Preventative Health Care Exam 1 Evidence Based Medicine A.

QALY 1) One of the best measures of health status as it combines with mortality and morbidity 2) Takes into account the quality of life versus the length of life B. Levels of Prevention 1) Primary 2) Secondary 3) Tertiary C. EBM 1) The practice of Evidence-Based Medicine Means integrating individual clinical expertise with the best available external clinical evidence from systematic research 2) EBM is Conscientious, Explicit and Judicious use of current best evidence in making decisions about the care of patients. 3) Conventional Wisdom y only about 15% of medical interventions are supported by solid scientific evidence y Problems with Conventional Wisdom o uses clinical results, rather than patients, as the denominator. o tends to focus on high-technology, big ticket items. o relies on simple literature searches that miss over half of the most rigorous types of evaluations. o conducted from armchairs. 4) When did EBM begin ? y Certainly in post-revolutionary Paris. y Arguably in B.C China. y Cochrane in 1972 5) The Problems: y We need evidence (about the accuracy of diagnostic tests, the power of prognostic markers, the comparative efficacy and safety of interventions, etc.) about 5 times for every in-patient (and twice for every 3 out-patients). y We get less than a third of it 6) What evidence-based medicine is: y The practice of EBM is the integration of o Individual Clinical Expertise: a Clinical skills and clinical judgement b Vital for determining whether the evidence (or guideline) applies to the individual patient at all and, if so, how? o Best External Evidence: a From real clinical research among intact patients. b Has a short doubling-time (10 years). c Replaces currently accepted diagnostic tests and treatments with new ones that are more powerful, more accurate, more efficacious, and safer. o Patients Values & Expectations a Have always played a central role in determining whether and which interventions take place b Were getting better at quantifying and integrating them 7) What EBM is not: y EBM is not cook-book medicine o evidence needs extrapolation to my patients unique biology and values y EBM is not cost-cutting medicine o when efficacy for my patient is paramount, costs may rise, not fall 8) Cycle: y Formulate question y Efficiently track down best available evidence y Critically review the validity and usefulness of the evidence y Implement changes in clinical practice

y Evaluate performance 9) Barriers to implementing EBM for individual patients y Cost y Time y Its new-ish y What will patients think y What will my colleagues think y I dont have the skills to assess the quality of the evidence 10) Why the move to EBM? y Controlled trials pre-1960 were oddities y Reviews and meta analysis are becoming available as accessible digests of evidence y Access to evidence via digitization of literacy D. Types of study- Hypothesis Testing 1) Case control

y Odds Ratio = ad/bc (1 = no association, > 1 = possible association, < 1 = protective effect) 2) Cohort studies

Attributable risk (absolute risk or risk difference)-"What is the incidence of disease attributable to exposure" y Relative risk "How many times are exposed persons more likely to develop the disease, relative to nonexposed persons?" i.e. the incidence in the exposed divided by the incidence in the non-exposed. 3) Randomized Controlled Trials y Relative risk reduction: How many fewer patients will get the outcome measured if they get active treatment versus comparison intervention a /a+b - c/c+d a/a+b Absolute risk reduction: What is the size of this effect in the population? a/a+b - c/c+d 4) Making sense of the evidence- Are these results valid?- i.e. should I believe them? y Randomized (where appropriate)? y Drop outs and withdrawals? y Follow-up complete? y Analyzed in the groups to which randomized?-Intention to treat 5) Making sense of the evidence- Are these results useful?- i.e. should I be impressed by them, are they relevant to my patients (generalizable) y How large was the treatment effect? y

y How precise was the estimate of treatment effect y Were all important clinical outcomes considered? y Do benefits outweigh risks? E. Reading Critically 1) General y The aims of the study are not stated y The study is not novel y The study is not particularly useful or relevant to your needs y There could be ethical objections to the design or reporting of the study 2) Method y The design of the study is not consistent with the aims y The sample is not representative of the whole population in question y Controls are needed and not used y Controls used are not appropriate y Method(s) used for selecting cases / controls not clearly described y Other method details (e.g. numbers, time periods, statistical methods used) are not clear and consistent y Questionnaires are not thoroughly tested or are not relevant. 3) Results y There is missing data. e.g. drop-out rates, non-responders y Other details e.g. numbers, percentages, p values are inaccurate / unclear y Statistical methods would be useful but are not used y The tests of significance used do not meet the conditions for the application of these tests y The sample size is so small that potentially clinically significant findings do not achieve statistical significance y The sample size is so large that statistically significant findings have little clinical significance 4) Discussion y The study is not discussed critically y The results are not discussed in relation to other important literature in the field y The discussions and conclusions speculate too far beyond what has been shown in this study 5) The most common errors are: y Errors in sample groups or questionnaire design y Failure to describe the method clearly y Problems with alternative risk factors, exclusions and withdrawals y End points and diagnostic definitions unclear y Population is not typical of mine Chronic Disease Epidemiology A. Chronic Disease 1) Conquer chronic or lifestyle forged diseases, many of which are associated with the aging process 2) Stress, career pressure, sedentary lifestyles, high density population living, poor diet, crime, drugs, gangs, poverty.. 3) Examples of Chronic Diseases: Alzheimers Disease, Cancer, Cardiovascular Disease, Congestive Heart Failure, Osteoporosis, Parkinsons Disease, Rheumatoid Arthritis, Stroke B. Chronic Disease Epidemiology 1) Studies are undertaken to demonstrate a link [relationship or association] between a condition/agent and disease 2) Issues to consider y Etiology (cause) of chronic disease is often difficult to determine y Many exposures cause more than one outcome y Outcomes may be due to a multiple exposures or continual exposure over time y Causes may differ by individual 3) Causation and Association y Epidemiology does not determine the cause of a disease in a given individual

Instead, it determines the relationship or association between a given exposure and frequency of disease in populations y We infer causation based upon the association and several other factors 4) Association vs. Causation y Association - an identifiable relationship between an exposure and disease o Implies that exposure might cause disease o Exposures associated with a difference in disease risk are often called risk factors y Most often, we design interventions based upon associations y Causation - implies that there is a true mechanism that leads from exposure to disease y Finding an association does not make it causal 5) General Models of Causation y Cause: event or condition that plays an role in producing occurrence of a disease 6) Consistency of Findings of Effect y Relationships that are demonstrated in multiple studies are more likely to be causal y Look for consistent findings o Across different populations o In differing circumstances o With different study designs 7) Strength of Association y Strong associations are less likely to be caused by chance or bias y A strong association is one in which the relative risk is o very high, or o very low 8) Biological Gradient y There is evidence of a dose-response relationship y Changes in exposure are related to a trend in relative risk 9) Temporal Sequence y Exposure must precede disease y In diseases with latency periods, exposures must precede the latent period y In chronic diseases, often need long-term exposure for disease induction 10) Plausibility and Coherence y The proposed causal mechanism should be biologically plausible y Causal mechanism must not contradict what is known about the natural history and biology of the disease, but o The relationship may be indirect o Data may not be available to directly support the proposed mechanism o Must be prepared to reinterpret existing understanding of disease in the face of new findings 11) Causal Inference: Realities y No single study is sufficient for causal inference y Causal inference is not a simple process o Consider weight of evidence o Requires judgment and interpretation y No way to prove causal associations for most chronic diseases and conditions 12) Development of Chronic Diseases y Risk Factorso Ex: y At-Risk behaviorso Ex: y Pre-disposing factorso Ex: C. Web of Causation 1) Multiple Exposures2) Demonstrates the interconnectedness of possible causes 3) Ex) Smokeless Tobacco: y

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y Cancer of the lips, mouth and throat y The chewing of tobacco is the single agent and single source used in multiple exposures 4) Social Influences, sex, age, place, parental influences, physiological factors, etc. 5) Construction of a web of Causation/ Decision Trees y Identify the problem y Place the diagnosis at the center of the web y Brainstorm and list all possible sources for the disease y Brainstorm and list all risk factors and predisposing factors of the disease y Develop sub-webs and tertiary level sub webs y Organize and arrange lists of sources and risk factors from general to more distant y Develop and work through causation decision trees for each element under consideration 6) Decision Trees y Help to make decisions y Diamond shaped boxes are decision points y Rectangular boxes are activities 7) Fish Bone Diagrams y Cause and Effect Diagrams y Provide a visual presentation of all possible factors that could contribute to a disease, disability, or death y Statements are answered yes/no or true/not true Cigarette Smoking in the US 1) Relationship between failing & dropping out of high school is highest for smokers 2) 8.2% of students first smoked before the age of 11 3) 24% of the people in the US smoke Hip Fractures 1) About 20% of the people that have a hip fracture die within the next year 2) Cost to the US Healthcare System $5.4 billion a year 3) Bone mass is genetically determined 4) Many factors included in risk including race and sex Prevention and Control 1) There are several functions of the local public health units 2) The ultimate aim is to prevent and control diseases in the population Health Belief Model 1) The convictions a person holds about health phenomenon are true for them 2) Used by health promotion professionals, researchers, public health activities

Coronary Artery Disease A. Cardio Vascular Disease 1) Leading cause of death in the U.S. 2) Affects nearly 80 million Americans 3) Claims one life every 37 seconds 4) The high rate of CVD is primarily caused by Americans lifestyles B. The Cardiovascular System 1) The Heart y Pulmonary circulation o Blood to and from the lungs y Systemic circulation o Left side of the heart pumps blood through the rest of the body y Path of blood flow: o Venae Cavae o Right Atrium o Right Ventricle o Pulmonary Artery a To the lungs o Pulmonary Vein o Left Atrium o Left Ventricle o Aorta a Bodys largest artery y Systole o Contraction y Diastole o Relaxation 2) The Blood Vessels y Veins o Carry blood to the heart o Thin walls y Arteries o Carry blood away from the heart o Thick elastic walls which expand and relax with the volume of blood o Coronary arteries a Vessels that supply blood to the heart y Capillaries o Tiny vessels only one cell thick y Venules o Blood empties from the capillaries into the venules, which connect to veins that return the blood back to the heart 3) Heart Attack Symptoms y Chest pain or pressure y Arm, neck, or jaw pain y Difficulty breathing y Excessive sweating y Nausea and vomiting y Loss of consciousness 4) Heart Disease and Heart Attack y Angina Arteries are narrowed by disease but open enough to deliver blood under normal circumstances o During times of stress heart can not receive enough oxygen o Angina pectoris o Usually felt as an extreme tightness in the chest and heavy pressure behind the breastbone or in the shoulder, neck, arm, hand, or back

y Arrhythmias and sudden cardiac death Electrical conduction system is disrupted 5) Helping a Heart Attack Victim y 911 y Aspirin y Most die within 2 hours from initial symptoms y Cardiopulmonary resuscitation (CPR) 6) Atherogenesis y The development or etiology of atherosclerosis is now understood to begin with a damaged/dysfunctional endothelium. y The endothelium was once thought to simply be the protective lining of the blood vessels. y We now know that the endothelium has many important functions and may be the most important endocrine gland in the human body. 7) Total Cholesterol Levels y <200 mg/dL (5.2 mmol/L) = Desirable cholesterol y 200-239 mg/dL (5.3-6.2 mmol/L) = Borderline high y >240 mg/dL (6.2 mmol/L) = High cholesterol 8) Stroke y 2 million brain cells die per minute during a stroke y Ischemic stroke blockage in a blood vessel o Thrombotic stroke clot forms in a cerebral artery; hypertension o Embolic stroke - wandering blood clot y Hemorrhagic stroke blood vessel ruptures in the brain o Intracerebral hemorrhage o Subarachnoid hemorrhage o Aneurysm y The effects of a stroke: o Interruption of the blood supply to any area of the brain prevents the nerve cells there from functioning in some cases causing death o Those who survive a stroke have some lasting disability a Paralysis b Walking disability c Speech impairment d Memory loss e Changes in behavior y Detecting and Treating a Stroke o Prompt recognition of symptoms a Sudden numbness or weakness of face, arm, leg or one side of the body b Loss of speech or difficulty speaking c Dimming or loss of vision in one eye d Unexplained dizziness in relation to other symptoms o Transient ischemic attack (TIA) a Temporary stroke-like symptoms o Computed tomography (CT) o MRI o Ultrasound o Clot-dissolving drugs o Carotid endarterectomy surgery plaque is removed from the artery o Rehabilitation a Physical therapy b Speech and language therapy c Occupational therapy 9) Detecting and Treating Heart Disease y Electrocardiogram (ECG or EKG) y Echocardiography y Nuclear myocardial perfusion imaging

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Angiogram PTCA Open Heart Surgery o On pump vs. Off pump o CABG y Stress Test o Pharmacologic o Different Protocols o Rock Port Walk Test? Peripheral Arterial Disease y PAD atherosclerosis in the leg (or arm) arteries, which can limit or obstruct blood flow y Patients typically also have coronary artery disease y Approximately 8 million people in the U.S. have PAD y Risk factors: o Smoking o Diabetes o Hypertension o High cholesterol y Symptoms o Claudication and rest pain Other Forms of Heart Disease y Congenital Heart Defects o Malformation of the heart or major blood vessels o Hypertrophic Cardiomyopathy (HCM) a 1:500 people b Most common cause of sudden death in athletes younger than 35 c Can be identified by a murmur y Rheumatic Heart Disease o Streptococcal infections causes damage to the heart muscle and valves o Strep throat needs to be treated, primary cause if not treated y Heart Valve Disorders o Congenital heart defects and certain types of infections Protecting Yourself from Cardiovascular Disease y Eat heart-healthy o Decreased fat and cholesterol intake y Total fats should be less than 30% of total calories y Low intake of saturated fats o Increased fiber intake o Decreased sodium intake and increased potassium intake o Moderation of Alcohol y Exercise regularly y Avoid tobacco y Know and manage your blood pressure (monitored once every two years) y Know and manage your cholesterol levels y Develop effective ways to handle stress and anger Benefits of Regular Physical Activity y Improvements in Cardiovascular and Respiratory Function: o Increased maximal oxygen uptake due to both o central and peripheral adaptations o Lower minute ventilation at a given submaximal intensity o Lower myocardial oxygen cost for a given absolute submaximal intensity y Reduction in Coronary Artery Disease Risk Factors: o Reduced resting systolic/diastolic pressures y y y

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Meta-analysis of 44 studies showed that increased physical activity reduced systolic/diastolic BP by 2/3 in normo-tensives and 7/6 in hypertensives b Moderate intensity activity recommended Reduced total body fat, reduced intra-abdominal fat a Sustained weight loss may require > 2500 cal per week of exercise Reduced insulin needs (increased insulin sensitivity), improved glucose tolerance a Combination of aerobic and strength training may provide optimal outcomes

Hypertension A. What is Blood Pressure? 1) Systole2) DiastoleB. Untreated Hypertension can lead to: 1) Cardiac Hypertrophy 2) Aneurysms in the vessels in the brain 3) Narrowing of the vessels in the kidneys 4) Hardening of the arteries 5) Possible links to dementia-like symptoms C. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 1) Purpose (Why JNC 7?) y Publication of many new studies. y Need for a new, clear, and concise guideline useful for clinicians. y Need to simplify the classification of BP. 2) New Features and Key Messages y For persons over age 50, SBP is a more important than DBP as CVD risk factor. y Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg y Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. y Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD. y Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. y Certain high-risk conditions are compelling indications for other drug classes. y Most patients will require two or more antihypertensive drugs to achieve goal BP. y If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazidetype diuretic. y The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated. y Motivation improves when patients have positive experiences with, and trust in, the clinician. y Empathy builds trust and is a potent motivator. y The responsible physicians judgment remains paramount. D. BP Measurement and Clinical Evaluation 1) Classification of BP Category SBP DBP Normal <120 <80 Prehypertension 120-139 80-89 Stage 1 hypertension 140-159 90-99 Stage 2 hypertension 160 100 2) CVD Risk y HTN prevalence ~ 50 million people in the United States. y The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors. y Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.

Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension. 3) Benefits of Lowering BP Average Percent Reduction Stroke 35-40% Myocardial Infarction 20-25% Heart Failure 50% y 4) BP Control Rates 5) BP Measurement Techniques y In-office o Use auscultatory method with a properly calibrated and validated instrument. o Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level. o Appropriate-sized cuff should be used to ensure accuracy. o At least two measurements should be made. o Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals. y Ambulatory BP Monitoring o ABPM is warranted for evaluation of white-coat HTN in the absence of target organ injury. o Ambulatory BP values are usually lower than clinic readings. o Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg. o BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events. y Self-measurement o Provides information on: a Response to antihypertensive therapy b Improving adherence with therapy c Evaluating white-coat HTN o Home measurement of >135/85 mmHg is generally considered to be hypertensive. o Home measurement devices should be checked regularly. 6) Patient Evaluation y Evaluation of patients with documented HTN has three objectives: o Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. o Reveal identifiable causes of high BP. o Assess the presence or absence of target organ damage and CVD. y Laboratory Tests and Other Diagnostic Procedures o Routine Tests a Electrocardiogram b Urinalysis c Blood glucose, and hematocrit d Serum potassium, creatinine, or the corresponding estimated GFR, and calcium e Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides o Optional tests a Measurement of urinary albumin excretion or albumin/creatinine ratio o More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved E. CVD Risks 1) Hypertension* 2) Cigarette smoking 3) Obesity* (BMI >30 kg/m2) 4) Physical inactivity 5) Dyslipidemia*

Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome. F. Identifiable Causes of Hypertension 1) Sleep apnea 2) Drug-induced or related causes 3) Chronic kidney disease 4) Primary aldosteronism 5) Renovascular disease 6) Chronic steroid therapy and Cushings syndrome 7) Pheochromocytoma 8) Coarctation of the aorta 9) Thyroid or parathyroid disease G. Target Organ Damage 1) Heart y Left ventricular hypertrophy y Angina or prior myocardial infarction y Prior coronary revascularization y Heart failure 2) Brain y Stroke or transient ischemic attack 3) Chronic kidney disease 4) Peripheral arterial disease 5) Retinopathy H. Treatment Overview 1) Goals of therapy y Reduce CVD and renal morbidity and mortality. y Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. y Achieve SBP goal especially in persons >50 years of age. 2) Lifestyle modification Modification Approximate SBP reduction (range) Weight reduction 520 mmHg/10 kg weight loss Adopt DASH eating plan 814 mmHg Dietary sodium reduction 28 mmHg Physical activity 49 mmHg Moderation of alcohol consumption 24 mmHg 3) Pharmacologic treatment y Algorithm for treatment of hypertension 4) Classification and management of BP for adults y Pre-hypertension-No antihypertensive drug indicated. Drug(s) for compelling indications. y Stage 1-Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. y Stage 2-Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. 5) Follow-up and monitoring y Patients should return for followup and adjustment of medications until the BP goal is reached. y More frequent visits for stage 2 HTN or with complicating comorbid conditions. y Serum potassium and creatinine monitored 12 times per year. y After BP at goal and stable, followup visits at 3- to 6-month intervals. y Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits

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Minority Populations 1) In general, treatment similar for all demographic groups. 2) Socioeconomic factors and lifestyle important barriers to BP control. 3) Prevalence, severity of HTN increased in African Americans. 4) African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs. 5) These differences usually eliminated by adding adequate doses of a diuretic. Left Ventricular Hypertrophy 1) LVH is an independent risk factor that increases the risk of CVD. 2) Regression of LVH occurs with aggressive BP management: weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil. Peripheral Artery Disease 1) PAD is equivalent in risk to ischemic heart disease. 2) Any class of drugs can be used in most PAD patients. 3) Other risk factors should be managed aggressively. 4) Aspirin should be used. Hypertension in Older Persons 1) More than two-thirds of people over 65 have HTN. 2) This population has the lowest rates of BP control. 3) Treatment, including those who with isolated systolic HTN, should follow same principles outlined for general care of HTN. 4) Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets. Postural Hypotension (Orthostatic) 1) Decrease in standing SBP >10 mmHg, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs. 2) BP in these individuals should be monitored in the upright position. 3) Avoid volume depletion and excessively rapid dose titration of drugs. Dementia 1) Dementia and cognitive impairment occur more commonly in people with HTN. 2) Reduced progression of cognitive impairment occurs with effective antihypertensive therapy. Hypertension in women 1) Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP. 2) Development of HTN-consider other forms of contraception. 3) Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy. Children and Adolescents 1) HTN defined as BP95th percentile or greater, adjusted for age, height, and gender. 2) Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications. 3) Drug choices similar in children and adults, but effective doses are often smaller. 4) Uncomplicated HTN not a reason to restrict physical activity. Hypertensive Urgencies and Emergencies 1) Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy. 2) Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy. Additional Considerations in Anti-hypertensive Drug Choices 1) Potential favorable effects y Thiazide-type diuretics useful in slowing demineralization in osteoporosis. y BBs useful in the treatment of atrial tachyarrhythmias/fibrillation, migraine, thyrotoxicosis (shortterm), essential tremor, or perioperative HTN. y CCBs useful in Raynauds syndrome and certain arrhythmias. y Alpha-blockers useful in prostatism.

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2) Potential unfavorable effects y Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia. y BBs should be generally avoided in patients with asthma, reactive airways disease, or second- or thirddegree heart block. y ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant. y ACEIs should not be used in individuals with a history of angioedema. y Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia. Improving Hypertension Control 1) Adherence to regimens y Clinician empathy increases patient trust, motivation, and adherence to therapy. y Physicians should consider their patients cultural beliefs and individual attitudes in formulating therapy. 2) Resistant hypertension y Causes of Resistant Hypertension o Improper BP measurement o Excess sodium intake o Inadequate diuretic therapy o Medication a Inadequate doses b Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) c Over-the-counter (OTC) drugs and herbal supplements o Excess alcohol intake o Identifiable causes of HTN Hypertension Statistics 1) Estimated 50 million adults in the US are hypertensive 2) Two-thirds of people over the age of 65 are hypertensive 3) Only 70% are aware of their condition 4) Only 59% are being treated 5) Only 34% have it under control Treatment of Hypertension 1) Lose weight if overweight 2) Limit alcohol intake to no more than 1 oz. of alcohol per day 3) Reduce sodium intake (< 2.3 grams of sodium or < 6 grams sodium chloride) 4) Be careful to maintain electrolyte balance (supplements may help) 5) Stop smoking 6) Reduce saturated fat and cholesterol 7) Reduce dietary fat, especially saturated fat and cholesterol, as well as total calories - promotes weight loss and better CV health 8) Increase physical activity: y Reduces BP as well as risk for CVD y Recommendations for frequency, duration and intensity are the same as for apparently healthy. Physical Activity Recommendations 1) However, exercise at lower intensities appears to be as effective (if not more so) in lowering BP and promotes weight loss 2) Aerobic exercise should be part of initial treatment strategy for pre-hypertension and Stage 1 hypertension. 3) Persons with Stage 2 hypertension should add exercise to their treatment regimen after beginning pharmacologic therapy 4) Resistance training should not be the primary form of exercise and used with caution in persons with severe hypertension Exercise Caveats 1) High intensity exercise should be discouraged for persons whose hypertension is poorly controlled as it may produce excessively high blood pressures 2) Heavy weight lifting should be discouraged in these individuals. Five strategies to minimize risk: y BREATHE!!!

y Spot the person at the beginning as well as end of the lift y Dont take the set to fatigue y Perform exercises with one arm/leg at a time y Dont grip too tightly X. The Public Health Challenges of Hypertension (from JNC VI) 1) Prevent the rise of BP with age y More than 2/3 of people over the age of 60 are hypertensive 2) Decrease the existing prevalence of hypertension 3) Increase hypertension awareness and detection 4) Improve control of hypertension 5) Reduce cardiovascular risks y Most persons with hypertension have additional risk factors 6) Increase recognition of the importance of controlled isolated systolic hypertension 7) Improve recognition of the importance of high-normal BP 8) Reduce ethnic, socioeconomic, and regional variations in hypertension 9) Improve opportunities for treatment 10) Enhance community programs Dyslipidemia A. Lipoprotein Essentials 1) Serum Lipids and Lipoproteins y Cholesterol o 97% in cell membranes; 7% circulating in blood o Precursor of steroid hormones and vitamin D o Structural Component of cell membranes o Used by liver to form bile acids y Triglycerides o Usual storage form for lipids o 3 Fatty Acids + 1 Glycerol y BOTH ARE TRANSPORTED IN BLOOD VIA LIPOPROTEINS 2) Lipoproteins y Chylomicrons o Made from dietary fats o largest of the lipoproteins o 90% triglycerides by weight o Typically not found in fasting serum y Very Low Density Lipoprotein (VLDL) o Synthesized by the liver to carry triglycerides to cells for storage and metabolism o 60% triglycerides by weight; 10-15% of total cholesterol o 12% phospholipids;13% protein o Removal of TG from VLDL results in Intermediate Density Lipoproteins (IDL)

Low Density Lipoproteins o Linked to hepatic VLDL production and IDL catabolism o Main role in transport cholesterol to various cells of the body o 70% of serum cholesterol is carried by LDL

o 70-80% is removed by LDL receptors; 20-30% are degraded by macrophages o 23% phospholipids; 25% protein; 9% triglycerides; 43% cholesterol y High Density Lipoproteins (HDL) o Smallest and densest of the lipoprotein o Produced by the liver and small intestine o Reverse cholesterol transport o 1% rise in HDL results in a 1.5-2% lowering of CHD risk o 30% phospholipids; 50% protein; 2% triglycerides; 18% cholesterol B. Risk Ratio

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C. Epidemiologic Data 1) Framingham Heart Study y The higher a persons TC/HDL-c, the greater the risk of having symptomatic CHD y A ration 4.4 for 50-70 year old men is considered average risk y A ration of 3.0 corresponds with half the average risk y A ration of 6.2, 7.7, or 9.5 corresponds with 2, 3, or 4 times the average risk, respectively D. Major Risk Factors that Modify LDL Goals 1) Cigarette Smoking 2) Hypertension (or on anti-hypertensive medication) 3) Low HDL cholesterol (< 40 mg/dL) 4) Family history of premature Coronary Heart Disease (CHD) y CHD in male 1st degree relative < 55 years or y CHD in female 1st degree relative < 65 years 5) Age (men > 45 years; women > 55 years) E. Triglycerides and Coronary Artery Disease 1) Prevalence of persons with TG level > 200 mg/dl is nearly twice as great in persons with CAD (21.8 vs. 40.3%) 2) TG levels are a greater predictor of CAD in women than men 3) Diet modification and exercise should be the first line of therapy to reduce TG levels. However, benefits of lowering TG levels has yet to be definitively determined (confounded by other blood lipids) 4) Causes of Elevated TG Level y High fat diet y High alcohol intake y Medications: steroids, beta-blockers, oral contraceptives y Age y Weight y Diabetes and other metabolic disorders 5) Potential Atherogenic Mechanisms of Elevated TGs y Stimulates synthesis of prothrombic factors such as fibrinogen

y Alters HDL metabolism resulting in small, dense LDL y Promotes vasoconstriction y Increases expression of cell adhesion molecules y Increases cholesterol levels F. Other Measures of Serum Lipids 1) Lipoprotein (a) 2) Genetic variant of LDL-C 3) Greater propensity to infiltrate endothelial barrier 4) More readily taken up by scavenger receptors (i.e., macrophages) 5) Inhibits the action of plasmin by competing for binding sites 6) Levels are genetically determined higher levels in African-Americans 7) Levels > 30 mg/dl are considered to be high (atherogenic) G. Potential Factors Contributing to Early Statin Benefit 1) High baseline risk 2) Intensive LDL-C lowering 3) Rapid anti-inflammatory effect H. Lipoprotein Associated Phospholipase A2 (LP-PLA2) 1) Produced by inflammatory cells 2) Hydrolyzes oxidized phospholipids to generate proinflammatory molecules y Lysophosphatidylcholine y Oxidized fatty acids 3) Upregulated in atherosclerotic lesions where it co-localizes with macrophages