How to Prevent Heart Disease: Top tests and habits to start in your 40s

The full transcript of this episode is below. Lightly edited for readability.

Kelly:

Welcome to the show, Jason. I really, really appreciate you being here. I think that this is such an important topic. It’s one that affects so many Australians. I know for myself, I never got to meet my grandfather because he died of a heart attack when my father was only 24. And I think most Australians would have some experience of heart disease somewhere in their connections. And so I think this lens that we’re putting on today of prevention and starting early is so important. So I really appreciate you being here.

Dr. Jason Kaplan:

Thank you so much for having me.

Kelly:

Before we jump into the nuts and bolts of why we’re here and the important discussion, I always like to give my audience a bit of a sense of the person that they’re listening to. So I’d love to hear — how do you start your day? You obviously work at a very high level. How do you set yourself up for success and focus?

Dr. Jason Kaplan:

Look, I do start my day with a coffee with non-dairy milk, usually soy milk. We have three primary school aged children at home and two dogs, so life is busy in our household. But generally I’ll spend a few minutes sitting outside with a cup of coffee, usually around sunrise or just before, sometimes the morning stretches. Some mornings before work I will go to an exercise group. We live near the beach, and I’ll join a bunch of other people exercising and sometimes go for a swim before work in the ocean all year round. And I find that quite invigorating and gets me set up for the day.

Kelly:

Beautiful. Yeah, you’re hitting lots of boxes there with sunlight and community and exercise and everything. So let’s jump in. I think heart disease is still seen as something that happens to older people or people who don’t look after themselves. So what’s the reality of what you’re seeing in the clinic right now?

Dr. Jason Kaplan:

So that is the perception — in reality, that’s not quite the truth. For most people, when we say heart disease in Australia, we think coronary artery disease. So this is the buildup of fibro-fatty plaque in the blood supply to the heart called the coronary arteries. And the disease process is called atherosclerosis.That is usually a combination of all of an individual’s risk, including genetic risk, lifestyle risk, traditional cardiovascular risk factors such as cholesterol, blood pressure, diabetes, smoking, inactivity, obesity — and inflammation — and that all contributes to the development of disease in the arteries. But we know that those markers start earlier than people think. So when someone presents with heart disease or a heart attack in their 50s and 60s, that has its origin in their 40s or sometimes in their 30s.So I do diagnose young people with early plaque in their arteries, early atherosclerosis, cardiovascular events before the age of 50 in men. And interestingly, one of the most famous cardiologists in the world — Valentin Fuster — suggests that childhood dietary and lifestyle decisions impact cardiovascular health later in life.

Kelly:

It makes so much sense to me, but yeah, I think for people that could be quite shocking — that they actually need to be thinking about their heart health from their 30s, or even for their children. Okay, so what are the greatest risk factors for cardiovascular disease and how much of that is genetic versus lifestyle choices?

Dr. Jason Kaplan:

I always tell patients, you cannot ignore your genetics — both your family history, and more and more we are now able to look at people’s genome. There was a wonderful paper in the New England Journal of Medicine by Amit Khera showing that if you had a high genetic risk but made positive lifestyle changes — healthy weight, healthy dietary patterns, regular exercise, stopping smoking, controlled blood pressure — you could reduce your genetic risk by around 50%.Not only did patients reduce their risks — they also attenuated and stopped plaque building up in their arteries. So despite having a high genetic risk, your genes are not your destiny. You have to work harder. And often in my practice, the work is in how we implement those changes in people’s actual lives. Because it’s the daily habits — the ordinary things — that make the major changes.

Kelly:

I just want to underline what you said about the 50%, because that’s really important — that despite your genetics, 50% is about your lifestyle choices. That’s super significant.

Dr. Jason Kaplan:

Absolutely. The people who had bad genetics and bad lifestyle choices were in real trouble — a lot of those people had significant events. But the lifestyle choices improved cardiovascular health and reduced risk all throughout the underlying genetic risk spectrum. I can’t underscore enough the importance of making those changes earlier on in the life cycle.

Kelly:

Let’s talk about testing and genetics. Is it just knowing your family history, or do you recommend people having their DNA done?

Dr. Jason Kaplan:

Family history is very important. What we do routinely is get people’s traditional risk factors through blood tests, including cholesterol. And there’s a risk marker called lipoprotein(a), or Lp(a). It’s a genetically inherited lipoprotein that causes accelerated plaque formation in arteries, can cause accelerated aortic valve disease, and carries an increased risk for blood clotting. We now recommend screening with Lp(a) at least once in someone’s life cycle.One of the key advances in cardiovascular testing is the coronary artery calcium score. We are lobbying hard to get this on Medicare. Currently it’s not — but anyone can request it, and it should only be around $100. Most GPs can order it. It tells us purely about long-term atherosclerotic plaque.If you’re a man in your 40s with multiple risk factors, it’s certainly something you should get. Or if you’re a woman around 50 or menopause. The gold standard is a cardiac CT angiogram — slightly more involved, intravenous contrast, slightly more expensive, but it visualises the degree of narrowing in people’s arteries and identifies high-risk plaque — which is basically a heart attack waiting to happen.I want to share a story. When I was doing my cardiology fellowship at Royal Prince Alfred Hospital, one of my consultants — a very fit man in his late 40s with a family history — was out running one evening, had chest pain, had a cardiac arrest. Sadly he passed away. He had undiagnosed coronary artery disease. A simple cardiac CT scan done the week before would have prevented that. So these tests are very powerful.

Kelly:

So of the three tests you’ve mentioned — could you talk me through the order you’d recommend, and how people go about getting them?

Dr. Jason Kaplan:

A patient’s primary care doctor can order most of the bloods, including Lp(a) and a cholesterol panel. I also recommend getting ApoB — a slightly more accurate marker of all the potentially harmful cholesterol particles in someone’s bloodstream. And don’t ignore the simple things: blood sugar levels, blood pressure. Get the basics first.Then as a screening tool, I think it’s very reasonable for men from the age of 40 to have either a calcium score or a cardiac CT — probably a cardiac CT from the age of 45. For women around menopause. Then that can lead on to further testing. So: start with the blood work, a proper risk analysis by a primary care physician, and then more advanced imaging to help risk stratify and direct therapy.

Kelly:

Let’s go back to lifestyle risk factors and unpack them one by one. In 2022, the American Heart Association updated the cardiovascular health checklist and added short sleep duration as an official risk factor for the first time. Why does how long we sleep actually matter for your heart?

Dr. Jason Kaplan:

More and more we’re learning that both the quality and duration of sleep have an association with heart disease. Sleep is now a key cardiovascular metric — part of what the AHA calls Life’s Essential 8.Reduced sleep duration — less than six hours a night — is associated with an increased incidence of cardiovascular disease. We also know that interrupted sleep is certainly problematic. Interestingly, more than eight or nine hours a night doesn’t really help from a cardiovascular risk profile either. Poor sleep habits also lead to downstream behavioural issues, lifestyle issues, and neurohormonal issues.We also know that people who are overweight may be predisposed to obstructive sleep apnoea. And sleep apnoea — beyond how it makes you feel — is associated with increased risk of heart disease and particularly high blood pressure. Patients who can lose around 15% of their body weight also see significant improvement.

Kelly:

But I think it starts with the mindset — because amongst high achievers, which my audience are, there’s this attitude of: I have too much to do, I’m too busy, everything else will go first. So I think it’s really important to hear clearly how the evidence shows that sleep is critical for your health.

Dr. Jason Kaplan:

And often, having a bit more sleep allows your brain to function better too. For high achievers, that’s a compelling reason.

Kelly:

Let’s talk about cholesterol because there is a lot of noise about different things.

Dr. Jason Kaplan:

There is a lot of noise about cholesterol. The development of heart disease is not just about cholesterol. Not everyone with high cholesterol develops heart disease, though it certainly is a risk factor.In secondary prevention — someone who’s already had a heart attack or stroke — one of the best-correlated relationships in cardiovascular medicine is that achieving a lower LDL level improves outcomes. But the same principle applies in prevention.After many years of exposure to elevated cholesterol, the body starts depositing it in the arteries — not just the heart arteries, but the femoral artery, the carotid artery. The arterial system is a complex network of kilometres of small blood vessels, and it can all be diseased.We talk about cholesterol a lot because it’s a modifiable risk factor. And this is really important: if you do have plaque or atherosclerosis in your arteries, we know we can achieve regression — reversing plaque by achieving much lower cholesterol levels. We’ve proven that on multiple studies using ultrasound in people’s arteries. And usually in my practice, lifestyle is number one.

Kelly:

Could you talk to me about that? The diet?

Dr. Jason Kaplan:

I always tell my patients: please don’t follow the fad. Follow the evidence.The dietary pattern that has the most evidence in terms of having effects on biomarkers — including lowering cholesterol and potentially reducing plaque — is a PESCO-Mediterranean style diet. The key seminal study was the PREDIMED study, published in the New England Journal of Medicine in 2013. It included high amounts of extra virgin olive oil, whole grains, some fermented dairy, a reasonable amount of fish, plenty of legumes, and high amounts of fruit and vegetables.But what was really interesting was this: the more plant-based you made that Mediterranean diet, the better patients did. Replacing animal protein with plant protein and using more plant-based sources — including large amounts of legumes — improved cholesterol markers and outcomes.And I firmly believe that besides giving up smoking and vaping, choosing a mostly plant-forward diet is one of the best interventions people can make younger in life to set themselves up for reduced cardiovascular risk later on. Food is, in a way, biological information.

Kelly:

In terms of protein — is there a recommendation on how much, or is there a cap?

Dr. Jason Kaplan:

There’s a big trend right now around high protein — a lot of foods being fortified with protein. One of the studies I show in my talks: choosing to replace around 10% of animal protein consumption with plant-based protein options makes a significant difference. The Nurses’ Health Study and Physicians’ Health Study both showed that made a significant difference in both cancer and cardiovascular outcomes.I strongly recommend paying attention to plant-based protein sources. And they’re easier to get than people think: legumes, water lentils, spirulina, quinoa, black beans. At home, we freeze cannellini beans and put them in our morning smoothies as a plant-based protein source instead of processed protein powder. We put them in the kids’ smoothies as well.

Kelly:

Just before we run out of time — exercise. You’ve worked with elite athletes. Is there such a thing as too much exercise? And what’s the right type and balance for heart health?

Dr. Jason Kaplan:

Cardiorespiratory fitness — particularly over the age of 50 and especially 60 — is probably the best cardiovascular metric of longevity and reduction in cardiovascular events. I want my patients to be in the fittest 20% of people of their age group.It doesn’t really matter how they get there because the heart doesn’t tell the difference between rowing versus cycling versus running versus swimming. At a minimum, I tell patients: 75 to 90 minutes of high intensity exercise where they’re getting their heart rate between 70 to 85% of maximal — or at least over 300 minutes of moderate intensity exercise.That said, there is a U-shape curve. When you go beyond around 300 minutes of high intensity exercise a week, the cardiovascular effect starts to attenuate. And in a predisposed person who does a lot of endurance work — usually more than 5,000 hours — you increase the chance of atrial fibrillation by around threefold.So there is such a thing as too much. But the broad principle is: the fitter you are in terms of cardiorespiratory fitness, the longer you’re going to live and the lower your chance of events. And I encourage patients to balance the yin and the yang — high intensity exercise balanced with something like yoga, Tai Chi, Qigong, or a meditative practice.

Kelly:

This has been so useful. I always like to end by bringing it down to one thing. For the listeners right now — before they see their doctor, before they do anything — what’s the number one habit you’d recommend for long-term heart health?

Dr. Jason Kaplan:

For patients under the age of 50, I would say: adopting a more plant-forward diet is one of the most important things you can start doing. And it doesn’t have to be all the way. Even just replacing 10% of animal protein with plant protein. Just start. Start small. Learn how to cook a legume dish. Start introducing beans into your diet. And then develop a regular exercise habit — how you can do it reliably and stay motivated. For me, groups are very motivating.And the last point: if you haven’t had a proper cardiovascular risk assessment and you’re in your 40s or 50s, please go to your primary care doctor and get it done. I see a lot of heart attacks in hospital where there was a chance for prevention. My passion is being able to prevent those events before they happen.

Kelly:

I think it’s so critical and I really hope that everybody listening to this episode will hear that and will go out and book those assessments. Hopefully from this episode we might be able to help prevent something. That’s always the hope. How can people find out about your work?

Dr. Jason Kaplan:

I consult in Sydney’s CBD as well as St. Vincent’s Clinic and at the North Shore Health Hub on the North Shore campus. My website is drjasonkaplan.com — it has all the information. I work with two great practices: NSW Cardiology based at St. Vincent’s and Envira Heart Care based at St. Leonards.

Kelly:

Beautiful. Thank you so much for your time. I really, really appreciate it.

Dr. Jason Kaplan:

Thank you.