Diagnosis and Prevention of Heart Disease

Diagnosis and Prevention Diagnosis and Prevention of Heart Diseaseof Heart Disease

MASOUMEH SADEGHICARDIOLOGIST

ISFAHAN CARDIOVASCULAR RESEARCH INSTITUTE

What is Heart Disease? What is Heart Disease?

• HeartHeart : The most hard-working muscle of our body – pumps 4-5 liters of blood every minute during rest

• Supplies nutrients and oxygen rich blood to all body parts, including itself

• Coronary arteries surrounding the heart keep it nourished with blood

What is AtherosclerosisWhat is Atherosclerosiswhat is coronary artery what is coronary artery

disease? disease?

• Over time, fatty deposits called plaqueplaque build up within the artery walls. The artery becomes narrow. This is atherosclerosis

• When this occurs in the coronary arteries, heart does not get sufficient blood, the condition is called coronary artery disease, or coronary heart disease

Myth : fat deposits at old age! Myth : fat deposits at old age! It starts from 2 years of ageIt starts from 2 years of age

FoamCells

FattyStreak

IntermediateLesion Atheroma

FibrousPlaque

ComplicatedLesion/Rupture

Adapted from Pepine CJ. Am J Cardio. 1998;82(suppl 104).

From FirstDecade

From ThirdDecade

From FourthDecade

Are Other organs Affected?Are Other organs Affected?

Ischemic StrokeIschemic Stroke

Peripheral Vascular Peripheral Vascular DiseaseDisease

Coronary Heart DiseaseCoronary Heart Disease• AnginaAngina• MI (Heart Attack)MI (Heart Attack)• Sudden Cardiac DeathSudden Cardiac Death

What are the symptoms of What are the symptoms of Coronary artery disease?Coronary artery disease?

• No symptoms for long period• Chest pain for short period on

exertion also known as Angina or minor heart attack

• Myocardial Infarction or major heart attack-Severe chest pain, death of heart muscle, heart failure, irregular heart beats

• Sudden Death

How Big is the Problem ?How Big is the Problem ?• No. 1 killer disease worldwide

– 12 Million deaths annually

• During last 30 years large declines in developed countries -rising health awareness and government programmes

• Alarming increase in developing countries especially India

Why Me ?Why Me ?

• Genetic predisposition

• Poor handling of fats and metabolic

syndrome

– Diabetes, obesity, high BP, Coronary artery

disease

Environmental insults

• Urbanization

• Sudden change in lifestyle

What Increases Risk?What Increases Risk?

You can’t help it !• Age:

Men > 45; Women > 55

• Sex• Race• Family History

You can !!• High Cholesterol• Smoking• High Blood Pressure• Diabetes• Obesity• Alcohol• Physical Inactivity

Cholesterol ( A type of fat)Cholesterol ( A type of fat)Cholesterol ( A type of fat)Cholesterol ( A type of fat)• Everybody needs cholesterol, it

serves a vital function in the body.• It circulates in the blood.

• Too much cholesterol can deposit in the arteries in the form of plaque and block them• No symptoms till heart attack

Where does it come from ?Where does it come from ?

• Two sources of cholesterol: Food & made in your body

• Food sources: All foods containing animal fat and meat products

65%65% 35%35%

Good vs. BAD CholesterolGood vs. BAD CholesterolGood vs. BAD CholesterolGood vs. BAD Cholesterol• LDL cholesterol is known as bad

cholesterol. It has a tendency to increase risk of heart disease

• LDL cholesterol is a major component of the plaque that clogs arteries

• HDL cholesterol is known as the good cholesterol. Higher in women, increases with exercise

• HDL cholesterol helps carry some of the bad cholesterol out of arteries.

ObesityObesityObesityObesity• People who are overweight (10-30 % more

than their normal body weight)

• Obese have 2 to 6 times the risk of

developing heart disease

• Normal Waist-Hip Ratio

< 0.85 for women;

< 0.95 for men

• Pears or apples?

Pears and ApplesPears and Apples

Apple-shaped paunch store body fat around the abdomen and chest, surrounding internal organs

Pear-shaped paunch store fat on the hips and thighs, just below the surface of the skin.

Apple- shaped are at a higher riskApple- shaped are at a higher risk

Physical InactivityPhysical InactivityPhysical InactivityPhysical Inactivity

Every morning my brain tells me to exercise…

….. and my body laughs at the idea

Cigarette SmokingCigarette SmokingCigarette SmokingCigarette Smoking• Increases blood pressure• Decreases HDL• Damages arteries and blood cells• Increases heart attacks• Cigarette smoke contains more than

4,000 chemicals, and 200 of these chemicals are poisonous

DiabetesDiabetesDiabetesDiabetes• At any given cholesterol level, diabetic

persons have a 2 or 3 x higher risk of heart attack or stroke

• A diabetic is more likely to die of a heart attack than a non-diabetic

• ~80% Diabetics die from heart disease• Risk of sudden death from a heart attack

for a diabetic is the same as that of someone who has already had a heart attack.

Risk operates across a continuum - no clear-cut line

(Blood Pressure; Cholesterol; overweight; Smoking)

The risk is multiplicative when many risk factors co-

exist; risk factors often cluster together

Majority of events arise in individuals with modest

elevations of many risk factors than from marked

elevation of a single risk factor

Interactions of Risk FactorsInteractions of Risk Factors

Everyday you make choices to try to help protect yourself and your family. In fact, protecting yourself has become second nature—you just do it. But do you know what you can do to help protect yourself from this number 1 cause of death- Heart Disease?

For my car, I want the For my car, I want the best mechanic.best mechanic.

But for my own body, I follow hearsay and advice from friends, kitty party, local

quacks…. Just anyone

And decide for the worst

Creative strategies do not Creative strategies do not work !work !

• Never had a test or retest

• Never been to Doctor ! I hate them

• Never take medicines!

• My BP is normal, so stopped meds!

• Miracle men and Miracle Medicines! So many of them

• I am my own doctor! No fees too

Preventing Heart DiseasePreventing Heart Disease Rule #1 Look before your eatRule #1 Look before your eat

Preventing Heart DiseasePreventing Heart Disease Rule #1 Look before your eatRule #1 Look before your eat

• Eat a variety of fruits and vegetables every day. (5 servings - they are naturally low in fat and high in vitamins and minerals and anti oxidants). Eat colored vegetables and fruits

• Eat a variety of grain products • Choose nonfat or low-fat products.• Use less fat meats- chicken, fish and lean cuts Switch to fat-free milk—toned/skimmed milk

Dietary GuidelinesDietary GuidelinesDietary GuidelinesDietary Guidelines• Limit your intake of foods high in

calories and low in nutrition, including foods like soft drinks, candy, junk food

• Limit foods high in saturated fat, trans- fat and cholesterol

• Eat less than 6 gms of salt a day• Have no more than1-2 alcoholic drink

a day if you are a regular drinker

Limit / AvoidLimit / AvoidLimit / AvoidLimit / Avoid• Foods rich in Cholesterol and

Saturated fats– Egg Yolk– Fatty meat & organ meat( Liver)– Butter chicken / Batter fried fish !– Milk fat – Desi Ghee, Butter, Cheese,

Malai, Rabri, Khurchan, Doda, Ice Cream, full cream milk,

– Hidden Fat like Bakery biscuits, Patties (!), Cakes, Pastries,

Cooking Oils: The mystery of Cooking Oils: The mystery of PUFA / MUFAPUFA / MUFA

Cooking Oils: The mystery of Cooking Oils: The mystery of PUFA / MUFAPUFA / MUFA

• Saturated Fats : Increase Cholesterol – Avoid– Coconut oil, Palm oil, ghee

• Monounsaturated Fats (MUFA): Heart healthy– Olive oil, Groundnut oil, Canola oil, Mustard oil

• Polyunsaturated Fats (PUFA): Heart healthy– Sunflower oil, Soybean oil

• Omega-3-Fatty acids Fish oil : Heart Healthy

Rotate the oils or Mixture of oils

Preventing Heart DiseasePreventing Heart Disease Rule #2 ExerciseRule #2 Exercise

Preventing Heart DiseasePreventing Heart Disease Rule #2 ExerciseRule #2 Exercise

• Maintain a level of physical activity that keeps you fit and matches the calories you eat

• Serves several functions in preventing and treating those at high risk

• Reduces incidence of obesity• Increases HDL• Lowers LDL and total cholesterol• Helps control diabetes and

hypertension

Exercise, Exercise, ExerciseExercise, Exercise, Exercise•Mortality is halved in retired men who walk more than two miles every day

•Regular exercise can halve the risk of heart disease, particularly in men who walk briskly

•Someone who is inactive has as great a risk of having heart disease as someone who smokes, has high blood pressure or has high cholesterol

•Exercise significantly reduces the chances of diabetes and stroke

•With regular exercise, blood pressure in those with hypertension is reduced by as much as 20mms Hg

Exercise and Heart DiseaseExercise and Heart DiseaseExercise and Heart DiseaseExercise and Heart DiseaseModerate to intense physical activity for 30-45

minutes on most days of the week is recommended

Walking for a healthy heartWalking for a healthy heart

• Complicated exercise machines or sweating it out in the gym not essential

JUST WALK!

Rule # 3 Stop Smoking Rule # 3 Stop Smoking NOW!NOW!

• The risk of heart attack starts decreasing within 24 hours of quitting smoking, within 1 year of quitting, CHD risk decreases significantly, within 2 years it reaches the level of a nonsmoker

• Smell and taste improve within days

• Within three months of quitting, the smokers' cough disappears in most people

Rule # 3 Stop Smoking Rule # 3 Stop Smoking NOW!NOW!

Tobacco

Diet

Physical Activity

Alcohol

Cardiovascular

Cancers

Diabetes

Chronic Respiratory Diseases

Osteoporosis

Oral Health

Mental Health

Benefits much beyond Heart Benefits much beyond Heart Disease Disease

Rule # 4 Know your Rule # 4 Know your Number!Number!

Desirable numbers• Total cholesterol < 200;• LDL < 100 • HDL > 40• triglycerides < 200

• Get the levels tested routinely and keep them under control

• The only thing worse than finding out that you have one of these conditions is…….NOT finding out that you have it!!

And that’s not your Mobile Number!And that’s not your Mobile Number!

10% reduction of blood cholesterol produces 20-30%

decline in CHD deaths

Benefits of reducing Benefits of reducing cholesterolcholesterol

All Adults >20 yrs must get tested- if normal test again

after 5 years, if elevated, work towards normalizing the

levels with lifestyle modification and drugs as needed

Controlling Blood PressureControlling Blood Pressure• Adults should have their blood pressure

checked at least once every two years, as there are no symptoms to tell if you have high blood pressure

• Optimal levels : 120 /80 mm Hg• If high

– Modify your lifestyle – Diet, Weight, Exercise, Salt restriction

– Adhere to the prescribed medication without fail, to decrease chances of getting heart disease – Do not stop your medicines without consulting your doctor, even if the blood pressure becomes normal

Controlling Blood SugarControlling Blood Sugar• All adults should have their blood sugar

checked regularly, as there are no early symptoms of diabetes

• Normal blood sugar:• Fasting < 100; post meals <140• If high

– Modify your lifestyle – Diet, Weight, Exercise– Adhere to the prescribed medication without fail,

to decrease chances of getting heart disease – Do not stop your medicines without consulting your doctor, even if the blood sugar becomes normal

If you or someone in your family If you or someone in your family already diagnosed with heart already diagnosed with heart

diseasedisease• Don’t get disheartened – science has made

significant progress

• Just monitor risk factors much more aggressively– Eat healthy

– Walk regularly

– Watch your weight

– Quit smoking immediately

– Keep your weight under control

– In addition to improving your heart – health these measures are sure to enhance your appearance !!

• Adhere to you medicines & listen to your doctor

Don’t wait for a heart attack to Don’t wait for a heart attack to take an action !take an action !

Don’t wait for a second life Don’t wait for a second life we are not cats!we are not cats!

Heart disease is often avoidable. Following a heart-healthy lifestyle doesn't have to be complicated, and it doesn't mean you need to live a life of self-deprivation. Instead, find ways to incorporate heart-healthy habits

into your lifestyle — and you may well enjoy a healthier life for years to come.

1/001/00 medslides.commedslides.com4040

Objectives

• Clinical Assessment

• Stress Testing

• Treatment

• Patient Follow Up

JACC 1999; 33, 7:2092-2197JACC 1999; 33, 7:2092-2197Circulation 1999;99::2829-2848Circulation 1999;99::2829-2848

http://www.acc.org/clinical/http://www.acc.org/clinical/guidelines/index.htmlguidelines/index.html


Definition of AnginaDefinition of Angina

A pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.


Coronary Artery Disease Coronary Artery Disease

• a chronic disorder

• the disease typically cycles in and out of clinically defined phases: – asymptomatic

– stable angina

– progressive angina

– acute coronary syndromeunstable angina, NQMI, acute MI


Clinical AssessmentClinical Assessment

A. Recommendations forHistory and Physical


Evaluation and DiagnosisEvaluation and Diagnosis

• In patients presenting with chest pain– detailed symptom history

– focused physical examination

– directed risk-factor assessment

• Estimate the probability of significant CAD (i.e., low, intermediate, high)


History:History: chest discomfort chest discomfort• Quality - "squeezing," "griplike," "pressurelike," "suffocating" and

"heavy”; or a "discomfort" but not "pain." Angina is almost never sharp or stabbing, and usually does not change with position or respiration.

• Duration - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina

• Location - usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely anginal.

• Provocation - angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes.


Clinical Classification of Clinical Classification of Chest PainChest Pain

Typical angina (definite) 1) substernal chest discomfort with a characteristic

quality and duration that is ... 2) provoked by exertion or emotional stress and 3) relieved by rest or nitroglycerin

Atypical angina (probable)meets 2 of the of characteristics

Noncardiac chest painmeets 1 of the typical angina characteristics

J Am Coll Cardiol. 1983;1:574, LetterJ Am Coll Cardiol. 1983;1:574, Letter


Alternative Diagnoses to Angina for Alternative Diagnoses to Angina for Patients with Chest PainPatients with Chest Pain

• Non-Ischemic CV– aortic dissection– pericarditis

• Pulmonary– pulmonary embolus– pneumothorax– pneumonia– pleuritis

• Chest Wall– costochondritis– fibrositis– rib fracture– sternoclavicular

arthritis– herpes zoster

Gastrointestinal• Esophageal

– esophagitis– spasm– reflux

• Biliary– colic– cholecystitis– choledocholithi

asis– cholangitis

• Peptic ulcer• Pancreatitis

PsychiatricPsychiatric

• Anxiety disordersAnxiety disorders

– hyperventilationhyperventilation

– panic disorderpanic disorder

– primary anxietyprimary anxiety

• Affective disordersAffective disorders

– depressiondepression

• Somatiform disordersSomatiform disorders

• Thought disordersThought disorders

– fixed occlusionsfixed occlusions


Conditions Provoking or Exacerbating Conditions Provoking or Exacerbating IschemiaIschemia

Increased Oxygen DemandNon-Cardiac

HyperthermiaHyperthyroidismSympathomimetic toxicity (cocaine

use)HypertensionAnxietyArteriovenous fistula

CardiacHypertrophic cardiomyopathyAortic stenosisDilated cardiomyopathyTachycardia

ventricularsupraventricular

Decreased Oxygen SupplyNon-Cardiac

AnemiaHypoxemia

pneumonia, asthma, COPD,pulmonary hypertension,interstitial pulmonary fibrosis,obstructive sleep apnea

Sickle-cell diseaseSympathomimetic toxicityc (cocaine

use)Hyperviscosity

polycythemia, leukemia,thrombocytosis, hypergammaglobulinemia

CardiacAortic stenosisHypertrophic cardiomyopathy


History: History: Risk Factors for CADRisk Factors for CAD

Increases the likelihood that CAD will be present– cigarette smoking

– hyperlipidemia

– diabetes

– hypertension

– family history of premature CAD

– past history of CVA or PVD



B. Recommendations for Initial

Laboratory Tests, ECG, and Chest X-Ray for Diagnosis


Recommendations for Initial Recommendations for Initial Laboratory Tests, Laboratory Tests,

ECG, and Chest X-Ray for DiagnosisECG, and Chest X-Ray for Diagnosis

Class I• Hemoglobin• Fasting glucose• Fasting lipid panel• Resting ECG• Rest ECG during an

episode of chest pain• Chest x-ray in patients with

signs or symptoms of CHF, valvular heart disease, pericardial disease, or aortic dissection/aneurysm

Class IIa• chest x-ray in patients

with signs or symptoms of pulmonary disease

Class IIb• Chest x-ray in other

patients• Electron beam computed

tomography


12 Lead Resting ECG12 Lead Resting ECG

• should be recorded in all patients with symptoms suggestive of angina pectoris

• normal in 50% of patients• a normal ECG does not exclude

severe CAD; however, it does imply normal LV function with favorable prognosis



C. Recommendations for Echocardiography or

Radionuclide Angiography


Stress Tests - cost issues Stress Tests - cost issues

• exercise ECG is least costly 1X

• stress echocardiography 2X

• stress SPECT myocardial imaging 5X

• coronary angiography 20X


DIAGNOSIs


Exercise Stress TestsExercise Stress Testsstepwise strategystepwise strategy

• Exercise ECG – simplicity, lower cost and familiarity

– the initial test in patients who are not taking digoxin, have a normal rest ECG, and are able to exercise

• Stress-imaging techniques – for patients with widespread rest ST depression

(>1 mm), complete left bundle-branch block, ventricular paced rhythm or preexcitation


• PROGNOSIS


Direct Referral For Direct Referral For Diagnostic Coronary AngiographyDiagnostic Coronary Angiography

• When Noninvasive Testing Is Contraindicated Or Unlikely To Be Adequate Due To Illness, Disability Or Physical Characteristics. For Example:– coexisting chronic obstructive pulmonary disease

– noninvasive testing is abnormal but not clearly diagnostic

– patient's occupation or activity could constitute a risk to themselves or others

– a high clinical probability of severe CAD

– diabetics with paucity of symptoms of myocardial ischemia due to autonomic and sensory neuropathy


TreatmentTreatment

A. Recommendations for A. Recommendations for Pharmacotherapy to Prevent MI Pharmacotherapy to Prevent MI

and Death and Reduce Symptomsand Death and Reduce Symptoms


Chronic Stable AnginaChronic Stable Angina

Treatment ObjectivesTreatment Objectives• to reduce the risk of mortality and

morbid events

• reduce symptoms - anginal chest pain or exertional dyspnea; palpitations or syncope; fatigue, edema or orthopnea


Initial TreatmentInitial Treatment

• A = Aspirin and Antianginal therapy

• B = Beta-blocker and Blood pressure

• C = Cigarette smoking and Cholesterol

• D = Diet and Diabetes

• E = Education and Exercise


TreatmentTreatment

B. Pharmacotherapy B. Pharmacotherapy

to Prevent MI and Deathto Prevent MI and Death


Antiplatelet AgentsAntiplatelet Agents to Prevent to Prevent MI and DeathMI and Deathaspirin - Class Iaspirin - Class I

• Aspirin 75 to 325 mg daily should be used routinely in all patients with acute and chronic ischemic heart disease with or without manifest symptoms in the absence of contraindications

– aspirin exerts an antithrombotic effect by inhibiting cyclo-oxygenase and synthesis of platelet thromboxane A2

– in >3,000 patients with stable angina, aspirin reduced the risk of adverse cardiovascular events by 33%

– in patients with unstable angina, aspirin decreases the short and long-term risk of fatal and nonfatal MI

– in the Physicians' Health Study, aspirin (325 mg), given on alternate days to asymptomatic persons, was associated with a decreased incidence of MI

BMJ 1995;308:81-106BMJ 1995;308:81-106


Antiplatelet AgentsAntiplatelet Agents to Prevent MI to Prevent MI and Death and Death

thienopyridine derivative - Class IIathienopyridine derivative - Class IIa

• thienopyridine derivative irreversibly inhibiting the binding of adenosine diphosphate (ADP) to its platelet receptors and thereby affecting ADP-dependent activation of the GP IIb-IIIa complex

• Ticlopidine (Ticlid), unlike aspirin, has not been shown to decrease adverse cardiovascular events, but may induce neutropenia and thrombotic thrombocytopenic purpura (TTP)

• Clopidogrel (Plavix), appears to possess a greater antithrombotic effect than ticlopidine. In patients with previous MI, stroke and peripheral vascular disease (i.e., at risk of ischemic events), clopidogrel appeared to be slightly more effective than aspirin in decreasing the combined risk of MI, vascular death or ischemic stroke (CAPRIE Trial)

Lancet 1996;348:1329-39Lancet 1996;348:1329-39


TreatmentTreatment

C. Pharmacotherapy to ReduceC. Pharmacotherapy to Reduce

Ischemia and Relieve SymptomsIschemia and Relieve Symptoms


Antianginal and Anti-ischemic Antianginal and Anti-ischemic TherapyTherapy

• beta-adrenoreceptor blocking agents (-blockers)

• calcium antagonists

• nitrates

• Other drugs (clinical effectiveness has not been confirmed)– ACE inhibitors

– amiodarone

– "metabolic agents"

– nonconventional therapy


• elimination of anginal chest pain • return to normal activities

• functional capacity of CCS class I angina

• good patient compliance - minimal side effects of therapy, cost-effective

• Goal must be modified in light of the clinical characteristics and preferences of each patient


Definition of Successful TherapyDefinition of Successful Therapy


TreatmentTreatment

E. Revascularization with E. Revascularization with PCI and CABG in Patients withPCI and CABG in Patients with



Patient Follow UpPatient Follow Up

Monitoring of Symptoms and Anti-anginal Therapy


5 Questions to Be Addressed in Follow-up 5 Questions to Be Addressed in Follow-up of Patients With Chronic Stable Anginaof Patients With Chronic Stable Angina

• Has the patient decreased his or her level of physical activity since the last visit?

• Have the patient's anginal symptoms increased in frequency and become more severe since the last visit? If the symptoms have worsened or the patient has decreased his or her physical activity to avoid precipitating angina, then he or she should be evaluated and treated appropriately according to either the unstable angina or chronic stable angina guideline.

• How well is the patient tolerating therapy?

• How successful has the patient been in modifying risk factors and improving knowledge about ischemic heart disease?

• Has the patient developed any new comorbid illnesses or has the severity or treatment of known comorbid illnesses worsened the patient's angina?


Information for PatientsInformation for Patients General Aspects of Ischemic Heart General Aspects of Ischemic Heart

DiseaseDisease

• PATHOLOGY AND PATHOPHYSIOLOGY– interested in varying level of detail

• RISK FACTORS – useful to review the important known risk

factors

• COMPLICATIONS – unstable angina, mi, heart failure, arrhythmia

and sudden cardiac death


Patient-Specific InformationPatient-Specific Information• PROGNOSIS

– useful to provide numerical estimates for risk of MI or death

• TREATMENT

– informed about their medications, including mechanisms of action, method of administration, and potentially adverse effects

• PHYSICAL ACTIVITY

– reassurance about returning to normal activities, activity limitations, and sexual relations; potentially serious consequences of using both sildenafil and nitrates within 24 h of one another

• RISK FACTOR REDUCTION

– greatest emphasis should be placed on modifiable factors


Patient-Specific InformationPatient-Specific Information

CONTACTING THE MEDICAL SYSTEM

• instructed about how and when to seek medical attention

• provide an action plan that covers:1) prompt use of aspirin and nitroglycerin if available2) how to access emergency medical services3) location of the nearest hospital that offers 24-h

emergency cardiovascular care

OTHER INFORMATION

• CPR training for family members is advisable

• counseling on potentially heritable condition (such as familial hypercholesterolemia) responsible for premature coronary disease.

THANK YOUTHANK YOU

ANY QUESTION?

Diagnosis and Prevention of Heart Disease

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