Coronary heart diseases Coronary heart diseases Definition Magnitude

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Coronary heart diseases

Coronary heart diseases

Coronary heart diseases üDefinition üMagnitude of the problem üRisk factors üRisk stratification üPrevention

Coronary heart diseases üDefinition üMagnitude of the problem üRisk factors üRisk stratification üPrevention

definition IHD is defined as a state of lack of supply of oxygen to

definition IHD is defined as a state of lack of supply of oxygen to the myocardium vis-a-vis the demands, due to narrowing of the coronary arteries as a result of the atherosclerotic process

Spectrum of IHD ü Asymptomatic coronary insufficiency ü Typical angina ü Atypical angina ü

Spectrum of IHD ü Asymptomatic coronary insufficiency ü Typical angina ü Atypical angina ü Acute myocardial infarction ü Cardiac failure ü Sudden death

introduction • In developed countries, half of all deaths are due to CVD and

introduction • In developed countries, half of all deaths are due to CVD and a quarter due to IHD • By the year 2025, become a leading cause of death and disability in our country • Most of the affected in their middle age: Maximal productive phase, maximum family and social obligations to fulfil

introduction ü In developed countries 25% of those who suffer from AMI would die

introduction ü In developed countries 25% of those who suffer from AMI would die within one hour and would never reach the hospital ü Another 8 to 10% would die in the next 24 hours

Special Features of IHD among South Asians ü Occur at an earlier age (almost

Special Features of IHD among South Asians ü Occur at an earlier age (almost a decade earlier) ü Proportion of females to males among IHD cases higher ü Higher case fatality (either biological differences or due to poor health services)

Special Features of IHD among South Asians ü Occurs even in presence of normal

Special Features of IHD among South Asians ü Occurs even in presence of normal or near-normal levels of “conventional” coronary risk factors as BMI, Total cholesterol and smoking ü High level of “unconventional” risk factors (increased central obesity in the face of normal BMI and low HDL / high TGs in the face of normal total cholesterol levels) as occurs in metabolic syndrome ‘X’, may play an important role

Risk factors Non-Modifiable modifiable Age Obesity Sex Physical inactivity Race: Thrifty genes & Black

Risk factors Non-Modifiable modifiable Age Obesity Sex Physical inactivity Race: Thrifty genes & Black Stress race Genetic Hypertension & DM Fetal & Childhood Influences Tobacco & Alcohol OCPs Type A personality

Modifiable risk factors

Modifiable risk factors

Modifiable risk factors

Modifiable risk factors

Metabolic syndrome ü Dr. Gerald Raven ü Insulin Resistance: obesity, central obesity, physical inactivity,

Metabolic syndrome ü Dr. Gerald Raven ü Insulin Resistance: obesity, central obesity, physical inactivity, and certain genetic reasons ü Fasting hyperinsulinaemia: An effort to compensate ü A very unique and specific “clustering” of certain specific CVS risk factors (BP, IGT, low HDL and raised TGs)

Metabolic syndrome ü “Diabetes or IFG or IGT or evidence of insulin resistance PLUS

Metabolic syndrome ü “Diabetes or IFG or IGT or evidence of insulin resistance PLUS any two of the following : ü Obesity as defined BMI > 30 or WHR > 0. 9 for males or > >0. 80 for Indian females ü Hypertension : >140 systolic or > 90 diastolic ü Dyslipidaemia: TGs > 150 mg / dl or HDL < 35 mg / dl for males or < 40 mg / dl for females ü Microalbuminuria: Albumin excretion > 20 mg/ mt

 • HRT is not recommended as a preventive step against IHD, from public

• HRT is not recommended as a preventive step against IHD, from public health point of view • Effect of Multiple Risk Factors: “multiplicative” (in simple corollary, it is not 2+2+2 =6 but rather 2 x 2 x 2 = 8)

WHO/ISH risk prediction chart

WHO/ISH risk prediction chart

WHO/ISH risk prediction chart (without dm)

WHO/ISH risk prediction chart (without dm)

WHO/ISH risk prediction chart (with dm)

WHO/ISH risk prediction chart (with dm)

Lifestyle Modifications Modification Recommendations Approximate Systolic Blood Pressure Reduction Weight Reduction Maintain normal body

Lifestyle Modifications Modification Recommendations Approximate Systolic Blood Pressure Reduction Weight Reduction Maintain normal body weight (BMI 18. 5 -24. 9) 5 -20 mm Hg for each 10 kg weight loss Adapt DASH eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat 8 -14 mm Hg Dietary sodium reduction Reduce sodium to no more than 2. 4 g/day sodium or 6 g/day Na. Cl 2 -8 mm Hg Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days) 4 -9 mm Hg Moderate alcohol consumption Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women. 2 -4 mm Hg Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003; 289: 2560 -2572.

Risk factor intervention trials ü Framingham study ü Stanford 3 community study ü North

Risk factor intervention trials ü Framingham study ü Stanford 3 community study ü North Karelia project ü Multiple risk factor intervention trial ü Oslow diet/smoking intervention study

Secondary prevention trials üAspirin üClofibrate üAtorvastatin üBeta-blockers

Secondary prevention trials üAspirin üClofibrate üAtorvastatin üBeta-blockers

Revascularization procedures üCABG üPTCA

Revascularization procedures üCABG üPTCA

Short Notes (1) magnitude of problem of IHD in India (2) Special features of

Short Notes (1) magnitude of problem of IHD in India (2) Special features of IHD among Indians (3) Metabolic syndrome (4) Population versus high risk strategy in IHD prevention.