Cardiovascular Disease: Prevention and Treatment

1
Cardiovascular Disease Prevention and Treatment
2
Dietary Factors that Affect Blood Lipids
3
Saturated Fatty Acids

• Elevate blood cholesterol in all lipoprotein
  fractions (LDL and HDL) when substituted for CHO
  or other fatty acids
• Dose-response between SFA and LDL-C
• For every 1 of energy intake increase in sfa
  plasma cholesterol increases 2.7
• Most hypercholesterolemic sfas are lauric (C120)
  myristic (C140) and palmitic (C160) (palmitic
  is 60 of sfa intake)
• Stearic (C180) is neutral

4
Saturated Fatty Acids

• The most hypercholesterolemic fats are palm
  kernel coconut and palm oils lard and butter
• SFAs also associated with CAD progression milk
  cheese butter lamb bakery goods fast foods
  snacks
• Average American intake is 11 of kcals

5
Polyunsaturated Fatty Acids

• If CHO is replaced by linoleic acid (C182) LDL-C
  and HDL-C
• When SFA is replaced by PUFA in a low fat diet
  both LDL and HDL
• Eliminating SFA is twice as effective in lowering
  cholesterol as PUFA
• A 1 increase in PUFA TC by 1.4 mg/dl

6
Polyunsaturated Fatty Acids

• Major source of omega-6 PUFAs are vegetable oils
  salad dressings and margarines made with the oil
• U.S. population intake 7 of calories
• Large amounts may increase LDL oxidation

7
Omega-3 Polyunsaturated Fatty Acids EPA DHA

• Found in fish oils fish oil capsules and ocean
  fish (eicosapentaenoic and docosahexaenoic acid)
• Do not affect TC may LDL-C (5-10) and
  decrease TG (25-30) especially in patients with
  high TG
• Anticoagulant effect
• Decrease vasoconstriction
• Improve endothelial dysfunction
• Reduce inflammation

8
Omega-3 Fatty Acids ALA

• Alpha-linolenic acid
• An essential fatty acid
• Shorter-chain found in various plant sources such
  as flax canola walnuts and soy
• Benefits less clear may protect against CVD by
  reducing inflammation

9
Omega-3 Fatty Acids

• Consumption of fish and fish oils rich in EPA
  DHA will lower cholesterol LDL and TG and
  reduce sudden cardiac death
• One fatty fish meal/week resulted in 50 decrease
  in risk of cardiac arrest
• 1 g supplement of omega-3 daily reduced risk of
  CVD nonfatal MI nonfatal stroke

10
Cis-Monounsaturated Fat

• Naturally occurring monounsaturated fat
• Found in olive oil canola oil avocado olives
  pecans peanuts and other nuts
• Oleic acid is the most prevalent MFA in the US
  diet

11
Cis-Monounsaturated Fat

• When fat is replaced by CHO it lowers HDL as
  well as LDL-C
• When sfa is replaced by mfa lowers LDL-C without
  lowering HDL-C
• When substituted for carbohydrate mfa reduces
  serum triglyceride levels
• Can recommend a higher fat diet if much of the
  fat comes from mfa

12
Cis-Monounsaturated Fat

• Mediterranean diet high in fat especially MFA
  (olive oil) fish nuts low in red meat
  associated with risk of CVD
• Emphasizes fruits root vegetables flax canola
• High fat diets should be used with caution

13
Mediterranean vs Standard AHA Low Fat Diet

• Subjects 202 post-MI patients
• 50 put on AHA lowfat diet (30 fat)
• 51 on Mediterranean (40 fat fish 3-5
  times/week olive oil avocado)
• Both limited to 7 SFA and 200 mg cholesterol/day
• Both groups received two individual diet
  counseling sessions in the first month and six
  group sessions over the next two years.
• 101 controls given advice in the hospital

Tuttle et al presented at ACC meeting New
Orleans 3-07
14
Mediterranean vs Standard AHA Low Fat Diet

• After 4 years 83 of those on either therapeutic
  diet had survived without problems cholesterol
  profile improved in both groups
• People on either diet had one-third the risk of
  suffering another heart attack a stroke death
  or other heart problem as controls
• Those on Mediterranean diet found it harder to
  stick to ( fish olive oil)
• 53 of control patients survived without
  problems cholesterol profile did not improve

15
Trans-Monounsaturated Fats

• Produced in the hydrogenation process
• Commonly used in the food industry to harden
  unsaturated oils and soft margarines
• 50 of trans-fatty acids come from animal foods
  (beef butter milk fats)
• Major foods sources in US are stick margarine
  shortening commercial frying fats high fat
  baked goods

16
Trans Fatty Acids

• Elaidic acid (trans-isomer of oleic acid) raises
  blood cholesterol compared with PUFA
• Has less of a cholesterol raising effect than sfa
• Lowers HDL

17
Margarine vs Butter

• The combined amount of saturated fat and trans
  fat in butter is higher than that in margarine
• Soft or liquid margarine is the preferred spread
• Average intake of trans fats is 7-8 of total fat
  intake
• Choose lowfat desserts dairy products meats
  will lower trans fatty acid intakes

18
Fat Type Per Serving
Source FDA http//www.cfsan.fda.gov/dms/qatrans2
.html
19
Effects of Various Dietary Fat Sources on TCHDL
Ratio
Mensink RP et al. AJCN 2003771146-1155.
20
Total Fat Content of Diet

• High fat diets are associated with obesity which
  increases the risk of CHD
• Low fat diets (lt25 of kcals from fat) raise
  triglycerides and lower HDL however these
  changes are not associated with risk
• Low fat diets lower LDL only when they are low in
  sfa
• AHA total fat lt30 of kcals
• ATP III 25-35 of kcals from fat

21
Dietary Cholesterol

• Dietary cholesterol raises total and
  LDL-cholesterol but less than sfa
• A 25 mg increase in dietary cholesterol raises
  serum cholesterol 1 mg/dl
• At 500 mg intake increments are even less
  appears to be a threshold for response
• TLC guidelines lt200 mg/day
• AHA guidelines lt300 mg/day

22
Dietary Cholesterol

• Response to dietary cholesterol is highly
  variable hyper-responders may have poor rates of
  conversion of cholesterol to bile acids
• Dietary intakes of cholesterol have been
  declining since the 1960s
• Intake acts synergistically with sfa positively
  related to CHD risk

23
Fiber

• Soluble fibers (pectins gums mucilages algal
  polysaccharides some hemicelluloses) in legumes
  oats fruit and psyllium lower serum cholesterol
  and LDL-C
• Quantity needed varies by food (more legumes than
  pectins or gums)

24
Fiber

• Average decline in LDL-C is 14 for
  hypercholesterolemics and 10 for
  normocholesterolemics when soluble fiber is added
  to a low fat diet
• Fiber may bind bile acids which lowers serum
  cholesterol to replete the bile acid pool

25
Fiber

• Insoluble fibers have no effect (celluloses and
  lignin)
• Of total fiber (25-30 grams) 6 to 10 grams should
  be from soluble fiber
• Can be achieved with 5 or more servings of fruits
  or vegetables a day and 6 or more servings of
  whole grains and high-fiber cereals

26
Alcohol

• Affects total triglyceride and HDL-C
• Effects on TG are dose dependent and are greater
  in persons with TGgt150 mg/dl
• Moderate alcohol consumption has been associated
  with decreased risk of MI and CHD mortality in
  white men
• Alcohol raises both HDL2 and HDL3 subfractions
• Current intake in US is 2 of total kcals
• No increase is recommended to decrease CHD risk

27
Coffee

• Mixed results in studies on effect of coffee on
  lipids
• Heavy intake of regular coffee (720 ml) causes
  minor increases in TC (9 mg/dl) LDL-C (6 mg/dl)
  and HDL-C (4 mg/dl)
• Boiled coffee (European) produces greater
  elevations than filtered coffee

28
Coffee

• Large population studies have failed to find
  associations between coffee consumption and CHD
  incidence or mortality
• Coffee drinkers consume more saturated fat and
  cholesterol smoked more cigarettes and were
  less likely to exercise

29
Antioxidants

• Antioxidants have been studied for possible role
  in preventing oxidation of LDL-C
• Epidemiological studies suggest vitamin E and
  carotenoids are inversely related to CVD but
  randomized trials have not supported this
• Vitamin E no primary or secondary prevention
  trials show positive effect
• B-carotene supplements appear to have no benefits
• Use food sources

30
Calcium

• Supplementation produces small decreases in LDL-C
  in hypercholesterolemic men
• May form insoluble soaps with fatty acids

31
Soy Protein

• Substituting soy protein lowers TC (9) and LDL-C
  (13) and TG (11) with no effect on HDL-C
• Effect in addition to a Step 1 diet occurs only
  in persons with hypercholesterolemia
• Dose response
• Daily intake of 25 g of soy will lower LDL-C by 4
  to 8 in hypercholesterolemic persons

32
Stanols/Sterols

• Isolated from soybean oils or pine tree oil
• Lowers blood cholesterol
• Esterified and made into margarines
• Consuming 2-3 grams/day lowers cholesterol by
  9-20 in persons with hypercholesterolemia
• Inhibits absorption of dietary cholesterol

33
Stanols/Sterols
34
Nuts

• Tree nuts can reduce risk of CHD via
  lipid-lowering effects
• Peanuts also cardioprotective
• Almonds hazelnuts pecans pistachio nuts and
  walnuts modestly reduce serum cholesterol
• Nuts are a rich source of fiber vitamin E
  magnesium and MUFA and PUFA
• ALA in walnuts arginine and antioxidant and
  antithrombotic effects
• May reduce insulin resistance

35
Nuts

• Epidemiological evidence suggests an inverse
  relationship between nut consumption and CHD risk
  and type 2 diabetes
• Nurses Health Study women who ate 5 servings
  lowered risk of CHD by 45

36
Nuts

• Recommend 1 to 2 ounces of nuts (1 to 2 large
  handfuls) in place of other sources of energy
• Choose unsalted roasted or raw nuts

37
AHA 2006 Diet/Lifestyle Recommendations for CVD
Risk Reduction

• These recommendations apply to the general public
  for primary prevention and can be used clinically
• New focus on weight management
• More focus on practical strategies for
  implementation

38
AHA 2006 Diet/Lifestyle Recommendations for CVD
Risk Reduction

• Balance calorie intake and physical activity to
  achieve or maintain a healthy body weight.
• Consume a diet rich in vegetables and fruits
• Choose whole-grain high-fiber foods
• Consume fish especially oily fish at least
  twice a week

Circulation 200611482-96
39
AHA 2006 Diet/Lifestyle Recommendations for CVD
Risk Reduction

• Limit your intake of SFA to lt7 of energy trans
  fat to lt1 of energy cholesterol to lt300 mg/day
  by
• Choosing lean meats and vegetable alternatives
• Selecting fat-free (skim) 1-fat and lowfat
  dairy products and
• Minimizing intake of partially hydrogenated fats

Circulation 200611482-96
40
AHA 2006 Diet and Lifestyle Recommendations for
CVD Risk Reduction

• Minimize your intake of beverages and foods with
  added sugars
• Choose and prepare foods with little or no salt
• If you consume alcohol do so in moderation
• When you eat food that is prepared outside of the
  home follow the AHA Diet and Lifestyle
  Recommendations

Circulation 200611482-96
41
Implementation 2006 AHA Diet/Lifestyle Guidelines

• Know your calorie needs to achieve and maintain a
  healthy weight
• Know the calorie content of the foods and
  beverages you consume
• Track your weight physical activity and calorie
  intake
• Prepare and eat smaller portions
• Track and when possible decrease screen time

Circulation 200611482-96
42
Implementation 2006 AHA Diet/Lifestyle Guidelines

• Incorporate physical movement into habitual
  activities
• Do not smoke or use tobacco products
• If you consume alcohol do so in moderation (1
  drink/day in women 2 in men)

Circulation 200611482-96
43
Implementation 2006 AHA Diet/Lifestyle Guidelines

• Use the nutrition facts panel and ingredients
  list when choosing foods to buy
• Eat fresh frozen and canned vegetables and
  fruits without high-calorie sauces and added salt
  and sugars
• Replace high-calorie foods with fruits and
  vegetables
• Increase fiber intake by eating beans whole
  grain products fruits and vegetables

Circulation 200611482-96
44
Implementation 2006 AHA Diet/Lifestyle Guidelines

• Use liquid vegetable oils in place of solid fats
• Limit beverages and foods high in added sugars
  (fructose sucrose glucose maltose dextrose
  corn syrups concentrated fruit juice and honey
• Choose foods made with whole grains
• Cut back on pastries and high-calorie bakery
  products (e.g. muffins doughnuts)

Circulation 200611482-96
45
Implementation 2006 AHA Diet/Lifestyle Guidelines

• Select milk and dairy products that are either
  fat free or lowfat
• Reduce salt intake by
• Comparing the sodium content of similar products
  and choosing those with less
• Choosing processed foods including cereals and
  baked goods that are reduced in salt
• Limiting condiments e.g. soy sauce catsup

Circulation 200611482-96
46
Implementation 2006 AHA Diet/Lifestyle Guidelines

• Use lean cuts of meat and remove skin from
  poultry before eating
• Limit processed meats that are high in saturated
  fat and sodium
• Grill bake or broil fish meat and poultry
• Incorporate vegetable-based meat substitutes into
  favorite recipes
• Encourage the consumption of whole vegetables and
  fruits in place of juices

Circulation 200611482-96
47
AHA on Antioxidant Supplements

• Antioxidant vitamin supplements or other
  antioxidants such are selenium are not
  recommended
• Although observational studies suggest that high
  intakes of antioxidant vitamins from food and
  supplements are associated with lower risk of
  CVD intervention trials have not confirmed this

Circulation 200611482-96
48
Antioxidant Supplements

• Trials have documented potential harm e.g.
  higher risk of lung cancer with beta-carotene
  supplements in smokers and increased risk of
  heart failure and total mortality from high dose
  vitamin E supplements
• Although supplements are not recommended food
  sources of antioxidant nutrients are

Circulation 200611482-96
49
AHA on Soy Protein

• Evidence of a direct cardiovascular health
  benefit from consuming soy protein is minimal
• However there may be some benefit if soy protein
  is used to replace animal and dairy products that
  contain SFA and cholesterol

Circulation 200611482-96
50
AHA on Folate and Other B Vitamins

• Evidence is inadequate to recommend folate and
  other B vitamins to reduce heart disease risk
• Folate intake and B6 and B12 are inversely
  associated with serum homocysteine levels which
  are associated with increased risk of CVD
• Trials of homocysteine-reducing vitamin therapy
  have been disappointing

Circulation 200611482-96
51
AHA on Fish Oil Supplements

• Fish intake is associated with decreased risk of
  CVD
• Patients without documented CHD eat fish
  preferably oil fish twice a week
• Patients with documented CVD should consume 1
  gram of EPA DHA per day preferably from oily
  fish though supplements can be considered with
  physician input

Circulation 200611482-96
52
Fish Oil Supplements

• For persons with hypertriglyceridemia 2 to 4 g
  of EPA DHA per day provided as capsules under
  a physicians care are recommended.

Circulation 200611482-96
53
Adult Treatment Panel III (NCEP 2001)

• First published guidelines 2001
• Update published 2004
• Raises diabetes as an important risk factor for
  CHD
• Uses Framingham projections of 10-year absolute
  risk to identify patients for more intensive
  treatment
• Identifying persons with multiple metabolic risk
  factors as candidates for therapeutic lifestyle
  changes

Circulation 2004110227-239
54
ATP III

• Targets LDL-C first with TLC
• When LDL-C goals are met treat metabolic
  syndrome by increasing physical activity and
  decreasing energy intake to facilitate weight loss

55
ATP III Risk Factors That Modify LDL Goals

• Cigarette smoking
• Hypertension gt140/90 mmHg or on medication
• Low HDL-C (lt40 mg/dl)
• Family history of premature CHD (male first
  degree relativelt55 femalelt65)
• Age (men gt45 years women gt55 years

56
LDL-C Goals and Cutpoints for TLCand Drug
Therapy by Risk Categories
57
Therapeutic Lifestyle Changes in LDL-Lowering
Therapy

• TLC Diet
• Reduced intake of cholesterol-raising nutrients
  (same as previous Step II Diet)
• Saturated fats lt7 of total calories
• Dietary cholesterol lt200 mg per day
• LDL-lowering therapeutic options
• Plant stanols/sterols (2 g per day)
• Viscous (soluble) fiber (1025 g per day)
• Weight reduction
• Increased physical activity

58
Steps in Therapeutic Lifestyle Changes
Visit N
6 wks
Q 4-6 mo
6 wks
MonitorAdherenceto TLC

• Emphasizereduction insaturated fat
  cholesterol
• Encouragemoderate physicalactivity
• Consider referral toa dietitian

• Reinforce reductionin saturated fat
  andcholesterol
• Consider addingplant stanols/sterols
• Increase fiber intake
• Consider referral toa dietitian

• Initiate Tx forMetabolicSyndrome
• Intensify weightmgt physical activity
• Consider referral to a dietitian

59
The Metabolic Syndrome as a Secondary Target of
Therapy

• Abdominal obesity
• Atherogenic dyslipidemia
• Elevated triglycerides
• Small LDL particles
• Low HDL cholesterol
• Raised blood pressure
• Insulin resistance ( glucose intolerance)
• Prothrombotic state
• Proinflammatory state

60
Therapeutic Lifestyle Changes (TLC)

• TLC Diet
• Saturated fat lt7 of calories cholesterol lt200
  mg/dal
• Consider increased viscous (soluble) fiber (10-25
  g/day) and plant stanols/sterols (2g/day)
• Weight management
• Increased physical activity

61
Nutrient Composition of TLC Diet

• Nutrient Recommended Intake
• Saturated fat Less than 7 of total calories
• Polyunsaturated fat Up to 10 of total calories
• Monounsaturated fat Up to 20 of total calories
• Total fat 2535 of total calories
• Carbohydrate 5060 of total calories
• Fiber 2030 grams per day
• Protein Approximately 15 of total calories
• Cholesterol Less than 200 mg/day
• Total calories (energy) Balance energy intake and
  expenditure to maintain desirable body
  weight

62
ATP III Recommendations Compared with the
American Diet
Carson JA Grundy SM VanHorn L Stone N. MNT in
prevention and management of coronary heart
disease. In Carson JS et al. Cardiovascular
Nutrition. Am Diet Assoc 2004
63
TLC Diet
64
TLC Healthy Cooking

• Bake steam roast broil stew or boil instead
  of frying
• Remove poultry skin before eating
• Use a nonstick pan with cooking oil spray or
  small amount of liquid vegetable oil instead of
  lard butter shortening other solid fats
• Trim visible fat before you cook meats
• Chill meat and poultry broth until fat becomes
  solid remove

65
TLC Diet Eat More

• Fresh frozen canned vegetables without added
  fat sauce salt
• Fresh frozen canned or dried fruit
• Nonfat ½ and low-fat milk buttermilk yogurt
  cheese
• Unsaturated oils soft or liquid margarines and
  spreads salad dressings seeds and nuts
• Lean cuts of meat extra lean hamburger fish
  meat alternatives made with soy or TVP
• Whole grain breads and cereals pasta rice
  potatoes dried beans and peas lowfat crackers
  pretzels cookies

66
TLC Diet Eat Less

• High-fat bakery products (doughnuts biscuits
  croissants pies cookies
• Chips cheese puffs snack mix regular crackers
  buttered popcorn
• Whole and reduced-fat milk and dairy products
  ice cream cream half and half cream cheese
  sour cream and cheese

67
TLC Diet Eat Less

• Whole eggs yolks
• Fatty meat such as ribs tbone steak regular
  hamburger bacon sausage salami hot dogs
  organ meats liver brains sweetbreads fried
  meat poultry and fish
• Butter shortening stick margarine chocolate
  tropical oils coconut palm and palm kernel

68
Dealing with Problem Foods

• Reduce the portion size
• Prepare the food more healthfully
• Reduce the frequency it is eaten
• Substitute a more healthful food for the problem
  food

69
TLC Healthy Shopping

• Choose chicken breast or drumstick instead of
  wing and thigh
• Select skim milk or 1 percent instead of 2
  percent or whole milk
• Buy lean cuts of meat such as round sirloin and
  loin
• Buy more vegetables fruits and grains
• Read nutrition labels on food packages

70
TLC Dining Out

• Choose restaurants that have low fat options
  available
• Ask that sauces gravies and salad dressings be
  served on the side
• Control portions by asking for an appetizer
  serving or sharing with a friend

71
TLC Dining Out

• At fast food restaurants go for salads grilled
  (not fried or breaded) skinless chicken
  sandwiches regular-sized hamburgers or roast
  beef sandwiches
• Avoid regular salad dressings and fatty sauces.
  Limit jumbo or deluxe burgers sandwiches french
  fries and other foods.

72
Lipid-Lowering DrugsAdded if Diets Are Not
Successful

• After a 6-month trial on each diet drugs are
  added to the treatment.
• Types
• Nicotinic acid and lovastatin
• Gemfibrozil probucol clofibratefor high TGs
• Cholestyramine and colestipol (bile acid
  sequestrants)to lower high cholesterol may
  increase TGs

73
HMG CoA Reductase Inhibitors (Statins)

• Reduce LDL-C 1855 TG 730
• Raise HDL-C 515
• Major side effects
• Myopathy
• Increased liver enzymes
• Contraindications
• Absolute liver disease
• Relative use with certain drugs

74
HMG CoA Reductase Inhibitors (Statins)

• Statin Dose Range
• Lovastatin 2080 mg
• Pravastatin 2040 mg
• Simvastatin 2080 mg
• Fluvastatin 2080 mg
• Atorvastatin 1080 mg
• Cerivastatin 0.40.8 mg

75
HMG CoA Reductase Inhibitors (Statins)
(continued)

• Demonstrated Therapeutic Benefits
• Reduce major coronary events
• Reduce CHD mortality
• Reduce coronary procedures (PTCA/CABG)
• Reduce stroke
• Reduce total mortality

76
Figure 35. Cholesterol-lowering statin drug
visits among adults 45 years of age and over by
sex United States 1995-2002
Men 65 years and over
Women 65 years and over
Men 45-64 years
Women 45-64 years
Year
NOTES Cholesterol-lowering statin drug visits
are physician office and hospital outpatient
department visits with cholesterol-lowering
statin drugs prescribed ordered or provided.
See Data Table for data points graphed specific
drugs included standard errors and additional
notes.
SOURCES Centers for Disease Control and
Prevention National Center for Health
Statistics National Ambulatory Medical Survey
and National Hospital Ambulatory Medical Care
Survey.
Centers for Disease Control and Prevention
National Center for Health Statistics. Health
United States 2004
77
Bile Acid Sequestrants

• Major actions
• Reduce LDL-C 1530
• Raise HDL-C 35
• May increase TG
• Side effects
• GI distress/constipation
• Decreased absorption of other drugs
• Contraindications
• Dysbetalipoproteinemia
• Raised TG (especially gt400 mg/dL)

78
Bile Acid Sequestrants

• Drug Dose Range
• Cholestyramine 416 g
• Colestipol 520 g
• Colesevelam 2.63.8 g

79
Bile Acid Sequestrants (continued)

• Demonstrated Therapeutic Benefits
• Reduce major coronary events
• Reduce CHD mortality

80
Nicotinic Acid

• Major actions
• Lowers LDL-C 525
• Lowers TG 2050
• Raises HDL-C 1535
• Side effects flushing hyperglycemia
  hyperuricemia upper GI distress hepatotoxicity
• Contraindications liver disease severe gout
  peptic ulcer

81
Nicotinic Acid

• Drug Form Dose Range
• Immediate release 1.53 g(crystalline)
• Extended release 12 g
• Sustained release 12 g

82
Nicotinic Acid (continued)

• Demonstrated Therapeutic Benefits
• Reduces major coronary events
• Possible reduction in total mortality

83
Fibric Acids

• Major actions
• Lower LDL-C 520 (with normal TG)
• May raise LDL-C (with high TG)
• Lower TG 2050
• Raise HDL-C 1020
• Side effects dyspepsia gallstones myopathy
• Contraindications Severe renal or hepatic disease

84
Fibric Acids

• Drug Dose
• Gemfibrozil 600 mg BID
• Fenofibrate 200 mg QD
• Clofibrate 1000 mg BID

85
Fibric Acids (continued)

• Demonstrated Therapeutic Benefits
• Reduce progression of coronary lesions
• Reduce major coronary events

86
Secondary Prevention

• Patients with established CHD have 5-7x greater
  risk of subsequent MI
• Smoking cessation
• Reducing BP to lt140/90 or 130/85 with CHF renal
  insufficiency DM
• Reduce LDL-C to lt100 mg/dl non-HDL levels to
  lt130 mg/dl

87
Secondary Prevention (cont)

• Moderate physical activity for 30 minutes daily
  3-4 days a week
• Weight management to attain BMIlt25
• A1Clt7
• Use of 75 to 325 mg aspirin daily unless
  contraindicated
• Use of ACE inhibitors and B-blockers indefinitely

88
CVD Medical Intervention
89
Coronary Angioplasty (PTCA)

• Percutaneous coronary intervention (PCI) uses a
  balloon to break up plaque in an occluded artery
• Performed under local anaesthetic so recovery
  quicker than with bypass surgery
• Persons with no more than 2 blockages are
  candidates

90
Angioplasties

• 601000 angioplasties done in 1999 1.2 million
  last year
• Most common problem is restenosis of the artery
  (10-20)
• Require intensive lifestyle management

91
Angioplasties

• Study by Boden et al suggests that in low risk
  pts lifestyle changes and medications are just as
  effective as PCI
• Angioplasties did not prevent heart attacks or
  save lives angioplasties produced a slight and
  temporary improvement in chest pain symptoms
• Angioplasty costs 30000 to 40000. The drugs
  used in the study are almost all available in
  generic form.
• Many health insurers including Medicare do not
  cover MNT for cardiovascular diseases

Boden et al NEJM 2007 Volume 3561503-1516
92
PCI with Stent
93
Coronary Artery Bypass Surgery

• Candidates have more than two occluded arteries
• Procedures have decreased since 1995 because of
  angioplasties
• Does not cure atherosclerosis new grafts are
  also susceptible
• Restonosis is common within 10 years of surgery

94
CABG