What is Heart Disease and How Can We Prevent It?

Robert A. Vogel, MD

University of Maryland School of Medicine

What is Cardiovascular Disease?• Heart Disease

– Coronary heart disease (blocked heart arteries)

– Heart failure (weak heart muscle)

– Valvular heart disease (leaking or narrowed heart valves)

• Stroke• High blood pressure

What are the Symptoms of Cardiovascular Disease?

• Chest pain or pressure, especially on exertion

• Shortness of breath, especially on exertion

• Palpitations or passing out

• Sudden weakness, numbness, or inability to

speak

• Dying suddenly 911

Why is Cardiovascular Disease Important?

• 42% of American die from CVD

• Most common cause of death on earth

• Kills more Americans than the next leading 6

causes (including cancer)

• Costs Americans 7 years of life on average

• Costs more than $200 billion annually in U.S.

What Causes Cardiovascular Disease?

• High cholesterol

• High blood pressure

• Diabetes

• Cigarette smoking

• Older age

• Male sex

• Family history of early heart disease

Obesity

Poor diet

Inactivity

Progression of AtherosclerosisHealthyartery

Earlylesion

Vulnerableplaque

Stable plaque“Fibrofatty” stage

Lumen maintained

Thin cap = high risk of thrombosis

Thick cap = low risk of thrombosis;

stenosis may cause angina, claudication

Intima thickens, atheromatous gruel

forms under cap

Lumen narrows

teenager 50 year old

Atherosclerosis is the progressive narrowing of arteries caused by the body’s natural response (scarring) to the chronic injury of high cholesterol, improper diet, high

blood pressure, diabetes, smoking, etc.

How Does a Heart Attack Occur?

Abnormal Treadmill Stress Test

Coronary Arteriography

8/25/97 10/19/99

Ventriculography

What Can You Do to Prevent Heart Disease?

Lose weight

Eat properly

Become more physically active

Stop smoking

Drink only moderately

“French Paradox”

Obesity

Atherogenic diet

Inactivity

Death from Preventable Causes in the U.S. - 2000

Number % of Total

Tobacco 435,000 19

Diet & Activity 400,000 14

Alcohol 100,000 5

Microbial Agents 90,000 4

Toxic Agents 60,000 3

Firearms 35,000 2

High-risk Sexual Behavior 30,000 1

Motor Vehicle Injuries 25,000 1

Illicit Drugs 20,000 <1

Total 1,060,000 49

Mokdad et al. JAMA. 1999;282:16.

Obesity Obesity (BMI >30 kg/m(BMI >30 kg/m22)) Trends Among US Trends Among US AdultsAdults

No data <10% 10-14% 15-19% >20%

19851985 19901990

19951995 20002000

Al Suwaidi J, et al. Clin Card 8/01

How much sooner does obesity give you a heart attack?

56

58

60

62

64

66

68

70

72

74

Normal Overweight Obese

Age

(Y

ears

)

Schwimmer JB et al, JAMA 2003;289:1813

Who is more unhappy, an obese child or one with cancer?

50

55

60

65

70

75

80

85

Non-obese Obese Cancer

Are You Overweight?

BMI

25 (Overwt) 30 (Obese) 40 (Extremely obese)

5’0” 128 153 204

5’3” 141 169 225

5’6” 155 186 247

5’9” 169 203 270

6’0” 184 221 294

6’3” 200 240 319

6’6” 216 260 344

Obesity and Dieting Facts

3500 cal = 1 pound weight

1 mile = 100 cal

Δ 100 cal/day = 10 pound/year

Dansinger ML et al, JAMA 2005;293:43

How well do popular diets work in 1 Year?

-10

0

10

20

30

40

50

Weight (kg) Drop-outs (%)

Atkins

Zone

WeightWatchersOrnish

How to Lose Weight

• Drink diet; water is even better

• Start with a salad or soup

• Cut portion size in advance - “pepper half your pie”

• Stay away from “fast food”

• Walk more; watch less

How much sugar do we Americans eat in a year?

0

50

100

150

200

250

1800 1900 1980 2000 2000

teenagers

Pou

nd

s

Schulze MR et al, JAMA 2004;292:927

Why drink diet?

1991 1995 1999 Year

80

78

76

74

72

70

68

66

diet beverages

regular beverages

Wei

ght

(kg)

Rolls B et al, Obesity Res 2003;11:A22

Why should we eat a salad first?

500

550

600

650

700

750

800

850

900

950

1000

Pasta Salad/Low CalorieDressing + Pasta

Salad/High CalorieDressing + Pasta

Tot

al C

alor

ies

Pereira MA et al, Lancet 2005;365:36

Why should you stay away from “fast food” restaurants?

0

1

2

3

4

5

Weight Gain (kg) Diabetes or Prediabetes

10 lbs

2X

How to burn* 400 calories:Walk 2 hr 20 Minutes

20 Years Ago Today

210 Calories How many calories are in these fries?

610 Calories

Calorie Difference: 400 Calories

*Based on 130 pound person

Why are portion sizes important?

Jakicic JM et al: JAMA 1999;282:1554

Why is exercising important for weight loss?

-14

-12

-10

-8

-6

-4

-2

0

6 months 12 months 18 months

<150

150-200

>200

Exercise (min/wk)

Ch

ange

in w

eigh

t (k

g)

Good Foods for Your HeartFruits and vegetables

Fish (baked or broiled)Whole grains, nuts, and soy

Skim milk productsCanola oil and other PUFA’s

de Longeril et al, Am J Clin Nutr 1995;61:1360S, JACC 1996;28:1103

Effect of a Modified Mediterranean Diet

• 5 year RCT trial in

605 CHD subjects

• more whole grains

more fruits, beans,

and vegetables

more fish

less meat

skim milk products

canola oil margarine -80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

Chol CVE's Death Late Cancer

Miettinen TA, et al. NEJM 1995;333:1308

Benecol, Take Control, & Smart Balance Omega Plus Margarines or Minute Maid Heart Wise

Orange Juice

2.6 g/day

1.6 g/day

Control

GISSI Investigators. Lancet 1999;354:447

GISSI Prevention Study: Effect of 1 gm/d Omega-3 (70% DHA) on CV Risk in 11,324

Post-MI Patients over 3.5 Years

-30%

-25%

-20%

-15%

-10%

-5%

0%

CVE CV Mortality Sudden Death

*

*

*

* P <0.05

* P <0.05

Why is eating “fast food” similar to smoking 2 cigarettes?

Egg McMuffin, Sausage McMuffin,

2 Hash Browns

10%

8%

6%

4%

2%

0%

0 2 4 6

SHAM

ONE CIGARETTE

HOURSLeKakis JP et al, Circulation 1996;97:I-355Vogel RA et al, Am J Cardiol 1997;79:350

Hard-Cider House Rules

• Drink 1 drink/day

• Alcohol is alcohol

• Drink a little every day

• Drink with meals

• Drink responsibly!

Smoking Cessation• You lose one minute of life for every minute that

you smoke• A lifetime smoker loses 7 years of life• Stop smoking at age 30, add 5 years of life• Make a commitment• Join an organized program• Bupropion and nicotine substitutes help (use

them long-term)• Substitute exercise • Recommend low-calorie “treats”

Exercise American Style

Hu FB et al, JAMA 2003;289:1785

Effect of Daily Activities on Obesity and Diabetes

-35%-30%-25%-20%-15%-10%-5%0%5%

10%15%

TV SedentaryWork

ADLs BriskWalking

Obesity

Diabetesper 1 hour/day

Mittleman MA et al, N Engl J Med 1993;329:1677 Rodriquez BL et al, Circulation 1994;89:2540

Hakim AA et al, Circulation 1999;100:9

Effects of Exercise on Heart Disease Risk

-100%-90%-80%-70%-60%-50%-40%-30%-20%-10%

0%

Daily WalkingMidde-Aged

Daily WalkingElderly

Heavy Exertion1-2/week

Heavy Exertion5-7/Week

Age

Exertion

Frequency

Red

uct

ion

CH

D R

isk

Blumenthal JA et al, Arch Intern Med 1999;159:2349

Comparison of Exercise and Antidepressants

0

5

10

15

20

25

Medication Exercise

Baseline

16 Weeks

Bec

k’s

Dep

ress

ion

In

dex

10,000 Step Program

• Each add’n 3000 steps/day (½ hr) 15 lb ↓/yr

15-50% ↓ CHD

• Doesn’t have to be continuous

• Incorporate into daily activities

Effect of Video Viewing on FMD

FMD Before & After Video

Brachial artery during

Hyperemia

Stress Reduction Made Simple

• exercise regularly

• get sufficient sleep

• develop close relationships

• laugh

• touch and be touched by

people

• enjoy a sexual relationship

• get a pet, especially a dog

• do daily enjoyable activities

• take a vacation

• develop spirituality

• volunteer

• try meditation

• stop watching television

Know Your Numbers; Medications Can Help

OK Very

Good

Total cholesterol: <200 <150

LDL (bad) cholesterol: <130 <100

HDL (good) cholesterol: >40/50 >60

Blood pressure: <140/90

<120/80

Fasting blood sugar: <126 <100