Coronary Heart Diseases

Definition

Coronary heart disease CHD (also known as ischemic heart disease IHD or coronary artery disease CAD), defined as disease of the blood vessels supplying the heart muscle, is the most common type of heart disease, the No. 1 killer of women in the world.

CHD falls under a group of diseases called cardiovascular diseases (CVDs) which are diseases of the heart and blood vessels and include besides CHD: cerebrovascular disease, peripheral arterial disease, congenital heart disease, rheumatic heart disease, and others…

Facts & Figures

• Coronary heart disease among women in Lebanon has a very high prevalence (7.8% of hospitalized women), DALY (1) rating (1270) and mortality rates (151 per 100,000), as well as a lack in services provided (Ref: Booz & Company Analysis)

• Coronary heart disease is the main cause of death among women with 7,000 predominantly underprivileged women hospitalized in Lebanon in 2009 and over 3,000 female deaths in 2004 (Ref: Booz & Company Analysis)

• Heart disease is the No. 1 killer of women, and is more deadly than all forms of cancer combined (Ref: Go Red for women)

• Heart disease causes 1 in 3 women’s deaths each year, killing approximately one woman every minute (Ref: Go Red for women)

• 90% of women have one or more risk factors for developing heart disease (Ref: Go Red for women)

• Since 1984, more women than men have died each year from heart disease (Ref: Go Red for women)

• Women tend to be more sensitive to heart disease risk factors.Heart disease is still considered as an old men’s disease despite being the number 1 killer of women in Lebanon" and thus women hesitate to seek care

• In a recent survey, 75% of women identified cancer as their leading cause of death and considered heart disease as an old men’s issue

• Women, particularly young women, have twice the morbidity and mortality of men following coronary artery bypass graft surgery (open heart)

• Disorders such as gestational diabetes, hypertension, preeclampsia that occur during pregnancy increase the risk of a cardiovascularevent later in the life of women

• Psychosocial factors such as depression, inadequate economic resources, caregiver stress, etc. are highly prevalent among Lebanese women, and have been linked to adverse cardiovascular outcomes

• Cardiovascular Disease (CVD) , proved to be the leading cause of mortality (45% of total deaths) in Lebanon. CVD was responsible for 56% of deaths among females, caused by non-communicable diseases (NCDs) (Ref: WHO - NCD Country Profile, 2011 report " last update May 2012 " Lebanon)

• More than one in three female adults has some form of cardiovascular disease (Ref: American Heart Association " 2013)

• 64% of women who died suddenly of coronary heart disease had no previous symptoms (Ref: American Heart Association " 2013)

• 26% of women age 45 and older, who have an initial recognized Myocardial Infarction (heart attack) , die within a year as compared to 19% of men (Ref: American Heart Association " 2013)

• Women having heart attacks are less likely to get immediate treatment and more likely to die in the hospital (partly because of such delays, 15% of female heart attack patients die in the hospital compared to 10% of men)

• Risk factors, symptoms, hospital stay, treatment, mortality and morbidity for ischemic heart disease can differ between men and women. Research is very important for a better understanding of women’s heart disease

• Women comprise only 24% of participants in all heart-related studies (Ref: Go Ref for women)

Key Diseases Affecting Women in Lebanon

Year 2011

Causes

Coronary Heart Disease (CHD) is a disease in which plaque builds up on the inner walls of your coronary arteries. These arteries carry oxygen-rich blood to your heart. When plaque builds up in the arteries, the condition is called atherosclerosis.

Plaque is made up of fat (triglycerides), cholesterol, calcium, white blood cells and other substances found in the blood. Over time, plaque can harden or rupture (break open).

Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. This leads to an imbalance between the oxygen demand of the heart muscle and the supply by the narrowed arteries, and can cause chest pain or discomfort called angina.

If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack. Over time, ruptured plaque also hardens and narrows the coronary arteries.

In addition to angina and heart attack, CHD can cause other serious heart problems. The disease may lead to heart failure, irregular heartbeats (arrhythmia), and sudden cardiac death. Stroke is also a related vascular disease.

Risk Factors

I. Modifiable risk factors
(controlled or treated by changing lifestyle or taking medication, they are considered as preventable risk factors)

Tobacco Smoke

Smokers' risk of developing CHD is 2-4 times that of nonsmokers. Cigarette smoking is a powerful independent risk factor for sudden cardiac death in patients with coronary heart disease. Cigarette smoking also acts with other risk factors to greatly increase the risk for coronary heart disease. People who smoke cigars, pipes and narghile seem to have a higher risk of death from coronary heart disease (and possibly stroke). Exposure to other people's smoke (second-hand smoking) increases the risk of heart disease even for nonsmokers.

High blood cholesterol

As blood cholesterol rises, so does risk of coronary heart disease. When other risk factors (such as high blood pressure and tobacco smoke) are present, this risk increases even more. A person's cholesterol level is also affected by age, sex, heredity and diet. You can be thin and have high cholesterol! Here's the lowdown on where those numbers need to be:

• Total Cholesterol (TC): Less than 200 mg/dL
• LDL (bad) Cholesterol:

• If you're at low risk for heart disease: Less than 160 mg/dL
• If you're at intermediate risk for heart disease: Less than 130 mg/dL
• If you're at high risk for heart disease (including those with existing heart disease or diabetes): Less than 100mg/dL

• HDL (good) Cholesterol: 50 mg/dL or higher for women (High HDL defined as 60 mg/dL and above is considered protective against heart disease)
• Triglycerides (TG): Less than 150 mg/dL

High blood pressure

High blood pressure is considered a silent killer (can be present with no signs and symptoms). It increases the heart's workload, causing the heart muscle to thicken and become stiffer. This stiffening of the heart muscle is not normal, and causes the heart not to work properly. High blood pressure also scars and damages your arteries and increases your risk of heart attack, stroke, kidney failure and congestive heart failure. When high blood pressure exists with obesity, smoking, high blood cholesterol levels or diabetes, the risk of heart attack or stroke increases several times.Here’s how the blood pressure numbers are evaluated:

• Normal: less than 120/80 mmHg
• Pre-hypertension: 120-139/80-89 mmHg
• Hypertension: 140+/90+ mmHg
• Hypertensive Crisis: 180+/110+ mmHg

Diabetes

Diabetes seriously increases your risk of developing cardiovascular disease. Even when glucose levels are under control, diabetes increases the risk of heart disease and stroke, but the risks are even greater if blood sugar is not well controlled. At least 65% of people with diabetes die of some form of heart or blood vessel disease. Persons who are obese or overweight should lose weight to keep blood sugar in control. You should always monitor your blood sugar level (fasting plasma glucose FPG) even if you do not have any symptoms. This test is usually done first thing in the morning, before breakfast and checks your fasting blood glucose levels. Fasting means after not having anything to eat or drink (except water) for at least 8 hours before the test. here’s a look at the numbers:

• Normal: FPG less than 100 mg/dL
• Impaired fasting glucose (or prediabetes): FPG 100 " 125 mg/dL
• Diabetes:

• FPG 126+ mg/dL (on 2 different occasions)
• 2 hour plasma glucose after 75g oral glucose tolerance test OGTT > 200 mg/dL (on 2 different occasions) - the OGTT is a two-hour test that checks your blood glucose levels before and 2 hours after you drink a special sweet drink. It tells the doctor how your body processes glucose.
• Random plasma glucose higher than 200 + symptoms (this test is a blood check at any time of the day if you have diabetic symptoms)
• HBA1C > 6.5% (HBA1C measures your average blood glucose for the past 2 to 3 months)

Obesity and overweight

People who have excess body fat - especially if a lot of it is at the waist - are more likely to develop heart disease and stroke even if they have no other risk factors. Excess weight increases the load on the heart. It also raises blood pressure and blood bad cholesterol (LDL) and triglyceride levels, and lowers HDL ("good") cholesterol levels. It can also make diabetes more likely to develop. Many obese and overweight people may have difficulty losing weight. But by losing even 10% from your current weight, you can lower your heart disease risk.

That’s why it’s important to know your Body Mass Index (BMI), a numerical value of your weight in relation to your height (divide your weight in Kg by your height squared in meters). Here’s how it breaks down:

• Underweight: Less than 18.5
• Healthy weight: Less than 25
• Overweight: Between 25 and 29.9
• Obese: 30 or higher

Physical inactivity

An inactive sedentary lifestyle is a risk factor for coronary heart disease. Regular, moderate-to-vigorous physical activity helps prevent heart and blood vessel disease. The more vigorous the activity, the greater your benefits. However, even moderate-intensity activities help if done regularly and long term. Physical activity can help control bad cholesterol, boost your level of good cholesterol, control diabetes and obesity, as well as help lower blood pressure by as much as 4 to 9 mm Hg in some people, which is the same reduction in blood pressure you’d get by anti-hypertensive medications.

Moderate-intensity exercise for 30 minutes a day is highly recommended to prevent the risk of premature heart attacks.

Unhealthy diet

Excess alcohol and salt consumption in conjunction with limited intake of fruits and vegetables increase the risk of heart disease. Drinking too much alcohol can raise blood pressure, cause heart failure and lead to stroke. It can contribute to high triglycerides, cancer and other diseases, and produce irregular heartbeats. It contributes to obesity, alcoholism, suicide and accidents. If you drink, limit your alcohol consumption to no more than one drink per day. Also, Choose nutrient-rich foods " which have vitamins, minerals, fibers and are lower in calories " over nutrient-poor foods. A diet rich in vegetables, fruits, whole-grain and high-fiber foods, fish, lean protein and fat-free or low-fat dairy products is the key.

Chronic stress

The American Heart Association explains that chronic stress that causes an increase in heart rate and blood pressure may damage the artery walls. Doctors have used the term "Type A" personality or behavior to describe a person who is always in a hurry, impatient, often irritated, angry or hostile, and who strives for perfection. Studies found that Type A personality is associated with increased risk of heart disease. Some scientists have noted a relationship between coronary heart disease risk and stress in a person's life, their health behaviors and socioeconomic status. These factors may affect established risk factors. For example, people under stress may overeat, start smoking or smoke more than they otherwise would.

• Total Cholesterol (TC): Less than 200 mg/dL
• LDL (bad) Cholesterol:

• If you're at low risk for heart disease: Less than 160 mg/dL
• If you're at intermediate risk for heart disease: Less than 130 mg/dL
• If you're at high risk for heart disease (including those with existing heart disease or diabetes): Less than 100mg/dL

• HDL (good) Cholesterol: 50 mg/dL or higher for women (High HDL defined as 60 mg/dL and above is considered protective against heart disease)
• Triglycerides (TG): Less than 150 mg/dL

• Normal: less than 120/80 mmHg
• Pre-hypertension: 120-139/80-89 mmHg
• Hypertension: 140+/90+ mmHg
• Hypertensive Crisis: 180+/110+ mmHg

• Normal: FPG less than 100 mg/dL
• Impaired fasting glucose (or prediabetes): FPG 100 " 125 mg/dL
• Diabetes:

• FPG 126+ mg/dL (on 2 different occasions)
• 2 hour plasma glucose after 75g oral glucose tolerance test OGTT > 200 mg/dL (on 2 different occasions) - the OGTT is a two-hour test that checks your blood glucose levels before and 2 hours after you drink a special sweet drink. It tells the doctor how your body processes glucose.
• Random plasma glucose higher than 200 + symptoms (this test is a blood check at any time of the day if you have diabetic symptoms)
• HBA1C > 6.5% (HBA1C measures your average blood glucose for the past 2 to 3 months)

• Underweight: Less than 18.5
• Healthy weight: Less than 25
• Overweight: Between 25 and 29.9
• Obese: 30 or higher

Moderate-intensity exercise for 30 minutes a day is highly recommended to prevent the risk of premature heart attacks.

II. Non-modifiable risk factors
(you can't control your age, sex and race, and family history. Therefore, it is more important to treat and control the preventable risk factors, but it is always important to keep the non-modifiable ones in mind to understand your overall risk)

Age

Simply getting older increases your risk of damaged and narrowed arteries and weakened or thickened heart muscle, which contribute to heart disease. About 82% of people who die of coronary heart disease are 65 or older. At older ages, women who have heart attacks are more likely than men are to die from them within a few weeks.

Heredity and Family History of Premature Heart Disease

Children of parents with heart disease are more likely to develop it themselves. Most people with a strong family history of heart disease have one or more other risk factors. Family history of premature heart disease is defined as follows:

• before age 55 for a first-degree male relative, such as your brother or father
• before age 65 for a first-degree female relative, such as your mother or sister

Homocysteine

Homocysteine is a substance your body uses to make protein and to build and maintain tissue. But too much homocysteine may increase your risk of stroke, certain types of heart disease, and disease of the blood vessels of the arms, legs and feet (peripheral artery disease).Your doctor may check your homocysteine level if you've had cardiovascular problems but don't have any of the traditional risk factors, such as smoking. Your doctor may also suggest screening if any family members developed heart problems at a young age or have high homocysteine levels.

• A normal homocysteine level is between 4.4 and 10.8 micromoles per liter (µmol/L)

C-reactive protein (CRP)

C-reactive protein (CRP) is a protein your liver produces as part of your body's response to injury or infection (inflammatory response). CRP is a sign of inflammation somewhere in the body. However, CRP tests can't pinpoint where in the body this may be happening. Inflammation plays a central role in the process of atherosclerosis, in which fatty deposits clog your arteries. Measuring CRP alone won't tell your doctor your risk of heart disease. But factoring in CRP test results with other blood test results and risk factors for heart disease helps create an overall picture of your heart health.According to the American Heart Association, your CRP test result can be interpreted as putting your heart disease risk at:

• Low risk (less than 1.0 milligrams per liter, or mg/L)
• Average risk (1.0 to 3.0 mg/L)
• High risk (above 3.0 mg/L)

Fibrinogen

Fibrinogen is a protein in your blood that helps blood clot. But too much fibrinogen can cause a clot to form in an artery, leading to a heart attack or stroke.Having too much fibrinogen may also mean that you have atherosclerosis. It may also worsen existing injury to artery walls.Your doctor may check your fibrinogen level if you have an increased risk of heart disease. Smoking, inactivity, drinking too much alcohol and taking supplemental estrogen " whether from birth control pills or hormone therapy" may increase your fibrinogen level.

• A normal fibrinogen level is considered to be between 200 and 400 mg/L

Lipoprotein (a)

Lipoprotein (a), or Lp(a), is a type of LDL cholesterol. Your Lp(a) level is determined by your genes and isn't generally affected by lifestyle.High levels of Lp(a) may be a sign of increased risk of heart disease, though it's not clear how much risk. Your doctor might order an Lp(a) test if you already have atherosclerosis or heart disease but appear to have otherwise normal cholesterol levels.Lp(a) is often tested if you have a family history of early-onset heart disease or sudden death. It should also be tested if your LDL cholesterol doesn't respond well to drug treatment.

• before age 55 for a first-degree male relative, such as your brother or father
• before age 65 for a first-degree female relative, such as your mother or sister

• A normal homocysteine level is between 4.4 and 10.8 micromoles per liter (µmol/L)

• Low risk (less than 1.0 milligrams per liter, or mg/L)
• Average risk (1.0 to 3.0 mg/L)
• High risk (above 3.0 mg/L)

• A normal fibrinogen level is considered to be between 200 and 400 mg/L

Heart Attack Symptoms

Symptoms of Heart Attacks

Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or stroke may be the first warning of underlying disease. Symptoms of a heart attack include:

• Pain or discomfort in the center of the chest that lasts more than a few minutes, or goes away and comes back (pain can manifest as an uncomfortable pressure, squeezing or fullness)
• Pain or discomfort in one or both arms, the shoulders, elbows, jaw, neck, back or stomach
• Difficulty breathing or shortness of breath
• Feeling sick or vomiting
• Feeling light-headed or faint
• Breaking into a cold sweat
• Becoming pale

As with men, the most common heart attack symptom in women is chest pain or discomfort. But it’s important to note that women are more likely to experience the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

Symptoms of Strokes

The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often on one side of the body. Other symptoms include sudden onset of:

• Numbness of the face, arm, or leg, especially on one side of the body
• Confusion, difficulty speaking or understanding speech
• Difficulty seeing with one or both eyes
• Difficulty walking, dizziness, loss of balance or coordination
• Severe headache with no known cause
• Fainting or unconsciousness

What to do during a heart attack or Stroke

If you experience any of these signs or symptoms mentioned above:

• Do not wait to call for help!
• Dial 140 (Lebanese Red Cross) IMMEDIATELY
• Make sure to follow the operator’s instructions and get to a hospital right away
• Do not drive yourself or have someone drive you to the hospital unless you have no other choice
• Try to stay as calm as possible and take deep, slow breaths while you wait for the emergency responders