Doc. MUDr. Jindra Šmejkalová, CSc.

Doc. MUDr. Jindra Šmejkalová, CSc. Primary and early secondary prevention of cardiovascular diseases.The screeninig investigation of risk factors of ischemic heart disease in students (practical part).

The risk factors of cardiovascular disease Non-preventable • gender- males • age • genetic predisposition – positive family history Preventable • atherosclerosis • hypertension • nutritional status – central type of obesity • high concentration of total and LDL cholesterol and/or other fats in blood • low concentreation olf HDL cholesterol • diabetes • increased level of triacylglycerols • smoking • low physical activity – sedentary way of life • A – type of behaving and long lasting excessive stress • other factors

Overweight and obesity Overweight means excessive weight, obesity means the fat tissue accumulation. To define and assess the grade of obesity there exist various criterions. According to the relative overweight we distinguish: light obesity with 120 – 140 % of ideal weight medium obesity with 140 – 200 % morbid obesity above 200 %. Body mass index (BMI) is calculated by weight in kg / height in m2. BMI does not take into account fat distribution and it is much harder to interpret in children

BMI evaluation :The criterions of the total population: < 18.5 underweight; 18.5 – 24.9 normal weight; 25.0 – 29.9 overweight 30.0 – 34.9 the 1st degree of obesity / light obesity 35.0 – 39.9 the 2nd degree obesity / marked obesity > 40 the 3rd degree obesity / malignant / morbid obesity Optimal BMI in accordance with age: Age (years) BMI (kg/m2)‏ 19 – 24 19 – 24 25 – 34 20 – 25 35 – 44 21 – 26 45 – 54 22 – 27 55 – 65 23 – 28 > 65 let 24 – 29 Assessment of the % of body tissue • Measurement of skinfolds by kaliper • Measurement of bioelectric impedance (instrument Bodystat, personal weighting machine with fat meter)

Physiological values: men max. 20% of body fat women max. 25% of body fat In diagnostics of obesity there is important not only the percentage of fat tissue but also its distribution. Body fat distribution • central (abdominal, android)type of obesity = accumulation of fat in the visceral region. Risk of complications is higher in this type. • peripheral (gynoid) type of obesity = depositionoffatpreferentially into the buttocks and thighs. Often inherit from mother to daughter.

The central type of obesity may be determined by measuring circumference of waist and hips. Proportion of these measures in cm is called: WHR(waist hip ratio). Android/central obesity: WHR > 0,95 in men > 0,85 in women Waist circumference: > 102 cm in men indicated risk even if BMI is normal > 88 cm in women

Health consequences of obesity: • Hypertension • Atherosclerosis • Coronary heart disease • Stroke • Dislipidemia • Type 2 diabetes • Gallstones from increase cholesterol saturation • Cancers: colorectal cancer, gall bladder cancer, biliary tract cancer, breast cancer, endometrial and cervix uteri cancer • Weight related arthritis • Sleep apnoea and respiratory problems • Osteoporosis • Menstrual abnormalities • Psychological problems • Pregnancy complications

Benefits: 10 kg loss in weight can lead to an improvement in following: • > 20% fall in total mortality • > 30% fall in diabetes related deaths • > 40% fall in obesity related cancers • fall in 10 mm Hg of systolic blood pressure • fall of 50% in fasting glucose • fall of 10% in total cholesterol • fall of 15% in LDL • fall of 30% in triglycerides • increase of 8% in HDL

Prevention possibilities Doctor and nurse working in the sphere of primary prevention should: • Check the nutritional conditions of the patient – routinely follow his weight and height (BMI) and fat distribution. • Inform the patient about the results. • Inform about the risks connected with overweight. • Ask the patient about his current feeding habits and the extent of his physical activity. • Offer an advice about the ways and methods of the weight reduction. • Support a gradual weight reduction by 0,5 – 1 kg per week. • To reach such a goal to recommend: - modification of diet with the restriction of energy intake - an increase of movement activity.

Hypertension Blood pressure (mmHg) SBP DBP Normal: < 140 < 90 Low hypertension: 140 – 180 90 – 105 Middle or serious hypertension: > 180> 105 Isolate systolic hypertension: > 140 > 90 Persons withsystolic BP 140 – 160 mmHg and diastolic BP 90 – 95 mmHg are indicated for non-pharmaceutical treatment.

Hypertension is one of the most important risk factors of atherosclerosis, myocardial infarction and ictus. Risk of cardiovascular diseases increases mainly in concurrent influence of smoking, hyperlipoproteinemia or diabetes. Risk factors of hypertension: • high sodium intake; - high alcohol consumption; • obesity; - low physical activity. Recommendation concerning decrease of blood pressure: changes of nutritional habits, increase of physical activity, non-smoking.

Non pharmacological treatment of hypertension includes: • Body weight reduction; • Limitation of using the salt (2,3 g Na or 6 g NaCl); • Supplement of potassium and magnesium, calcium; • Limitation of alcohol consumption (less than 25 ml of pure ethanol per day)‏ • Reduction of intake of saturated fats; • An increase of intake of poly-non saturated ones; • Increase the physical activity (PA) – aerobic (endurance) PA. At least 3 times a week intensive physical movement, when the pulse rate reaches 70% - 85% of maximum. Exercising lasting at least 20 minutes; • Stop smoking; • Stress management, mastering the relaxation techniques; • Intervention of other risk factors, namely hyper-cholesterolemia. Non pharmacological procedures may quite normalize a light hypertension and support the pharmacotherapy of more advanced hypertension.

High level of cholesterol Blood level of cholesterol represents one of the basic indicators of CVD risk. Within the life span the level of total blood cholesterol increases from 2,8 mmol/l in small children up to 6,2 in elderly. Higher LDL cholesterol level represents the risk factor of CVD, an increased HDL cholesterol level on the contrary acts protectively. Total cholesterol (mmol/l): normal level under 5,2 (better still under 4,1!)‏ limit level 5,21 – 6,49 high risk above 6,5 In people under 30 years of age we recommend the level being bellow 4,2 mmol/l The LDL concentration in patients with already present cardiac ischemic disease should not exceed 2,6 mmol/l, in patients without ischemiabut with two risk factors present 3,4 mmol/l and in others 4,1 mmol/l.

Note: For all physical function maintenance LDL concentration 0.7 mmol/l is sufficient. HDL (mmol/l) : men: normal level: > 1,62 level of mild risk: 1,62 – 0, 91 high risk: < 0,9 women: normal level: > 1,68 level of mild risk: 1,67 – 1,17 high risk: < 1,16 LDL (mmol/l) normal level: < 3,4 level of mild risk: 3,4 – 4,1 high risk: > 4,5 Triacylglycerols (mmol/l) normal level: < 2,3 level of mild risk: 2,31 – 4,5 high risk: > 4,5

The risk of CVD is markedly higher, if there are present even other risk factors, as hypertension, left ventricle hypertrophy, glucose intolerance, obesity, smoking, and others. From the point of view of the risk and development of arteriosclerosis the cholesterol intake in food is not that important. Important is saturated fat acids and the high energetic intake. Possibilities of hypercholesterolemia prevention There exist three basic intervention approaches: • Food with a low contents of fat and a high portion of fibres and antioxidants; • Pharmacotherapy; • Multifactorial intervention.

Preventive procedures recommended in primary care: • Assessment of cholesterol blood level should be performed selectivelyin persons with a found or suspected some other risk. The wholesale screening investigations are not being recommended. • The check ups should be repeated in adults with normal or borderline results within the 5 years intervals. In the Czech health insurance institutions plans the interval are lasting 10 years but if necessary also shorter. The persons with a high risk are indicated for the preferential investigation. These high risks are: • Xantelasmata occurrence before 50 years of age; • Family history of premature death for coronary episode, myocardial infarction in persons younger than 50 years; • Diabetes or CVD appearance before 65 years of age; • Familiar hypercholesterolemia above 7,8 mmol/l;

Persons of middle age with two or more other risk factors: smoking, hypertension, obesity, diabetes, lack of movement. • Each investigation of cholesterol must be completed by a qualified discussion explaining the reason of check up, implication of data found, and recommendation of healthy feeding. • We recommend to restrict the fat intake, so that their share in the whole energetic income was lower than 30 % (even better less than 25%) and from that amount the saturated fatty acids represent only 10%. To cut the daily intake of cholesterol in diet for less than 300 mg. • The comprehensive analysis of lipids spectrum as well as the pharmacotherapy to consider in patients with the total cholesterol level above 7,8 mmol/l and in those with the level above 6,5 mmol/l, whose answer for the diet intervention was not satisfactory during the 3 – 6 months interval.

HDL – transports cholesterol from the peripheral tissues into the liver. The HDL concentration should be 0,9 mmol/l at least. Reasons for lower level of HDL: - after meal (as much as for 10%)‏ - smoking - android type of obesity, - hypertriacylglycerolemia - some drugs (beta blocators)‏ - genetic disposition. To increase the HDL is possible by - Reduction of weight; - Sufficient movement activity; - spirits consuming; - some hypolipidemics (statins, fibrates, nicotin acid). Aterogenic index: ratio between total cholesterol to HDL – it should be<5,5

Cigarets smoking: • increases the sympatetic activity, • lowers the HDL concentration, • increases LDL concentration, • increases pCO, which may lead to endothelium hypoxia, • supports the monoclonal proliferation of smooth muscle • by multiplying the erythrocytes it leads to a higher blood viscosity -  Smoking takes part in both the origin of atherosclerosis and its trombogenic complications. If the smoker quits smoking, within 2-3 years his endothelium recovers.

High alcohol consumption The total amount of alcohol consumed is important. • Protective effect of moderate drinking against CVD. • Health risks of excessive alcohol drinking: • CNS disturbances (brain activity, peripheral nerves) • Liver function failures, cirrhosis • Pancreatitis, gastritis • Hypertension • Hyperlipidemia‏ • Cardiomyopathy‏ • Cancer of oral cavity, larynx, pharynx and oesophagus (risk even worse in smokers) • Carcinoma of stomach, colon, breast • Osteoporosis • Disturbances of genital system, impotence

Ways of quantification of alcohol consumption • Quantification of week alcohol consumption by transfer different alcohol drinks with different amount of alcohol on common equivalent – unit of alcohol. • Patient should tell us the average number of beer, vine or spirit units consumed per week, when: 1 unit 1 unit – more precisely - estimation (cca 10 g pure alcohol)‏ ------------------------------------------------------------------- Beer 1 glass12º: 1 unit = 250 ml (0,5 l = 2 units)‏ 10º: 1 unit = 330 ml (0,5 l = 1,5 units)‏ Vine 1 glass 100 ml Spirits 1 glass small dram (jigger):‏ 25 ml great dram (jigger): 50 ml = 2 units

Health assessment of alcohol consumption • consider mainly the risk of somatic damage by chronic exposition • „Save“ level of alcohol consumption: 14 units per week for women and 21 units per week for men. • Weekly consumption ought to be spread uniformly; daily consumption ought not to be higher than 4 units. Lack of physical activity, sedentary way of life Recommendation: - 1 hour of quick walking every day + 1 hour of intensive physical training per week; - 4 hours of „non-sedentary“ activities per day.

A-type of behaviour-Bortner questionnaire Behaviour with a high activation of neurological system. Inner need to reach ever more and more results with still shorter time intervals. This behaviour is typical with: high ambitions, competition, vigour, aggression, easily roused hostility, ever lasting feelings of lack of time, permanent time planning and organizing, impatience. Among the specific manifestations of type A behaviour there belong a fast pace of most of the activities and permanent readiness. Also typical are loud, quick and emphatic speech and strained muscles. In emotional answers irritability, anger and hostility are easy to be traced. Type A behaviour is a complex reaction and results from a number of personal and social environment components.

Prevention of cardiovascular diseases Strategy has been established on the modification of CVD causes. Etiology of CVD is often multifactorial, while combination of riskfactors (RF) brings an increased risk. Each individual RF has the gradual characterization (light and grave smoking, overweight and obesity, light and heavy hypertension).). The systems for scoring the RF were created. These take into account their gradual character and interactivity, and they thus help in stating priorities of interventions. E.g.: - „Dundee coronary risk score“ (age, smoking, blood pressure, cholesterolaemia). - „GP score“ – enables to select a group of middle aged people, who are most endangered by myocardial infarction and who will benefit from intervention most.

Table of coronary risks(see bellow) – estimationofischemic heart disease risks inpatients, who still have no ischemic disease manifestation. This serves to the determination of absolute risk of ischemeic cardiac disease during the next 10 years. Into the group with the high risk there belong asymptomatic individuals, whose absolute risk reaches 20 % and more within the next 10 years or in the younger age projected into 60 years reaches 22% or more. In accordance with the fact that ischemic cardiac disease is conditioned multifactorially, the prevention should not stress too much any individual risk factor. On the basis of assessment of presence and gravity of all the main risk factors to point out the individuals with an increased absolute risk. Level of risk:low - slightly increased - medium- high - very high

Doc. MUDr. Jindra Šmejkalová, CSc.