 As Kaylee mentioned, I'm Dr. Naguse, cardiologist at Bayshore and Riverview Particular Heart Group, and we're giving a talk on a general heart attack. And we will touch upon topics such as heart disease itself, what causes it, what the prevalence of disease is, how it is diagnosed, and ways to go about treatment. So, to start off, what is heart disease? Heart disease has many forms, and it can include issues with the valves of the heart, it can include issues involving the muscle itself, and it can also involve abnormalities with the conduction system of the heart. But the most common form of heart disease is coronary artery disease, and that's what we're going to focus our discussion on today. And coronary artery disease is essentially where you develop plaque or blockages in the artery of the heart, and over years this plaque or blockage can progress and deprive the heart of well-needed nutrient rich blood. And so this plaque, the love that I mentioned before, is essentially atherosclerosis. And with atherosclerosis over time, you can have blockages in the arteries of the heart which condemn the strict blood flow, and it can progressively build up to the point where the majority of the artery is blocked off, or it can start up with just a mild plaque, which then can have a part of the wall that breaks off, causes a block, and then causes an acute issue to develop. And usually when we talk about the arteries, a lot of people focus on the arteries of the heart, but there are arteries throughout the body, the vasporature expands the brain to the kidneys, to the lower extremities, etc. So atherosclerosis isn't just something that's specific to the arteries of the heart, it can evolve the hearty throughout the body. And so how do these coronary arteries platform? And it usually starts with the damaged portion of the interlining of the wall, of the artery wall forms, and as coping mechanism, the body will then go ahead and try to repair it, and it'll leave over a scab. And this scab essentially acts as a scaffold for other particles throughout the body, including the bad cholesterol particles, but also any inflammatory markers, well, to then pile up and layer upon each other to eventually form plaque. And that plaque over time can progress and obviously lead to many of the issues that involve heart disease. And here's a schematic detailing the progression of atherosclerosis of that plaque. So as you can see, you have the interlining of the artery of the heart, and if there's damage for whatever reason, that damage then leads to that inner scab forming, and then on top of that scab, you start developing this fatty streak or cholesterol fatty streak robust. And this over time with the addition of additional cholesterol plaque to the layer on top of the original plaque that was there. And on top of that, you cause migration of white blood cells or other inflammatory cells to then further layer upon that. And then eventually, you have progression in which was once minor fatty streaks and then developments were made to your clogged artery. So why do these cholesterol plaques form in the first place? Research looking at the mechanism of atherosclerosis has shown that the initial damage to the artery lining is due to inflammation, is due to a misregulation or imbalance between the inflammatory markers in the body and also the blood cells that lead to clotting formation. And this imbalance can be triggered by high glucose and high insulin levels throughout the blood, high blood pressure, smoking, obesity, inactivity and not sleeping enough by any type of infection because, again, same thing. And it provokes inflammatory response and also exposure to metals and air pollution. Essentially, when you look at all these different risk factors, the underlying theme is blood clotting tendency in a state where you are more likely to have increased inflammatory markers. And that creates the purpose when we go ahead and not only cause that initial damage to allow the scaffold for the catheterous purpose to form, but also its progression. And why is this important? It's important because that initial plaque that was starting to build can over time through years of progression become an issue where it leads to an acute blockage in the arteries throughout the body, namely in the heart in particular. And when that happens, that can lead to cardiovascular disease and an ultimate death. And so, as you can see here, this is a graph detailing the trend of cardiovascular mortality in the U.S. over the past 50 years or so. And for the most part it's been trending down, but what we are starting to see is a rise in both men and women when it comes to cardiovascular disease in the U.S. And with this rise, this has allowed heart disease to remain the leading cause of death for both men and women, not only in the U.S., but throughout the world. And nearly 700,000 Americans die each year. That's about one in four deaths in the U.S. It can be attributed to heart disease. And essentially every 40 seconds there is an American who is developing a heart attack. And it's not just, even within different racial and ethnic groups, it also remains the leading cause of death. So it's something that's very important. And there is a misconception out there that cancer is a leading cause of death, and heart disease numbers are on over two to one base. And when you're looking at a disease process that is a leading cause of death and morbidity and mortality in the U.S., it's very costly as well. And the entire cost of the system in the U.S. is nearly 200 billion dollars each year. And when it comes to coronary artery disease, or CAD, we broadly categorize it into two categories. So first is stable and the other is unstable. And stable CAD is essentially a disease state where you are easily able to provoke symptoms that can be attributed to CAD. And the provocation is on patients can be emotionally stressed. Other patients could be walking outside or doing any activity. And the others, it can just be due to an illness or any other type of illness that can bring about increased inflammation and stress. And the common theme is that it is something that you can anticipate because you know what it's associated with as far as what can provoke it. It's brief in duration and it's something that can go away or at least be abated by breast or medication. Now, unstable CAD is the category where you can develop chest pain without any reason. It's not something that you can anticipate and it's not something that goes away either. So we usually stable CAD. It's something that you can rest or take medications at both and have the symptoms go away. But with unstable coronary artery disease, it happens at rest and it just doesn't go away even after 10, 15, 20 minutes. What are the symptoms of a heart attack? So as you can imagine, chest discomfort and difficulty breathing are going to be the mainstays of symptoms. But there are other symptoms associated with heart attacks as well. And that includes squeezing of the upper body, the upper arms. You can have pain that reneged to the shoulders, to the neck, to the jaw area. You can be associated with you breaking out and it's cold sweat. When you haven't done any activity that will warrant that, unusual or unexplained fatigue, particularly in women, can be associated with nausea and vomiting and also just light head pain. And different symptoms present differently in different patients. But the predominant presentation of both men and women is going to be chest discomfort and difficulty breathing. And it's important to be able to recognize this because time is hard. You know, minutes do matter. And so recognizing what the early warning signs are is going to allow you to act faster to be able to put you in the best position for the best outcome. And so if you have symptoms that are out of the ordinary that you typically don't develop, that can be concerning for a potential heart attack or a heart-related issue, you want to call 911. Okay, don't be a hero and put things off because if it is something emergent, delaying treatment will only delay your care and increase the risk that you develop plastic damage to your heart. And uncertainty is normal. No one feels great about potential false alarms, but it's better to be safe than sorry. Okay, and also do not drive yourself to the hospital because if you are developing an attack, heart attack essentially, it can lead to abnormal rhythms. It can cause you to pass out. And the last thing you want to do is be a danger to yourself and to others by driving yourself. And as all the other diagrams have displayed, with having a heart attack, it essentially is due to an acute blockage and blood flow. And so essentially, your heart muscle is not getting enough nutrient rich blood to be able to use this activity. And so it leads to a cascade of processes that makes things worse than they already are and can lead to abnormal rhythms. It can lead to heart failure. It can lead to a sudden death. And so when you do arrive to the hospital, if you do develop symptoms that are concerning for a potential heart attack, they will do some standard testing. And that testing includes getting blood tests for an enzyme called troponin, which is made in the heart predominantly. And if it is elevated and you have symptoms that are concerning for a potential heart attack, it essentially confirms it. An electrocardiogram is another test that we'll look to see if you have any changes in the conduction process of the heart, which could potentially signal a heart attack. And if there is any concern there for a potential blockage, there are two main ways to go about evaluating it. In the acute setting, if there's a concern for a acute heart attack, an angiogram for catheterization is something that would be pursued. But if everything else comes essentially, comes back normal, and the physician's treating you feel as appropriate to complete the workup in the hospital, then they can either do an inpatient stress test, which essentially is looking for as a functional test, looking for changes in blood flow, or they can choose to evaluate you from an anatomical standpoint. That's with either an angiogram, or they can do a coronary CT scan of the chest where they are taking pictures of the arteries of the heart. But instead of doing it in a invasive way, the angiogram, they will be doing a monobasic luteal cascane. And a lot of the tests that I mentioned before are mainly chiefly meant to evaluate to see if you have any blockages in the main artery of the heart. But as you can see, but there are two other predominant ways that you can have chest pain without having a main blockage in the artery of the heart. And if you look at this diagram, you can see that this is the main artery of the heart, but then it branches out into small little blood vessels that supply the remaining part of the heart muscle itself. And if you have a blockage, then as we just showed you in all the other schematic before, you will have a blockage in the main artery of the heart that we can see on an angiogram. But there are instances where you can have the main artery itself wide open, but then it just clamps down. It spasms essentially. And that's something that would show up as a normal angiogram if you weren't developing spasm at the time of the procedure And then the other issue is if you're not having spasm, you could in the very small arteries or arterials, small branches, you can have decreased blood flow there, which you're not going to be able to detect on an angiogram a lot of times not on a stress test. So you want to have additional testing to be able to evaluate for these non-main artery causes of chest spasm. And special tests that would include an exam called a PET stress test is essentially similar to the nuclear stress test in that it looks for changes in blood flow. But on top of that, it also measures the amount of blood flow in the territories of three or the three main territories of the heart. And so it gives you that added evaluation of the small branches, the really small branches of the arteries of the heart that you otherwise wouldn't be able to do with this traditional testing that's available. And similarly with the cardiac MRI, you can do a stress MRI where you can evaluate to see if there are changes in the blood flow to the small branches of the arteries of the heart, the same way that a PET stress can be. And as far as that spasm that I mentioned before, that would be an angiogram, but where you are trying to provoke the spasm to occur by giving medications that cause the arteries of the heart to become a little bit more irritable. And so we've identified the different ways that heart disease can present and we explain how it can be diagnosed, but let's transition to strategies to mitigate and prevent it in the first place. And in 2022, AHA created what's called a life simple seven. There are simple categories that are lifestyle implementation that patients can undergo to essentially control the risk factors that eventually, when they're not controlled, can lead to coronary artery. And so categories include eating healthy, as you can imagine, maintaining a healthy weight, being active, stopping smoking, do smoke, making sure your blood pressure is normal, not only at the doctor's office, but at home, maintaining a healthy cholesterol level, and making sure your blood sugar is normal. Essentially, all the pro-inflammatory conditions that I mentioned on one of the earlier slides, all of those pro-inflammatory conditions can lead to coronary artery disease. And we essentially with life simple seven, want patients to focus on these lifestyle changes that can put them in the best place to be able to prevent a disease or plaque progression in the future. And within life simple seven, there are risk factors you can control and the risk factors that you cannot control. Now the risk factors that you can control include eating a healthy diet, being active, and stopping smoking. Now, blood pressure controlling weight and controlling diabetes are being at risk for developing pre-diabetes are things that are associated with genetic abnormalities, are associated with metabolic disorders that can be beyond your control, but by and large, for the most part, it can be at least mitigated by lifestyle, if not completely avoided in some patients. As far as the risk factors beyond your control, that includes age. And as we get older, the cholesterol levels do increase, more plaque forms and additional medical conditions can then complicate your care, not only associated with your heart, but also the cardiovascular system throughout the body. Gender, so before men and women tend to have lower levels of cholesterol because of estrogen that's associated with that are higher before menopause, but after menopause, the risk becomes equal to men because of estrogen and also genetics. So having family members who all have high cholesterol, all had heart attacks before the age of 50, that's going to put you at a disadvantage compared to typical patient in the US. And so that's why try to control what you can control, but if you have high risk, then you need to be seen and treated appropriately by a specialist to put you in the best position to be able to do well. Now, within the simple seven, we mentioned lowering cholesterol, so it's briefly touched upon the different types of cholesterol. So total cholesterol is essentially the sum of all the individual components. And if it's elevated, it is associated with the higher risk of developing coronary artery. HDL is high density lipoprotein, one of the larger molecule subsets of total cholesterol. And it has in the past been thought to potentially lower risk, although new information, new data has been published that shows that having a high HDL doesn't necessarily provide patients with reduced risk of coronary artery disease. And some patients can actually signal an increased risk. And that's something that's more research is required to elucidate further. LDL are the bad cholesterol, the low density lipoprotein of the small molecules. And they are the cholesterol components that stick to the wall, essentially. And so having a high level of that can raise your cardiovascular risk. And BLDL, which is not something that typically shows up on a different panel, that goes along the same lines of the LDL that is the higher risk. Because this is a smaller molecule that can potentially go through the wall and the problem is up there. As far as the measurements of cholesterol, the desired number for total cholesterol is less than 200. For HDL, one to be higher than 45 for men and higher than 55 for women. As far as LDL or the bad cholesterol, you want that to be less than 100. But less than 70 or even 55 in certain patients who already had cardiovascular events. That's just something you have to individualize with your doctor. And so here is really, it depends on your current comorbidity of cardiovascular conditions as far as which particular targets are meant for you. And now going back to the simple seven, what are the strategies to eat healthy? We mentioned that is one of the main things and you want to choose lean meats and poultry. Okay, when it comes to cooking, you want to remove visible fat, you want to grill, bake, and boil your meats and poultry. Select non-fat or low-fat dairy products. And skim, low-fat or 1% milk is going to be good for you. Low-fat or non-fat yoghurt achieves. Don't rinse the solids and veggies into much dressing because that essentially offsets the immune in front of you. And then use spices, if you want to add some flavor instead of using butter and salt, use spices instead. With cholesterol in particular, you want to limit total cholesterol intake as well as intake of saturated fats. And so for most people, increased dietary cholesterol, saturated fat, sugar, excess calories, all will raise limited blood amounts. And so in general, you want to limit your total cholesterol intake from the diet to about 300 milligrams per day. So that means minimizing egg yolk, butter, cheese, whole milk, red meats, fatty cuts of meats, etc. And also limiting fats. And that in particular are going to be saturated fats to about 10% of your total intake. And you can do that easily by limiting the amount of animal fats in your diet or red meat, etc. Now, one particular goal when it comes to fat is limiting trans fat. So essentially trans fat is a process where you hydrogenate vegetable oil. And it's meant to increase the shelf life of the particular fat or any particular food that you're cooking. And when it comes to processing foods. But the issue is that this is how this hydrogenated oil can essentially become solid at really temperature. And you can think about it in your blood, it makes you more likely to know a plaque above the arteries throughout the body. And so anything which can think of that, that unfortunately tastes good, baked goods, cookies, crackers, snack cakes, fried foods, all of those have undergone the hydrogenation process. And that increases your risk of having untoward effects from the cardiovascular standpoint due to diet. And it increases your LDL, lowers the HDL and does increase your triglyceride. And of note, just keep an eye on food label. So for food label says that their food is trans fat free, that just means that the food contains less than 0.5 grams of trans fat per serving. So if you have a lot of servings of that particular food that that quote unquote is trans fat free, it can add up something that you want to keep in mind. So anything that's baked when it comes to cookies, goods, crackers, snacks, fried foods, it's going to have trans fat. So the type of fats that you want to focus on consuming in your diet are going to be healthy fats. And so that's going to be the polyunsaturated and the monounsaturated fats. And benefits of polyunsaturated fats are going to be that it lowers your LDL with about cholesterol. And examples of that would be corn, sunflower, soybean, sesame oils, and nuts and seeds as well. For monounsaturated fats, also lowers your LDL. And that would include olive oil, nuts, and avocados. And research is still, the verdict is still out regarding medium chain fatty acids as far as whether or not it comes to coconut and palm kernel oil and whether or not it's helpful for the cardiovascular standpoint. And when it comes to the polyunsaturated fats, use a good source of that would essentially be the fish. Omega three and omega six fatty acids are these polyunsaturated fats that you hear about. So any fats that are omega three, omega six, these are the examples of following the category of polyunsaturated fats. And omega threes in particular are helpful because they have components that are known to lower the treblous red levels in your body. And they also have an anti-inflammatory effect as well. And so you're looking for a great source without any fish. So when it comes to salmon, mackerel, herring, those are all great sources of polyunsaturated fats, particularly omega three fatty acids. Now following the same trends of making your diet healthier, you can do that very easily by minimizing sugars. Anything with simple, that are simple sugars or simple carbohydrates are going to be stored in excess as fat. Okay, so soda has large amounts of sugar that can enter the bloodstream very quickly. There's no boundary when it comes to having any side foods that can help buffer that increase stream of sugar content. There's no fiber associated with it. And so anything like candy, fruit, fruits, even dried fruits, anything that will cause a spike in the blood glucose level of your body, that can over time lead to fat build up as a result. And the same thing with alcohol. Alcohol also has large amounts of sugar, depending on the type of you get. And it can increase your triglyceride levels and cause weight gain as well. If you don't use them out of range. Fiber is key. So both soluble and non soluble fiber are helpful. And you can find fiber in your diet when it comes to vegetables as well as whole fruits. And the soluble fiber, the beneficial aspect of that is that it lowers the total as far as and the LDL or fatty cholesterol. And the insoluble fiber benefits is that it essentially bolts your gut and decreases absorption or slows the absorption of a lot of these simple carbohydrates that you can find in your regular diet. And so starchy carbs, when you're selecting you want to choose whole grain of a process that you'll find or anything instant essentially. Because that will help slow down the digestive process, decrease the amount that you're absorbing and ultimately prevent excess fuel storage by decreasing the amount that gets absorbed in you. Whole old speeds, lentils, peas are all too high in soluble fiber. If you want to be able to use the sort of act as a buffer and offset a lot of the different dietary intake that is not as helpful in your diet. And then exercise. That's also part of the healthy seven or the simple seven. And any activity is better than not. It's not something that you want to approach or think about from an all or nothing standpoint, because that can be daunting for a lot of patients who haven't been as active as they like. They think, you know, you have to go to the gym and work out 60 minutes a day every single day or else you're not going to get any benefit. That is not true. Even doing five minutes of light activity is infinitely better than no activity at all. Okay. And start off in small increments. It can be five, 10, 15 minutes a day. And then once you get accustomed to it, once it becomes a lifestyle change for you where you don't think about it, gradually increase. Okay. Instead of doing 10 to 15, 15 to 20, and eventually you'll be doing 60 minutes, not even think about it. Okay. And use an activity that you enjoy. So if you have a spouse, a partner, a friend, you can walk with, you have a pet, if you have children, you can ride a bike with, you can swim with. As long as you're doing something where time can go by and you can be doing activity and it being a part of your lifestyle and not a fat or an extra or a diet essentially. And also not just aerobic activity, you want to do weight-bearing exercises as well. And it doesn't mean that you have to be lifting 300 pounds at the gym. All it means is you can even just lift in your body weight. You could do push-ups if you could spot your body weight. That'll be enough to really stimulate the muscles in the body and give you exponentially better cardiovascular increase profile compared to just doing aerobic activity alone. It's great for your bones and all the organ systems in your body as far as increasing cardiovascular efficiency. Then losing weight. And the same thing with exercise, it doesn't have to be something where you do 60 pounds of weight. A little bit of weight loss goes a long way. Just losing five to 10 pounds can include your metabolic health and can reduce blood pressure. It can put you on the diabetes and pre-diabetes category. But essentially having excess fat, especially if it's stored around the torso increases the inflammation in the body. And that pro-inflammatory state is what essentially puts the weight towards developing potential plaque. Whether it's a balance between the anti-inflammatory components in your body and as far as pro-inflammatory components. And you don't want the weight to be swayed towards a pro-inflammatory state. And so being overweight, having high blood pressure, having diabetes, tips the scale in the direction of being pro-inflammatory and making you more likely to develop plaque throughout the body. Now we touched around the different lifestyle modifications that can be implemented. But there are some times it's not enough, but not in itself, especially before the cardiovascular events. In which case, you would need to be on a cholesterol level. Now who are particular patients who would benefit from being on a cholesterol level? So as I alluded to before, if you've already had a cardiovascular event, whether that be a heart attack or a stroke, or if you're cholesterol, even in spite all of the attempts you've made to limit, to mitigate or improve your lifestyle, bad cholesterol, the LDL remaining greater than 190 people who are diabetic between the age of 40 and 75 who have LDL greater than 70 have been shown to have improvements from the cardiovascular standpoint over time by being on a statin. And also those who have an increased 10-year cardiovascular risk profile. So these are the subsets of patients who, despite maintaining lifestyle modifications or improvements, would still benefit from a cholesterol drug. Now the two most common forms of cholesterol-mediating drugs are going to be statins and then a lesser-known drug called PCSK9 inhibitors. And statins work primarily by lowering the LDL and bad cholesterol. It also lowers triglycerides and some cases can raise the HDL. Now the PCSK9 inhibitors is an alternative for statin for patients who are high risk and cannot tolerate a statin. Or if they already are on a statin yet have not reached their target levels. And so you add this in addition. And the way it works is that it works the level of the liver and it blocks a certain protein to make it easier to remove the bad cholesterol of the old particles easier and easier. So there are other cholesterol-lowering medications that are listed here but these are less common. And so the main ones that you will most likely see if you have cardiovascular disease will be statins and PCSK9 inhibitors. Now when it comes to which medications you use it really is up to you and the physician's treat that you're taking care of you as far as discussing the pros and cons of medication itself and what are the long-term potential side effects of the medication that we can describe to you. And for statins two common questions that come up or side effects that arise in patients are going to be muscle aches. And on the very, very rare occasion we're talking one in 10,000 having liver abnormalities to the point where it leads to a long-term liver disease. And I know there have been questions that have been brought up as far as dementia risk with statins over a long period of time and the data from that aspect has not gone true as of yet. And there's nothing that definitively links statins to dementia or long-term neurovascular damage. So to summarize to take home the messages are essentially that cardiovascular disease although we've been doing much better compared to 50 years ago it is back on the rise. And this is important because heart disease is the number one killer for men and women not only in the US but worldwide. So it is important to be able to identify all the signs of cardiovascular disease that I mentioned before. And there are risk factors that we cannot control but of the things that we can control. We really want to focus on the simple seven because focusing on the simple seven has been shown time and time again to reduce or in some cases eliminate the risk of cardiovascular and prevention begins with you. So take one day each one step at a time. You don't have to go from zero to 60. If you're not active at all just do a little bit. Five minutes of walking you take your dog out go to the mail you can grab your mail instead of taking the stair instead of taking the elevator you can take the stairs. Any little bit of increased physical activity has exponential benefits from the cardiovascular system. And if you smoke you don't have to necessarily quit the next day just dropping the amount of cigarettes. So the idea here is to gradually eventually be able to optimize your cardiovascular lifestyle. But something is better than nothing. I was one of stress that because otherwise it becomes too daunting and you don't start then that's time that's wasted. Okay. And then it could have been some strides that we made in the intro.