Heart Disease Genesis

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1 Heart Disease Genesis The Ultimate Lecture on CAD origins Petr Polasek MD FRCPC FACC

2 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.

3 Heart Disease: the Epidemic of the 20th Century The twentieth century was the first century in which heart disease was the commonest cause of death in North America How did it happen?

4 US HEART DISEASE DEATHS/100, % INCREASE

5 What Caused the Marked Increase in Heart Disease Deaths from 1900 to the 1960s? North Americans were living longer due to decreased death from infectious disease and: Introduction of cigarettes Changes in the US daily diet Decreased physical activity

7 The Marked Decline in CHD Deaths How did it happen? Research- clarified the pathophysiology of CHD Which led to: Prevention Early, accurate diagnosis Effective therapy

8 Prevalence of Coronary Heart Disease by Age 20% and Sex ( ) 15% 10% Male Female 5% 0% Age, years Source: National Health and Nutrition Examination Survey

9 Prevention of CHD the Identification of Risk Factors Framingham heart study The Seven countries study The Interheart study

10 Seven Countries Study The link between diet, serum cholesterol and coronary artery disease

11 Seven Countries Study Lowest cholesterol levels and lowest incidence of coronary artery disease in countries with a Mediterranean diet Low in animal products and sat. fat Principal fat = olive oil (mono sat) Rich in legumes, fruit, fish

12 The Interheart Study* Risk factor RR AMI Increased lipids 3.3 Current smoker 2.9 Diabetes 2.4 Hypertension 1.9 Abdom. Obesity 1.6 Yusuf: Lancet,2004

13 The Interheart Study* Current smoking, diabetes, hypertension and increased lipids accounted for 75% of the cases of myocardial infarction RR with all 4 risk factors = 42 * Yusuf: lancet,2004

14 Risk Factors for Coronary Heart Disease Reversible Irreversible Increased LDL Advanced age Decreased HDL Male sex (75 y age) Cigarette Smoking Positive family Hx Hypertension Diabetes Estrogen Type A (?) Physical Inactivity Stress (???) Abdominal obesity

15 % Early Appearance of Atherosclerosis: Bogalusa Heart Study Prevalence of Fibrous Plaque Lesions Aorta Coronary Arteries Age (Years) p = for trend toward increasing prevalence with age in aorta and coronary arteries. 6/26/

16 War victims(us) Korean war: 70% of soldiers killed had CAD Iraq war: 12% had atherosclerosis 2% had CAD

24 Åkeson Swedish men, age 45-79, followed Healthy Diet 2. Moderate ETOH (1 drink/day) 3. No smoking 4. Physically Active (walk/bycicle>40 minutes/day, exercise 1 hr/wk 5. Waist <95 cm

25 Åkeson 2014

26 Åkeson out of 5 m.i. s in men are preventable Benefit with HIGHER intake of healthful food (not lower intake unhealthy foods) 5 servings of fruit+veg, 4 servings of whole grains, 2 weekly serving of fish

27 PREDIMED persons at high cvd risk Group A: Advice on Med diet PLUS provision of olive oil (1L/week) Group B: Advice on Med diet PLUS provision of mixed nuts 30g/day) Group C: Advice to reduce dietary fat (control)

28 PREDIMED 2013 End points: Myocardial infarction, Stroke or death from cv disease Group A + B: 30% REDUCTION vs. Group C Groups A + B: 41% calories from fat, Group C: 37%, saturated fat 9% in all 3 Greatest reduction: BP and STROKE

29 Cardiovascular Nutrition Controversies Dietary RCT s: difficult, long + expensive Epidemiological studies: definite association among diet, ASCVD risk factors and events. Patients bombarded by new or miracle diet. REGARDS study: Southern pattern-56% acute CHD events/6 years, 30% CVA s, also DM2, HTN, BMI.

30 Eggs bottom line 2015 Dietary Guidelines Advisory Committee Report confusion Highest effect on blood cholesterol: saturated and trans fats 100 mg/day of extra CHL in the diet: Total CHL by 2.17 mg/dl ( mmol/l) and LDL by 1.93 mg/dl (0.05 mmol/l) 1 egg:

31 Vegetable Oils - bottom line Tropical Oils: high in Saturated Fatty Acids (SFA s) Palm oil: LDL by 0.24 mmol/l (9.3 mg/dl) Canola, Olive, Sunflower oils: high in Mono-Unsaturated FA 4 tablespoons of corn/e-v olive oil: LDL by 10.9%/3.5% Polyphenols, antioxidants, increased HDL size, enhanced HDL stability, improved endothelial function, decreased inflammation.

32 Berries bottom line Anthocyanins (subclass of flavonoids) = antioxidants. Scavenging free radicals, improve NO production, effect on insulin resistance. Nurses Health Study II: >3 servings/week risk of mi by 35% 2015, 1 cup of blueberries: sbp from 138 to 131, dbp from 80 to 75 mmhg. Nurses Health Study I+II: DM2 reduced (3 servings/week)

33 Antioxidant supplements Beta Carotene, Vitamin C, Vitamin E, Selenium: hormesis process. Hormesis: biphasic dose response to a stressor. Substance beneficial at a low dose, but harmful at higher doses.

34 Nuts PREDIMED Reduced DM2, Nut eaters - Healthier lifestyle? Nutritionally dense: portion control!

35 Green Leafy Vegetables Arugula, Swiss chard, celery, green beans, kale, spinach. High in lutein antioxidant and antiinflammatory. CARDIA study: lutein intake inversely related to hypertension. Meta-analysis of persons: increment of 1/5 cup daily=13% lower risk of T2DM (JIM, 2007) =?Mg effect. JUICING: unknown, but better than a steak

36 Vegetarians/plant based diets Seventh Day Adventists (183,000): 25% reduced risk of CHD events and 30% cerebral vascular events Vegetarians : lower BMI, lower non-hdl-c, lower BP and 32% reduced risk of developing CAD. Vegans: rarely develop CHD. Reversal of CVD!

37 Bottom Line CAD is not inevitable. Combination of dietary, lifestyle and pharmaceutical interventions will bring benefits. Health care providers should lead by example. Governments need to invest in the future of the people, not their own.

Hot off the press. What s new and potentially relevant. Petr Polasek MD FRCPC FACC

Hot off the press. What s new and potentially relevant. Petr Polasek MD FRCPC FACC Hot off the press What s new and potentially relevant Petr Polasek MD FRCPC FACC Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted