DALLAS -- Heart attacks are the No. 1 cause of death and a major cause of disability in America. For nearly half of the casualties, the first symptom is the last. That's how cardiovascular disease has earned the nickname "silent killer" -- you never know when it will strike.
Doctors are trying to change that by treating heart disease as a progressive problem. They are becoming "heart whisperers," seeking new tests to read the small stresses that can, unchecked, grow into big ones.
"By the time someone rolls in with a heart attack, his family will look at me bewildered, and the patient might say, 'Doc, what happened?' " said Dr. Bruce Gordon of Heart Hospital Baylor Plano in Texas. "But it's not what happened. It's what's been happening. The process has been going on for decades."
It's a process that can be accelerated by high cholesterol, high blood pressure, obesity, diabetes, tobacco use and secondhand smoke.
The heart's most common enemy is LDL, a cholestein saturated fats, from fatty meats to egg yolks, shellfish and whole milk. As LDL wends its way through the bloodstream, it can turn to plaque, which can clog the blood vessels. That can lead to the blockages of blood flow that result in a heart attack or stroke.
The plaque buildup can start in childhood with unhealthy high-fat diets and a lack of exercise, said Dr. Amit Khera, director of preventive cardiology at the University of Texas Southwestern Medical Center and co-chair of the American Heart Association's state advocacy committee.
"The earlier we intervene the better," Khera said. "Risk factors show up in kids in the form of obesity, diabetes and occasionally hypertension."
The benefits of starting young are not unlike the compound-interest benefits you can get by saving early for retirement, Khera notes.
"With modest reductions of cholesterol of just 25 percent, those kids can have more than a 50 percent reduction in heart disease as adults."
The stakes are enormous. An estimated 785,000 Americans had a new coronary attack in 2009, according to the Centers for Disease Control and Prevention. About 470,000 had a recurrent attack in 2009.
Improved tests, many developed over the past decade, are helping spot previously silent trouble signs. Doctors can break down cholesterol into bad LDL and the good HDL cholesterol that returns to the liver.
Additional tests gaining favor are:
Cardiologist and television celebrity Dr. Mehmet Oz makes a case for traditional tests, too, in the February Family Circle: blood pressure (hypertension more than triples cardiovascular risk), cholesterol and triglycerides (high triglycerides also contribute to artery plaque), fasting blood glucose (excess blood sugar damages blood vessels), ankle-brachial index (if the foot's blood pressure is much lower than the arm's, plaque may be collecting in the leg arteries) and waist circumference (belly fat produces hormones that cause inflammation).
Experts also endorse stress tests, where a patient goes on a treadmill while being monitored by an electrocardiogram.
There are new, more widely available genetic tests that can identify an aberration in one or two genes that significantly elevates risk even for someone with an impeccably healthy lifestyle.
To order a genetic test, you need to show some cause.
That's why Dr. Jorge Cheirif, chief of cardiology at Texas Health Presbyterian Hospital Dallas, considers a family medical history to be so important.
"When there is a family history of early coronary disease, we can look to see if patients have the genetic markers that predispose them to heart attacks."
If a genetic test comes up positive, Cheirif takes that as an indication that the patient should be treated pre- emptively for heart disease, with a look at establishing a heart-healthy lifestyle and potential prescriptions of cholesterol-lowering statin drugs or low-dose aspirin.
The bottom line that the experts stress is that no one should be complacent about heart health at any age.
Wenter Blair almost died because she dismissed her first heart attack as a hot flash when she suddenly found herself "sweating from every pore" at age 41.
Her cardiologist at the time agreed: The petite Frisco, Texas, mother of two seemed too young to have a heart attack. She ate healthfully and was fit, riding horses twice a week.
A heart catheter, considered the gold standard for identifying heart disease, revealed that she had four arteries blocked at 90 percent and needed the insertion of five stents, which are tubes to help blood flow, to survive. She had a sixth stent put in this December.
Blair, now 42, credits her medical team, including Khera, who became her cardiologist after the incident, with saving her life.
It turned out that Blair has a rare, previously undiagnosed genetic disorder, called heterozygous familial hypercholesterolemia, which floods her body with LDL cholesterol, turning it into plaques that course through her bloodstream.
Still, for the current breed of "heart whisperers," her chronically high cholesterol readings probably would have generated more attention and alarm than they did 20 years ago.
"The writing was on the wall," Khera said. "It was just hard for people to read."