Coronary Artery Disease

Overview: Coronary Artery Disease

• Despite the many advances, cardiovascular disease is responsible for more than 2000 deaths every day in the United States.

• Investigators estimate that 1 of 3 US residents to des tined to die of cardiovascular cause. Clearly, we have work to do.

• The causes of cardiovascular disease are diverse hat. in large part, are related to lifestyle and environment. Rates of stress. obesity, and diabetics continue to soar.

• The Centers for Disease Control and Prevention estimates that I out of 3 children born in the year 2000 will go on to develop diabetes during his or her lifetime.

• Consequently, for the first time in history, it is possible that children will have a shorter life expectancy than their parents.

• An integrative approach acknowledges the great value and potentially lifesaving benefits of modern pharmacology and procedures while at the same time recognizing limitations of these approaches when they are used isolation.

• An integrative approach is ideally suited for prevention and treatment of coronary disease became it address many of the root casus, especially those influenced by lifestyle.

• The goal of this chapter is to gain perspective into the power of a border spectrum of therapies beyond those that typically constitute convectional cardiovascular care.

Important points to consider

• A mild coronary lesion can be considered a "fault Iine" that, in a quiescent phase, appears quite passive and harmless. However, similar to any fault Iine, these seemingly harmless plaques may erupt at any moment and cause a potentially lethal cardiac event

• The results of the Lyon Mediterranean diet study underlie my personal recommendation for daily consumption of five servings of vegetables per day and two servings of fruits.

• The manner in which grains are prepared also has important health implications. Boiled whole graining, oat, quinoa, barley) are typically a heathier choice than bread made from the flour of whole grains.

• The success of nutritional interventions is greatly enhanced when the patient perceives that nutrition is a priority of the health care practitioner. At every clinical encounter with a patient, I recommend making a point to inquire about the number of servings of vegetables and fruit consumed every day, the e type of grains, the and the servings of nuts consumed on a weekly basis. Emphasizing the importance of diet during each visit allows obstacles to be identified and progress celebrated.

• Alternatives to the use of prescription statins can play an important role when prescription statins cannot be tolerated because of adverse reactions and in patients philosophically opposed to the use of prescription statins.

• Water-soluble statins such as rosuvastatin and pravastatin may cause fewer myalgias in some patients. Fluvastatin may also cause fewer muscle symptoms because of its unique metabolism.

• Strategies to reduce niacin flush: Take niacin with dinner, or after dinner with apple sauce. Take aspirin or a nonsteroidal anti-inflammatory drug with niacin. Avoid "no flush" niacin because it is usually ineffective.

• Fish oil dosing: Dosage should specify eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA) content, rather than total fish oil. Advise patients to check the nutrition label of products

  to confirm the EPA and DHA content. The typical dosage for prevention is approximately 1000 mg combined EPA and DHA. The typical dosage for treatment of hypertriglyceridemia is 1000 to 4000 mg combined EPA and DHA.

• Given the high safety margin and evidence of improvement in some patients, many clinicians find it reasonable to attempt a trial of Coenzyme Q10, 100 mg/day, in patients with a history of suspected statin-related muscle symptoms.

• Folic acid supplementation has not proven useful for prevention of cardiovascular events, but foods rich in folate, especially dark green leafy vegetables, are associated with significant benefit.

• The evidence to date does not support the use of the synthetic alpha-tocopherol isomer of vitamin E for prevention of cardiac disease. Additional research is needed to evaluate the effect of mixed tocopherols and tocotrienols on cardiovascular events.

• A wide range of therapies is available to assist patients with cardiac disease to manage their stress and anxiety more effectively. In addition to the conventional treatments with psychoactive medication or referral for cognitive-behavioral therapy, the palette available to the integrative practitioner includes meditation, yoga, biofeedback, healing touch, Reiki, massage, and acupuncture.

Prevention Prescription

• Nutrition (Mediterranean diet)

• Weight management

• Smoking cessation if needed

• Exercise (aerobics and resistance training)

• Tools for management of stress and anxiety

• Lipid management

Integrative therapeutics review

Nutrition

• Mediterranean-style diet

• Five servings vegetables/day

• Two servings fruit/day

• Whole grains, elimination of refined carbohydrates

• Two servings fish/week

• Reduction of red meat consumption

• Frequent nut consumption.

Exercise

• 30 minutes/day walking or more intensive aerobics for a minimum of 30 minutes three times/week

• Resistance training at least 30 minutes/week

Smoking Cessation

Lipid Management

• For low-density lipoprotein cholesterol

• Fiber supplements (e.g., psyllium, 10 g/day)

• Stanols and sterols: 1.8 g/day

• Niacin: 500 to 2000 mg/day

• Prescription statins: dose varies

• Red yeast rice: 1200 to 2400 mg/day divided

  twice daily

For high-density lipoprotein cholesterol

• Exercise

• Weight loss

• Reduced intake of carbohydrates

• Niacin: 500 to 2000 mg/day

For triglycerides:

• Exercise

• Weight loss

• Reduced intake of carbohydrates

• Fish oil: 1000 to 4000 mg eicosapentaenoic acid and docosahexaenoic acid per day

• Fibrates: fenofibrate, 45 to 150 mg/day

To reduce statin-related myalgias

• Consider coenzyme Q10: 100 mg/day

• Replete vitamin D deficiency: goal is level greater than 30 ng/ml.

Stress and Anxiety Reduction

• Breathing exercises

• Biofeedback

• Meditation

• Yoga

• Acupuncture

• Cognitive-behavioral therapy

• Anxiolytics

Antianginal Therapy

• Acetylsalicylic acid: 81 to 325 mg daily

• Beta blockers (e.g., metoprolol succinate: usual

• dose 50 to 200 mg daily)

• Nitrates (e.g., isosorbide mononitrate: usual dose 30 to 120 mg daily)

• Calcium channel blockers (e.g.. amlodipine: 2.5 to 10 mg daily)

• Angioplasty and stents (for angina) Enhanced external counterpulsation

Key Web Sources

• http://my.americanheart.org/professional/StatementsGuidelines/Statements-Guidelines_UCM_316885_SubHomePage.jsp

• www.naturaldatabase.com.

• http://www.consumerlab.com.