Cardiovascular Disease:
Risk Factors, Symptoms,
and Screening
Gary Michael Idelchik, MD, FACC
April 15, 2015
Disclosures
I have nothing to disclose.
Outline
What is/are…
• What is Cardiovascular Disease and its manifestations?
– What is Coronary Artery Disease (CAD)?
– What is Peripheral Artery Disease (PAD)?
– What is Cerebrovascular Disease (CVD)?
• Acute Coronary Syndromes (ACS)?
• ST-segment Elevation Myocardial Infarction (STEMI)?
• Risk factors?
• Screenings?
• What are the therapies for care and why?
• What role does Percutaneous Coronary Intervention (PCI)
play?
• Additional Questions Needed Answering?
Cost of Coronary Artery Disease and Cardiovascular
Disease
Historically,
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17,600,000 Americans adults have a history of CAD.
8,500,000 American adults have a history of MI.
400,000 deaths annually (approx. 1 of every 6 deaths).
300,000 die from their initial Acute Coronary Syndrome (ACS)
event.
Today…
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785,000 will have their initial cardiac event.
470,000 will have a recurrent event.
195,000 will have a silent cardiac event.
Estimated direct and indirect costs for Cardiovascular Disease
– $503.2 billion.
• Estimated direct and indirect costs for Coronary Artery
Disease – $177.1 billion.
AHA Heart Disease and Stroke Statistics 2010 Update. Circulation 2010;121:e41-e215.
Cardiovascular Disease
Cerebrovascular Disease (CVD)
Peripheral Artery Disease (PAD)
Coronary Artery Disease (CAD)
Pathophysiology of Cardiovascular
Disease
Foam
Cells
Fatty
Streak
Intermediate
TCFA/Fibrous Lesion
Rupture
Lesion Atheroma Plaque
Endothelial Dysfunction
Atherosclerotic Burden
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
Heart Attack
Heart Attack Symptoms - MEN
Chest pain
Discomfort in other areas of the
upper body
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One or both arms
Back, neck or jaw
Stomach
Shortness of breath
Other signs
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Cold sweat
Nausea
Lightheadedness
Fatigue
Heart Attack Symptoms - WOMEN
As with men, chest pain or
discomfort
More likely- other
symptoms:
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Shortness of breath
Nausea/vomiting
Back or jaw pain
Not feeling right
Fatigue
Palpitations
Musculoskeletal complaints
Hot flashes
Pathophysiology of ACS/STEMI
‘Heart Attacks’
• 1980 DeWood et al. provided definitive Angiographic
and Histologic Evidence that intra-arterial
thrombosis was the inciting event for STEMI,
resulting in:
– Treatment with Antiplatelet and Antithrombotic therapies.
– The ‘Open Artery’ Theory, for AMI and patients with
hemodynamically significant CAD.
STEMI and ACS
STEMI
Presumed prognosis: very
high risk of in-hospital
death
Treatment goal: prevent
death by restoring
coronary blood flow
Fibrinolytic
therapy
Direct
PCI
NSTEMI/Unstable Angina
Presumed prognosis: low risk of
in-hospital death, unless MI develops
Treatment goal: stabilize with aspirin
heparin +/-GIIb/IIIa & monitor for MI
development
+ Cardiac enzymes
Scheduled
PCI
– Cardiac Enzymes
Highrisk
features
Low risk
features
Manage
medically
The Continuum
Unstable
Angina
Non-occlusive
thrombus
Non-specific
EKG
Normal cardiac
enzymes
NSTEMI
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/T wave inversion on
EKG
Elevated cardiac
enzymes
STEMI
Complete thrombus
occlusion
ST elevations on
EKG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
Percutaneous Coronary Intervention
(PCI) for ACS and STEMI
GE Cardiac Catheterization Lab
Unstable Angina PCI
NSTEMI PCI
STEMI PCI
TIME IS MUSCLE
• Reduce patient symptoms
• Decrease amount of myocardial necrosis
• Preserve heart function
• Prevent major adverse cardiac events
• Treat life threatening complications
Stroke aka ‘Brain Attack’
Carotid Artery Disease
• Stroke is the third leading cause of
death in the U.S., accounting for
164,000 deaths/year.
• Approx. 1 million stroke-related
events per year.
– 500,000 New strokes
– 200,000 Recurrent strokes
– 240,000 TIAs.
• Carotid Occlusive Disease
accounts for 5% to 12% of new
strokes
• Screening with Carotid Arterial
Duplex
Stroke Symptoms – F.A.S.T.
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Loss of vision from one or both eyes
Sudden onset of severe headache
Loss of coordination, balance
Sudden onset of confusion
Carotid Artery Disease
Carotid Artery Disease
Peripheral Artery Disease
Peripheral Artery Disease (PAD)
♥ PAD is a narrowing of the
peripheral arteries, most
common in the arteries of the
pelvis and legs
♥ The most common symptoms
of PAD are:
• Cramping
• Pain or tiredness in the leg
or hip muscles while
walking or climbing stairs
PAD
PAD Screening
♥ Two-fold Purpose
- Preventing progression of
asymptomatic to symptomatic
PAD
- Detect high-risk CVD patients
for risk-reduction
♥ Ankle-Brachial Index (ABI)
- Ratio of blood pressure in arm
and ankle
Abdominal Aorta Aneurysm (AAA)
• Localized Dilation of the Aorta with an Increase of > 50% of
the normal diameter
• Varies by age, gender and body surface area.
• Diagnosed if the aortic diameter is > 3 cm.
Abdominal Aorta Aneurysm (AAA)
• Affects 6-9% of patients over 65 years of age.
– 1.7% of Women and 5% of Men have an AAA > 3 cm.
– Incidence Increases by 6% per decade thereafter.
• Estimated > 1.5 Million Patients in the U.S. have an AAA.
• Cause Approx. 15, 000 Unexpected Deaths Per Year.
• > 2.7 Million Patients by 2025.
AAA Size
Age
Men
Women
45 - 54
1.3%
0%
75 - 84
12.5%
5.2%
2.9 - 4.9 cm
Risk of AAA Rupture Related to Size
30%
26%
25%
Annual Rupture…
20%
15%
11%
10%
5%
0%
0%
1%
< 4.0 cm
4.0 - 4.9 cm
5.0 - 5.9 cm
6.0 - 6.9 cm
AAA Screening
SAAAVE ACT
• One-time AAA screening as part of a ‘Welcome to
Medicare’ physical for men.
• Eligibility limited to males turning 65
• History of smoking 100 cigarettes or more.
• Family history of AAA (men and women).
Cardiovascular Care
Cardiac Screening – See your Doctor
• Know your personal and
family history
• Routine medical
appointments
• Talk to your health care
provider
• Know your medications and
drug allergies
• Take charge of your health
• Get appropriate screening
High-risk for future cardiovascular disease?
High-risk for future cardiovascular disease?
High-risk for future cardiovascular disease?
Cardiovascular Disease Risk Factors
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History of CAD/PAD
Male Sex
History of TIA/CVA
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
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Family History - event in
first degree relative > 55
male, > 65 female
– Low HDL < 40
– Elevated LDL / TG
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Chronic Kidney Disease
Obesity
Lack of regular physical
activity
Diet poor in fruits,
vegetables, and fiber
Age > 45 male, > 55 female
Risk Factors that Can’t Be Changed
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♥
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Age
Gender: Male
Heredity – Family History
Race
Previous CAD, PVD or
CVA
Smoking,
Smoking,
…and Smoking
Diet
Western Lifestyle
Treatments and Therapy
Cardiovascular Medical Therapy
 Antiplatelet agents
– Aspirin
– Brilinta/Plavix/Effient
 Lipid lowering agent
– High-dose Statin (Lipitor, Crestor)
 Antihypertensive agent
– Beta blocker
– ACE-I/ARB
– Aldactone (as appropriate)
 Appropriate therapy for risk factors
Cardiovascular Care
 Blood Pressure
– Goal < 135/85
– Maximize use of beta-blockers and ACE-I
 Lipids
– LDL < 100 (70) ; TG < 200
– Maximize use of statins; consider fibrates/niacin
first line for TG > 500; consider omega-3 fatty
acids, CoEnzyme Q10
 Diabetes
– HbA1c < 7%
Cardiovascular Care
 Smoking cessation
– Cessation-class, medications, counseling
 Physical activity
– Goal 30 - 60 minutes daily
– Risk assessment prior to initiation
 Diet
– DASH diet, Mediterranean diet, fiber,
omega-3 fatty acids
– <7% total calories from saturated fats
Cardiovascular Diet
Thank You