Life style modification for the prevention of the heart attack

Coronary artery disease (CAD) is becoming a major health challenge in India.   The increase in incidence of coronary artery disease is thought to be secondary to the effect of modernisation.   Modernisation results in increased levels of stress, affluence, which in turn brings about changes in eating habits and levels of exercise.   This has given rise to an urban rural division of prevalence.   We also noticed that there is a north south division in terms of prevalence.  Prevalence rates in urban India are 7 – 10% in the north and 14% in the south, in rural India 3% in the north and 7% in the south.

The heart is a muscular pump which pumps blood for distribution to all parts of the body.  The heart receives its blood supply through the coronary arteries. Narrowing of these vessels progressing to total occlusion leads to a heart attack.  This narrowing occurs as a result of fat deposition in the inner layer of the blood vessels and thus encroaching upon the lumen of the blood vessels. This disease process is called coronary artery disease.

CAD is a multi factorial disease. The causative factors can broadly be classified into modifiable and non-modifiable risk factors.  Non modifiable risk factors are age, sex and family aggregation. As age advances there is an increased chance of developing CAD.   Males are more prone to develop the disease as compared to women. Once women attain menopause their risk gradually keep increasing to match that of men by 60-70 year of age.

The modifiable risk factors are hyperlipidemia (high levels of cholesterol and triglyceride levels) smoking, diabetes mellitus, hypertension, obesity, and sedentary life style.  The South  Asian population has the highest risk for development of CAD.   Not only is the incidence higher, but disease takes a more aggressive form and tends to afflict a much younger population as compared to the west.

Prevention is based on control of risk factors, which essentially involves appropriate treatment  of hypertension, diabetes and hyperlipidemia along with aggressive modification of lifestyle.  The dramatic decline in CAD in the west is attributed to aggressive modification of lifestyle by the entire population, rather than  to high tech. hospital care of individual cardiac patients.

To achieve the goal of preventing  cardiovascular disease it  is important to avoid the occurrence of the major risk factors themselves.  This calls for changing the socioeconomic status of the society.   Better socio economic and cultural status correlates inversely with life style factors  of smoking,  abnormal food patterns and exercise.   Primordial prevention is concerned with control of smoking, faulty eating and exercise habits and begins in childhood when health risk behaviour begins.   Parents, teachers and peer groups are important in imparting health education to children.

Primary prevention refers to prevention measures taken in individuals who have risk factors but have not developed the disease as yet and secondary prevention refers to preventive measures in individuals with the disease to prevent or retard progression of the disease and prevent further cardiac events.

Prevention Guidelines

Smoking has an unfavourable effect on the lipid profile.   It tends to increase the level  of LDL cholesterol and reduces HDL cholesterol.  It causes endothelial dysfunction, acute rise in blood pressure and has a pro-coagulant effect.

Cigarette smoking is not only a risk for those who smoke, but also for those who associate with them.   This is called as passive smoking.   The goal should be complete cessation.   What is encouraging is that if the habit is stopped the risk associated  with smoking abates with time.

The most common factor responsible of hyperlipidemia is faulty dietary habits and in a few patients secondary to some accompanying illness and rarely genetic abnormalities.

Dietary management along with regular exercise is the most important measure required to bring down the lipid levels.   In patients in whom diet and exercise are not sufficient they will need drug therapy.

In India, hypertension (> 140/90 mm Hg) is present in 25-30% urban and 10-15% rural adults.   Goal of treatment is to achieve a systolic blood pressure < 140 mmHg  and a diastolic blood pressure < 90 mm Hg.   The following measures are appropriate in all hypertensives.

• Reduction of overweight; even a loss of 4 to 5 kg lowers blood pressure in many patients.
• Reducation of alcohol intake
• Increase in aerobic physical activity
• Reduction of salt intake to 4 gm per day.

Maintain < 120% of ideal weight for height.  Combine exercise program with changes in diet.   Immediate benefits would be in terms of improved appearance.  Long term benefits would be in terms of longer life span, lower LDL cholesterol and triglycerides and higher HDL cholesterol level lowers blood pressure and lessens risk of diabetes.

The reducing diet consists of a maintained or increased intake of low energy – density foods, such as green vegetables, salad vegetables and clear soups.   A decreased intake of high energy density and nonsatiating foods including alcohol, of fats and oils and sugar containing foods.

Exercises like walking, jogging, cycling and calisthenics are beneficial in preventing coronary artery disease by helping maintain body weight, brings about a  favourable change in the lipid  profile and  helps in better control of hypertension and diabetes.   An initial warm up period of 4-5 minutes and a final cool-down  period is advised in all exercise programs.

Exercise needs to be done at least 4-5 times weekly.  The intensity can be judged subjectively and persons should aim for comfortable intensity, sufficient to extend them slightly.   Mild shortness of breath during exercise should abate within 4 minutes or less of resting.  Another way of monitoring the intensity is to achieve a pulse rate of 60-70% of maximum predicted heart rate (MPHR=220-age).  Any symptoms should be reported.   At least 2-3 weeks is required before the beneficial effects are seen.   Discontinuation results in loss of the attained beneficial effects.

Diet should include a generous intake of whole grains, cereal food, fruits and vegetables, fat-free and low-salt dairy products, fish, low-salt poultry, moderate amount of low-fat meats.   Avoid egg yolk, red meat, reduce consumption of dry fruits.   Unsaturated vegetables oils to be used and to be restricted to 2-3 tsp.per day.  Antioxidants consumed as fruits and vegetables  in naturally occurring forms are recommended.

In summary coronary heart disease can be prevented by stopping tobacco and controlling intake of salt, saturated fats and calories, by increasing consumption of heart healthy foods such as fruits and vegetables, high fiber cereals, oils containing balanced amount of polyunsaturated and monounsaturated salts, and spices and cereals with high flavenoid content. Stress management techniques especially yoga may be important.