Cardiovascular Disease: Cardiovascular Disease: an Overviewan Overview

Jon W. Wahrenberger, MDJon W. Wahrenberger, MD

March 10, 2007March 10, 2007

The Good NewsThe Good NewsWe are living longer than We are living longer than ever!ever!

So Why Worry about So Why Worry about Cardiovascular Disease?Cardiovascular Disease?

• Cardiovascular disease Cardiovascular disease is the number one killeris the number one killer• About 42% of all deathsAbout 42% of all deaths• Nationwide: 921,819 Nationwide: 921,819

annuallyannually• NH: 3468NH: 3468• VT: 1751VT: 1751

• Cardiovascular disease Cardiovascular disease continues to strike continues to strike young and middle-aged young and middle-aged individualsindividuals

• We are losing ground on We are losing ground on several important risk several important risk factorsfactors

Cardiovascular, 35.74

Cancer, 22.91

Respiratory, 5.09

Diabetes, 2.95

Influenza, 2.57

Alzheimers, 2.22

Kidney, 1.63

Septicemia, 1.34

Injuries, 4.2

Obesity in the USAObesity in the USA

Prevalence of Prevalence of Diabetes 1980-Diabetes 1980-

20042004

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1.0

2.0

3.0

4.0

5.0

6.0

80 83 86 89 92 95 98 01 04

Ag

e A

dju

sted

Rat

e (%

)

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey.

Smoking in YouthSmoking in Youth

2005 Youth Risk Behavior Survey (YRBS)

19.721.4

24.327.6

0

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10

15

20

25

30Sm

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g in

Las

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Day

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9th 10th 11th 12th

Grade Level

Potential for Falling Potential for Falling Longevity?Longevity?

Life Life Extending Extending TechnologyTechnology

Public Health Public Health MeasuresMeasures

Health Health adverse adverse behaviorbehavior

Evolution of Cardiovascular DiseaseEvolution of Cardiovascular Disease

Normal Child

OverweightInactive Child

OverweightInactive Adult

Sick Adult

Suffering, Loss of QOL

Premature Death

Food Overabundance

CulturalChanges

MassMarketing

of Junk Food

TechnologyInfluences

DrugsDevices

SurgicalProcedures

Chain ofSurvival

We must tackle heart disease at all points!

KnowledgeDeficits

Tobacco

Women are not immune to Women are not immune to heart disease!heart disease!

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50

100

150

200

250

300

350

400

De

ath

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CVD Resp. Cancer Colon Cancer Breast Cancer

Men

Women

What is Cardiovascular What is Cardiovascular Disease?Disease?

““Cardiovascular disease” refers to Cardiovascular disease” refers to diseases involving the heart and diseases involving the heart and blood vesselsblood vessels

AnginaAnginaHeart Heart AttackAttack

StrokeStrokeTIATIA

ClaudicationClaudicationUlcerationUlcerationAmputationAmputation

HeartHeart BrainBrainPeripheral Peripheral VasculatuVasculaturere

The heart, brain and extremities The heart, brain and extremities share a disease processshare a disease process

Coronary Disease

Peripheral VascularDisease

19%

30%25%

4% 12%

7%

3%

Cerebral Disease

The Common Thread?The Common Thread?

• Circulatory system Circulatory system (arteries, veins, etc.)(arteries, veins, etc.)

• Susceptibility to Susceptibility to atherosclerosisatherosclerosis

AtherosclerosisAtherosclerosis

• Complex, self-Complex, self-sustaining sustaining inflammatory inflammatory processprocess

• Thickens arterial Thickens arterial wallwall

• Occurs slowly Occurs slowly over decadesover decades

AKA “Arteriosclerosis”, “hardening of the arteries”AKA “Arteriosclerosis”, “hardening of the arteries”

Atherosclerosis Atherosclerosis ProgressionProgression

Time (years to decades)Time (years to decades)

Ischemic Heart Ischemic Heart DiseaseDisease

Cerebrovascular Cerebrovascular DiseaseDisease

Peripheral Peripheral Vascular Vascular DiseaseDisease

No Symptoms Mild Symptoms Severe SymptomsNo Symptoms Mild Symptoms Severe Symptoms

What causes What causes atherosclerosis?atherosclerosis?

• SmokingSmoking• High Blood PressureHigh Blood Pressure• High CholesterolHigh Cholesterol• DiabetesDiabetes• Hereditary FactorsHereditary Factors• Sedentary LifestyleSedentary Lifestyle• ObesityObesity• Other FactorsOther Factors

Normal Coronary ArteriesNormal Coronary Arteries

Right Coronary ArteryRight Coronary Artery Left Coronary ArteryLeft Coronary Artery

Diseased Coronary ArteryDiseased Coronary Artery

Peripheral Vascular Peripheral Vascular DiseaseDisease

Stroke – “Brain Attack”Stroke – “Brain Attack”

Symptoms of Cardiovascular Symptoms of Cardiovascular DiseaseDisease

Heart Heart DiseaseDisease

Stroke or Stroke or TIATIA

Peripheral Peripheral VascularVascular

•Chest Chest DiscomfortDiscomfort•Shortness of Shortness of breathbreath•FatigueFatigue•PalpitationsPalpitations

•Sudden Sudden numbness or numbness or weakness. weakness. •Sudden Sudden confusion, confusion, trouble speaking trouble speaking or understanding or understanding •Sudden visual Sudden visual loss loss •Sudden trouble Sudden trouble walking, walking, instability instability •Sudden severe Sudden severe headache with no headache with no known causeknown cause

•Pain in calves, Pain in calves, thighs or thighs or buttocksbuttocks•Non-healing Non-healing ulcersulcers

SuspecteSuspected Stroke d Stroke or Heart or Heart Attack?Attack?

Call Call 911911

Time = saved heart muscleTime = saved heart muscleTime = saved brain Time = saved brain functionfunction

Other Causes of Heart Other Causes of Heart DiseaseDisease

•Heart failureHeart failure•Heart rhythm disturbances Heart rhythm disturbances (arrhythmias)(arrhythmias)•Congenital heart diseaseCongenital heart disease•Heart Valve DiseaseHeart Valve Disease•Heart infectionsHeart infections

Heart FailureHeart Failure

Heart FailureHeart Failure

• state in which the heart is unable to pump state in which the heart is unable to pump blood at a rate commensurate with the blood at a rate commensurate with the requirements of the metabolizing tissues requirements of the metabolizing tissues

DefinitionDefinition

Heart FailureHeart Failure

Heart Heart Muscle Muscle InjuryInjury

VirusVirusToxinsToxins

HypertensionHypertensionPost PartumPost Partum

IschemiaIschemiaValve DiseaseValve Disease

Heart Heart FailureFailure

Heart Failure: SymptomsHeart Failure: Symptoms

• Shortness of breathShortness of breath• FatigueFatigue• Edema (swelling)Edema (swelling)

ArrhythmiasArrhythmias

Heart Electrical SystemHeart Electrical System

A wave of electrical discharge proceeds A wave of electrical discharge proceeds mechanical contraction of the heart.mechanical contraction of the heart.

Types of ArrhythmiasTypes of Arrhythmias

• Premature atrial Premature atrial contractions (PAC)contractions (PAC)

• Atrial fibrillationAtrial fibrillation• Atrial flutterAtrial flutter• SVTSVT• Wolf Parkinson WhiteWolf Parkinson White• Heart blockHeart block• Premature ventricular Premature ventricular

contractions (PVC)contractions (PVC)• Ventricular Ventricular

tachycardiatachycardia• Ventricular fibrillationVentricular fibrillation

Arrhythmia SymptomsArrhythmia Symptoms

• Palpitations (a feeling of thumping, Palpitations (a feeling of thumping, fluttering, skipping or racing of the fluttering, skipping or racing of the heart) heart)

• Lightheadedness/loss of consciousnessLightheadedness/loss of consciousness• Chest pain or tightness Chest pain or tightness • Shortness of breath Shortness of breath • Fatigue Fatigue • Anxiety Anxiety

Diagnosis of ArrhythmiasDiagnosis of Arrhythmias

• ElectrocardiogramElectrocardiogram• Holter MonitorHolter Monitor• Event MonitorEvent Monitor• Loop recordLoop record• Implantable loop Implantable loop

recordrecord

Treatment of ArrhythmiaTreatment of Arrhythmia

• Removal of precipitantsRemoval of precipitants• CaffeineCaffeine• Electrolyte ImbalancesElectrolyte Imbalances• Thyroid abnormalitiesThyroid abnormalities

• MedicationsMedications

• AblationAblation• Implantable defibrillatorImplantable defibrillator

TraditionalTraditional

Ablation of ArrhythmiasAblation of Arrhythmias

Particularly useful with:Particularly useful with:•SVTSVT•Atrial fibrillationAtrial fibrillation•Atrial flutterAtrial flutter•WPWWPW•Some types of Ventricular TachycardiaSome types of Ventricular Tachycardia

Implantable Implantable Cardioverter/DefibrillatorCardioverter/Defibrillator

View Defibrillator

Ventricular Ventricular FibrillationFibrillation

Heart Valve DiseaseHeart Valve Disease

Valve DiseaseValve Disease

• Normal Function:Normal Function:• Allow blood to flow Allow blood to flow

freely one direction freely one direction and none backwardsand none backwards

• Dysfunction:Dysfunction:• Become narrow and Become narrow and

impede forward flow impede forward flow (stenosis)(stenosis)

• Become incompetent Become incompetent and allow backward and allow backward flow (regurgitation)flow (regurgitation)

Valves are intended to allow blood flow Valves are intended to allow blood flow in only one direction from one heart in only one direction from one heart chamber to anotherchamber to another

Pulmonic Pulmonic ValveValve

Mitral Mitral

ValveValve

Tricuspid Tricuspid ValveValve

Aortic Aortic ValveValve

Valve DiseaseValve Disease

• Shortness Shortness of breathof breath

• FatigueFatigue• Chest PainChest Pain• SusceptibiliSusceptibili

ty to ty to infectioninfection

• DeathDeath

Congenital Congenital AbnormalityAbnormality

InfectionInfection

Age Related Age Related DegenerationDegeneration

Rheumatic Rheumatic FeverFever

Valve Valve DysfunctioDysfunctio

nn

Treatment of Valve Treatment of Valve DiseaseDisease

• MedicationsMedications• SurgerySurgery• Percutaneous repairPercutaneous repair

Open Heart SurgeryOpen Heart Surgery

Mitral ValvuloplastyMitral Valvuloplasty Aortic ValvuloplastyAortic Valvuloplasty

Percutaneous Percutaneous ValvuloplastyValvuloplasty

Percutaneous Aortic Valve Percutaneous Aortic Valve ReplacementReplacement

Percutaneous Aortic Valve Percutaneous Aortic Valve ReplacementReplacement

What can you do to stay What can you do to stay healthy?healthy?

Know your Enemies!Know your Enemies!

• InactivityInactivity• ObesityObesity• SmokingSmoking• Elevated Elevated

cholesterolcholesterol• DiabetesDiabetes• HypertensionHypertension

Calculate Your RiskCalculate Your RiskFramingham Risk CalculatorFramingham Risk Calculator

MenMen WomenWomen

Make the right choicesMake the right choices

• Use the stairs; take a daily walk!Use the stairs; take a daily walk!• Stay away from all fast food Stay away from all fast food

restaurants!restaurants!• Eat smaller portionsEat smaller portions• Read food labelsRead food labels• Choose foods made from whole Choose foods made from whole

grainsgrains• Stay away from restaurants that Stay away from restaurants that

allow smokingallow smoking

Learn about Trans Fatty Learn about Trans Fatty AcidsAcids

• Low level presence in meat and Low level presence in meat and milk of ruminant animalsmilk of ruminant animals

• High levels in “partially High levels in “partially hydrogenated vegetable oils”hydrogenated vegetable oils”

• Lot of bad consequences:Lot of bad consequences:• Raise LDL & lower HDLRaise LDL & lower HDL• Increase risk of heart disease by 30%Increase risk of heart disease by 30%

Trans Fatty AcidsTrans Fatty Acids

• Saturated fats < 7% Saturated fats < 7% of total caloric intakeof total caloric intake

• Trans fats to < 1% of Trans fats to < 1% of total caloric intaketotal caloric intake

• Cholesterol to < 300 Cholesterol to < 300 mg per day mg per day

• Total fat to 25-35% of Total fat to 25-35% of total caloric intaketotal caloric intake

FDA mandated trans fat food labeling after January 1, 2006FDA mandated trans fat food labeling after January 1, 2006

AHA Recommendations:AHA Recommendations:

Some Unlikely Friends?Some Unlikely Friends?

Dark ChocolateDark Chocolate

• Raises HDLRaises HDL• Improves insulin Improves insulin

sensitivitysensitivity• Lowers blood Lowers blood

pressurepressure• Improves blood Improves blood

vessel reactivityvessel reactivity

Rx: Recommended Dose – 100 gm Rx: Recommended Dose – 100 gm per dayper dayDark Chocolate Dark Chocolate ≠ ≠ Milk ChocolateMilk Chocolate

AlcoholAlcohol

• Elevation of HDLElevation of HDL• Antithrombotic Antithrombotic

effectseffects• Promote Promote

formation of formation of nitric oxide (NO)nitric oxide (NO)

• Reduced coronary Reduced coronary heart diseaseheart disease

Rx: Recommended Dose – 1-2 drinks Rx: Recommended Dose – 1-2 drinks per dayper day

Olive OilOlive Oil

• Increase in HDLIncrease in HDL• ReductionsReductions

• Total CholesterolTotal Cholesterol• Total to HDL Total to HDL

RatioRatio• TriglyceridesTriglycerides

• Reduction in Reduction in oxidative stress oxidative stress markersmarkers

Green TeaGreen Tea

• Decrease in total and Decrease in total and cardiovascular mortalitycardiovascular mortality

• Decrease in myocardial Decrease in myocardial infarctioninfarction

• Decrease in strokeDecrease in stroke• Reduced mortality after Reduced mortality after

MIMI• Increases coronary flow Increases coronary flow

reservereserve• Improved endothelial Improved endothelial

functionfunction

Where are we heading?Where are we heading?