Smoking
		High cholesterol and triglycerides
		High blood pressure

		Diabetes
		Obesity
		Lack of exercise
		Female hormones

		Depression
		Homocysteine
		C-reactive protein

		Age
		Family history
		Gender
		Economic factors

Risk factors increase your chances of developing a disease. Such factors include lifestyle (the foods you eat, how active you are, whether you smoke, and so on), other illnesses you may have, and the genes you inherited from your parents. Your doctor may ask you specific questions about your life to help determine your risk factors.

If you have more than one risk factor, your chances of developing angina and coronary artery disease (CAD) may multiply. An explanation of major risk factors for heart disease follows. Level I risk factors mean that if the problem is stopped or reversed, it has been proven that your risk of heart disease will be decreased. Level II risk factors are those that, if stopped or reversed, will likely reduce your risk of heart disease. Lastly, Level III risk factors are those that might reduce your risk of heart disease.¹

Level I

• Smoking. Smoking tobacco is dangerous, any way you look at it. It's the number-one cause of premature deaths in the United States, and the more cigarettes you smoke, the greater the risk. Fortunately, smoking is a completely preventable risk factor—and once you quit, you've already done your health a huge favor. People who stop smoking before 50 years of age can reduce their risk of death by one-half over the next 15 years.²

  But cigarettes are just part of the problem. Smoking cigars, pipes, and inhaling second-hand smoke all increase your risk for CAD and angina by as much as three times over nonsmokers. Plus, many smokers already have other risk factors such as family history, obesity, and lack of exercise. If you smoke, see the Five-Day Stop Smoking Plan for specific tips to help you kick the habit.

• High cholesterol and triglycerides. If your body contains more fat than it needs to survive, two things can happen. First, your body may store fat under the skin, causing weight gain. Second, "bad cholesterol," also called LDL, can begin to stick to the arteries of your heart at an early age. As years go by, cholesterol adds to the buildup of fatty deposits called plaques (the main sign of CAD), which slowly decreases the opening of the arteries, constricting blood flow to the heart. See Nutrition Matters for more information about cholesterol, and Angina Medications to read more about the medications used to manage high cholesterol.

• High blood pressure. Also known as hypertension, high blood pressure is a serious risk factor for heart disease. Many Americans are unaware that they have it (which is why high blood pressure is often called the silent killer). High blood pressure occurs when blood vessels narrow and tighten. Your heart must then work harder against the increased pressure to keep the same amount of blood flowing throughout the body. And the heart itself may not be receiving enough of the oxygen-rich blood required to keep working at full strength. When the heart doesn't get enough oxygen, painful or uncomfortable angina attacks can strike. Lifestyle changes you can make to help control blood pressure include exercise, eating low-fat and possibly low-salt meals, and weight loss. Some people may also require the use of medications to control high blood pressure.

Level II

• Diabetes. Your body converts the carbohydrates in the food you eat into glucose, a simple sugar, which supplies energy to the body's cells. Insulin, a hormone produced by the pancreas, helps the body's cells either store or use glucose.

  People with diabetes either don't make enough insulin, or their cells are unable to use insulin effectively. This causes sugar levels to rise in the blood, a condition called hyperglycemia. High sugar levels over a long time can damage the body's organs. To make matters worse, people with diabetes are more likely to have higher cholesterol and triglyceride levels. When combined, high sugar and high fats make diabetes a major risk factor for angina and CAD.

• Obesity. More than one-third of American adults are more than 30% over their ideal body weight.³ Among children and adolescents, 13%—about one in seven — are overweight. Since 1980, the number of overweight adolescents has tripled.⁴

  Being overweight puts you at risk for many illnesses, including angina and heart disease. For Americans, lack of regular exercise and a high-fat diet are mainly to blame. Why are these habits so bad? One, an inactive lifestyle means your body is not as fit as it could be. Exercise reduces weight gain, builds your muscles, and keeps your body—including your heart — in good working order. Two, eating high-fat foods increases fat levels in the body. Having more fat than your body can use may increase your weight, lead to blocked arteries and, eventually, may lead to CAD and angina. Find helpful tips and information in Nutrition Matters and Exercise for Heart Health.

• Lack of exercise. Your heart is a muscle and, just like other muscles in the body, needs regular exercise to keep fit. Plenty of research proves lack of exercise is a major risk factor for heart disease. In fact, an active lifestyle can help reduce several risk factors for CAD at once. Exercise fights obesity, lowers blood pressure, increases levels of "good cholesterol" (HDL), and helps improve blood-sugar levels. Enjoying exercise several times a week can help decrease your chance of developing angina and CAD. The more fit your body is, the better chance your heart will be more fit, too. See Exercise for Heart Health for smart ways to get—and keep—your body moving.

• Female hormones. Estrogen, the female hormone, may play a role in heart disease, though exactly how is still a mystery. After menopause, a woman's body doesn't make much estrogen anymore.

  The results of a study called HERS (Heart and Estrogen/Progestin Replacement Study), published in 1998, suggested that postmenopausal women taking estrogen replacement had the same rates of heart problems as women who didn't take it.⁵ However, the Women's Health Initiative has now shown that not only does hormone replacement therapy not protect the heart but, in fact, it may even increase the risk of coronary artery disease.⁶ Read more in Women and Heart Disease.

Level III

• Depression. Depression is a condition marked by feelings of prolonged sadness, hopelessness, and guilt. Depression can affect the heart, possibly when signals from the brain tell the artery walls of the heart to tighten, a response to the stressful emotions a depressed person feels. Narrowed coronary arteries mean less oxygen-rich blood reaches the heart, increasing the risk for painful angina attacks.

  Research shows that people with both depression and angina are less able to get around to do their usual daily activities than other people.⁷ If you're unable to do the activities you enjoy or need to do, you could become even more depressed. A vicious cycle of depression and angina pain can result. See Depression and Heart Disease for more.

• Homocysteine. High levels of homocysteine (an amino acid) in the blood may be a sign of increased risk for CAD. However, the risk appears modest, according to recent studies that challenge earlier research that found greater risk.⁸ Scientists once believed that a high level of this amino acid was an important predictor of heart disease. However, new studies suggest that elevated homocysteine is probably a less important risk factor than established ones such as high cholesterol, high blood pressure, diabetes, and smoking.

  Even though the general risk seems lower than previously believed, it may still be helpful to keep homocysteine levels in check. For example, some research suggests that lowering homocysteine by 25% may cut heart disease risk by about 11% and stroke risk by roughly 19%. Homocysteine is harmful because it may help "bad cholesterol" (LDL) add to fatty plaque buildup on the artery wall. To lower levels, eat healthy portions of fruit and vegetables high in B vitamins. Other research suggests that taking folic acid supplements—one of the B vitamins—can decrease homocysteine levels. Ask your doctor about this and any other dietary supplement before you try it.

• C-reactive protein. This chemical is produced by the liver in response to inflammation and is becoming more important as a predictor of heart disease risk. A simple blood test can check for levels of C-reactive protein (CRP), and researchers have discovered that people with high levels of CRP may have a greater risk of heart attack than those with lower levels.

  Scientists have long focused on cholesterol as a main culprit in heart disease. Yet, in the past decade, they have also turned their attention to inflammation—the process that protects our bodies from outside invaders such as bacteria and viruses—as a key player in the fatty buildup of plaque on artery walls. Researchers believe that chronic, low-grade inflammation may help weaken and damage blood vessel walls, making plaque buildup occur more easily. Later, if a plaque breaks loose, it may trigger a heart attack.⁹

  What are the sources of inflammation? It's not clear, but researchers suspect that infections, possibly from bacteria or viruses, may cause inflammation in the arteries. These types of infections may be common and chronic, for example, gum disease, urinary tract infections, or other problems.

  At this point, not everyone needs to be tested for CRP. But new guidelines from the American Heart Association and the Centers for Disease Control and Prevention suggest that doctors consider testing patients at moderate risk of heart disease, meaning that they may face a 10% to 20% risk over ten years, based on age, high cholesterol, high blood pressure, and other risk factors. The results of CRP can help doctors plan for further testing or treatment.¹⁰

Other factors

Your doctor may consider the following points when evaluating your risk for heart disease.

• Age. People in the United States are living longer, thanks largely to new advances in public health like cleaner water and an improved food supply, better medications (such as vaccines and antibiotics), and new types of surgery. In fact, the 55-years-and-older age group—those most at risk for angina and CAD—may increase by as much as 80% by the year 2030.¹¹ As this group gets older, doctors may see more people with angina.

• Family history. Some families have more cases of angina and CAD than others. Parents pass along genes for certain conditions, including heart disease, to their children. But a family history of heart disease doesn't mean you can't take action. Frequent checkups and taking the medicines your doctor prescribes are two very important steps. Regular exercise and eating healthy foods can also decrease your risk of heart disease — even if it's in your genes.

• Gender. Your sex can help determine your risk for heart disease. The risk for angina and CAD in men begins to increase around 45 years of age. Women are about 10 years behind men; their risk begins to increase at about age 55 years. Also, women are two to three times more likely to get CAD after they pass menopause compared with non-menopausal women of the same age.¹² Overall, women live longer than men. In women past the age of 75 years, the risk of a serious cardiovascular event roughly triples compared with younger women.
  
  When women do have heart attacks, their gender may work against their chances of survival. In one 2000 study, researchers at New York's Montefiore Medical Center and Albert Einstein College of Medicine discovered that even when men and women received the same treatment after a heart attack, the women were still 2.5 times more likely to die. This finding remained true even after the scientists corrected for other factors such as age and illnesses (including diabetes or high blood pressure). When it comes to heart disease, women must also decide with their doctor whether to take estrogen replacement therapy for prevention—a difficult decision that men don't need to confront.¹³ Read more about Women and Heart Disease.

• Economic factors. Many people have limited access to medical care and health education for a variety of reasons: low income, living in a remote area or in a low-income neighborhood, lack of health insurance, and so on. These situations could lead to a delay in diagnosing angina and CAD, and in prescribing effective medications early.¹⁴ Without proper care, people cannot learn about the lifestyle changes that they need to make to stay fit and healthy.

	The average angina attack lasts three to five minutes. True or False? Click here. According to one large study, angina patients typically have how many attacks per week? Click here.

Sources

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11. Statistical Information Staff, U.S. Census Bureau. "Projections of the Total Resident Population by 5-Year Age Groups, and Sex with Special Age Categories: Middle Series, 2001 to 2005." Jan. 13, 2000. http://www.census.gov/population/projections/nation/
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