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Cardiovascular Disease: Risk Factors, Symptoms, and Screening Gary Michael Idelchik, MD, FACC April 15, 2015

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Disclosures I have nothing to disclose.

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Outline What is/are What is Cardiovascular Disease and its manifestations? What is Coronary Artery Disease (CAD)? What is Peripheral Artery Disease (PAD)? What is Cerebrovascular Disease (CVD)? Acute Coronary Syndromes (ACS)? ST-segment Elevation Myocardial Infarction (STEMI)? Risk factors? Screenings? What are the therapies for care and why? What role does Percutaneous Coronary Intervention (PCI) play? Additional Questions Needed Answering?

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Cost of Coronary Artery Disease and Cardiovascular Disease 17,600,000 Americans adults have a history of CAD. 8,500,000 American adults have a history of MI. 400,000 deaths annually (approx. 1 of every 6 deaths). 300,000 die from their initial Acute Coronary Syndrome (ACS) event. 785,000 will have their initial cardiac event. 470,000 will have a recurrent event. 195,000 will have a silent cardiac event. Estimated direct and indirect costs for Cardiovascular Disease $503.2 billion. Estimated direct and indirect costs for Coronary Artery Disease $177.1 billion. Historically, Today AHA Heart Disease and Stroke Statistics 2010 Update. Circulation 2010;121:e41-e215.

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Cardiovascular Disease Cerebrovascular Disease (CVD) Coronary Artery Disease (CAD) Peripheral Artery Disease (PAD)

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Pathophysiology of Cardiovascular Disease Foam Cells Fatty Streak Intermediate Lesion Atheroma TCFA/Fibrous Plaque Lesion Rupture Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104). Endothelial Dysfunction Atherosclerotic Burden

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Heart Attack

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Chest pain Discomfort in other areas of the upper body One or both arms Back, neck or jaw Stomach Shortness of breath Other signs Cold sweat Nausea Lightheadedness Fatigue Heart Attack Symptoms - MEN

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As with men, chest pain or discomfort More likely- other symptoms : Shortness of breath Nausea/vomiting Back or jaw pain Not feeling right Fatigue Palpitations Musculoskeletal complaints Hot flashes Heart Attack Symptoms - WOMEN

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Pathophysiology of ACS/STEMI Heart Attacks 1980 DeWood et al. provided definitive Angiographic and Histologic Evidence that intra-arterial thrombosis was the inciting event for STEMI, resulting in: Treatment with Antiplatelet and Antithrombotic therapies. The Open Artery Theory, for AMI and patients with hemodynamically significant CAD.

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STEMI and ACS Presumed prognosis: very high risk of in-hospital death Treatment goal: prevent death by restoring coronary blood flow Direct PCI Presumed prognosis: low risk of in-hospital death, unless MI develops Treatment goal: stabilize with aspirin heparin +/-GIIb/IIIa & monitor for MI development + Cardiac enzymes Cardiac Enzymes Scheduled PCI Manage medically Low - risk features High- risk features Fibrinolytic therapy STEMI NSTEMI/Unstable Angina

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The Continuum NSTEMI Non-occlusivethrombusNon-specificEKG Normal cardiac enzymes Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/- T wave inversion on EKG Elevated cardiac enzymes Complete thrombus occlusion ST elevations on EKG or new LBBB Elevated cardiac enzymes More severe symptoms STEMI UnstableAngina

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Percutaneous Coronary Intervention (PCI) for ACS and STEMI

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GE Cardiac Catheterization Lab

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Unstable Angina PCI

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NSTEMI PCI

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STEMI PCI

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Reduce patient symptoms Decrease amount of myocardial necrosis Preserve heart function Prevent major adverse cardiac events Treat life threatening complications TIME IS MUSCLE

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Stroke aka Brain Attack

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Carotid Artery Disease Stroke is the third leading cause of death in the U.S., accounting for 164,000 deaths/year. Approx. 1 million stroke-related events per year. 500,000 New strokes 200,000 Recurrent strokes 240,000 TIAs. Carotid Occlusive Disease accounts for 5% to 12% of new strokes Screening with Carotid Arterial Duplex

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Stroke Symptoms F.A.S.T. Loss of vision from one or both eyes Sudden onset of severe headache Loss of coordination, balance Sudden onset of confusion

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Carotid Artery Disease

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Peripheral Artery Disease

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PAD is a narrowing of the peripheral arteries, most common in the arteries of the pelvis and legs The most common symptoms of PAD are: Cramping Pain or tiredness in the leg or hip muscles while walking or climbing stairs Peripheral Artery Disease (PAD)

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PAD

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Two-fold Purpose - Preventing progression of asymptomatic to symptomatic PAD - Detect high-risk CVD patients for risk-reduction Ankle-Brachial Index (ABI) - Ratio of blood pressure in arm and ankle PAD Screening

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Localized Dilation of the Aorta with an Increase of > 50% of the normal diameter Varies by age, gender and body surface area. Diagnosed if the aortic diameter is > 3 cm. Abdominal Aorta Aneurysm (AAA)

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Affects 6-9% of patients over 65 years of age. 1.7% of Women and 5% of Men have an AAA > 3 cm. Incidence Increases by 6% per decade thereafter. Estimated > 1.5 Million Patients in the U.S. have an AAA. Cause Approx. 15, 000 Unexpected Deaths Per Year. > 2.7 Million Patients by 2025. Abdominal Aorta Aneurysm (AAA)

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Risk of AAA Rupture Related to Size

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SAAAVE ACT One-time AAA screening as part of a Welcome to Medicare physical for men. Eligibility limited to males turning 65 History of smoking 100 cigarettes or more. Family history of AAA (men and women). AAA Screening

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Cardiovascular Care

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Know your personal and family historyKnow your personal and family history Routine medical appointmentsRoutine medical appointments Talk to your health care providerTalk to your health care provider Know your medications and drug allergiesKnow your medications and drug allergies Take charge of your healthTake charge of your health Get appropriate screeningGet appropriate screening Cardiac Screening See your Doctor

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High-risk for future cardiovascular disease?

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History of CAD/PAD Male Sex History of TIA/CVA Smoking Hypertension Diabetes Mellitus Dyslipidemia Low HDL < 40 Elevated LDL / TG Family History - event in first degree relative > 55 male, > 65 female Chronic Kidney Disease Obesity Lack of regular physical activity Diet poor in fruits, vegetables, and fiber Age > 45 male, > 55 female Cardiovascular Disease Risk Factors

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Age Gender: Male Heredity Family History Race Previous CAD, PVD or CVA Risk Factors that Cant Be Changed

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Smoking,

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and Smoking

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Diet

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Western Lifestyle

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Treatments and Therapy

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Antiplatelet agents Aspirin Brilinta/Plavix/Effient Lipid lowering agent High-dose Statin (Lipitor, Crestor) Antihypertensive agent Beta blocker ACE-I/ARB Aldactone (as appropriate) Appropriate therapy for risk factors Cardiovascular Medical Therapy

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Blood Pressure Goal < 135/85 Maximize use of beta-blockers and ACE-I Lipids LDL < 100 (70) ; TG < 200 Maximize use of statins; consider fibrates/niacin first line for TG > 500; consider omega-3 fatty acids, CoEnzyme Q10 Diabetes HbA1c < 7% Cardiovascular Care

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Smoking cessation Cessation-class, medications, counseling Physical activity Goal 30 - 60 minutes daily Risk assessment prior to initiation Diet DASH diet, Mediterranean diet, fiber, omega-3 fatty acids