Atherosclerosis

Atherosclerosis a common cause of diseases and deaths, and what we can do for prevention and treatment

Atherosclerosis is a pathologic process that causes disease of the coronary, cerebral, and peripheral arteries (cardiovascular disease, CVD). They are many causes for the development of this pathologic process that affects so many of us. Diseases like diabetes, hypertension, elevated cholesterol and chronic kidney disease are major important risk factors that contribute to the development of atherosclerosis. Also the some of our life style that also play a significant role: smoking, obesity, sedentary life, and stress and conflicts in our life.

At Bandera Family Health Care, diseases that contribute to arthrosclerosis and cardiovascular conditions itself, account for fifty percent of the patients we see. It is also a major factor in diseases requiring hospital admissions and transfers to emergency rooms. An unfortunately, together with cancer is the leading cause for death on our patients. Because of the prevalence of these diseases in our patient population is that we are committed for the first quarter of 2013 to learn and disseminated information about atherosclerosis and the dire consequences of it to our health and wellness.

 Atherosclerosis begins in childhood with the development of fatty streaks. These advanced lesions of atherosclerosis occur with increasing frequency along with aging. Nonetheless, they can be seen at any age and initially are very subtle. They can be seen on routine chest x-ray as calcifications in an aorta or coronary arteries. It can be seen as an enlarge heart or a fatty liver. The presence of protein or albumin in the urine is also an early indicator of inflammation of the arteries. For others having sugars higher than 100 is also a very early indicator.  Sugar that doesn’t get use as fuels is stored as fat and it is this free floating fat that goes to action by damaging our arteries. Our waist line is another good indication of it.  For men a measurement of 40 inches and 35 for woman is a factor on the initiation and progression of these deadly diseases.

Cardiovascular disease (CVD) is common in the general population affecting the majority of adults past the age of 60 years. In 2012, CVD was estimated to result in 17.3 million deaths worldwide on an annual basis. While CVD remains the leading cause of death in most developed countries, with approximately one million Americans annually dying from CVD, mortality from acute MI appears to have decreased by as much as 50 percent in the 1990s and 2000s. The prevalence of CVD is rapidly increasing in developing countries as well.

In an autopsy study of 2,876 men and women aged 15 to 34 years who died of external causes, all individuals had aortic fatty streaks.

As a diagnostic category, CVD includes four major areas:

• Coronary heart disease (CHD), manifested by myocardial infarction (MI), angina pectoris, heart failure, and coronary death.
• Cerebrovascular disease, manifested by stroke and transient ischemic attack.
• Peripheral artery disease, manifested by intermittent claudication.
• Aortic atherosclerosis and thoracic or abdominal aortic aneurysm.

In the United States, coronary heart disease is the leading cause of death in adults accounting for about one-third of all deaths in subjects over age 35.The 2010 Heart Disease and Stroke Statistics update of the American Heart Association reported that the 2006 overall death rate from cardiovascular disease was 262.5 per 100,000.

Multiple factors contribute to the pathogenesis of atherosclerosis, including endothelial dysfunction, dyslipidemia, inflammatory, immunologic factors, plaque rupture, and smoking

Many risk factors for cardiovascular disease are modifiable by specific preventive measures. In the worldwide INTERHEART study of patients from 52 countries, nine potentially modifiable factors accounted for over 90 percent of the population-attributable risk of a first MI: smoking, dyslipidemia, hypertension, diabetes, abdominal obesity, psychosocial factors, daily consumption of fruits and vegetables, regular alcohol consumption, and regular physical activity.

CHD RISK EQUIVALENTS: Some patients without known coronary heart disease (CHD) have a risk of subsequent cardiovascular events that is equivalent to that of patients with established CHD. All patients with a CHD risk equivalent should be managed as aggressively as those with prior CHD.

NONCORONARY ATHEROSCLEROTIC DISEASE: Non-coronary atherosclerotic arterial disease includes patients with carotid artery disease, peripheral artery disease, or abdominal aortic aneurysm. Patients with any form of non-coronary atherosclerotic arterial disease have a 10-year risk of developing CHD that exceeds 20 percent. Concurrent risk factors should be treated aggressively in such patients.

DIABETES MELLITUS: Insulin resistance, hyperinsulinemia, and elevated blood glucose are associated with atherosclerotic cardiovascular disease.  In the INTERHEART study, diabetes accounted for 10 percent of the population-attributable risk of a first myocardial infarction (MI).  The all-cause mortality risk associated with diabetes has been compared to the all-cause mortality risk associated with a prior MI. While the causes of death are not equally frequent in these groups (CVD death is more frequent after MI, while non-CVD death is more frequent in patients with diabetes), the 2002 National Cholesterol Education Program Report designated diabetes a CHD risk equivalent, thereby elevating it to the highest risk category. Although a recent publish study found that having DM is equivalent to having heart disease, as we initially thought.

In addition to the importance of diabetes as a risk factor, diabetics have a greater burden of other atherogenic risk factors than non-diabetics, including hypertension, obesity, increased total-to-HDL-cholesterol ratio, hypertriglyceridemia, and elevated plasma fibrinogen. The CHD risk in diabetics varies widely with the intensity of these risk factors.

Guidelines published by the National Cholesterol Education Program and the sixth Joint National Committee have provided a framework to treat coronary risk factors aggressively in diabetics.

There is compelling evidence of the value of aggressive therapy of serum cholesterol and hypertension in patients with diabetes. In our practice we make a great effort on controlling the three major diseases. We start by creating a physician patient collaborating agreement for the management of these conditions. We make patients aware of the laboratory results and the importance of their vital signs. We called them “The ABCs of Diabetes”. For example: “A” for Hemoglobin A1C, “B” for Blood Pressure and “C” for LDL- cholesterol. Every patient needs to know there ABCs and failure to control these three elements would result in the loss of sight, a limb, or heart attacks, strokes and kidney failure.

HYPERGLYCEMIA WITHOUT OVERT DIABETES MELLITUS: There is good evidence from observational studies that higher levels of blood glucose and glycated hemoglobin correlate with cardiovascular risk in patients with and without diabetes (DM) at baseline. Sugars higher than 100 on fasting state are as stated before a risk for patients. Providers and patient then to minimize this issue but this is not a good practice. Remember, this is a sign that we are consuming more calories and carbohydrates than we should. This will eventually lead to diabetes and subsequently could lead to CVD. It is important to reduce these values as soon as the high goal is less than 100 sugar value in fasting and not higher than 140 after eating. The earlier we do this the better and easier it gets. At the beginning, a lifestyle change that includes a reduction of 10 percent of weight is enough to bring sugars back to normal and stop the progression of DM. By the time we get diagnosis with DM, we already have lost fifty percent of the function of the pancreas and the use of drugs for treatment is then imperative. So the message is, don’t be fooled by a little of high sugar because you will pay the price later.

CHRONIC KIDNEY DISEASE: The increased CHD risk in patients with end-stage renal disease has been well described, but there is now clear evidence that mild to moderate renal dysfunction is also associated with a substantial increase in CHD risk. Practice guidelines from the National Kidney Foundation in 2002 and the American College of Cardiology/American Heart Association task force in 2004 recommended that chronic kidney disease be considered a CHD risk equivalent. The data supporting this conclusion are presented elsewhere

The presence of established risk factors is associated with CHD, and the achievement and maintenance of good health is being emphasized in programs from The American Heart Association that promote seven ideal cardiovascular health metrics, including:

• Not smoking
• Being physically active
• Having a normal blood pressure
• Having a normal blood glucose level
• Having a normal total cholesterol level
• Being normal weight
• Eating a healthy diet

Family history is an independent risk factor for CHD, particularly among younger individuals with a family history of premature disease. The definition of what constitutes a family history of premature atherosclerosis has been somewhat variable in different studies. However, there is a general agreement that a myocardial infarction (MI) or death from CHD in a first degree relative (i.e., parent or sibling) prior to age 50 (males) or 60 (females) denotes a significant family history.

Cigarette smoking is an important and reversible risk factor for CHD. The incidence of a myocardial infarction (MI) is increased six fold in women and threefold in men who smoke at least 20 cigarettes per day compared with subjects who never smoked

Diets with a high glycemic index (GI) or glycemic load (GL) may contribute to the risk of CHD

There is growing evidence suggesting that fruit and vegetable consumption is inversely related to the risk of CHD and stroke.

Exercise of even moderate degree has a protective effect against coronary heart disease and all-cause mortality. Exercise may have a variety of beneficial effects including an elevation in serum HDL-cholesterol, a reduction in blood pressure, less insulin resistance, and weight loss

Obesity as measured by body mass index (BMI) significantly and independently predicted the occurrence of CHD and cerebrovascular disease after adjusting for traditional risk factors.

Psychosocial factors may contribute to the early development of atherosclerosis as well as to the acute precipitation of myocardial infarction and sudden cardiac death. The link between psychological stress and atherosclerosis may be both direct, via damage of the endothelium, and indirect, via aggravation of traditional risk factors such as smoking, hypertension, and lipid metabolism. Depression, anger, stress, and other factors have been correlated with cardiovascular outcomes

SUMMARY

• Cardiovascular disease (CVD) is the leading cause of death in most developed countries, with a prevalence that is rapidly increasing in developing countries as well. Many risk factors for cardiovascular disease are modifiable by specific preventive measures, therein offering an opportunity to reduce the burden of CVD worldwide.
• Some patients without known coronary heart disease (CHD) have a risk of subsequent cardiovascular events that is equivalent to that of patients with established coronary disease. Examples of such high-risk patients include patients with noncoronary atherosclerotic arterial disease, diabetes mellitus, and chronic kidney disease. All patients with a CHD risk equivalent should be managed as aggressively as those with prior CHD.
• Family history is a significant independent risk factor for CHD, particularly among younger individuals with a family history of premature disease.
• Hypertension and dyslipidemia are well established risk factors for CVD. Effectively treating both hypertension and dyslipidemia can significantly reduce the risk of future CVD events.
• A variety of lifestyle factors, including cigarette smoking, diet, exercise, alcohol intake, and obesity, significantly impact the risk of developing CVD.

At Bandera Family Healthcare we are committed to provide the best quality care to our patients to reduce the risk of CVD disease and the impact that it has on our patients and their families. We also recognize that the treatment of heart attacks, strokes and amputations is major burden to our patients and dramatically increase the cost of health care. As a result, we have created a Quality Initiative for the first quarter of 2013. This initiative will encompass the following:

• Provides education and seminars. We will have monthly continued medical educations for all physicians, nurse practitioners and physician assistant. The first one was held on January 24^th, 2013 Sponsor by Cardiovascular Consultants, Dr Jorge Alvarez and Methodist Hospital.
• We have two more seminars on cutting new technologies: Health Diagnostic Laboratory with advance lipid testing and Carotid Measurement Intimae Thickness (CMIT).This are to be held February 28^th, 2013.
• Develop and implement training programs and competency testing for our nursing staff.
• Develop and implement a Health and Wellness program for our staff and eventually over to our patients and their families. About 70% of our staff members showed an interest and commitment to our program that was launched in December 2012. With the leadership and expertise of Laura Norris with FITopia TX, we are implementing the program. She is an outstanding fitness and wellness instructor. She has activated many of our start-to-start exercising and is helping them with a weight monitor program. She has created a rewards program for the biggest weight loser and runner-up. The winner is rewarded $500, $200 and $75 respectively.
•  We have hired two nurse educators that come to our office 3 hours every day to educate our patients. They will also help with the nurse education program and competency testing.
•  We have upgraded our stress testing equipment and develop protocols for stress echocardiography and dobutamine stress echocardiography.
•  We are in the process of creating transfer agreements with hospitals for the timely transfers of ST elevation acute myocardial infarctions (STEMIS) and acute stokes.
•  We have created a Provider and Practice Report Card. These we allow us to see how well each provider is doing in regard to the standard of cardiovascular care. Will also let us compare how well we do in compare to other practices.

As you can in Bandera Family Health Care we are committed to provide the best quality care. We believe in the power of knowledge and how this empowers and motivates people to change. In an ongoing ABC study being conducted by our medical school in SA, it was shown that sixty five percent of our patients are at goal with ABC care. This is astonishing fact when only seven of them are at goal in our nation.

I am very proud of the accomplishment of our organization and much we have improved on the delivery of care to our community. I am very grateful to each staff member for their dedication and contributions to the practice success. But most important I am deeply grateful and honor to the patients that have entrusted their health and wellness to our organization.

Best wishes,

Ramon G, Reyes MD