Can heart attacks be prevented?

When Ben Aitken (pictured above) went to his GP surgery for an NHS Health Check aged 42, he did not expect anything more than routine results. 

So, he was shocked when he was told his chance of having a heart attack in the next 10 years was more than 18 per cent. “I went to my car, and I burst into tears,” he remembers.

Ben, now 46, from Consett, County Durham, says his greatest fear was dying. “I thought about my husband, David, who’s deaf and relies on me for telephone calls, doctors’ appointments and hospital checks. How would he manage if I was ill or died?”

This fear spurred Ben, who was already taking medication for high blood pressure (hypertension), to make immediate lifestyle changes. 

This included stopping smoking, starting on statins to lower his cholesterol and losing 6 stone in weight.

His efforts paid off. Ten months later his GP checked his heart attack risk again. It was down to almost 4 per cent.

Many heart attacks do not have to happen

By taking action in his 40s, Ben has lowered his chances of being part of the UK’s shocking heart attack statistics – which sees 100,000 hospital admissions for heart attack each year. That's about 270 a day, or 1 every 5 minutes. 

Yet, many could be prevented with early health checks, improvements to diet and exercise, and medicines to lower risk factors such as high blood pressure, high cholesterol and high blood sugar.

“For the vast majority of people, heart attack is completely preventable,” says Professor Bryan Williams, Chief Scientific and Medical Officer at British Heart Foundation (BHF), pictured below.

Heart attacks cause at least 24,000 deaths in the UK each year.

Many are in younger people, with over a third of these deaths in the under 75s, says Professor Williams, who also works as an NHS consultant.

“It’s very frustrating for me as a doctor to see middle-aged people have heart attacks. For most of them, it did not have to happen.”

Why do heart attacks happen?

The reason we have heart attacks is because, over time, the blood vessels that supply our heart with oxygen-rich blood, called coronary arteries, can get a build-up of a fatty material called plaques, causing them to narrow – a condition called coronary heart disease.

A heart attack happens when the blood vessel becomes blocked, usually when a plaque breaks open and a blood clot forms around a piece of the fatty material inside.

This reduces blood flow to the heart, which in turn causes damage and chest pain (angina) because not enough oxygen-rich blood is getting to the heart muscle.

It’s a medical emergency and without treatment it can cause death or heart failure (where the heart cannot pump blood as well as it should) and other heart complications.

Risk factors include:

• high blood pressure
• high cholesterol
• excess weight
• high blood sugar levels from uncontrolled diabetes
• smoking.

The key to preventing a heart attack is lowering these risk factors with a healthy diet, regular physical activity, stopping smoking and taking medicines to lower blood pressure, cholesterol and blood sugar when needed.

“Anyone who wants to try to prevent a heart attack should try to adopt a healthy lifestyle,” explains BHF-funded researcher Dr Michael McDermott.

“We all know that eating fruits and vegetables, pulses and grains is much healthier than a diet heavy in salt and unhealthy, saturated fats that can raise blood pressure and cholesterol levels.

"And we know that being just a little bit more active per day reduces your risk too,” says Dr McDermott from the University of Edinburgh.

Calculating heart attack risk 

Because these risk factors are so important, doctors measure them to work out an individual’s risk of heart attack.

They do this by taking blood pressure, cholesterol and blood sugar levels, working out your body-mass index (BMI) to identify if you are overweight or obese, and asking about your lifestyle.

“All these risk factors are important, but working together they're more dangerous,” warns Professor Williams. “Even a modest increase in blood pressure and cholesterol together is more dangerous than a high level of one or the other alone.”

All these risk factors are important, but working together they're more dangerous.

To work out your risk of heart attack in the next 10 years, doctors put the measurements, plus other factors such as age, sex, medical conditions and family history, into an online calculator called QRISK that gives a score.

This is the score Ben received saying his risk of a heart attack was 18 per cent, putting him at moderate risk (a score of 20 per cent and over is classed as high risk and under 10 per cent is low risk).

However, like Ben, most people with risk factors do not have any symptoms, so they do not know they’re heading for a heart attack, says Professor Williams. 

“We, as doctors, can’t do anything unless you get your heart attack risk measured. The sooner you get it checked, the sooner we can get you on a treatment plan to reduce your risk of ever having a heart attack,” he says.

Tech set to transform heart care

In the future, new technology will help doctors spot people at risk of heart attack earlier than they can now, Professor Williams adds.

He points to BHF-funded research led by Professor Charalambos Antoniades at the University of Oxford that is using artificial intelligence (AI) to analyse the CT scans of people with chest pain, which is a sign of coronary heart disease.

These CT coronary angiogram scans are used to check for narrowing or blocked areas within the coronary arteries.

However, in some people who go on to have a heart attack, this narrowing or blockages are not visible.

We’re on the cusp of a revolution in science and technology and we must embrace it.

To pick up these people, Professor Antoniades' AI tool looks for inflammation in the fat around the coronary arteries, which he previously discovered was a key warning sign of future heart attacks.

Together with an individual’s other risk factors, the AI tool can help better detect who with chest pain will go on to have a heart attack in the next 10 years.

Several NHS hospitals are already using the tool, and it’s hoped it will be rolled out more widely in the next few years.

“This kind of process is going to transform heart healthcare. When they’re routinely available, everyone will get the same high standard of care," says Professor Williams.

"We’re on the cusp of a revolution in science and technology, and we must embrace it.”

AI powered personal plans

Another big gamechanger will be technology that allows doctors to create personal heart-attack prevention plans based on the latest medical research.

BHF is developing an AI tool to make this a reality.

“We know it can be a challenge for non-specialist doctors to take in all the new research information and make sure each person gets the best treatment,” says Professor Williams.

“At BHF we want to change that. We want to use AI to integrate all that information as it emerges from studies and then use it with an individual’s health data to generate an up-to-date personalised heart attack prevention treatment plan.

More medicines to lower risk

Alongside technology, new medicines will also be key to lowering risk factors and preventing heart attacks in the future, says Professor Williams.

“As doctors, we already have a lot of medicines we can use to reduce someone’s lifetime risk of heart attack to almost zero, and with advances in science we’re getting an even broader set of medicines to do that.”

For example, statins are very effective at reducing cholesterol.

But Professor Williams is now also prescribing a revolutionary cholesterol-lowering treatment called inclisiran, a type of therapy called RNA interference therapy.

It works by telling your liver to stop making the protein that blocks the clean-up of cholesterol, so your body can clear bad cholesterol more effectively.

“It is a twice-yearly injection and for the whole 6 months it’s knocking down your cholesterol to normal levels,” explains Professor Williams.

“In a year or so we’ll get the data to see if it works as well as statins. But I would be very surprised if it wasn’t very effective.”

A gene therapy is also being developed for high blood pressure, reveals Professor Williams. “It’s still being tested but it's expected to also be a 6-monthly injection. It’s an exciting development.”

Finding motivators for change

However, at the core of heart attack prevention lies personal motivation to make hard lifestyle changes, take medicines, and attend appointments for health checks, tests, treatments and procedures.

For Ben, discovering his high QRISK score was the motivator he needed to take action to become heart-healthy.

Looking back, he says, he should not have been surprised he was at such high risk of a heart attack.

He was overweight at 18.5 stone, had smoked since his early 20s, and was already taking medicines for high blood pressure.

“I had a lot to tackle all at once to bring down my risk of a heart attack. But that reality check of hearing my heart attack risk motivated me to do it,” Ben says.

But, not everyone's motivated by their risk score.

That's why Dr McDermott, led by Professor David Newby and his research team, investigated other motivation methods in the SCOT HEART 2 IMPACT trial.

Their research looked to see if having a CT coronary angiogram motivated people to change their behaviour and take preventative medicines more than a heart attack risk score did.

They found 6 months after having a CT, participants had healthier diets, greater weight loss, and were more likely not to smoke and to take preventative medicines than those who had a heart attack risk score.

“It showed us that heart scans helped people understand their future risk better than a score, and this resulted in healthier lifestyle behaviours and improved uptake of preventative medicines,” says Dr McDermott.

“The next stage is for us to test to see if these changes will prevent more people from having heart attacks.”

Heart scans helped people understand their future risk.

Using motivational tools to encourage people to make behavioural changes is already part of NHS care.

Take Ben and his 20-a-day cigarette habit. Ben knew he had to quit so he downloaded the NHS Stop Smoking app, which encouraged him with regular motivational messages.

This meant, even before he attended a stop smoking clinic, he had cut down to just a few cigarettes a day with the help of nicotine patches and a vape.

“The app’s messages about how my health was improving the longer I went without cigarettes gave me the motivation I needed to continue,” he says.

In the future, smartphones and watches will likely play an even bigger role in monitoring and motivating people to have better heart health, says Professor Williams.

“Wearable technology will be able to track your risk factors, feed the data back to your doctor, and nudge you to exercise or eat more healthily.”

For Ben, it was a mix of personal motivation, technology, medicines and the support of family, friends and health professionals, that helped him lower his heart attack risk.

“My husband David (pictured above) kept me going, friends at work, family, and Hazel the nurse at my GP surgery. But in the back of my mind, it was the fear of dying – I knew I had to do it,” Ben says.

“Less than a year after I started making changes, I’d quit smoking and my blood pressure, weight and cholesterol had all come down.

“When I went back to the doctor to have my risk score done again and it had dropped to almost 4 per cent, I was just beaming.”

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