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Heart Matters—All Things Cardiac

Heart Matters—All Things Cardiac. Barb Bancroft RN, MSN, PNP Chicago IL. OK, so what are we going to do today?. Some numbers Risk factors for heart disease Drugs used to treat cardiovascular conditions

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Heart Matters—All Things Cardiac

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  1. Heart Matters—All Things Cardiac Barb Bancroft RN, MSN, PNP Chicago IL

  2. OK, so what are we going to do today? • Some numbers • Risk factors for heart disease • Drugs used to treat cardiovascular conditions • Lab Tests for cardiac risks and function—lipid profile, BNP, Troponin, hs-CRP, blood pressure, microalbumin • The cardiac exam • The evaluation of the patient with chest pain • Selected cardiac conditions—acute coronary syndromes, hypertension, CHF, AF, valvular heart disease, cardiomyopathies

  3. Some numbers? • Cardiovascular disease costs $273 billion per year • Heart disease is the number one cause of death in the U.S. • Between 1999 and 2009 the rate of deaths from CVD declined 32.7 percent. However, it still accounts for 1 out of 3 deaths per year • Older adults living a healthy lifestyle are more likely to delay the onset of cardiovascular problems by at least seven to 14 years…

  4. Some numbers?? • Meeting 5 of 7 of the following criteria decreases likelihood of dying from heart disease by 88% • No smoking • BMI less than 25 • 150 minutes/week moderate activity; 75 minutes of strenuous activity • Healthy diet • Total cholesterol level less than 200 mg/dL • BP less than 120/80 • Fasting plasma glucose less than 100 mg/dL

  5. Risk factors for cardiovascular disease—the usual suspects • In general, cardiovascular disease is gender-blind—smoking, hypercholesterolemia, diabetes mellitus, hypertension, and the lack of exercise are the major controllable risk factors for both sexes • But let’s first take a look at the NON-controllable risk factors—age, gender, family history

  6. Your age…and gender • Women have the onset of heart disease an average of 10 years later than men and their first heart attack 20 years later than men • Here you are, celebrating your 75th birthday with all of your GIRLfriends in the nursing home

  7. Why? • Estrogen protects our heart even after our ovaries die…for about another 10-15 years—estrogen is an anti-oxidant, lowers LDL-C, anti-inflammatory • HOWEVER, hormone replacement therapy is NOT cardioprotective • Prior to menopause, menstrual bleeding decreases iron stores on a monthly basis; women’s iron stores are 50% less than men until menopause; high iron acts as an oxidant on LDL-cholesterol • Oxidation puts LDL-cholesterol into arterial walls • Once we stop menstruating iron levels creep up and the CV risk increases

  8. Family history • Father, mother, brother, or sister who first developed clinical CAD at age younger than 45-55 for males and at age younger than 55 to 60 for females; • An early heart attack (myocardial infarction) or other cardiovascular event (stroke or peripheral vascular disease) • Important to ascertain, but it only modestly adds to the predictive power of global assessments

  9. Things you can change…Controllable risk factors • Smoking • Hyperlipidemia with LDL cholesterol as the most important contributor to CVD— • Diabetes mellitus— “sugar diabetes” • Hypertension

  10. Stop Smoking • 36% reduction with smoking cessation • appears at least as great as other secondary preventive therapies, such as the use of statins for lowering cholesterol levels (29%), aspirin (15%), β-blockers (23%),or ACE inhibitors (23%),which have received the bulk of the attention in recent years.

  11. Smoking and women • Women who smoke have their first heart attack almost 20 years earlier than women who don’t smoke

  12. “When should I quit smoking?” How about NOW? • If you quit smoking the risk of heart disease drops substantially in only 2-3 years, reaching baseline after ten years • Patients who cut down but continue to smoke 1-4 cigarettes per day continue to have an elevated risk of heart disease

  13. How about smoking and clotting with estrogen-containing products? • Pills of yesteryear—80 to 100 μg per pill • Could stop an elephant from ovulating • Pills of 2012—20-35 μg per pill • Less clotting risk, greater chance of pregnancy if you MISS A PILL • It’s not JUST the pill…weight plays a role too…

  14. The Pill, obesity, and clotting risk • European Active Surveillance study (2000-2006); 59,000 women from seven European countries, looking at heart health in women using OCs • For every 100,000 years of pill-taking, 44 women had blood clots in the placebo group • For every 100,000 years of pill-taking, 90 women had blood clots (double the placebo group) • BUT, and that’s a big BUTT—when the study looked specifically at women with a BMI over 30, the number skyrocketed to 230 cases (5x more likely than those in the placebo group)

  15. Drospirenone in OCs • April 30, 2012 • FDA Warning about drospirenone in oral contraceptives • Yaz, Yasmin, BeYaz, and Safyral, and others may be at a higher risk for thromboembolism than CHCs containing other progestins (levonorgestrel, norgestimate, or norethindrone) • Controversial warning…all CHCs increase the risk of venous thromboembolism, whether the progestin component affects risk continues to be controversial • And, the risk of clotting during pregnancy is much higher

  16. Comparison of risk of levonorgestrelvsdrospirenone • Drospirenone rate is 30.8 per 100,000 women-years • Levonorgestrel rate is 12.5 per 100,000 women-years • Another study—23.0/100000 w/ drospirenone vs. 9.1/100,000 with levonorgestrel Jick SS and Hernandez RK. BMJ 2011 April 21;342; Parkin L et al. BMJ 2011;342

  17. Lowering LDL-cholesterol • To 70 mg/dL or less (2.0 mmol/L or even lower to 1.8 mmol/L) if you have cardiovascular disease, diabetes, hypertension or smoke) • Triglycerides less than 150 mg/dL • It appears as if the HDLs have fallen out of favor due to a couple of studies that boosted HDLs for cardioprotection; the studies found no differences in CAD with boosting HDLs (The Lancet, December 8/14, 2012; J Am College of Cardiology, December 19, 2012)

  18. LDL-cholesterol is the primary problem • HOWEVER, there’s more to it than just a “cholesterol” level • NEWEST RESEARCH: LDL particle size is most important • Subtype/Pattern A—large, loose LDL molecule • Subtype/Pattern B—small, dense molecules, prone to oxidation and penetration of artery walls forming fatty plaques

  19. Expanded cholesterol test • Ratio of small to large LDL molecules • Test is between $39--$100 and is not covered by insurance • One clue that your LDL particles are small—your triglycerides are high (diabetics have high triglycerides with higher rates of CV disease) • The drugs that specifically lower LDL-cholesterol, the statin drugs, are most effective when the LDL molecules are small and dense

  20. Type 2 Diabetes Mellitus— “sugar diabetes” • Over 28 million type 2 diabetics in the U.S. • Heart disease and  stroke are the No. 1 and 2 causes of death and disability among people with type 2 diabetes. In fact, at least 65 percent of people with diabetes die from some form of heart disease or stroke.

  21. Diabetes Mellitus • Adults with diabetes are two to four times more likely to have heart disease or a stroke than adults without diabetes. • Women with diabetes have a greater risk of heart disease than men with diabetes • When patients have both hypertension and diabetes (the “deadly duo”), which is a common combination ~70% of the time, the risk for cardiovascular disease doubles.

  22. How about patients with Type 1 diabetes? • How long have they had the disease? • Are they smokers? Have hypertension? • How are their kidneys? microalbuminuria? • In T1DM kidney disease rarely occurs within the first 5 to 10 years of diabetes, with increasing incidence of nephropathy over the next decade to a peak at about 15-17 years of having diabetes • Kidney disease and cardiovascular disease go hand-in-hand

  23. Hypertension (high blood pressure) • Hypertension is a risk factor for heart disease in both men and women • What is “normal” blood pressure? Less than 120/80 • Diabetes and hypertension—new guidelines (ADA January 2013, Diabetes Care)—140 /80; old guidelines of less than 130 systolic showed that intensive BP control did NOT decrease deaths or heart attacks and only a slight decrease in strokes

  24. Another important note about hypertension… • Are you a dipper? 10% decline @ night • Or a non-dipper*? BP doesn’t fall when your head hits the pillow…non-dippers have a higher risk of CV disease, strokes, and end-stage renal disease *consider night time dosing of anti-hypertensive for . non-dippers (American Journal of Kidney Diseases December 2007)

  25. The Deadly duo and Kidney disease • Hypertension and diabetes increase the risk of chronic kidney disease • Increased pressure in the glomerulus—intraglomerular hypertension • One of the first manifestations of intraglomerular hypertension is microalbuminuria

  26. Diabetic/hypertensive nephron…hyperglycemia/HTN/high animal protein in the diet • Afferent arteriole ( ↑ vasodilation by ( ↑ prostaglandins—increasing GFR) • Blood entering glomerulus • Glomerulus→filter • Efferent arteriole ( ↑ vasoconstriction via ( ↑ angiotensin II) • Intraglomerular hypertension and microalbuminuria Microalbuminuria

  27. Why is microalbuminuria a “bad” thing? • The presence of microalbuminuria suggests that large vessel walls are more permeable to lipoproteins (causing atherosclerosis) and/or damage from the local release of growth factors • There is a 4-fold increase in acute coronary syndromes in Type 1 DM greater than 35 years old; • When microalbuminuria is present the cardiovascular risk is increased by a factor of 140!

  28. What else increases the risk for heart disease? • Weight gain—if a woman gains 44 pounds after high school her risk of heart disease increases by 250%

  29. Weight gain • “But Barb, I’ve only gained a pound a year since high school!” • And, when, pray tell, did you graduate from high school? • “1960”…you do the math…it’s now 2013 or 53 years since you graduated from high school • And you’ve only gained 1 pound per year?

  30. Location, location, location of those extra pounds—waist size • Are you an apple or are you a pear?

  31. What’s going on with belly (visceral) obesity? • Visceral fat is Insulin resistant • Visceral fat (now considered endocrine tissue—a NEW organ, yes you have GROWN a NEW organ) produces adipokines to regulate glucose transport and boost inflammation responses • Inflammatory mediators are produced by visceral fat--Tumor Necrosis Factor alpha; Interleukin-6

  32. Throw it all together…metabolic syndrome • Central obesity—waist size greater than 40.2 inches in men, 34.6 inches in women • High TG (>150 mg/dL), • Low HDL (less than 40 mg/dL in men, less than 50 mg/dL in women)**NEW INFORMATION • Hypertension (≥ 130/85 mm Hg) • Fasting glucose ≥ 110 mg/dL • Metabolic syndrome is present when any 3 of these risk factors are present • PCOS (polycystic ovary syndrome is a form of metabolic syndrome/IRS)

  33. Inflammation—high sensitivity CRP • hs-CRP (vascular inflammation) and coronary artery disease risk level—best use in younger individuals believed to be at intermediate risk for heart disease • Use of hs-CRP + lipid values together are more accurate at predicting risk than lipid studies alone • The bigger the waistline the greater the hs-CRP low risk < 1 mg/L; Average 1-3 mg/L; high risk > 3 mg/L (Noncardiovascular causes should be considered if values are > 10 mg/L) Ridker PM et al. N Engl J of Med 2000; 342:836-43; Ridker PM et al. N Engl J of Med 1997;336:973-9)

  34. What can reduce hs-CRP? • Exercise • Loss of abdominal fat—walkin’, walkin’ walkin’… • Statins not only reduce LDL but are also potently anti-inflammatory • Aspirin • Omega-3 fatty acids • Nuts (especially walnuts) • The Mediterranean diet

  35. Depression • Depression is associated with an elevated risk of fatal CHD in men and women, and it is a stronger risk factor in women. • Depression increases the risk of having an AMI by 400% • If untreated following an MI or bypass surgery, the patient is less likely to survive • Say yes to anti-depressants if necessary

  36. The Cardiologist’s funeral • A cardiologist died and his funeral was attended by a multitude of physicians showing their respect • At the funeral his casket was elevated on the dais and behind the casket was a huge heart covered in red roses • The eulogy was given and as the last words were said, the massive rose-covered heart opened and the casket rolled through the open heart of roses • The gynecologist attending the funeral burst out laughing and choked…I’m imagining what my casket will roll through… • And that’s when the proctologist got up and left…

  37. Didja’ laugh at that joke? • A study of patients who recently had a heart attack compared humor responses to matched controls who did not have a history of heart disease • They were all given a multiple choice questionnaire—asking about laughing…how often, how little, how much ? The highest humor score was 105 and lowest was 21 • People with a humor score above 50 had the least risk of heart disease • The heart patients were least likely to laugh in different situations and the least likely to use humor in adaptive situations

  38. Hypothyroidism • Subclinical hypothyroidism (TSH 5.01-10.0 mIU/L) w/ normal T4 has been associated with an elevated cardiovascular risks and mortality in patients under 70 (Arch Internal Med 2012) • Decreased metabolism decreases the clearance of lipids from the blood • Increases the risk for heart disease • The American College of Endocrinology suggests age 35 for baseline TSH levels

  39. Conversely…subclinical hyperthyroidism • Raises the risk for mortality and cardiac events as well • Especially when TSH levels are < 0.45 mIU/> and even more so when levels were <0.10 mIU/L • 29% higher CHD mortality • 68% higher risk for atrial fibrillation

  40. Other risk factors • PCOS (polycystic ovary syndrome)—insulin resistance • Autoimmune disease—SLE, RA (inflammation)--Risk of cardiovascular disease in patients with Lupus—Lupus patients are 140% more likely to have atherosclerosis; for patients under 40 the risk is 480% (N Engl J Med, Dec. 3, 2003); • CV disease in RA patients—3 x >risk of hosp. w/MI; 5x >risk of silent MI before dx w/RA; sudden cardiac death ?feel chest pain • Atorvastatin and inflammation (RA, SLE, MS)(Lancet 2004 June 19;363:2015-21) • Cocaine and methamphetamine use—duh…potent vasoconstrictors

  41. Like father, like son? • For some men, CV disease may be inevitable • Variant gene on the Y sex chromosome increases the risk of CV disease by 50% • The variant gene was found on an area of the chromosome responsible for the immune system, suggesting an inflammatory link • May explain why certain men without traditional CV risk factors still develop heart disease

  42. Cardiovascular drugs • Drugs to lower lipids • Drugs to decrease blood pressure • Drugs to treat heart failure • Drugs to reduce platelet aggregation and clotting factors • Drugs that lower blood sugar • Drugs to reduce arrhythmias

  43. Drugs to lower LDL-cholesterolThe “statins”? • Lovastatin (Mevacor) • Pravastatin (Pravachol) • Fluvastatin (Lescol) • Simvastatin (Zocor) • Rosuvastatin (Crestor) • Atorvastatin (Lipitor) • Pitavastatin (Livalo)

  44. The “Statin Sisters”…what do they do? • Inhibit an enzyme in the liver responsible for the production of the LDL-cholesterol; works primarily at night to reduce LDL, so the “statins” work the best when taken before bedtime (exceptions to the rule—atorvastatin/Lipitor and rosuvastatin/Crestor)

  45. LDL-lowering effects • If so, how low should your LDL go? • Atorvastatin/Lipitor 10 mg = 39% • Fluvastatin/Lescol 40 mg BID = 36% • Fluvastatin XL/Lescol 80 mg = 35% • Lovastatin /Mevacor 40 mg = 31% • Pitavastatin/Livalo 2 mg = 36% • Rosuvastatin/Crestor 5 mg = 45% • Simvastatin/Zocor 20 mg = 38% (Circulation 2004;110:227-239)

  46. Green tea, grapefruit juice, and simvastatin • Both green tea and grapefruit juice inhibit the intestinal enzyme that metabolizes simvastatin. As inhibitors of this enzyme, both “Gs” have the capability of increasing the concentration of simvastatin which in turn increases side effects. The higher the statin dose, the greater the toxicity. The manufacturer of simvastatin reports that the incidence of myopathy is 25 times higher with the 80 mg dose of simvastatin versus the 20 mg dose. (Med Letter 2008 (October 20; 50:83) • P.S. The bioavailability of simvastatin can increase by 700% with grapefruit or grapefruit juice

  47. LDL guidelines • Guidelines—with CAD or a risk equivalent (PAD, TIA, stroke, abdominal aneurysm), the LDL should be ~70 mg/dL (2.0 mmol/L or even lower, perhaps 1.8 mmol/L) • For the rest of us with other risk factors—100 mg/dL (<2.85 mmol/L) • Unless you’re perfect…--130 mg/dL (<3.37 mmol/L)

  48. Summary: What do the statins do? • Decrease total cholesterol • Decrease LDL-cholesterol • Decrease oxidation of LDL-cholesterol • Shrink plaques including plaques in the renal artery and improve blood flow to vital organs • Stabilize fatty plaques and prevent plaques from rupturing • Prevent the formation of new plaques in the renal and other arteries • Decrease mesangial proliferation • Decrease vascular inflammation

  49. SIDE EFFECTS • Myalgias **(other causes in elderly patients…) • About 1/20 patients experience muscle pain or weakness • Myositis; rhabdomyolysis (rare) (ASA is 100x more likely to cause a fatal side effect than taking a statin) • Simvastatin at higher doses is the riskiest “statin” for rhabdomyolysis—never use the 80 mg dose; lots of drug interactions; do NOT drink green tea or eat grapefruit or drink grapefruit juice with this statin • How about adding CoQ10 for muscle aches and pains? take 50-100 mg/day of CoQ10 • Either switch statins, lower the dose of statins, consider every other day dosing

  50. How about lowering triglycerides? • Fenofibrates (Tricor, Triglide) • GemfibrozilLopid)—not to be used with statins • Niacin? Fallen out of favor… for primary and secondary prevention especially when LDL levels are achieved w/ statins(N Engl J Med 2011 Nov 15) • Fish oil? Lower plasma TG, but recent studies do not offer any convincing evidence that fish oil supplements prevent primary or secondary cardiovascular disease; • Prescription fish oil, Lovaza 4 grams/day

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