Risk stratification and risk factor modification.pptx

risk stratification and risk factor in cardiovascular disease

1. RISK STRATIFICATION AND RISK FACTOR MODIFICATION By Dr.V enkata r amana M pt ( Cardiovascular and Pulmonary Sciences )

2. CONTENTS Definition - Risk Stratification Importance and procedure of risk stratification Risk stratification criteria Risk factors of heart disease Impact of risk factors on heart disease Classification of risk factors Non - Modifiable risk factors Modifiable risk factors

3. WHAT IS RISK STRATIFICATION? R isk stratification is process of assigning a risk status to patients (low, moderate or high), & then using this information to either direct care and improve overall health outcomes. Reference: National Association of Community Health Centres.

4. IMPORTANCE OF RISK STRATIFICATION T o prescribe the appropriate exercise intensity for each patient, it is first necessary to know the patient’s level of risk, and for this purpose cardiac risk stratification becomes critical. Anne Kastelianne et al; Braz Jour. Cardiovasc Surg , 2014.

5. PROCEDURE OF RISK STRATIFICATION

6. RISK STRATIFICATION CRITERIA FOR CARDIAC PATIENTS LOW RISK U ncomplicated Myocardial Infarction (MI) P ost Coronary Artery Bypass Grafting (CABG) or Angioplasty (PTCA) P ost Atherectomy F unctional capacity of ≥ 6 MET s (metab olic equivalents) N o resting or exercise induced myocardial ischemia manifested as angina N o resting or exercise-induced complex arrythmias N o significant Left Ventricular Dysfunction (LVD) – Ejection Fraction (EF) ≥ 50%

7. MODERATE RISK F unctional capacity of <5-6 METS o r 3 or more weeks after clinical event M oderately depressed LVD - Ejection fraction (EF) – 40-50% F ailure to comply with exercise prescription E xercise induced ST-segment depression of 1-2mm or reversible ischemia

8. HIGH RISK S everely depressed LVD (EF<40%) C omplex ventricular arrythmias at rest or starting to increase with exercise D ecrease in systolic blood pressure (SBP) of >15mm Hg during exercise or failure to rise consistent with exercise workloads MI complicated by congestive heart failure (CHF), cardiogenic shock and/or complex-ventricular arrythmias P atients with severe Coronary artery disease (CAD) and marked >2mm exercise - induced ST - segment depression S urvivor of cardiac arrest Recent pulmonary embolism or deep vein thrombosis — Williams & W`ilkins et al; 1995.American College of Sports Medicine: Guidelines for Exercise Testing, — Applied Physiol , Department of health 2011.

9. RISK FACTORS OF HEART DISEASE

10. CLASSIFICATION OF RISK FACTORS

11. NON-MODIFIABLE RISK FACTORS

12. collagen and calcium deposits in arterial wall Decreased Elastin Arterial stiffness - Aortic and coronary (Arteriosclerosis) Systolic BP (Isolated systolic hypertension) Decreased Diastolic BP Force of LV contraction LV hypertrophy Angiotensin – II Hormone, Aldosterone Cholesterol plaques (coronary atherosclerosis) Limits O2 supply to aging heart by blocking blood flow Promotes thickening of arterial walls – further impedes Vasomotion CLINICAL ASPECTS OF AGING HEART

13. Mediators – Angiotensin – II and Aldosterone further increase BP

14. EFFECT OF EXERCISE ON AGING HEART A Recent study demonstrated with following below FITT principle in sedentary middle-age group slows the aging factor of heart, improving longevity. Frequency : 4-5 days per week Intensity : low-moderate intensity Time: 30 minutes Type: Aerobic – cycling, treadmill and cross trainer Erin J. Howden et al; Journal of Circulation – AHA; 2018

15. GENDER The proportion of deaths and disability from heart disease was significantly higher in men than in women. A joint Project from Indian Council of Medical Research (ICMR), Public Health Foundation of India (PHFI), and Institute for Health Metrics and Evaluation

16. GENETIC PREDISPOSITION

17. MODIFIABLE RISK FACTORS

18. HYPERTENSION & ITS EFFECTS ON CVS Blood pressure (Chronic Hypertension)

19. MODIFICATION OF HYPERTENSION BY EXERCISE

20. LIPID PROFILE

21. MODIFICATION OF LIPID PROFILE

22. CARDIOVASCULAR EFFECTS OF TOBACCO AND WATER PIPE SMOKING (HOOKAH) SHORT TERM EFFECTS

23. Long term effects: Elevates arterial stiffness in sedentary individuals Water-pipe smokers have greater odds of angiographically diagnosed Coronary artery stenosis, Ischemic Heart disease. Initiation & progression of atherosclerotic plaques Greater Susceptibility of ST-segment Elevation Myocardial Infarction (STEMI) — Scientific Statement from American Heart Association, 2019.

24. MODIFICATION OF SMOKING

25. EFFECT OF EXERCISE ON TOBACCO WITHDRAWAL & CRAVINGS

26. Recent Studies have shown that nicotine stimulates brain by increasing beta-endorphin levels. Relieves pain and stress levels – nicotine dependence. Exercise causes similar release of these hormones and provide alternate reinforcer to smoking. Ussher et al, Exercise Intervention for Smoking Cessation, Cochrane Reviews, 2014

27. SEDENTARY LIFESTYLE

28. A Distinct class of behaviours (Sitting, watching tv, driving) characterized by little physical movement and low energy expenditure (≤ 1.5 METS)

29. EFFECT OF OBESITY ON CVS

30. Weight reduction Increased Physical activity by exercise Dietary restriction – less calorie foods – healthy diet Negative energy balance – Expend more calories than consuming from food – energy deficit Energy deficit met from adipose tissue – fat storage – weight loss Reduction in CO, reduction in SNS activity - reduction in blood pressure MODIFICATION OF OBESITY

31. Factors of Diabetes II Increased Blood Glucose – Blood Volume – blood pressure Increased Insulin Resistance Exercise – Increased Demand – Increased Stimulation of Glucose UpTake Elimination of blood glucose by sweat Control of Diabetes