HEART DISEASE
WHY WE GET THEM
AND
WHAT TO DO ABOUT THEM
SOMNATH KUMAR
CONSULTANT CARDIOLOGIST
Department of Cardiology
LANCASHIRE TEACHING HOSPITALS
UNITED KINGDOM
The Problem….
• Cardiovascular disease continues to be the
biggest killer in the UK today
• Almost 200,000 deaths per year
• One in three premature deaths
• Half of these CHD
• A quarter stroke
• Most can be prevented/delayed
Objectives
• Prevention: Primary versus Secondary
• Coronary Artery Disease (CHD) Risk Factors
• Q RISK 2 Risk Assessment
• Do You Know Your Numbers? AND your Pulse ?
• Q&A
INTER-HEART:
52 Countries - every inhabited continent
15,152 cases with14,820 control group
• ”Disease” related risk factors
-
Diabetes
Hypertension
Abdominal obesity
ApoB/ApoA1
• Behaviour related risk factors
Alcohol intake
Exercise
Psychosocial stress
Current smoking
INTERHEART Study
”nine potentially modifiable
risk factors account for over 90% of the risk of an initial acute
myocardial infarction” Population attributable risk fractions
Smoking
Hypertension
Lipids (ApoB/A1 ratio)
Abdom obesity
Diabetes
Fruit & Veg
Alcohol
Physical Activity
Psychosocial
Other
Salim Yusuf et al . Effect of potentially modifiable risk factors associated with myocardial
infarction in 52 countries (the INTERHEART study). Lancet 2004 364 9437
____________________________________________________________
Lifetime Risk of Coronary Heart
Disease
in
the
Framingham
Study
______________________________________________________________
Men
At age 40 years: 48.6%
At age 70 years: 34.9%
Women
31.7%
24.2%
_________________________________________________________________
Lloyd-Jones et al. Lancet 1999; 353:89-92
Life style is a Driver of CVD
Physical
inactivity
Life style
intervention
Excessive
food intake
Stress
Smoking
Obesity
Hypertension
Risk factor
modification
Diabetes
Dyslipidaemia
Atherosclerosis
Chronic
heart failure
Atherosclerosis
Arterial & venous
thrombosis/
cardiac & cerebral events
Arrhythmia
Cardiovascular risk factors
Non-modifiable:
Age
Gender
Family History
Ethnicity
Socio-economic status
Modifiable:
Smoking
Hypertension
Obesity
Hyperlipidaemia
Salt intake
Alcohol intake
Diet
Diabetes
Physical activity
Psychosocial factors
Healthy Lifestyle?
Physical activity
• If maintained BP can be reduced by 3.8 to 2.6
mmHg, systolic and diastolic
• 30 minutes - on five or more days/wk
• Reduces the risk of CHD by more than 18%,
• If no exercise is taken studies show that
people are 30% more likely to become
hypertensive.
DE-NIAL IS JUST NOT A RIVER IN
EGYPT
Abdominal ObesityKNOW YOUR FIGURES
• BMI
– Normal < 25
– Obese 25-29.9
– Obese > 30
• Waist circumference
– > 40 inches in men
– > 35 inches in women
• Waist circumference is more sensitive of
risk of heart attack than BMI
New Definition of High Blood
Pressure
• Old – BP a number to keep below 140/90
• New - a disease of the blood vessel where vascular
biology is altered
– Arteries cannot vasodilate properly and sodium
and glucose accumulate in the arterial wall
• New Goals 140 systolic / 90 diastolic
– Lowers damage to heart brain, eyes, kidneys,
pancreas, blood vessels of the legs/feet, sexual
function
What is Cholesterol?
• Cholesterol is used to form cell membranes
• LDL (BAD)  pro-inflammatory
– High levels are a predictor of
atherosclerosis and heart disease
• HDL (GOOD)  anti-inflammatory
– Removes excess cholesterol from arteries
– Slows the growth of plaques
– High levels protect against heart attack
– Low levels increase risk
http://www.fundaciondiabetes.org/activ/prevenir_obesidad/images/obesidad.jpg
Cholesterol Management
Guidelines
Lower LDL
Increase HDL
• Exercise
• Smoking Cessation
• Weight Reduction
•
•
•
•
< 7% saturated fat
10-25 grams fiber
2 grams plant stanols
like Take Control
Statins
Questionable:
• Alcohol – Red Wine
• Estrogen
Definition of Metabolic Syndrome
Central obesity (waist circumference ≥ 94cm
for European men and ≥ 80cms for European
women) and any two of the four factors below:
• ↑ Trigs ≥ 1.7 mmol/L or treatment for this
• ↓ HDL < 1.03 mmol/L in men, < 1.29 mmol/L in
women or specific treatment for this
• ↑ BP ≥130/85 or treatment of previously
diagnosed hypertension
• ↑ FPG ≥ 5.6mmol/L or diagnosed T2 diabetes
International Diabetes Federation, 2004
Alcohol intake
• Low to moderate intake is associated with a
•
•
•
•
lower risk of CVD
Heavy alcohol is associated with high risk for
hypertension and stroke
Drinkers of more than 35 units/wk double
their risk of mortality
Binge drinking strongly associated with a
large rise in BP
Women drinking more than ever before.
Red Flags
• Blood pressure • Cholesterol
>160/100
mmHg
>7.5 mmol/l
GIVE SOUND ADVICE
Smoking
• Strong association with CVD
• Smoking as few as 3 per/day doubles
risk of MI or death
• Best quit success with counselling and
pharmacological therapy
• Level of risk falls with abstinence
Health Benefits after Smoking
Cessation
Stress Management
INTERHEART Study confirmed that
psychosocial factors can contribute to
sudden cardiac death
Well being
Wellbeing in Lancashire
Q risk-2
Levels of risk
• <10% risk over the next 10 years classed as low CVD risk
• 10-20% risk over the next 10 years -
classed as moderately increased CVD
risk
• >20% estimated risk over the next
10 years - classed as high risk.
Putting prevention first
• National vascular
checks programme
• Commenced 04/09
• Comprehensive CV
risk assessment to
be offered to all
aged 40-74
• PCT delivery
It’s all atheroma….
•
•
•
•
•
Common aetiology
Systemic disease
Risk factors
Common treatment
aim
Prevention of events
The “Calcium Score”
Source:
services.epnet.com/getimage.aspx?imageiid=6857
EBCT = electron-beam computed tomography
NHS
Health Checks
Programme
Multi-level framework for identifying facilitators and
barriers to attaining a healthy life
Macro Level
Economic Policies; Government Policies; Laws; Media;
Technology; Industry Relations ; Transport
Micro environment
Level
Local Community; School settings; Worksites Fast food
outlets; Cafes & restaurants
Household Level
Food availability; Role models;
Culture; Feeding Styles
Individual Level
Demographic factors
Biology; Genetics;
Flavour experiences;
Learning history
Action Plan
1. Get a annual check-up, know your numbers and follow-up
–
–
–
2.
3.
4.
5.
6.
Monitor your cholesterol and fasting blood glucose
BP targets vary according to patients
Check thyroid, liver and kidney function, Vitamin D levels,
hormones
Examine your diet and get a nutrition assessment with a dietitian
Exercise Non-Negotiable daily appointment for you 30-60 minutes
5 days a week
Develop a management plan to control stress and anxiety and
depression... and seek help if no improvement
Quit smoking
Learn to measure your own pulse – practice brings perfection
Balance your life when possible…
…and make time for fun…
And help others to achieve
well-being
We, the cardiology team at LTH
THROUGH IMPROVED
PATIENT CARE &
COMMUNICATION
Between primary and secondary care