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THE BEST DIABETIC CENTERS IN YELAHANKA NEW TOWN BANGALORE Treatment of dyslipidaemia The important components of a treatment program for dyslipidaemia are as follows: 1 calculate the patient’s total risk 2 reduce the patient’s weight (reduces triglycerides, cholesterol) 3 increase the patient’s exercise activity (increases HDL, aids weight management) 4 modify the patient’s diet, as follows: • ensure maximum of 30% kJ from fat • ensure maximum of 30% fat as saturated fat • increase plant and fish sources of fat • increase anti-oxidant nutrients from food • reduce alcohol intake if triglyceride level or blood pressure is high 5 treat secondary causes (drugs, diabetes, hypothyroidism) 6 modify other risk factors (e.g. smoking) to reduce overall risk 7 consider drug treatment. By ranking patients according to their risk of future coronary events it is possible to tailor treatment (especially drug treatment) appropriately. This is the basis for the current recommendations for lipid management in the Pharmaceutical Benefits Schedule. This rather complicated schedule tries to take into account the importance of combinations of risk factors . Drug treatment should be delayed in most patients without existing coronary disease until after six weeks to three months of dietary and lifestyle intervention, with the possible exception of those at very high risk. At present, the following drugs are used in the treatment of dyslipidaemia: n statins (HMGcoA reductase inhibitors) n absorption inhibitors n resins
GOOD CARDIOLOGY CLINICS IN YELAHANKA NWE TOWN BANGALORE Summary of recommendations for CHD risk factor reduction Assess the severity and presence of all risk factors: family history blood pressure non-fasting serum cholesterol (if greater than 5.5 mmol/L, or other risk factors are present, proceed to fasting HDL, LDL, trig.) diabetesn smoking dietary history. 1• CORONARY RISK FACTORS 23 Manage risk factors by: encouraging smoking cessation undertaking dietary modification: • ensure dietary fat is less than 30% of total kJ intake and less than 30% of total saturated fat • increase intake of fish and plant oils • restrict kJ intake if patient is overweight • reduce salt and alcohol intake in hypertensive patients controlling blood pressure with lifestyle and medication maintaining diabetic control encouraging regular physical activity using prophylactic drugs in high-risk patients • aspirin • statins • beta-blockers or ACE inhibitors after AMI • ACE inhibitors in left ventricular (LV) dysfunction screening relatives of high-risk patie
HEART SPECIALISTS IN HEBBALABANGALORE Case-based learning: cardiovascular risk assessment Mr RF is 60 years old and presents for a check-up because he is concerned he may be at risk of heart disease. Objectives for the group to understand How should this type of request be managed What can be done to assess an individual’s future cardiac risk, and what can be done to improve the prognosis for those at increased risk Epidemiology and population health The presenter should ask the group to consider the concept of risk factors for cardiovascular disease and the differences between population risk factors and those for an individual. How did the concept of risk factors arise Presenting symptoms and clinical examination What questions should be asked of Mr RF to begin the risk factor assessment 1 Is there a history of ischaemic heart disease or symptoms of heart disease 2 Has his cholesterol level been checked in the past What was itHas it been treated with diet or drugs, or both Has the level improved 3 Is he a diabetic, or has he had an abnormal blood sugar measurement 4 Is there a history of high blood pressure Has this been treated If so, how 5 Is there a history of heart disease in the familIf so, who has been affected and at what age 6 Does he smoke? How many cigarettes a day If he has ceased smoking, when did he stop 7 Does he exercise regularly 8 Have any cardiac investigations been performed before What were the results 9 Is there a history of peripheral arterial disease (claudication) or erectile dysfunction The group should appreciate that considerable information about risk can be obtained by asking simple questions. What physical examination should be performed
SAMIKSHA HEART AND DIABETIC CARE ''CONNECTIVE TISSUE DISORDERS'' ''Marfan Syndrome'' Marfan syndrome is a systemic connective tissue disorder with a frequency of 2 to 3 in 10, 000. The disorder is characterized by manifestations involving the cardiovascular, skeletal, and ocular systems. Current diagnostic criteria are based on involvement of above organ systems and family history. Cardiovascular manifestations include mitral valve prolapse, progressive aortic root enlargement, and ascending aortic aneurisms, possibly leading to aortic regurgitation, dissection, or rupture. Some characteristic skeletal manifestations of this syndrome include disproportional increase of linear bone growth resulting in malformations of the digits (arachnodactyly), craniofacial abnormalities, pectus excavatum/carinatum, and scoliosis. A common ocular involvement is severe myopia and lens dislocation in one or both eyes (ectopia lentis). Marfan syndrome is an autosomal dominant disorder caused by fibrillin-1 gene mutations encoding for the extracellular matrix protein fibrillin (Fbn-1). Fibrillin is an integral component of both elastic and nonelastic connective tissue. The mechanism of fibrillin mutation in Marfan syndrome remains unclear. However, animal models of Fbn-1 have demonstrated a role of TGF-beta signaling. In some patients with phenotypes similar to Marfan syndrome but without fibrillin- 1 gene mutations, TGF-beta receptor mutations have been identified, suggesting a significant role of TGF-beta pathway in the pathogenesis of Marfan syndrome features. Aortic root involvement remains the leading cause of death in patients with Marfan syndrome. Echocardiography is recommended to routinely screen and to follow aortic root dilation. In addition, all first-degree relatives of the family should have screening echocardiography. Patients should be advised against strenuous exercises. Medical therapy for Marfan syndrome includes beta-blockers to reduce myocardial contractility and pulse pressure. Animal models of Marfan syndrome have demonstrated a possible benefit of losartan in preventing progression of the disease by inhibiting the TGF-beta pathway, and this therapy is the subject of an active clinical trial. Elective aortic root replacement remains the therapy of choice once the aortic root becomes significantly enlarged. Marfan patients who become pregnant need to be counseled not only about the 50% chance of transmitting the disease but also the substantially increased risk of aortic rupture/dissection during and after pregnancy. Important components of Marfan syndrome counseling are consideration of contraception and pregnancy management. Loeys-Dietz Syndrome Recently, an aortic aneurysm syndrome has been identified with TGF-beta receptor mutations. Loeys-Dietz syndrome is an autosomal dominant condition with a characteristic triad of arterial tortuosity/aneurysm, hypertelorism, and bifid uvula or cleft palate. There is significant overlap with Marfan syndrome, and the management is similar in terms of cardiovascular manifestation. Early, elective, surgical intervention should be considered in patients with significant aneurysmal dilation of the aorta. Some clinicians have argued for much earlier surgical intervention for the dilated aorta in this condition, compared with Marfan syndrome, since there appears to be a much greater risk of rupture and dissection at earlier ages and smaller aortic sizes. Pregnancy counseling is also an integral part of therapy. Ehlers-Danlos Syndrome Ehlers-Danlos syndrome is a group of disorders that affect connective tissue development due to defects in collagen and connective tissue biosynthesis. Prevalence of the disease is about 1 in 400, 000 people in the United States. Cardiac manifestations include spontaneous rupture of medium to large sized arteries including the aorta. Frequently, extracardiac presentations include hyperextensible skin and hypermobile joints. To date, 11 types of the disorder have been recognized, but collagen defects have been described in only 6 types. Although all types of Ehlers-Danlos syndrome affect the joints and the skin, clinical features vary by type. Different features characterize each type of the syndrome. Type IV carries the poorest prognosis, especially due to spontaneous ruptures of arteries and organs. Extreme caution needs to be taken if surgical intervention is needed due to weakened connective tissue structures. Many genes, including ADAMTS2, COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, PLOD1, and TNXB, have been implicated in the pathogenesis of Ehlers- Danlos syndrome, but the predominant cardiovascular concern exists in the Type IV vascular form of Ehlers-Danlos associated with mutations in the COL3A1 gene and aortic dilation/aneurysms. Other less commonly associated anomalies include ventricular septal defect, patent ductus arteriosus, bicuspid pulmonic valve, and Ebstein’s anomaly. Bicuspid aortic valve has been shown to demonstrate familial clustering. However, identifying culprit genes have been difficult due to variable penetrance and the common nature of the disorder.
How sleeping less than 6 hours affects your health After being awake for almost 14-16 hours, our body demands sleep. Minimum sleeping time required for a healthy mind and body is 7-8 hours. Although, this duration varies according to age. Because generally speaking, where a child can sleep for 12-14 hours, grownups can sleep for not more than 9 hours. Sound sleep is very essential otherwise, it can be harmful for our health. Let’s see how sleeping for less than 6 hours affects our health. Headache, weight gain and poor vision: When you sleep for less than 6 hours a day, it can not only give you headache all the time but can lead to a poor vision also. And if continued for a long time, may hamper your eyesight. The lesser you sleep the more weight you gain. And after-effects of gaining weight could be even more hazardous. Memory loss, heart disease, infection: Sleeplessness can have an adverse effect on one’s memory too. A person may find it difficult to remember even simple things. Also, infections can take a longer time to heal because sleep is something that stabilises and balances everything that goes wrong while we are awake. If we don’t get proper sleep, the process of healing takes longer. Lack of sleep can also elevate blood pressure which ultimately affects the heart. Urine overproduction, stammering and accident: Sleeping slows down urinating process but when you are awake for longer hours, you might have to urinate more than usual. Lack of sleep can also make you stammer while speaking. If lack of sleep continues, you may not be able to communicate properly. When you do not have sound sleep, your mental condition would not be stable because of declining concentration. You can be accident prone if you drive in such a condition. These are just a few of the ill effects. Sleeping for less than 5 hours is far more dangerous than you can even think. From behavioural to mental to physical effects, it can harm you in many more ways, So, have a sound sleep to avoid complications in life.
Important coronary risk factors 1 Existing vascular disease (coronary, cerebral or peripheral) 2 Age 3 Dyslipidaemia 4 Smoking 5 Family history 6 Hypertension 7 Male sex/hormonal factors 8 Diabetes 9 Renal impairment 10 Obesity 11 Inactivity 12 Thrombogenic factors 13 Other dietary factors 14 Homocystinaemia 15 Psychological factors 16 Elevated hsCRP 17 Abnormal CT calcium score/coronary angiogram 18 Left ventricular hypertrophy (hypertensive patients) 19 Abnormal
THE CARDIOLOGY CLINICS IN BANGALORE Important coronary risk factors 1 Existing vascular disease (coronary, cerebral or peripheral) 2 Age 3 Dyslipidaemia 4 Smoking 5 Family history 6 Hypertension 7 Male sex/hormonal factors 8 Diabetes 9 Renal impairment 10 Obesity 11 Inactivity 12 Thrombogenic factors 13 Other dietary factors 14 Homocystinaemia 15 Psychological factors 16 Elevated hsCRP 17 Abnormal CT calcium score/coronary angiogram 18 Left ventricular hypertrophy (hypertensive patients) 19 Abnormal
HEART SPECIALISTS IN YELAHANKA NEW TOWN BANGALORE The causes of coronary symptoms The symptoms of coronary artery disease are caused by the reduction of myocardial perfusion that results from narrowing of the lumen of one or more of the coronary arteries. This narrowing is most often the result of atherosclerosis. Other much less common causes include: 1 coronary artery spasm (often in an already diseased segment of artery but sometimes as a result of the use of cocaine) 2 thrombosis (usually on an already diseased, or occasionally aneurismal, segment) 3 embolism (e.g. from an infected aortic valve) 4 congenital coronary abnormality 5 vasculitis. Numerous other cardiac symptoms and problems can be the eventual result of atheromatous coronary disease. These include myocardial infarction , cardiac failure cardiac arrhythmias and some cardiac valve problems. Risk factor mechanisms of action Atherosclerosis is thought to result primarily from a disturbance of the vascular endothelium. The final common pathway for the effects of endothelial dysfunction is largely through abnormalities of nitric oxide (NO) production. This chemical, released by a healthy endothelium, is a potent vasodilator and has anti-inflammatory and other favourable actions on the arteries. Causes of this disturbance can be: n mechanical (hypertension) n chemical (oxidised lipids, components of cigarette smoke, hyperinsulinaemia) or n due to immunological injury. The damaged endothelium attracts inflammatory mediators, platelets and circulating lipids and promotes fibroblast and smooth muscle proliferation. This results in the formation of a plaque, which may narrow the arterial lumen. Plaques can remain stable (or sometimes regress), enlarge, rupture or erode (more common in diabetics). Most acute ischaemic events (acute coronary syndromes or acute myocardial infarctions) are thought to be the result of further luminal narrowing caused by the formation of partly or fully occlusive thrombus on a ruptured or eroded plaque. Coronary risk factors may therefore operate because they are atherogenic or thrombogenic. Plaque rupture Plaque rupture may be at least partly an inflammatory process involving inflammatory cells, cytokines and even bacteria. This may explain the association between inflammatory markers such as high-sensitivity C reactive protein (hsCRP) and a risk of acute coronary events. Although this association seems well established, there is still uncertainty about its role in overall risk assessment Plaques at risk of rupture are called vulnerable plaques. They typically have a thin fibrous cap. The shoulde of these caps are at risk of rupturing and allowing material from within the plaque to come
DIABETOLOGISTS IN HSR LAYOUT BANGALORE Obesity and the metabolic syndrome Obesity (body mass index, or BMI, > 30) is associated with an increased risk of all-cause mortality, largely due to an increase in cardiovascular mortality. Central obesity (waist/hip ratio > 0.9 in men and 0.8 in women) confers most risk, probably because of its association with important risk factors. Risk factors associated with obesity include: 1 increased LDL cholesterol and triglycerides 2 reduced HDL cholesterol 3 hypertension 4 glucose intolerance/insulin resistance. Treatment of obesity The benefits of weight loss should be explained to patients. It is suggested that patients keep a food diary, as this makes them more aware of their food intake, which is always underreported, even by people who are not overweight. Appetite suppressants such as sibutramine, a serotonin and noradrenaline uptake inhibitor, can be useful in selected patients. It is contraindicated for patients with a history of stroke or with uncontrolled hypertension. Patients must have a BMI > 30, or other risk factors and a BMI between 25 and 30. Orlistat, a gastrointestinal lipase inhibitor, causes fat malabsorption and diarrhoea when fat intake exceeds 30% of total dietary intake. There are similar guidelines for its use. Table 1.13 Target heart rates Age Target heart rate (based on 60–70% maximal) 30 110–140 40 105–130 50 100–125 60 95–115 1• CORONARY RISK FACTORS 19 There is evidence that gastric banding or bypass can lead to sustained weight loss in very obese patients. The operation can be performed laparoscopically and at much lower risk than for previous open operations. Successful surgery appears to be associated with a reduction in blood pressure, lipid levels and cardiovascular events. The metabolic syndrome Obesity represents part of the definition of this syndrome. It has recently been redefined by the World Health Organisation (WHO) and the US National Cholesterol Education Program (NCEP) Expert Panel. The diagnosis of the metabolic syndrome does not include any estimation of insulin resistance but requires three or more of the following: 1 central obesity (waist circumference > 102 cm in men, > 88 cm in women) 2 impaired glucose tolerance (fasting