HEART ATTACKS ARE OPTIONAL
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1 HEART ATTACKS ARE OPTIONAL Eric A Goulder, MD, FACC Heart Attack and Stroke Prevention Center of Central Ohio 350 West Wilson Bridge Rd Suite 320 Worthington, Ohio 43065
2 Our mission
3 Vin Prothro CEO, Dallas Semiconductor No heart history Heart Attack during board meeting Died: Age 58
4 Jim Cantalupo Jim Cantalupo CEO, McDonalds CEO McDonalds Heart Attack Heart Attack Age 60 Age 60
5 Michael Browne CEO, Datacom Group Heart Attack Died: Age 47
6 Luke Visconte Naval Aviator CEO, DiversityInc Chol/BP good Non-smoker Stroke: Age 54
7 Jerry Junkins CEO, Texas Instruments Heart Attack Died: Age 58
8 Brenda Barnes CEO, SaraLee Stroke Age: 56
9 Phil Baxter CEO, CVP Heart Attack Died: Age 48
10 David Letterman Tonight Show Host Heart Attack / 5 Vessel Bypass Surgery Age: 52
11 James Gandolfini Actor: The Sopranos Heart Attack Died: Age 52
12 John Candy Actor Heart Attack Died: Age 43
13 Bob Harper Celebrity Personal Trainer Heart Attack Age: 52
14 John Warner, MD President, AHA Heart Attack CPR by Daughter Age: 52
15 Lifetime Risk of a Heart Attack Once you Reach 40 Men: 2 out of 3 Women 1 out of 2
16 How Common is Cardiovascular Disease? Every 40 seconds someone in the US has a heart attack Every minute someone in the US dies from a heart attack Every 40 seconds someone has a stroke Every 4 minutes someone dies from a stroke
17 Over 2,200 Americans die each day from cardiovascular disease
18 Life Expectancy with Cardiovascular Disease Average life lost because of a Heart Attack is 17 years Following a Heart Attack the average life expectancy for men is 8 years Following a Heart Attack the average life expectancy for women is 5 years
19 Women and Cardiovascular Disease More women die from Cardiovascular Disease than men 420,000 women die each year from Cardiovascular Disease 270,000 women die annually from ALL forms of cancer combined Most women are afraid of breast cancer; most are not aware that it is Cardiovascular Disease that is their biggest killer
20 Presentation of Cardiovascular Disease For 64% of women and 50% of men, the presentation of Coronary Artery Disease is either a Heart Attack or Sudden Death!
21 What do You Look Like the Day Before a Heart Attack?
22 What do You Look Like the Day Before a Heart Attack?
23 What do You Look Like the Day Before a Heart Attack?
24 So, How do You Know if You are at Risk for a Heart Attack?
25 Standard of Care Current standard of care is not optimal care. Based on the Framingham Study started in 1948 Looks at the Risk Factors for CVD in the town of 5,200 people What you should be interested in is optimal care: care based on you as an individual, not based on a population study
26 Example 50 year old man without high blood pressure, reasonable diet and exercise, no smoking, no diabetes: his 10 year risk of having a heart attack is 6%. Your physician is going to tell you you are doing well, keep it up! But this is not your personal risk based on you as an individual. If we haven t looked for evidence of arterial disease, we really don t know your individual risk. Knowing if you have arterial disease or not can drastically change your risk profile and our treatment of you.
27 Classic Risk Factors Hypertension Diabetes Cholesterol Cigarette Smoking
28 Prevalence of Major Risk Factors in Heart Attacks 3 major risk factors 8.9% 4 major risk factors 0.9% 0 major risk factors 19.4% 2 major risk factors 27.8% 62.4% have 0-1 major risk factors 4 major risk factors: hypertension, smoking, hypercholesterolemia, diabetes 1 major risk factor 43.0% Khot,U.N., Kho, M.B., Bajzer, C.T., & et al. (2003). Prevalence of conventional risk factors in patients with coronary heart disease. JAMA, 290(7),
29 Prevalence of Major Risk Factors in Heart Attacks 0 or 1 Major Risk Factors 62.4%
30 Risk for You as an Individual If we haven t looked for evidence of arterial disease, we really don t know your individual risk. Knowing if you have arterial disease or not can drastically change your risk profile and our treatment of you. All those CEOs we discussed at the beginning most likely had executive physicals and were told they were fine right before they had a heart attack or sudden death. Statistically they were not at risk; but individually they were a walking time bomb!
31 How Reliable is the Framingham Risk Score? A study of 220 young men and women with heart attacks Men less than 55; women less than 65 years old Framingham risk score type assessment MISSED 82% of the women and 66% of the men! Internal Medicine News; 9/15/2002
32 How do we Make Heart Attacks Optional? We have to go beyond the standard of care. Looking for evidence of arterial disease rather than checking a list of risk factors. A stress test isn t good enough; it only looks for disease bad enough to fix with a bypass operation or a stent. We need to know if you have mild arterial disease. It s the mild blockage with its soft, inflamed plaque that is the vulnerable blockage.
33 Why do People Not Know they have Coronary Artery Disease?
34 Meta study of Stenosis Prior to MI 14% 18% 68% Erling Falk et al. Circulation. 1995;92:
35 Sub-clinical Atherosclerosis Positive Stress Test Sub clinical ASVD Negative Stress Test
36 What does Arterial Disease Look Like? Normal Coronary Artery Coronary Artery with mild vulnerable plaque
37 Clot from a Plaque Rupture Hole for blood flow Tennis court cracked Clot Plaque Copyright Bale/Doneen Paradigm
38 How can we Look for Asymptomatic Arterial Disease? Carotid Intimal Medial Thickness test Non-invasive Takes 20 minutes American Heart Association endorsed as reliable and repeatable Insurance and standard of care medicine will catch up in 20 years you may not have 20 years to wait. Knowledge is power
39 Look somewhere else for evidence of disease? The carotid arteries serve as a window to systemic atherosclerosis
40 The location of the common carotid intima-media thickness (IMT) measurements (rectangular box) is 0.5 to 1.0 cm below the bulb (vertical line). Polak J F et al. Stroke 2011;42:
41 If Plaque is Present, we Have a Problem!
42 Sub-clinical Atherosclerosis Predicts CV Risk 10,000 healthy subjects followed 10 yrs.; 40% female; aged y/o; base line B-mode US carotids and femorals No treatment allowed over 10 years - Class 1 (normal artery): 7989 subjects Class 2 (wall thickening): 930 subjects Class 3 (disease present): 611 subjects Class 4 (stenotic disease): 470 subjects Belcaro, G., et. al. CAFES-CAVE Study. Atherosclerosis : Copyright Bale/Doneen Paradigm
43 Framingham Risk Scores 35 Year old Male 1.5% 35 year old Female 1.5% 65 year old Male 11% 65 year old Female 5%
44 The Risk of Not Treating Plaque 40% Belcaro, G., et. al. Atherosclerosis Vol. 156: Copyright Bale/Doneen Paradigm
45 Copyright Bale/Doneen Paradigm
46 Drives Arterial Disease Inflammation plays a key role in the development and progression of atherosclerosis. Inflammation destabilizes plaque and promotes thrombosis. Arbab-Zadeh A et al. Circulation 3/6/2012;125: Copyright Bale/Doneen Paradigm
47 Nicotine Endodontic Disease Gut Dysbiosis Copyright Bale/Doneen Paradigm
48 PERIODONTAL DISEASE Endodontic Disease Nicotine Gut Dysbiosis Copyright Bale/Doneen Paradigm
49 Nicotine Endodontic Disease ENDODONTIC DISEASE Gut Dysbiosis Copyright Bale/Doneen Paradigm
50 of our population has periodontal disease of unexpected heart attacks are triggered by oral bacteria
51 Periodontal Disease (PD) and CV Risk 3.8 X more likely to have a heart attack 2X more likely to have a stroke Connections: Oral & Systemic Health Review, July 2005, Vol. 1 No. 1:1-8 Copyright Bale/Doneen Paradigm
52 AHA Conclusions Level A evidence that PD is independently associated with arterial disease Available evidence shows a trend toward reducing CV risk with the therapy of PD Peter B. Lockhart, et. al. Circulation published online April 18, 2012 DOI: /CIR.0b013e f3 Copyright Bale/Doneen Paradigm
53 It is the bacteria that drive the arterial risk. Periodontal disease definition must include both clinical parameters and causative bacterial burden. Copyright Bale/Doneen Paradigm
54 Definition of Periodontal Disease +
55 The oral systemic connection is tightly linked with atherogenic triad: a) lipoprotein serum concentration b) endothelial permeability c) binding of lipoproteins in the intima Copyright Bale/Doneen Paradigm
56 High-risk Periodontal Pathogens Contribute to the Pathogenesis of Atherosclerosis Periodontal disease (PD) caused by high-risk pathogens can adversely influence all elements of the atherogenic triad. Therefore, this type of PD can be considered a contributory cause of arterial disease. Bale, B. F., Doneen, A. L., & Vigerust, D. J. (2016). High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgraduate Medical Journal. doi: /postgradmedj Copyright Bale/Doneen Paradigm
57 Oral Pathogens and Acute Heart Attack 101 patients having a heart attack Culprit blood clots aspirated Oral viridans streptococci found in 78% of thrombi; PD pathogens found in 35% of thrombi Pessi, T., et. al. (2013). Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction. Circulation, 127(11), Copyright Bale/Doneen Paradigm
58 Oral Pathogens and Acute Heart Attack: Conclusions Dental infection and oral bacteria are associated with the development of a heart attack!!! Dental health and dental care should be one major element in preventing heart attacks!!! Pessi, T., et. al. (2013). Bacterial Signatures in Thrombus Aspirates of Patients With Myocardial Infarction. Circulation, 127(11), Copyright Bale/Doneen Paradigm
59 OBSTRUCTIVE SLEEP APNEA Endodontic Disease Nicotine Gut Dysbiosis Copyright Bale/Doneen Paradigm
60
61 OSA and Hypertension: CPAP treatment lowers BP in hypertensives Meta-analysis of 28 studies; 1,948 pts.; by Montesi et al 2012 Found mean decrease in systolic and diastolic BP of 2.58 and 2.01 mm Hg, respectively, favoring those treated with CPAP. Konecny, T., Kara, T., & Somers, V. K. (2013). Obstructive Sleep Apnea and Hypertension: An Update. Hypertension. doi: /hypertensionaha Copyright Bale/Doneen Paradigm
62 Less Than Six Hours of Sleep a Night More Than Quadruples the Risk of Pre-diabetes 364 individuals followed for six years; 91 developed IFG; 273 controls who did not develop IFG Three sleep categories: < 6hrs. (25); 6-8 hrs. (314); > 8hrs. (24) If in group of < 6hrs., 4.7 times more likely to develop IFG Adjusted for: age, baseline glucose; BP; smoking; fam hx of DM; weight change; depression Lisa Rafalson, Ph.D. presented at the AHA Epidemiology and Prevention Meeting April, 2009 Copyright Bale/Doneen Paradigm
63 CV events in subjects with CAD and OSA (obstructive sleep apnea) End point Treated, n (%) Untreated, n (%) p Composite end point event 6 (24) 17 (58) < pts.; 25 rx ed either CPAP or surgery (4); follow-up 7 yrs. Baseline characteristics and treatment of CAD similar End point = CVD death, ACS, HF, revascularization 76% decreased risk of CV event in rx ed group; p<0.01 Time to first event also reduced with rx: 26.6 mos mos. Milleron O et al. Eur Heart J 2004 May; 25: Copyright Bale/Doneen Paradigm
64 Sleep apnea & CV risk factors Autonomic dysfunction ---- BP rise Increased aldosterone ---- resistant BP Insulin resistance Endothelial dysfunction Inflammation & increased oxidative radicals Increased adhesion, coagulation and vascular endothelial growth factors Vascular remodeling and growth of arterial smooth muscle Sleep Review. Fall Swedish Sleep Medicine Institute Seattle, WA Copyright BALE HAPC
65 Nicotine Endodontic Disease DIABETES/ INSULIN RESISTANCE Gut Dysbiosis Copyright Bale/Doneen Paradigm
66 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
67 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
68 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
69 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
70 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
71 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
72 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
73 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
74 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
75 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
76 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
77 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
78 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
79 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
80 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
81 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
82 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
83 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
84 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
85 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
86 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
87 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI>30 kg/m Diabetes
88
89 Nicotine Endodontic Disease Gut Dysbiosis Copyright Bale/Doneen Paradigm
90 What s the Good News?
91 We can all live a long healthy life with hardening of the arteries. What we cannot live with is soft inflamed plaque (blockages).
92 As long as that plaque doesn t act up (erode, rupture), the flow through the artery is usually adequate.
93 We now know how to keep the inflammation in the arteries under control and prevent plaque from rupturing.
94 We can monitor the inflammation with simple blood tests to make sure the arteries are staying cool.
95 Longitudinal changes in carotid artery intima-media thickness in a community based prevention clinic Cheng, HG, Patel,BS, Martin,SS, Blaha,M, Doneen,A, Bale,B, Jones, SR(2016) Effect of comprehensive cardiovascular disease risk management on longitudinal changes in carotid artery nintima-media thicknesss in a community-based medicine clinic Archive of Medical Science 12(4): Copyright Bale/Doneen Paradigm
96 You are an Individual: Genetics Dr. John Warner of the American Heart Association said his heart attack was preordained since all the men in his family died prematurely of heart attacks.
97 It ain t what you don t know that gets you into trouble. It s what you know for sure that just ain t so. Mark Twain
98 You are an Individual: Genetics : if you are heterozygous you have a 25% increased risk hardening of the arteries; if you are homozygous you have a 50% chance If you are Kif6 positive you don t respond to some statins as well, even though your cholesterol numbers drop: you don t get the full protection of the statin. gene: codes for cholesterol metabolism. Your APO E genes determine what foods are best handled by you.
99 Who Can Benefit from this Approach? If you have a family history of hardening of the arteries. If you have already had an event (heart attack, stroke, stents, bypass). If you have some of the risk factors: High blood pressure High cholesterol Diabetes Tobacco abuse Remember, 62% of the people with heart attacks have only 0-1 Risk Factor. 90% of heart attack victims had 0-2 Risk Factors
100 Take Home
101 Take Home Atherosclerosis is common in the United States.
102 Take Home Atherosclerosis is common in the United States. Detection of sub clinical ASVD plays an important role in risk assessment.
103 Take Home Atherosclerosis is common in the United States. Detection of sub clinical ASVD plays an important role in risk assessment. The culprit arterial blockage leading to a heart attack is often mild (<50%).
104 Take Home Atherosclerosis is common in the United States. Detection of sub clinical ASVD plays an important role in risk assessment. The culprit arterial blockage leading to a heart attack is often mild (<50%). Finding evidence of inflammation is crucial in driving ASVD.
105 Take Home Atherosclerosis is common in the United States. Detection of sub clinical ASVD plays an important role in risk assessment. The culprit arterial blockage leading to a heart attack is often mild (<50%). Finding evidence of inflammation is crucial in driving ASVD. Treating the Root Causes of inflammation helps control the ASVD.
106 Take Home Atherosclerosis is common in the United States. Detection of sub clinical ASVD plays an important role in risk assessment. The culprit arterial blockage leading to a heart attack is often mild (<50%). Finding evidence of inflammation is crucial in driving ASVD. Treating the Root Causes of inflammation helps control the ASVD. Using a preventive approach can slow, halt and even reverse ASVD.
107 Take Home
108 Take Home
109 Do the best you can until you know better. Then when you know better, do better. Maya Angelou
110 Heart Attacks Are Optional!
111
112 Eric A Goulder, MD, FACC 350 West Wilson Bridge Road Worthington, Ohio HASPCofcentralohio.com
10/1/2016. CVD KILLS 2,150 Americans PER DAY. 1 person every 40 seconds. Sandra Aristodemo, DDS, CHHC
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