An Ounce of Prevention - Preventative Cardioloy

An Ounce of Prevention: Preventative Cardiology Francis Yuvienco, MD, Cardiology www.SpringfieldClinic.com

DISCLAIMER
Scientific Evidence
Evidence Based Medicine

DESIRABLE ATTRIBUTES OF GUIDELINES AND RECOMMENDATIONS
Validity
Reproducibility
Reliability
Clinical applicability
Clinical flexibility
Clarity
Meticulous documentation of evidence

The Basics
THE HEART:
Size of your fist
1 lb
Behind & slight to the left of breastbone
5 quarts (4.7 L) of blood is pumped every minute or 1500 – 2000 gallons of blood/day
Functions as a pump
Beats an average of 70/min or 36.5 million times/yr
Beats about 2.5 billion times over a 70 year lifetime

Cardiovascular Disease – It’s Big!

THE INCONVENIENT TRUTH
Since 1900, CVD has been the No.1 killer in the US (except for 1918).
Nearly 2,600 Americans die of CVD daily, an average of 1 death every 33 seconds.
CVD claims 39.4% of all deaths or 1:2.5 deaths in the US.
Claims more lives each yr. than the next 5 leading causes of death combined.
82% of CVD mortalities are <65 yrs. old.

WHO SHOULD BE EVALUATED FOR CVD ?
Presence of CV risks:
smoking history
high blood pressure
high cholesterol
obesity
diabetes
family history
reduction or loss of kidney function
Symptoms suggestive of CVD
Pre-existing CVD
Adults who plan to participate in a vigorous exercise/wt. loss program
If the patient asks for it

CARDIOVASCULAR DISEASE PREVENTION STRATEGIES

NICOTINE CESSATION
Tobacco contains tar, nicotine, CO, benzene, NO, formaldehyde, HCYN, nitrosamines & Polycyclic aromatic hydrocarbons.
3-4X risk of having MI
10X greater risk of SCD as compared to non-smokers
Second hand smoke is just as BAD !
Individuals w/ CAD & quit, their risk falls w/in 2-3 yrs to the level of those pxs w/ CAD who never smoked.
Asymptomatic individuals, it takes about 10 years to reach the risk level of those who were non-smokers.
Among long-term smokers, treatment with chantix is associated with a smoking cessation rate of 23% at 1 yr as compared with 15% and 10% in the groups treated with buproprion and nicotine replacement therapy respectively.

NUTRITION
Food lipids are made up of 3 major classes of FA: saturated, monounsaturated & polyunsaturated FAs
Saturated FAs are mainly from animal origin (meats & dairy), oils (coconut & palm oils) and cooking fats (lard & hard margarine).
Trans FAs are derived from meat, dairy, margarine and processed meals.
Buyer Beware ! “partially hydrogenated”  Trans Fat

DIETARY RECOMMENDATIONS GOAL: HEALTHY EATING PATTERN
Fruits, vegetables, grains, legumes, fat-free or low-fat dairy products, fish, poultry lean meats.
Fish consumption 1-3X/mo showed an 11%  CVD mortality 
once/wk 15% 
2-4X/wk 23% 
≥ 5X/wk 38% 
α-Linolenic acid (ALA) from vegetable oils (soybean, sunflower & linen oils) is associated with a  in fatal CV events.
Risk reduction of 25-30% when whole grain consumption ≥ 3 servings/day.
Consumption of 2g/day of plant sterols associated w/ 10%  LDL-C.
Limit calorie intake to meet the basic metabolic & energy needs to attain weight loss.
Reduce saturated & trans fats to <10% of calories w/cholesterol <300mg/day.
Na <1500mg/day
Limit ETOH ≤ 2/day in men and 1/day in women to those who drink ETOH.

Different Food Pyramids

Physical Inactivity
The relative risk of CHD associated with physical inactivity ranges from 1.5 to 2.4, an increase in risk comparable to that observed for high blood cholesterol, high blood pressure or cigarette smoking (JAMA. 1995;273;402-407)
Less-active, less-fit persons have a 30-50 percent greater risk of developing high blood pressure. (Cardiovascular benefits and assessment of physical activity and physical fitness in adults. Med Sci Sports Exerc. 1992;24 (suppl 6); S201-S220)
In 1997-98, 38.3 percent of Americans age 18 or older reported no physical activity. 61.7 percent engaged in at least some physical activity. 22.7 percent engaged in light-moderate physical activity at least 5 times per week. (Advance Data. No. 325, April 7, 2002. CDC/NCHS)

Exercise!
Dr. Ken Cooper, of the Cooper Institute of Aerobic Research, found that exercise was associated with a 40$ reduction in heart attacks in females and a 60% reduction in heart attacks in males. In another study, he found that people who were in the lower 20% of cardiovascular fitness had a death rate that was three times higher than the most fit group. The Study also showed that men taking up exercise, even after age 60, will increase their life expectancy.

RECOMMENDATIONS FOR PHYSICAL ACTIVITY
30-45 min at least 5 days/week
220 – age = Target HR ≈ Aim for 60-75% of THR at peak exercise
Low intensity and longer duration is preferred
Flexibility Training
Benefits:  CVD mortality & morbidity
 HR & BP
 weight
 Coronary Blood Flow
Cardioprotective effect on lipids and insulin sensitivity
Effects on platelets and fibrinolysis
Regular physical activity can  up to 20-25% in overall CVD mortality

Other Beneficial Effects of Exercise
The risk of developing colon cancer is decreased by half in people who exercise regularly.
Estrogen-dependent cancers (breast, ovarian, and endometrial cancers) and prostate cancers are decreased with regular exercise.
The risk of dying from cancer declines sharply as exercise increases.
Regular weight-bearing exercise can reduce the incidence of osteoporosis, a reduction of bone strength (and susceptibility to fractures) responsible for thousands of deaths yearly in the U.S.

EFFECTIVE BLOOD PRESSURE CONTROL
FACTS: 73M or 1:3 of the adult US population have HTN
2-3X to have MI
7X more likely to suffer from a CVA
25% of ESRD on HD are due to poorly controlled HTN
45% are unaware they have HTN
Of those who are aware, only ½ are being treated
Lifestyle Modifications: Weight reduction
DASH diet
Na restriction
 Physical Activity
Moderate ETOH intake
Smoking Cessation
General Treatment Goals: <140/90
<130/80 established CAD, PVD, DM & CKD
<120/70 LVD & aortic aneurysm

LOWER YOUR LIPIDS The 2004 NCEP treatment goals according to risk categories Risk category Initiate TLC if LDL is: Consider drugs + TLC if LDL is: RLDL goal CHD or equivalent (FRS 10 yr risk >20%) <100 ≥ 130 ≥ 130 mg/dl 2+ Risk factors <130 ≥ 130 130 ≥130 (10 yr. risk 10-20%) ≥160 (10 yr. risk <10%) 0- 1 Risk factors <160 ≥ 160 ≥ 190 mg/dl, drug optional if LDL is 160-189

OPTIMIZATION OF BLOOD SUGAR CONTROL
FACTS: CVD equivalent
Diabetics are 2-4 fold  in developing CAD, CVA & PAD
Risk of MI & death from CVD in diabetics is the same as non-diabetics w/ prior MI
(UKPDS )  14% of CVD risks per 1% reduction in HgA1c
RECOMMENDATIONS: ( STENO2 Study) Lifestyle modifications (eg. diet & exercise) reduces the risk of developing DM.
HgA1c < 7%
LDL-C ≤ 100 mg/dl
BP < 130/80 mmHg

UTILITY OF BIOMARKERS IN CARDIOVASCULAR DISEASES
ESTABLISHED: Cardiac Troponin & CPK –MB are used primary for diagnosis ACS/AMI
EMERGING: CRP currently a Class III recommendation by the ACC/AHA
Should we do genetic testing in patients for screening purposes?
NO, because at the present time, “ DNA based tests do not add to the diagnostic utility or to patient management, over-and-above the use of measures of established CHD risk factors.“ Janssens & et al. Predictive testing of complex diseases using multiple genes: Fact of fiction? Genetics Med 2006; 8:395-400.

IMAGING METHODS OF DETECTING ASYMPTOMATIC INDIVIDUALS WHO ARE AT RISK OF CARDIOVASCULAR DISEASE NO evidence of mass screening for detection of early stages of CVD is a cost-effective way to prevent disease.

CHEST X-RAY

STRESS TESTS

ECHOCARDIOGRAPHY

NUCLEAR CARDIOLOGY

CARDIAC CATHETERIZATION

CT ANGIOGRAPHY

USE OF CORONARY CA SCORE AND CTA FOR SCREENING CAD
High NPV for obstructive CAD
High false positive rate
Anatomy not ischemia
Unclear if info obtained is better than ex testing
Radiation exposure – JACC 2010;55
In addition….
CCA is neither an indicator for stability nor instability of an atherosclerotic plaque – Circulation 1997;96
Lack of prospective data to prove it’s value as a screening tool.
If results are applied incorrectly, may  unnecessary dxtic cardiac catheterizations &/or coronary interventions in asymptomatic persons. Therefore…. ACC/AHA/ESC Class III – Cannot be recommended at this time.

CAROTID US: INTIMA-MEDIA THICKNESS

ANKLE-BRACHIAL INDEX

CARDIAC MRI

CARDIOPROTECTIVE DRUG THERAPY

SUPPLEMENTS
Vitamin E – Not indicated for CVD prevention
Vitamin A – No proven role in CVD prophylaxis
Multivitamins – (SLVLMA study) 13017 adults were randomized to receive 120mg ascorbic acid, 30mg Vit E, 6mg β-carotene, 100μg selenium & 20mg Zc or a placebo. After 7.5 yrs, the MVI supplements had no effect on CVD incidence.
Homocysteine, Vit B12, folic acid and Vit B6 – (VISP, HOPE & NORVIT) interventional trials that tested the hypothesis that  homocysteine will prevent CVD. There was no evidence of benefit for  CV end-points (new fatal & non-fatal MI, CVA & SCD).

CONCLUSIONS
Evidence confirms that aggressive & comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures and improves the quality of life of patients.
Every effort should be made to ensure that patients are treated with evidence-based, guideline recommended, life-prolonging therapies in the absence of contraindications or intolerance

Questions? Thank you all for coming!

An Ounce of Prevention - Preventative Cardioloy

by Springfield Clinic on Feb 02, 2012

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