A man's heart after 40: what really protects it

Heart and blood vessel disease is the leading cause of death in men. It sounds frightening, but there's good news in it: the risk is driven by a few things you can largely control. Not supplements and not your watch's readings, but a handful of "boring" levers.

What matters most

Nine factors you can influence account for more than 90% of the risk of a first heart attack: blood pressure, smoking, cholesterol, diabetes and belly fat, inactivity, diet, alcohol, stress. The gap between these levers and trendy "optimisations" is huge.

The levers — by strength

Fitness. The most underrated lever. Even a small improvement in stamina noticeably lowers mortality — comparable to quitting smoking. The biggest jump comes when you go from "barely moving" to "moderately fit". A guide: 150 minutes of aerobic exercise a week and two strength sessions.

Don't smoke. The fastest lever. Even one cigarette a day carries about half the excess risk of a pack — "cutting down" doesn't work, only quitting does. A year after quitting, the risk of heart disease halves. E-cigarettes are probably less harmful, but not harmless.

Blood pressure. The single biggest risk factor. Measure it at home with a validated upper-arm cuff.

A Mediterranean style. Proven in large trials: about 30% fewer heart events. Olive oil as the main fat, a handful of nuts a day, legumes, fish, vegetables. Salt — under 5 g a day, less ultra-processed food.

Fish, not fish oil. Oily fish twice a week is good for you. Over-the-counter omega-3 capsules haven't shown a benefit for the heart, and high doses raise the risk of rhythm problems.

Belly and sleep. Fat around the waist and sleep apnea raise blood pressure and the risk of rhythm problems.

Alcohol. "A glass of wine is good for the heart" — it didn't hold up. Don't start for your heart's sake, and if you drink — drink less.

Know your numbers

What your watch can't see, you find out from a doctor: blood pressure, cholesterol and, if possible, ApoB, Lp(a) — once in a lifetime (it's inherited and raised in about one in five people), blood sugar. At intermediate risk, a doctor may suggest a coronary artery calcium scan.

What about watches and rings?

An irregular rhythm notification is the most useful thing a watch can do: it's worth showing a doctor. But no notification doesn't rule out rhythm problems. Wrist blood pressure hasn't been validated yet — re-measure with an upper-arm cuff. And most importantly: a "perfect" dashboard can't see plaque in your arteries.

"Heart" supplements

No supplement has been shown to reduce heart attacks. In a head-to-head comparison, popular supplements didn't lower cholesterol, while a low dose of a statin lowered it noticeably. Red yeast rice is essentially a statin with no dose control and possible contaminants. Niacin showed no benefit in large trials, but there was harm. "Artery cleansing" and "dissolving plaque" have no data in humans.

About statins — honestly

We don't prescribe them. They're among the most studied medicines. Most "side effects" in blinded studies happened just as often on placebo. The decision is made with a doctor based on your personal risk. Fear and stopping them on your own raise the risk of heart attack and stroke.

When it's urgent

• Pressing, squeezing or burning pain behind the breastbone, especially on exertion, spreading to the arm, jaw or neck, with breathlessness, sweating or nausea — at rest, this is a reason to call an ambulance.
• Fainting during exertion.
• New or worsening breathlessness.
• Calf pain when walking that goes away at rest.
• New erection problems — also a reason to get your heart checked.

What to try this week

• Three brisk 30-minute walks.
• Measure your blood pressure at home morning and evening, two or three days in a row.
• Two portions of oily fish this week.

This is general information, not a prescription. Tests and treatment are chosen by a doctor.