THE WAY TO YOUR HEART Is it through

THE WAY TO YOUR HEART: Is it through your stomach or from elsewhere? DR M J NIENKEMPER VERGELEGEN MEDICLINIC 15 NOVEMBER 2017

ALL ROADS LEAD TO ROME or do they not?

• HEART DISEASE IS THE LEADING CAUSE OF DEATH FOR BOTH MEN AND WOMEN. • IT TAKES THE LIVES OF 610 000 PEOPLE IN THE USA EVERY YEAR • CORONARY HEART DISEASE KILLS OVER 370 000 OF THIS NUMBER

IN THE QUEST TO IMPROVE OUTCOMES, RESEARCH HAS FOCUSSED ON NEW MODIFIABLE RISK FACTORS WITH SPECIAL ATTENTION TO ENVIRONMENTAL FACTORS

• THE FOOD YOU EAT CAN BE EITHER THE SAFEST AND MOST POWERFUL FORM OF MEDICINE OR THE SLOWEST FORM OF POISON

HIPPOCRATES • LET FOOD BE THY MEDICINE AND THY MEDICINE BE THY FOOD

• MEDICINE IS ONLY PALLIATIVE, FOR BEHIND THE DISEASE LIES THE CAUSE AND THIS CAUSE NO DRUG CAN REACH

SOME NEW IDEAS

INTESTINAL MICRO ORGANISMS

• 2 TERMS NEED EXPLANATION: • MICROBIOTA: ALL THE MICROORGANISMS IN THE HUMAN GUT, • WEIGHING APPROXIMATELY 2 KG. • MICROBIOME: TOTAL GENETIC DATA OF ALL THE ORGANISMS WHICH • IS 100 X MORE THAN THE HUMAN’S GENETIC DATA!

RECENT FINDINGS HAVE IMPLICATED THE GUT MICRO-ORGANISMS AS CONTRIBUTORS OF METABOLIC DISEASES BY MODULATION OF THE HOST METABOLISM.

• THERE ARE 3 MAJOR PATHWAYS VIA WHICH INTESTINAL MICROORGANISMS CAN ALTER HUMAN CARDIO-METABOLISM

From: The gut microbiome as novel cardio-metabolic target: the time has come! Eur Heart J. 2013; 35(14): 883 -887. doi: 10. 1093/eurheartj/eht 467 Eur Heart J | Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2013. For permissions please email: journals. permissions@oup. com

VISCERAL FAT • FAT STORED AROUND IMPORTANT ORGANS, INCLUDING THE HEART, LIVER AND PANCREAS. • VISCERAL FAT IS METABOLICALLY ACTIVE AND PRODUCES FACTORS THAT CAUSES INSULIN RESISTANCE • EVEN HEALTHY LOOKING SKINNY PEOPLE HAVE VISCERAL FAT! • LIMIT TRANS FATS, ALCOHOL INTAKE AND EXERCISE REGULARLY

GUT MICROBIOME, CVD& RISK FACTORS MICROBIOTA ASSOCIATED WITH KNOWN RISK FACTORS: • TYPE II DIABETES • METABOLIC SYNDROME: OBESITY AND INSULIN RESISTANCE MICROBIOTA PRODUCES TOXINS THAT DAMAGES THE BLOODVESSEL WALLS LEADING TO ATHEROSCLEROSIS. TMAO FORMED BY THE MICROBIOME AND LEADS TO PLAQUE FORMATION AND BLOOD CLOTTING: TMAO IS FORMED FROM CHOLINE(VIT B IN ANIMAL PRODUCTS AND SOY). THIS ENZYME IS BLOCKED BY DMB, FREQUENT IN OLIVE OIL, GRAPE SEED OIL, BALSAMIC VINEGAR AND RED WINE

SUMMARY • THE HUMAN MICROBIOTA INTERACTS EXTENSIVELY WITH THE HOST THROUGH METABOLIC EXCHANGE AND CO METABOLISM OF FOOD SUBSTRATES. • TRADITIONAL CARDIAC RISK FACTORS, OBESITY, DYSLIPIDEMIA AND INSULIN RESISTANCE OBVIOUSLY HAS A METABOLIC ORIGIN • THE METABOLITE, TMAO IS FORMED FROM A TYPICAL WESTERN DIET AND HAS A DEFINITIVE ASSOCIATION WITH BLOODVESSEL DAMAGE AS WELL AS BLOODCLOTTING

• STOMACH/GUT PLAYS AN OBVIOUS ROLE IN ABSORPTION OF DRUGS FOR CARDIOVASCULAR USE • THE GUT DETERMINES THE NUTRITIENT UPTAKE AND PLAYS A CENTRAL ROLE IN METABOLIC DISEASES • IBD PATIENTS HAVE A HIGHER RISK FOR IHD DESPITE ABSENCE OF CLASSIC RISK FACTORS • HEARTFAILURE CAUSES SWELLING OF THE INTESTINAL WALLS WITH POOR ABSORPTION OF NUTRITIENTS AND INCREASED PERMEABILITY TO TOXINS THAT MAY SUPPRES CARDIAC FUNCTION EVEN FURTHER. A VISCIOUS CIRCLE!

ALL GUT BACTERIAL ACTIONS ARE NOT BAD • SYNTHESIS OF VITAMIN K • EXTRACT CALORIES FROM PLANT PRODUCTS • HARVESTING ENERGY

JUST BECAUSE YOU ARE NOT SICK DOES NOT MEAN YOU ARE HEALTHY

• THE STOMACH CARRIES THE HEART AND NOT THE HEART THE STOMACH

THE HEART AND THE STOMACH

NOW THAT WE KNOW THE ASSOCIATION OF THE STOMACH/GUT AND HEART, LET US LOOK AT ELSEWHERE?

THE WAY TO YOUR HEART: Is it through your stomach or from elsewhere

SYMPTOMS AND SIGNS FROM “ELSEWHERE” POINTING TO A HEART PROBLEM ALTHOUGH NOT SEEN AS SUCH

THERE IS INCREASING AWARENESS THAT ASSOCIATED SYMPTOMS OF ANGINAL CHEST PAIN, DO NOT RELIABLY DISTINGUISH BETWEEN CARDIAC AND GASTROINTESTINAL ORIGINS OF CHEST PAIN, WHICH CAN COEXIST IN UP TO 35% OF PATIENTS

TYPICAL HEART PAIN DESCRIPTION

DIGESTIVE RELATED PAINS • HEARTBURN: GASTROESOPHAGEAL REFLUX • ESOPHAGEAL SPASM: • ESOPHAGITIS: DUE TO ACID REFLUX OR INFECTIONS(CANDIDA) • BELCHING/BURPING AS SYMPTOM OF ANGINA: MOSTLY INFERIOR WALL PROBLEMS

CHEST PAINS NOT FROM CORONARY ARTEY DISEASE • PERICARDITIS: INFLAMMATION OF THE PERICARDIAL SAC SURROUNDING THE HEART • ACUTE MIOCARDITIS • SYNDROME X • VALVULAR HEART DISEASE LIKE AORTIC STENOSIS/MITRAL VALVE PROLAPSE • AORTIC ROOT DISSECTION; TEAR IN THE AORTIC WALL • ACUTE HERPES ZOSTER(SHINGLES) • PULMONARY EMBOLISM

BELOW THE DIAPHRAGM CONDITIONS SIMULATING CARDIAC PROBLEMS • ACUTE PEPTIC ULCER DISEASE • ACUTE GALLSTONE COLIC • KIDNEY STONES • DISSECTING ABDOMINAL ANEURYSMS

HEART ATTACK SYMPTOMS ARE DIFFERENT IN WOMEN

CORONARY ARTEY DIEASE IN WOMEN • SYMPTOMS VERY OFTEN ATYPICAL • WOMEN OFTEN IGNORE THEIR SYMPTOMS • These six heart attack symptoms are common in women: • Chest pain or discomfort. Chest pain is the most common heart attack symptom, but some women may experience it differently than men. . • Pain in your arm(s), back, neck, or jaw. . • Stomach pain. . • Shortness of breath, nausea, or light headedness. . • Sweating. . • Fatigue.

HEART ATTACKS IN WOMEN • MORTALITY FROM HEART ATTACKS IS TWICE THAT OF BREAST CA • WOMEN OFTEN DENY SYMPTOMS • TYPICAL CHEST PAIN NOT ALWAYS PRESENT OR MAY BE ABSENT • DEGREE OF CHEST PAIN NOT ALWAYS IMPRESSIVE (FEELING FINE) • SOMETIMES JUST FEELING “UNWELL” • NB: TAKE NOTE OF ANY SUGGESTIVE SYMPTOMS IN A FEMALE WITH CARDIAC RISK FACTORS: HT, DM, SMOKING AND FAMILY HISTORY • HEART DISEASE IS NOT AN ONLY MALE PROBLEM!

NOW THAT WE KNOW THAT ALL ROADS DO NOT LEAD TO ROME…

PLEASE TAKE CARE OF YOURSELF: IF YOU DO NOT TAKE CARE OF YOURSELF, THE UNDERTAKER WILL GLADLY OVERTAKE THAT RESPONSIBILITY FROM YOU!