Are you at risk for a heart attack during your workout?

Spoiler alert! This column contains details from Sunday's "Billions" season premiere, which is streaming now.

Recently, a second TV show character experienced a heart attack while riding the high-end interactive Peloton bike. This time it was Mike "Wags" Wagner (David Costabile) of Showtime's “Billions.” Wags survives his ordeal, and in a jab to his HBO Max counterpart says, "I'm not going out like Mr. Big," referencing Chris Noth's character's death on the "Sex and the City" reboot. 

It’s no wonder that both Peloton customers and others starting new exercise regimens in the New Year are asking, "Could this happen to me?" 

In the United States, someone has a heart attack every 40 seconds. The primary culprit is coronary artery disease (CAD), which affects 18.2 million adults. CAD is caused by plaque buildup in the wall of the coronary arteries that supply blood to the heart. These plaque deposits can break open or rupture, and a blood clot can get stuck where the rupture happened. If the clot blocks the artery, this can deprive the heart muscle of blood and cause a heart attack.

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Although moderate physical activity like brisk walking is safe for most people, if you live a relatively sedentary lifestyle and don't exercise regularly, heed those signs at the gym that warn “Always consult a physician before beginning any exercise program.” Here’s what you need to know about how your doctor assesses your risk for CAD before your start exercising.

Health conditions and heart health

Chief among the health conditions that increases your risk for CAD is hypertension, or high blood pressure. The majority of people with hypertension don’t know they have it, which is why it’s important to establish care with a primary care doctor and have it checked in the doctor’s office regularly or with carefully calibrated home device.

Are you next? More Americans than ever are being diagnosed with high blood pressure.

Excess cholesterol, particularly “bad” cholesterol can directly contribute to plaque formation in the coronary arteries. However, “good” cholesterol can actually be cardio-protective. Ask your doctor to run a “lipid panel” test on your next visit to check your levels of various types of cholesterol.

The risk of death from heart disease for adults with diabetes is higher than for adults who do not have diabetes. Rampant elevated blood sugar levels can be genetic or due to lifestyle choices. Your doctor can check your glucose levels in a “basic metabolic panel” and long-term glucose control with an HbA1c test.

Perhaps the most dangerous risk factor is obesity, particularly when excess fat tissue is concentrated in the waist, giving an “apple-shaped” appearance. In obese patients, there is a high likelihood for additional risk factors. Three or more risk factors indicates the presence of Metabolic Syndrome, which significantly increases a person’s risk for serious cardiovascular events.

The good news is that these risk factors can be mitigated thru lifestyle changes and medication under the watchful eye of your physician.

Lifestyle choices that increase your risk for heart disease

Physical inactivity and a sedentary lifestyle are intrinsically linked to heart disease because they increase the chances of having the health conditions mentioned earlier. A diet heavy in salt, saturated fats, trans fats and cholesterol can contribute to CAD. Excess alcohol can raise blood pressure and triglycerides, both risk factors for CAD. Smoking can directly damage the lining of coronary arteries, increasing the risk of plaque rupture and thrombosis.

On the flip side, regular physical activity can lower your risk for heart disease. Diet changes such as limiting portion size, adding more fruits and vegetables, choosing whole grains, switching to healthier fats like avocado and olive oil, and opting for lean meat, poultry and fish can make a huge difference.

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Consider your age and family history

There are a few risk factors for CAD that are beyond our control. Heart disease can occur at any age, but it does increase as we get older. Certainly, a family history of risk factors like diabetes and hypertension will be taken into consideration by your doctor. In addition, your doctor will want to know about any history of sudden cardiac death in younger relatives.

Following this assessment, your doctor may schedule you for a monitored exercise stress test, in which they can measure your heart rate while you walk on a treadmill at a progressively increased speed. This helps to determine how well your heart is working when it has to pump more blood.

If you have chest pain or shortness of breath during the test, and there are signs of ischemia, or weakness in part of your heart, your doctor could order a cardiac catheterization, which checks the inside of your arteries for blockage by inserting a thin, flexible tube through an artery in the groin, arm or neck to reach the heart. Your doctor could also schedule a CT scan that looks in the coronary arteries for calcium buildup and plaque.

Once your doctor has finished assessing your risk for CAD and gives you the “all clear” to start exercising, I highly recommend proceeding slowly. Remember, you don’t have to immediately start pumping out hours on the Peloton to achieve a cardiovascular benefit. A new study just published in JAMA Internal Medicine of 5,000 participants showed that 110,000 US deaths could be prevented each year if adults over 40 added just 10 minutes of daily moderate physical activity to their normal routines.

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Michael Daignault, MD, is a board-certified ER doctor in Los Angeles. He studied Global Health at Georgetown University and has a Medical Degree from Ben-Gurion University. He completed his residency training in emergency medicine at Lincoln Medical Center in the South Bronx. He is also a former United States Peace Corps Volunteer. Find him on Instagram @dr.daignault