Cardiovascular Disease: Cardiovascular Disease: an Overviewan Overview

Jon W. Wahrenberger, MDJon W. Wahrenberger, MD

February 7, 2009February 7, 2009

The Good NewsThe Good News

We are living We are living longer!longer!

Heart & stroke Heart & stroke death rates are death rates are falling!falling!

So Why Worry about So Why Worry about Cardiovascular Disease?Cardiovascular Disease?

• Cardiovascular disease Cardiovascular disease is the number one killeris the number one killer• About 42% of all deathsAbout 42% of all deaths• Nationwide: 921,819 Nationwide: 921,819

annuallyannually• NH: 3468NH: 3468• VT: 1751VT: 1751

• Cardiovascular disease Cardiovascular disease continues to strike continues to strike young and middle-aged young and middle-aged individualsindividuals

• We are losing ground on We are losing ground on several important risk several important risk factorsfactors

Cardiovascular, 35.74

Cancer, 22.91

Respiratory, 5.09

Diabetes, 2.95

Influenza, 2.57

Alzheimers, 2.22

Kidney, 1.63

Septicemia, 1.34

Injuries, 4.2

Changing demographicsChanging demographics

Obesity in the USAObesity in the USA

Obesity in ChildrenObesity in Children

Prevalence of Prevalence of Diabetes 1980-Diabetes 1980-

20042004

Source: Wonder.cdc.govSource: Wonder.cdc.gov

Adult SmokingAdult Smoking

Smoking in YouthSmoking in Youth

2005 Youth Risk Behavior Survey (YRBS)

19.721.4

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9th 10th 11th 12th

Grade Level

Women are not immune to Women are not immune to heart disease!heart disease!

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100

150

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350

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CVD Resp. Cancer Colon Cancer Breast Cancer

Men

Women

Potential for Falling Potential for Falling Longevity?Longevity?

Life Life Extending Extending TechnologyTechnology

Public Health Public Health MeasuresMeasures

Health Health adverse adverse behaviorbehavior

Evolution of Cardiovascular DiseaseEvolution of Cardiovascular Disease

Normal Child

OverweightInactive Child

OverweightInactive Adult

Sick Adult

Suffering, Loss of QOL

Premature Death

Food Overabundance

CulturalChanges

MassMarketing

of Junk Food

TechnologyInfluences

DrugsDevices

SurgicalProcedures

Chain ofSurvival

We must tackle heart disease at all points!

KnowledgeDeficits

Tobacco

What is Cardiovascular What is Cardiovascular Disease?Disease?

““Cardiovascular disease” refers to Cardiovascular disease” refers to diseases involving the heart and diseases involving the heart and blood vesselsblood vessels

AnginaAnginaHeart Heart AttackAttackHeart Heart

FailureFailureArrhythmiasArrhythmias

StrokeStrokeTIATIA

ClaudicationClaudicationUlcerationUlcerationAmputationAmputation

HeartHeart BrainBrain Peripheral Peripheral VasculatuVasculaturere

The heart, brain and extremities The heart, brain and extremities share a disease processshare a disease process

Coronary Disease

Peripheral VascularDisease

19%

30%25%

4% 12%

7%

3%

Cerebral Disease

The Common Thread?The Common Thread?

• Circulatory system Circulatory system (arteries, veins, etc.)(arteries, veins, etc.)

• Susceptibility to Susceptibility to atherosclerosisatherosclerosis

AtherosclerosisAtherosclerosis

• Complex, self-Complex, self-sustaining sustaining inflammatory inflammatory processprocess

• Thickens arterial Thickens arterial wallwall

• Occurs slowly Occurs slowly over decadesover decades

AKA “Arteriosclerosis”, “hardening of the arteries”AKA “Arteriosclerosis”, “hardening of the arteries”

Atherosclerosis Atherosclerosis ProgressionProgression

Time (years to decades)Time (years to decades)

Ischemic Heart Ischemic Heart DiseaseDisease

Cerebrovascular Cerebrovascular DiseaseDisease

Peripheral Peripheral Vascular Vascular DiseaseDisease

No Symptoms Mild Symptoms Severe SymptomsNo Symptoms Mild Symptoms Severe Symptoms

What causes What causes atherosclerosis?atherosclerosis?

• SmokingSmoking• High Blood PressureHigh Blood Pressure• High CholesterolHigh Cholesterol• DiabetesDiabetes• Hereditary FactorsHereditary Factors• Sedentary LifestyleSedentary Lifestyle• ObesityObesity• Other FactorsOther Factors

The Big 5The Big 5

Diseased Coronary ArteryDiseased Coronary Artery

Peripheral Vascular Peripheral Vascular DiseaseDisease

Stroke – “Brain Attack”Stroke – “Brain Attack”

Symptoms of Cardiovascular Symptoms of Cardiovascular DiseaseDisease

Heart Heart DiseaseDisease

Stroke or Stroke or TIATIA

Peripheral Peripheral VascularVascular

•Chest Chest DiscomfortDiscomfort•Shortness of Shortness of breathbreath•FatigueFatigue•PalpitationsPalpitations

•Sudden Sudden numbness or numbness or weakness. weakness. •Sudden Sudden confusion, confusion, trouble speaking trouble speaking or understanding or understanding •Sudden visual Sudden visual loss loss •Sudden trouble Sudden trouble walking, walking, instability instability •Sudden severe Sudden severe headache with no headache with no known causeknown cause

•Pain in calves, Pain in calves, thighs or thighs or buttocksbuttocks•Non-healing Non-healing ulcersulcers

SuspecteSuspected Stroke d Stroke or Heart or Heart Attack?Attack?

Call Call 911911

Time = saved heart muscleTime = saved heart muscleTime = saved brain Time = saved brain functionfunction

Other Causes of Heart Other Causes of Heart DiseaseDisease

•Heart failureHeart failure•Heart rhythm disturbances Heart rhythm disturbances (arrhythmias)(arrhythmias)•Congenital heart diseaseCongenital heart disease•Heart Valve DiseaseHeart Valve Disease•Heart infectionsHeart infections

Heart FailureHeart Failure

Heart FailureHeart Failure

Heart Heart Muscle Muscle InjuryInjury

VirusVirusToxinsToxins

HypertensionHypertensionPost PartumPost Partum

IschemiaIschemiaValve DiseaseValve Disease

Heart Heart FailureFailure

Heart Failure: SymptomsHeart Failure: Symptoms

• Shortness of Shortness of breathbreath

• FatigueFatigue• Edema Edema

(swelling)(swelling)

Heart Failure: TreatmentHeart Failure: Treatment

• Salt and fluid restrictionSalt and fluid restriction• MedicationsMedications

• ACE InhibitorsACE Inhibitors• Beta blockersBeta blockers• Angiotensin receptor blockersAngiotensin receptor blockers• DigoxinDigoxin

• Devices (Resynchronization Devices (Resynchronization therapy)therapy)

ArrhythmiasArrhythmias

Heart Electrical SystemHeart Electrical System

A wave of electrical discharge proceeds A wave of electrical discharge proceeds mechanical contraction of the heart.mechanical contraction of the heart.

Arrhythmia Arrhythmia Consequences and Consequences and

treatmenttreatment

Examples Consequences Treatment

Rapid heart beating

•Supraventricular tachycardia (SVT)•Ventricular tachycardia•Atrial fibrillation

•Awareness (Palpitations)•Reduced blood delivery (lightheadedness; loss of consciousness)•Possible stroke risk (AF)

•Drugs to slow heart;•ablation

Slow heart beating

•Sinus bradycardia•Heart block

Reduced blood delivery (fatigue; lightheadedness; loss of consciousness)

Removal of offending drugs; possible pacemaker

Arrhythmia SymptomsArrhythmia Symptoms

• Palpitations (a feeling of thumping, Palpitations (a feeling of thumping, fluttering, skipping or racing of the fluttering, skipping or racing of the heart) heart)

• Lightheadedness/loss of consciousnessLightheadedness/loss of consciousness• Chest pain or tightness Chest pain or tightness • Shortness of breath Shortness of breath • Fatigue Fatigue • Anxiety Anxiety

Heart Valve DiseaseHeart Valve Disease

Valve DiseaseValve Disease

• Normal Function:Normal Function:• Allow blood to flow Allow blood to flow

freely one direction freely one direction and none backwardsand none backwards

• Dysfunction:Dysfunction:• Become narrow and Become narrow and

impede forward flow impede forward flow (stenosis)(stenosis)

• Become incompetent Become incompetent and allow backward and allow backward flow (regurgitation)flow (regurgitation)

Valves are intended to allow blood flow Valves are intended to allow blood flow in only one direction from one heart in only one direction from one heart chamber to anotherchamber to another

Pulmonic Pulmonic ValveValve

Mitral Mitral

ValveValve

Tricuspid Tricuspid ValveValve

Aortic Aortic ValveValve

Valve DiseaseValve Disease

• Shortness Shortness of breathof breath

• FatigueFatigue• Chest PainChest Pain• SusceptibiliSusceptibili

ty to ty to infectioninfection

• DeathDeath

Congenital Congenital AbnormalityAbnormality

InfectionInfection

Age Related Age Related DegenerationDegeneration

Rheumatic Rheumatic FeverFever

Valve Valve DysfunctioDysfunctio

nn

Treatment of Valve Treatment of Valve DiseaseDisease

• MedicationsMedications• SurgerySurgery• Percutaneous repairPercutaneous repair

Open Heart SurgeryOpen Heart Surgery

Mitral ValvuloplastyMitral Valvuloplasty Aortic ValvuloplastyAortic Valvuloplasty

Percutaneous Percutaneous ValvuloplastyValvuloplasty

Percutaneous Aortic Valve Percutaneous Aortic Valve ReplacementReplacement

Percutaneous Aortic Valve Percutaneous Aortic Valve ReplacementReplacement

What can you do to stay What can you do to stay healthy?healthy?

Know your Enemies!Know your Enemies!

• InactivityInactivity• ObesityObesity• SmokingSmoking• Elevated Elevated

cholesterolcholesterol• DiabetesDiabetes• HypertensionHypertension

Exercise RecommendationExercise Recommendation

Age 18-65Age 18-65• Moderate aerobic Moderate aerobic

activity for 30 min 5 x activity for 30 min 5 x per week, orper week, or

• Vigorous aerobic Vigorous aerobic activity 20 minutes 3x activity 20 minutes 3x per weekper week

• Can reach moderate Can reach moderate activity goal with activity goal with multiple 10 min periodsmultiple 10 min periods

Age > 65Age > 65• Same aerobic Same aerobic

recommendationsrecommendations• Intensity based on Intensity based on

fitness levelfitness level• Additional:Additional:

• Muscle strengtheningMuscle strengthening• Flexibility exercisesFlexibility exercises• Balance exerciseBalance exercise

Source: ACSM/AHA Recommendations, 2007Source: ACSM/AHA Recommendations, 2007

Body Mass Index (BMI)Body Mass Index (BMI)

Below 18.5 = Underweight

18.5-24.9 = Normal25-29.9 = Overweight30 and above = Obese

BMI = BMI = Weight (Kg)Weight (Kg)HeightHeight2 2 (M(M22))

(Full table provided (Full table provided with registration with registration materials)materials)

Calculate Your RiskCalculate Your RiskFramingham Risk CalculatorFramingham Risk Calculator

MenMen WomenWomen

Make the right choicesMake the right choices

• Use the stairs; take a daily walk!Use the stairs; take a daily walk!• Stay away from all fast food Stay away from all fast food

restaurants!restaurants!• Eat smaller portionsEat smaller portions• Read food labelsRead food labels• Choose foods made from whole grainsChoose foods made from whole grains• Minimize saturated fats and trans fatsMinimize saturated fats and trans fats• Stay away from restaurants that allow Stay away from restaurants that allow

smokingsmoking

Some Unlikely Friends?Some Unlikely Friends?

Dark ChocolateDark Chocolate

• Raises HDLRaises HDL• Improves insulin Improves insulin

sensitivitysensitivity• Lowers blood Lowers blood

pressurepressure• Improves blood Improves blood

vessel reactivityvessel reactivity

Rx: Recommended Dose – 100 gm Rx: Recommended Dose – 100 gm per dayper dayDark Chocolate Dark Chocolate ≠ ≠ Milk ChocolateMilk Chocolate

AlcoholAlcohol

• Elevation of HDLElevation of HDL• Antithrombotic Antithrombotic

effectseffects• Promote Promote

formation of formation of nitric oxide (NO)nitric oxide (NO)

• Reduced coronary Reduced coronary heart diseaseheart disease

Rx: Recommended Dose – 1-2 drinks Rx: Recommended Dose – 1-2 drinks per dayper day

Olive OilOlive Oil

• Increase in HDLIncrease in HDL• ReductionsReductions

• Total CholesterolTotal Cholesterol• Total to HDL Total to HDL

RatioRatio• TriglyceridesTriglycerides

• Reduction in Reduction in oxidative stress oxidative stress markersmarkers

Green TeaGreen Tea

• Decrease in total and Decrease in total and cardiovascular mortalitycardiovascular mortality

• Decrease in myocardial Decrease in myocardial infarctioninfarction

• Decrease in strokeDecrease in stroke• Reduced mortality after Reduced mortality after

MIMI• Increases coronary flow Increases coronary flow

reservereserve• Improved endothelial Improved endothelial

functionfunction

NutsNuts

• Nutritionally Nutritionally densedense

• Associated with Associated with reduction in:reduction in:• Heart diseaseHeart disease• Certain cancersCertain cancers• InflammationInflammation

• Allergic issues?Allergic issues?

What’s New?What’s New?

• A new category of drugs - CETP inhibitors A new category of drugs - CETP inhibitors (anacetrapib) - has been shown to (anacetrapib) - has been shown to dramatically increase the levels of dramatically increase the levels of protective HDL cholesterolprotective HDL cholesterol

• FDA advisory panel just voted unanimously FDA advisory panel just voted unanimously in favor of approving prasugrel, a new in favor of approving prasugrel, a new platelet inhibiting drugplatelet inhibiting drug

• The JUPITOR Trial has shown a mortality The JUPITOR Trial has shown a mortality benefit from Crestor in healthy people with benefit from Crestor in healthy people with normal lipids but elevated CRPnormal lipids but elevated CRP

Where are we heading?Where are we heading?