Cardiovascular Disease: Cardiovascular Disease: Prevention and Prevention and TreatmentTreatment

Dietary Factors that Dietary Factors that Affect Blood LipidsAffect Blood Lipids

Saturated Fatty AcidsSaturated Fatty Acids

Elevate blood cholesterol in all Elevate blood cholesterol in all lipoprotein fractions (LDL and HDL) when lipoprotein fractions (LDL and HDL) when substituted for CHO or other fatty acidssubstituted for CHO or other fatty acids

Dose-response between SFA and LDL-CDose-response between SFA and LDL-C– For every 1% of energy intake increase in For every 1% of energy intake increase in

sfa, plasma cholesterol increases 2.7%sfa, plasma cholesterol increases 2.7% Most hypercholesterolemic sfas are Most hypercholesterolemic sfas are

lauric (C12:0) myristic (C14:0) and lauric (C12:0) myristic (C14:0) and palmitic (C16:0) (palmitic is 60% of sfa palmitic (C16:0) (palmitic is 60% of sfa intake)intake)

Stearic (C18:0) is neutralStearic (C18:0) is neutral

Saturated Fatty AcidsSaturated Fatty Acids

The most hypercholesterolemic The most hypercholesterolemic fats are palm kernel, coconut and fats are palm kernel, coconut and palm oils, lard, and butterpalm oils, lard, and butter

SFAs also associated with CAD SFAs also associated with CAD progression: milk, cheese, butter, progression: milk, cheese, butter, lamb, bakery goods, fast foods, lamb, bakery goods, fast foods, snackssnacks

Average American intake is 11% Average American intake is 11% of kcalsof kcals

Polyunsaturated Fatty Polyunsaturated Fatty AcidsAcids If CHO is replaced by linoleic acid If CHO is replaced by linoleic acid

(C18:2) LDL-C (C18:2) LDL-C ↓ and HDL-C ↑↓ and HDL-C ↑ When SFA is replaced by PUFA in a When SFA is replaced by PUFA in a

low fat diet, both LDL and HDL ↓low fat diet, both LDL and HDL ↓ Eliminating SFA is twice as Eliminating SFA is twice as

effective in lowering cholesterol as effective in lowering cholesterol as ↑ PUFA↑ PUFA

A 1% increase in PUFA ↓ TC by 1.4 A 1% increase in PUFA ↓ TC by 1.4 mg/dlmg/dl

Polyunsaturated Fatty Polyunsaturated Fatty AcidsAcids Major source of omega-6 PUFAs Major source of omega-6 PUFAs

are vegetable oils, salad are vegetable oils, salad dressings, and margarines made dressings, and margarines made with the oilwith the oil

U.S. population intake 7% of U.S. population intake 7% of caloriescalories

Large amounts may increase LDL Large amounts may increase LDL oxidationoxidation

Omega-3 Omega-3 Polyunsaturated Fatty Polyunsaturated Fatty Acids: EPA, DHAAcids: EPA, DHA Found in fish oils, fish oil capsules, and Found in fish oils, fish oil capsules, and

ocean fish (eicosapentaenoic and ocean fish (eicosapentaenoic and docosahexaenoic acid)docosahexaenoic acid)

Do not affect TC; may Do not affect TC; may ↑ LDL-C (5-10%) ↑ LDL-C (5-10%) and decrease TG (25-30%) especially and decrease TG (25-30%) especially in patients with high TGin patients with high TG

Anticoagulant effectAnticoagulant effect Decrease vasoconstrictionDecrease vasoconstriction Improve endothelial dysfunctionImprove endothelial dysfunction Reduce inflammationReduce inflammation

Omega-3 Fatty Acids: Omega-3 Fatty Acids: ALAALA Alpha-linolenic acidAlpha-linolenic acid An essential fatty acidAn essential fatty acid Shorter-chain found in various Shorter-chain found in various

plant sources such as flax, canola, plant sources such as flax, canola, walnuts, and soywalnuts, and soy

Benefits less clear; may protect Benefits less clear; may protect against CVD by reducing against CVD by reducing inflammationinflammation

Omega-3 Fatty AcidsOmega-3 Fatty Acids

Consumption of fish and fish oils Consumption of fish and fish oils rich in EPA, DHA will lower rich in EPA, DHA will lower cholesterol, LDL, and TG and cholesterol, LDL, and TG and reduce sudden cardiac deathreduce sudden cardiac death

One fatty fish meal/week resulted One fatty fish meal/week resulted in 50% decrease in risk of cardiac in 50% decrease in risk of cardiac arrestarrest

1 g supplement of omega-3 daily 1 g supplement of omega-3 daily reduced risk of CVD, nonfatal MI, reduced risk of CVD, nonfatal MI, nonfatal strokenonfatal stroke

Cis-Monounsaturated Cis-Monounsaturated FatFat Naturally occurring Naturally occurring

monounsaturated fatmonounsaturated fat Found in olive oil, canola oil, Found in olive oil, canola oil,

avocado, olives, pecans, peanuts, avocado, olives, pecans, peanuts, and other nutsand other nuts

Oleic acid is the most prevalent Oleic acid is the most prevalent MFA in the US dietMFA in the US diet

Cis-Monounsaturated Cis-Monounsaturated FatFat When fat is replaced by CHO, it When fat is replaced by CHO, it

lowers HDL as well as LDL-Clowers HDL as well as LDL-C When sfa is replaced by mfa, lowers When sfa is replaced by mfa, lowers

LDL-C without lowering HDL-CLDL-C without lowering HDL-C When substituted for carbohydrate, When substituted for carbohydrate,

mfa reduces serum triglyceride mfa reduces serum triglyceride levelslevels

Can recommend a higher fat diet if Can recommend a higher fat diet if much of the fat comes from mfamuch of the fat comes from mfa

Cis-Monounsaturated Cis-Monounsaturated FatFat Mediterranean diet: high in fat, Mediterranean diet: high in fat,

especially MFA (olive oil), fish, especially MFA (olive oil), fish, nuts, low in red meat associated nuts, low in red meat associated with with ↓ risk of CVD↓ risk of CVD

Emphasizes fruits, root Emphasizes fruits, root vegetables, flax, canolavegetables, flax, canola

High fat diets should be used with High fat diets should be used with cautioncaution

Mediterranean vs Mediterranean vs Standard AHA Low Fat Standard AHA Low Fat DietDiet Subjects: 202 post-MI patientsSubjects: 202 post-MI patients 50 put on AHA lowfat diet (30% fat) 50 put on AHA lowfat diet (30% fat) 51 on Mediterranean (40% fat; fish 3-5 51 on Mediterranean (40% fat; fish 3-5

times/week, olive oil, avocado) times/week, olive oil, avocado) Both limited to 7% SFA and 200 mg Both limited to 7% SFA and 200 mg

cholesterol/daycholesterol/day Both groups received two individual diet Both groups received two individual diet

counseling sessions in the first month counseling sessions in the first month and six group sessions over the next two and six group sessions over the next two years.years.

101 controls given advice in the hospital101 controls given advice in the hospitalTuttle et al, presented at ACC meeting, New Orleans, 3-07

Mediterranean vs Mediterranean vs Standard AHA Low Fat Standard AHA Low Fat DietDiet After 4 years 83% of those on either After 4 years 83% of those on either

therapeutic diet had survived without therapeutic diet had survived without problems; cholesterol profile improved problems; cholesterol profile improved in both groupsin both groups

People on either diet had one-third the People on either diet had one-third the risk of suffering another heart attack, a risk of suffering another heart attack, a stroke, death or other heart problem stroke, death or other heart problem as controlsas controls

Those on Mediterranean diet found it Those on Mediterranean diet found it harder to stick to (harder to stick to (↑ fish, olive oil)↑ fish, olive oil)

53% of control patients survived 53% of control patients survived without problems; cholesterol profile without problems; cholesterol profile did not improvedid not improve

Trans-Trans-Monounsaturated FatsMonounsaturated Fats Produced in the hydrogenation processProduced in the hydrogenation process Commonly used in the food industry to Commonly used in the food industry to

harden unsaturated oils and soft harden unsaturated oils and soft margarinesmargarines

50% of trans-fatty acids come from 50% of trans-fatty acids come from animal foods (beef, butter, milk fats)animal foods (beef, butter, milk fats)

Major foods sources in US are stick Major foods sources in US are stick margarine, shortening, commercial margarine, shortening, commercial frying fats, high fat baked goodsfrying fats, high fat baked goods

Trans Fatty AcidsTrans Fatty Acids

Elaidic acid (trans-isomer of oleic Elaidic acid (trans-isomer of oleic acid) raises blood cholesterol acid) raises blood cholesterol compared with PUFAcompared with PUFA

Has less of a cholesterol raising Has less of a cholesterol raising effect than sfaeffect than sfa

Lowers HDLLowers HDL

Margarine vs ButterMargarine vs Butter

The combined amount of saturated fat The combined amount of saturated fat and trans fat in butter is higher than and trans fat in butter is higher than that in margarinethat in margarine

Soft or liquid margarine is the preferred Soft or liquid margarine is the preferred spreadspread

Average intake of trans fats is 7-8% of Average intake of trans fats is 7-8% of total fat intaketotal fat intake

Choose lowfat desserts, dairy products, Choose lowfat desserts, dairy products, meats will lower trans fatty acid intakesmeats will lower trans fatty acid intakes

Fat Type Per ServingFat Type Per Serving

ProducProductt

Total Total fat gfat g

Sfa gSfa g Trans Trans fat gfat g

CombCombinedined

cholecholesterolsterol

ButterButter 10.810.8 7.27.2 .3.3 7.57.5 31.131.1Stick Stick margmarg

1111 2.12.1 2.82.8 4.94.9 00

SpreaSpread d margmarg

9.79.7 1.81.8 2.72.7 4.54.5 00

Tub Tub margmarg

6.76.7 1.21.2 .6.6 1.81.8 00

Source: FDA http://www.cfsan.fda.gov/~dms/qatrans2.html

Effects of Various Dietary Effects of Various Dietary Fat Sources on TC:HDL Fat Sources on TC:HDL RatioRatio

Mensink RP et al. AJCN 2003;77:1146-1155.

Total Fat Content of Total Fat Content of DietDiet High fat diets are associated with obesity, High fat diets are associated with obesity,

which increases the risk of CHDwhich increases the risk of CHD Low fat diets (<25% of kcals from fat) raise Low fat diets (<25% of kcals from fat) raise

triglycerides and lower HDL; however these triglycerides and lower HDL; however these changes are not associated with changes are not associated with ↑ risk↑ risk

Low fat diets lower LDL only when they are Low fat diets lower LDL only when they are low in sfalow in sfa

AHA: total fat <30% of kcalsAHA: total fat <30% of kcals ATP III: 25%-35% of kcals from fatATP III: 25%-35% of kcals from fat

Dietary CholesterolDietary Cholesterol

Dietary cholesterol raises total and Dietary cholesterol raises total and LDL-cholesterol, but less than sfaLDL-cholesterol, but less than sfa

A 25 mg increase in dietary A 25 mg increase in dietary cholesterol raises serum cholesterol cholesterol raises serum cholesterol 1 mg/dl1 mg/dl

At 500 mg intake, increments are At 500 mg intake, increments are even less; appears to be a threshold even less; appears to be a threshold for responsefor response

TLC guidelines: <200 mg/dayTLC guidelines: <200 mg/day AHA guidelines: <300 mg/dayAHA guidelines: <300 mg/day

Dietary CholesterolDietary Cholesterol

Response to dietary cholesterol is Response to dietary cholesterol is highly variable; hyper-responders highly variable; hyper-responders may have poor rates of conversion may have poor rates of conversion of cholesterol to bile acidsof cholesterol to bile acids

Dietary intakes of cholesterol have Dietary intakes of cholesterol have been declining since the 1960sbeen declining since the 1960s

Intake acts synergistically with sfa; Intake acts synergistically with sfa; positively related to CHD riskpositively related to CHD risk

FiberFiber

Soluble fibers (pectins, gums, Soluble fibers (pectins, gums, mucilages, algal polysaccharides, mucilages, algal polysaccharides, some hemicelluloses) in legumes, some hemicelluloses) in legumes, oats, fruit and psyllium lower oats, fruit and psyllium lower serum cholesterol and LDL-Cserum cholesterol and LDL-C

Quantity needed varies by food Quantity needed varies by food (more legumes than pectins or (more legumes than pectins or gums)gums)

FiberFiber

Average decline in LDL-C is 14% Average decline in LDL-C is 14% for hypercholesterolemics and for hypercholesterolemics and 10% for normocholesterolemics 10% for normocholesterolemics when soluble fiber is added to a when soluble fiber is added to a low fat dietlow fat diet

Fiber may bind bile acids, which Fiber may bind bile acids, which lowers serum cholesterol to lowers serum cholesterol to replete the bile acid poolreplete the bile acid pool

FiberFiber

Insoluble fibers have no effect Insoluble fibers have no effect (celluloses and lignin)(celluloses and lignin)

Of total fiber (25-30 grams) 6 to 10 Of total fiber (25-30 grams) 6 to 10 grams should be from soluble fibergrams should be from soluble fiber

Can be achieved with 5 or more Can be achieved with 5 or more servings of fruits or vegetables a servings of fruits or vegetables a day and 6 or more servings of day and 6 or more servings of whole grains and high-fiber cerealswhole grains and high-fiber cereals

AlcoholAlcohol

Affects total triglyceride and HDL-CAffects total triglyceride and HDL-C Effects on TG are dose dependent and Effects on TG are dose dependent and

are greater in persons with TG>150 are greater in persons with TG>150 mg/dlmg/dl

Moderate alcohol consumption has Moderate alcohol consumption has been associated with decreased risk of been associated with decreased risk of MI and CHD mortality in white menMI and CHD mortality in white men

Alcohol raises both HDL2 and HDL3 Alcohol raises both HDL2 and HDL3 subfractionssubfractions

Current intake in US is 2% of total kcalsCurrent intake in US is 2% of total kcals No increase is recommended to No increase is recommended to

decrease CHD riskdecrease CHD risk

CoffeeCoffee

Mixed results in studies on effect of Mixed results in studies on effect of coffee on lipidscoffee on lipids

Heavy intake of regular coffee (720 Heavy intake of regular coffee (720 ml) causes minor increases in TC (9 ml) causes minor increases in TC (9 mg/dl) LDL-C (6 mg/dl) and HDL-C (4 mg/dl) LDL-C (6 mg/dl) and HDL-C (4 mg/dl)mg/dl)

Boiled coffee (European) produces Boiled coffee (European) produces greater elevations than filtered coffeegreater elevations than filtered coffee

CoffeeCoffee

Large population studies have Large population studies have failed to find associations failed to find associations between coffee consumption and between coffee consumption and CHD incidence or mortalityCHD incidence or mortality

Coffee drinkers consume more Coffee drinkers consume more saturated fat and cholesterol, saturated fat and cholesterol, smoked more cigarettes, and smoked more cigarettes, and were less likely to exercisewere less likely to exercise

AntioxidantsAntioxidants

Antioxidants have been studied for Antioxidants have been studied for possible role in preventing oxidation of possible role in preventing oxidation of LDL-CLDL-C

Epidemiological studies suggest Epidemiological studies suggest vitamin E and carotenoids are inversely vitamin E and carotenoids are inversely related to CVD, but randomized trials related to CVD, but randomized trials have not supported thishave not supported this

Vitamin E: no primary or secondary Vitamin E: no primary or secondary prevention trials show positive effectprevention trials show positive effect

B-carotene supplements appear to B-carotene supplements appear to have no benefitshave no benefits

Use food sourcesUse food sources

CalciumCalcium

Supplementation produces small Supplementation produces small decreases in LDL-C in decreases in LDL-C in hypercholesterolemic menhypercholesterolemic men

May form insoluble soaps with May form insoluble soaps with fatty acidsfatty acids

Soy ProteinSoy Protein

Substituting soy protein lowers TC (9%) Substituting soy protein lowers TC (9%) and LDL-C (13%) and TG (11%) with no and LDL-C (13%) and TG (11%) with no effect on HDL-Ceffect on HDL-C

Effect in addition to a Step 1 diet; occurs Effect in addition to a Step 1 diet; occurs only in persons with hypercholesterolemiaonly in persons with hypercholesterolemia

Dose responseDose response Daily intake of 25 g of soy will lower LDL-C Daily intake of 25 g of soy will lower LDL-C

by 4 to 8% in hypercholesterolemic by 4 to 8% in hypercholesterolemic personspersons

Stanols/SterolsStanols/Sterols

Isolated from soybean oils or pine Isolated from soybean oils or pine tree oil tree oil

Lowers blood cholesterolLowers blood cholesterol Esterified and made into margarinesEsterified and made into margarines Consuming 2-3 grams/day lowers Consuming 2-3 grams/day lowers

cholesterol by 9-20% in persons cholesterol by 9-20% in persons with hypercholesterolemiawith hypercholesterolemia

Inhibits absorption of dietary Inhibits absorption of dietary cholesterolcholesterol

Stanols/SterolsStanols/Sterols

NutsNuts

Tree nuts can reduce risk of CHD via Tree nuts can reduce risk of CHD via lipid-lowering effects; lipid-lowering effects;

Peanuts also cardioprotectivePeanuts also cardioprotective Almonds, hazelnuts, pecans, pistachio Almonds, hazelnuts, pecans, pistachio

nuts, and walnuts modestly reduce nuts, and walnuts modestly reduce serum cholesterolserum cholesterol

Nuts are a rich source of fiber, vitamin Nuts are a rich source of fiber, vitamin E, magnesium, and MUFA and PUFAE, magnesium, and MUFA and PUFA

ALA in walnuts, arginine, and ALA in walnuts, arginine, and antioxidant and antithrombotic effectsantioxidant and antithrombotic effects

May reduce insulin resistanceMay reduce insulin resistance

NutsNuts

Epidemiological evidence Epidemiological evidence suggests an inverse relationship suggests an inverse relationship between nut consumption and between nut consumption and CHD risk and type 2 diabetesCHD risk and type 2 diabetes

Nurses’ Health Study: women Nurses’ Health Study: women who ate 5+ servings lowered risk who ate 5+ servings lowered risk of CHD by 45% of CHD by 45%

NutsNuts

Recommend 1 to 2 ounces of nuts Recommend 1 to 2 ounces of nuts (1 to 2 large handfuls) in place of (1 to 2 large handfuls) in place of other sources of energyother sources of energy

Choose unsalted, roasted, or raw Choose unsalted, roasted, or raw nutsnuts

AHA 2006 Diet/Lifestyle AHA 2006 Diet/Lifestyle Recommendations for CVD Recommendations for CVD Risk ReductionRisk Reduction These recommendations apply to These recommendations apply to

the general public for primary the general public for primary prevention and can be used prevention and can be used clinicallyclinically

New focus on weight New focus on weight managementmanagement

More focus on practical strategies More focus on practical strategies for implementationfor implementation

AHA 2006 Diet/Lifestyle AHA 2006 Diet/Lifestyle Recommendations for CVD Recommendations for CVD Risk ReductionRisk Reduction Balance calorie intake and physical Balance calorie intake and physical

activity to achieve or maintain a activity to achieve or maintain a healthy body weight. healthy body weight.

Consume a diet rich in vegetables Consume a diet rich in vegetables and fruitsand fruits

Choose whole-grain, high-fiber Choose whole-grain, high-fiber foodsfoods

Consume fish, especially oily fish, Consume fish, especially oily fish, at least twice a weekat least twice a week

Circulation 2006;114:82-96

AHA 2006 Diet/Lifestyle AHA 2006 Diet/Lifestyle Recommendations for CVD Recommendations for CVD Risk ReductionRisk Reduction Limit your intake of SFA to <7% of Limit your intake of SFA to <7% of

energy, trans fat to <1% of energy, energy, trans fat to <1% of energy, cholesterol to <300 mg/day bycholesterol to <300 mg/day by– Choosing lean meats and vegetable Choosing lean meats and vegetable

alternativesalternatives– Selecting fat-free (skim), 1%-fat, and Selecting fat-free (skim), 1%-fat, and

lowfat dairy products, andlowfat dairy products, and– Minimizing intake of partially Minimizing intake of partially

hydrogenated fatshydrogenated fats

Circulation 2006;114:82-96

AHA 2006 Diet and Lifestyle AHA 2006 Diet and Lifestyle Recommendations for CVD Recommendations for CVD Risk ReductionRisk Reduction

Minimize your intake of beverages and Minimize your intake of beverages and foods with added sugarsfoods with added sugars

Choose and prepare foods with little or Choose and prepare foods with little or no saltno salt

If you consume alcohol, do so in If you consume alcohol, do so in moderationmoderation

When you eat food that is prepared When you eat food that is prepared outside of the home, follow the AHA Diet outside of the home, follow the AHA Diet and Lifestyle Recommendationsand Lifestyle RecommendationsCirculation 2006;114:82-96

Implementation 2006 Implementation 2006 AHA Diet/Lifestyle AHA Diet/Lifestyle GuidelinesGuidelines Know your calorie needs to achieve Know your calorie needs to achieve

and maintain a healthy weightand maintain a healthy weight Know the calorie content of the foods Know the calorie content of the foods

and beverages you consumeand beverages you consume Track your weight, physical activity, Track your weight, physical activity,

and calorie intakeand calorie intake Prepare and eat smaller portionsPrepare and eat smaller portions Track and, when possible, decrease Track and, when possible, decrease

screen timescreen time

Circulation 2006;114:82-96

Implementation 2006 Implementation 2006 AHA Diet/Lifestyle AHA Diet/Lifestyle GuidelinesGuidelines Incorporate physical movement Incorporate physical movement

into habitual activitiesinto habitual activities Do not smoke or use tobacco Do not smoke or use tobacco

productsproducts If you consume alcohol, do so in If you consume alcohol, do so in

moderation (1 drink/day in moderation (1 drink/day in women, 2 in men)women, 2 in men)

Circulation 2006;114:82-96

Implementation 2006 Implementation 2006 AHA Diet/Lifestyle AHA Diet/Lifestyle GuidelinesGuidelines Use the nutrition facts panel and Use the nutrition facts panel and

ingredients list when choosing foods to buyingredients list when choosing foods to buy Eat fresh, frozen, and canned vegetables Eat fresh, frozen, and canned vegetables

and fruits without high-calorie sauces and and fruits without high-calorie sauces and added salt and sugarsadded salt and sugars

Replace high-calorie foods with fruits and Replace high-calorie foods with fruits and vegetablesvegetables

Increase fiber intake by eating beans, Increase fiber intake by eating beans, whole grain products, fruits and vegetableswhole grain products, fruits and vegetables

Circulation 2006;114:82-96

Implementation 2006 Implementation 2006 AHA Diet/Lifestyle AHA Diet/Lifestyle GuidelinesGuidelines Use liquid vegetable oils in place of Use liquid vegetable oils in place of

solid fatssolid fats Limit beverages and foods high in Limit beverages and foods high in

added sugars (fructose, sucrose, added sugars (fructose, sucrose, glucose, maltose, dextrose, corn syrups, glucose, maltose, dextrose, corn syrups, concentrated fruit juice, and honeyconcentrated fruit juice, and honey

Choose foods made with whole grainsChoose foods made with whole grains Cut back on pastries and high-calorie Cut back on pastries and high-calorie

bakery products (e.g. muffins, bakery products (e.g. muffins, doughnuts)doughnuts)

Circulation 2006;114:82-96

Implementation 2006 Implementation 2006 AHA Diet/Lifestyle AHA Diet/Lifestyle GuidelinesGuidelines Select milk and dairy products that Select milk and dairy products that

are either fat free or lowfatare either fat free or lowfat Reduce salt intake byReduce salt intake by

– Comparing the sodium content of Comparing the sodium content of similar products and choosing those similar products and choosing those with lesswith less

– Choosing processed foods, including Choosing processed foods, including cereals and baked goods that are cereals and baked goods that are reduced in saltreduced in salt

– Limiting condiments, e.g. soy sauce, Limiting condiments, e.g. soy sauce, catsupcatsupCirculation 2006;114:82-96

Implementation 2006 Implementation 2006 AHA Diet/Lifestyle AHA Diet/Lifestyle GuidelinesGuidelines Use lean cuts of meat and remove skin Use lean cuts of meat and remove skin

from poultry before eatingfrom poultry before eating Limit processed meats that are high in Limit processed meats that are high in

saturated fat and sodiumsaturated fat and sodium Grill, bake, or broil fish, meat and Grill, bake, or broil fish, meat and

poultrypoultry Incorporate vegetable-based meat Incorporate vegetable-based meat

substitutes into favorite recipessubstitutes into favorite recipes Encourage the consumption of whole Encourage the consumption of whole

vegetables and fruits in place of juicesvegetables and fruits in place of juicesCirculation 2006;114:82-96

AHA on Antioxidant AHA on Antioxidant SupplementsSupplements

Antioxidant vitamin supplements or Antioxidant vitamin supplements or other antioxidants such are selenium other antioxidants such are selenium are not recommendedare not recommended

Although observational studies Although observational studies suggest that high intakes of suggest that high intakes of antioxidant vitamins from food and antioxidant vitamins from food and supplements are associated with supplements are associated with lower risk of CVD, intervention trials lower risk of CVD, intervention trials have not confirmed thishave not confirmed thisCirculation 2006;114:82-96

Antioxidant Antioxidant SupplementsSupplements Trials have documented potential Trials have documented potential

harm, e.g. higher risk of lung cancer harm, e.g. higher risk of lung cancer with beta-carotene supplements in with beta-carotene supplements in smokers and increased risk of heart smokers and increased risk of heart failure and total mortality from high failure and total mortality from high dose vitamin E supplementsdose vitamin E supplements

Although supplements are not Although supplements are not recommended, food sources of recommended, food sources of antioxidant nutrients areantioxidant nutrients are

Circulation 2006;114:82-96

AHA on Soy ProteinAHA on Soy Protein

Evidence of a direct Evidence of a direct cardiovascular health benefit cardiovascular health benefit from consuming soy protein is from consuming soy protein is minimalminimal

However, there may be some However, there may be some benefit if soy protein is used to benefit if soy protein is used to replace animal and dairy products replace animal and dairy products that contain SFA and cholesterolthat contain SFA and cholesterol

Circulation 2006;114:82-96

AHA on Folate and AHA on Folate and Other B VitaminsOther B Vitamins Evidence is inadequate to recommend Evidence is inadequate to recommend

folate and other B vitamins to reduce folate and other B vitamins to reduce heart disease riskheart disease risk

Folate intake and B6 and B12 are Folate intake and B6 and B12 are inversely associated with serum inversely associated with serum homocysteine levels, which are homocysteine levels, which are associated with increased risk of CVDassociated with increased risk of CVD

Trials of homocysteine-reducing vitamin Trials of homocysteine-reducing vitamin therapy have been disappointingtherapy have been disappointing

Circulation 2006;114:82-96

AHA on Fish Oil AHA on Fish Oil SupplementsSupplements Fish intake is associated with Fish intake is associated with

decreased risk of CVDdecreased risk of CVD Patients without documented CHD eat Patients without documented CHD eat

fish, preferably oil fish, twice a weekfish, preferably oil fish, twice a week Patients with documented CVD should Patients with documented CVD should

consume ~1 gram of EPA + DHA per consume ~1 gram of EPA + DHA per day, preferably from oily fish, though day, preferably from oily fish, though supplements can be considered with supplements can be considered with physician inputphysician input

Circulation 2006;114:82-96

Fish Oil SupplementsFish Oil Supplements

For persons with For persons with hypertriglyceridemia, 2 to 4 g of hypertriglyceridemia, 2 to 4 g of EPA + DHA per day, provided as EPA + DHA per day, provided as capsules under a physician’s care capsules under a physician’s care are recommended. are recommended.

Circulation 2006;114:82-96

Adult Treatment Panel Adult Treatment Panel III (NCEP, 2001)III (NCEP, 2001) First published guidelines 2001First published guidelines 2001 Update published 2004*Update published 2004* Raises diabetes as an important risk Raises diabetes as an important risk

factor for CHDfactor for CHD Uses Framingham projections of 10-Uses Framingham projections of 10-

year absolute risk to identify patients year absolute risk to identify patients for more intensive treatmentfor more intensive treatment

Identifying persons with multiple Identifying persons with multiple metabolic risk factors as candidates metabolic risk factors as candidates for therapeutic lifestyle changesfor therapeutic lifestyle changes

*Circulation 2004;110:227-239

ATP IIIATP III

Targets LDL-C first with TLCTargets LDL-C first with TLC When LDL-C goals are met, treat When LDL-C goals are met, treat

metabolic syndrome by metabolic syndrome by increasing physical activity and increasing physical activity and decreasing energy intake to decreasing energy intake to facilitate weight lossfacilitate weight loss

ATP III Risk Factors ATP III Risk Factors That Modify LDL GoalsThat Modify LDL Goals Cigarette smokingCigarette smoking Hypertension Hypertension >>140/90 mmHg or on 140/90 mmHg or on

medicationmedication Low HDL-C (<40 mg/dl)Low HDL-C (<40 mg/dl) Family history of premature CHD (male Family history of premature CHD (male

first degree relative<55; female<65)first degree relative<55; female<65) Age (men Age (men >>45 years, women 45 years, women >>55 55

yearsyears

LDL-C Goals and Cutpoints for TLCLDL-C Goals and Cutpoints for TLCand Drug Therapy by Risk and Drug Therapy by Risk CategoriesCategories

Risk CategoryRisk Category

LDL GoalLDL Goal(mg/dL)(mg/dL)

LDL Level to LDL Level to Initiate Initiate

Therapeutic Therapeutic Lifestyle Lifestyle

Changes (TLC) Changes (TLC) (mg/dL)(mg/dL)

LDL Level at LDL Level at Which Which

to Considerto ConsiderDrug Therapy Drug Therapy

(mg/dL)(mg/dL)

CHD or CHD CHD or CHD Risk Risk

EquivalentsEquivalents(10-year risk (10-year risk

>20%)>20%)

<100 <100

Optional Optional Goal: Goal:

< 70 mg/dl< 70 mg/dl

100100130 130

(100–129: drug (100–129: drug optional)optional)

2+ Risk 2+ Risk Factors Factors

(10-year risk (10-year risk 20%)20%)

<130<130 130130

10-year risk 10-year risk 10–20%: 10–20%: 130130

10-year risk 10-year risk <10%: <10%: 160 160

0–1 Risk 0–1 Risk FactorFactor <160<160 160160

190 190 (160–189: LDL-(160–189: LDL-lowering drug lowering drug

optional)optional)

Therapeutic Lifestyle Changes Therapeutic Lifestyle Changes in in LDL-Lowering TherapyLDL-Lowering Therapy TLC DietTLC Diet

– Reduced intake of cholesterol-raising Reduced intake of cholesterol-raising nutrients (same as previous Step II Diet)nutrients (same as previous Step II Diet) Saturated fats <7% of total caloriesSaturated fats <7% of total calories Dietary cholesterol <200 mg per dayDietary cholesterol <200 mg per day

– LDL-lowering therapeutic optionsLDL-lowering therapeutic options Plant stanols/sterols (2 g per day)Plant stanols/sterols (2 g per day) Viscous (soluble) fiber (10–25 g per day)Viscous (soluble) fiber (10–25 g per day)

Weight reduction Weight reduction Increased physical activityIncreased physical activity

• Reinforce reductionin saturated fat andcholesterol

• Consider addingplant stanols/sterols

• Increase fiber intake

• Consider referral toa dietitian

• Initiate Tx forMetabolicSyndrome

• Intensify weightmgt &physical activity

• Consider referral to a dietitian

6 wks 6 wks Q 4-6 mo

• Emphasize

reduction insaturated fat &cholesterol

• Encouragemoderate physicalactivity

• Consider referral toa dietitian

Visit I

Begin LifestyleTherapies

Visit 2Evaluate LDLresponse

If LDL goal notachieved, intensifyLDL-Lowering Tx

Visit 3Evaluate LDLresponse

If LDL goal notachieved, consideradding drug Tx

Steps in Steps in Therapeutic Lifestyle Therapeutic Lifestyle Changes Changes

MonitorAdherenceto TLC

Visit N

The Metabolic Syndrome as a The Metabolic Syndrome as a Secondary Target of TherapySecondary Target of Therapy

Abdominal obesityAbdominal obesity

Atherogenic dyslipidemiaAtherogenic dyslipidemia– Elevated triglyceridesElevated triglycerides– Small LDL particlesSmall LDL particles– Low HDL cholesterolLow HDL cholesterol

Raised blood pressureRaised blood pressure Insulin resistance (Insulin resistance ( glucose intolerance) glucose intolerance) Prothrombotic stateProthrombotic state Proinflammatory stateProinflammatory state

Therapeutic Lifestyle Therapeutic Lifestyle Changes (TLC)Changes (TLC) TLC DietTLC Diet

– Saturated fat <7% of calories, Saturated fat <7% of calories, cholesterol <200 mg/dalcholesterol <200 mg/dal

– Consider increased viscous (soluble) Consider increased viscous (soluble) fiber (10-25 g/day) and plant fiber (10-25 g/day) and plant stanols/sterols (2g/day)stanols/sterols (2g/day)

Weight managementWeight management Increased physical activityIncreased physical activity

Nutrient Composition of TLC Nutrient Composition of TLC DietDietNutrientNutrient Recommended IntakeRecommended Intake Saturated fatSaturated fat Less than 7% of total caloriesLess than 7% of total calories Polyunsaturated fatPolyunsaturated fat Up to 10% of total caloriesUp to 10% of total calories Monounsaturated fat Monounsaturated fat Up to 20% of total caloriesUp to 20% of total calories Total fatTotal fat 25–35% of total calories25–35% of total calories CarbohydrateCarbohydrate 50–60% of total calories50–60% of total calories FiberFiber 20–30 grams per day20–30 grams per day ProteinProtein Approximately 15% of total caloriesApproximately 15% of total calories CholesterolCholesterol Less than 200 mg/dayLess than 200 mg/day Total calories (energy)Total calories (energy) Balance energy intake and Balance energy intake and

expenditure expenditure to maintain desirable body to maintain desirable body weightweight

ATP III Recommendations ATP III Recommendations Compared with the American Compared with the American DietDiet

American American DietDiet

ATP IIIATP III

Total fat %Total fat % 25-3525-35 32.832.8

SFA %SFA % 11.311.3 <7<7

MUFAMUFA 12.512.5 <<2020

PUFAPUFA 6.46.4 <<1010

Cholesterol Cholesterol mgmg

256256 <200<200

Dietary fiber Dietary fiber gg

15.115.1 20-3020-30Carson JA, Grundy SM, VanHorn L, Stone N. MNT in prevention and management of coronary heart disease. In Carson JS et al. Cardiovascular Nutrition. Am Diet Assoc 2004

TLC DietTLC Diet

FoodFood AmountAmount

Breads and Breads and cerealscereals

>6 servings (adjust to >6 servings (adjust to meet energy needs)meet energy needs)

Vegetables and Vegetables and fruitsfruits

3-5 servings 3-5 servings vegetablesvegetables

2-4 servings fruits2-4 servings fruits

Dairy productsDairy products 2-3 servings2-3 servings

EggsEggs <2 yolks per week<2 yolks per week

Meat, fish, Meat, fish, poultrypoultry

<5 ounces per day<5 ounces per day

Fats and oilsFats and oils Adjust to caloric levelAdjust to caloric level

TLC: Healthy CookingTLC: Healthy Cooking Bake, steam, roast, broil, stew or Bake, steam, roast, broil, stew or

boil instead of fryingboil instead of frying Remove poultry skin before eatingRemove poultry skin before eating Use a nonstick pan with cooking oil Use a nonstick pan with cooking oil

spray or small amount of liquid spray or small amount of liquid vegetable oil instead of lard, butter, vegetable oil instead of lard, butter, shortening, other solid fatsshortening, other solid fats

Trim visible fat before you cook Trim visible fat before you cook meatsmeats

Chill meat and poultry broth until Chill meat and poultry broth until fat becomes solid, removefat becomes solid, remove

TLC Diet: Eat MoreTLC Diet: Eat More

Fresh, frozen, canned vegetables without Fresh, frozen, canned vegetables without added fat, sauce, saltadded fat, sauce, salt

Fresh, frozen, canned or dried fruitFresh, frozen, canned or dried fruit Nonfat, ½%, and low-fat milk, buttermilk, Nonfat, ½%, and low-fat milk, buttermilk,

yogurt, cheeseyogurt, cheese Unsaturated oils, soft or liquid margarines Unsaturated oils, soft or liquid margarines

and spreads, salad dressings, seeds and nutsand spreads, salad dressings, seeds and nuts Lean cuts of meat; extra lean hamburger, Lean cuts of meat; extra lean hamburger,

fish; meat alternatives made with soy or TVPfish; meat alternatives made with soy or TVP Whole grain breads and cereals, pasta, rice, Whole grain breads and cereals, pasta, rice,

potatoes, dried beans and peas, lowfat potatoes, dried beans and peas, lowfat crackers, pretzels, cookiescrackers, pretzels, cookies

TLC Diet: Eat LessTLC Diet: Eat Less

High-fat bakery products High-fat bakery products (doughnuts, biscuits, croissants, (doughnuts, biscuits, croissants, pies, cookiespies, cookies

Chips, cheese puffs, snack mix, Chips, cheese puffs, snack mix, regular crackers, buttered popcornregular crackers, buttered popcorn

Whole and reduced-fat milk and Whole and reduced-fat milk and dairy products, ice cream, cream, dairy products, ice cream, cream, half and half, cream cheese, sour half and half, cream cheese, sour cream and cheesecream and cheese

TLC Diet: Eat LessTLC Diet: Eat Less

Whole eggs, yolksWhole eggs, yolks Fatty meat such as ribs, tbone Fatty meat such as ribs, tbone

steak, regular hamburger, bacon, steak, regular hamburger, bacon, sausage, salami, hot dogs, organ sausage, salami, hot dogs, organ meats, liver, brains, sweetbreads, meats, liver, brains, sweetbreads, fried meat, poultry and fishfried meat, poultry and fish

Butter, shortening, stick Butter, shortening, stick margarine, chocolate, tropical margarine, chocolate, tropical oils, coconut, palm and palm oils, coconut, palm and palm kernelkernel

Dealing with Problem Dealing with Problem FoodsFoods Reduce the portion sizeReduce the portion size Prepare the food more healthfullyPrepare the food more healthfully Reduce the frequency it is eatenReduce the frequency it is eaten Substitute a more healthful food Substitute a more healthful food

for the problem foodfor the problem food

TLC: Healthy ShoppingTLC: Healthy Shopping

Choose chicken breast or drumstick Choose chicken breast or drumstick instead of wing and thighinstead of wing and thigh

Select skim milk or 1 percent instead Select skim milk or 1 percent instead of 2 percent or whole milkof 2 percent or whole milk

Buy lean cuts of meat such as round, Buy lean cuts of meat such as round, sirloin, and loinsirloin, and loin

Buy more vegetables, fruits and grainsBuy more vegetables, fruits and grains Read nutrition labels on food packagesRead nutrition labels on food packages

TLC: Dining OutTLC: Dining Out

Choose restaurants that have low Choose restaurants that have low fat options availablefat options available

Ask that sauces, gravies, and Ask that sauces, gravies, and salad dressings be served on the salad dressings be served on the sideside

Control portions by asking for an Control portions by asking for an appetizer serving or sharing with appetizer serving or sharing with a frienda friend

TLC: Dining OutTLC: Dining Out

At fast food restaurants, go for salads, At fast food restaurants, go for salads, grilled (not fried or breaded) skinless grilled (not fried or breaded) skinless chicken sandwiches, regular-sized chicken sandwiches, regular-sized hamburgers, or roast beef sandwicheshamburgers, or roast beef sandwiches

Avoid regular salad dressings and fatty Avoid regular salad dressings and fatty sauces. Limit jumbo or deluxe burgers, sauces. Limit jumbo or deluxe burgers, sandwiches, french fries, and other sandwiches, french fries, and other foods. foods.

Lipid-Lowering DrugsLipid-Lowering DrugsAdded if Diets Are Not Added if Diets Are Not SuccessfulSuccessful

Lipid-Lowering DrugsLipid-Lowering DrugsAdded if Diets Are Not Added if Diets Are Not SuccessfulSuccessful

After a 6-month trial on each diet, After a 6-month trial on each diet, drugs are added to the treatment.drugs are added to the treatment.

Types:Types: Nicotinic acid and lovastatinNicotinic acid and lovastatin Gemfibrozil, probucol, clofibrate—for Gemfibrozil, probucol, clofibrate—for

high TGshigh TGs Cholestyramine and colestipol (bile Cholestyramine and colestipol (bile

acid sequestrants)—to lower high acid sequestrants)—to lower high cholesterol; may increase TGscholesterol; may increase TGs

After a 6-month trial on each diet, After a 6-month trial on each diet, drugs are added to the treatment.drugs are added to the treatment.

Types:Types: Nicotinic acid and lovastatinNicotinic acid and lovastatin Gemfibrozil, probucol, clofibrate—for Gemfibrozil, probucol, clofibrate—for

high TGshigh TGs Cholestyramine and colestipol (bile Cholestyramine and colestipol (bile

acid sequestrants)—to lower high acid sequestrants)—to lower high cholesterol; may increase TGscholesterol; may increase TGs

HMG CoA Reductase HMG CoA Reductase Inhibitors (Statins)Inhibitors (Statins)

Reduce LDL-C 18–55% & TG Reduce LDL-C 18–55% & TG 7–30%7–30%

Raise HDL-C 5–15%Raise HDL-C 5–15% Major side effectsMajor side effects

– MyopathyMyopathy– Increased liver enzymesIncreased liver enzymes

ContraindicationsContraindications– Absolute: liver diseaseAbsolute: liver disease– Relative: use with certain drugsRelative: use with certain drugs

HMG CoA Reductase HMG CoA Reductase Inhibitors (Statins)Inhibitors (Statins)

StatinStatin Dose RangeDose Range

LovastatinLovastatin 20–80 mg20–80 mgPravastatinPravastatin 20–40 mg20–40 mgSimvastatinSimvastatin 20–80 mg20–80 mgFluvastatinFluvastatin 20–80 mg20–80 mgAtorvastatinAtorvastatin 10–80 mg10–80 mgCerivastatinCerivastatin 0.4–0.8 mg0.4–0.8 mg

HMG CoA Reductase HMG CoA Reductase Inhibitors (Statins) Inhibitors (Statins) (continued)(continued)

Demonstrated Therapeutic Demonstrated Therapeutic BenefitsBenefits

Reduce major coronary eventsReduce major coronary events Reduce CHD mortalityReduce CHD mortality Reduce coronary procedures Reduce coronary procedures

(PTCA/CABG)(PTCA/CABG) Reduce strokeReduce stroke Reduce total mortalityReduce total mortality

0

20

40

60

80

1995-96 1997-98 1999-2000 2001-02

Figure 35. Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex: United States, 1995-2002

NOTES: Cholesterol-lowering statin drug visits are physician office and hospital outpatient department visits with cholesterol-lowering statin drugs prescribed, ordered, or provided. See Data Table for data points graphed, specific drugs included, standard errors, and additional notes.

SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Survey and National Hospital Ambulatory Medical Care Survey.

Men, 45-64 years

Women, 45-64 years

Year

Men, 65 years and over

Women, 65 years and over

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

Bile Acid SequestrantsBile Acid Sequestrants

Major actionsMajor actions

– Reduce LDL-C 15–30%Reduce LDL-C 15–30%– Raise HDL-C 3–5%Raise HDL-C 3–5%– May increase TGMay increase TG

Side effectsSide effects– GI distress/constipationGI distress/constipation– Decreased absorption of other drugsDecreased absorption of other drugs

ContraindicationsContraindications– DysbetalipoproteinemiaDysbetalipoproteinemia– Raised Raised TG (especially >400 mg/dL)TG (especially >400 mg/dL)

Bile Acid SequestrantsBile Acid Sequestrants

DrugDrug Dose Dose RangeRange

CholestyramineCholestyramine 4–16 g4–16 g

ColestipolColestipol 5–20 g5–20 g

ColesevelamColesevelam 2.6–3.8 2.6–3.8 gg

Bile Acid Sequestrants Bile Acid Sequestrants (continued)(continued)

Demonstrated Therapeutic Demonstrated Therapeutic BenefitsBenefits

Reduce major coronary Reduce major coronary eventsevents

Reduce CHD mortalityReduce CHD mortality

Nicotinic AcidNicotinic Acid

Major actionsMajor actions– Lowers LDL-C 5Lowers LDL-C 5––25%25%– Lowers TG 20Lowers TG 20––50%50%– Raises HDL-C 15Raises HDL-C 15––35%35%

Side effects: flushing, Side effects: flushing, hyperglycemia, hyperuricemia, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicityupper GI distress, hepatotoxicity

Contraindications: liver disease, Contraindications: liver disease, severe gout, peptic ulcersevere gout, peptic ulcer

Nicotinic AcidNicotinic Acid

Drug FormDrug Form Dose Dose RangeRange

Immediate releaseImmediate release 1.5–3 g1.5–3 g(crystalline)(crystalline)

Extended releaseExtended release 1–2 g1–2 g

Sustained releaseSustained release 1–2 g1–2 g

Nicotinic Acid Nicotinic Acid (continued)(continued)

Demonstrated Therapeutic Demonstrated Therapeutic BenefitsBenefits

Reduces major coronary eventsReduces major coronary events Possible reduction in total Possible reduction in total

mortalitymortality

Fibric AcidsFibric Acids

Major actionsMajor actions

– Lower LDL-C 5–20% (with normal TG)Lower LDL-C 5–20% (with normal TG)– May raise LDL-C (with high TG)May raise LDL-C (with high TG)– Lower TG 20–50%Lower TG 20–50%– Raise HDL-C 10–20%Raise HDL-C 10–20%

Side effects: dyspepsia, gallstones, Side effects: dyspepsia, gallstones, myopathymyopathy

Contraindications: Severe renal or Contraindications: Severe renal or hepatic diseasehepatic disease

Fibric AcidsFibric Acids

DrugDrug DoseDose

GemfibrozilGemfibrozil 600 mg BID600 mg BID FenofibrateFenofibrate 200 mg QD200 mg QD ClofibrateClofibrate 1000 mg 1000 mg

BIDBID

Fibric Acids Fibric Acids (continued)(continued)

Demonstrated Therapeutic BenefitsDemonstrated Therapeutic Benefits

Reduce progression of coronary Reduce progression of coronary lesionslesions

Reduce major coronary eventsReduce major coronary events

Secondary PreventionSecondary Prevention

Patients with established CHD have Patients with established CHD have 5-7x greater risk of subsequent MI5-7x greater risk of subsequent MI

Smoking cessationSmoking cessation Reducing BP to <140/90 or 130/85 Reducing BP to <140/90 or 130/85

with CHF, renal insufficiency, DMwith CHF, renal insufficiency, DM Reduce LDL-C to <100 mg/dl; non-Reduce LDL-C to <100 mg/dl; non-

HDL levels to <130 mg/dlHDL levels to <130 mg/dl

Secondary Prevention Secondary Prevention (cont)(cont) Moderate physical activity for 30 Moderate physical activity for 30

minutes daily 3-4 days a weekminutes daily 3-4 days a week Weight management to attain Weight management to attain

BMI<25BMI<25 A1C<7%A1C<7% Use of 75 to 325 mg aspirin daily Use of 75 to 325 mg aspirin daily

unless contraindicatedunless contraindicated Use of ACE inhibitors and B-Use of ACE inhibitors and B-

blockers indefinitelyblockers indefinitely

CVD: Medical CVD: Medical InterventionIntervention

Coronary Angioplasty Coronary Angioplasty (PTCA)(PTCA) Percutaneous coronary Percutaneous coronary

intervention (PCI) uses a balloon intervention (PCI) uses a balloon to break up plaque in an occluded to break up plaque in an occluded arteryartery

Performed under local Performed under local anaesthetic so recovery quicker anaesthetic so recovery quicker than with bypass surgerythan with bypass surgery

Persons with no more than 2 Persons with no more than 2 blockages are candidatesblockages are candidates

AngioplastiesAngioplasties

601,000 angioplasties done in 601,000 angioplasties done in 1999; 1.2 million last year1999; 1.2 million last year

Most common problem is Most common problem is restenosis of the artery (10-20%)restenosis of the artery (10-20%)

Require intensive lifestyle Require intensive lifestyle managementmanagement

AngioplastiesAngioplasties Study by Boden, et al suggests that in low Study by Boden, et al suggests that in low

risk pts lifestyle changes and medications risk pts lifestyle changes and medications are just as effective as PCIare just as effective as PCI

Angioplasties did not prevent heart attacks Angioplasties did not prevent heart attacks or save lives; angioplasties produced a or save lives; angioplasties produced a slight and temporary improvement in chest slight and temporary improvement in chest pain symptomspain symptoms

Angioplasty costs $30,000 to $40,000. The Angioplasty costs $30,000 to $40,000. The drugs used in the study are almost all drugs used in the study are almost all available in generic form.available in generic form.

Many health insurers including Medicare do Many health insurers including Medicare do not cover MNT for cardiovascular diseasesnot cover MNT for cardiovascular diseases

Boden et al, NEJM 2007 Volume 356:1503-1516

PCI with StentPCI with Stent

Coronary Artery Coronary Artery Bypass SurgeryBypass Surgery Candidates have more than two Candidates have more than two

occluded arteriesoccluded arteries Procedures have decreased since Procedures have decreased since

1995 because of 1995 because of ↑ angioplasties↑ angioplasties Does not cure atherosclerosis; new grafts Does not cure atherosclerosis; new grafts

are also susceptibleare also susceptible Restonosis is common within 10 years of Restonosis is common within 10 years of

surgerysurgery

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