Dr. Randi Foraker is a professor of medicine within the Division of General Medical Sciences at Washington University in St. Louis (WUSTL), and the Deputy Director for WUSTL’s Institute for Informatics. She helped co-author the American Heart Association’s (AHA) Life’s Essential 8, a prescription of eight lifestyle metrics for cardiovascular health. They include modifiable risk factors such as diet, physical activity, nicotine exposure, sleep duration, body mass index, blood lipids, blood glucose and blood pressure.

Last June, the AHA added sleep to their lifestyle recommendations. “Poor sleep has been something we have suspected as a contributor to cardiovascular health for some time,” Foraker says. “Sleep has been identified recently as a risk factor for cardiovascular disease and other chronic diseases. Interrupted sleep is a problem, because our body isn’t able to rebuild and recharge if we don’t have adequate sleep. That’s a recent finding, and the evidence around that is building.”

In addition, research into how sleep patterns affect heart health is ongoing. Experts are looking at when people are sleeping, and if it’s broken into three- or four-hour increments. The demands of one’s occupation may lead to sleeping during the day instead of at night, or broken sleep that may or may not lead to a total of eight hours of sleep.

“Not managing stress well can be linked to insulin resistance, gut issues, high blood pressure and inflammation, which directly contribute to heart disease,” says Charlotte Nussbaum, M.D., a functional medicine practitioner based in Medford, New Jersey. “That’s a lifestyle factor that people need to address—and it can be the hardest one to address. Even if you’re dialed in to a healthy diet and exercise routines, you’re not going to keep yourself healthy if you have unresolved stress issues.”

Nussbaum further notes that unaddressed childhood traumas can lead to unhealthy stress management techniques. She encourages people to consult with a therapist or other practitioner to work through childhood traumas. Try to identify and eliminate the stressor. If a job is causing stress, we can’t always change jobs, but using techniques such as yoga, meditation and mindfulness can help.

She also recommends bodywork and movement, breathing techniques, biofeedback and going outdoors and into nature as effective stress relieving techniques.

Foraker notes that the Life’s Essential 8 framework has specifically called out mental health and social determinants of health. These underlying factors can be barriers to achieving ideal cardiovascular health. “Mental health can impact depression and be a proxy for nicotine addiction and poor diet,” she says.

Social determinants may include living in a food desert without access to healthy foods. Some people may not be able to achieve physical fitness because they might live in a high crime area, preventing them from being physically active outdoors. “Social determinants of health are often cost prohibitive to achieving health goals,” Foraker reiterates.

Nationwide, nonprofits such as The Food Trust are helping to bring nutritious food to low-income communities. The National Youth Sports Strategy, an initiative of the U.S. Department of Health and Human Services, strives to expand children’s participation in youth sports and encourage regular physical activity.

Nussbaum observes that while much attention is placed on lowering fat and cholesterol for a healthier heart, what is more important is choosing fats that don’t oxidize easily. When low-density lipoprotein (LDL) is oxidized, it can lead to atherosclerosis, the buildup of plaque on the artery walls.

“Seed oils like canola oil, safflower oil, sunflower oil or corn oil have been promoted as heart healthy, but those are very easily oxidized because they contain linoleic acid, an inflammatory omega-6 fatty acid that can contribute to heart disease,” Nussbaum says. “While omega-6 is an essential fatty acid, we only need a small amount in our diets. Our modern diet has become very high in omega-6.”

Nussbaum advises increasing omega-3 intake to balance the omega-3s/omega-6 ratio. Cold water, fatty fish that’s low in mercury, such as salmon, along with shellfish, are good sources of omega-3s. For people that don’t eat seafood, marine algae provide omega-3s.

Polyphenols are plant-based foods— that boost heart health and immunity. Polyphenol-rich foods include green tea, citrus fruits, hibiscus tea and turmeric. Nussbaum adds that organ meats such as liver are high in antioxidants such as retinol and vitamin A.

Red meat has gotten a bad rap, but Nussbaum notes how meat is sourced makes a difference. The nutritional quality of a fast-food burger is much different than a cut of beef from grassfed cows that are sustainably raised; the latter having a very different nutrition profile, along with omega-3s.

Nussbaum cautions that consuming a low-fat diet may not lower risk of heart disease because many low-fat diets substitute fat with carbohydrates. A high-carbohydrate diet can lead to obesity and insulin resistance, which are risk factors for heart disease.

It can be intimidating to start a workout regimen, especially if time is limited. “What’s more important is not being sedentary and finding ways to keep moving,” Nussbaum reassures. “Even if you have desk job, there are ways to incorporate short bursts of movement into your day. Walking can be helpful.”

She adds that high-intensity interval training—short bursts of intense exercise alternated with low-intensity recovery periods—can be effective for those with limited time. “Some of those workouts are only five to 10 minutes long but can have just as much benefit as a 90-minute cardiovascular workout.”

Dr. Yale (Yoel) R. Smith is a Melbourne, Florida-based physician who is triple board-certified and an Advanced Fellow in Anti-Aging Metabolic and Functional Medicine. “There are millions of people walking around with severe cardiac disease that do not even know it, because heart attacks and death from an acute coronary syndrome (ACS) can kill someone without warning,” he cautions. “Thus, preventing such an event with specialized testing can allow people to live long lives with loved ones.”

Smith emphasizes the importance of a complete lipid profile. “I see many patients that come to me with incomplete lipid profiles,” he notes. They do not include sensitive biomarkers that go beyond just total cholesterol, LDL, high-density lipoprotein (HDL) and triglycerides.

There’s a misconception that if one’s cholesterol is within normal range, they need not worry about heart disease. “But someone could have ‘unstable plaque’ just waiting to burst in a coronary artery that kills the patient,” Smith explains. “When an unstable plaque ruptures in a major vessel, the body senses it as bleeding and sends clotting factors to stop the bleeding, thus creating the heart attack and death. We can look for this with cutting-edge testing.”

Such testing includes Cleerly, which uses artificial intelligence to look within the coronary arteries. It provides actual visualization of the patients’ vessels and pinpoints locations of stenotic lesions, total plaque volume and unstable plaque locations. “This is revolutionary and allows me to provide information to the patient and the interventional cardiologist vital information before catheterization,” Smith says.

The Protein Unstable Lesion Signature test looks for cellular markers for high-risk patients and determines risk for plaque rupture. The Vibrant Health CardiaX allows doctors to look at 22 different genes that can contribute to various heart disease issues.

“Family history is a look into the future of your chance of developing heart diseases,” Smith shares. “The genetics of a patient’s family is quite important, and genes can jump a generation. Thus, the patient could have their grandfather’s or grandmother’s genes that can put them at risk and lead to an early death.”

There are natural ways to control and reverse heart disease, Smith reiterates, but he cautions against over-the-counter, unregulated supplements marketed toward improving heart health. A comprehensive workup and cardiovascular health plan should be monitored by a qualified medical doctor.

“Meditation and massage are beneficial to lower stress,” Smith concurs. “Stress and high cortisol levels create a pathway to heart disease, elevated blood pressure and other issues. Thus, anything that can lower stress and create a happy lifestyle will help with heart health.”