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Prevention is the key. CVD - Is it preventable ?? - Very much Yes. The risk assessment must start very early At the age of 20 years itself Healthy life style and hearty eating habits Regular physical exercise from young age Maintaining ideal weight and hour glass waist

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Prevention is the key

  • CVD - Is it preventable ?? - Very much Yes.

  • The risk assessment must start very early

  • At the age of 20 years itself

  • Healthy life style and hearty eating habits

  • Regular physical exercise from young age

  • Maintaining ideal weight and hour glass waist

  • Avoiding tobacco and reducing alcohol

  • There are enough guidelines – Implementation ?

www.drsarma.in


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Non-Modifiable

6. Phenotype B

5. Personality

4. F. Hx CVD

3. Ethnicity

2. Gender

1. Age

Modifiable

6. Physical Inactive

5. Obesity, ↑ WC

4. Lipid Abnor

3. Smoking

2. Inc.BP

1. DM

CHD RF

Emerging

6.Homocysteines

5. ApoA1/ ApoB

4. hs- CRP

3. ↑SLDL

2. Lp(a)

1. ED


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CHD – Makers and Markers

The Makers – Risk Factors

  • Non Modifiable – The tough six

  • Modifiable – The conventional six

  • Modifiable – The contributing six

    The Markers – Surrogate tests

  • We rarely care – The simple six

  • We barely know – The complex six

  • We hardly need – The experimental six

www.drsarma.in


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CHD Risk Factors - Makers

  • Non Modifiable – The Tough Six

    • Age

    • Gender

    • Ethnicity

    • Family H/o of premature CHD

    • Phenotype B

    • Type A personality (partly modifiable)

www.drsarma.in


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CHD Risk Factors - Makers

  • Modifiable – The Conventional Six

    • Diabetes Mellitus

    • Dyslipidemia

    • Hypertension

    • Smoking / tobacco

    • Over weight and Obesity

    • Physical inactivity

www.drsarma.in


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CHD Risk Factors - Makers

  • Modifiable – The Contributing Six

    • hs-CRP

    • Lp(a)

    • sLDL

    • Endothelial dysfunction

    • Apo B / Apo A1 ratio

    • Homocysteine

www.drsarma.in


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CHD Risk Factors - Markers

  • We rarely care to identify – The Simple Six

    • WC – Waist Circumference – Are we tailors?

    • ED – Erectile Dysfunction; ED = ED

    • ABI – Ankle Brachial Index, IC, Pedal pulse

    • PP – Pulse Pressure – Importance of ISH

    • MAU – Micro Albuminuria – Dip stick test

    • LVH – By Echocardiography, ECG, CXR

www.drsarma.in


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CHD Risk Factors - Markers

  • We barely know & test – The Complex Six

    • ABPM – Dippers & Non Dippers

    • FMD – Brachial Flow Mediated Dilatation

    • PCOS – Polycystic Ovarian Syndrome - USG

    • CIMT – Carotid Intima Media Thickness

    • FFAG – Florescence Fundus Angiography

    • STS – Stress Thallium Scan – for perfusion study

www.drsarma.in


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CHD Risk Equivalents

  • Diabetes Mellitus

  • Peripheral Vascular Disease (PVD)

  • Framingham risk score of > 20%

  • Carotid artery disease –

    • Stroke, TIA

    • > 50% Narrowing, Carotid Bruit

  • Abdominal Aortic Aneurysm (AAA)

Adult Treatment Panel III. NIH publication 01-3095.

www.drsarma.in


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The CADI Volcano

  • We are in the middle of the wave of CAD epidemic

  • This CADI epidemic will peak by 2015

  • 50% deaths in India are CVD deaths.

  • CADI will overtake Infectious diseases in morbidity too

  • By 2015 CADI will be six times more than the West

  • CADI will be 20 times more than the Chinese, although

  • Our culture shuns smoking, 50% are vegetarians and

  • We lack many of the classic risk factors for CAD

  • Remember CADI is preventable & predictable

www.drsarma.in


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Lipid and Other RF for CAD

  • ‘Good’, ‘Bad’, ‘Ugly’ and ‘Deadly”

  • Total Cholesterol – TC 200 mg

  • Triglycerides – TG 150 mg

  • Low density lipoprotein LDL 100 mg

  • High density lipoprotein HDL 50 mg (40 ♂)

  • Lipoprotein (a) or Lp(a) 25 mg

  • Apo B ÷ Apo A 1 (Normal) < 1.5

  • hs-CRP – Normal < 3 mg/L

  • MAU – Normal per 24 hours 30–300 mg

www.drsarma.in


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Dyslipidemia and CAD

  • Non HDL = TC – HDL = 200 – 50 = 150

  • TC ÷ HDL = 200 ÷ 50 = 4 (Often used)

  • TG ÷ HDL = 150 ÷ 50 = 3 (Imp. Indians)

  • LDL ÷ HDL = 100 ÷ 50 = 2 (Often used)

  • LTI – Lipid Tetrad Index (New one 2005)

    [TC x TG x Lp(a) ] 200 x 150 x 25

    HDL 50

    = 15000; Normal is up to 10 K

    10 K to 20 K is boarder line

    More than 20 K is abnormal

=

www.drsarma.in


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Our cut off values !

For Indians

  • BMI < 23 Normal

  • BMI of 23 to 24.9 Over weight

  • BMI of > 25 Obesity

  • WC for ♂ Normal 90 cm (36”)

  • WC for ♀ Normal 80 cm (32”)

Central adiposity causes

↑IL6, which ↑hepatic hs-CRP


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Risk Factor Defining Level

Abdominal Obesity Waist Circumference

Men >90 cm (>36 in)

Women >80 cm (>32 in)

Triglycerides >150 mg/dl

HDL cholesterol

Men <40 mg/dl

Women <50 mg/dl

Blood pressure >130/>85 mmHg

Fasting glucose >110 mg/dl

Metabolic Syndrome, Syndrome X, Deadly Quartet, Reaven’s Syndrome

NCEP guidelines 2001 (WHO Modified for Indians)


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MAU: 30-300mg albumin in urine over 24 hrs

Occurs in DM and HT

Detected by new dipstick tests for MAU

Most accurate assessment is 24hr collection

Screening by ACR on spot urine (first morning)

MAU is a marker of early stage renal damage

Regression of MAU decreases risk

A marker of generalized CVD risk

Micro Albuminuria (MAU)


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CVD Risk Management

Braunstein JB et al. Cardiol Rev. 2001;9:96-105.


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ATP III: Nutritional

Components of the TLC Diet

Nutrient

Recommended Intake

Saturated fat*

<7% of total calories

Polyunsaturated fat

Up to 10% of total calories

Monounsaturated fat

Up to 20% of total calories

Total fat

25%–35% of total calories

Carbohydrate (esp. complex carbs)

50%–60% of total calories

Fiber

30–40 g/d

Protein

~15% of total calories

Cholesterol

<200 mg/d

*Trans fatty acids also raise LDL-C and should be kept at a low intake.

Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight.

Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.


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Hypertension and DM control

Beta blockers for HT and IHD

Aspirin 150 to 300 mg

ACEi or ARB for DM and HT

Aggressive therapy for DM and ↑ Lipids

Smoking cessation, ↓ in Alcohol intake

Physical activity at least 45 min/ day

No role for estrogen replacement Rx.

Prevention of CHD