1. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved. 1 Chapter 19 Coronary Heart Disease and Hypertension

2. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.2 Key Concepts Cardiovascular disease is a leading cause of death in the United States. Several risk factors contribute to the development of cardiovascular disease and hypertension, many of which are preventable by improved food habits and lifestyle factors.

3. Cardiovascular Disease Heart Disease Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.3

4. 4 Key Concepts, cont’d Other risk factors are nonmodifiable, such as age, gender, family history, and race.

5. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.5 Coronary Heart Disease Atherosclerosis : underlying pathology of coronary heart disease Acute cardiovascular disease : myocardial infarction Chronic heart disease : Congestive heart disease

6. ath Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.6

7. di Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.7

8. 8 Atherosclerosis Disease process –Fatty fibrous plaques develop into fatty streaks on inside lining of major blood vessels Fatty streaks largely composed of cholesterol Thickens, narrowing the interior part of the blood vessel –If affected vessel is major artery supplying heart muscle, result could be myocardial infarction Local area of dead tissue is an infarct

9. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.9 Atherosclerosis, cont’d Disease process, cont’d –If affected vessel is major artery supplying brain, result could be cerebrovascular accident Common name, “stroke”

10. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.10 Atherosclerosis, cont’d Disease process, cont’d –Identified as coronary heart disease –Common symptom is angina pectoris, chest pain usually radiating down the arm, sometimes brought on by excitement or physical effort

11. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.11 Atherosclerosis, cont’d Disease process, cont’d –Key terms related to Atherosclerosis: Myocardial infarction Cerebrovascular accident Coronary heart disease Angina pectoris Lipids

12. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.12 Atherosclerotic Plaque in Artery

13. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.13 Atherosclerosis: Relation to Fat Metabolism Elevated blood lipids associated with coronary heart disease –Triglycerides: Simple fats in body or food –Cholesterol: Fat-related compound produced in body; also in foods from animals –Lipoproteins: “Packages” wrapped with protein that carry fat in the bloodstream

14. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.14 Atherosclerosis: Types of Lipoproteins Very-low-density lipoproteins (VLDLs) –Carry large load of fat to cells Low-density lipoproteins (LDLs) –Carry two thirds of total plasma cholesterol to body tissues High-density lipoproteins (HDLs) –Carry less total fat and more protein

15. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.15

16. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.16 Cholesterol and Lipoprotein Profile Classification

17. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.17 Risk Factors in Cardiovascular Disease Lipid risk factors –LDL cholesterol >130 mg/dl –HDL cholesterol <40 mg/dl –Total cholesterol >200 mg/dl –Triglycerides >150 mg/dl –Atherogenic dyslipidemia

18. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.18 Risk Factors in Cardiovascular Disease, cont’d Nonlipid risk factors –Nonmodifiable Male gender Age (men >45 years, women >55 years) Heredity (including race) Family history of premature cardiovascular disease

19. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.19 Risk Factors in Cardiovascular Disease, cont’d Nonlipid risk factors, cont’d –Modifiable Cigarette smoking Hypertension (>140/90 mm Hg or on antihypertensive medication) Physical inactivity Obesity (body mass index >30 kg/m2) and overweight (body mass index 25 to 29.9 kg/m2) Diabetes mellitus Metabolic syndrome Atherogenic diet

20. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.20 Risk Factors in Cardiovascular Disease, cont’d Emerging risk factors –Emerging lipid risk factors Elevated lipoprotein remnants Elevated lipoprotein(a) Small LDL particles Elevated apolipoprotein B Low apolipoprotein A1 High total cholesterol/HDL cholesterol ratio

21. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.21 Risk Factors in Cardiovascular Disease, cont’d Emerging risk factors, cont’d –Emerging nonlipid risk factors Hyperhomocysteinemia Thrombogenic and hemostatic factors Inflammatory markers such as C-reactive protein Impaired fasting glucose

22. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.22 Diagnosing Metabolic Syndrome

23. Metabolic Syndrome Metabolic syndrome : a group of health disorders such as diabetes, elevated triglycerides, hypertension etc… that when they occur together, increase the risk of CVD and diabetes. See Table 19-2 on page 368. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.23

24. Metabolic Syndrome Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved. 24

25. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.25 Dietary Recommendations for Reduced Risk Dietary Guidelines for Americans, 2005 –Reduce total amount of fat: no more than 30% of total energy (kilocalories) intake from fat –Reduce use of animal fat: no more than one third of total fat kilocalories from saturated animal fat –Reduce intake of cholesterol: limit to 300 mg/day

26. TLC diet Total fat should not exceed 25% - 35% Mono-unsaturated fats in greatest proportion Total cholesterol intake < 200 mg/day Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.26

27. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.27 Dietary Recommendations for Reduced Risk, cont’d National Cholesterol Education Program Guidelines –Energy intake should reflect energy expenditure –Total fat intake no more than 25% to 35% of total kilocalories –Carbohydrates comprise 50% to 60% of total energy intake per day –Total protein intake should be 15% of total energy intake –Less than 200 mg dietary cholesterol per day

28. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.28 American Heart Association and NCEP Recommendations for Lowering Cholesterol

29. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.29 ATP III LDL Cholesterol Goals and Cut Points for TLC and Drug Therapy

30. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.30 Acute Cardiovascular Disease Objective: Cardiac rest Principles of diet therapy –Energy intake : reduced energy –Texture :soft –Fat : TLC diet –Sodium : mild restriction ( 2g )

31. Medical Nutritional Therapy Principles of : Energy: period of reduced energy Texture: soft, easily digested Fat: TLC diet Sodium: mild Na restriction would be app. 2g/day. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.31

32. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.32 Chronic Heart Disease / CHF Objective: Control of pulmonary edema –Fluid shift mechanism –Hormonal alterations Principles of diet therapy –Sodium restriction –Fluid restriction –Texture –Small meals –Alcohol

33. CHF Pulmonary edema causing difficulty breathing Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.33

34. Congestive Heart Failure Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.34

35. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.35 Key Concepts Hypertension, or chronically elevated pressure, may be classified as essential (primary) or secondary. Hypertension damages the endothelium of blood vessels.

36. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.36 Key Concepts, cont’d Early education is critical for the prevention of cardiovascular disease.

37. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.37 Essential Hypertension Incidence and nature –23% of American adults have high blood pressure (hypertension) –Injury to inner lining of blood vessel wall appears to be underlying link to cause –Secondary hypertension is symptom or side effect of another primary condition –Hypertension called the “silent disease”

38. Hypertension Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.38

39. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.39 Types of Hypertensive Blood Pressure Levels Prehypertension –Focus on lifestyle modifications Stage 1 hypertension –Diet therapy and drugs as needed Stage 2 hypertension –Diet therapy and vigorous drug therapy

40. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.40 Drug-Nutrient Interaction The grapefruit conundrum –Calcium channel blockers Gastrointestinal complaints such as constipation and nausea Headache Flushing Bradycardia or reflex tachycardia Skin rash

41. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.41 Drug-Nutrient Interaction, cont’d The grapefruit conundrum, cont’d –HMG-CoA reductase Inhibitors Gastrointestinal complaints such as constipation, diarrhea, stomach pain, heartburn, gas Headache Muscle pain Increased risk of myopathy Skin rash

42. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.42 Classification of Blood Pressure for Adults

43. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.43 Principles of Nutrition Therapy Weight management: Lose weight and maintain appropriate weight for height Sodium control Other minerals: Calcium, magnesium DASH diet: Lower blood pressure through diet alone Additional lifestyle factors

44. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.44 Education and Prevention Practical Food Guides Food planning and purchasing –Control energy intake; read labels –Eat fresh foods with small selection of processed foods Food preparation –Use less salt and fat –Use seasonings instead (herbs, spices, lemon, onion, garlic, etc.) Special needs

45. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.45 Education Principles Start early –Prevention begins in childhood, especially with children in high-risk families Focus on high-risk groups –Direct education to people and families with risk of heart disease and hypertension Use variety of resources –National organizations, community programs, registered dietitians

46. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.46 Summary Coronary heart disease is the leading cause of death in the United States. Its underlying blood vessel disease is atherosclerosis. The risk for atherosclerosis increases with the amount and type of blood lipids (fats), or lipoproteins, available. Elevated serum cholesterol is a primary risk factor for development of atherosclerosis.

47. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.47 Summary, cont’d Current recommendations to help prevent coronary heart disease involve a low-fat balanced diet, weight management, and increased physical activity. Dietary recommendations for acute cardiovascular disease (e.g., heart attack) include measures to ensure cardiac rest (e.g., energy restriction, and small meals, modified in fat, cholesterol, and sodium).

48. Copyright © 2009, by Mosby, Inc. an affiliate of Elsevier, Inc. All rights reserved.48 Summary, cont’d Persons with chronic heart disease involving congestive heart failure benefit from a low-sodium diet to control pulmonary edema. Persons with hypertension may improve their condition with weight control, exercise, sodium restriction, and adequate calcium and potassium intake.