Transcript 2012-arantx

BLOOD PRESSURE AND
CHOLESTEROL
THE BEGINNING OF YOUR END!
Billy S. Arant, Jr., M.D., FASH
Professor Emeritus, UTCOM-Chattanooga
ASH Specialist in Clinical Hypertension
Diplomate, American Board of Clinical Lipidology
VASCULAR DISEASE—JUST THE FACTS
• 70 % of US deaths due to heart attack,
stroke, heart failure and aneurysm--all
vascular problems!
• ALL diabetics develop vascular disease and
most are fat!
• Vascular disease causes serious long-term
disability!
• Annual expenditures for vascular diseases
of all causes exceed total costs of war in Iraq
RUN FROM THE
CURE!
ARE YOU AT RISK?
BEYOND YOUR CONTROL
•
•
•
•
•
•
•
Age
Gender
Race
Heredity
Prior cardiovascular event
[Vascular abnormality]
[Congenital heart defect]
STROKEBELT
WD Hall, AHA 1999
WITHIN YOUR CONTROL
•
•
•
•
•
•
•
Blood pressure
Lipids
Weight [waist]
Blood sugar
Tobacco
Drugs
Hormones
ELEVATED BLOOD PRESSURE
earliest indication of trouble
•
•
•
•
Normal is below 120/80 mmHg at any age
BP >115/75 is earliest indicator of vascular risk
Systolic (top #) most reliable indicator of risk
Every drug that lowers BP may not reduce but
actually increase risk
• Drugs that raise BP increase risk
• Lowering BP to normal with proven drugs
reduces risk
Impact of High-Normal Blood Pressure
on the Risk of Cardiovascular Disease
Women
Hi-Normal Hi-Normal
Hazar
d
Ratio
2.
5
(n = 1794)
130 – 139/ 85 – 89
Normal
Optimal
Time, years
*P < 0.001 for trend across categories.
Vasan RS, et al. N Engl J Med. 2001;345:1291–1297.
Normal*
1.
(n = 2185)
120 – 129/ 80 – 84 5
Optimal
(n = 2880)
< 120/80
1.
0
NORMAL BP <120/80 mmHg
Robinson & Brucer: Arch Int Med 1939
NEXT, THE FAT IN YOUR
ARTERIES
or
Atherosclerosis
Cholesterol buildup
Hardening of the arteries
THE GENESIS OF
ATHEROSCLEROSIS
unrelated to age
LIPID PROFILE
• Total cholesterol (good + bad)
– HDL (good) retrieves LDL (bad)
– LDL (bad) sticks to lining of artery
– Non-HDL (LDL, VLDL, IDL) Total – HDL
– Key to most vascular diseases (MI, stroke, PVD, ED)
• Triglycerides (animal and plant fat, glucose)
– Insulin makes TG from excess glucose in blood
– Used to make LDL and HDL in liver
– Risks death from pancreatitis or NASH (fatty liver)
CHOLESTEROL
normal values
•
•
•
•
Triglycerides
Total cholesterol
HDL-C [good}
LDL-C [bad]
• Non-HDL-C [TC – HDL]
• Particle size
• Pattern A or B
<150 mg/dl
<200 mg/dl
>50 F; >40 M
<100 mg/dl [no risk]
< 80 mg/dl [DM]
< 70 mg/dl [CAD]
<130 mg/dl
large fluffy
A
WHAT ARE THE SOURCES?
• All human cells make cholesterol
– Cell membrane functions
– Used to make bile
– Steroid hormones
• Dietary sources
– Eggs
– Animal fat (meat, skin, milk, organs, lard)
– Plant fat (saturated: palm, coconut, oleo)
• Bile salts – recycled
• Sugar changed to triglycerides for storage
CORONARY ARTERY
KOREA
LAD 22yo White ♂
LAD 22yo Japanese♂
Enos et al: JAMA 158:912, 1955
CORONARY ARTERIES
VIETNAM
22 yo ♂ 50% RCA
3+ gross disease
McNamara et al: JAMA 216:1185, 1971
CORONARY ARTERY DISEASE IN CHILDREN
•
•
•
•
10-14 yr olds
Traumatic death
>85 pct body weight
70% significant CAD w/ calcifications
Bogalusa 2002
STORMIE JONES
Homozygous FH
1985 NOBEL LAUREATES
LDL Receptor
Michael Brown,
Joseph Goldstein, M.D.
ATP III 2001, 2004
Scott Grundy, M.D., Ph.D.
TREATMENT OUTCOMES
EVIDENCED-BASED
adults
JUPITER TRIAL 2008
• “Low risk” subjects
– LDL-C 100-130 mg/dl
– Elevated CRP [C-reactive protein]
•
•
•
•
Rosouvastatin 20 mg daily v. placebo
Reduced heart attack and strokes by 47%
Drug company excluded from study
Confirmed HPS 2003 with simvistatin
LDL-C: HOW LOW?
NOW FOR THE FAT
AROUND YOUR WAIST!
VISCERAL OBESITY
CT scans from men matched for
BMI and total body fat
Visceral obesity
Fat mass: 19.8 kg VFA: 155 cm2
Subcutaneous obesity
Fat mass: 19.8 kg VFA: 96 cm2
Visceral obesity
drives CV risk
progression independent
of BMI
Després J-P. Eur Heart J Suppl. 2006;8(suppl B):B4-12.
HEALTH CONSEQUENCES OF OBESITY
not just a variation of normal anymore
•
•
•
•
•
•
•
•
•
•
•
Hypertension
Cholesterol
Insulin resistance
Diabetes mellitus
Sleep apnea
Coronary artery disease
Stroke
Erectile Dysfunction
Gallbladder disease
Osteoarthritis [joint replacement]
Some cancers (uterine, breast, colon,
prostate)
WHO HAS A WEIGHT PROBLEM ?
• Body mass index (BMI) for adults
– > 25 kg/m² overweight
– > 30 kg/m² obese
– > 35 kg/m² morbidly obese
• > 30 lbs over ideal body weight for height
• Waist measurement
– women >33” overweight; >35” obese
– men
<37” overweight; >40” obese
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
YOUR WEIGHT
greatest morbid factor for health
• >60% of children and adults are overweight
• 1:3 children and adults are obese
• Costs >$100 billion in healthcare and lost
productivity (50% paid by MCD + MC)
• Obese employee costs ~$8,000 extra/yr in
missed days of work and healthcare
• Life expectancy of obese 5 year old is 47 yrs
LOVE IS BLIND—NOT !
• Survey of parents whose 6-11 yo child was
obese
– 43%
– 37%
– 13%
– 7%
“about the right weight”
“slightly overweight”
“very overweight”
“slightly underweight”
HOW DID WE GET SO
FAT SO FAST?
ENERGY BALANCE
• NRG in = expended = no ▲body wt
• 3600 unanswered calories = +1 lb fat
• New fat comes mostly from sugar not fat!
UNANSWERED CALORIES
• 12 oz soda = run 1.25 miles
• 12 oz soda daily for 10 years
– 36 g corn syrup = 144 kcal
– 144 kcal x 365 days = 52,560 kcal
– 3600 unanswered kcal = + 1 lb fat
– 14.6 lb fat/yr or 146 lb/10 years!
BURNING EXTRA CALORIES
• BigMac, large fries, 32 oz drink
Sedentary 12 yo must jog 3 hours to avoid
weight gain if already/will ingest daily
requirement for growth of 2200 kcal
UNANSWERED CALORIES
10 yo sedentary ♂
•
•
•
•
•
•
Requirements ~ 2270 kcal/day
Pop Tart + OJ 8 oz
320
Pizza 2 sl + 24 oz DP + 2 Oreos
1042
Chips 5 oz + 24 oz DP
1050
Big Mac, Fries, 32 oz Coke
1410
Popcorn + 32 oz Coke
540
Total kcal in 4362
required - 2270
kcal net [1400 kcal from soda] +2192
Dilemma: Jog 4 hr 42 min or gain 9 oz fat
FAT KIDS become FAT ADULTS !
Fat Adults Spend Lots Of Money
[theirs and ours] on food, health
care, disability and death
$1 Trillion annually
CAN YOU DO THIS?
RISKS OF OBESITY
compounding risk
Obesity
BP
DM
CVD
Lipid
VASCULAR EVENT
2x
tobacco
OSA
2x
↓O₂
↑BP
HT v. BMI in Blacks
RS Cooper, AHA 1999
PREVALENCE OF HYPERTENSION IN
ADOLESCENTS
Sorof et al Am J Hypertension 16:217A, 2003
SUGAR
• Carbohydrates
– Fruits
– Vegetables
– Grains
• Food additives
– Cane or beet
– High fructose corn syrup
GLUCOSE METABOLISM/DISPOSAL
• Dietary intake
• Insulin effect
– Immediate use
– Storage
– Triglycerides
BLOOD SUGAR
pre-diabetes and diabetes
• after 12 hr fast [water only]
– normal
– pre-diabetes
– diabetes
<100 mg/dl
100-125 mg/dl
>125 mg/dl
• 2 hr post-prandial or GTT
– normal
– pre-diabetes
– diabetes
<140 mg/dl
140-199 mg/dl
>200 mg/dl
• Hemoglobin A1C >6.5
Who has insulin resistance?
100
90
88
80
%
Patients
60
50
50
45
50
40
40
20
0
DM21
↓HDL
+ ↑TG2
HTN3
Stroke4
1Haffner
CHD5
Refer to
cardiol.6
Age
40 to 747
et al. Diabetes. 1997. 2McLaughlin et al. Am J Cardiol. 2005.
et al. N Engl J Med. 1996. 4NIH. www.clinicaltrials.gov.
5Lankisch et al. Clin Res Cardiol. 2006.
6Savage et al. Am Heart J. 2005. 7www.diabetes.niddk.nih.gov/.
3Reaven
“Ticking clock” hypothesis: Glucose
abnormalities increase CV risk
Nurses’ Health Study, N = 117,629 women, aged 30–55 years; follow-up 20
years (1976–1996)
6
5.0
Relative risk 5
of MI or
stroke*
4
3.7
2.8
3
2
1
1.0
No diabetes
Before
diabetes
diagnosis
After
diabetes
diagnosis
Diabetes at
baseline
0
*Adjusted
n = 1508 diabetes at baseline
n = 5894 new-onset diabetes
Hu FB et al. Diabetes Care. 2002;25:1129-34.
US Diabetes Trends - CDC
1994
US Diabetes Trends - CDC
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
US Diabetes Trends - CDC
2009
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who
Had Diagnosed Diabetes
Obesity
kg/m2)
Obesity (BMI ≥30
1994
No Data
2000
<14.0%
14.0-17.9%
18.0-21.9%
2009
22.0-25.9%
>26.0%
Diabetes
Diabetes
1994
No Data
2000
<4.5%
4.5-5.9%
6.0-7.4%
2009
7.5-8.9%
>9.0%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
90% of patients with newly diagnosed diabetes
are overweight or obese
National Health Interview Survey, 2003; N ≈ 31,000 aged 18 to 79 years
100
Diabetes patients
with BMI ≥25
kg/m2
(%)
90%
80
60
Obese
(BMI ≥30)
60
40
20
30
Overweight
(BMI 25 to <30)
0
Geiss LS et al. Am J Prev Med. 2006;30:371-7.
Estimated lifetime risk of developing diabetes for
individuals born in the United States in 2000
60
Percent
50
Total
Non-Hispanic Black
Non-Hispanic White
Hispanic
40
30
20
10
0
Men
Narayan et al, JAMA, 2003
Women
DIABETES MELLITUS
risk equivalent to previous heart attack
• Two types
– DM1 insulin deficient, normal weight [10%]
– DM2 insulin resistant, overweight [90%]
•
•
•
•
Juvenile v. adult type
2:3 people with CAD have DM, half undiagnosed
DM is risk equivalent to previous heart attack
May take 5-10 yrs of pre-diabetes before diabetes
recognized
• Diabetes costs $132 billion in medical expenses
and lost productivity (twice that of non-diabetics)
COMPLICATIONS OF DIABETES
diabetics die from vascular disease
• Macrovascular disease
– coronary artery disease [heart]
– cerebrovascular disease [stroke]
– peripheral vascular disease [legs]
• amputations
• Microvascular disease
– blindness [eyes]
– renal failure [kidneys]
– neuropathy [sensation]
– erectile dysfunction
DIABETES MELLITUS 2
•
•
•
•
Complication of obesity almost always [90%]
Preventable if normal waist maintained
Possible to “cure” by losing weight/waist
Leading cause of
– kidney failure >50% on dialysis
– Blindness
– Associated with 2/3 of heart attacks
• Economic disaster [$1 trillion annually]
OBSTRUCTIVE SLEEP APNEA
• Suspect when
– Snoring
– Stops breathing
– Tired when awake despite 8 hours of “sleep”
– Yawns while awake
– Restless sleep – bedding disaray
– Obese
– Hypertension – systemic and pulmonary
TOBACCO
nicotine toxic to vascular lining
INTERHEART: Any smoking increases
CV risk
N = 27,098 from 52 countries
8
4
Odds
ratio for
first MI*
2
1
-0.75
Never
1–2
3–4
5–6
7–8
9–10
11–12 13–14 15–16 17–18
19–20
≥21
Cigarettes smoked (n/day)
*vs never smoked
Teo KK et al. Lancet. 2006;368:647-58.
DRUGS
DRUGS CAN INCREASE RISK
• Recreational drug use
– Amphetamines, cocaine
• Decongestants increase BP
– Pseudophedrine
• Hormones: estrogen, testosterone
• NSAID’s [ibuprofen,naproxen,celebrex]
–
–
–
–
15,000 deaths/yr to GI bleeding
Raise BP
Reduces kidney function
Reverses aspirin benefit to prevent blood clots
PROSTAGLANDINS [inhibition]
• Mediators of inflammation [reduces pain/retards
healing]
• Vasodilators to regulate organ blood flow [VC]
– HTN, AMI/angina, CVA, CHF, ARF [intravascular volume]
• Alters renal functions
– RBF, GFR, loop NaCl, AVP/water in CD
• GI mucus production to protect mucosa [bleed]
READ PI/LABEL!
REGARD TORT POTENTIAL!
IBUPROFEN PRECAUTIONS
• OTC – no longer than 3 days for fever
• Allergy to NSAID including ASA
• DO NOT take aspirin or acetaminophen w/ ibuprofen
unless MD tells you to
• DO NOT take if fluid intake is unreliable
• Hx heart liver GI or renal disease, HBP, stroke
• Pregnant, plans or breast feeding
• Surgery planned
• If taking warfarin, ß-blockers, CYA, digoxin, diuretics,
lithium, metotrexate, phenytoin
• DO NOT drive or operate machinery until…
• NO alcohol w/ ibuprofen
OTHER FACTORS
your doctor may not be measuring
• Uric acid [gout, stones]
–
–
–
–
< 6 mg/dl
Stroke risk increased when values higher
Seems to facilitate cholesterol build up
Risk equivalent to heart attack
Rx- ↓production or ↑excretion
• Homocysteine [dementia]
< 9 mg/dl
– Stroke risk increased when values higher
– Treatment with folic acid and B₁₂ high dose
• C-reactive protein [CRP]
< 1 mg/dl
– indicates vascular inflammation and risk of a
cardiovascular event
• Kidney function [eGFR] >60 ml/min/1.73m²
– Reduced kidney function increases CV risk
– Hypertension destroys kidneys [20% dialysis patients]
ISCHEMIC STROKE V.
PLASMA HOMOCYSTEINE
14
12
10
8
ischemic stroke rate
6
4
2
0
<10
10--15
>15
umol/L
Sacco et al NOMAS Stroke 35:2663, 2004
CAD SURVIVAL V. HOMOCYSTEINE
Nygard et al;
NEJM 337:230, 1997
CV EVENTS v. eGFR
Go et al; NEJM 351:1296, 2004
SO, WHATCHA
GONNADO ABOUT IT?
KNOW YOUR NUMBERS
don’t leave it to your doctor
• BP <120/80 + treatment
– drugs that affect angiotensin [ACEi or ARB]
• Cholesterol to goal for your specific risk
–
–
–
–
–
–
•
•
•
•
•
•
high HDL reduces risk >50 F; >40 M
low LDL reduces risk <100 no risk; <80 DM, <70 prior CVE
non-HDL (TC – HDL) is total bad cholesterol <130 no risk, <100 w/ risk
triglycerides <150 but lower is better
don’t wait for diet and exercise alone to work
statins proven to reduce risk independent of LDL
Fasting blood sugar <100 (A1C <6.0) + DM
Waist <33” F; <37” M
CRP < 1.0
Uric acid < 6.0
Homocysteine < 9.0
Kidney function [eGFR] > 60
Treat the problems you have with
outcome-proven drugs
•
•
•
•
•
•
Blood pressure – include ACEi or ARB
Statin
Niacin
Omega 3 ‘s
Anticoagulant – aspirin, coumadin
Antiarrhythmic- beta blocker
HOW TO LOSE WEIGHT
works every time!
• Know what you’re eating—read the label!
• Eat less
– Maintain normal weight m-1800 kcal, f-1500 kcal
– Lose weight reduce calories by > 300 kcal/day – portion control
• Eat healthy
– Protein: fish, eggs, less meat, low fat dairy, beans
– Fat: no trans, less saturated, more olive or canola oil
– Carbs: fresh fruits, no juices, colored vegetables + cauliflower, whole grain
bread or cereal, no high fructose corn sugar ever, use sugar substitutes
– Adkins, South Beach, Sugar Busters are healthy
• Exercise more
– 30 minutes 3 times a day to start, then daily (walking will burn 1.25 lb
fat/month
• Sleep 8 hours every night
HOW TO FAIL LONG-TERM WEIGHT LOSS!
• Choose anything other than what’s on the
previous slide
• Try advertised products for diet or exercise
• Buy something sold in doctor’s office or with
some doctor’s name on it
• Get your advice from Dr. Feelgood
• Believe everything the nutritionist tells you
ANTIDOTE TO VASCULAR EVENT
reducing your risk
•
•
•
•
•
•
•
•
•
•
•
Can you afford to survive?
Family history of vascular disease?
Have you had vascular screening?
What about your weight/waist?
Do you have erectile dysfunction?
Do you abuse tobacco?
Do you exercise regularly?
Do you take an aspirin daily?
Do you take any drug that raises BP?
Still taking hormones?
Do you know your numbers?
WHAT TO DO?
if you think you’re having a heart attack or stroke
• Chew and swallow 325 mg aspirin
• Call 911
• Ask to be taken to a certified Heart or Stroke
Center
Plan ahead
– Determine the heart or stroke center closest to you
– Ask if a neurologist who is a stroke specialist will be
available to you
– Clot busters and Merci retriever to remove blood clots
– Confirm that door to cath lab time is <60 minutes
HOW TO IMPROVE YOUR CHANCES OF
ACTUALLY HAVING A VASCULAR EVENT?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ignore symptoms or signs
Have a previous TIA, stroke or heart attack
Ignore your blood pressure or skip your medicine to save money
Have a sibling or parent with cerebral aneurysm at young age
Don’t take blood thinners for atrial fibrillation
Treat your diabetes by diet and exercise
Smoke, chew or dip liberally
Weight no problem as long as you don’t look fat
Lower your cholesterol by diet and exercise only
Don’t take daily aspirin >40 yrs of age
Don’t have vascular screening >50 years of age
Take NSAID for pain and decongestants for cold/sinus problem
Get off the hormones—embrace menapause
Be blood kin to someone who has vascular disease
Active sex life with uncontrolled high blood pressure
Be black
Live in the Southeastern USA
Avoid certified heart or stroke centers
MOST VASCULAR
EVENTS ARE
PREVENTABLE !
THANK YOU !