A Cardiologist’s Perspective On Preventing Heart Disease (and Strokes!) C. Michael Wright, MD FACC Medical Director The LifeScore Clinic

A Cardiologist’s A Cardiologist’s PerspectivePerspective

On Preventing Heart On Preventing Heart Disease (and Strokes!)Disease (and Strokes!)C. Michael Wright, MD FACCC. Michael Wright, MD FACC

Medical DirectorMedical Director

The LifeScore ClinicThe LifeScore Clinic

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1.1. Cardiovascular Disease (CVD)-Cardiovascular Disease (CVD)-Scope of the ProblemScope of the Problem

2.2. What is Atherosclerosis?What is Atherosclerosis?

3.3. Who is at Risk?Who is at Risk?

4.4. How Do We Measure Risk?How Do We Measure Risk?

5.5. How Can You Prevent It?How Can You Prevent It?

6.6. Random Cartoons to keep it light!Random Cartoons to keep it light!

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1. Scope of the 1. Scope of the ProblemProblem102 million with cholesterol >200102 million with cholesterol >200

50 million with systolic blood pressure >140, diastolic 50 million with systolic blood pressure >140, diastolic >90>90

47 million current smokers age 18+47 million current smokers age 18+

44 million obese (BMI 44 million obese (BMI ≥30)≥30)

10 million diabetics10 million diabetics

StrokesStrokes500 000500 000

Heart AttacksHeart Attacks650 000650 000

Heart FailureHeart Failure 550 550 000000

Annual direct and indirect cost of CVD - $329 billion in 2002Annual direct and indirect cost of CVD - $329 billion in 2002

Types of CVDTypes of CVD

Cardiovascular Disease- Cardiovascular Disease- It’s Big!It’s Big!

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2. What Is 2. What Is Atherosclerosis?Atherosclerosis?

Tunica adventitia

Tunica media

Tunica intimaEndothelium

Subendothelial connective tissue

Internal elastic membrane

Smooth muscle cells

Elastic/collagen fibers

External elastic membrane

Plaque DevelopmentPlaque DevelopmentNormalFatty streak

Lipid-rich plaque

Lipid coreThrombus

Foam cells

Stages of AtherosclerosisStages of Atherosclerosis

Evolution of PlaqueEvolution of Plaque

Coronary Wall Dynamics Coronary Wall Dynamics with Plaquewith Plaque

NormalNormalvesselvessel

No NarrowingNo NarrowingMild PlaqueMild Plaque

Severe NarrowingSevere NarrowingExtensive PlaqueExtensive Plaque

Mild NarrowingMild NarrowingModerate PlaqueModerate Plaque

Vessel wallVessel “lumen”

Time [years]

Mural Plaque

Plaque RupturePlaque Rupture

Lipid CoreLipid Core

ThrombusThrombus

Fibrous Cap

IVUS vs. AngiographyIVUS vs. Angiography

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3. Who is at Risk?3. Who is at Risk?

Lifestyle Determines Cardiovascular Health Lifestyle Determines Cardiovascular Health

Refined Carbohydrates

Low intakeOf Omega 3

Low intakeof antioxidants

Trans fattyacids

InactivityLow intake of

Omega 9

CaloricIntake >Caloric

expenditure

High intakeof sodium

Low intake ofEssentialminerals

Oxidative StressLipid abnormalitiesInsulin Resistance

Sympathetic activationInflammation

RAS activation

EndothelialDysfunction

&Vascular

Injury

Atherosclerosis Begins in Atherosclerosis Begins in ChildhoodChildhood

0

20

40

60

80

100

2-15 yr olds 21-39 year olds

0

1020

30

40

5060

70

80

2-15 yr olds 15-20 21-25 26-39

The Bogalusa Heart Study

% with Coronary Fatty Streaks

% with Coronary Atheromas

The At Risk PatientThe At Risk Patient

Physical InactivityPhysical Inactivity

Risk Factors and Coronary Risk Factors and Coronary Atherosclerosis in Young Atherosclerosis in Young

AdultsAdults

The Bogalusa Heart Study

Early High TC Levels Early High TC Levels Associated With Later CHD Associated With Later CHD

EventsEvents

6.9

11.5

17.5

35.2

0

5

10

15

20

25

30

35

40

118-172 173-189 190-208 209-315

TC (mg/dL)

Results After 40 Years

No.

of

CH

D e

ven

ts*

Adapted from Klag MJ, et al. N Engl J Med. 1993;328:313-318.

*1017 men, average age 22

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4. How Do We Measure 4. How Do We Measure Risk?Risk?

15

1.25

1.6

1.6

1.8

2.15

2.35

2.5

5

0 5 10 15

Lp(a)

Homocysteine

TC

Fibr

t-PA Ag

TC/HDL

hs-CRP

hs-CRP + TC/HDL

EBT Score > 75th

Relative risk in men from thePhysicians Health Study(highest quartile)

Effect of Risk FactorsEffect of Risk Factors

The Cholesterol Overlap The Cholesterol Overlap IssueIssue

Total Cholesterol (mg/dL)

No CHD

CHD

35% of CHD occurs35% of CHD occursIn people withIn people withTC <200 mg/dLTC <200 mg/dL

150150 200200 250250 300300

CME Monograph Based on an Expert Panel Discussion. Cardiovascular risk stratification using high-sensitivity C-reactive protein (hs-CRP), a cardiovascular inflammatory risk marker. Certified Continuing Medical Education Series 2001; April 16, 2001; Castelli WP. Atherosclerosis 1996;S1-S9

Calcium in PlaqueCalcium in Plaque

Cooper Clinic 6 Year F/UCooper Clinic 6 Year F/UCVD Risk by Calcium ScoreCVD Risk by Calcium Score

1

2.2 2.4

7.1

27.8

0

3

6

9

12

15

0 1-15 16-95 96-407 >407

Adju

sted R

ela

tive R

isk

*A

dju

sted R

ela

tive R

isk

*

P < .01

n=17,256; 461 events, 17 deathsn=17,256; 461 events, 17 deaths

(Abstract # P3) Final Program & Abstracts: AHA - 42nd Annual Conference on Cardiovascular Disease Epidemiology and Prevention. April 23-26, 2002, Honolulu, HA

CVD Events By CAC CVD Events By CAC QuartileQuartile

1 1 1 1

6 6.2

19

21.5

0

5

10

15

20

25

1st 2nd 3rd 4th

No. EventsOdds Ratio

Cal

cium

Sco

re P

erce

ntil

eC

alci

um S

core

Per

cent

ile

QuartileQuartile

Raggi P, Callister TQ, Cooikl B , He Z-X, Lippolis NJ, Russo DJ, Zelinger A, Mahmarian JJ. Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography. Circulation 2000;101:850-55

MI or SCD with Very MI or SCD with Very High CACHigh CAC

25%

12.3%Circ 1998;97:535-43

7.1%JACC 2001;37:1551-7

17%Cancer Database

0

5

10

15

20

25

30

EBTScore

>1,000

SevereSPECT

Abn.

MWMAStressEcho

LungCancer

Mortality

* Wayhs JACC 2002;39:225-30

Annual event rate

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5. How Can You Prevent 5. How Can You Prevent It?It?

Discover, Design, Do =Discover, Design, Do =3D Health3D Health

Discover your risk!Discover your risk! If high, then aggressive risk factor If high, then aggressive risk factor

managementmanagement If Moderate, then moderate risk factor If Moderate, then moderate risk factor

managementmanagement If low, then just try to follow a If low, then just try to follow a

reasonably healthy lifestyle!reasonably healthy lifestyle! Design your goalsDesign your goals Do your program to achieve your Do your program to achieve your

goalsgoals

Two Books To ReadTwo Books To Read

10 Key Dietary 10 Key Dietary GuidelinesGuidelines

1.1. Eat omega-3 Rich FoodsEat omega-3 Rich Foods - - Fatty Fish (salmon, trout, tuna, Fatty Fish (salmon, trout, tuna, herring, mackerel); walnuts, herring, mackerel); walnuts, canola oil, flaxseeds, green leafy canola oil, flaxseeds, green leafy vegetablesvegetables

2.2. Eat mono-unsaturated fatsEat mono-unsaturated fats - - Olive oil (extra virgin), canola oilOlive oil (extra virgin), canola oil

3.3. Get 7 or more servings of Get 7 or more servings of vegetablesvegetables and and fruitsfruits per day per day

Dietary Guidelines Dietary Guidelines ContinuedContinued

4.4. Balance Balance animal proteinanimal protein with with vegetable protein- vegetable protein- legumes legumes (especially soybeans), nuts(especially soybeans), nuts

5.5. Avoid saturated fatAvoid saturated fat by choosing by choosing lean meat over fatty meat, low fat lean meat over fatty meat, low fat over full fat in dairy productsover full fat in dairy products

6.6. AvoidAvoid oils high in oils high in omega-6 fatty omega-6 fatty acidsacids (corn, safflower, sunflower, (corn, safflower, sunflower, soybean and cottonseed oils)soybean and cottonseed oils)


7.7. Reduce intake of trans-fatty acids:Reduce intake of trans-fatty acids:1.1. Most margarinesMost margarines

2.2. Vegetable shorteningVegetable shortening

3.3. Commercial pastriesCommercial pastries

4.4. Deep fat fried foodsDeep fat fried foods

5.5. Most prepared snacks, mixes and Most prepared snacks, mixes and convenience foodsconvenience foods

8.8. Eat unrefined cereals and grainsEat unrefined cereals and grains


9. Drink plenty of water every day9. Drink plenty of water every day

10. Be aware of the sodium content of 10. Be aware of the sodium content of foods and consume less than 2 foods and consume less than 2 grams/daygrams/day

Country Diet Country Diet ComparisonsComparisons

INTERNATIONAL COMPARISONS reveal that total fat intake is a poor indicator of heart disease risk. What is important is the type of fat consumed. In regions where saturated fats traditionally made up much of the diet (for example, eastern Finland), rates of heart disease were much higher than in areas where monounsaturated fats were prevalent (such as the Greek island of Crete). Crete's Mediterranean diet, based on olive oil, was even better for the heart than the low-fat traditional diet of Japan.

January ’03 Scientific January ’03 Scientific AmericanAmerican

Walter C. Willett and Meir J. Stampfer, professors of epidemiology and nutrition at the Harvard School of Public Health

Different Food PyramidsDifferent Food Pyramids

Key Supplements-Omega-Key Supplements-Omega-3 Fatty Acids3 Fatty Acids

Fish oil for DHA and EPAFish oil for DHA and EPA Flaxseed or borage oil for Alpha-Flaxseed or borage oil for Alpha-

linolenic acidlinolenic acid DHA eggsDHA eggs Decreased inflammationDecreased inflammation Decreased arrhythmiasDecreased arrhythmias Decreased clotting tendenciesDecreased clotting tendencies 1-4 grams a day1-4 grams a day

Key Supplements- Key Supplements- Vitamins C and EVitamins C and E

Reduced risk of neurodegenerative Reduced risk of neurodegenerative diseasesdiseases

Reduced risk of cataracts Reduced risk of cataracts E- Inhibits oxidation of LDL cholesterolE- Inhibits oxidation of LDL cholesterol Prevent progression of atherosclerosis Prevent progression of atherosclerosis

is carotid arteriesis carotid arteries Doses: Vitamin E- 400-800 IU; Vitamin Doses: Vitamin E- 400-800 IU; Vitamin

C- 500-2,000mg per dayC- 500-2,000mg per day

Key Supplements- Alpha Key Supplements- Alpha Lipoic AcidLipoic Acid

Fat and water-soluble antioxidantFat and water-soluble antioxidant Regenerates vitamins C and ERegenerates vitamins C and E Binds toxic metalsBinds toxic metals Improves insulin sensitivityImproves insulin sensitivity Helps the body use glucose for Helps the body use glucose for

energyenergy Dose- 100-300 mg/dayDose- 100-300 mg/day

Key Supplements- Co-Key Supplements- Co-enzyme Q10enzyme Q10

Fat-soluble antioxidantFat-soluble antioxidant Involved in energy production in mitochondriaInvolved in energy production in mitochondria Regenerates Vitamins C,E and ARegenerates Vitamins C,E and A Inhibits oxidation of LDL cholesterol, cell Inhibits oxidation of LDL cholesterol, cell

membranes, and DNAmembranes, and DNA Improves insulin sensitivityImproves insulin sensitivity Lowers blood pressureLowers blood pressure Depleted by statin drugsDepleted by statin drugs Dose- 30-90 mg/day (gel) Dose- 30-90 mg/day (gel)

Key Supplements- Folic Key Supplements- Folic Acid, Vitamins B6 & B12Acid, Vitamins B6 & B12

Lower homocysteine levelsLower homocysteine levels Homocysteine can raise risk for stroke, Homocysteine can raise risk for stroke,

heart attacks and alzheimer’s diseaseheart attacks and alzheimer’s disease B6 lowers blood pressureB6 lowers blood pressure Doses-Doses-

Folic acid 400-800mcg/dayFolic acid 400-800mcg/day B6 100-200mg/dayB6 100-200mg/day B12 1-2mg/dayB12 1-2mg/day

Key Supplements- L-Key Supplements- L-CarnitineCarnitine

Helps convert fatty acids to energyHelps convert fatty acids to energy Transports fatty acids into mitochondriaTransports fatty acids into mitochondria 98% of carnitine in the body is in the heart 98% of carnitine in the body is in the heart

and muscle cellsand muscle cells Slows age-dependent decline in Slows age-dependent decline in

mitochondrial functionmitochondrial function Slows neuro-degeneration and loss of Slows neuro-degeneration and loss of

cognitive functioncognitive function Improves insulin sensitivityImproves insulin sensitivity Improves thyroid functionImproves thyroid function

Key Supplements- L-Key Supplements- L-CarnitineCarnitine

Heart-Heart- Increases heart’s energy productionIncreases heart’s energy production Reduces heart rate during exerciseReduces heart rate during exercise Reduces size of heart attacksReduces size of heart attacks Reduces chest pain (angina)Reduces chest pain (angina)

MuscleMuscle Increases power and enduranceIncreases power and endurance Reduces fatigueReduces fatigue Helps maintain and increase muscle massHelps maintain and increase muscle mass Speeds recovery time after exerciseSpeeds recovery time after exercise

Key Supplements- Key Supplements- CarnosineCarnosine

Two amino acids linked togetherTwo amino acids linked together Blocks glycation (sugar bonding to Blocks glycation (sugar bonding to

proteins)proteins) Glycated proteins cause stiffness and Glycated proteins cause stiffness and

thickening of artery wall and heart musclethickening of artery wall and heart muscle Slows aging in animal modelsSlows aging in animal models May be useful in treatment of cataractsMay be useful in treatment of cataracts How much? 1 to 2 grams per dayHow much? 1 to 2 grams per day

Effects of 10% Weight Effects of 10% Weight LossLoss

Exercise!Exercise!

Dr. Ken Cooper, of the Cooper Institute of Aerobic Research, found that exercise was associated with a 40 % reduction in heart attacks in females and a 60 % reduction in heart attacks in males. In another study, he found that people who were in the lower 20 % of cardiovascular fitness had a death rate that was three times higher than the most fit group. The study also showed that men taking up exercise, even after the age of 60, will increase their life expectancy.

After adjustment for age, the peak exercise capacity measured in metabolic equivalents (MET) was the strongest predictor of the risk of death among both normal subjects and those with cardiovascular disease.

Each 1-MET increase in exercise capacity conferred a 12 percent improvement in survival. CONCLUSIONS: Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for cardiovascular disease.

Exercise capacity and mortality among men referred for exercise testing.

Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE.

Division of Cardiovascular Medicine, Stanford University Medical Center

Other Beneficial Effects of Other Beneficial Effects of ExerciseExercise

•The risk of developing colon cancer is decreased by half in

people who exercise regularly.

•Estrogen-dependent cancers (breast, ovarian and

endometrial cancers) and prostate cancer are decreased with

regular exercise.

•The risk of dying from cancer declines sharply as exercise

increases.

•Regular weight-bearing exercise can reduce the incidence of

osteoporosis, a reduction of bone strength (and susceptibility

to fractures) responsible for thousands of deaths yearly in the

U.S.

Diet & Lifestyle-Diet & Lifestyle-Longitudinal StudyLongitudinal Study

Nurses’ Health StudyNurses’ Health Study- 84,129 women aged 34-- 84,129 women aged 34-5959

During 14 yrs, 1129 cases of CHD (1.3%)During 14 yrs, 1129 cases of CHD (1.3%) Low risk group- non-smokers, BMI <25, ½ drink Low risk group- non-smokers, BMI <25, ½ drink

or more/day, ½ or more/day of moderate or or more/day, ½ or more/day of moderate or vigorous physical activity, upper 40% for 6 vigorous physical activity, upper 40% for 6 dietary variables (cereal fiber, omega 3 fatty dietary variables (cereal fiber, omega 3 fatty acids, folate, high polyunsat/sat fat ratio, low acids, folate, high polyunsat/sat fat ratio, low intake of trans fat, low glycemic loadintake of trans fat, low glycemic load

This group had a relative risk of 0.17 compared This group had a relative risk of 0.17 compared to women in other groups.to women in other groups.

Coronary Artery Calcium Coronary Artery Calcium Predicts Heart AttacksPredicts Heart Attacks

0.36 0.51 0.710.99

1.38

1.922.64

3.62

4.9

6.54

0

1

2

3

4

5

6

7

0 10 20 30 40 50 60 70 80 90

Annual Annual AbsoluteAbsolute Risk (%) Risk (%)676 initially asymptomatic patients 32+7 months f/u

Percentile Rank for Baseline EBCT Calcium ScoreRaggi et al AHJ 2001;141:193-199Raggi et al AHJ 2001;141:193-199

LDL GoalsLDL Goals

LDL-C Lowering With LDL-C Lowering With Statins: Statins:

Reduced CHD EventsReduced CHD Events

50

Secondary Prevention

Primary Prevention

CARE-Rx

4S-Rx

LIPID-Rx

CARE-PL

LIPID-PL

4S-PL

AFCAPS-Rx

AFCAPS-PL

WOSCOPS-RxWOSCOPS-PL

70 90 110 130 150 170 190 210

0

5

10

15

20

25

Adapted from Illingworth DR. Med Clin North Am. 2000;84:23-42.

LDL Cholesterol (mg/dL)

Even

ts (

%)

Heart Protection Study- Heart Protection Study- Vascular Events by LDLVascular Events by LDL

Plaque Regression Related to LDL-Plaque Regression Related to LDL-LoweringLowering

+120%+120%

00

– – 80%80%

6060 120120 200200

LDL (mg/dL)LDL (mg/dL)

TreatedTreated UntreatedUntreated Suboptimal Therapy (LDL >120 mg/dl)Suboptimal Therapy (LDL >120 mg/dl)

Callister TQ. N Engl J Med 1998;339:1972-78

% change in lesion volume vs. final LDL achieved% change in lesion volume vs. final LDL achieved

THE END!THE END!

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A Cardiologist’s Perspective On Preventing Heart Disease (and Strokes!) C. Michael Wright, MD FACC Medical Director The LifeScore Clinic