Program 120 Female Handbook A

Steps We Use To Prevent

USA Top Ten Causes of Death

Chapter 1

Cardiovascular Disease

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The heart is powered for up to 120 years by an electrical node in the left atrium smaller than a watch battery. 

Think about that a moment.

For nearly a hundred years or more this little battery seems to magically fire away causing the muscles in your heart to contract, pumping oxygen-carrying blood throughout your body.

And you can’t live even two minutes without it.

The heart and your vascular system is that important! Cardiovascular disease is by far and away the number one cause of death in the USA in both sexes – in 2004 nearly 500,000 Americans died from cardiovascular disease and about one half of these were sudden[1] and from coronary artery disease! In 2006 more than one million Americans had a coronary artery thrombosis/myocardial infarction (MI)/heart attack[2] and this is where this text and your preventative attempt is most effectively focused. Interestingly and significantly, it’s also where the biggest improvement in medical care and in your patient’s life expectancies has occurred in the last ten to fifteen years.

Atherothrombotic Clot or Arterial Thrombosis—#1 Cause of Death Worldwide

From the World Health Organization in Geneva, Switzerland we know that 23% of deaths worldwide were caused by arterial thrombosis in 2002[3].

Key Definitions, Formulas, etc.

BMI (Body Mass Index)

Metric Formula: weight (kg) / [height (m)]²

With the metric system, the formula for BMI is weight in kilograms divided by height in meters squared.

Example: Height = 165 cm (or 1.65 meters), Weight = 68 kg

Calculation: 68 ÷ (1.65)² = 24.98

Pounds and inches Formula: weight (lb) / [height (in)]² x 703

Calculate BMI by dividing weight in pounds (lbs) by height in inches (") squared and multiplying by a conversion factor of 703.

Example: Weight = 150 lbs, Height = 5'5 (65)

Calculation: [150 ÷ (65)²] x 703 = 24.96

(Remember 1 pound = 0.453 kilogram and 1 inch = 2.54 centimeters)

Framingham/NCEP ATPIII Formula:

For estimation[4] of absolute 10-year risk for hard CHD events (CHD death + myocardial infarction), most clinicians now utilize a point system based on the Framingham Heart Study and updated for NCEP guidelines[5].

Based on their Framingham risk score, patients at low risk have a less than 10 percent 10-year CAD risk, patients at intermediate risk have a 10 to 20 percent 10-year CAD risk, and those at high risk have a more than 20 percent 10-year CAD risk[6]. This translates to expected annual rates of CAD death or myocardial infarction (MI) of less than 0.6 percent (low risk), 0.6 percent to 2.0 percent (intermediate risk), and more than 2.0 percent (high risk)[7].

The online Framingham risk estimate calculator can be found at: http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof.

Calculate your risk factor accordingly, especially if you are asymptomatic – if you fall within the 10-20 point range it is the recommendation of you should definitely have further testing (see below), usually an initial resting 12-lead EKG/ECG (non-invasive and simple this can be done in most offices)[8][9].

Women Can Check The Reynolds Risk Score Online

Women can check their cardiovascular risk score online at

www.ReynoldsRiskScore.org

Quit Smoking First!

First Line Smoking Cessation Therapies—Exercise is #1

To some this may seem counter-intuitive but we know now that all patients who wish to quit should be put on an exercise program first[10] (after they are cleared medically of course). This can increase their success rate by as much as 80%!

When Exercising First, Quitting Comes Like Second Nature!

We don’t care the level of your age or health status, if you are in a position to have preventive steps taken you should exercise vigorously and do it consistently – when exercise comes first, smoking cessation will often follow naturally. A number of recent well done studies have confirmed this and these points:

Vigorous exercise facilitates short- and longer-term smoking cessation in women [and why not men?—Program 120® Ed.]when combined with a cognitive-behavioral smoking cessation program. Vigorous exercise improves exercise capacity and delays weight gain following smoking cessation[11].

Women who exercised vigorously while trying to quit smoking were twice as likely to remain smoke-free and gained about half the weight of those who did not exercise[12], according to a study in a recent issue of the Archives of Internal Medicine[13].

Vigorous exercise appears to produce acute improvements in withdrawal symptoms, cigarette craving, and negative affect among sedentary women attempting to quit smoking[14].

Among participants in one study, those with higher adherence to the exercise prescription were significantly more likely to achieve smoking cessation at the end of treatment than were participants reporting lower adherence to exercise[15].

We recommend that physicians and health care professionals recommend exercise and NRT (nicotine replacement therapy) together for highly motivated women interested in quitting smoking[16].

Medications are Second

Nicotine dependence is a chronic relapsing disorder that often requires at least 5 to 7 quit attempts[17].

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Bupropion

Bupropion is one of the first-line pharmacotherapies for smoking cessation[18]. Bupropion selectively inhibits reuptake of noradrenaline and dopamine[19]. It is dosed 150 mg each day for 3 days; then 150 mg twice daily for 7 to 12 weeks and is both effective and cost effective[20].

Various Nicotine Replacements

If commercially available nicotine replacement therapy (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) is used in a smoking cessation attempt they usually, regardless of setting or other therapies used, increase the odds of quitting approximately 1.5 to 2 fold[21].

Use them all if needed – though watch out for nicotine toxicity[22] (very possible as nicotine was used in the dark ages as a deadly poison by such royal luminaries as Marie Antoinette and others – of course after Christopher Columbus returned with tobacco from the Americas).

Next—Eat A Proper Diet

(Refer to Chapter 13 The Program 120® Proper Eating & Lifestyle Modifications for more information)

Remember as reported in JAMA, a Stanford study showed that Atkins is best but the Mediterranean style diet works, too – lowering harmful lipids such as LDL-C—and is cardioprotective and is anti-inflammatory.

You should treat the food you eat like medicine – being that careful with how you choose food to eat and know what you’re taking.

The Mediterranean diet is similar to the American Heart Association's Step I diet, but it contains less cholesterol and has more fats that contain the beneficial linolenic acid (a type of omega-3 fatty acid)[23].

Key components of the Mediterranean diet include[24]:

Eating a generous amount of fruits and vegetables

Consuming healthy fats such as olive oil and canola oil

Eating small portions of nuts

Drinking red wine, in moderation, for some

Consuming very little red meat

Eating fish on a regular basis

Avoid Air Pollution/Secondhand Smoke

Everyone should use a late model car that’s got a cabin air filter. (See Chapter 4 Lower Pulmonary Disease)

Advise patients to avoid casinos and restaurants where secondhand smoke prevails.

Tell them to not run outside or exercise in pollution or polluted areas (near busy roads or highways). If they run, they should use a treadmill inside where the air is more pure.

They should always wear proper respirators in polluted work environments.

Exercise EVERY Day

Before starting to exercise, according the Screening for Heart Attack Prevention and Education (SHAPE) Task Force[25], even if asymptomatic, you should be screened with noninvasive tests for heart disease. According to SHAPE a cIMT or 64-slice CT scan[26] would be most appropriate; of course an Exercise Stress Test if it’s the only thing available is a starting point. At Program 120® we believe, if available, the 64 Slice Cat scan is the most preferable and a great new non-invasive way to perform a bloodless angiography (also called ECG-Gated 64-MDCT Angiography)[27]. [We also realize this is currently on a IIb recommendation[28] and the radiation exposure is potentially high with this test but it is non-invasive and so less frightening and a strong viable consideration in asymptomatic patients at moderate Framingham risk – Program 120 Ed.]

WARNING: Do not just get an Exercise Stress Test (EST) to be screened – this won’t be positive until your very critical anterior descending coronary artery is 70-80% occluded. Regardless, always start with a resting ECG/EKG.

NEW Minimum exercise recommendations for you from the Institute of Medicine in 2002 were increased to one hour a day[29]. Remember 1-4-7 FITT ((Refer to Chapter 13 The Program 120® Proper Eating & Lifestyle Modifications for more information)

Everyone past age 50 has to exercise every day! If you won’t, then start with just 1 minute, then go up to 2 minutes the next time you are seen by your doctor, and so forth[30].

Seems inflammatory but exercise is really very anti-inflammatory (probably due to decrease in body fat)[31].

You should do smooth (nonpounding) exercises like speed walking or swimming, but do it! Fewer injuries, less inflammation.

If you exercise at home you should either have a pool or buy the nicest treadmill you can get ($3500-$5000 but worth it).

The 10,000 Steps Program®[32]is one of the best we’ve seen—if you can get on it and follow it. If you’re just too fatigued talk to your physician and see if he can help with thyroid testing or discovering what the issue might be. Otherwise, get a pedometer and get on it!

Softball or volleyball at a company picnic does not count as exercise!

Smoking while exercising is extra bad. Only counts as negative exercise!

Though exercising programs during smoking cessation performed along with nicotine gum or patch can increase success to up to 80%[33]! (Remember 1-4-7 FITT.)

Ezetimibe (Zetia®)

Helps patients (and weak minded physicians who love cookies) as a novel cholesterol absorption inhibitor that selectively and potently blocks intestinal absorption of dietary and biliary cholesterol[34]. Ezetimibe is well tolerated, with an adverse event profile similar to that of placebo.

Data from two multicenter, placebo-controlled, double-blind, randomized, parallel-group, 12-week studies of ezetimibe taken alone were pooled to evaluate the drug's effect on lipid parameters in patients with primary  hypercholesterolemia. The 10-mg dose of ezetimibe significantly reduced LDL-C levels by 18.5% and significantly increased high-density lipoprotein cholesterol (HDL-C) levels by 3.5%[35].

The EXPLORER study[36] suggested that a treatment regimen using rosuvastatin [our favorite statin, see below – Program 120® Ed.] and ezetimibe can help patients not only to achieve optimal cholesterol targets (reduced LDL-cholesterol levels by 70%), but also to significantly reduce their levels of CRP. These two drugs work better together than separately – they have pharmaceutical synergism.

Statins (Rosuvastatin [Crestor®])

Better to take a small dose of a potent statin rather than a large dose of a weak statin – fewer side effects – remember, the ASTEROID trial told us to use rosuvastatin (Crestor®)[37].

From the STELLAR trial we know rosuvastatin is the most potent of all the statins on lowering LDL-C and other harmful lipids[38][39].

Rosuvastatin also is the only statin that has been shown to shrink atheroma size as determined by cIMT (carotid intimal medial thickness) in the ASTEROID study[40]. (Though now simvastatin has also been shown to shrink atheromas and comes in a generic.)

Start with a low dose (example: 2.5 mgm of rosuvastatin at night) and move up slowly (no more than one elevation per month).

Statins are incredibly safe but regardless watch for side effects (please refer to the statin package insert or to the PDR for more detailed information). Pfeffer found no cases of severe myopathy in over 112,000 patient years of treatment during clinical trials of pravastatin[41] but these are still worth considering:

Myalgias can occur in up to 5% (not accompanied by a CPK elevation[42] and usually goes away after a few weeks or months), and

rarely advances to myopathy but can in <1% of cases (muscle pain and elevation of CPK[43]). D/C the statin at this time!

Myopathy is more common (2 to 3%) when used with gemfibrozil, niacin, or cyclosporine.

Rhabdomyolysis occurs in <0.2% (muscle symptoms with CK elevation greater than 10 times the upper limit of normal, usually associated with myoglobinuria[44]) (excluding cerivastatin).

Hepatic dysfunction or liver toxicity occurs <2% (elevation of serum aminotransferases to more than 3X normal and some clinics advise watching up to 10X normal elevations). Check LFTs after 3 months and 6 months. Make sure any perceived liver