I eat well, my blood pressure is fine and I don’t smoke. It won’t happen to me.”
Unfortunately that isn’t always the case.
And for some, learned helplessness is prevalent. There is a feeling that whatever you do, it won’t make a difference.
I’ve discussed taking action on your own learned helplessness here.
I see patients in my clinic, seemingly healthy who come in with early heart attacks. Action could have been taken earlier.
What actually causes heart attacks if it’s not the cholesterol?
The INTERHEART study, one of the largest studies of its kind, looked at heart attack risk factors across 52 countries and over 29,000 people.
It identified nine factors that account for over 90% of the risk of a first heart attack.
The harmful six:
High blood pressure
Smoking
Abnormal cholesterol profiles
Diabetes (all types)
Excess abdominal obesity
Psychosocial stress
The protective three:
Regular physical activity
Daily fruit & vegetable intake
Avoiding high alcohol intake.
The critical insight is that these factors are modifiable.
They are within your control.
These risk factors don’t work in isolation. It’s the combination that compounds the danger.
And it’s what you’re doing now, in your 30s, 40s, and 50s, that determines what happens later.
Stress is a killer contributor.
Stress is the risk factor that almost nobody talks about.
A collaborative meta-analysis published in The Lancet, drawing on nearly 200,000 participants across 13 European cohort studies, found that job strain alone was associated with a 23% increased risk of coronary heart disease events.
A separate meta-analysis found that perceived psychosocial stress was associated with an increased risk of stroke.
Chronic stress contributes through multiple pathways.
It activates the sympathetic nervous system, raises cortisol and adrenaline.
Stress promotes inflammation, and accelerates the disease process in your arteries.
Your body has autonomic nervous system modes: rest and digest, or fight and flight.
You need both.
But too long in fight or flight, and the body starts to break down.
The immune system falters. Blood pressure stays elevated. Inflammation builds.
People dying of a “broken heart” after losing a loved one isn’t just a saying. Chronic stress can trigger a cardiac event. It’s a recognised medical phenomenon.
Stress doesn’t get entered into the risk calculators.
The 2021 ESC Guidelines on cardiovascular disease prevention now list psychosocial factors as a recognised risk modifier that should be considered alongside standard risk scores.
Family history is the other factor that’s often underweighted.
If your mother or father had a heart attack before the age of 60, your risk is significantly elevated.
The INTERHEART study showed that if your parents had a heart attack, this was associated with an increased regardless of your other risk factors.
A CT Coronary Scan changed this patient’s understanding of her risk.
I have a patient in her mid-50s: her father had a heart attack around the same age she is now.
He had a different lifestyle to hers, but there is still the possibility of a very high genetic risk.
When we scanned her arteries and her calcium score was 22. Technically, that’s classified as “low risk.”
But for her age and gender, she is in the highest risk category.
That means she had more calcification in her coronary arteries than 85% of women her age.
What should a cardiovascular risk assessment actually look like?
Here’s what I’d recommend you ask your doctor for, and what you should expect from the conversation.
Most cardiovascular risk assessment currently works like this: your GP takes your age, sex, cholesterol, blood pressure, and smoking status, and plugs them into a risk calculator.
The calculator gives a percentage. You’re told you’re “low,” “moderate,” or “high” risk.
These calculators are useful.
The Australian guidelines suggested you can have a CVD risk assessment for every person over the age of 30, which is also funded by medicare.
There are some drawbacks.
They predict risk over a fixed time period, which is inadequate for someone in their 30s or 40s who wants to know what’s coming in 20 or 30 years.
They don’t always adequately weight family history. They don’t look at the subtypes of your cholesterol.
And they don’t see inside your arteries.
Your GP isn’t getting it wrong. They are operating within the training we have been provided, what we are expected to cover according to the guidelines and within the time constraints we have.
But this really isn’t enough.
Here’s what a more effective heart health consultation can look like:
Start with the basics.
Ask your doctor to check your blood pressure properly and explain what the numbers mean, not just whether it’s “fine.”
Know your height, weight, and BMI. Ask for a waist circumference.
Most people don’t know what their blood pressure actually is. They’ve had it checked, but nobody has explained where it should be, or what the trend looks like over time. Ask.
And own it. Own your own blood pressure. The trend of multiple readings is far more accurate than an isolated reading in your doctor’s office.
Have the conversation about your family and lifestyle.
Talk about your family history. Did your mother or father have a heart attack? At what age?
What about diabetes, strokes, or sudden cardiac death in the family? Don’t assume your doctor knows.
Tell them. Talk about your lifestyle honestly.
Smoking, alcohol, physical activity, diet, and stress. A risk calculator doesn’t ask about your stress levels.
The calculator doesn’t know you’ve been eating takeaway for seven months because you don’t have a kitchen during your house renovations.
Your lifestyle matters.
Your eating habits. Your exposure to stress, your movement, whether you work an active or sedentary job and your sleep.
Then make sure the blood tests are comprehensive. Don’t settle for just a cholesterol number.
Ask for a full panel:
Your cholesterol, and ask for a clear explanation.
Your blood glucose to check for diabetes and pre-diabetes, your liver and kidney function, your thyroid, your inflammatory markers, and a full blood count.
Each one tells part of the story.
Your blood glucose might be creeping up before you’re diabetic.
Pre-diabetes is the best time to take action.
That’s something you’d want to know about and act on early, not discover years later when you’ve crossed the threshold into diabetes.
Your liver function matters before starting any medication. Your thyroid affects your metabolism.
Ask about the tests that aren’t always funded.
But by knowing about them you can decide whether it’s right for you to get them checked.
Depending on your risk and blood tests it may be helpful to do further tests. Some may have much more use than others;
this includes:
Lp(a) - pronounced “lipoprotein little a” - a specific cholesterol marker that most people haven’t heard about.
ApoB/ApoA1 ratios - more specific cholesterol markers to better understand risk
A deep dive discussion of his cholesterol so he as a patient understands what LDL, non-HDL means. Why the TC:HDL ratio is important. What triglycerides actually are and how this impacts risk.
Understand what cholesterol is and why we actually treat it.
A CT Coronary Calcium Score for an objective view of calcification on his arteries.
Challenge your doctor (nicely).
Ask your doctor whether checking your lipoprotein(a) is appropriate for you.
The European Society of Cardiology recommends measuring it at least once in every adult’s lifetime, because elevated levels are an independent, genetically determined risk factor for cardiovascular disease that standard tests don’t pick up.
Then ask your doctor to sit with you and actually explain what all the numbers mean.
Not just, “your cholesterol is a bit high.”
Ask them to break it down: what’s your LDL? What’s your HDL? What are your triglycerides? What’s the ratio? What should each one be?
One of my patients, a 35-year-old Australian man said it best: “The more I can understand it, the more likely I am to implement it.”
He’s right. I’ll go into the cholesterol breakdown in detail in my next article so you can look at your own results and actually understand them.
For some people, it’s worth going further. Ask your doctor whether imaging might be appropriate for you.
CT coronary calcium scores are often a useful addition.
A CT coronary calcium score looks directly at the arteries of your heart for calcification, the hard deposits that indicate atherosclerotic disease has started.
It’s not something everyone needs, and there are risks to be taken into account if you’re contemplating having this scan.
If you’ve got a family history of heart attacks, elevated cholesterol, or risk factors that concern your doctor, it can add a layer of information that blood tests alone simply can’t provide.
Build a plan.
Medication if it’s needed.
Specific, evidence-based guidance on nutrition, exercise, stress, and sleep, built around your actual life, your work, your commute, your home environment.
Medication if it's needed, and referrals to consider further interventions sooner rather than later.
You can read more on my perspective on prevention here.
Follow-up
Agree when you’re going to check in again. Three months, six months.
Repeat the blood tests.
See if things have moved.
If you need referrals, whether to a dietitian, exercise physiologist, or cardiologist, ask about them.
In Australia, a GP management plan can provide Medicare rebatable sessions to reduce your costs if you have a long term condition.
The key risk factors for heart attack are modifiable. They are within your control.
But you need to know what they are first. And you need someone to explain them to you properly.
If no one has ever sat with you, gone through your bloods in detail, discussed your family history, considered whether imaging might be appropriate, and built a plan with you, then you haven’t had the full conversation yet.
Don’t wait until you have symptoms.
In my next article, I’ll walk you through what your cholesterol numbers actually mean, what most people are never told about their results, and what you can do right now to change them.
It’s the article I will give to patients after we’ve had the conversation.
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