Five Priorities for a Healthy Heart, from a Cardiologist

1. Sniper's Alley: Why over-50s have heart attacks "out of nowhere"

Patients ask how someone can be fine on Monday and dead on Wednesday. It feels like being picked off by a sniper, but the biology was fifteen or 20 years in the making.

The plaque that gives you a heart attack at 55 probably started forming in your thirties. The plaque that ruptures isn't necessarily the biggest one. A 40% narrowing with a thin, inflamed cap is more dangerous than a stable, calcified 70% blockage. It causes no symptoms and sails through a treadmill test. Then a surge in blood pressure (exertion, stress, the early-morning adrenaline peak) tears the cap, a clot forms within minutes and the artery closes.

Some people don't feel it at all. High blood sugar damages the coronary arteries of some people and the nerves that carry cardiac pain, so people with diabetes often have silent heart attacks found later on an ECG. In women, "atypical" symptoms are the rule.

So "I feel fine" tells you nothing about your arteries. Only a CT coronary angiogram can do that.

2. Things to look out for

Crushing central chest pain spreading to the arm or jaw is only one presentation. Also watch for:

• Jaw ache that feels like toothache, heaviness in both arms, or pain between the shoulder blades on exertion or suddenly at rest with a feeling of “impending doom” • "Indigestion" that comes on with exertion • Breathlessness on exertion, when lying flat, or that wakes you at night • Fast, sustained palpitations with dizziness or breathlessness • Fainting during or just after exercise, or without any warning causing injury • Ankle swelling with unexplained tiredness

If chest discomfort is new, comes on with effort, lasts more than a few minutes, or comes with sweating, nausea or breathlessness, call an ambulance. Not your GP. Time is muscle.

Watch your waistline. Researchers used machine learning to rank predictors of soft, vulnerable plaque in 263 patients, BMI and visceral (belly) fat came top, ahead of every cholesterol number. Aim for a waist under half your height. Measure it 1cm above your belly button.

3. How often should you get your heart checked?

"Normal" isn't the same as healthy. A resting ECG is a 10-second snapshot of the electrics, not the plumbing, and a treadmill test misses about one in three cases of significant disease.

My rough guide:

• Blood pressure: at home, Monthly but more often if it's creeping up.

• Bloods from 40, every year or two: beyond standard cholesterol panels, ask for ApoB (All the bad lipid particles), HbA1c (How sugar frosted are you!), hsCRP (inflammation) and fasting insulin (are you resistant and at risk?).

• Lp(a): once in your life. It's partially genetically determined; if it's high, be stricter with everything else across all other risk factors!

• CT coronary calcium score +/- CTCA: Consider it if you're over 40 with any risk factors. It is the ultimate referee as it sees any disease inside your arteries and allows us to fine tune your plan.

4. Wearables: ECG apps and HRV tracking

I'm broadly a fan, if you know what they can and can't do. Your heart rate should be 35-50 in deep sleep, so don’t go running to the GP worried about this!

Single-lead ECG watches and apps are good at one job: catching arrythmia and atrial fibrillation, an often-symptomless rhythm that raises stroke risk. If yours flags AF, get it checked. But a watch can't see blocked arteries, or rule out a heart attack. Chest pain with a "normal" watch ECG is still a 999 call.

Heart rate variability (HRV) is a useful window on recovery, stress and sleep. Compare it only with your own baseline. A falling trend matters; one bad reading doesn't…Alcohol will make it bad!

The most useful number on your wrist is probably fitness. Resting heart rate, Heart rate recovery are measures of CV fitness but an estimated VO2max is the strongest single predictor of cardiovascular death. Every 1 MET gained cuts that risk by around 13–15%. Use the watch to get fitter, not more anxious.

5. What your blood pressure means

Blood pressure is two numbers: the pressure when your heart squeezes (systolic) over the pressure when it relaxes (diastolic). Optimal is about 120/80 or below, and hypertension starts at around 130/80. Keep it above 100 though or you will be dizzy.

High blood pressure hammers the lining of your arteries, accelerates plaque, thickens the heart muscle due to wall stress and raises your risk of stroke, kidney disease and heart failure. It's the silent killer, and pressure surges are what pull the trigger in Sniper's Alley!

After smoking, it's the biggest risk factor you can change. Lifestyle first (exercise (CV and Resistance work), weight loss, less salt and sugar, sleep well, stress reduction), medication if that isn't enough. A home BP monitor costs about the same as a portion of takeaway and a reading takes two minutes so there really is no excuse!

The bottom line

Don't smoke. Sleep properly (a good 7-8 hours). Move every day. Eat colourful, single-ingredient foods. Know your numbers. Take your blood pressure very seriously.

The disease is silent until the most critical part, but you don't have to leave it until symptoms start. Get checked!

Dr Scott W Murray is a Consultant Cardiologist at Venturi Cardiology