PATIENT ENQUIRY

How to Treat Cardiovascular Disease


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What Is?
What is Cardiovascular Disease
How to Treat Cardiovascular Disease
Natural Treatments for Cardiovascular Disease

What is cardiovascular disease?

Cardiovascular disease (CVD) is the general term for blood vessel disease of the heart or body. CVD is the most common disease process in Western society and the financially well-off sections of developing countries. Blood vessel disease, called atherosclerosis, is the build up of atheroma or plaques in an artery, which leads to narrowing or complete blockage of the artery. Significant narrowing reduces the amount of arterial blood supply to an organ or body region and causes tissue hypoxia, reduced cell metabolism, and organ dysfunction.

In Australia, people in lower socioeconomic groups, Aboriginal and Torres Strait Islander people, and people living in remote locations, are more likely to be affected by CVD compared with the rest of the population.

There are five main types of CVD, which cause ischaemia or a lack of blood flow.

  • Ischaemic heart disease of coronary artery disease can cause a myocardial infarction or heart attack.
  • Cerebrovascular disease (of the brain) can cause a stroke or cerebral infarct.
  • Peripheral artery disease of the arms and legs can cause claudication (calf pain with walking), distal tissue atrophy, and in severe cases gangrene.
  • Renovascular disease affects blood flow to the kidneys and can cause renal failure.
  • Aortic disease means atherosclerosis and narrowing of the main artery from the heart, the aorta. Atheroma can cause weakening of the wall of the aorta and aneurysmal dilation, which can rupture the artery causing fatal internal bleeding.

Atherosclerosis means the deposition of atheroma in the vessel wall of large and small arteries causing ischaemia, which means a lack of blood. Atheromatous plaques can contain a mixture of fat, cholesterol, blood cells, and fibrous tissue.

The overall death rate for cardiovascular disease has fallen by about 80% since the 1960s and continues to fall. Death rates from coronary heart disease, stroke, heart failure, rheumatic heart disease, and peripheral vascular disease, have all fallen markedly during the past 20 years. (Cardiovascular disease – Australian Facts 2011).

Cardiovascular disease facts and trends

  • During 2007–08, approximately 3.5 million Australians had long-term CVD.
  • Nearly 50,000 deaths were attributed to CVD in Australia in 2008 – more than any other disease group and 34% of the total.
  • CVD was the main cause for 475,000 hospitalisations in 2007–08 and played a secondary role in a further 797,000.
  • CVD accounted for about 18% of the overall burden of disease in Australia in 2003, with coronary heart disease and stroke contributing more than 80% of this burden.
  • CVD remains the most expensive disease group in Australia, costing approximately $5.9 billion in 2004–05. Just over half of this money was from the cost of admitting patients to hospital for treatment.
What are the most common types of cardiovascular disease?

What are the most common types of cardiovascular disease?

Coronary heart disease and stroke may be caused by the same problem – atherosclerosis, when your arteries become narrowed because of a gradual build up of fatty plaque (called atheroma) along arterial walls.

Over time, the arteries may become too narrow to deliver enough oxygen-rich blood to your heart, which could cause angina – a pain or discomfort in the chest. Narrowing of the artery is called a stenosis, while complete blockage is called an occlusion.

If a piece of the atheroma in your arteries breaks away it may cause a blood clot to form. If the blood clot blocks one of the coronary arteries and cuts off the supply of oxygen-rich blood to the cardiac muscle, that part of the cardiac muscle may become permanently damaged because of myocardial infarction, or heart attack.

When an artery that carries blood to your brain is significantly affected by atheromatous plaque, blood supply to part of your brain is reduced and that part of the brain may die. A person with this problem can have transient ischemic attacks (TIAs) or a stroke, which can be very debilitating.

  • A blockage in the coronary arteries can cause symptoms of chest pain (angina) or a heart attack.
  • A blockage in the carotid arteries, the main neck arteries that supply the brain) can lead to a transient ischemic attack (TIA) or stroke.
  • A blockage in the legs can lead to leg pain or cramps with exercise (claudication), changes in skin colour, lower leg sores or ulcers, and feeling tired in the legs. A complete occlusion of the artery could lead to gangrene and loss of a limb.
  • A blockage in the renal arteries, the arteries that supply the kidneys, can cause renal artery stenosis or occlusion. The symptoms include uncontrolled hypertension (high blood pressure), heart failure, and abnormal kidney function.
What is ischaemic heart disease

What is ischaemic heart disease

During 2011, ischaemic heart disease (IHD), also called coronary artery, disease killed more than 21,513 Australians (14% of all deaths). Approximately 380,000 Australians (1.7%) alive today have had a heart attack at some time.

Heart attacks, or myocardial infarcts, are the most common single cause of death. When athero¬matous plaque narrows or blocks the coronary arteries a myocardial infarction can result. The myocardium needs a continuous supply of oxygenated blood to keep pumping enough blood to many organs and body parts, for proper function.

The primary initiator of atheroma in the arterial wall appears to be endothelial injury leading to increased adherence of monocytes and T-lymphocytes to the affected area. As plaque continues to build over the years, localised thickening of the arterial wall reduces the artery lumen and when severd enough can compromise blood flow.

IHD occurs when blood supply is insufficient for the oxygen demand of the muscle of the heart, called the myocardium manifests as:

  • Chronic, progressive myocardial dysfunction resulting in limited exercise capacity, recurrent angina and congestive cardiac failure
  • Acute myocardial ischaemia that occurs as a result of either intra-arterial thrombosis or coronary artery spasm
What is cerebrovascular disease?

What is cerebrovascular disease?

Cerebrovascular disease (CVD) means arterial disease of haemorrhage or the arteries in the brain. If interruption to the arterial blood supply to the brain is restricted significantly, a person can suffer a stroke due to brain tissue ischaemia. Multiple underlying factors contribute to CVD.

Two types of stroke can occur but an ischemic stroke is the most common type. When an artery that supplies the brain with blood becomes blocked that part of the brain is affected and brain cells die because the area is deprived of oxygenated blood. The extent and location vary greatly and so the resultant symptoms vary greatly.

A haemorrhagic stroke occurs when one of the arteries in the brain ruptures, usually because of uncontrolled hypertension. The resultant haemorrhage, or localised bleed, affects brain function. An intracerebral haemorrhage is a bleed within the brain tissue and a subarachnoid haemorrhage is a bleed into the space around the brain.

Short, recurrent episodes of cerebrovascular ischaemia, called transient ischaemic attacks (TIAs), often precede a major stroke and act as a warning sign. TIAs occur before approxi¬mately 50% of strokes and present as sudden-onset but short-term, temporary symptoms such as dizziness, confusion and disorientation, visual disturbance or loss of vision, skin tingling or loss of feeling, muscle weakness, or even paralysis. TIAs may also occur during an episode of migraine headache, due to arterial vascular spasm. The incidence of stroke is increased in patients with a history of frequent and prolonged episodes of migraine headaches.

What is peripheral arterial disease

What is peripheral arterial disease

Peripheral arterial disease occurs when atheromatous plaque builds up in the arteries of the arms or legs. As for arterial disease elsewhere, when plaque is significant enough to narrow the lumen of the artery, blood flow to either the arm and hand or leg and foot is restricted, causing leg or arm claudication – a cramping pain in the leg calf muscle during when walking. In severe cases gangrene might develop in the most distal body part.

What is renovascular disease

What is renovascular disease

Renovascular disease means impaired blood flow to the kidneys due to narrowing or occlusion to one or both renal arteries. Each kidney has at least one artery arising from the abdominal aorta. A small percentage of people patients have two arteries going to one kidney.

Reduced renal perfusion leads to hyperactivation of the rennin-angiotensin-aldosterone axis, which causes high blood pressure (hypertension).

In developed countries, atherosclerosis is the most common cause of renovascular disease, usually at the renal artery origin, leading to chronic renal ischaemia. In the Caucasian population more than 90% of renovascular disease is caused by atherosclerosis.

In the Indian subcontinent and Far East Asian, arterial inflammation called Takayasu’s arteritis causes approximately 60% of renal ischaemia. Fibromusclar dysplasia, an angiopathy of unknown cause, of the renal artery accounts for the remaining cases.

Aortic aneurysm and dissection

Aortic aneurysm and dissection

Each time the heart contracts blood is pumped out of the left ventricle through the aorta, which is the largest artery in the body. Because the aorta is such a large artery, atheroma is rarely significant enough to cause enough narrowing to restrict blood flow. Instead atheroma weakens the wall and causes aneurismal dilation, which could lead to rupture.

A focal dilation of an artery is called aneurysm. Abdominal and thoracic aortic aneurysms require vigilant surveillance because rupture can be life threatening. When an aneurysm reaches a certain diameter, surgical endovascular repair may be necessary to prevent rupture.

How is cardiovascular disease diagnosed?

How is cardiovascular disease diagnosed?

If a doctor suspects a person has cardiovascular disease, he or she will listen to heart sounds, take a blood pressure, check pulses, and may order a chest X-ray and/or ECG. The type of diagnostic procedure depends on which part of the body is affected. Referral to a vascular surgeon who specialises in treating vascular disease may be appropriate.

In order to make a diagnosis, a doctor assess signs and symptoms, medical history, and risk factors. Based on this information, a doctor may order further tests to assess the hearth including:

The type of diagnostic procedure depends on which part of the body is affected.

  • Electrocardiogram (ECG or EKG)
  • X-ray
  • Blood tests
  • Echocardiogram
  • Stress echo test of the heart
  • Nuclear heart scan/nuclear stress test
  • Cardiac CT
  • Magnetic resonance angiography (MRA), or
  • Cardiac angiography.

Cause and risk factors

Cardiovascular disease (CVD), or arteriosclerosis, is caused by a build-up of fatty deposits along arterial walls that have been injured in some way. All parts of the body, but in particular the brain, kidney, heart muscles, arms and legs, require a constant supply of oxygenated blood and nutrients to function.

A risk factor is something that that increases a person’s likelihood of developing a medical disease. For CVD the risk factors are linked to inherited characteristics and behaviour that encourage atheromatous plaque to form.

Several risk factors exist for CVD. The more risk factors a person has the more likely he or she will develop arteriosclerosis. Moderate reductions is several risk factors is more effective than a major change in just one risk factor.
In Australia, 90% of the adult population has at least one modifiable risk factor, and 64% of the adult population have three or more modifiable risk factors, which means that CVD is largely preventable.

Adults with any of these issues is at high risk of CVD:

  • Diabetes and age >60 years
  • Diabetes with microalbuminuria
  • Moderate or severe chronic kidney disease
  • A previous diagnosis of familial hypercholesterolaemia
  • Systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg
  • Serum total cholesterol >7.5 mmol/L,
  • Overweight or obese
  • Cigarette smoking
  • Lack of physical exercise
  • Aboriginal or Torres Strait Islander descent.

While age, gender, and ethnicity can’t be changed, a person can reduce risk by choosing to live a healthy and active lifestyle, including eating nutritious food and taking regular exercise.

Pharmacotherapy for lipid lowering should aim towards the following targets while balancing the risks/benefits:

  • TC <4.0 mmol/L
  • HDL-C ≥1.0 mmol/L
  • LDL-C <2.0 mmol/L
  • Non HDL-C <2.5 mmol/L
  • TG <2.0 mmol/L.

Low to moderate alcohol consumption can protect a person against hypertension, ischaemic heart disease, stroke, and gallstones for some subgroups of the population. The cardiovascular health benefit of low to moderate alcohol consumption relates mainly to men 40 years of age or more and post-menopausal women.

For healthy men and women, drinking no more than two standard drinks on any day reduces your risk of harm from alcohol-related disease or injury over a lifetime. MORE>

Comprehensive risk assessment for cardiovascular disease

Comprehensive risk assessment for cardiovascular disease

In adults without known CVD, a comprehensive assessment of cardiovascular risk includes consideration of the following:

Modifiable risk factors

  • Smoking status
  • Blood pressure
  • Serum lipids
  • Waist circumference and Body Mass Index (BMI)
  • Nutrition
  • Physical activity level, and
  • Alcohol intake.

Non-modifiable risk factors

  • Age and gender
  • Family history of premature CVD, and
  • Social history including cultural identity, ethnicity and socioeconomic status.
  • Related conditions

    • Diabetes
    • Chronic Kidney Disease (albuminuria ± urine protein, eGFR)
    • Familial hypercholesterolaemia, and
    • Evidence of atrial fibrillation (history, examination, electrocardiogram).

    Atrial fibrillation, socioeconomic disadvantage, and depression can all make a person more prone to developing CVD.

    How to prevent cardiovascular disease

    How to prevent cardiovascular disease

    Because cardiovascular disease (CVD) is largely preventable, a comprehensive risk assessment by a health professional will enable a person to address modifiable risk factors, to reduce the likelihood of CVD.

    The most important preventative change to prevent CVD is to quit smoking. Eating less saturated fat balanced with more monounsaturated fats is essential. Fresh fruit and vegetables should be eaten at least five times per day. Reduce the amount of salt in the diet. Limit alcohol to two standard drinks each day.

    Take regular exercise to slow the progression of CVD and modify metabolic syndrome. Lose weight by reducing food intake and increasing exercise. Keep blood pressure controlled.

    Manage lipid levels through diet modification. Eat less ‘bad’ LDL cholesterol and more ‘good’ HDL cholesterol. Statin medication may be needed to address hypercholesterolemia.

    People with diabetes need to maintain rigorous control of blood glucose levels to lessen the risk of CVD.

    How to treat cardiovascular disease

    The aim of treating cardiovascular disease is to open the narrowed or blocked arteries that are causing symptoms and delay or prevent further arterial disease.

    Treatment of cardiovascular disease combines changes to lifestyle factors that promote arteriosclerosis and prescribing medicines, in order to lower cholesterol and blood pressure.

    A doctor may recommend prescription medicines that thin the blood or medication that lowers blood pressure, such as ACE inhibitors, angiotensin receptor blockers, calcium channel blockers and thiazide-like diuretics. Statins are used to lower lipid levels. Treatment depends on which part of the body is affected.

    Surgical treatment of specific, significant arterial stenosis may be necessary to restore arterial blood flow. The invasiveness of the procedure varies according to the severity of the problem. For example, coronary artery triple bypass surgery (three arteries affected) is more invasive than balloon dilation of short segment stenosis in a single leg artery.

    The goals of surgery are to improve blood flow, relieve symptoms and improve long-term survival. Surgical treatment of CVD may include:

    • Coronary artery bypass grafting – reduces mortality compared with medical treatment alone, particularly in those with poor left ventricular function.
    • Percutaneous transluminal coronary angioplasty (PTCA)
    • Intracoronary stent – particularly useful for restenosis after PTCA
    • Atherectomy – removal of atheromatous plaque
    • Arterial bypass graft
    • Endoluminal stent

    Nutritional medicine treatment of cardiovascular disease

    How do nutritional medicine specialists assess cardiovascular disease?

    Clinical examination should focus on assessment of both cardiovascular and nutritional status.

    Cardiovascular assessment includes recording of pulse rate, pulse rhythm and blood pressure, peripheral perfusion, arterial murmurs (bruits are indicative of widespread arteriosclerosis) and cardiac pump inadequacy (cardiac failure).

    Nutritional assessment focuses on:

    • Overweight and obesity – increased BMI indicates increased risk of insulin resistance, particularly when the umbilical:hip ratio exceeds 0.9 in males or 0.8 in females.
    • Body composition – a lean weight less than 85% of the minimum weight for height may suggest a protein depletion state secondary to a) inadequate dietary intake, b) impaired digestion and/or c) impaired protein synthesis due to B6/zinc insufficiency and/or low anabolic hormone status.
    • Signs of EFA imbalance and antioxidant insufficiency.
    • Signs suggestive of mild or early nutrient inadequacy, e.g. Vitamin B6, zinc, magnesium, calcium etc., and
    • Signs suggestive of food reactivity, impaired digestion and bowel dysbiosis.

    The goal in treating cardiovascular disease using nutritional medicine is to reduce the damage to artery walls and delay or prevent the development of arterial disease, which can narrow, even occlude, small blood vessels.

    Laboratory Investigations for cardiovascular disease

    Laboratory investigation should be used to provide further data that is crucial to the understanding of a patient’s metabolic requirements.

    Blood lipid analysis:

    • Elevated LDL-cholesterol suggests that saturated and trans fatty acid intake may be excessive and dietary intake of antioxidants, omega-3-FA, phytosterols and fibre inadequate.
    • Reduced HDL-cholesterol suggests impaired hepatic cholesterol clearance that may be associated with insulin resistance, EFA imbalance and/or increased metabolic requirement for niacin and taurine (taurine synthesis is Vitamin B6 dependant).
    • Elevated triglyceride level (VLDL) may be indicative of excessive intake of refined carbohydrates and saturated fats, insulin resistance and/or inadequate intake of omega-3-FA. It may also indicate an increase need for niacin, pantethine, chromium and/or vanadium.
    • Elevated Lp(a) above 0.3 g/L suggests an increased need for ascorbate and niacin.

    Apo E phenotype has a substantial influence on an individual’s response to dietary change in fat and carbohydrate intake. Patients with the Apo E-4 allele respond well to a low fat, high (60%) carbohydrate diet, whereas this type of diet will reduce HDL-cholesterol and increase triglycerides in those people with Apo E-3/2 phenotype. As this later phenotype is more common, Apo E phenotype testing is helpful in determining the basic diet type required.

    Serum fibrinogen, ferritin and high-sensitivity CRP are acute-phase reactants and elevated levels are predictive of increased cardiovascular risk. Raised levels may indicate the presence of a low-grade inflammatory process and/or hepatic fatty infiltration secondary to insulin resistance. If ferritin level is markedly raised, haemochromatosis must be excluded by further testing. Elevated fibrinogen levels suggest an increased need for Vitamin E, ascorbate, quercetin and omega-3-FA.

    Blood/serum urea, creatinine, urate and serum albumin may be useful in evaluating protein status with low U/C ratio and albumin indicative of protein depletion. In the majority of IHD patients, protein depletion may be due to low anabolic hormone production and appropriate hormone testing is advisable (DHEA, androstenedione, free testosterone, progesterone and oestrogen).

    Insulin resistance and hyperinsulinaemia should be excluded by a 3-hour glucose tolerance test, with 30 minute sampling and measurement of both glucose and insulin levels – a peak insulin rise eight-fold above the fasting level or above 100mU/L indicates hyperinsulinaemia and strongly suggests insulin resistance is present. Insulin resistance indicates an increased need for antioxidants, omega-3-FAs and possibly also chromium and vanadium.

    Elevation of glycated-Hb (HbA1c) above 5.5% indicates that protein glycation is increased, which suggests that a) dietary carbo¬hyd¬rate intake should be reduced and b) Vitamin E intake should be increased together with other plant-derived antioxidants.

    Elevated serum homocysteine above 15mmol/L indicates impaired homocysteine metabolism and indicates a greater need for folic acid, Vitamin B6 and betaine. As endothelial damage may occur at lower levels, between 9–15 mmol/L, several practitioners suggest that folate and B6 supplementation should be commenced even with homocysteine levels in this range.