Peter Angelopoulos, M.D., F.A.C.C., F.S.C.A.I., F.S.V.M. What is CardioVascular Disease? Includes: Coronary Artery Disease Myocardial Infarction (Heart Attack) Atherosclerosis (Hardening of Arteries) Cerebrovascular Accidents (CVA/TIA‐ Strokes/Mini Strokes) High Blood Pressure Congestive Heart Failure Peripheral Arterial Disease (blockages in arteries other than the heart) Coronary Artery Disease  CAD is the major form of Cardiovascular Disease  Arteries are narrowed by fatty deposits such as cholesterol and triglycerides.  Blood supply to the heart muscle is thereby limited, precipitating chest pain (angina) and possibly a heart attack. Cerebrovascular Disease  Due to blockages in the brain arteries leading to neurologic symptoms  If duration of symptoms is less than 24 hours  “Mini Stroke”‐ TIA‐ Transient Ischemic Attack  Prolonged symptoms  “Stroke” – CVA‐ Cerebrovascular Accident  Tissue damage to area of the brain due to disruption in blood supply, depriving that area of the brain of oxygen. Peripheral Arterial Disease  Similar to CAD but the blockages occur in arteries other than the coronary arteries  Can affect the: ‐leg arteries Claudication, leg pains, nonhealing wounds, gangrene ‐kidney arteries  hypertension ‐abdominal arteries  aortic occlusions  The plaque in the arteries may alternatively weaken the wall and cause stretching (aneurysm) and subsequent rupture of the vessel  Abdominal Aortic Aneurysm ‐ AAA Overlap of Atherosclerotic Diseases Coronary Artery Disease Cerebrovascular Disease 40% 15% 16% 9.1% 11% 38% overlap of 2 vascular beds © Cordis Corporation 2006 155-3642 3% 6% Peripheral Arterial Disease Ness, Aronow. JAGS. 1999;47:12551999;47:1255-56. A Public Health Crisis: 60 Mil Americans Have Cardiovascular Disease  High blood pressure: 50 million  Coronary artery disease: 12.2 million  Acute myocardial infarction: 7.2 million  Angina pectoris: 6.3 million  Stroke: 4.4 million  CHF: 4.6 million Note: individuals may have more than one type of CVD Morbidity & Mortality: 2000 Chart Book on Cardiovascular, Lung, and Blood Diseases. NHLBI. May 2000. The Annual Toll Of Cardiovascular Disease  Acute MI : 1,100,000 first; 450,000 recurrent  Acute MI: 450,000 deaths*  Stroke: 500,000 first; 100,000 recurrent  Stroke: 160,000 deaths  Every 33 seconds someone dies from cardiovascular disease *Includes Acute MI plus CHD deaths Morbidity & Mortality: 2000 Chart Book on Cardiovascular, Lung, and Blood Diseases. NHLBI. May 2000. PAD- Prevalence  Affects ~12 million Americans  ~2 million Americans have Critical Limb Ischemia  More than 100,000 Amputations per year  Mostly disease of the elderly  2.5% in 40-59 y/o  18.8% in 70-79 y/o CVD and other major causes of death: both sexes. (United States: 2006). Source: NCHS and NHLBI. Atherosclerosis Timeline Foam Cells Complicated Fatty Intermediate Fibrous Lesion/ Streak Lesion Atheroma Plaque Rupture Endothelial Dysfunction From First Decade From Third Decade Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 10A). From Fourth Decade CAD Symptoms ‐ Angina  Chest pain/pressure/tightness  May radiate to the neck/jaw/arms/back  Usually precipitated by exertion/stress and relieved with rest  Occasionally occurs with rest and after a large meal  May be associated with shortness of breath, nausea, vomiting, or sweating  Prolonged angina may lead to a Heart Attack (Myocardial Infarction) Heart Attack  Due to occlusion of a coronary (heart) artery with decreased blood flow and oxygen to the heart muscle  20 min after blockage of a coronary artery, parts of the heart muscle start to die  The earlier we open the blocked artery, the more heart muscle we can save and decrease the patient’s morbidity and mortality  TIME = HEART MUSCLE Symptoms of a Stroke  Sudden  weakness or numbness of the face, arm, or leg (usually on one side of the body)  dimness or loss of vision (usually one eye)  Loss of speech or trouble talking or understanding speech  Unexplained, severe headache  Dizziness, unsteadiness, or sudden fall Causes of Strokes Infarction – blockage in cerebral artery that cuts off or reduces blood supply a) Thrombosis – blood clot b) Embolus – piece of plaque becomes lodged in the artery. 2. Hemorrhage – happens suddenly. Less frequent than infarction but more damaging and more likely to cause death. 1. PAD- Symptoms  Asymptomatic – Great Majority  Cerebrovascular Insufficiency  Hypertension/Renal Insufficiency  Arm Weakness/Pain  Post-Prandial Abdominal Pain  Claudication, Leg Fatigue, Leg Pain at Rest, Nonhealing ulcers, Gangrene PAD Diagnosis ‐ History CLAUDICATION Syndrome 1. 2. 3. 4. Absence of symptoms at rest Onset of limb pain with defined activity level Progression of pain with activity intolerance of pain and need to stop Relief of symptoms with rest Leading Risk Factors for CVD  Physical Inactivity (greatest impact)  High Blood Pressure  Excessive Body Fat (Abdominal Obesity)  Low HDL‐ High LDL Cholesterol  Diabetes  Smoking  Family History of Early Heart/Vascular Disease  Age  Gender PAD – Risk Factors  Age‐ most common in elderly  Smoking‐ 80% with IC have used tobacco‐ incidence of Intermittent Claudication 3x higher in smokers  HTN‐ 2.5 fold increased risk of PAD in males and 3.9 fold in women (Framingham)  DM‐ 3‐4 fold increase of PAD, 2.9 fold increase of ischemic ulcerations, 1.7 fold increase of rest pain  Hyperlipidemia/Hypertriglyceridemia  Hyperhomocysteinemia‐ noted in 30% of pts with PAD‐ stronger relationship than with CAD  Increased fibrinogen and hematocrit PAD - Prognosis  Over 5 years:  27% PAD pts have worsening symptoms  4% have limb loss  20% sustain nonfatal MIs and CVAs  30% DIE Weitz Circulation 1996;94:3026-3049  In patients presenting with critical limb ischemia, 30% will have an amputation in 6 months and 20% will DIE Dormandy J. Vasc Surg 2000;31: S1-S296 Prevention of CVD  Primary Prevention‐ to prevent a first heart attack or stroke  Secondary Prevention‐ to prevent a subsequent heart attack or stroke  Both involve control of diabetes, hypertension, cholesterol levels, quitting smoking, and exercise  “Life Style Modification”  Medications Cholesterol‐ Know Your Numbers!  Total Cholesterol should be kept below 200mg/dl  Current recommendations: LDL under 130 HDL over 45  My recommendations:  2 or more risk factors for CVD: LDL under 100  Documented CAD/PAD or coronary/peripheral stents: LDL under 70  Diabetes: LDL under 70 How do I lower LDL Cholesterol?  Diet low in saturated fat and cholesterol  Avoid fried foods  Increase fiber intake  Use Polyunsaturated Fatty Acids  Keep cholesterol under 200mg/day to lower LDL  Exercise  Statins …more on LDL reduction Avoid commercially baked foods Avoid trans‐fatty foods Drink low fat milk Avoid coconut oil, palm oil, cocoa butter Bake, broil, grill, poach or steam food Avoid fatty sauces How can I raise my HDL?  Aerobic exercise increases HDL levels! ‐‐‐the more the exercise, the higher HDL  Weight loss raises HDL  Quitting Smoking raises HDL  Medications raise HDL Why is high blood pressure a risk factor?  Heart has to work harder.  Since the heart muscle is working harder, it can become enlarged and thickened.  Wear and tear on the arterial wall can increase the likelihood of lipid and calcium deposits adhering to the arterial wall. This leads to hardening of the arteries. High Blood Pressure‐Know Your Numbers Ideal BP under 120/80  Normal:  Pre‐HTN:  HTN, Stage 1:  HTN, Stage 2: Systolic <120 and 120–139 or 140–159 or ≥160 or Diastolic <80 80–89 90–99 ≥100 High Blood Pressure  Lifestyle modification‐ low salt diet, weight loss and aerobic exercise  Treat if: ‐BP >140/90 mmHg or ‐BP >130/80 mmHg in patients with diabetes or chronic kidney disease.  Majority of patients will require two or more medications to reach goal. Diabetes Increases Risk of CVD and CVD Events  Diabetes increases CVD risk and accelerates development of CVD an independent risk factor for CVD  commonly associated with other CVD risk factors (hypertension, dyslipidemia, obesity)  CVD risk in diabetes  doubled in men  3‐4 times increase in women  Annual CVD event rate is doubled  CVD: cause of death in 70% of persons with diabetes  Medical Management of Type 2 Diabetes, 4th ed., 1998; Laasko M. Diabetes. 1999;48:937-942. The Increase In Diabetes Is Epidemic 33% from 1990-1998 76% in Individuals Aged 30-39 …With More to Come • Obesity/weight gain are major risk factors • In this study, 1 kg weight gain translated to a 9% increase in risk of developing diabetes • Increasing prevalence of obesity is likely to lead to increasing prevalence of diabetes Mokdad AH, et al. Diabetes Care. 2000;23:1278-1283. Diabetes‐ An American Epidemic Obesity: An American Epidemic Obesity and Diabetes‐Hand in Hand? Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI ≥30 kg/m2 No Data 2008 2000 1994 <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0% Diabetes 1994 No Data 2008 2000 <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0% CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics Diabetes-Know Your Numbers  A1c is the primary target for glycemic control, with a target goal of < 7%  Goals should be individualized  Certain populations (children, pregnant women, and the elderly) require special considerations  More stringent glycemic goals (i.e., a normal A1C<6%) may further reduce complications at the cost of increased risk of hypoglycemia Obesity Epidemic  Overweight and Obesity ranges are determined by using weight and height to calculate a number called the "body mass index" (BMI).  An adult who has a BMI between 25 and 29.9 is considered overweight.  An adult who has a BMI of 30 or higher is considered obese.  More than 1/3 of Americans are OBESE  Waist Circumference: Men > 40 in Women > 35 in PAD Treatment – Smoking Cessation Patients with PAD who continue to smoke have a 10 year mortality of 40-50% (usually due to MI and CVA) Smokers who quit increase max walking distance by 46.7 m and decrease chances of developing resting leg ischemia by half (9% vs 18% for smokers) Quick,,C Br J Surg 1982;69: S24-S26 Jonason,T Acta Med Scan 1987;221:253-260 EXERCISE Recommendations Basic recommendations from ACSM and AHA  Do moderately intense cardio 30 min/d, 5 d/wk Or Do vigorously intense cardio 20 min/d, 3 d/wk And Do 8-10 strength-training exercises, 8-12 reps of each exercise 2 x/wk.  For weight loss need 60-90 minutes of exercise ACSM‐ American College of Sports Medicine Top 10 reasons to exercise 1. Helps keep the weight down 2. Reduces fatigue and increases stamina 3. Activates the immune system 4. Decreases risk of diabetes 5. Decreases risk of hypertension 6. Decreases risk of heart disease 7. Decreases risk of osteoporosis 8. Lowers cholesterol 9. Improves the mood 10.Increases life expectancy CAD and Exercise PAD – Pharmacologic Treatment  Strict Glycemic control in diabetics (however much insulin or meds are required)  STATINS (“cholesterol meds”)  ANTIHYPERTENSIVES- (as many meds as needed to control blood pressure)  ANTIPLATELETS- Aspirin, Plavix PAD – Newer Treatments INTERVENTIONAL TREATMENTS  Balloon Angioplasty  Plain Balloon, Cryotherapy (Polar Cath), Subintimal Angioplasty, Angioscore  Thrombectomy- Angiojet  Stent Implantation Balloon expandable - ? DES  Self-expanding – Nitinol, Covered stent grafts   Atherectomy Laser  Foxhollow  Orbital  PAD Treatment- Advantages of Endovascular Therapy Potential advantages of peripheral angioplasty over surgery in PAD:  No general anesthesia or lengthy incisions  Shorter hospitalization  Lower morbidity and mortality  Earlier intervention in the course of the disease  Less complicated reintervention with recurrence Dietrich EB. Surg Today 1994;24(11):949-56 Nitinol stents Gender Differences  Incidence of CVD is higher in men at a younger age  Women “catch‐up” after menopause  Estrogens considered “protective”  Premenopausal women with CAD are at higher risk  Women are more likely to die from a heart attack or bypass surgery and more likely to have recurrent heart attacks ? Gender Treatment Bias Women:  Were not included in early clinical trials (VA)  Have more atypical symptoms: more back or shoulder pains, more exertional dyspnea  Present later in the course of a heart attack  Get less angiography  Referred less often for bypass  ? Get less aggressive treatment  ? Treatments geared toward men (larger arteries, larger body mass) 60 y/o lady with HTN, obesity, smoking, diabetes, high cholesterol, and 5 days of off and on chest pain After angioplasty and drug eluting stent Iliac PTA and Stent 49 y/o male smoker with 6 mo h/o progressive claudication from the calf, to the thigh, and finally to the left buttock. There were no palpable pulses in the femoral, popliteal, PT & DP Iliac PTA and Stent Balloon Angioplasty with a 7.0 mm x 40 mm balloon with residual stenosis Iliac PTA and Stent A 10 mm x 40 mm Self Expanding stent was deployed without any residual gradient Iliac PTA and Stent In Summary  Diabetes management with a goal of the A1c < 6%  Blood pressure control with a goal BP of <120/80  Cholesterol treatment with STATINS with the goal of LDL <70  Quit smoking  Lose weight  EXERCISE till you drop! Enjoy Lunch!!!!