Transcript A Cardiologist’s Perspective On Preventing Heart Disease

A Cardiologist’s Perspective
On Preventing Heart Disease (and
Strokes!)
C. Michael Wright, MD FACC
Medical Director
The LifeScore Clinic
Outline
1.
2.
3.
4.
5.
6.
Cardiovascular Disease (CVD)-Scope of the
Problem
What is Atherosclerosis?
Who is at Risk?
How Do We Measure Risk?
How Can You Prevent It?
Random Cartoons to keep it light!
Outline
1.
2.
3.
4.
5.
6.
Cardiovascular Disease (CVD)-Scope of the
Problem
What is Atherosclerosis?
Who is at Risk?
How Do We Measure Risk?
How Can You Prevent It?
Random Cartoons to keep it light!
1. Scope of the Problem
102 million with cholesterol >200
50 million with systolic blood pressure >140, diastolic >90
47 million current smokers age 18+
44 million obese (BMI ≥30)
10 million diabetics
Annual direct and indirect cost of CVD - $329 billion in 2002
Strokes
500 000
Heart Attacks
650 000
Heart Failure
550 000
Types of CVD
Cardiovascular DiseaseIt’s Big!
Outline
1.
2.
3.
4.
5.
6.
Cardiovascular Disease (CVD)-Scope of the
Problem
What is Atherosclerosis?
Who is at Risk?
How Do We Measure Risk?
How Can You Prevent It?
Random Cartoons to keep it light!
2. What Is Atherosclerosis?
Tunica adventitia
Tunica media
Tunica intima
Endothelium
Subendothelial connective
tissue
Internal elastic membrane
Smooth muscle cells
Elastic/collagen fibers
External elastic membrane
Stages of Atherosclerosis
Normal
Plaque Development
Fatty streak
Lipid-rich plaque
Foam cells
Thrombus
Lipid core
Evolution of Plaque
Coronary Wall Dynamics with
Plaque
Mural Plaque
Vessel wall
Vessel “lumen”
Normal
vessel
No Narrowing
Mild Plaque
Mild Narrowing
Moderate Plaque
Time [years]
Severe Narrowing
Extensive Plaque
Plaque Rupture
Thrombus
Fibrous
Cap
Lipid Core
IVUS vs. Angiography
Outline
1.
2.
3.
4.
5.
6.
Cardiovascular Disease (CVD)-Scope of the
Problem
What is Atherosclerosis?
Who is at Risk?
How Do We Measure Risk?
How Can You Prevent It?
Random Cartoons to keep it light!
3. Who is at Risk?
Lifestyle Determines Cardiovascular Health
Inactivity
Refined
Carbohydrates
Low intake
Of Omega 3
High intake
of sodium
Low intake of
Omega 9
Trans fatty
acids
Oxidative Stress
Lipid abnormalities
Insulin Resistance
Sympathetic activation
Inflammation
RAS activation
Low intake
of antioxidants
Low intake of
Essential
minerals
Caloric
Intake >
Caloric
expenditure
Endothelial
Dysfunction
&
Vascular
Injury
Atherosclerosis Begins in Childhood
% with Coronary
Fatty Streaks
100
80
60
40
20
0
2-15 yr olds
21-39 year olds
The Bogalusa Heart Study
% with Coronary Atheromas
80
70
60
50
40
30
20
10
0
2-15 yr olds
15-20
21-25
26-39
The At Risk Patient
Physical Inactivity
Risk Factors and Coronary
Atherosclerosis in Young Adults
The Bogalusa Heart Study
Early High TC Levels Associated
With Later CHD Events
Results After 40 Years
No. of CHD events*
40
35.2
35
30
25
17.5
20
11.5
15
10
6.9
5
0
118-172
*1017 men, average age 22
173-189
190-208
TC (mg/dL)
Adapted from Klag MJ, et al. N Engl J Med. 1993;328:313-318.
209-315
Outline
1.
2.
3.
4.
5.
6.
Cardiovascular Disease (CVD)-Scope of the
Problem
What is Atherosclerosis?
Who is at Risk?
How Do We Measure Risk?
How Can You Prevent It?
Random Cartoons to keep it light!
4. How Do We Measure Risk?
EBT Score > 75th
15
hs-CRP + TC/HDL
5
hs-CRP
2.5
TC/HDL
2.35
t-PA Ag
2.15
Fibr
1.8
TC
1.6
Homocysteine
1.6
Lp(a)
1.25
0
Relative risk in men from the
Physicians Health Study
(highest quartile)
5
10
15
Effect of Risk Factors
The Cholesterol Overlap Issue
No CHD
35% of CHD occurs
In people with
TC <200 mg/dL
150
CHD
200
250
Total Cholesterol (mg/dL)
300
CME Monograph Based on an Expert Panel Discussion. Cardiovascular risk stratification using high-sensitivity Creactive protein (hs-CRP), a cardiovascular inflammatory risk marker. Certified Continuing Medical Education Series
2001; April 16, 2001; Castelli WP. Atherosclerosis 1996;S1-S9
Calcium in Plaque
Cooper Clinic 6 Year F/U
CVD Risk by Calcium Score
27.8
15
Adjusted Relative Risk *
n=17,256; 461 events, 17 deaths
12
P < .01
9
7.1
6
3
2.2
2.4
1-15
16-95
1
0
0
96-407
>407
(Abstract # P3) Final Program & Abstracts: AHA - 42nd Annual Conference on Cardiovascular Disease Epidemiology
and Prevention. April 23-26, 2002, Honolulu, HA
CVD Events By CAC Quartile
25
Calcium Score Percentile
21.5
20
19
No. Events
Odds Ratio
15
10
6.2
6
5
1
1
1
1
0
1st
2nd
3rd
4th
Quartile
Raggi P, Callister TQ, Cooikl B , He Z-X, Lippolis NJ, Russo DJ, Zelinger A, Mahmarian JJ. Identification of patients at increased
risk of first unheralded acute myocardial infarction by electron-beam computed tomography. Circulation 2000;101:850-55
MI or SCD with Very High CAC
Annual event rate
30
25%
25
17%
20
Cancer Database
12.3%
Circ 1998;97:535-43
15
7.1%
JACC 2001;37:1551-7
10
5
0
EBT
Score
>1,000
* Wayhs JACC 2002;39:225-30
Severe
SPECT
Abn.
MWMA
Stress
Echo
Lung
Cancer
Mortality
Outline
1.
2.
3.
4.
5.
6.
Cardiovascular Disease (CVD)-Scope of the
Problem
What is Atherosclerosis?
Who is at Risk?
How Do We Measure Risk?
How Can You Prevent It?
Random Cartoons to keep it light!
5. How Can You Prevent It?
Discover, Design, Do =
3D Health
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Discover your risk!
If high, then aggressive risk factor management
 If Moderate, then moderate risk factor management
 If low, then just try to follow a reasonably healthy
lifestyle!
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Design your goals
Do your program to achieve your goals
Two Books To Read
10 Key Dietary Guidelines
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2.
3.
Eat omega-3 Rich Foods - Fatty Fish
(salmon, trout, tuna, herring, mackerel);
walnuts, canola oil, flaxseeds, green leafy
vegetables
Eat mono-unsaturated fats - Olive oil
(extra virgin), canola oil
Get 7 or more servings of vegetables and
fruits per day
Dietary Guidelines Continued
4.
5.
6.
Balance animal protein with vegetable
protein- legumes (especially soybeans), nuts
Avoid saturated fat by choosing lean meat
over fatty meat, low fat over full fat in dairy
products
Avoid oils high in omega-6 fatty acids
(corn, safflower, sunflower, soybean and
cottonseed oils)
Dietary Guidelines Continued
7.
Reduce intake of trans-fatty acids:
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2.
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4.
5.
8.
Most margarines
Vegetable shortening
Commercial pastries
Deep fat fried foods
Most prepared snacks, mixes and convenience
foods
Eat unrefined cereals and grains
Dietary Guidelines Continued
9. Drink plenty of water every day
10. Be aware of the sodium content of foods and
consume less than 2 grams/day
Country Diet Comparisons
INTERNATIONAL COMPARISONS
reveal that total fat intake is a poor
indicator of heart disease risk. What is
important is the type of fat consumed. In
regions where saturated fats
traditionally made up much of the diet
(for example, eastern Finland), rates of
heart disease were much higher than in
areas where monounsaturated fats
were prevalent (such as the Greek
island of Crete). Crete's Mediterranean
diet, based on olive oil, was even better
for the heart than the low-fat traditional
diet of Japan.
January ’03 Scientific American
Walter C. Willett and Meir J. Stampfer, professors of epidemiology and nutrition at the Harvard School of Public Health
Different Food Pyramids
Key Supplements-Omega-3 Fatty
Acids
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Fish oil for DHA and EPA
Flaxseed or borage oil for Alpha-linolenic
acid
DHA eggs
Decreased inflammation
Decreased arrhythmias
Decreased clotting tendencies
1-4 grams a day
Key Supplements- Vitamins C and
E
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Reduced risk of neurodegenerative diseases
Reduced risk of cataracts
E- Inhibits oxidation of LDL cholesterol
Prevent progression of atherosclerosis is
carotid arteries
Doses: Vitamin E- 400-800 IU; Vitamin C500-2,000mg per day
Key Supplements- Alpha Lipoic
Acid
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Fat and water-soluble antioxidant
Regenerates vitamins C and E
Binds toxic metals
Improves insulin sensitivity
Helps the body use glucose for energy
Dose- 100-300 mg/day
Key Supplements- Co-enzyme
Q10
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Fat-soluble antioxidant
Involved in energy production in mitochondria
Regenerates Vitamins C,E and A
Inhibits oxidation of LDL cholesterol, cell
membranes, and DNA
Improves insulin sensitivity
Lowers blood pressure
Depleted by statin drugs
Dose- 30-90 mg/day (gel)
Key Supplements- Folic Acid,
Vitamins B6 & B12
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Lower homocysteine levels
Homocysteine can raise risk for stroke, heart
attacks and alzheimer’s disease
B6 lowers blood pressure
DosesFolic acid 400-800mcg/day
 B6 100-200mg/day
 B12 1-2mg/day
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Key Supplements- L-Carnitine
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Helps convert fatty acids to energy
Transports fatty acids into mitochondria
98% of carnitine in the body is in the heart and
muscle cells
Slows age-dependent decline in mitochondrial
function
Slows neuro-degeneration and loss of cognitive
function
Improves insulin sensitivity
Improves thyroid function
Key Supplements- L-Carnitine
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Heart
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Increases heart’s energy production
Reduces heart rate during exercise
Reduces size of heart attacks
Reduces chest pain (angina)
Muscle
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Increases power and endurance
Reduces fatigue
Helps maintain and increase muscle mass
Speeds recovery time after exercise
Key Supplements- Carnosine
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Two amino acids linked together
Blocks glycation (sugar bonding to proteins)
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Glycated proteins cause stiffness and thickening
of artery wall and heart muscle
Slows aging in animal models
May be useful in treatment of cataracts
How much? 1 to 2 grams per day
Effects of 10% Weight Loss
Exercise!
Dr. Ken Cooper, of the Cooper Institute of Aerobic Research, found that
exercise was associated with a 40 % reduction in heart attacks in females
and a 60 % reduction in heart attacks in males. In another study, he found
that people who were in the lower 20 % of cardiovascular fitness had a
death rate that was three times higher than the most fit group. The study
also showed that men taking up exercise, even after the age of 60, will
increase their life expectancy.
Exercise capacity and mortality among men
referred for exercise testing.
Myers J, Prakash M, Froelicher V, Do D, Partington
S, Atwood JE.
Division of Cardiovascular Medicine, Stanford
University Medical Center
After adjustment for age, the peak exercise capacity measured in
metabolic equivalents (MET) was the strongest predictor of the risk of
death among both normal subjects and those with cardiovascular
disease.
Each 1-MET increase in exercise capacity conferred a 12 percent
improvement in survival. CONCLUSIONS: Exercise capacity is a
more powerful predictor of mortality among men than other
established risk factors for cardiovascular disease.
Other Beneficial Effects of Exercise
•The risk of developing colon cancer is decreased by half in
people who exercise regularly.
•Estrogen-dependent cancers (breast, ovarian and
endometrial cancers) and prostate cancer are decreased with
regular exercise.
•The risk of dying from cancer declines sharply as exercise
increases.
•Regular weight-bearing exercise can reduce the incidence of
osteoporosis, a reduction of bone strength (and susceptibility
to fractures) responsible for thousands of deaths yearly in the
U.S.
Diet & Lifestyle-Longitudinal
Study
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Nurses’ Health Study- 84,129 women aged 34-59
During 14 yrs, 1129 cases of CHD (1.3%)
Low risk group- non-smokers, BMI <25, ½ drink or
more/day, ½ or more/day of moderate or vigorous physical
activity, upper 40% for 6 dietary variables (cereal fiber,
omega 3 fatty acids, folate, high polyunsat/sat fat ratio, low
intake of trans fat, low glycemic load
This group had a relative risk of 0.17 compared to women
in other groups.
Coronary Artery Calcium
Predicts Heart Attacks
7
Annual Absolute Risk (%)
6
676 initially asymptomatic patients
32+7 months f/u
5
6.54
4.9
3.62
4
2.64
3
1.92
1.38
2
1 0.36 0.51
0.71
0.99
0
0
10
20
30
40
50
60
70
80
Percentile Rank for Baseline EBCT Calcium Score
Raggi et al AHJ 2001;141:193-199
90
LDL Goals
LDL-C Lowering With Statins:
Reduced CHD Events
Secondary Prevention
4S-PL
Primary Prevention
25
LIPID-PL
20
4S-Rx
15
CARE-PL
CARE-Rx
10
LIPID-Rx
5
WOSCOPS-Rx
WOSCOPS-PL
AFCAPS-Rx
AFCAPS-PL
0
50
70
90
110
130
150
LDL Cholesterol (mg/dL)
Adapted from Illingworth DR. Med Clin North Am. 2000;84:23-42.
170
190
210
Heart Protection Study- Vascular
Events by LDL
Plaque Regression Related to LDL-Lowering
% change in lesion volume vs. final LDL achieved
+120%
0
– 80%
60
120
200
LDL (mg/dL)
Treated
Untreated
Callister TQ. N Engl J Med 1998;339:1972-78
Suboptimal Therapy (LDL >120 mg/dl)
THE END!