Cardiovascular health

Early testing can help reduce your risk of heart disease and stroke.
 
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01 .Introduction

lead

Cardiovascular health − healthy blood vessels throughout your body − greatly reduces the risk of heart attack, stroke, kidney disease, eye diseases and circulatory problems. Even Alzheimer’s disease may be linked to the health of the minute blood vessels in the brain.

Control of CVD has traditionally focused on single risk factors, such as high cholesterol or being overweight. This is the ‘relative risk’ approach, where a relative risk of, say 2, for a risk factor means you’re twice as likely to develop CVD as someone without that factor.

But the absolute risk approach, first used in the 1990s, recognises that several risk factors contribute to CVD and their combined effect is greater than the sum of the individual parts. This approach takes a person’s age, sex, cholesterol levels, blood pressure, diabetes status and smoking status and applies these to the Cardiovascular Risk Charts. From this, you (or your GP) arrive at your absolute risk of a CVD event in the next five years. The risk is expressed as a percentage (eg ‘20% chance of a CVD event in next five years’).

How to find the CVD risk charts

To find the charts, go to the Heart Foundation website. The charts need to be printed in colour to be effective. For a DIY assessment, you must know your:

  • blood pressure
  • total cholesterol-to-HDL ratio
  • asymptomatic diabetes status

Ask your GP to give you an absolute CVD risk assessment as part of your regular health check if you are over 45. You can have a cardiovascular health plan that may aim to modify two or three risk factors rather than just, for example, lowering your cholesterol. You can work to achieve the lowest risk possible.

For people at high or very high risk, according to the chart (a five-year CVD event risk that exceeds 15%), interventions to reduce the risk should begin at once. The risk charts, developed from data collected by the Framington Heart Study in the US, do not take into account being overweight, a lack of exercise or family history of heart disease. However, inactivity and being overweight have strong indirect influences on your result, because they affect cholesterol levels, blood pressure and risk for diabetes. Future research may well conclude that a CVD five-year risk percentage should be increased when body fat exceeds a certain level.

 
 

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The National Vascular Disease Prevention Alliance claims there is a low level of understanding and use of absolute risk tools by GPs. A 2008 study showed a nominal uptake of 60%, but when patients were classified as at ‘high risk’, the usefulness of the charts was often discounted, and about two-thirds of these patients were not prescribed medication to lower their blood pressure and cholesterol.

Current GP guidelines recommend the absolute risk approach to CVD and in 2009 the Heart Foundation carried out extensive GP education.

Understanding your risk factors

Risk factors of age, sex, family history of premature CVD, ethnicity and social status are outside your control. Family history means a first-degree relative (parent or sibling) has had a stroke or a heart attack, before 55 for men and 65 for women.

Factors you can influence are high blood pressure, elevated cholesterol and blood fats (lipids), smoking, physical inactivity, overweight/obesity, diabetes, excessive use of alcohol, and stress.

Blood pressure

BP should be recorded for adults aged 18 to 50 every two years, provided systolic (heart pumping) pressure remains less than 120 and diastolic (heart relaxing) pressure remains less than 80. If your BP is higher than that, you need more frequent checking. Gone forever are the days when an estimate of ‘normal’ systolic BP came from adding your age in years to 100. Easy-to-use home BP monitoring devices are reasonably accurate and readily available from pharmacies for less than $100.

Cholesterol levels

Cholesterol levels in the blood are affected by diet, genetics and exercise. Saturated animal fats and some cooking oils (palm oil used by some fast food chains) are major contributors to cholesterol build-up. How individuals handle dietary fats depends on their genetics, and the results of lifestyle changes on cholesterol levels can be disappointing. Adopting the NHMRC Dietary Guidelines for Australian Adults, exercising vigorously and frequently, and maintaining a healthy weight will only reduce cholesterol by up to 30%. Some very effective prescription medicines, such as statins, lower blood lipids.

When your GP requests a blood lipid test from a laboratory, your results and a ‘normal’ range (which may differ slightly between laboratories) are both provided. These ‘normal ranges’ were those used by the SA Institute of Medical and Veterinary Science in 2009:

Total triglycerides 0.3-2.0 mmol/L
Total cholesterol < 5.5
High Density Lipoprotein (HDL) 0.9-2.0
Low Density Lipoprotein (LDL) < 3.7
Total cholesterol/HDL ratio < 5.0


(The National Heart Foundation, in 2001, recommended a total cholesterol of < 4mmol/L.)
To find your CVD risk, the chart requires your total cholesterol-to-HDL ratio (total cholesterol divided by HDL). HDL is the ‘good’ cholesterol, since it reduces CVD risk. LDL is the ‘bad’ cholesterol as it lays down fat in blood vessel walls. The lower your LDL levels are the better.

Overweight

Overweight can be assessed using BMI, waist circumference and waist-to-hip ratio (WHR). The build-up of body fat in and around the abdomen, rather than on your thighs and buttocks, may be a better predictor of future CVD than BMI, so waist circumference or WHR may be more accurate indicators.

The August 2006 edition of the American Journal of Clinical Nutrition asserts that if WHR was to be used instead of BMI, the number of people considered to be at risk of CVD would triple. The WHR figures below are adapted from that journal.

CVD Risk             Men                 Women
Low risk             <0.96                <0.81
Moderate risk    0.96 – 1.0        0.81 – 0.85
High risk             >1.0                  >0.85

heart-traffic-lights

1. Blood lipid (cholesterol) monitoring Use diet, and medication if necessary, to achieve your goals.

2. Blood pressure monitoring Use exercise, diet, reduced salt intake, and medication if necessary, to achieve your goals.

3. Diabetes screening for hidden early diabetes. Good diet, exercise and weight control can keep type 2 diabetes at bay.

4. Stop smoking Ask your GP for help, which may include medication, or call the Quitline on 13 78 48.

5. Absolute CVD risk assessment Assess the combined impact of the above four factors with your GP. This applies to people aged 45 to 74 without a known history of CVD. For low risk (less than 10% risk of a CVD event in the next five years), recheck every two years. For moderate risk (10% to 15% risk of a CVD event in the next five years), review every six to 12 months. For high or very high risk (over 15%), review is according to clinical requirements.

6. Weight control If weight loss is difficult for you, physical activity can still provide real health benefits  for overweight people.

7. Regular exercise Ideally, 30 minutes on most days with enough intensity to make you ‘huff and puff’.

8. Family history assessment Medication may be suggested even if other risk factors are good.

9. The ‘stress factor’ should figure in any life decisions that you may make. High stress levels have been linked to increased risk of both heart attack and stroke.

Case studyCase study

As an experienced nurse, Kathryn is aware of the importance of family history in indicating disease risk. Her father had a heart attack at 42 and a fatal heart attack at 58. On family history alone, Kathryn is considered at ‘very high risk’ of CVD. Kathryn knew that she should aim for very low LDL cholesterol, and that the cholesterol-lowering statins can be beneficial as a preventative action. She knew the risks associated with their use are low if liver function is not affected. Kathryn also knew she was eligible for the PBS subsidy immediately, without attempts at ‘diet therapy’ to reduce cholesterol levels. She asked two GPs for a prescription without success, because her cholesterol levels were ‘reasonable’, and they ‘could not find the entitlements information’. She then downloaded the PBS prescribing guidelines and visited a third GP who gave her the prescription immediately.

  • CVD event means new angina (heart pain), a heart attack (damage to the heart caused by a blocked heart artery), stroke, peripheral vascular disease or CVD-related death.
  • Stroke refers to the blockage or bursting of an artery taking blood to the brain. It can be minor with temporary symptoms, which is called a ‘transient ischaemic attack’ or TIA.
  • Vascular refers to blood vessels.
  • Coronary heart disease (CHD) is the full name for heart disease.
  • Cardiovascular disease (CVD) refers collectively to CHD, stroke, and arterial disease in other parts of the body such as peripheral arterial disease and renovascular (kidney) disease.
  • Atherosclerosis is sometimes used as an alternative to CVD. It is a more descriptive name, alluding to the thickening and hardening of the blood vessel walls, which causes CVD.
  • Pharmaceutical Benefits Scheme (PBS) is the federal government program that determines the eligibility guidelines for government-subsidised medication.
  • Body Mass Index (BMI) is a measure of overweight. It is a person’s weight divided by height squared (kg/m²). An index of <18.5 is underweight, 18.5 to <25
    is ideal, 25 to <30 is overweight and 30+ is obese.
  • Waist circumference, at belly button level, of 94cm-101cm in men and 80cm-87cm in women represents overweight, and above 101cm and 87cm, respectively, is a measure of obesity.
  • Waist-to-hip ratio (WHR) gives a measure of central or abdominal fat relative to peripheral fat. The waist is measured at belly button level and the hips at maximum circumference.

First aid - Stroke

Know the symptoms and limit damage. Use the FAST test:

  • Facial weakness – can the person still smile?
  • Has their mouth or an eye dropped?
  • Arm weakness – can the person raise both arms?
  • Speech – can the person speak clearly and logically and understand what you say?
  • Time to act – call 000.
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