Heart disease is the leading killer of adults nationwide and it carries a significant morbidity for the population at risk. Learn about traditional and non-traditional risk factors associated with coronary artery disease, and how to modify your risk and prevent heart disease. Also, learn about how heart disease affects different ethnic backgrounds, particularly the high-risk groups, such as South Asians.

1. Heart of the Matter
Ali Ahmad, MD, FACC
Diplomate of ABIM Cardiovascular Disease
Diplomate of Nuclear Cardiology
Diplomate of Echocardiography
Diplomate of Cardiovascular CTA
Registered Physician in Vascular Interpretation. RPVI.
Monday, January 6, 2020
Livingston Public Library

2. Introduction
CVD (CardioVascular Disease) includes four major areas:
• Coronary heart disease (CHD), manifested by “heart attacks” or myocardial
infarction (MI), angina pectoris, heart failure, and coronary death
• Cerebrovascular disease, manifested by stroke and “mini-stroke” or transient
ischemic attack
• Peripheral artery disease, manifested by intermittent claudication
• Aortic atherosclerosis and thoracic or abdominal aortic aneurysm

3. Atherosclerosis
• Atherosclerosis is responsible for almost all cases of coronary heart
disease (CHD).
• This insidious process begins with fatty streaks that are first seen in
adolescence.
• These lesions progress into plaques in early adulthood, and culminate
in thrombotic occlusions and coronary events in middle age and later
life.

5. Epidemiology
• Lifetime risk of overall cardiovascular disease (CVD) approaches 50 percent for
persons age 30 years without known CVD.
• In the Framingham heart study, the lifetime risk for individuals at age 40 was 49
percent in men and 32 percent in women.
• While CVD remains the leading cause of death in most developed countries,
mortality from acute myocardial infarction (heart attack) appears to have
decreased by as much as 50 percent in the 1990s and 2000s.
 Among 49 countries in Europe and northern Asia, over four million persons die annually from CHD. In
the United States, approximately 1.5 million persons suffer a heart attack or stroke annually, resulting
in over 250,000 deaths.

6. Epidemiology: Regional Variation

8. Conventional Risk Factors
• Older age: Over age 45 years in men and over age 55 years in
women
• Family history of early heart disease
• Race: Among persons with CAD, the cardiovascular death rate
for African Americans is reported to be particularly high; in
Asians, low levels of high-density lipoprotein cholesterol (HDL-
C), which are considered to be a risk factor for coronary heart
disease, appear to be especially prevalent; South Asians appear
to have a higher independent risk for cardiovascular disease as
well.

9. Modifiable Risk Factors
• High blood cholesterol levels (specifically, low-density lipoprotein
cholesterol [LDL-C])
• High blood pressure
• Cigarette smoking: Cessation of cigarette smoking constitutes the
single most important preventive measure for CAD
• Diabetes
• Obesity
• Lack of physical activity
• Metabolic syndrome
• Mental stress and depression

10. Nontraditional or Novel Risk Factors
• C-reactive protein (CRP): High levels are related to the
presence of inflammation and, according to some research
results, may be associated with an increased risk of CAD
development and heart attack [2]
• Lipoprotein(a)
• Homocysteine: In the general population, mild to moderate
elevations are due to insufficient dietary intake of folic acid, but
homocysteine levels may also identify people at increased risk
for heart disease
• Small, dense LDL-C particles
• Fibrinogen

11. Various medical conditions that can
contribute to CAD include the following:
• End-stage renal disease (ESRD)
• Chronic inflammatory diseases affecting connective
tissues (e.g. lupus, rheumatoid arthritis) [3, 4]
• Human immunodeficiency virus (HIV) infection
(acquired immunodeficiency syndrome [AIDS], highly
active antiretroviral therapy [HAART]) [5]
• Xanthelasmata (raised yellow patches around the
eyelids)

12. Miscellaneous Risk Factors
• Low serum testosterone levels: Have a
significant negative impact on patients with
CAD
• Hysterectomy: A study suggests that this
becomes a risk factor later in life in women
who have the surgery at or before age 50
years
• Lack of sleep

13. Prevalence of CVD Risk Factors
• The five leading modifiable risk factors:
 Hypercholesterolemia
 Diabetes
 Hypertension
 Obesity
 Smoking
…..are estimated to be responsible for more
than half of cardiovascular mortality.

14. Hyperlipidemia
• Cholesterol is a fatty
substance
manufactured in the
liver and is carried
throughout the body
in the bloodstream.

15. Why Does High Cholesterol Matter?
• High cholesterol is one of the major risk factors for
coronary artery disease, heart attacks, and strokes. It
also appears to boost the risk of Alzheimer's disease.
• High cholesterol leads to a buildup of plaque that
narrows the arteries. The most dangerous or
rupture-prone plaques are caused by lesions that
were less than 70% stenotic (abnormal narrowing)
and not by those with the most severe narrowing.

16. HDL
• Up to a third of blood cholesterol is carried by high-
density lipoproteins or HDL or the good cholesterol.
• HDL helps remove bad cholesterol, preventing it from
building up inside the arteries.
• The higher the level of HDL cholesterol, the better.
People with too little are more likely to develop heart
disease.

17. Triglycerides
• The body converts excess calories, sugar, and alcohol into
triglycerides, a type of fat that is carried in the blood and stored
in fat cells throughout the body.
• People who are overweight, inactive, smokers, or heavy
drinkers and those who eat a very high carbohydrate diet tend to
have high triglycerides.
• A triglycerides score of 150 or higher puts you at risk for
metabolic syndrome, which is linked to heart disease and
diabetes.

18. Cause of High TG
• In the general population:
 Overweight and obesity
 Physical inactivity
 Cigarette smoking
 Excess alcohol intake
 Very high carbohydrate diets (>60% of energy)
 Other disease (diabetes, renal failure, kidney disease)
 Drugs: steroids, protease inhibitors, estrogen, etc.
 Genetic factors

19. Risk Classification of Serum Triglycerides
• Normal <150 mg/dL
• Borderline high 150–199 mg/dL
• High 200–499 mg/dL
• Very high 500 mg/dL

20. Ways to Lower Your Cholesterol
• Dietary Modifications
• Lifestyle Modifications
• Medications/Drugs
• Statins
• Non-Statins

21. Eat More Fiber
• Good sources of soluble fiber include
whole-grain breads and cereals,
oatmeal, fruits, dried fruits, vegetables,
and legumes such as kidney beans.

22. Know Your Fats
• No more than 35% of your daily calories
should come from fat.
• But not all fats are equal
• Saturated Fats
• Trans Fats
• Unsaturated Fats

23. Know Your Fats
• Saturated fats -- from animal products and
tropical oils -- raise LDL cholesterol.
• Trans fats increase bad cholesterol and
lowers the good cholesterol.
• These two bad fats are found in many baked
goods, fried foods (doughnuts, french fries,
chips), stick margarine, and cookies.

24. Limit Dietary Cholesterol
• Can raise blood cholesterol
• Limit foods high in cholesterol
 Liver, organ meats, egg yolks,
full-fat dairy products
• The American Heart Association
recommends:
 Less than 300 mg/day
 Less than 200 mg/day (with diabetes or heart
disease)

25. Know Your Fats
• Unsaturated fats may lower LDL when
combined with other healthy diet
changes. They're found in avocados,
olive oil, and peanut oil.

26. Smart Protein
• Meat and full-fat milk are protein but they are
also major sources of cholesterol.
• Switch to soy protein, such as tofu.
• Fish is rich in omega-3 fatty acids, which can
improve cholesterol levels.
• The AHA recommends eating fish at least
twice a week.

27. Exercise
• Important even as we get older!
Increase HDL Cholesterol
Decrease LDL Cholesterol
Decrease triglycerides
• 30 minutes or more on most days
 Moderate intensity (150 minutes/week)
 High intensity (75 minutes/week)

28. Statins: Message for Patients
• Statins can produce muscle pain and weakness,
which can very rarely become an important medical
problem.
• Serious liver damage due to statins is extremely rare.
• Marketed doses of statins do not have any direct
adverse effects on the kidney.
• Statins do not cause peripheral neuropathy and do
not impair memory or cognition.

29. Non Statins
• Ezetimibe
• Niacin
• Bile acid sequestrant agents
• Omega 3 Fatty acids
• PCSK9 inhibitors

30. Hypertension
• Systolic pressure — pressure in arteries
when the heart beats
• Diastolic pressure — pressure when the
heart rests between beats
• Goal: below 120/80 mm Hg

31. Hypertension
• 65% of all hypertension remains either
undetected or inadequately treated
• People who are normotensive at 55 have a
90% lifetime risk of developing HTN
• Prevalence increases with age
• HTN is more common with oral contraception
pill (OCP) and obesity

32. Lifestyle Approaches to Hypertension
• Maintain ideal body weight
 Weight loss of as little as 10 lbs. reduces blood pressure
• Heart healthy diet
 Even without weight loss, a diet rich in fruits, vegetables, and
low fat dairy products can help to reduce blood pressure
• Sodium restriction to 1500 mg/d
• Increase physical activity
• Limit alcohol to one drink per day
 Alcohol raises blood pressure
 One drink = 12 oz beer, 4 oz wine, or 1 oz. liquor

33. Diabetes
• 10% of patients with first heart attack
are Diabetics.
• The presence of diabetes is clinically
equivalent to having established
coronary artery disease or prior heart
attack

34. Stop Smoking!
• Smoking is the single most preventable cause of death in the
US.
• Cigarette smoking accounts for nearly 440,000 deaths per year
in men and women.
• 50% of heart attacks among women are due to smoking.
• Smokers tend to have their first heart attack 10 years earlier
than nonsmokers.
• If you smoke, you are 4-6x more likely to suffer a heart attack
and increase your risk of a stroke.
• Women who smoke and take OCP’s increase their risk of heart
disease 30x.

35. (Lack of) Exercise
• Increases heart disease and stroke risk
• 30 minutes or more of activity on most or all
days of the week helps
reduce risk!
• Exercise helps:
Control blood cholesterol
Control diabetes and obesity
Lower high blood pressure

36. Exercise: Resistance Training
• Resistance training appears to have a
beneficial impact on several risk factors for
cardiovascular disease.
• These include lowering blood pressure,
reducing fasting serum glucose
concentrations, improving insulin sensitivity
and dyslipidemia, decreasing waist
circumference, and improving body
composition

37. Obesity
• Obesity, defined as a BMI greater than 30, is a highly
prevalent condition, particularly in developed
countries, with estimates that 35 percent of the
population of the United States in 2011 to 2012 was
obese.
• In addition to the risk associated with obesity,
patients with more significant fluctuations in body
weight (i.e., cycles of weight gain and weight loss)
appear to have an increased risk of future CVD
events

38. Psychosocial Factors
• Early development of atherosclerosis as well as to
the acute precipitation of heart attacks and sudden
cardiac death.
• The link between psychologic stress and
atherosclerosis may be both direct, via damage of the
endothelium, and indirect, via aggravation of
traditional risk factors such as smoking, hypertension,
and lipid metabolism.
• Depression, anger, stress, and other factors have
been correlated with cardiovascular outcomes

39. South Asians and Heart Disease
• Heart disease is the leading killer of adults
nationwide, and South Asians, the second fastest-
growing ethnic group in America, have a higher death
rate from the disease than any other ethnic group.
• People of South Asian descent, includes countries
like India, Pakistan, Bangladesh, Nepal, Sri Lanka,
Bhutan and the Maldives
• 4x the risk of heart disease compared to the general
population, and they develop the disease up to a
decade earlier.

40. Mediators of Atherosclerosis in South Asians
Living in America
• MASALA trial: UCSF and Northwestern
University
• South Asians tend to develop high
blood pressure, high triglycerides,
abnormal cholesterol and Type 2
diabetes at lower body weights than
other groups.

41. South Asians and Heart Disease
• Normal body weight— people of any Asian
ancestry, including those who are Chinese, Filipino
and Japanese, have a greater likelihood of carrying
visceral fat.
• Despite having lower obesity rates than whites,
Asian-Americans have twice the prevalence of Type
2 diabetes, which promotes heart attacks and
strokes.

42. South Asians and Heart Disease
• Cardiovascular risks tended to be
highest in two groups:
 Those who maintained very strong ties to
traditional South Asian religious, cultural
and dietary customs
 Those who vigorously — embraced a
Western lifestyle.

43. South Asians and Heart Disease
• Almost 40 percent of MASALA participants
are vegetarian, a common practice in India
that is widely regarded in the West as heart
healthy.
• But some vegetarians eat traditional South
Asian foods like fried snacks, sweetened
beverages and high-fat dairy products

44. Top 10 Take Home Messages
1. The most important way to prevent
CVD, heart failure, and atrial fibrillation
is to promote a healthy lifestyle
throughout life.

45. Top 10 Take Home Messages
2. A team-based care approach is an
effective strategy for the prevention of
cardiovascular disease. Clinicians should
evaluate the social determinants of health
that affect individuals to inform treatment
decisions.

46. Top 10 Take Home Messages
3. Adults who are 40 to 75 years of age and are being
evaluated for cardiovascular disease prevention should
undergo 10-year atherosclerotic cardiovascular disease
(ASCVD) risk estimation and have a clinician–patient
risk discussion before starting on pharmacological
therapy, such as antihypertensive therapy, a statin, or
aspirin. In addition, assessing for other risk-enhancing
factors can help guide decisions about preventive
interventions in select individuals, as can coronary
artery calcium scanning.

47. Top 10 Take Home Messages
4. All adults should consume a healthy diet that
emphasizes the intake of vegetables, fruits, nuts, whole
grains, lean vegetable or animal protein, and fish and
minimizes the intake of trans fats, red meat and
processed red meats, refined carbohydrates, and
sweetened beverages. For adults who are overweight
and/or obese, counseling and caloric restriction are
recommended for achieving and maintaining weight
loss.

48. Top 10 Take Home Messages
5. Adults should engage in at least 150
minutes per week of accumulated
moderate-intensity physical activity or 75
minutes per week of vigorous-intensity
physical activity.

49. Top 10 Take Home Messages
6. For adults with type 2 diabetes, lifestyle
changes, such as improving dietary habits and
achieving exercise recommendations, are
crucial. If medication is indicated, metformin is
first-line therapy, followed by consideration of a
sodium-glucose cotransporter 2 inhibitor or a
glucagon-like peptide-1 receptor agonist.

50. Top 10 Take Home Messages
7. All adults should be assessed at every
healthcare visit for tobacco use, and
those who use tobacco should be
assisted and strongly advised to quit.
8. Aspirin should be used infrequently in
the routine primary prevention of ASCVD
because of lack of net benefit.

51. Top 10 Take Home Messages
9. Statin therapy is first-line treatment for
primary prevention of ASCVD in patients with
elevated low-density lipoprotein cholesterol
levels (≥190 mg/dL), those with diabetes, who
are 40 to 75 years of age, and those
determined to be at sufficient ASCVD risk after
a clinician–patient risk discussion.

52. Top 10 Take Home Messages
10. Nonpharmacological interventions are
recommended for all adults with elevated
blood pressure or hypertension. For those
requiring pharmacological therapy, the
target blood pressure should generally be
<130/80 mm Hg.

53. Questions?