Download - How to Prevent Heart Attacks
Preventing Heart Attacks
V.S.Ramchandra,MD,DM,FACC,FSCAI,FESC.Consultant Cardiologist
Formerly: Professor & Head of Cardiology, KMC, Manipal
Chief Electrophysiologist, Apollo HospitalsAssociate in Cardiology, UAB Hospital, AL, USA
Staff Cardiologist, St Vincent Health, IN, USA
Magnitude of the Problem: Global Burden of Cardiovascular
Disease•½ way through a 2 century transition ; CVD will dominate as the major cause of Death Globally•Although CVD is ↓in EstME it is ↑ in the rest of the world with 85% of the worlds population. •10% (1900) → 25% (2000) → 50% (2020) of Global Deaths.
CAUSES OF DEATH
• 1. MYOCARDIAL INFARCTION (HEART ATTACK) DUE TO CORONARY ARTERY DISEASE • 2. CEREBROVASCULAR ACCIDENT (STROKE) DUE TO BLOCK IN BRAIN TUBES• CANCER
INDIAN SCENARIO
Prevalence of CAD in Different Countries
•
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
WomenMen
Coronary Artery Disease – Indian Scenario: Indians Vs West
•Average Age of first MI in west is 70 years. In India it is 45 to 55 years.•At any level of conventional RF – Indians have X2 CAD than whites with similar RF
Coronary Artery Disease – Indian Scenario: Past Vs Present
•CAD rates have halved in W in last 30 yrs – Increasing alarmingly (doubled) in India•Average Total Cholesterol was 120mg% - increased to 200mg% •Average Age of first MI has ↓ by 20 yrs- ½ < 50yrs, ¼ < 40 yrs of age• Diabetes has increased by 60%.
WHAT IS A HEART ATTACK
WHAT IS A HEART ATTACK
WHAT IS A HEART ATTACK
WHAT IS A HEART ATTACK
WHAT IS THE HEART
Non-Invasive Diagnosis of CAD
Ischemia detection• ECG/ TMT- Sen-60%,Sp-80%• Stress ECHO• SPECTCoronary CalciumCTA- 99% sensitivity- may overestimate
COURAGE TRIAL
• OMT Vs (Revascularisation+ OMT)•2300 pts- 70% proximal lesion+Ischemia or 80%+angina, 2/3TVD• At 5 Yrs- No difference in Mortality, MI, hospitalisations, Stroke.
WHERE IS REVASCULARISATION USEFUL
• UNSTABLE ANGINA- Symptoms /Trop/ varying ST-T ECG changes• PRIMARY ANGOPLASTY FOR AMI• TVD with LV DYSFUNCTION• ? Lt MAIN, Silent Ischemia, Severe Stenosis
How Predictable & Preventable is CVD
• Interheart Study: 90% Predictable• Multiple Risk Factor Interventional Trials: 0 to 60% reduction•Observational studies in migrant populations show vast differences in CVD mortality
Cardiac Risk Factors- Modifiable• Smoking• Hypertension• Diabetes• Metabolic Syndrome• Dyslipidemia• Obesity• Sedentary Life style• Lack of fruits, GV & fiber in diet• Anger, Hostility, Work stress, Depression, LSS• Alcohol
Surrogate Markers of Coronary Artery Disease
• Vascular Disease Elsewhere – Strokes, TIA, PVD, Carotid bruits, Abdominal Aneurysms
• Diabetes• Chronic Renal Failure
Coronary Artery Disease Risk Factors-Non Modifiable
• Male Sex• Post Menopausal State• (+) Family History• Genetic Susceptibility• Lp (a)• Diabetes• ? Infection
Smoking Cessation
• Risk of CAD/Re- MI/CABG failure X2• Leading preventable cause of Death• 25% in US to 70% in China• 80% start before age 18 yrs• In US: 55% →25% (M), 35% →20% (W)• Risk falls rapidly after cessation
Smoking Cessation (Cont..)•Cessation highly Cost effective •Intervention usually short term•1 yr success rates- 6% Physician counseling , 20% self help programs, 40% with Buproprion /nicotine patch•3 types of Behavioral therapy- Problem solving, social support in & outside treat•Most effective after event
Alcohol•20 to 45% risk ↓ with moderate consumption (60ml-male, 30 ml- Female)•↑HDL, ↑Fibrinolysis, ↓Platelet aggregation•10-20% become chronic alcoholics•Consider HTN, DM, ↑TG, Hgic Stroke, Liver Disease, f/h alcoholism /Breast Ca/ Colon Ca•Prescription should be individualized“Whether wine is a nourishment,medicine, or poison, is a matter of dosage”-Celsus
HTN- The Magnitude of the Problem
•HTN is the commonest medical diagnosis, affecting 1 billion worldwide•Prevalence of HTN: 3% in 18 to 24 yrs age 13% in 35 to 44 yrs age & 70% in those >75 yrs.•For persons over age 50, SBP is a more important than DBP as a CVD risk factor.
HYPERTENSION
• >120/80-PREHYPERTENSION, >140/90- HTN• NO SYMPTOMS. 2/3 OF AMERICAN
HYPERTENSIVES NOT AWARE • SAME GOALS FOR ALL AGES • SYTOLIC BLOOD PRESSURE MORE
DANGEROUS• MOST NEED 2 OR MORE DRUGS• GOALS: <130/80. <115/75 IN DIABETICS
WITH PROTEINURIA.
Pre-Hypertension: A New Disease Is Created
Starting at 115/75 mmHg, CVD risk doubles every 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.Intent in creating Pre-HTN(22% of adult population) is to stress LSM, prevent progression & to treat other CVRF
Hypertension- treatment most cost effective
• Risk ↑ Linearly from 115/75mmHg.• 5 mm ↓ in BP Reduces strokes by 40% , CVD by 15% & Heart failure by 25%• In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated
.
Lifestyle Modification
Modification Approximate SBP reduction(range)
Weight reduction 5–20 mmHg/10 kg weight loss
DASH eating plan 8–14 mmHg
Dietary sodium ↓ 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Diabetes Mellitus
• Confers X 4 Risk. Young stroke X 10. No menstrual protection for women. • Deemed a Coronary Artery Disease equivalent by AHA• Worldwide ↑ by 35% (from 5%) by 2025, max in China (↑68%) & India (60%) •Thrifty Gene Hypothesis
•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test
Calculating your risk of Developing Diabetes Mellitus
•Overweight – 5•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test
Preventing Diabetes with LSM
•DPP: Weight loss by 7% & 150 mins/ wk of moderate ex – reduced chance of becoming Diabetic by 55% in IFG/ IGT compared to 30% with metformin•Delaying may be preventing- Glitazone•Once Diabetic no degree of control of sugars shown to prevent macrovascular complications
OBESITY
1. BODY MASS INDEX: WEIGHT in Kg/ HEIGHT in M.SQ. 25 – 30(OWERWEIGHT) 30 – 35(OBESE)
2. WAIST CIRCUMFERENCE <90Cms(M), <85Cms
3. PROTRUDING TUMMY 4. WAIST >HIP
Physical Inactivity / Exercise
•75% American Adults•Inverse Linear Dose Response relationship. Ex & all-cause mortality •CAD, MI, HTN, DM, Dyslipidemia, MS•50% Primary, 25% Secondary protection
Exercise
• Goals: Maintain 70-80% of THR for 45 Mins 5 days/Week. • THR= 220-AGE• Maintain ideal Body Weight & muscle mass & Flexibility.
CHOLESTEROL
• A NATURAL MEMBRANE BUILDER .• THE FINAL ROUTE TO BLOCKAGES IN ARTERIES• GOOD - HDL CHOLETEROL• BAD - LDL CHOLESTEROL• UGLY - TRIGLYCERIDES• DEADLY- Lp (a).
1% ↑ Heart Attacks for every 2% ↑ in LDL or 1% ↓ in HDL
Naturalization
AVERAGE IS NOT NORMAL!!•Average LDL of Hunter-gatherers, Neonates, Mammals is 50-70mg%. No Atherosclerosis even in 7th & 8th decades.•Avg American LDL is 130. 50% above 50Yrs have atherosclerosis.
LDL - Naturalisation HOW LOW IS LOW ENOUGH? IS IT SAFE?•10% of highest LDL account for 20% of CAD. • Only 25% risk reduction with current LDL Trt.•Threshold for atherosclerosis progression is LDL of 67mg%, CVD event rate 0 at LDL 57 (primary) & 30 mg% (secondary prevention).•50% ↓ in LDL for secondary & 30% ↓ for primary prevention.•? All people above 55yrs should receive statins
ACT BEFORE DISEASE IS FIXED
• More beneficial to Treat High Risk or Low Risk patients •50% reduction by bringing LDL to 55mg% in “low risk”- Jupiter trial
Metabolic Syndrome
Any 3 of the below:• TG > 150mg/dl• HDL-C <40 (M), <50 (F)• FBS (plasma) >100mg/dl• BP >130/85• Waist Circumf > 90cm(M) > 85cm(W)Incidence: 40%, 28% (No IFG), 75%(DM/IFG)
Diet & Cholesterol
• Contribution of dietary cholesterol to Blood T-C is small (10mg%) compared to dietary fats (100mg%)• 4 types of Fatty acids:• Good - Poly unsaturated (PUFA)• Great - Mono unsaturated (MUFA)• Bad - Saturated (SAFA)• Deadly - Trans saturated (TFA)
Diet & Cholesterol- Milk
• In Indians SFA come from diary products & cooking oils• Avoid whole fat milk & milk products Diary products are more saturated & athero/throbogenic than meat products• Nonfat Milk- Calcium, B12, ↓ BP, decreases diabetes risk.
Cooking Oils / Fats
• Oils have powerful cholesterol increasing & lowering actions• 1/3rd of the 54% decline in CAD in US attributed to ↑ PUFA by 5%.• 30mg% ↓ in T-C by banning palm oil & substituting it by soybean oil•Nuts are high in fat(cashew 21%, peanut14%) but low in SAFA and do not ↑T-C
Cooking Oils
• SAFA: Butter, coconut and palm oil is more athero / thrombogenic than lard & beef tallow• MUFA: Oleic acid in Canola & Olive oil reduces LDL & increases HDL.• PUFA: ð-3 (fatty fish, walnuts, canola & soybean oil) ð-6 ( corn, soybean, cotton) 4:5 decreases LDL and HDL•TFA- Pastries, fried chicken, margarines/ dalda, ready foods, crispy bakery products.
Diet- Energy•Carbohydrates – Rice•Fats – Milk, Cooking oils•Proteins – Pulses, Milk •Marked ↓in Fat intake or ↑in Carbs will ↓HDL•Marked ↑ in protein ↑load on kidneys•Fibre – Cereals•Micronutrients- Fresh fruits, undercooked vegetables
Diet- Carbs- Rice
•Carbohydrates – Polished Rice, Maida, White bread, Biscuits, Upma, Dosa, Sugar, Sweets•Cereals with their outer fibrous coating removed•Glycemic Index •Satiety •Fibre -Soluble & Insoluble
Substituting Fats with Carbs
Diet (Cont..)•Balance Total Calories with expenditure to maintain ideal BMI•Minimize Saturated /trans fat to 7% of cal•Mono-unsaturated fats rest 20% of cal•Omit rapidly digested Carbs – White Rice •Whole grains are excellent source of energy, fiber & protein
Diet (Cont…)•Maximize fruits & fresh Vegetables to 5 servings/day + some nuts•Use only very low fat Dairy products•2-3 servings of Fatty fish /week•Dietary supplements- 1gm/D 3 fatty acids, Folate, B6&12, Multivitamins•Alcohol.
•US: 1960-30%, 2000- 65%, 2-5yrs-5%, 6-19yrs-15%. ↑ ↑ ↑ DM, ↑ CVD later.•Abdominal Obesity poses greater risk•3part strategy- Caloric restriction, Structured physical activity, Behavior therapy for BMI>30•Failure rates extremely high
FOOD
PYR
AMID
Indian Paradox Less RF- More CAD. 1. Genetic predisposition.?Lp(a) 2. Central obesity-Insulin Resistance 3. Metabolic Syndrome 4. Processed carbohydrates, Increased energy. 5. Increased dairy Fats 6. Frying/ Reuse of oils- TFA.
Sleep & Obstructive Sleep Apnea
Less than 6 or More than 8 hrs/day Sleep Deprivation & Altering Cycles Sun-Ambient Light & Sleep Getting up and getting ready for work Snoring, Daytime drowsiness, HTN, Age, BMI & Neck Cicumference- OSA
3 Main causes of heart Attacks
Food Exercise
Mental Stress
Type A,Type D behavior
•Compulsive overachievers, excessively competitive & ambitious, aggressive, hostile, unable to relax, impatient & get easily frustrated / angry•Anger, Suppressed Anger, hostility.•Large Prospective studies of healthy x 2 risk of developing CAD•Type D- suppressed negative emotions
Psychosocial Factors
• Depression• Social Isolation• Anger & Frustration• Hostility• Job Strain-High demand with little autonomy• Marital stress
Tackling Negative Emotions
• Connection between Emotions & Breath• Observe Sensations• Everything Changes – Including emotions • Opposite values are complimentary• Be Centered• Pranayama & Meditation
Lp(a) - The Deadly Cholesterol• >15-20mg/dl• Purely Genetic• Best childhood
predictor• Highly atherogenic,
thrombogenic, antifibrinolytic
• Highest among all races except blacks
• 40 % of Indians.
Tobacco10%
HTN10%
Diabetes10%
TC/LDL15%TC/HDL
15%
lp(a)25%
Hcy5%
Other10%
Tobacco
HTN
Diabetes
TC/LDL
TC/HDL
lp(a)
Hcy
Other
Contributions of various risk factors for CAD among Asian Indians
Tobacco10%
HTN10%
Diabetes10%
TC/LDL15%TC/HDL
15%
lp(a)25%
Hcy5%
Other10%
Tobacco
HTN
Diabetes
TC/LDL
TC/HDL
lp(a)
Hcy
Other
Prevention- From Womb to Tomb
• Womb - Measures to prevent IUGR• Infancy- Infections?• Childhood – Physical activity, prevent obesity, proper nutrition and lifestyle enforcement. Lp(a)• Early Adulthood – FLP if F/h, screen for DM if Obese.•Adulthood – Screen for all RF, HsCRP
Prevention- The Caveats
• Eat Less - Eat a variety• Be Natural- Exercise, Diet, Sleep • Learn to Relax• Act Before Diseases are Fixed
Predicting CAD
Biomarkers- Hs CRP• LP PLA2Vascular Imaging• Carotid IMT (<1 to>3 mm)- Young• CACS by EBCT or MSCT (>100Au)
Genomic markers• High Density Genotyping- SNP• Genome expression Assays
PRIMARY PREVENTION DRUGS- ASPRIN & ROSUVASTATIN
• More HDL raising & TG (Stellar)• Safer than any other Statin• More reduction in HsCRP• First IVUS regression (Asteroid Trial)• Multiple sites of action (HMG, CETP, PPAR a, ApoA1, Longest half life
Life Style & Behavioral Modifications
• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
Life Style & Behavioral Modifications- Doing it
• Understand & be Motivated• Like it & be part of a group• Structured program & should become part of routine life by strength of habit• Started early in life & should have social/family/ work place support
Population-Based Strategy SBP Distributions
BeforeIntervention
AfterIntervention
Reduction in SBPmmHg
2
3
5
Reduction in BP
% Reduction in MortalityStroke CHD Total
–6 –4 –3–8 –5 –4
–14 –9 –7
“SUPERIOR DOCTORS PREVENT DISEASE; MEDIOCRE DOCTORS TREAT DISEASE BEFORE IT IS EVIDENT; INFERIOR DOCTORS TREAT FULL BLOWN DISEASE”
Huang dee. First Chinese Medical Text. 2600 BC.
How Predictable & Preventable is CVD
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
Women
Men
Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)
Cardiac Metaphors of Daily Life• Races with Excitement• Pounds in Anticipation• Stands still in Dread, Skipped a Beat• Aches with Grief• With a Heavy Heart• The Lion Hearted, Large hearted, Heartless• Broken Hearted
Preventing Heart Attacks Role of Lifestyle Modifications &
Behavioral ChangesV.S.Ramchandra MD,DM,FACC,FSCAI,FESC.
Global HospitalsFormerly:
Professor & Head of Cardiology, KMC, ManipalChief Electrophysiologist, Apollo Hospitals
Associate in Cardiology, UAB Hospital, AL, USAStaff Cardiologist, St Vincent Health, IN, USA
WHAT IS THE HEART
WHAT IS CIRCULATION
• Supplies Nutrients• Removes Waste• Supplies Oxygen• Removes CO2• Single Pump• Blood Pressure• Gradient = 120-10• Extremely Low
Resistance
WHAT HAPPENS IF CIRCULATION TO PART OF THE
BODY IS STOPPED
• BRAIN (STROKE)• HEART ( HEART
ATTACK or MI )• KIDNEY
(HYPERTENSION)• LEG (GANGRENE)• EYE (BLINDNESS)
WHAT HAPPENS IF THE HEART STOPS
WHAT IS A HEART ATTACK
Prevalence of Heart Attacks in Different Countries
•
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
WomenMen
WHAT IS A HEART ATTACK
WHAT IS A HEART ATTACK
WHAT IS A HEART ATTACK
CAUSES OF DEATH
• 1. MYOCARDIAL INFARCTION (HEART ATTACK) DUE TO CORONARY ARTERY DISEASE • 2. CEREBROVASCULAR ACCIDENT (STROKE) DUE TO BLOCK IN BRAIN TUBES• CANCER
Heart Attacks – Indian Scenario: Indians Vs West
•Overseas Indians–CAD X 4 Americans•Urban Indian Epidemic(10%)Vs USA(2.5%)•Hear Attack rates have halved in W in last 30 yrs – Increasing alarmingly (doubled) in India•Average Age of first Heart Attack in west is 70 years. In India it is 45 to 55 years.
Heart Attacks – Indian Scenario: Past Vs Present
•Heart Attack rates have increased alarmingly (doubled) in India in last 25 years•Average Total Cholesterol was 120mg% - increased to 200mg% •Average Age of first Heart Attack has ↓ by 20 yrs- ½ < 50yrs, ¼ < 40 yrs of age• Diabetes has increased by 60%.
Heart Attacks – Indian Scenario Urban Vs Rural
•Rural Vs Urban: ½ Despite higher smoking •RF incidences: Smoking- 55%®,35(U) •Diabetes- 3%®, 11% (U)•Hypertension- 14%®, 25% (U)•TC/HDL >5 – 28%®, 46% (U)•Urb Vs Rural: BMI 25Vs20, WHR0.99Vs.95•Higher CAD in South India- Urb Kerala13%
How Predictable & Preventable are Heart Attacks
• Interheart Study: 90% Predictable• Multiple Risk Factor Interventional Trials: 0 to 60% reduction•Observational studies in migrant populations show vast differences in CVD mortality
Heart Attack Risk Factors- Modifiable
• Smoking• High BP (Hypertension)• High Sugars (Diabetes)• High/ Bad fats/cholesterol (Dyslipidemia)• Increased weight/fat (Obesity)• Sedentary Life style (lack of Exercise)• Metabolic Syndrome• Lack of fruits, GV & fiber in diet• Anger, Hostility, Work stress, Depression, LSS• Alcohol
SMOKING
• COMMONEST CAUSE OF DEATH IN YOUNG ADULTS AND ELDERLY
• NICOTINE + LARGE NUMBER OF TOXINS• IMMEDDIATE SPASM• DAMAGES EPITHELIUM (INNER LINING OF
TUBES) EVERYWHERE• PRECIPITATES DIABETES• SUDDEN DEATH
Smoking Cessation
• Risk of CAD/Re- MI/CABG failure X2• Leading preventable cause of Death• 25% in US to 70% in China• 80% start before age 18 yrs• In US: 55% →25% (M), 35% →20% (W)• Risk falls rapidly after cessation
Smoking Cessation (Cont..)•Cessation highly Cost effective •Intervention usually short term•1 yr success rates- 6% Physician counseling , 20% self help programs, 40% with Buproprion /nicotine patch•3 types of Behavioral therapy- Problem solving, social support in & outside treat•Most effective after event
Alcohol•20 to 45% risk ↓ with moderate consumption (60ml-male, 30 ml- Female)•↑HDL, ↑Fibrinolysis, ↓Platelet aggregation•10-20% become chronic alcoholics•Consider HTN, DM, ↑TG, Hgic Stroke, Liver Disease, f/h alcoholism /Breast Ca/ Colon Ca•Prescription should be individualized“Whether wine is a nourishment,medicine, or poison, is a matter of dosage”-Celsus
Diabetes Mellitus
• Confers X 4 Risk. Young stroke X 10. No menstrual protection for women. • Deemed a Heart attack equivalent by AHA• Worldwide ↑ by 35% (from 5%) by 2025, max in China (↑68%) & India (60%) •Thrifty Gene Hypothesis
•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test
Calculating your risk of Developing Diabetes Mellitus
•Overweight – 5•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test
Preventing Diabetes with LSM
•DPP: Weight loss by 7% & 150 mins/ wk of moderate ex – reduced chance of becoming Diabetic by 55% in IFG/ IGT compared to 30% with metformin•Once Diabetic no degree of control of sugars shown to prevent heart attacks or strokes
HYPERTENSION
• NO SYMPTOMS. 2/3 OF AMERICAN HYPERTENSIVES NOT AWARE
• SAME GOALS FOR ALL AGES • SYTOLIC BLOOD PRESSURE MORE
DANGEROUS• MOST NEED 2 OR MORE DRUGS• GOALS: <130/80. <115/75 IN DIABETICS
WITH PROTEINURIA.
Hypertension
• >140/90. Prehypertension >120/80• Risk ↑ Linearly from 115/75mmHg.• 5 mm ↓ in BP Reduces strokes by 40% , CVD by 15% & Heart failure by 25% • In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated
.
Pre-Hypertension: A New Disease Is Created
Starting at 115/75 mmHg, Heart Attack/Stroke risk doubles for every 20/10 mmHg increase throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.Intent in creating Pre-HTN(22% of adult population) is to stress LSM, prevent progression & to treat other CVRF
Lifestyle Modification
Modification Approximate SBP reduction(range)
Weight reduction 5–20 mmHg/10 kg weight loss
DASH eating plan 8–14 mmHg
Dietary sodium ↓ 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Life Style & Behavioral Modifications
• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
Life Style & Behavioral Modifications
• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
Life Style & Behavioral Modifications
• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
Life Style & Behavioral Modifications- Doing it
• Understand & be Motivated• Like it & be part of a group• Structured program & should become part of routine life by strength of habit• Started early in life & should have social/family/ work place support
Population-Based Strategy SBP Distributions
BeforeIntervention
AfterIntervention
Reduction in SBPmmHg
2
3
5
Reduction in BP
% Reduction in MortalityStroke CHD Total
–6 –4 –3–8 –5 –4
–14 –9 –7
“SUPERIOR DOCTORS PREVENT DISEASE; MEDIOCRE DOCTORS TREAT DISEASE BEFORE IT IS EVIDENT; INFERIOR DOCTORS TREAT FULL BLOWN DISEASE”
Huang dee. First Chinese Medical Text. 2600 BC.
MENTAL STRESS & PHYSICAL STRESS
• DEPRESSION, SOCIAL ISOLATION, ANGER, AGGRESSIVENESS (TYPE A BEHAVIOUR)
• INCREASED MENTAL OR PHYSICAL WORK NOT DANGEROUS.
How Predictable & Preventable is CVD
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
Women
Men
Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)
Psychosocial Factors
•Studies hampered by imprecision in definitions & accepted metrics•Depression, Chronic Hostility, Social isolation, Perceived lack of Social support consistently linked with ↑ risk •Data inconsistent with anxiety, work related stress & Type A behavior
Psychosocial Factors (Cont..)
• Low socioeconomic status• Acute mental stress /stress induce SMI• Sudden emotion-↑RR in 1-2 hrs of event• Lethal arrhythmias & SCD following mentally stressful events• HTN–Relaxation training,meditation & biofeedback for pt with subjective stress
CAUSES (Risk Factors) OF HEART ATTACK
SMOKINGDIABETES
HYPERTENSIONCHOLESTEROL
OBESITY/ METABOLIC SYNDROMELACK OF EXERCISE
MENOPAUSEMENTAL STRESS
MENOPAUSE
• SUDDEN SURGE IN HEART ATTACKS• TOTAL MORTALITY> MALES• DIABETES TOTALLY NEGATES
PROTECTION OF MENSES.• HRT HARMFULL• MALES WILL BE SAVED IF WE KNOW
WHAT PROTECTS FEMALES!
Lp(a) - The Deadly Cholesterol MULTIPLIER EFFECT
Contributions of various risk factors for CAD among Asian Indians
Tobacco10%
HTN10%
Diabetes10%
TC/LDL15%TC/HDL
15%
lp(a)25%
Hcy5%
Other10%
Tobacco
HTN
Diabetes
TC/LDL
TC/HDL
lp(a)
Hcy
Other
THIS IS WHAT KILLS US!
• INCREASED PROCESSED CARBOHYDATES.• RAPID ABSORPTION OF SUGAR• INCREASED INSULIN, ARTERY
THICKENING, TRIGLYCERIDES, DECRESED HDL.
• RICE IS TOXIC!• THERE IS AN EPIDEMIC COMING!
NON MODIFIABLE FACTORS:
• Age,• Sex• Family History
HOW MUCH LESS IS LESS ENOUGH
CARBOHYDRATESLDL<100
BP<120/80BMI<25
INCRESED FIBERINCREASED EXERCISE
BE HAPPY!
REVOLUTION OR EVOLUTION
HASTEN SLOWLY
CABGs
WHAT IS THE HEART
WHAT IS THE HEART
STENT RESTENOSIS
WHAT IS THE HEART
Magnitude of the Problem: Global Burden of Cardiovascular
Disease•½ way through a 2 century transition ; CVD will dominate as the major cause of Death Globally•Although CVD is ↓in EstME it is ↑ in the rest of the world with 85% of the worlds population. •10% (1900) → 25% (2000) → 50% (2020) of Global Deaths.
INDIAN SCENARIO
Epidemiological Transitions•Age of Pestilence & Famine – LE is 30yrs•Age of Receding Pandemics - ↑ Food & ↓ ↓ in Infant and child mortality •Age of Degenerative & Man Made Diseases – Easier access to cheaper carb/fatty foods, mechanization leads to ↓ energy expenditure, Urbanization → ↑ crowding, smoking & work stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD (>50%), ↑ Cancers. LE>50yrs.
Epidemiological Transitions•Age of Delayed Degenerative Diseases – LSM, ↓Smoking (45% →23%) , Trt of HTN – CHD ↓2% per yr, Stroke ↓ 3% per yr, CVD strikes later.•Age of LSM plateau & Early Obesity - ↑ caloric intake & ↓Physical activity- 75% Overweight or Obese - ↑ HTN/DM. LE = 75yrs(M), 80yrs(W)•Future Age of Intense LSM , Behavioral Changes & Naturalization
Surrogate Markers of Coronary Artery Disease
• Vascular Disease Elsewhere – Strokes, TIA, PVD, Carotid bruits, Abdominal Aneurysms
• Diabetes• Chronic Renal Failure
Coronary Artery Disease Risk Factors-Non Modifiable
• Male Sex• Post Menopausal State• (+) Family History• Genetic Susceptibility• Lp (a)• Diabetes• ? Infection
Risk factors- from Womb to Tomb
•Thrifty Phenotype(Barkers) Hypothesis•Thrifty Genotype Hypothesis•Brenners Hypothesis for essential HTN•IUGR and CAD - ↑LDL & apo B.
Risk factors- from Womb to Tomb- Child/Adulthood
• Increasing T-Chol (from 75 in cord blood to 120-150 by 2 wks- stable till 20 yrs – rises to 200 - 240 in most adults.• Catch-up obesity• Middle age bulge• Increasing Systolic BP
The Magnitude of the Problem
•HTN is the commonest medical diagnosis, affecting 1 billion worldwide•Prevalence of HTN: 3% in 18 to 24 yrs age 13% in 35 to 44 yrs age & 70% in those >75 yrs.•For persons over age 50, SBP is a more important than DBP as a CVD risk factor.
DIABETES MELLITUS
• DECLARED NOW AS A CORONARY ARTERY DISEASE EQUIVALENT
• MORTALITY ALMOST X 4• DAMAGES ARTERIES• PROMOTES THICKENING• CONTROLL OF BLOOD SUGARS NOT
ENOUGH• GOALS: FBS<110, PPBS<140
LACK OF EXERCISE
• CENTRAL OBESITY. • DIABETES• HYPERTENSION.• CHOLESTEROL• GOALS: MAINTAIN 80% OF THR FOR 45
MINS 5 DAYS A WEEK. MAINTAIN IDEAL BODY WEIGHT AND MUSCLE MASS.
• THR= 220-AGE
Dyslipidemia-Importance of Statins
• American Heart Association DietChol Total Fat TC LDL
Step I 300 8 - 10 % 8% 10%Step II 200 < 7 % 10% 15%Only 15% motivated, only 1.5% achieved goals
• Marked ↓in Fat intake can ↓ LDL-C by 30%•Viscous fiber + plant sterols + soy protein + almonds - 30% ↓ equivalent to 10mg lovastatin•Marked ↓in Fat intake or ↑in Carbs will ↓HDL
LDL - Naturalisation HOW LOW IS LOW ENOUGH? IS IT SAFE?•10% of highest LDL account for 20% of CAD. • Only 25% risk reduction with current LDL Trt.•Threshold for atherosclerosis progression is LDL of 67mg%, CVD event rate 0 at LDL 57 (primary) & 30 mg% (secondary prevention).•50% ↓ in LDL for secondary & 30% ↓ for primary prevention.•? All people above 55yrs should receive statins
Metabolic Syndrome Indian scenario
Incidence: 40%, 28% (No IFG), 75%(DM/IFG)Waist Circumf: 30%, Low HDL: 65%, TG: 45%, HTN: 55%, IFG: 27%.•Diet, Lack of Ex•Childhood Obesity (20% in U India)•Indian Obesity Phenotype: lean BMI, High waist to hip ratio, High % of Body fat.•Barker’s Fetal priming for Insulin resistance
Psychosocial Factors
•Social isolation, Lack of Social support & Social Disruption•Life stress (major stressful life events & minor recurrent irritants/frustrations•Job Strain – High demand with little autonomy•Marital stress
Diet•DASH Trial: Diet rich in Vegetables & Fruits & Low Fat Dairy ↓ BP•Marked ↓in Fat intake can ↓ LDL-C by 30%•Lyon Diet Heart Study: Mediterranean diet ↓ Re-MI/Death by 65% compared to Western Diet •Marked ↓in Fat intake or ↑in Carbs will ↓HDL•Marked ↑ in protein ↑load on kidneys
Cardiac Metaphors of Daily Life• Races with Excitement• Pounds in Anticipation• Stands still in Dread, Skipped a Beat• Aches with Grief• With a Heavy Heart• The Lion Hearted, Large hearted, Heartless• Broken Hearted
Psychosocial Factor Modifications
• ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
Epidemiological Transitions•Age of Pestilence & Famine – LE is 30yrs•Age of Receding Pandemics - ↑ Food & ↓ ↓ in Infant and child mortality •Age of Degenerative & Man Made Diseases – Easier access to cheaper carb/fatty foods, mechanization leads to ↓ energy expenditure, Urbanization → ↑ crowding, smoking & work stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD (>50%), ↑ Cancers. LE>50yrs.
Life Style & Behavioral Modifications
• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
Life Style & Behavioral Modifications
• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective
• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality
•Cancer- Natural Killer Cells Increase with SK
•Heart Autonomics – Increased heart rate variability with SK
•Deaddiction – Smoking, Alcoholism, Drugs
•Metabolic Syndrome- Central Obesity
•Hypertension- Respirate
•Insomnia
•Diabetes
Core Technique Core Technique -- ‘‘Sudarshan KriyaSudarshan Kriya’’Scientific Validations Scientific Validations Regular Practice of the ‘Sudarshan Kriya’ will lead to:
Stress creating hormone Cortisol & Oxygen free radicals will get eliminated from the blood system.
Natural Killer Cells will Increase (Immunity)
Blood Lactate will decrease
HDL Cholesterol (useful cholesterol) will increase & LDL Cholesterol (harmful) will decrease. (Effective against blood pressure & Cardiac problems)
Increase in Alpha activity in brain with interspersed Beta activity (create calmed alertness in the brain - Study done with EEG)
70% of Depression is curable with ‘The Sudarshan Kriya’ practice.
Cancer / HIV & Sudarshan Kriya
• Cancer- Natural Killer Cells Increase with SK• Heart Autonomics – Increased heart rate variability with
SK• Deaddiction – Smoking, Alcoholism, Drugs• Metabolic Syndrome- Central Obesity• Hypertension- Respirate• Insomnia• Diabetes
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