Hello Paulo,

It will be great to see progress in sleep-wake cycles regulation as a  key determinant of health of the brain, the organ that regulates all voluntary and involuntary functions, including coronary. 

Best wishes,

Tatyana

Paulo,

This is indeed an interesting topic.  I would like to see this comparison research that you write about in the question.  This is a great research question that can be addressed in numerous ways.  The one way that comes to mind is to use a cohort of individuals that have been followed for a long time like the Framingham cohort.  Are you trying to identify the genetic makeup of individuals with lower risk?  When you are running a statistical test, the magnitude of the beta always gives a good clue as to the strongest factor.

Kumar

Dear Paulo,

Dr. Crumpaker chairman of Department of Medicine, Harvard School of Medicine says in his research published in 2009, that "keep anti viral into consideration while treating the atherosclerotic disease". We find that to be very true.

Regards.

Prof. Dr. Shahid H. Sheikh

Stop researching risk factors and get into prevention. If you want to research risk factors, find a disease we haven't already studied to death. 

Dr. Paulo

How get better in ADHERENCE to all aplicable measure is the key.

Abracos

Adail

Dear Paulo

The attempt of modulating the lifestyle of a patient in terms of reduction of cardiovascular risk factors often faces a series of insurmountable obstacles, starting from complaints that we impair their quality of life, etc. Ultimately, primary prevention is usually unsuccessful, the results are better in secondary prevention, but far from expected results. In recent years, I have been telling people the story that we do not need to die only of a heart attack or brain insult. The life span is extended, we grow older, have elevated cholesterol, non-regulated hypertension, we smoke, are obese, have diabetes; the conditions for progressive atherosclerosis with consequent cerebral dementia have been fulfilled. We become the burden for our families that are supposed to look after us, we are disabled, the quality of life is largely damaged, as such we can vegetate for years.

Surprisingly, this story is often very effective. My patients respond to it very well. I do not suggest that I have "discovered" something. However, populism obviously works.

Best regards

prof. dr. Vjerran Nikolić Heitzler

 Thank you Prof. Heitzler

Your observations are very interesting and I think we have to apply it.

Dear Colleagues,

researchers and clinicians should consider the global burden of CHD, so it would be great if they invest in testing and applying intervention programs that feasible and applicable for all countries and communities all over the world.

Best regards

Dear Paulo

Primary prevention of atherosclerosis should be implemented as early as possible. The normalization of endothelial function in the reversible phase of atherosclerosis may be crucial in the prevention of CVD in children. 

Healthy life habits and eating, with the involvement of all the family, are the most important approach. The CARDIA-study demonstrates that BMI and healthy lifestyles correlate with a low cardiovascular risk. The screenings are a valuable means to identify children at risk (CSCS Study).

Preventive interventions in childhood and adolescence include diet and physical exercise implementation (mainly as a game rather than gym practice).

The Mediterranean diet, intangible heritage of humanity since 2010, has a peculiar nutritional pattern that is more effective in changing CVD risk factors in comparison with low-fat diets and can have a positive impact on epigenetic modifications: recently Mediterranean diet was shown to be effective in reducing CVD risk in children with hypercholesterolemia.

The addition of nutraceuticals to the diet, such as high viscosity glucomannan, significantly improves metabolic imbalances and reduces blood pressure and body weight. In current treatment guidelines use of statins and antihypertensive drugs should be considered in selected patients at high risk who do not respond to lifestyle changes.

In the near future epigenetics could offer a possibility of an earlier prediction of CVD risk and the development of innovative therapies intimately connected with lifestyles.

Best regards

Prof Francesco Martino

Dear Paulo: stress is an endothelial cells injuring factor. When plasma CRP is higher than 1.0 mg/L, LDL and Ox-LDL cholesterol can enter to  the subendothelial space and monocytes/ macrophages receptors take them  giving rise to foam cells   and  also  the atherogenic plaque.  OX LDL is a component of those plaques because the availability of NO is lower and the oxidative stress is higher. Another atherogenic condition is insulin resistance, whose biomarkers are   high   HOMA Insulin Resistance and low Insulin sensitivity.

Best regards.Regina Wikinski

Dear Colleagues,  

oxidative stress is an important mechanism leading to a reduced availability of endothelial NO in response to cardiovascular risk factors and subsequently promotes the development and progression atherosclerosis. We have shown that oxidative stress in children with hypercholesterolemia causes platelet activation (with release of proatherogenic, inflammatory and vasoconstrictive substances) and monocytic activation with increased expression of pro-oxidant substances and altered synthesis of adhesion molecules. We have also shown that children with multiple cardiovascular risk factors have increased oxidative stress and arterial dysfunction.

 Best regards

Prof Francesco Martino

The most important way to prevent CAD is Education.

It means to  teach childrens early  in his life to has or develop adecuate healthy life-styles. And addiotinally, it´s  more cost-effective or cheaper.

And if a child learns about healthy styles, probably it impacts into his family.

In conclussion, as the OMS enfatize, PRiMORDIAL PREVENTION:. To avoid exposure to the Risk.

Diseases ar health problems.

Prevention is educational action.

Ithink a healthy life style is important to reduce the risk of coronary heart disease.

wet cupping therapy is help the body to get red  toxins in blood  flow which increse the blood visitocity, and it reduce cholestrol, LDL in blood thus reduce the risk of CHD  

Dear Colleagues,

Thank you for your considerations.

Reducing LDL-cholesterol besides stop smoking ist the best way to prevent atherosclerosis and ist complications.  The next step would probably be increasing HDLcholesterol. Unfortunately, so far, this has not been successful, unless by modifying Lifestyle. So we wait for the data with the CETP Inhibitors anacetrapib and evacetrapib

The most  important  new approach is to improve adherence . We can save 90,000 lives and a billion $ is we get 100% adherence to drugs and behavior.

David Nash 

As everyone knows,although adherence is the most inexpensive approach to primary prevention of cardiac disease, it's the hardest thing for people to achieve. This is due to the responses of ignorance of the problem and denial of what has to be done, and to the addictive characteristics of nicotine (smoking) and of simple carbohydrates (unhealthy diet) combined. I think it's clear that formal follow-up interventions like regular phone calls, group meetings etc. have beneficial effects on people's self efficacy, their ability to keep to a plan. But many people will never receive or search out those interventions, and will not be able to adhere to a regimen. Also, providers seem to find it difficult to address the problems of smoking, overeating and physical inactivity until the patient has already had a cardiac event. Not primary prevention. Equal research should be undertaken to study how to influence people to achieve success in changing their life style - as much as on new drugs and operative procedures.

Psychologists such as James Prochaska (Stages of Change) and Brian Wansink (Mindless Eating) have done a great deal of work to improve our understanding of the problem of poor adherence to lifestyle prescriptions and how to move patients toward taking action to change their behavior. Only 80% of people have enough motivation to actually do what we ask them to do. Most are mired in the non-action stages of denial, weighing the pros verses the cons of taking action or taking baby steps at changing. However, most providers prescribe treatment plans that are very action oriented. The most recent guidelines for obesity (2013) ask people to cut daily calories to 1,200 to 1,500 for women and 1,500 to 1,800 for men and exercise aerobically most days of the week. While this approach will absolutely work for weight loss, very few obese patients will have enough motivation to carry it out. They may nod their head as if they will do it and may even try for a few days but ultimately fail...repeating this cycle time and again. A better approach is to help them work through their barriers and provdie lifestyle prescriptions that are more realistic and simpler to follow: walk 5 minutes from the house, add a fruit to the diet, take the stairs, park further away, get up out of the chair every hour, etc. Success with small changes enhances self efficacy and leads to more behavior change. My new book (Wake Up Call 911: It's Time to Reduce Your Risk for a Heart Attack and Stroke-www.tatepublishing.com) was written for the 80% mired in ambivalence and non-action. While it was written for patients, healthcare providers will learn what the research indicates helps to enhance motivation. Hope that helps...

Dear Colleagues, atherosclerosis prevention (or regression) and CHD prevention (or therapy) are very complex. Today we have a lot of questions and few answer, usually based of weak evidences. So, in the next future, only the new approach to medicine (see also the recent book of Eric Tool, "Creative destruction of medicine") based on system medicine and on 2nd level code biology, can help us. In the meantime, we must not confuse the epidemiological approach (which has its own logic and its scientific basis; however is based on the idea of "treat all to save one") with the individual clinical care. Are different logics, are based on different methods and on different experiments, not mixable.

In my opinion, we now have at least a 25% of asymptomatic patients in which you can do EXCELLENT individual integrated prevention, through a traditional clinical approach, not based on EBM/GuideLine translation on individual patient,  but on a rational use of the new technologies. 

Prof. Antonio V. Gaddi

Please note a correction to my previous post...only 20% of adults who need to change a behavior have enough motivation to enter the action stage, while 80% are mired in the non-action stages of denial, weighing the pros versus the cons or taking small baby steps at changing. This research was conducted by psychologist James Prochaska. In addition, the future direction of prevention is utilizing more effective strategies that help people move toward taking action to change their harmful behaviors. I apologize for the typing error.

To keep you healthy & free from CVS problems, make your life simple & laborious.Enjoy your life with simple things, simple but nutritive foods.Don't make high ambitions, least material, less need  AND ALCOHOLS AND VULGAR society and acts, illegal  and unnatural sex etc.Be spiritual, use more vegetables and fruits (vitamins&minerals),No over eating but fasting on & off.

Lifelong adoption of - avoidance of tobacco smoking  or exposure to enviromental tobacco smoke, regular aerobic physical activity, less sedentary lifestyle, indulgence in diet low in LDL cholesterol and sugar,increase intake of fruits and vegetables should be next in prevention of coronary artey disease.

Thank you Kingsley for you answer.

Cardiovascular disease (CVD) arise in the early stages of development and growth. Genetic and environmental factors may interact resulting in epigenetic modifications with abnormal phenotypic expression of genetic information without change in the nucleotide sequence of DNA. Maternal dietary imbalance, inadequate to meet the nutritional needs of the foetus can lead to intrauterine growth retardation, decreased gestational age, low birth weight, excessive postnatal growth and metabolic alterations, with subsequent appearances of cardiovascular risk factors . Foetal exposure to high cholesterol, diabetes and maternal obesity is associated with increased risk and progression of atherosclerosis. Maternal smoking during pregnancy and exposure to various environmental pollutants induce epigenetic alterations of gene expression relevant to the onset or progression of CVD. In children with hypercholesterolemia and/or obesity, oxidative stress activates platelets and monocytes, which release pro-inflammatory and proatherogenic substances, inducing endothelial dysfunction, decreased Doppler flow-mediated dilation and increased carotid intima-media thickness. Primary prevention of atherosclerosis should be implemented early. It is necessary to identify, through screening, high-risk apparently healthy children and take care of them enforcing healthy lifestyle (Mediterranean diet and physical activity), prescribing nutraceuticals and eventual medications, if required by a high-risk profile. The key issue is the restoration of endothelial function in the reversible stage of atherosclerosis. Epigenetics may provide new markers for an early identification of children at risk and thereby develop innovative therapies and specific nutritional interventions in critical times.

Cardiovascular disease (CVD) arise in the early stages of development and growth. Genetic and environmental factors may interact resulting in epigenetic modifications with abnormal phenotypic expression of genetic information without change in the nucleotide sequence of DNA. Maternal dietary imbalance, inadequate to meet the nutritional needs of the foetus can lead to intrauterine growth retardation, decreased gestational age, low birth weight, excessive postnatal growth and metabolic alterations, with subsequent appearances of cardiovascular risk factors . Foetal exposure to high cholesterol, diabetes and maternal obesity is associated with increased risk and progression of atherosclerosis. Maternal smoking during pregnancy and exposure to various environmental pollutants induce epigenetic alterations of gene expression relevant to the onset or progression of CVD. In children with hypercholesterolemia and/or obesity, oxidative stress activates platelets and monocytes, which release pro-inflammatory and proatherogenic substances, inducing endothelial dysfunction, decreased Doppler flow-mediated dilation and increased carotid intima-media thickness. Primary prevention of atherosclerosis should be implemented early. It is necessary to identify, through screening, high-risk apparently healthy children and take care of them enforcing healthy lifestyle (Mediterranean diet and physical activity), prescribing nutraceuticals and eventual medications, if required by a high-risk profile. The key issue is the restoration of endothelial function in the reversible stage of atherosclerosis. Epigenetics may provide new markers for an early identification of children at risk and thereby develop innovative therapies and specific nutritional interventions in critical times.

In the past we distinguish between pre-primary, primary, secondary and tertiary prevention. These classifications may still have some avail in the field of public health policies, in certain regions of the world.

In the past and even recently, we apply -uncritically to all patient- rules derived from clinical trials or copied by guidelines. Actually, law (in Eu & US) is contrary to this practice (or habit) of physicians, which confuses "general" (when not  generic) guide-line indications with the patient-customized reccommendations&prescriptions.

Today there are diagnostic tools (from phenomics, genomics, and diagnostic and functional imaging) that help identify risk factors in very early ages of life, or in adults/elderly, and, above all, there are instrumental ininvasive means to identify asymptomatic patients with coronary or carotid atherosclerotic lesions (...omissis...)

Today we can identify several personal, environmental, genetic risk factors (please see the excellent definition of FR written by McGill) and study their interactions, estimating the individual prognostic weight, avoiding the biggest logical and methodological mistake of the last century, which is to "translate" an estimate  derived by a population (n >> 1000) to  n = 1 (our patient !) 

System Medicine and the most advanced mathematical models are helping us to throw some light on the complexity of individual response to diseases. Today there are still doubts, little knowledge, and, as S Lenzi (Clinician in Bologna University)  said in 1979,  "we have to study the lights and shadows in borderline  diseases". However, road is marked, at least for the next decade.

Today, on a large percentage of patients, you can have excellent results (= improving the prognosis quo ad vitam et valetudinem) simply harmonizing good clinical approach (medical history, family histrory, deep knowledge of the patient, his style life, etc.) along with investigations of genomics / phonemics  and imaging with methods  simple, not dangerous and not expensive. In short, using the most modern methods and clinical reasoning. Never, I say never, I repeat never, simplify diagnosis "flattening" the individual patient on the mean. On the contrary investigating the patient in the deep and possibly early (see Dr Martino letter)

I apologize to colleagues for having erroneously mentioned in the previous answer, twice my account on cardiovascular prevention in children. Thank you.