MNT in

Cardiovascular
Disease

Prevalence and
Incidence

The United States ranks 14th and 16th,

among industrialized nations for the
prevalence of CVD in women and men,
respectively.
More than 61 million Americans have at least
one form of CVD (i.e., hypertension, CHD,
stroke, rheumatic heart disease, or congestive
heart failure).
The incidence of CHD is high; an American
experiences a coronary event almost every
29 seconds.

Leading Causes of
Death
U.S. 2000

From http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf; accessed 3-05

Percentage Breakdown of Deaths From

Cardiovascular Diseases
United States:2002 Preliminary
Coronary Heart Disease
13%
Stroke

0%
4%

Congestive Heart Failure

5%
High Blood Pressure
6%

53%

18%

Diseases of the Arteries

Rheumatic Fever/Rheumatic
Heart Disease
Congenital Cardiovascular
Defects
Other

Source: CDC/NCHS.

Prevalence of Coronary Heart Diseases

by Age and Sex
NHANES :1999-2002

Percent of Population

20

16.8

15
11.6

10

11.5
6.3

5
0

10.3

0.0 0.3
20-34

1.4

3.0
0.2

35-44

3.6

1.6

45-54

55-64
Ages

Men

Source: CDC/NCHS and NHLBI.

Women

65-74

75+

New and Recurrent Attacks

Annual Number of Americans Having

Diagnosed Heart Attack by Age and Sex
ARIC: 1987-2000
500,000
410,000 372,000

400,000
300,000

250,000

200,000
100,000

88,000
34,000

10,000

0
29-44

45-64

65+

Ages
Men

Women

Source: Extrapolated from rates in the NHLBIs ARIC surveillance

study, 1987-2000. These data dont include silent MIs.

Prevalence of Stroke by Age and Sex

NHANES: 1999-2002

Percent of Population

14

12.0 11.5

12
10
8

6.6 6.3

6
4
2

0.4

0.3

1.1 0.8

0
20-34

35-44

2.1

1.2

3.1 3.0

`
45-54

55-64
Ages

Men

Source: CDC/NCHS and NHLBI.

Women

65-74

75+

Percent of Population

Prevalence of High Blood Pressure

in Americans by Age and Sex
NHANES: 1999-2002

100
74.0

80
60

46.6

69.2

34.1 34.0

40
20

55.5

60.9

83.4

11.1

21.3 18.1
5.8

0
20-34

35-44

45-54

55-64

Ages
Men

Source: CDC/NCHS and NHLBI.

Women

65-74

75+

Prevalence of Congestive Heart

Failure by Age and Sex
NHANES: 1999-2002
9.8 10.9

Percent of Population

10
8
6

4.1

4
2

6.2

5.8

1.8
0.3 0.3

0.5

2.3

1.5

0.4

0
20-34

35-44

45-54

55-64
Ages

Men
Source: CDC/NCHS and NHLBI.

Women

65-74

75+

Cardiovascular Disease Mortality Trends

for Males and Females

Deaths in Thousands

United States: 1979-2002

520
500
480
460
440
420
400
380
Years
Males
Source: CDC/NCHS.

Females

CVD in Men and

Women

CVD mortality in men is holding

steady; in women it is increasing
Women have comparable CVD rates
about 10-15 years later than men, but
the gap diminishes with age
82% of coronary events in women are
attributable to unhealthy diet, lack of
activity, cigarette use, and overweight

CVD in Women

Women post MI are less likely to

receive aspirin, beta-blockers,
intravenous heparin, or nitrate
therapies within the first 24 hours of
hospital admission
They were less likely to undergo
coronary angiography, angioplasty, or
bypass surgery, but they were more
likely to die in the hospital.

CVD in Women

Women have a higher prevalence of

white-coat hypertension than men.
Women may have atypical symptoms
when suffering a heart attack or
angina
When they are sent home from the
hospital, they are more than twice as
likely to die as those who are admitted

A Nation at Risk

49 million Americans smoke

42 million have total cholesterols
>240 mg/dl
63 million have total cholesterols
200-239
17 million Americans have diabetes
61 million Americans are obese; 68
million are overweight

There is Encouraging
News!

Framingham
Milestones

1960: cigarette smoking found to

increase the risk of heart disease
1961: Cholesterol level, blood
pressure, and EKG abnormalities found
to increase the risk of heart disease
1967: physical activity found to reduce
the risk of heart disease; obesity found
to increase the risk of heart disease
1970: High blood pressure found to
increase the risk of stroke

Framingham
Milestones

1976: Menopause found to increase

the risk of heart disease
1978: Psychosocial issues found to
affect the risk of heart disease
1988: High levels of HDL found to
reduce risk of death
1994: Enlarged left ventricle found to
increase the risk of stroke
1996: Progression from hypertension
to heart failure described

Favorable Trends

Over past 30 years, mortality and

in-hospital case fatality has
declined 50%
Prevalence of risk factors of
smoking, hypertension, high
cholesterol has declined 25 to
46%

Cigarette smoking among men, women, high school students,

and mothers during pregnancy: United States, 1965-2003

Men

Percen
t

High school students

Women

Mothers during pregnancy

1965

1970

1975

1985

1980

1990

1995

Year
NOTES: Percents for men and women are age adjusted. See
Data Table for data points graphed, standard errors, and
additional notes. Cigarette smoking is defined as: (for men and
women 18 years of age and older) at least 100 cigarettes in
lifetime and now smoke every day or some days; (for students
in grades 9-12) 1 or more cigarettes in the 30 days preceding
the survey; and (for mothers with a live birth) during pregnancy.

SOURCES: Centers for Disease Control and Prevention,

National Center for Health Statistics, National Health Interview
Survey (data for men and women); National Vital Statistics
System (data for mothers during pregnancy); National Center
for Chronic Disease Prevention and Health Promotion, Youth
Risk Behavior Survey (data for high school students).

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

2003

Percent of Population 20-74

with High Serum Cholesterol by
Race and Sex 1971-74 to 198894

http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf accessed 3-05

THE BAD NEWS: Overweight and obesity by

age: United States, 1960-2002

Overweight including obese, 20-74 years

Overweight, but not obese, 20-74 years

Obese, 20-74 years

Overweight, 6-11 years

Overweight, 12-19 years

1960-62 1963-65

1966-70

1971-74

1976-80

1988-94

Year
NOTES: Percents for adults are age adjusted. For adults: "overweight
including obese" is defined as a body mass index (BMI) greater than or equal
to 25, "overweight but not obese" as a BMI greater than 25 but less than 30,
and "obese" as a BMI greater than or equal to 30. For children: "overweight" is
defined as a BMI at or above the sex- and age-specific 95th percentile BMI cut
points from the 2000 CDC Growth Charts: United States. "Obese" is not
defined for children. See Data Table for data points graphed, standard errors,
and additional notes. Data are for the civilian noninstitutionalized population
and are age adjusted. See Data Table for data points graphed and additional
notes.

19992002

SOURCES: Centers for Disease Control and Prevention,

National Center for Health Statistics, National Health
Examination Survey and National Health and Nutrition
Examination Survey.

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

The Decrease in CVD

Mortality

25% is due to primary prevention

75% is due to behavioral changes
affecting risk factors or
improvements in treatment

Benefits of Risk Factor

Reduction

50-70% lower risk in former vs current

smokers within 5 years of cessation
2-3% decline in risk for each reduction
of 1% serum cholesterol
2-3% decline in risk for each reduction
of 1 mm Hg in diastolic blood pressure
35-55% lower risk for those who
maintain desirable body weight as
compared to those 20%+ above

Benefits of Risk Factor

Reduction

45% lower risk for those who

maintain an active lifestyle
compared with a sedentary
lifestyle
35% lower risk in aspirin users
compared with nonusers

Coronary Heart Disease

(CHD) or Coronary Artery

Disease involves
Disease
(CAD)impeded blood flow to

the network of blood vessels surrounding

and serving the heart
Major cause is atherosclerosis; structural
and compositional changes in the inner
wall of the arteries
Manifested in clinical end points of
myocardial infarction (MI) and sudden
death

Pathophysiology of
Atherosclerosis

Vessel lining is injured (often at

branch points)
Plaque is deposited to repair
injured area
Plaque thickens, incorporating
cholesterol, protein, muscle cells,
and calcium (rate depends partly
on level of LDL-C in the blood)

Pathophysiology of
Atherosclerosis (cont)

Arteries harden and narrow as

plaque builds, making them less
elastic
Increasing pressure causes
further damage
A clot or spasm closes the
opening, causing a heart attack

Pathophysiology of
Atherosclerosis

Proliferation of smooth-muscle
cells, macrophages, and
lymphocytes
Formation of smooth muscle cells
into a connective tissue matrix
Accumulation of lipid and
cholesterol in the matrix around
the cells

Endothelial Injury
Caused by

Hypercholesterolemia
Oxidized low-density lipoprotein
Hypertension
Cigarette smoking
Diabetes
Obesity
Homocysteine
Diets high in saturated fat and cholesterol

Natural Progression of
Atherosclerosis

(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

Plaque or Atheroma

Lipid deposits and other materials

(cellular waste products, calcium,
fibrin) that build up in the intimal
layer

Heart Attack
(Myocardial Infarction)

Heart Attack
(Myocardial Infarction)

When blood supply to the heart is

disrupted, the heart is damaged
May cause the heart to beat
irregularly or stop altogether
25% of people do not survive
their first heart attack

Symptoms of a Heart
Attack

Intense, prolonged chest pain or

pressure
Shortness of breath
Sweating
Nausea and vomiting
(especially women)
Dizziness (especially women)
Weakness
Jaw, neck and shoulder pain
(especially women)
Irregular heartbeat

Factors That May Bring

On Heart Attack (in atrisk)
Dehydration

Emotional stress
Strenuous physical activity when
not physically fit
Waking during the night or
getting up in the morning
Eating a large, high-fat meal
(increases risk of clotting)

Cerebrovascular
Accident (CVA) or
Brain Attack

Brain Attack (Stroke)

or Cerebrovascular
Accident

Symptoms of Stroke
(Brain Attack)

Sudden numbness or weakness of the

face, arm or leg, especially on one side
of the body
Sudden confusion, trouble speaking or
understanding
Sudden trouble seeing in one or both
eyes
Sudden trouble walking, dizziness, loss
of balance or coordination
Sudden severe headache

Functions of
Lipoproteins

Lipids are transported in the blood bound

to protein
Lipoproteins vary in composition, size, and
density
Consist of varying amounts of triglyceride,
cholesterol, phospholipid, and protein
The ratio of protein to fat determines the
density (HDLs have more protein than
LDLs)

Lipoproteins combine
Lipids (triglycerides,
cholesterol)
Protein
Phospholipids

Functions of the
Plasma Lipoproteins

ChylomicronTransport of dietary
triglyceride
VLDLTransport of endogenous
triglyceride
IDLLDL precursor
LDLMajor cholesterol transport
lipoprotein
HDLReverse cholesterol transport

Lipoprotein Summary

Lipoprotein
Assessment

Includes measurement of total

cholesterol, LDL cholesterol, HDL
cholesterol, and triglyceride level
after fasting

Total Cholesterol

Captures cholesterol contained in all

lipoprotein fractions
60%-70% is carried on LDL
20%-30% is carried on HDL
10%-15% on VLDL

Total Cholesterol

Direct, positive association between TC

and CHD risk
Diets high in saturated fats raise total
cholesterol and CHD incidence and
mortality
ATP-III Guidelines: lowering total
cholesterol and LDL-C reduces CHD risk
10% reduction in TC decreases CHD risk
by about 30%

Factors Affecting Total

Cholesterol

Age
Diets high in fat,
saturated fat,
cholesterol
Genetics
Endogenous sex
hormones (premenopause)
Exogenous steroids

Drugs (beta
blockers, thiazide
diuretics)
Body weight
Glucose tolerance
Physical activity
Season of the year
Diseases

Prevalence of High
Total Cholesterol

Serum cholesterol levels in the U.S.

population have been declining since
1960
More than half that decline occurred
between 1976 and 1991, when national
preventive education efforts were begun
Proportion of adults with TC>240 mg/dl
fell from 27% to 19%, while HDL and
VLDL remained unchanged

Total Triglycerides

Triglyceride-rich lipoproteins include

chylomicrons, VLDL, remnants or
intermediary products
Are atherogenic
At very high levels, risk of
pancreatitis
Can be evidence of metabolic
syndrome

Chylomicrons

Largest particles
Transport dietary fat and cholesterol
from the small intestine to the liver
In the bloodstream, triglycerides are
hydrolyzed by lipoprotein lipase (LPL)
in muscle and adipose tissue
When 90% of triglyceride is
hydrolyzed, released into blood as a
remnant
Liver metabolizes remnants, but some
deliver cholesterol to the arterial wall
Absent in fasting studies

Very-Low-DensityLipoproteins

Manufactured in the liver to transport

endogenous triglyceride and
cholesterol
60% is triglyceride
Large VLDL may be nonatherogenic
VLDL remnants or IDL appear to be
atherogenic
Not routinely measured, but TG in
them is measured in total triglyceride

Intermediate-Density
Lipoprotein

Formed with catabolism of VLDL, a

precursor of LDL
Rich in cholesterol and apo E
High concentrations of IDL and VLDL
remnants directly related to lesion
progression and coronary events
Not routinely measured, though
components can be

Low-Density
Lipoprotein

Primary cholesterol carrier in blood

Total cholesterol and LDL-cholesterol
are strongly correlated
95% of apolipoproteins in LDL are apoB-100
LDL is formed in VLDL catabolism, 60%
is taken up by LDL receptors in liver,
adrenals, other tissues; rest is
metabolized via alternative pathways
Number and activity of receptors
determines LDL cholesterol levels in the
blood

LDL-C

Particles heterogeneous in size, density,

lipid components
Phenotype A: large particles, not associated
with disease risk
Phenotype B typified by small, dense LDL
particles; triglyceride rich, cholesterol
depleted; predictive of
CHD risk in men and women

High Density
Lipoproteins (HDL)

Contain more protein than

the other lipoproteins
Apo A-1 is involved in
tissue cholesterol removal
High HDL is associated with
low levels of chylomicrons,
VLDL remnants, and small,
dense LDL

Lipoprotein Profile

Measures total cholesterol, LDLcholesterol, HDL-cholesterol, and

triglycerides
8-12 hour fast allows chylomicrons
to clear
Friedenwald formula for calculating
LDL-C = (TC) (HDL-C) (TG/5)

ATP III Guidelines

Adult Treatment Panel for the

Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults
convened by the National Heart,
Lung & Blood Institute of the NIH
Published 2002
Updated in 2004
Next revision expected in 2009
(panel convened 2/08)

Lipoprotein Profile

If nonfasting, can measure total

and HDL cholesterol
If TC>200 mg/dl or HDL-C is <40
mg/dl, get fasting analysis

Evaluating Blood
Lipids: Total
Cholesterol
<200
mg/dL Desirable
200-239
mg/dL

Borderline high

240 mg/dL

High

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Evaluating Blood
Lipids: Triglycerides
<150 mg/dL

Normal

150-199

Borderline high

200-499

High

>500 mg/dl

Very high

Source: ATP-III Guidelines, NHLBI, accessed 4-2005

Evaluating Blood
Lipids: LDL
<100 mg/dL

Optimal

100-129

Near optimal

130-159

Borderline high

160-189

High

190

Very high

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Evaluating Blood
Lipids: HDL
< 40 mg/dL

Low

60 mg/dL

High

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Risk Factors affect

Lipid Targets

Major, independent risk factors

Life-habit risk factors
Emerging risk factors

Major Risk Factors That

Modify LDL Goals

Cigarette smoking
Hypertension (BP 140/90 mmHg or
on
antihypertensive medication)
Low HDL cholesterol (<40 mg/dL)
Family history of premature CHD

CHD in male first degree relative <55

CHD in female first degree relative <65
Age (men 45 years; women 55
years)

Life-Habit Risk Factors

Obesity (BMI 30)

Physical inactivity
Atherogenic diet

Emerging Risk Factors

Lipoprotein (a)
Homocysteine
Prothrombotic factors
Proinflammatory factors
Impaired fasting glucose
Subclinical atherosclerosis

Risk Assessment
Count major risk factors*

For patients with multiple (2+) risk factors

Perform 10-year risk assessment

For patients with 01 risk factor

10 year risk assessment not required
Most patients have 10-year risk <10%

*HDL cholesterol 60 mg/dL counts as a negative risk

factor; its presence removes one risk factor from the total
count.

CHD Risk Equivalents

Risk for major coronary events

equal to that in established CHD
10-year risk for hard CHD >20%

Hard CHD = myocardial infarction + coronary

death

Diabetes
In ATP III, diabetes is
regarded
as a CHD risk equivalent.

Diabetes as a CHD Risk

Equivalent

10-year risk for CHD 20%

High mortality with established
CHD
High mortality with acute MI
High mortality post acute MI

CHD Risk Equivalents

Other clinical forms of

atherosclerotic disease (peripheral
arterial disease, abdominal aortic
aneurysm, and symptomatic carotid
artery disease)
Diabetes
Multiple risk factors that confer a
10-year risk for CHD >20%

Calculate Your 10-Year

Risk of Heart Attack

Risk Calculation
http://hp2010.nhlbihin.net/atpiii/
calculator.asp?usertype=pub
At-A-Glance treatment guidelines:
http://www.nhlbi.nih.gov/guideline
s/cholesterol/atglance.htm

Three Categories of
Risk that Modify LDL-C
Risk Category
LDL Goal
GOALS
(mg/dL)
CHD and CHD risk
equivalents
Multiple (2+) risk
factors
Zero to one risk
factor

<100
<130
<160

ATP III Guidelines

Goals and Treatment
Overview

Primary Prevention
With
LDL-Lowering
Therapy
Public Health Approach

Reduced intakes of saturated fat

and cholesterol
Increased physical activity
Weight control

Causes of Secondary
Dyslipidemia

Diabetes
Hypothyroidism
Obstructive liver disease
Chronic renal failure
Drugs that raise LDL cholesterol and
lower HDL cholesterol (progestins,
anabolic steroids, and
corticosteroids)

Secondary Prevention
W/
Benefits: reduction in total mortality,
LDL-Lowering Therapy

coronary mortality, major coronary

events, coronary procedures, and stroke
LDL cholesterol goal: <100 mg/dL
Includes CHD risk equivalents
Consider initiation of therapy during
hospitalization
(if LDL 100 mg/dL)

LDL-C Goals in Different Risk

Categories

Risk Category

LDL Goal
(mg/dL)

CHD or CHD
Risk
Equivalents
(10-year risk
>20%)

<100;
optional
goal <70
mg/dL

Moderately
high risk
2+ Risk
Factors
(10-year risk
10-20%)

<130

LDL for Total

Lifestyle
Change (TLC)
(mg/dL)

LDL for
Drug Therapy
(mg/dL)

100

100
(<100:
consider drug
options

130

>130 mg/dL
(100-129
mg/dL,
consider drug
options)

ATP-3 update, Circulation, 2004

LDL-C Goals in
Different Risk
Categories

LDL for Total

Lifestyle
Change (TLC)
(mg/dL)

LDL for
Drug Therapy
(mg/dL)

Moderate risk: <130 mg/dL

2+ risk factors
(10 year
risk<10%)

>130 mg/dL

>160 mg/dL

Lower risk (01 risk factors)

>160 mg/dL

>190 mg/dL
(160-189
mg/dL, drug
optional)

Risk Category

LDL Goal
(mg/dL)

<160 mg/dL

ATP-3 update, Circulation, 2004