Coronary Heart Disease: Surprising New Risk Factors

By Marc Gillinov, MD, Cardiac Surgeon at Cleveland Clinic and StevenNissen, MD, Chairman of the Department of Cardiovascular Medicine at Cleveland Clinic Dr. Gillinov and Dr. Nissen are authors of Heart 411: The Only Guide to Heart Health You'll Ever Need

Coronary Heart Disease: Surprising New Risk Factors

Coronary heart disease (also called coronary artery disease or coronary atherosclerosis) is characterized by cholesterol-filled plaques that block arteries and can cause chest pain (angina) or heart attacks. As with every medical condition, the development of coronary heart disease depends upon the presence of predisposing conditions or behaviors, known as risk factors. The more risk factors that you have, the greater the likelihood that you will end up in a hospital with chest pain or a heart attack. On the other hand, if you recognize these risk factors and reduce them as much as possible, you may never need to see a heart doctor.

Risk Factors: The Usual Suspects

While some basic risk factors are beyond your control – advancing age, a family history of heart disease – others are completely up to you. Most people are aware of the usual suspects leading to coronary heart disease: high blood pressure, diabetes, obesity, tobacco use, lack of exercise, and abnormal cholesterol levels. Managing these risk factors can go a long way toward reducing your risk of coronary heart disease.

Risk Factor

Can You Change It

Your Goal

High blood pressure


BP 120/80 or less



LDL less than 130

Tobacco use


Quit smoking


Yes, if Type II

Lose weight with diet and exercise

Lack of exercise


Exercise 30 minutes a day



Mediterranean diet, watch calories, exercise daily

Family history


Be aware of your family history

Advanced age


Control the risk factors you can beginning as early as possible—That means starting right now!

The “New” Risk Factors

In the last few years, scientists have extended our understanding of the genesis of heart disease. We now recognize a host of factors and conditions with previously unsuspected links to heart disease, including inflammatory diseases, gum disease, air pollution and even sleep problems. While the link between these emerging risk factors is not as strong as the association between heart disease and high blood pressure, cholesterol or tobacco use, a growing body of evidence supports their relationship to the development of heart disease.

Inflammatory Diseases: Rheumatoid Arthritis, Psoriasis and Lupus

While scientists at one time thought that coronary heart disease was all about cholesterol, we now know that inflammation contributes to the development of artery-blocking plaque. Therefore, we are not surprised by links between a variety of inflammatory diseases and coronary heart disease, including rheumatoid arthritis, psoriasis, inflammatory bowel disease, certain muscle disorders, and systemic lupus erythematosus. Of these, we have the strongest evidence supporting the association between rheumatoid arthritis and coronary heart disease.

What should the person with rheumatoid arthritis or another inflammatory disease do about his or her heart? We suggest two important strategies.

First, manage your other cardiac risk factors; the more risk factors you accumulate, the greater your risk of heart disease. Quit smoking. Exercise. Watch your diet. Have your blood pressure and cholesterol checked.

Second, be vigilant about signs or symptoms that suggest potential heart problems (e.g., chest pain, shortness of breath, new fatigue). Don’t write these warning signs off to your arthritis or lupus. It could be your heart.

The Link Between Your Heart and Your Teeth

Large observational studies link poor dental hygiene to the development of heart disease. People with infection and inflammation of the gums face a 20-40% increase in their risk of developing coronary heart disease. In one study, people who rarely or never brushed their teeth experienced a 70% higher rate of serious heart problems; we suspect that they also had very bad breath.

As with rheumatoid arthritis, inflammation is the likely link between gum disease and arterial disease. Gum disease is actually the most common chronic inflammatory condition in the world. Recent studies suggest that improved dental hygiene both reduces gum disease and reduces inflammation in the body, leading to the possibility of improved heart health. The message is clear: brush and floss!

Air Pollution: Hold Your Breath

Most people fear that air pollution will hurt their lungs, but it turns out that their hearts also face an increased risk. Fossil fuel combustion from traffic, industry and power generation releases particles of different sizes into the air. The smallest among them – tiny invisible particles just a fraction of the width of a human hair – seem to pose a cardiovascular risk. When these particles come into contact with the inner linings of arteries, they tend to diminish blood vessel function and increase the tendency of blood to clot. These changes may explain the finding that the number of cardiac arrests in New York City tends to increase on days that the Environmental Protection Agency reports poor air quality.

What can you do about this? First, don’t worry too much. In a given individual, the actual risk posed by air pollution is actually quite small: Exposure to severe air pollution increases the odds of having a heart attack by less than 5% (by comparison, cocaine use increases the risk 230%). If possible, try not to travel during rush hour. You can determine your local air quality by visiting the website When the air quality index for particulate matter is in the unhealthy range, limit your outdoor activity, and try to schedule your outdoor workouts away from rush hour traffic.

A Good Night’s Sleep: Rest for the Heart

Over the last 50 years, the average American’s nightly sleep has been cut by 2 hours. And recent observational studies suggest a link between sleeping 6 hours per night or less and coronary heart disease. In addition, irregular sleep schedules associated with working the night shift or rotating shifts have been tied to changes in blood pressure and blood sugar that could adversely affect cardiovascular health. The message here: A good night’s sleep makes you feel better and may also be a good strategy for your heart.

The evidence linking sleep disturbances to cardiovascular health is strongest with the condition of obstructive sleep apnea, a malady that affects about 10% of adults. In obstructive sleep apnea, periods of sleep are interrupted when the muscles of the throat and airway relax enough to narrow or block the upper airway. As the person struggles to draw a breath, breathing halts for a moment and the person awakens briefly as he gasps for breath. During the struggle to breathe, blood pressure can reach 240 mm Hg. Over the course of the night, this pattern may repeat itself dozens of times, although the affected person has no memory of the struggle to breath or waking up.

People with sleep apnea face increased risks of coronary heart disease, heart attack, stroke, high blood pressure, and abnormal heart rhythms.

Clues to a diagnosis of sleep apnea include loud snoring and constant fatigue. If you have these symptoms, see a sleep specialist.

Treatment of sleep apnea includes weight loss in those who are overweight and continuous positive airway pressure (CPAP), delivered via a tight-fitting mask. These measures are effective in most people; they restore good sleep and may provide some welcome relief to your cardiovascular system.

The Key to Avoiding Coronary Heart Disease

Cardiovascular disease is our nation’s number-one health problem. The good news here is that we recognize many of its causes. Manage your risk factors, both the traditional risk factors and the emerging markers of disease. You can control your heart health. You can prevent a heart attack!

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