Clinical 1- Lecture 8: CVD

atherosclerotic cardiovascular disease (ASCVD)

A disorder characterized by yellowish plaques of cholesterol, other lipids, and cellular debris in the inner layers of the arteries of the heart

peripheral artery disease

A form of peripheral vascular disease in which there is partial or total blockage of an artery, usually one leading to a leg or arm. *especially the legs ASCVD can contribute to the formation of this condition

60

Among students in grades 9 to 12 in 2017, only 26.1% met the recommendation of ____ minutes of physical activity every day. More high school boys (35.3%) than girls (17.5%) reported having been physically active at least 60 minutes per day on all 7 days.

immediate and intense

Symptoms of a myocardial infarction may be ______ such as angina, chest pain, caused by lack of blood flow to the heart. More often, though, symptoms start slowly and persist for hours, days or weeks before a heart attack. Unlike with sudden cardiac arrest, the heart usually does not stop beating during a heart attack. The MI symptoms in women can be different than men.

Coronary Heart Disease (CHD)

________ is a result of coronary artery disease, or CAD With ______ plaque first grows within the walls of the coronary arteries until the blood flow to the heart's muscle is limited. This is also called ischemia. It may be chronic, narrowing of the coronary artery over time and limiting of the blood supply to part of the muscle. Or it can be acute, resulting from a sudden rupture of a plaque and formation of a thrombus or blood clot.

sudden cardiac arrest (SCA)

___________ occurs suddenly and often without warning. It is triggered by an electrical malfunction in the heart that causes an irregular heartbeat (arrhythmia) . With its pumping action disrupted, the heart cannot pump blood to the brain, lungs and other organs. Seconds later, a person loses consciousness and has no pulse. Death occurs within minutes if the victim does not receive treatment

Atrial Fibrillation (A-Fib)

an irregular and often very fast heart rate originating from abnormal conduction in the atria -may form a clot as a result of pooled blood -patients may report dizziness and that their heart feels like its skipping a beat

immune response triggered in the wall of the blood vessel -> it thickens (as a result of inflammation) -> it narrows the artery -> less oxygen can reach other parts of the bodyb

how does arterial stenosis (narrowing) occur?

systolic blood pressure

indicates how much pressure your blood is exerting against your artery walls when the heart beats; contraction phase -imagine squeezing a fist

distolic blood pressure

indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats; relaxation phase -imagining releasing a squeezed fist

Atherogenesis

is the process leading to the development of atherosclerosis. It can be chronic, local, inflammatory response; made up of cholesterol, fatty substance, cellular waste products, calcium, and fibrin.

transient ischemic attack

often called a "mini stroke," it's caused by a serious temporary clot. This is a warning stroke and should be taken seriously -can lead to ischemic and hemorrhagic stroke if left untreated

carotid artery disease

plaque in neck arteries supplying blood to the brain narrowing of the carotid arteries, usually caused by atherosclerosis; may eventually lead to thrombus formation and stroke ASCVD can contribute to the formation of this condition

fibrin

protein that forms the basis of a blood clot

crytohenic stroke

stroke of unknown cause (stroke may caused by congenital heart condition for example, but until this is diagnosed, then the stroke would be classified as a ______)

hypertensive crisis (consult your doctor immediately)

systolic / diastolic higher than 180 mm Hg and/or higher than 120 mm Hg

high blood pressure stage 2

systolic/ diastolic 140mm Hg or higher / or 90mm Hg or higher *if either level is elevated, it is classified as this stage of high blood pressure

high blood pressure stage 1

systolic/diastolic 130-139mm Hg/ or 80-89mm Hg *if either level is elevated, it is classified as this stage of high blood pressure

Tunica adventitia (outer), tunica media , tunica intima (inner)

three layers of the artery

when a patient has elevated glucose values (poor glycemic control)

what can be a cause of triglyceride elevation?

1. looking at the patient as a whole 2. looking at ASCVD score (risk calculator) 3. an individualized cholesterol target for each patient, as opposed to a value set across the board

what has become the clinical emphasis regarding cholesterol lab values?

physical activity

what is a critical component to get a patient's HDL to increase? -a heart-heathy diet can lower LDL but ______ has been shown in the literature to be effective at increasing HDL

it is an inexpensive, effective and highly tolerated cholesterol lowering treatment

what is statin therapy so commonly used?

heart attack (myocardial infarction)

A ______ occurs when a blocked artery prevents oxygen-rich blood from reaching a section of the heart. If the blocked artery is not reopened quickly, the part of the heart normally nourished by that artery begins to die. The longer a person goes without treatment, the greater the damage.

Angina

chest pain from reduced blood flow to heart muscle ASCVD can contribute to the formation of this condition

two

-patients with Afib have five times the likelihood of stroke -patients with high blood pressure have ___ times the likelihood of a stroke

Statin Therapy

2018 AHA/ACC CHOLESTEROL GUIDELINES Fifty-six million (48.6%) US adults over 40 years of age are eligible for ______ on the basis of the 2013 guideline for managing blood cholesterol from the American College of Cardiology and the American Heart Association. • This is significant when you consider that having a high level of LDL-C as a major risk factor for ASCVD. Because LDL-C contributes to fatty buildups and atherosclerosis, High LDL-C at any age can cumulatively increase the risk for heart disease and stroke.

lower is better

2018 AHA/ACC CHOLESTEROL GUIDELINES While there is no ideal target blood level for LDL-C, the 2018 guideline recognizes, in principle, that "lower is better." Studies suggest that an optimal total cholesterol level is about 150 mg/dL, with LDL-C at or below 100 mg/dL, and adults with LDL-C in this level have lower rates of heart disease and stroke. • In all individuals, emphasize a heart-healthy lifestyle across the life course. A healthy lifestyle reduces ASCVD risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction.

stroke

A sudden attack of weakness or paralysis that occurs when blood flow to an area of the brain is interrupted, caused by plaque in arteries in or leading to the brain ASCVD can contribute to the formation of this condition

primary prevention

ASCVD risk calculator The ACC/AHA 2018 Cholesterol Guidelines and 2017 Hypertension Guidelines recommend the use of quantitative 10-year risk assessment, based on measurement of traditional ASCVD risk factors and with use of a validated risk prediction tool, as the first step in considering treatment options for __________. Results of 10-year risk estimation should be communicated through a clinician-patient risk discussion to decide upon the intensity of preventive measures, especially whether to initiate medical therapy.

plaque

ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (ASCVD) ______ itself can pose a risk. A piece of _____ can break off and be carried by the bloodstream until it gets stuck. And ______ that narrows an artery also allows for the possibility that a blood clot (thrombus) may adhere to the blood vessel's inner wall. This can precipitate various conditions, including: coronary heart disease, stroke, angina, carotid artery disease, peripheral artery disease (PAD) and chronic kidney disease

40

According to data from 2005 to 2014, the estimated annual incidence of heart attack in the US was 605,000 new attacks and 200,000 recurrent attacks. The average age at the first heart attack was 65.6 years for males and 72.0 years for females. • Approximately every ____ seconds an American will have a heart attack

bile acid sequestrant or ezetimibe

Adding a _______ to a statin regimen further lowers LDL-C, by approximately 15% to 30% and 13% to 20%, respectively. And adding a PCSK9 inhibitor to a statin regimen has been shown to further reduce LDL-C by 43% to 64%

systolic over diastolic

BP is reported as ________.

Patients with extremely high LDL-C (190 mg/dL or higher)

CHOLESTEROL MANAGEMENT _________ have a high lifetime risk for a cardiovascular event. For patients aged 20 to 75, providers should prescribe a maximally tolerated statin. Adults aged 40 to 75 who have diabetes are usually considered at moderate to high risk for cardiovascular disease.

adults 20 years or older who have an initial non-fasting lipid profile with triglycerides 400 mg/dL or higher

CHOLESTEROL MANAGEMENT For _________, repeat the lipid profile with the patient fasting to establish fasting triglyceride levels and baseline LDL-C.

adults 20 years or older who are free from ASCVD

CHOLESTEROL MANAGEMENT For __________(and not on lipid-lowering therapy), measure LDL-C with either a fasting or non-fasting plasma lipid profile when estimating ASCVD risk, and document baseline LDL-C. *Always estimate ASCVD risk for any patient to assess risk and establish a baseline

atherosclerosis

CORONARY ARTERY DISEASE When cholesterol and fatty deposits build up in the heart's arteries, less blood can reach the heart muscle. This buildup is known as ________. The result may be chest pain (angina) or, if blood flow becomes totally obstructed, a heart attack. Coronary artery disease can also contribute to having high blood pressure, which may lead to heart failure over time.

859,125

Cardiovascular disease (CVD), listed as the underlying cause of death, accounted for ______ deaths in the US in 2017. • Cardiovascular diseases claim more lives each year than all forms of cancer and Chronic Lower Respiratory Disease combined. • CVD is the leading global cause of death. CVD accounted for approximately 17.8 million deaths in 2017. This number is expected to grow to more than 22.2 million by 2030, according to a 2014 study. • Total direct medical costs of CVD are projected to increase to $749 billion in 2035, according to a 2016 study.

9.4

DIABETES Using data from 2013 to 2016, an estimated ____ million, or 3.7%, of American adults had undiagnosed diabetes. Additionally, about 91.8 million, or 37.6%, of American adults had prediabetes. • In 2017, 83,564 US deaths were attributed to diabetes. • In 2017, an estimated 1.4 million deaths were attributed to diabetes globally. This represents a mortality rate of 17.5 per 100,000.

460%

HIGH BLOOD PRESSURE • Using data from 2013 to 2016, _____ of US adults had hypertension. • In 2017, there were 90,098 deaths primarily attributable to High Blood Pressure. • In 2017, the age-adjusted death rate primarily attributable to high blood pressure was 23.0 per 100,000. • Projections show that by 2035, the total direct costs of High Blood Pressure could increase to an estimated $220.9 billion. *setting alarm to the health care community *what recommendations can we provide to prevent and mitigate high blood pressure?

high levels

HYPERCHOLESTEROLEMIA: Using data from 2013-2016, 28.9% of American adults had _____ of LDL cholesterol (the "bad" kind; 130 mg/dL or higher). • Using data from 2013-2016, 19.2% (about one-fifth) of American adults had low levels of HDL cholesterol (the "good" kind; less than 40 mg/dL).

365,914

Heart Disease remains the number 1 cause of death in the US. • Coronary heart disease accounted for approximately 13% of deaths in the US in 2017, causing ______deaths.

you want to look at the total number, as well as the ratio between the two (1 HDL to 3 LDLs)

How do you interpret cholesterol lab values (HDL & LDL) ?

ADVERSE PROGNOSIS IN HYPERTENSION: associated with high blood pressure

Hypercholesterolemia • Obesity • Excessive ETOH intake • End-organ damage • Cardiac enlargement • Myocardial Infraction • Heart Failure • Retinal exudates and hemorrhages • Papilledema • Impaired renal function • Stroke (CVA) (can be a silent killer)

14.0%

In 2017, 27.1% of high school students and 7.2% of middle school students used a tobacco product. Additionally, 8.1% of high school students and 1.8% of middle school students smoked cigarettes in the past 30 days. • In 2017, _____ of adults were current smokers (15.8% of males and 12.2% of females) • Among adults in 2017, 24.0% of American Indians or Alaska Natives, 14.9% of NH blacks, 7.1% of NH Asians, 9.9% of Hispanics, and 15.2% of NH whites were current smokers.

Chronic Kidney Disease (CKD)

Inability of kidneys to excrete wastes; staged from 1 (mild damage to kidney) to 5 (complete kidney failure requiring either dialysis or a renal transplant). Stage 5 is also called end stage renal disease ASCVD can contribute to the formation of this condition

analogy to remember HDL and LDL

LDL: garbage piling up HDL: garbage truck, helps pick up the LDL and bring it back to the sanitation station (the liver, then excreted)

Rhythm

MI and cardiac arrest are linked: • Sudden cardiac arrest can occur after a heart attack, or during recovery. Heart attacks increase the risk for sudden cardiac arrest. Most heart attacks do not lead to sudden cardiac arrest. But when sudden cardiac arrest occurs, heart attack is a common cause. Other heart conditions may also disrupt the heart's ______ and lead to sudden cardiac arrest. • These include a thickened heart muscle (cardiomyopathy), heart failure, arrhythmias, particularly ventricular fibrillation and long Q-T syndrome

whole grains and nuts, seeds, and legumes

NUTRITION: Between 2003 to 2004 and 2015 to 2016 in the United States, the mean AHA healthy diet score improved in adults. The prevalence of a poor diet improved from 56.0% to 47.8% for the primary score and 43.7% to 36.4% for the secondary score. • Changes in score were largely attributable to increased consumption of _______ and decreased consumption of SSBs (sugar sweetened beverages). No significant changes were observed for consumption of total fruits and vegetables, fish and shellfish, sodium, processed meat, and saturated fat.

RISK FACTORS FOR HYPERTENSION

Non-modifiable: Family History, Age, Race/Ethnicity, Gender Modifiable: Poor Diet, Physical Inactivity, Overweight or Obesity, Sleep Apnea, High Cholesterol, Diabetes, Smoking/Tobacco Use, Stress

38.3%

OVERWEIGHT AND OBESITY: In the US, the prevalence of obesity among adults increased from 1999 to 2000 through 2013 to 2016 from 30.5% to _____. • In the US between 2013 and 2016, the prevalence of overweight and obesity among children and adolescents 2 to 19 years of age, was 34.2% (16.4% were overweight and 17.8% were obese). (about one-third of the population)

increased

OVERWEIGHT AND OBESITY: According to 2015 to 2016 data, the prevalence of obesity for children 2 to 5 years of age was 13.9 %; for children 6 to 11 years of age, prevalence was 18.4%; and for adolescents 12 to 19 years of age, prevalence was 20.6%. • Worldwide, between 1980 and 2013, the proportion of overweight or obese adults ______ from 28.8% to 36.9% among males and from 29.8% to 38.0% among females

ischemic stroke

Occurs when a blood vessel supplying blood to the brain is obstructed. It accounts for 87 percent of all strokes (the most prevalent stroke type) -can be caused from Afib -symptoms can be rapid and onset: passing out, slurred speech, headache

hemorrhagic stroke

Occurs when a weakened blood vessel ruptures. The two types of weakened blood vessels that usually cause hemorrhagic stroke are aneurysms and arteriovenous malformations. The most common cause of hemorrhagic stroke is uncontrolled high blood pressure

25.9%

PHYSICAL ACTIVITY: In 2017, _____ of adults did not engage in leisure- time physical activity. • In 2016, the overall prevalence of meeting the 2018 Physical Activity Guidelines for Americans for both aerobic and muscle-strengthening guidelines was 24.3% in adults (NH White, 26.8%; NH Black 20.8%; Hispanic or Latino, 18.7%; Asian 22.4%; American Indian/Alaska Native, 21.3%.)

three

SMOKING: Tobacco use is one of the leading preventable causes of deaths in the US and globally. • According to a 2013 study, overall mortality among US smokers was ___ times higher than that for never-smokers.

19

STROKE (hypertension is a risk factor and contributing factor for stroke) Someone in the US has a stroke every ___ seconds on average. • In 2017, stroke accounted for about 1 of every ___ deaths in the US. - On average in 2016, someone died of stroke every 3 minutes 35 seconds. • When considered separately from other cardiovascular diseases, stroke ranks number five among all causes of death in the US, causing 146,383 deaths in 2017.

related

STROKE - RISK FACTORS The two risk factors are also ______ to each other: High blood pressure is a risk factor for atrial fibrillation. Middle-aged men and women with high blood pressure are at increased risk for atrial fibrillation later in life.

rapid heartbeat

STROKE - RISK FACTORS Then there's atrial fibrillation (also called AFib or AF), is a quivering or arrhythmia that can lead to blood clots, stroke, heart failure and other heart-related complications. At least 2.7 million Americans are living with AFib. That's when stroke risk increases because the _______ allows blood to pool in the heart, which can cause clots to form and travel to the brain, thus can contribute to a stroke

force

STROKE - RISK FACTORS: For people with high blood pressure, the _____ of blood pushing against the arteries as the heart pumps blood is too high. That causes gradual damage to the arteries, including those to the brain. A weakened blood vessel may rupture in or near the brain, or diseased arteries may become blocked by a clot or plaque buildup.

a home or residence

SUDDEN CARDIAC ARREST • In 2017, any-mention sudden cardiac arrest mortality in the US was 379,133. • According to 2018 data, the majority of Out of Hospital Cardiac Arrests (OHCA) occur at _______ (69.8%). Public settings (18.8%) and nursing homes (11.5 %) were the second and third most common locations of OHCA. • According to 2018 data, OHCA was witnessed by a layperson in 37.7% of cases and by an EMS provider in 12.7% of cases.

Life's Simple 7

The American Heart Association gauges the cardiovascular health of the nation by tracking seven key health factors and behaviors that increase risks for heart disease and stroke. We call these "______" and we measure them to track progress toward our 2020 Impact Goal: to improve the cardiovascular health of all Americans by 20% and reduce deaths from cardiovascular diseases and stroke by 20%, by the year 2020. _______ are: not-smoking, physical activity, healthy diet, body weight, and control of cholesterol, blood pressure, and blood sugar.

coronary arteries

The ________ are the blood vessels that supply blood to your heart. They branch off of the aorta at its base. The right coronary artery, the left main coronary, the left anterior descending, and the left circumflex artery, are the four major coronary arteries. Blockage of these arteries is a common cause of angina, heart disease, heart attacks and heart failure.

E-cigarettes/vaping

The definition of "smoking" has been extended to include:

moderate intensity

The guideline recommends _______ statins, regardless of the patient's estimated 10-year risk for ASCVD

ASCVD Risk

The purpose of the _______ Calculator is to estimate a patient's 10-year ________ at an initial visit to establish a reference point. ACC (American College of Cardiology) /AHA (American Heart Association) guidelines recommend the use of the PCE as an important starting point, not as the final arbiter, for decision making in primary prevention of ASCVD. The information required to estimate ______ includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.

stepwise approach

Use a ________ to manage high cholesterol, adding therapies as tolerated until the cholesterol levels are lowered adequately. If a patient has problems taking a statin or if a statin alone doesn't sufficiently lower LDL-C, additional drug options are available.

240

Using data from 2013 to 2016 about 28.5 million, or 11.7%, of American adults had total cholesterol of ____ mg/dL or higher. The race and gender breakdown was: o 10.5% of NH white males o 13.6% of NH white females o 8.9% of NH black males o 9.0% of NH black females o 13.0% of Hispanic males o 10.1% of Hispanic females o 11.7% of NH Asian males o 10.8% of NH Asian females

200

Using data from 2013 to 2016, 92.8 million, or 38.2%, of American adults had total cholesterol of ______mg/dL or higher. The race and gender breakdown was: o 35.4% of NH white males o 41.8% of NH white females o 29.8% of NH black males o 33.1% of NH black females o 39.9% of Hispanic males o 38.9% of Hispanic females o 38.7% of NH Asian males o 39.6% of NH Asian females

26

Using data from 2013 to 2016, an estimated ____ million, or 9.8%, of American adults had diagnosed diabetes. The race and gender breakdown was: o 9.4% of NH white males o 7.3% of NH white females o 14.7% of NH black males o 13.4% of NH black females o 15.1% of Hispanic males o 14.1% of Hispanic females o 12.8% of NH Asian males o 9.9% of NH Asian females *there are disparities between ethnicities and gender

usually they cannot sense it when they have elevated or stage 1, but they can feel a difference when it is too late for a lifestyle modification to be effective (when BP is extremely elevated, impairment of renal or heart function)

When can patients usually detect or feel they have elevated blood pressure?

50%

When lifestyle interventions alone are not enough to lower LDL-C, statins generally provide the most effective lipid- lowering treatment. There are 3 main treatment regimens for statins: High intensity, which typically lowers LDL-C by ____ or more Moderate intensity, which lowers LDL-C by 30% to 49% Low intensity, which lowers LDL-C by 30% or less

brain stem stroke

When stroke occurs in the brain stem, it can affect both sides of the body and may leave someone in a 'locked-in' state. When a locked-in state occurs, the patient is generally unable to speak or move below the neck

coronary artery disease (CAD)

atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle ________ begins in childhood, so that by the teenage years, there is evidence that plaques that will stay with us for life are formed in most people Coronary heart disease , or CHD, is a result of ________. risk factors: elevated triglycerides, cholesterol, smoking (accelerates plaque growth)

age, previous history and LDL

cardiologist's medication recommendations are based on:

complete occlusion thrombus (complete blockage of the artery from a formation of plaque)

causes angina and heart attack -depends on the location and the artery

establish a baseline for the patient & help the clinician or cardiologist determine what measures they need to take to meet the goals (help with primary prevention of CVD) or if a patient is high risk, what are the more extreme measures that may need to be taken to lower risk?

what is the purpose of using the ASCVD risk calculator?

High triglyceride (150mg/dL) + High LDL + Low HDL

what lab values increase the risk for atherosclerosis, and consequently increases risk of heart attack or stroke?

make a timeline for lowering the blood pressure, make a plan and communicate with the physician

what should we do as dietitians when we have a patient with high BP?

Other risk factors such as physical activity, diet etc. Take into account the patients COMPLETE profile, holistic view

what should you do in addition to looking at the cholesterol lab values?

if someone has preexisting conditions or comorbidities (diabetes, obesity etc.)

when would you use a lower cut off for cholesterol values (lower than 240 mg/dL total cholesterol)?

-diabetics have a two-fold increased risk for CVD -prevention of diabetes or management of risk factors can lessen the risk of experiencing complications regarding diabetes and CVD

why is taking diabetes into account for CVD important?

to be able to appropriately identify individuals with increased blood pressure and make lifestyle interventions early (before it reached hypertensions stage 1) before implementing pharmacological intervention

why was an elevated blood pressure category added? Systolic / diastolic : 120-129/ less than 80 *both systolic and diastolic need to be elevated for the patient to have elevated blood pressure

so that clinicians may intervene sooner, not necessarily to put more patients on medications

why were the ranges for elevated blood pressure lowered in 2017? (the ranges were newly defined in 2017)