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Disease: Disease: What You Can Do and What We Can What You Can Do and What We Can Do Do Robert A. Phillips, MD, PhD, Robert A. Phillips, MD, PhD, FACC, FAHA FACC, FAHA Director, Heart and Vascular Director, Heart and Vascular Center of Excellence Center of Excellence Professor of Medicine & Professor of Medicine & Clinical and Population Health Clinical and Population Health Research Research UMass Memorial Med Center and UMass Memorial Med Center and Medical School Medical School 03/18/2009 03/18/2009
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Preventing Heart and Vascular Disease:Preventing Heart and Vascular Disease:What You Can Do and What We Can Do What You Can Do and What We Can Do
Robert A. Phillips, MD, PhD, FACC, FAHARobert A. Phillips, MD, PhD, FACC, FAHADirector, Heart and Vascular Center of Director, Heart and Vascular Center of
ExcellenceExcellenceProfessor of Medicine & Clinical and Professor of Medicine & Clinical and
Population Health ResearchPopulation Health ResearchUMass Memorial Med Center and Medical UMass Memorial Med Center and Medical
SchoolSchool03/18/200903/18/2009
Inside a diseased artery
Atherosclerotic plaque—
Begins as a fatty streak composed of foamy macrophages containing cholesterol and other elements
Over time accumulates cholesterol and Over time accumulates cholesterol and fatfat
Narrows arteries
Contributes to heart attacks, strokes, renal failure and other vascular problems
A fatty streak, possibly occurring
in the early teen years
February 26, 2009
The Endothelium and Vascular Disease
•Physical Stenosis
•Plaque Rupture•Platelet Adhesion
•Thrombosis
•Vasospasm
UMassMemorialUMassMemorial
How Heart Attacks and Strokes OccurHow Heart Attacks and Strokes Occur
•Blocked
Artery
Prevalence of Cardiovascular Disease in adults age 20 Prevalence of Cardiovascular Disease in adults age 20 and older by age and sex. and older by age and sex. These data include coronary heart These data include coronary heart disease, heart failure, stroke and hypertension.disease, heart failure, stroke and hypertension.
15.9
37.9
73.3
7.8
79.385.9
38.5
72.6
0
10
20
30
40
50
60
70
80
90
100
20-39 40-59 60-79 80+
Per
cen
t of P
op
ula
tion
Men Women
Annual number of U.S. Adults having diagnosed heart Annual number of U.S. Adults having diagnosed heart attack by age and sex. attack by age and sex.
30,000
265,000
180,000
290,000
235,000
95,00095,000
10,000
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
35-44 45-64 65-74 75+
Ages
New
an
d R
ecu
rren
t M
I o
r F
atal
CH
D
Men Women
Prevalence of stroke by age and sexPrevalence of stroke by age and sex
0.20.9
7.8
0.3
2.9
7.6
13.5
17.1
0
2
4
6
8
10
12
14
16
18
20-39 40-59 60-79 80+
Per
cent
of P
opul
atio
n
Men Women
Established Risk Factors for Cardiovascular Established Risk Factors for Cardiovascular DiseaseDisease
Nonmodifiable Nonmodifiable –AgeAge
»>45 male>45 male
»>55 female>55 female
–SexSex
–Family HistoryFamily History
»age <55 father or age <55 father or other first degree other first degree male relative male relative
»age <65 mother or age <65 mother or first degree female first degree female relativerelative
ModifiableModifiable–HypertensionHypertension
–CholesterolCholesterol
–Elevated Low Density Elevated Low Density Lipoprotein (LDL)Lipoprotein (LDL)
–Reduced HDLReduced HDL
–Physical inactivityPhysical inactivity
–Obesity Obesity
–Diabetes Mellitus Diabetes Mellitus
–Cigarette SmokingCigarette Smoking
Classification of BP for Adults Classification of BP for Adults Age 18 Years and OlderAge 18 Years and Older
Category Systolic (mmHg) Diastolic (mmHg)
Normal <120 <80
Pre-Hypertension 120-139 80-89
Hypertension
Stage I 140-159 90-99
Stage II 160-179 100-109
Stage III 180-209 110-119
Stage IV >210 >120
Prevalence of high blood pressure in Adults by age and Prevalence of high blood pressure in Adults by age and
sex sex (NHANES: 2005-2006)(NHANES: 2005-2006). . Source: NCHS and NHLBI.Source: NCHS and NHLBI.
13.4
35.9
55.8
69.6
23.2
36.2
53.764.7 64.1
6.2
76.4
16.5
0102030405060708090
20-34 35-44 45-54 55-64 65-74 75+
Per
cen
t o
f P
op
ula
tio
n
Men Women
Consequences of High Consequences of High Blood PressureBlood Pressure
–Heart attacksHeart attacks–Strokes (Brain attacks)Strokes (Brain attacks)–Heart failureHeart failure–Kidney DysfunctionKidney Dysfunction–Vascular DiseaseVascular Disease
Lifestyle Modifications That Lifestyle Modifications That Lower Blood PressureLower Blood Pressure
ExerciseExerciseDietDietAlcoholAlcohol
Exercise- How Is it Helpful?Exercise- How Is it Helpful?
Lowers blood pressureLowers blood pressure Facilitates weight loss and maintenance Facilitates weight loss and maintenance
of weightof weight Raises HDLRaises HDL Reduces chances of getting diabetesReduces chances of getting diabetes Overall, less likely to have a clot Overall, less likely to have a clot
coronary arterycoronary artery Improves quality of lifeImproves quality of life
How Much Exercise is Enough How Much Exercise is Enough to Reduce Risk of Heart Attack to Reduce Risk of Heart Attack and Improve Quality of Life?and Improve Quality of Life?
Moderate exercise 3x Moderate exercise 3x weekweek–25 minutes 3x/week – some 25 minutes 3x/week – some
benefitbenefit–40 minutes 3x/week – more 40 minutes 3x/week – more
benefitbenefit–60 minutes 3x/week – more 60 minutes 3x/week – more
benefitbenefit
JAMA. 1996;276:241-246.Martin, C. K. et al. Arch Intern Med 2009;169:269-278.
What types of activities What types of activities count?count?
brisk walkingbrisk walking joggingjogging treadmill set at 5 miles per hourtreadmill set at 5 miles per hour snowshoeingsnowshoeing X-country skiingX-country skiing bicyclingbicycling singles tennis singles tennis SkiingSkiing Farm workFarm work
JAMA. 1996;276:241-246.Martin, C. K. et al. Arch Intern Med 2009;169:269-278.
Consume Less Sodium and Consume Less Sodium and Eat More Potassium Eat More Potassium
Sodium restriction Sodium restriction – Typical American diet >6 gm sodium/dayTypical American diet >6 gm sodium/day– Limit should be 2 gm sodium/dayLimit should be 2 gm sodium/day– Read labels, make your own foodRead labels, make your own food
Potassium is good for youPotassium is good for you– Good evidence that high intake lowers BPGood evidence that high intake lowers BP– Fresh fruit - banana, apricots, grapefruit, plumsFresh fruit - banana, apricots, grapefruit, plums– Vegetables - potatoes, spinach, brocolli, Vegetables - potatoes, spinach, brocolli,
mushrooms, cauliflower, artichoke globemushrooms, cauliflower, artichoke globe– Legumes - beans, lentils, chick peasLegumes - beans, lentils, chick peas
Alcohol - Moderation Alcohol - Moderation
1 oz of ETOH: Neutral or 1 oz of ETOH: Neutral or lowering effect on BPlowering effect on BP– 24 ounces of beer24 ounces of beer
– 8 ounces of wine8 ounces of wine
– 2 ounces of 100 proof whiskey2 ounces of 100 proof whiskey
Greater than 1 oz of alcohol Greater than 1 oz of alcohol raises blood pressureraises blood pressure
Medications – Many choicesMedications – Many choices
Diuretics (water-pills)Diuretics (water-pills) Angiotensin Converting Enzyme Angiotensin Converting Enzyme
InhibitorsInhibitors Calcium Channel BlockersCalcium Channel Blockers Angiotensin II Receptor BlockersAngiotensin II Receptor Blockers Renin InhibitorsRenin Inhibitors Beta BlockersBeta Blockers Alpha BlockersAlpha Blockers
Optimumcholesterol levels
Total cholesterol <200
LDL cholesterol <100
HDL cholesterol >40
Triglycerides <150
Your coronary heartdisease (CHD) risk level
Target levels for LDL-C are determined by the following questions:
Do you have coronary heart disease (CHD)? Do you have a coronary risk equivalent? Do you have major risk factors other than LDL
cholesterol?
Someone with CHD or equivalent is considered at high risk and has an LDL-C goal of <100 and perhaps even <70
Coronary Heart Disease Equivalents
This classification includes— Diabetes mellitus Peripheral artery disease Abdominal aortic aneurysm Symptomatic carotid artery disease
(stroke, transischemic attack) Any combination of multiple risk factors
with a 10-year risk of CHD > 20 percent,based on the Framingham risk calculation
Patients in this classification have the most aggressive LDL-C goal (<100 and perhaps even <70).
LDL-C goals
CHD risk category 10-yearCHD risk
LDL-C goal (mg/dL)
CHD or CHD risk equivalents
>20 percent
<100 or <70
2 or more risk factors (CHD equivalent)
>20 percent
<100 or <70
2 or more risk factors 10 to <20 percent
<130
0 to 1 risk factor <10 percent
<160
Imaging Modalities of Your Imaging Modalities of Your Heart and Blood VesselsHeart and Blood Vessels
CT AngiographyCT AngiographyMagnetic Resonance Magnetic Resonance
ImagingImagingEchocardiographyEchocardiography
1490s, Leonardo da Vinci1490s, Leonardo da Vinci
Historical Perspective on Coronary Artery Imaging: 1490s, Leonard da Vinci - 2 Days to Draw
UMassMemorialUMassMemorial
1490s da Vinci, 2 days1490s da Vinci, 2 days
2003, Sensation 16, <20 sec 2003, Sensation 16, <20 sec
2006 Definition, <10 sec
CT Angiogram of the Right Coronary ArteryCT Angiogram of the Right Coronary Artery
RCA
UMassMemorialUMassMemorial
Severe atherosclerotic lesion in the Severe atherosclerotic lesion in the mid- left anterior descending arterymid- left anterior descending artery
UMassMemorialUMassMemorial
MRI of a Normal Heart and One MRI of a Normal Heart and One with A Leaky Aortic Valvewith A Leaky Aortic Valve
Echocardiogram of a Echocardiogram of a Normal HeartNormal Heart
Echocardiogram of a Dilated Heart Echocardiogram of a Dilated Heart (L) and a Hypertensive Heart (R)(L) and a Hypertensive Heart (R)
New and Minimally Invasive New and Minimally Invasive Vascular SurgeryVascular Surgery
Anatomy of An Abdominal Anatomy of An Abdominal Aortic AneurysmAortic Aneurysm
Open Repair of Abdominal Open Repair of Abdominal Aortic Aneurysm Aortic Aneurysm
Why do it?Why do it?– If Aneurysm bursts, If Aneurysm bursts,
chance of death is highchance of death is high
Disadvantages of Disadvantages of Surgery:Surgery:
– Long, complicated Long, complicated surgerysurgery
– Long recoveryLong recovery
– DisfiguringDisfiguring
Open Surgical AAA Repair Open Surgical AAA Repair – Long Recovery, Big Scar– Long Recovery, Big Scar
Endovascular AAA RepairEndovascular AAA Repair
AdvantagesAdvantages– No SurgeryNo Surgery
– Miniminal to no Miniminal to no recovery timerecovery time
– Excellent Excellent FunctionFunction
Endovascular Repair of Endovascular Repair of Abdominal Aortic AneurysmAbdominal Aortic Aneurysm
BEFORE AFTER
ST Segment Elevation Myocardial Infarction (STEMI)UMMHC Process Improvement: 2005-2008
0
20
40
60
80
100
120
140
160
Jan'05 Apr'05 Jul'05 Oct'05 Jan'06 Apr'06 Jul'06 Oct'06 Jan'07 Apr'07 Jul'07 Oct'07 Jan'08 Apr'08 Jul'08 Oct' 08
Door
to B
allo
on T
ime
(min
utes
)
Median Mean Goal
Cardiac Alert Team Initiative Began
Number of CasesCY2005: 55 CY2006: 62 CY2007: 89 CY2008 (through 10/2008): 63
ST Elevation Myocardial Infarction (STEMI): Door To Balloon (DTB) and Mortality Improvement
81.0%
72.0%
61.5%
96.0%
84.6%
74.2%
57.1%
50.0%
43.5%
89.5% 92.6% 92.4%91.3%91.7%
1.90%
1.10%
0.79%
1.40%
0.70%
1.30%1.40%
1.70%
2.40%
0.82%
1.11%
2.98%
0.70%
0.79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1Q-CY05 2Q-CY05 3Q-CY05 4Q-CY05 1Q-CY06 2Q-CY06 3Q-CY06 4Q-CY06 1Q-CY07 2Q-CY07 3Q-CY07 4Q-CY07 1Q-CY08 2Q-CY08
% D
TB T
ime
< 90
Min
s
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
Mor
talit
y R
ate
DTB time < 90 Minutes Mortality Rate
Right Coronary ArteryRight Coronary Artery with Normal Blood Flow with Normal Blood Flow
RCA
UMassMemorialUMassMemorial
Heart Attack with Blocked Right Heart Attack with Blocked Right Coronary Artery – No Blood Coronary Artery – No Blood FlowFlow
Heart Attack Aborted with Heart Attack Aborted with Angioplasy – Blood Flow RestoredAngioplasy – Blood Flow Restored
Aborted Heart Attack with Stent Aborted Heart Attack with Stent in Right Coronary Arteryin Right Coronary Artery
Thank you!Thank you!Stay Healthy!Stay Healthy!
