Chapter 7

1. Chapter 7 Cardiovascular Disease

2. Cardiovascular Disease Is the #1 Cause of Mortality Arteriosclerosis: hardening of the arteries Atherosclerosis: buildup of plaque inside arteries and blood vessels Cardiovascular disease (CVD) often used interchangeably with coronary heart disease (CHD) and coronary artery disease (CAD) CVA: “stroke,” or cerebral vascular accident MI: “heart attack,” or myocardial infarction Thrombosis: clot formation Peripheral arterial disease: a form of atherosclerosis

3. Progression of Atherosclerosis Natural progression of atherosclerosis. (From Harkreader H: Fundamentals of nursing: caring and clinical judgment, ed 2, St Louis, 2004, Saunders.)

4. History of Knowledge 1950s (Korean War)—young men first recognized to have signs of atherosclerosis 1960s—serum cholesterol linked to heart disease Egg restriction began Research showing saturated fat has greater impact on serum cholesterol was ignored Today it is recognized that saturated fat is the #1 culprit Monounsaturated fats are now preferred over polyunsaturated fats to maintain HDL-C levels and reduce risk of inflammation/cancer

5. Risk Factors CVD/2004 ATP III High LDL-C (>100 mg/dL or >70 if high-risk CVD) Cigarette smoking Hypertension (HTN) ≥140/90 Low HDL-C <40 mg/dL; <50 for women Family hx premature coronary heart disease (CHD) Age: men ≥45 years; women ≥55 years Diabetes Metabolic syndrome with central obesity, dyslipidemia, prediabetes Protective: HDL-C >60 mg/dL

6. Other Risk Factors Vitamin D deficiency (Michos and Melamed, 2008) Possible role of stress Low intake of antioxidants causing production of free radicals Mg++ deficiency Excess or no alcohol intake* *Alcohol cannot be advised for nondrinkers because of risk of alcoholism in those without demonstrated ability to consume moderate intake

7. Risk Factors for Cerebral Vascular Accident (CVA or “Stroke”)* HTN, diabetes, obesity Inactivity High–glycemic-load meals, especially with fatty meats Trans fatty acids; lowered risk from omega-3 fatty acids Diet low in antioxidant vitamins Oral contraceptives *Decreased risk with high-fiber diet and fish (omega-3 fats)

8. Lipids Effect on CVD HDL: High-density lipoprotein—high PRO content helps clear cholesterol from the body; called the “good cholesterol” LDL: Low-density lipoprotein—high fat content; promotes atherosclerosis; called the “bad cholesterol” Triglycerides—form of food fat in the bloodstream and affected by carbohydrate and alcohol intake; also contributes to atherosclerosis

9. Types of Lipid Disorders Hypercholesterolemia (>200mg/dL) Usually high LDL-C (>100 mg/dL) Hyperlipidemia—high LDL-C and high triglycerides (TG >150 mg/dL) Dyslipidemia—low HDL-C (<40 mg/dL; <50 for women) and usually high TG Hypocholesterolemia (total cholesterol <160) may be an indicator of poor health status (malabsorption, cancer)and higher cholesterol levels advised with critical illness (Bonville et al., 2004)

10. Medical Nutrition Therapy for Dyslipidemia Low saturated and trans fats and low cholesterol diet Moderate carbohydrate intake; emphasize soluble fiber Lose weight as needed Include omega-3 fatty acids (preferably fatty fish) Emphasize monounsaturated fats—nuts, olives and olive oil, canola oil, peanut oil, avocados Follow the American Heart Association’s Therapeutic Lifestyle Changes diet

11. Plant Stanols Found in some margarines Consider stanols as a medication to lower cholesterol Produced from naturally occurring plant sterols Inhibit absorptive process Can take 6 to 8 weeks of use for impact May interfere with absorption of certain nutrients (e.g., beta carotene and vitamin E) (Tuomilehto et al., 2008)

12. Role of Insulin and Triglycerides (for persons with insulin resistance) High CHO meal → Hyperinsulinemia → Reduced action of the enzyme lipoprotein lipase → Decreased breakdown of triglycerides (TGs) → Increased TG level and reduced HDL-C level Moderate CHO meal → Normalized insulin → Increased action of lipoprotein lipase → Increased breakdown of TG → Decreased levels of TG and increased HDL-C level

13. Benefit of Nuts American Heart Association advises a handful (¼ cup) of nuts daily to lower risk of heart disease by 35% This may be due to vitamin E content and monounsaturated fats The majority of nuts are primarily high in monounsaturated fats (grown in moderate climates) Except Brazil nuts (grown in tropical climates) that are high in saturated fat Except walnuts (grown in cold climates) that are high in polyunsaturated fats Other compounds found in nuts contribute to cardiovascular health, including fiber, phytochemicals, and the minerals potassium and magnesium (Kris-Etherton et al., 2008)

14. Benefit of Dark Chocolate (Non-dairy) Promotes vasodilation to lower blood pressure and improve circulation, and reduces oxidative stress (Flammer et al., 2007; Taubert et al., 2007) Read ingredients to ensure no butter fat or milk fat has been added

15. FYIRole of Magnesium in CVD As found in leafy greens, legumes, fish, milk, and supplements Improves endothelial health (Cuevas and Germain, 2004) Reduces arrhythmia and risk of heart failure(Ohtsuka and Yamaguchi, 2005) Acts as an HMG-Co reductase inhibitor (same effect as statin medications) and needed to convert omega-3 and omega-6 fats into prostaglandin hormones (Rosanoff and Seelig, 2004) Supplementation reduces complications of coronary artery bypass graft (CABG) surgery (Pasternak et al., 2006)

16. Hypertension (HTN) Stage 1 HTN ≥140/90 mm/Hg Stage 2 HTN ≥160/100 mm/Hg Stage 3 HTN ≥180/110 mm/Hg Children may be treated with blood pressure >90th percentile (see Appendix 10, Evolve) Optimal blood pressure: <120/80 for adults HTN linked to: All forms of CVD Stroke Peripheral vascular disease (PVD) Heart failure Renal disease

17. Possible Contributing Factors to HTN Obesity and lack of exercise Altered nitric oxide metabolism with increased vasoconstriction History of low birth weight High ratio of sodium to potassium intake (high salt and low intake of high-potassium foods) Deficiencies of vitamin C, folic acid, and zinc Magnesium deficiency resulting from altered calcium metabolism with decreased vasodilation and decreased inhibition of norepinephrine hormone High intake of red meat Chronic coffee intake promotes aortic stiffness (Vlachopoulos et al., 2005)

18. Omni Heart Study (Optimal Macronutrient Intake Trial to Prevent Heart Disease) 2300 mg Na+ 2000 kcal (approximately) 6% saturated fat Up to 20% monounsaturated fats Up to 200 mg cholesterol Moderate carbohydrate intake at 48% to 58% Moderate protein intake at 15% to 25% Moderate fat intake at 27% to 37% (Swain et al., 2008)

19. Guidelines and Benefits of Exercise Minimum of 30 minutes of brisk walking on most days of the week If there is risk of impaired nerve impulses preventing increased heart rate, lower levels of exercise are warranted Seek medical input for preexisting CAD or complications of diabetes (neuropathy) Both aerobic and anaerobic exercises contribute to reduced CVD Reduce blood pressure and risk of stroke Raise HDL-C

20. Treating Heart Failure Limit Na+ intake; may require <2 g Na+ diet Higher intake may cause edema Advise thiamin supplementation with potential of beriberi as etiology of heart failure; B1 deficiency common among persons taking diuretics or with excess urination from uncontrolled diabetes or excess fluid intake (Sica, 2007) Consider supplementation related to energy production by the heart muscle (e.g., vitamins B1, B2, B6, L-carnitine, coenzyme Q10, creatine, and taurine) (Allard et al., 2006)

21. Statin Medications Lipid lowering (with positive and negative impacts) (+) Statins (HMG-Co reductase) inhibit liver’s production and lowers LDL-C and lowers inflammation (–) Statins interfere with liver’s production of CoQ10 enzyme (–) Statins can cause myopathy (any disease of the muscles), rhabdomyolysis (rupture of body cells), and polyneuropathy; this may be due to selenium deficiency (Moosmann and Behl, 2004). (–) Statins less effective in women and persons over 65 years and linked with increased breast cancer and hemorrhagic stroke(Preobrazhenskii et al., 2007) (–) Limited research among persons >85 years; may increase neurodegeneration and heart failure among the elderly population (Golomb, 2005; Deedwania and Volkova, 2005)

22. Other Medications and CVD Risk Reduction Nicotinic acid (a form of vitamin B3), and often referred to as niacin, normalizes all lipids (Berra, 2004); slow release form safe at doses 1000 to 3000 mg and more effective in women (Goldberg, 2004) Aspirin lowers inflammation and inhibits clot formation; aspirin resistance related to ischemic heart disease, cigarette smoking, and statin medications (Coma-Canella et al., 2005) Thyroid medications lower triglycerides among persons with subclinical hypothyroidism (Milionis et al., 2005) Stopping oral contraceptives can lower BP (Lubianca et al., 2005)

23. Study Guide • Vocabulary: • Arteriosclerosis • Atherosclerosis • Cerebral Vascular Accident • Myocardial Infarction • Thrombosis • Peripheral arterial disease • Hypercholesterolemia • Hyperlipidemia • Dyslipidemia • Edema • Distinguish between the types of lipids • Risk factors for CVD (ATP III) • What decreases risk for stroke?

24. Study Guide (continued) • MNT for dyslipidemia • How do stanols help lower cholesterol? • How do nuts decrease heart disease risk? • How does chocolate decrease risk? • What electrolyte may help reduce risk? • How does insulin affect TG? • Factors contributing to HTN • Benefits of exercise? How much exercise is recommended? What type? • Biggest nutritional factor affecting people with heart failure? • How do statins decrease cholesterol?