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The True Cause of Heart Disease

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Quick Summary tl;dr

Heart disease is not as simple as it sounds; it is not as simple as maintaining a cholesterol level within normal range. Heart disease is an intricate disorder of genetics, metabolism, inflammation, oxidation and plaque formation.

A high-speed CT or (EBT) scan of the heart will show you a picture of the amount of plaque in your arteries. A calcium score higher than 100 is a concern, and a score higher than 400 indicates severe risk of cardiovascular disease.

The risk of heart disease can be lowered by following a low-carb or ketogenic diet.

Table of Contents

Prevalence and Risk of Heart Disease

The True Cause of Heart Disease

Normally the heart pumps blood and oxygen to the body's cells through veins and arteries.

Heart disease describes a group of problems that occur when the heart and blood vessels aren't working the way they should. For example a blood clot blocks an artery and the heart muscle is starved of oxygen, heart muscle cells die and this leads to a heart attack; or if blood flow to the brain is blocked or a blood vessel is ruptured, a stroke occurs.

Most diseases of the heart (coronary artery disease, congestive heart failure) can lead to a heart attack (1, 2, 3).

Heart diseases are responsible for 31% of deaths globally ( 4). In men, the risk for coronary heart disease increases starting at age 45. In women, the risk for coronary heart disease increases starting at age 55.

Symptoms of Heart Disease

Knowing the symptoms of heart disease can save your life. Initial symptoms may start as a mild discomfort that progress to significant pain typically lasting 30 minutes. Do not ignore it.

The most common symptom of heart disease is chest pain; described as a discomfort, heaviness, pressure, aching, burning, fullness, squeezing, or painful feeling in your chest, shoulders, arms, neck, jaw or back. It can be mistaken for indigestion or heartburn. Other symptoms include:

  • Shortness of breath, anxiety
  • Palpitations (an irregular "flip-flop" feeling in your chest), faster heartbeat, or increased awareness of your heartbeat
  • Fullness, indigestion, or choking feeling (may feel like heartburn)
  • Sweating, nausea, vomiting, or dizziness
  • Some people have a heart attack without having any symptoms, which is known as a "silent" myocardial infarction (MI)

If you think you are having a heart attack, get help immediately. Quick treatment is very important to minimize the amount of damage to your heart.

What Are the Emerging Predictors of Heart Disease?

The True Cause of Heart Disease

Not too long ago normalizing cholesterol levels was viewed as a high priority in heart care. What we thought was very important in regards to “Good” and “Bad” cholesterol is not so.

While cholesterol still counts, we now know to focus on types of blood lipids: LDL size, HDL/cholesterol ratio and triglyceride/HDL ratio. Although experts disagree on this, large particle LDLs may not be harmful to your health while the smaller, denser LDL particles can more easily oxidize and trigger inflammation.

Today we know oxidation, inflammation, blood clotting factors, plaque and genetics all predict heart disease. If you are interested in heart health, expand on your discussion with your doctor to include these 4 risk categories to help identify heart disease risk early. A quick interesting point is that many of these risks for heart disease are also diabetes risks as well. ( 5)

1. Inflammation

Inflammation is a natural part of the body’s immune system. It is a response to help repair different types of damage.

Inflammation can be acute (healthy) or chronic (unhealthy). Acute inflammation occurs over seconds, minutes, hours, and days; for example swelling after an injury; while chronic inflammation occurs over long periods of time and is associated with chronic diseases such as diabetes, heart disease and obesity.

How to Identify Inflammation?

Cytokines such as the ones below help identify inflammation ( 6):

The True Cause of Heart Disease

  • Tumor necrosis factor alpha -1 receptor (TNF) is a cytokine secreted in fat tissue involved in signalling and regulating normal body functions like the immune response. High levels are linked to heart disease and other medical conditions like cancer, rheumatoid arthritis and diabetes. Less than 5.6 pg/mL is normal.
  • Interleukin 6 (IL-6) is both a pro-inflammatory cytokine and an anti-inflammatory myokine secreted by T cells and macrophages to stimulate an immune response leading to inflammation. Less than 5.0 pg/mL is normal.
  • High-sensitivity C Reactive Protein (HS-CRP) is a protein that increases in the blood with inflammation. Less than 1 mg/L is normal, ideally below 0.7 mg/L.
  • Homocysteine is an amino acid produced as part of the body's methylation process (also related to genetics, see below). High homocysteine levels contribute to plaque formation by damaging arterial walls leading to increased risk of heart attacks and strokes. Less than 15 mcmol/L is normal.

2. Oxidation

Fat and mineral imbalances contribute to oxidation (cell damage from excessive free radicals). Each nutrient imbalance carries its own specific risk for heart disease. Too much polyunsaturated fat and iron increase risk while deficiencies in magnesium can contribute to heart disease.

Fat Imbalances

The True Cause of Heart Disease

Lipid peroxides (oxidized lipids) are the products of free radical damage to fatty acid cell membranes ( 7). Free radicals "steal" electrons from the lipids in cell membranes, resulting in cell damage.

Polyunsaturated fats (PUFA) are more readily oxidized because they contain methylene –CH2– groups. That’s why diets high in PUFA contribute to oxidation and increase risk of heart disease. Like TNF and other inflammation markers, lipid peroxides are not just tied to heart disease, there is a link with diabetes, cancer and neurodegenerative diseases including Parkinson's disease and Alzheimer's disease.

Thiobarbituric acid reactive substances (TBARS) is a marker that measures lipid peroxides (oxidative breakdown of fats). It is a strong and independent predictor of coronary heart disease ( 8).

Magnesium Imbalance

Magnesium is a mineral that acts against oxidation and is a co-factor for over 300 enzymes in the body. Its relation to heart health is deep ( 9).

Magnesium deficiency leads to an increase in both sodium and calcium deposits in the heart, and therefore increased risk of heart disease. Artery calcification is the basis for plaque build-up in the arteries and is measured with a total calcium score (no evidence of CAD: 0 calcium score, minimal: 1-10, mild: 11-100). Normal magnesium level range is 1.7 to 2.2 mg/dL.

Iron Imbalance

Iron is a mineral that carries oxygen in the hemoglobin of red blood cells helping cells produce energy. Men and post menopausal women are at higher risk for heart disease if iron is too high. Healthy levels range between 40-60 ng/mL ( 10).

3. Genetics and Metabolic Markers

The True Cause of Heart Disease

Associations continue to build between heart disease and both genetic factors and metabolic markers. Genes have been found to regulate lipid and cholesterol metabolism, while metabolic markers, such as blood sugar and insulin, are already cemented in science.

Apo E Genes and Heart Disease

Apo E genes influence heart disease risk by providing instruction for making a protein called apolipoprotein E. This protein combines with fats (lipids) in the body to form molecules called lipoproteins. These lipoproteins are components of cholesterol. The ApoEε4 mutation raises risk of CHD, while ApoEε2 allele lowers risk of CHD ( 11).

MTHFR and Heart Disease

Methylenetetrahydrofolate reductase (MTHFR) is an enzyme regulated by the methylenetetrahydrofolate gene. It plays a role in processing amino acids, and it is important for chemical reactions involving forms of the vitamin folate and converting homocysteine to another methionine. If there is a mutation in this gene there is an increased risk of heart disease ( 12) and homocysteine levels will be high.

Insulin and Heart Disease

Insulin is a fat storing hormone automatically released after sugar or carbohydrates are consumed. Insulin is directly related to elevated triglycerides (therefore raising the TG:HDL ratio) and weight gain in the belly (increased level of visceral fat - a well known risk factor for heart disease). A healthy fasting insulin level is less than 3-5 mcU/ml.

Diabetes and Heart Disease

Diabetes (Type 1 and Type 2) contributes to heart disease as high circulating blood sugar levels can contributes to sugar laden plaque build up.

Even when blood sugar levels are within pre-diabetic range 100-125 mg/dl risk of heart disease increases ( 13). One study completed by Cleveland Clinic showed that compared with individuals whose blood sugar was below 79 mg/dl, those who had blood sugar between 100-125 mg/dl had a 300% increase of coronary heart disease risk ( 14).

4. Artery Plaque

The True Cause of Heart Disease

Blood clots and calcium build up in the arteries (calcification) are physical (vs. biochemical) contributors to heart disease risk factors.

Fibrinogen and calcium are two of these underlying factors in heart disease.

Fibrinogen and Heart Disease

Fibrinogen, or factor I, is a blood protein made in the liver. Fibrinogen is responsible for normal blood clotting. Elevated fibrinogen may decrease blood flow, especially through partially blocked arteries, and may promote the formation of abnormal blood clots inside coronary arteries and directly contribute to the atherosclerosis process by binding to LDL. Fibrinogen should be less than 300 mg/dl.

Calcium and Heart Disease

Calcium along with fat and cholesterol deposit as artery plaque over time. The imaging test provides an early look at calcium build up. If calcium is deposited there is stiffening and narrowing of the artery which can restrict blood flow or trigger a blood clot causing a stroke or heart attack.

Can a Ketogenic Diet Lower Heart Disease Risk?

Despite its complexity, the risk of suffering heart disease can be lowered with a simple dietary change: by lowering carbs to less than 45% of total calories and with a ketogenic diet ( 15,  16).

Many of the risks associated with heart disease should be included as part of heart health check ups. It is wise to understand the symptoms and totality of the risks to maintain good heart health.

Next time, we’ll explore exciting research that that looks at mechanisms to lower the risk and prevent heart disease.

The True Cause of Heart Disease

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Valerie Goldstein, MS, RD, CDE
Author and Health & Blood Sugar Expert

Valerie Goldstein

Valerie is a Dr. Atkins trained registered dietitian and certified diabetes educator. She is acknowledged in his books, "Dr. Atkins New Diet Revolution" and "Atkins for Life".

Valerie always says, "The ketogenic diet provides the most nutrient bang for the calorie buck" and so she uses this nutritional approach and personalizes it for all her medical, weight loss and athletic clients throughout the country.

Expert Article

This article was written by Valerie Goldstein, MS, RD, CDE who is a qualified expert. At KetoDiet we work with a team of health professionals to ensure accurate and up-to-date information. You can find out more on the About us page.

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Evidence-Based articles are based on medical research, and scientific evidence. Our expert authors focus on hard evidence alone and include relevant research references from trusted sources to support their articles. We always aim to deliver relevant, trustworthy and up-to-date information based on trusted evidence and proven research.

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Comments (11)

I believe that the vast majority of information in this post is excellent and accurate.  However, no one eating a ketogenic diet would get 45% of their calories from carbohydrates.  Also, I am quite familiar with using the TRI/HDL ratio to predict insulin resistance, pre-diabetes and diabetes, but what is the value of the HDL/TRI ratio?  I have not seen this ratio referenced before.

Hi Patty, I think you may have misunderstood. It says: "Despite its complexity, the risk of suffering heart disease can be lowered with a simple dietary change: by lowering carbs to less than 45% of total calories and with a ketogenic diet."
So to me it sounds like lowering carbs even above the ketogenic level is beneficial and it is beneficial to follow the ketogenic diet. You may be right on the ratio though.

Hi Patty, thanks for spotting the typo in the ratio!

Interesting article. I am 8 stone overweight and have this week lost 7lb on keto diet. I have a dreadful family history of heart disease and I have Psoriatic Arthritis. I am on anti-TNF therapy. A recent cholesterol blood test which I was really dreading came back as within normal range, despite previously being high 7 years ago. I have previously lost 2 stone on keto which is why I am back on it. I feel so much better eating low carbs.

If, like me, you have already been diagnosed with cardiomyopathy, what can be done, other than medication,  to minimise my chances of having a heart attack?

Hello Annie,
I would say there are 2 very important things you can do:
1. Adopt a healthy lifestyle. Eating anti-inflammatory foods as part of a healthy ketogenic diet and doing exercise like yoga to help bring oxygen into the body. Your goal is to support the heart muscle. Find a balance, do not over exert yourself but also do not avoid activities that will help strengthen the heart.
2. Monitor clinical labs, seek heart scans and any other preventive relevant medical information you can use towards preventive care.
I wish you the best.
Take care,

I love the topic. Problems like heart disease tend to be much more complex than we realize and it's always great to have more details and research.

Thank you for the information. I have been taking 2 forms of vitamin K2 this past year and feel it has benefited me,  MK-4 and MK-7. Can you please discuss these in the context of heart disease and calcium plaque build up? thanks

Awesome articles by experts here!

One of the best articles on this subject I have seen!  Thank you Valerie!

Thank you Bruce. I hope it is helpful.