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AHA SHAPE Symposium 2017 Dr. Kloner Presentation

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AHA Unofficial SHAPE Satellite Symposium 2017 Presentation

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AHA SHAPE Symposium 2017 Dr. Kloner Presentation

  1. 1. Triggers of Cardiovascular Events Robert A. Kloner MD, PhD Vice President of Translation and Director of Cardiovascular Research Institute Interim Chief Science Officer Huntington Medical Research Institutes, Pasadena, CA Professor of Medicine (Clinical Scholar) Cardiovascular Division, Dept. of Medicine Keck School of Medicine of University of Southern California, Los Angeles, CA Editor-in-Chief, Journal of Cardiovascular Pharmacology And Therapeutics
  2. 2. Conflict of Interest/Disclosure: None
  3. 3. Definitions  Trigger: An activity that produces short-term physiological changes that may lead directly to onset of acute cardiovascular disease.  Acute risk factors: A short-term physiological change, such as a surge in arterial pressure or heart rate, an increase in coagulability, or vasoconstriction, that follows a trigger and may result in disease onset. From Tofler GH, Muller JE. Circulation 2006; 114:1863-1872.
  4. 4. Triggers of Cardiovascular Events 1. The wake-up time (morning) 2. Day of the week (Monday) 3. Seasonal variation • winter, cold, blizzards • the winter holiday season • heat waves • infection • influenza 4. Physical activity • heavy, moderate exertion • sexual activity
  5. 5. Triggers of Cardiovascular Events 5. Psychosocial • emotional upset • anger • anxiety • bereavement • work-related stress (high-pressure work deadline) 6. Sporting events 7. Sexual activity
  6. 6. Triggers of Cardiovascular Disease 8. Lack of sleep 9. Overeating 10. Population stressors • earthquake • blizzard • wartime missile attacks • sporting events • terrorist attacks (?) • high air pollution days 11. Respiratory infection (flu season) 12. Drugs • cocaine • marijuana
  7. 7. Possible Triggers of Acute Myocardial Infarction
  8. 8. Myocardial Infarction Onset Study Anger can trigger myocardial infarction
  9. 9. CCU Admissions for Myocardial Infarction Overall, a 35% increase in the number of infarctions in the week after the earthquake
  10. 10. % of CCUs With Increase in Number of MI Admissions In the Week After the Earthquake Miles from Epicenter
  11. 11. Increase in Deaths from Ischemic Heart Disease after Blizzards  Death certificates in eastern Massachusetts after 6 blizzards in 1974-1978 were examined to identify effects of mortality from these storms.  Total number of deaths was 8% higher in a “blizzard week” than in preceding and subsequent control weeks (114 vs. 105 deaths per day). Glass RI, Zack MM. Lancet, 1979
  12. 12. Increase in Deaths from Ischemic Heart Disease after Blizzards (cont.)  Deaths from ischemic heart disease rose by 22% in blizzard week from 36.7 to 44.6 deaths per day.  Increase was greater in males than in females (30% vs. 12%).  Since increase in ischemic heart disease deaths continued for 8 days after the snowstorm, the effect was likely related to activities such as show shoveling.
  13. 13. Mean Coronary Deaths
  14. 14. Total Number of CAD Deaths by Day Nov, Dec, Jan
  15. 15. Introduction to Super Bowl Study  Intense European soccer has been associated with an increase in cardiac events  There is less information about high-profile sporting events in the U.S.  The purpose of our study was to determine whether there were changes in local death rates when a football team, representing a local population (Los Angeles), participated in the Super Bowl  We analyzed death rates from LA County for the day of and 2 weeks after a losing (1980) and winning (1984) Super Bowl and compared them with deaths for all other days from Jan 15 to the end of Feb for 1980-1983 and then for 1984- 1988 (control days).
  16. 16. Super Bowl 1980 versus 1984 1980 (Jan 20, 1980)  Los Angeles Rams lost to Pittsburg Steelers  Rams had been in LA for many years (much loved team)  Very intense game. The lead changed 7 times  Rams were underdogs  Rams went into the 4th quarter with a lead but went on to lose  Game was played locally (Rose Bowl)
  17. 17. Super Bowl 1980 versus 1984  1984 (Jan 22, 1984)  Los Angeles Raiders beat the Washington Redskins  Raiders had been in LA only a few years  Raiders had a victory from the beginning  Raiders won by a large margin  Game was played out-of-state
  18. 18. Mortality Rates All Deaths Control 1980 Super Bowl Deaths/day/100,000 0.0 0.5 1.0 1.5 2.0 2.5 3.0 p < 0.001 Mortality Rates Circulatory Death Control 1980 Super Bowl Deaths/day/100,000 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 p < 0.001 Mortality Rates Ischemic Heart Disease Control 1980 Super Bowl Deaths/day/100,000 0.0 0.2 0.4 0.6 0.8 1.0 p < 0.001 1980 Super Bowl
  19. 19. Mortality Rates Ischemic Heart Disease Control 1984 Super Bowl Deaths/day/100,000 0.0 0.2 0.4 0.6 0.8 p = 0.81 Mortality Rates All Deaths Control 1984 Super Bowl Deaths/day/100,000 0.0 0.5 1.0 1.5 2.0 2.5 p = 0.03 Mortality Rates Circulatory Death Control 1984 Super Bowl Deaths/day/100,000 0.0 0.2 0.4 0.6 0.8 1.0 1.2 p = 0.32 1984 Super Bowl
  20. 20. Fat Intake After Losing Game  Cornil ,Y. , Chandon, P. Psychol Sci . 2013 ; 24: 1936  On Mondays following a Sunday NFL game, saturated fat increased 16% and food calorie intake increased 10% in cities with losing teams; decreased in cities with winning teams, and is unchanged in cities without NFL teams or in cities with NFL teams that did not play.
  21. 21.  Our first Super Bowl studies were done in the 1980’s. Would the same phenomenon occur in recent years considering the widespread use of statins, antiplatelet therapies, drug-eluting stents and better overall control of high cholesterol, hypersention and smoking?
  22. 22. In the 2008 Super Bowl, the New York Giants beat the New England Patriots in an intense game. There was a 20% increase in circulatory deaths in Massachusetts (P = 0.004) Schwartz et al. Clin Res Cardiol.2013;102:807 Control 2008 Super Bowl Deaths/100,000 0.0 0.2 0.4 0.6 0.8 1.0 0.74 0.89 Circulatory Deaths (Mass)
  23. 23. 24% increase (p = 0.01) Schwartz et al. Clin Res Cardiol.2013;102:807 Control 2008 Super Bowl Deaths/100,000 0.0 0.1 0.2 0.3 0.4 0.5 0.34 0.42 Ischemic Heart Disease Deaths (Mass)
  24. 24. In the 2009 Super Bowl, Pittsburg beatArizona. In Pittsburg, circulatory deaths decreased by 25% (p = 0.046), and heart disease deaths decreased by 31% (p = 0.03) Schwartz et al. Clin Res Cardiol.2013;102:807 ↓ 25% ↓ 31% Control 2009 Super Bowl Deaths/100,000 0.0 0.2 0.4 0.6 0.8 0.67 0.46 Ischemic Heart Disease Deaths Control 2009 Super Bowl Deaths/100,000 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.23 0.92 Circulatory Deaths
  25. 25. Conclusions A Super Bowl with high drama/intensity can be associated with changes in cardiovascular death rates in a fan base with a strong attachment to the team, even in the contemporary era (with statins, antiplatelet therapies, etc.)
  26. 26. Potential Therapies  Control all long term risk factors for CVD: for example statins for dyslipidemia; antihypertensive medicines; stop smoking; control diabetes; weight loss, etc.  Stress reduction, anger management, behavioral modification  Exercise programs to condition the heart
  27. 27. Potential Therapies (Continued)  Avoiding certain forms of heavy exertion (snow shoveling), especially if you are deconditioned  Avoid over-eating  ? Slow, gradual awakening, gradual change in posture  Limiting time outdoors during high air pollution days
  28. 28. Potential Therapies (Continued)  Medicines – aspirin, beta blockers, calcium blockers, statins; ? Prophylactic nitroglycerin  Flu Shots  Devices – ICDs; public access defibrillators
  29. 29. Summary  Stress (physical or emotional) can adversely affect the heart by sympathetic and catecholamine mediated mechanisms.  Wake-up time, physical exertion, emotional stress, overeating, or lack of sleep may trigger cardiac events.  Emotional and physical stress associated with natural disasters such as earthquakes, blizzards, the holiday season and intense sporting events can contribute.  Recognizing the triggers, modulating stress and treating with some pharmacologic therapies may reduce the effects of these triggers.
  30. 30. Acknowledgements  Jonathan Leor, MD  Bryan Schwartz, MD  Research Triangle Institute, NC ( Ken Poole, PhD, Scott McDonald, PhD, R Perritt , PhD)  County of Los Angeles, Dept of Health Services Data Collection and Analysis Unit  Los Angeles County Coroner’s Office

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