Let’s talk Cardiovascular Disease 2017

The size of the problem?

 CVD 5

The World Health Organisation has identified cardiovascular disease as the commonest cause of death worldwide.  Projected to 2030 ischemic heart disease (atherosclerosis of coronary arteries) and stroke (atherosclerosis of head and neck arteries) will be two out of the top three killers in the world.  Even more worrying though, cardiovascular disease disables many more people than it kills.

What is atherosclerosis?

artery-plaque

Atherosclerosis (ath”er-o-skleh-RO’sis) comes from the Greek words athero (meaning gruel or paste) and sclerosis (hardness). It is a chronic inflammatory process in which deposits of fatty substances (lipoproteins), cellular waste products, calcium and other substances build up in the wall and inner lining of an artery. This build up is called “plaque” (atherosclerotic plaque). It usually affects large and medium-sized arteries and is a progressive disease over the decades of life starting in some, as early as 20-30 years old.

Atherosclerosis

Plaque develop over time to grow large enough to significantly reduce the blood’s flow through an artery, but most of the damage occurs when plaque become fragile and rupture and cause blood clots to form that can block blood flow or break off and travel to vital organs.  The vulnerability of plaque to rupture is due to the inflammatory content of the plaque and the local forces the plaque is exposed to within the artery (blood pressure and artery wall stress in particular).

ruptured-coronary-plaque

Ruptured atherosclerotic coronary plaque

There is a misconception that women are less at risk than men.  who-burden-of-diseaseWhile women do tend to be protected from cardiovascular disease throughout their childbearing years, this protection falls away rapidly after the menopause, when they are more likely to die from cardiovascular disease than from any other illness.

The spectrum of cardiovascular disease?

spectrum-of-cvdAtherosclerosis of our arteries is a diffuse disease generally affecting many vascular
beds.  When this occurs in the arteries that supply blood to the heart this may
manifest as heart attack, angina, arrhythmia, sudden death or heart failure.  Atherosclerosis of the head and neck vessels may lead to stroke, dementia or
other cognitive dysfunction (memory loss).  Arterial disease of the peripheral arteries may
cause poor circulation to the legs, kidneys or bowel and even lead to aneurysms
(swelling and rupture of the weakened arteries).

Who is at risk for cardiovascular disease?

conventional-cv-risks People with established cardiovascular disease require the most intensive lifestyle and medication intervention.

Seemingly “healthy” individuals who are at risk, can be identified by genetic predisposition to vascular disease with strong family history of members succumbing to heart attack, heart failure, dementia, stroke and peripheral vascular disease. They can also be identified by their own risk factor profile (by identifying conventional risks for cardiovascular disease) and the presence or absence of sub clinical vascular disease (atherosclerosis and vascular disease not clinically apparent).

High risk individuals with increased short term (next 10 years) or high LIFE TIME risk should receive intensive lifestyle counselling and aggressive risk factor modification with modern medication where appropriate.

High prevalence of “sub-clinical” cardiovascular disease

The development of atherosclerotic vascular disease is a “silent” process actually starting from childhood.  Advanced imaging technology (vascular ultrasound) has demonstrated plaque in coronary arteries of high risk teenage children.  Clinical cardiovascular examination and risk stratification shows a high rate of cardiovascular disease in otherwise “healthy” individuals with up to one third of all healthy 50-60 yr men and women (of normal weight) and ½ of overweight 50-60 yr men and woman already have significant sub-clinical cardiovascular disease.  Using trans-vascular ultrasound we often see significant atherosclerosis in otherwise completely healthy people.  Aggressive risk reduction and therapy in these asymptomatic individuals reduces the risk of subsequent vascular events through plaque stabilization and plaque reduction over time.

carotid-ultrasound

How to reduce your risk of developing atherosclerotic cardiovascular disease?

  1.  Never smoke or stop smoking all forms of tobacco (including E-cigarettes) – it triples the risk of heart disease and prematurely ages your arteries by 10 to 15 years.
  2. Make healthy food choices.  A healthy diet reduces cardio vascular risk by several mechanisms including weight reduction, lowering blood pressure, improved effects on lipoproteins, control of glucose and reduction of the development of arterial blood clots.  Foods should be varied, and energy intake (based on calories) must be adjusted to maintain an ideal body weight.  No one diet “fits all” but generally Mediterranean style diets rich in fruits, vegetables, whole grain, dairy products; oily fish and lean meat should be encouraged.  Low carbohydrate & high “good” fat (LCHF) style diets are particularly useful those with carbohydrate intolerance (Insulin resistance) or “metabolic syndrome”.

    Patients with high blood pressure, diabetes (glucose abnormalities) and lipoprotein abnormalities should receive dietary advice such as salt and carbohydrate restriction but may need medication to reduce risk.

  3. Exercise regularly.  Physical activity should be promoted in all age groups from children to the elderly.  High risk individuals need special care to increase their physical activity safely to reduce vascular disease.  Although the goal is at least half an hour to an hour of physical activity on most days of the week, more moderate intense activity (averaging 75% of their maximum heart rate for their age) appears to offer better health benefits.
  4. Lose weight.  Weight reduction is recommended for obese people with a body mass index (BMI) > 30 (weight in kg/height in m2); or overweight individuals with BMI > 25-30 kg/m2.  Particularly at risk are those with increased abdominal (visceral) fat as indicated by a waist > 102 cm in men and > 88 cm in Women.
  5. Manage your blood pressure.  The risk of cardiovascular disease increases continuously as blood pressure rises from the lowest risk at 110/70.  The decision to start treatment, however, depends not only on the level of blood pressure but also on assessment of total cardiovascular risk and the presence or absence of target organ damage.  In patients with established hypertension the choice of anti-hypertensive drug depends on the exact underlying cardiovascular disease.  In most patients the goal of therapy is blood pressure < 140/90 mm Hg but lower (< 130/80) for high risk people.
  6. Manage your lipoproteins.  Lifelong it is important to keep atherogenic lipoproteins (Apo B containing lipoproteins) as low as possible whist maintaining the anti-atherogenic Apo A1 containing lipoproteins.  lp-28With optimal lifestyle; diet and exercise oxidation and glycation of lipoproteins is reduced leading to lower “systemic” inflammation and lower rates of plaque instability. Apparently healthy individuals, should be assessed for total cardiovascular risk over the short term (10 years) and their lifetime as clinical trials have shown improved survival rates with aggressive Apo B lowering with extremely low Apo B/ Apo A1 ratio.  The reduction in morbidity and mortality is through plaque stabilization and plaque reduction.

    If this is not achieved with diet, lifestyle and exercise, modern potent effective Statin therapy or PCSK9-inhibitors (a group of lipoprotein lowering drugs) will be required as lifelong therapy.

  7. Manage your sugar.  If you have “impaired glucose tolerance” (fasting Glucose > 5.5), or Insulin resistance try to prevent or delay the onset of diabetes mellitus by healthy lifestyle intervention (low carbohydrate high good fat lifestyle).  Good metabolic control prevents vascular complications, by far the commonest cause of death and disability in the diabetic patient.
  8. Be evaluated for the “Metabolic Syndrome” as it increases your risk for vascular disease by 3-5 times.  Sufferers require intense lifestyle changes, particularly to reduce body weight and increase physical activity. Elevated blood pressure, sugar and lipoproteins may need additional drug treatment.  The syndrome is confirmed when three or more of the following features are present.
  • Waist circumference > 102 cm in males and > 88 cm in females
  • Serum triglycerides > 1.7 mmol/l
  • HDL cholesterol < 1.0 in males and < 1.2 in females
  • Blood pressure > 130/85
  • Plasma (fasting) glucose > 6.1 mmol/l

Early Cardiovascular Screening?

Whilst early screening for asymptomatic cancers such as breast, colon and prostate cancer is widely acceptable, screening for atherosclerotic cardiovascular is not widely practiced despite more than 19 million deaths worldwide per year from cardiovascular disease, compared to about 8 million deaths from all cancers combined.

Fortunately new insights into the development and progression cardiovascular disease, innovative technologies to assess it, and effective therapy to slow it down have been the subject of successful research over the past decade.  By focusing on functional and structural abnormalities of the arteries and heart, it is possible to identify and track the progression of disease.  There is therefore a tremendous incentive for active and aggressive preventative programs to delay vascular disease to the end of life (compression of morbidity theory) and to live without chronic cardiovascular or respiratory disease and good quality of life.

Compression of morbidity

Blessings for 2017 Cardiologydoc

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