Occurs when the coronary arteries that supply the heart muscle become blocked.

• Partially blocked it causes angina.

• Fully blocked it causes a myocardial infarction or a heart attack!

Coronary Artery Disease

• Hypertension

• Serum cholesterol

• Obesity

• Diabetes Mellitus

• Physical Inactivity

• Cigarette Smoking

• Alcohol Intake

Changeable Risk Factors

Q = serum cholesterol quintile.Kannel WB et al. Am Heart J. 1986;112:825-836.

Multiple Risk Factor Intervention Trial (MRFIT) N=325,346

Correlation Between Serum Cholesterol and CVD Mortality

6-Y

ear

CV

D D

eath

Rat

e P

er 1

000

0

5

10

15

20

25

30

Q1

(<182)

Q2

(182-202)

Q3

(203-220)

Q4

(221-244)

Q5

(>244)

35-39 years

40-44 years

45-49 years

50-54 years

55-57 years

Serum Cholesterol Quintile (mg/dL)

Untreated Patients

Lifetime Risk of CHD Increases with Serum Cholesterol

0

10

20

30

40

50

60

Per

cen

t

Men Women

<200 mg

200-239 mg

>240 mg

Framingham Study: Subjects age 40 yearsDM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972

34

44

57

19

2933

Cholesterol

___________________________________________________________________________

_______________________________________________________________________________

FRAMINGHAM HEART STUDYFRAMINGHAM HEART STUDY

0

0.5

1

1.5

2

2.5

3

220 160 100

8565

4525

LDL Cholesterol (mg/dL)

CAD risk as a function of LDL-C and HDL-C in men (50 to 70 years)

HDL-Choles

terol

(mg/dl)

CASTELLI Am J Cardiol 1998; 82:60-65

Re l

ativ

e C

HD

Ris

ks

23.1 21.9

61.8

24.6

0

10

20

30

40

50

60

70

Pre

vale

nce

(%

)

HYPERCHOLESTEROLEMIA HYPERTRIGLYCERIDEMIA LOW HDL LEVELS HIGH LDL LEVELS

PREVALENCE OF DYSLIPIDAEMIA

Mohan et al., CUPS,NMJI, 2003

• People who are obese have 2 to 6 times the risk of developing hypertension.

• Location of the body fat is significant.

• Pears of apples?

Obesity

The future…?

Mhurchu N et al. Int J Epidemiol 2004;33:751-758

0.5

1.0

2.0

4.0

16 20 24 28 32 36

Body Mass Index (kg/m2)*

Haz

ard

Rat

io

0.5

1.0

2.0

4.0

16 20 24 28 32 36

0.5

1.0

2.0

4.0

16 20 24 28 32 36

HemorrhagicStroke

IschemicStroke

Ischemic HeartDisease

CV Risk Increases with Body Mass IndexCV Risk Increases with Body Mass Index

CV=Cardiovascular

Body mass index is calculated as the weight in kilograms divided by the body surface area in meters2.

Ponderal obesity

Intramuscular

Intrahepatic

Subcutaneous

Intra-abdominal

Abdominal obesity and increased risk of cardiovascular events

Dagenais GR et al, 2005

Adj

uste

d re

lati

ve r

isk

1 1 1

1.17 1.16 1.14

1.29 1.27

1.35

0.8

1

1.2

1.4

CVD death MI All-cause deaths

Tertile 1

Tertile 2Tertile 3

Men Women<95

95–103>103

<87

87–98>98

Waistcircumference (cm):

The HOPE study

Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C; CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol

• Increasing physical activity has been shown to decrease blood pressure.

• Moderate to intense physical activity for 30-45 minutes on most days of the week is recommended.

Physical Inactivity

• At any given cholesterol level, diabetic persons have a 2 or 3 x higher risk of atherosclerosis!

• Insulin is required to maintain adequate levels of lipoprotein lipase, an enzyme needed to break down bad cholesterols.

Diabetes Mellitus

Mortality rates per 100,000 per year from coronary heart disease, for males aged 45-54 years, as a function of the number of cigarettes smoked.

5 5 0

4 5 0

3 5 0

2 5 0

1 5 0

5 0

< 1 0 1 0 – 2 0 2 1 – 3 9 4 0 +

BEEDIES ARE AS BAD AS CIGARETTES

Odds Ratio

> 10 beedies / day 4.36

>10 Cig / day 3.58

Diabetes 2.35

Hypertension 2.23

WHR/100 1.10

Pais et al Indian Heart J 2001; 53:731

Dietary Effects on Lipids• Seven Countries study- significant

correlation between saturated fat intake and blood cholesterol levels

• Meta-analysis of randomized controlled trials showed lowering saturated fat and cholesterol reduces total and LDL-C 10-15%

• For every 1% increase in intake of saturated fat, blood cholesterol increases 2 mg/dl

Lipoproteins- 4 main classes• Chylomicrons

• Very low density lipoproteins (VLDL)

• Low Density Lipoprotein (LDL)

• High Density Lipoprotein (HDL)

Types of Cholesterol

• LDL is known as bad cholesterol. It has a tendency to increase risk of CHD.

• LDL’s are a major component of the atherosclerotic plaque that clogs arteries.

• Levels should be <130

Good vs. BAD

• HDL is known as the good cholesterol.

• It helps carry some of the bad cholesterol out of the body.

• It does not have the tendency to clog arteries.

• Levels should be >35.

• High levels of HDL >60 can actually negate one other risk factor.

Good vs. BAD

• 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.

The Skinny on Fat

• 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.

What about Omega 3?

The INTERHEART Study9 RF Accounted for 90% of PAR

OR PAR

APO B/A1 3.2 49 %

SMOKING 2.9 36 %

PSY. FAC. 2.7 33 %

AB. OBESITY 1.6 20 %

HTN 1.9 18 %

DM 2.4 10 %

FRUIT/VEG .7 14 %

PHY. ACT. .8 12 %

ALCOHOL .9 7 %

The INTERHEART Study

Effects of the RF directionally similar in all regions and ethnic groups.

Suggests that approaches to prevention can be based on similar principals world wide and can prevent majority of premature MI

Majority of risk factors are related to lifestyle Lifestyle modification is of paramount

importance

CVD PREVENTION WORKS

Age-adjusted mortality rates of

coronary heart disease in North Karelia and the

whole of Finland among males

aged 35-64 years from 1969 to

2001

Mortality per 100 000 population

100

200

300

400

500

600

700

70 75 80 85 90 95 2000

Year

Start of the NorthKarelia Project Nationwide activity

Comparing the observed male mortality rates from CHD in N.E. Finland with those predicted from changes in the risk factors.

Vartiainen et al. 1994.

1975 1980 1985 1990-70

-60

-50

-40

-30

-20

-10

0

Observed mortality

Smoking

Blood pressure

All three risks

Cholesterol

Per

cen

t d

ecli

ne

Therapeutic Lifestyle Changes in LDL-Lowering Therapy: Major Features

• Saturated fats <7% of total calories

• Dietary cholesterol <200 mg per day

• Plant stanols/sterols (2 g per day)

• Viscous (soluble) fiber (10–25 g per day)

• Weight reduction • Increased physical activity

Therapeutic Lifestyle ChangesNutrient Composition of TLC Diet

Nutrient Recommended Intake

• Saturated fat Less than 7% of total calories

• Polyunsaturated fat Up to 10% of total calories

• Monounsaturated fat Up to 20% of total calories

• Total fat 25–35% of total calories

• Carbohydrate 50–60% of total calories

• Fiber 20–30 grams per day

• Protein Approximately 15% of total calories

• Cholesterol Less than 200 mg/day

• Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/

prevent weight gain

Dietary fats*

*Values for SFA, MUFA, and PUFA represent percentage of total fat calories, whereas those for cholesterol are expressed as mg per tablespoon. SFA is the sum of lauric, myristic, palmitic, and stearic acids. †Contain a considerable amount (>5%) of alpha-linolenic acid.‡Some are high in trans fatty acids: vegetable shortening>margarine fat>animal fat shortening>butter fat.SFA, saturated fatty acids; MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids.

Canola oilCanola oil†† 6 6 6262 313100

Corn oilCorn oil 13 13 2525 626200

Olive oilOlive oil 1414 7777 9 900

Palm oilPalm oil 5151 3939 101000

Safflower oilSafflower oil 9 9 12 12 787800

Soybean oilSoybean oil†† 1515 2424 616100

Sunflower oilSunflower oil 1111 2020 696900

FatFat SFASFA MUFAMUFA PUFA PUFA CholesterolCholesterol

Benefits of fish oil supplementation

• In the Diet and Reinfarction Trial (DART) in 2033 men with CHD increased intake of fish or use of 2 fish oil caps/day reduced CHD mortality 29% over 2 years

• In GISSI 11324 men and woman with CHD use of 1 gr. of n-3 PUFA decreased CVD events including mortality 15%

Lancet 1989; 2;757-761, and 1999; 345:447-455.

Nuts, Soy, Phytosterols, Garlic• Nurses’ Health Study: five 1oz servings of nuts per

week associated with 40% lower risk of CHD events

• Metaanalysis of 38 trials of soy protein showed 47g intake lowered total, LDL-C, and trigs 9%, 13%, and 11%

• Phytosterol-supplemented foods (e.g., stanol ester margarine) lowers LDL-C avg. 10%

• Meta-analysis of garlic studies showed 9% total cholesterol reduction (1/2-1 clove daily for 6 months).

Trans Fatty Acids

Effect of Fruit & Vegetables on Risk of CHD Joshipura et al Ann Intern Med’2001

Total intake of fruits and vegetables andmultivariate relative risk for coronary heart disease.

NHS & HPS: 84251 women (14 yrs FU) & 42148 men (8 yrs FU)

Food Choices and Preparation Tips

Dietary Approaches to Stop Hypertension (DASH)

• Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet

• Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish.

• NEJM 1997; 366: 1117-24.

Tips for Reducing Sodium

• Buy fresh, plain frozen or canned “no added salt” veggies.

• Use fresh poultry, lean meat, and fish.

• Use herbs, spices, and salt-free seasonings at the table and while cooking.

• Choose convenience foods low in salt.

• Rinse canned foods to reduce sodium.

• Causes an increase in blood pressure

• Usually have lower levels of HDL

• Within 1 year of quitting, CHD risk decreases, within 2 years it reaches the level of a nonsmoker.

Cigarette Smoking

• In small amounts it acts as a vasodilator-Good! 1-2 drinks

• In large amounts it acts as a vasoconstrictor-BAD! 3-4 drinks

• This is a very fine line!

Alcohol Consumption

EXERCISE FOR PRIMARY & SECONDARY PREVENTION

• both– leisure & recreational activity as well as intermittent activity (walking stair climbing, house work, gardening)

• Effects both direct and indirect• Proof for primary prevention weak

• Assess whether activities meet recommendations (equivalent to at least 30 min brisk walk @ 4.5 Km/hr on most or all days)

• Formulate schemes for activity at home aswell as workplace

• Special incentives,early start,,public health campaigns

• Serves several functions in preventing and treating those at high risk.

• Reduces incidence of obesity.• Increases HDL• Lowers LDL and total cholesterol• Helps control diabetes and hypertension• Those at high risk should take part in a

specially supervised program.

Exercise and CVD

The effects of lifestyle change The effects of lifestyle change

and drug therapy on and drug therapy on

cardiovascular risk reduction cardiovascular risk reduction

appear to be appear to be independent independent

and additiveand additive..

++

Hunninghake DB et al. NEJM 1993;32:1213Hunninghake DB et al. NEJM 1993;32:1213Barnard RJ et al. AJC 1997;79:1112Barnard RJ et al. AJC 1997;79:1112Sdringola S et al. JACC 2003;41:263Sdringola S et al. JACC 2003;41:263

Courtesy of Barry Franklin, PhD, William Beaumont Hospital, Royal Oak, MI

Approximate Mortality Reduction Potential of Drug Vs Lifestyle Interventions in Patients with Coronary Disease*

DrugDrug

LifestyleLifestyle

LowLow dosedose aspirinaspirin 18%18%StatinsStatins21%21%ßß Blockers

Blockers23%23%ACEACE Inhibitors

Inhibitors26%26%

SmokingSmoking cessation

cessation 35%35%PhysicalPhysical activityactivity

25%25%ModerateModerate alcoholalcohol

20%20%Combined lifestyle

Combined lifestyle changeschanges

45%45%

Iestra JA et al. Circ 2005;112:924Iestra JA et al. Circ 2005;112:924Courtesy of Barry Franklin, PhD, William Beaumont Hospital, Royal Oak, MI

• Cardiovascular disease is the number one killer.

• It is highly preventable and controllable with diet and exercise.

• Good resource: www.americanheart.org

• 1-800-AHA-USA

Conclusion