Sitting is the New Smoking: What Can Be Done to Reduce Cardiovascular Risk? Jayme Rock-Willoughby, DO, FACC May 20th, 2016

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1 Sitting is the New Smoking: What Can Be Done to Reduce Cardiovascular Risk? Jayme Rock-Willoughby, DO, FACC May 20th, 2016

2 Disclosures None 2

3 Overview Give an overview of the statistics of cardiovascular disease Review risk factors for cardiovascular disease Discuss ways to reduce cardiovascular risk 3

4 4

5 Cardiovascular Disease = Heart and Vascular Disease A broad term for all diseases that affect the heart or blood vessels including: Heart attack Stroke High blood pressure Coronary artery disease Aortic aneurysm + Artery and vein disease Arrhythmia Cardiac Arrest 5 5

6 Cardiovascular Disease (CVD) Impact Heart disease and stroke are the 1st & 4th leading causes of death in the United States Globally, heart disease is the leading cause of death, accounting for more than 17.3 million deaths/year Expected to grow to more than 23.6 million by 2030 Americans suffer more than 2 million heart attacks and strokes each year CAD is responsible for ~1 of every 3 deaths Stroke accounts for ~1 of every 19 deaths 6 6 Go AS et al.circulation. 2013; 127: e6-e245

7 Scope of the Problem An estimated 80,000,000 American adults (one in three) have one or more types of Cardiovascular Disease (CVD) High Blood Pressure - 73,600,000 Coronary heart disease - 16,800,000 Myocardial infarction - 7,900,000 Angina pectoris - 9,800,000 Heart failure - 5,700,000 Stroke - 6,500,000 Congenital CVD - 650,000-1,300,000 7 Source: American Heart Association. Heart Disease and Stroke Statistics 2009 Update. Circulation. 2009;119:e1-e161.

8 Cardiovascular Disease Cost Heart disease and stroke are among the leading causes of disability in our country More than 3 million people report serious illness and decreased quality of life due to cardiovascular disease 8

9 Cost of Heart Disease-United States Estimated Direct & Indirect cost 2014 *Includes health expenditures and lost productivity $316.6 billion Projected cost 2030 $818 billion 9 Go A et al. Circulation 2014;129:e28-e292

10 10 The Scope of the Problem-Ohio

11 11 The Scope of the Problem-Ohio

12 12

13 Risk Factors Uncontrollable Age (over 55) Sex Family history in first degree relative <55yrs for a man, <65yrs for a woman Modifiable Hypertension Hyperlipidemia Diabetes Tobacco Abuse Obesity Physical Inactivity 13

14 Other Risk Factors Sleep apnea Stress/depression Excessive alcohol intake Unhealthy diet 14

15 15 History of preeclampsia/eclampsia History of gestational diabetes History of pregnancy-induced hypertension History of miscarriages, stillbirths

16 16

17 Impact of Family History Premature paternal history of a heart attack doubles risk of a heart attack in men increases the risk in women by 70% History of a heart attack in both parents increases the risk of heart attack Sibling history of Heart Disease (HD) has been shown to increase the odds of HD in men and women by 50% A history of stroke in a first-degree relative increases the odds of stroke in men and women by 50% 17 Circulation. January 21, 2014 vol. 129 no. 3e28-e292

18 Ideal Cardiovascular Health The Simple 7 Three Factors Optimal total cholesterol Optimal Blood Pressure Optimal Blood Sugar (absence of diabetes) Four Behaviors Not Smoking Keeping Physically Active Healthy Diet Healthy Weight / Energy Balance Go A et al. Circulation 2014;129:e28-e292 18

19 19

20 Tobacco Abuse Estimated to cause 10% of cardiovascular disease (CVD) and is the second leading cause of CVD after hypertension (HTN) Causes 1 of every 3 deaths from CVD Secondhand smoke causes nearly 34,000 early deaths from coronary heart disease each year in the United States among nonsmokers. Nonsmokers who breathe secondhand smoke at home or at work increase their risk of developing heart disease by 25 30%. Secondhand smoke increases the risk for stroke by 20 30%. 20

21 Tobacco Abuse The risk for coronary heart disease is 25% higher in female smokers than in male smokers. The risk of a non-fatal heart attack increases by 5.6% for every cigarette smoked and persists even at only one to two cigarettes per day. Smoking bans have been shown to be one of the most cost-effective ways to reduce heart attacks 21

22 Tobacco Abuse Raises triglycerides Lowers HDL Decreases amount of oxygen that blood can carry Make blood sticky and more likely to clot Damage cells that line the blood vessels Temporarily raises blood pressure Decreases exercise tolerance 22

23 Tobacco Abuse Within 20 minutes of quitting smoking, blood pressure and pulse return to normal, and circulation improves. Within eight hours, blood oxygen levels increase and the chances of a heart attack start to fall. Within 24 hours, carbon monoxide is eliminated from the body and the lungs start to clear out mucus and debris. Within 72 hours, the lungs can hold more air and breathing becomes easier. 23

24 Tobacco Abuse Within five years, the risk of a heart attack falls to about half that of a smoker. Within 10 years, the risk of lung cancer falls to around half that of a smoker. Within 15 years, the risk of CVD becomes nearly the same as someone who has never smoked. Never too late to quit: among smokers who quit at age 66 years, men gained up to two years of life, and women gained up to 3.7 years. 24

25 25

26 Eat a Healthy Diet Mediterranean Diet Limit red meats. Drink one or two glasses of wine each day if alcohol is enjoyable and there are no reasons to restrict its use. Limit whole fat dairy products. Eat moderate amounts of fish and poultry. Fish is the diet s main protein source. Eat plenty of fresh fruits and vegetables, nuts, legumes, beans, and whole grains. Season foods with garlic, onions, and herbs. Use virgin olive oil. Health_UCM_305173_Article.jsp#.Vv_jv7grLIU 26

27 Attaining Goal Body Weight Be honest with yourself Set reasonable goals and expectations Keep a food diary Watch portion sizes Move! 27

28 Move! A person who gets in 10,000 steps/day will burn about 3,500 calories per week. You have the opportunity to lose a pound of fat every week (1lb=3,500 calories) 28 American Council on Exercise

29 Exercise Recommendations For Overall Cardiovascular Health: At least 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 Or at least 25 minutes of vigorous aerobic activity at least 3 days per week for a total of 75 minutes; or a combination of moderate- and vigorousintensity aerobic activity And moderate- to high-intensity musclestrengthening activity at least 2 days per week for additional health benefits. 29

30 Effect of Exercise on Risk Factor Modification Decrease in resting heart rate Decrease in heart rate and systolic blood pressure at any matched submaximal workload Exercise can affect other risk factors-smoking cessation, lipids, blood pressure, body weight Overall effect of sustained physical activity on global risk scores is dramatic Increases in fitness, physical activity, or both have demonstrated to reduce morbidity and mortality INDEPENDENT of changes in other risk factors 30

31 31

32 Sitting is the New Smoking Sitting Disease 50-70% of people spend 6+ hours sitting/day 34 chronic disease and conditions have been associated with excess sitting 32

33 For people who sit most of the day, their risk of heart attack is about the same as smoking. Dr. Martha Grogan, Cardiologist, Mayo Clinic 33

34 Sitting is the New Smoking Average American sits 9.3 hours a day, more than time spent sleeping (7.7) Obese people sit for 2.5 more hours/day than thin people Between 1980 and 2000, exercise rates stayed the same, sitting time increased 8% and obesity doubled Studies have shown sitting for 6 or more hours a day increases risk of death up to 40% within 15 years compared to individuals who sit less than 3 hours a day If you spend more than 11 hours in a chair, you are 40% more likely to die in the next 5 years than one who sits 6-7 hours/day. 34 https://www.diygenius.com/your-desk-job-is-killing-you-the-truth-about-sitting-downinfographic/

35 Sitting is the New Smoking Study done (Levine et, al) compared adults who watched tv less than 2 hours/day to those who watched >4 hours/day Nearly 50% increased risk of death from any cause About a 125% risk of events associated with cardiovascular disease (chest pain, MI) Increased risk independent from other traditional risk factors for cardiovascular disease like tobacco abuse or hypertension Also increases risk of obesity, diabetes, some cancers 35 https://www.diygenius.com/your-desk-job-is-killing-you-the-truth-about-sitting-down-infographic;

36 Sitting is the New Smoking The active couch potato Standing is like walking: energy expenditure increase, tones muscles, improves posture, increases metabolism 10 minutes of every hour spent sitting should involve some sort of movement More exercise time may not even reverse sitting disease 36

37 37

38 Hypertension: JNC-8 Published 12/18/13 in JAMA >/= 60 years of age: goal blood pressure (BP) <150/90 mmhg years of age: diastolic blood pressure (DBP) goal <90 mmhg, no consensus on systolic blood pressure (SBP) goal <30 years of age: no consensus in DBP goal ***based on expert opinion*** goal BP: <140/90 mmhg <140/90 mmhg in diabetics or nondiabetic chronic kidney disease (CKD) regardless of age 38

39 Hypertension: JNC-8 Moderate evidence: start treatment with acei/arb/calcium channel blocker/thiazide diuretic in nonblack patient, including those with diabetes Black population, including those with diabetes, CCB or thiazide diuretic are first line Moderate evidence to support initial or add-on anti-hypertension therapy with acei/arb in persons with CKD to improve kidney outcomes Beta-blockers are not recommended to be used for control 39

40 40

41 41

42 42

43 Dyslipidemia New guidelines Released in November 2013 Very controversial Looking away from the numbers: Moderate or high intensity statin rather for different risk categories rather than treatment to targets Uses risk calculator to guide therapy Assesses 10 year risk (40-79 years of age) and lifetime risk (20-59 years of age) Limited role for non-statin therapy 43

44 Dyslipidemia Lipids: New guidelines 4 categories: Clinical ASCVD, HF or ESRD on HD Ages with DM and LDL LDL >190 (ages 21 and older) Ages 40-75, LDL , estimated 10- year risk of 7.5% or greater 44

45 Dyslipidemia Risk calculator Heavily driven by age, also includes ethnicity/race, BP, cholesterol, current tobacco use and DM 65 yo M or 71 yo F with optimal RF has >7.5% 10 year risk of ASCVD If uncertain, can take into consideration other factors: Primary LDL-C 160 Family history CRP 2 Calcium score 300 or 75% Abnormal ABI (<0.9) 45

46 46

47 Diabetes 47

48 Cardiovascular Impact of Diabetes versus People without Diabetes Cardiovascular Disease Death Rates 2-4x higher Heart Attack Rates 1.8x higher Stroke Rate 1.5x higher 48

49 49

50 Depression Risk factor for CAD, but often unrecognized or unacknowledged Study in 2014 by Shah, et. al showed women 55 years were 2.17 times as likely to suffer a heart attack, die of heart disease or require PCI during the follow-up period if they had moderate or severe depression Each 1-point increase in symptoms of depression was associated with a 7 percent increase in the presence of heart disease. Women 55 years were 2.45 times as likely to die from any cause during the follow-up period if they have moderate or severe depression Didn t predict presence of heart disease in men or women >55 years 50 J Am Heart Assoc. 2014;3:e000741

51 51

52 Sleep Apnea (OSA) 1 in 5 adults have OSA Affects men more than women Untreated, it is associated with hypertension, arrhythmia, stroke, and heart failure Obesity is a risk factor for OSA, but untreated, can worsen obesity 52

53 53

54 Role of Aspirin (USPSTF) Ages 50-69: aspirin 81mg daily reduces risk of heart attack and stroke (primary prevention) *ONLY if they have a 10% or greater CVD risk, do not have bleeding risk factors, and are willing to take aspirin for at least 10 years. Insufficient evidence before 50 and after ationstatementfinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

55 Thank you! Special thanks to Dr. Anne Albers for presentation assistance 55

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