Heart Disease Runs in Your Family. Which Kind?
Specificity could save your life 💌
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A 60-something year old patient I’ve known for ages recently came to see me, bursting with news to share. She had just learned that her grandfather died of heart disease in his 50s, and she wanted to know: should she see a cardiologist?
As my patients will attest, teaching cardiac anatomy and physiology to my patients is one of my favorite office activities. So when patients ask whether they should see a cardiologist, or tell me that they have a family history of heart problems, I instantly become that persnickety high school English teacher who marks up your papers in red pen, instructing you to BE MORE SPECIFIC.
So I asked my patient, “What kind of heart disease did your grandfather have?”
She looked down at her notes. She looked back up and wrinkled her nose. “Umm … I’m not sure. Just … heart disease, I guess?”
I reassured her that it’s okay not to know! And that even the most well-informed, motivated patients often don’t have a clue what “heart disease runs in my family” really means. But until you know, you can’t formulate a targeted prevention plan.
Specificity matters. Asking a doctor for general advice on preventing heart disease is, of course, very reasonable. It will fetch you a decent answer. But to get the heart health advice you actually need, let’s practice posing more targeted questions to your doctor—and, even before that, to your family tree.
What I need to know first is, What kind of heart disease runs in your family? Once I know that information, I can answer the question you’re intending to ask, How do I protect myself against THAT kind of heart disease?
“Heart disease” is more than one disease
Heart disease is the #1 cause of death in the United States. In 2022, it was responsible for roughly 941,000 deaths in this country, more than all cancers and accidents combined. When people say “heart disease,” they almost always mean the kind where cholesterol plaque narrows the blood vessels feeding the heart muscle itself. It is the most common type. Coronary heart disease accounted for about 39.5% of all cardiovascular deaths in 2022, and it is why someone in the U.S. has a heart attack every 40 seconds.
But coronary disease is only one type of heart disease.
The way I explain it to patients is this: your heart is a house. And like any house, it has three main systems that can break:
Plumbing
This is the network of blood vessels that brings oxygen and nutrients to the heart muscle—aka the coronary arteries. When cholesterol plaque builds up in these arteries, the pipes narrow. Blood flow to the heart muscle diminishes. If a plaque ruptures and a clot forms, the pipe closes shut and a section of heart muscle gets deprived of oxygen and can “die.” That’s a “myocardial infarction” or heart attack. This is coronary disease. This is what most people are thinking of when they say “heart disease runs in my family.” The risk of coronary disease—aka clogged pipes—is one of the main reasons doctors beat the diet and exercise drum.
Electricity
The heart is also an electrical organ. It beats roughly 100,000 times a day because of a sophisticated electrical signal that travels through the muscle in a precise rhythm. When this electrical wiring misfires, the heart beats too fast, too slow, or chaotically. Atrial fibrillation is the most common type of electrical heart disease. PSVT (paroxysmal supraventricular tachycardia), heart block, and inherited conditions like long QT syndrome are others. These are called arrhythmias. Some are dangerous; some are just nuisances. Most have little to do with cholesterol. Most are informed by lifestyle factors that patients often have no idea about. (E.g, sleep apnea and alcohol are major risk factors for atrial fibrillation, yet very few patients with afib seem to be informed about this.)
Windows and doors
Finally, the heart has structure—four chambers separated by valves that swing open and shut with every beat, keeping blood flowing in the right direction. When a valve gets leaky or stiff (think: mitral valve prolapse, aortic stenosis, a congenital bicuspid valve), blood can flow backward, in the wrong direction, or get stuck. These are the windows and doors of the house: valvular and other structural problems. Sometimes you are born with them. Sometimes they develop with age or after a viral infection. And sometimes they stem from lifestyle factors that are very much under your control.
So when a patient tells me heart disease runs in her family, the first thing I want to know is which house system was broken. Was it your grandfather’s plumbing (a heart attack at 55)? Your aunt’s electricity (atrial fibrillation that caused a stroke)? Your cousin’s structure (a leaky valve repaired in his 40s)? Each of these has a different inheritance pattern, a different workup, and (this is the part most people miss) a different set of levers you can pull to prevent and treat it.
Make sure you are solving the right problem
Once you know which kind of heart disease actually runs in your family, you can take more selective action, be it lifestyle changes or medication adjustments or practicing acceptance over the things you cannot control.
Take coronary disease, which is the concern my patient walked in with. Yes, genetics matter. A first-degree relative (a parent or sibling) with premature coronary disease—that is, men before 55, women before 65—roughly doubles your risk. Grandparents, aunts, and uncles count too, especially when a pattern emerges across generations. Lipoprotein(a), a genetically determined particle that I now check on every adult at least once, is another inherited driver that mainstream medicine has been slow to discuss.
And yet.
A landmark 2016 study in the New England Journal of Medicine looked at more than 55,000 people and sorted them by their genetic risk for coronary disease. The researchers then asked a simple question: among people dealt the worst genetic hand, how much does lifestyle actually move the needle?
The answer is empowering! Among participants at the highest genetic risk, a healthy lifestyle (e.g., not smoking, exercising regularly, and eating a reasonable diet) was associated with roughly a 50% lower rate of coronary events compared with an unhealthy lifestyle. Half! And this is in the people with the worst genes.
It’s not that genetics don’t matter. They do. It’s that even when biology has dealt you a difficult hand, your daily choices are still the single biggest variable in the equation.
What you cannot change, and what you can
What you cannot change:
Your age
Your sex at birth
Your family history (the actual facts of it)
Your Lp(a)
The genes you inherited
What you can change (with or without help):
Your LDL cholesterol (with diet, sometimes with a statin—and we should stop pretending statins are controversial; they aren’t)
Your blood pressure to a certain degree (see: my upcoming talk with cardiologist Greg Katz)
Whether you smoke
Whether you sleep, move, and manage stress
Your weight, to the extent that is possible for your body and life
How much alcohol you drink
Whether you take the medications you have been prescribed (and whether you trust the prescriber)
Roughly 47% of American adults have at least one of the three major modifiable risk factors for heart disease: high cholesterol, hypertension, or smoking. None of these is glamorous, but they are also the most powerful tools you have.
Your three A’s for cardiovascular health
Awareness. Instead of asking your family, “Did anyone have heart disease?” Ask: What kind of heart disease? At what age? Was it a heart attack, a rhythm problem, or a valve? Did anyone die suddenly? Did anyone get a stent or bypass before 60? Write it down. Bring it to your next physical. This conversation is worth more than any wearable device.
Acceptance. You did not pick your parents. You cannot optimize your way out of an elevated Lp(a). Despite what the fitness and nutrition industries will tell you, lifestyle is necessary but not sufficient for cardiovascular health. Some of your risk is fixed. Pretending otherwise is its own form of magical thinking. (To every fitness enthusiast with coronary disease, it’s not your fault...just please just take the statin!)
Agency. What patients often don’t realize is just how much control they have over their cardiovascular outcomes. Know your blood pressure. Know your LDL, and ask about Lp(a) at least once in your life. Don’t smoke if you can avoid it. Move your body most days. Sleep. Manage the drinking. Take the statin if you need one. If your family history points to coronary disease and you are over 40, ask your doctor about a coronary artery calcium scan, a 10-minute test that can tell you, with remarkable precision, whether plaque is already building in the pipes.
My patient went home and called her mother. It turned out her grandfather did not have coronary disease. He’d had a rheumatic fever which led to a heart valve problem. This structural problem, plus a battle with alcoholism, set him up for atrial fibrillation, an electrical problem, which, ultimately, caused heart failure. He did not have a plumbing problem after all—but her aunt did. She’d had a silent heart attack in her 60s despite being a lean, fit non-smoker.
That was a much sharper picture than “heart disease runs in my family.” So we checked my patient’s “plumbing” risks because of her aunt’s history—lipids (normal), her Lp(a) (elevated), and her CAC score (low, but not zero). She started a low-dose statin for a specific LDL target goal of < 70. She kept walking with her dog and decided to take up tennis for high-intensity cardio. And yes, I made the cardiology referral to check her “windows and doors” (unlikely to be a problem because rheumatic fever isn’t hereditary). So she walked in to the specialist with a specific question instead of a vague worry, and her cardiologist was glad of it.
This is what being an empowered patient looks like: trading worry for specific advice, and getting the answers you need by asking better questions—of yourself, and of the people responsible for your care. This doesn’t have to be fancy or expensive. It just takes time (with yourself and with your doctor) to make sure you’re solving the problem—and not someone else’s.
What kind of heart disease runs in your family—plumbing, electricity, or windows and doors? Have you ever asked?! Tell me in the comments!
Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.
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This is the best summary I have seen. Thank you for always making sense and order of often confusing information and teaching us how to use it for our own well being.
Thanks for the great information on family history of heart disease. More people need this information. Starting about 50 years ago, I had to figure this all out on my own. My dad had a deadly heart attack at 53, “a plumbing issue.” I was 15.
From my latest newsletter…”a personal update: all four of my brothers—both older and younger—have had stents or bypass surgery. I have had neither.
During my most recent 2025 exercise stress test, the physiologist remarked: “I’m impressed how you continue to exceed the expected maximum heart rate for your age.”
That’s not a story about genetics. It’s a story about alignment.
The only cardiologist to personally watch me on a treadmill stress test commented in 2007. “Brian, your long-term exercise habit saved you. Even though you have some blockage, your body adapted building new capillaries that meet your body’s exercise demand. I wish all my patients were like you.”