CVD prevention Flashcards
Discuss the medical model of treatment of ischaemic heart disease
- Patient presents with severe chest pain, diagnosed as heart attack
- Treated urgently with drugs and stent insertion
- Admitted to CCU, given long-term drugs (antiplatelets, statins, beta blockers, ACE inhibitors)
- Periodic review and blood tests to check cholesterol and detect signs of more blockages
- Patient presents with another heart attack after some time
- Coronary disease deteriorated; more stents or by-pass surgery is required
Describe the assumptions underlying the medical model
*IHD is a disease that needs medical treatment
*Most heart attacks are caused by severe stenoses
*We can prevent heart attacks by looking for and opening severe stenoses
*We can determine which lesions are at high risk of rupture and causing a heart attack. These lesions can be found and stented.
*Most coronary disease is caused by genetics
*There is no evidence that diet and exercise are effective at preventing future heart attacks
*Most people are not going to change their habits; therefore, we should focus on the proven treatment, statins
Describe the prevention model of IHD
- patien presents with severe chest pain, diagnosed as heart attack, treated urgently with drugs and stent
- potential causes of atheroma: diet, sedentary lifestyle, obesity, smoking, high cholesterol, HTN, diabetes
- treatment plan: focused on diet, exercise, weight loss, smoking cessation, also on blood pressure, lipids
- follow up discussions are foscused on diet and lifestyle goals, less emphasis on testing for ischaemia and imaging coronary arteries
- patient is the active protagonist in this model, not merely the subject of medcal investigations and treatment
*Patients are capable of taking responsibility for their condition
*Patients are capable of making diet and lifestyle changes
*Education, support and encouragement are essential for success in lifestyle modification
*It is possible to manage risk factors and prevent further adverse events with diet and lifestyle changes
*After acute treatment, the role of medical staff is mainly education, support and encouragement
*(Medical and Prevention models can work in harmony)
Describe CVD prevention in brief
*CVD remains a leading cause of morbidity and mortality, despite improvements in outcomes (mortality has declined since the 1980s)
*Many risk factors, particularly obesity and diabetes have been increasing substantially
*CVD prevention is defined as a coordinated set of actions, at the population level or targeted at an individual, that are aimed at eliminating or minimizing the impact of CVD
*Prevention is effective: the elimination of health risk behaviours would make it possible to prevent at least 80% of CVDs and even 40% of cancers
Discuss the medical vs prevention paradigms for treating heart disease
*Medical Paradigm:
Perform screening test (exercise test or CTCA) for everyone with risk factors
Treat those with significant stenosis with stents or CABG
Repeat CTCA at regular intervals
*Prevention Paradigm:
Focus on factors that determine risk of atheroma progression?
*Smoking
*Diet
*Prolonged sitting
*Weight
*Diabetes
*Hypertension
*High cholesterol
*Stress
Describe the relationship between genetics and IHD
*Genetic influence in IHD is complex and involves multiple genes associated with lipids, coagulation, renin/angiotensin system
*Most patients have no genetic defects detected
*Vast majority of heart attacks not caused by genetic hyperlipidaemia
*“Genes load the gun, but environment pulls the trigger.”
*We are all genetically predisposed to different illnesses. These genes can lay dormant or be activated by environment, which includes diet and lifestyle. Lifestyle can have a dramatic effect on what we used to think was our genetic destiny.
*Using a polygenic score of DNA sequence polymorphisms, genetic risk was quantified for coronary artery disease in three prospective cohorts
*A healthy lifestyle score was based on: no smoking, no obesity, regular physical activity, healthy diet.
*Endpoint: CV death, MI, PCI, CABG over 10 years
Discuss how an individual’s 5 year risk of CVD is assessed
*Estimate 5 year risk of death or cardiovascular disease
*Not for people with: known cardiovascular disease, Advanced kidney disease (GFR <45), familial hyperlipidaemia
*All people 45-79
*Diabetics 35-79
*First Nations people 30-79
Discuss advice to patients regarding a healthy diet
Healthy eating plan:
- plant-based foods: fruits and vegetables, whole grain food, plant-base d protein foods
More fibre and less saturated fat has a positive effect on health including reducing risk of:
- cancer
- heart disease
- T2D
Most healthy eating patterns have few or no highly processed foods
e.g. Mediterranean/vegan/vegetarian
- diet of whoel grains, vegetables, fruit, legumes, nuts
- small quantities of fish/poultry/dairy
- minimal processed and red meat
- nutritionally complete
Diet and lifestyle changes to reduce blood pressure
- higher intake of fruit, veg, whole grain, legumes and nuts
- limit intake of red meats, sugar-sweetened beverages and sweets
- reduce sodium to <2g/d
- moderate or vigorous aerobic activity 150m/wk
- reduce alcohol intake
- reduce weight
Diet and lifestyle to reduce LDL cholesterol
- plant based diet
- soluble fibres, plant sterols, almonds, soy protein
- reduce saturated animal fat, and trans fat
- weight loss
- limit intake of red meats, sugar-sweetened beverages and sweets
Discuss advice regarding exercise, weight loss, blood pressure control, lipid lowering and smoking
- smoking: no exposure to tobacco in any form
- diet: focus on plants, minimise saturated fat (meat and dairy)
- physical activity: 150 min moderate aerobic, or 75 mins vigorous
- body weight: 20-25 BMI, waist <94, <80
- blood pressure <130 (in high risk or with vascular disease)
- LDL <1.8, <2.6, <3
- diabetes: <7%
Note: effective communication
- establish rapport
- acknowledge person’s view of disease and contributing factors
- encourage expression of worries/anxieties, concerns for motivaion for behaviour change and chances of success
- ask questions to check individual understood advice
- acknowledge change is difficult, sustained gradual change is often more permanent in rapid change
- support for long time
- role model
Discuss advice regarding exercise, weight loss, blood pressure control, lipid lowering and smoking
Benefits of physical activity
*Regular exercise reduces the risk of many adverse health outcomes
*All-cause and CVD mortality are reduced by 20-30%: in healthy individuals, in subjects with coronary risk factors, in patients with cardiovascular disease
*Exercise has a positive effect on many risk factors, including hypertension, cholesterol, body weight and type 2 DM
*This applies to both men and women and across a broad range of ages from childhood to the very elderly
*A sedentary lifestyle is one of the major risk factors for CVD independent of participation in exercise
Recommendations for physical activity
- 150 minutes of moderate intensity aerobic
- or 75 minutes of vigorous intensity aerobic
- for additional benefit, increase aerobic to 300 mins of moderate intensity per week, or 150 mins of vigorous/week
- regular assessment and counselling to encourage and support an increase in exercise volume over time
Discuss advice regarding exercise, weight loss, blood pressure control, lipid lowering and smoking
*Smoking is a lethal addictive disorder. A lifetime smoker has a 50% probability of dying due to smoking, and on average will lose 10 years of life, contrasting with 3 years with severe hypertension and 1 year with mild hypertension
*Smoking is an established cause of a plethora of diseases and is responsible for 50% of all avoidable deaths in smokers, half of these due to CVD
*The 10-year fatal CVD risk is approximately doubled in smokers. The RR in smokers 50 years of age is five-fold higher than in non-smokers
- Identify smokers and provide repeated sensitive advice on stopping with offers to help, using follow up support, nicotine replacement therapies, varenicline (Champix) and bupropion (Zyban)
Discuss advice regarding exercise, weight loss, blood pressure control, lipid lowering and smoking
Overweight and obesity
- Prevalence of major risk factors such as high cholesterol, BP and smoking, has decreased in recent decades, translating into reduced CV mortality
- However, BMI has greatly increased in all countries over recent decades, resulting in an increase in the prevalence of type 2 DM
- Main clinical complications of increasing body weight are increases in BP, dyslipidaemia, insulin resistance, systemic inflammation
- Leads to development of DM and CV events (coronary disease, atrial fibrillation, heart failure, stroke)
Approach to weight loss
-Weight loss is difficult, need supportive, encouraging attitude, time, patience
- Help patient to take over control of weight management
- Need regular weight monitoring and follow up for success
- Energy intake needs to be less than energy expenditure
- Limiting food intake is more important than exercise
- Many dietary patterns have been associated with weight loss (Low Carb, Mediterranean, Vegetarian, intermittent fasting, etc)
Diet and lifestyle changes to reduce blood pressure
- higher intake of fruit, veg, whole grain, legumes and nuts
- limit intake of red meats, sugar-sweetened beverages and sweets
- reduce sodium to <2g/d
- moderate or vigorous aerobic activity 150m/wk
- reduce alcohol intake
- reduce weight
Diet and lifestyle to reduce LDL cholesterol
- plant based diet
- soluble fibres, plant sterols, almonds, soy protein
- reduce saturated animal fat, and trans fat
- weight loss
- limit intake of red meats, sugar-sweetened beverages and sweets
