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Coronary Artery Disease

Coronary Artery Disease. Occurs when the coronary arteries that supply the heart muscle become blocked. Partially blocked it causes angina. Fully blocked it causes a myocardial infarction or a heart attack!. Changeable Risk Factors. Hypertension Serum cholesterol Obesity

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Coronary Artery Disease

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  1. Coronary Artery Disease Occurs when the coronary arteries that supply the heart muscle become blocked. • Partially blocked it causes angina. • Fully blocked it causes a myocardial infarction or a heart attack!

  2. Changeable Risk Factors • Hypertension • Serum cholesterol • Obesity • Diabetes Mellitus • Physical Inactivity • Cigarette Smoking • Alcohol Intake

  3. Correlation Between Serum Cholesterol and CVD Mortality Multiple Risk Factor Intervention Trial (MRFIT) N=325,346 30 Untreated Patients 25 55-57 years 50-54 years 20 15 6-Year CVD Death Rate Per 1000 45-49 years 10 40-44 years 35-39 years 5 0 Q1 (<182) Q2 (182-202) Q3 (203-220) Q4 (221-244) Q5 (>244) Serum Cholesterol Quintile (mg/dL) Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986;112:825-836.

  4. ______________________________________________________________________________________________________________________________________________________________ Lifetime Risk of CHD Increases with Serum Cholesterol ___________________________________________________________________________ Cholesterol 57 44 34 33 29 19 Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972

  5. FRAMINGHAM HEART STUDY CAD risk as a function of LDL-C and HDL-C in men (50 to 70 years) 3 2.5 2 Relative CHD Risks 1.5 25 1 45 65 0.5 HDL-Cholesterol (mg/dl) 85 0 220 160 100 LDL Cholesterol (mg/dL) CASTELLI Am J Cardiol 1998; 82:60-65

  6. PREVALENCE OF DYSLIPIDAEMIA Mohan et al., CUPS,NMJI, 2003

  7. Obesity • People who are obese have 2 to 6 times the risk of developing hypertension. • Location of the body fat is significant. • Pears of apples?

  8. The future…?

  9. HemorrhagicStroke IschemicStroke Ischemic HeartDisease 4.0 4.0 4.0 2.0 2.0 2.0 Hazard Ratio 1.0 1.0 1.0 0.5 0.5 0.5 20 20 24 24 28 28 32 32 36 36 16 16 16 20 24 28 32 36 Body Mass Index (kg/m2)* CV Risk Increases with Body Mass Index CV=Cardiovascular Body mass index is calculated as the weight in kilograms divided by the body surface area in meters2. Mhurchu N et al. Int J Epidemiol 2004;33:751-758

  10. Ponderal obesity Intramuscular Subcutaneous Intrahepatic Intra- abdominal

  11. Abdominal obesity and increased risk of cardiovascular events The HOPE study Men Women Tertile 1 <95 <87 Waistcircumference (cm): Tertile 2 95–103 87–98 Tertile 3 >103 >98 1.4 1.35 1.29 1.27 1.17 1.2 1.16 1.14 Adjusted relative risk 1 1 1 1 0.8 CVD death MI All-cause deaths Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C; CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol Dagenais GR et al, 2005

  12. Physical Inactivity • Increasing physical activity has been shown to decrease blood pressure. • Moderate to intense physical activity for 30-45 minutes on most days of the week is recommended.

  13. Diabetes Mellitus • At any given cholesterol level, diabetic persons have a 2 or 3 x higher risk of atherosclerosis! • Insulin is required to maintain adequate levels of lipoprotein lipase, an enzyme needed to break down bad cholesterols.

  14. Mortality rates per 100,000 per year from coronary heart disease, for males aged 45-54 years, as a function of the number of cigarettes smoked.

  15. BEEDIES ARE AS BAD AS CIGARETTES Odds Ratio > 10 beedies / day 4.36 >10 Cig / day 3.58 Diabetes 2.35 Hypertension 2.23 WHR/100 1.10 Pais et al Indian Heart J 2001; 53:731

  16. Dietary Effects on Lipids • Seven Countries study- significant correlation between saturated fat intake and blood cholesterol levels • Meta-analysis of randomized controlled trials showed lowering saturated fat and cholesterol reduces total and LDL-C 10-15% • For every 1% increase in intake of saturated fat, blood cholesterol increases 2 mg/dl

  17. Types of Cholesterol Lipoproteins- 4 main classes • Chylomicrons • Very low density lipoproteins (VLDL) • Low Density Lipoprotein (LDL) • High Density Lipoprotein (HDL)

  18. Good vs. BAD • LDL is known as bad cholesterol. It has a tendency to increase risk of CHD. • LDL’s are a major component of the atherosclerotic plaque that clogs arteries. • Levels should be <130

  19. Good vs. BAD • HDL is known as the good cholesterol. • It helps carry some of the bad cholesterol out of the body. • It does not have the tendency to clog arteries. • Levels should be >35. • High levels of HDL >60 can actually negate one other risk factor.

  20. The Skinny on Fat • What are polyunsaturated fats? They are unsaturated fats which are liquid at room temperature and in the refrigerator. • Why are they good for us? • They help the body get rid of newly formed cholesterol.

  21. The Skinny on Fat • What are monounsaturated fats? • They are liquid at room temperature but start to solidify in the refrigerator. • Decrease total cholesterol and lower LDL levels.

  22. The Skinny on Fat • What are trans fatty acids? They are unsaturated fats but they tend to raise total and bad cholesterol. • Where do you find them? • In fast-food restaurants • Commercial baked goods. Examples: doughnuts, potato chips, cupcakes.

  23. What about Omega 3? • Type of polyunsaturated fat. • Consistently lowers serum triglycerides and may also have an effect on lowering blood pressure. • Found in oily fish such as salmon, tuna, and herring. • Is available as a supplement.

  24. The INTERHEART Study9 RF Accounted for 90% of PAR

  25. The INTERHEART Study • Effects of the RF directionally similar in all regions and ethnic groups. Suggests that approaches to prevention can be based on similar principals world wide and can prevent majority of premature MI • Majority of risk factors are related to lifestyle • Lifestyle modification is of paramount importance

  26. CVD PREVENTION WORKS Start of the North Karelia Project Nationwide activity Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35-64 years from 1969 to 2001 Mortality per 100 000 population

  27. Therapeutic Lifestyle Changes in LDL-Lowering Therapy: Major Features • Saturated fats <7% of total calories • Dietary cholesterol <200 mg per day • Plant stanols/sterols (2 g per day) • Viscous (soluble) fiber (10–25 g per day) • Weight reduction • Increased physical activity

  28. Therapeutic Lifestyle ChangesNutrient Composition of TLC Diet NutrientRecommended Intake • Saturated fat Less than 7% of total calories • Polyunsaturated fat Up to 10% of total calories • Monounsaturated fat Up to 20% of total calories • Total fat 25–35% of total calories • Carbohydrate 50–60% of total calories • Fiber 20–30 grams per day • Protein Approximately 15% of total calories • Cholesterol Less than 200 mg/day • Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/ prevent weight gain

  29. Dietary fats* Fat SFA MUFA PUFA Cholesterol Canola oil† 6 62 31 0 Corn oil 13 25 62 0 Olive oil 14 77 9 0 Palm oil 51 39 10 0 Safflower oil 9 12 78 0 Soybean oil† 15 24 61 0 Sunflower oil 11 20 69 0 *Values for SFA, MUFA, and PUFA represent percentage of total fat calories, whereas those for cholesterol are expressed as mg per tablespoon. SFA is the sum of lauric, myristic, palmitic, and stearic acids. †Contain a considerable amount (>5%) of alpha-linolenic acid. ‡Some are high in trans fatty acids: vegetable shortening>margarine fat>animal fat shortening>butter fat. SFA, saturated fatty acids; MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids.

  30. Benefits of fish oil supplementation • In the Diet and Reinfarction Trial (DART) in 2033 men with CHD increased intake of fish or use of 2 fish oil caps/day reduced CHD mortality 29% over 2 years • In GISSI 11324 men and woman with CHD use of 1 gr. of n-3 PUFA decreased CVD events including mortality 15%

  31. Nuts, Soy, Phytosterols, Garlic • Nurses’ Health Study: five 1oz servings of nuts per week associated with 40% lower risk of CHD events • Metaanalysis of 38 trials of soy protein showed 47g intake lowered total, LDL-C, and trigs 9%, 13%, and 11% • Phytosterol-supplemented foods (e.g., stanol ester margarine) lowers LDL-C avg. 10% • Meta-analysis of garlic studies showed 9% total cholesterol reduction (1/2-1 clove daily for 6 months).

  32. Trans Fatty Acids

  33. Effect of Fruit & Vegetables on Risk of CHD Joshipura et al Ann Intern Med’2001 NHS & HPS: 84251 women (14 yrs FU) & 42148 men (8 yrs FU) Total intake of fruits and vegetables and multivariate relative risk for coronary heart disease.

  34. Food Choices and Preparation Tips

  35. Dietary Approaches to Stop Hypertension (DASH) • Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet • Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. • NEJM 1997; 366: 1117-24.

  36. Tips for Reducing Sodium • Buy fresh, plain frozen or canned “no added salt” veggies. • Use fresh poultry, lean meat, and fish. • Use herbs, spices, and salt-free seasonings at the table and while cooking. • Choose convenience foods low in salt. • Rinse canned foods to reduce sodium.

  37. Cigarette Smoking • Causes an increase in blood pressure • Usually have lower levels of HDL • Within 1 year of quitting, CHD risk decreases, within 2 years it reaches the level of a nonsmoker.

  38. Alcohol Consumption • In small amounts it acts as a vasodilator-Good! 1-2 drinks • In large amounts it acts as a vasoconstrictor-BAD! 3-4 drinks • This is a very fine line!

  39. EXERCISE FOR PRIMARY & SECONDARY PREVENTION • both– leisure & recreational activity as well as intermittent activity (walking stair climbing, house work, gardening) • Effects both direct and indirect • Proof for primary prevention weak • Assess whether activities meet recommendations (equivalent to at least 30 min brisk walk @ 4.5 Km/hr on most or all days) • Formulate schemes for activity at home aswell as workplace • Special incentives,early start,,public health campaigns

  40. Exercise and CVD • Serves several functions in preventing and treating those at high risk. • Reduces incidence of obesity. • Increases HDL • Lowers LDL and total cholesterol • Helps control diabetes and hypertension • Those at high risk should take part in a specially supervised program.

  41. The effects of lifestyle change and drug therapy on cardiovascular risk reduction appear to be independent and additive. + Hunninghake DB et al. NEJM 1993;32:1213 Barnard RJ et al. AJC 1997;79:1112 Sdringola S et al. JACC 2003;41:263 Courtesy of Barry Franklin, PhD, William Beaumont Hospital, Royal Oak, MI

  42. Approximate Mortality Reduction Potential of Drug Vs Lifestyle Interventions in Patients with Coronary Disease* Lowdoseaspirin18% Statins21% ßBlockers23% ACEInhibitors26% Smokingcessation35% Physicalactivity25% Moderatealcohol20% Combined lifestyle changes45% Drug Lifestyle Courtesy of Barry Franklin, PhD, William Beaumont Hospital, Royal Oak, MI Iestra JA et al. Circ 2005;112:924

  43. Conclusion • Cardiovascular disease is the number one killer. • It is highly preventable and controllable with diet and exercise. • Good resource: www.americanheart.org • 1-800-AHA-USA

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