Nicholas Paivanas MD

Most of the time, when we talk to patients about dealing with their risk for heart disease, we’re speaking to people in their 50s or older. These patients unfortunately often present after they are feeling bad and need to make changes immediately.However, when it comes to younger adults—those in their 20s or 30s—it’s often a different story. These patients usually have a family history of heart disease, and either genetic predispositions or lifestyles may have them sitting on risk that could build up for decades, eventually leading to serious heart problems. It can be challenging to take action against heart disease when you might not even notice any problems for 10 or 20 years, but our goal for younger patients is to prevent problems before they ever start. We most often see young adults after they’ve been referred to us by their primary care doctors. They might have gone to the doctor for a regular checkup or some other problem. During that visit, warning signs such as inappropriately high blood pressure or cholesterol can identify an increased risk for developing cardiovascular disease. Sometimes, even when there are no other risk factors, a strong family history of heart disease can identify when someone is at an increased risk for developing heart disease.Related reading: High Blood Pressure in Young Adults: What Causes It, and How Do We Treat It?Sometimes, however, the process is driven by the younger patients themselves rather than their doctors. They tell us that their mom or dad had a heart attack in their 30s or 40s, and they want to know what they should be doing so that doesn’t happen to them. In both cases, it’s great when younger adults are proactive about their risk factors for heart disease, as it’s much better to prevent heart issues before they start than it is to treat them after damage has started to occur. It's often easier to address heart disease for older people compared to their younger counterparts. Unfortunately, older patients often have developed symptoms of heart disease or have seen a friend or loved one with heart disease, which has led them to the doctor’s office.In a younger patient with no symptoms, however, they’re much less likely to take a medication that causes unwelcome side effects, such as drowsiness, headaches, increased urination, or nausea (common effects of some medicines). From the young adult’s perspective, this makes sense. They feel fine, they’re not sick, so why take medicine that makes them feel bad?We have to be more strategic with our treatment plans for young adults. They have to have therapies that are simpler to incorporate into their lives. It’s much easier to make time for a pill taken just once a day versus one that they have to take two, three, or more times in a day. Also, we have to consider medications with minimal side effects so the patients continue to take their medications as directed, rather than skipping doses or stopping treatment. Click to Tweet With older patients, as well as those with active heart disease, it’s obvious when we’re making progress in our treatment regimens. They may experience less pain or shortness of breath, increased energy, and other benefits that are clear to see. However, with a younger adult who may not yet have experienced heart disease symptoms, it’s often harder to see progress. That can make it harder to keep them motivated to continue with their treatment. So we frequently have to take a deeper dive with how we measure our efforts. Many times, we’ll follow younger patients’ bloodwork more closely to demonstrate the benefits of their treatment, which might not be so obvious otherwise. For example, if a patient has high cholesterol, and we get them on lifestyle changes and cholesterol-lowering medications, I’ll follow their blood cholesterol over several office visits to demonstrate how well they’re doing and how much progress they’ve made over a period of time. That data can provide the gratification and sense of accomplishment a younger adult needs to stay on track with their treatment. Seeing data is another great way to help track progress. That’s why I’ve enjoyed seeing smartwatches and fitness trackers become more prevalent in recent years. These devices are a great way to let young adults set and measure goals related to their heart health, such as: Heart rate Quality of sleep, especially for patients with or at risk of sleep apnea Steps taken Time active per day With busy schedules in both work and home lives, many young patients find it difficult to set aside 30, 60, or 90 minutes each day to hit the gym or go for a jog. But if their regular activities allow them to get in about 10,000 steps per day—which has been shown as a reasonable amount for most healthy adults—and if they can track that with their fitness trackers, they can see that they’re still getting their heart rate up and getting the cardiovascular exercise they need each day. Also, the ability to track often can motivate younger adults to have fun healthy competitions with family members, friends, or coworkers on who can get the most steps in, which can only help them with their heart disease risk in the long run.Prevention of heart disease can have massive positive effects in the life of a young adult—far more than simply reacting to heart disease that has already developed. By living a healthy lifestyle, increasing activity levels, eating right, and not smoking, these patients are avoiding the kind of damage that can build for decades and develop into heart disease. By the time someone develops heart disease, our options are much more limited.If you have a family history of heart disease, or if you are concerned about your risk, talk to your primary care doctor or a cardiologist and get a complete evaluation. It’s much easier to take action today to prevent heart disease than it is to try to treat it after damage has been done.

We often see patients who aren’t the type of people you’d expect to see in a cardiologist’s office. They’re not older folks with obvious risk factors for heart disease, such as obesity or diabetes. These are young, physically fit adults—often young men—who have been referred to us after having high blood pressure or other heart-related trouble with no apparent reason for their symptoms. Along with the usual tests, we’ve gotten into the habit of asking these patients if they’re currently taking any workout or pre-workout supplements, as patients often don’t think to note these items on their lists of current medications. Many times, they tell me they are taking one or more of these supplements. It’s important to note that not all supplements are bad; in fact, some can provide a powerful edge in workout routines. But due to the nature of supplements, it’s sometimes difficult to know exactly what you’re putting into your body, and very easy to suffer heart-related side effects from them if you’re not careful. Almost invariably, if one of my patients is taking a pre-workout supplement, its ingredients will include caffeine or some other stimulant. Caffeine is included in many supplements taken before exercise because it makes you feel good, gives a slight sense of euphoria, and gives you a burst of energy during your workout. In moderation, caffeine is safe for your heart. Studies have found that it’s safe for adults to consume about 400 milligrams of caffeine per day. That’s the equivalent of the amount of caffeine in just over four 8-ounce cups of coffee, according to the U.S. Department of Agriculture (USDA). The problem with supplements, energy drinks, and other workout-related products, however, is that they often contain huge amounts of caffeine—far more than the USDA’s recommended daily limit in one concentrated serving. Some popular pre-workout supplements contain more than the USDA’s maximum dose of caffeine in just one serving. Consuming high doses of caffeine from pre-workout supplements, on top of your normal daily intake of caffeine in coffee, soda, or other sources, can lead to a number of heart-related side effects, including increased blood pressure (hypertension), which can raise your risk of a heart attack. It can also lead to palpitations and other heart rhythm problems. These effects can vary from person to person, which is why it’s important to discuss your pre-workout and workout regimen on an individual basis with your primary care doctor or a cardiologist. Click to Tweet Related Reading: How much caffeine is safe for you and your child Unfortunately, supplements aren’t controlled or regulated by the Food and Drug Administration (FDA) as strictly as medications are, so we often don’t know exactly what they contain. This often makes it easier for supplements to cause harmful side effects that are challenging to track down due to hard-to-identify ingredients. When patients who are taking workout supplements come see me, I do a search of pharmacology references and medical literature to look for side effects other people may have experienced as a result of that specific supplement. For example, I had one patient who was experiencing vasospasms, a sudden contraction of the blood vessels that can reduce blood flow. As we talked about what medications and supplements the patient was taking, to our surprise we found that the patient was taking a number of supplements that are marketed as being heart healthy, but can also cause vasospasms. By eliminating the supplements that could lead to vasospasm, we were able to improve the patient’s symptoms. I’ve seen patients who have noticed many symptoms, whether heart-related or affecting other areas of the body, that ended up being related to their intake of workout supplements, such as: High blood pressure Heart palpitations or tachycardia Liver toxicity Rhabdomyolysis, a breakdown of muscle fibers and tissue Spontaneous coronary artery dissection (SCAD), a tear in the wall of an artery I wish I could say there was a “magic bullet” out there—a single supplement you could take or one thing you could do to protect yourself from heart-related supplement side effects. But it takes patience and discipline to live a healthy lifestyle that complements your fitness routine. I believe that a natural approach is best, but I'm talking about real, wholesome foods, not supplements that often are ground up; concentrated; and sold to you in pill, powder, or drink form. If you can look at something on the shelf at your grocery store and know it’s a tomato, a carrot, or some other fruit or vegetable, that’s a natural product. If it’s hard to identify what ingredients originally went into the product because it’s in a pill bottle, I would treat that as a potentially powerful medicine, and check with your doctor before taking it. Another thing I tell patients is that moderation is key. Too much of any one thing is dangerous. It’s important to get a wide variety of vegetables, fruits, and other foods to boost your energy naturally and fuel a productive workout. When I was growing up, our parents and teachers used to tell us to “eat the rainbow.” That refers to having a plate that’s full of many colors of fruits and veggies, which means you’re getting a good balance of nutrients. If you find yourself craving a snack or wanting a little extra energy for your workout, reach for some nuts, especially almonds. Healthy, low-sodium nuts can boost your energy levels while cutting your cholesterol and lowering your blood pressure, and they’re pretty light on calories. Some of my patients take protein supplements for weightlifting because they want to build muscle. However, my advice is to put away the protein shake and increase the amount of natural protein in your diet. Good dietary protein sources include: Chicken Chickpeas Eggs Fish Lentils Milk Peas Of course, many people take their supplements because they feel good from the energy boost they get to power through their workouts. However, if you’re doing a high-intensity, calorie-burning workout, carbohydrates are an excellent source of long-lasting energy. I know many fitness enthusiasts avoid carbs at all costs, but consider incorporating some healthy sources of unprocessed carbohydrates, such as: Beans Oatmeal Starchy vegetables, such as potatoes, carrots, and squash Whole-wheat bread As our country faces an ongoing obesity epidemic, which affects nearly 40 percent of the U.S. population, exercising and living a healthy, active lifestyle is essential. Just recognize that, when you incorporate supplements into your fitness routine, you are taking medications that have side effects. And because supplements aren’t as well-regulated as pharmaceutical drugs are, we often can’t say for sure what effects those supplements are having on your heart. Whenever possible, stick to natural foods as part of your overall wellness regimen, and ask your primary care doctor or cardiologist if you have concerns about how your workout routine might be affecting your heart.

We all know that cold weather can contribute to many common health conditions, such as colds or the flu. However, a new study shows that more serious health complications also can arise—such as heart attacks. In November 2018, the journal JAMA Cardiology published a study that examined the relationship between cold weather and heart attacks. Researchers looked at incredibly detailed data from a 15-year period in Sweden using the country’s online cardiac registry, Swedeheart, along with information from the Swedish government’s weather institution. They found that days with below-freezing temperatures had the country’s highest incidence of heart attacks. Days with high wind speeds and shorter durations of sunshine were also associated with a higher risk of citizens having heart attacks. When I look at this study and its results, I see two areas of potential risk for patients: the actual effects cold temperatures have on the body and people’s activity levels after a sudden winter storm. Both of these factors can combine with tragic results in patients who aren’t properly prepared. Cold temperatures affect the body in many ways that can increase your heart attack risk. For example, cold causes the body’s blood vessels to constrict, or narrow, especially in the arms and legs. This is called peripheral vasoconstriction, and it’s a phenomenon that allows the body to conserve its core heat for as long as possible by restricting blood flow to the areas farthest from the heart. However, this constriction of the blood vessels causes your blood pressure to increase, which can put added stress on the heart, as it has to force blood throughout your body against higher pressure. Additionally, colder temperatures cause your blood’s platelets to stick together more than normal. While platelets typically clump together to form clots that help seal bleeding wounds, cold weather can increase your risk for a dangerous blood clot to form inside your body. Also, if you have a buildup of plaque (a hard substance made of fat, cholesterol, calcium, and other substances in your blood) in your arteries, the colder air could increase the risk of that plaque rupturing, which can lead to a heart attack. All of these factors cause your heart to work harder to pump the exact same amount of blood. Logically, that means people should scale back on their physical exertions during cold weather to take it easy on their hearts. Unfortunately, many people actually increase their physical exertion in the cold, not decrease it, which can dramatically increase their heart attack risk. Much of the increased physical activity we see relating to cold weather comes from shoveling snow. Most folks don’t realize how stressful shoveling the driveway or walks will be, as their frame of reference is what they were doing in the yard last spring, summer, or fall. Shoveling is a deceptively extreme exertion that many people aren’t used to, especially if they’re not already exercising regularly or otherwise lowering their risk of heart disease. On top of this, most people are driven by completion of the task at hand rather than their body’s signals to rest and take a break. In just a couple hours of shoveling, some people can double or triple their usual daily activity levels. I attended medical school here at Georgetown, but did my post-graduate medical training in Rochester, N.Y.—an area that routinely sees more than 100 inches of snow during the winter. After a big snowstorm, my colleagues and I would often wonder if we would get a patient in the hospital who had suffered a heart attack after shoveling snow, and we often did. Essentially, if people aren’t getting much exercise on a regular basis, and then they’re shifting into high gear to shovel out driveways and sidewalks after a massive snowstorm, they’re putting their hearts through an extreme stress test. Unfortunately, in many cases, they’re failing that test by having heart attacks. Click to Tweet One interesting item I noticed in the Swedeheart study was that there was a greater increase in heart attacks relating to cold weather in places where the weather changed from warm to cold. In places where it’s always cold, people seemed to tolerate it better, whether their bodies have adapted to the temperatures or whether they’ve adapted their behaviors to the weather. There are three main levels of heart attack risk relating to the cold and snow. The first level includes people who have been under a doctor’s care for some time for heart disease, heart failure, high blood pressure, high cholesterol, or other heart-related issues, as well as those who have had a heart attack in the past. I put these patients in the lowest risk level because, they’re taking care of themselves —that is, taking their medications, controlling their risk factors, and generally protecting themselves. The next level up includes people who have recently been diagnosed with heart problems and who are still working with their doctors to optimize their treatment plans. These patients are vulnerable because they may not have a risk factor fully controlled yet, such as their high blood pressure, which can skyrocket after a hard session of shoveling snow or other strenuous activity in the cold. The people who are at greatest risk are those who never see the risk coming. They’re the people who feel good at rest, but have unknowingly developed severe narrowing in an artery. If they decide to go shovel snow when it’s 20 degrees, the stress on their blood vessels can cause a blockage to rupture, and then they suffer a heart attack. That can be a life-threatening emergency, especially if they’re outside alone. The best overall protection for your heart is to take steps to reduce or eliminate major risk factors for heart disease. These steps include: If you smoke, stop: The Pulmonary Services department at MedStar Washington Hospital Center can help you quit Get enough exercise: The American Heart Association recommends at least 2.5 hours of vigorous exercise per week, which works out to 30 minutes a day, five days a week Eat a heart-healthy diet: Consume everything in moderation! Make sure you’re getting a variety of fruits and vegetables, whole grains, low-fat dairy, and other healthy choices, and limit red meats and sweets If you have high blood pressure and monitor your blood pressure numbers at home, watch your numbers after you’ve been active in the cold. Don’t let them rise too high without taking a break. While you’re in the cold, pay attention to what you’re doing and how tired you are. Make a conscious effort to limit your activity levels to less than what you normally would do in moderate or warm temperatures. If you must shovel snow, make sure someone knows where you are and can either share the workload or check on you from time to time. Finally, watch for symptoms that could indicate a heart attack. These symptoms can include: Chest pain, discomfort, or pressure Pain in other areas of the body, such as the back, neck, or jaw Fatigue, lightheadedness, or dizziness Nausea, indigestion, heartburn, or pain in the abdomen Shortness of breath If you notice any of these symptoms, call 9-1-1 right away. Frigid weather can be dangerous for your heart. If you’re at risk for heart disease, get checked out by your primary care doctor or a cardiologist. And when the cold and snow strike, take it slow, don’t overexert yourself, and stay safe out there. Request an Appointment