Cardiovascular Disease By

Dambar B Khadka

Alexander Cherepov

Emma Dermitzaki

Serpil Acar

Ohiakwu Beard

Bee Geok

INTRODUCTION
One of the leading death causing NCDs Main types: CHDs and Strokes Cause 17.3 millions death word wide ( WHO, 2008) Equally distributed on men and women Most affected Group are elderly >30 years old High in low and medium income groups

CVD Risk Factors

Behaviour Risk Factor Tobacco use Physical inactivity Unhealthy diet ( High in salt, fat and calorie) Harmful use of alcohal Metabolic Risk factor Hyper tension ( Blood pressure Diabetes ( Blood sugar) Blood lipid (eg Cholesterol) Overweight and obesity Other Risk factor Poverty and low education Advancing group Gender Genetic disposition Psychological factor ( Stress depression...) Other ( excess homocysteine)

Fig: Ranking of death of top 10 selected risk factors ( WHO Atlas 2011)

Saturated Fat ( SFAs) & CVD

One of the considered risk factor of CVD Lipid Hypothesis or Diet Heart Hypothesis
SFAs intake believe to or associated with elevated level of Cholesterol and LDL (Marker of CVD)Hypercholesterolemic

MUFA and PUFA -Hypocholesteromic effects( beneficial association )

SFAs and CVD

Cholesterol & LDL elevating effect Cholesterol & LDL elevating effect & HDL Lowering

Cholesterol & LDL lowering

Source: Kris Etherton & Yu, 1997

SFAs & Total: LDL

Saturated fat does not significantly change the Total: HDL ratio (Milsinki et al 2003)

Source : Milsinki et al. 2003

Epidemiological studies
Ecological studies
Seven country study support lipid hypothesis Prone to bias (influence of external and other dietary factor)

Case Control study

Limited and prone to several biass

Systematic Review and perspective cohort study

shows weak associations except some studies (Mente
2009: Siri-Tarino et al.2010) 2009; Skeaff

Positive association in some studies only (Parodi et al 2009)

Randomised control trial

either improperly designed or have short intervention periods.

Discussion
Different Saturated fatty acid has different association A few positive and some negative association & most of cohort studies have null association Uncertantity on Association & Cholesterol controversy Mechanism between Cholesterol, LDL , HDL and CVD still not sufficiently clear Newer marker such as apoB protein are emerging.

In spite of the conventional understanding about reduced dietary SFAs is beneficial for cardiovascular health, independent association & Plausible Mechanism is still lacking

Fish Consumption, Fish Oil, Omega3 Fatty Acids, and Cardiovascular Disease

William.S Harris, 2002

William.S Harris, 2002

The essential omega-3 FA is alpha-linolenic acid (ALA) that is a substrate for eicosapentaenoic (EPA) and docosaheaxaenoic (DHA) which found in fish meat or fish oil, respectively (salmon, mackerel, trout) (Nettleton 1991).

Ryan Andrews,2009

(M. Vrablk et. al., 2009)

GISSI-Prevenzione Study
Total Mortality reduced by 28% Sudden Death reduced by 47%

CV Mortality reduced by 30%

>11.300 post-MI patients were given usual care with or without 850 mg EPA+DHA for 3.5 years
Early benefit of omega-3 polyunsaturated fatty acid (-3 PUFA) therapy on total mortality, sudden death, coronary heart disease (CHD) mortality, and cardiovascular mortality.
(Marchioli R, Barzi F, Bomba E, et al. , Circulation 2002;105:1897-1903)

-3 PUFA
Produces vasodilation and blood pressure Improves arterial and endothelial function and Reduces platelet aggregation

However the antiplatelet, anti-inflammatory, and triglyceride-lowering effects of -3 PUFA require relatively higher doses of DHA and EPA (e.g., 3 to 4 g/day), whereas some of the antiarrhythmic effects, reduction of SCD, and improvement in HF can be achieved at lower doses (500 to 1,000 mg/day).
(Mozaffarian and Rimm, JAMA 2007;297:5091)

The DART study -2033 men who were recovering from acute myocardial infarction.

Follow-up of 4.6 years, a 19% relative reduction in major coronary events was noted
Unstable angina and non-fatal coronary events were also significantly reduced in the EPA group. Sudden cardiac death and coronary death did not differ between groups. In patients with a history of coronary artery disease who were given EPA treatment, major coronary events were reduced significantly by 19%. In patients with no history of coronary artery disease, EPA treatment reduced major coronary events by 18%, but this finding was not significant.

These findings suggest that EPA administration was effective also when added to the statin therapy.

Recommendations
AHA dietary guidelines
Protective dose is 1g/day EPA + DHA in patients with CHD (Randomized Control Trials) 2 oily fish meals per week

FDA
4 g/day -3 PUFA in patients with hypertriglyceridemia

Safety and Adverse Effect

Adverse Effect
Increased body weight (30ml fish oil= 248 Kcal/day) Nausea, gastrointestinal upset, and fishy burp Prolonged bleeding times Excessive bleeding and the possible increase in stroke increase hemorrhagic complications in higher intake

EPA +DHA >3 g/d, improve cardiovascular disease risk factors,

including decreasing plasma triacylglycerols, blood pressure, platelet aggregation, and inflammation, while improving vascular reactivity

Consumption of contaminants,
PCB and methyl mercury Chlorohydrocarbons and dioxines
can reduce their exposure to PCBs by removing the skin and fat from these fish before cooking

Peroxides and aldehydes intake from autooxidized fish oils

CARDIOVASCULAR DISEASE AND SMOKING IN RUSSIAN FEDERATION

CVDs that are caused by smoking

Stroke Coronary heart disease Aneurysms Peripheral arterial disease Thromboangiitis Angina

components of tobacco smoke nicotine CO2 sympathetic nervous system glycoprotein benzpyrene Platelet aggregation, increased levels of fibrin, the formation of free radicals and endothelial damage atherogenesis, hypertension, and occlusive peripheral vascular disease

HbCO decrease in oxygen transport

The increase in blood pressure and heart rate beat, decrease in infarction, vasoconstriction

tissue hypoxia, hypoxia infarction, myocardial ischemia

myocardial infarction apoplexy sudden death

Share (%) of deaths associated with smoking for leading cause of death in Russia, (Karpov R, Kiseleva S et al, 2002).

Reason of death
malignant tumor Lung cancer CVD Diseases related to lungs Other reasons All

Men
35-69 years old 43 89 25 60 >75 36 90 10 61 35-69 2 10 3 12

Women
>75 5 15 5 20

1 25

7 20

10 2

15 3

Age 35-69 Older 70 95% CI RR 95% CI

Reason of death

A history of smoking factor

RR

Smoked last 5 years 1-19 cigarettes a day 20 cigarettes a day >20 cigarettes a day

1.6

1.14-2.24 1.16-2.65 0.85-2.010 0.93-6.32

1.48 1.32
1.57 1.45

1.17-1.87 0.98-1.78
1.20-2.05 0.90-2.34

1.75 1.31 2.43

CHD

Stopped smoking 20 years ago Stopped smoking 5-19 years ago Smoked last 5 years 1-19 cigarettes a day 20 cigarettes a day >20 cigarettes a day Stopped smoking 20 years ago Stopped smoking 5-19 years ago

0.43 0.77

0.20-0.94 0.46-1.28 1.13-1.98

0.7 1.42 1.43 1.48 1.3 1.84 0.68 1.34

0.36-1.36 0.74-2.73 1.04-1.96 0.99-2.21 0.88-1.92 0.68-5.08 0.35-1.30 0.69-2.61

1.5 1.48 1.49 1.4 0.58 1.09

1.05-2.09 1.08-2.06 0.76-2.58 0.25-1.37 0.57-2.09

STROKE

The link between smoking and risk of death from cardiovascular disease. RR relative risk Ci confidence interval, (Source: Onishchenko G, Skulls V, 1999)

Recommendations
Insufficient amount of studies, only in 90s (mortality) There is not enough developed methodology to assess the effectiveness of population programs, so that it is difficult to make such an assessment and to compare these data with other researchers According to a several single studies, smoking is one of the major causes of high mortality of CVD in Russian Federation

QUIET SMOKING!

BEGIN EXERCISE!

EAT HEALTHY!

Relation between Alcohol and Cardiovascular Disease

Alcohol is major risk factor of cardiovascular disease and sudden cardiac death in many parts of the world, but according to several epidemiological studies it was defined by WHO that alcohol offers cardio-protective effect at regular or moderate level of consumption.

Pattern of Drinking
Alcohols are likely to be drunk as spirits, in binges in some eastern European countries like Russia which are categories as heavy drinkers. In France alcohol are consumed as wine with meal and are categories as a regularly or moderate drinkers. Moderate alcohol consumption proved to have cardioprotective effects Russia have a high rate of sudden cardiac death and cardiac death incidence recorded and other related case of cardiovascular disease as a result of heavy and excessive consumption of alcohol.

Cohort studies
The epidemiological evidence seen on conducting Cohort study between an American and Russian men and women on the cardio protective effect of alcohol and results shows that Americans have a protective effect while the other Russian men and women have no effect These cohort study proved that the pattern which alcohol are been drunk influence the rate of cardiovascular disease, like frequency hangovers

Possible Mechanism
Cardiovascular death resulting from binge drinking are influence by four main mechanism involved, Lipids: firstly the effect of alcohol on lipids that increase the amount of cholesterol deposited on the artery hence increases the risk of coronary artery disease Moderate alcohol intake increases the level of anti-atherogenic high density lipoproteins(LDL) hence exert a cardio protective effect on the heart. Arrhythmias: alcohol causes delay of ventricular conduction Hypertension : as a result of increases in blood pressure caused by excessive alcohol intake. Thrombosis: the alcoholic effect blood clotting.

A graph moderate alcohol intake versus concentration of HDL

Recommendations
Epidemiological evidences seen cant proved that pattern of drinking are responsible for the link between heart disease and alcohol consumption Regularly or moderate drinking increases the HDL that produces a cardio-protective effect on heart while excessive or binge drinking increases LDL level been the risk of cardiovascular disease and sudden cardiac death in man and among middle aged group Moderate or regular alcohol consumption reduces the risk effect of thrombosis while binge drinkers have a high risk of thrombosis excessive alcohol consumption will led to arrhythmias effect on the heart and also reduces the threshold for ventricular fibrillation that led to myocardium.

PHYSICAL ACTIVITY and CARDIOVASCULAR DISEASE

PHYSICAL ACTIVITY
Petrella at al study (2005). A ten year follow-up Age and status of participants: initially inactive healthy men and women aged 55-75. PA: 30 to 45 minutes of walking three times per week Favourable changes: systolic blood pressure, high density lipoprotein and total cholesterol, triglycerides, insulin, waist circumference and fewer abnormal electrocardiogram findings on exercise treadmill testing.

PHYSICAL ACTIVITY
TYPE: aerobic and resistance exercise. According to the Health Professionals 8year Follow-up study training sessions with weights for at least 30 minutes per week reduces the risk to develop CHD by 23% (Tanasescu et al 2002).

VS
INTENSITY DURATION

PRIMARY AND SECONDARY PREVENTION

Reduced risk of premature death from CVD. Particularly among asymptomatic men and women. Mortality benefit up to 50% (Myers et al 2005) Benefits to patients with established CVD. 1600 kcal per week halting the progression of CAD. 2200 kcal per week plaque reduction in patients with heart disease (Franklin et al 2003).

PREVENTIVE MECHANISMS
Reduced abdominal adiposity and improved weight control.

Enhancements in lipid lipoprotein profiles.

Improvements sensitivity. in glucose homeostasis and insulin

Reductions in blood pressure. Decreasing blood coagulation and direct improvements on the vascular wall. Reducing chronic inflammation.

Reduced stress, anxiety and depression (Dunn et al 2001).

Cardiovascular Disease Prevention and Intervention

Reduce salt consumption

Changing the recipe and processing method to reduce the sodium content in common food Ensure low salt products are sold at lower price

In UK, product which is naturally high in sodium has to be labelled using the traffic light system and state that the product should not be consumed frequently.
Discourage the use of potassium or other sodium replacer to readjust the perception of saltiness in the population

Reduce fat intake

1. Saturated fat Ensure the manufacture are providing product with lower content of saturated fat Ensure products with lower saturated fat are sold at cheaper price. Provide a condition for industry and agriculture to produce dairy product with lower saturated fat content Promote semi-skimmed milk for children older than 2 years old

2. Trans fat In Denmark, Austria and New York, TF has been banned. EU is considering this ban, too, throughout EU. legislation to ensure that TF used in industry and cooking are less than 2% local authorities: monitor the level of TF in fast food, home-food trade and restaurant support the reduction of TF in food and encourage the replacement of TF with unsaturated fat

Tobacco control policy

Tobacco control include both smoking and secondhand smoke exposure.

six key areas: - monitor tobacco use - protection from second hand smoke - assistance to quit tobacco - warning about the dangers of tobacco - bans on tobacco advertising and promotion - taxation on tobacco products.

setting high price display health warning on all tobacco product banning advertising of tobacco related product or brand supporting research on smoking Taxation on tobacco products Protection from exposure to tobacco smoke Ban misleading terms e.glightandmild Education and public awareness campaigns Tobacco cessation services Control of illegal trade in tobacco products Control of sales to children and adolescent

These policies successfully reduced more than 40% of tobacco use in developed countries within 1960 to 1990. However, it is not effective in developing countries especially in China, East Asia and South Africa.

Food and Agriculture Policies

In Mauritius, the government has implemented policies to change the composition of cooking oil through limiting the content of palm oil. After 5 years, the mean population cholesterol levels were decreased significantly In Poland, Hungary, Romania and Bulgaria, policies were implemented to reduce the subsidies for animal fat products. The eating pattern in the country changed with less saturated fat and more polyunsaturated fat intake. In order to overcome undernutrition, the oil price policies in China and staple commodity subsidies in Egypt were implemented. However these policies influence the food choices and shift to eating pattern which promote CVD. The consumption of oils in China has increased significantly with the drops in prices, especially among the poor.

Urban Planning Policies and the Built Environment

In Agita Sao Paulo in Brazil, the government increase the number of walking areas, facilities for cycling and recreation. After 5 years, - inactive population:14.9% to 11.2% - irregularly active population: 30.3% to 27%, - active population: 54.8% to 61.8% (Matsudo et al., 2006).

However, its effect on cardiovascular health was not evaluated. In developing countries, investment or changes on the existing environment or urban planning policies are not focus on CVD health

Conclusion
Prevention and intervention is always a cost effective way for a disease Prevention of cardiovascular disease can be done by addressing the risk factors at individual and population level.

Changes in individuals behavior are as important as policy and legislation.

References
Nettleton Ja: Omega-3 fatty acids: comparison of plant and seafood sources in human nutrition. J Am Diet Assoc 91:331-337, 1991. GISSI- Investigators. Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial.Lancet. 1999;354:447-455. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_ui ds=10465168 Marchioli R, Barzi F, Bomba E, et al. ,2002 on behalf of the GISSI-Prevenzione Investigators. Early against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione. Circulation 2002, 105:1897-1903, doi:10.1161/01.CIR.0000014682.14181.F2 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_ui ds=11997274 O'Keefe JH Jr, Abuissa H, Sastre A, Steinhaus DM, Harris WS. Effects of omega-3 fatty acids on resting heart rate, heart rate recovery after exercise, and heart rate variability in men with myocardial infarctions and depressed ejection fractions. Am J Cardiol. 2006;97:1127-1130. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_ui ds=16616012 Ryan Andrews, 2009, All about Healthy Fats http://www.droptenfitness.com/drop10/blog/?p=510

Referances
M. Vrablk, M. Pruskov, M. nejdrlov, L. Zlatohlvek, 2009, Omega-3 Fatty Acids And Cardiovascular Disease Risk: Do We Understand The Relationship? Physiol. Res. 58 (Suppl. 1): S19S26, 2009

Marchioli R, Barzi F, Bomba E, et al., 2002 Early Protection Against Sudden Death by n-3 Polyunsaturated Fatty Acids After Myocardial Infarction : Time-Course Analysis of the Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzion,
Carl J. Lavie, Richard V. Milani, MD,Mandeep R. Mehra, MD, Hector O. Ventura, MD, 2009, Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Diseases, Journal of the American College of Cardiology Volume 54, Issue 7, 585594, http://dx.doi.org/10.1016/j.jacc.2009.02.084 D. Mozaffarian, E.B. Rimm, 2007, Fish intake, contaminants, and human health: evaluating the risks and the benefits [errata in JAMA 2007;297:5091] JAMA, 296 (2006), pp. 18851899 Burr ML et al. Effects of changes in fat, fish and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet, 1989, 2:757-761

Yokoyama M, Origasa H, Matsuzaki M, et alfor the Japan EPA lipid intervention study (JELIS) Investigators. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet 2007; 369: 1090-1098

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