MNT in Cardiovascular Disease Prevalence and Incidence The

MNT in Cardiovascular Disease Prevalence and Incidence The

MNT in Cardiovascular Disease Prevalence and Incidence The United States ranks 14th and 16th, among industrialized nations for the prevalence of CVD in women and men, respectively. More than 61 million Americans have at least one form of CVD (i.e., hypertension, CHD, stroke, rheumatic heart disease, or congestive heart failure). The incidence of CHD is high; an American

experiences a coronary event almost every 29 seconds. Leading Causes of Death U.S. 2000 From http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf; accessed 3-05 Percentage Breakdown of Deaths From Cardiovascular Diseases United States:2002 Preliminary Coronary Heart Disease 13% Stroke 0% 4% Congestive Heart Failure

5% High Blood Pressure 6% 53% 18% Diseases of the Arteries Rheumatic Fever/Rheumatic Heart Disease Congenital Cardiovascular Defects Other Source: CDC/NCHS. Prevalence of Coronary Heart Diseases by Age and Sex

NHANES :1999-2002 Percent of Population 20 16.8 15 11.6 10 11.5 6.3 5 0 10.3

0.0 0.3 20-34 1.4 3.0 0.2 35-44 3.6 1.6 45-54 55-64 Ages

Men Source: CDC/NCHS and NHLBI. Women 65-74 75+ New and Recurrent Attacks Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex ARIC: 1987-2000 500,000 410,000 372,000 400,000 300,000

250,000 200,000 100,000 88,000 34,000 10,000 0 29-44 45-64 65+ Ages Men

Women Source: Extrapolated from rates in the NHLBIs ARIC surveillance study, 1987-2000. These data dont include silent MIs. Prevalence of Stroke by Age and Sex NHANES: 1999-2002 Percent of Population 14 12.0 11.5 12 10 8 6.6 6.3

6 4 2 0.4 0.3 1.1 0.8 0 20-34 35-44 2.1 1.2

3.1 3.0 ` 45-54 55-64 Ages Men Source: CDC/NCHS and NHLBI. Women 65-74 75+ Percent of Population

Prevalence of High Blood Pressure in Americans by Age and Sex NHANES: 1999-2002 100 74.0 80 60 46.6 69.2 34.1 34.0 40 20 55.5

60.9 83.4 11.1 21.3 18.1 5.8 0 20-34 35-44 45-54 55-64 Ages

Men Source: CDC/NCHS and NHLBI. Women 65-74 75+ Prevalence of Congestive Heart Failure by Age and Sex NHANES: 1999-2002 9.8 10.9 Percent of Population 10 8 6

4.1 4 2 6.2 5.8 1.8 0.3 0.3 0.5 2.3 1.5 0.4

0 20-34 35-44 45-54 55-64 Ages Men Source: CDC/NCHS and NHLBI. Women 65-74 75+

Cardiovascular Disease Mortality Trends for Males and Females Deaths in Thousands United States: 1979-2002 520 500 480 460 440 420 400 380 Years Males Source: CDC/NCHS.

Females CVD in Men and Women CVD mortality in men is holding steady; in women it is increasing Women have comparable CVD rates about 10-15 years later than men, but the gap diminishes with age 82% of coronary events in women are attributable to unhealthy diet, lack of activity, cigarette use, and overweight CVD in Women

Women post MI are less likely to receive aspirin, beta-blockers, intravenous heparin, or nitrate therapies within the first 24 hours of hospital admission They were less likely to undergo coronary angiography, angioplasty, or bypass surgery, but they were more likely to die in the hospital. CVD in Women

Women have a higher prevalence of white-coat hypertension than men. Women may have atypical symptoms when suffering a heart attack or angina When they are sent home from the hospital, they are more than twice as likely to die as those who are admitted A Nation at Risk 49 million Americans smoke

42 million have total cholesterols >240 mg/dl 63 million have total cholesterols 200-239 17 million Americans have diabetes 61 million Americans are obese; 68 million are overweight There is Encouraging News! Framingham Milestones

1960: cigarette smoking found to increase the risk of heart disease 1961: Cholesterol level, blood pressure, and EKG abnormalities found to increase the risk of heart disease 1967: physical activity found to reduce the risk of heart disease; obesity found to increase the risk of heart disease 1970: High blood pressure found to increase the risk of stroke Framingham Milestones 1976: Menopause found to increase

the risk of heart disease 1978: Psychosocial issues found to affect the risk of heart disease 1988: High levels of HDL found to reduce risk of death 1994: Enlarged left ventricle found to increase the risk of stroke 1996: Progression from hypertension to heart failure described Favorable Trends Over past 30 years, mortality and in-hospital case fatality has declined 50% Prevalence of risk factors of smoking, hypertension, high

cholesterol has declined 25 to 46% Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965-2003 60 50 Men 40 Percen t High school students Women 30

20 Mothers during pregnancy 10 0 1965 1970 1975 1985 1980 1990

1995 Year NOTES: Percents for men and women are age adjusted. See Data Table for data points graphed, standard errors, and additional notes. Cigarette smoking is defined as: (for men and women 18 years of age and older) at least 100 cigarettes in lifetime and now smoke every day or some days; (for students in grades 9-12) 1 or more cigarettes in the 30 days preceding the survey; and (for mothers with a live birth) during pregnancy. SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (data for men and women); National Vital Statistics System (data for mothers during pregnancy); National Center for Chronic Disease Prevention and Health Promotion, Youth Risk Behavior Survey (data for high school students). Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

2003 Percent of Population 20-74 with High Serum Cholesterol by Race and Sex 1971-74 to 198894 http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf accessed 3-05 THE BAD NEWS: Overweight and obesity by age: United States, 1960-2002 70 60 50 Overweight including obese, 20-74 years 40

Overweight, but not obese, 20-74 years 30 20 Obese, 20-74 years Overweight, 6-11 years 10 Overweight, 12-19 years 0 1960-62 1963-65 1966-70 1971-74 1976-80

1988-94 Year NOTES: Percents for adults are age adjusted. For adults: "overweight including obese" is defined as a body mass index (BMI) greater than or equal to 25, "overweight but not obese" as a BMI greater than 25 but less than 30, and "obese" as a BMI greater than or equal to 30. For children: "overweight" is defined as a BMI at or above the sex- and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts: United States. "Obese" is not defined for children. See Data Table for data points graphed, standard errors, and additional notes. Data are for the civilian noninstitutionalized population and are age adjusted. See Data Table for data points graphed and additional notes. 19992002 SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Examination Survey and National Health and Nutrition Examination Survey.

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004 The Decrease in CVD Mortality 25% is due to primary prevention 75% is due to behavioral changes affecting risk factors or improvements in treatment Benefits of Risk Factor Reduction

50-70% lower risk in former vs current smokers within 5 years of cessation 2-3% decline in risk for each reduction of 1% serum cholesterol 2-3% decline in risk for each reduction of 1 mm Hg in diastolic blood pressure 35-55% lower risk for those who maintain desirable body weight as compared to those 20%+ above Benefits of Risk Factor Reduction 45% lower risk for those who

maintain an active lifestyle compared with a sedentary lifestyle 35% lower risk in aspirin users compared with nonusers Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD) (CAD) Disease

Disease involves involves impeded impeded blood blood flow flow to to the the network network of of blood blood vessels vessels surrounding surrounding and and serving serving the the heart heart Major Major cause

cause is is atherosclerosis; atherosclerosis; structural structural and and compositional compositional changes changes in in the the inner inner wall wall of of the the arteries arteries Manifested Manifested in in clinical clinical end

end points points of of myocardial myocardial infarction infarction (MI) (MI) and and sudden sudden death death Pathophysiology of Atherosclerosis

Vessel lining is injured (often at branch points) Plaque is deposited to repair injured area Plaque thickens, incorporating cholesterol, protein, muscle cells, and calcium (rate depends partly on level of LDL-C in the blood) Pathophysiology of Atherosclerosis (cont) Arteries harden and narrow as plaque builds, making them less elastic

Increasing pressure causes further damage A clot or spasm closes the opening, causing a heart attack Pathophysiology of Atherosclerosis Proliferation of smooth-muscle cells, macrophages, and lymphocytes Formation of smooth muscle cells into a connective tissue matrix Accumulation of lipid and cholesterol in the matrix around

the cells Endothelial Injury Caused by Hypercholesterolemia Oxidized low-density lipoprotein Hypertension Cigarette smoking Diabetes Obesity Homocysteine

Diets high in saturated fat and cholesterol Natural Progression of Atherosclerosis (From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000) Plaque or Atheroma Lipid deposits and other materials (cellular waste products, calcium, fibrin) that build up in the intimal layer Heart Attack (Myocardial Infarction) Heart Attack (Myocardial Infarction)

When blood supply to the heart is disrupted, the heart is damaged May cause the heart to beat irregularly or stop altogether 25% of people do not survive their first heart attack Symptoms of a Heart Attack

Intense, prolonged chest pain or pressure Shortness of breath Sweating Nausea and vomiting (especially women) Dizziness (especially women) Weakness Jaw, neck and shoulder pain (especially women) Irregular heartbeat Factors That May Bring

On Heart Attack (in atrisk) Dehydration Emotional stress Strenuous physical activity when not physically fit Waking during the night or getting up in the morning Eating a large, high-fat meal (increases risk of clotting) Cerebrovascular Accident (CVA) or

Brain Attack Brain Attack (Stroke) or Cerebrovascular Accident Symptoms of Stroke (Brain Attack) Sudden numbness or weakness of the face, arm or leg, especially on one side

of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache Functions of Lipoproteins Lipids are transported in the blood bound

to protein Lipoproteins vary in composition, size, and density Consist of varying amounts of triglyceride, cholesterol, phospholipid, and protein The ratio of protein to fat determines the density (HDLs have more protein than LDLs) Lipoproteins combine Lipids (triglycerides, cholesterol) Protein Phospholipids Functions of the Plasma Lipoproteins

ChylomicronTransport of dietary triglyceride VLDLTransport of endogenous triglyceride IDLLDL precursor LDLMajor cholesterol transport lipoprotein HDLReverse cholesterol transport Lipoprotein Summary Lipoprotein Assessment

Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting Total Cholesterol Captures cholesterol contained in all lipoprotein fractions 60%-70% is carried on LDL 20%-30% is carried on HDL 10%-15% on VLDL

Total Cholesterol Direct, positive association between TC and CHD risk Diets high in saturated fats raise total cholesterol and CHD incidence and mortality ATP-III Guidelines: lowering total cholesterol and LDL-C reduces CHD risk 10% reduction in TC decreases CHD risk by about 30% Factors Affecting Total

Cholesterol Age Diets high in fat, saturated fat, cholesterol Genetics Endogenous sex hormones (premenopause) Exogenous steroids

Drugs (beta blockers, thiazide diuretics) Body weight Glucose tolerance Physical activity Season of the year Diseases Prevalence of High Total Cholesterol

Serum cholesterol levels in the U.S. population have been declining since 1960 More than half that decline occurred between 1976 and 1991, when national preventive education efforts were begun Proportion of adults with TC>240 mg/dl fell from 27% to 19%, while HDL and VLDL remained unchanged Total Triglycerides

Triglyceride-rich lipoproteins include chylomicrons, VLDL, remnants or intermediary products Are atherogenic At very high levels, risk of pancreatitis Can be evidence of metabolic syndrome Chylomicrons

Largest particles Transport dietary fat and cholesterol from the small intestine to the liver In the bloodstream, triglycerides are hydrolyzed by lipoprotein lipase (LPL) in muscle and adipose tissue When 90% of triglyceride is hydrolyzed, released into blood as a remnant Liver metabolizes remnants, but some deliver cholesterol to the arterial wall Absent in fasting studies Very-Low-DensityLipoproteins

Manufactured in the liver to transport endogenous triglyceride and cholesterol 60% is triglyceride Large VLDL may be nonatherogenic VLDL remnants or IDL appear to be atherogenic Not routinely measured, but TG in them is measured in total triglyceride Intermediate-Density Lipoprotein

Formed with catabolism of VLDL, a precursor of LDL Rich in cholesterol and apo E High concentrations of IDL and VLDL remnants directly related to lesion progression and coronary events Not routinely measured, though components can be Low-Density Lipoprotein Primary cholesterol carrier in blood

Total cholesterol and LDL-cholesterol are strongly correlated 95% of apolipoproteins in LDL are apoB-100 LDL is formed in VLDL catabolism, 60% is taken up by LDL receptors in liver, adrenals, other tissues; rest is metabolized via alternative pathways Number and activity of receptors determines LDL cholesterol levels in the blood LDL-C Particles heterogeneous in size, density, lipid components

Phenotype A: large particles, not associated with disease risk Phenotype B typified by small, dense LDL particles; triglyceride rich, cholesterol depleted; predictive of CHD risk in men and women High Density Lipoproteins (HDL) Contain more protein than the other lipoproteins Apo A-1 is involved in tissue cholesterol removal High HDL is associated with

low levels of chylomicrons, VLDL remnants, and small, dense LDL Lipoprotein Profile Measures total cholesterol, LDLcholesterol, HDL-cholesterol, and triglycerides 8-12 hour fast allows chylomicrons to clear Friedenwald formula for calculating LDL-C = (TC) (HDL-C) (TG/5) ATP III Guidelines

Adult Treatment Panel for the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults convened by the National Heart, Lung & Blood Institute of the NIH Published 2002 Updated in 2004 Next revision expected in 2009 (panel convened 2/08) Lipoprotein Profile

If nonfasting, can measure total and HDL cholesterol If TC>200 mg/dl or HDL-C is <40 mg/dl, get fasting analysis Evaluating Blood Lipids: Total Cholesterol <200 mg/dL Desirable 200-239 mg/ dL Borderline high 240 mg/dL High

Source: ATP-III Guidelines, NHLBI, accessed 2-2005 Evaluating Blood Lipids: Triglycerides <150 mg/dL Normal 150-199 Borderline high 200-499 High >500 mg/dl Very high

Source: ATP-III Guidelines, NHLBI, accessed 4-2005 Evaluating Blood Lipids: LDL <100 mg/dL Optimal 100-129 Near optimal 130-159 Borderline high 160-189 High

190 Very high Source: ATP-III Guidelines, NHLBI, accessed 2-2005 Evaluating Blood Lipids: HDL < 40 mg/dL Low 60 mg/dL High Source: ATP-III Guidelines, NHLBI, accessed 2-2005 Risk Factors affect

Lipid Targets Major, independent risk factors Life-habit risk factors Emerging risk factors Major Risk Factors That Modify LDL Goals Cigarette smoking

Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL) Family history of premature CHD CHD in male first degree relative <55 CHD in female first degree relative <65 Age (men 45 years; women 55 years) Life-Habit Risk Factors Obesity (BMI 30)

Physical inactivity Atherogenic diet Emerging Risk Factors Lipoprotein (a) Homocysteine Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis Risk Assessment Count major risk factors*

For patients with multiple (2+) risk factors Perform 10-year risk assessment For patients with 01 risk factor 10 year risk assessment not required Most patients have 10-year risk <10% *HDL cholesterol 60 mg/dL counts as a negative risk factor; its presence removes one risk factor from the total count. CHD Risk Equivalents

Risk for major coronary events equal to that in established CHD 10-year risk for hard CHD >20% Hard CHD = myocardial infarction + coronary death Diabetes In ATP III, diabetes is regarded as a CHD risk equivalent. Diabetes as a CHD Risk Equivalent 10-year risk for CHD 20% High mortality with established

CHD High mortality with acute MI High mortality post acute MI CHD Risk Equivalents Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) Diabetes Multiple risk factors that confer a 10year risk for CHD >20% Calculate Your 10-Year Risk of Heart Attack

Risk Calculation http://hp2010.nhlbihin.net/atpiii/c alculator.asp?usertype=pub At-A-Glance treatment guidelines: http://www.nhlbi.nih.gov/guideline s/cholesterol/atglance.htm Three Categories of Risk that Modify LDL-C GOALS Risk Category LDL Goal CHD and CHD risk equivalents Multiple (2+) risk

factors Zero to one risk factor (mg/dL) <100 <130 <160 ATP III Guidelines Goals and Treatment Overview Primary Prevention With LDL-Lowering Therapy Public Health Approach

Reduced intakes of saturated fat and cholesterol Increased physical activity Weight control Causes of Secondary Dyslipidemia Diabetes Hypothyroidism Obstructive liver disease Chronic renal failure

Drugs that raise LDL cholesterol and lower HDL cholesterol (progestins, anabolic steroids, and corticosteroids) Secondary Prevention W/ LDL-Lowering Therapy Benefits: reduction in total mortality, coronary mortality, major coronary events, coronary procedures, and stroke LDL cholesterol goal: <100 mg/dL Includes CHD risk equivalents Consider initiation of therapy during hospitalization (if LDL 100 mg/dL)

LDL-C Goals in Different Risk Categories Risk Category LDL Goal (mg/dL) CHD or CHD Risk Equivalents (10-year risk >20%) <100; optional goal <70 mg/dL

Moderately high risk 2+ Risk Factors (10-year risk 10-20%) <130 LDL for Total Lifestyle Change (TLC) (mg/dL) LDL for Drug Therapy (mg/dL) 100

100 (<100: consider drug options 130 >130 mg/dL (100-129 mg/ dL, consider drug options) ATP-3 update, Circulation, 2004 LDL-C Goals in Different Risk Categories LDL for Total Lifestyle Change (TLC)

(mg/dL) LDL for Drug Therapy (mg/dL) Moderate risk: <130 mg/dL 2+ risk factors (10 year risk<10%) >130 mg/dL >160 mg/dL Lower risk (01 risk factors) >160 mg/dL >190 mg/dL

(160-189 mg/dL, drug optional) Risk Category LDL Goal (mg/dL) <160 mg/dL ATP-3 update, Circulation, 2004

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