Risk Factors for Coronary Artery Disease and Related Health Promotion Strategies Mosby items and...

Risk Factors for Coronary Artery Disease and Related Health Promotion Strategies

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Coronary Artery Disease

Coronary artery disease (CAD) is

the most common type of

cardiovascular disease in the US

Accounts for the majority of

deaths from cardiovascular

disease



CAD results from atherosclerosisAtherosclerosis

Begins as soft deposits of fat that harden with age

Described as “hardening of arteries”



Progressive disease Develops over time When it becomes symptomatic, it is

usually well advanced


Risk Factors for CAD

Risk factors can be categorized Nonmodifiable risk factors Modifiable risk factors



Nonmodifiable risk factors Age Gender Ethnicity Family history Genetic predisposition



Nonmodifiable risk factors Age

CAD increases with age



Nonmodifiable risk factors Gender

Incidence is highest in white middle-aged men

After age 65, incidence in men

and women similar



Nonmodifiable risk factors Gender

Women tend to manifest CAD 10 years later than men

When symptoms develop, women experience symptoms of angina rather than MI



Nonmodifiable risk factors Ethnicity

White middle-aged men have highest incidence is highest

African American women have a higher incidence and death rate compared to white women

Native Americans have mortality rates 2x high as other Americans



Nonmodifiable risk factors Family history and genetic predisposition Exact mechanism of inheritance is not

fully understood



Modifiable risk factors Elevated serum lipids Hypertension: BP > 140/90 Tobacco use Physical inactivity



Modifiable risk factors Obesity: BMI > 30 kg/m2

Diabetes mellitus Psychologic states



Modifiable risk factors Elevated serum lipids

Cholesterol >200 mg/dl Triglycerides >150 mg/dl



Modifiable risk factors Lipoproteins

HDLs - high density LDLs - low density VLDLs - very low density




HDLs – high levels desirable HDLs – low levels associated with

risk for CAD




2 types of HDLs: HDL2 and HDL3 Premenopausal women have 3x times

HDL2 compared to men

After menopause HDL2 levels similar to men




HDLs increased by Exercise Moderate alcohol intake Estrogen administration




Elevated LDL and VLDL levels correlate most closely with increased incidence of CAD



Modifiable risk factors Hypertension: BP > 140/90 Increases risk of atherosclerosis Salt intake is correlated with

BP



Modifiable risk factors Tobacco use Nicotine can cause catecholamine

release HR, peripheral vasoconstriction,

BP platelet adhesion leading to emboli

formation



Modifiable risk factors Physical inactivity People who are active have HDLs Exercise

Increases collateral circulation Lowers BP




Leads to increased LDLs and triglycerides

Associated with hypertension




People who are apple-shaped (store fat in abdomen) have higher incidence of CAD



Modifiable risk factors Diabetes mellitus Incidence of CAD 2-4x higher



Modifiable risk factors Psychologic states increase risk of

CAD Include depression, hopelessness,

anxiety, hostility, anger Stress correlated with CAD



Metabolic syndromeObesityElevated triglycerides HypertensionAbnormal serum lipidsElevated fasting blood glucose


Health Promotion Strategies Related to CAD

Prevention and early treatment of CAD requires a multifactorial approach Obtain lipid profile every 5 years

beginning at age 20 People with cholesterol > 200 mg/dl

are at increased risk for CAD



If cholesterol > 200 mg/dl, start dietary modifications Calorie restrictions Decrease dietary fat/cholesterol

Increase physical activity



Therapeutic Lifestyle Changes Diet - Limit saturated fats and

cholesterol and emphasize complex carbohydrates

Fats – only about 30% of calories Reduce or omit red meats, eggs,

whole milk



Therapeutic Lifestyle Changes Omega-3 fatty acids

Found in fatty fish (salmon, tuna) Reduce risk for CAD

α-linolenic acid becomes omega-3 fatty acid in the body

Foods containing it include tofu, soybeans, canola, flax seed



If LDL remains elevated, drug therapy is considered Guidelines are based on a person’s

10-yr history of having a nonfatal heart attack or dying from a coronary event



Drug Therapy Statins

Inhibit synthesis of cholesterol in the liver

Need to monitor liver enzymes Creatine kinase assessed if myopathy

suspected



Drug Therapy Niacin

Interferes with the synthesis of LDL and triglycerides

Increases HDL Adverse effects include flushing,

pruritus, GI complaints, orthostatic hypotension

Flushing may be prevented by aspirin or NSAIDs



Drug Therapy Fibric acid derivatives (e.g.,

gemfibrozil [Lopid]) Decrease hepatic synthesis and

secretion of VLDL Lower triglycerides Side effects may include rashes and

mild GI disturbances



Drug Therapy Bile acid sequestrants (e.g.,

cholestyramine [Questran]) Increase conversion of cholesterol to

bile acids Decrease hepatic cholesterol Side effects include complaints of

palatability and upper and lower GI symptoms



Drug Therapy Inhibit the intestinal absorption of

cholesterol (e.g., ezetimibe (Zetia)



Control blood pressure

Limit salt (NaCl) to <6 g or

sodium to <2.4 g

Address smoking cessation



Increase physical activity: 30 min

> 5 days/weekUse the FITT approach:

Frequency IntensityTypeTime



Antiplatelet therapy ASA Clopidogrel (Plavix)


Health Promotion Strategies and Recommended Lifestyle Changes

Risk screening begins with a thorough personal and family health history

Attitudes and beliefs about health and illness should be explored



Realistic goals related to risk reduction should be identified

Case scenario follows to provide an example of how this is accomplished


Case Scenario

A 58-year-old white male is admitted for an

elective knee replacement.

On his admission history, you note that he

is taking medication for hypertension.

When asked, he tells you that he does not

know what his BP usually is.

His BMI is 40 kg/m2 and his fasting blood

glucose level is elevated.


Case Scenario

His job is very physical (he is a bricklayer).

It has become more difficult due to his “bad

knees.” He is worried that he will be fired.

Apart from work, he does not participate in

any regular physical activity and he does

not smoke.

He tells you that he has not had a check- up

with his physician in several years.



What are his nonmodifiable risk factors? Age Gender Ethnicity



What are his modifiable risk factors? Hypertension Physical inactivity Serum lipids??? Obesity Psychologic state



Summary High risk for developing CAD Discuss lifestyle changes: diet and

exercise Consider low dose aspirin Follow-up with primary care

physician


Risk Factors for Coronary Artery Disease and Related Health Promotion Strategies Mosby items and...

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