Step 1: Take This SeriouslyIf you have sufficient risk factors for cardiac disease to place you in a high-risk category, this means one of two things. Either your risk of developing heart disease within the next few years is high, or you already have heart disease and don't know about it.
Unfortunately, a substantial proportion of individuals upon learning that they're in the "high risk" category turn out to already have significant coronary artery disease - they just don't know about it because, so far, they are not having symptoms. The fact a high-risk patient is not having symptoms is no reason to relax, especially since, in 30% of patients with coronary artery disease (CAD), the very first symptom is sudden death.
So being at high risk is very serious stuff, and requires a very serious response.
Step 2: Make Sure Your Doctor Takes This SeriouslyFinding that a patient is at high risk for a serious cardiac event, particularly one of the Acute Coronary Syndromes (ACS), ought to elicit a certain type of response from a doctor. The doc should act with alacrity to accomplish two things: a) Evaluate whether you may already have coronary artery disease, and if so, institute appropriate therapy, and b) Modify all the risk factors that are producing the high risk in the first place.
Because some high-risk patients will already have significant CAD, a non-invasive evaluation ought to be strongly considered to rule out this possibility. This evaluation generally will consist of a stress/thallium study. In some cases a cardiac calcium scan might be appropriate.
If the non-invasive evaluation strongly suggests CAD, then steps should be taken to reduce the chances of developing ACS.
At the same time, your doctor should also lay out a clear plan for attacking all modifiable risk factors -- including diet, weight loss, smoking cessation, hypertension, and cholesterol -- and should initiate therapy immediately. Your doctor should offer you all the resources at his/her disposal to encourage and assist in exercise, weight loss, and smoking cessation, and should ride you pretty hard about accomplishing these things.
He/she should display an especially aggressive attitude toward reducing LDL cholesterol, increasing HDL cholesterol, and controlling the blood pressure, since accomplishing these tasks is usually primarily the doctor's responsibility, and since doing so often requires using the right drug therapy in the right doses. In general, controlling cholesterol and hypertension will require fairly frequent office visits and frequent measurements of blood pressure and/or cholesterol levels, as well as many medication adjustments. This all should be done on a fairly aggressive schedule, with clear targets in mind.
Beware of the doctor who merely puts you on a medication or two, pats you on the back, and then considers his job done. Your doctor should clearly understand what "high risk" implies, and should behave accordingly. If this physician is also the one who neglected to mention assessing your cardiac risk in the first place, you may want to find another doctor who will take a more active role in helping you reduce your heart disease risk.
However, also keep in mind that doctors are human, and human nature makes it difficult to pull out all the stops for a patient who is refusing to act in his/her own best interests. It's hard to motivate yourself as a doctor to go the extra mile for the patient who just won't make a genuine and persistent effort to exercise, lose weight, or stop smoking. Which brings us to -