Heart healthy lifestyle

Healthy lifestyle choices can significantly reduce the risk of developing HF. Healthy behaviors can also reduce the severity of some HF symptoms. Currently a heart health lifestyle includes regular physical activity, eating healthy foods and eating breakfast, weight management, and not smoking.

Regular physical activity

The CDCs Physical Activity Guidelines for Americans, 2nd edition (2018) recommendations for adult exercise includes 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity such as brisk walking every week. They also add this exercise can be done at 10-minute increments, 30 minutes a day. https://health.gov/paguidelines/second-edition/pdf/PAG_ExecutiveSummary.pdf.

Pal, Radavelli-Bagatini, and Ho (2013) reviewed original articles on the impact of exercise on blood pressure and vascular function. They found regular exercise of 30 minutes most days a week improved blood pressure level.

A recent study (Hirsch, 2016) showed 25% of Americans use some type of digital process to monitor health activities. Of the ones that are used 40% are wearables, are used to track steps and/or heart rate. Information on bracelets and clip on monitors that measure steps and calorie output could also be included in exercise instructions.

Healthy foods and cholesterol

The following foods are described in Harvard’s heart letter (2019) as foods that lower cholesterol:

Omega-3 fatty acids

Researchers from the Mayo Clinic (Alexander, et al., 2017) conducted a meta-analysis with data from 18 randomized controlled trials and 16 prospective cohort studies on the impact of Omega-3 fatty acids (EPA+DHA) on coronary heart disease risk. They found EPA+DHA from foods or supplements resulted in a statistically significant lowered risk, up to 18%, of a CHD event in patients who were in a higher risk population, particularly those with elevated triglyceride levels and elevated LDL cholesterol levels. Patients with seafood allergies need to consult with their physicians, as Omega-3 supplements are usually derived from fish products.

Medications that lower cholesterol levels: Statins and PCSK9 inhibitors

Statins are important to the overall management of cardiovascular risk for many patients. They are relatively low cost, orally administered medications that effectively reduce plasma cholesterol. The most popular ones are atorvastatin (Lipitor), simvastatin (Zocor), and rosuvastatin (Crestor).
Total cholesterol levels for adults should be less than 200 milligrams per deciliter (mg/dL). A reading between 200 and 239 mg/dL is considered borderline high and a reading of 240 mg/dL and above is considered high. LDL cholesterol levels should be less than 100 mg/dL. HDL levels should be higher than 60 mg/dl

PCSK9 inhibitors

PCSK9 inhibitors are a new class of drugs that can dramatically reduce plasma levels of low-density cholesterol (LDL-C), the bad cholesterol.

PCSK9 inhibitors can be used alone or in combination with statins although research is ongoing to measure efficacy and side effects. The New England Journal of Medicine published several studies demonstrating the efficacy of evolocumab, bococizumab and alirocumab. Both drugs used separately with statins lowered cholesterol dramatically, sometimes as much as 60%. These are now niche drugs most commonly used in conjunction with statins to reduce cholesterol levels in patients who did not respond to statins alone.

There are some disadvantages to PCSK9 Inhibitors. They are currently given twice a month by injection. They are more expensive, up to $7,000 to $9,000 a year. They are generally well tolerated but the side effects can include nasopharyngitis, itching, flu, injection site reactions, and serious allergic response (Curfman, 2015).

Eating breakfast

According to a recent study by Rong, et al. (2019) eating breakfast every day promotes cardiovascular health. In a prospective study of 6,550 adults 40 to 75 years of age, subjects were interviewed to determine if they never ate breakfast (5.1%), rarely ate breakfast (10.9%), ate breakfast some days (25.0%), and ate breakfast every day (59.0%).

During the follow up, there were 2, 318 deaths of which 619 were deaths from cardiovascular disease. Participants who never ate breakfast compared with those eating breakfast everyday had hazard ratios of 1.87 (95% confidence interval: 1.14 to 3.04) for cardiovascular mortality and 1.19 (95% confidence interval: 0.99 to 1.42) for all-cause mortality. The authors concluded not eating breakfast significantly increased the risk of dying from cardiovascular disease.

This study supports the results of a study by Cahill, et al. (2013) who studied 26,902 men from the Health Professional follow-up study. It has been known from other research that skipping meals is associated with excess body weight, hypertension, insulin resistance, and elevated fasting lipid concentrations. Skipping breakfast seems to have the strongest health impact. Cahill et al. found men who skipped breakfast had a 27% higher risk of CHD compared with men who did not (relative risk, 1.27; 95% confidence interval, 1.06–1.53). The authors also concluded eating breakfast was associated with significantly lower CHD risk.

Weight management

According to Riaz (2014) there is an established link between obesity and hypertension and LVH in various epidemiologic studies. As many as 50% of obese patients have hypertension.
Patients should be encouraged to maintain their Body Mass Index (BMI), a calculation of height and weight, below 25 to reach a normal weight category.

BMI Metric formula

BMI Categories:
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater 

Weight in kilograms/height in meters2

BMI Imperial formula

(Weight in pounds x703) / height inches2

In a review of 45 weight loss studies of commercial weight loss programs, Gudzune, et al. (2015) found when compared with control and education groups participants in Weight Watchers achieved a minimum of a 2.6% greater weight loss with participants in Jenny Craig a 4.9% greater weight loss at 12 months. The authors recommended referrals to Weight Watchers or Jenny Craig. Other systems need further investigation of efficacy. (for more information refer to the following continuing education course: Obesity: Etiology, Assessment, Medical Treatment.)

Instant Feedback:
A BMI of over 25 is generally considered overweight.

Smoking cessation

Smoking is reported by the U.S. Department of Health and Human Services (2014) to be a major cause of CVD and the cause of one of every three deaths from CVD. It increases the buildup of plaque in blood vessels and causes thickening and narrowing of blood vessels all of which contribute to hypertension. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf

Smoking cessation programs are generally classified as pharmacotherapies or behavioral therapies. FDA approved pharmacotherapies include nicotine-based medications; patches, gum, inhaler, lozenges and nasal spray and non-nicotine-based medications such as bupropion and varenicline.
Behavioral therapies include the use of a partner, counseling services, hypnosis, and professional advice from a physician or nurse. There are many reports of the efficacy of these programs. The smoker's motivation and age is a significant factor besides the method used in producing smoking cessation.

Most reports show it takes multiple attempts due to relapse rates to produce permanent smoking cessation. One report showed hypnotherapy produced better efficacy than nicotine replacement therapies (NRT). The researchers reported 36% of hypnotherapy patients to be nonsmokers at 26 weeks compared with 18% of the NRT patients (Hasan, 2014).


Alexander, D. D., Miller, P. E., Van Elswyk, M. E., Karatko, C. N. & Bylsma, L. C. (2017). Meta-Analysis of Randomized Controlled Trials and Prospective Cohort Studies of Eicosapentaenoic and Docosahexaenoic Long-Chain Omega-3 Fatty Acids and Coronary Heart Disease Risk. Mayo Clin Proc. 92(1), 15-29.

Appel L., Brands M., Daniels S., Karanja N., Elmer P., Sacks F., (2006) Dietary Approaches to Prevent and Treat Hypertension. Hypertension, 47(2). Accessed 10/6/2016 http://hyper.ahajournals.org/content/47/2/296

Cahill, L. E., Chiuve, S.E., Mekary, R. A., Jensen, M. K., Flint, A. J., Hu, F. B., et al. (2013). Prospective Study of Breakfast Eating and Incident Coronary Heart Disease in a Cohort of Male US Health Professionals. Circulation.128, 337–343.

Curfman, G. (2015). PCSK9 inhibitors: a major advance in cholesterol-lowering drug therapy. Harvard Health Publications. Accessed August 7, 2016 at http://www.health.harvard.edu/blog/pcsk9-inhibitors-a-major-advance-in-cholesterol-lowering-drug-therapy-201503157801

Gudzune, K. A., et al. (2015). Efficacy of Commercial Weight-Loss Programs: An Updated Systematic Review. Ann Intern Med. 162(7),501-512.

Harvard Heart Letter (2019). 11 foods that lower cholesterol. Cambridge, Mass: Harvard Health Publishing.

Hasan, M., et al. (2014). Hypnotherapy is more effective than nicotine replacement therapy for smoking cessation: results of a randomized controlled trial. Complement Ther Med. 22(1),1-8.

Hirsch, M. (2016). Consumer Use of Digital Health Tools at 'Tipping Point’. Hospital and Health Network. http://www.hhnmag.com/articles/7950-consumer-use-of-digital-health-tools-at-tipping-point

Pal, S., Radavelli-Bagatini, S. & Ho, S.(2013). Potential benefits of exercise on blood pressure and vascular function. J Am Soc Hypertens. 7(6), 494-506.

Riaz, K. & Ali, Y.S. (2014). Hypertensive Heart Disease. The Heart.org. Medscape. Accessed from https://emedicine.medscape.com/article/162449-overview#a1

Rong, S., Snetselaar, L. G., Xu, G., Sun, Y., Liu, B., Wallace, R. B. et al. (2019). Association of Skipping Breakfast With Cardiovascular and All-Cause Mortality. Journal of the American College of Cardiology. 73(16). DOI: 10.1016/j.jacc.2019.01.065