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Heart to Heart Fighting Heart Disease with Diet: A Crucial Conversation George E. Matthews MD FACC, FACP 2
George E. Matthews, MD, FACC, FACP Clinical Assistant Professor - Department of Medicine SUNY Buffalo Buffalo Cardiology and Pulmonary Associates 3
Roadmap for Our Discussion How healthy are we? What is heart disease? What are the signs of heart disease? Causes and risks of heart disease How do we prevent heart disease? 4
Healthy Heart Test High blood pressure (hypertension) High blood cholesterol Smoking Obesity Physical inactivity Diabetes Stress (?) 5
The Problem Cardiovascular disease is the leading cause of death in the United States 1 in 3 Americans have some form of cardiovascular disease 6
1900-2003 Deaths from Cardiovascular Disease ;22 :22 Deaths in Thousands 922 822 722 622 522 422 322 2 3; 22 32 42 52 62 72 82 92 :2 ;2 22 Years CDC 7
Mortality Related to High Cholesterol (CDC)! #1 cause of death: Cardio-vascular diseases! #3 cause of death: Cerebro-vascular diseases! #1 + #3 = ~ 40% of all deaths (+ higher risk for Alzheimer & chronic liver disease) 8
Heart Disease? What is it, and what are the different types? 9
What is Heart Disease? Any disorder that will affect the hearts ability to function correctly Is an umbrella word Most common cause of heart disease Narrowing or blockage 10
Anatomy 11
Types of Heart Disease Coronary Artery Disease Heart Attack Sudden Cardiac Death 12
Types of Heart Disease (Cont.) Heart Muscle Disease Pericardial Disease Pericardial Effusion 13
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Normal EF (Ejection Fraction) Abnormal EF (Ejection Fraction) 16
Coronary Atherosclerosis Progression to Thrombosis
Roles of Cholesterol! Cell membrane structure! Human skin barrier (toxins, water loss)! Precursor of steroid hormones (testosterone, estrogen, progesterone, cortisone and aldosterone)! Precursor of bile acids! Formation of vitamin D (with UVs)
Cholesterol Metabolism! Esterification of dietary cholesterol by pancreatic exocrine glands! In the plasma: cholesterol ester associated with lipoproteins! 80% produced by the liver (0.8 gram/day)! 20% comes from the digestive tract
Cholesterol Transport! HDL (High Density Lipoprotein) It brings back cholesterol to the liver! LDL (Low Density Lipoprotein) Its over-accumulation and deposition lead to serious ailments! VLDL (Very Low Density Lipoprotein) Converted into LDL by endothelial cell-associated lipases
Optimal Cholesterol Levels (AHA) Total Cholesterol Less than 200 mg/dl Desirable level that puts you at lower risk for coronary heart disease 200 to 239 mg/dl Borderline high 240 mg/dl and above High blood cholesterol. Twice the risk of CAD as below 200 mg/dl
Optimal Cholesterol Levels (AHA) HDL Cholesterol Less than 40 mg/dl Low level. A major risk factor for CAD 40 to 59 mg/dl The higher the level the better 60 mg/dl and above High level. Considered protective against CAD
Optimal Cholesterol Levels (AHA) LDL Cholesterol Less than 100 mg/dl Optimal 100 to 129 mg/dl Near or above optimal 130 to 159 mg/dl Borderline high 160 to 189 mg/dl High 190 mg/dl and above Very high
Cholesterol Goals Your LDL cholesterol goal depends on how many other risk factors you have No CHD or diabetes and 1 or no risk factor: less than 160 mg/dl No CHD or diabetes and 2 or more risk factors: less than 130 mg/dl CHD or diabetes: less than 100 mg/dl
Factors Influencing Cholesterol Levels " Age " Weight and its body location " Gender (men, menopause) " Genetics (enzyme deficiencies) " Diseases " Lifestyle (exercise, stress, smoking)
Physiopathological Consequences of the Plague Coronary Artery Disease (CAD): angina, MI Peripheral Artery Disease (PAD) Ischemic Stroke (brain infarct) Transient Ischemic Attacks (TIAs) Secondary Erectile Disorder (ED) Chronic Renal Ischemia (renal failure)
Cholesterol as CAD Risk Factor! High LDL is responsible for 70% of heart diseases (leading killer of men and women after 45)! Age 49-82: The most potent risk factor for CAD is low HDL (Framingham study)! Every 2% raise in HDL = 2% in men and 3% in women decrease in CAD risk Clinical benefits shown by the VA-HIT study! Same impact for LDL reduction. Combined benefits suggested by the HAT study
Gender and Heart Disease (Women) Most important risk factors Diabetes Low HDL High triglycerides Waist measurement of 35 inches or more Inflammatory disorders Symptoms/disease Fatigue, malaise, shortness of breath, nausea, depression First heart attack at average age 70 with higher fatality rate than men More likely to have microvascular disease Diagnostic procedures ECG stress test less informative than nuclear test When angiography shows no discrete lesions: IVUs and pressure flow studies Treatment Less likely to have bypass surgery or angioplasty for coronary lesions Longer hospital stays, higher complication rate
GENDER AND HEART DISEASE (MEN) Most important risk factors High LDL High blood pressure in young men Symptoms/disease Unstable angina warrants immediate attention First heart attack at average age 65 Diagnostic procedures Stress tests more reliable than in women Angiography more likely to be informative Treatment More likely to receive bypass surgery, angioplasty for coronary lesions Shorter hospital stays More likely to enter cardiac rehabilitation
HDL-C CHD Protection Mechanisms! Promotion of peripheral cholesterol transport! Anti-oxidant / anti-inflammatory action! Antithrombotic effects
Cholesterol Profile Improvement 1. DIET 2. EXERCISE 3. SMOKING CESSATION 4. STRESS REDUCTION 5. WEIGHT CONTROL 6. BEHAVIOR CHANGE 7. NUTRITIONAL GENOMICS Strategy
Cholesterol Profile Improvement Strategy DIET! 3 types of fat come from the diet: saturated, mono-unsaturated and omega-3 omega-6 PUFAs Poly-Unsaturated Fatty Acids-! Diets high in omega-3 oils decrease the risk of sudden cardiac death (+ Eskimo paradox)! After 1 month a vegetarian diet rich in vegetal sterols, soya proteins and almonds, the LDL cholesterol decreased 28% (i.e., as much as the group on statins). It also decreased CRP levels, just like statins (Dr. David Jenkins, JAMA)! People with a high level of C-reactive protein (CRP) don t receive the same beneficial reductions while on a low-fat, low-cholesterol diet as those with lower CRP levels
The French Paradox A- Relatively low incidence of CAD B- Diet rich in saturated fat
The French Paradox! Red wine produces flavonoids (quercetin, resveratrol and ipatechin) after fermentation! Flavonoids decrease the oxidation of LDL and its uptake by macrophages! The alcohol content assures the effective absorption of flavonoids and tannins
The Problem
Modern Life Has Both Conveniences and Costs Illustration taken from: Lambert C, Bing C. The Way We Eat Now. Harvard Magazine. May-June, 2004;50.
Cholesterol Profile Improvement EXERCISE! Exercise increases the HDL and decreases the LDL levels! It also lowers triglyceride levels and blood pressure, reduces excess weight, improves heart and lung fitness and diminishes stress! Guidelines for maximizing the impact of exercise on blood cholesterol levels Aerobic exercise (jogging, swimming, brisk walking, bicycling, etc) As a rule, to be in aerobic conditions one should be able to hold a conversation without being too winded while exercising * Moderate intensity + strength training Strategy
Cholesterol Profile Improvement Strategy Adults are advised to accumulate 150 minutes of moderate-intensity aerobic activity every week in addition to strength training. Moderate intensity is 5 or 6 on a 10-point scale of effort (Centers for Disease Control and Prevention) They also are encouraged to wear pedometers to count the number of steps they take. Moderate intensity approximates 100 steps a minute
SMOKING CESSATION Smoking cessation increases HDL and decreases LDL levels Points a- Nicotine is not needed for less than 10 cigarettes per day and contraindicated in case of drug interaction, in pregnant or breast-feeding women and in the adolescent b- Four As: Ask, Advice, Assist and Arrange c- Nicotine inhaler or nasal spray is superior to patch d- Three prong approach: Nicotine (physiological dependence), Bupropion -Zyban- (aggressiveness, bulimia) and psychological advice (support, determining the need), Chantix?
Epidemiology of Tobacco Use The link between smoking and CVD (mainly CHD) was identified in 1940 Greatest risk: initiation <16 years Passive smoking: additional risk Women smokers: are at higher risk of CHD and CVD than male smokers Several mechanisms: damages the endothelium lining, increases atherosclerotic plaques, raises LDL and lowers HDL, promotes artery spasms, raises oxigen demand of the heart muscle Nicotine accelerates the heart rate (RR), and raises blood pressure
Systems Affected By Stress Immune system Cardiovascular system Gastrointestinal system Muscles Skin Sexual reproduction 41
Cholesterol Profile Improvement Strategy STRESS REDUCTION Stress reduction increases the HDL level Meditation, prayer, laughter, yoga, tai chi, Reiki healing, mindfulness-based stress management, HeartMath, music, reading, sport (especially martial arts), massage, breathing techniques, etc
Stress & Heart Disease Friedman & Rosenman (1974) Assessed 3200 healthy American men Stress-prone individuals (Type As) were identified: Anger & hostility Competitiveness Time-urgency www.psychlotron.org.uk
Stress & Heart Disease After 8½ years, men were reassessed 257 had developed CHD Of these, 70% were Type As Association remained when smoking and other lifestyle factors were accounted for www.psychlotron.org.uk
Stress & Heart Disease Kivimaki et al (2002) Highly stressed workers were 2x as likely to die from heart problems Sheps et al (2002) Stress-prone individuals with heart problems 3x more likely to die from heart attack Steptoe et al (2005) Stress-prone individuals more likely to accumulate LDL bad blood cholesterol www.psychlotron.org.uk
Stress & Heart Disease Stress increases risk of cardiovascular disease but is not a direct causal factor Effect is mediated by personality (stress prone-ness) The mechanism is complex Direct effects and lifestyle-mediated ones are both likely to be important Stress effects are clearest with pre-existing CHD If you have CHD stress will probably make it worse But we still don t know if stress causes CHD initially
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY 5- WEIGHT CONTROL Loosing weight increases the HDL level. Calculate your BMI Loose weight by decreasing the caloric intake with a hypocaloric diet and/or increasing output through an aerobic exercise.
Cholesterol Profile Improvement Keys: Strategy BEHAVIOR CHANGE # Self-management of lifestyle choices # Selecting behaviors you are ready to change # Setting realistic goals # Fifteen steps
Cholesterol Profile Improvement Strategy NUTRITIONAL GENOMICS One size does not fit all The current evidence based on nutrigenetics has begun to identify subgroups of individuals who benefit more from different diets. The continuous progress in nutrigenomics will allow some time in the future to provide targeted gene-based dietary advice Genotype Phenotype Associations: Modulation by Diet and Obesity. Jose M. Ordovas Obesity (2008) 16, S40 S46;
Coronary Atherosclerosis Progression to Thrombosis 50
The End 51
QUESTIONS 52