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					Cardiovascular Disease and
 Ways to Lower Your Risk!


           Alison L. Bailey, MD
     Director, Cardiac Rehabilitation
   Division of Cardiovascular Medicine



     The University of Kentucky
     Linda and Jack Gill Heart Institute
A disclaimer…

“Everything that can be invented has
  been invented”
  Charles H. Duell,Commissioner, U.S. patent
    office, 1899 (attributed)
What is Cardiovascular Disease?




  Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.9
CVD in the United States

 Cardiovascular disease is, and has been, the
  leading cause of death since 1900 in the
  United States and claims more lives each year
  than the next four leading causes of death
  combined
 CVD accounts for 1/3 of all deaths for women
  in the world




     Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.6-7
Leading Causes of Death in the United States




       410,628                                                          459,096

                 286,830                                                           267,058




      From Heart Disease and Stroke Statistics — 2008 Update, American Heart Association: p. 8
Women & CVD

   CHD is the leading cause of death of women in the
    US, killing about 250,000 women annually
   About 6 million females in the US alive today have
    CHD
   More than 9,000 women <45 have a heart attack
    each year
   This year an estimated 485,000 women will have a
    new or recurrent cardiac event
   Since 1984, more women than men have died of
    CHD yearly
      Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.6-7
Women & CVD

   Deaths from CHD in men are decreasing, but in
    women the numbers are stable to increasing
   64% of women who died suddenly of CHD had no
    prior symptoms
   CHD rates in women after menopause are 2-3 times
    those of women the same age before menopause
   The estimated average number of years of life lost
    due to a heart attack is 14.2




      Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.6-7
What is the Greatest health problem for women?


                   2003   2000   1997
 Breast cancer     35     36     34

Cancer (general)   16     25     27

 Heart disease 13         8      7

   Obesity         6      NA     NA

    Other          19     17     17
CVD in Kentucky

 The burden of cardiovascular disease is
  particularly high in Kentucky
        The state ranks 6th highest in total cardiovascular
         disease deaths
        73 of Kentucky’s 120 counties have
         cardiovascular disease death rates above the
         national average
        The number of female deaths attributed to
         cardiovascular disease in Kentucky is higher
         than the national average



       Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.3
Estimated Costs (in Billions of Dollars) (US 2004)




       * Totals do not add up due to rounding and overlap.

                   Source: All estimates prepared by Thomas Thom, NHLBI.
   U.S. Heart Disease Prevalence: Doubling in the
   Next Half Century


              30
                                                                                              24.6
              25
              20
Number of
  Patients    15                            12.4
 (Millions)
              10
              5
              0
              1970 1980 1990 2000 2010 2020 2030 2040 2050

                   ACC/AHA Guidelines 2001, NHLBI Chartbook 2000 and Foot et al (JACC 2000)
The ―Glagov Phenomenon‖
■ Early plaque growth shows an outward remodeling of
  the vessel wall such that the lumen diameter is
  preserved

                                                                      <80% stenosis
                                                            <50%
                                                           stenosis




 Coronary artery disease is a disease of arterial wall ,
                        not the lumen

                  Glagov S. N Engl J Med 1987;316:1371-5
Plaque Rupture
Fate of the of Plaque…




            Lilly, Pathophysiology of Heart Disease, 2007
Prevention of CVD

   Prevention is key when discussing any
    disease process, especially CVD
   Primary prevention focuses on the prevention
    of disease in individuals without established
    disease
   Secondary prevention focuses on the
    recurrence of disease in individuals with
    established disease
Prevention of CVD

        Currently, our assessment of CVD risk is based
         on the number of risk factors an individual has
        We know that:
        1.      The presence of multiple risk factors confers
                increased risk for CVD events
        2.      The greatest increase in mortality is related to
                uncontrolled risk factors




    Kannel WB. High-density lipoproteins: epidemiologic profile and risks of coronary artery disease. Am J Cardiol 1983;52(4):9B-12B.
 What are the Modifiable Risk Factors?
What are the Risk Factors?

   ■ Age
   ■ Family History (<55 for ♂ and <65 for ♀)
   ■ Diabetes
   ■ Dyslipidemia
   ■ Hypertension
   ■ Overweight & Obesity
   ■ Physical Inactivity
   ■ Tobacco Use
Prevention

■ Data from the 2003 Behavioral Risk Factor
  Surveillance System survey reveal that Kentucky
  had the highest prevalence of multiple risk factors
  for heart disease in adults (46.2%) among the fifty
  states
■ The surveyed risk factors were those just
  discussed: high blood pressure, high cholesterol,
  diabetes, current smoking, physical inactivity, and
  obesity




               Morb Mortal Wkly Rep 2005;54(5):113-7.
   INTERHEART: 9 Modifiable factors
   account for 90% of first-MI risk worldwide

    100
                                                                                                                 90

      80


      60
PAR                                                                                                   50
(%)
      40        36                                                                              33

                                                                                         20
                                                              18
      20                   14         12                                    10
                                                  7

       0
             Smoking     Fruits/   Exercise    Alcohol     Hyper-       Diabetes Abdominal Psycho-   Lipids   All 9 risk
                          veg                              tension                obesity   social             factors



N = 15,152 patients and 14,820 controls in 52 countries
PAR = population attributable risk, adjusted for all risk factors
                                                      Yusuf S et al. Lancet. 2004;364:937-52.
Diabetes

   Fasting glucose >126
   An estimated 15 million Americans are diagnosed with
    diabetes
   Another 5 million are diabetic but unaware of the
    diagnosis
   Another 14.7 million have pre-diabetes (glucose 110-126)
   At least 65 percent of people with diabetes die of some
    form of heart or blood vessel disease




     Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.29
Cholesterol
   Total cholesterol
      <200 desirable, >240 “high”

   Low-density lipoprotein (LDL)
      Optimum <100 mg/dL

   High-density lipoprotein (HDL)
      >40 mg/dL in ♂
      >50 mg/dL in ♀

   Triglycerides
      <150 mg/dL




    Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.26-7
      Log-Linear Relationship Between LDL Levels
      and Relative Risk for CHD



                     3.7
                                                                                         ■       This relationship is consistent
                     2.9
                                                                                                 with a large body of
Relative Risk
              2.2                                                                                epidemiologic data and data
  for CHD,
                                                                                                 available from clinical trials of
 Log Scale 1.7
                                                                                                 LDL–lowering therapy.
                     1.3                                                                 ■       These data suggest that for
                     1.0
                                                                                                 every 30-mg/dL change in LDL,
                                                                                                 the relative risk for CHD is
                                                                                                 changed in proportion by about
                           40       70      100 130 160 190                                      30%.
                                         LDL-C, mg/dL                                    ■       The relative risk is set at 1.0 for
                                                                                                 LDL = 40 mg/dL.



  Reprinted with permission from Grundy SM, Cleeman JI, Merz CNB, et al. Implications of recent clinical trials for the National Cholesterol
                  Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227–239; http://lww.com.
   Low HDL and High LDL
   Increase Coronary Artery Disease Risk



                                      Framingham Heart Study

Relative Risk
of CAD After
   4 Years




                                     LDL, mg/dL

                This information was adapted from The Canadian Journal of Cardiology1988;4(Suppl A):5A–10A.
Cholesterol

■ Estimated number of US adults with abnormal
  cholesterol 105,200,000
       <50% of patients who qualify for any kind of lipid-lowering
        therapy are receiving it
              <1/3 are at goal
       <50% of the highest risk persons (those with known CHD)
        are receiving lipid-lowering therapy
              <20% are at goal




     Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.26-7
                               Residual Cardiovascular Risk
                               Despite LDL Lowering

Therapies based on LDL-C lowering reduce the risks of CAD
 Relative risk reduction (%)




                                         Despite the benefits of LDL lowering,
                                            60-70% residual risk remains
   4S=Scandinavian Simvastatin Survival Study; CARE=Cholesterol and Recurrent Events; WOSCOPS=West of Scotland Coronary Prevention Study;
 LIPID=Long-term Intervention with Pravastatin in Ischemic Disease; AFCAPS=Air Force/Texas Coronary Atherosclerosis Prevention Study; HPS=Heart-
Protection Study; PROSPER=Prospective Study of Pravastatin in Elderly at RISK; CARDS=Collaborative Atorvastatin Diabetes Study; ASCOT-LLA=Anglo-
                                                            Scand. Cardiac Outcomes Trial.
High Blood Pressure

■ Hypertension
   >140/90
   >130/80 in DM or CKD
   1 in 3 US Adults has hypertension
        72% are aware of the hypertension
        61% are under treatment
        35% have control




    Heart Disease and Stroke Statistics — 2007 Update, American Heart Association: Update-At-A-Glance, p.26-7
  Hypertension Remains Undertreated and
  Poorly Controlled in USA


                                                                                      Control*
         NHANES                                                        Control*         (all
          Survey        Awareness            Treatment                 (treated)   hypertensives)

         2003-2004         66.5%                53.7%                    63.9%         33.1%


         2001-2002         62.5%                50.1%                    63.9%         30.3%


         1999-2000         63.0%                47.3%                    51.3%         25.0%




*<140/90 mm Hg, age-adjusted data


                                    Ong KL et al. Hypertension. 2007;49:69–75.                      28
High Blood Pressure Remains One of the Most Important
Multipliers for CV Risk



■    BP >140/90 mm Hg associated with:
       69% of first MIs
       74% of cases of HF
       77% of first strokes

■   HBP is associated with a 2x to 3x higher
    risk for developing HF

■   277,000 deaths in 2002

■   The estimated direct and indirect cost of
    HBP for 2007 is $66.4 billion

                                                                               2005 Anatomical Travelogue Inc.
                                                                              Underwritten by Novartis.



                           Rosamond W et al. Circulation. 2007;115:e69-171.                                       29
       Blood Pressure and Risk for Coronary Heart Disease



                      60                                                                    60
                      50      Ages 35–64                                                    50      Ages 35–64




                                                                      Age-adjusted Annual
Age-adjusted Annual




                                                                       Incidence per 1000
 Incidence per 1000




                              Ages 65–94                                                            Ages 65–94
                      40                                                                    40
                      30                                                                    30
                      20                                                                    20
                      10                                                                    10
                       0                                                                     0


                       Systolic Blood Pressure, mmHg                                         Diastolic Blood Pressure, mmHg

      Based on 30-year follow up of Framingham Heart Study subjects free of CHD at baseline.

                                       Stokes J III et al. Hypertension. 1989;13(suppl):I13–I18.
      With Each 20/10 mm Hg Increase in BP
      CV Mortality Risk Doubles
            Increasing Cardiovascular Mortality Risk*


                                                                                                                   RR = X8



                                                                                                        RR = X4
                                                                                                                   175/105


                                                                               RR = X2
                                                                                                          155/95


                                                        RR = X1
                                                                                135/85

                                                        115/75

                                                                                     SBP/DBP, mm Hg
BP = blood pressure; CV = cardiovascular
*Individuals aged 40 to 69 years (N=1 million)

                                                                 Lewington S et al. Lancet. 2002;360:1903−1913.              31
Overweight & Obesity

   BMI optimally <25 kg/m2 and/or waist
    <40‖ in men and <35‖ in women
Weight continues to be an issue
Obesity

■ Overweight and Obesity
   140,000,000 U.S. adults are overweight
   66,000,000 are obese
   65% of adults are either overweight or obese
    Relationship Between BMI and Diabetes

                             100
Age-Adjusted Relative Risk



                                                          Men

                             75                        Women


                             50


                             25


                              0
                                   <22   <23         23          24           25          27           29           31     33    35+
                                                      -           -            -           -            -            -      -
                                                    23.9        24.9         26.9        28.9         30.9         32.9   34.9
                                                                 Body Mass index (kg/m2)


                                         Chan, J. Diabetes Care 1994;17:961 Colditz, G. Ann Intern Med 1995;122:481.
Relationship Between BMI & Blood Pressure
       SBP 160
           155

           150

           145

           140

           135

                 <20          22-23.9          26-27.9           >30
        DBP 95

            90

            85

            80

            75                                                       >7700 Males Age 40-59
                                                                  15 year follow-up (1978) Britain
            70
            Shaper AG BMJ (Clinical Research Ed) 1997;314(7090):1311-7.
                        Relationship Between BMI & Hypercholesterolemia

                                           Females                                                                   Males
                      50                                                                 50
Percent of Subjects




                      40                                                                 40


                      30                                                                 30


                      20                                                                 20


                      10                                                                 10

                           <18.5   18.5-24.9   25-26.9    27-29.9        >30                  <18.5      18.5-24.9   25-26.9   27-29.9   >30


                                                                      Body Mass Index

                          >25,000 Females Age 30-54                                                >23,000 Males Age 30-54
                      12 year follow-up (1974) Netherlands                                    12 year follow-up (1974) Netherlands
                                                         Seidell, JC,.Arch of Intern Med 1996;156(9):958-63.
      BMI and Cardiovascular Disease Mortality

                         3.0
                                              Men
Relative Risk of Death




                         2.6
                                            Women
                         2.2

                         1.8

                         1.4

                         1.0
                                         Lean                           Overweight   Obese
                         0.6
                               <18.5 18.5 20.5 22.0 23.5 25.0 26.5 28.0 30.0 32.0 35.0 >40.0
                                      –    –    –    –    –    –    –    –    –    –
                                     20.4 21.9 23.4 24.9 26.4 27.9 29.9 31.9 34.9 39.9

                                                     Body Mass index
                                                Calle , EE. NEJM 1999;341:1097.
    CHD Events Increase with BMI

                    CVD Mortality                                                               CHD Events
HR 4.0                                                            HR 4.0




   2.0                                                                 2.0




   1.0                                                                 1.0




   0.5                                                                 0.5

         <20          22-23.9       26-27.9        >30                        <20           22-23.9       26-27.9        >30
               20-21.9       24-25.9       28-29.9                                   20-21.9       24-25.9       28-29.9

                              BMI                                                                   BMI


                     >7700 Males Age 40-59 15 year follow-up (1978) Britain
                                 Shaper ,AG BMJ (Clinical research ed) 1997;314(7090):1311-7.
Inactivity

■ Physical Inactivity
    Adults with 30+ minutes of moderate physical
     activity five or more days per week, or vigorous
     physical activity for 20+ minutes three or more
     days per week
       Kentucky 34.7% (#50)
       US 49%




                 http://apps.nccd.cdc.gov/brfss/list.asp
                 ?cat=TU&yr=2005&qkey=4396&state
                                  =KY
Tobacco Use

■ Smoking
   Kentucky 28.7% (#1)
   US 20.6%




         http://apps.nccd.cdc.gov/brfss/list.asp?cat=TU&yr=2005&qkey=4396&state=KY
   Tobacco Use is Associated with Increased Mortality

Common Preventable Causes of Death in the US in 1990 & 2000




                         Mokdad AH, JAMA, 2004
Cessation of Tobacco Lowers the Risk of MI




                    Critchley JA, JAMA, 2003
Prevention of CVD

■   Prevention is key when discussing any
    disease process, especially CVD
■   Primary prevention focuses on the
    prevention of disease in individuals without
    established disease
■   Secondary prevention focuses on the
    recurrence of disease in individuals with
    established disease
Prevention of CVD

■   Currently, our assessment of CVD risk is based on the
    number of risk factors an individual has
■   We know that
       The presence of multiple risk factors confers increased risk for
        CVD events
       The greatest increase in mortality is related to uncontrolled risk
        factors




                       Kannel WB. Am J Cardiol 1983;52(4):9B-12B.
              Spectrum of CVD Risk
Risk Group                                Clinical Examples

High risk                                • Established CHD
                                         • Cerebrovascular disease
                                         • Peripheral arterial disease
                                         • Abdominal aortic aneurysm
                                         • Diabetes mellitus
                                         • Chronic kidney disease
                                         • 10-year risk >20%




      CHD indicates coronary heart disease; CVD, cardiovascular disease.
                                     .
             Spectrum of CVD Risk
Risk Group                              Clinical Examples

At Risk                           ≥1 major risk factor for CVD including:
                                    • Cigarette smoking
                                    • Poor diet
                                    • Physical inactivity
                                    • Obesity, especially central
                                    • Family history of premature CVD
                                      (<55 in male & <65 in female)
                                    •Hypertension
                                    • Dyslipidemia



     CHD indicates coronary heart disease; CVD, cardiovascular disease.
                                    .
             Spectrum of CVD Risk
Risk Group                               Clinical Examples

At Risk                                 • Subclinical Vascular Disease

                                        • Metabolic syndrome

                                        • Poor exercise capacity on treadmill
                                             test and/or abnormal heart rate
                                             recovery after stopping exercise




     CHD indicates coronary heart disease; CVD, cardiovascular disease.
                                    .
               Spectrum of CVD Risk
Risk Group                                Clinical Examples

Optimal Risk                            • 10-year Risk <10%

                                        • Healthy Lifestyle

                                        • No risk factors




     CHD indicates coronary heart disease; CVD, cardiovascular disease.
                                    .
■How Can we Lower CVD Risk???
Exercise!!!!!
Exercise

■   Women should accumulate a minimum of 30
    minutes of moderate intensity on most, and
    preferably, all days of the week


■   Women who need to lose or sustain weight
    loss should accumulate a minimum of 60-90
    minutes of moderate intensity on most, and
    preferably, all days of the week



                    Mosca L. Circulation, 2007
Exercise and lipids

■   Average increase in HDL levels of 4.6% and
    reductions in triglycerides 3.7% and LDL
    5.0%
■   Exercise serves primarily as adjunctive
    therapy for most patients with lipid disorders,
    although some individuals experience
    greater lipid effects




              Thompson PD. Arteriosclerosis, thrombosis and vascular biology, 2003.
Exercise and high blood pressure

■   Average reductions in systolic blood
    pressure of 2.6 mmHg and diastolic blood
    pressure of 1.8 mm Hg in normotensive
    subjects and 7.4 and 5.8 mm Hg in
    hypertensive subjects, respectively.
■   Exercise may serve as the only therapy
    required in some mildly hypertensive
    subjects.




             Thompson PD. Arteriosclerosis, thrombosis and vascular biology, 2003.
Exercise and Diabetes

■   Average reduction of hemoglobin (Hgb) A1c of
    0.5% to 1%,


■   An average 4-kg decrease in body weight and a
    593-kcal increase in weekly energy expenditure
    (approximately 6 miles of walking) reduced the
    onset of type II diabetes in individuals at high
    risk for this disease by 58% compared with usual
    care.




              Thompson PD. Arteriosclerosis, thrombosis and vascular biology, 2003.
Exercise and Weight Control

■   The National Weight Control Registry
    supports a role of physical activity in
    achieving and maintaining weight loss.
■   This registry includes 3000 individuals who
    maintained an average weight loss of 30 kg
    for an average of 5.5 years. Eighty-one
    percent of the registrants reported increased
    physical activity, with women and men
    reporting weekly expenditures of 2445 and
    3298 kcal, respectively.


             Thompson PD. Arteriosclerosis, thrombosis and vascular biology, 2003.
Exercise and Weight




    Rockhill, B. Physical activity and mortality: a prospective study among women. 2001.
Exercise and CHD

■   Studies of occupational and leisure-time
    physical activity as well as studies of
    exercise capacity (treadmill tests, etc) have
    consistently documented a reduced
    incidence of CAD events in the more
    physically active and fit subjects
■   The results are strong, with the most
    physically active subjects generally
    demonstrating CAD rates half those of the
    most sedentary group.
■   The data demonstrate a graded relationship
    of decreasing CAD rates with increasing
    levels of activity.
                     Thompson PD, Circulation 2003
―Fitness‖ is associated with improved survival

     13,344 Healthy men and women undergoing treadmill
              Testing and followed for 8 years




                        Blain SN, JAMA, 1989
Exercise is associated with improved survival

     772 Men with CHD and self-reported Physical Activity




                      Wannamethee SG, Circulation, 2000
Physical Activity and Mortality




                 Leon, AS . Int J Sports Med 1997.
Exercise is associated with Lower Risk for CHD

        73,743 Women in the Women’s Health Initiative




                        Manson JE, NEJM, 2002
Watch Your Diet!!!!!
AHA 2006 Diet and Lifestyle Recommendations

   Limit the intake of saturated fat to <7% of
    energy, trans fat to <1% of energy and
    cholesterol to <300 mg daily


   Minimize your intake of beverages and foods
    with added sugar


   Choose and prepare foods with little or no salt


   If you consume alcohol, do so in moderation,
    <1 drink/day
                    Lichtenstein, AH. Circulation, 2006
AHA 2006 Diet and Lifestyle Recommendations

   Balance calorie intake and physical activity to
    achieve or maintain a healthy body weight


   Consume a diet rich in vegetables and fruits


   Choose whole-grain, high-fiber foods


   Consume fish, especially oily fish, at least
    twice a week

                    Lichtenstein, AH. Circulation, 2006
                        Benefit of Fruits & Vegetables
                        Nurses Health Study & Health Professionals Follow Study
Relative Risk for CHD




                          1.2
                         1.0

                         0.8

                         0.6
                                                                                             RR 0.80 (0.69-0.93)
                         0.4

                         0.2

                          0
                                        <3   3.0-3.9      4.0-4.9         5.0-5.9      6.0-7.9   >8
                                         Fruit & Vegetable Intake, servings/day

                                126,399 persons followed for 8-14 years to assess the
                                 relationship between fruit/vegetable intake and CHD
                                                  Joshipura KJ, Ann Intern Med, 2001
                              Benefit of Whole Grain & Fiber
                              Nurses Health Study & Health Professionals Follow Study
Relative Risk for CHD Death




                                1.6

                               1.4
                                                                                                       RR 0.73 (0.61-0.87)
                               1.2

                               1.0

                               0.8

                               0.6

                               0.4
                                           <12   12-<15    15-<18 18-<21                   21-<24   24-<27   ≥27
                                          Total Dietary Fiber Intake, Energy-Adjusted g/day

                                      336,244 persons followed for 6-10 years to assess the
                                        relationship between dietary fiber intake and CHD
                                                          Pereria MA, Arch Int Med, 2004
Control your Blood Pressure!!!!!
Blood Pressure


■   Women should opt for a blood pressure of
    <120/80 through lifestyle approaches such
    as weight control, increased physical activity,
    alcohol moderation, sodium restriction, and
    increased consumption of fresh fruits,
    vegetables, and low-fat dairy products




                      Mosca L. Circulation, 2007
   Small Reductions in BP May Result in
   Large Risk Reductions for CV Events


     ■   1 million adults



                                                                      7% reduction in
                                                                      risk of IHD*
2 mm Hg decrease                                                      mortality
   in mean SBP

                                                                      10% reduction in
                                                                      risk of stroke
                                                                      mortality



                     Lewington S et al. Lancet. 2002;360:1903−1913.                      76
BP Control Usually Requires
Combination Therapy

                     Most patients require 2 antihypertensives to reach BP goal
Trial/SBP Achieved




            Copley JB et al. Dis Mon. 2005;51:548–614. Dahlof B et al. Lancet. 2005;366:895–906.
Improve Your Cholesterol!!!!!
Lipids


■   Women should opt for:
       HDL > 50
       LDL < 100
       TG < 150
       Non-HDL < 130




                        Mosca L. Circulation, 2007
HMG-CoA Reductase Inhibitors: Primary Prevention

               Relationship between LDL-C Levels and Event
                10 Rates in Primary Prevention Trials

                 8        Statin
                          Placebo                                                         WOSCOPS
                                                    WOSCOPS
   Event (%)




                 6
                                                                         AFCAPS
                                      AFCAPS
                 4
                                                       ASCOT
                 2
                               ASCOT
                 0
                –1
                     55   75        95       115         135         155          175    195
                                          LDL-C (mg/dL)




                               O’Keefe JH Jr et al. J Am Coll Cardiol. 2004;43:2142-6.
 HMG-CoA Reductase Inhibitors: Secondary Prevention

   Relationship between LDL-C Levels and Event Rates in
  Secondary Prevention Trials of Patients with Stable CHD

            30
                 Statin                                                                   4S
            25   Placebo
                                                 4S
            20
Event (%)




            15                           LIPID                              LIPID
                               CARE                             CARE
            10         HPS
                                            HPS
                                  TNT (atorvastatin 10 mg/d)
            5          TNT (atorvastatin 80 mg/d)
            0
             3    70         90           110          130           150            170        190   210
                                              LDL-C (mg/dL)




                           LaRosa et al. N Engl J Med 2005;352:1425–1435.
Stop Smoking!!!!!
Maintain an Ideal Weight!!!!!
Weight


■   Women should maintain or lose weight
    through an appropriate balance of physical
    activity, caloric intake, and formal behavioral
    programs when indicated to
    maintain/achieve a BMI between 18.5 and
    24.9 and a waist circumference <35 inches




                      Mosca L. Circulation, 2007
Relationship Between Weight Change and CHD
Risk Factor Sum

                                Weight Change During 16-y Follow-up
Change in Risk Factor Sum (%)



                                  Loss >2.25 kg                  Gain >2.25 kg
                                                                                      +37%
                                               +20%




                                                                                      -40%
                                              -48%

                                      Men                                          Women

                                       Wilson, PW. Arch Intern Med 1999;159:1104
Live Longer….
■   4 healthy habits can add 14 years to your
    life
       Stop smoking
       Eat 5 servings of fruits and vegetables daily
       Moderate alcohol consumption (1-14
        drinks/week)
       Not be physically inactive
           Physically inactive (sedentary job and no
            recreational activity) and not physically inactive
            (any category with activity levels above the latter)

                          Khaw KT , PLoS Med 2008
UK Cardiac Rehabilitation

				
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