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Transcript of Coronary Artery Disease1
8/3/2019 Coronary Artery Disease1
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Coronary Heart Disease
(CHD)
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Coronary Heart Disease (CHD)
>58 million American have
at least one form of CHD.
50% of all cardiac deaths
result from CHD
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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
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Coronary Heart Disease
The major underlying cause is
atherosclerosis.atherosclerosis.
Atherosclerosis Atherosclerosis is a slow,
progressive disease which
begins in childhood and takesdecades to advance
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Coronary Heart Disease
Plaque (the build-up of
lipid/cholesterol) in the artery
wall forms as a response toinjury injury to the endothelium in the
artery wall.
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Risk Factors for
Coronary Heart Disease
Age:
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)
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Risk Factors for
Coronary Heart Disease
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
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s ac ors or
Coronary Heart Disease
Diabetes
50% of deaths related to DM is
due to CHD
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Risk Factors for
Coronary Heart Disease
Inactivity
Sedentary person has 2x risk
for developing CHD as a personwho is active.
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Risk Factors for
Coronary Heart Disease
Obesity
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Risk Factors for
Coronary Heart Disease
Abnormal Blood Lipids
LDL Cholesterol (low density
lipoprotein)
HDL Cholesterol (high density
lipoprotein)
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Cholesterol
Diet Liver
Cholesterol Metabolism
15% 75%
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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.
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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.
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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 contraceptivesand steroids, hypertriglyceridemia
and some genetic factors.
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Cholesterol and the CHD Patient
Goal:
The goal is a LDL-C level of
100 mg/dL
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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
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Treatment in CHD Patients
LDL-CLevels
Diet & LifeHabits
DrugTherapy
<100 mg/dL Yes No
100-129mg/dL
Yes ClinicalJudgment
>130 mg/dL Yes Yes
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Cholesterol and the CHD Patient
Scandinavian Sinvastatian SurvivalScandinavian Sinvastatian Survival
Study: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.
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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
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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
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Diet Therapy of High Blood
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
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Diet Therapy of High Blood
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
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-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
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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
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Diet Therapy of High Blood
Cholesterol
Trans-Fatty Acids
Increase LDL Cholesterol and
decrease HDL CholesterolRecommendations: Intakes of
trans-fatty acids should be as low
as possible
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FoodCalories
Trans
Fatty
Acids
(g)
Saturated
Fatty
Acids
(g)
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-
food
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Treatment for CHD
Physical ActivityPhysical 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.
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Treatment for CHD
Weight ControlWeight Control
5-10# weight loss
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Diet Therapy of High Blood
Cholesterol
Soluble Fiber
10-20 g/day
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Drug Treatment
Statins -
Bile Acid Sequestrants
Nicotinic Acid
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Dietary Issues Requiring Further
Research
Elevated levels of
homocysteinehomocysteine
Elevated homocysteine levels
may be present in 15% of
Americans.
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Dietary Issues Requiring Further
Research
Several vitamins, including
folic acid, vitamin B6 and
B12, function are cofactors inthe metabolism of methionine
and homocysteine.
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Dietary Issues Requiring Further
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.
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Dietary Issues Requiring Further
Research
Very low-fat diets (<15 % fat)
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Steps for Lowering LDL-C in the
Diet
Eggs:
<300 mg. cholesterol: < 4
yolks/wk
< 200 mg. Cholesterol: < 2
yolks/wk
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Guidelines for Selecting &
Preparing Foods
Milk and Milk Products:
2-3 servings/day
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Steps for Lowering LDL-C in the
Diet
Fats, oils:
<6-8 tsp./day
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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
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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
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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 milkand meats
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Steps for Lowering LDL-C in the
Diet
Plant Sterols and Stanols:
Natural substances derived from
wood, vegetables, vegetable oilsand other plants - sitosterol andsitostanol
S f C
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Steps for Lowering LDL-C in the
Diet
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
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Steps for Lowering LDL-C in the
Diet
Tongue, kidneys Liver, sweetbreads,
heart and brains are high in
cholesterol.
St f L i LDL C i th
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Steps for Lowering LDL-C in the
Diet
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
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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
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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
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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 &
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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
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Risk Factors for
Coronary Heart Disease
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
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Risk Factors for
Coronary Heart Disease
High Triglycerides (>200 mg/dl) and low
HDL cholesterol is associated with
increased risk.
Stronger in women than men and older
adults
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Hypertriglyceridemia
Factors Associated with Increased
Triglycerides:
Diets - low fat, high refined sugar
Estrogens
Alcohol
Obesity
Untreated Diabetes, hypothyroidism,chronic renal failure and liver disease
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Hypertriglyceridemia
Treatment:
Weight Loss
Low cholesterol, low saturated fat diet
Increased physical activity
Smoking cessation
Management of Diabetes
Restricted alcohol use