Coronary arteries are blood vessels that supply blood and oxygen to the heart.

The inner walls of coronary arteries can be damaged by:

Blood-borne chemicalsHigh Blood PressureChronic ingestion of contaminants such as arsenicPhysical Factors (blows, viral and bacterial infections)

Over time, plaque builds up on the injured inside walls of coronary arteries.

Low Density Lipoproteins (LDL) will associate with the plaque and form atherosclerotic plaque.

The atherosclerotic plaque will then rupture, causing blood clot on its surface.

The blood clot enlarges to partially or completely block the blood vessels

Blood flow is interrupted.

Picture courtesy of: http://www.nlm.nih.gov/medlineplus/ency/imagepages/17004.htm

Heart cells die due to lack of oxygen and nutrients.

Heart Attack

Statistics

• In Malaysia, cardiovascular disease is the main cause of death among women, accounting for about 25% of all female deaths in government hospitals (about 1 in 4) [2]

• Heart attack hits Malaysians at the age of as early as 50 years old.[3]

• Heart disease is one of the top killers in government hospitals(GH) in Malaysia where 16.5% of 45,936 deaths in 2008 were due to heart disease.[4]

• Cerebrovascular diseases accounted for 8.65% of the causes of death at the GH.[4]

When a blood vessel that supplies blood to the brain is blocked by a blood clot or ruptures.

When a blood vessel that supplies blood to the brain is blocked by a blood clot or ruptures.

Brain cells die due to lack of oxygen and nutrients.

Blood flowing to that part of the brain is interrupted.

Picture courtesy of: http://www.nlm.nih.gov/medlineplus/ency/imagepages/17133.htm

Picture courtesy of: http://www.bidmc.org/CentersandDepartments/Departments/Medicine/Divisions/CardiovascularMedicine/DiseasesandConditions/Stroke.aspx http://www.nlm.nih.gov/medlineplus/ency/imagepages/8968.htm

There are 3 types of Stroke: [5]

HemorrhagicStroke

• Ischemic Stroke accounts for 69% to 91%, while Hemorrhagic Stroke, 9% to 31% of those who suffer stroke for the first time.

• Stroke occurs predominantly in the middle and later years of life.

• Most Ischemic Strokes occur between the ages of 71 and 80 years old while most Hemorrhagic Strokes between 60 and 70 years old.

• Stroke, is the most common cause of death worldwide, after Ischemic Heart Disease and Cancer.

Statistics [6]

Statistics [7]

• Although the entire older population is at risk for Stroke, there are gender differences in the incidence by age subgroups.

• The incidence of Stroke which is higher in men up to the age of 75, is similar for the 75-84 age group, and higher in women in the age group older than 85 years old.

• However, the lifetime risk of Stroke is higher in women compared to men.

Cause of Heart Attack and Stroke[8,9]

•Blood vessels provide oxygenated blood to the heart and brain.

• Problems arise whenthe blood flow is reduced or blocked.

•The blockage that causes Heart Attack or Stroke is due to a sticky build-upknown as ATHEROSCLEROTIC PLAQUE.

Picture courtesy of: National Heart Lung and Blood Institute:Disease and Conditions Index

Atherosclerosis[9]

Arteries are blood vessels that carry oxygenated blood to the heart, brain and other parts of the body.

Atherosclerotic plaque is composed of cholesterol, fats, cellular debris and other substances.

Atherosclerosis is a disease in which plaque builds up on the insides of your arteries.

Passage for blood flow along the artery walls narrows or becomes completely blocked

HEART ATTACK / STROKE

Over time, plaque hardens and narrows your arteries.

Atherosclerosis[9]

Heart muscles or brain tissues do not get

enough oxygenated blood and nutrients.

Picture courtesy of: http://www.nlm.nih.gov/medlineplus/ency/imagepages/19314.htm

Risk Factors of Heart Attack & Stroke[10]

High Blood Pressure

High Cholesterol

Diabetes Mellitus

If you have one or more of these conditions, you may be at higher risk of Heart Attack and Stroke as compared to others.

Picture courtesy of: http://www.nlm.nih.gov/medlineplus/ency/imagepages/19190.htm

Way towards Healthy Lifestyle[10]

Manage your Blood Pressure

Reduce your Cholesterol Level as close as possible to ideal.

Manage your Diabetes.

If you were to have one or more of these conditions, what should you do?

According to WHO, health is a state of physical, mental and social well-being, and not merely the absence of disease and infirmity.[11]

Healthy Lifestyle

Maintain a Healthy Blood Pressure:

Blood Pressure Classification

Systolic BP (mm Hg)

Diastolic BP (mm Hg)

Normal < 120 < 80

Prehypertension 120 – 139 80 – 89

Stage 1 Hypertension 140 – 159 90 – 99

Stage 2 Hypertension 160 – 179 100 – 109

Stage 3 Hypertension ≥ 180 ≥ 110

Source: Clinical Practice Guidelines Management of Hypertension, 3rd Ed. 2008 February;MOH/P/PAK/156.08(GU)

High blood pressure (hypertension) means that your blood is pumping with more force than normal through your arteries.

Healthy LifestyleMaintain a Healthy Blood Pressure: [12,13,14]

Over time, the added stress on the arteries accelerates the deposition of fatty plaques (atherosclerosis) and narrows the artery walls

Healthy LifestyleMaintain a Healthy Blood Pressure: [12,13,14]

Picture courtesy of: http://www.nlm.nih.gov/medlineplus/ency/imagepages/18020.htm

The narrowed artery blocks the flow of blood to the heart muscles or brain tissues.

Picture courtesy of: http://www.web-books.com/eLibrary/Medicine/Cardiovascular/HeartAttack.htm

Healthy LifestyleMaintain a Healthy Blood Pressure: [12,13,14]

Deprived of oxygen and nutrients

HEART ATTACK / STROKE

Healthy Lifestyle

•Diabetes mellitus is a condition caused by decreased secretion of insulin from the islets of Langerhans cells of the pancreas or by the ineffective use of insulin.

•Insulin is important for the cells to use glucose.

•Diabetes mellitus will disturb carbohydrate metabolism.

Good Control of Diabetes Mellitus: [15,16,17]

Healthy Lifestyle

Insulin deficiency causes glucose to accumulate in the blood, rather than being transported to the cells and converted into energy.

High sugar level in the blood will damage the blood vessels.

Damaged blood vessels will increase the deposition of fatty materials in the artery walls.

Atherosclerosis

HEART ATTACK / STROKE

Good Control of Diabetes Mellitus: [15,16,17]

Healthy Lifestyle

•For a healthy person, the blood glucose levels should be:

Fasting – 4.0 to 6.0 mmol/LAfter food – >8.0 mmol/LHbA1c - not more then 6.5

( HbA1c is a blood test to measure the amount of glucose bound to the red blood cells in the last 3 months. The HbA1c values is proportional to the blood sugar level.)

Good Control of Diabetes Mellitus: [18]

Table 1: Targets for Type 2 Diabetes Mellitus [19]

Levels

Glycaemic Control

Fasting 4.4 – 6.1 mmol/L

Non- fasting 4.4 – 8.0 mmol/L

HbA1c < 6.5%

Lipids

Triglycerides ≤ 1.7 mmol/L

HDL cholesterol ≥ 1.1 mmol/L

LDL cholesterol ≤ 2.6 mmol/L

Exercise 150 minutes/week

Blood Pressure

Normal Renal Function ≤ 130/80 mmHg

Renal Impairment/ Gross Proteinuria

≤ 125/75 mmHg

Healthy Lifestyle

•There are 3 forms of Cholesterol:Low Density Lipoprotein (LDL)High Density Lipoprotein (HDL)Triglycerides

Well-Balanced Cholesterol Levels: [20]

•A healthy person should

have a higher level of HDL

and a low level of LDL and

triglyceride.

Healthy Lifestyle

•HDL (good) Cholesterol removes excess cholesterol in the blood stream.•LDL (bad) Cholesterol enters the arterial wall and is taken up by our body’s scavenger cells.

Well-Balanced Cholesterol Levels : [21]

•Subsequently, they will turn into fatty streaks which progress into atheromatous plaques.•Hence, LDL cholesterol is said to promote atherosclerosis.

Well-Balanced Cholesterol Levels : [22]

Healthy Lifestyle

•As the cholesterol levels directly affect the risks for coronary diseases, it is important to control them.•LDL:HDL cholesterol ratio is among the best predictor of risks for subsequent coronary diseases.

•The ideal LDL:HDL ratio is less than 3.•A LDL:HDL ratio greater than 4 is considered at a higher risk of developing atherosclerosis.

•Cholesterol readings includes:Total cholesterol

Desirable : < 5.2 mmol/LBorderline High : 5.2 – 6.2 mmol/LHigh : ≥ 6.2 mmol/L

LDL cholesterolDesirable : < 3.3 mmol/LBorderline High : 3.3 – 4.1 mmol/LHigh : ≥ 4.1 mmol/L

Well-Balanced Cholesterol Levels : [23]

Healthy Lifestyle

HDL cholesterolAcceptable: ≥ 0.9 mmol/LRisky : < 0.9 mmol/L

TriglycerideDesirable : < 2.3 mmol/L

•A healthy person should have a higher level of HDL and a low level of LDL and triglyceride.

Well-Balanced Cholesterol Levels : [23]

Healthy Lifestyle

References1. Elaine N. Mareib, Katja Hoehn. Human anatomy & physiology. 7th ed. San Francisco.

Pearson Benjamin Cummings. 2007.p. 718-719.2. Kementerian kesihatan Malaysia. Clinical practice guideline: prevention of

cardiovascular disease in women [online]. 2008 [cited 2009 Dec 5]; Available from: URL: http://moh.gov.my/MohPortal/cpgDetail.jsp?action=view&id=61

3. Chai mei ling. National heart association of Malaysia: Keep the arteries unclogged. [online] 2008 Sept 28 [cited 2009 Nov 29]; Available from: URL: http://www.malaysianheart.org/article.php?aid=123

4. National heart association of Malaysia: heart disease top killer in government hospitals. [online] 2009 Oct 25 [cited 2009 Nov 29]; Available from: URL: http://www.malaysianheart.org/article.php?aid=427

5. American Stroke Association. A Division of American Heart Association. What is stroke? [online]. 2009 Oct 6 [cited 2009 Nov 27]; Available from: URL: http://www.strokeassociation.org/presenter.jhtml?identifier=3030066

6. T Z Ong, A A Raymond. Risk factors for stroke and predictors of one-month mortality. Singapore Med J [serial online]. 2002 [cited 2009 Nov 27];43(10):517-21. Available from: URL: http://www.sma.org.sg/smj/4310/4310a4.pdf

References7. Guido Falcone, Ji Y. Chong. Gender differences in stroke among older adults. Medscape

Today [serial online] 2007 Oct 30 [cited 2009 Nov 27];10(08):497-500. Available from: URL: http://www.medscape.com/viewarticle/564629

8. Moore S, editor. Chapter 30 Cardiovascular disease. In: Frogge MH, Goodman M, Yarbro CH. Cancer symptom management. 3rd ed. United States of America: Jones & Barlett Publishers; 2004. p. 576

9. National Heart Lung and Blood Institute. Atherosclerosis. [online]. 2004 [cited 2009 Nov 27]; Available from: URL:http://www.nhlbi.nih.gov/health/dci/Diseases/Atherosclerosis/Atherosclerosis_WhatIs.html

10. Kam SW, Dianna M, editors. Chapter 4 Novel atherosclerosis risk factors and management. In: Tonkin A, editor. Atherosclerosis and heart disease. United Kingdom: Informa Health care; 2003. p. 41

11. World Health Organization. WHO definition of health. [online]. 2003 [cited 2009 Dec 15]; Available from: URL: http://www.who.int/about/definition/en/print.html

12. Sherwood L. The blood vessels and blood pressure. In: Sherwood L. Human physiology:from cells to systems. 7th ed. United States of America: Cengage Learning; 2007. p. 382-9

References13. Vanhoutte P, Boulanger C, editors. Endothelium derived factors and pathology.

In: Levy Bernard, Tedgui Alain, editors. Biology of the arterial wall. United States of America: Kluwer Academic Publishers; 1999. p. 62-3

14. Plutzky J, Libby P, editors. Pathophysiology of atherosclerosis heart disease. In: Tonkin A, editor. Atherosclerosis and heart disease. United Kingdom: Informa Health Care; 2003. p. 4-5

15. The Diabetes Library. Causes of atherosclerosis in diabetics. [online]. 2004 [cited 2009 Nov 30]; Available from: URL:http://diabetes.boomja.com/Causes-of-Atherosclerosis-in-Diabetics-439.html

16. Scott A, Fong E. Endocrine system. In: Scott A, Fong E. Body structures and functions. 11th ed. Canada. Cengage Learning; 2009. p. 215-7

17. Emanuel R, Strayer DS, editors. Cell injury. In: Rubin R, Strayer DS, editors. Rubin’s pathology: clinicopathologic foundations of medicine. 5th ed. China. Lippincott William & Wilkins; 2008. p. 22-6

18. National diabetes institute. Managing diabetes and its complications. [online]. 2009 Nov 12 [cited 2009 Dec 5]; Available from: URL:http://www.nadidiabetes.com.my/nadimgr09e9.html?xsection=complications&xdate=20020603&xname=article1

References19. Kementerian kesihatan Malaysia. Senarai clinical practice guidelines:

managemant of type 2 diabetes mellitus 4th ed. [online]. 2009 [cited 2009 Dec 5]; Available from: URL:http://moh.gov.my/MohPortal/cpgDetail.jsp?action=view&id=67

20. Academy of medicine Malaysia: Clinical practice guidelines on dyslipidaemia. [online] 2003 Aug [cited 2009 Dec 5]; Available from: URL:http://www.acadmed.org.my/index.cfm?&menuid=28

21. Lauralee Sherwood. Cardiac physiology. In: Lauralee Sherwood. Human physiology: from cells to systems. 7th ed. USA: Brooks/Cole, Cengage Learning. 2010.p. 334-336.

22. Mary Lee. Lipid disorders. In : Mary Lee. Basic skills in interpreting laboratory data. 4th ed. Wisconsin (USA): American Society of Health-System Pharmacists. 2009.p. 325-328.

23. Yayasan Jantung Malaysia. The heart foundation of Malaysia. Inherited cholesterol disorder. [online] [cited 2009 Dec 5]; Available from: URL:http://www.yjm.org.my/index.cfm?menuid=5