Source: American Heart Association. Heart Disease and Stroke Statistics, 2010 Update

4. CVD IN USA Rates of death from cardiovascular disease from 1900-2006 Deaths in Thousands Years Source: American Heart Association. Heart Disease and Stroke Statistics, 2010 Update

5. Primary Prevention

7. Risk Factors Non-modifiable risk factors Some risk factors you can't control, like your: age ethnic background having family history of heart disease Modifiable risk factors Other risk factors you can change, like: smoking - both active smoking and being exposed to second-hand smoke high blood cholesterol high blood pressure diabetes being physically inactive being overweight depression, social isolation and lack of quality support

8. To reduce your risk of a heart attack and aid your recovery, you should: Be smoke free and avoid second hand smoke Enjoy healthy eating Be physically active Achieve and maintain a healthy body weight Maintain your social and emotional health Control your blood pressure and cholesterol, as advised by your health professional Take medicines, as prescribed by your doctor.

9. What is healthy eating? You can start enjoying a healthy balanced diet today simply by following these five tips: Eat a variety of foods. Include vegetables, whole grains, fruit, nuts and seeds every day. Choose healthier fats and oils. Try to limit sugary, fatty and salty take-away meals and snacks. Drink mainly water.

10. One of the easiest and tastiest ways to stay healthy is to eat plenty of fruit and vegetables. Aim to eat a variety of at least 5 serves of vegetables and 2 serves of fruit every day. Fruit and vegetables contain lots of fibre, vitamins, minerals and antioxidants.

11. Fish & seafood Oily fish and seafood contain omega-3 fats which help to maintain good general health and reduce the risk of heart disease and stroke. Which fish and seafood contain omega-3s? Omega-3 fats are found primarily in fish such as Atlantic and Australian salmon, blue-eye trevalla, blue mackerel, gemfish, canned sardines, canned salmon, KING fish and some varieties of canned tuna. Other fish, such as barramundi, bream and flathead, and seafood, such as arrow squid, scallops and mussels, are also good sources of omega-3.

12. What about mercury levels in fish? You can safely eat all of the fish and seafood mentioned above without consuming high levels of mercury. How much fish and seafood do I need to eat? Eat two to three serves of oily fish or seafood every week. A serving size of fish is 150 grams or approximately the size of your whole hand. You can use fish oil capsules and omega-3 enriched foods and drinks to supplement your intake of omega-3 fats. Healthy heart tip Wrap fillets of fish in individual foil parcels with lemon slices, crushed garlic and a sprinkle of herbs and place into the oven for a few minutes until soft. Serve with salad. Easy!

13. Milk & dairy Dairy foods contain calcium, essential for strong bones and teeth. Milk and other dairy foods are an important source of calcium in the diet, the Australian Guide to Healthy Eating recommends that 2-3 serves of fat reduced dairy be consumed daily. They also provide protein, vitamins A, D and B2. A good calcium intake will help to reduce the risk of osteoporosis.

14. Good news on eggs Did you know that blood cholesterol levels are more influenced by the saturated and trans fat we eat than the cholesterol in foods? That's why it's OK to eat eggs - you can enjoy up to six eggs each week as part of a healthy balanced diet. Eggs are very nutritious, always available and easy to cook quickly. Did you know that eggs contain good quality protein and omega-3, plus 10 vitamins and minerals? They are an essential part of any healthy eating plan and also provide a quick delicious snack when time is short.

15. Eggs make great lunchbox fillers for adults and children and are very portable when hard boiled. Cholesterol in eggsOne egg has about 5 grams of fat – but most of this is the ”good” unsaturated fat that you need to be healthy. An egg contains only about 1.5 grams of saturated fat and no trans fat at all. The cholesterol in eggs has only a small insignificant effect on LDL cholesterol, especially when compared with the much greater effects that saturated and trans fats in our diet have on LDL cholesterol. Some people are more sensitive to dietary cholesterol. This means that their LDL cholesterol levels rise from eating foods containing cholesterol more than other people's do.

16. Legumes and pulsesLegumes and pulses are a great source of protein and they are also low in fat. They’re full of fibre and they have a low Glycaemic Index which means they can help you feel full for longer. Beans and lentils are also a useful source of iron for vegetarians. Try to include legumes and pulses in at least two meals a week. What is a Pulse? A pulse is an edible seed that grows in a pod. Pulses are a great source of protein for vegetarians, but they are also a very healthy choice for meat-eaters. Pulses include the whole range of beans, peas and lentils including: Split peas Butter beans Broad BeansChickpeas Lentils Baked beans Kidney beans Three bean mixBeans, in particular, have a reputation for causing wind or flatulence, especially those cooked from dried legumes. To stop them causing flatulence, soak them overnight before cooking them in fresh water.

17. Nuts and seeds Nuts and seeds are both delicious and nutritious. Try to include these in your meals every day using plain, unsalted unroasted varieties: Almonds Cashews Peanuts Pine nuts Brazil nuts Walnuts Tahini -sesame seedsmLinseed/Flax

18. There is no scientific consensus that sugar as a nutrient causes heart disease. We believe that while overall kilojoule intake is important, other factors such as levels of sodium, fibre and saturated fat and trans fat are more important in preventing cardiovascular disease. The advice of the National Heart Foundation of Australia is based on sound science. According to the 1995 National Nutrition Survey, the top five sources of added sugar in the Australian diet are: Soft drinks, flavoured mineral waters and electrolyte drinks Added (table) sugar, honey and syrups Cakes, buns, muffins etc. Frozen milk products, e.g. ice-creams Chocolate and chocolate-based confectionary

19. What the Heart Foundation recommends The Heart Foundation recommends limiting 'extra’ or ‘sometimes’ foods that are high in sugar such as sugar sweetened soft drinks, sports drinks, fruit drinks, cordials, confectionery, sweet biscuits and cakes, etc. If we were to consider only sugars in a food, it would mean foods like breakfast cereals, yoghurts and even fresh and dried fruit would appear to be poor choices as they can be higher in sugars than other foods despite providing vital nutrients for good health. For example, based on sugar levels alone, you’d choose a diet soft drink over skim milk, but you’d miss out on much needed calcium as well as protein, vitamins D and A. The Heart Foundation encourages people to look at the total make-up of a food, not just one element, such as sugar, to determine if it is a healthier choice.

20. What are carbohydrates? Many people think of rice, potatoes and pasta as 'carbs' but that's only a small part of the huge range of foods know as carbohydrates. All fruit and vegetables, all breads and all cereal products are carbohydrates as well as sugars and sugary foods. Choosing the healthier carbohydrates is common sense. Fresh fruit and veggies, wholegrain breads, wholegrain cereals and pasta and rice are all healthy foods and form part of a healthy eating pattern.

21. Why choose whole grains? Wholegrain cereals include all the parts of the natural grain. They contain more fibre and other nutrients than white or refined starchy foods. That means they retain all of their nutrients including dietary fibre, B vitamins, vitamin E and the healthier fats. Choosing wholegrain options will also help to keep your digestive system healthy. Here are some of the whole grains you might like to try: Whole wheat Porridge oats Popcorn Brown rice Barley Wild rice Buckwheat Bulgur/ cracked wheat Millet How can I add more whole grains into my meals and snacks? Try a wholegrain or high fibre breakfast cereal like rolled oats or porridge for your breakfast. Swap white bread for whole mealbread. Look for the words ‘wholegrain’ or ‘whole meal’ on the label. Try brown rice instead of white – look for quick-cook brown rice. Choose whole meal crackers

22. Bread Bread may be a food you and your family eat most regularly. Not all breads are made the same so it’s important to choose the healthier varieties. What should you look out for? The Heart Foundation recommends choosing breads that are lower in salt (sodium) and higher in fibreeg. made from whole grains, whole meal flour and breads that contain seeds. So when comparing nutritional information panels, choose breads with sodium 400mg or less per 100g and fibre 4g or more per 100g.

23. Meat & poultry Meat is a good source of protein and vitamins and minerals, such as iron, selenium, zinc, and B vitamins. It is also one of the main sources of vitamin B12. For women lean red meat provides iron in a form that is more easily absorbed by the body than iron found in vegetables, beans and whole grains. Low iron stores can lead to tiredness and increased susceptibility to colds and infections. For men lean red meat is a good source of zinc, beneficial for reproductive health. Which meats are best to eat? Select lean meat and game trimmed of all visible fat. Lean beef, lamb, mutton, veal, pork, venison, rabbit, emu, kangaroo, buffalo and goat are all good choices. Select poultry trimmed of visible fat and without the skin. Choose chicken, turkey, duck or other wild birds.

24. Why would I need to reduce my salt intake? Salt is found in almost every food we eat, but the amount varies greatly. Most of the salt we eat, about 75%, comes from processed foods. Did you know that high intakes of salt can increase your blood pressure and your risk of cardiovascular disease including heart, stroke and blood vessel disease? Most people with high blood pressure don't know it.

25. How much is too much? The goal for an average adult is to consume less than 2300 mg of sodium (6 grams of salt) a day. Salt is listed on nutrition panels as sodium. Foods with less than 120 mg per 100 grams are low in salt, while foods with more than 500 mg are high in salt.

26. What can I do? You can easily get your daily requirements from the natural salts found in fresh foods. There is no need to add salt when cooking at home or at the dinner table. Salt is often used in packaged foods as a flavor enhancer or preservative. High levels of salt are often added to foods such as hot chips, crisps, salted nuts, packet soups and sauces, baked beans, canned vegetables, pies, sausage rolls, sausages, chorizo, pizzas and ready meals.

27. Water Water is best Did you know that water makes up about two-thirds of our body weight? Most of the chemical reactions that happen in our cells need water. We also need water for our blood to be able to carry nutrients around the body. So it makes sense to choose mainly water to drink. When the weather is warm or we are exercising, our bodies need more than usual. Avoid sports drinks, fizzy drinks, cordial and soft drinks which are all high in added sugar. A small glass of fruit or vegetable juice can be consumed occasionally but should not replace water. Try adding fizzy or still water to make the drink last longer. Drink coffee (regular or decaffeinated) and tea in moderation and use reduced, low or no fat milk. Healthy heart tip One of the first signs of dehydration is feeling thirsty. If you think you might not be getting enough fluids, other common signs of dehydration include headaches, confusion and irritability and lack of concentration. Carrying water with you to drink when you are out and about can help avoid dehydration, especially on warmer days.

28. Making it easy to be active everyday Active Living is a way of life that values and integrates physical activity into our everyday routines, helping people lead healthier, more active lives. Active Living brings together communities, urban planners, designers, architects, transportation engineers, public health professionals, elected officials and other professionals to build places that encourage physical activity.

30. Primordial Prevention

31. Primordial prevention • Primordial prevention consists of actions and measures that inhibit the emergence of risk factors in the form of environmental, economic, social, and behavioral conditions and cultural patterns of living etc.

32. Primordial prevention (cont.) • It is the prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared • For example, many adult health problems (e.g., obesity, hypertension) have their early origins in childhood, because this is the time when lifestyles are formed (for example, smoking, eating patterns, physical exercise).

33. Primordial prevention (cont.) • In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles • The main intervention in primordial prevention is through individual and mass education

34. Assessing the risk

35. Opportunity for Early Preventive Interventions Long asymptomatic latent period of Coronary Heart Disease (CHD) Half of all cardiovascular sudden death not preceded by cardiac symptoms, diagnoses High prevalence of atherosclerotic risk factors in population Methodology available to evaluate prognostic value of risk factors, risk markers Target intensity of intervention to severity of risk Lower the high burden of coronary death in asymptomatic adults

36. Key Considerations when Testing for CV Risk Efficacy of test procedure in assignment of risk status Short-term risk Long-term risk Independent statistical association with risk beyond traditional readily available inexpensive risk markers Incremental predictive value of test Effect on reclassification of risk compared to traditional risk factors alone Accuracy and reproducibility of test Requirement for serial testing, which may be indicated to assess risk accurately for some tests 2010 ACCF/AHA Guideline, JACC 55:e27, 2010

37. Effect on performance of added testing Noninvasive, invasive Post-test referral bias Effect on initiation of interventions Lifestyle Pharmacologic Effect on outcomes Short-term Long-term Effect on individual undergoing testing Financial Emotional Cost of test or procedure Financial Test risks Key Considerations when Testing for CV Risk (continued)

38. I IIa IIb III B Recommendations for General Approaches to Risk Stratification Global risk scores (such as the Framingham Risk Score [FRS]) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD. These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to target preventive interventions.

39. Comparison of a Sample of Global Coronary and Cardiovascular Risk Scores Note: Table 2 in full-text Guideline

41. I IIa IIb III B I IIa IIb III B Recommendations for Family History and Genomic Testing Family history of atherothrombotic cardiovascular disease (CVD) should be obtained for cardiovascular risk assessment in all asymptomatic adults. Genotype testing for CHD risk assessment in asymptomatic adults is not recommended.

42. Risk Assessment: Clinical Implications(continued) Initial step: Ascertainment of global risk score and family history of atherosclerotic CV disease • Class I recommendations • Simple, inexpensive If a patient is low-risk – no further testing is necessary If a patient is high-risk (CHD, CHD risk equivalents) – he/she is candidate for intensive preventive interventions – no incremental benefit added testing If a patient is intermediate-risk – additional testing can further define risk status • IIa - benefit exceeds cost and risk • IIb - less robust evidence for benefit, but shown to be helpful in selected patients • III - not recommended for use; has no or limited evidence of benefit, or can cause harm

43. I IIa IIb III B Recommendations for Measurement of C-Reactive Protein (CRP) In men 50 years of age or older or women 60 years of age or older with LDL cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy.

44. I IIa IIb III B Recommendation for Measurement of Hemoglobin A1C Measurement of hemoglobin A1C (HbA1C) may be reasonable for cardiovascular risk assessment in asymptomatic adults without a diagnosis of diabetes.

45. I IIa IIb III B I IIa IIb III B Recommendations on testing for Microalbuminuria(Urinary Albumin Excretion) In asymptomatic adults with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk assessment. In asymptomatic adults at intermediate risk without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment.

46. I IIa IIb III I IIa IIb III Recommendations for Resting Electrocardiogram A resting electrocardiogram (ECG) is reasonable for cardiovascular risk assessment in asymptomatic adults with hypertension or diabetes. A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes.

47. I IIa IIb III B I IIa IIb III Recommendation for Transthoracic Echocardiogram Echocardiography to detect left ventricular hypertrophy may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension. Echocardiography is not recommended for cardiovascular risk assessment of CHD in asymptomatic adults without hypertension.

48. I IIa IIb III B Recommendation for Measurement of Carotid Intima-Media Thickness Measurement of carotid artery intima-media thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk. Published recommendations on required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high-quality results.

49. I IIa IIb III B I IIa IIb III B I IIa IIb III B Recommendations for Calcium Scoring Methods Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk. Measurement of CAC may be reasonable for cardiovascular risk assessment persons at low to intermediate risk (6% to 10% 10-year risk). Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment.

50. I IIa IIb III B Recommendation for Exercise Electrocardiography An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity.