BLOOD PRESSURE AND CHOLESTEROL THE BEGINNING OF YOUR END! Billy S. Arant, Jr., M.D., FASH Professor Emeritus, UTCOM-Chattanooga ASH Specialist in Clinical

BLOOD PRESSURE AND CHOLESTEROL

THE BEGINNING OF YOUR END!

Billy S. Arant, Jr., M.D., FASH

Professor Emeritus, UTCOM-ChattanoogaASH Specialist in Clinical Hypertension

Diplomate, American Board of Clinical Lipidology

VASCULAR DISEASE—JUST THE FACTS

• 70 % of US deaths due to heart attack, stroke, heart failure and aneurysm--all vascular problems!

• ALL diabetics develop vascular disease and most are fat!

• Vascular disease causes serious long-term disability!

• Annual expenditures for vascular diseases of all causes exceed total costs of war in Iraq

RUN FROM THE CURE!

ARE YOU AT RISK?

BEYOND YOUR CONTROL

• Age • Gender • Race• Heredity• Prior cardiovascular event• [Vascular abnormality]• [Congenital heart defect]

STROKEBELTWD Hall, AHA 1999

WITHIN YOUR CONTROL

• Blood pressure• Lipids• Weight [waist]• Blood sugar • Tobacco • Drugs • Hormones

ELEVATED BLOOD PRESSUREearliest indication of trouble

• Normal is below 120/80 mmHg at any age• BP >115/75 is earliest indicator of vascular risk• Systolic (top #) most reliable indicator of risk• Every drug that lowers BP may not reduce but

actually increase risk• Drugs that raise BP increase risk• Lowering BP to normal with proven drugs

reduces risk

Hi-Normal (n = 1794) 130 – 139/ 85 – 89

Normal* (n = 2185) 120 – 129/ 80 – 84

Optimal(n = 2880) < 120/80

Hazard Ratio

*P < 0.001 for trend across categories.

2.5

1.5

1.0

Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease

Cu

mu

lat i

ve C

VD

Inci

de n

ce, %

Time, years

Normal

Optimal

Hi-Normal

Women

Vasan RS, et al. N Engl J Med. 2001;345:1291–1297.

NORMAL BP <120/80 mmHgRobinson & Brucer: Arch Int Med 1939

NEXT, THE FAT IN YOUR ARTERIES

orAtherosclerosis

Cholesterol buildupHardening of the arteries

THE GENESIS OF ATHEROSCLEROSISunrelated to age

LIPID PROFILE• Total cholesterol (good + bad)

– HDL (good) retrieves LDL (bad)– LDL (bad) sticks to lining of artery– Non-HDL (LDL, VLDL, IDL) Total – HDL– Key to most vascular diseases (MI, stroke, PVD, ED)

• Triglycerides (animal and plant fat, glucose)– Insulin makes TG from excess glucose in blood– Used to make LDL and HDL in liver– Risks death from pancreatitis or NASH (fatty liver)

CHOLESTEROLnormal values

• Triglycerides <150 mg/dl• Total cholesterol <200 mg/dl• HDL-C [good} >50 F; >40 M• LDL-C [bad] <100 mg/dl [no risk]

< 80 mg/dl [DM]< 70 mg/dl [CAD]

• Non-HDL-C [TC – HDL]<130 mg/dl• Particle size large fluffy• Pattern A or B A

WHAT ARE THE SOURCES?

• All human cells make cholesterol– Cell membrane functions– Used to make bile– Steroid hormones

• Dietary sources– Eggs– Animal fat (meat, skin, milk, organs, lard)– Plant fat (saturated: palm, coconut, oleo)

• Bile salts – recycled• Sugar changed to triglycerides for storage

CORONARY ARTERYKOREA

Enos et al: JAMA 158:912, 1955

LAD 22yo White ♂ LAD 22yo Japanese♂

CORONARY ARTERIESVIETNAM

McNamara et al: JAMA 216:1185, 1971

22 yo ♂ 50% RCA3+ gross disease

CORONARY ARTERY DISEASE IN CHILDREN

• 10-14 yr olds• Traumatic death• >85 pct body weight• 70% significant CAD w/ calcifications

Bogalusa 2002

STORMIE JONESHomozygous FH

1985 NOBEL LAUREATESLDL Receptor

Michael Brown, M.D.

Joseph Goldstein, M.D.

ATP III 2001, 2004

Scott Grundy, M.D., Ph.D.

TREATMENT OUTCOMES EVIDENCED-BASED

adults

JUPITER TRIAL 2008

• “Low risk” subjects– LDL-C 100-130 mg/dl– Elevated CRP [C-reactive protein]

• Rosouvastatin 20 mg daily v. placebo• Reduced heart attack and strokes by 47%• Drug company excluded from study• Confirmed HPS 2003 with simvistatin

LDL-C: HOW LOW?

NOW FOR THE FAT AROUND YOUR WAIST!

VISCERAL OBESITY CT scans from men matched for BMI and total body fat

Després J-P. Eur Heart J Suppl. 2006;8(suppl B):B4-12.

Subcutaneous obesityFat mass: 19.8 kg VFA: 96 cm2

Visceral obesityFat mass: 19.8 kg VFA: 155 cm2

Visceral obesitydrives CV risk progression independent of BMI

HEALTH CONSEQUENCES OF OBESITYnot just a variation of normal anymore

• Hypertension• Cholesterol• Insulin resistance• Diabetes mellitus• Sleep apnea• Coronary artery disease• Stroke• Erectile Dysfunction• Gallbladder disease• Osteoarthritis [joint replacement]• Some cancers (uterine, breast, colon,

prostate)

WHO HAS A WEIGHT PROBLEM ?

• Body mass index (BMI) for adults– > 25 kg/m² overweight– > 30 kg/m² obese– > 35 kg/m² morbidly obese

• > 30 lbs over ideal body weight for height• Waist measurement

– women >33” overweight; >35” obese– men <37” overweight; >40” obese

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

YOUR WEIGHTgreatest morbid factor for health

• >60% of children and adults are overweight• 1:3 children and adults are obese• Costs >$100 billion in healthcare and lost

productivity (50% paid by MCD + MC)• Obese employee costs ~$8,000 extra/yr in

missed days of work and healthcare• Life expectancy of obese 5 year old is 47 yrs

LOVE IS BLIND—NOT !

• Survey of parents whose 6-11 yo child was obese– 43% “about the right weight”– 37% “slightly overweight”– 13% “very overweight”– 7% “slightly underweight”

HOW DID WE GET SO FAT SO FAST?

ENERGY BALANCE

• NRG in = expended = no body wt▲

• 3600 unanswered calories = +1 lb fat

• New fat comes mostly from sugar not fat!

UNANSWERED CALORIES

• 12 oz soda = run 1.25 miles• 12 oz soda daily for 10 years

– 36 g corn syrup = 144 kcal– 144 kcal x 365 days = 52,560 kcal – 3600 unanswered kcal = + 1 lb fat

– 14.6 lb fat/yr or 146 lb/10 years!

BURNING EXTRA CALORIES

• BigMac, large fries, 32 oz drinkSedentary 12 yo must jog 3 hours to avoid weight gain if already/will ingest daily requirement for growth of 2200 kcal

UNANSWERED CALORIES10 yo sedentary ♂

• Requirements ~ 2270 kcal/day• Pop Tart + OJ 8 oz 320• Pizza 2 sl + 24 oz DP + 2 Oreos 1042• Chips 5 oz + 24 oz DP 1050• Big Mac, Fries, 32 oz Coke 1410• Popcorn + 32 oz Coke 540 Total kcal in 4362

required - 2270 kcal net [1400 kcal from soda] +2192

Dilemma: Jog 4 hr 42 min or gain 9 oz fat

FAT KIDS become FAT ADULTS !

Fat Adults Spend Lots Of Money [theirs and ours] on food, health

care, disability and death

$1 Trillion annually

CAN YOU DO THIS?

RISKS OF OBESITYcompounding risk

Obesity

BP DM CVD Lipid OSA

VASCULAR EVENT

tobacco

2x

↓O₂↑BP

2x

HT v. BMI in BlacksRS Cooper, AHA 1999

PREVALENCE OF HYPERTENSION IN ADOLESCENTSSorof et al Am J Hypertension 16:217A, 2003

SUGAR• Carbohydrates

– Fruits– Vegetables– Grains

• Food additives– Cane or beet– High fructose corn syrup

GLUCOSE METABOLISM/DISPOSAL

• Dietary intake• Insulin effect

– Immediate use– Storage– Triglycerides

BLOOD SUGARpre-diabetes and diabetes

• after 12 hr fast [water only]– normal <100 mg/dl– pre-diabetes 100-125 mg/dl– diabetes >125 mg/dl

• 2 hr post-prandial or GTT– normal <140 mg/dl– pre-diabetes 140-199 mg/dl– diabetes >200 mg/dl

• Hemoglobin A1C >6.5

Who has insulin resistance?

90 88

50 5045

50

40

0

20

40

60

80

100

DM21 HTN3 Stroke4 CHD5 Refer to cardiol.6

Age40 to 747

1Haffner et al. Diabetes. 1997. 2McLaughlin et al. Am J Cardiol. 2005.3Reaven et al. N Engl J Med. 1996. 4NIH. www.clinicaltrials.gov.

5Lankisch et al. Clin Res Cardiol. 2006.6Savage et al. Am Heart J. 2005. 7www.diabetes.niddk.nih.gov/.

%Patients

↓HDL+ ↑TG2

“Ticking clock” hypothesis: Glucose abnormalities increase CV risk

1.0

2.8

3.7

5.0

0

1

2

3

4

5

6

Nurses’ Health Study, N = 117,629 women, aged 30–55 years; follow-up 20 years (1976–1996)

Hu FB et al. Diabetes Care. 2002;25:1129-34.

Relative risk of MI or stroke*

No diabetes

Before diabetesdiagnosis

After diabetesdiagnosis

Diabetes atbaseline

*Adjustedn = 1508 diabetes at baselinen = 5894 new-onset diabetes

1994

US Diabetes Trends - CDC

1995


1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009


Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2009

2009

Diabetes

Obesity

90% of patients with newly diagnosed diabetes

are overweight or obese

30

60

0

20

40

60

80

100

Geiss LS et al. Am J Prev Med. 2006;30:371-7.

Obese (BMI ≥30)

Overweight(BMI 25 to <30)

Diabetes patients with BMI ≥25

kg/m2

(%)

National Health Interview Survey, 2003; N ≈ 31,000 aged 18 to 79 years

90%

0

10

20

30

40

50

60

Men Women

Per

cen

t

Total Non-Hispanic WhiteNon-Hispanic Black Hispanic

Narayan et al, JAMA, 2003

Estimated lifetime risk of developing diabetes for individuals born in the United States in 2000

DIABETES MELLITUSrisk equivalent to previous heart attack

• Two types– DM1 insulin deficient, normal weight [10%] – DM2 insulin resistant, overweight [90%]

• Juvenile v. adult type• 2:3 people with CAD have DM, half undiagnosed• DM is risk equivalent to previous heart attack• May take 5-10 yrs of pre-diabetes before diabetes

recognized• Diabetes costs $132 billion in medical expenses and

lost productivity (twice that of non-diabetics)

COMPLICATIONS OF DIABETESdiabetics die from vascular disease

• Macrovascular disease– coronary artery disease [heart]– cerebrovascular disease [stroke]– peripheral vascular disease [legs]

• amputations

• Microvascular disease– blindness [eyes]– renal failure [kidneys]– neuropathy [sensation]– erectile dysfunction

DIABETES MELLITUS 2

• Complication of obesity almost always [90%]• Preventable if normal waist maintained• Possible to “cure” by losing weight/waist• Leading cause of

– kidney failure >50% on dialysis– Blindness– Associated with 2/3 of heart attacks

• Economic disaster [$1 trillion annually]

OBSTRUCTIVE SLEEP APNEA

• Suspect when– Snoring– Stops breathing– Tired when awake despite 8 hours of “sleep”– Yawns while awake– Restless sleep – bedding disaray– Obese– Hypertension – systemic and pulmonary

TOBACCOnicotine toxic to vascular lining

INTERHEART: Any smoking increases CV risk

Teo KK et al. Lancet. 2006;368:647-58.

Odds ratio for first MI*

*vs never smoked

N = 27,098 from 52 countries

Cigarettes smoked (n/day)

Never 1–2 3–4 5–6 7–8 9–10 11–12 13–14 15–16 17–18 19–20 ≥21

-0.75

1

2

4

8

DRUGS

DRUGS CAN INCREASE RISK

• Recreational drug use– Amphetamines, cocaine

• Decongestants increase BP– Pseudophedrine

• Hormones: estrogen, testosterone

• NSAID’s [ibuprofen,naproxen,celebrex]

– 15,000 deaths/yr to GI bleeding– Raise BP– Reduces kidney function– Reverses aspirin benefit to prevent blood clots

PROSTAGLANDINS [inhibition]

• Mediators of inflammation [reduces pain/retards healing]

• Vasodilators to regulate organ blood flow [VC]– HTN, AMI/angina, CVA, CHF, ARF [intravascular volume]

• Alters renal functions– RBF, GFR, loop NaCl, AVP/water in CD

• GI mucus production to protect mucosa [bleed]READ PI/LABEL!

REGARD TORT POTENTIAL!

IBUPROFEN PRECAUTIONS

• OTC – no longer than 3 days for fever • Allergy to NSAID including ASA• DO NOT take aspirin or acetaminophen w/ ibuprofen

unless MD tells you to• DO NOT take if fluid intake is unreliable• Hx heart liver GI or renal disease, HBP, stroke• Pregnant, plans or breast feeding• Surgery planned• If taking warfarin, ß-blockers, CYA, digoxin, diuretics,

lithium, metotrexate, phenytoin• DO NOT drive or operate machinery until…• NO alcohol w/ ibuprofen

OTHER FACTORSyour doctor may not be measuring

• Uric acid [gout, stones] < 6 mg/dl– Stroke risk increased when values higher– Seems to facilitate cholesterol build up– Risk equivalent to heart attack– Rx- ↓production or ↑excretion

• Homocysteine [dementia] < 9 mg/dl– Stroke risk increased when values higher– Treatment with folic acid and B₁₂ high dose

• C-reactive protein [CRP] < 1 mg/dl– indicates vascular inflammation and risk of a cardiovascular

event• Kidney function [eGFR] >60 ml/min/1.73m²

– Reduced kidney function increases CV risk– Hypertension destroys kidneys [20% dialysis patients]

ISCHEMIC STROKE V. PLASMA HOMOCYSTEINE

0

2

4

6

8

10

12

14

<10 10--15 >15 umol/L

ischemic stroke rate

Sacco et al NOMAS Stroke 35:2663, 2004

CAD SURVIVAL V. HOMOCYSTEINE

Nygard et al; NEJM 337:230, 1997

CV EVENTS v. eGFR

Go et al; NEJM 351:1296, 2004

SO, WHATCHA GONNADO ABOUT IT?

KNOW YOUR NUMBERSdon’t leave it to your doctor

• BP <120/80 + treatment– drugs that affect angiotensin [ACEi or ARB]

• Cholesterol to goal for your specific risk– high HDL reduces risk >50 F; >40 M– low LDL reduces risk <100 no risk; <80 DM, <70 prior CVE– non-HDL (TC – HDL) is total bad cholesterol <130 no risk, <100 w/ risk– triglycerides <150 but lower is better– don’t wait for diet and exercise alone to work– statins proven to reduce risk independent of LDL

• Fasting blood sugar <100 (A1C <6.0) + DM• Waist <33” F; <37” M• CRP < 1.0• Uric acid < 6.0• Homocysteine < 9.0• Kidney function [eGFR] > 60

Treat the problems you have with outcome-proven drugs

• Blood pressure – include ACEi or ARB• Statin• Niacin• Omega 3 ‘s• Anticoagulant – aspirin, coumadin• Antiarrhythmic- beta blocker

HOW TO LOSE WEIGHTworks every time!

• Know what you’re eating—read the label!• Eat less

– Maintain normal weight m-1800 kcal, f-1500 kcal– Lose weight reduce calories by > 300 kcal/day – portion control

• Eat healthy– Protein: fish, eggs, less meat, low fat dairy, beans– Fat: no trans, less saturated, more olive or canola oil– Carbs: fresh fruits, no juices, colored vegetables + cauliflower, whole grain bread or

cereal, no high fructose corn sugar ever, use sugar substitutes– Adkins, South Beach, Sugar Busters are healthy

• Exercise more– 30 minutes 3 times a day to start, then daily (walking will burn 1.25 lb fat/month

• Sleep 8 hours every night

HOW TO FAIL LONG-TERM WEIGHT LOSS!

• Choose anything other than what’s on the previous slide

• Try advertised products for diet or exercise• Buy something sold in doctor’s office or with

some doctor’s name on it• Get your advice from Dr. Feelgood• Believe everything the nutritionist tells you

ANTIDOTE TO VASCULAR EVENTreducing your risk

• Can you afford to survive?• Family history of vascular disease?• Have you had vascular screening?• What about your weight/waist?• Do you have erectile dysfunction?• Do you abuse tobacco?• Do you exercise regularly?• Do you take an aspirin daily?• Do you take any drug that raises BP?• Still taking hormones?• Do you know your numbers?

WHAT TO DO?if you think you’re having a heart attack or stroke

• Chew and swallow 325 mg aspirin• Call 911• Ask to be taken to a certified Heart or Stroke Center

Plan ahead– Determine the heart or stroke center closest to you– Ask if a neurologist who is a stroke specialist will be

available to you– Clot busters and Merci retriever to remove blood clots– Confirm that door to cath lab time is <60 minutes

HOW TO IMPROVE YOUR CHANCES OF ACTUALLY HAVING A VASCULAR EVENT?

• Ignore symptoms or signs• Have a previous TIA, stroke or heart attack• Ignore your blood pressure or skip your medicine to save money• Have a sibling or parent with cerebral aneurysm at young age • Don’t take blood thinners for atrial fibrillation• Treat your diabetes by diet and exercise• Smoke, chew or dip liberally• Weight no problem as long as you don’t look fat• Lower your cholesterol by diet and exercise only• Don’t take daily aspirin >40 yrs of age• Don’t have vascular screening >50 years of age• Take NSAID for pain and decongestants for cold/sinus problem• Get off the hormones—embrace menapause• Be blood kin to someone who has vascular disease• Active sex life with uncontrolled high blood pressure• Be black• Live in the Southeastern USA• Avoid certified heart or stroke centers

MOST VASCULAR EVENTS ARE

PREVENTABLE !

THANK YOU !

Documents

BLOOD PRESSURE AND CHOLESTEROL THE BEGINNING OF YOUR END! Billy S. Arant, Jr., M.D., FASH Professor Emeritus, UTCOM-Chattanooga ASH Specialist in Clinical