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CAD Risk factors
Lowering Novel Risk Marker Levels
Lowering Novel Risk Marker Levels
METABOLIC SYNDROME
Criteria for Clinical Diagnosis of Metabolic
SyndromeMeasure (any three of five constitute a diagnosis of metabolic syndrome)
Criteria for Clinical Diagnosis of Metabolic
Syndrome
Complication of Metabolic syndrome
Involvement Of Liver In Metbolic Syndrome
OBESITY
Body Mass Index (BMI)
Obesity-Related Organ Systems Review
Obesity-Related Organ Systems Review
LIFE STYLE MODIFICATION (LSM)
RISK FACTOR MODIFICATION(RFM)
FAST FOOD BOMB
WEIGHT WATCHING:
Care About Weight
Weight watching: Care About Weight
Weight watching: Care About Weight
A few behavioral techniques to achieve a long-term weight loss
include:Establishing weight goals (e.g., 10 percent loss of body weight in 1 year)
A few behavioral techniques to achieve a long-term weight loss
include:Establishing physical activity (e.g., exercise 30 minutes daily)
Learning to avoid situations where overeating is likely to occur
A few behavioral techniques to achieve a long-term weight loss
include:Establishing a regular eating schedule
Avoiding eating or snacking between meals (eating on schedule)
A few behavioral techniques to achieve a long-term weight loss
include:Taking smaller portions
Eating slowly Keeping a diet diary (self-monitoring)
A few behavioral techniques to achieve a long-term weight loss
include:Developing a social support structure
Learning to manage stressful situations that promote overeating
A few behavioral techniques to achieve a long-term weight loss
include:Developing a regular schedule for physical activity
A few behavioral techniques to achieve a long-term weight loss
include:Identifying circumstances leading to eating binges and avoiding them
EXERCISE & PHYSICAL ACTIVITY:
(an important way for
intervention in metabolic syndrome)
EXERCISE & PHYSICAL ACTIVITY
EXERCISE & PHYSICAL ACTIVITY
It is currently recommended that everyone engage in 30 minutes daily of moderate-intensity physical activity.
EXERCISE & PHYSICAL ACTIVITY
Moderate-intensity activities (40 to 60% of maximum capacity) are equivalent to a brisk walk (15–20 minutes per mile).
EXERCISE & PHYSICAL ACTIVITY
Goal At least 30 minutes of moderate-intensity physical activity on most (and preferably all) days of the week.
EXERCISE & PHYSICAL ACTIVITY
Even more benefit is achieved by increasing activity to 60 minutes daily.
EXERCISE & PHYSICAL ACTIVITY
Additional benefits are gained from vigorous-intensity activity (>60% of maximum capacity) for 20–40 minutes on 3–5 days per week.
EXERCISE & PHYSICAL ACTIVITY
The following are examples of moderate-intensity activity:
Brisk WalkingJoggingSwimmingBikingGolfing Team Sports
EXERCISE & PHYSICAL ACTIVITY
Using simple exercise equipment (e.g., treadmills)
Several short (10 to 15 minutes) bouts of activity (brisk walking)
EXERCISE & PHYSICAL ACTIVITY
Substituting more active leisure activities for sedentary ones (television watching and computer games)
EXERCISE & PHYSICAL ACTIVITY
If cardiovascular, respiratory, metabolic, orthopedic, or neurologic disorders are suspected, or if patient is middle-aged or older and is sedentary, consult physician before initiating vigorous exercise program.
EXERCISE & PHYSICAL ACTIVITY
Recommend resistance training with 8–10 different exercises, 1–2 sets per exercise, and 10–15 repetitions at moderate intensity 2 days per week.
EXERCISE & PHYSICAL ACTIVITY
Flexibility training and an increase in daily lifestyle activities should complement this regimen.
Diet & Eating
HEALTHY FOODS
Food pyramid
Food Pyramid
Food Pyramid
Food Pyramid
NUTSWalnut :ExcellentPeanut :ExcellentCoconut : Bad fat
CIGARETTE SMOKING
Cigarette SmokingA strong dose–response relationship between cigarette smoking and CHD has been observed in both sexes, in the young, in the elderly, and in all racial groups.
Cigarette SmokingCigarette smoking increases risk two- to threefold and interacts with other risk factors to multiply risk.
Cigarette SmokingThere is no evidence that filters or other modifications of the cigarette reduce risk.
Cigarette SmokingPipe smoking and cigar smoking increase the risk of CHD.
Cigarette Smoking More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking.
Cigarette SmokingExposure to environmental tobacco smoke, or passive smoking, is now recognized as a modifiable risk factor.
Cigarette Smoking
In a meta-analysis of 18 epidemiologic studies, exposure to tobacco smoke by nonsmokers was consistently associated with a 20 to 30 percent increase in risk.
Cigarette Smoking
This is in addition to an increased risk for respiratory tract cancers and other smoking-related diseases.
Cigarette Smoking
Pathophysiologic studies have identified multiple mechanisms through which cigarette smoking may cause CHD.
Cigarette Smoking
Oxidative stress plays a central role in smoking-mediated dysfunction of nitric oxide biosynthesis in endothelial cells.
Cigarette Smoking
Cigarette smoking also lowers HDL-C.
Cigarette Smoking
These effects, along with direct effects of carbon monoxide and nicotine, produce endothelial damage.
(apoptosis)
Cigarette Smoking
Increased vascular reactivity
Reduced oxygen-carrying capacity
A lower threshold for myocardial ischemia
Increased risk of coronary spasm.
Cigarette Smoking
Cigarette smoking is also associated with increased levels of fibrinogen and increased platelet aggregability.
For Patients Who Are Not Ready To Quit, Clinicians Should Apply
The 5 R:
For Patients Who Are Not Ready To Quit, Clinicians Should Apply
The 5 R:
CHOLESTEROL AND HYPERLIPIDEMIA
(HLP)
94
Intestinal Cholesterol Absorption
Bays H et al. Expert Opin Pharmacother 2003;4:779-790.
Intestinal epithelial cell
Biliarycholesterol
Dietarycholesterol
Luminalcholesterol
Micellarcholesterol
Bileacid
Cholesteryl esters
Freecholesterol
excretion
uptake
ACAT
ABCG5ABCG8
(esterification)
MTPCM
Through lymphatic system to the liver
100
Therapeutic Lifestyle Changes (TLC) and Nutrient Composition of TLC Diet
Nutrient Recommended Intake Saturated fat Less than 7% of total calories Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Total fat 25–35% of total calories Carbohydrate 50–60% of total calories Fiber 20–30 grams per day Protein Approximately 15% of total
calories
Cholesterol Less than 200 mg/day Total calories (energy) Balance energy intake and expenditure
to maintain desirable body weightprevent weight gain
PREVENTIVE STRATEGIES FOR CORONARY HEART
DISEASE
Identification of Very-High-Risk Patients
An update to the NCEP ATP III guidelines proposed a new classification of patients as very high risk who deserve especially aggressive low-density lipoprotein cholesterol (LDL-C) lowering.
Identification of Very-High-Risk Patients
These individuals are those with the presence of established cardiovascular disease plus:
(1) multiple major risk factors (especially diabetes),
(2) severe and poorly controlled risk factors (especially continued cigarette smoking),
(3) the metabolic syndrome (especially triglycerides 200 mg/dL plus non–high-density lipoprotein cholesterol [HDL-C] 130 mg/dL with HDL-C <40 mg/dL)
(4) patients with acute coronary syndromes.
Identification of Very-High-Risk Patients
Clinical trial data also indicate that those with established coronary disease and elevated levels of C-reactive protein (CRP) represent a very high risk group.
Identification of Very-High-Risk Patients
A national survey of outpatients with CHD found that 75 percent meet the criteria for very high risk.
Identification of High-Risk Patients
A CHD risk equivalent is defined when the absolute 10-year risk for hard CHD events exceeds 20 percent.
Identification of High-Risk Patients
Clinical Coronary Heart Disease:
Included in the category of clinical CHD are a history of acute coronary syndromes, stable angina, and coronary revascularization procedures.
Identification of High-Risk Patients
Evidence from clinical trials of cholesterol-lowering therapy indicates that patients with a prior history of myocardial infarction (MI) have a 10-year risk for recurrent nonfatal or fatal MI of about 26 percent.
Identification of High-Risk Patients
Patients with stable angina pectoris have a 10-year risk for acute MI of approximately 20 percent.
Identification of High-Risk Patients
Noncoronary Atherosclerosis: Patients in this group include: peripheral arterial disease, abdominal aortic aneurysm, symptomatic carotid artery
disease or asymptomatic disease with greater than 50 percent stenosis.
Identification of High-Risk Patients
The absolute risk for MI in patients with noncoronary atherosclerosis equals that for recurrent MI in patients with established CHD.
Identification of High-Risk Patients
DiabetesPatients with diabetes, particularly
middle-age and older patients with type 2 diabetes, who do not manifest CHD commonly carry a risk for major coronary events equivalent to that of nondiabetic patients with established CHD.
Identification of High-Risk Patients
Moreover, many patients with type 2 diabetes have had a silent MI, and many others have silent ischemia.
Identification of High-Risk Patients
Thus most patients with diabetes are at high risk, and ATP III has designated diabetes as a CHD equivalent.
Identification of High-Risk Patients
Multiple Risk Factors Without Clinical Coronary Heart Disease
Persons without known atherosclerosis who have multiple risk factors (other than diabetes) often have risk that is equivalent to CHD.
PRIMARY PREVENTION
SECONDARY PREVENTION
Nonpharmachologic therapy in HTN
Risk Factor In Acute Coronary
Syndrome(ACS)
Vulnerable (High-risk) Plaque
+Vulnerable (High-Risk) Blood
=High-Risk (Vulnerable) Patient
Plaque - Blood - Patient
Family/Genes Gender Age (menopause)DietInflammation HypertensionObesitySedentary Life others
SmokingCathecholaminesFibrinogenLp(a)/HomocysteinFactor V LeidenPlatelet polymorph.HypercoagulabilityHypofibrinolysisGenetic Protein deficiencies
DiabetesHyperlipidemiaApoptosis?Shear StressDepression ? CRP?
ATHEROGENESIS THROMBOSIS
Risk Factor and Atherothrombosis
Inflammation Thrombosis Atherosclerosis
Apoptosis Tissue factor micro-particles
Aggregated Platelets
PDGFThrombin
IL-6
TFMMP
ICAM-1
IL-1
CRP
CV
Ris
k F
acto
rsA
CS
The Inflammation-Thrombosis Link
Clinical evidence: Septic shockInflammation subsequent to bacterial endotoxin induces endothelialTF and PAI-1 expression leading to thrombotic complications (DIC)
Vulnerable (Thrombogenic) Blood
Vulnerable + Vulnerable
Plaque Blood
= Vulnerable patient
“ Vulnerable /Hyper-reactive” Blood
Several risk factors correlate with hyperreactive blood. These factors modulate the severity of the event after plaque disruption
“Classic”Diabetes Smoking HyperlipidemiaInflammation/ Apoptosis/ Infection? CathecholaminesFibrinogen Lp(a) HomocysteinemiaFactor V Leiden Platelet polymorph Shear rate Genetic Protein deficiencies (AT III, Prot C or S)Hypercoagulable state (FVII, F1.2, FPA)Hypofibrinolytic state (PAI-1, t-PA, u-PA)
“Not so-classic”Depression Circulating TF activity Stress
128
Atherosclerosis: A Progressive Process
NormalFatty
StreakFibrousPlaque
Occlusive Atherosclerotic
Plaque
PlaqueRupture/Fissure &
Thrombosis
MI
Stroke
Critical Leg Ischemia
Clinically Silent
Coronary Death
Increasing Age
Effort AnginaClaudication
UnstableAngina
AND FINALLY