Introduction 1

Welcome to the Cardiac Care and Heart Health ClinicCardiovascular disease remains the most important health care problem in North America. It is a disease thatbegins in youth and develops progressively over time resulting in inflammation, narrowing and sometimes bloodclot formation in vital arteries, particularly those of the heart. While family heredity determines some of therisk in developing such narrowings, a great deal of this disease may be successfully altered by diet, exercise,weight loss and control of blood pressure, cholesterol and diabetes.

These issues involve everyday habits and lifestyle, which can be modified through information, education andgroup participation. Improving these risk factors is the goal of our Secondary Prevention Program, which aimsto help you help yourself steer a better lifestyle for better health and longer life.

Bad habits and poor diets are not as difficult to change when in the company of others like yourself guided andencouraged by experts and teachers in the field. Past damage need not continue and aggressive or even modestchanges to past habits can make significant differences to the expectations of future complications and possiblesuffering. Nurses, dietitians, pharmacists, exercise specialists, psychologists, primary care and specialty physiciansare at your disposal to form a partnership which can reduce future complications. Much of our well being restsin our own hands and we are essentially what we eat. You are strongly invited to read the information that follows and consider seriously investing in a new start to a healthier and longer life.

Dr. James B. NasmithDirector of the S.P.A.C.E. Program

May 2003

Linda Belford, ACNPLinda Brubacher, RN, MN, ACNPMargaret Brum, BASc, RDVeola Caruso, RNKeith Denny, MLS, MAVaska Micevski, RN, MScN, PhD(c), ACNPDr. Robert Nolan, Ph.D., C. Psych.Dr. Brian O’Kelly M.B., F.R.C.P.C.Beth Polyak, Pharm. D.Adrienne Kovacs, Ph.D

Contributors List:

Intoduction2

What is the Cardiac Care and Heart Health Program?It is a program whose major aims are to reduce your risk of future heart problems, and maximize your overall health.Most people visit the program about 4 to 5 times. Why should you come to the program? Because preventing futureheart problems, and maximizing your health, depends a lot on how you live your life. Simple changes in your life -like getting regular exercise, eating well, and taking whatever medication you need on a regular basis - will make a bigdifference to your future health. But to make these changes, and to stick with them, you really need to understandwhat causes heart disease. So the first aim of this program is to educate you about your own heart so that you canactively participate in your own care.

Self-education is a cornerstone of our clinic and reading the information that follows is an important first step in thateducation. Some people learn better from talking to other people and so we also encourage you to attend the educationsession held in the clinic. These group discussions are led by our experienced dietitian, nurse, exercise specialist, psychologist and pharmacist who will give you specific advice about diet, exercise, medication, readiness for change andcoping with heart disease. The exercise personnel will also outline the various exercise programs available at TorontoWestern Hospital, which include a formal supervised group exercise program (cardiac rehabilitation) or, if that doesn’tsuit you, a program that you can do yourself at home. In addition, these discussions offer you a chance to meet otherpeople who have had heart problems, and to learn from their experience. These sessions will also introduce you to otherprograms available in the hospital that may be of great benefit to you. For instance, there are programs on stress reduc-tion and on the management of diabetes.

This binder, and our education sessions, will also introduce you to the important concept of “risk factors”. A risk factor is a personal characteristic that increases the chance that one of your heart blood vessels will become blocked.Such a blockage is usually due to fat building up in the wall of one of these blood vessels, called the coronary arteries.When these arteries become partially or completely blocked then you may have a heart attack. Why does fat build-upin the wall of the coronary arteries and block them? A very important reason is that the smooth lining of these arteriesbecomes damaged and inflamed, causing cholesterol and blood clots to stick onto the wall of the artery. What candamage this smooth lining? Well pretty much all of the risk factors that cause heart disease do so by damaging theblood vessel lining. High blood pressure, diabetes, high cholesterol and low good cholesterol, and smoking are themain risk factors and they are harmful for this reason.

A key goal of the program is to correct these risk factors. Correcting risk factors is best achieved by adopting healthyhabits in your life but also often requires you to take medication to reach your target levels for blood pressure, cholesterol and diabetes. Our program will also educate you about the drugs we use to achieve these targets. Our phar-macist will review your medication with you at your first and subsequent visits. Our acute care nurse practitioners playa key role in evaluating your overall health and in identifying your major risk factors. They participate in your education, co-ordinate your drug treatment and form a partnership with you to maximize your health, and reduceyour risk. They also work closely with the physicians in the clinic and with your own cardiologist and family practi-tioner to achieve these goals. It often takes several visits for you to get onto the right kind of medication at the rightdosage to correct your risk factors.

Reducing your risk of further heart trouble will take time and effort. However, by working together we can achieve a lot.We believe that you will understand the causes of heart disease well enough to actively participate in your own care. Wealso believe that by a careful combination of healthy living habits and needed medication you will be healthier and havea much reduced risk of further heart problems. We look forward to working with you to achieve these goals.

About the Heart 3

What are the ways I can work on improving my health?In this section of the binder you will find out how you can help yourself and your health care teammanage your heart health.

“The journey of a thousand miles begins with a single step”

-Chinese Proverb

What can help me change my behaviour?There are a number of steps that can help me change my behaviour or actions.

I need to think about how my actions or emotions contribute to my health. These include feelings oractivities that make it hard for me to eat right, exercise or to take my medication. For example, stress ornot knowing how to do something may influence my health care habits. If I share this information withthe health care team, they can help me set my personal goals for a healthy way of living.

Here are a few steps to help change my behaviour or actions:

Y Believe that I can change my behaviour and can learn to live a more healthy lifestyle

Y Identify important goals for myself after I have been given information about my health, and my riskfactors for heart disease

Y Discuss these goals with my health care team members

Y Identify situations or issues that may make my goals difficult to reach and discuss how I will over-come these issues with my health care team

Y Identify and discuss my progress towards my goals with my health care team

Y Once I have achieved my goals, I will set new goals and plans to achieve them together with myhealth care team

Y Realize that changing behaviour is a difficult activity that takes time and sometimes several tries

Y I realize that my healthy activities may help my family and friends live a heart healthy lifestyle

Y Applaud my successes and pat myself on the back

4 About the Heart

Who is responsible for my health care?The team of health care professionals that help me manage my heart health consist of doctors, nursepractitioners, nurses, pharmacists, dietitians, social workers and exercise specialists.

My role on this team is very important. I am the person that is responsible for most of my care. I make sure that I understand my heart disease and the risk factors that can make it worse.

This team provides information to me so that I can make better decisions about my own health care.

Y I understand that the best and most complete treatment for my heart and for reducing my risk factors may include medication, diet counseling, exercise and stress management

Y My team will help me quit unhealthy habits I may have picked up like smoking, unhealthy eating ornot getting enough exercise

Y I can change my behaviour. My health care team will help me do this

Y I will actively take part in setting my goals for each of my risk factors

About the Heart 5

The Workings of Your Heart

Where Is My Heart Located?Y Your heart lies in the middle of your chest, slightly to the

left and is protected by the breastbone (sternum) and rib cage. (see picture1)

What Does My Heart Look Like?

Y Your heart is a hollow, muscular organ about the same size as your fist

Y It is a two-sided pump, with a muscular wall called the septum separating the right and left sides

Y On the inside of the heart, both the right and theleft sides have an upper and lower chamber. Theupper chambers are called atria and the lowerchambers are called ventricles. The chambers(atria and ventricles) are separated by smalldoors called valves. These valves open andclose when your heart beats

Picture 1

Picture 2

pulmonaryvalve

tricuspidvalve

mitralvalve

aorticvalve

6 About the Heart

How Does My Heart Work?Y Clench your fist, relax it, clench it again, and you can imagine your heart beating. In the same way,

the heart tightens and relaxes when it beats or contracts

Y As a pump, the heart works non-stop to keep blood moving around the body

Y The blood pumped by the heart carries oxygen and nutrients (food) to body cells and tissues andremoves waste

Y Blood is pumped through your heart in the following way: (see picture 2)

1) The right side of the heart receives blood that has just come from the body (muscles, organs, and brain)

2) The blood is then pumped to the lungs where waste material (carbon dioxide) is removed and freshoxygen is picked up

3) The blood then returns to the left side of the heart. Here it is pumped from the ventricle into theaorta. The aorta is a large blood vessel

4) From the aorta the blood flows to all parts of the body, delivering food (such as sugar and oxygen)

Y The heart also has four valves which act as doors in the heart. They work to make sure that the bloodmoves through the heart in one direction (see picture 2)

4 tricuspid valve is found on the right side

4 pulmonic valve is found on the right side

4 mitral valve is found on the left side

4 aortic valve is found on the left side

Coronary Arteries

Y For your heart to work, it also needsits own supply of oxygen-rich blood.The heart muscle is fed by the coronary arteries. Coronary arteriesare blood vessels that surround yourheart (see picture 3)

Picture 3

About the Heart 7

Y Three main coronary arteries lie on the outside of the heart:1. The left coronary artery starts with a short part called the left main. It divides into the left anterior

descending (LAD) branch and the circumflex branch. The LAD feeds the left side and front of theheart muscle, and the circumflex takes blood to the back of the heart on the left side

2. The right coronary artery feeds the right side of the heart as well as the back and underside of the leftside of the heart

8 About the Heart

Common Procedures 9

What are some of the Common Problems of the Heart?The following information will help you understand terms you may have already heard while in the hospitalor while visiting with your doctor. If you want more information about your heart problem, ask when youare at the clinic.

Atherosclerosis: Atherosclerosis or coronary artery disease (CAD) means thickening or hardening of the arteries. Overtime, the walls of the arteries sometimes develop a fatty build-up called plaque. This plaque is a sticky, yellow material made up of cholesterol and cell waste. When this build-up blocks the flow of blood to the heart muscle, less blood and oxygen gets to the heart. This can lead to angina or a heart attack.

Angina:Angina can be described as chest pain or chest discomfort, and is often the first sign of coronary arterydisease. Angina is the heart muscle’s way of warning you that it is not getting enough blood and oxygenbecause of clogged arteries. Angina does not usually last for more than 30 minutes and causes no heart damage.

What are the Warning Signs?Y tightness, pressure, squeezing and/or aching feeling in the chest, arms, neck or jaw

Y discomfort beginning in the chest may spread to the neck, jaw, throat, shoulder, back ofarm(s) and is often associated with sweating, shortness of breath, and/or nausea

Y feeling of heart burn that will not go away

Y sometimes people do not experience chest discomfort but only feel breathless, weak orsweaty. This is common in older people, women, and in people with high blood pressure, ordiabetes

Y usually happens with exercise or emotional stress and goes away within 5 to 15 minutes withrest or nitroglycerin

** go to the EMERGENCY section of this book to know the difference between angina and a heart attack, and how to treat them

Common Procedures10

Arrhythmias:Arrhythmias are abnormal or irregular beatings of the heart. Everyone’s heart skips a beat every now andthen so it’s normal to sometimes feel your heart give an extra thump. However, the rhythm of your heartcan go wrong and then your heart may beat too slowly (bradycardia) or too quickly (tachycardia).

With a slow heart rhythm you may feel the following:

What are the Warning Signs?Y tiredness

Y dizziness, lightheadedness

Y fainting or near fainting spells

The slow heart rhythm can easily be corrected with a pacemaker.

The fast rhythm (tachycardia) may be happening in the upper chambers of the heart (the atria) and becalled a supraventricular tachycardia. The fast rhythm may also be happening in the lower chambers ofthe heart (the ventricles) and be called a ventricular tachycardia. Ventricular tachycardia is far more seri-ous and can lead to death.

What are the Warning Signs?Y flutters or palpitations in the chest

Y chest pain

Y breathlessness, tiredness

Y dizziness, fainting or near fainting spells

These fast rhythms may be treated with drugs, surgery or an implantable defibrillator (shock treatment).

Atrial Fibrillation:Atrial fibrillation is one type of supraventricular tachycardia. This is a heart rhythm in which the upperchambers of the heart beat much too fast. Normal hearts beat with both the upper heart chambers andthe lower heart chambers pumping blood at the same speed. Atrial fibrillation causes irregular beats in theupper chambers causing the lower chambers to also beat irregularly. These irregular heart beats can lead toblood clots forming in the heart. These blood clots can break free and travel to the brain causing a stroke.

What are the Warning Signs?Y flutters or palpitations in the chest

Y chest pain

Y breathlessness, tiredness

Y dizziness

This irregular heart rhythm can be treated with drugs or sometimes shock treatment to the chest.

Common Procedures 11

Congestive Heart Failure:Congestive heart failure is a condition in which the heart does not pump as strongly as it should. Theheart has become weak. When this happens, blood that should be pumped out of the heart backs up intothe lungs and other parts of the body. This may cause breathlessness or swelling of the ankles and legs.

What are the Warning Signs?Y breathlessness with activity or at rest

Y feeling tired with very little work

Y sudden weight gain (4 or more pounds in 4 days)

Y swelling of the ankles or legs

Y swelling or pain in the belly

Y trouble sleeping unless you are propped up on 2 or more pillows

Y dry, hacking cough (often when lying down)

Y loss of appetite or bloating

Congestive heart failure can be treated with drugs and living with healthy habits. Ask more about whatyou can do for your heart failure when you visit the doctor or here in the clinic.

Heart Attack or Myocardial Infarction:** Go to the EMERGENCY section of this book to know what to do in the case of a heart attack

A heart attack happens when blood flow to part of the heart muscle is cut off. The blood flow is cut offbecause one or more of the coronary arteries has become clogged by a combination of fat in the walls ofthe artery, and blood clot in its centre. With no blood and oxygen, a part of the heart muscle dies. Thedamage done is permanent.

Signs of a heart attack are like angina but are more severe and last longer than 30 minutes. The pain doesnot go away with rest or nitroglycerin. It may begin suddenly, at rest or during some activity.

What are the Warning Signs?

Y Chest pain: tightness, discomfort or crushing pain, heaviness, pressure, squeezing, fullness orburning

Y Pain spreading from chest: down one or both arms, up to neck, jaw, shoulders or upper back

Y Other signs: shortness of breath, paleness, sweating, weakness, faintness, nausea, vomiting orindigestion, anxiety, fear or DENIAL (refusing to admit that anything is wrong)

Common Procedures12

Heart Valve Disease:The 4 valves of the heart are made to keep blood moving through the heart in ONE direction. When thevalves are damaged, they may not open or close properly.

The damage to the heart valves may be mild, moderate or severe.

Y very mild damage does not affect one’s life very much

Y moderate damage may cause one to feel short of breath, or tired

Y severe damage can cause very unpleasant feelings (see “warning signs”) and must be fixed before theheart muscle itself becomes badly damaged

The heart valves can have 3 types of problems: 1) stenosis – the heart valve is narrow and makes opening of the valve hard

2) prolapse - a part of the heart valve can slip out of place

3) regurgitation – there is backwards flow through the heart valve and there is trouble with the valve closing all the way

When valves do not open and close as they should, less blood gets through. This causes the heart to workharder to pump blood to the body. If the heart is not able to do this, heart failure occurs. Abnormalvalves can also cause an irregular heartbeat or blood clots to form in the heart.

What are the Warning Signs?Y chest pain

Y feeling very tired

Y fluttering or palpitations in the chest

Y shortness of breath

Y swelling of the ankles, wrists or stomach

Y dizziness, fainting or near fainting spells

These valve problems may be treated with drugs, or with surgery to either repair or replace the heart valve.

For more information on heart valve disease ask when you visit the clinic.

Procedures 13

What Tests or Procedures Might I Have Done for My Heart?The following information may not give you all you need to know about a heart test or procedure.However, it will give you some general information for the more common tests and procedures. If you want to have more information, ask when you are visiting the clinic.

Angiography or Angiogram: What is this test?An angiogram (sometimes called a heart catheterization) is a test that you will have done in the hospital.This test uses x-rays to record the movement of x-ray dye in the arteries of the heart. The test looks at theheart and its circulation system.

Long thin tubes called catheters are used. The tubes are put into a blood vessel in your groin or your armunder local freezing. The tube is then gently guided to your heart under x-ray, which you cannot feel.This test is not usually painful.

Why might I have this test done? The test is done to look for blockages in the arteries of the heart from fat build-up. People who have angina or chest pain might need to have this test done. This test also looks at the valves of the heart, andcan be used for people who have problems with their heart valves.

Angioplasty: What is this procedure?Angioplasty is a procedure that is not surgery. The procedure is very much like the angiogram.

A catheter with a balloon on the tip is put in an artery of the heart that has a blockage. The small balloonis blown up for a few seconds and pushes the fatty build-up against the artery wall. This widens the artery,and good blood flow comes back.

Procedures14

Why might I have this procedure done? The procedure is done for people who have 1 or more blockages in the arteries of their heart. However,angioplasty is not suited for all patients with blockages in the arteries of the heart. Your doctor will tellyou if angioplasty or bypass surgery is needed for any blockages seen in your arteries.

Angioplasty with Stents: What is this procedure?This is a newer method of angioplasty which uses a coronarystent to keep the artery of the heart open after angioplasty. Astent is a mesh tube made of stainless steel (almost like chickenwire). The procedure is like the angioplasty. The stent is placedover the balloon during the angioplasty. When the balloon isblown-up, the stent gets bigger and is pressed into the arterywall. The balloon is then deflated and removed. The stent staysin place forever to help keep the artery open. In a short time, theinside skin of the artery covers the stent.

Coronary Artery Bypass Graft Surgery: What is this procedure?Coronary artery bypass graft surgery is a type of open heart surgery. The procedure is done to reroute orbypass blood around a clogged artery of the heart. A variety of blood vessels are used to bypass theblocked artery. Most commonly, the surgeon takes a leg vein and sews one end into the aorta above theblockage and the other end into the coronary artery below the blockage. The vein lets blood flow from theaorta to the lower part of the heart’s artery, bypassing the blockage (see diagram below). Often an arteryfrom the chest wall or arm is also used for the bypass.

**Note: the narrowed or clogged arteries are not removed.

Why might I have this procedure done? Bypass surgery is an option for people who have angina orchest pain that is not well controlled by drugs, or the loca-tion of their blockages does not allow for angioplasty to bedone. The surgery is done to improve blood flow to theheart muscle. This helps to make the heart work better andhelps to get rid of angina or chest pain.

Echocardiogram (Echo): What is this test?The echocardiogram is a test that uses sound waves (ultra-sound) to look at your heart. The test is done to look atthe heart’s size and how the valves and chambers of theheart are working.

Procedures 15

How is the test done? Having an echo does not hurt and takes about 20 to 30 minutes. You remove upper body clothing and liequietly on a bed. A trained person moves a scanner over your chest, taking pictures and recording themon videotape or computer.

Electrocardiogram (ECG or EKG): What is this test?The test records the electrical activity of the heart muscle. The ECG can show abnormal heartbeats andareas of damage or enlargement in the heart muscle.

How is the test done? An ECG does not hurt, and it lasts about 5 to 10 minutes. Wires will be attached to your chest, arms andlegs. As recordings of your heart activity are made, you are asked to lie quietly without moving your armsor legs or talking.

Exercise Treadmill or Stress Test: What is this test?A treadmill or stress test records the heartbeat duringrest, exercise and just after exercise.

How is the test done? You will be hooked up to a monitor with wires inorder to monitor your ECG and blood pressure. Youwill walk on a treadmill. A trained person will gradu-ally adjust the speed and angle of the belt to forceyou to exercise a little harder. The test will be stoppedif you begin to have chest pain, feel short of breath,feel very tired, or the ECG shows your heart is notgetting enough blood and oxygen. Altogether the testtakes about 1 hour, though only 10 minutes of this isspent actually walking.

Holter Monitor Test: What is this test?The Holter monitor test takes a constant recording of your ECG while you are walking and moving around.

How is the test done? Wires are hooked up to your chest and you carry a small box over your shoulder. It is usually carried for24 or 48 hours. Wearing the monitor does not hurt, and there is no danger to you wearing it. You cancarry on doing your normal daily activities, but should not bathe or shower while wearing the monitor.

Why might I have this test done? This test is done to look for abnormal beats of the heart. You may have this test done if you complain offluttering or palpitations in the chest, dizziness, fainting or near fainting spells.

Procedures16

Nuclear Perfusion Scanning: What is this test?A nuclear perfusion scan is a type of x-ray. The test will show the blood flow to the heart muscle at restand during exercise. It will help show where there might be clogged arteries to the heart.

How is the test done? For this test, a small amount of radioactive material is put into a vein in your arm through a small needle.This material is not harmful to you. You are exposed to less radiation than during a routine chest x-ray.

There are several types of nuclear scans:1. Exercise thallium or sestamibi

You will be asked to walk on a treadmill. After you are done exercising on the treadmill, a smallamount of radioactive material is put through the IV (needle) in your arm. You will lie on a bed and a special camera will take pictures of your heart. The camera is looking to see how much of theradioactive material got to your heart muscle while you were exercising. A second set of pictures is done at rest, usually 4 hours later. The total length of time for the test is 5 to 6 hours.

2. Persantine thallium or sestamibiIf you are not able to walk on a treadmill for any reason, you may have this test done instead. This testis similar to the exercise thallium scan but you do not have to walk on a treadmill. Instead of walking,the doctor will give you a drug (persantine) that will speed up your heart artificially. The test also showswhere there is poor blood supply or damage to the heart muscle.

Pacemaker: What is a pacemaker?An “artificial pacemaker” is a small battery-operated metal case that helps the heart to beat regularly. Apacemaker uses batteries to send electrical charges to the heart to help it pump better. The pacemakerworks like a "mini-computer".

Procedures 17

What is involved in getting a pacemaker? Getting a pacemaker requires small surgery. You are usually awake during the procedure, but they give youlocal freezing. The pacemaker is put under the skin below the left collarbone. The newest pacemakers arealmost as small as a book of matches.

Valve Surgery: What is this procedure?Valve surgery is open heart surgery. When possible, your own heart valve is repaired. If the heart valve is too badly damaged to be repaired, the valve must be replaced. The valve is replaced, with either amechanical valve or a tissue valve.

1) mechanical valve:These valves are made of a long-lasting metal and plastic. They last a long time. They can also cause blood clots to form. To prevent clots from forming, patients must take blood-thinning pills(called coumadin) every day for the rest of their lives.

2) tissue valve:These valves are specially treated and come from humans or animals. They do not last as long as themechanical valves. They also do not cause blood clots to form like the mechanical valves, so a bloodthinner pill may not have to be taken.

an example of a pacemaker

Procedures18

Risk Factors 19

Risk Factors for Heart Disease• There can be many reasons why people develop coronary artery disease. These reasons are called “risk

factors”. Risk factors are conditions that make your chances of getting heart disease more likely. Themore risk factors you have, the greater the chance you have of getting heart disease.

• There are two kinds of risk factors: risk factors you can control and risk factors you cannot control.

What are the risk factors that I cannot control?

Y Age The older you get, the more at risk you are for heart disease

Y Gender Men are at higher risk for heart disease, but after menopause, women are at the same risk as men

Y Family History If someone in your immediate family (mother, father, grandparent, brother or sister) has heart disease, you may be at higher risk of getting heart disease

What are the risk factors that I can control?Y High blood pressure – “hypertension”

Y Diabetes

Y High cholesterol – too much “bad” cholesterol and/or too little “good” cholesterol

Y Being overweight – “obesity”

Y Smoking

Y Not enough exercise

Y Stress

Reminder: Risk factors such as hypertension, diabetes and high cholesterol are “silent”. That means you can have these risk factors without knowing.

The following pages will give you more information on the risk factors that you can control.

Risk Factors20

Hypertension: “High Blood Pressure”

What is blood pressure?• Blood pressure is the force of blood against the walls of your arteries

• You need blood pressure to move blood through your body

• Blood pressure is recorded as two numbers (for example 110/70), usually measured as millimeters ofmercury (mm Hg)

• The top number is the “systolic” pressure and represents the pressure in the arteries when the heart beats

• The bottom number is the “diastolic” pressure and represents the pressure in the arteries when the heartrests between beats

Systolic pressure (top number) i.e. 110

Diastolic pressure (bottom number) 70

What is high blood pressure?• High blood pressure or “hypertension” occurs when the blood pressure is almost always above the

normal limit when it is measured

• Your blood pressure needs to be high on three separate visits to the doctor before you are considered tohave high blood pressur

• A normal blood pressure is less than140/90 if you do not have diabetes

• A normal blood pressure is less than130/80 if you do have diabetes

What causes high blood pressure?• In 90-95% of people, the cause of high blood pressure is not known

• Even though we often do not know the cause of high blood pressure, there are certain risk factors thatare often related to high blood pressure or may increase your chance of developing high blood pressure

Risk Factors 21

Why is it important to control high blood pressure?• High blood pressure makes your heart work harder than normal. High blood pressure puts extra pres-

sure on the walls of your arteries and inflames the smooth lining of the arteries, making it rough andsticky. Inflammation and damage of the lining of the arteries makes it easier for cholesterol and fatdeposits to collect along the walls. Blood clots begin to form on the damaged, roughened lining of theartery. The combination of fat deposits and blood clot may cause angina and heart attacks

• Therefore, high blood pressure will:

4 damage the arteries in your body, including the arteries that feed the heart

4 cause the heart to get bigger making it harder for it to pump properly

4 increase your chance of getting a stroke

4 increase the chance of kidney damage

Risk factors related to high blood pressureAGE The chance of developing high blood pressure goes up as we

get older

FAMILY HISTORY People with a family history of high blood pressure may be athigher risk of getting high blood pressure

GENDER: High blood pressure is more common in men, but womenafter menopause are also at higher risk

DIABETES If diabetes is not well controlled, the risk of getting high bloodpressure gets higher

SALT If you have a high salt intake, it can make high blood pressure worse

OVERWEIGHT If you are overweight, you are more likely to develop highblood pressure

ALCOHOL A high alcohol intake may lead to getting high blood pressure

STRESS Although it is not certain, high levels of stress may lead togetting high blood pressure

EXERCISE People who do not do any exercise have a higher chance ofgetting high blood pressure

Risk Factors22

How is high blood pressure treated?1. Healthy lifestyle: a healthy lifestyle may be enough for some people to control high blood pressure.

A healthy lifestyle includes:

4 No smoking

4 Limiting your alcohol intake ( less that 2 drinks per day)

4 Regular exercise (minimum of 20 -30 minutes 4 times a week)

4 Managing stress

4 Keeping a healthy weight

4 Limiting your salt intake

2. Medications: a healthy lifestyle alone may not be enough to control high blood pressure and medications are often necessary. You may be put on one or more of the following types of medicationsto help control your blood pressure:

4 Diuretics

4 Beta-Blockers

4 ACE Inhibitors

4 Calcium Channel Blockers

4 Angiotensin II Receptor Blockers

4 Alpha-Blockers

NOTE: These medications aredescribed in detail in the medicationsection and additional informationwill be provided at your meeting withthe pharmacist.

Risk Factors 23

Diabetes

What is Diabetes?Diabetes is a disease that causes your body to have trouble controlling the blood glucose or “sugar” levels.Insulin is a substance made by the body that helps our body use glucose. If you have diabetes, your bodycannot make enough insulin, or it cannot properly use the insulin it makes. Therefore, your body cannotuse the glucose properly to give you energy.

How is diabetes diagnosed?A normal blood sugar measured on an empty stomach should be between 4 and 7 mmol/L. (mmol/L or millimoles per liter is the unit of measure used for this blood test).

If you tested your blood and your blood sugar or “glucose” levels are higher than 7mmol/L, then you mayhave diabetes. You have to be on an empty stomach for at least 8 hours for this test to be accurate.

You may also hear the term Haemaglobin A1c used by a health care professional. This is a blood test thattells us how well your blood sugar has been for the three months before the test. These are the ranges:

How is diabetes treated?Diet: Some people may be able to control their diabetes by making the best food choices. You

should see a dietitian to help you understand what kind of foods to eat and how much.

Exercise: Regular exercise will also help your body control diabetes.

Medication: If you need medication to control your diabetes, it is very important to take the medicationas it is prescribed. Over time, your medication may need to be changed. See your nurse,doctor or pharmacist regularly to make sure you are on the right medications.

Keep Track Of Your Blood GlucoseYou should measure and keep track of your blood sugar everyday. Recording your blood sugars will helpthe doctor understand how well your diabetes is being managed and whether changes are needed.

*It is important for you to learn about this disease so you can help to keep it under good control. There are many education programs available to you to help you learn more about diabetes.

Talk with your nurse or doctor about making arrangements for you to attend one of these programs.

Haemaglobin A1c Level of blood sugar (glucose) control

0.040 – 0.060 Ideal – very good control

less than 0.070 Optimal – Good target range

0.070 – 0.084 Not very good

greater than 0.084 Very bad – action is needed to make this better

Risk Factors24

What should you do if you have a low blood sugar level?Do one of the following:

4 Drink orange juice (4oz)

4 Drink regular pop (4oz)

4 Eat 2 teaspoons of sugar or honey

4 Eat 4 to 6 “Lifesavers” or three hard candies

4 Eat two “glucose tabs”

4Check your blood sugar again in 10-15 minutes. If it is still low, repeat one of the above choices again.

4Always follow this with a snack that has carbohydrate in it like unsalted crackers or bread.

** Remember, if you can’t test your blood glucose but you think you are having a low blood glucose reaction, go ahead and follow the instructions above.

Why is it important to control diabetes?Diabetes that is not well controlled will damage the arteries around the heart and in the rest of your body.Poorly controlled diabetes means that there is too much sugar in the blood. This extra sugar inflames anddamages the smooth lining of the arteries, just like high blood pressure. Fat deposits and blood clots start todevelop in the arteries, leading to angina and heart attacks. Poorly controlled diabetes can also damageother areas of the body, especially your eyes and kidneys. Keeping your sugar levels between 4 and 7 willhelp to minimize the damage caused by diabetes, and help prevent any existing damage from getting worse.

What are the signs of a low blood sugar? (A blood sugar level of less than 3.5)

Hunger Cold sweats

Feeling light-headed Weakness

Nervousness Confusion

Faster heart beat Trembling

What are the signs of a high blood sugar?

Extreme tiredness Drowsiness

Dry mouth Frequent urge to urinate

Extreme thirst

Risk Factors 25

Obesity or Overweight

What is obesity? Obesity is when your weight is greater than what is recommended for your height.

What is a healthy weight?• Healthy bodies come in all different shapes and sizes.

The Body Mass Index (BMI) is a scale that shows you if your weight is in a healthy range.

• A healthy body weight is a BMI between 18 and 24.9.

• The higher your BMI goes above 25, the greater your risk is of having health problems.

• Eating the proper foods and exercising regularly will help to keep you at a healthy weight.

• If your weight is too high, there are many ways to help bring it down. A dietitian can help you withyour meal planning to help you lose weight.

What is your BMI?To calculate your BMI, use the equation below or use scale on page 26.

Five ways to help control or reduce your weight:1. Be more active – Regular exercise will:

• Help your body use more calories so they won’t be stored as fat• Help to decrease your appetite so you will eat less• Help speed up your metabolism so that your body will use more calories even while you are resting

2. Healthy eating• Eat more fruits and vegetables• Add flavor to food with herbs and spices instead of with fat• Eat foods high in fiber to help you feel less hungry

3. Cut down on fat: • Everyone needs some fat in their diet, but most people eat too much fat. Fat is very high in calories

and too much fat may cause you to gain weight

4. Cut down on calories: • Reducing the number of calories can help you to lose weight

5. Write down the food that you eat every day:• Writing down what you eat will help you decide what changes you may need to make to

help you to lose weight

BMI = weight in kgheight in m2

Risk Factors26

Why is it important to control your weight?• Being overweight puts extra stress on your heart and this can lead to heart disease

or make your existing heart disease worse

• It can also raise your blood pressure and your cholesterol levels and will increase your risk of developing diabetes

Note: For persons 65 years and older the normal range may begin slightly� above BMI 18.5 and extend into the "overweight" range

BMI Risk of developing problemsIncreased< 18.5

Least18.5 – 24.9 Increased25.0 – 29.9

High30.0 – 34.9 Very High35.0 – 39.9

Extremely High≥ 40.0

BMI

Height (cm)

Height (in)

We

igh

t(k

g)

We

igh

t(k

g)

145 150 155 160 165 170 175 180 185 190 195 200 20540

45

50

5048

4644

42

3836

30

35

40

25

3432

2826

2422

2018

16

1455

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

88

99

110

121

132

143

154

165

176

187

198

209

220

231

242

253

264

275

286

297

30857 59 61 63 65 67 69 71 73 75 77 79 81

18.5

145 150 155 160 165 170 17540

45

50

55

60

65

70

75

23

For a quick determination ofBMI (kg/m2), use a straight-edge to help locate the pointon the chart where height (inor cm) and weight (lb or kg)intersect. Read the number onthe dashed line closest to thispoint. For example, an indi-vidual who weights 69 kg andis 173 cm tall has a BMI ofapproximately 23.

Refer to the table below to identify the level of health riskassociated with a particular BMI.

Adapted from: WHO (2000) Obesity: Preventing and Managing the Global Epidemic: Report of aWHO Consultation on Obesity.

Risk Factors 27

Cholesterol

What is cholesterol?• Cholesterol is a fat. It is a soft waxy substance made by our bodies. Our bodies need cholesterol to

work properly. Some people have too much cholesterol in their blood. Too much cholesterol can causeproblems for your body.

• When there is too much cholesterol, the extra attaches to the inside of our arteries and builds up toform fat deposits or “plaques”. Remember the fat deposits and inflammation we talked about in the section on high blood pressure and diabetes? Too much cholesterol and plaque causes the same thing tohappen to the arteries. The plaques block the arteries so that blood cannot pass through easily, andblood clots tend to develop on these plaques.

In addition to cholesterol, there are other kinds of “fats” in the body that you should know about. Not allcholesterol is bad. There are “bad” kinds and there is one “good” kind.

1. LDL – Low Density Lipoprotein – “the lousy cholesterol”:• LDL is another kind of fat that our body needs to work properly. But, just like cholesterol, too

much LDL also leads to plaque build up causing blocking of the artery.

• To help you remember that LDL is the bad cholesterol, think of “L” as lousy or low.

2. HDL – High Density Lipoprotein – “the healthy cholesterol”:• HDL is often referred to as the good cholesterol because it actually helps to remove LDL

cholesterol from plaque. Higher levels of HDL in the blood may help to protect you from heartdisease.

• To help you remember that HDL is the good cholesterol, think of “H” as healthy or high.

3. Triglycerides:

• Triglycerides are the most common form of fat found within our bodies. Too much triglyceridemay also lead to heart disease.

• High triglyceride levels are often associated with high alcohol intake, being overweight or poorlycontrolled diabetes.

Cholesterol TestingAs part of your regular check-up, you will probably have your cholesterol levels checked. You have to be onan empty stomach for 12-14 hours to have this test done. The blood test will include all of the following:

• Total Cholesterol

• LDL – Low Density Lipoprotein

• HDL – High Density Lipoprotein

• Triglycerides

Risk Factors28

What Should My Cholesterol Levels Be?If you already have coronary artery disease, the chart below will tell you what your cholesterol levelsshould be.

Why is it important to control cholesterol levels?Well controlled cholesterol levels can reduce your chance of developing coronary artery disease or frommaking coronary disease worse and will reduce your chance of having a heart attack.

How can I control my cholesterol levels?Diet: Making the best food choices is very important to help control cholesterol levels. If your cholesterollevels are too high, meeting with a dietitian will help you to make any necessary changes to your diet tomake your cholesterol levels better. See Nutrition section for more information.

Medication: Often changes in your diet alone may not be enough to bring down your cholesterol levels and medication may be required. For more information on medications for cholesterol, see Medication section.

Exercise: Regular exercise can help to improve your cholesterol levels by raising the “good or healthy”HDL cholesterol. For more information, please see Exercise section.

Smoking: Smoking can lower the amount of “good or healthy” HDL cholesterol in the blood. Quittingsmoking will help raise the amount of good cholesterol and it will also help lower your chance of having aheart attack in the future.

Total Cholesterol Less than 5 mmol/L

Triglycerides Less than 2 mmol/L

High Density Lipoprotein (HDL) More than 1.0 mmol/L for menMore than 1.2 mmol/L for women

Low Density Lipoprotein (LDL) Less than 2.5 mmol/L

Risk Factors 29

Alcohol

Is alcohol bad for the heart?Drinking more than the recommended level of alcohol can cause many problems that affect your heart.These problems include:

• Raising your blood pressure

• Increasing your triglyceride levels

• Increasing your weight

• Causing the heart to become stretched and weaker

How much alcohol is okay to drink?Generally speaking, you should not have more than 2 drinks per day.

One drink is measured as:

1.5 oz of hard liquor (for example whiskey, rum, rye)

1 bottle of beer (350ml or 12 oz)

5 oz of wine

Can I drink any alcohol if I am taking medications?Alcohol may interact with some medications. Speak with your doctor or pharmacist to see if it is a problem for you.

Risk Factors30

Smoking

Is smoking bad for my heart?

• YES! Smoking increases your risk of getting heart disease or making heart disease worse. Someonewho smokes is at 2-3 times higher risk for getting heart disease or having a stroke than someone whodoes not smoke

• You can decrease your chance of getting a heart attack or having another heart attack by 50% withinthe first year by quitting smoking

• If you continue to smoke after having bypass surgery, you are 3- 4 times more likely to need anotherbypass surgery within 5 years

• If you continue to smoke after angioplasty, you are almost twice as likely to have the artery block upagain within 7 months as compared to someone who does not smoke

• Smoking may also cause other health problems such as lung cancer

How does smoking cause heart disease?• Smoking makes the blood sticky. This increases the chance of a blood clot forming and causing a

heart attack

• Smoking also makes it easier for cholesterol to attach to the artery wall and cause a blockage

• Smoking may also cause the coronary arteries to go into spasm

Quitting SmokingIf you smoke, quitting can be very hard. Many people try to quit several times before they are successful.On average, many smokers try to quit about 7 times before they are successful. If you would like to quitsmoking or are thinking about quitting smoking, there are programs available to help you.

Remember, being part of a smoking cessation program can increase your chances of quitting for good by sixtimes compared with not being part of a program. Don’t be afraid to ask for help. Speak to your nurseabout how you can get help. See Smoking cessation section for more information on quitting smoking.

Your risk of a heart attack falls quickly once you stop smoking. If you stop smoking for three years yourrisk of having a heart attack is the same as someone who never smoked.

**Remember….it is never too late to think about quitting!

Risk Factors 31

Stress

What is stress?• Stress can happen when circumstances in your life (work or personal) are more than you can handle

easily. Stress is very individual. We do not all respond to the same situations in the same way.

• For some people, a little bit of stress can be good. If you have too much stress, you may experience some of the following:

4 Heart pounding

4 Sweating

4 Upset stomach

4 Feeling under pressure

4 Anxiety

4 Feeling overly tired

4 Increase in smoking, coffee drinking or alcohol consumption

4 Trouble sleeping

4 Memory loss

4 Personality change

Why is it important to control stress?• Although we do not know this for sure, stress may make your heart disease worse. It may cause you to

experience angina and/or will make your blood pressure higher. Controlling stress will not only makeyou feel better but it will also decrease the chances of making your heart problem worse.

See Coping with Heart Disease section for more information on how to manage stress.

Risk Factors32