CORONARY HEART DISEASE (CHD) Wassim Shaheen h MD Cardiology KU School of Medicine 2011
CORONARY HEART DISEASE (CHD) >58 million Americans have at least one form of CHD. 50% of all cardiac deaths result from CHD
MORTALITY FROM DISEASES OF THE HEART BY RACE/ETHNICITY (DEATHS/100,000) Age Hispanic Asian Native Amer. Black White 45-64 166 99 224 426 244 >65 1336 870 1128 2181 2079
CORONARY HEART DISEASE The major underlying cause is atherosclerosis. Atherosclerosis is a slow, progressive disease which h begins in childhood and takes decades to advance
CORONARY HEART DISEASE Plaque (the build up of lipid/cholesterol) pd/c oeste o) in the eartery wall forms as a response to injury to the endothelium in the artery wall.
RISKFACTORS RISKFACTORS FOR FOR CORONARYHEART C H DISEASE DISEASE Age: Male > 45 years Female > 55 years or premature menopause without estrogen replacement therapy Family History of premature disease Male first degree relative <55 years Female first degree relative < 65 years
RISKFACTORS FOR CORONARYHEART DISEASE Hypertension Appears to weaken the artery wall at points of high pressure leading to injury and invasion of cholesterol. Cigarette Smoking #1 cause of preventable death in US 1i in 5CHDd deaths attributable t bl to smoking
RELATIVE RISK OF CORONARY EVENTS FOR SMOKERS COMPARED TO NON SMOKERS 6 5 5.48 Relative Risk 4 3 2 3.12 1 1 0 Never Smoked 1-14 Cigarettes per day 15 Cigarettes per day Source: Adapted from Stampfer 2000
RISKFACTORS FOR CORONARYHEART DISEASE Diabetes 50% of deaths related to DM is due to CHD
RISKFACTORS FOR CORONARYHEART DISEASE Inactivity Sedentary yperson has 2x risk for developing CHD as a person who is active.
RISKFACTORS FOR CORONARYHEART DISEASE Obesity
RISKFACTORS FOR CORONARYHEART DISEASE Abnormal Blood Lipids LDL Cholesterol (low density lipoprotein) HDL Cholesterol (high density lipoprotein)
Cholesterol Metabolism Diet Cholesterol Liver 15% 75%
BLOOD LIPIDS AND LIPOPROTEINS Some S LDL C can be oxidized dand taken up by endothelial cells and macrophages in the arterial wall, which leads to the first stages of atherosclerosis.
BLOOD LIPIDS AND LIPOPROTEINS HDL C is thought to be involved in the transport of excess cholesterol from membranes to the liver for removal from the body.
BLOOD LIPIDS AND LIPOPROTEINS HDL C IS INCREASED: Exercise, loss of weight, and moderate consumption of ETOH. HDL C is lowered: Obesity, inactivity, cigarette smoking, some oral contraceptives and steroids, hypertriglyceridemia and some genetic factors.
CHOLESTEROL AND THE CHD PATIENT Goal: The goal is an LDL C level of 100 mg/dl
Blood Lipid Cholesterol: <200 mg/dl 200-239 mg/dl >240 mg/dl HDL Cholesterol l <40 mg/dl >60 mgl/dl LDL Cholesterol <100 mg/dl 100 129 mg/dl 130-159 mg/dl >160 mg/dl Classification Desirable Borderline high-risk High-risk Low High, negates one risk factor Desirable Above optimal Borderline High High Risk
TREATMENT INCHD PATIENTS LDL-C Diet & Life Drug Levels Habits Therapy <100 mg/dl Yes No 100-129 129 Yes Clinical mg/dl Judgment >130 mg/dl Yes Yes
CHOLESTEROL AND THE CHD PATIENT Scandinavian Sinvastatian Survival Study: N = 4,444 patients with history of angina or MI Cholesterol levels = 213 310 mg/dl Treatment A: Placed on cholesterol lowering diet and B: a statin drug or a placebo.
CHOLESTEROL AND THE CHD PATIENT Results: Cholesterol Levels total cholesterol decreased 25%, LDL decreased 35% 34% decrease in major coronary events 42% decrease in CHD mortality 30% decrease in total mortality 37% decrease in surgery for CHD
THE SKINNY ON FAT Saturated fats basically means the fat is saturated with hydrogen, they are solid at room temperature. Examples are lard and butter. Why are they bad for you? They increase levels of LDL, decrease HDL and increase total cholesterol.
THE SKINNY ON FAT What are polyunsaturated fats? They are unsaturated fats which are liquid at room temperature and in the refrigerator. Why are they good for us? They help the body get rid of newly formed cholesterol.
THE SKINNY ON FAT What are monounsaturated fats? They are liquid at room temperature but start to solidify in the refrigerator. Decrease total cholesterol and lower LDL levels.
THE SKINNY ON FAT What are trans fatty acids? They are unsaturated fats but they tend to raise total and bad cholesterol. Where do you find them? In fast food restaurants Commercial baked goods. Examples: doughnuts, potato chips, cupcakes.
WHAT ABOUT OMEGA3? Type of polyunsaturated fat. Consistently lowers serum triglycerides and may also have an effect on lowering blood pressure. Found in oily fish such as salmon, tuna, and herring. Is available as a supplement.
DIET THERAPY OF HIGH BLOOD CHOLESTEROL Healthy Heart Diet Therapeutic Lifestyle Change Diet (TLC) 8-10% calories from <7% calories from saturated fat saturated fat 20-35% calories from fat 20-35% calories from fat <300 mg. cholesterol <200 mg. cholesterol 5-10% of energy from PUFA Up to 20% MUFA Calories to maintain IBW 5-10% of energy from PUFA Up to 20% MUFA Calories to maintain IBW
DIETTHERAPY OF HIGHBLOOD CHOLESTEROL Total Fat 20 35% calories from fat Average of total calories consumed over a one week period. Saturated fatty acid Intake is the strongest dietary determinant of LDL C Recommendation: 8 10% calories
DIETTHERAPY OF HIGHBLOOD CHOLESTEROL Polyunsaturated df fatty acids Reduces LDL C and risk of CHD when substituted for saturated fat in the diet Can cause small reduction in HDL C when present in high amounts Recommendation: ~10% of energy intake
Α OMEGA 3 FATTY ACIDS Help to thin blood and prevent blood platelets from clotting and sticking to artery walls. Food Sources: fatty fish, such as salmon, sardines, trout, swordfish, herring, albacore tuna, mackerel and, soy, canola and flaxseed oil. Consumption of 2 servings (~8ounces)per week of fish high in α linolenic acid
Monounsaturated fatty acids If equal amounts of MUFAs are substituted for saturated fatty acids, LDL C decreases MUFAs do not lower HDL C Recommended intakes: up to 20% of total calories
DIETTHERAPY OF HIGHBLOOD CHOLESTEROL Trans Fatty Acids Increase LDL Cholesterol and decrease HDL Cholesterol Recommendations: R d Intakes of trans fatty acids should be as low as possible
Food TRANS FATTY ACID CONTENT OF FAST FOOD Calories Trans Fatty Acids (g) Saturated Fatty Acids (g) Hamburger (7 oz) 660 3 14 McDonalds chicken McNuggets (9 oz) Burger King chicken sandwich (8 oz) Burger King fries (6 oz King size) Starbucks cinnamon scone (5 oz) 510 3 6 610 2 7 540 7 6 530 3 13 (Data compiled from Nutrition Action Health Letter, June 1999)
TREATMENT FOR CHD Physical Activity prescribed by physician for patients with CHD When aerobic activity is appropriate, activity that places moderate stress on the cardio respiratory system can be included.
TREATMENT FOR CHD Weight Control 5 10# weight loss
DIETTHERAPY OF HIGHBLOOD CHOLESTEROL Soluble l Fiber 10 20 g/day
DRUG TREATMENT Statins Bile Acid Sequestrants Nicotinic Acid
DIETARYISSUES REQUIRING FURTHER RESEARCH Elevated levels of homocysteine Elevated homocysteine levels may be present in 15% of Americans.
DIETARYISSUES REQUIRING FURTHER RESEARCH Several vitamins, including folic acid, vitamin B6 and B12, function are cofactors in the metabolism of methionine and homocysteine.
DIETARYISSUES REQUIRING FURTHER RESEARCH Antioxidant Vitamin Supplements Vitamins E, C and A Results of epidemiological observations suggest a Results of epidemiological observations suggest a relationship between increased intake of these vitamins and decreased CHD risk.
DIETARYISSUES REQUIRING FURTHER RESEARCH Very low fat diets (<15 % fat)
STEPS FOR LOWERING LDL C IN THE DIET Eggs: <300 mg. cholesterol: < 4 yolks/wk < 200 mg. Cholesterol: < 2 yolks/wk
GUIDELINES FOR SELECTING & PREPARING FOODS Milk and Milk Products: 2 3 servings/day
STEPS FOR LOWERING LDL C IN THE DIET Fats, oils: <6 8 tsp./day p/
STEPS FOR LOWERING LDL C IN THE DIET Monounsaturated Fats: Canola, olive and peanut oil Avocado Olives: black and green Nuts: almonds, cashews, peanuts, pecans Sesame seeds
STEPS FOR LOWERING LDL C IN THE DIET Polyunsaturated Fats Margarine made with corn, soybean, safflower, sesame oils Tub, squeeze or stick Nuts: walnuts and English Salad dressings Seeds: pumpkin, sunflower
STEPS FOR LOWERING LDL C IN THE DIET Saturated Fat: Butter, Coconut & Coconut Oil, Palm Oil Cream, half and half Cream cheese Shortening or lard Sour cream Fat from animal products including milk and meats
STEPS FOR LOWERING LDL C IN THE DIET Plant Sterols and Stanols: Natural substances derived from wood, vegetables, vegetable oils and other plants sitosterol and sitostanol
STEPS FOR LOWERING LDL C IN THE DIET Meat, Fish and Poultry Select lean meat and poultry <6 oz/day for Step I diet and <5 oz/day for Step II Eat fish on a weekly basis
STEPS FOR LOWERING LDL C IN THE DIET Tongue kidneys Liver sweetbreads heart and Tongue, kidneys Liver, sweetbreads, heart and brains are high in cholesterol.
STEPS FOR LOWERING LDL C IN THE DIET Breads and Cereals: 6 11 servings/day Low fat crackers Tortillas Hot and cold cereals except granola or muesli
STEPS FOR LOWERING LDL C IN THE DIET Vegetables: 3 5 servings per day Fruits 2 4 servings per day Use sweets and modified fat desserts in moderation
READING THE LABEL Extra Lean <5 g total fat, 2 g saturated fat, and 95 mg cholesterol Lean < 10 g total fat, 4 g saturated fat and 95 mg cholesterol
READING THE LABEL Fat Free less than 0.5 gm fat Low Fat 3 grams or less fat Reduced fat at least 25% less fat Light one third fewer calories or 50% less fat
GUIDELINES FOR SELECTING & PREPARING FOODS Try reducing fat by 1/4 to 1/3 in baked products. E.g. if recipe calls for 1 cup oil, try 2/3 C. In casseroles and main dishes, cut back or eliminate the fat. Sauté or stir fry with very little fat or use water, wine, or broth. Chill soups, gravies and stews and skim off ffhardened d fat before serving.
RISKFACTORS FOR CORONARYHEART DISEASE Triglycerides Normal: < 200 mg/dl Borderline: 200 400 mg/dl High: 400 1000 mg/dl Very High:> 1000 mg/dl
RISKFACTORS FOR CORONARYHEART DISEASE High Triglycerides (>200 mg/dl) and low HDL cholesterol is associated with increased risk. Stronger in women than men and older adults
HYPERTRIGLYCERIDEMIA Factors Associated with Increased Triglycerides: gy Diets low fat, high refined sugar Estrogens Alcohol l Obesity Untreated Diabetes, hypothyroidism, y chronic renal failure and liver disease
HYPERTRIGLYCERIDEMIA Treatment: Weight Loss Low cholesterol, low saturated fat diet Increased physical activity i Smoking cessation Management of Diabetes Restricted alcohol use