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

Urban China

France

Rural China

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 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

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

lp(a)25%

Other10%

Tobacco

Diabetes

TC/LDL

TC/HDL

Contributions of various risk factors for CAD among Asian Indians

Tobacco10%

HTN10%

Diabetes10%

TC/LDL15%TC/HDL

lp(a)25%

Other10%

Tobacco

Diabetes

TC/LDL

TC/HDL

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

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.

0 100 200 300 400 500 600 700 800 900

Russia

Scotland

Finland

England

U.S.A.

Australia

Canada

Sweden

Urban China

France

Rural China

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

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

Urban China

France

Rural China

WomenMen

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- 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

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.

0 100 200 300 400 500 600 700 800 900

Russia

Scotland

Finland

England

U.S.A.

Australia

Canada

Sweden

Urban China

France

Rural China

Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)

•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

lp(a)25%

Other10%

Tobacco

Diabetes

TC/LDL

TC/HDL

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

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

•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.

•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

How to Prevent Heart Attacks

Healthcare

Take the EHAC Pledge I understand that heart attacks …dha.acc.org/assets/pdf/EHAC-Brochure.pdfRemember: When in doubt, call 9-1-1! Prevent a Heart Attack • Learn the risk factors

Using Directional Antennas to Prevent Wormhole Attacks

Kaiser Permanente: P.H.A.S.E. Preventing Heart …...Medications to Prevent Heart Attacks and Strokes These four important medications may save your life Beta Blockers help the heart

fatty acids which prevent heart attacks. growth.images.quickhunts.com/scavenger/133fb01514cfc41bbba4e392dec8… · fatty acids which prevent heart attacks. This is a green veggie

Using Labeling to Prevent Cross-Service Attacks … Labeling to Prevent Cross-Service Attacks Against Smart ... Abstract. Wireless devices ... Using Labeling to Prevent Cross-Service

Lifesaving information on Heart Attacks

Three Simple Steps to Prevent Targeted Attacks

How to Prevent RFI and LFI Attacks

Early Heart Attack Care Heart Attacks Have Beginnings

Ransomware and tips to prevent ransomware attacks

How to Prevent Heart Attacks

Personalised Medicine – the Future of Blockbuster Pharma? · White Paper: Personalised Medicine – the Future of Blockbuster Pharma? October 2013 5. prevent heart attacks, strokes,

37th Annual Cancer Convention Program Cancer Control SocietyTherapies For Lung Cancer 3:45 Immune Institute Cancer ProgramVijaya Nair, M.D., Prevent Cancer, Strokes, Heart Attacks

Packet-Hiding Methods: To Prevent Selective Jamming Attacks

Using Advanced Threat Analytics to Prevent Privilege Escalation Attacks

Tips to prevent heart disease

A FIRST STATE COALITION TO PREVENT HEART ATTACK AND … · Research shows focusing on the “ABCS” can help prevent heart attacks and strokes: Aspirin when appropriate, Blood pressure

Using Capability to prevent Internet Denial-of-Service attacks

Avoiding heart attacks

Configuring Security Onion Detect Prevent Web Application Attacks