The Heart of HealthThe Heart of HealthThe Heart of HealthThe Heart of Health

Molly Ware, MDMolly Ware, MDBoulder HeartBoulder Heart

Boulder Community HospitalBoulder Community Hospital303-442-2395303-442-2395

Molly Ware, MDMolly Ware, MDBoulder HeartBoulder Heart

Boulder Community HospitalBoulder Community Hospital303-442-2395303-442-2395

TopicsTopics

EpidemiologyEpidemiologyMechanism of diseaseMechanism of diseaseScreening for disease: classic and Screening for disease: classic and

newer risk factors and testsnewer risk factors and testsGuidelines for prevention of heart Guidelines for prevention of heart

disease: the importance of lifestyledisease: the importance of lifestyleDiagnostic testsDiagnostic tests

EpidemiologyEpidemiologyMechanism of diseaseMechanism of diseaseScreening for disease: classic and Screening for disease: classic and

newer risk factors and testsnewer risk factors and testsGuidelines for prevention of heart Guidelines for prevention of heart

disease: the importance of lifestyledisease: the importance of lifestyleDiagnostic testsDiagnostic tests

The Numbers The Numbers

Heart disease is the most common cause of Heart disease is the most common cause of death in the USdeath in the US

17.6 million people have coronary disease17.6 million people have coronary disease One death per minuteOne death per minute 1/3 of all deaths over age 351/3 of all deaths over age 35 Over age 40, risk of developing disease is 49% in Over age 40, risk of developing disease is 49% in

men, 32% in womenmen, 32% in women

Heart disease is the most common cause of Heart disease is the most common cause of death in the USdeath in the US

17.6 million people have coronary disease17.6 million people have coronary disease One death per minuteOne death per minute 1/3 of all deaths over age 351/3 of all deaths over age 35 Over age 40, risk of developing disease is 49% in Over age 40, risk of developing disease is 49% in

men, 32% in womenmen, 32% in women

The NumbersThe Numbers

Since 1984, more cardiovascular Since 1984, more cardiovascular deaths in women than in mendeaths in women than in men

80% of people with sudden cardiac 80% of people with sudden cardiac death had no prior symptomsdeath had no prior symptoms

Younger people are affected too!Younger people are affected too!

Since 1984, more cardiovascular Since 1984, more cardiovascular deaths in women than in mendeaths in women than in men

80% of people with sudden cardiac 80% of people with sudden cardiac death had no prior symptomsdeath had no prior symptoms

Younger people are affected too!Younger people are affected too!

Heart Disease Heart Disease

Problems with the arteries Problems with the arteries Problems with the valvesProblems with the valvesProblems with the rhythmProblems with the rhythmProblems with the heart muscle function Problems with the heart muscle function

(usually caused by one of the above)(usually caused by one of the above)

Problems with the arteries Problems with the arteries Problems with the valvesProblems with the valvesProblems with the rhythmProblems with the rhythmProblems with the heart muscle function Problems with the heart muscle function

(usually caused by one of the above)(usually caused by one of the above)

Symptoms Symptoms

SymptomsSymptoms

Chest pain: pressure, tightness, Chest pain: pressure, tightness, burningburning

Shortness of breathShortness of breathJaw, neck, arm, back painJaw, neck, arm, back painNausea/vomitingNausea/vomitingSweatingSweatingFatigue, weakness, lightheadednessFatigue, weakness, lightheadednessTrouble sleeping, uneasinessTrouble sleeping, uneasiness

Chest pain: pressure, tightness, Chest pain: pressure, tightness, burningburning

Shortness of breathShortness of breathJaw, neck, arm, back painJaw, neck, arm, back painNausea/vomitingNausea/vomitingSweatingSweatingFatigue, weakness, lightheadednessFatigue, weakness, lightheadednessTrouble sleeping, uneasinessTrouble sleeping, uneasiness

From: Microemboli and Microvascular Obstruction in Acute Coronary Thrombosis and Sudden Coronary Death: Relation to Epicardial Plaque Histopathology

J Am Coll Cardiol. 2009;54(23):2167-2173. doi:10.1016/j.jacc.2009.07.042

Coronary Artery Occlusion From Eroded Plaque

Epicardial coronary arteries with occlusive macroscopic thrombus (A to C) due to plaque erosion. Longitudinal sections (A, B, and C) and transaxial sections from a different vessel (D, E, and F) show the deep lipid core is not exposed. Immunostains of the thrombus for platelet (CD61, B and E) and fibrin (C and F) components reveal that the typical thrombus frequently is a mixed platelet-fibrin mixture. Images are from patients not included in the study, but illustrate typical coronary thrombus in sudden death due to plaque erosion. CD61 immunostain shows platelets within the thrombus are diffusely scattered throughout (slender arrow in B); junction between thrombus and the arterial plaque (thick arrow in B). The ‘cap’ of this thrombus is very fibrin-rich (arrow in C).

Figure Legend:

What is a Heart Attack? What is a Heart Attack?

Key role of inflammationKey role of inflammationUnstable plaqueUnstable plaqueTriggering eventTriggering event

Spike in blood pressureSpike in blood pressure Fatty mealFatty meal Mental stress Mental stress Physical stressPhysical stress

Key role of inflammationKey role of inflammationUnstable plaqueUnstable plaqueTriggering eventTriggering event

Spike in blood pressureSpike in blood pressure Fatty mealFatty meal Mental stress Mental stress Physical stressPhysical stress STRESS HORMONES

Are You at Risk? Are You at Risk?

Screening = detection of disease before Screening = detection of disease before it causes an event it causes an event

Diagnosis = confirmation of diseaseDiagnosis = confirmation of disease

Screening = detection of disease before Screening = detection of disease before it causes an event it causes an event

Diagnosis = confirmation of diseaseDiagnosis = confirmation of disease

Goal: prevent eventsGoal: prevent events

Are You at Risk? Are You at Risk?

Classic cardiac risk factorsClassic cardiac risk factors:: High blood pressure (even if treated)High blood pressure (even if treated) High cholesterolHigh cholesterol DiabetesDiabetes SmokingSmoking Family history of early heart diseaseFamily history of early heart disease Age > 55 for women, >45 for menAge > 55 for women, >45 for men ObesityObesity Lack of exercise and poor exercise toleranceLack of exercise and poor exercise tolerance Chronic kidney diseaseChronic kidney disease

Classic cardiac risk factorsClassic cardiac risk factors:: High blood pressure (even if treated)High blood pressure (even if treated) High cholesterolHigh cholesterol DiabetesDiabetes SmokingSmoking Family history of early heart diseaseFamily history of early heart disease Age > 55 for women, >45 for menAge > 55 for women, >45 for men ObesityObesity Lack of exercise and poor exercise toleranceLack of exercise and poor exercise tolerance Chronic kidney diseaseChronic kidney disease

Are You at Risk? Are You at Risk?

Newer cardiac risk factorsNewer cardiac risk factors

Add to classic risk factorsAdd to classic risk factorsCan further refine riskCan further refine risk

Newer cardiac risk factorsNewer cardiac risk factors

Add to classic risk factorsAdd to classic risk factorsCan further refine riskCan further refine risk

Newer Screening Tools Newer Screening Tools

Coronary artery calcium scoring Coronary artery calcium scoring Advanced cholesterol testingAdvanced cholesterol testing

Lp(a), particle size/particle numberLp(a), particle size/particle numberMeasures of inflammation (hs-CRP)Measures of inflammation (hs-CRP)

(hs-CRP naturally higher in women)(hs-CRP naturally higher in women)Carotid artery thickness by ultrasound Carotid artery thickness by ultrasound

Coronary artery calcium scoring Coronary artery calcium scoring Advanced cholesterol testingAdvanced cholesterol testing

Lp(a), particle size/particle numberLp(a), particle size/particle numberMeasures of inflammation (hs-CRP)Measures of inflammation (hs-CRP)

(hs-CRP naturally higher in women)(hs-CRP naturally higher in women)Carotid artery thickness by ultrasound Carotid artery thickness by ultrasound

Ultrasound of the Carotid Artery

Image of Carotid Artery

Other Links to Heart DiseaseOther Links to Heart Disease

Low Vitamin DLow Vitamin D

Obstructive Sleep ApneaObstructive Sleep Apnea

Other vascular disorders:Other vascular disorders: Raynaud’s, migraineRaynaud’s, migraine Autoimmune Autoimmune

Low Vitamin DLow Vitamin D

Obstructive Sleep ApneaObstructive Sleep Apnea

Other vascular disorders:Other vascular disorders: Raynaud’s, migraineRaynaud’s, migraine Autoimmune Autoimmune

Other Links to Heart DiseaseOther Links to Heart Disease

HIV infectionHIV infection

History of chest radiationHistory of chest radiation

GoutGout

History of pregnancy complications: high blood History of pregnancy complications: high blood pressure, pre-eclampsia gestational diabetespressure, pre-eclampsia gestational diabetes

Polycystic ovarian diseasePolycystic ovarian disease

HIV infectionHIV infection

History of chest radiationHistory of chest radiation

GoutGout

History of pregnancy complications: high blood History of pregnancy complications: high blood pressure, pre-eclampsia gestational diabetespressure, pre-eclampsia gestational diabetes

Polycystic ovarian diseasePolycystic ovarian disease

Who Should be Screened? Who Should be Screened?

Everybody should know their numbers!All people should be asked about

classic risk factors“In the middle” people could consider

additional screeningWe ALL need to focus on primary

prevention

Everybody should know their numbers!All people should be asked about

classic risk factors“In the middle” people could consider

additional screeningWe ALL need to focus on primary

prevention

Know those numbers Know those numbers

Blood pressure 120/80Blood pressure 120/80LDL cholesterol <100LDL cholesterol <100HDL cholesterol > 50 HDL cholesterol > 50 Triglycerides < 150Triglycerides < 150Non HDL cholesterol <130Non HDL cholesterol <130BMI 18.5-24.9 (kg/m2)BMI 18.5-24.9 (kg/m2)Waist < 35 inches female or 40 maleWaist < 35 inches female or 40 maleDiabetes: hemoglobin A1C <7%Diabetes: hemoglobin A1C <7%

Blood pressure 120/80Blood pressure 120/80LDL cholesterol <100LDL cholesterol <100HDL cholesterol > 50 HDL cholesterol > 50 Triglycerides < 150Triglycerides < 150Non HDL cholesterol <130Non HDL cholesterol <130BMI 18.5-24.9 (kg/m2)BMI 18.5-24.9 (kg/m2)Waist < 35 inches female or 40 maleWaist < 35 inches female or 40 maleDiabetes: hemoglobin A1C <7%Diabetes: hemoglobin A1C <7%

New Risk Algorithm New Risk Algorithm

ASCVD pooled cohort2013 Lipid Mangement GuidelinesGender, age, race, total cholesterol,

HDL, Systolic BP, on BP meds, diabetes, smoker

High risk = >7.5% chance of developing heart disease over next 10 years

ASCVD pooled cohort2013 Lipid Mangement GuidelinesGender, age, race, total cholesterol,

HDL, Systolic BP, on BP meds, diabetes, smoker

High risk = >7.5% chance of developing heart disease over next 10 years

Our bodies are meant to exercise

Our bodies are meant to exercise

Check with your doctor . . . Check with your doctor . . .

Then go for it! At least 30 minutes of Then go for it! At least 30 minutes of moderate activity MOST days of the weekmoderate activity MOST days of the week

Some is better than noneSome is better than none

More is better than lessMore is better than less

Strength training has a BIG roleStrength training has a BIG role

Check with your doctor . . . Check with your doctor . . .

Then go for it! At least 30 minutes of Then go for it! At least 30 minutes of moderate activity MOST days of the weekmoderate activity MOST days of the week

Some is better than noneSome is better than none

More is better than lessMore is better than less

Strength training has a BIG roleStrength training has a BIG role

Duke Treadmill Score Predicts Survival

What about Hormones? What about Hormones?

Naturally occurring hormones are Naturally occurring hormones are protectiveprotective

Menopause: metabolic changes Menopause: metabolic changes including decreased HDLincluding decreased HDL

Women’s Health Initiative (2002)Women’s Health Initiative (2002)

Naturally occurring hormones are Naturally occurring hormones are protectiveprotective

Menopause: metabolic changes Menopause: metabolic changes including decreased HDLincluding decreased HDL

Women’s Health Initiative (2002)Women’s Health Initiative (2002)

Women’s Health Initiative

What about Hormones What about Hormones

Concerns: increased risk heart attack, Concerns: increased risk heart attack, stroke, blood clots, breast cancerstroke, blood clots, breast cancer

For symptoms only (ages 50-59)For symptoms only (ages 50-59)Lowest dose possibleLowest dose possibleShortest time possible ( <5 years)Shortest time possible ( <5 years)Do not use if cardiac eventDo not use if cardiac eventPatch preparations and plant-derived Patch preparations and plant-derived

compounds may carry less riskcompounds may carry less risk

Concerns: increased risk heart attack, Concerns: increased risk heart attack, stroke, blood clots, breast cancerstroke, blood clots, breast cancer

For symptoms only (ages 50-59)For symptoms only (ages 50-59)Lowest dose possibleLowest dose possibleShortest time possible ( <5 years)Shortest time possible ( <5 years)Do not use if cardiac eventDo not use if cardiac eventPatch preparations and plant-derived Patch preparations and plant-derived

compounds may carry less riskcompounds may carry less risk

What Should I Eat? What Should I Eat?

Joshipura KJ et al. Ann Intern Med 2001;134:1106-1114

Nurses’ Health Study and Health Professional’s Follow-up Study

*Includes nonfatal MI and fatal coronary heart disease

CV=Cardiovascular

Diet Evidence:Diet Evidence:Benefits of Fruits and VegetablesBenefits of Fruits and Vegetables

126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes*

Increased fruit and vegetable intake reduces CV risk

ENHANCEMENT ENHANCEMENT (not deprivation)(not deprivation) ENHANCEMENT ENHANCEMENT (not deprivation)(not deprivation)

Do not read food labels Do not read food labels

Think: Think: high fiberhigh fiber

Think: Think: unprocessedunprocessed

Think: Think: low glycemic indexlow glycemic index

Think: Think: high quality proteinhigh quality protein

Think: Think: high fiberhigh fiber

Think: Think: unprocessedunprocessed

Think: Think: low glycemic indexlow glycemic index

Think: Think: high quality proteinhigh quality protein

Fat is not the enemy Fat is not the enemy Eat “fatty” fish (5-6 oz per week)Eat “fatty” fish (5-6 oz per week)

Salmon, mackerel, herring, tuna, sardinesSalmon, mackerel, herring, tuna, sardines

Consider fish oil supplements (mercury free)Consider fish oil supplements (mercury free) 500-4000 mg EPA and DHA500-4000 mg EPA and DHA

ALA acids for vegetariansALA acids for vegetarians Almonds, walnuts, canola oil, flaxseedAlmonds, walnuts, canola oil, flaxseed

Monounsaturated fats: Monounsaturated fats: olive oil, nuts, avocadoesolive oil, nuts, avocadoes

And did I mention nuts . . . . And did I mention nuts . . . .

Eat “fatty” fish (5-6 oz per week)Eat “fatty” fish (5-6 oz per week) Salmon, mackerel, herring, tuna, sardinesSalmon, mackerel, herring, tuna, sardines

Consider fish oil supplements (mercury free)Consider fish oil supplements (mercury free) 500-4000 mg EPA and DHA500-4000 mg EPA and DHA

ALA acids for vegetariansALA acids for vegetarians Almonds, walnuts, canola oil, flaxseedAlmonds, walnuts, canola oil, flaxseed

Monounsaturated fats: Monounsaturated fats: olive oil, nuts, avocadoesolive oil, nuts, avocadoes

And did I mention nuts . . . . And did I mention nuts . . . .

Supplemental Information Supplemental Information

A varied diet rich in lean protein, good A varied diet rich in lean protein, good fats, and vegetables is the best defensefats, and vegetables is the best defense

Vitamin D -- possiblyVitamin D -- possiblyCalcium: 700-1000 mg dailyCalcium: 700-1000 mg dailyVitamin E, high dose Vitamin C, beta Vitamin E, high dose Vitamin C, beta

carotene, and folate no clear benefitcarotene, and folate no clear benefitFolate is important for women who are Folate is important for women who are

pregnant or may become pregnantpregnant or may become pregnant

A varied diet rich in lean protein, good A varied diet rich in lean protein, good fats, and vegetables is the best defensefats, and vegetables is the best defense

Vitamin D -- possiblyVitamin D -- possiblyCalcium: 700-1000 mg dailyCalcium: 700-1000 mg dailyVitamin E, high dose Vitamin C, beta Vitamin E, high dose Vitamin C, beta

carotene, and folate no clear benefitcarotene, and folate no clear benefitFolate is important for women who are Folate is important for women who are

pregnant or may become pregnantpregnant or may become pregnant

Visit Your Dentist Visit Your Dentist

And your heart will be happy And your heart will be happy

Less Stress = Big Plus Less Stress = Big Plus

Heart attacks are less frequent in the summer

UptoDate

For some people . . .For some people . . .

Statins and other cholesterol Statins and other cholesterol medicationsmedications

Blood pressure medicinesBlood pressure medicinesDiabetes medicinesDiabetes medicinesAspirinAspirin

High risk: 75-325 mg dailyHigh risk: 75-325 mg daily Low risk: over age 65/55 consider aspirin Low risk: over age 65/55 consider aspirin

if low bleeding riskif low bleeding risk

Statins and other cholesterol Statins and other cholesterol medicationsmedications

Blood pressure medicinesBlood pressure medicinesDiabetes medicinesDiabetes medicinesAspirinAspirin

High risk: 75-325 mg dailyHigh risk: 75-325 mg daily Low risk: over age 65/55 consider aspirin Low risk: over age 65/55 consider aspirin

if low bleeding riskif low bleeding risk

Tip the Scales in Your Favor Tip the Scales in Your Favor

Diagnostic Tests Diagnostic Tests

Stress testsCardiac catheterization (angiogram)Noninvasive angiogram

Stress testsCardiac catheterization (angiogram)Noninvasive angiogram

Noninvasive Coronary AngiogramNoninvasive Coronary Angiogram

If you have heart disease If you have heart disease

Keep working on your risk factors!Keep working on your risk factors! Lifestyle change as important as Lifestyle change as important as

medicationsmedicationsRegular follow up with your doctorRegular follow up with your doctorCardiac rehabilitation programs -- great Cardiac rehabilitation programs -- great

confidence buildersconfidence builders

Keep working on your risk factors!Keep working on your risk factors! Lifestyle change as important as Lifestyle change as important as

medicationsmedicationsRegular follow up with your doctorRegular follow up with your doctorCardiac rehabilitation programs -- great Cardiac rehabilitation programs -- great

confidence buildersconfidence builders

Resources Resources

Your primary health care professionalYour primary health care professional

www.womensheart.orgwww.womensheart.org

American Heart Association website: American Heart Association website: www.americanheart.org

www.nhbli.nih.gov/health/hearttruthwww.nhbli.nih.gov/health/hearttruth

Younger Next YearYounger Next Year by Henry Lodge, MD and Chris by Henry Lodge, MD and Chris CrowleyCrowley

Eat to LiveEat to Live by Joel Furhman, MD by Joel Furhman, MD

Your primary health care professionalYour primary health care professional

www.womensheart.orgwww.womensheart.org

American Heart Association website: American Heart Association website: www.americanheart.org

www.nhbli.nih.gov/health/hearttruthwww.nhbli.nih.gov/health/hearttruth

Younger Next YearYounger Next Year by Henry Lodge, MD and Chris by Henry Lodge, MD and Chris CrowleyCrowley

Eat to LiveEat to Live by Joel Furhman, MD by Joel Furhman, MD