Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

How to Prevent Heart Attacks

147 views

Published on

How Can a Heart Attack Be Prevented?
Making lifestyle changes is the most effective way to prevent having a heart attack.
Lowering your risk factors for coronary heart disease can help you prevent a heart attack. Even if you already have coronary heart disease.

For more information visit:
www.srisriholistichospitals.com

Published in: Healthcare
  • The 3 Secrets To Your Bulimia Recovery ★★★ http://tinyurl.com/yxcx7mgo
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Be the first to like this

How to Prevent Heart Attacks

  1. 1. Preventing Heart Attacks V.S.Ramchandra,MD,DM,FACC,FSCAI,FESC. Consultant Cardiologist Formerly: Professor & Head of Cardiology, KMC, Manipal Chief Electrophysiologist, Apollo Hospitals Associate in Cardiology, UAB Hospital, AL, USA Staff Cardiologist, St Vincent Health, IN, USA
  2. 2. Magnitude of the Problem: Global Burden of Cardiovascular Disease •½ way through a 2 century transition ; CVD will dominate as the major cause of Death Globally •Although CVD is ↓in EstME it is ↑ in the rest of the world with 85% of the worlds population. •10% (1900) → 25% (2000) → 50% (2020) of Global Deaths.
  3. 3. CAUSES OF DEATH • 1. MYOCARDIAL INFARCTION (HEART ATTACK) DUE TO CORONARY ARTERY DISEASE • 2. CEREBROVASCULAR ACCIDENT (STROKE) DUE TO BLOCK IN BRAIN TUBES • CANCER
  4. 4. INDIAN SCENARIO
  5. 5. Prevalence of CAD in Different Countries • 0 100 200 300 400 500 600 700 800 900 Russia Scotland Finland England U.S.A. Australia Canada Sweden Italy Urban China France Rural China Japan Women Men
  6. 6. Coronary Artery Disease – Indian Scenario: Indians Vs West •Average Age of first MI in west is 70 years. In India it is 45 to 55 years. •At any level of conventional RF – Indians have X2 CAD than whites with similar RF
  7. 7. Coronary Artery Disease – Indian Scenario: Past Vs Present •CAD rates have halved in W in last 30 yrs – Increasing alarmingly (doubled) in India •Average Total Cholesterol was 120mg% - increased to 200mg% •Average Age of first MI has ↓ by 20 yrs- ½ < 50yrs, ¼ < 40 yrs of age • Diabetes has increased by 60%.
  8. 8. WHAT IS A HEART ATTACK
  9. 9. WHAT IS A HEART ATTACK
  10. 10. WHAT IS A HEART ATTACK
  11. 11. WHAT IS A HEART ATTACK
  12. 12. WHAT IS THE HEART
  13. 13. Non-Invasive Diagnosis of CAD Ischemia detection • ECG/ TMT- Sen-60%,Sp-80% • Stress ECHO • SPECT Coronary Calcium CTA- 99% sensitivity- may overestimate
  14. 14. COURAGE TRIAL • OMT Vs (Revascularisation+ OMT) •2300 pts- 70% proximal lesion+Ischemia or 80%+angina, 2/3TVD • At 5 Yrs- No difference in Mortality, MI, hospitalisations, Stroke.
  15. 15. WHERE IS REVASCULARISATION USEFUL • UNSTABLE ANGINA- Symptoms /Trop/ varying ST-T ECG changes • PRIMARY ANGOPLASTY FOR AMI • TVD with LV DYSFUNCTION • ? Lt MAIN, Silent Ischemia, Severe Stenosis
  16. 16. How Predictable & Preventable is CVD • Interheart Study: 90% Predictable • Multiple Risk Factor Interventional Trials: 0 to 60% reduction •Observational studies in migrant populations show vast differences in CVD mortality
  17. 17. Cardiac Risk Factors- Modifiable • Smoking • Hypertension • Diabetes • Metabolic Syndrome • Dyslipidemia • Obesity • Sedentary Life style • Lack of fruits, GV & fiber in diet • Anger, Hostility, Work stress, Depression, LSS • Alcohol
  18. 18. Surrogate Markers of Coronary Artery Disease • Vascular Disease Elsewhere – Strokes, TIA, PVD, Carotid bruits, Abdominal Aneurysms • Diabetes • Chronic Renal Failure
  19. 19. Coronary Artery Disease Risk Factors-Non Modifiable • Male Sex • Post Menopausal State • (+) Family History • Genetic Susceptibility • Lp (a) • Diabetes • ? Infection
  20. 20. Smoking Cessation • Risk of CAD/Re- MI/CABG failure X2 • Leading preventable cause of Death • 25% in US to 70% in China • 80% start before age 18 yrs • In US: 55% →25% (M), 35% →20% (W) • Risk falls rapidly after cessation
  21. 21. Smoking Cessation (Cont..) •Cessation highly Cost effective •Intervention usually short term •1 yr success rates- 6% Physician counseling , 20% self help programs, 40% with Buproprion /nicotine patch •3 types of Behavioral therapy- Problem solving, social support in & outside treat •Most effective after event
  22. 22. Alcohol •20 to 45% risk ↓ with moderate consumption (60ml-male, 30 ml- Female) •↑HDL, ↑Fibrinolysis, ↓Platelet aggregation •10-20% become chronic alcoholics •Consider HTN, DM, ↑TG, Hgic Stroke, Liver Disease, f/h alcoholism /Breast Ca/ Colon Ca •Prescription should be individualized “Whether wine is a nourishment,medicine, or poison, is a matter of dosage”-Celsus
  23. 23. HTN- The Magnitude of the Problem •HTN is the commonest medical diagnosis, affecting 1 billion worldwide •Prevalence of HTN: 3% in 18 to 24 yrs age 13% in 35 to 44 yrs age & 70% in those >75 yrs. •For persons over age 50, SBP is a more important than DBP as a CVD risk factor.
  24. 24. HYPERTENSION • >120/80-PREHYPERTENSION, >140/90- HTN • NO SYMPTOMS. 2/3 OF AMERICAN HYPERTENSIVES NOT AWARE • SAME GOALS FOR ALL AGES • SYTOLIC BLOOD PRESSURE MORE DANGEROUS • MOST NEED 2 OR MORE DRUGS • GOALS: <130/80. <115/75 IN DIABETICS WITH PROTEINURIA.
  25. 25. Pre-Hypertension: A New Disease Is Created Starting at 115/75 mmHg, CVD risk doubles every 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Intent in creating Pre-HTN(22% of adult population) is to stress LSM, prevent progression & to treat other CVRF
  26. 26. Hypertension- treatment most cost effective • Risk ↑ Linearly from 115/75mmHg. • 5 mm ↓ in BP Reduces strokes by 40% , CVD by 15% & Heart failure by 25% • In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated .
  27. 27. Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction 5–20 mmHg/10 kg weight loss DASH eating plan 8–14 mmHg Dietary sodium ↓ 2–8 mmHg Physical activity 4–9 mmHg Moderation of alcohol consumption 2–4 mmHg
  28. 28. Diabetes Mellitus • Confers X 4 Risk. Young stroke X 10. No menstrual protection for women. • Deemed a Coronary Artery Disease equivalent by AHA • Worldwide ↑ by 35% (from 5%) by 2025, max in China (↑68%) & India (60%) •Thrifty Gene Hypothesis
  29. 29. Calculating your risk of Developing Diabetes Mellitus •Overweight – 5 •Sedentary – 5 •Age > (45-64) – 5, > (65) - 9 •Parent DM- 1, Sibling DM- 1 •Women with Baby >9lb - 1 •Asian - 4 •Total > 3-9= Low Risk, 10+ = need test
  30. 30. Preventing Diabetes with LSM •DPP: Weight loss by 7% & 150 mins/ wk of moderate ex – reduced chance of becoming Diabetic by 55% in IFG/ IGT compared to 30% with metformin •Delaying may be preventing- Glitazone •Once Diabetic no degree of control of sugars shown to prevent macrovascular complications
  31. 31. OBESITY 1. BODY MASS INDEX: WEIGHT in Kg/ HEIGHT in M.SQ. 25 – 30(OWERWEIGHT) 30 – 35(OBESE) 2. WAIST CIRCUMFERENCE <90Cms(M), <85Cms 3. PROTRUDING TUMMY 4. WAIST >HIP
  32. 32. Physical Inactivity / Exercise •75% American Adults •Inverse Linear Dose Response relationship. Ex & all-cause mortality •CAD, MI, HTN, DM, Dyslipidemia, MS •50% Primary, 25% Secondary protection
  33. 33. Exercise • Goals: Maintain 70-80% of THR for 45 Mins 5 days/Week. • THR= 220-AGE • Maintain ideal Body Weight & muscle mass & Flexibility.
  34. 34. CHOLESTEROL • A NATURAL MEMBRANE BUILDER . • THE FINAL ROUTE TO BLOCKAGES IN ARTERIES • GOOD - HDL CHOLETEROL • BAD - LDL CHOLESTEROL • UGLY - TRIGLYCERIDES • DEADLY- Lp (a).
  35. 35. 1% ↑ Heart Attacks for every 2% ↑ in LDL or 1% ↓ in HDL
  36. 36. Naturalization AVERAGE IS NOT NORMAL!! •Average LDL of Hunter-gatherers, Neonates, Mammals is 50-70mg%. No Atherosclerosis even in 7th & 8th decades. •Avg American LDL is 130. 50% above 50Yrs have atherosclerosis.
  37. 37. LDL - Naturalisation HOW LOW IS LOW ENOUGH? IS IT SAFE? •10% of highest LDL account for 20% of CAD. • Only 25% risk reduction with current LDL Trt. •Threshold for atherosclerosis progression is LDL of 67mg%, CVD event rate 0 at LDL 57 (primary) & 30 mg% (secondary prevention). •50% ↓ in LDL for secondary & 30% ↓ for primary prevention. •? All people above 55yrs should receive statins
  38. 38. ACT BEFORE DISEASE IS FIXED • More beneficial to Treat High Risk or Low Risk patients •50% reduction by bringing LDL to 55mg% in “low risk”- Jupiter trial
  39. 39. Metabolic Syndrome Any 3 of the below: • TG > 150mg/dl • HDL-C <40 (M), <50 (F) • FBS (plasma) >100mg/dl • BP >130/85 • Waist Circumf > 90cm(M) > 85cm(W) Incidence: 40%, 28% (No IFG), 75%(DM/IFG)
  40. 40. Diet & Cholesterol • Contribution of dietary cholesterol to Blood T-C is small (10mg%) compared to dietary fats (100mg%) • 4 types of Fatty acids: • Good - Poly unsaturated (PUFA) • Great - Mono unsaturated (MUFA) • Bad - Saturated (SAFA) • Deadly - Trans saturated (TFA)
  41. 41. Diet & Cholesterol- Milk • In Indians SFA come from diary products & cooking oils • Avoid whole fat milk & milk products Diary products are more saturated & athero/throbogenic than meat products • Nonfat Milk- Calcium, B12, ↓ BP, decreases diabetes risk.
  42. 42. Cooking Oils / Fats • Oils have powerful cholesterol increasing & lowering actions • 1/3rd of the 54% decline in CAD in US attributed to ↑ PUFA by 5%. • 30mg% ↓ in T-C by banning palm oil & substituting it by soybean oil •Nuts are high in fat(cashew 21%, peanut14%) but low in SAFA and do not ↑T-C
  43. 43. Cooking Oils • SAFA: Butter, coconut and palm oil is more athero / thrombogenic than lard & beef tallow • MUFA: Oleic acid in Canola & Olive oil reduces LDL & increases HDL. • PUFA: ð-3 (fatty fish, walnuts, canola & soybean oil) ð-6 ( corn, soybean, cotton) 4:5 decreases LDL and HDL •TFA- Pastries, fried chicken, margarines/ dalda, ready foods, crispy bakery products.
  44. 44. Diet- Energy •Carbohydrates – Rice •Fats – Milk, Cooking oils •Proteins – Pulses, Milk •Marked ↓in Fat intake or ↑in Carbs will ↓HDL •Marked ↑ in protein ↑load on kidneys •Fibre – Cereals •Micronutrients- Fresh fruits, undercooked vegetables
  45. 45. Diet- Carbs- Rice •Carbohydrates – Polished Rice, Maida, White bread, Biscuits, Upma, Dosa, Sugar, Sweets •Cereals with their outer fibrous coating removed •Glycemic Index •Satiety •Fibre -Soluble & Insoluble
  46. 46. Substituting Fats with Carbs
  47. 47. Diet (Cont..) •Balance Total Calories with expenditure to maintain ideal BMI •Minimize Saturated /trans fat to 7% of cal •Mono-unsaturated fats rest 20% of cal •Omit rapidly digested Carbs – White Rice •Whole grains are excellent source of energy, fiber & protein
  48. 48. Diet (Cont…) •Maximize fruits & fresh Vegetables to 5 servings/day + some nuts •Use only very low fat Dairy products •2-3 servings of Fatty fish /week •Dietary supplements- 1gm/D 3 fatty acids, Folate, B6&12, Multivitamins •Alcohol.
  49. 49. F O O D P Y R AM I D
  50. 50. Indian Paradox Less RF- More CAD. 1. Genetic predisposition.?Lp(a) 2. Central obesity-Insulin Resistance 3. Metabolic Syndrome 4. Processed carbohydrates, Increased energy. 5. Increased dairy Fats 6. Frying/ Reuse of oils- TFA.
  51. 51. Sleep & Obstructive Sleep Apnea Less than 6 or More than 8 hrs/day Sleep Deprivation & Altering Cycles Sun-Ambient Light & Sleep Getting up and getting ready for work Snoring, Daytime drowsiness, HTN, Age, BMI & Neck Cicumference- OSA
  52. 52. 3 Main causes of heart Attacks Food Exercise Mental Stress
  53. 53. Type A,Type D behavior •Compulsive overachievers, excessively competitive & ambitious, aggressive, hostile, unable to relax, impatient & get easily frustrated / angry •Anger, Suppressed Anger, hostility. •Large Prospective studies of healthy x 2 risk of developing CAD •Type D- suppressed negative emotions
  54. 54. Psychosocial Factors • Depression • Social Isolation • Anger & Frustration • Hostility • Job Strain-High demand with little autonomy • Marital stress
  55. 55. Tackling Negative Emotions • Connection between Emotions & Breath • Observe Sensations • Everything Changes – Including emotions • Opposite values are complimentary • Be Centered • Pranayama & Meditation
  56. 56. Lp(a) - The Deadly Cholesterol • >15-20mg/dl • Purely Genetic • Best childhood predictor • Highly atherogenic, thrombogenic, antifibrinolytic • Highest among all races except blacks • 40 % of Indians. Tobacco 10% HTN 10% Diabetes 10% TC/LDL 15% TC/HDL 15% lp(a) 25% Hcy 5% Other 10% Tobacco HTN Diabetes TC/LDL TC/HDL lp(a) Hcy Other
  57. 57. Contributions of various risk factors for CAD among Asian Indians Tobacco 10% HTN 10% Diabetes 10% TC/LDL 15% TC/HDL 15% lp(a) 25% Hcy 5% Other 10% Tobacco HTN Diabetes TC/LDL TC/HDL lp(a) Hcy Other
  58. 58. Prevention- From Womb to Tomb • Womb - Measures to prevent IUGR • Infancy- Infections? • Childhood – Physical activity, prevent obesity, proper nutrition and lifestyle enforcement. Lp(a) • Early Adulthood – FLP if F/h, screen for DM if Obese. •Adulthood – Screen for all RF, HsCRP
  59. 59. Prevention- The Caveats • Eat Less - Eat a variety • Be Natural- Exercise, Diet, Sleep • Learn to Relax • Act Before Diseases are Fixed
  60. 60. Predicting CAD Biomarkers- Hs CRP • LP PLA2 Vascular Imaging • Carotid IMT (<1 to>3 mm)- Young • CACS by EBCT or MSCT (>100Au) Genomic markers • High Density Genotyping- SNP • Genome expression Assays
  61. 61. PRIMARY PREVENTION DRUGS- ASPRIN & ROSUVASTATIN • More HDL raising & TG (Stellar) • Safer than any other Statin • More reduction in HsCRP • First IVUS regression (Asteroid Trial) • Multiple sites of action (HMG, CETP, PPAR a, ApoA1, Longest half life
  62. 62. Life Style & Behavioral Modifications • Difficult to qualify,quantify & study in isolation due to multiple linked factors • Intensely Individual but the only modifications possible on a global scale • Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
  63. 63. Life Style & Behavioral Modifications- Doing it • Understand & be Motivated • Like it & be part of a group • Structured program & should become part of routine life by strength of habit • Started early in life & should have social/family/ work place support
  64. 64. Population-Based Strategy SBP Distributions Before Intervention After Intervention Reduction in SBP mmHg 2 3 5 Reduction in BP % Reduction in Mortality Stroke CHD Total –6 –4 –3 –8 –5 –4 –14 –9 –7
  65. 65. “SUPERIOR DOCTORS PREVENT DISEASE; MEDIOCRE DOCTORS TREAT DISEASE BEFORE IT IS EVIDENT; INFERIOR DOCTORS TREAT FULL BLOWN DISEASE” Huang dee. First Chinese Medical Text. 2600 BC.
  66. 66. How Predictable & Preventable is CVD 0 100 200 300 400 500 600 700 800 900 Russia Scotland Finland England U.S.A. Australia Canada Sweden Italy Urban China France Rural China Japan Women Men Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)
  67. 67. Cardiac Metaphors of Daily Life • Races with Excitement • Pounds in Anticipation • Stands still in Dread, Skipped a Beat • Aches with Grief • With a Heavy Heart • The Lion Hearted, Large hearted, Heartless • Broken Hearted
  68. 68. Preventing Heart Attacks Role of Lifestyle Modifications & Behavioral Changes V.S.Ramchandra MD,DM,FACC,FSCAI,FESC. Global Hospitals Formerly: Professor & Head of Cardiology, KMC, Manipal Chief Electrophysiologist, Apollo Hospitals Associate in Cardiology, UAB Hospital, AL, USA Staff Cardiologist, St Vincent Health, IN, USA
  69. 69. WHAT IS THE HEART
  70. 70. WHAT IS CIRCULATION • Supplies Nutrients • Removes Waste • Supplies Oxygen • Removes CO2 • Single Pump • Blood Pressure • Gradient = 120-10 • Extremely Low Resistance
  71. 71. WHAT HAPPENS IF CIRCULATION TO PART OF THE BODY IS STOPPED • BRAIN (STROKE) • HEART ( HEART ATTACK or MI ) • KIDNEY (HYPERTENSION) • LEG (GANGRENE) • EYE (BLINDNESS)
  72. 72. WHAT HAPPENS IF THE HEART STOPS
  73. 73. WHAT IS A HEART ATTACK
  74. 74. Prevalence of Heart Attacks in Different Countries • 0 100 200 300 400 500 600 700 800 900 Russia Scotland Finland England U.S.A. Australia Canada Sweden Italy Urban China France Rural China Japan Women Men
  75. 75. WHAT IS A HEART ATTACK
  76. 76. WHAT IS A HEART ATTACK
  77. 77. WHAT IS A HEART ATTACK
  78. 78. CAUSES OF DEATH • 1. MYOCARDIAL INFARCTION (HEART ATTACK) DUE TO CORONARY ARTERY DISEASE • 2. CEREBROVASCULAR ACCIDENT (STROKE) DUE TO BLOCK IN BRAIN TUBES • CANCER
  79. 79. Heart Attacks – Indian Scenario: Indians Vs West •Overseas Indians–CAD X 4 Americans •Urban Indian Epidemic(10%)Vs USA(2.5%) •Hear Attack rates have halved in W in last 30 yrs – Increasing alarmingly (doubled) in India •Average Age of first Heart Attack in west is 70 years. In India it is 45 to 55 years.
  80. 80. Heart Attacks – Indian Scenario: Past Vs Present •Heart Attack rates have increased alarmingly (doubled) in India in last 25 years •Average Total Cholesterol was 120mg% - increased to 200mg% •Average Age of first Heart Attack has ↓ by 20 yrs- ½ < 50yrs, ¼ < 40 yrs of age • Diabetes has increased by 60%.
  81. 81. Heart Attacks – Indian Scenario Urban Vs Rural •Rural Vs Urban: ½ Despite higher smoking •RF incidences: Smoking- 55%®,35(U) •Diabetes- 3%®, 11% (U) •Hypertension- 14%®, 25% (U) •TC/HDL >5 – 28%®, 46% (U) •Urb Vs Rural: BMI 25Vs20, WHR0.99Vs.95 •Higher CAD in South India- Urb Kerala13%
  82. 82. How Predictable & Preventable are Heart Attacks • Interheart Study: 90% Predictable • Multiple Risk Factor Interventional Trials: 0 to 60% reduction •Observational studies in migrant populations show vast differences in CVD mortality
  83. 83. Heart Attack Risk Factors- Modifiable • Smoking • High BP (Hypertension) • High Sugars (Diabetes) • High/ Bad fats/cholesterol (Dyslipidemia) • Increased weight/fat (Obesity) • Sedentary Life style (lack of Exercise) • Metabolic Syndrome • Lack of fruits, GV & fiber in diet • Anger, Hostility, Work stress, Depression, LSS • Alcohol
  84. 84. SMOKING • COMMONEST CAUSE OF DEATH IN YOUNG ADULTS AND ELDERLY • NICOTINE + LARGE NUMBER OF TOXINS • IMMEDDIATE SPASM • DAMAGES EPITHELIUM (INNER LINING OF TUBES) EVERYWHERE • PRECIPITATES DIABETES • SUDDEN DEATH
  85. 85. Smoking Cessation • Risk of CAD/Re- MI/CABG failure X2 • Leading preventable cause of Death • 25% in US to 70% in China • 80% start before age 18 yrs • In US: 55% →25% (M), 35% →20% (W) • Risk falls rapidly after cessation
  86. 86. Smoking Cessation (Cont..) •Cessation highly Cost effective •Intervention usually short term •1 yr success rates- 6% Physician counseling , 20% self help programs, 40% with Buproprion /nicotine patch •3 types of Behavioral therapy- Problem solving, social support in & outside treat •Most effective after event
  87. 87. Alcohol •20 to 45% risk ↓ with moderate consumption (60ml-male, 30 ml- Female) •↑HDL, ↑Fibrinolysis, ↓Platelet aggregation •10-20% become chronic alcoholics •Consider HTN, DM, ↑TG, Hgic Stroke, Liver Disease, f/h alcoholism /Breast Ca/ Colon Ca •Prescription should be individualized “Whether wine is a nourishment,medicine, or poison, is a matter of dosage”-Celsus
  88. 88. Diabetes Mellitus • Confers X 4 Risk. Young stroke X 10. No menstrual protection for women. • Deemed a Heart attack equivalent by AHA • Worldwide ↑ by 35% (from 5%) by 2025, max in China (↑68%) & India (60%) •Thrifty Gene Hypothesis
  89. 89. Calculating your risk of Developing Diabetes Mellitus •Overweight – 5 •Sedentary – 5 •Age > (45-64) – 5, > (65) - 9 •Parent DM- 1, Sibling DM- 1 •Women with Baby >9lb - 1 •Asian - 4 •Total > 3-9= Low Risk, 10+ = need test
  90. 90. Preventing Diabetes with LSM •DPP: Weight loss by 7% & 150 mins/ wk of moderate ex – reduced chance of becoming Diabetic by 55% in IFG/ IGT compared to 30% with metformin •Once Diabetic no degree of control of sugars shown to prevent heart attacks or strokes
  91. 91. HYPERTENSION • NO SYMPTOMS. 2/3 OF AMERICAN HYPERTENSIVES NOT AWARE • SAME GOALS FOR ALL AGES • SYTOLIC BLOOD PRESSURE MORE DANGEROUS • MOST NEED 2 OR MORE DRUGS • GOALS: <130/80. <115/75 IN DIABETICS WITH PROTEINURIA.
  92. 92. Hypertension • >140/90. Prehypertension >120/80 • Risk ↑ Linearly from 115/75mmHg. • 5 mm ↓ in BP Reduces strokes by 40% , CVD by 15% & Heart failure by 25% • In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated .
  93. 93. Pre-Hypertension: A New Disease Is Created Starting at 115/75 mmHg, Heart Attack/Stroke risk doubles for every 20/10 mmHg increase throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Intent in creating Pre-HTN(22% of adult population) is to stress LSM, prevent progression & to treat other CVRF
  94. 94. Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction 5–20 mmHg/10 kg weight loss DASH eating plan 8–14 mmHg Dietary sodium ↓ 2–8 mmHg Physical activity 4–9 mmHg Moderation of alcohol consumption 2–4 mmHg
  95. 95. Life Style & Behavioral Modifications • Difficult to qualify,quantify & study in isolation due to multiple linked factors • Intensely Individual but the only modifications possible on a global scale • Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
  96. 96. Life Style & Behavioral Modifications • Difficult to qualify,quantify & study in isolation due to multiple linked factors • Intensely Individual but the only modifications possible on a global scale • Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
  97. 97. Life Style & Behavioral Modifications • Difficult to qualify,quantify & study in isolation due to multiple linked factors • Intensely Individual but the only modifications possible on a global scale • Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
  98. 98. Life Style & Behavioral Modifications- Doing it • Understand & be Motivated • Like it & be part of a group • Structured program & should become part of routine life by strength of habit • Started early in life & should have social/family/ work place support
  99. 99. Population-Based Strategy SBP Distributions Before Intervention After Intervention Reduction in SBP mmHg 2 3 5 Reduction in BP % Reduction in Mortality Stroke CHD Total –6 –4 –3 –8 –5 –4 –14 –9 –7
  100. 100. “SUPERIOR DOCTORS PREVENT DISEASE; MEDIOCRE DOCTORS TREAT DISEASE BEFORE IT IS EVIDENT; INFERIOR DOCTORS TREAT FULL BLOWN DISEASE” Huang dee. First Chinese Medical Text. 2600 BC.
  101. 101. MENTAL STRESS & PHYSICAL STRESS • DEPRESSION, SOCIAL ISOLATION, ANGER, AGGRESSIVENESS (TYPE A BEHAVIOUR) • INCREASED MENTAL OR PHYSICAL WORK NOT DANGEROUS.
  102. 102. How Predictable & Preventable is CVD 0 100 200 300 400 500 600 700 800 900 Russia Scotland Finland England U.S.A. Australia Canada Sweden Italy Urban China France Rural China Japan Women Men Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)
  103. 103. Psychosocial Factors •Studies hampered by imprecision in definitions & accepted metrics •Depression, Chronic Hostility, Social isolation, Perceived lack of Social support consistently linked with ↑ risk •Data inconsistent with anxiety, work related stress & Type A behavior
  104. 104. Psychosocial Factors (Cont..) • Low socioeconomic status • Acute mental stress /stress induce SMI • Sudden emotion-↑RR in 1-2 hrs of event • Lethal arrhythmias & SCD following mentally stressful events • HTN–Relaxation training,meditation & biofeedback for pt with subjective stress
  105. 105. CAUSES (Risk Factors) OF HEART ATTACK SMOKING DIABETES HYPERTENSION CHOLESTEROL OBESITY/ METABOLIC SYNDROME LACK OF EXERCISE MENOPAUSE MENTAL STRESS
  106. 106. MENOPAUSE • SUDDEN SURGE IN HEART ATTACKS • TOTAL MORTALITY> MALES • DIABETES TOTALLY NEGATES PROTECTION OF MENSES. • HRT HARMFULL • MALES WILL BE SAVED IF WE KNOW WHAT PROTECTS FEMALES!
  107. 107. Lp(a) - The Deadly Cholesterol MULTIPLIER EFFECT
  108. 108. Contributions of various risk factors for CAD among Asian Indians Tobacco 10% HTN 10% Diabetes 10% TC/LDL 15% TC/HDL 15% lp(a) 25% Hcy 5% Other 10% Tobacco HTN Diabetes TC/LDL TC/HDL lp(a) Hcy Other
  109. 109. THIS IS WHAT KILLS US! • INCREASED PROCESSED CARBOHYDATES. • RAPID ABSORPTION OF SUGAR • INCREASED INSULIN, ARTERY THICKENING, TRIGLYCERIDES, DECRESED HDL. • RICE IS TOXIC! • THERE IS AN EPIDEMIC COMING!
  110. 110. NON MODIFIABLE FACTORS: • Age, • Sex • Family History
  111. 111. HOW MUCH LESS IS LESS ENOUGH CARBOHYDRATES LDL<100 BP<120/80 BMI<25 INCRESED FIBER INCREASED EXERCISE BE HAPPY!
  112. 112. REVOLUTION OR EVOLUTION
  113. 113. HASTEN SLOWLY
  114. 114. CABGs
  115. 115. WHAT IS THE HEART
  116. 116. WHAT IS THE HEART
  117. 117. STENT RESTENOSIS
  118. 118. WHAT IS THE HEART
  119. 119. Magnitude of the Problem: Global Burden of Cardiovascular Disease •½ way through a 2 century transition ; CVD will dominate as the major cause of Death Globally •Although CVD is ↓in EstME it is ↑ in the rest of the world with 85% of the worlds population. •10% (1900) → 25% (2000) → 50% (2020) of Global Deaths.
  120. 120. INDIAN SCENARIO
  121. 121. Epidemiological Transitions •Age of Pestilence & Famine – LE is 30yrs •Age of Receding Pandemics - ↑ Food & ↓ ↓ in Infant and child mortality •Age of Degenerative & Man Made Diseases – Easier access to cheaper carb/fatty foods, mechanization leads to ↓ energy expenditure, Urbanization → ↑ crowding, smoking & work stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD (>50%), ↑ Cancers. LE>50yrs.
  122. 122. Epidemiological Transitions •Age of Delayed Degenerative Diseases – LSM, ↓Smoking (45% →23%) , Trt of HTN – CHD ↓2% per yr, Stroke ↓ 3% per yr, CVD strikes later. •Age of LSM plateau & Early Obesity - ↑ caloric intake & ↓Physical activity- 75% Overweight or Obese - ↑ HTN/DM. LE = 75yrs(M), 80yrs(W) •Future Age of Intense LSM , Behavioral Changes & Naturalization
  123. 123. Surrogate Markers of Coronary Artery Disease • Vascular Disease Elsewhere – Strokes, TIA, PVD, Carotid bruits, Abdominal Aneurysms • Diabetes • Chronic Renal Failure
  124. 124. Coronary Artery Disease Risk Factors-Non Modifiable • Male Sex • Post Menopausal State • (+) Family History • Genetic Susceptibility • Lp (a) • Diabetes • ? Infection
  125. 125. Risk factors- from Womb to Tomb •Thrifty Phenotype(Barkers) Hypothesis •Thrifty Genotype Hypothesis •Brenners Hypothesis for essential HTN •IUGR and CAD - ↑LDL & apo B.
  126. 126. Risk factors- from Womb to Tomb- Child/Adulthood • Increasing T-Chol (from 75 in cord blood to 120-150 by 2 wks- stable till 20 yrs – rises to 200 - 240 in most adults. • Catch-up obesity • Middle age bulge • Increasing Systolic BP
  127. 127. The Magnitude of the Problem •HTN is the commonest medical diagnosis, affecting 1 billion worldwide •Prevalence of HTN: 3% in 18 to 24 yrs age 13% in 35 to 44 yrs age & 70% in those >75 yrs. •For persons over age 50, SBP is a more important than DBP as a CVD risk factor.
  128. 128. DIABETES MELLITUS • DECLARED NOW AS A CORONARY ARTERY DISEASE EQUIVALENT • MORTALITY ALMOST X 4 • DAMAGES ARTERIES • PROMOTES THICKENING • CONTROLL OF BLOOD SUGARS NOT ENOUGH • GOALS: FBS<110, PPBS<140
  129. 129. LACK OF EXERCISE • CENTRAL OBESITY. • DIABETES • HYPERTENSION. • CHOLESTEROL • GOALS: MAINTAIN 80% OF THR FOR 45 MINS 5 DAYS A WEEK. MAINTAIN IDEAL BODY WEIGHT AND MUSCLE MASS. • THR= 220-AGE
  130. 130. Dyslipidemia-Importance of Statins • American Heart Association Diet Chol Total Fat TC LDL Step I 300 8 - 10 % 8% 10% Step II 200 < 7 % 10% 15% Only 15% motivated, only 1.5% achieved goals • Marked ↓in Fat intake can ↓ LDL-C by 30% •Viscous fiber + plant sterols + soy protein + almonds - 30% ↓ equivalent to 10mg lovastatin •Marked ↓in Fat intake or ↑in Carbs will ↓HDL
  131. 131. LDL - Naturalisation HOW LOW IS LOW ENOUGH? IS IT SAFE? •10% of highest LDL account for 20% of CAD. • Only 25% risk reduction with current LDL Trt. •Threshold for atherosclerosis progression is LDL of 67mg%, CVD event rate 0 at LDL 57 (primary) & 30 mg% (secondary prevention). •50% ↓ in LDL for secondary & 30% ↓ for primary prevention. •? All people above 55yrs should receive statins
  132. 132. Metabolic Syndrome Indian scenario Incidence: 40%, 28% (No IFG), 75%(DM/IFG) Waist Circumf: 30%, Low HDL: 65%, TG: 45%, HTN: 55%, IFG: 27%. •Diet, Lack of Ex •Childhood Obesity (20% in U India) •Indian Obesity Phenotype: lean BMI, High waist to hip ratio, High % of Body fat. •Barker’s Fetal priming for Insulin resistance
  133. 133. Psychosocial Factors •Social isolation, Lack of Social support & Social Disruption •Life stress (major stressful life events & minor recurrent irritants/frustrations •Job Strain – High demand with little autonomy •Marital stress
  134. 134. Diet •DASH Trial: Diet rich in Vegetables & Fruits & Low Fat Dairy ↓ BP •Marked ↓in Fat intake can ↓ LDL-C by 30% •Lyon Diet Heart Study: Mediterranean diet ↓ Re-MI/Death by 65% compared to Western Diet •Marked ↓in Fat intake or ↑in Carbs will ↓HDL •Marked ↑ in protein ↑load on kidneys
  135. 135. Cardiac Metaphors of Daily Life • Races with Excitement • Pounds in Anticipation • Stands still in Dread, Skipped a Beat • Aches with Grief • With a Heavy Heart • The Lion Hearted, Large hearted, Heartless • Broken Hearted
  136. 136. Psychosocial Factor Modifications • ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths •Meta-analyses of 37 stress management programs show reduced cardiac mortality
  137. 137. Epidemiological Transitions •Age of Pestilence & Famine – LE is 30yrs •Age of Receding Pandemics - ↑ Food & ↓ ↓ in Infant and child mortality •Age of Degenerative & Man Made Diseases – Easier access to cheaper carb/fatty foods, mechanization leads to ↓ energy expenditure, Urbanization → ↑ crowding, smoking & work stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD (>50%), ↑ Cancers. LE>50yrs.
  138. 138. Life Style & Behavioral Modifications • Difficult to qualify,quantify & study in isolation due to multiple linked factors • Intensely Individual but the only modifications possible on a global scale • Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
  139. 139. Life Style & Behavioral Modifications • Difficult to qualify,quantify & study in isolation due to multiple linked factors • Intensely Individual but the only modifications possible on a global scale • Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
  140. 140. •Cancer- Natural Killer Cells Increase with SK •Heart Autonomics – Increased heart rate variability with SK •Deaddiction – Smoking, Alcoholism, Drugs •Metabolic Syndrome- Central Obesity •Hypertension- Respirate •Insomnia •Diabetes
  141. 141. Core TechniqueCore Technique -- ‘‘Sudarshan KriyaSudarshan Kriya’’ Scientific ValidationsScientific Validations Regular Practice of the ‘Sudarshan Kriya’ will lead to: Stress creating hormone Cortisol & Oxygen free radicals will get eliminated from the blood system. Natural Killer Cells will Increase (Immunity) Blood Lactate will decrease HDL Cholesterol (useful cholesterol) will increase & LDL Cholesterol (harmful) will decrease. (Effective against blood pressure & Cardiac problems) Increase in Alpha activity in brain with interspersed Beta activity (create calmed alertness in the brain - Study done with EEG) 70% of Depression is curable with ‘The Sudarshan Kriya’ practice.
  142. 142. Cancer / HIV & Sudarshan Kriya • Cancer- Natural Killer Cells Increase with SK • Heart Autonomics – Increased heart rate variability with SK • Deaddiction – Smoking, Alcoholism, Drugs • Metabolic Syndrome- Central Obesity • Hypertension- Respirate • Insomnia • Diabetes
  143. 143.

×