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.
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
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