Preventing Cardiovascular Preventing Cardiovascular DiseaseDisease

Chapter 11

ObjectivesObjectives Define cardiovascular disease and coronary

heart disease. Explain the importance of a healthy lifestyle in

preventing cardiovascular disease. Become familiar with the major risk factors that

lead to the development of coronary heart disease.

Assess your own risk for developing coronary heart disease.

Outline a comprehensive program for reducing the risk for coronary heart disease and managing the overall risk for cardiovascular disease.

Determine your risk for heart disease.

Most prevalent degenerative diseases in the US. About 30% of all deaths About 33% of the

population suffers from cardiovascular disease.

60% die unexpectantly The 2008 estimated cost

of heart and blood vessel disease in the US exceeded $475 billion.

The incidence declined by 28 percent between 1960 and 2000

Prevalence of Cardiovascular Prevalence of Cardiovascular DiseaseDisease

StrokeStroke Caused by the narrowed cranial

arteries due to fatty deposits, reducing blood supply to specific areas of the brain

Third leading cause of death in the United States, accounting for approximately 143,600 deaths each year.

About 800,000 new stroke victims are reported each year and more than one-third are left with permanent disabilities.

Coronary Heart DiseaseCoronary Heart Disease Caused by the narrowed coronary arteries due to fatty deposits,

reducing the blood supply to the heart muscles. Single leading cause of death in the U.S.

Fig. 11-3a, p. 363

Pulmonary artery Left main

coronary arteryAorta artery Circumflex

coronary artery

Right coronary artery

Anterior descending coronary artery

Normal healthy heart

Fig. 11-3b, p. 363

Blockage in the anterior descending coronary arteryAreas

of partial obstruction

Area of myocardial infarction

Myocardial infarction (heart attack) The result of acute reduction in blood flow through the anterior descending coronary artery.

Leading Risk Factors for Leading Risk Factors for CHDCHD

Profile Purpose To screen individuals who may be at high risk for

the disease. To educate people regarding the leading risk

factors for developing CHD. To implement programs aimed at reducing the

risks. To use the analysis as a starting point with which

to compare changes induced by the intervention program.

Lab 11A

Leading Risk Factors for Leading Risk Factors for CHDCHD

Weighted system for CHD risk factors

Risk categories Very low Low Moderate High Very high

Daily physical activity and aerobic exercise greatly reduces the overall risk for heart disease.

AHA strongly suggests incorporating strength training as well

PLUS: An active lifestyle can not eliminate the increase CVD risk caused by poor lifestyle habits smoking, eating too many fatty/

salty/sweet foods, being overweight, and having high stress level

CHD Risk FactorsCHD Risk Factors- Physical Inactivity- Physical Inactivity

EKG allows doctors to identify abnormalities in heart functioning in five general areas: heart rate, heart rhythm, axis of the heart, enlargement or hypertrophy of the heart, and myocardial infarction.

Recommended for: Men over age 45 and women over age 55. Individuals with two or more CHD risk factors who wish to

participate in a vigorous exercise program. Stress EKG versus Resting EKG

Abnormal Abnormal Electrocardiograms (ECG Electrocardiograms (ECG or EKG)or EKG)

Abnormal Cholesterol Abnormal Cholesterol ProfileProfile

Contributes to atherosclerosis, the build-up of fatty tissue in the walls of the arteries The plaque blocks the coronary arteries that

supply the myocardium with oxygen and nutrients.

These obstructions can trigger a myocardial infarction (heart attack).

Chest pain (angina pectoris) does not start until the arteries are about 75% blocked.

The Atherosclerosis The Atherosclerosis ProcessProcess

Comparison of a Normal Comparison of a Normal Healthy & Diseased Healthy & Diseased ArteriesArteries

Abnormal Cholesterol Abnormal Cholesterol ProfileProfile

Cholesterol and triglycerides are transported primarily in the form of HDL, LDL, VLDL and chylomicrons

National Cholesterol Education Program (NCEP) recommendations Below 200 mg/dL for all members of the

population Total cholesterol is not the best predictor

for cardiovascular risk More significant is the way it is carried in

the bloodstream.

Cholesterol GuidelinesCholesterol Guidelines

Abnormal Cholesterol Abnormal Cholesterol ProfileProfile

Cholesterol transportation Low Density Lipoproteins

LDLs tend to release cholesterol, which may penetrate the lining of arteries and speed up the process of atherosclerosis

Oxidized by free radicals

Pattern A (large) and Pattern B (small) Lipoprotein-a [Lp(a)] promotes blood clots

and earlier development of atherosclerosis and is elevated in 10 percent of the population.

Abnormal Cholesterol Abnormal Cholesterol ProfileProfile

Cholesterol transportation Intermediate-Density Lipoproteins

These mid-sized particles are more likely to cause atherosclerosis than a similar amount of LDL cholesterol.

Abnormal Cholesterol Abnormal Cholesterol ProfileProfile

Cholesterol transportation High-Density Lipoproteins

act as scavengers, removing cholesterol from the body and preventing plaque from forming in the arteries.

reverse cholesterol transport HDL2 are larger particles that carry

cholesterol from the arterial wall to the liver for disposal. These particles also have antioxidant and anti-inflammatory effects.

HDL3 also transports cholesterol out of the arterial wall but may not be as effective as HDL2.

Counteracting CholesterolCounteracting Cholesterol Saturated and trans fats raise cholesterol and produce

approximately 1,000 mg of cholesterol per day.

Beef contains more saturated fat than poultry and fish, and increases the risk of dying from heart disease by at least 30 percent and from cancer by about 20 percent.

Unsaturated fats are mainly of plant origin and cannot be converted to cholesterol.

Vitamin C might inactivate free radicals and slow the oxidation of LDL cholesterol.

Vitamin E might protect LDL from oxidation, preventing heart disease before damage takes place.

Counteracting CholesterolCounteracting Cholesterol

Relative Risk of Sudden Cardiac Relative Risk of Sudden Cardiac Death By Base-Line Omega-3 Death By Base-Line Omega-3 Fatty Acid LevelFatty Acid Level

Trans FatsTrans Fats Elevate LDL cholesterol as much as saturated fats

do. Increase triglycerides and lower HDL cholesterol.

The AHA limits trans fat intake to less than 1 percent of total daily calories.

Read food labels carefully The FDA allows food manufacturers to label any

product that has less than half a gram of trans fat per serving as zero.

The label terms "partially hydrogenated" and "trans fatty acids" indicate that the product carries a health risk just as high as that of saturated fat.

Trans FatsTrans Fats

Lowering LDL CholesterolLowering LDL Cholesterol Lose body fat Participate in a regular aerobic exercise program Make dietary modifications

Replace saturated fat with polyunsaturated and monounsaturated fats with total saturated fat intake providing <7% of the total daily calories.

Trans fat intake should be <1% of the daily caloric intake. Consume 25 to 38 grams fiber per day: soluble fiber helps bind and

excrete fats from the body. NCEP Guidelines

Consuming up to 35% of calories from fat, including 10% from polyunsaturated fats and 20% from monounsaturated fats.

Consuming soy protein (25 grams). Consuming about 3 grams of margarine or 6 tablespoons of salad

dressing containing stanol ester The best prescription is the combination of a healthy diet, a

sound aerobic exercise program, and weight control. Consider drug therapy if, after 6 months on a low-cholesterol, low-

saturated-fat diet, cholesterol remains unacceptably high

Elevated TriglyceridesElevated Triglycerides Triglycerides are known as free fatty acids and make up

most of the fat in our diet and most of the fat that circulates in the blood.

Speed up plaque formation in combination with cholesterol. Carried in the blood by VLDLs and chylomicrons. Found in poultry skin, lunch meats, and shellfish. Manufactured mainly in the liver from refined sugars, starches,

and alcohol. Manufactured in the liver Lowering triglycerides

Avoid pastries, candies, soft drinks, fruit juices, white bread, pasta, and alcohol.

Cut down on overall fat consumption. Quit smoking. Reduce weight (if overweight). Do aerobic exercise. Take 2–4 daily grams of fish oil under a physician's supervision.

Triglyceride GuidelinesTriglyceride Guidelines

Cholesterol-Lowering Cholesterol-Lowering MedicationsMedications

Statins group can lower cholesterol by up to 60 percent in 2 to 3 months. Slow down cholesterol production. Increase the liver's ability to remove blood

cholesterol. Decrease triglycerides. Produce a small increase in HDL levels.

High doses of niacin (a B vitamin) help lower LDL cholesterol, triglycerides, and increase HDL cholesterol.

Fibrates are primarily used to lower triglycerides.

Elevated Homocysteine Elevated Homocysteine A high level of this amino acid in the blood is

thought to enhance plaque formation and subsequent blockage of the arteries.

Normally homocysteine helps build proteins and carry out cellular metabolism and is metabolized rapidly.

High blood levels of homocysteine might result from either a genetic inability to metabolize homocysteine or a deficiency in the vitamins required for its conversion.

Keeping homocysteine from accumulating in the blood: Eating five servings of fruits and vegetables daily

provides sufficient levels of folate and vitamin B6 to remove and clear homocysteine from the blood.

Inflammation Inflammation C-reactive protein (CRP), a protein whose levels

in the blood increase with inflammation. Individuals with elevated CRP have twice the risk for

a heart attack. An inexpensive high-sensitivity CRP (hs-CRP) test

that measures the probability of plaque rupture within the arterial wall has been approved by the FDA (Table 11.8).

Excessive intake of alcohol and high-protein diets increase CRP.

CRP can be decreased with statin drugs, exercise, weight loss, proper nutrition, quitting smoking, and aspirin.

Relationship Between CRP, Relationship Between CRP, Cholesterol, and Risk for Cholesterol, and Risk for CVDCVD

People with both elevated CRP and cholesterol have an almost nine-fold increase in the risk for a heart attack

DiabetesDiabetes A condition in which blood glucose is unable to enter cells

because: The pancreas no longer makes enough insulin, or The cells no longer respond to insulin, called insulin

resistance. Diabetes affects about 24 million people in the US.

Two out of three diabetics will die from cardiovascular disease

Chronic high blood sugar can also lead to stroke, nerve damage, vision loss, kidney damage, sexual dysfunction, and decreased immune function.

An 8-hour fasting blood glucose level above 125 mg/dL on two separate tests confirms a diagnosis of diabetes (Table 11.9).

DiabetesDiabetes Types of diabetes

Type 1 (insulin-dependent diabetes mellitus; IDDM)

Known as "juvenile diabetes," found mainly in young people.

The pancreas produces little or no insulin.

DiabetesDiabetes Type 2 diabetes (non-insulin-dependant

diabetes mellitus; NIDDM) Once limited primarily to overweight adults,

now accounts for almost one-half of the new cases diagnosed in children.

Accounts for 90–95 percent of all diabetes cases.

The pancreas either does not produce sufficient insulin or it produces adequate amounts but the cells become insulin-resistant, keeping glucose from entering the cell.

About 60–80 percent related to overeating, obesity, and lack of physical activity.

DiabetesDiabetes In most cases this

condition can be corrected through regular exercise, improving nutrition, and weight loss.

Regular physical activity increases the body's sensitivity to insulin.

Diet high in complex carbohydrates and water-soluble fibers, low in saturated fat, and low in sugar.

Low-fat dairy products.

A1C TestA1C Test Hemoglobin A1c test

Also called Hb A1c. Measures the amount of glucose that

has been in a person's blood over the last 3 months.

If kept under 7 percent, risk of developing diabetic-related problems of the eyes, kidneys, and nerves is lower.

Includes abdominal obesity, elevated blood pressure, high blood glucose, low HDL cholesterol, high triglycerides, and an increased blood-clotting mechanism.

Increases the risk for CHD and the other diabetic-related conditions (blindness, infection, nerve damage, and kidney failure).

Approximately 50 million Americans are afflicted by this condition.

Metabolic SyndromeMetabolic Syndrome

Diagnosis of Diagnosis of Metabolic SyndromeMetabolic Syndrome

Treatment Distribute daily

caloric intake so that 45 percent of the calories are derived from carbohydrates (primarily low-glycemic), 40 percent from fat, and 15 percent from protein.

Lose weight (if overweight), exercise, and quit smoking.

HypertensionHypertension Blood pressure

Measured in milliliters of mercury (mm Hg). Systolic blood pressure (the higher number). Diastolic blood pressure (the lower number).

HypertensionHypertension Approximately 74 million Americans are hypertensive. More than 57,000 Americans die each year as a result of

high blood pressure. Hypertension, "the silent killer," is a risk factor for CHD,

congestive heart failure, strokes, kidney failure, and osteoporosis.

Hypertension is thought to damage the endothelial lining of blood vessels, beginning the atherosclerosis process.

Hypertension makes the heart continually work harder.

About 90 percent have no definite cause, called essential hypertension.

About 10 percent are caused by pathological conditions

Hypertension Hypertension A combination of aerobic exercise, weight

loss, and less sodium in the diet before recommending medication (Table 11.12) The upper limit (UL) for sodium intake is 2,300

mg per day. New recommendations are significantly lower

than 2,000 mg per day

Effects of Long-Term Effects of Long-Term Aerobic Exercise on Aerobic Exercise on Resting BPResting BP

Excessive Body FatExcessive Body Fat Obesity is a risk factor for CHD.

Its location is important as well

CHD is also associated with high blood lipids, hypertension, and diabetes that tend to accompany obesity.

Even slight reduction in body fatness has been found to reduce CHD risk

Cigarette SmokingCigarette Smoking The single most preventable cause of illness and

premature death in the U.S. About 20%of cardiovascular deaths are attributed to

smoking. Speeds the process of atherosclerosis and carries a

threefold increase in the risk of sudden death after a myocardial infarction.

Some of the 1,200 toxic compounds in cigarette smoke damage the inner membrane of blood vessels.

Smoking promotes blood clotting. Carbon monoxide in cigarette smoke decreases the blood's

oxygen-carrying capacity. Smoking increases heart rate, raises blood pressure, and

irritates the heart, which can trigger fatal cardiac arrhythmias.

Smoking decreases HDL cholesterol.

Cigarette SmokingCigarette Smoking Pipe and cigar smoking and tobacco

chewing also increase the risk for heart disease.

Risk for disease decreases after smoking cessation. One year after quitting, the risk of CHD

decreases one-half. Within 15 years, the relative risk of dying

from CVD and cancer approaches that of a lifetime nonsmoker.

Tension and StressTension and Stress It is the response (not the stressor) that creates the

health hazard. The body releases catecholamines that prepare the body

for "fight or flight." Catecholamines increase heart rate, blood pressure, and

blood glucose. Unless metabolized due to the action taken (person fights

or flees), the catecholamines remain elevated in the bloodstream.

People who are not able to relax place a constant low-level strain on the cardiovascular system that could manifest itself as heart disease.

The coronary arteries that feed the heart muscle constrict, reducing the oxygen supply to the heart.

Anger and hostility also contribute to heart disease by increasing heart rate, blood pressure, blood glucose, cholesterol, and interleukin-6.

AgeAge Age

The higher incidence of heart disease occurs as people get older.

Caused partly by other factors stemming from changes in lifestyle as we get older.

The process begins early in life. Approximately 70% have early stages of

atherosclerosis. Elevated blood cholesterol levels found in

children as young as 10 years old. Aging process can be slowed down through

risk factor management and positive lifestyle habits.

Other Risk Factors for CHDOther Risk Factors for CHD Gum disease

The oral bacteria that build up with dental plaque can enter the bloodstream and contribute to inflammation, formation of blood vessel plaque, and blood clotting and thus increase the risk for heart attack.

Daily flossing Loud snoring

Heavy snoring may triple the risk of a heart attack and quadruple the risk of a stroke.

Low birth weight Under 5.5 pounds

Aspirin therapy A daily aspirin dose of about 81 mg per day decreases

nonfatal heart attack by about a third by preventing or dissolving clots.

Real Life StoriesReal Life Stories

Real Life Stories Real Life Stories Critical Thinking Critical Thinking QuestionsQuestions

1. What risk factors for coronary heart disease did Peter have prior to changing his lifestyle? Is this something he needed to worry about at such a young age? Explain why or why not.

2. Are there any other changes Peter could implement to further decrease his personal risk for CHD?

3. What risk factors might contribute to your own possibility of developing coronary heart disease? At what age should you concern yourself with them, and what are you willing to do about them?