Chapter 7 Cardiovascular Disease. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an...

Chapter 7Chapter 7

Cardiovascular DiseaseCardiovascular Disease

2Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Cardiovascular Disease Is Cardiovascular Disease Is the #1 Cause of Mortalitythe #1 Cause of Mortality

Arteriosclerosis: hardening of the arteriesArteriosclerosis: hardening of the arteries Atherosclerosis: buildup of plaque inside arteries Atherosclerosis: buildup of plaque inside arteries

and blood vesselsand blood vessels Cardiovascular diseaseCardiovascular disease (CVD) often used (CVD) often used

interchangeably with interchangeably with coronary heart diseasecoronary heart disease (CHD) and (CHD) and coronary artery diseasecoronary artery disease (CAD) (CAD)

CVA: “stroke,” or cerebral vascular accidentCVA: “stroke,” or cerebral vascular accident MI: “heart attack,” or myocardial infarctionMI: “heart attack,” or myocardial infarction Thrombosis: clot formationThrombosis: clot formation Peripheral arterial disease: a form of Peripheral arterial disease: a form of

atherosclerosisatherosclerosis


Progression of AtherosclerosisProgression of Atherosclerosis

Natural progression of atherosclerosis. (From Harkreader H: Fundamentals of nursing: caring and clinical judgment, ed 2, St Louis, 2004, Saunders.)


History of KnowledgeHistory of Knowledge

1950s (Korean War)—young men first recognized 1950s (Korean War)—young men first recognized to have signs of atherosclerosisto have signs of atherosclerosis

1960s—serum cholesterol linked to heart disease1960s—serum cholesterol linked to heart disease Egg restriction beganEgg restriction began Research showing saturated fat has greater impact on Research showing saturated fat has greater impact on

serum cholesterol was ignoredserum cholesterol was ignored Today it is recognized that saturated fat is the #1 Today it is recognized that saturated fat is the #1

culpritculprit Monounsaturated fats are now preferred over Monounsaturated fats are now preferred over

polyunsaturated fats to maintain HDL-C levels polyunsaturated fats to maintain HDL-C levels and reduce risk of inflammation/cancerand reduce risk of inflammation/cancer


Risk Factors CVD/2004 ATP IIIRisk Factors CVD/2004 ATP III

High LDL-C >100 mg/dL or >70 if high-risk CVD*High LDL-C >100 mg/dL or >70 if high-risk CVD* Cigarette smokingCigarette smoking Hypertension (HTN) Hypertension (HTN) ≥140/90≥140/90 Low HDL-C <40 mg/dL; <50 for womenLow HDL-C <40 mg/dL; <50 for women Family hx premature coronary heart disease (CHD)Family hx premature coronary heart disease (CHD) CVD in first-degree male relative <55 years of ageCVD in first-degree male relative <55 years of age CVD in first-degree female relative <65 years of ageCVD in first-degree female relative <65 years of age Age: men ≥45 years; women ≥55 yearsAge: men ≥45 years; women ≥55 years DiabetesDiabetes Metabolic syndrome with central obesity, dyslipidemia,Metabolic syndrome with central obesity, dyslipidemia, prediabetesprediabetes

*HDL-C >60 mg/dL: deduct one risk factor for CVD*HDL-C >60 mg/dL: deduct one risk factor for CVD


Other Risk Factors for CVDOther Risk Factors for CVD

Elevated homocysteine levels (may be a marker Elevated homocysteine levels (may be a marker not a cause)not a cause)

Increased prothrombotic and inflammatory factorsIncreased prothrombotic and inflammatory factors Postprandial dysmetabolism (high glucose/lipids Postprandial dysmetabolism (high glucose/lipids

post-meals)post-meals) Periodontal disease and/or bacterial infections Periodontal disease and/or bacterial infections

with role of inflammationwith role of inflammation Endothelial dysfunction and/or MgEndothelial dysfunction and/or Mg++++ deficiency deficiency Elevated serum ferritinElevated serum ferritin Vitamin D deficiency Vitamin D deficiency (Michos and Melamed, 2008)(Michos and Melamed, 2008)

Possible role of stressPossible role of stress


Other Risk FactorsOther Risk Factors

Low intake of antioxidants causing Low intake of antioxidants causing production of free radicalsproduction of free radicals

Excess or no alcohol intake*Excess or no alcohol intake* Hypoglycemia, caffeine, electrolyte Hypoglycemia, caffeine, electrolyte

imbalance with cardiac arrhythmiaimbalance with cardiac arrhythmia*Alcohol cannot be advised for nondrinkers*Alcohol cannot be advised for nondrinkersbecause of risk of alcoholism in thosebecause of risk of alcoholism in thosewithout demonstrated ability to consumewithout demonstrated ability to consumemoderate intakemoderate intake


Risk Factors for Cerebral Vascular Risk Factors for Cerebral Vascular Accident (CVA or “Stroke”)*Accident (CVA or “Stroke”)*

HTN, diabetes, obesityHTN, diabetes, obesity InactivityInactivity HighHigh––glycemic-load meals, especially with glycemic-load meals, especially with

fatty meatsfatty meats Trans fatty acids; lowered risk from Trans fatty acids; lowered risk from

omega-3 fatty acidsomega-3 fatty acids Diet low in antioxidant vitaminsDiet low in antioxidant vitamins Oral contraceptivesOral contraceptives

*Decreased risk with high-fiber diet and *Decreased risk with high-fiber diet and fish (omega-3 fats)fish (omega-3 fats)


Types of Lipid DisordersTypes of Lipid Disorders

HypercholesterolemiaHypercholesterolemia——usually high LDL-C usually high LDL-C (>100 mg/dL)(>100 mg/dL)

HyperlipidemiaHyperlipidemia——high LDL-C and high high LDL-C and high triglycerides(TG >150 mg/dL)triglycerides(TG >150 mg/dL)

DyslipidemiaDyslipidemia——low HDL-C low HDL-C (<40 mg/dL; <50 for women) and usually high (<40 mg/dL; <50 for women) and usually high TGTG

Hypocholesterolemia (total cholesterol <160) Hypocholesterolemia (total cholesterol <160) may be an indicator of poor health status may be an indicator of poor health status (malabsorption, cancer)and higher cholesterol (malabsorption, cancer)and higher cholesterol levels advised with critical illness levels advised with critical illness (Bonville et al., 2004)(Bonville et al., 2004)


Lipids Effect on CVDLipids Effect on CVD

HDL: High-density lipoproteinHDL: High-density lipoprotein——high PRO high PRO content helps clear cholesterol from the body; content helps clear cholesterol from the body; called the “good cholesterol”called the “good cholesterol”

LDL: Low-density lipoproteinLDL: Low-density lipoprotein——high fat high fat content; promotes atherosclerosis; called the content; promotes atherosclerosis; called the “bad cholesterol”“bad cholesterol”

TriglyceridesTriglycerides——form of food fat in the form of food fat in the bloodstream and affected by food intake; the bloodstream and affected by food intake; the higher the fasting level, the greater the meal higher the fasting level, the greater the meal associated rise; also contributes to associated rise; also contributes to atherosclerosisatherosclerosis


Medical Nutrition Therapy for High LDL*Medical Nutrition Therapy for High LDL*

Maximum of 10% saturated fat and 300 mg Maximum of 10% saturated fat and 300 mg cholesterol initially; if not adequate for LDL-C cholesterol initially; if not adequate for LDL-C goals: 6% to 7% saturated fat (and trans fats) and goals: 6% to 7% saturated fat (and trans fats) and 200 mg cholesterol200 mg cholesterol Increasing recognition that cholesterol intake has minor Increasing recognition that cholesterol intake has minor

role in LDL-C; individualized guidance by an RD is role in LDL-C; individualized guidance by an RD is warrantedwarranted

Reducing saturated fat lowers liver production of LDL-CReducing saturated fat lowers liver production of LDL-C Increase soluble fiber to help absorb what liver Increase soluble fiber to help absorb what liver

needs (bile salts) to manufacture cholesterolneeds (bile salts) to manufacture cholesterol Lose weight as neededLose weight as needed*May benefit from low*May benefit from low––glycemic-load meals if there is anyglycemic-load meals if there is anyevidence of insulin resistanceevidence of insulin resistance


FYIFYI

Intake of one serving of beans daily is Intake of one serving of beans daily is associated with 40% lower risk of MI associated with 40% lower risk of MI (Kabagambe et al., 2005)(Kabagambe et al., 2005)

High-fiber foods along with low-saturated High-fiber foods along with low-saturated fat diet double the lowering of total fat diet double the lowering of total cholesterol and LDL-C levels cholesterol and LDL-C levels (Gardner et al., 2005)(Gardner et al., 2005)

National Academy of Sciences advises 25 National Academy of Sciences advises 25 to 38 g fiber/day based on kilocalorie to 38 g fiber/day based on kilocalorie needs at 14 g/1000 kcal needs at 14 g/1000 kcal


Medical Nutrition Therapy for Medical Nutrition Therapy for Hyperlipidemia and Reduced Risk of CVDHyperlipidemia and Reduced Risk of CVD

6% to 10% saturated fat and trans fats, 200 to 300 mg 6% to 10% saturated fat and trans fats, 200 to 300 mg cholesterolcholesterol

Increase soluble fiberIncrease soluble fiber Lose weight as neededLose weight as needed Limit carbohydrate to 45% to 50% kilocalories to lower Limit carbohydrate to 45% to 50% kilocalories to lower

insulin levels and promote breakdown of triglycerides (TGs)insulin levels and promote breakdown of triglycerides (TGs) Include as much as 35% kilocalories as unsaturated fats if Include as much as 35% kilocalories as unsaturated fats if

TGs <300 mg/dL TGs <300 mg/dL (if TGs >300, very low-fat diet is needed to help prevent (if TGs >300, very low-fat diet is needed to help prevent

pancreatitis)pancreatitis) Increase omega-3 fatty acids (preferably from fatty fish) to Increase omega-3 fatty acids (preferably from fatty fish) to

lower TGs and reduce risk of clot formation for decreased lower TGs and reduce risk of clot formation for decreased risk of MI or cerebrovascular accident (CVA)risk of MI or cerebrovascular accident (CVA)


Medical Nutrition Medical Nutrition Therapy for DyslipidemiaTherapy for Dyslipidemia

Low saturated and trans fats and low cholesterol Low saturated and trans fats and low cholesterol dietdiet

Moderate carbohydrate intake; emphasize Moderate carbohydrate intake; emphasize soluble fibersoluble fiber

Lose weight as neededLose weight as needed Include omega-3 fatty acids (preferably fatty fish)Include omega-3 fatty acids (preferably fatty fish) Emphasize monounsaturated fatsEmphasize monounsaturated fats——nuts, olives nuts, olives

and olive oil, canola oil, peanut oil, avocadosand olive oil, canola oil, peanut oil, avocados Follow the American Heart Association’s Follow the American Heart Association’s

Therapeutic Lifestyle Changes dietTherapeutic Lifestyle Changes diet


Benefit of NutsBenefit of Nuts

American Heart Association advises a handful American Heart Association advises a handful (¼ cup) of nuts daily to lower risk of heart (¼ cup) of nuts daily to lower risk of heart disease by 35%disease by 35%

This may be due to vitamin E content and This may be due to vitamin E content and monounsaturated fatsmonounsaturated fats• The majority of nuts are primarily high in The majority of nuts are primarily high in

monounsaturated fats (grown in moderate climates) monounsaturated fats (grown in moderate climates) Except Brazil nuts (grown in tropical climates) that Except Brazil nuts (grown in tropical climates) that

are high in saturated fat are high in saturated fat Except walnuts (grown in cold climates) that are high Except walnuts (grown in cold climates) that are high

in polyunsaturated fatsin polyunsaturated fats Other compounds found in nuts contribute to cardiovascular Other compounds found in nuts contribute to cardiovascular

health, including fiber, phytochemicals, and the minerals health, including fiber, phytochemicals, and the minerals potassium and magnesium potassium and magnesium (Kris-Etherton et al., 2008)(Kris-Etherton et al., 2008)


Benefit of Dark Chocolate (Non-dairy)Benefit of Dark Chocolate (Non-dairy)

Promotes vasodilation to lower blood Promotes vasodilation to lower blood pressure and improve circulation, and pressure and improve circulation, and reduces oxidative stress reduces oxidative stress (Flammer et al., 2007; (Flammer et al., 2007;

Taubert et al., 2007)Taubert et al., 2007)

Read ingredients to ensure no butter fat or Read ingredients to ensure no butter fat or milk fat has been addedmilk fat has been added


FYIFYI

Medical nutrition therapy to lower inflammation (CRP)Medical nutrition therapy to lower inflammation (CRP) Improve glycemic control Improve glycemic control (Ridker, 2004)(Ridker, 2004)

Include high-fiber, low-saturated fat Include high-fiber, low-saturated fat (Richter et al., 2004)(Richter et al., 2004)

Include high-folate foodsInclude high-folate foods (Bertran et al., 2005) (Bertran et al., 2005)

Increase foods rich in arginine (e.g., nuts/fish) Increase foods rich in arginine (e.g., nuts/fish) (Wells et al., 2005)(Wells et al., 2005)

Include alcohol in moderate amounts (for those who already Include alcohol in moderate amounts (for those who already drink), fatty fish, vitamin E sourcesdrink), fatty fish, vitamin E sources (Liepa et al., 2003) (Liepa et al., 2003)

For women, evidence suggests further increased intake of For women, evidence suggests further increased intake of foods high in B vitamins, vitamin C, carotenoids, selenium, foods high in B vitamins, vitamin C, carotenoids, selenium, and zincand zinc (Scheurig et al., 2008) (Scheurig et al., 2008)


FYIFYI Role of Magnesium in CVDRole of Magnesium in CVD

As found in leafy greens, legumes, fish, As found in leafy greens, legumes, fish, milk, and supplementsmilk, and supplements Improves endothelial health Improves endothelial health (Cuevas and Germain, 2004)(Cuevas and Germain, 2004)

Reduces arrhythmia and risk of heart failureReduces arrhythmia and risk of heart failure(Ohtsuka and Yamaguchi, 2005)(Ohtsuka and Yamaguchi, 2005)

Acts as an HMG-Co reductase inhibitor (same Acts as an HMG-Co reductase inhibitor (same effect as statin medications) and needed to effect as statin medications) and needed to convert omega-3 and omega-6 fats into convert omega-3 and omega-6 fats into prostaglandin hormones prostaglandin hormones (Rosanoff and Seelig, 2004)(Rosanoff and Seelig, 2004)

Supplementation reduces complications of Supplementation reduces complications of coronary artery bypass graft (CABG) surgery coronary artery bypass graft (CABG) surgery (Pasternak et al., 2006)(Pasternak et al., 2006)


Hypertension (HTN)Hypertension (HTN)

Stage 1 HTN Stage 1 HTN ≥140/90 mm/Hg≥140/90 mm/Hg Stage 2 HTN ≥160/100 mm/HgStage 2 HTN ≥160/100 mm/Hg Stage 3 HTN ≥180/110 mm/HgStage 3 HTN ≥180/110 mm/Hg Children may be treated with blood pressure Children may be treated with blood pressure

>90th percentile (see Appendix 10, Evolve)>90th percentile (see Appendix 10, Evolve) Optimal blood pressure: <120/80 for adultsOptimal blood pressure: <120/80 for adults HTN linked to:HTN linked to:

All forms of CVDAll forms of CVD StrokeStroke Peripheral vascular disease (PVD)Peripheral vascular disease (PVD) Heart failureHeart failure Renal diseaseRenal disease


Possible Contributing Factors to HTNPossible Contributing Factors to HTN

Obesity and lack of exerciseObesity and lack of exercise Altered nitric oxide metabolism with increased Altered nitric oxide metabolism with increased

vasoconstrictionvasoconstriction History of low birth weightHistory of low birth weight High ratio of sodium to potassium intake (high salt and low High ratio of sodium to potassium intake (high salt and low

intake of high-potassium foods)intake of high-potassium foods) Deficiencies of vitamin C, folic acid, and zincDeficiencies of vitamin C, folic acid, and zinc Magnesium deficiency resulting from altered calcium Magnesium deficiency resulting from altered calcium

metabolism with decreased vasodilation and decreased metabolism with decreased vasodilation and decreased inhibition of norepinephrine hormoneinhibition of norepinephrine hormone

High intake of red meatHigh intake of red meat Chronic coffee intake promotes aortic stiffness Chronic coffee intake promotes aortic stiffness

(Vlachopoulos et al., 2005)(Vlachopoulos et al., 2005) Excess licorice related to hypokalemia Excess licorice related to hypokalemia (Sontia et al., 2008)(Sontia et al., 2008)


Omni Heart Study (Optimal Macronutrient Omni Heart Study (Optimal Macronutrient Intake Trial to Prevent Heart Disease) Intake Trial to Prevent Heart Disease)

2300 mg Na2300 mg Na++

2000 kcal (approximately)2000 kcal (approximately) 6% saturated fat6% saturated fat Up to 20% monounsaturated fatsUp to 20% monounsaturated fats Up to 200 mg cholesterolUp to 200 mg cholesterol Moderate carbohydrate intake at 48% to 58%Moderate carbohydrate intake at 48% to 58% Moderate protein intake at 15% to 25%Moderate protein intake at 15% to 25% Moderate fat intake at 27% to 37% Moderate fat intake at 27% to 37% (Swain et al., 2008)(Swain et al., 2008)


Guidelines and Benefits of ExerciseGuidelines and Benefits of Exercise

30 minutes of brisk walking on most days of the 30 minutes of brisk walking on most days of the weekweek

If there is risk of impaired nerve impulses If there is risk of impaired nerve impulses preventing increased heart rate, lower levels of preventing increased heart rate, lower levels of exercise are warrantedexercise are warranted Seek medical input for preexisting CAD or Seek medical input for preexisting CAD or

complications of diabetes (neuropathy)complications of diabetes (neuropathy) Both aerobic and anaerobic exercises contribute Both aerobic and anaerobic exercises contribute

to reduced CVDto reduced CVD Reduce blood pressure and risk of strokeReduce blood pressure and risk of stroke Raise HDL-CRaise HDL-C


Treating Heart FailureTreating Heart Failure

Limit Na+ intake; may require <2 g NaLimit Na+ intake; may require <2 g Na++ diet diet Advise thiamin supplementation with potential of Advise thiamin supplementation with potential of

wet beriberi as etiology of heart failure; Bwet beriberi as etiology of heart failure; B11

deficiency common among persons taking deficiency common among persons taking diuretics or with excess urination from diuretics or with excess urination from uncontrolled diabetes or excess fluid intake uncontrolled diabetes or excess fluid intake (Sica, 2007)(Sica, 2007)

Consider supplementation related to energy Consider supplementation related to energy production by the heart muscle (e.g., vitamins Bproduction by the heart muscle (e.g., vitamins B11, ,

BB22, B, B66, , LL-carnitine, coenzyme Q10, creatine, and -carnitine, coenzyme Q10, creatine, and

taurine) taurine) (Allard et al., 2006)(Allard et al., 2006)


Statin MedicationsStatin Medications

Lipid lowering (with positive and negative impacts)Lipid lowering (with positive and negative impacts) (+) Statins (HMG-Co reductase) inhibit liver’s production (+) Statins (HMG-Co reductase) inhibit liver’s production

and lowers LDL-C and lowers inflammationand lowers LDL-C and lowers inflammation ((––) Statins interfere with liver’s production of CoQ10 ) Statins interfere with liver’s production of CoQ10

enzymeenzyme ((––) Statins can cause myopathy (any disease of the ) Statins can cause myopathy (any disease of the

muscles), rhabdomyolysis (rupture of body cells), and muscles), rhabdomyolysis (rupture of body cells), and polyneuropathy; this may be due to selenium deficiency polyneuropathy; this may be due to selenium deficiency (Moosmann and Behl, 2004).(Moosmann and Behl, 2004).

((––) Statins less effective in women and persons over 65 ) Statins less effective in women and persons over 65 years and linked with increased breast cancer and years and linked with increased breast cancer and hemorrhagic hemorrhagic strokestroke (Preobrazhenskii et al., 2007) (Preobrazhenskii et al., 2007)

((––) Limited research among persons >85 years; may ) Limited research among persons >85 years; may increase neurodegeneration and heart failure among the increase neurodegeneration and heart failure among the elderly population elderly population (Golomb, 2005; Deedwania and Volkova, 2005)(Golomb, 2005; Deedwania and Volkova, 2005)


Other Medications and Other Medications and CVD Risk ReductionCVD Risk Reduction

Nicotinic acid (a form of vitamin BNicotinic acid (a form of vitamin B33), and often referred ), and often referred

to as to as niacin,niacin, normalizes all lipids normalizes all lipids (Berra, 2004); (Berra, 2004); slow release slow release form safe at doses 1000 to 3000 mg and more form safe at doses 1000 to 3000 mg and more effective in women effective in women (Goldberg, 2004)(Goldberg, 2004)

Aspirin lowers inflammation and inhibits clot formation; Aspirin lowers inflammation and inhibits clot formation; aspirin resistance related to ischemic heart disease, aspirin resistance related to ischemic heart disease, cigarette smoking, and statin medications cigarette smoking, and statin medications (Coma-Canella et al., (Coma-Canella et al., 2005)2005)

Thyroid medications lower triglycerides among Thyroid medications lower triglycerides among persons with subclinical hypothyroidism persons with subclinical hypothyroidism (Milionis et al., 2005)(Milionis et al., 2005)

Stopping oral contraceptives can lower BP Stopping oral contraceptives can lower BP (Lubianca et al., (Lubianca et al., 2005)2005)

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