Copyright 2017 by Sea Courses Inc.

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1 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

2 Superior doctors prevent the disease Mediocre doctors treat the disease before evident Inferior doctors treat the full blown disease Huang Dee: Nai-Chang (2600 BC. 1st Chinese Medical text)

3 Burden of Disease CVD causes 1:3 deaths in Canada Neurodegenerative 2% Causes of Death, Canada Psychiatric 5% Diabetes 3% Other 17% Heart 34% Respiratory 8% Accidents 4% Cancer 27% StatsCan/Canada

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5 Most common Q s or: Defend Yourself! Petr Polasek

6 What we know Non-modifiable: Age, Genetics (BP, CHL, DM) Modifiable: Smoking Diet/CHL Activity BP

7 Age The only truly incurable disease Home team: Elastin, Collagen, NO Visitors: Smoking, Caloric, Salt + Dietary Fat Overload, Inactivity, Metabolic disorders (Diabetes)

8 Epidemiology Percentage of canadian population comprised of persons aged 65 or older, 1921 to 2005 and projection to 2056 percentage Source: Statistics Canada. Censuses of Canada: Population projections for Canada, provinces and territories.

9 Smoking 1492 Columbus Jen Nicot 2000:1.22B 2010:1.45B 2025:1.9B 20% of adults in NA 20% of teens Developing countries: + 3.5%/year Advertising $12.5B/year

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11 Loss of 14 years of life Smoking 50% lifelong smokers die PREMATURELY US: 443K premature deaths/year = 3 Jumbo Jets crashing EVERY DAY World: 1 Jumbo Jet/hr 24/7/365 Fly any day just don t smoke!

12 FOOD Calories Fat Salt Quality Access Expenditure Food Industry Habit is an iron shirt.

13 Average MET Levels and Caloric Costs for Common Activities Activity METs Calories/Hour Walking 2.0 mph Walking 3.0 mph Golf (with cart) Golf (without cart) Calisthenics (no weights) Gardening Cycling (leisurely) Cycling (moderately) Swimming (slowly) Swimming (fast) Climbing hills Tennis (singles) Tennis (doubles) Running (10 min mile) Running (7.5 min/mile) Sex (30 minutes)??? Shopping (2 hours)???

14 Never too late. Too late to start? Habitual vs. inactive: 10 fold increase in events 30 minutes every day What heart rate?

15 Estimation of Exercise Intensity Using Heart Rate Reserve Desired exercise intensity is usually 60% to 80% of Max. HR. (Maximal heart rate* resting heart rate) desired exercise intensity + resting heart rate. Max HR = 220-age. Example for a 70 year old: Maximal heart rate = 150 beats/min Resting heart rate = 70 beats/min = 80 beats/min Desired intensity = 60% (0.60) = 48 beats/min + Resting heart rate = 70 beats/min = Training heart rate 118 beats/min A reasonable training heart rate for this individual would be 115 to 120 beats/min

16 Age-adjusted mortality rates in healthy men categorized by level of fitness. Myers J Circulation 2003;107:e2-e5 Copyright American Heart Association

17 Endothelium

18 LUMEN The Role of LDL in CHD LDL Lp-PLA2 INTIMA MEDIA

19 LUMEN The Role of LDL in CHD LDL Adhesion Molecules Cytokines Lp-PLA2 INTIMA Oxidized LDL Lyso-PC + OxFA MEDIA

20 LUMEN The Role of LDL in CHD LDL Adhesion Molecules Monocytes Cytokines Plaque Formation Lp-PLA2 Foam Cell INTIMA Oxidized LDL Lyso-PC + OxFA Macrophage MEDIA

21 Baseline IVUS Atheroma Area mm 2 Lumen Area 6.19 mm 2 Atheroma Area 5.81 mm 2 Lumen Area 5.96 mm 2 Nissen S et al. JAMA 2006; 295:

22 It s the Donut not the Donut Hole

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24 Relative Risk for Incident CHD What is the Optimal LDL-C? Men Women LDL-C Quintiles mmol/l mg/dl (median) Adjusted for age and race, 12-year follow-up; N=12, Sharrett AR et al. Circulation 2001;104:

25 % Reduction of Major Coronary Events Lower Is Better: Improved CV Outcomes with Lower LDL-C A 50% reduction in LDL-C confers close to optimal benefit A-Z ALLIANCE GISSI JUPITER AFCAPS/TexCAPS ASCOT-LLA WOSCOPS CARDS MEGA ALERT TNT IDEAL ALLHAT-LLT LIPS PROVE-IT CARE LIPID 4D PROSPER ASPEN Post-CABG HPS SPARCL GREACE 4S Mean Absolute Reduction in LDL-C (mmol/l) Delahoy PJ et al. Clin Ther 2009;31(2):

26 Proportional Reduction in Event Rate (% SE) Evidence Favouring LDL Reduction for the Prevention and Treatment of Atherosclerosis is Strong and Compelling A prospective meta-analysis of data from 90,056 individuals from 14 statin trials: A 1-mmol/L (39 mg/dl) reduction in LDL-C was associated with a 23% reduction in major coronary events 21% reduction in major vascular events (19) 1.0 (39) 1.5 (58) 2.0 (77) (19) 1.0 (39) 1.5 (58) 2.0 (77) Reduction in LDL-C mmol/l (mg/dl) Reduction in LDL-C mmol/l (mg/dl) Adapted from Baigent C et al, for the Cholesterol Treatment Trialists (CTT) Collaborators. Lancet 2005;366:

27 ESTIMATED CHANGE IN THE 5-YEAR RRR OF NON-FATAL MI OR CAD DEATH for DIET, BILE ACID SEQUESTRANTS, SURGERY AND STATIN TRIALS REDUCTION OF CAD EVENTS RELATES TO LDL-C LOWERING Robinson et al. J Am Coll Cardiol 2005;46:

28 Coronary event rate (%) Multiple studies show a relationship between LDL-C reduction and coronary events reduction Major statin trials ASCOT LDL-cholesterol (mmol/l) Secondary Prevention TNT Primary Prevention Updated from Larosa JC et al. N Engl J Med 2005; 352: S IDEAL CARE Lipid HPS-P AFCAPS ASCOT WOS JUPITER

29 Apo B and LDL-cholesterol Sample a Sample b LDL LDL LDL apo B LDL LDL LDL apo B LDL-C 3.0 mmol/l apo B 0.8 g/l LDL LDL LDL LDL-C 3.0 mmol/l apo B 1.6 g/l NOTE: apo B level does not correlate well with serum triglyceride level

30 Endothelium:Battle of GOOD + EVIL

31 What everyone wants to know Dark Chocolate: flavonoid effect. Increased vasodilatation, drop BP (-6/-3). Not the chocolate you buy! Green tea: drop LDL to 0.34 Black tea: raised BP (+5/3). Red wine: antiinflammatory Berries: HTN prevention (8% RR) Nuts, seeds, fruit+veggies: 18%RR CVD, 37% CVA death RR, 10% IHD RR.

32 What are polyphenols and flavonoids? Polyphenols are natural compounds found in plants that are believed to have beneficial health effects. There are thousands of polyphenols, but one has attracted the most attention to date resveratrol, which is found mainly in red wine and has been suggested to have potential cardiovascular, anticancer, and antiaging benefits. Flavonoids are a class of polyphenols. They include the following subclasses: Anthocyanidins In blueberries, red wine, and strawberries. Flavan-3-ols In apples, black tea, blueberries, chocolate, and red wine. Flavanones In citrus fruit and juices and herbal tea. Flavones In celery, garlic, green peppers, and herbal tea. Flavonols In blueberries, garlic, kale, onions, spinach, tea, broccoli, red wine, and cherry tomatoes. Proanthocyanidins In apples, black tea, blueberries, chocolate, mixed nuts, peanuts, red wine, strawberries, and walnuts. Isoflavones In soy products and peanuts.

33 Triggers to change Pain/significant emotional event Chronic discomfort Discovery of an alternative ideal

34 I am helpless It is not my fault I can t do it I can t believe it happened again (= I pretend) deny reality I own my life/actions/consequences = I can change

35 Mixed messages Environment: ads, industry schools+work food sources (soda, cafeteria food), parents, restaurants, vitamin/supplement industry VERSUS Health and allied professionals

36 Addiction sustains itself FAT = not so innocent Nicotine = modified to please faster+harder Activity = painful Have car will drive to the mail box

37 WHAT CAN BE DONE? Public awarness Start with yourself Social policies (Money, Money and again MONEY)

38 The Cycle of Change Relapse Maintenance Precontemplation Cycle of change Action Contemplation Preparation Adapted from Prochaska JO, DiClemente CC. J Consult Clin Psychol 1983; 51:

39 Take home points Keep your endothelium happy + healthy (food, exercise, salt, smoke, mood) Change is difficult, but possible Allocate ownership of the issue properly Start early Raise your voice/vote for a societal attitude change

40 Superior doctors prevent the disease Mediocre doctors treat the disease before evident Inferior doctors treat the full blown disease Huang Dee: Nai-Chang (2600 BC. 1st Chinese Medical text)