Regina S. Druz, MD, FACC, FASNC

Director of Nuclear Cardiology North Shore University Hospital

Manhasset, New York

Concept of the relative and absolute risk

Risk factors

Modification of risk factors based on risk

stratification

Setting up an individualized plan with

specific goals

Implementing the plan into actions!

Consistency=change

12: Chronic Coronary Artery Disease 2010;(DOI:10.1016/B978-1-4377-0637-6.00012-X)

Elsevier Inc.

Figure: Risk Factors and Coronary Atherosclerosis in Youth The critical flaw in the use of the 10-year risk of a coronary event as

an initiation criterion. An example of the approximate 10- and 30-year Framingham risk of coronary heart disease for a 25-

year-old man with or without clinical risk factors (total cholesterol 150 mg/dl vs. 260 mg/dl; high-density lipoprotein

cholesterol 35 mg/dl vs. 60 mg/dl; systolic blood pressure 110 mm Hg vs. 160 mm Hg), smoking, and diabetes. A young man

with 4 risk factors is at low 10-year risk (<5%) whereas his risk of a cardiac event before age 55 years exceeds 40%, and his risk

is 5-fold greater than a man with no risk factors. The arbitrary choice of 10-year risk of a coronary event needs to be replaced

with a method reflecting the pathogenesis of coronary artery disease, which begins in young adults. This concept is

incorporated in both the absolute 30-year risk and in the individual's relative risk within his/her age group.

Redefining Normal Low-Density Lipoprotein Cholesterol August 17,

2010;56(DOI:10.1016/j.jacc.2009.11.090)

2010 American College of Cardiology Foundation

Figure: Age-specific mean (95% CI) of 10-year coronary heart disease risk prediction based on the Framingham model and

National Cholesterol Education Program Adult Treatment Panel III (NCEP) among aged 20 through 79 years old. aEstimated

from those without self-reported coronary heart disease (total: myocardial infarction, angina pectoris, heart failure, left

ventricular hypertrophy and other cardiac arrhythmia). bEstimated from those without self-reported coronary heart disease

(hard: myocardial infarction) or a CHD equivalent (peripheral vascular disease, diabetes mellitus).

Assessing risk factors of coronary heart disease and its risk prediction among Korean adults: The 2001 Korea

National Health and Nutrition Examination Survey June 16, 2006;110(DOI:10.1016/j.ijcard.2005.07.030)

2006 Elsevier Ireland Ltd

Figure: Relative risks associated with various cardiac risk factors among men (M) and women (F) in the INTERHEART Study. PAR

= population attributable risk.

CHAPTER 76: Cardiovascular Disease in Women 2008;

Elsevier Inc.

Figure: Data from post hoc analysis of the Treating to New Targets (TNT) study in 2,661 statin-treated patients show a low

plasma level of high-density lipoprotein (HDL) cholesterol (<37 mg/dL after 3 months on treatment) was associated with an

increased 5-year risk of major cardiovascular events (defined as death from coronary artery disease; nonfatal, nonprocedural-

related myocardial infarction; resuscitation after cardiac arrest; or fatal or nonfatal stroke) in patients with low-density

lipoprotein cholesterol levels <70 mg/dL. This association was evident even after adjustment for conventional cardiovascular

risk factors, including systolic blood pressure, fasting glucose, triglycerides at 3 months, and the presence or absence of

diabetes mellitus and cardiovascular disease. For cholesterol, 1 mg/dL = 0.02586 mmol/L. CI = confidence interval; Q =

quintile. (Adapted from N Engl J Med. 87 )

The Residual Risk Reduction Initiative: A Call to Action to Reduce Residual Vascular Risk in Patients with

Dyslipidemia November 17, 2008;102(DOI:10.1016/j.amjcard.2008.10.002)

2008 Elsevier Inc.

Figure: Estimated Annual Risk of CHD Death or MI Rate Rate shown is by tertile of the Agatston score in patients at

intermediate coronary heart disease (CHD) event risk using definitions of an intermediate Framingham Risk Score (FRS) or

greater than 1 cardiac risk factor. Intermediate FRS was defined as follows: Greenland et al. (20) 10% to 20%; Vliegenthart et

al. (22) 20%; LaMonte et al. (28), greater than 1 cardiac risk factor; and Arad et al. (19) 10% to 20%. CACS = coronary artery

calcium score; MI = myocardial infarction.

ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed

Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain

January 23, 2007;49(DOI:10.1016/j.jacc.2006.10.001)

2007 American College of Cardiology Foundation

Must address multiple cardiac risk factors

Must emphasize that the oxidative damage is

CUMULATIVE

Practice the SELF™ method:

Avoid Salt, Sugar, Saturated fat, Stress

Nutrients for Energy (portion control)

Healthy Lipids (omega-3 and monounsaturated)

for Lifelong commitment

Make Fitness your Friend

Avoid highly-processed, calorie-

dense, nutrient-deprived foods (leads to

immediate release of free radicals and

inflammation EVERY TIME YOU EAT!!)

Rely on high-fiber, minimally-

processed, plant-based foods

Lean protein, fish, grains and legumes

Incorporate vinegar, tea, cinnamon, nuts

Low to moderate alcohol consumption

Mediterranean and Okinawan diets reduce

inflammation and cardiovascular risk

Measures the magnitude of the glucose

“spike” in the blood stream after 50 g of a

specific food consumed as compared with 50

g of oral glucose

White bread and jelly:80

Whole wheat and peanut butter: 40

2 fold-higher increase in post-prandial

glucose for the same amount of calories!

Small quantities of high glycemic index foods

are just as bad as large quantities of low

glycemic index foods!

Broccoli, spinach, grapefruits, cherries –high-fiber, high-water content and low glycemicindex leads to lower “spike”

Berries, red wine, dark chocolate, tea, pomegranates-anti-oxidants attenuating post-prandial inflammation

Cinnamon-calorie-free, slows gastric emptying, reduces glucose “spike”

EXERCISE: a single bout of 90 min walking within 2 hrs before or after the meal lowers post-prandial glucose and triglycerides by 50%!

Almonds, pistachios, peanuts reduce glycemicindex 30-50% (when eaten with high glycemicindex foods)

Tree nuts and olive oil (monounsaturated fat) reduce oxidative stress and post-prandial glucose (at least 5xweek)

Fish oil: dose –dependent decrease in triglyceriders (16-40%)

Vinegar (1-2 tbs): lowers post-prandial glucose 25-35%, increases satiety (calorie restriction and portion control)

Alcohol: 1-2 drinks before a meal (0.5-1 women) lowers glucose “spike”

Egg whites

Fish

Game meat, very lean red meat,

Skinless poultry breast meat,

Whey protein (decreased glucose spike by

56%, increased insulin response by 60% when

added to a glucose drink)

Proteins increase basal metabolic rate and

reduce inflammation and obesity

Weight loss of 5-10% reduces risk of diabetes

Calorie reduction by 30% in animals makes

them live longer

30% reduction possible in humans with

preserved nutritional requirements

Optimal calories for health and longevity are

not known

Experts (Andrew Weil, MD) recommend

periodic fasting or overall reduced caloric

intake when fasting is not possible

Not a single agent with a solid evidence of

clearly-defined benefit

Vitamins A, C, E not beneficial for secondary

prevention (may interact with Rx drugs)

Anti-oxidants, flavonols, vit.D, fish oil, soy,

resveratrol have evidence of benefit (but not

confirmed in large, randomized trials)

NOTHING substitutes a healthy approach:

practice SELF™ method for SURVIVAL!