Role of Inflammation in Heart Disease: What PCPs Should Know

In the United Sates, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups. Not only that but also the number of heart-disease related deaths began increasing in 2012, following decades of progress. There are numerous theories as to why, but the bottom line as a primary care physician is that you’re going to have patients with high risk factors for heart issues.

In that role, your own understanding of heart disease is critical, so that you can translate the information to your patients. One sometimes misunderstood factor in heart disease is inflammation — what it is, how it raises heart health risks, and how patients can keep its impact to a minimum. One thing is for certain: Chronic inflammation plays a contributing role to heart disease in several ways.

When occurring in the right dose, inflammation is a key piece of your immune system. Say you twist an ankle — the immediate puffing up is an inflammatory response and is designed to help with the healing process. In this acute, specific setting, inflammation is good. Where it becomes problematic — especially with regard to heart health — is when it enters a chronic, and/or systemic state.

“Inflammation works in both chronic and acute ways to increase cardiovascular disease,” said Erica Spatz, MD, cardiologist and associate professor at Yale School of Medicine, New Haven, Connecticut. “In its chronic form, inflammation can be subclinical, only detectable with biomarkers such as hs-CRP [ high-sensitivity C-reactive protein test] and IL-6 [interleukin-6]. Subclinical inflammation can lead to atherosclerosis and coronary artery disease.”

Erica Spatz, MDEven when controlling for traditional risk factors, studies have revealed how big a role inflammation plays. The liver makes CRP, and when there’s inflammation in the body, these numbers increase. A simple blood test can reveal this information, and a hs-CRP picks up on smaller increases in CRP.

High levels of hs-CRP are linked to increased risks for heart attack, and for people who have already experienced a heart attack, the risks for another are higher if they have a high hs-CRP. While these tests cannot point specifically to where the inflammation is occurring, they are a good indicator that the patient could be vulnerable to heart disease and its related issues.

To help your patients mitigate inflammation in their systems — and thus help them reduce the odds of heart-related health issues, you need to be armed with the right information.

Mitigating RisksInflammation in many settings or body parts can be a positive thing, but when it’s chronic and occurring in the arteries, it contributes to plaque buildup and a narrowing of the arteries — atherosclerosis. That same plaque buildup can also create an environment that produces blood clots, another life-threatening effect.

This result and inflammatory state don’t happen overnight.

“It builds up slowly over time,” said Niya Jones, MD, a cardiologist at the University of Maryland Medical Center. “Even more concerning is that we’re seeing these changes earlier and earlier. People in their 20s are already presenting with changes that predispose them to a heart attack later.”

Lifestyle choices are a likely contributing factor in this unfortunate trend. “Given our current diets, young people are setting up for issues down the road,” said Jones.

Research long ago established that diets high in saturated fats, sugars, and highly processed foods are all contributing factors to heart disease. Yet Americans continue to eat diets rich in all these foods. Providing your patients with standard heart-healthy diet advice and warning against diets full of foods that raise inflammation is essential, and it’s never too early to begin those conversations.

Other common contributing factors to inflammation include smoking, obesity, and even high stress levels.

“We know people are more likely to have heart attacks on Monday morning before returning to work,” Jones said. “It’s important to prioritize overall wellness and find stress release.”

Another contributor — and a growing trend — is mental health issues, which is why it’s important from primary care providers to address things like depression, anxiety, and trauma/posttraumatic stress disorder, “which can directly increase inflammation and thereby increase cardiovascular risk,” Spatz said.

The role of adequate sleep and rest is also key. Studies have demonstrated that sleep deprivation contributes to inflammation. Coaching patients on good sleep hygiene — dark, cool rooms, shutting down screens an hour before bed, and a regular bedtime — can all be a part of your toolkit.

While lifestyle is likely the biggest role you can address with your patients when it comes to reducing inflammation that might lead to heart disease, don’t overlook preexisting conditions.

“Autoimmune diseases like lupus and rheumatoid arthritis are hard on the body,” said Jim Liu, MD, a cardiologist at The Ohio State University Wexner Medical Center, Upper Arlington, Ohio. “Dysregulation is a risk factor for coronary artery disease, so it’s important that your patients have those conditions under control, too.”

While addressing these conditions is essential, sometimes you’ll need to add medications to the mix.

“There are also several pharmacological classes that lower inflammation,” Spatz said. “Statins not only lower cholesterol but they also lower inflammation. In doing so, they reduce plaque progression and stabilize existing plaque, so it doesn’t rupture.”

Other medications can play a role in inflammation reduction, too.

Jim Liu, MD“Colchicine is an anti-inflammatory medication typically used for pericarditis and gout,” Spatz said.

Clinical trials, however, have shown colchicine also helps reduce cardiovascular events in patients discharged from the hospital after acute coronary syndrome and in with chronic coronary disease, Spatz said. Also, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors have anti-inflammatory effects, which may contribute to their efficacy in reducing cardiovascular events, he said.

Another preventative is getting an annual flu shot, especially in the case of patients with autoimmune disease.

“This is a recommendation from the American College of Cardiology,” said Liu. Research shows that when patients understand flu prevention is linked to heart attack prevention, they’re more likely to seek the annual vaccine.

Finally, whenever you believe a patient is likely to be suffering chronic inflammation and more likely to therefore suffer a heart-related incident, referring them on to your cardiologist partners is the right move.

“It’s really never too early for that,” said Liu. “If you’re wondering if they should have bigger preventative measures, or if they show any risk factors, it’s fine to send them on to a specialist.”

Jones agrees with this. “Most primary care physicians can handle the garden variety of high cholesterol,” she said. “But if they’re on a statin and their numbers are still sky high, consider a cardiologist.”

Likewise, if your patients’ triglycerides are high, it may be a harbinger of a predisposition. “A specialist might have more time to dig into a patient’s history and lifestyle, and uncover a contributing factor,” said Jones. “These can be tough conversations to have with patients, but it’s smart to act before they develop coronary disease.”