How Can a Heart Attack Be Prevented? Making lifestyle changes is the most effective way to prevent having a heart attack. Lowering your risk factors for coronary heart disease can help you prevent a heart attack. Even if you already have coronary heart disease. For more information visit: www.srisriholistichospitals.com

1. Preventing Heart Attacks
V.S.Ramchandra,MD,DM,FACC,FSCAI,FESC.
Consultant Cardiologist
Formerly:
Professor & Head of Cardiology, KMC, Manipal
Chief Electrophysiologist, Apollo Hospitals
Associate in Cardiology, UAB Hospital, AL, USA
Staff Cardiologist, St Vincent Health, IN, USA

2. Magnitude of the Problem:
Global Burden of Cardiovascular
Disease
•½ way through a 2 century transition ; CVD
will dominate as the major cause of Death
Globally
•Although CVD is ↓in EstME it is ↑ in the rest of
the world with 85% of the worlds population.
•10% (1900) → 25% (2000) → 50% (2020)
of Global Deaths.

3. CAUSES OF DEATH
• 1. MYOCARDIAL INFARCTION
(HEART ATTACK)
DUE TO CORONARY ARTERY DISEASE
• 2. CEREBROVASCULAR ACCIDENT
(STROKE)
DUE TO BLOCK IN BRAIN TUBES
• CANCER

4. INDIAN SCENARIO

5. Prevalence of CAD in Different
Countries
•
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
Women
Men

7. Coronary Artery Disease – Indian
Scenario: Indians Vs West
•Average Age of first MI in west is 70 years.
In India it is 45 to 55 years.
•At any level of conventional RF – Indians
have X2 CAD than whites with similar RF

8. Coronary Artery Disease – Indian
Scenario: Past Vs Present
•CAD rates have halved in W in last 30 yrs –
Increasing alarmingly (doubled) in India
•Average Total Cholesterol was 120mg% -
increased to 200mg%
•Average Age of first MI has ↓ by 20 yrs- ½
< 50yrs, ¼ < 40 yrs of age
• Diabetes has increased by 60%.

9. WHAT IS A HEART ATTACK

10. WHAT IS A HEART ATTACK

11. WHAT IS A HEART ATTACK

12. WHAT IS A HEART ATTACK

13. WHAT IS THE HEART

14. Non-Invasive Diagnosis of CAD
Ischemia detection
• ECG/ TMT- Sen-60%,Sp-80%
• Stress ECHO
• SPECT
Coronary Calcium
CTA- 99% sensitivity- may overestimate

15. COURAGE TRIAL
• OMT Vs (Revascularisation+ OMT)
•2300 pts- 70% proximal lesion+Ischemia
or 80%+angina, 2/3TVD
• At 5 Yrs- No difference in Mortality, MI,
hospitalisations, Stroke.

16. WHERE IS
REVASCULARISATION USEFUL
• UNSTABLE ANGINA- Symptoms
/Trop/ varying ST-T ECG changes
• PRIMARY ANGOPLASTY FOR AMI
• TVD with LV DYSFUNCTION
• ? Lt MAIN, Silent Ischemia, Severe
Stenosis

18. How Predictable & Preventable
is CVD
• Interheart Study: 90% Predictable
• Multiple Risk Factor Interventional
Trials: 0 to 60% reduction
•Observational studies in migrant
populations show vast differences in
CVD mortality

19. Cardiac Risk Factors- Modifiable
• Smoking
• Hypertension
• Diabetes
• Metabolic Syndrome
• Dyslipidemia
• Obesity
• Sedentary Life style
• Lack of fruits, GV & fiber in diet
• Anger, Hostility, Work stress, Depression, LSS
• Alcohol

20. Surrogate Markers of Coronary
Artery Disease
• Vascular Disease Elsewhere – Strokes, TIA,
PVD, Carotid bruits, Abdominal
Aneurysms
• Diabetes
• Chronic Renal Failure

21. Coronary Artery Disease Risk
Factors-Non Modifiable
• Male Sex
• Post Menopausal State
• (+) Family History
• Genetic Susceptibility
• Lp (a)
• Diabetes
• ? Infection

22. Smoking Cessation
• Risk of CAD/Re- MI/CABG failure X2
• Leading preventable cause of Death
• 25% in US to 70% in China
• 80% start before age 18 yrs
• In US: 55% →25% (M), 35% →20% (W)
• Risk falls rapidly after cessation

23. Smoking Cessation (Cont..)
•Cessation highly Cost effective
•Intervention usually short term
•1 yr success rates- 6% Physician
counseling , 20% self help programs, 40%
with Buproprion /nicotine patch
•3 types of Behavioral therapy- Problem
solving, social support in & outside treat
•Most effective after event

24. Alcohol
•20 to 45% risk ↓ with moderate consumption
(60ml-male, 30 ml- Female)
•↑HDL, ↑Fibrinolysis, ↓Platelet aggregation
•10-20% become chronic alcoholics
•Consider HTN, DM, ↑TG, Hgic Stroke, Liver
Disease, f/h alcoholism /Breast Ca/ Colon Ca
•Prescription should be individualized
“Whether wine is a nourishment,medicine, or
poison, is a matter of dosage”-Celsus

25. HTN- The Magnitude of the
Problem
•HTN is the commonest medical diagnosis,
affecting 1 billion worldwide
•Prevalence of HTN: 3% in 18 to 24 yrs age
13% in 35 to 44
yrs age & 70% in those >75 yrs.
•For persons over age 50, SBP is a more
important than DBP as a CVD risk factor.

26. HYPERTENSION
• >120/80-PREHYPERTENSION, >140/90- HTN
• NO SYMPTOMS. 2/3 OF AMERICAN
HYPERTENSIVES NOT AWARE
• SAME GOALS FOR ALL AGES
• SYTOLIC BLOOD PRESSURE MORE
DANGEROUS
• MOST NEED 2 OR MORE DRUGS
• GOALS: <130/80. <115/75 IN DIABETICS
WITH PROTEINURIA.

27. Pre-Hypertension: A New
Disease Is Created
Starting at 115/75 mmHg, CVD risk doubles
every 20/10 mmHg throughout the BP range.
Persons who are normotensive at age 55 have a 90%
lifetime risk for developing HTN.
Intent in creating Pre-HTN(22% of adult population)
is to stress LSM, prevent progression & to treat other
CVRF

28. Hypertension- treatment most
cost effective
• Risk ↑ Linearly from 115/75mmHg.
• 5 mm ↓ in BP Reduces strokes by 40% , CVD by
15% & Heart failure by 25%
• In stage 1 HTN and additional CVD risk factors,
achieving a sustained 12 mmHg reduction in SBP
over 10 years will prevent 1 death for every 11
patients treated
.

29. Lifestyle Modification
Modification Approximate SBP reduction
(range)
Weight reduction 5–20 mmHg/10 kg weight loss
DASH eating plan 8–14 mmHg
Dietary sodium ↓ 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of
alcohol consumption
2–4 mmHg

30. Diabetes Mellitus
• Confers X 4 Risk. Young stroke X 10. No
menstrual protection for women.
• Deemed a Coronary Artery Disease
equivalent by AHA
• Worldwide ↑ by 35% (from 5%) by 2025,
max in China (↑68%) & India (60%)
•Thrifty Gene Hypothesis

31. Calculating your risk of
Developing Diabetes Mellitus
•Overweight – 5
•Sedentary – 5
•Age > (45-64) – 5, > (65) - 9
•Parent DM- 1, Sibling DM- 1
•Women with Baby >9lb - 1
•Asian - 4
•Total > 3-9= Low Risk, 10+ = need test

32. Preventing Diabetes with LSM
•DPP: Weight loss by 7% & 150 mins/
wk of moderate ex – reduced chance of
becoming Diabetic by 55% in IFG/ IGT
compared to 30% with metformin
•Delaying may be preventing- Glitazone
•Once Diabetic no degree of control of
sugars shown to prevent macrovascular
complications

33. OBESITY
1. BODY MASS INDEX: WEIGHT in Kg/
HEIGHT in M.SQ. 25 – 30(OWERWEIGHT)
30 – 35(OBESE)
2. WAIST CIRCUMFERENCE <90Cms(M),
<85Cms
3. PROTRUDING TUMMY
4. WAIST >HIP

34. Physical Inactivity / Exercise
•75% American Adults
•Inverse Linear Dose Response
relationship. Ex & all-cause mortality
•CAD, MI, HTN, DM, Dyslipidemia, MS
•50% Primary, 25% Secondary protection

35. Exercise
• Goals: Maintain 70-80% of THR for 45
Mins 5 days/Week.
• THR= 220-AGE
• Maintain ideal Body Weight & muscle
mass & Flexibility.

36. CHOLESTEROL
• A NATURAL MEMBRANE BUILDER .
• THE FINAL ROUTE TO BLOCKAGES IN ARTERIES
• GOOD - HDL CHOLETEROL
• BAD - LDL CHOLESTEROL
• UGLY - TRIGLYCERIDES
• DEADLY- Lp (a).

37. 1% ↑ Heart Attacks for every 2% ↑ in
LDL or 1% ↓ in HDL

38. Naturalization
AVERAGE IS NOT NORMAL!!
•Average LDL of Hunter-gatherers, Neonates,
Mammals is 50-70mg%. No Atherosclerosis
even in 7th
& 8th
decades.
•Avg American LDL is 130. 50% above 50Yrs
have atherosclerosis.

39. LDL - Naturalisation
HOW LOW IS LOW ENOUGH? IS IT SAFE?
•10% of highest LDL account for 20% of CAD.
• Only 25% risk reduction with current LDL Trt.
•Threshold for atherosclerosis progression is
LDL of 67mg%, CVD event rate 0 at LDL 57
(primary) & 30 mg% (secondary prevention).
•50% ↓ in LDL for secondary & 30% ↓ for
primary prevention.
•? All people above 55yrs should receive statins

40. ACT BEFORE DISEASE IS
FIXED
• More beneficial to Treat High Risk or Low
Risk patients
•50% reduction by bringing LDL to
55mg% in “low risk”- Jupiter trial

41. Metabolic Syndrome
Any 3 of the below:
• TG > 150mg/dl
• HDL-C <40 (M), <50 (F)
• FBS (plasma) >100mg/dl
• BP >130/85
• Waist Circumf > 90cm(M) > 85cm(W)
Incidence: 40%, 28% (No IFG), 75%(DM/IFG)

42. Diet & Cholesterol
• Contribution of dietary cholesterol to Blood
T-C is small (10mg%) compared to dietary
fats (100mg%)
• 4 types of Fatty acids:
• Good - Poly unsaturated (PUFA)
• Great - Mono unsaturated (MUFA)
• Bad - Saturated (SAFA)
• Deadly - Trans saturated (TFA)

43. Diet & Cholesterol- Milk
• In Indians SFA come from diary
products & cooking oils
• Avoid whole fat milk & milk products
Diary products are more saturated &
athero/throbogenic than meat products
• Nonfat Milk- Calcium, B12, ↓ BP,
decreases diabetes risk.

44. Cooking Oils / Fats
• Oils have powerful cholesterol increasing &
lowering actions
• 1/3rd
of the 54% decline in CAD in US attributed
to ↑ PUFA by 5%.
• 30mg% ↓ in T-C by banning palm oil &
substituting it by soybean oil
•Nuts are high in fat(cashew 21%, peanut14%) but
low in SAFA and do not ↑T-C

45. Cooking Oils
• SAFA: Butter, coconut and palm oil is more
athero / thrombogenic than lard & beef tallow
• MUFA: Oleic acid in Canola & Olive oil reduces
LDL & increases HDL.
• PUFA: ð-3 (fatty fish, walnuts, canola & soybean
oil) ð-6 ( corn, soybean, cotton) 4:5 decreases LDL
and HDL
•TFA- Pastries, fried chicken, margarines/ dalda,
ready foods, crispy bakery products.

46. Diet- Energy
•Carbohydrates – Rice
•Fats – Milk, Cooking oils
•Proteins – Pulses, Milk
•Marked ↓in Fat intake or ↑in Carbs will ↓HDL
•Marked ↑ in protein ↑load on kidneys
•Fibre – Cereals
•Micronutrients- Fresh fruits, undercooked
vegetables

47. Diet- Carbs- Rice
•Carbohydrates – Polished Rice, Maida,
White bread, Biscuits, Upma, Dosa, Sugar,
Sweets
•Cereals with their outer fibrous coating
removed
•Glycemic Index
•Satiety
•Fibre -Soluble & Insoluble

48. Substituting Fats with Carbs

49. Diet (Cont..)
•Balance Total Calories with expenditure to
maintain ideal BMI
•Minimize Saturated /trans fat to 7% of cal
•Mono-unsaturated fats rest 20% of cal
•Omit rapidly digested Carbs – White Rice
•Whole grains are excellent source of
energy, fiber & protein

50. Diet (Cont…)
•Maximize fruits & fresh Vegetables to 5
servings/day + some nuts
•Use only very low fat Dairy products
•2-3 servings of Fatty fish /week
•Dietary supplements- 1gm/D 3 fatty
acids, Folate, B6&12, Multivitamins
•Alcohol.

51. F
O
O
D
P
Y
R
AM
I
D

52. Indian Paradox
Less RF- More CAD.
1. Genetic predisposition.?Lp(a)
2. Central obesity-Insulin Resistance
3. Metabolic Syndrome
4. Processed carbohydrates, Increased energy.
5. Increased dairy Fats
6. Frying/ Reuse of oils- TFA.

53. Sleep & Obstructive Sleep Apnea
Less than 6 or More than 8 hrs/day
Sleep Deprivation & Altering Cycles
Sun-Ambient Light & Sleep
Getting up and getting ready for work
Snoring, Daytime drowsiness, HTN, Age,
BMI & Neck Cicumference- OSA

54. 3 Main causes of heart Attacks
Food
Exercise
Mental Stress

55. Type A,Type D behavior
•Compulsive overachievers, excessively
competitive & ambitious, aggressive, hostile,
unable to relax, impatient & get easily
frustrated / angry
•Anger, Suppressed Anger, hostility.
•Large Prospective studies of healthy
x 2 risk of developing CAD
•Type D- suppressed negative emotions

56. Psychosocial Factors
• Depression
• Social Isolation
• Anger & Frustration
• Hostility
• Job Strain-High demand with little autonomy
• Marital stress

57. Tackling Negative Emotions
• Connection between Emotions & Breath
• Observe Sensations
• Everything Changes – Including emotions
• Opposite values are complimentary
• Be Centered
• Pranayama & Meditation

61. Lp(a) - The Deadly Cholesterol
• >15-20mg/dl
• Purely Genetic
• Best childhood
predictor
• Highly atherogenic,
thrombogenic,
antifibrinolytic
• Highest among all
races except blacks
• 40 % of Indians.
Tobacco
10%
HTN
10%
Diabetes
10%
TC/LDL
15%
TC/HDL
15%
lp(a)
25%
Hcy
5%
Other
10%
Tobacco
HTN
Diabetes
TC/LDL
TC/HDL
lp(a)
Hcy
Other

62. Contributions of various risk factors
for CAD among Asian Indians
Tobacco
10%
HTN
10%
Diabetes
10%
TC/LDL
15%
TC/HDL
15%
lp(a)
25%
Hcy
5%
Other
10%
Tobacco
HTN
Diabetes
TC/LDL
TC/HDL
lp(a)
Hcy
Other

63. Prevention- From Womb to Tomb
• Womb - Measures to prevent IUGR
• Infancy- Infections?
• Childhood – Physical activity, prevent
obesity, proper nutrition and lifestyle
enforcement. Lp(a)
• Early Adulthood – FLP if F/h, screen for
DM if Obese.
•Adulthood – Screen for all RF, HsCRP

64. Prevention- The Caveats
• Eat Less - Eat a variety
• Be Natural- Exercise, Diet, Sleep
• Learn to Relax
• Act Before Diseases are Fixed

65. Predicting CAD
Biomarkers- Hs CRP
• LP PLA2
Vascular Imaging
• Carotid IMT (<1 to>3 mm)- Young
• CACS by EBCT or MSCT (>100Au)
Genomic markers
• High Density Genotyping- SNP
• Genome expression Assays

66. PRIMARY PREVENTION DRUGS-
ASPRIN & ROSUVASTATIN
• More HDL raising & TG (Stellar)
• Safer than any other Statin
• More reduction in HsCRP
• First IVUS regression (Asteroid Trial)
• Multiple sites of action (HMG, CETP,
PPAR a, ApoA1, Longest half life

67. Life Style & Behavioral
Modifications
• Difficult to qualify,quantify & study in
isolation due to multiple linked factors
• Intensely Individual but the only
modifications possible on a global scale
• Large reductions in mortality with
minimum fear of unexpected side effects
on the long run & cost effective

68. Life Style & Behavioral
Modifications- Doing it
• Understand & be Motivated
• Like it & be part of a group
• Structured program & should become
part of routine life by strength of habit
• Started early in life & should have
social/family/ work place support

69. Population-Based Strategy
SBP Distributions
Before
Intervention
After
Intervention
Reduction in SBP
mmHg
2
3
5
Reduction
in BP
% Reduction in Mortality
Stroke CHD Total
–6 –4 –3
–8 –5 –4
–14 –9 –7

70. “SUPERIOR DOCTORS PREVENT
DISEASE; MEDIOCRE DOCTORS
TREAT DISEASE BEFORE IT IS
EVIDENT; INFERIOR DOCTORS
TREAT FULL BLOWN DISEASE”
Huang dee. First Chinese
Medical Text. 2600 BC.

71. How Predictable & Preventable
is CVD
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
Women
Men
Graph 1: Age-adjusted CAD Death Rates per
100,000 per year (Age 35-74)

72. Cardiac Metaphors of Daily Life
• Races with Excitement
• Pounds in Anticipation
• Stands still in Dread, Skipped a Beat
• Aches with Grief
• With a Heavy Heart
• The Lion Hearted, Large hearted, Heartless
• Broken Hearted

73. Preventing Heart Attacks
Role of Lifestyle Modifications &
Behavioral Changes
V.S.Ramchandra MD,DM,FACC,FSCAI,FESC.
Global Hospitals
Formerly:
Professor & Head of Cardiology, KMC, Manipal
Chief Electrophysiologist, Apollo Hospitals
Associate in Cardiology, UAB Hospital, AL, USA
Staff Cardiologist, St Vincent Health, IN, USA

74. WHAT IS THE HEART

75. WHAT IS CIRCULATION
• Supplies Nutrients
• Removes Waste
• Supplies Oxygen
• Removes CO2
• Single Pump
• Blood Pressure
• Gradient = 120-10
• Extremely Low
Resistance

76. WHAT HAPPENS IF
CIRCULATION TO PART OF THE
BODY IS STOPPED
• BRAIN (STROKE)
• HEART ( HEART
ATTACK or MI )
• KIDNEY
(HYPERTENSION)
• LEG (GANGRENE)
• EYE (BLINDNESS)

77. WHAT HAPPENS IF THE
HEART STOPS

78. WHAT IS A HEART ATTACK

79. Prevalence of Heart Attacks in
Different Countries
•
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
Women
Men

80. WHAT IS A HEART ATTACK

81. WHAT IS A HEART ATTACK

82. WHAT IS A HEART ATTACK

83. CAUSES OF DEATH
• 1. MYOCARDIAL INFARCTION
(HEART ATTACK)
DUE TO CORONARY ARTERY DISEASE
• 2. CEREBROVASCULAR ACCIDENT
(STROKE)
DUE TO BLOCK IN BRAIN TUBES
• CANCER

84. Heart Attacks – Indian Scenario:
Indians Vs West
•Overseas Indians–CAD X 4 Americans
•Urban Indian Epidemic(10%)Vs USA(2.5%)
•Hear Attack rates have halved in W in last
30 yrs – Increasing alarmingly (doubled) in
India
•Average Age of first Heart Attack in west is
70 years. In India it is 45 to 55 years.

85. Heart Attacks – Indian Scenario:
Past Vs Present
•Heart Attack rates have increased alarmingly
(doubled) in India in last 25 years
•Average Total Cholesterol was 120mg% -
increased to 200mg%
•Average Age of first Heart Attack has ↓ by
20 yrs- ½ < 50yrs, ¼ < 40 yrs of age
• Diabetes has increased by 60%.

86. Heart Attacks – Indian Scenario
Urban Vs Rural
•Rural Vs Urban: ½ Despite higher smoking
•RF incidences: Smoking- 55%®,35(U)
•Diabetes- 3%®, 11% (U)
•Hypertension- 14%®, 25% (U)
•TC/HDL >5 – 28%®, 46% (U)
•Urb Vs Rural: BMI 25Vs20,
WHR0.99Vs.95
•Higher CAD in South India- Urb Kerala13%

87. How Predictable & Preventable
are Heart Attacks
• Interheart Study: 90% Predictable
• Multiple Risk Factor Interventional
Trials: 0 to 60% reduction
•Observational studies in migrant
populations show vast differences in
CVD mortality

88. Heart Attack Risk Factors-
Modifiable
• Smoking
• High BP (Hypertension)
• High Sugars (Diabetes)
• High/ Bad fats/cholesterol (Dyslipidemia)
• Increased weight/fat (Obesity)
• Sedentary Life style (lack of Exercise)
• Metabolic Syndrome
• Lack of fruits, GV & fiber in diet
• Anger, Hostility, Work stress, Depression, LSS
• Alcohol

89. SMOKING
• COMMONEST CAUSE OF DEATH IN YOUNG
ADULTS AND ELDERLY
• NICOTINE + LARGE NUMBER OF TOXINS
• IMMEDDIATE SPASM
• DAMAGES EPITHELIUM (INNER LINING OF
TUBES) EVERYWHERE
• PRECIPITATES DIABETES
• SUDDEN DEATH

90. Smoking Cessation
• Risk of CAD/Re- MI/CABG failure X2
• Leading preventable cause of Death
• 25% in US to 70% in China
• 80% start before age 18 yrs
• In US: 55% →25% (M), 35% →20% (W)
• Risk falls rapidly after cessation

91. Smoking Cessation (Cont..)
•Cessation highly Cost effective
•Intervention usually short term
•1 yr success rates- 6% Physician
counseling , 20% self help programs, 40%
with Buproprion /nicotine patch
•3 types of Behavioral therapy- Problem
solving, social support in & outside treat
•Most effective after event

92. Alcohol
•20 to 45% risk ↓ with moderate consumption
(60ml-male, 30 ml- Female)
•↑HDL, ↑Fibrinolysis, ↓Platelet aggregation
•10-20% become chronic alcoholics
•Consider HTN, DM, ↑TG, Hgic Stroke, Liver
Disease, f/h alcoholism /Breast Ca/ Colon Ca
•Prescription should be individualized
“Whether wine is a nourishment,medicine, or
poison, is a matter of dosage”-Celsus

93. Diabetes Mellitus
• Confers X 4 Risk. Young stroke X 10. No
menstrual protection for women.
• Deemed a Heart attack equivalent by
AHA
• Worldwide ↑ by 35% (from 5%) by 2025,
max in China (↑68%) & India (60%)
•Thrifty Gene Hypothesis

94. Calculating your risk of
Developing Diabetes Mellitus
•Overweight – 5
•Sedentary – 5
•Age > (45-64) – 5, > (65) - 9
•Parent DM- 1, Sibling DM- 1
•Women with Baby >9lb - 1
•Asian - 4
•Total > 3-9= Low Risk, 10+ = need test

95. Preventing Diabetes with LSM
•DPP: Weight loss by 7% & 150 mins/
wk of moderate ex – reduced chance of
becoming Diabetic by 55% in IFG/ IGT
compared to 30% with metformin
•Once Diabetic no degree of control of
sugars shown to prevent heart attacks or
strokes

96. HYPERTENSION
• NO SYMPTOMS. 2/3 OF AMERICAN
HYPERTENSIVES NOT AWARE
• SAME GOALS FOR ALL AGES
• SYTOLIC BLOOD PRESSURE MORE
DANGEROUS
• MOST NEED 2 OR MORE DRUGS
• GOALS: <130/80. <115/75 IN DIABETICS
WITH PROTEINURIA.

97. Hypertension
• >140/90. Prehypertension >120/80
• Risk ↑ Linearly from 115/75mmHg.
• 5 mm ↓ in BP Reduces strokes by 40% , CVD by
15% & Heart failure by 25%
• In stage 1 HTN and additional CVD risk factors,
achieving a sustained 12 mmHg reduction in SBP
over 10 years will prevent 1 death for every 11
patients treated
.

98. Pre-Hypertension: A New
Disease Is Created
Starting at 115/75 mmHg, Heart Attack/Stroke
risk doubles for every 20/10 mmHg increase
throughout the BP range.
Persons who are normotensive at age 55 have a 90%
lifetime risk for developing HTN.
Intent in creating Pre-HTN(22% of adult population)
is to stress LSM, prevent progression & to treat other
CVRF

99. Lifestyle Modification
Modification Approximate SBP reduction
(range)
Weight reduction 5–20 mmHg/10 kg weight loss
DASH eating plan 8–14 mmHg
Dietary sodium ↓ 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of
alcohol consumption
2–4 mmHg

100. Life Style & Behavioral
Modifications
• Difficult to qualify,quantify & study in
isolation due to multiple linked factors
• Intensely Individual but the only
modifications possible on a global scale
• Large reductions in mortality with
minimum fear of unexpected side effects
on the long run & cost effective

101. Life Style & Behavioral
Modifications
• Difficult to qualify,quantify & study in
isolation due to multiple linked factors
• Intensely Individual but the only
modifications possible on a global scale
• Large reductions in mortality with
minimum fear of unexpected side effects
on the long run & cost effective

102. Life Style & Behavioral
Modifications
• Difficult to qualify,quantify & study in
isolation due to multiple linked factors
• Intensely Individual but the only
modifications possible on a global scale
• Large reductions in mortality with
minimum fear of unexpected side effects
on the long run & cost effective

103. Life Style & Behavioral
Modifications- Doing it
• Understand & be Motivated
• Like it & be part of a group
• Structured program & should become
part of routine life by strength of habit
• Started early in life & should have
social/family/ work place support

104. Population-Based Strategy
SBP Distributions
Before
Intervention
After
Intervention
Reduction in SBP
mmHg
2
3
5
Reduction
in BP
% Reduction in Mortality
Stroke CHD Total
–6 –4 –3
–8 –5 –4
–14 –9 –7

105. “SUPERIOR DOCTORS PREVENT
DISEASE; MEDIOCRE DOCTORS
TREAT DISEASE BEFORE IT IS
EVIDENT; INFERIOR DOCTORS
TREAT FULL BLOWN DISEASE”
Huang dee. First Chinese
Medical Text. 2600 BC.

108. MENTAL STRESS &
PHYSICAL STRESS
• DEPRESSION, SOCIAL ISOLATION, ANGER,
AGGRESSIVENESS (TYPE A BEHAVIOUR)
• INCREASED MENTAL OR PHYSICAL WORK
NOT DANGEROUS.

109. How Predictable & Preventable
is CVD
0 100 200 300 400 500 600 700 800 900
Russia
Scotland
Finland
England
U.S.A.
Australia
Canada
Sweden
Italy
Urban China
France
Rural China
Japan
Women
Men
Graph 1: Age-adjusted CAD Death Rates per
100,000 per year (Age 35-74)

110. Psychosocial Factors
•Studies hampered by imprecision in
definitions & accepted metrics
•Depression, Chronic Hostility, Social
isolation, Perceived lack of Social
support consistently linked with ↑ risk
•Data inconsistent with anxiety, work
related stress & Type A behavior

111. Psychosocial Factors (Cont..)
• Low socioeconomic status
• Acute mental stress /stress induce SMI
• Sudden emotion-↑RR in 1-2 hrs of event
• Lethal arrhythmias & SCD following
mentally stressful events
• HTN–Relaxation training,meditation &
biofeedback for pt with subjective stress

112. CAUSES (Risk Factors) OF
HEART ATTACK
SMOKING
DIABETES
HYPERTENSION
CHOLESTEROL
OBESITY/ METABOLIC SYNDROME
LACK OF EXERCISE
MENOPAUSE
MENTAL STRESS

113. MENOPAUSE
• SUDDEN SURGE IN HEART ATTACKS
• TOTAL MORTALITY> MALES
• DIABETES TOTALLY NEGATES
PROTECTION OF MENSES.
• HRT HARMFULL
• MALES WILL BE SAVED IF WE KNOW
WHAT PROTECTS FEMALES!

114. Lp(a) - The Deadly Cholesterol
MULTIPLIER EFFECT

115. Contributions of various risk factors
for CAD among Asian Indians
Tobacco
10%
HTN
10%
Diabetes
10%
TC/LDL
15%
TC/HDL
15%
lp(a)
25%
Hcy
5%
Other
10%
Tobacco
HTN
Diabetes
TC/LDL
TC/HDL
lp(a)
Hcy
Other

116. THIS IS WHAT KILLS US!
• INCREASED PROCESSED CARBOHYDATES.
• RAPID ABSORPTION OF SUGAR
• INCREASED INSULIN, ARTERY
THICKENING, TRIGLYCERIDES, DECRESED
HDL.
• RICE IS TOXIC!
• THERE IS AN EPIDEMIC COMING!

117. NON MODIFIABLE
FACTORS:
• Age,
• Sex
• Family History

118. HOW MUCH LESS IS LESS
ENOUGH
CARBOHYDRATES
LDL<100
BP<120/80
BMI<25
INCRESED FIBER
INCREASED EXERCISE
BE HAPPY!

119. REVOLUTION OR
EVOLUTION

120. HASTEN SLOWLY

121. CABGs

122. WHAT IS THE HEART

123. WHAT IS THE HEART

124. STENT RESTENOSIS

125. WHAT IS THE HEART

126. Magnitude of the Problem:
Global Burden of Cardiovascular
Disease
•½ way through a 2 century transition ; CVD
will dominate as the major cause of Death
Globally
•Although CVD is ↓in EstME it is ↑ in the rest of
the world with 85% of the worlds population.
•10% (1900) → 25% (2000) → 50% (2020)
of Global Deaths.

127. INDIAN SCENARIO

132. Epidemiological Transitions
•Age of Pestilence & Famine – LE is 30yrs
•Age of Receding Pandemics - ↑ Food & ↓ ↓ in
Infant and child mortality
•Age of Degenerative & Man Made Diseases –
Easier access to cheaper carb/fatty foods,
mechanization leads to ↓ energy expenditure,
Urbanization → ↑ crowding, smoking & work
stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD
(>50%), ↑ Cancers. LE>50yrs.

133. Epidemiological Transitions
•Age of Delayed Degenerative Diseases – LSM,
↓Smoking (45% →23%) , Trt of HTN – CHD
↓2% per yr, Stroke ↓ 3% per yr, CVD strikes
later.
•Age of LSM plateau & Early Obesity - ↑
caloric intake & ↓Physical activity- 75%
Overweight or Obese - ↑ HTN/DM. LE =
75yrs(M), 80yrs(W)
•Future Age of Intense LSM , Behavioral
Changes & Naturalization

134. Surrogate Markers of Coronary
Artery Disease
• Vascular Disease Elsewhere – Strokes, TIA,
PVD, Carotid bruits, Abdominal
Aneurysms
• Diabetes
• Chronic Renal Failure

135. Coronary Artery Disease Risk
Factors-Non Modifiable
• Male Sex
• Post Menopausal State
• (+) Family History
• Genetic Susceptibility
• Lp (a)
• Diabetes
• ? Infection

136. Risk factors- from Womb to
Tomb
•Thrifty Phenotype(Barkers) Hypothesis
•Thrifty Genotype Hypothesis
•Brenners Hypothesis for essential HTN
•IUGR and CAD - ↑LDL & apo B.

137. Risk factors- from Womb to
Tomb- Child/Adulthood
• Increasing T-Chol (from 75 in cord
blood to 120-150 by 2 wks- stable till 20
yrs – rises to 200 - 240 in most adults.
• Catch-up obesity
• Middle age bulge
• Increasing Systolic BP

138. The Magnitude of the Problem
•HTN is the commonest medical diagnosis,
affecting 1 billion worldwide
•Prevalence of HTN: 3% in 18 to 24 yrs age
13% in 35 to 44
yrs age & 70% in those >75 yrs.
•For persons over age 50, SBP is a more
important than DBP as a CVD risk factor.

139. DIABETES MELLITUS
• DECLARED NOW AS A CORONARY ARTERY
DISEASE EQUIVALENT
• MORTALITY ALMOST X 4
• DAMAGES ARTERIES
• PROMOTES THICKENING
• CONTROLL OF BLOOD SUGARS NOT
ENOUGH
• GOALS: FBS<110, PPBS<140

140. LACK OF EXERCISE
• CENTRAL OBESITY.
• DIABETES
• HYPERTENSION.
• CHOLESTEROL
• GOALS: MAINTAIN 80% OF THR FOR 45
MINS 5 DAYS A WEEK. MAINTAIN IDEAL
BODY WEIGHT AND MUSCLE MASS.
• THR= 220-AGE

141. Dyslipidemia-Importance of
Statins
• American Heart Association Diet
Chol Total Fat TC LDL
Step I 300 8 - 10 % 8% 10%
Step II 200 < 7 % 10% 15%
Only 15% motivated, only 1.5% achieved goals
• Marked ↓in Fat intake can ↓ LDL-C by 30%
•Viscous fiber + plant sterols + soy protein + almonds -
30% ↓ equivalent to 10mg lovastatin
•Marked ↓in Fat intake or ↑in Carbs will ↓HDL

143. LDL - Naturalisation
HOW LOW IS LOW ENOUGH? IS IT SAFE?
•10% of highest LDL account for 20% of CAD.
• Only 25% risk reduction with current LDL Trt.
•Threshold for atherosclerosis progression is
LDL of 67mg%, CVD event rate 0 at LDL 57
(primary) & 30 mg% (secondary prevention).
•50% ↓ in LDL for secondary & 30% ↓ for
primary prevention.
•? All people above 55yrs should receive statins

145. Metabolic Syndrome
Indian scenario
Incidence: 40%, 28% (No IFG), 75%(DM/IFG)
Waist Circumf: 30%, Low HDL: 65%, TG:
45%, HTN: 55%, IFG: 27%.
•Diet, Lack of Ex
•Childhood Obesity (20% in U India)
•Indian Obesity Phenotype: lean BMI, High
waist to hip ratio, High % of Body fat.
•Barker’s Fetal priming for Insulin resistance

146. Psychosocial Factors
•Social isolation, Lack of Social support
& Social Disruption
•Life stress (major stressful life events &
minor recurrent irritants/frustrations
•Job Strain – High demand with little
autonomy
•Marital stress

147. Diet
•DASH Trial: Diet rich in Vegetables &
Fruits & Low Fat Dairy ↓ BP
•Marked ↓in Fat intake can ↓ LDL-C by 30%
•Lyon Diet Heart Study: Mediterranean diet ↓
Re-MI/Death by 65% compared to Western Diet
•Marked ↓in Fat intake or ↑in Carbs will ↓HDL
•Marked ↑ in protein ↑load on kidneys

148. Cardiac Metaphors of Daily Life
• Races with Excitement
• Pounds in Anticipation
• Stands still in Dread, Skipped a Beat
• Aches with Grief
• With a Heavy Heart
• The Lion Hearted, Large hearted, Heartless
• Broken Hearted

149. Psychosocial Factor Modifications
• ENRICH Trial: Post MI cognitive behavior
therapy + drugs if necessary
•SADHART: Sertraline AntiDepressant Heart
Attack Randomised Trial
•Antidepressant therapy - significant ↓
reinfarction, heart failure & cardiac deaths
•Meta-analyses of 37 stress management
programs show reduced cardiac mortality

151. Epidemiological Transitions
•Age of Pestilence & Famine – LE is 30yrs
•Age of Receding Pandemics - ↑ Food & ↓ ↓ in
Infant and child mortality
•Age of Degenerative & Man Made Diseases –
Easier access to cheaper carb/fatty foods,
mechanization leads to ↓ energy expenditure,
Urbanization → ↑ crowding, smoking & work
stress. ↑BP, ↑Sugars, ↑BMI, ↑Lipids → CVD
(>50%), ↑ Cancers. LE>50yrs.

152. Life Style & Behavioral
Modifications
• Difficult to qualify,quantify & study in
isolation due to multiple linked factors
• Intensely Individual but the only
modifications possible on a global scale
• Large reductions in mortality with
minimum fear of unexpected side effects
on the long run & cost effective

153. Life Style & Behavioral
Modifications
• Difficult to qualify,quantify & study in
isolation due to multiple linked factors
• Intensely Individual but the only
modifications possible on a global scale
• Large reductions in mortality with
minimum fear of unexpected side effects
on the long run & cost effective

154. •Cancer- Natural Killer Cells
Increase with SK
•Heart Autonomics –
Increased heart rate
variability with SK
•Deaddiction – Smoking,
Alcoholism, Drugs
•Metabolic Syndrome- Central
Obesity
•Hypertension- Respirate
•Insomnia
•Diabetes

155. Core TechniqueCore Technique -- ‘‘Sudarshan KriyaSudarshan Kriya’’
Scientific ValidationsScientific Validations
Regular Practice of the ‘Sudarshan Kriya’ will lead to:
Stress creating hormone Cortisol & Oxygen free radicals will get eliminated
from the blood system.
Natural Killer Cells will Increase (Immunity)
Blood Lactate will decrease
HDL Cholesterol (useful cholesterol) will increase & LDL Cholesterol
(harmful) will decrease. (Effective against blood pressure & Cardiac problems)
Increase in Alpha activity in brain with interspersed Beta activity (create
calmed alertness in the brain - Study done with EEG)
70% of Depression is curable with ‘The Sudarshan Kriya’ practice.

156. Cancer / HIV & Sudarshan Kriya
• Cancer- Natural Killer Cells Increase with SK
• Heart Autonomics – Increased heart rate variability with
SK
• Deaddiction – Smoking, Alcoholism, Drugs
• Metabolic Syndrome- Central Obesity
• Hypertension- Respirate
• Insomnia
• Diabetes

158. •