Why Heart Attacks Are on the Rise in Younger People

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When you think of someone having a heart attack, you probably picture a person in their 50s or 60s. And that is typically the case. But over the last 20 years, more and more people who are younger than age 40 are having heart attacks. From 2006 to 2016, heart attacks for people in this age group have increased by 2 percent every year. What is driving this trend? UH cardiologist Raju Modi, MD, explains, and tells us how we can lower our risks at any age.

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Transcript

Pete Kenworthy

Many of us think we know what a heart attack looks like, right? An elderly person, pain showing in their face, clutching at the chest, followed by staggering steps and then a collapse to the floor. I mean, that's how they depict it in TV and on the movies, right?

Macie Jepson

If that's the case, I can honestly tell you, I've never seen anyone have a heart attack. But my friend's father had a heart attack. He didn't even realize he was having one until three days later. He actually thought he was just having a bad case of heartburn and it wouldn't go away. And it wasn't until he started feeling kind of not right, you know, you hear that a lot, not right, that he would see a doctor and he found out that it wasn't heartburn. It was, in fact, a heart attack.

Pete Kenworthy

Wow. That must've been super surprising to that guy. Now, maybe it was a guy thing, right, to downplay the symptoms he was feeling.

Macie Jepson

I wasn't going to say anything, but maybe it was. No, I don't think he was trying to tough it out though. He said that he just didn't realize it was a heart attack because in his mind a heart attack is a sudden, violent event that's unmistakable. It was the first time that he became aware that he even had cardiovascular disease in the first place. He was 63 years old at the time. Now he's fine. Now he's got a stent. But he said that he'd probably had heart disease for a while without even knowing it.

Pete Kenworthy

Well, 63 isn't exactly elderly. I actually read in the last 10 years, heart disease deaths have started to rise again and it's happening to people in their 40s and 50s. Why?

Macie Jepson

Hi everybody. I'm Macie Jepson.

Pete Kenworthy

And I'm Pete Kenworthy. And this is Healthy@UH. And it's time to look at some myths around heart attacks and get some answers about why heart disease is impacting younger people and what we can do about it. Joining us now is Raju Modi, a cardiologist at University Hospitals in Cleveland, Ohio. So, Dr. Modi, first of all, thanks for being with us.

Dr. Raju Modi

Thank you for having me.

Pete Kenworthy

So, when you see a heart attack depicted on TV or in a movie, is it that dramatic scene that I described of someone clutching their chest and collapsing to the ground?

Dr. Raju Modi

Well, it's a great question. I think just like everything else that's on TV, there can be a lot of drama. And while certainly some people do present with those classic symptoms where they're clutching their chest and turning beet red and in extremis, there's a great number of people who have very moderate or mild symptoms, some of which can be relatively unnoticed as your friend's father was. Chest pain is certainly the classic finding, but often it's shortness of breath. It's fatigue. It's maybe arm pain. It's maybe jaw pain. I've seen one person who presented with their tooth was hurting and that was indicative of the heart attack. So, we can't rely on any one core set of symptoms. I think it's the constellation of findings that might be going on. And it's really just having an increased level of awareness of the type of symptoms to look for.

Pete Kenworthy

And that's tough because some of the things you just described are the same symptoms for many other things, right? I mean, certainly fatigue seems to be a symptom of everything. So, what are we supposed to do when we have some of these symptoms and certainly in your 40s and 50s, when you're not even thinking about heart disease or heart attacks?

Dr. Raju Modi

Oh, that's a great question. And I wish I had the complete answer for you because we don't always know. If I'm sitting in an auditorium with a thousand people and I ask how many people have fatigue, I guarantee half the hands are going to go up. So yes, the symptoms can be rather nonspecific. There are certain symptoms which you definitely want to focus in on. And, of course, that's the chest pain, the arm pain, any kind of symptoms which are unusual, especially when you're exercising or walking or exerting yourself that is unusual for you. So, if you're normally able to go up a couple of flights of stairs without too much difficulty, and now all of a sudden you're breaking out into a sweat or you're getting short of breath or certainly having the classic symptoms, you need to pay attention to those types of findings.

But if you're going about your regular routine activities on a daily basis, and you're just noting an excessive amount of fatigue that perhaps you haven't noticed before, those are the kinds of things that you want to pay attention to. Unusual sensations in the chest. We speak of pain. It doesn't have to be a pain. It can be a pressure. It can be a heaviness. It can be a discomfort or fullness. And in general, everybody describes those symptoms somewhat differently. We refer to them all generically as a chest pain, but it doesn't have to be that. Fatigue, again, could be exercise induced fatigue. It could be fatigue at rest. That's a more difficult one for us to distinguish from heart disease versus other causes. Shortness of breath is probably one of the more concerning ones because shortness of breath can be a result of being deconditioned, just being out of shape. It can be a result of being overweight. It can be a result of intrinsic lung disease, but it can certainly be a result of heart disease. And when you put all of these symptoms together, really it's a matter of trying to identify and tease out what sounds like the heart, what doesn't sound like the heart in conjunction with just speaking with your physician and allowing them to know the symptoms that you're having.

Macie Jepson

And being really in tune with your body and knowing when something's not right.

Dr. Raju Modi

Critical.

Macie Jepson

So, before we get into the why, what are the numbers here? In the past 10 years, what is this rise in heart disease among younger people, especially women? Should we be sounding the alarm?

Dr. Raju Modi

I think it's a fair point. The numbers are fairly striking. Cardiovascular disease accounts for one out of every five deaths that occur in this country. In 2020, we actually saw an uptick of about 5% higher number of deaths with cardiovascular disease. What that translates to is about 32,000 more deaths in 2020 as compared to 2019.

Macie Jepson

So, what exactly is considered young in heart attacks?

Dr. Raju Modi

In general, when we talk about cardiovascular disease, typically in most individuals, you're talking about people in their fifth and sixth decade, right? So 50 and 60 year olds on up. We do see young people coming in with heart attacks, and young people are defined as those who are 40 to 50 years of age. The trend that we're seeing over the last two decades are the very young. And the very young are defined as people who are under the age of 40. From 2006 to 2016, we've seen about a 2% per year increase in very young people coming in with heart attacks, so those under the age of 40.

Macie Jepson

And then the facts are about half of all Americans have at least one of three key risk factors. Let's talk about those. High blood pressure, high cholesterol, of course, smoking. Could you explain how each of these contributes to heart disease?

Dr. Raju Modi

So, yeah, I think those three risk factors are extremely important, but I'm going to add two more than I think are equally important. And that is diabetes and obesity. All of these individual medical conditions, whether together or individually contribute to increased inflammation in the atherosclerosis, which is the plaque that causes the hardening of the arteries. That atherosclerosis, which starts developing early on in life, progressively gets worse. When you have these five risk factors that we are talking about…the diabetes, hypertension, high cholesterol and obesity…the inflammation in that plaque tends to progress much more rapidly causing the plaque to become more severe or potentially even to cause the plaque to tear, which can lead to a blood clot forming within the coronary artery that leads to a heart attack.

Pete Kenworthy

We’re going to get into genetics in just a second, but one contributor to high blood pressure, high cholesterol is, of course, obesity, right? So, I guess what I'm going with here is some high blood pressure, some high cholesterol you can't control. But certainly if obesity is a factor, you can somewhat control that, right? So, I guess I'm getting into how does lifestyle play into this? What kinds of things are preventable or at least you can reduce those risks?

Dr. Raju Modi

That's another great question. So, when we look at patients and we look at risk factors, we try to lump them into two groups. One group is what we consider modifiable risk factors. Those are the things that we have some element of control, either with medications or lifestyle. And then there is a group of unmodified or non-modifiable risk factors. You can't control if you're in the male gender. You can't control your family history. I always tell patients, you know, you got the genes, did you win the genetic lottery or not? So, that's a non-modifiable risk factor. As far as the things that you can control. Obesity to some degree can be controlled with diet and exercise. Cholesterol can be controlled with medications. Blood pressure can be controlled with medications, and diabetes can be controlled. So, what we really try to focus on are the modifiable risk factors when we have conversations with our patients in the office. We may get to a point in time where we're able to help more with the less modifiable risk factors, but we're just not there right now.

Macie Jepson

So, doctor, we know we're supposed to see our physician once a year. Is that enough to keep an eye on things that we can actually feel like we can control? Or is there any added benefit to seeing a preventive cardiologist?

Dr. Raju Modi

Certainly, starting with a yearly physician appointment with your primary care physician makes sense. That's to look and address the modifiable risk factors of high blood pressure, the diabetes, cholesterol and whatnot. Certainly, that frequency can be modified based upon the need. If the various risk factors are not easily controlled, sometimes you do need to see your physician more often than just once a year. If there's a concern about family history, about genetics or about just your overall risk of having underlying heart disease, a preventative cardiologist is an excellent option for many people to exercise. There's a whole host of testing that may be of benefit in certain individuals that are of intermediate or high risk to identify if they have disease, even at an asymptomatic stage. So, in essence, we would like to find the disease before it ever becomes clinically evident. Primary care physicians are very good at doing this. Preventative cardiologists can be very good at doing this.

Macie Jepson

You mentioned a couple of things, genetics. You mentioned high risk. What if you're only 30 years old though? And I ask that because a dear friend of ours passed away this year at the age of 30 of heart failure. And he wasn't sick. But his parents will now look back regretfully and realize that a great uncle passed away this same way at a very young age. And, but even still, when you've got that history, you know, as parents, they're not looking at their healthy, strong 30 year old son and saying, he needs to be under care. And now he's gone. So where is that red flag when it comes to genetics, when it comes to history that you should be on some type of plan or with a physician?

Dr. Raju Modi

That's certainly a tragic story with your friend. Very sorry to hear that. And it is something that we do hear not infrequently. I think if there's a family history of sudden cardiac death, if there's a family history of premature cardiac illness, that is something that you want to take seriously, and you want to start to address with your primary care physician and perhaps a preventative cardiologist. We're not going to be able to identify all genetic linkage as far as if a great uncle on one side had a problem. That may or may not translate to what any particular 30 year old would have. And certainly in a 30 year old, our diagnostic abilities are somewhat limited. Many of the tools that we have are really more applicable in ages 40 on up. But I think the lifestyle choices that somebody makes can certainly be implemented in the very early ages, including in your teenagers, 20s, and 30s, which include diet and a more active lifestyle. Seeing your primary care doctor, I think, is going to be helpful in those situations because they can identify electrolyte, cholesterol abnormalities, blood pressure, abnormalities, body mass index, which is where your weight is higher than it should be. If we can identify that early and have a treatment plan implemented that may alter the trajectory of your healthcare, I think that would be a benefit. Anything that we can do to mitigate the disease progression, whether it's recognized or unrecognized, is important.

Macie Jepson

So, I go back to what I mentioned earlier. It's about knowing your body, even at that young, healthy age, having a PCP, regular tests and really keeping up with what those numbers are showing you.

Dr. Raju Modi

Yeah, that's exactly it. Not so much testing, but at the younger age, I think it's lifestyle and meeting with your PCP, just to make sure that your lifestyle is on track to be as healthy as possible. It's not any one factor, but it's all the factors taken together, which will lead to a healthy lifestyle: diet, exercise, watching your weight, avoiding toxic habits, smoking, things like that.

Pete Kenworthy

I would think with most areas of medicine, as time goes by, things tend to improve, right? In the last 50 years, pick a disease or an ailment of some sort and they're getting better. And what you're telling me is things are getting worse in terms of heart disease among younger people, right? You're talking about a 2% increase each year. Now, I realize that's not medicine's fault, right? I realize that that that's other things that are happening there, but are there things that are coming down the pike that can reverse that trend? Are there, you know, I think about the calcium score test. That wasn't around 20 years ago, right? And explain that if you will, and then tell me, are there other things that are coming that could help reverse this and get people back on track?

Dr. Raju Modi

Yes and no. So, in as far as the early identification, I think the calcium scoring test is a fantastic opportunity for an intermediate risk individual who's above the age of 40 to see if they have any evidence of coronary artery disease or coronary atherosclerosis. It's a very easy test that's done on a CT scan machine without any IVs or contrast materials being administered and with a relatively low amount of radiation that that patient's exposed to. But the information that we get is not, is that person at risk of developing disease? It actually shows us the disease. So, if there's calcium in those arteries, it's not that they're going to develop the coronary disease. They already have it. That gives us the proper knowledge on how aggressively we need to treat their associated risk factors.

As far as trying to eliminate the disease or to cause what we call plaque regression, at this point, I'm going to say no for all intents and purposes, I don't have the equivalent of the Liquid Drano that I can give him something. And that cleans out the pipes. That's clearly our Holy Grail in cardiology. We're not there yet. But once we've identified that somebody has either a significant number of risk factors or actually has the disease based upon some sort of non-invasive testing, there are many things that we can do to try to prevent the plaque that they have from progressing. Every therapy that we have, every treatment that we talk about centers around reducing inflammation, which is what we mentioned earlier: exercise, diet, not smoking, reducing cholesterol, taking medications such as statins, reducing blood pressure, aggressively treating diabetes. The aim of every one of these treatments is to reduce the inflammation that's happening in the plaque and thereby hopefully reduce the progression of that plaque from maybe an insignificant area of narrowing and prevent it from getting to be severe.

Macie Jepson

Is there anything, Doctor, that we're not touching on? If you went, you've got this audience who is looking for a way to live their best life, perhaps even turn back the years a little, if they could, you know, in their heart, what would you tell them?

Dr. Raju Modi

So, once you've met with your primary care doctor or preventative cardiologist, once various risk factors have been identified, it really is incumbent upon everybody to try their very best to get those risk factors under control. We talk a lot about medications, and medications are incredibly important. And there have been tremendous developments over the last several decades. But let's go back to the basics. We have to take care of our lifestyle. The lifestyle is so critical. Exercise: we're really asking for 30 continuous minutes of some sort of aerobic activity, five days out of the week, 12 months out of the year. It doesn't have to be intense exercise. Go for a walk for 30 continuous minutes. Watch the diet. We've been harping on diets. And we talk about so many different types of diets out there, but we do know that diet has a major impact on the progression of coronary artery disease and for many other health-related concerns.

The less inflammatory the diet is, the better off you're going to be. So, I often will talk to patients about shifting more towards a plant-based diet. I don't expect perfection. I don't expect somebody to be a hundred percent vegan, but as close to that target as you can get, the healthier you're going to be. We focus on weight. And I tell patients all the time, I'm not interested in the aesthetics of weight. I look at weight as more of a predictor of what that person's lifestyle is. Are they leading a healthy lifestyle? Which means their weight is either staying stable or coming down? Or is the lifestyle not in order? Is the weight going up? And the lifestyle incorporates both diet and exercise. Certainly, medications play a huge role in treatments of associated medical conditions like diabetes and high cholesterol. But I think if we start with lifestyle, we can improve upon those other conditions.

Pete Kenworthy

Dr. Raju Modi, cardiologist at University Hospitals in Cleveland, Ohio. Thanks so much for joining us today.

Dr. Raju Modi

Thank you for having me.

Pete Kenworthy

We appreciate it. Remember, you can find and subscribe to this podcast on iTunes, Google Podcasts, Stitcher, or wherever you get your podcasts. Search University Hospitals, or Healthy@UH, depending on where you subscribe.

Macie Jepson

For more health news, advice from medical experts and Healthy@UH podcasts, go to UHHospitals.org/blog.