2. Risk Factors for Coronary Artery Disease and Related Health Promotion Strategies Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

3. Coronary Artery Disease Coronary artery disease (CAD) is the most common type of cardiovascular disease in the US Accounts for the majority of deaths from cardiovascular disease Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

4. Coronary Artery Disease CAD results from atherosclerosis Atherosclerosis Begins as soft deposits of fat that harden with age Described as “hardening of arteries” Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

5. Coronary Artery Disease Progressive disease Develops over time When it becomes symptomatic, it is usually well advanced Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

6. Risk Factors for CAD Risk factors can be categorized Nonmodifiable risk factors Modifiable risk factors Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

7. Risk Factors for CAD Nonmodifiable risk factors Age Gender Ethnicity Family history Genetic predisposition Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

8. Risk Factors for CAD Nonmodifiable risk factors Age CAD increases with age Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

9. Risk Factors for CAD Nonmodifiable risk factors Gender Incidence is highest in white middle- aged men After age 65, incidence in men and women similar Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

10. Risk Factors for CAD Nonmodifiable risk factors Gender Women tend to manifest CAD 10 years later than men When symptoms develop, women experience symptoms of angina rather than MI Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

11. Risk Factors for CAD Nonmodifiable risk factors Ethnicity White middle-aged men have highest incidence is highest African American women have a higher incidence and death rate compared to white women Native Americans have mortality rates 2x high as other Americans Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

12. Risk Factors for CAD Nonmodifiable risk factors Family history and genetic predisposition Exact mechanism of inheritance is not fully understood Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

13. Risk Factors for CAD Modifiable risk factors Elevated serum lipids Hypertension: BP > 140/90 Tobacco use Physical inactivity Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

14. Risk Factors for CAD Modifiable risk factors Obesity: BMI > 30 kg/m 2 Diabetes mellitus Psychologic states Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

15. Risk Factors for CAD Modifiable risk factors Elevated serum lipids Cholesterol >200 mg/dl Triglycerides >150 mg/dl Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

16. Risk Factors for CAD Modifiable risk factors Lipoproteins HDLs - high density LDLs - low density VLDLs - very low density Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

17. Risk Factors for CAD Modifiable risk factors Lipoproteins HDLs – high levels desirable HDLs – low levels associated with risk for CAD Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

18. Risk Factors for CAD Modifiable risk factors Lipoproteins 2 types of HDLs: HDL 2 and HDL 3 Premenopausal women have 3x times HDL 2 compared to men After menopause HDL 2 levels similar to men Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

19. Risk Factors for CAD Modifiable risk factors Lipoproteins HDLs increased by  Exercise  Moderate alcohol intake  Estrogen administration Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

20. Risk Factors for CAD Modifiable risk factors Lipoproteins Elevated LDL and VLDL levels correlate most closely with increased incidence of CAD Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

21. Risk Factors for CAD Modifiable risk factors Hypertension: BP > 140/90 Increases risk of atherosclerosis Salt intake is correlated with BP Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

22. Risk Factors for CAD Modifiable risk factors Tobacco use Nicotine can cause catecholamine release HR, peripheral vasoconstriction, BP platelet adhesion leading to emboli formation Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

23. Risk Factors for CAD Modifiable risk factors Physical inactivity People who are active have HDLs Exercise Increases collateral circulation Lowers BP Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

24. Risk Factors for CAD Modifiable risk factors Obesity: BMI > 30 kg/m 2 Leads to increased LDLs and triglycerides Associated with hypertension Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

25. Risk Factors for CAD Modifiable risk factors Obesity: BMI > 30 kg/m 2 People who are apple-shaped (store fat in abdomen) have higher incidence of CAD Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

26. Risk Factors for CAD Modifiable risk factors Diabetes mellitus Incidence of CAD 2-4x higher Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

27. Risk Factors for CAD Modifiable risk factors Psychologic states increase risk of CAD Include depression, hopelessness, anxiety, hostility, anger Stress correlated with CAD Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

28. Risk Factors for CAD Metabolic syndrome Obesity Elevated triglycerides Hypertension Abnormal serum lipids Elevated fasting blood glucose Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

29. Health Promotion Strategies Related to CAD Prevention and early treatment of CAD requires a multifactorial approach Obtain lipid profile every 5 years beginning at age 20 People with cholesterol > 200 mg/dl are at increased risk for CAD Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

30. Health Promotion Strategies Related to CAD If cholesterol > 200 mg/dl, start dietary modifications Calorie restrictions Decrease dietary fat/cholesterol Increase physical activity Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

31. Health Promotion Strategies Related to CAD Therapeutic Lifestyle Changes Diet - Limit saturated fats and cholesterol and emphasize complex carbohydrates Fats – only about 30% of calories Reduce or omit red meats, eggs, whole milk Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

32. Health Promotion Strategies Related to CAD Therapeutic Lifestyle Changes Omega-3 fatty acids Found in fatty fish (salmon, tuna) Reduce risk for CAD α-linolenic acid becomes omega-3 fatty acid in the body Foods containing it include tofu, soybeans, canola, flax seed Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

33. Health Promotion Strategies Related to CAD If LDL remains elevated, drug therapy is considered Guidelines are based on a person’s 10-yr history of having a nonfatal heart attack or dying from a coronary event Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

34. Health Promotion Strategies Related to CAD Drug Therapy Statins Inhibit synthesis of cholesterol in the liver Need to monitor liver enzymes Creatine kinase assessed if myopathy suspected Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

35. Health Promotion Strategies Related to CAD Drug Therapy Niacin Interferes with the synthesis of LDL and triglycerides Increases HDL Adverse effects include flushing, pruritus, GI complaints, orthostatic hypotension Flushing may be prevented by aspirin or NSAIDs Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

36. Health Promotion Strategies Related to CAD Drug Therapy Fibric acid derivatives (e.g., gemfibrozil [Lopid]) Decrease hepatic synthesis and secretion of VLDL Lower triglycerides Side effects may include rashes and mild GI disturbances Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

37. Health Promotion Strategies Related to CAD Drug Therapy Bile acid sequestrants (e.g., cholestyramine [Questran]) Increase conversion of cholesterol to bile acids Decrease hepatic cholesterol Side effects include complaints of palatability and upper and lower GI symptoms Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

38. Health Promotion Strategies Related to CAD Drug Therapy Inhibit the intestinal absorption of cholesterol (e.g., ezetimibe (Zetia) Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

39. Health Promotion Strategies Related to CAD Control blood pressure Limit salt (NaCl) to <6 g or sodium to <2.4 g Address smoking cessation Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

40. Health Promotion Strategies Related to CAD Increase physical activity: 30 min > 5 days/week Use the FITT approach: F requency I ntensity T ype T ime Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

41. Health Promotion Strategies Related to CAD Antiplatelet therapy ASA Clopidogrel (Plavix) Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

42. Health Promotion Strategies and Recommended Lifestyle Changes Risk screening begins with a thorough personal and family health history Attitudes and beliefs about health and illness should be explored Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

43. Health Promotion Strategies and Recommended Lifestyle Changes Realistic goals related to risk reduction should be identified Case scenario follows to provide an example of how this is accomplished Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

44. Case Scenario A 58-year-old white male is admitted for an elective knee replacement. On his admission history, you note that he is taking medication for hypertension. When asked, he tells you that he does not know what his BP usually is. His BMI is 40 kg/m 2 and his fasting blood glucose level is elevated. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

45. Case Scenario His job is very physical (he is a bricklayer). It has become more difficult due to his “bad knees.” He is worried that he will be fired. Apart from work, he does not participate in any regular physical activity and he does not smoke. He tells you that he has not had a check- up with his physician in several years. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

46. Health Promotion Strategies and Recommended Lifestyle Changes What are his nonmodifiable risk factors? Age Gender Ethnicity Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

47. Health Promotion Strategies and Recommended Lifestyle Changes What are his modifiable risk factors? Hypertension Physical inactivity Serum lipids??? Obesity Psychologic state Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

48. Health Promotion Strategies and Recommended Lifestyle Changes Summary High risk for developing CAD Discuss lifestyle changes: diet and exercise Consider low dose aspirin Follow-up with primary care physician Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.