atherosclerosis

atherosclerosis and primary prevention

Primary prevention:

dietary:

  • “prudent” diet is generally regarded as safe & desirable for all adults:
    • < 30% of energy from fat
    • maintenance of ideal weight (BMI 20-25):
      • abdominal obesity is associated with adverse changes in several major risk factors including diabetes, hyperlipidaemia, and hypertension
      • thus obesity is a useful marker for cardiovascular disease risk although nor always an independent risk factor
    • if diabetes then avoidance of simple carbohydrates
    • avoid dietary saturated fat, cholesterol & salt
    • stress importance of variety in diet
    • avoid foods with high energy density but low nutrient density
      • ⇒ use lean meat, low fat dairy products, skinless poultry & fish
      • ⇒ use cereals, fruit & vegetables with plentiful soluble fibre allows a more generous food intake
      • ⇒ use mono- or polyunsaturated fats instead of unsaturated fats
      • ⇒ avoid adding extra butter, sour cream, cheese, gravy to food
      • ⇒ avoid fried dishes, cream sauces, frequent take-aways
    • avoid carnitine (red meat, energy drinks)
    • benefits of Mediterranean diet (olive oil-based, minimal red meat, minimal simple carbohydrates)

alcohol

  • avoid alcohol if hyperTG, abdominal adiposity, hypertension or obstructive sleep apnoea is contributing to cardiovascular disease risk

cigarette smoking

manage hyperlipidaemia

treat hypertension

control diabetes

regular aerobic exercise:

  • important because of effects on cardiorespiratory fitness and energy balance
  • it may assist development of collateral circulation
  • improves caloric balance & may restore the link between appetite & energy requirements, thereby reducing obesity

oestrogen replacement therapy:

  • IHD is uncommon in premenopausal women
  • HRT has been shown to decrease risk of atherosclerotic disease - oral effect may be greater than patch
  • benefits of HRT in reducing atherosclerosis may be outweighed by its risks

aspirin:

  • low dose (75mg/day) may be associated with significant reductions in CVS disease but small increased risk of GIT bleeding and haemorrhagic stroke
  • aspirin for primary prevention if benefits outweigh risks:
    • women aged 55 to 79 yrs if benefit of stroke (CVA) reduction outweighs risk of GIT haemorrhage1)
    • men aged 45 to 79 yrs if benefit of acute myocardial infarction (AMI/STEMI/NSTEMI) reduction outweighs risk of GIT haemorrhage2)
    • do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years 3)
    • evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older 4)

prevent hyperhomocystinaemia if present:

  • ensure folic acid & B12 deficiency is recognised & treated
  • vitamin B6

anti-oxidants & other nutrients:

Vitamin E:
  • In 1993, 2 large studies showed that Vit E could reduce the risk of heart disease in both men & women by around 35%, with best results from those that took at least 100IU per day for 2 years. NEJM 1993; 328:1450-56; NEJM 1993; 328:1444-9.
  • In 1995, a study suggested that in pts with Hx of IHD, vitamin E intake of > 100IU/day was able to reduce coronary artery lesion progression when studied with serial angiography. JAMA 1995; 273:1849-54;
  • In 1996, a study of > 11,000 elderly persons (>67yrs old), found that combined supplement use of Vit E & C seemed to offer significant protection from both heart disease mortality (down 42%) and all-cause mortality (down 53%) Am.J.Clin.Nutr. 1996:190-6.
  • In 1996, Cambridge Heart Antioxidant Study (CHAOS) Lancet 1996; 347:781-86 studied 2000 pts with existing heart problems & found that supplementation with 400IU or 800IU per day for at least 1 year, reduced the risk of non-fatal heart attacks by up to 75%.
  • In 2008, it now seems that supplemental antioxidants of vitamin A group or vitamin E actually INCREASES mortality!!

Secondary prevention:

aspirin:

  • low dose aspirin 100-300mg/day unless C/I

beta blockers:

  • offer prognostic benefit post-AMI

ACE inhibitors:

  • offer prognostic benefit if significant LV dysfunction

fish oil n-3 fatty acids & other anti-oxidants post-revascularisation

  • *in 2018, the Cochrane review found that there is little evidence to support these fish oil supplements as benefiting reducing cardiovascular disease

statins:

  • help stabilise plaque and may induce plaque regression
atherosclerosis.txt · Last modified: 2018/07/20 02:01 by gary1