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Q1: Heart attack at the age of 29, the next one within a year. Both times treated in emergency department with the usual clot busting drugs and then off to the UK for angioplasty and stents. Patient is diabetic with hyper cholesterol both being treated along with medication for blood pressure.

Current lifestyle of the patient – apart from taking medicine regularly, no regard is given to diet and exercise, continues smoking and drinks excessive amounts of alcohol, also a type A personality, is overweight.

The patient is my brother and I am deeply worried about him. The obvious we all know – exercise regularly, watch your diet, drink in moderation and control your stress levels and take medication. He doesn’t. He is age 37 next birthday. I don’t know how to help him. What kind of problems is he looking at and at what intervals in the coming years?

Name and address supplied.

A1: I am sorry about your brother especially as heart attacks are rare at such an early age. When they do occur in the twenties and early thirties a great many patients are suffering from either diabetes or persistently raised cholesterol levels. Often it is found that the overall cholesterol, the low density lipoprotein cholesterol (LDL) and the triglycerides are raised and the HDL (high density lipoprotein) is lower than desirable. Another less frequent cause of an early myocardial infarction (coronary arterial thrombosis) is the presence of a coronary artery that has been unusually narrow since birth. If the artery is a small and unimportant one, a twig rather than a main branch of the coronary arterial tree, this may not matter much even if the patient suffers its blockage in early life.

Obviously we never discuss individual cases but in all medicine prevention is better than treatment. It is often not realised that the summation of the various risk factors is a more important calculation than the likely risk posed by one very dangerous factor. Having diabetes with raised lipids is a danger at any age group, although lifestyle may have made these factors even more relevant than usual, it is likely that a patient with them has inherited the genes that are liable to give rise to arterial problems. As well as having specific treatment for the diabetes, so that the blood sugar is kept at a slightly lower level than average and likewise the blood pressure and cholesterol levels are better than that of most people, lifestyle modification is essential.

When there are specific medical risk factors like diabetes type 2 and hypercholesterolaemia compliance with the doctor's recommendations concerning medication are essential. The crucial factors in lifestyle are smoking, eating, drinking and exercise. Nobody who has inherited risks such as diabetes and a raised cholesterol level should smoke. I have no moralistic or even strongly held opinions about smoking but the evidence that it increases the likelihood of having a heart attack or stroke is undeniable. A patient who is at risk of a heart attack, let alone someone who has already had two, is being wildly and dangerously unwise in continuing to smoke. Similarly weight control is important, whatever a male patient's height, his waist band should be under forty inches. Achieving this weight may also require a reduction in alcohol intake. A diabetic man with arterial disease might benefit from two small glasses of wine a day but any advantages of drinking would be lost if he drank at all heavily. Salt intake should also be cut.

Exercise for the patient with diabetes and hypercholesterolaemia should be brisk rather than violent. Once a patient's coronary arteries have reached the stage of needing stenting the type of exercise they should be taking as well as how much of it is needed should be discussed with their doctor. The worst type of exercise is occasional, for example once or twice a week, violent exercise. The usual advice is to try to exercise briskly but not violently at least five times a week. Brisk walking is the best exercise.

When patients seem to be absurdly foolhardy about taking reasonable steps the underlying motivation for this should be explored. It can be that their medical problem has eroded their social and self confidence and consciously or subconsciously they are now determined to show the world that they can overcome this difficulty by ignoring it. Denial is always a potentially dangerous state of mind but cognitive behavioural therapy may help.

It is always impossible to predict prognosis. Doctors can only say what will happen to the average patient but by definition to achieve the average expectancy some patients will do better and some worse. As every patient is different the question as to whether a patient should be told the average prognosis is always debatable. My policy is and was to tell patients the average figure but also to try and persuade them that this is not a prediction of how long they will live as nobody knows that. The policy of talking to the patients about prognosis is that it leads to all those dinner party conversations that start "the doctor's said that I only had months to live, but here I am ..."