Contents

• Heart Attack
• Sign & Symptom
• Causes
• Risk Factors
• Diagnosis
• Management
• Complications
• Prevention
• Prognosis
• Types of heart diseases
• Diet
• Ways to Lower Your Cholesterol Through Diet

Heart Attack

Myocardial infarction commonly known as a ‘heart attack’ occurs when the blood supply to part of the heart is interrupted causing some heart cells to die. This is most commonly due to blockage of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids like cholesterol, fats and white blood cells in the wall of an artery. These results in restriction in blood supply and oxygen shortage, if left untreated for a sufficient period, can cause damage and/or death of heart muscle tissue.

Classical symptoms of acute myocardial infarction include sudden chest pain, shortness of breath, sickness, vomiting, palpitations, sweating, and anxiety. Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a feeling of indigestion, and exhaustion. Approximately one quarter of all myocardial infarctions is silent, without chest pain or other symptoms.

Heart attacks are the leading cause of death for both men and women all over the world. Important risk factors are previous cardiovascular disease (previous heart attack or stroke), older age (especially men over 40 and women over 50), tobacco smoking, high blood levels of certain lipids, diabetes, high blood pressure, obesity, chronic kidney disease, heart failure, excessive alcohol consumption, the abuse of certain drugs (cocaine) and chronic high stress levels.

Immediate treatment for suspected acute myocardial infarction includes oxygen, aspirin and sublingual glyceryl trinitrate (Referred as NTG or GTN). Pain relief is also often given, classically morphine sulfate.

The patient will receive a number of diagnostic tests, such as an electrocardiogram (ECG, EKG), a chest X-ray and blood tests to detect elevations heart muscle damage. The most often used markers are the creatine kinase-MB fraction and the troponin I or troponin T levels. On the basis of the ECG, a distinction is made between ST elevation MI or non-ST elevation MI. Most cases of STEMI are treated with thrombolysis or if possible with percutaneous coronary intervention provided the hospital has facilities for coronary angiography. NSTEMI is managed with medication, although PCI is often performed during hospital admission. In patients who have multiple blockages and who are relatively stable, or in a few extraordinary emergency cases, bypass surgery of the blocked coronary artery is an option.

The phrase "heart attack" is sometimes used incorrectly to describe sudden cardiac death, which may or may not be the result of acute myocardial infarction. A heart attack is different from, but can be the cause of cardiac arrest, which is the stopping of the heartbeat and an abnormal heartbeat. It is also distinct from heart failure, in which the pumping action of the heart is impaired; severe myocardial infarction may lead to heart failure, but not necessarily.

Sign & Symptom

The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous. Chest pain is the most common symptom of acute myocardial infarction and is often described as a sensation of tightness, pressure, or squeezing. Chest pain lack of blood and hence oxygen supply of the heart muscle is termed angina pectoris. Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and part of the abdomen, where it may mimic heartburn. Levine's sign, in which the patient localizes the chest pain by tightening their fist over the sternum, study showed that it had a poor positive predictive value.

Shortness of breath occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema. Other symptoms include excessive sweating, weakness, light-headedness, nausea, vomiting, and palpitations. Loss of consciousness and even sudden death can occur in myocardial infarctions.

Women and older patients experience atypical symptoms more frequently than their male and younger counterparts. Women also have more symptoms compared to men (2.6 on average vs 1.8 symptoms in men). The most common symptoms of MI in women include dyspnea, weakness, and fatigue. Fatigue, sleep disturbances, and dyspnea have been reported as frequently occurring symptoms. In women, chest pain may be less predictive of coronary ischemia than in men.

Approximately half of all MI patients have experienced warning symptoms such as chest pain prior to the infarction.

Approximately one fourth of all myocardial infarctions are silent, without chest pain or other symptoms. These cases can be discovered later on electrocardiograms or at autopsy without a prior history of related complaints. A silent course is more common in the elderly, in patients with diabetes mellitus and after heart transplantation, probably because the donor heart is not connected to nerves of the host.

Any group of symptoms compatible with a sudden interruption of the blood flow to the heart is called an acute coronary syndrome.

Causes

Heart attack rates are higher in association with intense exertion, be it psychological stress or physical exertion, especially if the exertion is more intense than the individual usually performs. The period of intense exercise and subsequent recovery is associated with about a 6-fold higher myocardial infarction rate for people who are physically very fit. For those in poor physical condition, the rate differential is over 35-fold higher. One observed mechanism for this phenomenon is the increased arterial pulse pressure stretching and relaxation of arteries with each heart beat which, as has been observed with intravascular ultrasound, increases mechanical "shear stress" on atheromas and the likelihood of plaque rupture.

Acute severe infection, such as pneumonia, can trigger myocardial infarction. While the intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor. Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.

There is an association of an increased incidence of a heart attack in the morning hours, more specifically around 9 a.m. Some investigators have noticed that the ability of platelets to aggregate varies according to a circadian rhythm, although they have not proven causation. Some investigators theorize that this increased incidence may be related to the circadian variation in cortisol production affecting the concentrations of various cytokines and other mediators of inflammation.

Risk Factors

Risk factors for atherosclerosis are generally risk factors for myocardial infarction:

• Older age
• Male sex
• Tobacco smoking
• Hypercholesterolemia (more accurately hyperlipoproteinemia, especially high low density lipoprotein and low high density lipoprotein)
• Hyperhomocysteinemia (a toxic blood amino acid that is elevated when intakes of vitamins B2, B6, B12 and folic acid are insufficient)
• Diabetes
• High blood pressure
• Obesity
• Stress Occupations with high stress index are known to have susceptibility for atherosclerosis.

Many of these risk factors are modifiable, so many heart attacks can be prevented by maintaining a healthier lifestyle. Physical activity, for example, is associated with a lower risk profile. Non-modifiable risk factors include age, sex, and family history of an early heart attack (before the age of 60).

Socioeconomic factors such as a shorter education and lower income and unmarried cohabitation may also contribute to the risk of MI. To understand epidemiological study results, it's important to note that many factors associated with MI mediate their risk via other factors. For example, the effect of education is partially based on its effect on income and marital status.

Women who use combined oral contraceptive pills have a modestly increased risk of myocardial infarction, especially in the presence of other risk factors, such as smoking.
Inflammation is known to be an important step in the process of atherosclerotic plaque formation. C-reactive protein is a sensitive but non-specific marker for inflammation. Elevated CRP blood levels, especially measured with high sensitivity analysis, can predict the risk of MI, as well as stroke and development of diabetes. Moreover, some drugs for MI might also reduce CRP levels.

Inflammation in periodontal disease may be linked coronary heart disease, and since periodontitis is very common, this could have great consequences for public health. Serological studies measuring antibody levels against typical periodontitis-causing bacteria found that such antibodies were more present in subjects with coronary heart disease. Periodontitis tends to increase blood levels of CRP, fibrinogen and cytokines; thus, periodontitis may mediate its effect on MI risk via other risk factors.

Baldness, hair graying, a diagonal earlobe crease and possibly other skin features have been suggested as independent risk factors for MI. Their role remains controversial; a common denominator of these signs and the risk of MI is supposed, possibly genetic.

Calcium deposition is another part of atherosclerotic plaque formation. Calcium deposits in the coronary arteries can be detected with CT scans.

Diagnosis

The diagnosis of myocardial infarction is made by integrating the history of the presenting illness and physical examination with electrocardiogram findings and cardiac markers (blood tests for heart muscle cell damage). A coronary angiogram allows visualization of obstructions on the heart vessels, and therapeutic measures can follow immediately. At autopsy, a pathologist can diagnose a myocardial infarction based on anatomopathological findings.

A chest radiograph and routine blood tests may indicate complications or precipitating causes and are often performed upon arrival to an emergency department. New regional wall motion abnormalities on an echocardiogram are also suggestive of a myocardial infarction. Thallium may be used to determine viability of tissue, distinguishing whether non-functional myocardium is actually dead or merely in a state of hibernation.

Diagnostic criteria

WHO (World Health Organization) criteria have classically been used to diagnose MI; a patient is diagnosed with myocardial infarction if two (probable) or three (definite) of the following criteria are satisfied:

   1. Clinical history of ischaemic type chest pain lasting for more than 20 minutes
   2. Changes in serial ECG tracings
   3. Rise and fall of serum cardiac biomarkers

Physical examination

The general appearance of patients may vary according to the experienced symptoms; the patient may be comfortable, or restless and in severe distress with an increased respiratory rate. A cool and pale skin is common and points to vasoconstriction. Some patients have low-grade fever. Blood pressure may be elevated or decreased, and the pulse can be become irregular.

Electrocardiogram

The primary purpose of the electrocardiogram is to detect ischemia or acute coronary injury in broad, symptomatic emergency department populations. An ECG represents a brief sample in time. Because unstable ischemic syndromes have rapidly changing supply versus demand characteristics, a single ECG may not accurately represent the entire picture. It is therefore desirable to obtain serial 12 lead ECGs, particularly if the first ECG is obtained during a pain-free episode. Alternatively, many emergency departments and chest pain centers use computers capable of continuous ST segment monitoring. The standard 12 lead ECG also does not directly examine the right ventricle, and is relatively poor at examining the posterior basal and lateral walls of the left ventricle. In particular, acute myocardial infarction in the distribution of the circumflex artery is likely to produce a non-diagnostic ECG. The use of additional ECG leads like right-sided leads V3R and V4R and posterior leads V7, V8, and V9 may improve sensitivity for right ventricular and posterior myocardial infarction.

The 12 lead ECG is used to classify patients into one of three groups:

   1. Those with ST segment elevation or new bundle branch block    
   2. Those with ST segment depression or T wave inversion
   3. Those with a so-called non-diagnostic or normal ECG.

Cardiac markers

Cardiac markers or cardiac enzymes are proteins that leak out of injured myocardial cells through their damaged cell membranes into the bloodstream. The markers most widely used in detection of MI are MB subtype of the enzyme creatine kinase and cardiac troponins T and I as they are more specific for myocardial injury. The cardiac troponins T and I which are released within 4-6 hours of an attack of MI and remain elevated for up to 2 weeks have nearly complete tissue specificity and are now the preferred markers for asssessing myocardial damage

The diagnosis of myocardial infarction requires two out of three components (history, ECG, and enzymes). When damage to the heart occurs, levels of cardiac markers rise over time, which is why blood tests for them are taken over a 24-hour period. Because these enzyme levels are not elevated immediately following a heart attack, patients presenting with chest pain are generally treated with the assumption that a myocardial infarction has occurred and then evaluated for a more precise diagnosis.

Angiography

In difficult cases or in situations where intervention to restore blood flow is appropriate, coronary angiography can be performed. A catheter is inserted into an artery and pushed to the vessels supplying the heart. A radio-opaque dye is administered through the catheter and a sequence of x-rays is performed. Obstructed or narrowed arteries can be identified.

Histopathology

Histopathological examination of the heart may reveal infarction at autopsy. Under the microscope, myocardial infarction presents as a circumscribed area of ischemic, cell death. On gross examination, the infarct is not identifiable within the first 12 hours.

Management

A heart attack is a medical emergency which demands both immediate attention and activation of the emergency medical services. The ultimate goal of the management in the acute phase of the disease is to save as much myocardium as possible and prevent further complications. As time passes, the risk of damage to the heart muscle increases; hence the phrase that in myocardial infarction, "time is muscle," and time wasted is muscle lost.

Morphine is classically used if nitrogylcerin is not effective due to its ability to dilate blood vessels, which may aids in blood flow to the heart as well as the pain relief it provides. Morphine may also cause hypotension and should be avoided in the case of right ventricular infarction. Of the first line agents, only aspirin has been proven to decrease mortality.

First aid

Acting immediately by calling the emergency services can prevent sustained damage to the heart, remember "Time is Muscle".

Certain positions allow the patient to rest in a position which minimizes breathing difficulties. A half-sitting position with knees bent is often recommended. Access to more oxygen can be given by opening the window and widening the collar for easier breathing.

Aspirin can be given quickly (if the patient is not allergic to aspirin); but taking aspirin before calling the emergency medical services may be associated with unwanted delay. Aspirin has an antiplatelet effect which inhibits formation of further blood clots that clog arteries. Chewing is the preferred method of administration, so that the Aspirin can be absorbed quickly.

Glyceryl trinitrate (nitroglycerin) under the tongue can be given if available.
Other general first aid principles include monitoring pulse, breathing, level of consciousness and, if possible, the blood pressure of the patient.

Automatic external defibrillation (AED)

Since the publication of data showing that the availability of automated external defibrillators (AEDs) in public places may significantly increase chances of survival, many of these have been installed in public buildings, public transport facilities, and in non-ambulance emergency vehicles (e.g. police cars and fire engines). AEDs analyze the heart's rhythm and determine whether the rhythm is agreeable to defibrillation ("shockable").

Reperfusion

The concept of reperfusion has become the modern treatment of acute myocardial infarction, that we are said to be in the reperfusion era. Patients who present with suspected acute myocardial infarction and ST segment elevation or new bundle branch block on the 12 lead ECG are presumed to have an occlusive thrombosis in an epicardial coronary artery.

Individuals without ST segment elevation are presumed to be experiencing either non-ST segment elevation myocardial infarction (NSTEMI). If their condition remains stable, they can be offered either late coronary angiography with subsequent restoration of blood flow or non-invasive stress testing to determine if there is significant ischemia that would benefit from revascularization. If hemodynamic instability develops in individuals with NSTEMIs, they may undergo urgent coronary angiography and subsequent revascularization. The use of thrombolytic agents is contraindicated in this patient subset, however. Under this we have:

1. Thrombolytic therapy
2. Percutaneous coronary intervention
3. Coronary artery bypass surgery

Rehabilitation

Cardiac rehabilitation aims to optimize function and quality of life in those afflicted with a heart disease. This can be with the help of a physician, or in the form of a cardiac rehabilitation program.

Physical exercise is an important part of rehabilitation after a myocardial infarction, with beneficial effects on cholesterol levels, blood pressure, weight, stress and mood. Some patients become afraid of exercising because it might trigger another infarct. Patients are encouraged to exercise, and should only avoid certain exerting activities such as shovelling. Local authorities may place limitations on driving motorised vehicles. Some people are afraid to have sex after a heart attack. Most people can resume sexual activities after 3 to 4 weeks. The amount of activity needs to be dosed to the patient's possibilities.

Complications
Complications may occur immediately following the heart attack or may need time to develop. After an infarction, an obvious complication is a second infarction, which may occur in the domain of another atherosclerotic coronary artery, or in the same zone if there are any live cells left in the infarct.

Congestive heart failure

A myocardial infarction may compromise the function of the heart as a pump for the circulation, a state called heart failure. There are different types of heart failure; left- or right-sided or bilateral. Heart failure may occur depending on the affected part of the heart

Myocardial rupture

Myocardial rupture is most common three to five days after myocardial infarction, commonly of small degree, but may occur one day to three weeks later. Rupture occurs because of increased pressure against the weakened walls of the heart chambers due to heart muscle that cannot pump blood out effectively.

Risk factors for myocardial rupture include completion of infarction, female sex, advanced age, and a lack of a previous history of myocardial infarction.

Cardiogenic shock

A complication that may occur in the acute setting soon after a myocardial infarction or in the weeks following it is cardiogenic shock. Cardiogenic shock is defined as a state in which the heart cannot produce enough of a cardiac output to supply an adequate amount of oxygenated blood to the tissues of the body.

Prevention

The risk of myocardial infarction decreases with strict blood pressure management and lifestyle changes, ending smoking, regular exercise, a sensible diet for patients with heart disease, and limitation of alcohol intake.

• Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction.   
• Beta blocker therapy such as metoprolol or carvedilol should be commenced. These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction and/or continuing cardiac ischaemia.
• ACE inhibitor therapy should be commenced 24–48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct and/or evidence of left ventricular dysfunction.
• Statin therapy has been shown to reduce mortality and morbidity post-MI.
• Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI.

Prognosis  

The diagnosis for patients with myocardial infarction varies greatly, depending on the patient, the condition itself and the given treatment. For example, one study found that 0.4% of patients with a low risk profile had died after 90 days, whereas the mortality rate in high risk patients was 21.1%.

Although studies differ in the identified variables, some of the more reproduced risk factors include age, hemodynamic parameters (such as heart failure, cardiac arrest on admission, systolic blood pressure), ST-segment deviation, diabetes, peripheral vascular disease and elevation of cardiac markers.

Types of heart diseases:

• Coronary heart disease

Coronary artery disease is a disease of the artery caused by the accumulation of atheromatous plaques within the walls of the arteries that supply to the heart muscle tissue. Chest pain and myocardial infarction (heart attack) are symptoms of and conditions caused by coronary heart disease.

• Cardiomyopathy

Cardiomyopathy literally means "heart muscle disease". It is the weakening of the function of the heart muscle for any reason. People with cardiomyopathy are often at risk of arrhythmia and/or sudden cardiac death.

• Cardiovascular disease

Cardiovascular disease is any of a number of specific diseases that affect the heart itself and/or the blood vessel system, especially the veins and arteries leading to and from the heart. Research on disease dimorphism suggests that women who suffer with cardiovascular disease usually suffer from forms that affect the blood vessels while men usually suffer from forms that affect the heart muscle itself.

• Heart failure

Heart failure, also called congestive heart failure (CHF) and congestive cardiac failure (CCF), is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body. Therefore, leading to the heart and body's failure.

• Hypertensive heart disease

Hypertensive heart disease is heart disease caused by high blood pressure, especially localized high blood pressure.

• Inflammatory heart disease

Inflammatory heart disease involves inflammation of the heart muscle and/or the tissue surrounding it.

• Valvular heart disease

Valvular heart disease is disease process that affects one or more valves of the heart. The valves in the right side of the heart are the tricuspid valve and the pulmonic valve. The valves in the left side of the heart are the mitral valve and the aortic valve.

Diet

• Raw vegetables and fruits are extremely helpful. If necessary, cook very slightly in order to preserve the enzymes.
• Take several small meals which are low in salt in the first week following the heart attack. Do not use cold liquids. Vegetables such as cauliflower and carrots are very good as they are low in salt, easily accepted, and carry essential minerals and vitamins.
• Avoid red meat and processed food. Red meat has saturated fats where as processed foods contain fatty acids. Both are major causes of a heart attack. Consume omega-3 fatty acids as they reduce blood cholesterol level.
• Eat foods that contain magnesium such as wheat germ, potatoes, broccoli, and spinach. These will help regulate the heart activity.
• Consume garlic in your meal as it lowers the blood pressure, reduces cholesterol and prevents the formation blood clot.
• Onions have antioxidants and are beneficial for your heart.
• Drink fresh vegetable juices. These will provide you with energy and important vitamins and minerals, besides improving the health of your heart.
• Cayenne pepper is good for lowering your cholesterol level.
• Honey is known for its curative powers. One teaspoon of honey, taken two to three times a week will help strengthen your heart.
• Walnut reduces the risk of a heart attack dramatically.
• Avoid or reduce the use of alcohol, caffeine products and carbonated drinks.
• Use two egg whites instead of single whole egg.
• Reduce your sugar intake.

Rules For Eating

1. Do not take water with meals, but half an hour before or an hour after a meal.
2. Eat slowly, chew your food thoroughly and never eat to full stomach.
3. Restrict the intake of salt.
4. Take liberally foods rich in vitamin E.

Other Measures

1. Apply a hot compress on the left side of the neck for 30 minutes every alternate day and hot   packs on the chest over the heart for one minute. Followed by cold pack for Five minutes.
2. Practise yogic asanas like Shavasana, Vajrasana and Gomukhasana.
3. Moderate exercise like walking.
4. Massage of the abdomen and upper back muscles once a week.
5. Fresh air and right mental attitude.

Ways to Lower Your Cholesterol Through Diet

1. Cut your total fat intake.
The risk of heart disease falls sharply if you reduce fat to less than 30 percent of total calories. When you lower fat consumption, you also reduce your saturated fat intake, cut calories and lose weight.

2. Eat less cholesterol-rich food.
Your daily cholesterol intake should be 300 milligrams or less. Certain animal foods are rich in cholesterol, but no plant foods contain cholesterol. Keep these food facts in mind.

• A single egg yolk has 255 milligrams of cholesterol; if you are healthy, you should eat no more than two egg yolks per week.
• Egg white has no fat or cholesterol, so you might consider eating egg whites frequently. Egg white is also an excellent form of protein.
• Organ meats and certain seafoods -- shrimp, lobster and calamari -- have high levels of cholesterol.

3. Avoid saturated fats.
In terms of heart health, there is nothing good to be said for saturated fats! They are to blame for increasing total cholesterol, LDL cholesterol and triglycerides.

• Less than one-third of your fat intake should come from saturated fat.
• You find saturated fat in dairy fats such as cream, butter and cheese.
• Saturated fat is also in animal fats like chicken skin, visible fat on meat, and lard.
• The chemical structure of saturated fats makes them solid at room temperature.

4. Avoid tropical oils.
The tropical oils are palm, palm kernel and coconut oil. They are highly saturated. Many prepared foods contain them, so check labels for ingredients. You are likely to find tropical oils in these products.

• non-dairy coffee creamers
• whipped toppings
• baked goods
• cookies
• chocolate candy

5. Increase your use of monounsaturated fats within your total allotment for fat.
Monounsaturated fats lower blood cholesterol and will reduce your risk of heart disease.

• Monounsaturated fats are liquid at room temperature.
• They are the main fatty acids in olive oil and canola oil.
• Use olive and canola oil in your cooking and in salad dressings to promote heart health.

6. Use polyunsaturated fats.
Polyunsaturated fats are the major fat source in vegetable oils such as safflower oil and corn oil. They generally lower total cholesterol, although they may also lower HDL cholesterol (good cholesterol).

7. Get your Omega-3 fatty acids.
Omega-3 fatty acids are polyunsaturated fats from plant and marine sources. The richest sources are fish that swim in cold waters, such as salmon, bluefish, mackerel, tuna, herring, sardines, try to eat them 3-4 times a week.
The benefits of eating these food sources of Omega-3 include the following.

• significant reductions in high triglyceride levels
• slower blood clotting
• prevention of abnormal heart rhythms
• enhanced immune function
• improved eye and brain development

8. Shellfish

• Shrimp, although moderately high in cholesterol, is a very low-fat protein. Eaten once or twice a month it will not affect cholesterol levels.
• All other shellfish are also acceptable, except squid (calamari) and roe (caviar).
• Mollusks such as clams, mussels and scallops are all fine.
• Be sure shellfish are from reputable sources and are cooked well.
• Have your seafood baked, broiled, steamed or boiled - but not fried.
• Use only acceptable oils in preparing shellfish recipes which call for oil.

9. Increase the soluble fiber in your diet.
If you want to lower your cholesterol in abundance eat a lot of soluble fiber which is found in oat bran. Soluble fiber is found primarily in oats, legumes, apples, pears, plums, carrots, okra and barley.
10. Be sure to get enough folic acid, vitamin B6 and vitamin B12.
Low levels of folic acid and other B vitamins can cause excessive homocysteine to be produced in the body, and high homocysteine levels are an independent risk factor for heart attack and stroke.You need 400 micrograms of folic acid a day to prevent heart disease. Foods that will also do the job include the following.

• Total cereal
• Product 19
• lentils
• asparagus
• spinach
• kidney beans
• orange juice

11. Try more soy protein.
Studies show that soy protein lowers cholesterol. Soy protein is a good protein that can be substituted for animal protein in your diet. Here are some sources of soy protein.

• tofu
• tempeh
• veggie burgers made with textured vegetable soy protein
• soy milk

Experts recommend 25-50 grams of soy protein daily

12. Go beyond vitamins and get your phytochemicals.
Phytochemicals are plant chemicals that may help prevent chronic diseases and conditions such as diabetes, cancer and hypertension.

• Fruits and vegetables are chock-full of them; eating five servings a day is a good start on the road to better health.
• Garlic may help reduce blood cholesterol. It appears that raw garlic is the active ingredient.

13. Shape up!

• Get a lot of exercise. It will help you lose weight, increase your HDL (good) cholesterol and lower your triglycerides.
• Lose weight if you need to. Losing just 10 pounds can make a difference in your cholesterol level, especially if your body is an "apple shape."
• Your waist measurement divided by your hip measurement should be less than 0.9 for men and less than 0.8 for women.
• If you smoke, stop.