SOMNATH KUMAR CONSULTANT CARDIOLOGIST Department of Cardiology LANCASHIRE TEACHING HOSPITALS UNITED KINGDOM HEART DISEASE WHY WE GET THEM AND WHAT TO DO ABOUT THEM

The Problem…. Cardiovascular disease continues to be the biggest killer in the UK today Cardiovascular disease continues to be the biggest killer in the UK today Almost 200,000 deaths per year Almost 200,000 deaths per year One in three premature deaths One in three premature deaths Half of these CHD Half of these CHD A quarter stroke A quarter stroke Most can be prevented/delayed Most can be prevented/delayed

Objectives Prevention: Primary versus Secondary Prevention: Primary versus Secondary Coronary Artery Disease (CHD) Risk Factors Coronary Artery Disease (CHD) Risk Factors Q RISK 2 Risk Assessment Q RISK 2 Risk Assessment Do You Know Your Numbers? AND your Pulse ? Do You Know Your Numbers? AND your Pulse ? Q&A Q&A

INTER-HEART: 52 Countries - every inhabited continent 15,152 cases with14,820 control group ”Disease” related risk factors ”Disease” related risk factors -Diabetes -Hypertension -Abdominal obesity -ApoB/ApoA 1 Behaviour related risk factors Behaviour related risk factors Alcohol intake Exercise Psychosocial stress Current smoking

INTERHEART Study ”nine potentially modifiable risk factors account for over 90% of the risk of an initial acute myocardial infarction” Population attributable risk fractions INTERHEART Study ”nine potentially modifiable risk factors account for over 90% of the risk of an initial acute myocardial infarction” Population attributable risk fractions Salim Yusuf et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Lancet Salim Yusuf et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Lancet

Lifetime Risk of Coronary Heart Disease in the Framingham Study Men Women At age 40 years:48.6%31.7% At age 70 years:34.9%24.2% Lloyd-Jones et al. Lancet 1999; 353:89-92 ____________________________________________________________ ______________________________________________________________ _________________________________________________________________

Chronic heart failure Arrhythmia Arterial & venous thrombosis/ cardiac & cerebral events Atherosclerosis Hypertension Diabetes Dyslipidaemia Obesity Stress Smoking Physical inactivity Excessive food intake Life style intervention Risk factor modification Life style is a Driver of CVD

Cardiovascular risk factors Non-modifiable: Modifiable: Age Smoking Gender Hypertension Family History Obesity Ethnicity Hyperlipidaemia Socio-economic status Salt intake Alcohol intake Alcohol intake Diet Diet Diabetes Diabetes Physical activity Physical activity Psychosocial factors Psychosocial factors

Healthy Lifestyle?

Physical activity If maintained BP can be reduced by 3.8 to 2.6 mmHg, systolic and diastolic If maintained BP can be reduced by 3.8 to 2.6 mmHg, systolic and diastolic 30 minutes - on five or more days/wk 30 minutes - on five or more days/wk Reduces the risk of CHD by more than 18%, Reduces the risk of CHD by more than 18%, If no exercise is taken studies show that people are 30% more likely to become hypertensive. If no exercise is taken studies show that people are 30% more likely to become hypertensive.

DE-NIAL IS JUST NOT A RIVER IN EGYPT

Abdominal Obesity- KNOW YOUR FIGURES BMI BMI –Normal < 25 –Obese –Obese > 30 Waist circumference Waist circumference –> 40 inches in men –> 35 inches in women Waist circumference is more sensitive of risk of heart attack than BMI Waist circumference is more sensitive of risk of heart attack than BMI

New Definition of High Blood Pressure Old – BP a number to keep below 140/90 Old – BP a number to keep below 140/90 New - a disease of the blood vessel where vascular biology is altered New - a disease of the blood vessel where vascular biology is altered –Arteries cannot vasodilate properly and sodium and glucose accumulate in the arterial wall New Goals 140 systolic / 90 diastolic New Goals 140 systolic / 90 diastolic –Lowers damage to heart brain, eyes, kidneys, pancreas, blood vessels of the legs/feet, sexual function

What is Cholesterol? Cholesterol is used to form cell membranes Cholesterol is used to form cell membranes LDL (BAD)  pro-inflammatory LDL (BAD)  pro-inflammatory –High levels are a predictor of atherosclerosis and heart disease atherosclerosis and heart disease HDL (GOOD)  anti-inflammatory HDL (GOOD)  anti-inflammatory –Removes excess cholesterol from arteries –Slows the growth of plaques –High levels protect against heart attack –Low levels increase risk

Cholesterol Management Guidelines Increase HDL Exercise Exercise Smoking Cessation Smoking Cessation Weight Reduction Weight Reduction Questionable: Alcohol – Red Wine Alcohol – Red Wine Estrogen Estrogen Lower LDL < 7% saturated fat grams fiber 2 grams plant stanols like Take Control Statins

Definition of Metabolic Syndrome Central obesity (waist circumference ≥ 94cm for European men and ≥ 80cms for European women) and any two of the four factors below: ↑ Trigs ≥ 1.7 mmol/L or treatment for this ↑ Trigs ≥ 1.7 mmol/L or treatment for this ↓ HDL < 1.03 mmol/L in men, < 1.29 mmol/L in women or specific treatment for this ↓ HDL < 1.03 mmol/L in men, < 1.29 mmol/L in women or specific treatment for this ↑ BP ≥130/85 or treatment of previously diagnosed hypertension ↑ BP ≥130/85 or treatment of previously diagnosed hypertension ↑ FPG ≥ 5.6mmol/L or diagnosed T2 diabetes ↑ FPG ≥ 5.6mmol/L or diagnosed T2 diabetes International Diabetes Federation, 2004

Alcohol intake Low to moderate intake is associated with a lower risk of CVD Low to moderate intake is associated with a lower risk of CVD Heavy alcohol is associated with high risk for hypertension and stroke Heavy alcohol is associated with high risk for hypertension and stroke Drinkers of more than 35 units/wk double their risk of mortality Drinkers of more than 35 units/wk double their risk of mortality Binge drinking strongly associated with a large rise in BP Binge drinking strongly associated with a large rise in BP Women drinking more than ever before. Women drinking more than ever before.

Red Flags Blood pressure >160/100 mmHg Blood pressure >160/100 mmHg Cholesterol >7.5 mmol/l Cholesterol >7.5 mmol/l

GIVE SOUND ADVICE

Smoking Strong association with CVD Strong association with CVD Smoking as few as 3 per/day doubles risk of MI or death Smoking as few as 3 per/day doubles risk of MI or death Best quit success with counselling and pharmacological therapy Best quit success with counselling and pharmacological therapy Level of risk falls with abstinence Level of risk falls with abstinence

Health Benefits after Smoking Cessation

Stress Management INTERHEART Study confirmed that psychosocial factors can contribute to sudden cardiac death

Well being

Wellbeing in Lancashire

Q risk-2

Levels of risk <10% risk over the next 10 years - classed as low CVD risk <10% risk over the next 10 years - classed as low CVD risk 10-20% risk over the next 10 years - classed as moderately increased CVD risk 10-20% risk over the next 10 years - classed as moderately increased CVD risk >20% estimated risk over the next 10 years - classed as high risk. >20% estimated risk over the next 10 years - classed as high risk.

Putting prevention first National vascular checks programme National vascular checks programme Commenced 04/09 Commenced 04/09 Comprehensive CV risk assessment to be offered to all aged Comprehensive CV risk assessment to be offered to all aged PCT delivery PCT delivery

It’s all atheroma…. Common aetiology Common aetiology Systemic disease Systemic disease Risk factors Risk factors Common treatment aim Common treatment aim Prevention of events Prevention of events

The “Calcium Score” EBCT = electron-beam computed tomography Source: services.epnet.com/getimage.aspx?imageiid=6857

NHS Health Checks Programme

Individual Level Demographic factors Biology; Genetics; Flavour experiences; Learning history Household Level Food availability; Role models; Culture; Feeding Styles Micro environment Level Local Community; School settings; Worksites Fast food outlets; Cafes & restaurants Macro Level Economic Policies; Government Policies; Laws; Media; Technology; Industry Relations ; Transport Multi-level framework for identifying facilitators and barriers to attaining a healthy life

Action Plan 1. Get a annual check-up, know your numbers and follow-up –Monitor your cholesterol and fasting blood glucose –BP targets vary according to patients –Check thyroid, liver and kidney function, Vitamin D levels, hormones 2. Examine your diet and get a nutrition assessment with a dietitian 3. Exercise Non-Negotiable daily appointment for you minutes 5 days a week 5 days a week 4. Develop a management plan to control stress and anxiety and depression... and seek help if no improvement depression... and seek help if no improvement 5. Quit smoking 6. Learn to measure your own pulse – practice brings perfection

Balance your life when possible… …and make time for fun… And help others to achieve well-being well-being

Between primary and secondary care We, the cardiology team at LTH THROUGH IMPROVED PATIENT CARE & COMMUNICATION