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Intro to cardiology

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  • Cardiac disease in US
  • Poverty
  • Cardiac specialists
  • In Massachusetts
  • Alabama
  • Framingham Nurses Study WOMEN
  • Transcript

    • 1. Kim Altavesta MassBay Community College Paramedic Program Fall 2011
    • 2. Objectives 1. Discuss the incidence, prevalence, and risk factors associated with heart disease 2. Introduce specific diseases under the umbrella of heart disease 3. Explain prevention and treatment strategies
    • 3. What is Cardiology?  Cardiology from Greek καρδίᾱ, kardiā, "heart"; and -λογία, -logia  Medical specialty dealing with disorders of the heart  The field includes diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology
    • 4. The Human Heart
    • 5. http://en.wikipedia.org/wiki/File:Apikal4D.gif
    • 6. Synchronization of Ventricular Contraction is Facilitated by Rapidly Conducting Purkinje Fibers Johannes Evangelista Purkinje 1787 - 1869 From Garrison FH. History of Medicine. Philadelphia. Saunders, 1929 Purkinje System of the Left Ventricle From Wenckebach KF, Winterberg H. Die Unregelmäsige Herstäigkeit. Leipzig. Wilhelm Engelmann, 1927. Left Bundle Branch Anterior Fascicle Posterior Fascicle Purkinje Network
    • 7. Slow Pulse and Syncope Hippocrates 467 - 377 BCE Richards DW. JAMA. 1968; 206:377-378. Robert Adams 1791 – 1875 Willius FA, Keys TE, Cardiac Classics. “[He had] remarkable slowness of the pulse, which generally ranged at the rate of 30 in a minute [and] not less than twenty apoplectic attacks… When they attacked him, his pulse would become even slower than usual …” Dublin Hosp Reports. 1827;4:353-453. “[The combination] of permanently slow pulse [and] cerebral attacks of an apoplectic nature, though not followed by paralysis, [is] a very curious and… special combination of symptoms.” Dublin Quart J Med Sci. 1846;2:73-45. “Those who frequently feel very faint die suddenly from no discernable cause.” Aphorisms II:41 tr. P.B. Katz William Stokes 1804 - 1878 St. Louis, Mosby, 1941.
    • 8. Luigi Galvani 1737-1798 “I… applied the point of the scalpel [A] first to one and then the other [nerve], while at the same time one of the assistants produced a spark [B]… Violent contractions were induced in the individual muscles of the limbs…” Galvani L. De viribus electricitatis in motu musculari commentarius. De Bononiensi Scientarium et Atrium Instituto atque Academia Commentarii. 1791;7:363-418. (Tr. Acierno LJ. The History of Cardiology. London, Parthenon 1994) Muscular Contraction in Frogs Can Be Induced By Electrical Impulses A B
    • 9. Giovanni Aldini 1762-1834 (Nephew and assistant of Galvani who studied the effects of electrical stimulation on the bodies of executed criminals) Electrical Impulses Can Stimulate Human Hearts to Contract Figure from Aldini J. Essai Théoretique et Experimental pour le Galvanisme. Paris, Fournier Fils. 1804. “Upon Galvanic stimulation, the heart [of an executed criminal]… which possessed a great deal of vitality, was immediately very visibly contracted.” Aldini J. General Views on the Application of Galvanism to Medical Purposes. London, J. Callow, 1819
    • 10. Hugo van Ziemessen and his electrical stimulator. Schechter DC. NY State J Med. 1972;72:395. Catherina Serafin after removal of an enchondroma of her chest wall. van Ziemessen H. Arch Klin Med. 1882;30:270. Sphygmic responses to pacing by repetitive electrical stimuli applied through the skin directly over a human heart. Intrinsic beats: Paced beats: Onset of Cessation of Electrical Stimulation Electrical Stimulation Electric Shock Can Pace the Human Heart
    • 11. Electric Shock Can Pace the Human Heart… a young woman, a chronic morphine eater, was admitted to the Ste.-Anne asylum, Paris. [when] deprived of her daily dose of morphine she had a sudden attack of syncope, the pulse was almost imperceptible, and her face was blue - almost black-blue… We practiced rhythmic [electrical] excitations [and] as the excitations were being repeated, it was astonishing to see the accompanying change in color of the patient’s face; the dark blue color changed to pale, then to almost natural color; at the end of the thirty seconds of rhythmic excitations, the patient took a spontaneous breath, opened her eyes, and said: “Oh, I feel so cold in my back.” The cold she felt was the wet cotton of the electrodes… with our method we cause artificial heart beats, as well as artificial respirations, to take place…” Robinovitch LG. J Ment Path. 1907-1909;8:180. Disposition of electrodes favored by Robinovitch who laid stress on exclusion of the brain from electric field. Schechter DC. NY State J Med. 1972;72:395. “Cathode” “Anode”
    • 12. Paul Zoll http://www.bidmc- cardiology.com/images/dummy.jpg Paul Zoll and an Early Pacemaker Electrocardiogram from a man with complete heart block and an idioventricular rate of 38/min. : External pacemaker impulses. “During the first few hospital days the ventricular rate was between 30 and 40 beats per minute. At noon on the 6th hospital day, episodes of prolonged asystole with syncope and convulsions began… and electric shocks [from the external pacemaker] were employed… Constant ventricular responses to the electrical stimuli were observed in the electrocardiograms. For 3 days the electrical stimulator was turned on for repeated episodes of ventricular standstill… [After] a persistent spontaneous idioventricular rate of 44 per minute appeared that was adequate to maintain satisfactory cerebral and peripheral blood flow… the electrical stimulator was turned off… No further episodes of syncope or asystole occurred… [Two days later] his blood pressure remained stable at 110/70… no neurologic or other ill effects of the 5 days of ventricular standstill and external electrical stimulation were evident.” New Engl J Med. 1952;247:768.
    • 13. 1774: “Electricity Restored Vitality” “Sophia Greenhill, on Thursday last, fell out of a… window [and was] to all appearance dead. The surgeons at Middlesex Hospital, and the Apothecary, declared that nothing could be done for the child. Mr. Squires tried the effects of electricity. … upon transmitting a few shocks through the thorax, he perceived a small pulsation; after a few minutes the child began to breathe with great difficulty, and after some time she vomited. A kind of stupor… remained for several days, but, by the proper means being used, her health was restored.” Registers of the Royal Humane Society of London. London, Nichols & Sons, 1774-1784. (Cited by Acierno LJ. The History of Cardiology. London, Parthenon 1994). Electric Shock Can Restart Stopped Human Hearts
    • 14. Electric Shock Can Restart Stopped Human Hearts 1872: Electric Shock Can Reverse Chloroform-Induced Cardiac Arrest “I had operated on a small boy for stone, under chloroform. The operation was over… when Mr. Webster called after me to say the pulse had stopped. On turning around I found the boy deadly pale and pulseless, and his breathing stopped. The galvanic battery was in the theatre ready for use and it was instantly applied. After a few seconds, both pulse and breathing returned, and the patient entirely recovered. … The last five cases here related can leave no doubt as to the fact that galvanism saved life in each of them; that the pulsations of the heart stopped in an instant, and were instantly restored by this agent. … [galvanic stimulation is] the most powerful agent known to restore animation when [the heart beat] is suspended by chloroform… to be successful it must be ready for instantaneous use – on that depends its success… when galvanism is employed… one pole should be applied to the neck, and the other over the ribs at the left side” Green T. On death from chloroform; its prevention by galvanism. Br Med J. 1872;1:551-553.
    • 15. “With the electrodes applied directly to the heart, currents of 0.4 ampere for five seconds will cause fibrillation and currents of 0.8 ampere or more will stop fibrillation… Following the countershock the ventricles are quiescent for a brief period. When contractions begin they are very feeble but quickly increase in vigor and the circulation is reestablished if fibrillation has not continued for long. If fibrillation has lasted for two minutes or more, spontaneous recovery of effective beats will not follow. Under these circumstances cardiac massage may be of signal benefit.” Hooker DR, Kouwenhoven WB, Langworthy OR. Am J Physiol. 1933;103:444-454. ECG Documented Reversal of Ventricular Fibrillation by Electric Shock in Dogs Normal ECG Ventricular fibrillation Pause following countershock Recovery 1 2 3 4
    • 16. Bernard Lown http://www.hno.harvard.edu/gazette/ 1999/02.11/photos/lown2.200x236.gif Bernard Lown and an Early Cardioverter “All 9 episodes of ventricular tachycardia were successfully reverted with a single synchronized DC discharge… a normal sinus mechanism was observed in each patient within 2 to 3 seconds.” Lown B et al. JAMA. 1962;182:548. Shock applied by an external defibrillator
    • 17. Michel Mirowski and the Implantable Defibrillator Michel Mirowski http://www.webapps.jhu.edu/n amedprofessorships/professor “A laboratory model of an automatic defibrillator has been designed, developed, and tested successfully on dogs… For use outside the hospital, this device might be implanted on a permanent basis in selected patients with coronary heart disease identified as belonging to high-risk population.” Mirowski M et al. Arch Int Med. 1970;126:158. Shock applied automatically by an implanted defibrillator
    • 18. Why is heart disease such a problem?  2005 survey  92% recognized chest pain as a symptom of a heart attack  Only 27% were aware of all major symptoms and knew to call 911 when someone was having a heart attack Source: www. cdc.gov
    • 19. Why is it relevant to EMS?  About 47% of sudden cardiac deaths occur PREHOSPITAL  This suggests that many people with heart disease don't act on early warning signs  Even more of your patients will be living, breathing cardiac patients  Assessment and early management is key Source: www. cdc.gov
    • 20. Incidence, Morbidity & Mortality  Since 1900, cardiovascular disease has been the #1 killer in the United States every year except 1918  Claims as many lives each year as the next seven leading causes of death combined  Nearly 62,000,000 Americans have at least one type of cardiovascular disease Source: www. cdc.gov
    • 21. Incidence, Morbidity & Mortality  In 2006  631,636 people died of heart disease  Heart disease caused 26% of deaths—more than 1/4—in the United States Source: www. cdc.gov
    • 22. Incidence, Morbidity & Mortality  Heart disease is the leading cause of death for both men and women  Half of the deaths due to heart disease in 2006 were women  Coronary heart disease is the most common type of heart disease  In 2005, 445,687 people died from coronary heart disease Source: www. cdc.gov
    • 23. Incidence, Morbidity & Mortality  Every year  715,000 Americans have a MI/yr ○ 525,000 have 1st MI ○ 190,000 have another MI (2nd, 3rd…)  Strokes and heart attacks are among the leading causes of long-term chronic disability.  Up to 90 percent of all cases of impotence are now known to be directly related to vascular insufficiency Source: www. cdc.gov
    • 24. Economics  2010  Heart disease will cost the United States $316.4 billion ○ This total includes the cost of health care services, medications, and lost productivity (>$129 billion)  2001  Nationwide cost for all cardiovascular disease was $300 billion  Heart disease the cost was $109 billion and Stroke, $28 billion
    • 25. Cardiovascular Diseases Coronary Heart Disease Prevalence (Percentage) 3.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Mortality (Rate per 100,000) 157.5 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Acute Myocardial Infarction (Heart Attack) Prevalence (Percentage) 3.7% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Mortality (Rate per 100,000) 49.7 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Heart Failure Mortality (Rate per 100,000) 35.5 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Stroke Prevalence (Percentage) 1.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Mortality (cerebrovascular disease) (Rate per 100,000) 56.9 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Ischemic stroke mortality (Rate per 100,000) 2.7 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Hemorrhagic stroke mortality (Rate per 100,000) 8.4 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010.http://www.cdc.gov/dhdsp/.
    • 26. Risk Factors Hypertension Prevalence (Percentage) 25.1% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Medication (Percentage) 61.7% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Cholesterol Abnormalities High total cholesterol prevalence (18+) (Percentage) 32.5% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Screening prevalence (18+) (Percentage) 82.2% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Diabetes Prevalence (Percentage) 7.0% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Obesity Prevalence (Percentage) 20.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Smoking Prevalence (Percentage) 16.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Physical Inactivity Prevalence (Percentage) 20.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Fruit and Vegetable Prevalence 5+ fruits and vegetables per day (Percentage) 27.7% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010.http://www.cdc.gov/dhdsp/.
    • 27. Indicators Data Year Data Source Cardiovascular Diseases Coronary Heart Disease Prevalence (Percentage) 4.9% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Mortality (Rate per 100,000) 165.0 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Acute Myocardial Infarction (Heart Attack) Prevalence (Percentage) 4.6% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Mortality (Rate per 100,000) 72.2 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Signs and symptoms (Percentage) 12.4% 2005 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Rehabilitation (Percentage) 19.7% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Heart Failure Mortality (Rate per 100,000) 56.1 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Stroke Prevalence (Percentage) 3.5% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Mortality (cerebrovascular disease) (Rate per 100,000) 75.1 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Ischemic stroke mortality (Rate per 100,000) 3.4 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Hemorrhagic stroke mortality (Rate per 100,000) 11.8 2006 Vital Records Data Sources: Vital Records - Vital Records; National Center for Health Statistics, CDC. Signs and symptoms (Percentage) 21.0% 2005 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010.http://www.cdc.gov/dhdsp/.
    • 28. Risk Factors Hypertension Prevalence (Percentage) 31.9% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Medication (Percentage) 78.7% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Cholesterol Abnormalities High total cholesterol prevalence (18+) (Percentage) 35.0% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Screening prevalence (18+) (Percentage) 75.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Diabetes Prevalence (Percentage) 9.8% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Obesity Prevalence (Percentage) 30.3% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Smoking Prevalence (Percentage) 22.7% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Physical Inactivity Prevalence (Percentage) 29.5% 2007 BRFSS Data Sources: BRFSS - Behavioral Risk Factor Surveillance System; CDC. Fruit and Vegetable Prevalence 5+ fruits and vegetables per day (Percentage) 20.8% 2007 Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010.http://www.cdc.gov/dhdsp/.
    • 29. What is Heart Disease?  A general term that covers a number of diseases which affect the heart  Coronary artery disease  Heart failure  Angina  #1 killer in the United States
    • 30. What Causes Heart Disease?  Atherosclerosis  fatty deposits of cholesterol  Hypertension  High blood pressure
    • 31. Coronary Artery Disease  Occurs when the coronary arteries that supply the heart muscle become blocked  Ischemia or infarct result  Partially blocked  Angina  Fully blocked  myocardial infarction
    • 32. Myocardial Infarction  Symptoms may be diverse- NOT JUST CHEST PAIN  uncomfortable pressure, fullness, squeezing pain, pain spreading to the shoulders, neck and arms.  Chest discomfort and light headedness  Anxiety/nervousness  Paleness or pallor  Increased and/or irregular heart rate  Feeling of impending doom
    • 33. Congestive Heart Failure  Fits under the description of heart disease.  Does not mean the heart has failed, simply means the heart is not doing an efficient job.  It results from an injury or a reduction of function of the heart muscle.  Can be due to arteriosclerosis, hypertension, myocardial infarction, rheumatic fever or birth defect.
    • 34. Congestive Heart Failure  The right side of the heart collects the blood returning from the body and sends it to the lungs.  If it is failing, the blood backs up into the veins, and there are signs of edema.  The left side of the heart receives the blood from the lungs and pumps it out into the body. If it is failing the blood is not pumped effectively.
    • 35. Stroke  Blood vessel in the brain becomes blocked by atherosclerosis- the tissue supplied by the artery dies.  Embolus – which is a traveling blood clot.  Every 53 seconds, someone in the United States has a stroke  A death from a stroke takes places every three minutes
    • 36. Symptoms of Stroke  Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.  Sudden confusion, trouble speaking, or understanding.  Sudden trouble seeing in one or both eyes.  Sudden trouble walking, dizziness, loss of balance or coordination.
    • 37. Symptoms of Stroke  Sudden severe headache with no known cause.  If you have any of these symptoms you need immediate medical attention!
    • 38. • In 1948, under the direction of the National Heart Institute • now known as the National Heart, Lung, and Blood Institute or NHLBI • The Framingham Heart Study became a joint project of the National Heart, Lung and Blood Institute and Boston University. • At the time, little was known about the general causes of heart disease and stroke, but the death rates for CVD had been increasing steadily since the beginning of the century and had become an American epidemic. • The objective of the Framingham Heart Study was to identify the common factors or characteristics that contribute to CVD by following its development over a long period of time in a large group of participants who had not yet developed overt symptoms of CVD or suffered a heart attack or stroke. Framingham Heart Study
    • 39. Design •The researchers recruited 5,209 men and women between the ages of 30 and 62 from the town of Framingham, Massachusetts • began the 1st round of physical exams and lifestyle interviews that they would later analyze for common patterns related to CVD development • the subjects have continued to return to the study every 2 years for a detailed medical history, physical examination, and laboratory tests •1971 • enrolled a 2nd generation •5,124 of the original participants' adult children and their spouses - to participate in similar examinations. • 1994 •1st Omni cohort of the Framingham Heart Study was enrolled reflecting a more diverse community of Framingham •April 2002 • 3rd generation of participants •the grandchildren of the Original Cohort. •In 2003 • 2nd group of Omni participants was enrolled
    • 40. 10 yr Risk Score for Men
    • 41. 10 year risk for Women
    • 42. Unchangeable Risk Factors  Age  the older you get, the greater the chance  Sex  males have a greater rate even after women pass menopause  Race  minorities have a greater chance ○ Why?  Family history  if family members have had CHD, there is a greater chance  PMH  other diseases such as Diabetes Mellitus can increase chances.
    • 43. Race of Ethnic Group % of Deaths African Americans 25.8 American Indians or Alaska Natives 19.8 Asians or Pacific Islanders 24.6 Hispanics 22.7 Whites 27.5 All 27.2 cdc.gov
    • 44. Changeable Risk Factors  Hypertension  Serum cholesterol  Obesity  Diabetes Mellitus  Physical Inactivity  Cigarette Smoking  Alcohol Intake  Are all these controllable?
    • 45. Cholesterol  Cholesterol serves a vital function in the body  Component of the nerve tissue of the brain and spinal cord as well as other major organs.  Frequently measured to promote health and prevent disease  A major component of the plaque that clogs arteries
    • 46. Types of Cholesterol Lipoproteins- 4 main classes  Chylomicrons  Very low density lipoproteins (VLDL)  Low Density Lipoprotein (LDL)  High Density Lipoprotein (HDL)
    • 47. Good vs. BAD  LDL is known as bad cholesterol. It has a tendency to increase risk of CHD.  LDL’s are a major component of the atherosclerotic plaque that clogs arteries.  Levels should be <130
    • 48. Good vs. BAD  HDL is known as the good cholesterol.  It helps carry some of the bad cholesterol out of the body.  It does not have the tendency to clog arteries.  Levels should be >35.  High levels of HDL >60 can actually negate one other risk factor.
    • 49. The Facts About Fat  Certain fats are essential for good nutrition and health.  Fats provide essential fatty acids which the body can’t manufacture.  Act as insulators to maintain body temperature.  Improve the palatability of food and promote digestion.
    • 50. The Facts About Fat  Provide the greatest energy output per gram of any food source. ( 9 cals)  Carry fat soluble vitamins- A,D,E, and K.
    • 51. Obesity  People who are obese have 2 to 6 times the risk of developing hypertension.  Location of the body fat is significant.  Pears of apples?
    • 52. Diabetes Mellitus  At any given cholesterol level, diabetic persons have a 2 or 3 x higher risk of atherosclerosis!  Insulin is required to maintain adequate levels of lipoprotein lipase, an enzyme needed to break down bad cholesterols.
    • 53. Physical Inactivity  Increasing physical activity has been shown to decrease blood pressure.  Moderate to intense physical activity for 30-45 minutes on most days of the week is recommended.
    • 54. Cigarette Smoking  Causes an increase in blood pressure  Usually have lower levels of HDL  Within 1 year of quitting, CHD risk decreases, within 2 years it reaches the level of a nonsmoker.
    • 55. Alcohol Consumption  In small amounts it acts as a vasodilator  Good! 1-2 drinks  In large amounts it acts as a vasoconstrictor  BAD! 3-4 drinks  This is a very fine line!
    • 56. Prevention is #1
    • 57. How can You Stop CVD?  Diet and Nutrition  Exercise  In other words, control the controllable risk factors!
    • 58. After the disease starts: Cardiac Catherization/Angioplasty (PCTA) In the Unites States each year, > 900,000 angioplasties >121,000 carotid endarterectomies Coronary Artery Bypass Surgery (CABG) Medical Management- Drug therapies
    • 59. Conclusion  Cardiovascular disease is the number one killer  It is highly preventable and controllable with diet and exercise  One of most common medical emergencies and most critical to identify and treat aggressively in the field!
    • 60. What’s Next  Anatomy and Physiology of the Cardiovascular System  Cardiac Assessment

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