How to Prevent a Heart Attack - Overview

This e-book is for people who have never had a heart attack and are interested in doing what they can to avoid heart attacks, live longer, and feel better. The point of the program is to help you understand what you need to do to have a healthy heart. No scare tactics. I encourage you to act more than worry. I want you to use a balanced approach with knowledge about your risks, your motivations, and supplements that could help you—and when medications are necessary—to reduce your chance of heart attack to the minimum possible. The best tools for improving heart health are in your hands, available without prescription: attitude, eating, activity, and habits control your heart health. However, some issues, heart-wise, require the help of the US medical system, I am sorry to say.

And before we start, I want to “Keep it Real:” Any approach to preventing heart attacks is imperfect. Anyone who guarantees success in preventing all heart attacks is making it up and trying to take advantage of you.

Let’s review eight key steps to prevent heart attacks and promote overall good health.

8. Understand That Medications Can Indeed Decrease Your Chance for Heart Attack

Many people feel like doctors are shoveling meds onto them indiscriminately. Generally, the intentions are good, and docs are trying to help. But sometimes docs are robotically following rules written by the medical establishment, and they are not specifically thinking about what is the Very Best Thing for You. Anyway, there are several common situations where medications become necessary to decrease your chance for heart attack:

A) High Blood Pressure

• You could need meds if you have high blood pressure that you can’t decrease on your own by losing weight, getting enough sleep, doing a job that doesn’t drive you crazy, cutting out salt, eating fruits and veggies, and exercising a lot. I use a person’s average resting blood pressure to decide whether or not to recommend meds. If the pressure is more than 135 over 85 consistently, in spite of good effort to decrease it, I will attempt meds.

• Treating high blood pressure decreases the chance for stroke or heart attack by about 25%. The higher a person’s risk overall, the higher the chance for absolute benefit.

• The medications I use for blood pressure are all generic and inexpensive. Amlodipine and Lisinopril are my top choices. Many people can be controlled with these two. Specific choice of blood pressure medication varies, however, and there is a long list of reasonable selections.

B) Very High Cholesterol

• If your cholesterol is sky high, like with an LDL 190 or more, and you can’t make major improvements by changing diet, you need to reduce the cholesterol in most cases. Doing so can decrease lifetime risk for heart attack from 50% to 25%. That’s an absolute chance of benefit of 25%. My first choice for medication here is Rosuvastatin. For people who can’t tolerate statins, I will turn to the injectable cholesterol medications Evolocumab or Alirocumab. Inclisiran is another option. And Ezetimibe can be a little bit of a help. Medication therapy for cholesterol has major disadvantages, but in people with really high cholesterol, dealing with the disadvantages is totally worth it.

C) Diabetes

• If you have diabetes with high blood sugars in spite of doing everything possible to lower them, medications become necessary because high sugar over time injures blood vessels and causes stroke and heart attack, along with kidney, eye, and nerve trouble.

• When cost is not a factor, the injectable medications Semaglutide (Ozempic) and similar medications are reasonable options. SGLT2 inhibitor medications Empagliflozin and Dapagliflozin are also preferred. When cost is a major factor, my favorite medication is Metformin, which has been around a long time and is generally well tolerated.

• The best target for A1C for overall health for the average person is around 7.5. While the worth of reducing medications and getting sucked into the US healthcare machine for an A1C of 8 is debatable, when the A1C is up in the 9 to 10 range, it basically becomes a necessity.

D) Strong Family History for Heart Attack

• This situation requires further evaluation with testing to gauge your risk, and oftentimes medications such as Aspirin and Rosuvastatin to improve your chances. More on that topic later.

7. Understanding Supplements and Heart Health: What Do They Do? How Much Do They Help? What Is the Proof?

• Supplements for preventing heart attack are a huge draw. No doctor's visits. Transparent, easily understood costs. No blood tests required. Avoiding the bloated "know-it-all" US Healthcare Establishment. And there can be real benefits. Beet root extract supplements can lower blood pressure by dilating arteries. L-Arginine can prevent chest pains associated with blood vessel dysfunction. Berberine lowers LDL cholesterol. Potassium supplements can lower blood pressure. Turmeric can decrease inflammation.

• However, there are benefits that are perceived but not real:

  • Perception: Supplements are safer than prescription meds. Reality:  Let's face it, you can get seriously messed up with plenty of supplements. Natural does not equal safe.

  • Perception: Hoping for results better than meds, from some mystical property of the supplement. I personally experienced this with a supplement that I have taken for a health problem in my family. Reality: Recognize hope for what it is.

  • Perception: You are getting back at the US Medical System. For one reason or another (often a good one I might add), you are getting back at it by using supplements, like giving the middle finger to drug companies. Reality: That doesn’t make your health better — well, not a lot better anyway. And they don’t care what you do.

• The drawbacks of supplements:

  • Lack of clear proof. Belief does not equal proof. I see a lot of pseudoscience when I am looking into supplements.

  • Lack of quality assurance oversight. While things seem to be improving in this regard, the exact content of each batch of supplement isn't always known.

6. Avoid Things That Cause Chronic Inflammation

Inflammation is the body’s normal, useful response to injury and infection. But inflammation also happens in dangerous ways, and one of those is inside blood vessels.

We unfortunately do not know exactly what causes atherosclerosis, the buildup of cholesterol in arteries. The gunk that accumulates is called plaque. Two ways heart attacks occur are: (1) slow buildup over years to the point that the artery is so narrow the person gets damaged heart muscle from lack of blood flow; or (2) sudden breaking open of the plaque and then a blood clot causing complete blockage of the artery. This is the standard type of heart attack we think of when somebody is suddenly clutching their chest and falling over. Inflammation likely often plays a role in this classic type of heart attack, as it softens the cholesterol plaque and makes it more likely to break open. Anyway, inflamed blood vessels are bad. Anything that causes chronic inflammation increases the chance there will be inflammation in the blood vessel. Some ways to decrease inflammation:

• Get enough sleep. Most people need 7 to 8 hours of sleep. Experiments show that sleep deprivation causes higher CRP and other markers of inflammation. Obviously, getting the right amount of sleep is easier said than done. The three biggest sleep killers, in my opinion:

  • Lack of exercise/exertion. You need to be tired to fall asleep. Exercise is a big part of that. But if you exercise too late in the day, it’s a problem. Find a time that works for you.

  • Avoid chocolate. Chocolate is loaded with theobromine, a stimulant similar to caffeine. It has a much longer half-life and is still in your system 12 hours after consuming it. Chocolate is also fatty, so absorption is slow. You could have chocolate in the morning, and it could keep you awake at night. I learned this the hard way when I had Reese’s Peanut Butter Cups the evening before I took the MCAT, the entrance exam for medical school. I was awake all night, not a minute of sleep. I personally cannot consume chocolate after 10:00 a.m. and expect to sleep normally.

  • Avoid supplements with glucosamine/chondroitin if you notice that these cause sleeplessness. This is a super common supplement, and insomnia is a super common side effect. 

Other tips for improving sleep include using a lot of pillows to get comfortable (I use five or six), being a little obsessive about your routine—consistency helps—and doing something relaxing at night; for me it’s reading.

• Avoid chronic stress. We all have stress from our jobs and personal lives. Talking to someone supportive about things that bother you can go a long way. Recognize when you have to accept a situation rather than fight futile battles. For example, when loved ones are doing unhealthy or dangerous things to themselves. You can strive to be supportive, but it is not your burden to fix everything; or recognizing when a situation has to change, like a job with varied shifts causing massive disruption of your life and sleep.

• Avoid smog. Pollution is bad for overall health. Studies show increased coronary calcium with increased pollution. If you have the ability, seek fresh air. Unfortunately, this is mostly not realistic, and we are stuck breathing the air we have. A HEPA Filter Unit could be of some help, and especially worth it if you live in a high pollution area like next to a freeway.

• What you eat can set your arteries on fire. You don’t directly feel the harmful effects of what you eat, and we’re wired to crave energy- and protein-dense foods, so inflammation is largely unperceived. People vary; what causes inflammation in one person may not in another. What quenches inflammation for some may serve no benefit in somebody else.

  • Foods that increase inflammation: refined carbs, sugar, high-fructose corn syrup, alcohol, processed meat, burnt meat (sorry—that’s the grill and the smoker).

  • Foods that decrease inflammation: Curcumin (bioavailability improved with ~10 mg/day of Piperine), fish oil, ginger, Resveratrol, spirulina, bromelain, garlic, green tea extract, vitamin C; fatty fish, broccoli, avocados, green tea, peppers, mushrooms, grapes, turmeric, EVOO (extra-virgin olive oil), chocolate (watch out for insomnia!), tomatoes, cherries.

  • Some resources include Genopalate.com, where you can get an idea of what foods might be best for your genetics, and home CRP testing, to gauge your inflammatory response to different dietary patterns.

5. Physical Activity

Instinctively, we know that being active is good for health. As I mentioned in the introduction, an active heart is stronger and better able to withstand the stress of heart attack. People who are active will know about a problem sooner than someone who is inactive.

• Blue Zones are places where people have long healthy lives. A key feature of each of these areas is an active lifestyle.

• The happiest and healthiest elderly people, 90+, are those who exercise routinely!

• Exercise alleviates anxiety and depression. In my experience, anxiety and depression are the biggest controllable aspects of overall health and well-being.

A lot of things block activity:

• Pain. Do things that don’t hurt.

• Addiction to screens. You can break it. Go a month: no YouTube, Netflix, TikTok, Facebook, TV. You will survive and learn what it’s like to live without that stuff.

• Not knowing where to start. Inertia.

• Cost. You don’t need any money to improve your fitness. Cost isn’t a good excuse.

• No leftover mental energy. If you work out routinely, you’ll find energy—it helps overall mental energy. Getting started is hard, but worth it.

• No time. I have a 20-minute workout I do when I can’t squeeze anything in. Also, during fall and winter, when there’s less daylight and fewer chances to be active, I do a 5-minute workout each morning when I get up.

• You don’t like how it feels; it makes you feel sick. I used to get headaches from exercise. I thought I had to do cardio to be healthy. That belief led me to avoid exercise for over 10 years. Once I figured out I should do things I like—instead of what I thought I was “supposed” to do—I developed a super constructive enjoyment of exercise. It changed my life. I feel so much better now than when I was inactive.

• You dislike exercise. You have to do something you really love. Don’t do what you think you’re supposed to do. Then you can actually stick with it. Examples from my patients: Tai Chi (age 92), Taekwondo (age 70), dancing (age 75), hiking club (age 74), swimming (86), weight lifting (80, 68), golf while carrying the clubs (85), jump and sprint training (age 55). Some people  tell me they dislike all forms of exercise. For these folks, I encourage them to pick a goal—playing with grandkids, walking the dog, going on a vacation, living independently—and use that to motivate activity.

Variety helps you exercise daily. Walking is great, but some people can’t do it every day or they get hip, knee, or foot pain. Create variety before you develop an injury. I alternate workouts in 3-day cycles: weight lifting, sprinting/jumping, and static isometrics.

Bottom line: Where there’s a will, there’s a way. Motivation is key and helps you work around obstacles.

4. Eat Healthy

This is incredibly complex. What’s great for one person can be poison for another. Here is a list of some principles that most people would agree on:

• Avoid sugar, fruit juice, artificial sweeteners.

• Avoid processed carbs.

• Avoid nitrate and nitrate cured meats like hot dogs and bologna. Fish good. Hot dog bad.

• If you consume dairy, go for yogurt and cheese—fermented stuff.

• Focus on whole foods. You know the garbage—stay away.

When I talk about this with people, I keep it general. It’s an enormous topic—the biggest by far for heart and overall health. Thousands of books, studies, articles, websites, videos, conferences. A crushing number of opinions and guides. I’ve studied this for years, been to conferences, read tons of books, watched videos, talked to world experts. Many of you have too. All of this leads me to:

• Anyone who insists they know the best way to eat is making it up.

• Successful healthy patterns include: whole foods; minimized sugar (and its many forms); minimized processed meats.

• It’s not high vs. low carb—it’s which is better for you. You only know through experimentation.

• How you feel matters. I tried eating vegetarian with careful supplementation and felt horrible—lost 20 pounds and looked skeletal. I tried keto and felt intolerably awful after 2 days. I now eat a relatively high-fat, high-protein diet; I avoid processed carbs, sugar, processed meats; I eat fish occasionally.

• The Mediterranean diet is the best-proven pattern and is manageable.

• Avoid Atkins and its many forms. I’ve seen it precede heart attacks. If you want very low carb, choose whole-food keto with plenty of fatty plant foods to support animal proteins.

• Bottom line: Don’t obsess over single foods; choose a pattern you can live with long-term.

3. Don’t Smoke. Don’t Do Drugs. (Sorry Guys, that includes avoiding regular THC use.)

If you’re reading this, you probably don’t smoke. But it’s worth talking about tobacco. Nicotine is bad for arteries; it causes vasospasm. A great way to provoke a heart attack is to smoke a cigarette and then go out in the cold and shovel snow, because cold can also cause vasospasm and suddenly close a coronary artery. Anyone who smokes already knows they should quit. It’s hard. I’ve found Chantix (Varenicline) or Bupropion help about a quarter of people smoke less or quit. Most people who quit do it themselves. I don’t see nicotine replacement help much. Methods I see work:

• Slow taper. Smoke a specific number per day for a week, then decrease by one per day. Don’t shortchange yourself. If you’re on 15/day, don’t do 13—do the exact number you planned.

• Cold turkey. Works great for some.

• Start an exercise program when you try to quit. The agitation and anxiety of nicotine withdrawal can be eased a bit by the stress-hormone release from exercise.

Don’t vape. Swapping tobacco for vaping is unlikely to lower risk. Nicotine still causes vasospasm and arterial injury, and vaping can injure lungs as well.

2. Understand Your Risk

Understanding risk for heart disease is remarkably ignored by millions of people—and unfortunately by many doctors. I’ve seen folks with terrible family histories told they have low risk based on falsely reassuring cholesterol and blood pressure numbers.

The reverse happens too—people with truly low risk get loaded up on maximum statin for decades when the benefit is minimal or worse.

Here are tools for understanding your risk for blocked arteries and heart attack. When you actually understand your risk, you avoid denial, you can motivate yourself to act, and you can make rational choices:

• Risk calculator. A blunt instrument. It uses age, diabetes status, smoking status, blood pressure, sex, cholesterol numbers. Age dominates. It outputs your 10-year chance of heart attack, stroke, or stent: roughly from 1% to 50%. This is the main tool doctors use to decide whether to recommend a statin. If the risk is > 7.5%, doctors are generally supposed to medicate. That implies something like 80% of men ≥ 65 and 80% of women ≥ 75 should be on a statin. If statins are so great that nearly everyone should be on one—and so safe that benefits nearly always outweigh risks—why do you need a prescription? It’s one of the great inconsistencies of Modern Healthcare. “Everyone take this incredibly useful, safe medication. But pay a copay and come to my office to get it.” If it’s that good, how many lives are lost because access is controlled by the medical guild? (I went off on a tangent there!) Anyway, the risk calculator is what your doctor uses.

• Calcium score. A helpful measure of arterial plaque. Your body walls off cholesterol buildup with calcium; calcium is visible on CT scans (chest or abdomen). It takes time to develop, so people < 45 can have a falsely negative score. I find it useful for people with strong family history or moderate/high calculated risk who want to avoid a statin. Any prior chest/abdomen CT can show arterial calcium (not as accurate as a dedicated score). Reports of calcification will usually be classified none, mild, moderate, or severe. This is most useful for people 50–70. Almost all people 80+ have calcium, so it’s less useful then.

• Carotid ultrasound. Shows plaque in neck arteries—windows into the vascular system. If there’s no gunk in the neck, it’s less likely in the heart. Mobile screening ultrasounds vary in quality; I repeat them to verify for myself the appearance of the plaque.

• Carotid intima-media thickness (CIMT). Useful for people too young for a calcium score. It measures the thickness of the artery wall lining. Thicker than normal implies early buildup. It can confirm a high-risk state in younger people with strong family history and motivate lifestyle and medication use. It’s not widely offered.

• LDL. Not a perfect risk tool but useful. 160+ is high; 190+ is very high. About half of people with LDL 190+ will eventually have heart attack, stroke, or similar. If you’re in this range, act to lower it or go on a statin. Interestingly, some people with very high LDL never get blockage. In rare cases for people with very high LDL (no family history, calcium score 0, no carotid plaque), I might forgo medication.

• Lipoprotein(a). This is a critical risk factor for people with family history of heart and vascular disease. Like LDL, it’s a cholesterol particle. It likely evolved to aid clotting/injury repair. In present day, the pro-clot/inflammatory properties increase risk. It’s often high in people with strong family history. It’s easy to check with a blood test. It’s inherited autosomal dominant: children of someone with high Lp(a) have a 50/50 chance of having it; occasionally, people inherit two high lipoprotein(a) alleles and have a 100% chance of passing it on. Those with two high alleles have very high lifetime risk (~1-2% of the population). We lack proven medications to lower Lp(a) with outcome benefit (new drugs are in trials). But knowing you have elevated lipoprotein(a) can motivate you to lower risk in other ways, for example, take aspirin daily.

• CRP. C-reactive protein is an inflammation marker. It does not cause problems but rather is a signal that inflammation is present. It can detect chronic, low-level inflammation that contributes to coronary artery disease and heart attack. Low is < 1 mg/L, intermediate 1–3 mg/L, high > 3 mg/L (about 2–3× higher heart attack risk vs. < 1 mg/L). CRP rises with obesity, insulin resistance (metabolic syndrome), smoking, inactivity, high sugar/refined carbs/processed foods, chronic stress, poor sleep, autoimmune conditions, and infections. CRP can be lowered by aspirin, weight loss, exercise, healthy diet (e.g., Mediterranean), statins, curcumin, and smoking cessation. Don’t check CRP when you’re acutely ill. It can be checked at home or via your doctor (typically covered by insurance). If elevated, your clinician may recommend a statin. You can also use CRP yourself to motivate diet, activity, and sleep changes.

• LDL particle size. Large, fluffy LDL are thought to be less atherogenic. Small, dense LDL penetrate arterial walls more easily and are associated with ~2–3× higher heart attack risk. Your doctor can check size/number by NMR spectroscopy (often a send-out test to a specialty lab). An at-home option is a mail-in kit from empowerdx, which quantifies the amount of small dense LDL. Small particle size is caused by poor insulin sensitivity, smoking, inactivity, poor sleep, heavy alcohol, low fiber, high simple carbs, and visceral fat. Eating lots of saturated fat increases LDL particle size; it’s unclear if that lowers risk in that context. I view particle size as a “report card” for overall risk-factor management, not a specific target to aim at. Insurance rarely covers repeated testing. I don’t recommend high-saturated-fat diets just to increase particle size.

• Family history. This may be the single most important part of judging your risk. You can’t run, you can’t hide from a strong family history of vascular disease. Ignoring it leaves you at high risk for stroke, heart attack, or sudden death. What is a strong family history? I look at four things:

  • Exactly what happened. Stroke (clot vs. bleed)? Heart attack specifics? Was it stress-triggered (e.g., someone dropping dead at a funeral), which may not imply genetics? Did they have other vascular problems (leg artery stents/bypass)? This is the hardest part—understanding the actual event. Sometimes you need an inquisitive, knowledgeable doctor to help.

  • Age at event. A father dying of a heart attack at 85 isn’t very telling. People often say, “It runs in the family—my father and grandfather had heart attacks,” and they were in their 80s. That’s not strong family history.

  • Genetic pattern. If your mother had a heart attack at 55 and three of her six siblings had heart attacks before 60, that’s a strong autosomal-dominant pattern—implying a 50% chance you carry it.

  • Habits of the affected relatives. If your brother had a heart attack at 50 but smoked a pack a day and drank heavily, that doesn’t necessarily raise your genetic risk.

To Sum it Up: Pointing toward a strong family history – the relative had a standard heart attack or stroke; it; occurred at age less than 70 or so; the relative had absence of obvious harmful habits; and a clear multigenerational pattern is demonstrated. If a strong family history is present, get more assessment: calcium score, carotid ultrasound, Lipoprotein(a), CRP.

1. The Number One Way to Prevent a Heart Attack: Have Clear Purpose in Your Life

You need to know what you’re trying to get out of the day. Connect that purpose to your health. For me it’s my family, helping people with their mental and physical health, and basketball. 

This one is number one for good reason. The couch, phone, ice cream, tobacco, negativity, worry, drugs and alcohol, and all the other stuff are formidable enemies. How will you fight them without purpose? Only you can decide your purpose. If you have no idea, you need to take care of that, that is step one.

If you are without purpose, consider this: we are tiny specks in the universe. We are so small it’s hard to imagine we matter at all. But as small as we are, we are something. We are not infinitely small. In fact, compared to zero or nothing, we are infinitely large—because even the tiniest number, the tiniest thing, divided by zero is equal to infinity. Just surviving, my friends, is underrated. The fact is, to have ever existed is an improbable miracle.