Optimal Heart Health - AAP.org · Optimal Heart Health J. Kern Buckner, MD Chief, Division of Cardiology Professor of Medicine National Jewish Health ... Hippocrates 460BC-377BC .

Optimal Heart Health

J. Kern Buckner, MD

Chief, Division of Cardiology

Professor of Medicine

National Jewish Health

October 12, 2014

Objectives

Understand the natural history of atherosclerosis

Review evidence of diet and exercise on CVD

prevention

Compare efficacy to other proven secondary

prevention interventions.

Develop the components of a heart healthy

lifestyle

Disclosures

NONE

Outline

The natural history of atherosclerosis

Role of diet in CVD prevention

Role of exercise in CVD prevention

Develop the basics of a heart healthy lifestyle

The Natural History of Atherosclerosis

Prevalence of Atherosclerosis

020

4060

80

Korean War

Viet-Nam War

Iraq War

77%

45%

8.5%

Percentage of soldiers with Atherosclerosis

JAMA 2012; 308:2577-2583

Age (yrs)

P=.001 for trend toward increasing prevalence with age in coronary arteries.

Berenson J et al. N Engl J Med. 1998;338:1650-1656.

Early Appearance of AtherosclerosisPrevalence of Fibrous Plaque Lesions in Coronary Arteries

2–15 16–20 21–25 26–390

20

40

60

80

%

Glagov’s Phenomena

Progression of Plaque

Progression of Plaque

CBDA

NEJM 2005;352:2524-2533

Vulnerable versus Stable Plaque

Atherosclerosis is a disease of Inflammation!!

It’s the doughnut, not the hole

Sudden Cardiac Death

Role of Heart Healthy Diet

The Diet Heart Hypothesis

1957 Ancel Keys: indigenous diets across

populations have a variable impact on coronary

heart disease (CHD)

Patients with CHD tend to have higher

cholesterol levels than healthy counterparts

Intake of dietary fat varied considerably

by region

Keys launched the Seven Countries Study

Cholesterol Hypothesis: dietary saturated

fat increases serum cholesterol, which in

turn leads to coronary atherosclerosis

Diet Evidence

Primary Prevention Trials

Diet Evidence: Primary Prevention Trials (MRFIT)

12,886 men aged 35-57 years in top 15% of CHD risk by Framingham data

Randomized to:

Usual care by PCP

Special intervention

Smoking cessation

HTN treatment

Diet: <10% saturated fat and <300 mg/d cholesterol

JAMA 1982;248:1465-1477

Diet Evidence: Primary Prevention Trial (MRFIT)

The American Journal of Medicine (2014) 127, 364-369

Underpowered

Diet Evidence: Primary Prevention Trial

(PREDIMED Study)

7447 men and women in Spainat high CV risk, type 2 diabetesor 3 CV risk factors but withoutevidence of CV disease,randomized to 1 of 3 diets: 1. Mediterranean-style diet

supplemented withadditional extra virgin oliveoil,

2. Mediterranean-style dietsupplement with mixednuts, or

3. control group that wascounseled to follow a low fatdiet.

Diet Evidence: Primary Prevention Trial

(PREDIMED STUDY)

Diet Evidence: Primary Prevention Trial (PREDIMED STUDY)

NUTS

EVOO

(P=0.009)

(P=0.02)

Primary endpoint of combination CVA, MI and CVD deaths reduced by:

(1) 30% in Mediterranean diet supplemented in EVOO

(2) 28% in Mediterranean diet supplemented with nuts

Diet Evidence: Primary Prevention Trials (PREDIMED STUDY vs MRFIT)

The American Journal of Medicine (2014) 127, 364-369

Diet Evidence: Primary Prevention

Variable# of Deaths/

# of Participants

Fully Adjusted Hazard Ratio

(95% CI)

Death from any

cause275/22,043 0.75 (0.64-0.87)

Death from CHD 54/22,043 0.67 (0.47-0.94)

Death from

cancer97/22,043 0.76 (0.59-0.98)

22,043 Greek adults evaluated for adherence to a Mediterranean diet, with points

given for high consumption of vegetables, legumes, fruits, nuts, cereal, and fish and

points subtracted for high consumption of meat, poultry, and dairy

Trichopoulou A, et al. NEJM 2003;348:2595-6

High adherence to a Mediterranean diet is associated with a reduction in

death

Diet Evidence

Secondary Prevention Trials

Diet Evidence: Secondary Prevention Trial (Lyon Diet Heart Study)

605 survivors of an MI

Randomized to either a Mediterranean style diet or a “prudent” low fat diet

Mediterranean style diet, a whole diet approach, low in animal fat products and saturated fat, with emphasis on olive oil

Diet Evidence: Secondary Prevention Trial (Lyon Diet Heart Study 1988-1997)

Trial stopped at 27 months

73% reduction in CVD deaths

and nonfatal MI

At 46 months, 44 deaths or

nonfatal MI in control group vs

14 in Mediterranean diet, a

72% reduction (p<0001)

605 patients following a MI randomized to

a Mediterranean* or Western** diet for 4

years

*High in polyunsaturated fat and fiber

**High in saturated fat and low in fiber

Diet Evidence: Secondary Prevention(Lifestyle Heart Trial)

48 male and female CHD patients

Randomized to <10% fat vegetarian diet, exercise (3 hour/wk) and

meditation (1 hour/d) (Rx group) vs. Step 1 diet

At one year 37% LDL-C reduction, 22% weight

loss, and 1.8% regression in Rx group (n=28)

vs 2.3% progression in control group with atherosclerosis (n=20)

(quantitative coronary angiography)

At 5 years, 20% LDL-C reduction, 3.1% regression

in Rx group (n=20) vs 11.8% progression in control group

(n=15) Lancet 1990;336:313-315

JAMA 1998;280:2001-2007

Diet Evidence: Secondary PreventionTrials(TRANSCEND and ONTARGET Trials)

31,546 high risk CVD patients >55 year old in 40 countries and receiving drug therapy

for secondary prevention and adherence to Mediterranean diet

Circulation 2012;126:2705-2712

High Adherence to a heart healthy diet associated with additional

reduced risk of recurrent CVD events in patients

on proven medications

Diet Evidence: Effect on LDL and CRP

% C

hange f

rom

Baselin

e

Low Fat Diet

Low Fat Diet

+ Statin

Diet Portfolio

46 patients with dyslipidemia randomized to a low fat diet, a low fat diet and

lovastatin(20mg), or a dietary portfolio (almonds, plant sterols, fiber, soy protein) for 4 weeks

JAMA 2003;290:502-10

Dietary portfolio alone had comparable impact as low

fat diet and statin on the reduction in LDL-C, HDL-C

ratio, and CRP

Diet Evidence: Nurses’ Health Study and Health Professionals’ Follow-up Study

126,399 patients followed for 8-14 years to assess the relationship between fruit

and vegetable intake and adverse CV outcomes (non-fatal MI and CVD death)

Ann Intern Med 2001;134:1106-14

Each additional daily serving of fruit and vegetables was associated

with a 4% lower risk of CAD (CI 0.94-0.99)

Diet Evidence: Body Mass Index

0.5

1.0

2.0

4.0

16 20 24 28 32 36

Body Mass Index (kg/m2)*

Ha

zard

Ra

tio

0.5

1.0

2.0

4.0

16 20 24 28 32 36

0.5

1.0

2.0

4.0

16 20 24 28 32 36

Hemorrhagic

CVA

Ischemic

CVA

Ischemic Heart

Disease (IHD)

. Int J Epidemiol 2004;33:751-758

Each 2 kg/m2 reduction in BMI: (1) 11% lower risk of IHD (95% CI, 9-13%)

(2) 8% lower risk of hemorrhagic CVA (95% CI 4-12%)

(3) 12% lower risk of ischemic CVA (95% CI, 9-15%)

Role of Exercise in CVD prevention

Historical Perspective

“Walking is man’s best medicine”

Hippocrates 460BC-377BC

Exercise Evidence: Primary Prevention

(Mortality Rates)

Risk of death decreases as exercise capacity increases

1-6 METS

6-8 METS

8-10 METS

10-13 METS >13 METS

Exercise Evidence: Secondary Prevention

(Cardiac Rehab)

Benefits of Regular Exercise

Energy Expenditure for Common Activities

Calculation of Heart Rate Reserve

Physical Activity Recommendations

Heart Healthy Lifestyle

Heart Healthy Foods (Mediterranean Diet)

The American Journal of Medicine (2014) 127, 364-369

Mayo Clinic Nutritional Pyramid

Extra Virgin Olive Oil

Lifestyle Modification and BP Control

Modification Recommendation Approximate SBP Reduction Range

Weight reduction Maintain normal body weight (BMI=18.5-24.9)

5-20 mmHg/10 kg weight lost

Adopt DASH eating plan

Diet rich in fruits, vegetables, low fat dairy and reduced in fat

8-14 mmHg

Restrict sodium intake

<2.4 grams of sodium per day 2-8 mmHg

Physical activity Regular aerobic exercise for at least 30 minutes on most days of the week

4-9 mmHg

Moderate alcohol consumption

<2 drinks/day for men and <1 drink/day for women

2-4 mmHg

JAMA. 2003;289:2560-2572

Heart Healthy Behaviors

Mediterranean Diet

Exercise

Healthy Weight

QUESTIONS?

Coronary Thrombus

The Magnitude of CAD

1 million Americans suffer an acute coronary event

each year

150,000 die from sudden cardiac death

63% of women and 50% of men had no known

coronary artery disease

68% of AMI occur in patients without significant

stenosis

American Heart Association/American Stroke

Association (2002). Heart and Stroke Statistical

Update

American Heart Association/American

Stroke Association (2009). Heart and

Stroke Statistical Update

Coronary Stenosis in Infarction

Can coronary angiography predict the site

of a subsequent myocardial infarction in

patients with mild-to-moderate coronary

artery disease?

Diet Evidence: Primary Prevention Trial

(PREDIMED STUDY)

Male

Diabetic

HTN

Dyslipidemia

Non Smoker

No FH CAD

BMI>30

Waist>median

W to H>Median

Adhere to MD

Stroke

Age>70 y/o

Mediterranean diet with either supplement EVOO or mixed nuts

results in CVD risk reduction.

Subgroups

Diet Evidence: Primary Prevention Trials (MRFIT)

360,00 men age 35-57 years screened and 12,886 men in top 15% CAD risk by Framingham data enrolled.

Randomized to: (1) usual community care by PCP or (2) special intervention: Rx of HTN with standard meds and smoking cessation counseling, saturated fat <10% of caloric intake, and poly-unsaturated fat >10%, and cholesterol intake <300 mg/d.

JAMA 1982;248:1465-1477

Diet Evidence: Primary Prevention Trial

(MRFIT Revisted 2012)

Original trial was underpowered for mortality analysis as a consequence of fewer deaths observed than anticipated.

Post hoc analysis using pre-specified nonfatal outcomes but the new construct of composite outcomes

Significant reduction in CHD composite outcomes (SI/UC HR 0.86, 95% CI 0.76-0.97, p=.01) and CVD composite outcomes (HR 0.89, 95%CI 0.79-0.99, p=0.04)

Diet Evidence: Primary Prevention Trial

(MRFIT Revisited 2012)

Original trial was underpowered for mortality analysis as a

consequence of fewer deaths observed than anticipated.

Post hoc analysis using pre-specified nonfatal outcomes

but the new construct of composite outcomes

Significant reduction in CHD composite outcomes

(SI/UC HR 0.86, 95% CI 0.76-0.97, p=.01) and CVD

composite outcomes (HR 0.89, 95%CI 0.79-0.99, p=0.04)

Diet Evidence: Primary Prevention Trial (MRFIT)

The American Journal of Medicine (2014) 127, 364-369