11. Cardiovascular Health Flashcards

Question

What are PPAR-γ agonist foods?

Answer 1

1. Apigenin (celery juice and parsley) 2. Hesperidin 3. curcumin (add pepper) 4. resveratrol (red grapes, supplement) 5. EGCG (polyphenol from green tea).

Answer 2

1. Family history: Siblings of CVD patients = 40% risk increase. Offspring of parents with premature CVD = 60–75% risk increase. 2. Genetics: MnSOD, NOS3, MTHFR and ACE gene polymorphisms. 3. Ethnicity: Individuals of South Asian or sub-Saharan African origin have an enhanced risk of CVD. 4. Gender: Common view that CVD is predominantly a male pathology. CVD mortality in women (35–54) is increasing. Risk is underestimated as women tend to experience more vague physical signs e.g., lightheaded with exertion and symptoms can be mistaken for the menopause or heartburn. 5. Dyslipidaemia: ↑ total cholesterol ― ↑ LDL, VLDL, IDL, Lp(a) (better measure than LDL of CVD risks), ↓ HDL (take cholesterol back from our body cells to the liver for breakdown); ↑ triglycerides. 6. Hypertension: CVD pathologies tend to appear 5 years earlier in those with hypertension. 7. Mitochondrial dysfunction: ATP is required to pump Ca ions out of myocardial cells, allows relaxation and maintains electrochemical gradient across myocardial cell membrane. Consider statins/CoQ10.

Answer 3

Associated with sedentary lifestyle, excess alcohol, smoking, obesity, high intake of saturated and trans fat, menopause. Risk increases in T2DM, hypothyroidism and chronic kidney disease.

Answer 4

1. Elevated Homocysteine: Associated with LDL oxidation, monocyte adhesion and ED dysfunction. 2. Obesity: Excess adipose tissue perpetuates inflammation contributing to vascular breakdown and metabolic complications. 3. Insuline resistance: Generates chronic hyperglycaemia leading to oxidative stress, inflammation and cellular damage. 4. Advanced glycation end products (AGEs): Harmful compounds formed when protein or lipids becomes glycated after exposure to glucose. 5. * Smoking: ↑ oxidative stress (ROS react with NO to form harmful peroxynitrite) and lowers antioxidants (1 cigarette = 25 mg loss of vitamin C). Nicotine over-stimulates SNS and increases BP. 6. Sedentary lifestyle: Exercise has a positive effect on lipid profile and blood pressure and ↑ insulin sensitivity and NO production. Brisk walking 30 mins / day can protect against CVD mortality. 7. Chronic stress: May cause ED dysfunction especially in the presence of other risks e.g., smoking. Activates SNS and HPA-axis, ultimately ↑ inflammatory cytokines. ↑ heart rate and blood pressure through the SNS. Raised activity of the amygdala increases arterial inflammation. 8. Periodontal disease — ↑ systemic inflammation (↑ TNF, IL-1, IL-6, CRP) which impair vasodilation. Promotes endothelial dysfunction, arterial stiffness and ↑ fibrinogen (plaque formation). 9. Heavy metals — induce oxidative stress, lipid peroxidation and inflammatory cytokines. Cadmium and lead compete with zinc. A zinc deficiency increases atherosclerosis risk. 10. Melatonin deficiency — melatonin is a potent antioxidant with anti- hypertensive properties. It protects against coronary artery disease.

Answer 5

1. Low folate and B12 — needed for the re-methylation of homocysteine to methionine; vitamin B6 — a co-factor in the conversion of homocysteine to cysteine in the methylation cycle. 2. Genetic polymorphisms: MTHFR impacts supply of methyl groups needed to methylate B12 in the methionine cycle (in turn methylates homocysteine); FUT2, TCN impact B12 (all forms) absorption. MTR, MTRR impact B12 activation (application of a methyl group). 3. The other route for methylating homocysteine is dependent on choline (PEMT and CHDH genes) and betaine (BHMT gene). 4. Thyroid hormones (TH): TH receptors are present in the myocardium and vascular tissue and minor TH changes can alter CV homeostasis. Hypo and hyperthyroidism are linked with ED dysfunction, dyslipidaemia and BP changes. 5. Inflammation: Has various origins including dyslipidaemia, dysbiosis and intestinal permeability, ROS, diabetes, excess adipose tissue and smoking. Inflammation contributes to ED dysfunction. In turn, ED dysfunction, subintimal cholesterol accumulation and recruitment of monocytes and T-cells drives the inflammatory response.

Answer 6

1. Inflammation is linked with ↑ endothelin-1 (ET-1), a potent vasoconstrictor peptide. Elevated ET-1 leads to fibrosis of VSMCs and ↑ ROS. 2. Adiponectin, a peptide that influences expression of ED cells, protecting against CVD, is decreased in obesity. 3. Adiponectin also ↑ insulin sensitivity, thus low levels contribute to insulin resistance (IR). 4. Obesity is associated with high levels of leptin, which activates the SNS causing sodium retention, vasoconstriction & ↑ blood pressure

Answer 7

* IR contributes to the lipid triad (high plasma TGs, low HDL, small dense LDLs) and dyslipidaemia. * Dyslipidaemia along with ED damage (due to dysfunctional insulin signalling) leads to atherosclerotic plaque formation. * IR means that glucose is not cleared from the bloodstream as quickly as needed, increasing the risk of glycosylation reactions and the production of damaging compounds — advanced glycation end products (AGEs)..

Answer 8

1. Receptor-mediated: Bind to the cell receptor RAGE (ED, VSMCs and immune cells) increasing inflammatory cytokines and ROS via activation of NADPH oxidase (an enzyme that increases ROS) which activates NF-kB. 2. Non-receptor mediated: Increased EC matrix synthesis, trapping ED LDL and cross binding with collagen (vascular stiffening).

Answer 9

* AGEs increase with advancing age. Renal accumulation of AGEs promotes kidney dysfunction. * Polymorphisms of the AGER gene (encodes RAGE) can ↑ disease risk. * Diet (exogenous AGEs) contribute to overall AGE pool: High refined carbohydrates (sucrose, HFD), processed foods, meat and dairy. * Cooking methods: High heat, grilling, roasting, searing / frying promote AGE formation. * Smoking and sedentary lifestyles enhance AGE accumulation.

Answer 10

* SCFAs produced by the microbiota, ↓ risk of metabolic endotoxaemia (a key risk factor for CVD and IR) by maintaining intestinal barrier integrity. SCFAs reduce serum lipids by inhibiting cholesterol synthesis or redirecting lipids to the liver. * The gut microbiota play a role in cholesterol regulation by altering bile acids that influence systemic cholesterol levels. * Alterations in the gut microbiota can lead to an increase in harmful metabolites such as trimethylamine-N-oxide (TMAO). TMAO is associated with endothelial dysfunction and increased risk of CVD.

Answer 11

TMAO = a proinflammatory metabolite that originates from the bacterial metabolism of choline-rich foods

Answer 12

* High PRAL — foods rich in protein (e.g., meat, cheese) may induce low-grade metabolic acidosis, a risk factor for IR and CVD. * Trans fats — promote dyslipidaemia (↑ LDL-C, TGLs, ↓ HDL-C), increase inflammation, contribute to ED dysfunction, encourage visceral adiposity and increase risk of IR. * Fructose — high fructose intake promotes de novo lipogenesis, ↑ fatty acids, in particular palmitic acid. Palmitic acid ↑ expression of the receptor involved in the uptake of oxidised LDLs and is a major driver of atherosclerosis and CAD. * Nutrient deficiencies (e.g., vitamin C, D, E, CoQ10, Mg). See therapeutics.

Answer 13

Potential Renal Acid Load = measure potential acidity of a diet

Answer 14

* Cardiac risk tools (e.g., QRISK ®): calculate score based on CV risks e.g., age, BMI, smoking. QRISK score 10% = 1 in 10 chance of developing CVD in next ten years. * Cardiac troponin: Cardiac troponin proteins hs-cTnT and hs-cTnI are released into the blood when heart muscle is damaged e.g., MI. Often measured alongside an ECG (electrocardiogram). * Lipid profile: TC (total cholesterol), non-HDL, TG and LDL-C, TC:HDL ratio. * Lp-PLA 2: Enzyme produced by monocytes, macrophages, T-cells. Upregulated in atherosclerotic plaques and vascular inflammation. * hsCRP: Inhibits NO and e-NOS and is involved in plaque deposition. Low risk: < 1.0 mg / L. High risk: > 3.0 mg / L. * MPO: Released by macrophages and measures the body’s response to damaged arterial walls. High MPO is associated with inflammation / oxidative stress and a poor prognosis. Exacerbated by high BP, obesity and smoking. Low=<470 pmol/L, high ≥ 540 pmol/L.

Answer 15

* Adopt the principles of the CNM Naturopathic Diet. * Plant-based and Mediterranean-style diets are associated with significantly reduced CVD risk showing: ↓ inflammatory mediators, ROS and RNS; reduced adiposity (especially visceral) and risk of thrombosis; ↑ SCFA production, improved insulin sensitivity, ↑ adiponectin and improved ED function.

Answer 16

1. Downregulates NADPH oxidase, a key source of ROS in the vascular wall. 2. Upregulates endothelial NO synthase (catalyses synthesis of NO from arginine). 3. Lowers tendency for platelet aggregation. 500–1000 mg 3 x daily

Answer 17

1. Mixed tocotrienols and tocopherols — along with vitamin C protects the endothelium from ROS and supports NO synthesis. 2. ↓ oxidation of LDL-C and deposition in arterial walls. 3. Inhibits platelet aggregation and ↓ clotting factors to support healthy blood viscosity. Vitamin E 400–800 iu / day

Answer 18

1. Modulates NO synthesis and influences cells involved in atherogenesis e.g., ED, VSMCs, monocytes and cardiac myocytes. 2. Modulates RAAS and lowers BP. Vitamin D - 600–1000 iu / day

Answer 19

1. Improve lipid and lipoprotein profiles. 2. Involved in the synthesis of key regulators of inflammation, vasodilation and platelet aggregation. 3. EPA stabilises cellular membranes allowing neutralisation of extracellular ROS. 4. DHA supports membrane fluidity. 3–6 g / day

Answer 20

1. Through regulation of ion transporters e.g., potassium and calcium channels, plays a central role in modulating neuronal excitation, intracardiac conduction and myocardial contraction. 2. Helps regulate vascular tone and stabilise heart rhythm. 500–800 mg / day

Answer 21

1. Protects against endothelial dysfunction and reduces LDL oxidation (↓ atherosclerosis risk). 2. Increases superoxide dismutase activity, which preserves the activity of NO (↓ risk of high BP). 3. Supports mitochondrial health and production of ATP. 60–300 mg / day

Answer 22

1. Cardiac tonic; strengthens and improves vascular elasticity, has ACE-inhibiting actions (↓ BP). 2. Hawthorn reduces ET-1 and increases NO levels, hence having vasodilatory effects. 3. Antioxidant (e.g., ↑ SOD), anti-inflammatory (inhibits NF-κB). 1,000–1,500 mg

Answer 23

1. Antihypertensive effects by stimulating NO production in ED cells. Lowers homocysteine↓ CVD risk. 2. Decreases arterial calcification (stiffness). 3. Reduces LDL cholesterol and LDL oxidation. 4. Enhances glutathione and SOD. 5. Protects against abnormal platelet aggregation. 2–5 g fresh bulb /day

Answer 24

Exercise: regular physical activity and exercise significantly reduces CVD risk and is associated with a reduction in all-cause mortality. – Leads to a more favourable lipoprotein profile; ↓ TGs. – Improves insulin sensitivity, and insulin signaling in the vascular endothelium, activating eNOS, which ↑ NO synthesis. – Regular exercise promotes a net reduction in blood pressure at rest (cardiac output and BP transiently ↑ during exercise).

Answer 25

Stress management: Encourage diaphragmatic breathing exercises, humming, singing to promote parasympathetic activity. Include herbal teas to relieve stress e.g., chamomile, passionflower, lemon balm, lime flower tea.

Answer 26

1. Statins: Block HMG CoA-reductase ↓ coenzyme Q10 synthesis. 2. Cholestyramine (↓ cholesterol): A bile acid sequestrant. ↓ absorption of fat-soluble vitamins and beta-carotene. 3. Loop and thiazide diuretics: ↑ potassium, calcium, thiamine and zinc (thiazide) excretion. 4. ACE inhibitors: Bind with zinc preventing utilisation by the body. 5. Beta-blockers: ↓ melatonin production by inhibiting adrenergic beta1 receptors; block the biological pathway of CoQ10-dependent enzymes.

Answer 27

Hypertension (HTN) = a leading contributor to CVD. * Blood pressure (BP) reflects the force of circulating blood against the walls of the arteries (CO + total PR). * It is expressed as a ratio of systolic BP (the pressure blood exerts on arterial walls when the heart contracts) and diastolic BP (pressure when the heart relaxes). * In the UK, HTN is currently defined as 140/90 mmHg or higher.

Answer 28

Fatigue, headache, dizziness, visual disturbance. However, is often asymptomatic, hence BP testing is standard practice. HTN can ↓ life expectancy by 5 years.

Answer 29

* Essential [or primary] (95%) ― no specific underlying medical cause. Drivers include vascular resistance (due to vasoconstriction, atherosclerosis, loss of blood vessel elasticity, increased blood viscosity), obesity, stress and anxiety, smoking, high salt intake. * Secondary hypertension (5%) ― due to diseases of the kidneys, adrenals, thyroid, diabetes. * Malignant hypertension is pressure above 180/120, which risks damaging organs, e.g., kidneys (medical emergency).

Answer 30

1. Genetic — normotensive offspring of HTN parents often have ED impairment suggesting a genetic link. 2. Obesity (especially ↑ abdominal adiposity) — activates the RAAS causing vasoconstriction and water retention. 3. Excess alcohol — ↓ the baroreceptor reflex (ability to respond to BP changes) by interacting with receptors in the brain stem; ↑ sympathetic outflow ↑ heart rate and BP; stimulates the ED to release vasoconstrictors, activates the RAAS. 4. Stress — ↑ SNS activity causing vasoconstriction. High cortisol ↑ the potent vasoconstrictor ET-1; activates the RAAS (RAAS = renin angiotensin aldosterone system). 5. Nutritional deficiencies — especially magnesium (vasodilates), potassium (↑ urinary excretion of sodium, ↓ blood volume). 6. High table salt intake and / or low potassium. Salt-sensitive HTN occurs in 50% of HTN individuals. Unrefined salts e.g., Celtic are preferable (contain trace minerals), however, moderate intake. 7. Inactivity — associated with higher HR, increased cardiac contractility and greater force on the arteries. 8. Smoking — damages endothelium; nicotine constricts blood vessels and increases heart rate. 9. Drugs — NSAIDs, corticosteroids, decongestants can ↑ BP. *10. Raised uric acid — stimulates the RAGE pathway, which increases NF-KB and disrupts eNOS activity. It exacerbates endothelial insulin resistance and lowers NO, whilst also upregulating genes that code for components of the RAAS (increasing BP).

Answer 31

1. Increase potassium / sodium ratio >3:1 2. DASH Diet (dietary approach to stop hypertension) 3. ACE inhibitory peptides 4. Optimise sleep (see previous lectures) — melatonin is associated with anti-hypertensive effects through GABA stimulation, angiotensin-II inhibition and increases in NO. 5. Optimise weight; include aerobic and resistance exercise; stress management; support PSNS (Vagal) activity — see earlier lectures.

Answer 32

1. Include fresh fruit and vegetables (high potassium / sodium ratio). 2. Potassium increases natriuresis, encourages vasodilation reduces sensitivity to angiotensin II and lowers SNS activity. 3. Lowers NADPH oxidase, decreasing ROS in the vascular wall. 4. Avoid potassium supplements and take care with potassium intake in renal disease and with ACE inhibitors and K-sparing diuretics. 5. Restrict sodium intake to 1.5g / day.

Answer 33

Naturally-occurring ACE inhibitory peptides can be found in certain plants and foods and act like a decoy encouraging ACE to react with peptides, reducing vasoconstriction via angiotensin II. Sources: spirulina, mushrooms, spinach, hemp seeds, walnuts and bitter melon seeds.

Answer 34

DASH consists of fresh vegetables and fruits, legumes, nuts, seeds, whole grains, fish, lean meat and low-fat dairy and limits saturated fats and salt. PUFA / MUFA are preferred. Sodium is restricted.

Answer 35

* Deficiency of vitamin D leads to overexpression of renin, activating RAS — ↑ vasoconstriction and retention of sodium and water. * ↓ proinflammatory cytokines, ↑ NO, ED function and arterial elasticity and ↓ hs-CRP. * The lower the levels of vitamin D the greater the risk of hypertension. Dose as needed to reach optimal levels

Answer 36

Deficiency is associated with HTN. Alterations in intracellular and extracellular magnesium affects cardiac and vascular tone and reactivity. 500–800 mg / day

Answer 37

* Arginine is the principle substrate for vascular NO synthesis. * Modulates the RAS, inhibiting ACE activity, thereby decreasing angiotensin II and its downstream effects. * Hypertensive patients display high hs-CRP, low apelin (stimulates NO in ED) and increased arginase (breaks down arginine). 1000 to 2000 mg x 3 daily

Answer 38

B6 deficiency is associated with hypertension. It is an important co-factor (e.g. NA, adrenaline, serotonin). Increases cysteine synthesis, glutathione, blocks Ca channels and reduces SNS tone. Reduced with diuretics! 100 mg 1–2 x daily

Answer 39

Thetraditional ‘C.A.T.’ formula: Equal parts dried herbs infused, 1 cup 2–3 x daily. * Crataegus spp. [hawthorn] (cardiotonic, hypotensive). * Achillea millefolium [yarrow] (diuretic, hypotensive). * Tilia europea [lime flower] (nervine relaxant, diuretic, anti-hyperlipidaemic). To support blood pressure lowering, dandelion leaf is a diuretic and naturally rich in potassium. 1–2 teaspoons infused, 2–3 cups daily, or 3–4 fresh leaves in salads / smoothies.

Answer 40

Stress management: Essential because of the physiological effects of the stress response on CV health. 1. Diaphragmatic breathing: Shown to decrease systolic and diastolic BP, heart rate and anxiety, and promote a sense of relaxation in pre-hypertensive and hypertensive individuals. 2. Earthing: (Walking barefoot on grass or sand) improves heart rate variability, lowers night-time cortisol and promotes a parasympathetic state.

Answer 41

Atherosclerosis = narrowing and hardening of large and medium arteries, which reduces blood flow.

Answer 42

* ED dysfunction plays a central role in the formation of fatty streaks, a primary event in atherosclerosis. * Increased permeability facilitates entry of LDL into the intima. LDL becomes ‘trapped’ within the vessel wall and is oxidised to mLDL. * mLDL (modifiedLDL) recruit leukocytes expressing high levels of pro-inflammatory cytokines. Also trigger cytokine release from ED and VSMC cells. * Macrophages imbibe lipoproteins to form foam cells. Cellular debris is incorporated and inflammation drives plaque formation. * A cap is formed over the plaque to wall off the plaque from blood.

Answer 43

1. endothelial dysfunction 2. inflammation 3. dyslipidaemia

Answer 44

1. Disturbance to the protective glycocalyx layer and damage to ED cells. Factors include inflammation, ↑ oxidative stress, oxidised LDLs, hyperglycaemia, endotoxaemia, abnormal shear stress. 2. Leads to altered regulation of inflammatory cytokines, eicosanoids and compounds that promote clotting risk. 3. Upregulation of chemo-attractant molecules promotes migration of phagocytic and inflammatory immune cells into blood vessels. 4. Disturbs NO metabolism ↑ hypertension risk  increases shear stress worsening endothelial dysfunction => plaque development.

Answer 45

1. ED dysfunction, subintimal cholesterol accumulation and monocyte / T-cell recruitment drives the inflammatory response. 2. Monocytes become resident macrophages in the sub-endothelial space and form ‘inflammasomes’ releasing inflammatory cytokines which activate IL-6 and stimulate CRP production enhancing the inflammatory cascade in the vessel walls. 3. Inflammation thins the fibrous plaque cap => instability / rupture. 4. Pro-inflammatory cytokines differentiate VSMC into osteoblast-like cells increasing plaque calcification.

Answer 46

1. Lipids are a fundamental component of atherosclerotic plaques. Thus, dyslipidaemia is a significant risk factor and is marked by: – ↑ total cholesterol — ↑ LDL, VLDL, IDL, Lp(a), ↓ HDL; ↑ TGs. 2. TGs are hydrophobic and must combine with lipoproteins to travel in plasma. In a similar manner to oxidised LDLs, TG-rich lipoproteins (e.g., VLDLs and VLDL remnants) are prone to endothelial accumulation and uptake by foam cells and are strongly linked with endothelial dysfunction. 3. High TGs are also linked with low HDLs

Answer 47

1. Promote a healthy lipid profile 2. Support endothelial health and vasodilation 3. Promote and support liver detoxification

Answer 48

1. Avoid high saturated fat to reduce risk of CV events. 2. Increase omega-3 FAs (see later) and MUFAs: E.g., avocado, unrefined olive oil. Regular EVOO consumption reduces LDL-C and oxidised LDLs, and improves post-prandial glycaemic profiles. 3. EVOO polyphenols oleocanthal and oleacein have antioxidant and anti-inflammatory effects (↓ markers including CRP and IL-6). 4. Red yeast rice (2400–4800 mg / day) ― contains monacolin K, an inhibitor of cholesterol synthesis via HMG CoA reductase. 5. Soluble fibre (vegetables, fruits, psyllium husk, pectin, gums) are associated with a decrease in TC and LDL-C. 6. Include dietary sources of beta-glucans (soluble + insoluble fibre) e.g., oats, mushrooms, seaweed, barley. Interactwith lipids and biliary salts in the bowel and lower LDL-C, non-HDL-cholesterol and ApoB. 7. Are also a source of SCFAs — decrease liver cholesterol synthesis and increase bile excretion, and interact with innate immunity receptors to modulate immune function

Answer 49

1. Hawthorn berries, bilberry, blueberries and blackcurrants are antioxidant and support blood vessel integrity and tone. 2. Lower ET-1 levels: Enhance citrus flavonoids, quercetin, epicatechins, garlic, olive oil, ginkgo, folate, blackcurrant. 3. Beetroot contains inorganic nitrates that convert to NO in the body. Also ↓ homocysteine ― contains betaine which is utilised by the enzyme BHMT that re-methylates homocysteine to methionine. 4. L-theanine ↑ NO production in ED cells through eNOS phosphorylation (green tea is a key source). 5. Reduce homocysteine: B6, folate and B12 (supplement methylfolate and methylcobalamin supplementation), TMG (3 g twice daily). 6. Lower fibrinogen levels: High fibrinogen promotes atherosclerosis by increasing blood viscosity, stimulating fibrin formation and increasing platelet aggregation. Mediterranean-style diets promote healthy levels. Garlic reduces fibrinogen, ↑ fibrinolytic activity (also ↓ atherogenicity of LDLs). Mild to moderate exercise reduces fibrinogen levels.

Answer 50

1. Ensure availability of all substrates required for detoxification pathways (review Metabolic Detoxification lecture). 2. Poor liver function can increase circulation of inflammatory mediators, impede cholesterol metabolism and comprise essential fatty acid status. 3. Schisandra fruit supports liver function and is a powerful activator of phase I detoxification without increasing harmful bioactivation (antioxidant and hepatoprotective effects). Enhances phase II detoxification. Dose: 2–3 dried fruit infused twice daily. Dried berries can be eaten as a ‘superfood’.

Answer 51

1. L-citrulline 2. Pantothenic acid / pantetheine 3. Niacin (B3) 4. Omega 3 5. Pomegranate 6. Pycogenol 7. Lycopene 8. Citrus Bergamia 9. Globe artichoke

Answer 52

1. NO is synthesised from L-arginine by eNOS. 2. Arginase in intestinal enterocytes and first-pass metabolism (FPM) in the liver ↓ the availability of oral L-arginine supplementation. L-citrulline is not affected by arginase and skips FPM before conversion to arginine by argininosuccinate lyase in the kidneys, so is preferrable to enhance both arginine and NO bioavailability. 3. Renal arginine regulates BP, blocks formation of endothelin, ↓ renal sodium reabsorption and is a potent antioxidant. 500-3000mg/day

Answer 53

1. Metabolised to cystamine-SH. Reduces TC, LDL, Apo-B, TG and increases HDL over 4 months with a peak effect at 6 months. 2. Reduces lipid deposition, oxidation and fatty streak formation. Appears to be especially useful in lowering lipids in diabetic patients. 300mg 3x/day

Answer 54

1. Niacin reduces TC, LDL, Apo-B, LDL-P, TGs and VLDL. 2. Also shown to decrease fibrinogen. 3. Note: Can cause niacin flush, GI disturbance 500-3000mg/day

Answer 55

1. Reduces TG, VLDL, LDL-P and chylomicron remnants. Uniquely reduces Lp-PLA 2. 2. Anti-inflammatory, anti-thrombotic, lowers BP, heart rate and IR. PPAR-α agonist. 3. Reduces CVD progression and stabilises plaques 3000-5000 mg/day

Answer 56

1. Improves HDL function, ↑ reverse cholesterol transport. 2. Potent antioxidant, ↓ oxLDL and macrophage LDL uptake. 3. Decreases progression of carotid artery IMT (intima-media thickness - marker of atherosclerosis). 4. Reduces BP mostly in those with high oxidative stress. 250 ml of juice (pure) per day or 1–2 cups of seeds per day

Answer 57

1. Flavonoid, antioxidant, anti-inflammatory, anti-thrombotic. 2. Enhances NO and ED function, reduces BP and Hs-CRP. 3. ↓ myeloperoxidase ― an enzyme secreted from macrophages that ↑ oxidation of lipoproteins in atheroma. 4. Appears to reduce foam cell formation in atherosclerosis. 100-200mg/day

Answer 58

1. Anti-oxidant. Suppresses intestinal cholesterol absorption. Lowers TC, LDL-C, inflammation and increases HDL-C. 2. Activates PPAR-γ. 3. Studies show reduction in carotid atherosclerosis. 25mg/day

Answer 59

1. Bergamot (citrus fruit): Natural source of flavonoids, e.g., naringin, hesperidin, neohesperidin and neoeriocitrin. 2. Lowers LDL and TGs. Increases PPAR activation. 3. Reduces ROS, oxidised LDL, balances blood glucose and reduces weight. 4. Improves serum glucose via AMPK (AMPK (AMP-activated protein kinase) = a central regulator of energy homeostasis) and GLUT 4 receptor. 500-1000mg/day

Answer 60

1. Reduces serum LDL, TC and TGs. 2. Regulates lipid metabolism, increases bile production, is antioxidant and hepatoprotective. Dietary + 1–2 g / day powdered

Answer 61

1. Sauna: ↑ circulation and arterial vasodilation. Avoid in unstable angina / recent MI and hypertension. 2. Dry skin brushing: Supports circulation and lymphatic function, increases toxin elimination. 3. Contrast hydrotherapy (alternating warm / cold water): improves circulation and supports removal of toxins. If circulation is compromised end on warm. 4. Tai Chi Chuan, yoga and acupuncture have shown to reduce ET-1 levels.

Answer 62

an imbalance between myocardial oxygen supply and demand, associated with inadequate arterial supply via the coronary arteries. Atheroma and inappropriate vasoconstriction reduce blood vessel lumen size and coronary blood flow. When oxygen demand > oxygen supply, myocardial hypoxia, accumulation of waste metabolites and ischaemia ensues.

Answer 63

atherosclerosis

Answer 64

angina (stable and unstable) myocardial infarction.

Answer 65

Angina = chest pain caused by insufficient supply of oxygenated blood supply to the myocardium by the coronary arteries.

Answer 66

1. Stable angina: Predictable transient chest pain during exertion or emotional stress. Ischaemia with symptoms resolve once oxygen balance is restored. 2. Unstable angina: Unpredictable / occurs at rest. Plaque disruption initiates platelet aggregation, thrombus formation and vasoconstriction. May be a precursor to acute MI.

Answer 67

Constricting chest pain (can radiate to the neck, L shoulder / arm and jaw), worsened by exertion, relieved by rest. Shortness of Breath sweating nausea

Answer 68

1. See earlier section on CVD risk factors. Also consider: 2. Cigarette smoking ― linked to endothelial dysfunction, CAS (coronary artery spasm), vessel wall injury, oxidative stress, elevates fibrinogen, platelet activation and inflammation. Smoking cessation in angina can prevent recurrent angina events. 3. Vitamin D deficiency ― significant correlation between vitamin D deficiency and chronic angina. Improves endothelial function by signalling for the transcription of eNOS; modulates the RAAS to lower BP. 4. Family history of premature IHD is a strong risk factor for angina.

Answer 69

ECG, cardiac stress testing, angiography

Answer 70

Nitrates (e.g., GTN) calcium channel blockers (e.g., amlodipine) beta-blocker (e.g., atenolol) revascularisation (angioplasty, stents and coronary artery bypass graft surgery).

Answer 71

an acute blockage of a coronary artery usually due to a thrombus, resulting in the death of myocardial tissue.

Answer 72

* Prolonged ischaemia leads to myocardial necrosis. Ischaemic myocardial cells release adenosine and lactate onto nerve endings causing pain. * Infarcted areas produce scar tissue. The remaining tissue hypertrophies and can result in cardiac dysfunction and heart failure.

Answer 73

– ST-Segment Elevation MI (STEMI) = full occlusion (severe). – Non-ST-Elevation MI (NSTEMI) = partial occlusion.

Answer 74

* See earlier section on CVD risk factors. Also consider: * Sex: Males ~ 3 times more likely to experience MI. High androgen levels contribute to development of atherosclerosis. * Psychosocial factors: Stress (e.g., financial). Loss of locus of control, sudden life events (e.g., job loss, marital separation) increase MI risk. * Others: Drug-induced (cocaine), significant myocardial O2 demand (e.g., severe hypertension) or reduced O2 supply (e.g., severe anaemia), vasculitis syndromes (e.g., temporal arteritis).

Answer 75

1. Severe prolonged crushing retrosternal chest pain. Pain radiates to the left shoulder, jaw / neck or arms. Sweating, cool / clammy skin. Feeling of ‘impending doom’. 2. Dyspnoea and syncope. 3. Nausea, vomiting, weakness.

Answer 76

Complications: Arrhythmias, heart failure, cardiogenic shock, death. Diagnosis: ECG findings. Allopathic approach: Fibrinolysis, O2 therapy, morphine, nitrates, beta blockers, aspirin for acute management.

Answer 77

Apply the Natural Approach to CVD, with a focus on supporting myocardial blood flow. Key considerations: 1. Optimise vitamin D status – supports endothelial health and promotes vasodilation (↑ NO). 2. Warming herbs / spices to support blood flow, e.g., ginger, cayenne. 3. Increasing movement — care is needed to avoid triggering angina attacks — focus on gentle exercise i.e., Tai Chi, Qi Gong, walking. Gradually increase as capacity improves. 4. Address stress. Breathing exercises. Nervine herbs (e.g., passionflower 1–2 tsps dried herb 2–3 x per day (infusion).

Answer 78

1. L-Carnitine 2. Magnesium 3. CoQ10 4. L-Arginine

Answer 79

Improves FA utilisation and myocardial ATP production, which may also prevent the production of toxic FA metabolites. These would normally impact cardiac cell membranes = impaired myocardial contractility. 1000mg 2x/day

Answer 80

Magnesium deficiency has been shown to produce coronary artery spasms. Magnesium controls the movement of calcium into smooth muscle cells, leading to smooth muscle contraction. Deficiency also ↑ ROS. 200-400mg 3xdaily

Answer 81

* Increases eNOS and NO, improves ED function and vascular elasticity. * Exerts anti-inflammatory effects – lowers TNF-α and IL-6. NF-κB can be inhibited by CoQ10’s anti-oxidant activity. 100-300 (if on statin) mg / day

Answer 82

* Promotes vasodilation by increasing NO. * Increases SOD levels, reduces lipid peroxidation and xanthine oxidase activity (reducing uric acid formation); uric acid stimulates RAGE. 1000-2000mg 3x/day

Answer 83

Its flavonoids have been shown to inhibit the enzyme 3',5'-cyclic-AMP, which is thought to be responsible for dilating the coronary arteries. 1000-1500mg

Answer 84

Enhances microcirculation and tissue perfusion (antagonises ‘platelet activating factor’ by blocking receptors). Scavenges ROS 60-120mg/day

Answer 85

Heart failure (HF) = a syndrome in which the heart is impaired as a pump ― failing to supply sufficient blood flow.

Answer 86

Breathlessness (on exertion, at rest, orthopnoea) Nocturnal dyspnoea Fluid retention (e.g., ankle oedema, abdominal swelling) Fatigue Exercise intolerance Lightheadedness Syncope Tachycardia

Answer 87

Atrial fibrillation, ventricular arrhythmias, CKD (Chronic kidney disease), sudden cardiac death.

Answer 88

Allopathic approach: Digoxin (a synthetic form of digitoxin, from Digitalis purpurea (foxglove) that increases the force of myocardial contraction), diuretics, calcium channel blockers, ACE-inhibitors.

Answer 89

Results from various CV conditions ― e.g., IHD (most common cause ― review previous risks), hypertension, AF, cardiomyopathy, LVF (left ventricle failure), pulmonary hypertension, heart valve abnormalities. – See earlier risk factors, e.g., smoking (leads to LV hypertrophy and systolic dysfunction); raised homocysteine; sedentary etc. 1. IR ― IR ↓ myocardial glucose utilisation and ↑ FFA oxidation ==> ↑ myocardial oxygen consumption and the generation of ROS. This impairs cardiac contractibility by changing sarcoplasmic reticular calcium stores and ↑ mitochondrial dysfunction. 2. Obesity ― alters cardiac structure, promotes endothelial dysfunction, contributes to IR and ↑ inflammatory cytokines. 3. Nutrient deficiencies ― CoQ10 (normally ↓ ROS and ↑ NO), vitamin D (normally ↓ inflammatory cytokines and ↑ calcium absorption etc.), B1 (common in HF due to chronic alcohol ingestion; normally acts as a coenzyme for glucose metabolism). Also vitamin B2, folate, B12, Ca, Cu, Mg, Mn, K, Se, Fe — needed for normal cardiac metabolism

Answer 90

Co-morbidities (so causes of each apply) ― e.g., CKD (Chronic kidney disease), anaemia, T2DM, thyrotoxicosis, hypothyroidism, COPD all impair functional status and prognosis of HF. – CKD causes a chronic proinflammatory state that can result in atherosclerotic lesions and myocardial fibrosis.

Answer 91

1. CoQ10 (normally ↓ ROS and ↑ NO) 2. Vitamin D (normally ↓ inflammatory cytokines and ↑ calcium absorption etc.) 3. B1 (common in HF due to chronic alcohol ingestion; normally acts as a coenzyme for glucose metabolism) Also vitamin B2, folate, B12, Ca, Cu, Mg, Mn, K, Se, Fe — needed for normal cardiac metabolism

Answer 92

Apply the Natural Approach to CVD, with a focus on supporting myocardial energy production. Key considerations: * Lower CVD risk factors — follow previous naturopathic approaches e.g., hypertension. Consider approaches for obesity, IR and T2DM. * Correct nutrient deficiencies (see previous slides) — correct identified anaemias. Consider a high- quality multivitamin / mineral formula. Correct K:Na ratio. Work to achieve ideal body weight. * Encourage smoking cessation where applicable

Answer 93

1. CoQ10 2. D-ribose 3. Magnesium 4. Thiamine 5. L-Carnitine 1. Hawthorn

Answer 94

Cardiac myocytes contain >3500 mitochondria / cell and require the highest levels of ATP activity. CoQ10 is essential in the ETC and is a powerful antioxidant. CoQ10 depletion is associated with worse HF outcomes. 300–400 mg daily.

Answer 95

Has been shown to regenerate low myocardial ATP with an accompanying improvement in ventricular function following ischaemia. Symptom improvements (e.g., fatigue) in chronic HF have been observed. D-ribose 5–15 g daily

Answer 96

Critical for ATP. When deficient increases RAAS (increasing BP), predisposes to low K and may worsen cardiac contractility, increase vasoconstriction and deplete cardiac energy stores. 400-800mg daily magnesium citrate

Answer 97

Thiamine is a required coenzyme in energy-producing reactions — fuelling myocardial contraction. Note: CVD drugs e.g., diuretics cause a B1 deficiency 100-200mg/day

Answer 98

Facilitates the transfer of fatty acids across mitochondrial membranes to initiate beta-oxidation. The heart uses free fatty acids as its main energy source! 2000-3000mg/day

Answer 99

Benefits have been observed in cases of chronic heart failure. This is attributed to hawthorn’s vasodilatory effects on the coronary arteries and potent antioxidant properties. Increases NO. 1000-1500mg

Answer 100

Varicose veins = dilated / distorted superficial veins in the lower limbs where the pressure is higher due to gravity.

Answer 101

Visible vein dilation; aching, burning, throbbing, heaviness. Worse for prolonged standing and at the end of the day.

Answer 102

↑ venous pressure = fluid leakage into surrounding tissues (‘varicose eczema’). Slow healing varicose ulcers.

Answer 103

dilated veins in the anal canal. Internal or external.

Answer 104

Bright red blood with blood movements, protruding haemorrhoids, anal itching.

Answer 105

1. Increased abdominal pressure ― constipation, obesity, pregnancy, childbirth and post-labour, ascites. 2. Inherited valve defects ― an absence of some valves or faulty valves. 3. Cigarette smoking (= hypoxia, which results in endothelial damage, vessel wall inflammation and a loss of elasticity). 4. Being sedentary (increasing venous pressure). 5. Lack of dietary connective tissue support, e.g., low vitamin C (increases type I collagen synthesis), low bioflavonoids (support connective tissue integrity). 6. Portal hypertension ― increased portal vein pressure e.g., due to liver cirrhosis and heart failure. 7. Increased blood viscosity and stagnation ― dehydration, liver congestion, sedentary lifestyle. Also haemorrhoids, post-food fatigue, purple tongue, thick white / yellow tongue coating. 8. Abdominal bloating (not obesity) ― distended and uncomfortable. E.g., associated with SIBO. 9. Structural ― e.g., poor diaphragm motion (consider causes such as stress, asthma etc.), weak pelvic floor (consider pregnancy).

Answer 106

1. CNM Naturopathic Diet. Reduce inflammation, increase blood flow and speed up repair of damaged veins / valves. Correct root causes! 2. Vitamin C-rich foods (to support collagen synthesis). 3. Bioflavonoids such as rutin, proanthocyanidins and anthocyanins which improve the integrity of ground substance and the vascular system, whilst also acting as antioxidants. Food source examples: buckwheat (highest source of rutin) grapes, apples, cranberry, blueberry, figs, blackcurrants, capers, asparagus, green tea

Answer 107

1. Enhance fibrinolytic activity — garlic, onions, ginger, cayenne. Include bromelain sources to increase plasminogen activator status. 2. Optimise liver function — alleviate downward pressure. Fibre-rich plant foods: Reduce venous pressure with defecation. Ground flaxseed, or psyllium husk (15–30 g / day). See detox lecture. 3. Raise feet above heart (20 mins / day) — reduces blood pooling and improves venous return. 4. Lymphatic drainage / massage — for mild cases only — aids circulation and avoids blood pooling. Consider dry brushing. 5. Reduce weight: Address cause and exercise!

Answer 108

Vitamin C with bioflavonoids 1.5–2 g through the day Support connective tissue integrity ― increases collagen synthesis and ground substance integrity.

Answer 109

1. Horse chestnut 2. Gotu Kola 3. Butcher's broom 4. Pycnogenol

Answer 110

* An astringent herb that ↑ venous tone by ↑ the production of prostaglandin F2, which regulates the contractile action of veins, and inhibits the catabolism of venous tissue mucopolysaccharides. Also likely through its effects on 5-HT2A receptors. * Inhibits enzymes that destroy venous structures, e.g., collagenase, hyaluronidase, and elastase 400 mg (seed) daily or 15 drops of tincture 3 x daily between meals, for 3 months. Topically as a balm. Avoid raw seed, bark, flower or leaf.

Answer 111

* Contains triterpenic acids that are thought to be responsible for its supportive effects on connective tissue. * Stimulates glycosaminoglycan and collagen synthesis, which supports vein structure and improves blood flow. 500 mg x 2 daily Note: Avoid in liver disease

Answer 112

Vasoconstrictive and astringent (its ruscogenin content has anti-elastase activity, which ↓ the diameter of veins). 300–500 mg x 2 daily

Answer 113

Contains proanthocyanidins and has collagen stabilising properties. Decreases passive dilation and stretching and gives vein walls a greater tonic recovery and elasticity. 150–300 mg / day

Answer 114

1. Regular exercise (e.g., aim for a target of steps walking; jogging etc.). Exercise sitting (rotate ankles). Avoid prolonged standing. 2. Weight loss where applicable. Support stockings esp. if standing for prolonged periods is unavoidable. Elevate the legs periodically. 3. Tissue salts — calc. fluor. (tissue strengthening). If bleeding add ferrum. phos. 4 pills x 3 daily. 4. Topical application of astringent herbs: Horse chestnut (Aesculus hippocastanum),witch hazel (Hamamelis virginiana), yarrow (Achillea millefolium).

Answer 115

Homeopathy: 3 pills twice daily until symptoms subside. * Hamemelis 3 x ― varicose veins are large, sore and easily irritated and stinging. Bleed very easily. * Aesculus 3 x ― haemorrhoids are congested and purple. Pain in the rectum feels “as if the rectum were full of sticks”. Pain radiates to the small of the back and hips. Sharp, shooting pain upwards from the rectum. * Nux. vomica 6C ― haemorrhoids that are better for warmth and better for passing stool. History of overindulgence in alcohol, coffee, other stimulants, etc.

Answer 116

In TCM, it is associated with Blood stagnation (consistent with the Western understanding of poor blood circulation), but also a weak digestive system (Spleen Qi deficiency). The Spleen is said to produce Blood, govern smooth muscle and hold Blood in the vessels. 1. Support Spleen Qi (Nutrition year 1). 2. A tea with equal parts cinnamon, ginger, and tangerine peel stimulates Qi and blood circulation. 3. Resolve Blood stasis by reducing stress and exercising frequently. 4. Include foods that disperse stagnant blood, e.g., chives, leeks. 5. Include blood-nourishing dark leafy greens, beetroot Blood stagnation is associated with a purple tongue

11. Cardiovascular Health Flashcards

(140 cards)