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.”
It’s a mixed bag in my family. One grandfather was a heavy smoker and died of a heart attack in his early 60s. The other was active and healthy, but had angina and died from a stroke at 83. Father had a congenital kidney defect that caused an enlarged heart, eventually developing pulmonary hypertension and death at age 68. He also had Afib. Mother had a pacemaker implanted at age 75 due to a slowing heartbeat, but had no symptoms. Later diagnosed with a valve issue, but was not treated surgically due to Alzheimer’s Disease.
Heart murmurs are very common in my family— father, brother, cousins, etc. Mine was brushed off as nothing over the years until, at age 50, I decided to take part in a preventative heart check program done at our local hospital. I had this foreboding sense that something was wrong. It revealed a congenital heart defect (an ASD)—a large hole. The right side was also severely enlarged, and I had the beginnings of pulmonary hypertension. I had zero symptoms. Got it all patched up, heart is back to nearly normal size, and the PH has resolved. Medical technology is an amazing thing.
I’ve followed a healthy diet and exercise plan for most of my adult life, yet still have mild hypertension and slightly elevated LDL, which my cardiologist chalks up to genetics. They began to tick up around menopause, and I can't help but wonder if there is a hormone connection. I also had preclampsia with one pregnancy, and I remember my Ob-Gyn saying at the time (28 years ago): "Researchers don't know yet if having preclampsia causes high BP later in life or if preclampsia just reveals your likelihood to have it, but either way, you probably will." And she was right.
My maternal grandmother died in her mid-40s, in the mid-1940s, after being an invalid for many years because of rheumatic heart disease. Not many strep infections lead to that these days, I don't imagine.
After feeling unusually weak for a while, when doing ordinary things like carrying groceries, I had a fainting episode at home. A call to the doctor's office directed me to go to the local ER. That led to a lights and siren ambulance ride to the big hospital in Portland, ME, 50 miles away. Dx total heart block, and a pacemaker put in next morning. My heart's electrical system is failing.
When I told my nephew, my late brother's son--an M.D.--about it, he said: "You've got the family heart block." I knew my mother had a pacemaker, but didn't know why, or that my brother had also had one. My mother died of congestive heart failure, among other problems, so there is that possibility to look forward to. My father had triple bypass surgery in his 60s, modified his diet and walked a lot, and lived to 95.
My nephew has a lot of heart, but no heart disease so far. He dropped out of high school at 16. We were all thrilled when he got a GED, went to art school in NYC, and got a BFA. After that, he decided to become a doctor. He is now double board certified in neurology and psychiatry, practicing in The Bronx.
You should interview Dr Basmah Safdar who heads up Women’s Health Research at Yale, Dr Safdar has made some groundbreaking discoveries about heart disease in women - how it presents differently and what that means for how we ask women how they are feeling to gauge their cardiac health.
My dad and oldest brother both died in their 50s due to atherosclerosis. Of course driven by hypercholesterolemia, which I have too. I had two good doctors. The one who came to my treadmill stress test worked with me. Prior to prescribing a statin, he monitored my blood work while I ate nothing but vegetables for 60 days. My cholesterol didn't move. I have been on statins since age 50, 19 years. Thanks for asking!
That was the best article I have ever read on heart disease and explaining it so any lay person could understand. I forwarded it to friends and family and made a copy for my cardiologist. He tends to talk in medical language...am sure he has folks that do not understand. I have electrical issues, but the males in my family line all have/had plumbing issues! I am one of your big supporters and readers, ever since Covid! Jan
They mean different things - high TG can be a sign of metabolic dysfunction. LDL 196 is just high - goal LDL < 100 - normal CAC is good but still you want to get that down - with the combination of meds, lifestyle, etc. :)
Great article...thanks! My father had a heart attack at age 48, died at 56, so plumbing problems are in my history. I also have a wonky mitral valve, and am being followed by a cardiologist. But I'm encountering massive frustration with my insurance being unwilling to cover a calcium artery scan and reluctant to cover even the Lp(a) and ApoB blood tests. They keep citing "Medicare standards". How important is it to press the issue? I'm 75, mildly overweight, have great lipid scores but not much exercise, and passed a stress test with no problems. It just feels so complicated dealing with PCP, cardiologist, & insurance!
Insurance is the worst. So sorry. You should get an Lp(a) once at least! It would help break a tie on cholesterol meds or not. Wishing you all the best. xx
How do you balance the need to lose weight with an eating disorder history? Are there resources out there that are helpful for this? I haven’t been able to find them.
Great questions - suggest working with a registered dietician and a good ED therapist in tandem if that's an option - but of course talk with your doc, too! :)
I'm electric, now with a pacer after an afib ablation, also a little pump issue. CCTA=0. No hypertension but my chart lists hypertension maybe bec I take Losartan for a little HF. Once on the chart impossible to get off! Also a prosthetic mitral valve after a bad bout of endocarditis many years ago. I feel good now with the pacer; my cardiologists do a great job juggling/balancing, fixing everything!
At 52 years old, a runner, not overweight, not high cholesterol, a CT score of zero, a non-smoker…. I was identified with a 95% blockage in my left main artery, the widow maker. I experienced chest pain playing tennis called a friend whose husband was a cardiologist and quickly got in for a CTA which found the soft plaque. Why causes soft plaque blockage vs a clean CT? Is that just newer plaque that hasn’t hardened yet? Why do doctors and insurance companies even do a CT instead of a CTA if it won’t identify soft plaque?
Great Q and glad you got the CTA. Soft plaque that is not calcified will not show up on a coronary artery calcium score. The CAC is a better screening test but the CTA in the right context is also crucial - context matters here and you got good advice!!
Plumbing. Both grandfather's in tbeir 50 and 60s. Dad, heart failure but cause of death unknown in absence of an autopsy (he bled out per reports of those who found him). My past doc noticed an anomaly in my list of BPs and sent me for an echo 3 years ago, repeated last year, that showed mild mitral valve stenosis. No rheumatic fever, but that was the listed cause. Test to be repeated every 3 to 5 years, andl ow dose metropolol to address tachycardia. My current doc put me on low dose statin last year 'just to be safe', and recently low dose lisinopril,because my BP was running high. In the mean time I lead a reasonably healthy life style and worry more about my cranky gut.
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.
So glad it helped!!
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.”
I love hearing this!! Alignment is so important!
Excellent explanation!
It’s a mixed bag in my family. One grandfather was a heavy smoker and died of a heart attack in his early 60s. The other was active and healthy, but had angina and died from a stroke at 83. Father had a congenital kidney defect that caused an enlarged heart, eventually developing pulmonary hypertension and death at age 68. He also had Afib. Mother had a pacemaker implanted at age 75 due to a slowing heartbeat, but had no symptoms. Later diagnosed with a valve issue, but was not treated surgically due to Alzheimer’s Disease.
Heart murmurs are very common in my family— father, brother, cousins, etc. Mine was brushed off as nothing over the years until, at age 50, I decided to take part in a preventative heart check program done at our local hospital. I had this foreboding sense that something was wrong. It revealed a congenital heart defect (an ASD)—a large hole. The right side was also severely enlarged, and I had the beginnings of pulmonary hypertension. I had zero symptoms. Got it all patched up, heart is back to nearly normal size, and the PH has resolved. Medical technology is an amazing thing.
I’ve followed a healthy diet and exercise plan for most of my adult life, yet still have mild hypertension and slightly elevated LDL, which my cardiologist chalks up to genetics. They began to tick up around menopause, and I can't help but wonder if there is a hormone connection. I also had preclampsia with one pregnancy, and I remember my Ob-Gyn saying at the time (28 years ago): "Researchers don't know yet if having preclampsia causes high BP later in life or if preclampsia just reveals your likelihood to have it, but either way, you probably will." And she was right.
Good story. Thank you for sharing it, Lisa! Wow.
My maternal grandmother died in her mid-40s, in the mid-1940s, after being an invalid for many years because of rheumatic heart disease. Not many strep infections lead to that these days, I don't imagine.
After feeling unusually weak for a while, when doing ordinary things like carrying groceries, I had a fainting episode at home. A call to the doctor's office directed me to go to the local ER. That led to a lights and siren ambulance ride to the big hospital in Portland, ME, 50 miles away. Dx total heart block, and a pacemaker put in next morning. My heart's electrical system is failing.
When I told my nephew, my late brother's son--an M.D.--about it, he said: "You've got the family heart block." I knew my mother had a pacemaker, but didn't know why, or that my brother had also had one. My mother died of congestive heart failure, among other problems, so there is that possibility to look forward to. My father had triple bypass surgery in his 60s, modified his diet and walked a lot, and lived to 95.
My nephew has a lot of heart, but no heart disease so far. He dropped out of high school at 16. We were all thrilled when he got a GED, went to art school in NYC, and got a BFA. After that, he decided to become a doctor. He is now double board certified in neurology and psychiatry, practicing in The Bronx.
Wow what a tale. Thank you for writing in! I'd love to meet your nephew some day.
Dear Dr McBride:
You should interview Dr Basmah Safdar who heads up Women’s Health Research at Yale, Dr Safdar has made some groundbreaking discoveries about heart disease in women - how it presents differently and what that means for how we ask women how they are feeling to gauge their cardiac health.
My dad and oldest brother both died in their 50s due to atherosclerosis. Of course driven by hypercholesterolemia, which I have too. I had two good doctors. The one who came to my treadmill stress test worked with me. Prior to prescribing a statin, he monitored my blood work while I ate nothing but vegetables for 60 days. My cholesterol didn't move. I have been on statins since age 50, 19 years. Thanks for asking!
That was the best article I have ever read on heart disease and explaining it so any lay person could understand. I forwarded it to friends and family and made a copy for my cardiologist. He tends to talk in medical language...am sure he has folks that do not understand. I have electrical issues, but the males in my family line all have/had plumbing issues! I am one of your big supporters and readers, ever since Covid! Jan
So my zero coronary calcium score sounds dandy, but my Tri/LDL ratio is .959 (188/196)
As I understand you Dr McBride, this is the reddest of the red flags?
They mean different things - high TG can be a sign of metabolic dysfunction. LDL 196 is just high - goal LDL < 100 - normal CAC is good but still you want to get that down - with the combination of meds, lifestyle, etc. :)
of course consult w your doc on the specifics!
Great article...thanks! My father had a heart attack at age 48, died at 56, so plumbing problems are in my history. I also have a wonky mitral valve, and am being followed by a cardiologist. But I'm encountering massive frustration with my insurance being unwilling to cover a calcium artery scan and reluctant to cover even the Lp(a) and ApoB blood tests. They keep citing "Medicare standards". How important is it to press the issue? I'm 75, mildly overweight, have great lipid scores but not much exercise, and passed a stress test with no problems. It just feels so complicated dealing with PCP, cardiologist, & insurance!
Insurance is the worst. So sorry. You should get an Lp(a) once at least! It would help break a tie on cholesterol meds or not. Wishing you all the best. xx
How do you balance the need to lose weight with an eating disorder history? Are there resources out there that are helpful for this? I haven’t been able to find them.
Great questions - suggest working with a registered dietician and a good ED therapist in tandem if that's an option - but of course talk with your doc, too! :)
I'm electric, now with a pacer after an afib ablation, also a little pump issue. CCTA=0. No hypertension but my chart lists hypertension maybe bec I take Losartan for a little HF. Once on the chart impossible to get off! Also a prosthetic mitral valve after a bad bout of endocarditis many years ago. I feel good now with the pacer; my cardiologists do a great job juggling/balancing, fixing everything!
Glad to hear you have a good cardiologist!
At 52 years old, a runner, not overweight, not high cholesterol, a CT score of zero, a non-smoker…. I was identified with a 95% blockage in my left main artery, the widow maker. I experienced chest pain playing tennis called a friend whose husband was a cardiologist and quickly got in for a CTA which found the soft plaque. Why causes soft plaque blockage vs a clean CT? Is that just newer plaque that hasn’t hardened yet? Why do doctors and insurance companies even do a CT instead of a CTA if it won’t identify soft plaque?
Great Q and glad you got the CTA. Soft plaque that is not calcified will not show up on a coronary artery calcium score. The CAC is a better screening test but the CTA in the right context is also crucial - context matters here and you got good advice!!
Plumbing. Both grandfather's in tbeir 50 and 60s. Dad, heart failure but cause of death unknown in absence of an autopsy (he bled out per reports of those who found him). My past doc noticed an anomaly in my list of BPs and sent me for an echo 3 years ago, repeated last year, that showed mild mitral valve stenosis. No rheumatic fever, but that was the listed cause. Test to be repeated every 3 to 5 years, andl ow dose metropolol to address tachycardia. My current doc put me on low dose statin last year 'just to be safe', and recently low dose lisinopril,because my BP was running high. In the mean time I lead a reasonably healthy life style and worry more about my cranky gut.