how to prevent heart attacks

Preventing Heart Attacks

V.S.Ramchandra,MD,DM,FACC,FSCAI,FESC.Consultant Cardiologist

Formerly: Professor & Head of Cardiology, KMC, Manipal

Chief Electrophysiologist, Apollo HospitalsAssociate in Cardiology, UAB Hospital, AL, USA

Staff Cardiologist, St Vincent Health, IN, USA

Magnitude of the Problem: Global Burden of Cardiovascular

Disease•½ way through a 2 century transition ; CVD will dominate as the major cause of Death Globally•Although CVD is ↓in EstME it is ↑ in the rest of the world with 85% of the worlds population. •10% (1900) → 25% (2000) → 50% (2020) of Global Deaths.

CAUSES OF DEATH

• 1. MYOCARDIAL INFARCTION (HEART ATTACK) DUE TO CORONARY ARTERY DISEASE • 2. CEREBROVASCULAR ACCIDENT (STROKE) DUE TO BLOCK IN BRAIN TUBES• CANCER

INDIAN SCENARIO

Prevalence of CAD in Different Countries

•

0 100 200 300 400 500 600 700 800 900

Russia

Scotland

Finland

England

U.S.A.

Australia

Canada

Sweden

Italy

Urban China

France

Rural China

Japan

WomenMen

Coronary Artery Disease – Indian Scenario: Indians Vs West

•Average Age of first MI in west is 70 years. In India it is 45 to 55 years.•At any level of conventional RF – Indians have X2 CAD than whites with similar RF

Coronary Artery Disease – Indian Scenario: Past Vs Present

•CAD rates have halved in W in last 30 yrs – Increasing alarmingly (doubled) in India•Average Total Cholesterol was 120mg% - increased to 200mg% •Average Age of first MI has ↓ by 20 yrs- ½ < 50yrs, ¼ < 40 yrs of age• Diabetes has increased by 60%.

WHAT IS A HEART ATTACK

WHAT IS THE HEART

http://www.tctmd.com/expert-presentations/table-2.html?product_id=1421&sort_key=2&ppt_slide_id=8827

Non-Invasive Diagnosis of CAD

Ischemia detection• ECG/ TMT- Sen-60%,Sp-80%• Stress ECHO• SPECTCoronary CalciumCTA- 99% sensitivity- may overestimate

COURAGE TRIAL

• OMT Vs (Revascularisation+ OMT)•2300 pts- 70% proximal lesion+Ischemia or 80%+angina, 2/3TVD• At 5 Yrs- No difference in Mortality, MI, hospitalisations, Stroke.

WHERE IS REVASCULARISATION USEFUL

• UNSTABLE ANGINA- Symptoms /Trop/ varying ST-T ECG changes• PRIMARY ANGOPLASTY FOR AMI• TVD with LV DYSFUNCTION• ? Lt MAIN, Silent Ischemia, Severe Stenosis

How Predictable & Preventable is CVD

• Interheart Study: 90% Predictable• Multiple Risk Factor Interventional Trials: 0 to 60% reduction•Observational studies in migrant populations show vast differences in CVD mortality

Cardiac Risk Factors- Modifiable• Smoking• Hypertension• Diabetes• Metabolic Syndrome• Dyslipidemia• Obesity• Sedentary Life style• Lack of fruits, GV & fiber in diet• Anger, Hostility, Work stress, Depression, LSS• Alcohol

Surrogate Markers of Coronary Artery Disease

• Vascular Disease Elsewhere – Strokes, TIA, PVD, Carotid bruits, Abdominal Aneurysms

• Diabetes• Chronic Renal Failure

Coronary Artery Disease Risk Factors-Non Modifiable

• Male Sex• Post Menopausal State• (+) Family History• Genetic Susceptibility• Lp (a)• Diabetes• ? Infection

Smoking Cessation

• Risk of CAD/Re- MI/CABG failure X2• Leading preventable cause of Death• 25% in US to 70% in China• 80% start before age 18 yrs• In US: 55% →25% (M), 35% →20% (W)• Risk falls rapidly after cessation

Smoking Cessation (Cont..)•Cessation highly Cost effective •Intervention usually short term•1 yr success rates- 6% Physician counseling , 20% self help programs, 40% with Buproprion /nicotine patch•3 types of Behavioral therapy- Problem solving, social support in & outside treat•Most effective after event

Alcohol•20 to 45% risk ↓ with moderate consumption (60ml-male, 30 ml- Female)•↑HDL, ↑Fibrinolysis, ↓Platelet aggregation•10-20% become chronic alcoholics•Consider HTN, DM, ↑TG, Hgic Stroke, Liver Disease, f/h alcoholism /Breast Ca/ Colon Ca•Prescription should be individualized“Whether wine is a nourishment,medicine, or poison, is a matter of dosage”-Celsus

HTN- The Magnitude of the Problem

•HTN is the commonest medical diagnosis, affecting 1 billion worldwide•Prevalence of HTN: 3% in 18 to 24 yrs age 13% in 35 to 44 yrs age & 70% in those >75 yrs.•For persons over age 50, SBP is a more important than DBP as a CVD risk factor.

HYPERTENSION

• >120/80-PREHYPERTENSION, >140/90- HTN• NO SYMPTOMS. 2/3 OF AMERICAN

HYPERTENSIVES NOT AWARE • SAME GOALS FOR ALL AGES • SYTOLIC BLOOD PRESSURE MORE

DANGEROUS• MOST NEED 2 OR MORE DRUGS• GOALS: <130/80. <115/75 IN DIABETICS

WITH PROTEINURIA.

Pre-Hypertension: A New Disease Is Created

Starting at 115/75 mmHg, CVD risk doubles every 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.Intent in creating Pre-HTN(22% of adult population) is to stress LSM, prevent progression & to treat other CVRF

Hypertension- treatment most cost effective

• Risk ↑ Linearly from 115/75mmHg.• 5 mm ↓ in BP Reduces strokes by 40% , CVD by 15% & Heart failure by 25%• In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated

.

Lifestyle Modification

Modification Approximate SBP reduction(range)

Weight reduction 5–20 mmHg/10 kg weight loss

DASH eating plan 8–14 mmHg

Dietary sodium ↓ 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

Diabetes Mellitus

• Confers X 4 Risk. Young stroke X 10. No menstrual protection for women. • Deemed a Coronary Artery Disease equivalent by AHA• Worldwide ↑ by 35% (from 5%) by 2025, max in China (↑68%) & India (60%) •Thrifty Gene Hypothesis

•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test

Calculating your risk of Developing Diabetes Mellitus

•Overweight – 5•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test

Preventing Diabetes with LSM

•DPP: Weight loss by 7% & 150 mins/ wk of moderate ex – reduced chance of becoming Diabetic by 55% in IFG/ IGT compared to 30% with metformin•Delaying may be preventing- Glitazone•Once Diabetic no degree of control of sugars shown to prevent macrovascular complications

OBESITY

1. BODY MASS INDEX: WEIGHT in Kg/ HEIGHT in M.SQ. 25 – 30(OWERWEIGHT) 30 – 35(OBESE)

2. WAIST CIRCUMFERENCE <90Cms(M), <85Cms

3. PROTRUDING TUMMY 4. WAIST >HIP

Physical Inactivity / Exercise

•75% American Adults•Inverse Linear Dose Response relationship. Ex & all-cause mortality •CAD, MI, HTN, DM, Dyslipidemia, MS•50% Primary, 25% Secondary protection

Exercise

• Goals: Maintain 70-80% of THR for 45 Mins 5 days/Week. • THR= 220-AGE• Maintain ideal Body Weight & muscle mass & Flexibility.

CHOLESTEROL

• A NATURAL MEMBRANE BUILDER .• THE FINAL ROUTE TO BLOCKAGES IN ARTERIES• GOOD - HDL CHOLETEROL• BAD - LDL CHOLESTEROL• UGLY - TRIGLYCERIDES• DEADLY- Lp (a).

1% ↑ Heart Attacks for every 2% ↑ in LDL or 1% ↓ in HDL

Naturalization

AVERAGE IS NOT NORMAL!!•Average LDL of Hunter-gatherers, Neonates, Mammals is 50-70mg%. No Atherosclerosis even in 7th & 8th decades.•Avg American LDL is 130. 50% above 50Yrs have atherosclerosis.

LDL - Naturalisation HOW LOW IS LOW ENOUGH? IS IT SAFE?•10% of highest LDL account for 20% of CAD. • Only 25% risk reduction with current LDL Trt.•Threshold for atherosclerosis progression is LDL of 67mg%, CVD event rate 0 at LDL 57 (primary) & 30 mg% (secondary prevention).•50% ↓ in LDL for secondary & 30% ↓ for primary prevention.•? All people above 55yrs should receive statins

ACT BEFORE DISEASE IS FIXED

• More beneficial to Treat High Risk or Low Risk patients •50% reduction by bringing LDL to 55mg% in “low risk”- Jupiter trial

Metabolic Syndrome

Any 3 of the below:• TG > 150mg/dl• HDL-C <40 (M), <50 (F)• FBS (plasma) >100mg/dl• BP >130/85• Waist Circumf > 90cm(M) > 85cm(W)Incidence: 40%, 28% (No IFG), 75%(DM/IFG)

Diet & Cholesterol

• Contribution of dietary cholesterol to Blood T-C is small (10mg%) compared to dietary fats (100mg%)• 4 types of Fatty acids:• Good - Poly unsaturated (PUFA)• Great - Mono unsaturated (MUFA)• Bad - Saturated (SAFA)• Deadly - Trans saturated (TFA)

Diet & Cholesterol- Milk

• In Indians SFA come from diary products & cooking oils• Avoid whole fat milk & milk products Diary products are more saturated & athero/throbogenic than meat products• Nonfat Milk- Calcium, B12, ↓ BP, decreases diabetes risk.

Cooking Oils / Fats

• Oils have powerful cholesterol increasing & lowering actions• 1/3rd of the 54% decline in CAD in US attributed to ↑ PUFA by 5%.• 30mg% ↓ in T-C by banning palm oil & substituting it by soybean oil•Nuts are high in fat(cashew 21%, peanut14%) but low in SAFA and do not ↑T-C

Cooking Oils

• SAFA: Butter, coconut and palm oil is more athero / thrombogenic than lard & beef tallow• MUFA: Oleic acid in Canola & Olive oil reduces LDL & increases HDL.• PUFA: ð-3 (fatty fish, walnuts, canola & soybean oil) ð-6 ( corn, soybean, cotton) 4:5 decreases LDL and HDL•TFA- Pastries, fried chicken, margarines/ dalda, ready foods, crispy bakery products.

Diet- Energy•Carbohydrates – Rice•Fats – Milk, Cooking oils•Proteins – Pulses, Milk •Marked ↓in Fat intake or ↑in Carbs will ↓HDL•Marked ↑ in protein ↑load on kidneys•Fibre – Cereals•Micronutrients- Fresh fruits, undercooked vegetables

Diet- Carbs- Rice

•Carbohydrates – Polished Rice, Maida, White bread, Biscuits, Upma, Dosa, Sugar, Sweets•Cereals with their outer fibrous coating removed•Glycemic Index •Satiety •Fibre -Soluble & Insoluble

Substituting Fats with Carbs

Diet (Cont..)•Balance Total Calories with expenditure to maintain ideal BMI•Minimize Saturated /trans fat to 7% of cal•Mono-unsaturated fats rest 20% of cal•Omit rapidly digested Carbs – White Rice •Whole grains are excellent source of energy, fiber & protein

Diet (Cont…)•Maximize fruits & fresh Vegetables to 5 servings/day + some nuts•Use only very low fat Dairy products•2-3 servings of Fatty fish /week•Dietary supplements- 1gm/D 3 fatty acids, Folate, B6&12, Multivitamins•Alcohol.

•US: 1960-30%, 2000- 65%, 2-5yrs-5%, 6-19yrs-15%. ↑ ↑ ↑ DM, ↑ CVD later.•Abdominal Obesity poses greater risk•3part strategy- Caloric restriction, Structured physical activity, Behavior therapy for BMI>30•Failure rates extremely high

FOOD

PYR

AMID

Indian Paradox Less RF- More CAD. 1. Genetic predisposition.?Lp(a) 2. Central obesity-Insulin Resistance 3. Metabolic Syndrome 4. Processed carbohydrates, Increased energy. 5. Increased dairy Fats 6. Frying/ Reuse of oils- TFA.

Sleep & Obstructive Sleep Apnea

Less than 6 or More than 8 hrs/day Sleep Deprivation & Altering Cycles Sun-Ambient Light & Sleep Getting up and getting ready for work Snoring, Daytime drowsiness, HTN, Age, BMI & Neck Cicumference- OSA

3 Main causes of heart Attacks

Food Exercise

Mental Stress

Type A,Type D behavior

•Compulsive overachievers, excessively competitive & ambitious, aggressive, hostile, unable to relax, impatient & get easily frustrated / angry•Anger, Suppressed Anger, hostility.•Large Prospective studies of healthy x 2 risk of developing CAD•Type D- suppressed negative emotions

Psychosocial Factors

• Depression• Social Isolation• Anger & Frustration• Hostility• Job Strain-High demand with little autonomy• Marital stress

Tackling Negative Emotions

• Connection between Emotions & Breath• Observe Sensations• Everything Changes – Including emotions • Opposite values are complimentary• Be Centered• Pranayama & Meditation

Lp(a) - The Deadly Cholesterol• >15-20mg/dl• Purely Genetic• Best childhood

predictor• Highly atherogenic,

thrombogenic, antifibrinolytic

• Highest among all races except blacks

• 40 % of Indians.

Tobacco10%

HTN10%

Diabetes10%

TC/LDL15%TC/HDL

15%

lp(a)25%

Hcy5%

Other10%

Tobacco

HTN

Diabetes

TC/LDL

TC/HDL

lp(a)

Hcy

Other

Contributions of various risk factors for CAD among Asian Indians

Tobacco10%

HTN10%

Diabetes10%

TC/LDL15%TC/HDL

15%

lp(a)25%

Hcy5%

Other10%

Tobacco

HTN

Diabetes

TC/LDL

TC/HDL

lp(a)

Hcy

Other

Prevention- From Womb to Tomb

• Womb - Measures to prevent IUGR• Infancy- Infections?• Childhood – Physical activity, prevent obesity, proper nutrition and lifestyle enforcement. Lp(a)• Early Adulthood – FLP if F/h, screen for DM if Obese.•Adulthood – Screen for all RF, HsCRP

Prevention- The Caveats

• Eat Less - Eat a variety• Be Natural- Exercise, Diet, Sleep • Learn to Relax• Act Before Diseases are Fixed

Predicting CAD

Biomarkers- Hs CRP• LP PLA2Vascular Imaging• Carotid IMT (<1 to>3 mm)- Young• CACS by EBCT or MSCT (>100Au)

Genomic markers• High Density Genotyping- SNP• Genome expression Assays

PRIMARY PREVENTION DRUGS- ASPRIN & ROSUVASTATIN

• More HDL raising & TG (Stellar)• Safer than any other Statin• More reduction in HsCRP• First IVUS regression (Asteroid Trial)• Multiple sites of action (HMG, CETP, PPAR a, ApoA1, Longest half life

Life Style & Behavioral Modifications

• Difficult to qualify,quantify & study in isolation due to multiple linked factors• Intensely Individual but the only modifications possible on a global scale• Large reductions in mortality with minimum fear of unexpected side effects on the long run & cost effective

• •b ve•ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality

Life Style & Behavioral Modifications- Doing it

• Understand & be Motivated• Like it & be part of a group• Structured program & should become part of routine life by strength of habit• Started early in life & should have social/family/ work place support

Population-Based Strategy SBP Distributions

BeforeIntervention

AfterIntervention

Reduction in SBPmmHg

2

3

5

Reduction in BP

% Reduction in MortalityStroke CHD Total

–6 –4 –3–8 –5 –4

–14 –9 –7

“SUPERIOR DOCTORS PREVENT DISEASE; MEDIOCRE DOCTORS TREAT DISEASE BEFORE IT IS EVIDENT; INFERIOR DOCTORS TREAT FULL BLOWN DISEASE”

Huang dee. First Chinese Medical Text. 2600 BC.


0 100 200 300 400 500 600 700 800 900

Russia

Scotland

Finland

England

U.S.A.

Australia

Canada

Sweden

Italy

Urban China

France

Rural China

Japan

Women

Men

Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)

Cardiac Metaphors of Daily Life• Races with Excitement• Pounds in Anticipation• Stands still in Dread, Skipped a Beat• Aches with Grief• With a Heavy Heart• The Lion Hearted, Large hearted, Heartless• Broken Hearted

Preventing Heart Attacks Role of Lifestyle Modifications &

Behavioral ChangesV.S.Ramchandra MD,DM,FACC,FSCAI,FESC.

Global HospitalsFormerly:

Professor & Head of Cardiology, KMC, ManipalChief Electrophysiologist, Apollo Hospitals

Associate in Cardiology, UAB Hospital, AL, USAStaff Cardiologist, St Vincent Health, IN, USA

WHAT IS THE HEART

WHAT IS CIRCULATION

• Supplies Nutrients• Removes Waste• Supplies Oxygen• Removes CO2• Single Pump• Blood Pressure• Gradient = 120-10• Extremely Low

Resistance

WHAT HAPPENS IF CIRCULATION TO PART OF THE

BODY IS STOPPED

• BRAIN (STROKE)• HEART ( HEART

ATTACK or MI )• KIDNEY

(HYPERTENSION)• LEG (GANGRENE)• EYE (BLINDNESS)

WHAT HAPPENS IF THE HEART STOPS

Prevalence of Heart Attacks in Different Countries

•

0 100 200 300 400 500 600 700 800 900

Russia

Scotland

Finland

England

U.S.A.

Australia

Canada

Sweden

Italy

Urban China

France

Rural China

Japan

WomenMen

CAUSES OF DEATH

• 1. MYOCARDIAL INFARCTION (HEART ATTACK) DUE TO CORONARY ARTERY DISEASE • 2. CEREBROVASCULAR ACCIDENT (STROKE) DUE TO BLOCK IN BRAIN TUBES• CANCER

Heart Attacks – Indian Scenario: Indians Vs West

•Overseas Indians–CAD X 4 Americans•Urban Indian Epidemic(10%)Vs USA(2.5%)•Hear Attack rates have halved in W in last 30 yrs – Increasing alarmingly (doubled) in India•Average Age of first Heart Attack in west is 70 years. In India it is 45 to 55 years.

Heart Attacks – Indian Scenario: Past Vs Present

•Heart Attack rates have increased alarmingly (doubled) in India in last 25 years•Average Total Cholesterol was 120mg% - increased to 200mg% •Average Age of first Heart Attack has ↓ by 20 yrs- ½ < 50yrs, ¼ < 40 yrs of age• Diabetes has increased by 60%.

Heart Attacks – Indian Scenario Urban Vs Rural

•Rural Vs Urban: ½ Despite higher smoking •RF incidences: Smoking- 55%®,35(U) •Diabetes- 3%®, 11% (U)•Hypertension- 14%®, 25% (U)•TC/HDL >5 – 28%®, 46% (U)•Urb Vs Rural: BMI 25Vs20, WHR0.99Vs.95•Higher CAD in South India- Urb Kerala13%

How Predictable & Preventable are Heart Attacks

• Interheart Study: 90% Predictable• Multiple Risk Factor Interventional Trials: 0 to 60% reduction•Observational studies in migrant populations show vast differences in CVD mortality

Heart Attack Risk Factors- Modifiable

• Smoking• High BP (Hypertension)• High Sugars (Diabetes)• High/ Bad fats/cholesterol (Dyslipidemia)• Increased weight/fat (Obesity)• Sedentary Life style (lack of Exercise)• Metabolic Syndrome• Lack of fruits, GV & fiber in diet• Anger, Hostility, Work stress, Depression, LSS• Alcohol

SMOKING

• COMMONEST CAUSE OF DEATH IN YOUNG ADULTS AND ELDERLY

• NICOTINE + LARGE NUMBER OF TOXINS• IMMEDDIATE SPASM• DAMAGES EPITHELIUM (INNER LINING OF

TUBES) EVERYWHERE• PRECIPITATES DIABETES• SUDDEN DEATH

Smoking Cessation

• Risk of CAD/Re- MI/CABG failure X2• Leading preventable cause of Death• 25% in US to 70% in China• 80% start before age 18 yrs• In US: 55% →25% (M), 35% →20% (W)• Risk falls rapidly after cessation

Smoking Cessation (Cont..)•Cessation highly Cost effective •Intervention usually short term•1 yr success rates- 6% Physician counseling , 20% self help programs, 40% with Buproprion /nicotine patch•3 types of Behavioral therapy- Problem solving, social support in & outside treat•Most effective after event

Alcohol•20 to 45% risk ↓ with moderate consumption (60ml-male, 30 ml- Female)•↑HDL, ↑Fibrinolysis, ↓Platelet aggregation•10-20% become chronic alcoholics•Consider HTN, DM, ↑TG, Hgic Stroke, Liver Disease, f/h alcoholism /Breast Ca/ Colon Ca•Prescription should be individualized“Whether wine is a nourishment,medicine, or poison, is a matter of dosage”-Celsus

Diabetes Mellitus

• Confers X 4 Risk. Young stroke X 10. No menstrual protection for women. • Deemed a Heart attack equivalent by AHA• Worldwide ↑ by 35% (from 5%) by 2025, max in China (↑68%) & India (60%) •Thrifty Gene Hypothesis

•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test

Calculating your risk of Developing Diabetes Mellitus

•Overweight – 5•Sedentary – 5•Age > (45-64) – 5, > (65) - 9•Parent DM- 1, Sibling DM- 1•Women with Baby >9lb - 1•Asian - 4•Total > 3-9= Low Risk, 10+ = need test

Preventing Diabetes with LSM

•DPP: Weight loss by 7% & 150 mins/ wk of moderate ex – reduced chance of becoming Diabetic by 55% in IFG/ IGT compared to 30% with metformin•Once Diabetic no degree of control of sugars shown to prevent heart attacks or strokes

HYPERTENSION

• NO SYMPTOMS. 2/3 OF AMERICAN HYPERTENSIVES NOT AWARE

• SAME GOALS FOR ALL AGES • SYTOLIC BLOOD PRESSURE MORE

DANGEROUS• MOST NEED 2 OR MORE DRUGS• GOALS: <130/80. <115/75 IN DIABETICS

WITH PROTEINURIA.

Hypertension

• >140/90. Prehypertension >120/80• Risk ↑ Linearly from 115/75mmHg.• 5 mm ↓ in BP Reduces strokes by 40% , CVD by 15% & Heart failure by 25% • In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated

.

Pre-Hypertension: A New Disease Is Created

Starting at 115/75 mmHg, Heart Attack/Stroke risk doubles for every 20/10 mmHg increase throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.Intent in creating Pre-HTN(22% of adult population) is to stress LSM, prevent progression & to treat other CVRF

Lifestyle Modification

Modification Approximate SBP reduction(range)

Weight reduction 5–20 mmHg/10 kg weight loss

DASH eating plan 8–14 mmHg

Dietary sodium ↓ 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

Life Style & Behavioral Modifications- Doing it

• Understand & be Motivated• Like it & be part of a group• Structured program & should become part of routine life by strength of habit• Started early in life & should have social/family/ work place support

Population-Based Strategy SBP Distributions

BeforeIntervention

AfterIntervention

Reduction in SBPmmHg

2

3

5

Reduction in BP

% Reduction in MortalityStroke CHD Total

–6 –4 –3–8 –5 –4

–14 –9 –7

“SUPERIOR DOCTORS PREVENT DISEASE; MEDIOCRE DOCTORS TREAT DISEASE BEFORE IT IS EVIDENT; INFERIOR DOCTORS TREAT FULL BLOWN DISEASE”

Huang dee. First Chinese Medical Text. 2600 BC.

MENTAL STRESS & PHYSICAL STRESS

• DEPRESSION, SOCIAL ISOLATION, ANGER, AGGRESSIVENESS (TYPE A BEHAVIOUR)

• INCREASED MENTAL OR PHYSICAL WORK NOT DANGEROUS.


0 100 200 300 400 500 600 700 800 900

Russia

Scotland

Finland

England

U.S.A.

Australia

Canada

Sweden

Italy

Urban China

France

Rural China

Japan

Women

Men

Graph 1: Age-adjusted CAD Death Rates per 100,000 per year (Age 35-74)


•Studies hampered by imprecision in definitions & accepted metrics•Depression, Chronic Hostility, Social isolation, Perceived lack of Social support consistently linked with ↑ risk •Data inconsistent with anxiety, work related stress & Type A behavior

Psychosocial Factors (Cont..)

• Low socioeconomic status• Acute mental stress /stress induce SMI• Sudden emotion-↑RR in 1-2 hrs of event• Lethal arrhythmias & SCD following mentally stressful events• HTN–Relaxation training,meditation & biofeedback for pt with subjective stress

CAUSES (Risk Factors) OF HEART ATTACK

SMOKINGDIABETES

HYPERTENSIONCHOLESTEROL

OBESITY/ METABOLIC SYNDROMELACK OF EXERCISE

MENOPAUSEMENTAL STRESS

MENOPAUSE

• SUDDEN SURGE IN HEART ATTACKS• TOTAL MORTALITY> MALES• DIABETES TOTALLY NEGATES

PROTECTION OF MENSES.• HRT HARMFULL• MALES WILL BE SAVED IF WE KNOW

WHAT PROTECTS FEMALES!

Lp(a) - The Deadly Cholesterol MULTIPLIER EFFECT

Contributions of various risk factors for CAD among Asian Indians

Tobacco10%

HTN10%

Diabetes10%

TC/LDL15%TC/HDL

15%

lp(a)25%

Hcy5%

Other10%

Tobacco

HTN

Diabetes

TC/LDL

TC/HDL

lp(a)

Hcy

Other

THIS IS WHAT KILLS US!

• INCREASED PROCESSED CARBOHYDATES.• RAPID ABSORPTION OF SUGAR• INCREASED INSULIN, ARTERY

THICKENING, TRIGLYCERIDES, DECRESED HDL.

• RICE IS TOXIC!• THERE IS AN EPIDEMIC COMING!

NON MODIFIABLE FACTORS:

• Age,• Sex• Family History

HOW MUCH LESS IS LESS ENOUGH

CARBOHYDRATESLDL<100

BP<120/80BMI<25

INCRESED FIBERINCREASED EXERCISE

BE HAPPY!

REVOLUTION OR EVOLUTION

HASTEN SLOWLY

WHAT IS THE HEART

STENT RESTENOSIS

WHAT IS THE HEART

Magnitude of the Problem: Global Burden of Cardiovascular

Disease•½ way through a 2 century transition ; CVD will dominate as the major cause of Death Globally•Although CVD is ↓in EstME it is ↑ in the rest of the world with 85% of the worlds population. •10% (1900) → 25% (2000) → 50% (2020) of Global Deaths.

INDIAN SCENARIO

Epidemiological Transitions•Age of Pestilence & Famine – LE is 30yrs•Age of Receding Pandemics - ↑ Food & ↓ ↓ in Infant and child mortality •Age of Degenerative & Man Made Diseases – Easier access to cheaper carb/fatty foods, mechanization leads to ↓ energy expenditure, Urbanization → ↑ crowding, smoking & work stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD (>50%), ↑ Cancers. LE>50yrs.

Epidemiological Transitions•Age of Delayed Degenerative Diseases – LSM, ↓Smoking (45% →23%) , Trt of HTN – CHD ↓2% per yr, Stroke ↓ 3% per yr, CVD strikes later.•Age of LSM plateau & Early Obesity - ↑ caloric intake & ↓Physical activity- 75% Overweight or Obese - ↑ HTN/DM. LE = 75yrs(M), 80yrs(W)•Future Age of Intense LSM , Behavioral Changes & Naturalization

Surrogate Markers of Coronary Artery Disease

• Vascular Disease Elsewhere – Strokes, TIA, PVD, Carotid bruits, Abdominal Aneurysms

• Diabetes• Chronic Renal Failure

Coronary Artery Disease Risk Factors-Non Modifiable

• Male Sex• Post Menopausal State• (+) Family History• Genetic Susceptibility• Lp (a)• Diabetes• ? Infection

Risk factors- from Womb to Tomb

•Thrifty Phenotype(Barkers) Hypothesis•Thrifty Genotype Hypothesis•Brenners Hypothesis for essential HTN•IUGR and CAD - ↑LDL & apo B.

Risk factors- from Womb to Tomb- Child/Adulthood

• Increasing T-Chol (from 75 in cord blood to 120-150 by 2 wks- stable till 20 yrs – rises to 200 - 240 in most adults.• Catch-up obesity• Middle age bulge• Increasing Systolic BP

The Magnitude of the Problem

•HTN is the commonest medical diagnosis, affecting 1 billion worldwide•Prevalence of HTN: 3% in 18 to 24 yrs age 13% in 35 to 44 yrs age & 70% in those >75 yrs.•For persons over age 50, SBP is a more important than DBP as a CVD risk factor.

DIABETES MELLITUS

• DECLARED NOW AS A CORONARY ARTERY DISEASE EQUIVALENT

• MORTALITY ALMOST X 4• DAMAGES ARTERIES• PROMOTES THICKENING• CONTROLL OF BLOOD SUGARS NOT

ENOUGH• GOALS: FBS<110, PPBS<140

LACK OF EXERCISE

• CENTRAL OBESITY. • DIABETES• HYPERTENSION.• CHOLESTEROL• GOALS: MAINTAIN 80% OF THR FOR 45

MINS 5 DAYS A WEEK. MAINTAIN IDEAL BODY WEIGHT AND MUSCLE MASS.

• THR= 220-AGE

Dyslipidemia-Importance of Statins

• American Heart Association DietChol Total Fat TC LDL

Step I 300 8 - 10 % 8% 10%Step II 200 < 7 % 10% 15%Only 15% motivated, only 1.5% achieved goals

• Marked ↓in Fat intake can ↓ LDL-C by 30%•Viscous fiber + plant sterols + soy protein + almonds - 30% ↓ equivalent to 10mg lovastatin•Marked ↓in Fat intake or ↑in Carbs will ↓HDL

LDL - Naturalisation HOW LOW IS LOW ENOUGH? IS IT SAFE?•10% of highest LDL account for 20% of CAD. • Only 25% risk reduction with current LDL Trt.•Threshold for atherosclerosis progression is LDL of 67mg%, CVD event rate 0 at LDL 57 (primary) & 30 mg% (secondary prevention).•50% ↓ in LDL for secondary & 30% ↓ for primary prevention.•? All people above 55yrs should receive statins

Metabolic Syndrome Indian scenario

Incidence: 40%, 28% (No IFG), 75%(DM/IFG)Waist Circumf: 30%, Low HDL: 65%, TG: 45%, HTN: 55%, IFG: 27%.•Diet, Lack of Ex•Childhood Obesity (20% in U India)•Indian Obesity Phenotype: lean BMI, High waist to hip ratio, High % of Body fat.•Barker’s Fetal priming for Insulin resistance


•Social isolation, Lack of Social support & Social Disruption•Life stress (major stressful life events & minor recurrent irritants/frustrations•Job Strain – High demand with little autonomy•Marital stress

Diet•DASH Trial: Diet rich in Vegetables & Fruits & Low Fat Dairy ↓ BP•Marked ↓in Fat intake can ↓ LDL-C by 30%•Lyon Diet Heart Study: Mediterranean diet ↓ Re-MI/Death by 65% compared to Western Diet •Marked ↓in Fat intake or ↑in Carbs will ↓HDL•Marked ↑ in protein ↑load on kidneys

Cardiac Metaphors of Daily Life• Races with Excitement• Pounds in Anticipation• Stands still in Dread, Skipped a Beat• Aches with Grief• With a Heavy Heart• The Lion Hearted, Large hearted, Heartless• Broken Hearted

Psychosocial Factor Modifications

• ENRICH Trial: Post MI cognitive behavior therapy + drugs if necessary •SADHART: Sertraline AntiDepressant Heart Attack Randomised Trial •Antidepressant therapy - significant ↓ reinfarction, heart failure & cardiac deaths•Meta-analyses of 37 stress management programs show reduced cardiac mortality

Epidemiological Transitions•Age of Pestilence & Famine – LE is 30yrs•Age of Receding Pandemics - ↑ Food & ↓ ↓ in Infant and child mortality •Age of Degenerative & Man Made Diseases – Easier access to cheaper carb/fatty foods, mechanization leads to ↓ energy expenditure, Urbanization → ↑ crowding, smoking & work stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD (>50%), ↑ Cancers. LE>50yrs.

•Cancer- Natural Killer Cells Increase with SK

•Heart Autonomics – Increased heart rate variability with SK

•Deaddiction – Smoking, Alcoholism, Drugs

•Metabolic Syndrome- Central Obesity

•Hypertension- Respirate

•Insomnia

•Diabetes

Core Technique Core Technique -- ‘‘Sudarshan KriyaSudarshan Kriya’’Scientific Validations Scientific Validations Regular Practice of the ‘Sudarshan Kriya’ will lead to:

Stress creating hormone Cortisol & Oxygen free radicals will get eliminated from the blood system.

Natural Killer Cells will Increase (Immunity)

Blood Lactate will decrease

HDL Cholesterol (useful cholesterol) will increase & LDL Cholesterol (harmful) will decrease. (Effective against blood pressure & Cardiac problems)

Increase in Alpha activity in brain with interspersed Beta activity (create calmed alertness in the brain - Study done with EEG)

70% of Depression is curable with ‘The Sudarshan Kriya’ practice.

Cancer / HIV & Sudarshan Kriya

• Cancer- Natural Killer Cells Increase with SK• Heart Autonomics – Increased heart rate variability with

SK• Deaddiction – Smoking, Alcoholism, Drugs• Metabolic Syndrome- Central Obesity• Hypertension- Respirate• Insomnia• Diabetes

how to prevent heart attacks

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