CAD Risk factors

CAD Risk factors

Lowering Novel Risk Marker Levels

Lowering Novel Risk Marker Levels

METABOLIC SYNDROME

Criteria for Clinical Diagnosis of Metabolic

SyndromeMeasure (any three of five constitute a diagnosis of metabolic syndrome)

Criteria for Clinical Diagnosis of Metabolic

Syndrome

Complication of Metabolic syndrome

Involvement Of Liver In Metbolic Syndrome

OBESITY

Body Mass Index (BMI)

Obesity-Related Organ Systems Review

Obesity-Related Organ Systems Review

LIFE STYLE MODIFICATION (LSM)

RISK FACTOR MODIFICATION(RFM)

FAST FOOD BOMB

WEIGHT WATCHING:

Care About Weight

Weight watching: Care About Weight

Weight watching: Care About Weight

A few behavioral techniques to achieve a long-term weight loss

include:Establishing weight goals (e.g., 10 percent loss of body weight in 1 year)

A few behavioral techniques to achieve a long-term weight loss

include:Establishing physical activity (e.g., exercise 30 minutes daily)

Learning to avoid situations where overeating is likely to occur

A few behavioral techniques to achieve a long-term weight loss

include:Establishing a regular eating schedule

Avoiding eating or snacking between meals (eating on schedule)

A few behavioral techniques to achieve a long-term weight loss

include:Taking smaller portions

Eating slowly Keeping a diet diary (self-monitoring)

A few behavioral techniques to achieve a long-term weight loss

include:Developing a social support structure

Learning to manage stressful situations that promote overeating

A few behavioral techniques to achieve a long-term weight loss

include:Developing a regular schedule for physical activity

A few behavioral techniques to achieve a long-term weight loss

include:Identifying circumstances leading to eating binges and avoiding them

EXERCISE & PHYSICAL ACTIVITY:

(an important way for

intervention in metabolic syndrome)

EXERCISE & PHYSICAL ACTIVITY

EXERCISE & PHYSICAL ACTIVITY

It is currently recommended that everyone engage in 30 minutes daily of moderate-intensity physical activity.

EXERCISE & PHYSICAL ACTIVITY

Moderate-intensity activities (40 to 60% of maximum capacity) are equivalent to a brisk walk (15–20 minutes per mile).

EXERCISE & PHYSICAL ACTIVITYGoal

At least 30 minutes of moderate-intensity physical activity on most (and preferably all) days of the week.

EXERCISE & PHYSICAL ACTIVITY

Even more benefit is achieved by increasing activity to 60 minutes daily.

EXERCISE & PHYSICAL ACTIVITY

Additional benefits are gained from vigorous-intensity activity (>60% of maximum capacity) for 20–40 minutes on 3–5 days per week.

EXERCISE & PHYSICAL ACTIVITY

The following are examples of moderate-intensity activity:

Brisk WalkingJoggingSwimmingBikingGolfing Team Sports

EXERCISE & PHYSICAL ACTIVITY

Using simple exercise equipment (e.g., treadmills)

Several short (10 to 15 minutes) bouts of activity (brisk walking)

EXERCISE & PHYSICAL ACTIVITY

Substituting more active leisure activities for sedentary ones (television watching and computer games)

EXERCISE & PHYSICAL ACTIVITY

If cardiovascular, respiratory, metabolic, orthopedic, or neurologic disorders are suspected, or if patient is middle-aged or older and is sedentary, consult physician before initiating vigorous exercise program.

EXERCISE & PHYSICAL ACTIVITY

Recommend resistance training with 8–10 different exercises, 1–2 sets per exercise, and 10–15 repetitions at moderate intensity 2 days per week.

EXERCISE & PHYSICAL ACTIVITY

Flexibility training and an increase in daily lifestyle activities should complement this regimen.

Diet & Eating

HEALTHY FOODS

Food pyramid

Food Pyramid

Food Pyramid

Food Pyramid

NUTSWalnut :ExcellentPeanut :ExcellentCoconut : Bad fat

CIGARETTE SMOKING

Cigarette SmokingA strong dose–response relationship between cigarette smoking and CHD has been observed in both sexes, in the young, in the elderly, and in all racial groups.

Cigarette SmokingCigarette smoking increases risk two- to threefold and interacts with other risk factors to multiply risk.

Cigarette SmokingThere is no evidence that filters or other modifications of the cigarette reduce risk.

Cigarette SmokingPipe smoking and cigar smoking increase the risk of CHD.

Cigarette Smoking More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking.

Cigarette SmokingExposure to environmental tobacco smoke, or passive smoking, is now recognized as a modifiable risk factor.

Cigarette Smoking In a meta-analysis of 18 epidemiologic studies, exposure to tobacco smoke by nonsmokers was consistently associated with a 20 to 30 percent increase in risk.

Cigarette Smoking This is in addition to an increased risk for respiratory tract cancers and other smoking-related diseases.

Cigarette SmokingPathophysiologic studies have identified multiple mechanisms through which cigarette smoking may cause CHD.

Cigarette SmokingOxidative stress plays a central role in smoking-mediated dysfunction of nitric oxide biosynthesis in endothelial cells.

Cigarette SmokingCigarette smoking also lowers HDL-C.

Cigarette SmokingThese effects, along with direct effects of carbon monoxide and nicotine, produce endothelial damage.

(apoptosis)

Cigarette SmokingIncreased vascular reactivity Reduced oxygen-carrying capacity

A lower threshold for myocardial ischemia

Increased risk of coronary spasm.

Cigarette SmokingCigarette smoking is also associated with increased levels of fibrinogen and increased platelet aggregability.

For Patients Who Are Not Ready To Quit, Clinicians Should Apply

The 5 R:

For Patients Who Are Not Ready To Quit, Clinicians Should Apply

The 5 R:

CHOLESTEROL AND HYPERLIPIDEMIA

(HLP)

94

Intestinal Cholesterol Absorption

Bays H et al. Expert Opin Pharmacother 2003;4:779-790.

Intestinal epithelial cell

Biliarycholesterol

Dietarycholesterol

Luminalcholesterol

Micellarcholesterol

Bileacid

Cholesteryl esters

Freecholesterol

excretion

uptake

ACATABCG5ABCG8

(esterification)

MTPCM

Through lymphatic system to the liver

100

Therapeutic Lifestyle Changes (TLC) and Nutrient Composition of TLC Diet

Nutrient Recommended Intake Saturated fat Less than 7% of total calories Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Total fat 25–35% of total calories Carbohydrate 50–60% of total calories Fiber 20–30 grams per day Protein Approximately 15% of total calories Cholesterol Less than 200 mg/day Total calories (energy) Balance energy intake and expenditure

to maintain desirable body weightprevent weight gain

PREVENTIVE STRATEGIES FOR CORONARY HEART

DISEASE

Identification of Very-High-Risk Patients

An update to the NCEP ATP III guidelines proposed a new classification of patients as very high risk who deserve especially aggressive low-density lipoprotein cholesterol (LDL-C) lowering.

Identification of Very-High-Risk Patients

These individuals are those with the presence of established cardiovascular disease plus:

(1) multiple major risk factors (especially diabetes),

(2) severe and poorly controlled risk factors (especially continued cigarette smoking),

(3) the metabolic syndrome (especially triglycerides 200 mg/dL plus non–high-density lipoprotein cholesterol [HDL-C] 130 mg/dL with HDL-C <40 mg/dL)

(4) patients with acute coronary syndromes.

Identification of Very-High-Risk Patients

Clinical trial data also indicate that those with established coronary disease and elevated levels of C-reactive protein (CRP) represent a very high risk group.

Identification of Very-High-Risk Patients

A national survey of outpatients with CHD found that 75 percent meet the criteria for very high risk.

Identification of High-Risk Patients

A CHD risk equivalent is defined when the absolute 10-year risk for hard CHD events exceeds 20 percent.

Identification of High-Risk Patients

Clinical Coronary Heart Disease:

Included in the category of clinical CHD are a history of acute coronary syndromes, stable angina, and coronary revascularization procedures.

Identification of High-Risk Patients

Evidence from clinical trials of cholesterol-lowering therapy indicates that patients with a prior history of myocardial infarction (MI) have a 10-year risk for recurrent nonfatal or fatal MI of about 26 percent.

Identification of High-Risk Patients

Patients with stable angina pectoris have a 10-year risk for acute MI of approximately 20 percent.

Identification of High-Risk Patients

Noncoronary Atherosclerosis: Patients in this group include: peripheral arterial disease, abdominal aortic aneurysm, symptomatic carotid artery

disease or asymptomatic disease with greater than 50 percent stenosis.

Identification of High-Risk Patients

The absolute risk for MI in patients with noncoronary atherosclerosis equals that for recurrent MI in patients with established CHD.

Identification of High-Risk Patients

DiabetesPatients with diabetes, particularly

middle-age and older patients with type 2 diabetes, who do not manifest CHD commonly carry a risk for major coronary events equivalent to that of nondiabetic patients with established CHD.

Identification of High-Risk Patients

Moreover, many patients with type 2 diabetes have had a silent MI, and many others have silent ischemia.

Identification of High-Risk Patients

Thus most patients with diabetes are at high risk, and ATP III has designated diabetes as a CHD equivalent.

Identification of High-Risk Patients

Multiple Risk Factors Without Clinical Coronary Heart Disease

Persons without known atherosclerosis who have multiple risk factors (other than diabetes) often have risk that is equivalent to CHD.

PRIMARY PREVENTION

SECONDARY PREVENTION

Nonpharmachologic therapy in HTN

Risk Factor In Acute Coronary

Syndrome(ACS)

Vulnerable (High-risk) Plaque+Vulnerable (High-Risk) Blood

=High-Risk (Vulnerable) Patient

Plaque - Blood - Patient

Family/Genes Gender Age (menopause)DietInflammation HypertensionObesitySedentary Life others

SmokingCathecholaminesFibrinogenLp(a)/HomocysteinFactor V LeidenPlatelet polymorph.HypercoagulabilityHypofibrinolysisGenetic Protein deficiencies

DiabetesHyperlipidemiaApoptosis?Shear StressDepression ? CRP?

ATHEROGENESIS THROMBOSIS

Risk Factor and Atherothrombosis

Inflammation Thrombosis Atherosclerosis

Apoptosis Tissue factor micro-particles

Aggregated Platelets PDGFThrombin

IL-6

TFMMP

ICAM-1

IL-1

CRP

CV

Ris

k Fa

ctor

sA

CS

The Inflammation-Thrombosis Link

Clinical evidence: Septic shockInflammation subsequent to bacterial endotoxin induces endothelialTF and PAI-1 expression leading to thrombotic complications (DIC)

Vulnerable (Thrombogenic) Blood

Vulnerable + Vulnerable

Plaque Blood

= Vulnerable patient

“ Vulnerable /Hyper-reactive” BloodSeveral risk factors correlate with hyperreactive blood. These factors modulate the severity of the event after plaque disruption

“Classic”Diabetes Smoking HyperlipidemiaInflammation/ Apoptosis/ Infection? CathecholaminesFibrinogen Lp(a) HomocysteinemiaFactor V Leiden Platelet polymorph Shear rate Genetic Protein deficiencies (AT III, Prot C or S)Hypercoagulable state (FVII, F1.2, FPA)Hypofibrinolytic state (PAI-1, t-PA, u-PA)

“Not so-classic”Depression Circulating TF activity Stress

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Atherosclerosis: A Progressive Process

NormalFatty

StreakFibrousPlaque

Occlusive Atherosclerotic

Plaque

PlaqueRupture/Fissure &

Thrombosis

MI

Stroke

Critical Leg Ischemia

Clinically Silent

Coronary Death

Increasing Age

Effort AnginaClaudication

UnstableAngina

AND FINALLY