Coronary Artery Disease1

8/3/2019 Coronary Artery Disease1

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Coronary Heart Disease

Coronary Heart Disease (CHD)

>58 million American 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

The major underlying cause is

atherosclerosis.atherosclerosis.

Atherosclerosis Atherosclerosis is a slow,

progressive disease which

begins in childhood and takesdecades to advance

Plaque (the build-up of

lipid/cholesterol) in the artery

wall forms as a response toinjury injury to the endothelium in the

artery wall.

Risk Factors for

Male > 45 years

Female > 55 years or premature menopausewithout estrogen replacement therapy

Family History of premature disease

Male first-degree relative <55 years

Female first-degree relative < 65 years)

Risk Factors for

Hypertension

Appears to weaken the artery wall atpoints of high pressure leading toinjury and invasion of cholesterol.

Cigarette Smoking

#1 cause of preventable death in US

1 in 5 CHD deaths attributable tosmoking

s ac ors or

Diabetes

50% of deaths related to DM is

due to CHD

Risk Factors for

Inactivity

Sedentary person has 2x risk

for developing CHD as a personwho is active.

Risk Factors for

Obesity

Risk Factors for

Abnormal Blood Lipids

LDL Cholesterol (low density

lipoprotein)

HDL Cholesterol (high density

lipoprotein)

Cholesterol

Diet Liver

Cholesterol Metabolism

15% 75%

Blood Lipids and Lipoproteins

Some LDL-C can be oxidized and

takes up by endothelial cells and

macrophages in the arterial wall,which leads to the first stages of

atherosclerosis.

HDL-C is thought to be involved in

the transport of excess cholesterol

from membranes to the liver for removal from the body.

HDL-C IS INCREASED:

Exercise, loss of weight, and moderate

consumption of ETOH.

HDL-C is lowered:

Obesity, inactivity, cigarette

smoking, some oral contraceptivesand steroids, hypertriglyceridemia

and some genetic factors.

Cholesterol and the CHD Patient

The goal is a LDL-C level of

100 mg/dL

Blood Lipid ClassificationCholesterol:<200 mg/dl

200-239 mg/dl>240 mg/dl

Desirable

Borderline high-riskHigh-risk

HDL Cholesterol<40 mg/dl>60 mgl/dl

LowHigh, negates one

risk factorLDL Cholesterol<100 mg/dl100 ² 129 mg/dl130-159 mg/dL

>160 mg/dl

DesirableAbove optimalBorderline High

High Risk

Treatment in CHD Patients

LDL-CLevels

Diet & LifeHabits

DrugTherapy

<100 mg/dL Yes No

100-129mg/dL

Yes ClinicalJudgment

>130 mg/dL Yes Yes

Scandinavian Sinvastatian SurvivalScandinavian Sinvastatian Survival

Study:Study:

N= 4,444 patients with history of angina or MI

Cholesterol levels = 213-310 mg/dL

Treatment

Placed on cholesterol-lowering diet and

B: a statin drug or a placebo.

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

Diet Therapy of High Blood

Cholesterol

Healthy Heart Diet Therapeutic LifestyleChange Diet (TLC)

8-10% calories from

saturated fat

<7% calories from

saturated fat 20 - 35% calories from fat 20-35% calories

from fat

<300 mg. cholesterol <200 mg. cholesterol

5-10% of energy fromPUFA

5-10% of energy from PUFA

Up to 20% MUFA Up to 20% MUFA

Calories to maintain IBW Calories to maintain IBW

Cholesterol

Total FatTotal Fat

20-35% calories from fat

Average of total calories consumed over aone week period.

Saturated fatty acidSaturated fatty acid Intake is the strongest dietary determinant

of LDL-C

Recommendation: 8-10% calories

Cholesterol Polyunsaturated fatty acidsPolyunsaturated fatty acids

Reduces LDL-C and risk of CHD when

substituted for saturated fat in the diet

Can cause small reduction in HDL-C whenpresent in high amounts

Recommendation: ~10% of energy intake

-Omega-3 Fatty Acids

Help to thin blood and prevent bloodplatelets from clotting and sticking to

artery walls.

Food Sources: fatty fish, such assalmon, sardines, trout, swordfish,

herring, albacore tuna, mackerel and,

soy, canola and flaxseed oil. Consumption of 2 servings

(~8ounces)per week of fish high in -

linolenic acid

Monounsaturated fatty acidsMonounsaturated 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

Cholesterol

Trans-Fatty Acids

Increase LDL Cholesterol and

decrease HDL CholesterolRecommendations: Intakes of

trans-fatty acids should be as low

as possible

FoodCalories

Saturated

Hamburger (7 oz) 660 3 14

McDonalds chicken McNuggets

(9 oz)510 3 6

Burger King chicken sandwich

(8 oz)610 2 7

Burger King fries (6 oz King

size)540 7 6

Starbucks cinnamon scone (5

oz)530 3 13

Trans fatty acid content of fast-

Treatment for CHD

Physical ActivityPhysical Activity

prescribed by physician for patients with

When aerobic activity is appropriate,

activity that places moderate stress on

the cardio-respiratory system can be

included.

Treatment for CHD

Weight ControlWeight Control

5-10# weight loss

Cholesterol

Soluble Fiber

10-20 g/day

Drug Treatment

Statins -

Bile Acid Sequestrants

Nicotinic Acid

Dietary Issues Requiring Further

Research

Elevated levels of

homocysteinehomocysteine

Elevated homocysteine levels

may be present in 15% of

Americans.

Research

Several vitamins, including

folic acid, vitamin B6 and

B12, function are cofactors inthe metabolism of methionine

and homocysteine.

Research

Antioxidant Vitamin Antioxidant Vitamin

SupplementsSupplements -- Vitamins E, CVitamins E, C

and Aand A Results of epidemiological observations

suggest a relationship between

increased intake of these vitamins anddecreased CHD risk.

Research

Very low-fat diets (<15 % fat)

Steps for Lowering LDL-C in the

<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

Fats, oils:

<6-8 tsp./day

Monounsaturated Fats:

Canola, olive and peanut oil

Avocado Olives: black and green

Nuts: almonds, cashews, peanuts,

pecans Sesame seeds

Polyunsaturated Fats

Margarine made with corn, soybean,

safflower, sesame oils Tub, squeeze or stick

Nuts: walnuts and English

Salad dressings Seeds: pumpkin, sunflower

Saturated Fat:

Butter, Coconut & Coconut Oil, Palm Oil

Cream, half and half

Cream cheese

Shortening or lard

Sour cream

Fat from animal products including milkand meats

Plant Sterols and Stanols:

Natural substances derived from

wood, vegetables, vegetable oilsand other plants - sitosterol andsitostanol

Meat, Fish and PoultryMeat, 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

S f L i LDL C i h

Tongue, kidneys Liver, sweetbreads,

heart and brains are high in

cholesterol.

St f L i LDL C i th

Breads and Cereals:

6-11 servings/day

Low fat crackers Tortillas

Hot and cold cereals excepts granola or

meusli

St f L i LDL C i th

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

< 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

G id li f S l ti &

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

hardened fat before serving.

Ri k F t f

Risk Factors for

Triglycerides

Normal: < 200 mg/dl

Borderline: 200 - 400 mg/dl

High: 400 - 1000 mg/dl

Very High:> 1000 mg/dl

Ri k F t f

Risk Factors for

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:

Diets - low fat, high refined sugar

Estrogens

Alcohol

Obesity

Untreated Diabetes, hypothyroidism,chronic renal failure and liver disease

Hypertriglyceridemia

Treatment:

Weight Loss

Low cholesterol, low saturated fat diet

Increased physical activity

Smoking cessation

Management of Diabetes

Restricted alcohol use

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