Fortunately, most of the risk factors for coronary artery disease can be partially or totally addressed. Many are unhealthy habits, such as smoking and lack of exercise. Others, such as high blood cholesterol and obesity, can be partly or mostly due to poor diet choices, although genetic susceptibilities can dramatically influence the response to those choices.

Some are treatable illnesses such as depression and high blood pressure. And still others are circumstances, such as social isolation and stress, that can be mitigated to some degree. By addressing the risk factors that you have some control over, it’s possible to reduce your vulnerability to coronary artery disease by a third or more.

Tobacco Exposure

Everyone knows that smoking is a major health hazard: it’s the leading preventable cause of death in the United States. But some people may be surprised to learn that smoking is also the most potent cardiac risk factor, increasing risk by 250 percent.

Another surprise: exposure to secondhand smoke is also a major cardiac risk factor, which is why passive smoking is the nation’s thirdleading preventable cause of death. (Alcohol is the second.) In all, smoking accounts for 20 percent of all deaths from coronary artery disease.

But within a year of quitting, smokers can cut this risk in half. Within two years, the cardiovascular risk for a former smoker is very close to that of a person who never smoked. Because smoking probably contributes to blood vessel inflammation, removing that irritant should slow the inflammatory process, resulting in a quick drop in heart disease risk.

A lot of patients who know they should quit smoking, but they’re not sure how. The best approach is two-pronged: use medicine, and get counseling and support. Easing the craving for nicotine is a key part of stopping smoking. Several aids can help with this.

Nicotine patches, gum, lozenges, nasal spray, and cigarette-shaped inhalers deliver enough nicotine to satisfy the body without the tar, carbon monoxide, and other harmful chemicals found in cigarette smoke. An antidepressant known as bupropion (Zyban, Wellbutrin) also alleviates the symptoms of nicotine withdrawal, even in people who aren’t depressed.

Combining bupropion and nicotine replacement may work the best of all. Nicotine replacement is safe, even after a heart attack, and it’s much safer than continued smoking. These products don’t increase the clotting potential of blood or damage the fragile but important lining of blood vessels, as smoking does.

Nicotine replacement often isn’t enough on its own. Counseling and social support can help you break your “smoking cues,” the things you link to lighting up, like drinking coffee or finishing a big meal. You can get counseling one-on-one at a support group run by a hospital or local department of health, via the phone, or online.

Remember that quitting smoking is a huge change, so it might take you a few tries to get off cigarettes for good. If you slip by having a cigarette or two after your quit date, try to figure out what went wrong and how to fix it the next time.

Don’t convince yourself that as long as you had one, you may as well have another, and another. . . . The same holds true if you return to your old smoking habit. You may have to quit a few times. Not succeeding may just mean you need more help.

High Blood Pressure

High blood pressure (or hypertension) is nearly as dangerous as high cholesterol. People with this condition are more than twice as likely to suffer a heart attack as those with normal blood pressure are. Because fifty million Americans have hypertension, it’s a major cause of atherosclerosis, to say nothing of the death and disability that it brings about through stroke and other hypertensive diseases such as kidney failure.

Your blood pressure reading has two parts, the systolic blood pressure (the top number) and the diastolic blood pressure (the bottom number). The systolic number represents the pressure while the heart is beating, and the diastolic number represents the pressure when the heart is refilling with blood between beats.

To determine if you have high blood pressure, look up your numbers in Table 4.2. What if your systolic blood pressure is high but your diastolic is not, or vice versa? Use the higher category to determine your status. For example, if your blood pressure is 162/85 millimeters of mercury (mm Hg) you have Stage 2 hypertension.

The lower your blood pressure, the lower your risk for heart attack, stroke, kidney disease, and premature death. With this in mind, aim for a blood pressure of less than 140/90 mm Hg. But people with cardiovascular disease (or other conditions that increase the risk of cardiovascular disease) should aim for an even lower level, of no more than 135/85 mm Hg and, ideally, 120/80 mm Hg or less.

Because high blood pressure usually begins gradually between ages twenty and fifty, all adults should have their blood pressure checked regularly. Blood pressure checks every three years usually suffice for people with normal or optimal levels. But people with elevated blood pressure need more frequent measurement—at least once a year for those with high-normal blood pressure.

People who are at increased risk of developing high blood pressure (including African-Americans, relatives of people with hypertension, and patients with kidney disease) should also have their blood pressure checked at least once a year, even if their own numbers are normal.

If you have high blood pressure, there are medications you can take and lifestyle changes you can make. Many of the things that help prevent heart disease confer part of their benefit by lowering blood pressure. Regular exercise and weight loss are prime examples.

Smoking cessation, moderate alcohol use, stress reduction, and a low-fat, high-fiber, vitamin-rich diet may also help control blood pressure. An eating plan called Dietary Approaches to Stop Hypertension (DASH) has proved effective in reducing high blood pressure. The DASH diet is rich in fruits, vegetables, and low-fat dairy products and low in saturated fats.

It’s particularly effective if you also restrict the amount of salt you eat. No matter what treatment you’re on, make sure your doctor monitors you closely to ensure that you get good results. The benefits of blood pressure control are substantial; just a 1 mm Hg decline in diastolic blood pressure can reduce your cardiac risk by 2 percent to 3 percent.

Although diastolic blood pressure was previously considered most important, experts now understand that reducing the systolic blood pressure can be just as helpful. Because blood pressure tends to rise with age, even people in the “normal” and “optimal” ranges should consider taking steps to keep their blood pressure there.

Diabetes

Diabetes has long been recognized as a major risk factor for heart disease, but we now have evidence that an otherwise-healthy middle-aged individual with diabetes is just as likely to have a first heart attack as a nondiabetic person who has already suffered a heart attack is to have a second coronary event.

Because we have always treated individuals who have had a previous heart attack very aggressively—because this is one of the biggest predictors of future coronary events—we have begun to do the same thing in our diabetic patients.

To put some specific numbers to the magnitude of this risk, research has shown that people with diabetes have a 15 percent to 25 percent chance of developing serious heart problems over a ten-year period. Even more sobering, a person with diabetes who has a heart attack is twice as likely to die from it as a person without diabetes would be.

Two-thirds of people with diabetes die of some form of heart or blood vessel disease. Although there’s a genetic component to diabetes, the most common form of the disease, type 2 diabetes (formerly known as adult-onset diabetes), can often be controlled or even prevented by weight loss, regular aerobic exercise, and diet.

For anyone with diabetes, good blood sugar control is a major goal of medical therapy. Fasting blood sugar levels above 140 mg/dL indicate a need for additional treatment.

Studies are currently under way to determine if better blood sugar control in diabetics will reduce their risk for heart disease (we don’t know that for sure yet), but it has been clearly shown to prevent complications involving the kidney and eyes. If you have diabetes, be particularly careful to reduce your other heart disease risk factors.

Obesity

Because obesity is so closely linked to high blood pressure, unfavorable cholesterol levels, lack of exercise, and diabetes, it took scientists a long time to figure out whether obesity itself is an independent cardiac risk factor. Experts now agree that it is. Excess weight increases your risk for heart disease regardless of these other conditions.

All forms of obesity are bad for your health, but excessive upper-body fat (an apple-shaped body) is more dangerous to the heart than lower-body obesity (the pear shape). In other words, fat stored at or above your waistline is worse than fat in your hips and thighs.

Your body mass index (BMI), which takes both height and weight into consideration, provides an accurate reflection of your body fat. You should aim for a BMI of between 18.5 and 24, the range that’s considered normal. A BMI between 25 and 29 is considered overweight, and a value of 30 or higher is defined as obese.

You should also keep an eye on your waist measurement, which is an indication of your body-fat level. As people grow older, for example, their waist size often increases, though the scale tells them they weigh the same as they did the previous year.

That’s because people tend to lose muscle mass as they age, but if they gain enough fat, they maintain the same weight. Unfortunately, it’s much easier to diagnose obesity than to correct it. But because maintaining a healthy body weight can reduce cardiac risk by 35 percent to 55 percent, it’s an important goal.

Rather than focusing on the weight itself, it’s best to work toward a heart-healthy lifestyle featuring a lot of aerobic exercise and a diet low in saturated and trans fats. It’s no accident that this program works well for the waist as well as the heart.

Diet

When it comes to heart disease risk, you are what you eat. A poor diet—one high in saturated fat, trans-fatty acids (partially hydrogenated fats or oils), cholesterol, refined carbohydrates, and calories— can promote heart disease.

However, a healthy diet—one low in these substances and high in fruits, vegetables, and grains— can help protect you against it. Diet exerts tremendous influence on many of the risk factors for heart disease—not just cholesterol—including high blood pressure, diabetes, and obesity.