cad risk factors lowering novel risk marker levels
TRANSCRIPT
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CAD Risk factors
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Lowering Novel Risk Marker Levels
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Lowering Novel Risk Marker Levels
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METABOLIC SYNDROME
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Criteria for Clinical Diagnosis of Metabolic
SyndromeMeasure (any three of five constitute a diagnosis of metabolic syndrome)
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Criteria for Clinical Diagnosis of Metabolic
Syndrome
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Complication of Metabolic syndrome
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Involvement Of Liver In Metbolic Syndrome
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OBESITY
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Body Mass Index (BMI)
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Obesity-Related Organ Systems Review
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Obesity-Related Organ Systems Review
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LIFE STYLE MODIFICATION (LSM)
RISK FACTOR MODIFICATION(RFM)
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FAST FOOD BOMB
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WEIGHT WATCHING:
Care About Weight
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Weight watching: Care About Weight
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Weight watching: Care About Weight
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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)
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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
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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)
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A few behavioral techniques to achieve a long-term weight loss
include:Taking smaller portions
Eating slowly Keeping a diet diary (self-monitoring)
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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
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A few behavioral techniques to achieve a long-term weight loss
include:Developing a regular schedule for physical activity
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A few behavioral techniques to achieve a long-term weight loss
include:Identifying circumstances leading to eating binges and avoiding them
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EXERCISE & PHYSICAL ACTIVITY:
(an important way for
intervention in metabolic syndrome)
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EXERCISE & PHYSICAL ACTIVITY
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EXERCISE & PHYSICAL ACTIVITY
It is currently recommended that everyone engage in 30 minutes daily of moderate-intensity physical activity.
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EXERCISE & PHYSICAL ACTIVITY
Moderate-intensity activities (40 to 60% of maximum capacity) are equivalent to a brisk walk (15–20 minutes per mile).
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EXERCISE & PHYSICAL ACTIVITY
Goal At least 30 minutes of moderate-intensity physical activity on most (and preferably all) days of the week.
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EXERCISE & PHYSICAL ACTIVITY
Even more benefit is achieved by increasing activity to 60 minutes daily.
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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.
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EXERCISE & PHYSICAL ACTIVITY
The following are examples of moderate-intensity activity:
Brisk WalkingJoggingSwimmingBikingGolfing Team Sports
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EXERCISE & PHYSICAL ACTIVITY
Using simple exercise equipment (e.g., treadmills)
Several short (10 to 15 minutes) bouts of activity (brisk walking)
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EXERCISE & PHYSICAL ACTIVITY
Substituting more active leisure activities for sedentary ones (television watching and computer games)
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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.
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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.
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EXERCISE & PHYSICAL ACTIVITY
Flexibility training and an increase in daily lifestyle activities should complement this regimen.
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Diet & Eating
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HEALTHY FOODS
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Food pyramid
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Food Pyramid
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Food Pyramid
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Food Pyramid
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NUTSWalnut :ExcellentPeanut :ExcellentCoconut : Bad fat
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CIGARETTE SMOKING
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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.
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Cigarette SmokingCigarette smoking increases risk two- to threefold and interacts with other risk factors to multiply risk.
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Cigarette SmokingThere is no evidence that filters or other modifications of the cigarette reduce risk.
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Cigarette SmokingPipe smoking and cigar smoking increase the risk of CHD.
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Cigarette Smoking More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking.
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Cigarette SmokingExposure to environmental tobacco smoke, or passive smoking, is now recognized as a modifiable risk factor.
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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.
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Cigarette Smoking
This is in addition to an increased risk for respiratory tract cancers and other smoking-related diseases.
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Cigarette Smoking
Pathophysiologic studies have identified multiple mechanisms through which cigarette smoking may cause CHD.
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Cigarette Smoking
Oxidative stress plays a central role in smoking-mediated dysfunction of nitric oxide biosynthesis in endothelial cells.
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Cigarette Smoking
Cigarette smoking also lowers HDL-C.
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Cigarette Smoking
These effects, along with direct effects of carbon monoxide and nicotine, produce endothelial damage.
(apoptosis)
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Cigarette Smoking
Increased vascular reactivity
Reduced oxygen-carrying capacity
A lower threshold for myocardial ischemia
Increased risk of coronary spasm.
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Cigarette Smoking
Cigarette smoking is also associated with increased levels of fibrinogen and increased platelet aggregability.
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For Patients Who Are Not Ready To Quit, Clinicians Should Apply
The 5 R:
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For Patients Who Are Not Ready To Quit, Clinicians Should Apply
The 5 R:
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CHOLESTEROL AND HYPERLIPIDEMIA
(HLP)
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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
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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
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PREVENTIVE STRATEGIES FOR CORONARY HEART
DISEASE
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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.
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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.
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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.
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Identification of Very-High-Risk Patients
A national survey of outpatients with CHD found that 75 percent meet the criteria for very high risk.
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Identification of High-Risk Patients
A CHD risk equivalent is defined when the absolute 10-year risk for hard CHD events exceeds 20 percent.
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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.
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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.
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Identification of High-Risk Patients
Patients with stable angina pectoris have a 10-year risk for acute MI of approximately 20 percent.
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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.
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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.
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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.
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Identification of High-Risk Patients
Moreover, many patients with type 2 diabetes have had a silent MI, and many others have silent ischemia.
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Identification of High-Risk Patients
Thus most patients with diabetes are at high risk, and ATP III has designated diabetes as a CHD equivalent.
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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.
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PRIMARY PREVENTION
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SECONDARY PREVENTION
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Nonpharmachologic therapy in HTN
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Risk Factor In Acute Coronary
Syndrome(ACS)
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Vulnerable (High-risk) Plaque
+Vulnerable (High-Risk) Blood
=High-Risk (Vulnerable) Patient
Plaque - Blood - Patient
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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
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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)
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Vulnerable (Thrombogenic) Blood
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Vulnerable + Vulnerable
Plaque Blood
= Vulnerable patient
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“ 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
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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
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AND FINALLY
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