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The Heart of Health. Molly Ware, MD Boulder Heart Boulder Community Hospital 303-442-2395. Topics. Epidemiology Mechanism of disease Screening for disease: classic and newer risk factors and tests Guidelines for prevention of heart disease: the importance of lifestyle - PowerPoint PPT Presentation
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The Heart of HealthThe Heart of HealthThe Heart of HealthThe Heart of Health
Molly Ware, MDMolly Ware, MDBoulder HeartBoulder Heart
Boulder Community HospitalBoulder Community Hospital303-442-2395303-442-2395
Molly Ware, MDMolly Ware, MDBoulder HeartBoulder Heart
Boulder Community HospitalBoulder Community Hospital303-442-2395303-442-2395
TopicsTopics
EpidemiologyEpidemiologyMechanism of diseaseMechanism of diseaseScreening for disease: classic and Screening for disease: classic and
newer risk factors and testsnewer risk factors and testsGuidelines for prevention of heart Guidelines for prevention of heart
disease: the importance of lifestyledisease: the importance of lifestyleDiagnostic testsDiagnostic tests
EpidemiologyEpidemiologyMechanism of diseaseMechanism of diseaseScreening for disease: classic and Screening for disease: classic and
newer risk factors and testsnewer risk factors and testsGuidelines for prevention of heart Guidelines for prevention of heart
disease: the importance of lifestyledisease: the importance of lifestyleDiagnostic testsDiagnostic tests
The Numbers The Numbers
Heart disease is the most common cause of Heart disease is the most common cause of death in the USdeath in the US
17.6 million people have coronary disease17.6 million people have coronary disease One death per minuteOne death per minute 1/3 of all deaths over age 351/3 of all deaths over age 35 Over age 40, risk of developing disease is 49% in Over age 40, risk of developing disease is 49% in
men, 32% in womenmen, 32% in women
Heart disease is the most common cause of Heart disease is the most common cause of death in the USdeath in the US
17.6 million people have coronary disease17.6 million people have coronary disease One death per minuteOne death per minute 1/3 of all deaths over age 351/3 of all deaths over age 35 Over age 40, risk of developing disease is 49% in Over age 40, risk of developing disease is 49% in
men, 32% in womenmen, 32% in women
The NumbersThe Numbers
Since 1984, more cardiovascular Since 1984, more cardiovascular deaths in women than in mendeaths in women than in men
80% of people with sudden cardiac 80% of people with sudden cardiac death had no prior symptomsdeath had no prior symptoms
Younger people are affected too!Younger people are affected too!
Since 1984, more cardiovascular Since 1984, more cardiovascular deaths in women than in mendeaths in women than in men
80% of people with sudden cardiac 80% of people with sudden cardiac death had no prior symptomsdeath had no prior symptoms
Younger people are affected too!Younger people are affected too!
Heart Disease Heart Disease
Problems with the arteries Problems with the arteries Problems with the valvesProblems with the valvesProblems with the rhythmProblems with the rhythmProblems with the heart muscle function Problems with the heart muscle function
(usually caused by one of the above)(usually caused by one of the above)
Problems with the arteries Problems with the arteries Problems with the valvesProblems with the valvesProblems with the rhythmProblems with the rhythmProblems with the heart muscle function Problems with the heart muscle function
(usually caused by one of the above)(usually caused by one of the above)
Symptoms Symptoms
SymptomsSymptoms
Chest pain: pressure, tightness, Chest pain: pressure, tightness, burningburning
Shortness of breathShortness of breathJaw, neck, arm, back painJaw, neck, arm, back painNausea/vomitingNausea/vomitingSweatingSweatingFatigue, weakness, lightheadednessFatigue, weakness, lightheadednessTrouble sleeping, uneasinessTrouble sleeping, uneasiness
Chest pain: pressure, tightness, Chest pain: pressure, tightness, burningburning
Shortness of breathShortness of breathJaw, neck, arm, back painJaw, neck, arm, back painNausea/vomitingNausea/vomitingSweatingSweatingFatigue, weakness, lightheadednessFatigue, weakness, lightheadednessTrouble sleeping, uneasinessTrouble sleeping, uneasiness
From: Microemboli and Microvascular Obstruction in Acute Coronary Thrombosis and Sudden Coronary Death: Relation to Epicardial Plaque Histopathology
J Am Coll Cardiol. 2009;54(23):2167-2173. doi:10.1016/j.jacc.2009.07.042
Coronary Artery Occlusion From Eroded Plaque
Epicardial coronary arteries with occlusive macroscopic thrombus (A to C) due to plaque erosion. Longitudinal sections (A, B, and C) and transaxial sections from a different vessel (D, E, and F) show the deep lipid core is not exposed. Immunostains of the thrombus for platelet (CD61, B and E) and fibrin (C and F) components reveal that the typical thrombus frequently is a mixed platelet-fibrin mixture. Images are from patients not included in the study, but illustrate typical coronary thrombus in sudden death due to plaque erosion. CD61 immunostain shows platelets within the thrombus are diffusely scattered throughout (slender arrow in B); junction between thrombus and the arterial plaque (thick arrow in B). The ‘cap’ of this thrombus is very fibrin-rich (arrow in C).
Figure Legend:
What is a Heart Attack? What is a Heart Attack?
Key role of inflammationKey role of inflammationUnstable plaqueUnstable plaqueTriggering eventTriggering event
Spike in blood pressureSpike in blood pressure Fatty mealFatty meal Mental stress Mental stress Physical stressPhysical stress
Key role of inflammationKey role of inflammationUnstable plaqueUnstable plaqueTriggering eventTriggering event
Spike in blood pressureSpike in blood pressure Fatty mealFatty meal Mental stress Mental stress Physical stressPhysical stress STRESS HORMONES
Are You at Risk? Are You at Risk?
Screening = detection of disease before Screening = detection of disease before it causes an event it causes an event
Diagnosis = confirmation of diseaseDiagnosis = confirmation of disease
Screening = detection of disease before Screening = detection of disease before it causes an event it causes an event
Diagnosis = confirmation of diseaseDiagnosis = confirmation of disease
Goal: prevent eventsGoal: prevent events
Are You at Risk? Are You at Risk?
Classic cardiac risk factorsClassic cardiac risk factors:: High blood pressure (even if treated)High blood pressure (even if treated) High cholesterolHigh cholesterol DiabetesDiabetes SmokingSmoking Family history of early heart diseaseFamily history of early heart disease Age > 55 for women, >45 for menAge > 55 for women, >45 for men ObesityObesity Lack of exercise and poor exercise toleranceLack of exercise and poor exercise tolerance Chronic kidney diseaseChronic kidney disease
Classic cardiac risk factorsClassic cardiac risk factors:: High blood pressure (even if treated)High blood pressure (even if treated) High cholesterolHigh cholesterol DiabetesDiabetes SmokingSmoking Family history of early heart diseaseFamily history of early heart disease Age > 55 for women, >45 for menAge > 55 for women, >45 for men ObesityObesity Lack of exercise and poor exercise toleranceLack of exercise and poor exercise tolerance Chronic kidney diseaseChronic kidney disease
Are You at Risk? Are You at Risk?
Newer cardiac risk factorsNewer cardiac risk factors
Add to classic risk factorsAdd to classic risk factorsCan further refine riskCan further refine risk
Newer cardiac risk factorsNewer cardiac risk factors
Add to classic risk factorsAdd to classic risk factorsCan further refine riskCan further refine risk
Newer Screening Tools Newer Screening Tools
Coronary artery calcium scoring Coronary artery calcium scoring Advanced cholesterol testingAdvanced cholesterol testing
Lp(a), particle size/particle numberLp(a), particle size/particle numberMeasures of inflammation (hs-CRP)Measures of inflammation (hs-CRP)
(hs-CRP naturally higher in women)(hs-CRP naturally higher in women)Carotid artery thickness by ultrasound Carotid artery thickness by ultrasound
Coronary artery calcium scoring Coronary artery calcium scoring Advanced cholesterol testingAdvanced cholesterol testing
Lp(a), particle size/particle numberLp(a), particle size/particle numberMeasures of inflammation (hs-CRP)Measures of inflammation (hs-CRP)
(hs-CRP naturally higher in women)(hs-CRP naturally higher in women)Carotid artery thickness by ultrasound Carotid artery thickness by ultrasound
Ultrasound of the Carotid Artery
Image of Carotid Artery
Other Links to Heart DiseaseOther Links to Heart Disease
Low Vitamin DLow Vitamin D
Obstructive Sleep ApneaObstructive Sleep Apnea
Other vascular disorders:Other vascular disorders: Raynaud’s, migraineRaynaud’s, migraine Autoimmune Autoimmune
Low Vitamin DLow Vitamin D
Obstructive Sleep ApneaObstructive Sleep Apnea
Other vascular disorders:Other vascular disorders: Raynaud’s, migraineRaynaud’s, migraine Autoimmune Autoimmune
Other Links to Heart DiseaseOther Links to Heart Disease
HIV infectionHIV infection
History of chest radiationHistory of chest radiation
GoutGout
History of pregnancy complications: high blood History of pregnancy complications: high blood pressure, pre-eclampsia gestational diabetespressure, pre-eclampsia gestational diabetes
Polycystic ovarian diseasePolycystic ovarian disease
HIV infectionHIV infection
History of chest radiationHistory of chest radiation
GoutGout
History of pregnancy complications: high blood History of pregnancy complications: high blood pressure, pre-eclampsia gestational diabetespressure, pre-eclampsia gestational diabetes
Polycystic ovarian diseasePolycystic ovarian disease
Who Should be Screened? Who Should be Screened?
Everybody should know their numbers!All people should be asked about
classic risk factors“In the middle” people could consider
additional screeningWe ALL need to focus on primary
prevention
Everybody should know their numbers!All people should be asked about
classic risk factors“In the middle” people could consider
additional screeningWe ALL need to focus on primary
prevention
Know those numbers Know those numbers
Blood pressure 120/80Blood pressure 120/80LDL cholesterol <100LDL cholesterol <100HDL cholesterol > 50 HDL cholesterol > 50 Triglycerides < 150Triglycerides < 150Non HDL cholesterol <130Non HDL cholesterol <130BMI 18.5-24.9 (kg/m2)BMI 18.5-24.9 (kg/m2)Waist < 35 inches female or 40 maleWaist < 35 inches female or 40 maleDiabetes: hemoglobin A1C <7%Diabetes: hemoglobin A1C <7%
Blood pressure 120/80Blood pressure 120/80LDL cholesterol <100LDL cholesterol <100HDL cholesterol > 50 HDL cholesterol > 50 Triglycerides < 150Triglycerides < 150Non HDL cholesterol <130Non HDL cholesterol <130BMI 18.5-24.9 (kg/m2)BMI 18.5-24.9 (kg/m2)Waist < 35 inches female or 40 maleWaist < 35 inches female or 40 maleDiabetes: hemoglobin A1C <7%Diabetes: hemoglobin A1C <7%
New Risk Algorithm New Risk Algorithm
ASCVD pooled cohort2013 Lipid Mangement GuidelinesGender, age, race, total cholesterol,
HDL, Systolic BP, on BP meds, diabetes, smoker
High risk = >7.5% chance of developing heart disease over next 10 years
ASCVD pooled cohort2013 Lipid Mangement GuidelinesGender, age, race, total cholesterol,
HDL, Systolic BP, on BP meds, diabetes, smoker
High risk = >7.5% chance of developing heart disease over next 10 years
Our bodies are meant to exercise
Our bodies are meant to exercise
Check with your doctor . . . Check with your doctor . . .
Then go for it! At least 30 minutes of Then go for it! At least 30 minutes of moderate activity MOST days of the weekmoderate activity MOST days of the week
Some is better than noneSome is better than none
More is better than lessMore is better than less
Strength training has a BIG roleStrength training has a BIG role
Check with your doctor . . . Check with your doctor . . .
Then go for it! At least 30 minutes of Then go for it! At least 30 minutes of moderate activity MOST days of the weekmoderate activity MOST days of the week
Some is better than noneSome is better than none
More is better than lessMore is better than less
Strength training has a BIG roleStrength training has a BIG role
Duke Treadmill Score Predicts Survival
What about Hormones? What about Hormones?
Naturally occurring hormones are Naturally occurring hormones are protectiveprotective
Menopause: metabolic changes Menopause: metabolic changes including decreased HDLincluding decreased HDL
Women’s Health Initiative (2002)Women’s Health Initiative (2002)
Naturally occurring hormones are Naturally occurring hormones are protectiveprotective
Menopause: metabolic changes Menopause: metabolic changes including decreased HDLincluding decreased HDL
Women’s Health Initiative (2002)Women’s Health Initiative (2002)
Women’s Health Initiative
What about Hormones What about Hormones
Concerns: increased risk heart attack, Concerns: increased risk heart attack, stroke, blood clots, breast cancerstroke, blood clots, breast cancer
For symptoms only (ages 50-59)For symptoms only (ages 50-59)Lowest dose possibleLowest dose possibleShortest time possible ( <5 years)Shortest time possible ( <5 years)Do not use if cardiac eventDo not use if cardiac eventPatch preparations and plant-derived Patch preparations and plant-derived
compounds may carry less riskcompounds may carry less risk
Concerns: increased risk heart attack, Concerns: increased risk heart attack, stroke, blood clots, breast cancerstroke, blood clots, breast cancer
For symptoms only (ages 50-59)For symptoms only (ages 50-59)Lowest dose possibleLowest dose possibleShortest time possible ( <5 years)Shortest time possible ( <5 years)Do not use if cardiac eventDo not use if cardiac eventPatch preparations and plant-derived Patch preparations and plant-derived
compounds may carry less riskcompounds may carry less risk
What Should I Eat? What Should I Eat?
Joshipura KJ et al. Ann Intern Med 2001;134:1106-1114
Nurses’ Health Study and Health Professional’s Follow-up Study
*Includes nonfatal MI and fatal coronary heart disease
CV=Cardiovascular
Diet Evidence:Diet Evidence:Benefits of Fruits and VegetablesBenefits of Fruits and Vegetables
126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes*
Increased fruit and vegetable intake reduces CV risk
ENHANCEMENT ENHANCEMENT (not deprivation)(not deprivation) ENHANCEMENT ENHANCEMENT (not deprivation)(not deprivation)
Do not read food labels Do not read food labels
Think: Think: high fiberhigh fiber
Think: Think: unprocessedunprocessed
Think: Think: low glycemic indexlow glycemic index
Think: Think: high quality proteinhigh quality protein
Think: Think: high fiberhigh fiber
Think: Think: unprocessedunprocessed
Think: Think: low glycemic indexlow glycemic index
Think: Think: high quality proteinhigh quality protein
Fat is not the enemy Fat is not the enemy Eat “fatty” fish (5-6 oz per week)Eat “fatty” fish (5-6 oz per week)
Salmon, mackerel, herring, tuna, sardinesSalmon, mackerel, herring, tuna, sardines
Consider fish oil supplements (mercury free)Consider fish oil supplements (mercury free) 500-4000 mg EPA and DHA500-4000 mg EPA and DHA
ALA acids for vegetariansALA acids for vegetarians Almonds, walnuts, canola oil, flaxseedAlmonds, walnuts, canola oil, flaxseed
Monounsaturated fats: Monounsaturated fats: olive oil, nuts, avocadoesolive oil, nuts, avocadoes
And did I mention nuts . . . . And did I mention nuts . . . .
Eat “fatty” fish (5-6 oz per week)Eat “fatty” fish (5-6 oz per week) Salmon, mackerel, herring, tuna, sardinesSalmon, mackerel, herring, tuna, sardines
Consider fish oil supplements (mercury free)Consider fish oil supplements (mercury free) 500-4000 mg EPA and DHA500-4000 mg EPA and DHA
ALA acids for vegetariansALA acids for vegetarians Almonds, walnuts, canola oil, flaxseedAlmonds, walnuts, canola oil, flaxseed
Monounsaturated fats: Monounsaturated fats: olive oil, nuts, avocadoesolive oil, nuts, avocadoes
And did I mention nuts . . . . And did I mention nuts . . . .
Supplemental Information Supplemental Information
A varied diet rich in lean protein, good A varied diet rich in lean protein, good fats, and vegetables is the best defensefats, and vegetables is the best defense
Vitamin D -- possiblyVitamin D -- possiblyCalcium: 700-1000 mg dailyCalcium: 700-1000 mg dailyVitamin E, high dose Vitamin C, beta Vitamin E, high dose Vitamin C, beta
carotene, and folate no clear benefitcarotene, and folate no clear benefitFolate is important for women who are Folate is important for women who are
pregnant or may become pregnantpregnant or may become pregnant
A varied diet rich in lean protein, good A varied diet rich in lean protein, good fats, and vegetables is the best defensefats, and vegetables is the best defense
Vitamin D -- possiblyVitamin D -- possiblyCalcium: 700-1000 mg dailyCalcium: 700-1000 mg dailyVitamin E, high dose Vitamin C, beta Vitamin E, high dose Vitamin C, beta
carotene, and folate no clear benefitcarotene, and folate no clear benefitFolate is important for women who are Folate is important for women who are
pregnant or may become pregnantpregnant or may become pregnant
Visit Your Dentist Visit Your Dentist
And your heart will be happy And your heart will be happy
Less Stress = Big Plus Less Stress = Big Plus
Heart attacks are less frequent in the summer
UptoDate
For some people . . .For some people . . .
Statins and other cholesterol Statins and other cholesterol medicationsmedications
Blood pressure medicinesBlood pressure medicinesDiabetes medicinesDiabetes medicinesAspirinAspirin
High risk: 75-325 mg dailyHigh risk: 75-325 mg daily Low risk: over age 65/55 consider aspirin Low risk: over age 65/55 consider aspirin
if low bleeding riskif low bleeding risk
Statins and other cholesterol Statins and other cholesterol medicationsmedications
Blood pressure medicinesBlood pressure medicinesDiabetes medicinesDiabetes medicinesAspirinAspirin
High risk: 75-325 mg dailyHigh risk: 75-325 mg daily Low risk: over age 65/55 consider aspirin Low risk: over age 65/55 consider aspirin
if low bleeding riskif low bleeding risk
Tip the Scales in Your Favor Tip the Scales in Your Favor
Diagnostic Tests Diagnostic Tests
Stress testsCardiac catheterization (angiogram)Noninvasive angiogram
Stress testsCardiac catheterization (angiogram)Noninvasive angiogram
Noninvasive Coronary AngiogramNoninvasive Coronary Angiogram
If you have heart disease If you have heart disease
Keep working on your risk factors!Keep working on your risk factors! Lifestyle change as important as Lifestyle change as important as
medicationsmedicationsRegular follow up with your doctorRegular follow up with your doctorCardiac rehabilitation programs -- great Cardiac rehabilitation programs -- great
confidence buildersconfidence builders
Keep working on your risk factors!Keep working on your risk factors! Lifestyle change as important as Lifestyle change as important as
medicationsmedicationsRegular follow up with your doctorRegular follow up with your doctorCardiac rehabilitation programs -- great Cardiac rehabilitation programs -- great
confidence buildersconfidence builders
Resources Resources
Your primary health care professionalYour primary health care professional
www.womensheart.orgwww.womensheart.org
American Heart Association website: American Heart Association website: www.americanheart.org
www.nhbli.nih.gov/health/hearttruthwww.nhbli.nih.gov/health/hearttruth
Younger Next YearYounger Next Year by Henry Lodge, MD and Chris by Henry Lodge, MD and Chris CrowleyCrowley
Eat to LiveEat to Live by Joel Furhman, MD by Joel Furhman, MD
Your primary health care professionalYour primary health care professional
www.womensheart.orgwww.womensheart.org
American Heart Association website: American Heart Association website: www.americanheart.org
www.nhbli.nih.gov/health/hearttruthwww.nhbli.nih.gov/health/hearttruth
Younger Next YearYounger Next Year by Henry Lodge, MD and Chris by Henry Lodge, MD and Chris CrowleyCrowley
Eat to LiveEat to Live by Joel Furhman, MD by Joel Furhman, MD