GOAL OF INTERVENTION EFFORTS:
The goal of therapeutic intervention is the prevention of cardiovascular disease and stroke. Primary prevention is the term used to describe intervention efforts in patient who have no demonstrated cardiovascular disease, where the goal is the prevention of disease. Secondary prevention is the term used to describe intervention in patients with demonstrated disease, where the goal is to prevent the progression of disease and possibly a reversal of existing disease.
Patients who would benefit from intervention efforts would be the following:
(1.) Patients with cardiovascular disease.
(2.) Patients who have no cardiovascular disease but are at risk
(3.) Everybody else.
What we’re saying is that everybody can benefit to some degree by implementing intervention strategies appropriate to their situation.
INTERVENTION STRATEGIES FOR HEART DISEASE EVERYONE SHOULD OBSERVE
Intervention strategies everyone should observe fall into three categories:
3.) Risk Factor Assessment.
To reduce the risk of heart disease in patients with normal cholesterol and without demonstrated heart disease, the American Heart Association recommends what they refer to as the Step I Diet.
THE STEP I DIET CONSISTS OF THE FOLLOWING: RECOMMENDATIONS:
1.) TOTAL FAT INTAKE: It is recommended that the calories obtained from fat should be no more than 30% of total calories.
2.) SATURATED FAT: Calories from saturated fat (sat fat) should be limited to 8-10% of total calories.
3.) POLYUNSATURATED FAT: Calories from Polyunsaturated fat can account for up to 10% of total calories.
4.) MONOUNSATURATED FAT: Calories from monounsaturated fat can be up to 15% of total calories.
5.) CARBOHYDRATES: Calories from carbohydrates should be 55% or more of total calories.
6.) PROTEIN: Calories from protein should be approximately 15% of total calories.
7.) CHOLESTEROL: Cholesterol intake should be limited to 300 mg per day.
8.) TOTAL CALORIES: Total calories should be the number of calories that would allow you to achieve and maintain a desired weight.
The following chart will allow you to estimate fat intake at selected levels of total calorie intake according to the Step I Diet:
|TOTAL CALORIES||TOTAL FAT (grams)||SATURATED FAT (gm)|
|1200||40 or less||11-13|
|1500||50 or less||13-17|
|1800||60 or less||16-20|
|2000||67 or less||18-22|
|2200||73 or less||20-24|
|2500||83 or less||22-28|
|3000||100 or less||27-33|
Appropriate lifestyle modification should occur, and should address the following areas:
1.) SMOKING: The goal should be complete cessation of smoking. A smoking cessation program should be discussed, to include cessation strategies and pharmacological therapy where appropriate.
2.) EXERCISE: A goal should be set for physical activity to include 30 minutes of vigorous exercise 3 to 4 times per week. Daily activities should be modified so as to increase the amount of walking, such as parking farther from the store or office, taking stairs instead of elevators, etc.
3.) ALCOHOL INTAKE: Alcohol should be consumed in moderation, as excessive alcohol consumption has been linked to an increased risk of heart disease. Moderation is defined as no more than 2 alcohol containing beverages per day. Red Wine consumption, at no more than 2 glasses per day, has been shown to be associated with a reduced risk of cardiovascular disease. This is thought to be due to its content of tannins and isoflavones, which function as anti-oxidants.
4.) STRESS MANAGEMENT: Stress, and how we deal with it, is known to contribute to the development of cardiovascular disease. Life stressors should be examined, and an appropriate strategy to better deal with stress should be undertaken, to include the use of behavioral therapists or other treatment modalities, such as biofeedback, Yoga, meditation, and acupuncture.
PERIODIC RISK FACTOR ASSESSMENT:
Risk factors for cardiac disease should be assessed periodically by your primary care physician. These should include:
-Lipid Screening: to include measuring total cholesterol, LDL, and triglycerides.
-Blood Pressure Screening.
-Assessment of estrogen status.
When assessment of these risk factors shows the need, intervention strategies should be implemented as appropriate.
INTERVENTION STRATEGIES FOR PATIENTS WITH RISK FACTORS OR WITH ESTABLISHED HEART DISEASE
Patients who have risk factors for heart disease, or those who have established atherosclerosis as demonstrated by a heart attack or stroke, should follow all of the above advice, but with two modifications:
1.) Patients with established vascular disease, or those high-risk patients with elevations of blood lipids are advised to follow what is referred to as the Step II Diet.
2.) The addition of cholesterol lowering drugs should be considered.
As well, there are a number of Complementary and Alternative therapies that can be of benefit. These modifications, and the Complementary and Alternative Approaches will be addressed separately.
THE STEP II DIET
The Step II Diet is recommended for anyone who has had a heart attack or stroke, and for patients with elevations of cholesterol. As discussed above in the section on cholesterol screening, total cholesterol should be measured periodically. An LDL cholesterol is measured if:
-Total cholesterol is greater than 240, or
-Total cholesterol is greater than 200 in the presence of 2 or more risk factors.
Based on the LDL, then, the Step II Diet is advised if:
-The LDL is greater than 160, or
-The LDL is greater than 130 in the presence of 2 or more risk factors.
THE STEP II DIET CONSISTS OF THE FOLLOWING RECOMMENDATIONS:
1.) TOTAL FAT: Calories from fat should account for no more than 30% of total calories.
2.) SATURATED FATS: Calories from Sat Fat should account for no more than 7% of total calories.
3.) POLYUNSATURATED FATS: Should account for no more than 10% of total calories.
4.) MONOUNSATURATED FATS: Can account for up to 15% of total calories.
5.) CARBOHYDRATES: Should account for 55% or more of total calories.
6.) PROTEIN: Should account for approximately 15% of total calories.
7.) CHOLESTEROL: Cholesterol intake should be limited to 200 mg per day.
8.) TOTAL CALORIES: Should be adjusted to allow you to achieve and maintain a desired weight.
The following table will allow you to estimate fat intake at selected levels of calorie intake according to the Step II Diet:
|CALORIE INTAKE||TOTAL FAT (IN gm.)||SAT. FAT (IN gm.)|
|1200||40 OR LESS||LESS THAN 9|
|1500||50 OR LESS||LESS THAN 12|
|1800||60 OR LESS||LESS THAN 14|
|2000||67 OR LESS||LESS THAN 16|
|2200||73 OR LESS||LESS THAN 17|
|2500||83 OR LESS||LESS THAN 19|
|3000||100 OR LESS||LESS THAN 23|
THE GOAL OF THE STEP II DIET
The primary goal of the Step II Diet is to achieve an LDL less than 100.
The secondary goals of the Step II Diet are to achieve an HDL greater than 35, and a triglyceride less than 200.
It must be emphasized at this point that the Step II Diet should be followed along with attention to appropriate lifestyle issues and on-going risk factor assessment.
If the Step II Diet does not bring the LDL below 100, or, if the LDL remains above 130, consideration should be given to cholesterol lowering drug therapy.
CHOLESTEROL LOWERING DRUG THERAPY
Cholesterol lowering drug therapy should be considered for the following groups:
1.) Anyone who has been placed on the Step II Diet, but did not achieve the desired goal of an LDL less than 100.
2.) Anyone with heart disease and an LDL greater than 130.
3.) Anyone without heart disease and an LDL greater than 160 in the presence of 2 or more risk factors.
4.) Anyone without heart disease and an LDL greater than 190 with fewer than 2 risk factors.
The decision to initiate and monitor cholesterol lowering drug therapy should be made by you and your primary care physician or cardiologist. At Nature’s Healthcare, we consider our role to be advising you on which Complementary and Alternative methods of treatment show promise in further reducing your risk of atherosclerosis. As such, we prefer to avoid a detailed discussion of cholesterol lowering drugs so that we can focus on these methods of treatment.
Aspirin is now widely used in the prevention of heart disease. The question is, what is its’ role? Aspirin acts to inhibit platelet aggregation. Platelet aggregation is one of many factors involved in the formation of a clot within an atherosclerotic plaque. The formation of such a clot is often the trigger for a heart attack or stroke, and is refereed to as an occlusive vascular event. The evidence is clear with regards to secondary prevention. Aspirin reduces by approximately 25% the risk of developing a heart attack or stroke, when taken by patients with a prior heart attack, stroke, or other evidence of existing cardiovascular or peripheral vascular disease.The dose of aspirin in the study group ranged from 75 mg to 325 mg per day. Higher doses did not appear to be more effective.
With primary prevention, the evidence is less clear. The two large trials done using aspirin in patients with no evidence of existing heart disease showed results that were called inconclusive. That is, the findings did not allow a recommendation for or against the routine use of aspirin for primary prevention of a first heart attack or stroke. The decision to recommend aspirin in such patients is made on an individual basis, taking into account the patient’s individual risk profile and comparing it to the as yet unknown risks of such long term therapy. Studies are on going to elucidate further the use of aspirin in primary prevention.