Preventing Heart and Vascular Disease:Preventing Heart and Vascular Disease:ggWhat You Can Do and What We Can Do What You Can Do and What We Can Do

Robert A. Phillips, Robert A. Phillips, MDMD PhD FACCPhD FACC FAHA DirectorFAHA DirectorMDMD, PhD, FACC, , PhD, FACC, FAHA DirectorFAHA Director, ,

Heart Heart and Vascular Center of Excellenceand Vascular Center of ExcellenceP f f M di i & Cli i l dP f f M di i & Cli i l dProfessor of Medicine & Clinical and Professor of Medicine & Clinical and

Population Health Population Health ResearchResearchopu at o ea topu at o ea t esea cesea cUMass UMass Memorial Med Center Memorial Med Center

andand MedicalMedical SchoolSchooland and Medical Medical SchoolSchool03/18/200903/18/2009

Inside a diseased arteryInside a diseased artery

Ath l ti lAtherosclerotic plaque— Begins as a fatty streak

d f fcomposed of foamy macrophages containing cholesterol and other elementscholesterol and other elements

Over time accumulates Over time accumulates cholesterol andcholesterol and fatfatcholesterol and cholesterol and fatfat

Narrows arteries Contributes to heart attacks Contributes to heart attacks,

strokes, renal failure and other vascular problems

A fatty streak, possibly occurring in the early teen vascular problemsyears

How Heart Attacks and Strokes OccurHow Heart Attacks and Strokes OccurUMassMemorialUMassMemorial

•Physical Stenosis

•Plaque Rupture

•Platelet Adhesion

Th b i•Thrombosis

V•Vasospasm

Blocked ArteryFebruary 26, 2009

The Endothelium and Vascular Disease•Blocked Artery

Prevalence of Cardiovascular Disease in adults age 20 Prevalence of Cardiovascular Disease in adults age 20 and older by age and sexand older by age and sex These data include coronary heartThese data include coronary heartand older by age and sex. and older by age and sex. These data include coronary heart These data include coronary heart disease, heart failure, stroke and hypertension.disease, heart failure, stroke and hypertension.

79 385.990

100

73.379.3

72.6

607080

opul

atio

n

37.9 38.5

304050

cent

of P

o

15.97.8

0102030

Perc

020-39 40-59 60-79 80+

Men WomenMen Women

Annual number of U.S. Adults having diagnosed heart Annual number of U.S. Adults having diagnosed heart attack by age and sexattack by age and sexattack by age and sex. attack by age and sex.

265 000290,000

300 000350,000

I or

265,000

180,000

,

235,000

200,000250,000

300,000

urre

nt M

CHD

30 000

95,00095,000

50 000

100,000150,000

and

Recu

Fata

l C

30,00010,000

-50,000

35-44 45-64 65-74 75+

New

a

Ages

Men Women

Prevalence of stroke by age and sexPrevalence of stroke by age and sex

13 5

17.1

16

18

13.5

10

12

14

pula

tion

7.8 7.6

6

8

10

ent o

f Po

0 2 0.90.3

2.9

2

4

6

Perc

e

0.2 0.30

20-39 40-59 60-79 80+

Men Women

Established Risk Factors for Cardiovascular Established Risk Factors for Cardiovascular DiDiDiseaseDisease

Nonmodifiable Nonmodifiable ModifiableModifiableo od ab eo od ab e––AgeAge

»»>45 male>45 male

od ab eod ab e––HypertensionHypertension––CholesterolCholesterol»»>45 male>45 male

»»>55 female>55 femaleSexSex

CholesterolCholesterol––Elevated Low Elevated Low Density Lipoprotein Density Lipoprotein ––SexSex

––Family HistoryFamily History»»age <55 fatherage <55 father

(LDL)(LDL)––Reduced HDLReduced HDL

»»age <55 father age <55 father or other first or other first degree male degree male

––Physical inactivityPhysical inactivity––Obesity Obesity

relative relative »»age <65 age <65 mother or firstmother or first

––Diabetes Mellitus Diabetes Mellitus ––Cigarette SmokingCigarette Smoking

mother or first mother or first degree female degree female relativerelative

Classification of BP for Adults Classification of BP for Adults Age 18 Years and OlderAge 18 Years and OlderAge 18 Years and OlderAge 18 Years and Older

Category Systolic (mmHg) Diastolic (mmHg)

N l <120 <80Normal <120 <80

Pre-Hypertension 120-139 80-89

Hypertension

Stage I 140-159 90-99

Stage II 160-179 100-109

Stage III 180-209 110-119 Stage III 180 209 110 119

Stage IV >210 >120

Prevalence of high blood pressure in Adults by age and Prevalence of high blood pressure in Adults by age and sexsex (NHANES: 2005(NHANES: 2005 2006)2006) Source: NCHS and NHLBISource: NCHS and NHLBIsex sex (NHANES: 2005(NHANES: 2005--2006)2006). . Source: NCHS and NHLBI.Source: NCHS and NHLBI.

69.664 7 64 1

76.4

708090

tion

35 9

55.8

36.2

53.764.7 64.1

506070

Pop

ulat

13.4

35.923.2

36.2

6 216.520

3040

cent

of

6.2

010

20 34 35 44 45 54 55 64 65 74 75+

Per

20-34 35-44 45-54 55-64 65-74 75+

Men Women

Consequences of High Consequences of High Blood PressureBlood PressureBlood PressureBlood Pressure

Heart attacksHeart attacks Strokes (Brain attacks)Strokes (Brain attacks) Heart failureHeart failure Kidney DysfunctionKidney Dysfunction Vascular DiseaseVascular Disease

Lifestyle Modifications That Lifestyle Modifications That Lower Blood PressureLower Blood PressureLower Blood PressureLower Blood Pressure

ExerciseExercise DietDiet AlcoholAlcohol

ExerciseExercise How Is it Helpful?How Is it Helpful?ExerciseExercise-- How Is it Helpful?How Is it Helpful?

Lowers blood pressureLowers blood pressure Facilitates weight loss and Facilitates weight loss and gg

maintenance of weightmaintenance of weight Raises HDLRaises HDL Reduces chances of getting diabetesReduces chances of getting diabetes Overall less likely to have a clotOverall less likely to have a clot Overall, less likely to have a clot Overall, less likely to have a clot

coronary arterycoronary arteryImproves quality of lifeImproves quality of life Improves quality of lifeImproves quality of life

How Much Exercise is Enough to Reduce How Much Exercise is Enough to Reduce Risk of Heart Attack and Improve Quality of Risk of Heart Attack and Improve Quality of

f ?f ?Life?Life?

Moderate exercise Moderate exercise 3x3x weekweek–– 25 minutes 25 minutes 3x3x/week /week –– some benefitsome benefit–– 40 minutes 40 minutes 3x3x/week /week –– more benefitmore benefit–– 60 minutes 60 minutes 3x3x/week /week –– more benefitmore benefit

Martin, C. K. et al. Arch Intern Med 2009;169:269-278.JAMA. 1996;276:241-246.

What types of activities count?What types of activities count?What types of activities count?What types of activities count?

Brisk walkingBrisk walking JoggingJogging Treadmill set at 5 miles per hourTreadmill set at 5 miles per hour SnowshoeingSnowshoeing XX--country skiingcountry skiing BicyclingBicycling Singles tennis Singles tennis SkiingSkiing Farm workFarm work

JAMA. 1996;276:241-246.Martin, C. K. et al. Arch Intern Med 2009;169:269-278.

Exercise-Related Variables at Baseline and After Exercise Training4 8 or 12 kilocalories per kilogram of body weight/wk4,8, or 12 kilocalories per kilogram of body weight/wk

(KKW) = 74, 138 and 183 min/week respectively of exercise

Copyright restrictions may apply.Martin, C. K. et al. Arch Intern Med 2009;169:269-278.

Mean change (least-squares [LS] means {+/-} 95% confidence interval [CI]) in Medical Outcomes[CI]) in Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) scores for the control andscores for the control and exercise groups

Copyright restrictions may apply.Martin, C. K. et al. Arch Intern Med 2009;169:269-278.

Mean change (least-squares means {+/-}95% confidence interval) in Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) scores across the exercise groups was examined for 2 subgroups, those who lost g p ,weight vs those who maintained or gained weight, using analysis of covariance (ANCOVA) withof covariance (ANCOVA) with baseline age, antidepressant use, employment status, ethnicity marital status andethnicity, marital status, and smoking status as covariates

Copyright restrictions may apply.Martin, C. K. et al. Arch Intern Med 2009;169:269-278.

Consume Less Sodium and Consume Less Sodium and Eat More PotassiumEat More PotassiumEat More Potassium Eat More Potassium

Sodium restriction Sodium restriction –– Typical American diet >6 gm sodium/dayTypical American diet >6 gm sodium/day–– Limit should be 2 gm sodium/dayLimit should be 2 gm sodium/day–– Read labels, make your own foodRead labels, make your own food

Potassi m is good for oPotassi m is good for o Potassium is good for youPotassium is good for you–– Good evidence that high intake lowers BPGood evidence that high intake lowers BP

Fresh fruitFresh fruit -- banana apricots grapefruit plumsbanana apricots grapefruit plums–– Fresh fruit Fresh fruit -- banana, apricots, grapefruit, plumsbanana, apricots, grapefruit, plums–– Vegetables Vegetables -- potatoes, spinach, potatoes, spinach, brocollibrocolli, ,

mushrooms, cauliflower, artichoke globemushrooms, cauliflower, artichoke globe–– Legumes Legumes -- beans, lentils, chick peasbeans, lentils, chick peas

AlcoholAlcohol ModerationModerationAlcohol Alcohol -- Moderation Moderation

1 oz of ETOH: Neutral or lowering 1 oz of ETOH: Neutral or lowering effect on BPeffect on BP

–– 24 ounces of beer24 ounces of beer–– 8 ounces of wine8 ounces of wine

2 ounces of 100 proof whiskey2 ounces of 100 proof whiskey–– 2 ounces of 100 proof whiskey2 ounces of 100 proof whiskey

Greater than 1 oz of alcohol raises Greater than 1 oz of alcohol raises blood pressureblood pressureblood pressureblood pressure

MedicationsMedications Many choicesMany choicesMedications Medications –– Many choicesMany choices

Diuretics (waterDiuretics (water--pills)pills) AngiotensinAngiotensin Converting EnzymeConverting Enzyme AngiotensinAngiotensin Converting Enzyme Converting Enzyme

InhibitorsInhibitorsCalcium Channel BlockersCalcium Channel Blockers Calcium Channel BlockersCalcium Channel Blockers

AngiotensinAngiotensin II Receptor BlockersII Receptor Blockers ReninRenin InhibitorsInhibitors Beta BlockersBeta Blockers Beta BlockersBeta Blockers Alpha BlockersAlpha Blockers

Optimum cholesterol levelsOptimum cholesterol levelsOptimum cholesterol levelsOptimum cholesterol levels

Total cholesterol <200

LDL cholesterol <100

HDL cholesterol >40

Triglycerides <150

Your coronary heartdisease (CHD) risk leveldisease (CHD) risk level

Target levels for LDL-C are determined by the following questions:

Do you have coronary heart disease (CHD)? Do you have a coronary risk equivalent? Do you have major risk factors other than

LDL cholesterol?LDL cholesterol?

S ith CHD i l t iSomeone with CHD or equivalent is considered at high risk and has an LDL-C goal of <100 and perhaps even <70g p p

Coronary Heart Disease EquivalentsDisease Equivalents

This classification includes— Diabetes mellitus Peripheral artery disease Abdominal aortic aneurysm Symptomatic carotid artery disease

(stroke, transischemic attack)f f Any combination of multiple risk factors

with a 10-year risk of CHD > 20 percent,based on the Framingham risk calculationbased on the Framingham risk calculation

Patients in this classification have the most aggressive LDL-C goal (<100 and perhaps even <70).

Evaluating your CHD riskEvaluating your CHD riskEvaluating your CHD riskEvaluating your CHD risk

The CHD risk level for someone without CHD The CHD risk level for someone without CHD or CDor CD

risk equivalent is assessed through a tworisk equivalent is assessed through a two--step process.step process.

Count your risk factors.Count your risk factors. If you have two or more risk factors, use the If you have two or more risk factors, use the

Framingham algorithm to calculate your 10Framingham algorithm to calculate your 10--year absolute risk of CHD.year absolute risk of CHD.

If you have a risk factor of 0 or 1, you are If you have a risk factor of 0 or 1, you are generally considered to have a low absolute generally considered to have a low absolute CHD risk (<10 percent)CHD risk (<10 percent)CHD risk (<10 percent).CHD risk (<10 percent).

Evaluating your 10-year riskdi t F i haccording to Framingham

Age Men Women

20-34 -9 -735 39 -4 -335-39 -4 -340-44 0 045-49 3 350-54 6 655-59 8 8

10 1060-64 10 1065-69 11 1270-74 12 1470 74 12 1475-80 13 16

Evaluating your 10-year riskdi t F i haccording to Framingham

Chol/age

20-39

40-49

50-59

60-69

70-79

Chol/age

20-39

40-49 50-59

60-69 70-79

Men Women

/age 39 49 59 69 79

<160 0 0 0 0 0

/age 39 59 79

<160 0 0 0 0 0

160-199

4 3 2 1 0

200 7 5 3 1 0

160-199

4 3 2 1 1

200 8 6 4 2 1200-239

7 5 3 1 0

240-279

9 6 4 2 1

200-239

8 6 4 2 1

240-279

11 8 5 3 2279

>280 11 8 5 3 1

279

>280 13 10 7 4 2

Evaluating your 10-year riskdi t F i haccording to Framingham

Men, by age 20-39 40-49 50-59 60-60 70-79

Nonsmoker 0 0 0 0 0Nonsmoker 0 0 0 0 0

Smoker 8 5 3 1 1

Women, by 20-39 40-49 50-59 60-60 70-79ageNonsmoker 0 0 0 0 0

S k 8 5 3 1 1Smoker 8 5 3 1 1

Evaluating your 10-year riskdi t F i haccording to Framingham

HDL Points

>60 -1

50-59 0

40-49 140 49 1

<40 2

Evaluating your 10-year riskdi t F i haccording to Framingham

Systolic BP, men If untreated If treated

<120 0 0

120-129 0 1

130-139 1 2

140-159 1 2

>160 2 3

Systolic BP, women If untreated If treated

<120 0 0

120-129 1 3

130-139 2 4

140 159 3 5140-159 3 5

>160 4 6

Evaluating your 10-year riskdi t F i haccording to Framingham

Point total, men 10-year risk, %

0-4 1

5-6 2

Point total, women 10-year risk, %

<9-12 <1

13-14 25 6 2

7 3

8 4

9 5

13 14 2

15 3

16 4

17 59 5

10 6

11 8

12 10

17 5

18 6

19 8

20 1112 10

13 12

14 16

20 11

21 14

22 17

23 2215 20

16 25

>17 >30

23 22

24 27

>25 >30

LDL C goalsLDL-C goals

CHD risk category 10-yearCHD risk

LDL-C goal (mg/dL)

CHD or CHD risk equivalents

>20 percent

<100 or <70

2 or more risk factors (CHD equivalent)

>20 percent

<100 or <70

2 or more risk factors 10 to <20 percent

<130

0 to 1 risk factor <10 percent

<160

When is medication advisable?

Risk category LDL goal

LDL level at which to start…Lifestyle changes Drug therapy

Hi h <100 >100 >130High <100 >100 >130Moderate <130 >130 10-20%

risk: >130<10% risk: >160

Low <160 >160 >190

Imaging Modalities of Your Imaging Modalities of Your H t d Bl d V lH t d Bl d V lHeart and Blood VesselsHeart and Blood Vessels

CT AngiographyCT AngiographyM tiM ti RRMagnetic Magnetic Resonance Resonance ImagingImagingg gg gEchocardiographyEchocardiography

Historical Perspective on Coronary Artery Imaging: 1490s, Leonard da Vinci - 2 Days to Draw

UMassMemorialUMassMemorial

1490s1490s, Leonardo , Leonardo dada VinciVinci

1490s1490s dada Vinci, 2 daysVinci, 2 days

2003, Sensation 16, <20 sec 2003, Sensation 16, <20 sec

2006 Definition, <10 sec

CT Angiogram of the Right Coronary ArteryCT Angiogram of the Right Coronary ArteryCT Angiogram of the Right Coronary ArteryCT Angiogram of the Right Coronary ArteryUMassMemorialUMassMemorial

RCARCA

Severe atherosclerotic lesion in the Severe atherosclerotic lesion in the idid l ft t i d di tl ft t i d di tmidmid-- left anterior descending arteryleft anterior descending artery

UMassMemorialUMassMemorial

MRI of a Normal Heart and One MRI of a Normal Heart and One ith A L k A ti V lith A L k A ti V lwith A Leaky Aortic Valvewith A Leaky Aortic Valve

Echocardiogram of Echocardiogram of a a NormalNormal HeartHeartNormal Normal HeartHeart

Echocardiogram of a Dilated Heart Echocardiogram of a Dilated Heart (L) d H t i H t (R)(L) d H t i H t (R)(L) and a Hypertensive Heart (R)(L) and a Hypertensive Heart (R)

New and Minimally Invasive New and Minimally Invasive Vascular SurgeryVascular SurgeryVascular SurgeryVascular Surgery

Anatomy of An Abdominal Anatomy of An Abdominal Aortic AneurysmAortic AneurysmAortic AneurysmAortic Aneurysm

Open Repair of Abdominal Open Repair of Abdominal Aortic AneurysmAortic AneurysmAortic Aneurysm Aortic Aneurysm

Why do it?Why do it?–– If Aneurysm bursts, If Aneurysm bursts,

chance of death is highchance of death is highchance of death is highchance of death is high

Disadvantages of Disadvantages of Surgery:Surgery:Surgery:Surgery:

–– Long, complicated Long, complicated surgerysurgery

–– Long recoveryLong recovery–– DisfiguringDisfiguring

Open Surgical AAA Repair Open Surgical AAA Repair Long Recovery Big ScarLong Recovery Big Scar–– Long Recovery, Big ScarLong Recovery, Big Scar

Endovascular AAA RepairEndovascular AAA Repairdo ascu a epado ascu a epa

AdvantagesAdvantagesN SN S–– No SurgeryNo Surgery

–– Minimal Minimal to no to no titirecovery timerecovery time

–– Excellent Excellent F tiF tiFunctionFunction

Endovascular Repair of Endovascular Repair of Abdominal Aortic AneurysmAbdominal Aortic AneurysmAbdominal Aortic AneurysmAbdominal Aortic AneurysmBEFORE AFTERBEFORE AFTER

ST Segment Elevation Myocardial Infarction (STEMI)UMMHC Process Improvement: 2005-2008UMMHC Process Improvement: 2005 2008

160

Cardiac Alert Team Initiative Began

120

140

e

80

100

loon

Tim

tes)

60

80

or to

Bal

(min

u

20

40Do

0

20

Jan'05 Apr'05 Jul'05 Oct'05 Jan'06 Apr'06 Jul'06 Oct'06 Jan'07 Apr'07 Jul'07 Oct'07 Jan'08 Apr'08 Jul'08 Oct' 08

Median Mean GoalNumber of CasesCY2005: 55 CY2006: 62 CY2007: 89 CY2008 (through 10/2008): 63

ST Elevation Myocardial Infarction (STEMI): Door To Balloon (DTB) and Mortality Improvement( ) y p

92 4%91 3%91 7%

100% 3.5%

81.0%

96.0%

84.6%

89.5% 92.6% 92.4%91.3%91.7%

2.98%

80%

90%3.0%

72.0%

61.5%

74.2%

57.1%2.40%

60%

70%

0 M

ins

2 0%

2.5%

te

50.0%

43.5%

1.90%

1.40%1.70%40%

50%

TB T

ime

< 90

1.5%

2.0%

Mor

talit

y R

at

1.10%

0.79%

1.30%1.40%

0.82%

1.11%

0.79%

20%

30%

%

% D

T

1.0%

0.70% 0.70%

0%

10%

20%

0 0%

0.5%

0%1Q-CY05 2Q-CY05 3Q-CY05 4Q-CY05 1Q-CY06 2Q-CY06 3Q-CY06 4Q-CY06 1Q-CY07 2Q-CY07 3Q-CY07 4Q-CY07 1Q-CY08 2Q-CY08

0.0%

DTB time < 90 Minutes Mortality Rate

Right Coronary ArteryRight Coronary Artery with Normal Blood Flowwith Normal Blood FlowRight Coronary ArteryRight Coronary Artery with Normal Blood Flowwith Normal Blood FlowUMassMemorialUMassMemorial

RCA

Heart Attack with Blocked Right Heart Attack with Blocked Right C A tC A t N Bl d FlN Bl d FlCoronary Artery Coronary Artery –– No Blood FlowNo Blood Flow

Heart Attack Aborted with Heart Attack Aborted with A i lA i l Bl d Fl R t dBl d Fl R t dAngioplasy Angioplasy –– Blood Flow RestoredBlood Flow Restored

Aborted Heart Attack with Stent Aborted Heart Attack with Stent i Ri ht C A ti Ri ht C A tin Right Coronary Arteryin Right Coronary Artery

Th k !Th k !Thank you!Thank you!St H lth !St H lth !Stay Healthy!Stay Healthy!