The One Thing You Need to Get Right to Prevent Heart Disease
(How to avoid dying from the leading cause of death)
Estimated reading time: 25 minutes.
Atherosclerotic cardiovascular disease (herein “heart disease”) is the number one cause of death in the U.S. and worldwide. About 1/3 of all humans die from it. More women die from heart disease each year, than all forms of cancer combined. On average someone in the U.S. dies of heart disease every 34 seconds.[1]
But what if you could take a relatively safe and well-studied medication[2] that would reduce your risk of dying from heart disease by 93% or more? Would you take it?
I have learned a lot the last ten years dealing with my wife’s and my stubbornly high cholesterol. I thought the information I learned could benefit others. It is a complex topic, but the steps needed to protect yourself from heart disease are clear and easy to implement. Note: the information in this blog was reviewed for accuracy with a member of the American College of Cardiology.
If you are not a details person, you can skip to the “What should I do first?” section at the end.
Here is what I will cover:
Heart disease is caused by a fatty plaque buildup in the walls of the arteries, which is called atherosclerosis. This atherosclerotic plaque is made mostly of cholesterol, fatty substances, and calcium. Atherosclerosis is a slow, lifelong progression of changes in your arteries that starts in childhood and get worse faster as you age.
When a piece of plaque breaks off it can travel through the bloodstream until it gets stuck and cuts off blood flow. A plaque can also rupture and clot, which restricts blood flow. Atherosclerosis can affect arteries anywhere in the body. Blocked arteries to the heart cause heart attacks. Blocked arteries to the brain cause strokes and vascular dementia.
Atherosclerosis is caused by LDL and other cholesterol particles getting trapped in the walls of your arteries.[3] This causes inflammation and damage to the artery walls.
The latest guidelines state, “LDL is unequivocally recognized as the principal driving force in the development of atherosclerotic cardiovascular disease and its major clinical [consequences]”.[4] High LDL cholesterol is the only prerequisite for heart disease. Not everyone with high LDL will get heart disease. But no one without high LDL, for a prolonged period, will get it.
Researchers used to think the ratio of HDL to LDL was the most important metric, but newer research shows that neither HDL nor the ratio of HDL to LDL is what we should be trying to modify.[5] The best predictors of your risk of heart disease are LDL, non-HDL (total cholesterol minus HDL), and ApoB (a protein found on cholesterol-carrying particles).[6] ApoB is the most accurate way to determine your risk of heart disease,[7] but to keep things simpler, I refer only to LDL in this blog.
Babies are born with LDL of 20-40 mg/dL[8] (all cholesterol numbers in this blog are in mg/dL except for lp(a) reported in nmol/L).[9] At this level, you are unlikely to develop plaque in your arteries. As LDL increases, the risk of atherosclerosis increases in a dose-dependent manner.[10] The higher your LDL, the higher your lifetime risk of heart disease. For many people, high LDL is due to a poor diet of ultra-processed foods that are high in saturated fat, added sugar, added salt, and refined grains.
LDL goals for those at very high risk of heart disease, high risk, and moderate risk are 55, 70, and 100, respectively.[11] In the U.S., about 26% of adults have LDL above 130.[12] This is why heart disease continues to be the leading killer. Americans are not taking the necessary steps to lower their cholesterol. [See endnote 13 for a comparison of the LDL, non-HDL, and ApoB targets.[13]]
Yes, studies have consistently shown that you halt the progression of plaque when LDL reaches 70.[14] LDL below 70 will cause plaque to regress in most people.[15] And the lower your LDL (down to at least 36) the more your plaque shrinks.[16]
Time is an important variable when it comes to cholesterol and heart disease. The longer you have high LDL, the greater your risk of heart disease. And if you reduce your LDL, the longer you maintain it, the greater your reduction in risk.[17]
The plaque that causes heart disease begins to accumulate in early childhood. A 1953 study looked at autopsies of young soldiers killed in the Korean war, with an average age of 24. Over 70% had atherosclerosis in their coronary arteries.[18] Another study found that over 50% of children aged 10-14 killed in car accidents had evidence of early atherosclerotic heart disease.[19] The American Heart Association (AHA) and American College of Cardiology recommend primary prevention of heart disease begin as early as age 10 and should focus on promoting heart-healthy behaviors (discussed below) and preventing (as opposed to treating) abnormal risk factors.[20]
If you don’t pay attention to your LDL now, by the time you have clear symptoms it may be too late. About 50% of men will have a cardiac event before the age of 65, and 25% of those are in men younger than 54.[21] Women have about the same risk of heart disease as men, but on average they get it about six and a half years later.[22] About a third of women will have their first cardiac event before age 65.[23]
It is never too late to benefit from improving your heart health, but the earlier you start, the better.
Each 38.67 reduction in LDL reduces the relative risk of heart disease events by about 10% during the first year of treatment, by about 16% after two years, and by about 20% after three years of treatment. Each subsequent year of treatment is expected to further reduce heart disease events by1.5%. So, five years of treatment should reduce the relative risk of heart disease by about 20-25% (per 38.67 reduction in LDL), and 40 years of treatment (or approximately 40 years of exposure to the lower LDL) would be expected to reduce heart disease events by about 50-55%.
Assume you have LDL of 271. If you reduce your LDL to 136 for five years, then you can expect to reduce your risk of heart disease by 58%. But if you maintain your reduced LDL for 10, 20, 30, or 40 years, then you can expect a reduction in your risk of 68%, 81%, 89%, and 93%, respectively.[24] The longer you maintain lower cholesterol, the more your plaque shrinks, and the more stable the existing plaque becomes (remember, heart attacks are usually caused by unstable plaque breaking off and clogging an artery, or the plaque rupturing and clotting).
You can think of the plaque as a pimple that could burst at any time. Lowering LDL stabilizes the plaque and is like turning the pimple into a solid wart with almost no risk of bursting.
Yes, the two most common are a CT angiogram (CTA) and coronary artery calcium (CAC) score.
CAC Score. A CAC score is a type of CT scan that measures the amount of calcified plaque in your coronary arteries.
My LDL has been high for most of my life. I spent far too long trying to correct it with diet, exercise, and supplements. It wasn’t until 2022, when I checked my CAC score, that I finally went on a statin. According to my CAC score I have more calcified plaque in my arteries than 67% of people my age. Not good. I eat a heart-healthy diet, exercise, and have a low body fat percentage. But I have genetically high lp(a).
A positive CAC score is a warning sign for heart disease.[25] And a CAC score of zero is also an important factor to consider when determining your risk.[26] But a CAC score of zero does not mean you have zero risk of heart disease. Heart disease can still occur in those with a zero score.[27]
The MESA Risk Score and Coronary Age Calculator calculates your 10-year risk of heart disease, with and without, your CAC score.
CTA. A CTA is better than a CAC score, but it costs more and exposes you to more radiation and contrast die. A CTA can detect soft plaque that hasn’t hardened with calcium yet, and it can detect the narrowing of arteries.
Lipoprotein(a), known as lp(a), is an especially dangerous type of cholesterol-carrying protein. It is technically a type of LDL particle, but it raises your risk of heart disease much more than normal LDL. The normal range for lp(a) goes up to 100 nmol/L.[28] My lp(a) has been as high as 196.
Everyone should have their lp(a) checked at least once. About 20 to 30% of people have high lp(a).[29]
Unfortunately, lp(a) doesn’t respond to diet or exercise, and there are no approved drugs for it – yet.[30] If you have high lp(a), the recommended approach is to reduce your overall risk of heart disease as much as you can.[31] You can lower your overall risk with medication that lowers LDL, treating high blood pressure and high blood sugar, eating a heart-healthy diet, being physically active, maintaining a healthy weight, stopping tobacco and nicotine use, avoiding second-hand smoke, and getting at least seven hours of sleep per night.[32]
A new online calculator has been developed by the European Atherosclerosis Society to incorporate lp(a) into your overall risk of heart disease. The calculator gives your risk of having a heart attack or stroke up to age 80, and lets you compare your risk with and without your lp(a) number. It also shows how much your overall risk will be lowered if you reduce your LDL. This lets you determine how much you can counteract your high lp(a) by reducing your LDL. The calculator is available here.
Unfortunately, most doctors don’t routinely run lp(a) blood tests for their patients. Both my wife and I had to ask for it. If we hadn’t been proactive, we may have never known about this important independent risk factor.
There are online calculators that measure your 10-year risk of developing heart disease.[33] But if you wait until your 10-year risk is high, it may be too late. For 40 – 50% of people, the first sign of heart disease is a fatal heart attack. You usually don’t get a warning sign.
Heart disease organizations now acknowledge that those under age 60 should pay attention to lifetime risk.[34] Unfortunately, no calculator measures your lifetime risk after considering lp(a) and/or a CAC score. Plus, the online calculators only consider a few variables, such as age, sex, cholesterol, blood pressure, whether you smoke, and medication use. When assessing your risk of heart disease, you must consider other factors that may put you into a higher risk category, and require a lower LDL, than might be apparent from just looking at your 10-year risk. These factors include:[35]
Diabetes, high blood pressure, smoking, obesity, depression, lack of physical activity, and the other factors above all exacerbate atherosclerosis. You don’t need any of those factors to develop heart disease, but they can make it worse and cause it to progress faster. For example, smoking and high blood pressure (two of the most important risk factors, after cholesterol) damage the inner wall of the arteries, making it more likely any cholesterol deposited there will lead to heart disease.
Yes. According to the AHA, “The most important way to prevent [heart disease], is to promote a healthy lifestyle throughout life.”[37] The heritability of heart health is very low, meaning that lifestyle accounts for most of your risk. You may never need medication if you have a healthy lifestyle, according to the metrics discussed below.
Dean Ornish, who published one of the first studies showing you can reverse heart disease with lifestyle, had this to say:[38]
“Sometimes we have a hard time believing that such simple choices as what we eat, how we respond to stress, how much exercise we get, whether or not we smoke, and the quality of intimacy and social relationships in our lives can make such a powerful difference in our health and our well-being – but they do.”
Even if you have relatively low cholesterol, blood pressure, blood sugar, and BMI, you are not guaranteed to avoid heart disease, so everyone should pay attention to the lifestyle factors below, including psychological health.[39] A healthy lifestyle will also improve many other aspects of your mental, physical, and emotional health, and reduce your risk of cancer, diabetes, and Alzheimer’s disease.
In 2022, the AHA published a paper called Life’s Essential 8. It explains the ideal metrics for improving and maintaining cardiovascular health, along with a 100-point scoring system.[40] Check your 100-point scoring system.
Less than 1% of Americans have ideal cardiovascular health or even an ideal heart-healthy diet.[41] Those scoring higher on the Life’s Essential 8 quiz have a lower risk of heart disease, in a stepwise manner (the higher your score the lower your risk of heart disease). Those with the highest number of ideal metrics have an 80% reduced risk of heart disease.[42]
Below are the eight metrics for optimal cardiovascular health for adults 20 and older.[43]
Before taking your blood pressure, has your doctor ever asked whether you need to empty your bladder, or if you have exercised, consumed caffeine, or had alcohol in the last 30 minutes? Mine hasn’t. Have they asked you to sit quietly without talking for 5 minutes before taking a reading? And then taken two more readings a few minutes apart – still with no talking by them or you? Of course not, that never happens. This is why at home measurements are more accurate – you can actually follow the proper protocol.[50] Make sure to use a validated blood pressure device (see validatebp.org or stridebp.org/bp-monitors/).
If more than one factor needs to be improved, don’t try to address them all at the same time. This can be overwhelming.
Here is a little extra motivation. When the AHA analyzed the ideal lifestyle factors for optimal brain health, they realized the exact same factors above also reduce your risk of cognitive decline, dementia, and Alzheimer’s disease.[51] According to the Global Council for Brain Health, “what’s good for the heart is good for the brain.” You improve your brain health at the same time you improve your heart health.
The use of inhaled nicotine delivery products, including traditional cigarettes, e-cigarettes, and vaping, is the leading cause of preventable death in the U.S., including about a third of all deaths from heart disease.[52] Smoking may triple the risk of dying from heart disease.[53] Even low levels of smoking increase the risk of a heart attack.[54]
But all eight factors are important. For example, one study found that losing an hour of sleep, due to daylight savings time, was associated with a 24% increase in the number of heart attacks on the following Monday.[55] On average, every one hour/night decrease in sleep below seven hours is associated with a 6% higher risk of heart disease.[56]
The best analysis of the ideal foods for preventing heart disease is a 2017 study funded by the Bill & Melinda Gates Foundation.[57] Researchers from several universities collaborated to analyze the foods and nutrients associated with the lowest risk of heart disease, stroke, and diabetes. Below are their recommendations of what to consume.
Per day, at least:
Per week:
No more than:
Avoid all:
Yes, very important. One factor missing from the analysis above was the optimal amount of saturated fat.[59]
Humans don’t need to eat saturated fat, as our bodies make all we need. There are no known risks from consuming a low intake of saturated fat. The National Academy of Medicine and the European Food Safety Authority recommend intake of saturated fat be as low as possible while consuming a nutritionally adequate diet.[60] The National Academy did not set an upper limit on saturated fat because “any incremental increase in saturated fat” increases the risk of heart disease.[61] But it is almost impossible, and not necessary, to eliminate saturated fat from your diet. The most recent heart disease guidelines recommend saturated fat intake be less than 7% of calories if you have high cholesterol.[62] The largest contributors to saturated fat are fatty cuts of meat, full fat milk/cheese/yogurt/cream cheese, and foods made with coconut oil, butter, palm oil, and palm kernel oil.
YES, YOU READ THAT RIGHT – COCONUT OIL IS NOT A HEALTH PROMOTING FOOD. IT MAY BE MORE HARMFUL THAN BUTTER DUE TO THE SATURATED FAT THAT INCREASES LDL.[63]
Heart disease organizations recommend consuming liquid plant oils (such as canola oil, olive oil, avocado oil, hemp seed oil, flax seed oil, corn oil, soybean oil, safflower oil, sunflower oil, and grapeseed oil) in place of fats that are solid at room temperature (such as coconut oil, butter, ghee, palm oil, palm kernel oil, lard, bacon grease, poultry fat, and tallow).
The amount of saturated fat you consume is much more important than the amount of dietary cholesterol, but it shouldn’t be ignored. “Dietary cholesterol” is the cholesterol found in food, not the cholesterol in your blood. Previous dietary guidelines recommended limiting dietary cholesterol to 300 milligrams per day. But the current Dietary Guidelines for Americans recommend keeping dietary cholesterol “as low as possible without compromising the nutritional adequacy of the diet.”[64]
Eggs, shrimp, and lobster are particularly high in dietary cholesterol. The AHA recommends limiting eggs to seven per week, and limiting shrimp and lobster to 21 ounces per week, if you have a healthy LDL level.[65] But if you have high LDL, try to consume no more than two eggs per week and no more than six ounces of shrimp and lobster per week.
There is a lot of misinformation about soy. Soy foods such as tofu, tempeh, unsweetened soy milk, and edamame are healthy foods we should be eating more of. Eating soy foods can lower LDL.[66] But steer clear of ultra-processed soy foods that are packed with extra salt and added sugar.
Soy does not cause cancer, disrupt sex hormones, or impair thyroid function. The World Cancer Research Fund found evidence soy can reduce the risk of breast cancer recurrence and help you live longer.[67] The Dietary Guidelines for Americans consider fortified soy products a healthy alternative to dairy foods.
In the Lyon Diet Heart Study, participants were counseled to (1) eat more green vegetables, root vegetables, fish, and bread, (2) have fruit at least once daily, (3) replace red meat with poultry, and (4) replace butter and cream with a margarine that was very similar to olive oil. After about four years, the participants reduced their risk of heart disease-related events[68] by 50-70%.[69]
In the 4.8-year PREDIMED study, participants assigned to a Mediterranean diet high in olive oil or nuts had 30% and 28% reductions, respectively, in strokes, heart attacks, and heart disease-related deaths, compared to those eating the control diet that wasn’t supplemented with olive oil or nuts.[70]
When the results of PREDIMED were reanalyzed, they discovered that those eating the most plant foods (versus animal foods) reduced their risk of death during the study by 41%. [71] But all plant foods are not created equal. Consuming sugar-sweetened beverages, sweets, desserts, French fries, chips, fruit juice, and refined grains are associated with worse health.[72] These ultra-processed versions of plant foods are rich in added sugars, added salt, saturated fat, refined grains, and flavor enhancers.
Sorry Blue Zones devotees, due to updated research, alcohol, including wine, is no longer considered a health promoting beverage. Researchers recently found flaws in the studies indicating moderate alcohol consumption may have protective heart and brain benefits.[73] These studies did not distinguish between those who never drank and those who quit drinking due to a health condition.
According to the Global Burden of Disease research group, alcohol consumption was responsible for 2.44 million deaths in 2019.[74] They found the “healthiest amount of alcohol to consume is zero.”[75] The World Cancer Research Fund now warns, “for cancer prevention, it is best not to drink alcohol.” The World Health Organization no longer sets a particular limit on alcohol consumption because “the evidence shows that the ideal solution for health is not to drink at all.”[76] The American Heart Association’s Scientific Statement on nutrition states, “the AHA does not support initiation of alcohol intake at any level to improve cardiovascular health, given the uncertainty about net health effects, especially in light of the deleterious effects of alcohol on numerous other outcomes (injuries, violence, digestive diseases, infectious diseases, pregnancy outcomes, and cancer).”[77]
There are a few supplements worth mentioning. About two grams of phytosterols per day can lower LDL cholesterol by 7-10%.[78] And 3 to 10 grams of beta glucan fiber (from oats and barley) can lower LDL by 3-5%. Other supplements for lowering cholesterol are considered unproven or too dangerous.[79]
Fish oil is used to treat high triglycerides (over 500m g/dL),[80] but is no longer recommended generally for the prevention of heart disease as the studies have been inconsistent.[81] However, as described above in the ideal foods section, guidelines do recommend two to three servings of fatty fish[82] per week (fried or dried/smoked fish don’t count).[83]
The biggest risk with taking any supplement is that you may not get what is on the label.[84] In the US, dietary supplements are not regulated like medications. Anyone can slap a label on a product and start selling it online. That is why I check my supplements with a third-party tester, such as ConsumerLab or NSF.
Aspirin is no longer recommended for the primary prevention of heart disease, due to the lack of net benefit after considering the risk of gastrointestinal bleeding.[85]
Psychological health didn’t make it into Life’s Essential 8 as they found it to be an important foundational factor underlying all 8 metrics. Psychological health can also be difficult to measure and modify.
Psychological health and well-being take into account optimism, social support, resiliency, mindfulness, gratitude, sense of purpose, environmental mastery, anxiety, anger/hostility, chronic stress, pessimism, and depression.[86] These psychological factors influence heart health directly (by affecting inflammation, immune response, blood sugar, cholesterol, heart rhythms, blood coagulation, and vasospasm[87]) and indirectly (by affecting your likelihood of eating healthy, getting enough sleep and exercise, not smoking, and adhering to your prescription medications).[88]
Some research indicates these factors can be as important as more traditional risk factors, such as blood pressure and cholesterol. Work-related stress, social isolation/loneliness, and PTSD have been associated with a 40%, 50%, and 61% increased risk of heart disease, respectively.[89] Numerous studies have found that people with depression have an increased risk of developing heart disease, having a heart attack or stroke, and dying from heart disease. Depression can be improved with treatments such as antidepressants, psychotherapy, exercise, and light therapy. A 2024 network meta-analysis showed exercise is more effective than the leading drugs (SSRIs) but combining medication with exercise was even more effective.[90] Similarly light therapy is more effective than antidepressant drugs, but the combination of drugs and light therapy work even better.[91]
Optimism, having a sense of purpose, positivity, and an overall sense of well-being have been associated with a 65%, 83%, 78%, and 71% decreased risk of heart disease.[92]
The mind, heart, and body are all connected and can influence each other in powerful ways. This is why I created my Health & Well-Being Journal. It includes daily prompts to foster gratitude, optimism, a sense of purpose, and activities to manage stress.
Less than 20% of Americans know their numbers.[93] Don’t be one of them. Talk to your physician or go to WalkinLab.com and order lipoprotein(a), ApoB, HbA1c, and c-reactive protein tests, as well as a standard lipid panel (I have no affiliation with Walk-in Lab). Then take your results, and a list of your other risk factors, to a cardiologist to discuss your options.
If your LDL is not already in the ideal range, do everything you can to lower it to a healthy level. You can try diet, exercise, and sleep first, but don’t wait twenty-five years to talk to a cardiologist like I did. If you don’t get your numbers in check within a few months, then consider cholesterol lowering medication.
I used to think if my LDL wasn’t low enough, I wasn’t eating healthy enough. We are all different. Some may be able to hit their cholesterol goals with healthy foods but not everyone. My cholesterol varies widely, even when my diet, exercise, and weight are the same. So don’t be shy about retesting your cholesterol to ensure it stays in a healthy range.
There is a dangerous myth that if you eat a whole food plant-based or vegan diet, then you can ignore your high cholesterol. There is no evidence to support this. Believe me, I tried to find it, as I don’t like taking medications.
Even with no risk factors, official guidelines recommend keeping LDL under 116.[94] But many experts recommend 100 as a maximum LDL.[95] Peter Attia recommends LDL of 10 to 20, similar to what we are born with.[96] I now check my ApoB, instead of LDL, as it is a more accurate predictor of heart disease. My goal is to keep ApoB under 90. I encourage you to err on the side of caution and be aggressive lowering your numbers to the desired levels. Lower is usually better when it comes to LDL, ApoB, and Non-HDL cholesterol, if your lower cholesterol is due to a healthy lifestyle or one or more of the drugs discussed in this blog (or the endnotes).[97]
The purpose of this blog is to bring attention to the experts’ most recent guidelines on the prevention of heart disease, and to foster a productive and informed discussion with your cardiologist. After reading this blog you may know more about the prevention of heart disease than your primary physician. This is why I recommend having these discussions with a cardiologist who is an expert in heart disease, preferably one who is a member of the American College of Cardiology.
You can check the information in this blog with the official guidelines of the experts, such as the European Atherosclerosis Society, European Society of Cardiology, American College of Cardiology, and American Heart Association. When it comes to heart disease, beware of anyone claiming to have discovered the secret truth that the experts haven’t figured out. That is a big red flag telling you what you are about to read is quackery.
For other reputable resources on heart disease, nutrition, sleep, and physical activity, see the resources below (in addition to the references in the endnotes to this blog):
Yes, you can download my free heart disease prevention checklist.
It includes the ideal metrics and a place for you to record your numbers. It also includes the recommended foods (and amounts) for not only the prevention of heart disease, but also the prevention of cancer, diabetes, and Alzheimer’s disease. If you want to track your progress eating the right foods, improving your sleep, or exercising – enter your email at the bottom of this page and I will send you a printable habit tracker.
Please forward this to at least one person you care about. Following the advice in this blog could add decades to someone’s health span and lifespan, just by checking their cholesterol and treating it if it is high.
THE INFORMATION, INCLUDING BUT NOT LIMITED TO, TEXT, GRAPHICS, IMAGES AND OTHER MATERIAL CONTAINED IN THIS BLOG AND ON KEITHAHERMAN.COM ARE FOR INFORMATIONAL PURPOSES ONLY. NO MATERIAL ON THIS SITE IS INTENDED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS, OR TREATMENT. ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER WITH ANY QUESTIONS YOU MAY HAVE REGARDING A MEDICAL CONDITION OR TREATMENT AND BEFORE UNDERTAKING A NEW HEALTH CARE REGIMEN, AND NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY IN SEEKING IT BECAUSE OF SOMETHING YOU HAVE READ ON THIS WEBSITE.
I hope this contributes to your health and happiness.
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Keith Herman is a certified nutrition coach, personal trainer, and estate planning attorney. He is an elected Fellow of the American College of Trust and Estate Counsel, a former adjunct professor at Washington University in St. Louis School of Law, and winner of the Excellence in Writing Award from the American Bar Association.
Keith is the creator of the Health & Well-Being JournalTM, a daily accountability planner for optimizing your mind, body, and spirit, and tracking healthy behaviors.
He is also the author of Eat Like an Expert: How to Start Eating Healthy (and Stick to It), which combines the best of plant-based, Mediterranean, low-carb, and anti-inflammatory diets to create a customizable plan that delivers transformational results.
You can find more information about Keith at KeithAHerman.com
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