Optimal Heart Health J. Kern Buckner, MD Chief, Division of Cardiology Professor of Medicine National Jewish Health October 12, 2014
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