Transcript THE ROLE OF THE GENERAL PRACTITIONER IN THE …

THE ROLE OF THE GENERAL
PRACTITIONER IN THE
PREVENTION AND MANAGEMENT
OF CARDIOVASCULAR DISEASE
Dr Paul Hill
Specialist Family Physician
 Cardiovascular disease is the leading cause
of death worldwide, killing 17 million
people annually. General practitioners, as
the gatekeepers to healthcare, need to
respond appropriately to this challenge.
 General practice is that component of the
healthcare system which provides initial,
continuing, comprehensive, co-ordinated
and personalized care for individuals,
families and communities.
Coronary Artery Disease Statistics
 There is an alarming incidence of heart disease in
South Africa. One in three men and one in four
women will suffer a heart attack before the age of 60.
 Every year, more than 50,000 South Africans suffer
heart attacks. Of these, 25% (12,000) die immediately.
 Only Scotland, Finland and Northern Ireland have a
higher heart disease mortality rate according to data
from the Heart and Stroke Foundation of South
Africa.
Cancer Statistics in South Africa
 The Statistics SA (2013) report indicated that cancer did not
appear among the 10 most frequent causes of death. The
ICD – 10 Disease Classification does not provide for an allencompassing malignant disease category, thus making
the cancer death statistics totally inaccurate. The total
deaths from cancer are distributed over 15 anatomical sites
with the resulting inaccurate statistics. The true figure
reveals that cancer was in fact the second most frequent
cause of death in SA, second only to HIV / TB.
SAMJ Feb 2015
Cancer Risk Factors
 The main cancer risk factors include: tobacco use,
obesity, high fat diet, lack of physical activity,
excessive exposure to sunlight, infectious agents and
chemicals in food and the environment.
 Up to 40% of cancers are said to be preventable.
Trauma
 An estimated 70,000 South Africans are killed due to trauma
every year, with a further 3.5 million seeking health care as a
result of trauma.
 More than 9,000 people are killed in traffic accidents every
year and 33,000 are injured. 39% of those killed are
pedestrians.
 Substance abuse is implicated in 80% of trauma patients.
 Almost half of the deaths due to injury are as a result of
homicide.
 People, guns, knives, motor vehicles, open fires, unsafe
electrical appliances, household chemicals and medications,
manual and electrically powered tools, unguarded hazards like
high buildings, deep pits and open bodies of water; all these
are implicated in the high trauma statistics
Infections – HIV/Tuberculosis.
 Approximately 30% of Ante-natal Clinic attenders are HIV
positive. The overall incidence of HIV positive people in South
Africa is in the region of 10 – 12%. In the 15 – 49 year old group, 1518% are HIV +ve. The majority of deaths due to HIV are
misclassified on the death certificates, although this has
improved recently. Tuberculosis incidence in HIV+ patients is
extremely high. MDR and XDR TB in HIV +ve patients is proving
to be a big challenge.
 The high incidence of pediatric diarrheal disease and pneumonia
also needs to be addressed. The new rotavirus vaccine has
however decreased the incidence of diarrheal disease
significantly.
 The introduction of pneumococcal and haemophilus influenza
vaccines, the up scaling of immunization research against
measles, pertussis (whooping cough), tuberculosis and
respiratory syncytial virus are all positive developments.
 No slide on infection may be complete without making mention
of the increasing problem of antibiotic resistant organisms.
Cardiovascular Disease and
Endothelial Dysfunction
 Vascular endothelial cells are vital in regulating blood
flow through vessels and preventing intravascular
thrombosis. Endothelial dysfunction is associated
with most forms of cardiovascular disease, including
hypertension, coronary artery disease, heart failure,
peripheral vascular disease, stroke, diabetes and
chronic renal failure.
Endothelial Cell Risk Factors
 Risk factors for endothelial dysfunction include smoking,
diabetes, elevated lipids, hypertension and infections.
 Atherosclerosis refers to patches of small fatty lumps
that develop within the walls of blood vessels (arteries).
Patches of atheroma are often called plaques, and these
plaques may cause narrowing of the arteries, which can
reduce blood flow. This problem is clearly associated
with dyslipidemia, but it is now known that there is an
inflammatory component involved which adds to the
endothelial dysfunction.
Cardiovascular Disease Risk Factors
 The four most common modifiable risk factors include
an unhealthy diet, physical inactivity, tobacco use and
the excessive use of alcohol. These four risk factors
can lead to hypertension, diabetes, dyslipidemia, as
well as overweight and obese states.
 Addressing these risk factors can help to avoid up to
80% of heart disease.
Cardiovascular Risk Factors Continued
 These 4 risk factors are associated with the following
four diseases i.e. cardiovascular disease, cancer,
diabetes and chronic lung disease. Thus a great health
impact can be achieved by addressing the risk factors
Recognition of Coronary Artery
Disease.
 Stable angina: central chest discomfort or pain, usually of a
crushing heavy nature, brought on by exertion and relieved by
rest or sublingual nitrate.
 Unstable angina: Chest pain which increases rapidly in severity
and occurs at rest. This is due to sub-total coronary artery
obstruction.
 NSTEMI : non-ST elevation myocardial infarction. This
condition is similar to unstable angina except for elevated
cardiac enzymes due to sub-endocardial muscle injury.
 STEMI : ST elevation myocardial infarction; this is a true heart
attack. Here there is trans-mural full-thickness myocardial
injury.
Stroke – TIA (Transient Ischaemic
Attack)
 Sudden onset of the following suggests a stroke (or a TIA if
symptoms last less than 24 hours and resolve completely)
 Signs include:
 Weakness, numbness or paralysis of usually one side of the
body.
 Blurred or decreased vision of one eye, or double vision.
 Difficulty in speaking or understanding.
 Dizziness, loss of balance or unexplained fall, and unsteady
gait.
 Sudden onset of severe new headache.
Peripheral Vascular Disease
 Patients may be asymptomatic or can present with
intermittent claudication or critical limb ischaemia.
Intermittent claudication patients may describe pain,
lameness, discomfort, cramping or stiffness of calf
muscle, or to a lesser extent thigh muscles or buttocks,
with exercise. The incidence of peripheral vascular
disease is 3-10% overall, rising to 15-20% over the age of 70
years.
 The term critical limb ischaemia implies the presence of
rest pain, ulcer or gangrene.
Dementia
 In the USA, Alzheimer's disease ranks as the 4th
leading cause of death in adults after heart disease
and stroke.
 Alzheimer's disease and vascular dementia account
for more than 90% of the dementias. Incidence of
dementia in the >65yrs is 6.2%; 20% over the age of 80
and 40% over the age of 90. What is known is that
there is a strong association between the risk factors
for cardiovascular disease and the dementias
Sexual Dysfunction
 Sexual dysfunction is defined by the WHO as the
various ways in which an individual is unable to
participate in a sexual relationship as desired.
 Erectile dysfunction is considered to be an
independent predictor of future cardiovascular
disease. It may be viewed as a manifestation of
vascular and endothelial dysfunction. The incidence of
erectile dysfunction:
 4% : under 50 years
 27% : 50 -59 year group
 40% : 60 – 69 year group
Chronic Kidney Disease
 This produces a very wide range of symptoms
including tiredness, breathlessness, poor appetite,
nausea, passing excessive amounts of urine and
swelling. The most common cause is endothelial
dysfunction caused by diabetes and hypertension.
Diet
 It is very difficult to do long term controlled studies on diet
with a view to measuring cardiovascular endpoints. What is
however known is that the Mediterranean diet reduces
mortality by 25%, coronary heart disease deaths by 33% and
cancer by 24%. The beneficial components include a high
intake of vegetables, legumes, fruits, nuts, olive oil, cereal,
fish, mono-unsaturated fats with small amounts of meat,
poultry and high fat dairy products.
 What is recommended is a balanced diet low in fats
(particularly saturated fats and trans-fatty acids), high in
fibre, low in refined carbohydrate, with plentiful
vegetables and fruits.
The Banting Diet
 This is essentially a very low carbohydrate, high
saturated fat, high protein diet closely related to the
Atkins diet. It allows more attractive foods and has
good data to show weight loss and decreased insulin
sensitivity, but at the cost of increasing the LDL-C.
However and importantly, there has been no research
measuring the long-term endpoints of cardiovascular
disease from this diet.
UCT Statement regarding the
Banting Diet
 There is good reason for concern that this diet may result
in nutritional deficiencies, increased risk for heart disease,
diabetes mellitus, kidney problems, constipation, certain
cancers and excessive iron stores in some individuals in the
long-term. Research leaves no doubt that healthy balanced
eating is very important in reducing disease risk.
University of Cape Town, Faculty of Health Sciences; August
2014.
UCT Statement : Continued
 It is therefore a serious concern that Prof Timothy Noakes, a
colleague respected for his research in Sports Science, is
aggressively promoting this diet as a “revolution”, making
outrageous unproven claims about disease prevention, and
maligning the integrity and credibility of peers who criticize
his diet for being evidence-deficient and not conforming to
the tenets of good and responsible science. This goes
against the University of Cape Town’s commitment to
academic freedom as the prerequisite to fostering
responsible and respectful intellectual debate and free
enquiry.
University of Cape Town Health Sciences Statement; August
2014
 A recent systematic review combining the findings of 19 clinical
trials in 3,209 people found that low carbohydrate diets result in
similar weight losses over 2 years compared to diets containing
a recommended balance of carbohydrate, fat and protein.
 The review confirms that overall energy (kilojoule) intake over a
period of time will result in weight loss.
 Adherence to a reduced energy intake is key for successful
weight loss.
 The fundamental issue is not so much losing weight, but
maintaining weight loss.
Association for Dietetics in South Africa, Chronic Disease Initiative
for Africa, Heart and Stroke Foundation of South Africa, Nutrition
Society of South Africa and Professional Board for Dietetics and
Nutrition of the HPCSA July 2014
BANTING CONFERENCE FEBRUARY
2015
 Reports from this conference indicate that there was
some disagreement amongst participants at the
recent congress on the issue of high saturated fat diet
as advocated by Prof T Noakes
Dr Sunika Potgieter, Dietician, University of
Stellenbosch Winelands Conference
March 2015
Exercise
 Insufficient physical activity increases the risk of
cardiovascular death by 20 – 30%. The
recommendation is at least 30 minutes of moderate
exercise per day at least five times per week
Salt
 Excessive salt intake is associated with hypertension.
Limit salt to no more than one teaspoon per day.
Avoid or limit foods that are top contributors to high
salt intake including hard margarines, salty snacks,
soup and gravy powders, viennas, beef sausages and
meat pies.
Obesity
 Increased calorie intake and reduced physical activity
track this pattern, with more than 70% of women and
45% of men being overweight or obese.
Statins
 Since the introduction of statins in 1987 they have
become the largest selling prescription drug
worldwide. The principle therapeutic benefit is to
reduce the LDL-C. Every 1 mmol/L decrease in LDL-C
leads to a 20% reduction in major vascular events,
including coronary deaths, non-fatal myocardial
infarction and stroke.
 1:
500
people
in
South
Africa
have
inherited
hypercholesterolaemia.
 If untreated, 50% of men and 15% of women will die before 60
years of age.
 In addition to reducing LDL, statins also play a very important
part in plaque stabilization due to anti-inflammatory action.
 The criticism of statin trials by Prof Noakes that these are
pharmaceutical company driven has been disproved by a
comparison of all statin trials, both sponsored and un-sponsored.
Dr F Pecoraro, Cardiologist, Tygerberg Hospital
Winelands Conference
March 2015
Aspirin
 The first evidence for the benefits of Aspirin was in 1974.
Aspirin decreases mortality when given in acute myocardial
infarction, unstable angina, and is indicated for long term
secondary prevention of cardio-vascular disease.
 Aspirin use in primary prevention is most beneficial in high
risk individuals.
 In four trials involving 48,540 patients, the relative risk
reduction of myocardial infarction was 28 – 30%.
 Aspirin has been shown to reduce the risk of colon cancer by
40-50%.
 Aspirin should be used in most patients with diabetes,
hypertension, coronary artery disease, stroke and dementia.
Anti-hypertensives
 About 35% of hypertensive patients will discontinue
their medication within six months. The reason for
discontinuation relates to adverse side effects from
these drugs.
 The most common side effect is hypotension. The
symptoms may be subtle and include dizziness, fatigue
and tiredness.
 It is thus important to carefully tailor the therapy to suit
the individual patient. Using low doses of drugs in
combination is a good strategy to avoid side effects.
Stents
 This procedure was first introduced in South Africa in 1986.
 However, it is increasingly recognized that needless stenting
exposes patients to risk.
 In an emergency i.e. if the patient is having a heart attack,
angioplasty and stenting can restore blood flow to the heart and
this can be life-saving. Angioplasty and stenting is considered to
be the gold standard of management for restoring blood flow to
that area of the heart.
 In the absence of heart attack, research shows that the
procedure of non-urgent interval stenting may be no better than
medication, exercise and diet in preventing a heart attack.
 Interval stenting decision making is best left to the clinical
judgment of the cardiologist in consultation with the
cardiothoracic surgeon where indicated.
Thrombolytic Therapy
 This is indicated in patients with chest pain consistent
with myocardial infarction and ST segment elevation
on the ECG. These agents can achieve early reperfusion in 50 -70% of patients and can thus reduce
mortality and the extent of myocardial damage. This is
extensively used in South Africa due to the wide nonavailability of angioplasty and stenting
Bypass Surgery
 First introduced in South Africa in 1974, coronary bypass surgery has
been considered a routine operation for more than 30 years. Bypass
surgery is performed to relieve pain and also to prolong life.
 In the following scenarios bypass surgery is essential and life-saving:
 When the left main coronary artery is severely blocked or narrowed.
 If there are two or more blockages of which one is situated in the first
few cms of the left anterior descending coronary artery.
 If the patient has two or more coronary artery lesions and the left
ventricle is functioning poorly.
 If the patient has debilitating angina or chest pain because several of
the arteries which supply the heart muscle are narrowed.
 If the patient has a blockage that cannot be opened by means of
angioplasty, or that has reappeared after angioplasty.
Conclusion
 There is no doubt that the incidence of cardio-vascular
disease in South Africa is alarmingly high. Much still
needs to be done in addressing the risk factors which
contribute to this high incidence. Both education and
particularly motivation of people to appropriately
address the risk factors of cardio-vascular disease is
essential.
 General practitioners are undoubtedly ideally placed to
play a leading role in the prevention and management
of cardiovascular disease.