Heat-Related Illness(Hyperthermia)sun stroke

Heat-related illness facts

• Hyperthermia is overheating of the body.
• Heat-related illness occurs as a result of heat exposure.
• Heat-related illnesses include heat stroke, heat exhaustion, heat cramps, heat syncope, and heat rash.
• Heat stroke is the most severe form of heat-related illness, and requires immediate medical attention.
• Certain individuals, such as the elderly, infants and young children, the obese, and those with chronic medical conditions are at increased risk for developing heat-related illness.
• Signs and symptoms of heat-related illness vary based on the condition, but may include an elevated body temperature, headache, nausea, weakness, dizziness, fainting, muscle cramps, and coma.
• Treatment for heat-related illness generally includes moving the individual out of the hot environment, implementing cooling measures as needed, rest, and rehydration.
• Prevention of heat-related illness is best accomplished through proper planning and preparation, such as increasing fluid intake, wearing appropriate clothing and sunscreen, remaining in a cool environment, acclimating yourself to the hot environment, and using common sense.

What is a heat-related illness?

A heat-related illness is a medical condition that may occur as a result of heat exposure. Even short periods of high temperatures can cause serious health problems. Heat-related illness encompasses a spectrum of conditions that range from minor illnesses to life-threatening medical emergencies. There are several heat-related illnesses, including heat stroke, heat exhaustion, heat cramps, heat syncope (fainting), and heat rash.
Summer can bring heat waves with unusually high temperatures that can last for days and sometimes weeks. It is estimated that approximately 700 people die annually due to heat-related illness. In the summer of 1980, a severe heat wave hit the United States, and nearly 1,700 people lost their lives from heat-related illness. Likewise, in the summer of 2003, tens of thousands of people died in Europe from an extreme heat wave. High temperatures put people at risk.

What causes a heat-related illness?

People suffer heat-related illness when the body's normal temperature control system is unable to effectively regulate its internal temperature. Normally, at high temperatures the body primarily cools itself through the evaporation of sweat. However, under certain conditions (air temperatures above 95 F or 35 C and with high humidity), this cooling mechanism becomes less effective. When the humidity is high, sweat will not evaporate as quickly, preventing the body from releasing heat quickly. Furthermore, without adequate fluid intake, excessive fluid losses and electrolyte imbalances may also occur leading to dehydration. In such cases, a person's body temperature rises rapidly. Very high body temperatures can damage the brain and other vital organs.
Other conditions that can limit the ability to regulate body temperature include old age, obesity, fever, dehydration, heart disease, poor circulation, sunburn, and drug or alcohol use.
Those at greatest risk of heat-related illness include:

• infants and children up to four years of age,
• people 65 years of age or older,
• people who are overweight,
• people who overexert during work or exercise,
• people with mental illness, and
• people who are chronically ill or on certain medications.

Infants and children up to four years of age are very sensitive to the effects of high temperatures and rely on others to regulate their environments and to provide adequate fluid intake.
People 65 years of age or older may not compensate for heat stress efficiently, and are less likely to sense and respond to changes in temperature.
Overweight people may be prone to heat-related illness because of their tendency to retain more body heat.
Any health condition that causes dehydration makes the body more susceptible to heat-related illness. If you or someone you know is at higher risk, it is important to drink plenty of fluids, avoid overexertion, and get your doctor or pharmacist's advice about medications being taken for:

• high blood pressure,
• depression,
• nervousness,
• mental illness,
• insomnia, or
• poor circulation

• Heat Stroke

  
  Heat stroke is a medical emergency requiring immediate medical attention. It is the most severe form of heat-related illness, and it can sometimes lead to death or permanent disability. Heat stroke occurs when the body's ability to regulate its internal temperature has failed. The body's temperature rises rapidly in excess of 105 F (40.5 C), leading to damage to the brain and other vital organs. Generally, the extent of injury depends on the duration of exposure to excessive heat and the peak temperature attained. Heat stroke is sometimes referred to as sunstroke.
  Heat stroke can be categorized as either exertional heat stroke (EHS) or nonexertional heat stroke (NEHS). Exertional heat stroke generally occurs in young, healthy individuals who engage in strenuous activity in hot weather. Nonexertional heat stroke (also referred to as classic heat stroke) typically occurs in the elderly, the very young, or the chronically ill.
  What are the signs and symptoms of heat stroke?
  Warning signs of heat stroke vary but may include:
  
  • high body temperature (above 104 F or 40 C),
  • skin that is red, hot, and either moist or dry (sweating may have stopped),
  • rapid heart rate,
  • difficulty breathing,
  • headache, 
  • dizziness,
  • loss of coordination,
  • nausea and vomiting,
  • confusion and restlenssness,
  • seizures, and
  • unconsciousness/coma.
  What is the treatment for heat stroke?
  If you see any of these signs, you may be dealing with a life-threatening emergency. Have someone call for immediate medical assistance while you begin cooling the affected individual:
  
  • Get the person to a cool indoor or outdoor area and remove restricting clothing.
  • Cool the person rapidly using whatever methods you can. For example, if possible, immerse the person in a tub of cool water or place them in a cool shower. You may also spray them with lukewarm water and blow cool air from a fan towards them. If the humidity is low, loosely wrap the the person in a cool, wet sheet and fan him or her vigorously. Alternatively, place ice or cold packs to the armpits, neck, and groin areas.
  • Monitor body temperature, and continue cooling efforts until the body temperature drops to about 102 F or lower (38.8 C), in order to prevent overcooling the affected individual.
  • If emergency medical personnel are delayed, call the hospital emergency room for further instructions.
  • If the affected individual is awake and alert, give them cool fluids to drink Do not give alcohol to drink.
  Sometimes the affected individual's muscles will begin to twitch uncontrollably (seizure) as a result of heat stroke. If this happens, keep the the person from injuring his or herslef, but do not place any object in the mouth and do not give fluids. If there is vomiting, make sure the airway remains open by turning the the person on his or her side to prevent choking.
  
  

  Heat Exhaustion

  
  Heat exhaustion is the body's response to an excessive loss of water and salt contained in sweat as a result of engaging in physical activity (work or exercising) in a hot environment. The body temperature may be normal or mildly elevated, but not above 104 F (40 C). It generally occurs in individuals who are not accustomed to working or exercising in the heat. The symptoms may range from minor complaints to more pronounced symptoms, however the affected individual will not experience the nervous system manifestations noted with heat stroke. Many cases of heat exhaustion can be treated outside of the hospital setting.
  What are the signs and symptoms of heat exhaustion?
  Warning signs of heat exhaustion include:
  
  • a normal or mildly elevated body temperature,
  • heavy sweating,
  • palor (paleness),
  • muscle cramps and muscle pain,
  • fatigue,
  • weakness,
  • dizziness and lightheadedness,
  • headache, and
  • nausea.
  The skin may be cool and moist. The affected individual's pulse rate may be fast and weak, and breathing may be fast and shallow. If heat exhaustion is untreated and heat exposure continues, it may sometimes progress to heat stroke.
  What is the treatment for heat exhaustion?
  Cooling measures that may be effective include:
  
  • drink cool, non-alcoholic beverages, such as water and sports drinks,
  • eat salty snacks,
  • rest in the shade or in an air-conditioned environment,
  • take a cool shower or bath, and
  • loosen or remove clothing.
  Seek medical attention immediately if:
  
  • the symptoms are severe, or
  • the affected individual has serious underlying health problems (for example, heart disease or diabetes).
  Otherwise, help the person cool off, and seek medical attention if symptoms worsen or last longer than one hour.
  
  

  Heat Cramps

  Heat cramps usually affect people who sweat significantly during strenuous activity. This sweating depletes the body's salt and moisture. The low salt level in the muscles causes painful muscle cramps, often following exercise. Heat cramps may also be a symptom of heat exhaustion.
  What are the signs and symptoms of heat cramps?
  Heat cramps are muscle pains or muscle spasms (usually in the abdomen, arms, or legs) that may occur in association with strenuous activity. If you have heart problems or are on a low sodium diet, seek medical attention for heat cramps.
  What is the treatment for heat cramps?
  
  • Stop all activity, and sit and rest in a cool place.
  • Drink water juice or a sports beverage, and eat a salty snack.
  • Passively stretch the affected muscles.
  • Do not return to strenuous activity for a few hours after the cramps subside as further exertion may lead to heat exhaustion or heat stroke.
  • Seek medical attention for heat cramps if they do not subside in 1 hour.
  
  

  Heat syncope

  
  Heat syncope is a fainting episode that occurs in the heat, either during prolonged standing or exercise, or when rapidly standing from a lying or sitting position. It typically occurs in individuals who are not acclimatized to the heat. Dehydration can also contribute to this condition.
  What are the signs and symptoms of heat syncope?
  
  • dizziness or lightheadedness, and
  • fainting.
  What is the treatment for heat syncope?
  
  • Sit and rest in a cool place. The affected individual may also lie down and elevate the legs.
  • Drink water or a sports beverage.
  • Seek medical attention for repeated episodes of fainting, confusion, seizures, or if the individual experiences chest pain.

  • Heat Rash

    
    Heat rash is a skin irritation that occurs in hot, humid weather. It is caused by profuse sweating, which can lead to the blockage of sweat ducts. It can occur at any age, but is most common in young children.
    What are the signs and symptoms of heat rash?
    Heat rash appears as a cluster of small red pimples or blisters. This skin irritation can be itchy. It typically occurs on the neck and upper chest, in the groin, under the breasts, and in elbow creases.
    
    What is the treatment for heat rash?
    The best treatment for heat rash is to avoid a hot, humid environment and to try to remain in cooler, less humid conditions. Try to keep the affected area dry, and wear light, loose clothing. Dusting powder may be used to increase comfort, but avoid using ointments or creams because they keep the skin warm and moist and may make the condition worse.
    Treating heat rash is simple and usually does not require medical assistance.
    
    

    Heat-Related Illness Prevention

    
    To protect your health when temperatures are extremely high, remember to keep cool and use common sense. The following tips are important.
    Drink plenty of fluids
    Increase your fluid intake regardless of your activity level. During heavy exercise in a hot environment, drink 2-4 glasses (16-32 ounces) of cool fluids each hour.
    Caution: If your doctor has prescribed a fluid-restricted diet or diuretics for you, ask your doctor how much you should drink.
    
    • During hot weather, you will need to drink more liquid than your thirst indicates. This is especially true for people 65 years of age and older who often have a decreased ability to respond to external temperature changes.
    • Drinking plenty of liquids during exercise is especially important. However, avoid very cold beverages because they can cause stomach cramps.
    • In addition, avoid drinks containing alcohol or caffeine, because they will actually cause you to lose more fluid.
    Replace salt and minerals
    Heavy sweating removes salt and minerals from the body. These are necessary for your body and must be replaced. The easiest and safest way to replace salt and minerals is through your diet.
    
    • Drink fruit juice or a sports beverage during exercise or work in the heat.
    • Do not take salt tablets unless directed by your doctor.
    • If you are on a low-salt diet, ask your doctor before changing what you eat or drink, especially before drinking a sports beverage.
    Wear appropriate clothing and sunscreen
    
    • Wear as little clothing as possible when you are at home. Choose lightweight, light-colored, loose-fitting clothing. In the hot sun, a wide-brimmed hat will provide shade and keep the head cool.
    • Sunburn affects the body's ability to cool itself and causes a loss of body fluids. It also causes pain and damages the skin.
    • A variety of sunscreens are available to reduce the risk of sunburn. The protection that they offer against sunburn varies. Check the sun protection factor (SPF) number on the label of the sunscreen container. Select SPF 15 or higher to protect yourself adequately. Apply sunscreen 30 minutes before going outdoors and reapply according to package directions.
    Pace yourself
    
    • If you are unaccustomed to working or exercising in a hot environment, start slowly and pick up the pace gradually.
    • If exertion in the heat makes your heart pound and leaves you gasping for breath, STOP all activity, get into a cool area or in the shade, and rest, especially if you become lightheaded, weak, or faint.
    Stay cool indoors
    
    • The most efficient way to beat the heat is to stay in a cool or air-conditioned area.
    • If you do not have an air conditioner or evaporative cooling unit, consider a visit to a shopping mall, see a movie in a movie theater, or visit public library for a few hours.
    • Contact your local health department to see if there are any heat-relief shelters in your area.
    • Electric fans may be useful to increase comfort and to draw cool air into your home at night, but do not rely on a fan as your primary cooling device during a heat wave. When the temperature is in the 90s or higher, a fan will not prevent heat-related illness.
    • A cool shower or bath is a more effective way to cool off. Also, use your stove and oven less to maintain a cooler temperature in your home.
    Schedule outdoor activities carefully
    
    • If you must be out in the heat, try to plan your activities so that you are outdoors either before noon or in the evening.
    • While outdoors, rest frequently in a shady area.
    • Resting periodically will give your body's thermostat a chance to recover.
    Use a buddy system
    
    • When working in the heat, monitor the condition of your coworkers and have someone do the same for you. Heat-related illness can cause a person to become confused or lose consciousness.
    • During a heat wave, have a friend or relative call to check in on you twice a day if you are 65 years of age or older. If you know anyone in this age group, check on them at least twice a day.
    Adjust to the environment
    
    • Be aware that any sudden change in temperature, such as an early summer heat wave, will be stressful to your body. You will have a greater tolerance for the heat if you limit your physical activity until you become accustomed to the heat.
    • If traveling to a hotter climate, allow several days to become acclimated before attempting any vigorous exercise, and work up to it gradually.
    Use common sense
    
    • Avoid hot foods and heavy meals as they may add heat to your body.
    • Do not leave infants, children, or pets in a parked car.
    • Dress infants and young children in cool, loose clothing and shade their heads and faces with hats or an umbrella. Make sure they use sunscreen when outdoors.
    • Limit sun exposure during the mid-day hours and in places of potential severe exposure such as beaches.
    • Ensure that infants and children drink adequate amounts of liquids.
    • Make sure to keep your pet cool by giving them plenty of fresh water, and leave the water in a shady area.
    One last hot tip
    These self-help measures are not a substitute for medical care but may help you recognize and respond promptly to warning signs of trouble. Your best defense against heat-related illness is prevention. Staying cool and making simple changes in your fluid intake, activities, and clothing during hot weather can help you remain safe and healthy
    source:medicinenet.com
  
  

Stroke

What is a stroke?

Brain cell function requires a constant delivery of oxygen and glucose from the bloodstream. A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. Blood flow can be compromised by a variety of mechanisms.
Blockage of an artery

• Narrowing of the small arteries within the brain can cause a lacunar stroke, (lacune means "empty space"). Blockage of a single arteriole can affect a tiny area of brain causing that tissue to die (infarct).
• Hardening of the arteries (atherosclerosis) leading to the brain. There are four major blood vessels that supply the brain with blood. The anterior circulation of the brain that controls most motor  activity, sensation, thought, speech, and emotion is supplied by the carotid arteries. The posterior circulation, which supplies the brainstem and the cerebellum, controlling the automatic parts of brain function and coordination, is supplied by the vertebrobasilar arteries.

If these arteries become narrow as a result of atherosclerosis, plaque or cholesterol, debris can break off and float downstream, clogging the blood supply to a part of the brain. As opposed to lacunar strokes, larger parts of the brain can lose blood supply, and this may produce more symptoms than a lacunar stroke.

• Embolism to the brain from the heart. In some instances blood clots can form within the heart and the potential exists for them to break off and travel (embolize) to the arteries in the brain and cause a stroke.

Rupture of an artery (hemorrhage)

• Cerebral hemorrhage (bleeding within the brain substance). The most common reason to have bleeding within the brain is uncontrolled high blood pressure. Other situations include aneurysms that leak or rupture or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can bleed.

What causes a stroke?

Blockage of an artery
The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body that it controls stops working. Typically, a cholesterol plaque in a small blood vessel within the brain that has gradually caused blood vessel narrowing ruptures and starts the process of forming a small blood clot.
Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk factors include:

• high blood pressure (hypertension),
• high cholesterol,
• diabetes, and
• smoking.

Embolic stroke
Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain.
Cerebral hemorrhage
A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells. As well, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull further decreasing blood flow to brain tissue and cells.
Subarachnoid hemorrhage
In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache, nausea, vomiting, light intolerance, and a stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death may occur.
Vasculitis
Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed causing decreased blood flow to brain tissue.
Migraine headache
There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves

What are the risk factors for stroke?

Overall, the most common risk factors for stroke are:

• high blood pressure,
• high cholesterol,
• smoking,
• diabetes and
• increasing age.

Heart rhythm disturbances like atrial fibrillation, patent foramen ovale, and heart valve disease can also be the cause.
When strokes occur in younger individuals (less than 50 years old), less common risk factors to be considered include illicit drugs, such as cocaine or amphetamines, ruptured aneurysms, and inherited (genetic) predispositions to abnormal blood clotting.
An example of a genetic predisposition to stroke occurs in a rare condition called homocystinuria, in which there are excessive levels of the chemical homocystine in the body. Scientists are trying to determine whether the non-hereditary occurrence of high levels of homocystine at any age can predispose to stroke.

What is a transient ischemic attack (TIA)?

A transient ischemic attack (TIA, mini-stroke) is a short-lived stroke that gets better and resolves. It is a short-lived episode (less than 24 hours) of temporary impairment if brain function that is caused by a loss of blood supply. A TIA causes a loss of function in the area of the body that is controlled by the portion of the brain affected. The loss of blood supply to the brain is most often caused by a clot that spontaneously forms in a blood vessel within the brain (thrombosis). However, it can also result from a clot that forms elsewhere in the body, dislodges from that location, and travels to lodge in an artery of the brain (emboli). A spasm and, rarely, a bleed are other causes of a TIA. Many people refer to a TIA as a "mini-stroke."
Some TIAs develop slowly, while others develop rapidly. By definition, all TIAs resolve within 24 hours. Strokes take longer to resolve than TIAs, and with strokes, complete function may never return and reflect a more permanent and serious problem. Although most TIAs often last only a few minutes, all TIAs should be evaluated with the same urgency as a stroke in an effort to prevent recurrences and/or strokes. TIAs can occur once, multiple times, or precede a permanent stroke. A transient ischemic attack should be considered an emergency because there is no guarantee that the situation will resolve and function will return.
A TIA from a clot in the blood vessel that supplies the retina of the eye can cause temporary visual loss (amaurosis fugax), which is often described as the sensation of a curtain coming down. A TIA that involves the carotid artery (the largest blood vessel supplying the brain) can produce problems with movement or sensation on one side of the body, which is the side opposite to the actual blockage. An affected patient may experience temporary double vision, dizziness (vertigo), loss of balance, one sided weakness or complete paralysis of the arm, leg, face, or one whole side of the body or be unable to speak or understand commands

What is the impact of strokes?

In the United States, stroke is the third largest cause of death (behind heart disease and all forms of cancer). The cost of strokes is not just measured in the billions of dollars lost in work, hospitalization, and the care of survivors in nursing homes. The major cost or impact of a stroke is the loss of independence that occurs in 30% of the survivors. For some individuals, what was a self-sustaining and an enjoyable lifestyle prior to the stroke, many may lose most of their quality of life after a stroke. Family members and friends may have their lives altered as they find themselves in the new role as caregivers.

What are stroke symptoms?

When brain cells are deprived of oxygen, they cease to perform their usual tasks. The symptoms that follow a stroke depend on the area of the brain that has been affected and the amount of brain tissue damage.
Small strokes may not cause any symptoms, but can still damage brain tissue. These strokes that do not cause symptoms are referred to as silent strokes. According to The U.S. National Institute of Neurological Disorders and Stroke (NINDS), these are the five major signs of stroke:

1. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. There may an associated tingling sensation in the affected area.


2. Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling.


3. Sudden trouble seeing in one or both eyes


4. Sudden trouble walking, dizziness, loss of balance or coordination


5. Sudden, severe headache with no known causeWhat should be done if you suspect you or someone else is having a stroke?

6. What should be done if you suspect you or someone else is having a stroke?

7. 
   If any of the symptoms mentioned above suddenly appear, immediate emergency medical attention should be sought. The first action should be to activate the emergency medical system in your area (call 911 if it is available). The goal is to get the stroke victim to a hospital as quickly as possible to confirm the diagnosis. An urgent medical decision is necessary in the emergency room to determine whether thrombolytic or clot busting drugs can potentially reverse the stroke situation. There is a very limited window of opportunity from the onset of symptoms to when this therapy can be used. If delays occur, the opportunity to intervene is lost.
   The first priority is ensuring that the ambulance arrives as soon as possible since first responders, EMTs and paramedics may be able to help make the diagnosis and alert the hospital about the stoke victim's situation.
   While waiting for the ambulance, the following first aid suggestions may be helpful:
   
   • The affected person should lie flat to promote an optimal blood flow to the brain.
   • If drowsiness, unresponsiveness, or nausea are present, the person should be placed in the rescue position on their side to prevent choking should vomiting occur.
   • Although aspirin plays a major role in stroke prevention (see below), once the symptoms of a stroke begin, it is generally recommended that additional aspirin not be taken until the patient receives medical attention. If stroke is of the bleeding type, aspirin could theoretically make matters worse. Moreover, patients with stroke may have swallowing difficulties and may choke on the pill.
   Three commands, known as the Cincinnati Prehospital Stroke Scale (CPSS), may help to determine if the potential for stroke exists. Ask the patient to do the following:
   
   1. Smile: the face should move symmetrically
   2. Raise both arms: looking for weakness on one side of the body
   3. Speak a simple sentence
   If a potential stroke victim cannot perform these tasks, 911 should be called to activated the emergency medical system
   .
   

   How is a stroke diagnosed?

   
   A stroke is a medical emergency. Anyone suspected of having a stroke should be taken to a medical facility immediately for evaluation and treatment. Initially, the doctor takes a medical history from the patient if possible or from others familiar with the patient if they are available. Important questions include what the symptoms were, when they began, if they were getting better, worse or staying the same. Past medical history adds important information looking for risk factors for stroke and for medications that can cause bleeding (for example, warfarin [Coumadin], clopidogrel [Plavix], prasugrel [Effient]).
   Physical examination is key in confirming the parts of the body that have stopped functioning and may help determine what part of the brain has lost its blood supply. If available, a neurologist, a doctor specializing in disorders of the nervous system and diseases of the brain, can assist in the diagnosis and management of stroke patients.
   Just because a person has slurred speech or weakness on one side of the body does not necessarily signal the occurrence of a stroke. There are many other possibilities that can be responsible for these symptoms. Other conditions that can mimic a stroke include:
   
   • brain tumors,
   • brain abscess (a collection of pus in the brain caused by bacteria or a fungus),
   • migraine headache,
   • bleeding in the brain either spontaneously or from trauma,
   • meningitis or encephalitis,
   • an overdose of certain medications, or
   • an electrolyte imbalance in the body. Abnormal concentrations (too high or too low) of sodium, calcium, or glucose in the body may also cause changes in the nervous system that can mimic a stroke.
   In the acute stroke evaluation, many things will occur at the same time. As the physician is taking the history and performing the physical examination, nursing staff will begin monitoring the patient's vital signs, performing blood tests, and performing an electrocardiogram (EKG or ECG).
   Part of the physical examination that is becoming standardized is the use of a stroke scale. The American Heart Association has published a guide to the examination of the nervous system to help health care practitioners determine the severity of a stroke and whether aggressive intervention may be warranted.
   There is a narrow time frame to intervene in an acute stroke with medications to reverse the loss of blood supply to part of the brain (please see TPA below). The patient needs to be appropriately evaluated and stabilized before any clot-busting drugs can be potentially utilized.
   Computerized tomography: In order to help determine the cause of a suspected stroke, a special X-ray test called a CT scan of the brain is often performed. A CT scan is used to look for bleeding or masses within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic therapy with TPA.
   MRI scan: Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to image the brain. The MRI images are much more detailed than those from CT, but due to the length of time to do the test and lack of availability of the machines in many hospitals, is not a first line test in stroke. While a CT scan may be completed within a few minutes, an MRI may take more than an hour to complete. An MRI may be performed later in the course of patient care if finer details are required for further medical decision making. People with certain medical devices (for example, pacemakers) or other metals within their body, cannot be subjected to the powerful magnetic field of an MRI.
   Other methods of MRI technology: An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram). Another MRI method called diffusion weighted imaging (DWI) is being offered in some medical centers. This technique can detect the area of abnormality minutes after the blood flow to a part of the brain has ceased, whereas a conventional MRI may not detect a stroke until up to six hours after it has started, and a CT scan sometimes cannot detect it until it is 12 to 24 hours old. Again, this is not a first line test in the evaluation of a stroke patient, when time is of the essence.
   Computerized tomography with angiography: Using dye that is injected into a vein in the arm, images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. Moreover, other abnormalities of brain blood flow may be evaluated. With faster machines and better technology, CT angiography may be done at the same time as the initial CT scan to look for a blood clot within an artery in the brain.
   CT and MRI images often require a radiologist to interpret their results.
   Conventional angiogram: An angiogram is another test that is sometimes used to view the blood vessels. A long catheter tube is inserted into an artery in the groin or arm and threaded into the arteries of the brain. Dye is injected while X-rays are taken and information can be obtained about blood flow in the brain. The decision to perform CT angiography versus conventional angiography depends upon a patient's specific situation and the technical capabilities of the hospital.
   Carotid Doppler ultrasound: A carotid Doppler ultrasound is a non-invasive test that uses sound waves to look for narrowing or stenosis and decreased blood flow in the carotid arteries (the major arteries in the front of the neck that supply blood to the brain).
   Heart tests: Certain tests to evaluate heart function are often performed in stroke patients to search for the source of an embolism. Electrocardiograms (EKG or ECG) may be used to detect abnormal heart rhythms like atrial fibrillation that are associated with embolic stroke.
   Ambulatory rhythm monitoring may be considered if the patient complains of palpitations or passing out episodes (syncope) and the doctor cannot find reason for it on the EKG. The patient can wear a Holter monitor for 1-2 days and sometimes longer looking fro a potential electrical conduction problem with the heart.
   Echocardiograms or ultrasounds of the heart can help evaluate the structure and function of the heart including the heart muscle, valves and the motion of the heart chamber when the heart beats. As well, specifically for stroke patients, this test may be able to find blood clots within the heart and the presence of a patent foramen ovale, both potential causes of stroke.
   Blood tests: In the acute situation, when the patient is in the midst of a stroke, blood tests are done to check for anemia, kidney and liver function, electrolyte abnormalities and blood clotting function.
   In other situations, when time is not of the essence, similar blood tests may be done. In addition, screening test for inflammation may be considered including an ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein). These are non specific tests that may give direction to medical care.
   
   

   What is the treatment of a stroke?

   
   Tissue plasminogen activator (TPA)
   There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain.
   Present American Heart Association guidelines recommend that if used, TPA must be given within 4 1/2  hours after the onset of symptoms. for patients who waken from sleep with symptoms of stroke, the clock starts when they were last seen in a normal state.
   TPA is injected into a vein in the arm but, the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. Not all hospitals have access to this technology.
   TPA may reverse stroke symptoms in more than one-third of patients, but may also cause bleeding in 6% patients, potentially making the stroke worse.
   For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours.
   Heparin and aspirin
   Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs.
   Managing other Medical Problems
   Blood pressure will be tightly controlled often using intravenous medication to prevent stroke symptoms from progressing. This is true whether the stroke is ischemic or hemorrhagic.
   Supplemental oxygen is often provided.
   In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke.
   Patients who have suffered a transient ischemic attacks, the patient may be discharged with blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels. Smoking cessation is mandatory.
   Rehabilitation
   When a patient is no longer acutely ill after a stroke, the health care staff focuses on maximizing the individuals functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility.
   The rehabilitation process can include some or all of the following:
   
   1. speech therapy to relearn talking and swallowing;
   2. occupational therapy to regain as much function dexterity in the arms and hands as possible;
       
   3. physical therapy to improve strength and walking; and
   4. family education to orient them in caring for their loved one at home and the challenges they will face.
   The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is not necessarily a realistic goal in many cases. However, many stroke patients can return to vibrant independent lives.
   Depending upon the severity of the stroke, some patients are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy.
   Many times, home health providers can assess the home living situation and make recommendations to ease the transition home. Unfortunately, some stroke patients have such significant nursing needs that they cannot be met by relatives and friends and long-term nursing home care may be required.
   
   

   What complications can occur after a stroke?

   
   A stroke can become worse despite an early arrival at the hospital and appropriate medical treatment. Progression of symptoms may be due to brain swelling or bleeding into the brain tissue.
   It is not unusual for a stroke and a heart attack to occur at the same time or in very close proximity to each other.
   
   During the acute illness, swallowing may be affected. The weakness that affects the arm, leg, and side of the face can also impact the muscles of swallowing. A stroke that causes slurred speech seems to predispose the patient to abnormal swallowing mechanics. Should food and saliva enter the trachea instead of the esophagus when eating or swallowing, pneumonia or a lung infection can occur. Abnormal swallowing can also occur independently of slurred speech.
   
   Because a stroke often results in immobility, blood clots can develop in a leg vein (deep vein thrombosis). This poses a risk for a clot to travel upwards to and lodge in the lungs - a potentially life-threatening situation (pulmonary embolism). There are a number of ways in which the treating physician can help prevent these leg vein clots. Prolonged immobility can also lead to pressure sores (a breakdown of the skin, called decubitus ulcers), which can be prevented by frequent repositioning of the patient by the nurse or other caretakers.
   
   Stroke patients often have some problem with depression as part of the recovery process, which needs to be recognized and treated.
   
   The prognosis following a stroke is related to the severity of the stroke and how much of the brain has been damaged. Some patients return to a near-normal condition with minimal awkwardness or speech defects. Many stroke patients are left with permanent problems such as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak), or incontinence of the bowel and/or bladder. A significant number of persons become unconscious and die following a major stroke.
   
   If a stroke has been massive or devastating to a person's ability to think or function, the family is left with some very difficult decisions. In these cases, it is sometimes advisable to limit further medical intervention. It is often appropriate for the doctor and the patient's family to discuss and implement orders to not resuscitate the patient in the case of a cardiac arrest, since the quality of life for the patient would be so poor. In many cases, this decision is made somewhat easier if the patient has had a discussion with family or loved ones before an illness has occurred.
   
   

   What can be done to prevent a stroke?

   
   Risk factor reduction
   High blood pressure: The possibility of suffering a stroke can be markedly decreased by controlling the risk factors. The most important risk factor for stroke is high blood pressure. When a person's blood pressure is persistently too high, roughly greater than 130/85, the risk of a stroke increases in proportion to the degree by which the blood pressure is elevated. Managing high blood pressure so that it is well controlled and in the normal range decreases the chances of a stroke.
   Smoking: An important stroke risk factor is cigarette smoking or other tobacco use. Chemicals in cigarettes are associated with developing atherosclerosis or narrowing of the arteries in the body. This narrowing can involve the large carotid arteries as well as smaller arteries within the brain. Smoking is also a major risk factor in heart disease and artery disease.
   Diabetes: Diabetes causes the small vessels to close prematurely. When these blood vessels close in the brain, small (lacunar) strokes may occur. Good control of blood sugar is important in decreasing the risk of stroke in people with diabetes.
   High cholesterol: Elevated cholesterol and/or triglycerides in the bloodstream are risk factors for a stroke due to the eventual blockage of blood vessels (atherosclerosis) and plaque formation. A healthy diet and medications can help normalize an elevated blood cholesterol level.
   Blood thinner/warfarin: An irregular heart beat called atrial fibrillation whereby the upper chambers of the heart do not beat in a coordinated fashion can cause blood clots to form inside the heart. These can break off and travel or embolize to blood vessels in the brain blocking blood flow and causing a stroke. Warfarin (Coumadin) is a blood "thinner" that prevents the blood from clotting. This medication is often used in patients with atrial fibrillation to decrease this risk. Warfarin is also sometimes used to prevent the recurrence of a stroke in other situations, such as with certain other heart conditions and conditions in which the blood has a tendency to clot on its own (hypercoagulable states). Warfarin dosing is monitored by periodic blood tests to measure INR (international normalized ration) which assess how quickly the patient's blood clots. Aspirin may also be considered for anticoagulation in atrial fibrillation.
   Antiplatelet therapy: Many TIA and stroke patients may benefit from "antiplatelet" drugs that can decrease clotting risk and potentially reduce their risk of suffering another cerebrovascular event. These medicines act on platelets to decrease their stickiness and reduce the tendency to clot blood. The side effect is an increased risk of bleeding. Aspirin is the most commonly prescribed medication in this group. If the patient develops TIA or stroke symptoms while taking aspirin, other anti-platelet medications may be considered including clopidogrel (Plavix), prasugrel (Effient), and dipyridamole (Persantine).
   Carotid endarterectomy: In many cases, a person may suffer a TIA or a stroke that is caused by the narrowing or of the carotid arteries (the major arteries in the neck that supply blood to the brain). If left untreated, patients with these conditions have a higher risk of experiencing a major stroke in the future. An operation that cleans out the carotid artery and restores normal blood flow is known as a carotid endarterectomy. This procedure has been shown to markedly reduce the incidence of a subsequent stroke. In patients who have a narrowed carotid artery, but no symptoms, this operation may be indicated in order to prevent the occurrence of a first stroke.
   
   

   What is in the future for stroke treatment?

   
   New medications are also being tested that help slow the degeneration of the nerve cells that are deprived of oxygen during a stroke. These drugs are referred to as "neuroprotective" agents, an example of which is sipatrigine. Another example is chlormethiazole, which works by modifying the expression of genes within the brain. (Genes produce proteins that determine an individual's makeup.)
   Finally, stem cells, which have the potential to develop into a variety of different organs, are being used to try to replace brain cells damaged by a previous stroke. In many academic medical centers, some of these experimental agents may be offered in the setting of a clinical trial. While new therapies for the treatment of patients after a stroke are on the horizon, they are not yet perfect and may not restore complete function to a person who has had a stroke.
   source:medicinenet.com
   
   

coronary artery bypass graft (CABG)

What is coronary artery bypass graft (CABG) surgery?

According to the American Heart Association 427,000 coronary artery bypass graft (CABG) surgeries were performed in the United States in 2004, making it one of the most commonly performed major operations. CABG surgery is advised for selected groups of patients with significant narrowings and blockages of the heart arteries (coronary artery disease). CABG surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.

How does coronary artery disease develop?

Coronary artery disease (CAD) occurs when atherosclerotic plaque (hardening of the arteries) builds up in the wall of the arteries that supply the heart. This plaque is primarily made of cholesterol. Plaque accumulation can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. Patients are also at higher risk for plaque development if they are older (greater than 45 years for men and 55 years for women), or if they have a positive family history for early heart artery disease.
The atherosclerotic process causes significant narrowing in one or more coronary arteries. When coronary arteries narrow more than 50 to 70%, the blood supply beyond the plaque becomes inadequate to meet the increased oxygen demand during exercise. The heart muscle in the territory of these arteries becomes starved of oxygen (ischemic). Patients often experience chest pain (angina) when the blood oxygen supply cannot keep up with demand. Up to 25% of patients experience no chest pain at all despite documented lack of adequate blood and oxygen supply. These patients have "silent" angina, and have the same risk of heart attack as those with angina.
When a blood clot (thrombus) forms on top of this plaque, the artery becomes completely blocked causing a heart attack.
When arteries are narrowed in excess of 90 to 99%, patients often have accelerated angina or angina at rest (unstable angina). Unstable angina can also occur due to intermittent blockage of an artery by a thrombus that eventually is dissolved by the body's own protective clot-dissolving system.

How is coronary artery disease diagnosed?

The resting electrocardiogram (EKG) is a recording of the electrical activity of the heart, and can demonstrate signs of oxygen starvation of the heart (ischemia) or heart attack. Often, the resting EKG is normal in patients with coronary artery disease and angina. Exercise treadmill tests are useful screening tests for patients with a moderate likelihood of significant coronary artery disease (CAD) and a normal resting EKG. These stress tests are about 60 to 70% accurate in diagnosing significant CAD.
If the stress tests do not reveal the diagnosis, greater accuracy can be achieved by adding a nuclear agent (thallium or Cardiolite) intravenously during stress tests. Addition of thallium allows nuclear imaging of the blood flow to different regions of the heart, using an external camera. An area of the heart with reduced blood flow during exercise, but normal blood flow at rest, signifies significant artery narrowing in that region.
Combining echocardiography (ultrasound imaging of the heart muscle) with exercise stress testing (stress echocardiography) is also a very accurate technique to detect CAD. When a significant blockage exists, the heart muscle supplied by this artery does not contract as well as the rest of the heart muscle. Stress echocardiography and thallium stress tests are both at least 80% to 85% accurate in detecting significant coronary artery disease.
When a patient cannot undergo exercise stress test because of nervous system or joint problems, medications can be injected intravenously to simulate the stress on the heart due to exercise and imaging can be performed with a nuclear camera or ultrasound.
Cardiac catheterization with angiography (coronary arteriography) is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of the two main heart arteries (left and right). Iodine contrast, "dye," is then injected into the arteries while an x-ray video is recorded. Sometimes, an exercise study is then done to determine whether a moderate narrowing (40 - 60%) is actually causing ischemia and, therefore, requires treatment.
A newer modality, high speed CT scanning angiography has recently become available. This procedure uses powerful x-ray methods to visualize the arteries to the heart. Its role in the evaluation of CAD is currently being evaluated. For more, please read the CT Scanning Angiography article.

How is coronary artery disease (CAD) treated?

Medicines used to treat angina reduce the heart muscle demand for oxygen in order to compensate for the reduced blood supply. Three commonly used classes of drugs are the nitrates, beta blockers and calcium blockers. Nitroglycerin (Nitro-Bid) is an example of a nitrate. Examples of beta blockers include propranolol (Inderal) and atenolol (Tenormin). Examples of calcium blockers include nicardipine (Cardene) and  nifedipine (Procardia, Adalat). Unstable angina is also treated with aspirin and the intravenous blood thinner heparin. Aspirin prevents clumping of platelets, while heparin prevents blood clotting on the surface of plaques in a critically narrowed artery. When patients continue to have angina despite maximum medications, or when significant ischemia still occurs with exercise testing, coronary arteriography is usually indicated. Data collected during coronary arteriography help doctors decide whether the patient should be considered for percutaneous coronary intervention, or percutaneous transluminal angioplasty (PTCA), whereby a small balloon is used to inflate the blockage. Angioplasty (PTCA) is usually followed by placement of a stent or coronary artery bypass graft surgery (CABG) to increase coronary artery blood flow.
Angioplasty can produce excellent results in carefully selected patients. Under x-ray guidance, a wire is advanced from the groin to the coronary artery. A small catheter with a balloon at the end is threaded over the wire to reach the narrowed segment. The balloon is then inflated to push the artery open, and a steel mesh stent is generally inserted.
CABG surgery is performed to relieve angina in patients who have failed medical therapy and are not good candidates for angioplasty (PTCA). CABG surgery is ideal for patients with multiple narrowings in multiple coronary artery branches, such as is often seen in patients with diabetes. CABG surgery has been shown to improve long-term survival in patients with significant narrowing of the left main coronary artery, and in patients with significant narrowing of multiple arteries, especially in those with decreased heart muscle pump function

How is CABG surgery done?

The cardiac surgeon makes an incision down the middle of the chest and then saws through the breastbone (sternum). This procedure is called a median (middle) sternotomy (cutting of the sternum). The heart is cooled with iced salt water, while a preservative solution is injected into the heart arteries. This process minimizes damage caused by reduced blood flow during surgery and is referred to as "cardioplegia." Before bypass surgery can take place, a cardiopulmonary bypass must be established. Plastic tubes are placed in the right atrium to channel venous blood out of the body for passage through a plastic sheeting (membrane oxygenator) in the heart lung machine. The oxygenated blood is then returned to the body. The main aorta is clamped off (cross clamped) during CABG surgery to maintain a bloodless field and to allow bypasses to be connected to the aorta.
The most commonly used vessel for the bypass is the saphenous vein from the leg. Bypass grafting involves sewing the graft vessels to the coronary arteries beyond the narrowing or blockage. The other end of this vein is attached to the aorta. Chest wall arteries, particularly the left internal mammary artery, have been increasingly used as bypass grafts. This artery is separated from the chest wall and usually connected to the left anterior descending artery and/or one of its major branches beyond the blockage. The major advantage of using internal mammary arteries is that they tend to remain open longer than venous grafts. Ten years after CABG surgery, only 66% of vein grafts are open compared to 90% of internal mammary arteries. However, artery grafts are of limited length, and can only be used to bypass diseases located near the beginning (proximal) of the coronary arteries. Using internal mammary arteries may prolong CABG surgery because of the extra time needed to separate them from the chest wall. Therefore, internal mammary arteries may not be used for emergency CABG surgery when time is critical to restore coronary artery blood flow.
CABG surgery takes about four hours to complete. The aorta is clamped off for about 60 minutes and the body is supported by cardiopulmonary bypass for about 90 minutes. The use of 3 (triple), 4 (quadruple), or 5 (quintuple) bypasses are now routine. At the end of surgery, the sternum is wired together with stainless steel and the chest incision is sewn closed. Plastic tubes (chest tubes) are left in place to allow drainage of any remaining blood from the space around the heart (mediastinum). About 5% of patients require exploration within the first 24 hours because of continued bleeding after surgery. Chest tubes are usually removed the day after surgery. The breathing tube is usually removed shortly after surgery. Patients usually get out of bed and are transferred out of intensive care the day after surgery. Up to 25% of patients develop heart rhythm disturbances within the first three or four days after CABG surgery. These rhythm disturbances are usually temporary atrial fibrillation, and are felt to be related to surgical trauma to the heart. Most of these arrhythmias respond to standard medical therapy that can be weaned one month after surgery. The average length of stay in the hospital for CABG surgery has been reduced from as long as a week to only three to four days in most patients. Many young patients can even be discharged home after two days.
A new advance for many patients is the ability to do CABG with out going on cardiopulmonary bypass ("off pump"), with the heart still beating. This significantly minimizes the occasional memory defects and other complications that may be seen after CABG, and is a significant advance.

How do patients recover after CABG surgery?

Sutures are removed from the chest prior to discharge and from the leg (if the saphenous vein is used) after 7 to 10 days. Even though smaller leg veins will take over the role of the saphenous vein, a certain degree of swelling (edema) in the affected ankle is common. Patients are advised to wear elastic support stockings during the day for the first four to six weeks after surgery and to keep their leg elevated when sitting. This swelling usually resolves after about six to eight weeks. Healing of the breastbone takes about six weeks and is the primary limitation in recovering from CABG surgery. Patients are advised not to lift anything more than 10 pounds or perform heavy exertion during this healing period. They are also advised not to drive for the first four weeks to avoid any injury to the chest. Patients can return to normal sexual activity as long as they minimize positions that put significant weight on the chest or upper arms. Return to work usually occurs after the six week recovery, but may be much sooner for non-strenuous employment.
Exercise stress testing is routinely done four to six weeks after CABG surgery and signals the beginning of a cardiac rehabilitation program. Rehabilitation consists of a 12 week program of gradually increasing monitored exercise lasting one hour three times a week. Patients are also counseled about the importance of lifestyle changes to lower their chance of developing further CAD. These include stopping smoking, reducing weight and dietary fat, controlling blood pressure and diabetes, and lowering blood cholesterol levels.

What are the risks and complications of CABG surgery?

Overall mortality related to CABG is 3-4%. During and shortly after CABG surgery, heart attacks occur in 5 to 10% of patients and are the main cause of death. About 5% of patients require exploration because of bleeding. This second surgery increases the risk of chest infection and lung complications. Stroke occurs in 1-2%, primarily in elderly patients. Mortality and complications increase with:

• age (older than 70 years),

• poor heart muscle function,

• disease obstructing the left main coronary artery,

• diabetes,

• chronic lung disease, and

• chronic kidney failure.

Mortality may be higher in women, primarily due to their advanced age at the time of CABG surgery and smaller coronary arteries. Women develop coronary artery disease about 10 years later than men because of hormonal "protection" while they still regularly menstruate (although in women with risk factors for coronary artery disease, especially smoking, elevated lipids, and diabetes, the possibility for the development of coronary artery disease at a young age is very real). Women are generally of smaller stature than men, with smaller coronary arteries. These small arteries make CABG surgery technically more difficult and prolonged. The smaller vessels also decrease both short and long-term graft function.

What are the long-term results after CABG surgery?

A very small percentage of vein grafts may become blocked within the first two weeks after CABG surgery due to blood clotting. Blood clots form in the grafts usually because of small arteries beyond the insertion site of the graft causing sluggish blood run off. Another 10% of vein grafts close off between two weeks and one year after CABG surgery. Use of aspirin to thin the blood has been shown to reduce these later closings by 50%. Grafts become narrowed after the first five years as cells stick to the inner lining and multiply, causing formation of scar tissue (intimal fibrosis) and actual atherosclerosis. After 10 years, only 2/3 of vein grafts are open and 1/2 of these have at least moderate narrowings. Internal mammary grafts have a much higher (90%) 10 year rate of remaining open. This difference in longevity has caused a shift in surgical practices toward greater use of internal mammary and other arteries as opposed to veins for bypasses.
Recent data has shown that in CABG patients with elevated LDL cholesterol (bad cholesterol) levels, use of cholesterol-lowering medications (particularly the statin family of drugs) to lower LDL levels to below 80 will significantly improve long-term graft patency as well as improve survival benefit and heart attack risk. Patients are also advised about the importance of lifestyle changes to lower their chance of developing further atherosclerosis in their coronary arteries. These include stopping smoking, exercise, reducing weight and dietary fat, as well as controlling blood pressure and diabetes. Frequent monitoring of CABG patients with physiologic testing can identify early problems in grafts. PTCA (angioplasty) with stenting, in addition to aggressive risk factor modification, may significantly limit the need for repeat CABG years later. Repeat CABG surgery is occasionally necessary, but may have a higher risk of complication
source:medicinenet.com

Cholesterol Topics

Cholesterol facts

• High cholesterol is also referred to as hypercholesterolemia (hyper=high + cholesterol + emia = in the blood) or hyperlipidemia
• Cholesterol is a fatty substance that is an important part of the outer lining of cells in the body of animals.
• Cholesterol is also found in the blood circulation of humans.
• Cholesterol in the blood originates from dietary intake and liver production.
• Dietary cholesterol comes primarily from animal sources including meat, poultry, fish, and dairy products.
• Organ meats such as liver, are especially high in cholesterol content.
• LDL (low density lipoprotein) cholesterol is called "bad" cholesterol, because elevated levels of LDL cholesterol are associated with an increased risk of coronary heart disease.
• HDL (high density lipoprotein) cholesterol is called the "good cholesterol" because HDL cholesterol particles prevent atherosclerosis by extracting cholesterol from artery walls and disposing of them through liver metabolism.
• High levels of LDL cholesterol and low levels of HDL cholesterol are risk factors for atherosclerosis.
• Research has shown that lowering LDL cholesterol reduces the risk of heart attacks, strokes, and peripheral artery disease.
• The National Institute of Health, the American Heart Association and the American College of Cardiology publish guidelines to help physicians and patients with this risk reduction for heart attack and stroke.
• Factors that affect blood cholesterol levels include diet, body weight, exercise, age and gender, diabetes, heredity, and other causes including underlying medical conditions.
• Guidelines recommend that cholesterol screening occur every 5 years after age 20. Should elevated cholesterol levels be found, testing may need to occur more frequently.
• Health care practitioners and the National Institute of Health recommend that a person's cholesterol level stay below 200.
• Cholesterol levels 200-239 are considered borderline high.
• Cholesterol levels 240 or greater are considered high.
• Drugs available to treat high cholesterol include statins, bile acid resins, and fibric acid derivatives.
• Drugs to lower blood cholesterol levels are most effective when combined with a low cholesterol diet.

What is cholesterol?

Cholesterol is a chemical compound that is naturally produced by the body and is structurally a combination of lipid (fat) and steroid. Cholesterol is a building block for cell membranes and for hormones like estrogen and testosterone. About 80% of the body's cholesterol is produced by the liver, while the rest comes from our diet. The main sources of dietary cholesterol are meat, poultry, fish, and dairy products. Organ meats, such as liver, are especially high in cholesterol content, while foods of plant origin contain no cholesterol. After a meal, dietary cholesterol is absorbed from the intestine and stored in the liver. The liver is able to regulate cholesterol levels in the blood stream and can secrete cholesterol if it is needed by the body.

What are LDL and HDL cholesterol?

LDL cholesterol is called "bad" cholesterol, because elevated levels of LDL cholesterol are associated with an increased risk of coronary heart disease, stroke, and peripheral artery disease. LDL lipoprotein deposits cholesterol along the inside of artery walls, causing the formation of a hard, thick substance called cholesterol plaque. Over time, cholesterol plaque causes thickening of the artery walls and narrowing of the arteries, a process called atherosclerosis, which decreases blood flow through the narrowed area.
HDL cholesterol is called the "good cholesterol" because HDL cholesterol particles prevent atherosclerosis by extracting cholesterol from the artery walls and disposing of them through the liver. Thus, high levels of LDL cholesterol and low levels of HDL cholesterol (high LDL/HDL ratios) are risk factors for atherosclerosis, while low levels of LDL cholesterol and high levels of HDL cholesterol (low LDL/HDL ratios) are desirable and protect against heart disease and stroke.
Total cholesterol is the sum of LDL (low density) cholesterol, HDL (high density) cholesterol, VLDL (very low density) cholesterol, and IDL (intermediate density) cholesterol

What determines the level of LDL cholesterol in the blood?

The liver manufactures and secretes LDL cholesterol into the blood. It also removes LDL cholesterol from the blood by active LDL receptors on the surface of its cells. A decrease number of liver cell LDL receptors is associated with high LDL cholesterol blood levels.
Both heredity and diet have a significant influence on a person's LDL, HDL and total cholesterol levels. For example, familial hypercholesterolemia (hyper= more + cholesterol + emia= in blood) is a common inherited disorder whose victims have a diminished number or nonexistent LDL receptors on the surface of liver cells. People with this disorder also tend to develop atherosclerosis and heart attacks during early adulthood.
Diets that are high in saturated fats and cholesterol raise the levels of LDL cholesterol in the blood. Fats are classified as saturated or unsaturated (according to their chemical structure). Saturated fats are derived primarily from meat and dairy products and can raise blood cholesterol levels. Some vegetable oils made from coconut, palm, and cocoa are also high in saturated fats.

Does lowering LDL cholesterol prevent heart attacks and strokes?

Lowering LDL cholesterol is currently one of the primary public health initiatives preventing atherosclerosis and heart attacks. The benefits of lowering LDL cholesterol are:

• Reducing or stopping the formation of new cholesterol plaques on the artery walls
• Reducing existing cholesterol plaques on the artery walls and widening the arteries
• Preventing the rupture of cholesterol plaques, which initiates blood clot formation and blocks blood vessels
• Decreasing the risk of heart attacks
• Decreasing the risk of strokes
• Decreasing the risk of peripheral artery disease

The same measures that decrease narrowing in coronary arteries also may benefit the carotid and cerebral arteries (arteries that deliver blood to the brain) as well as the femoral arteries that supplies blood to the legs

How can LDL cholesterol levels be lowered?

Therapeutic lifestyle changes to lower cholesterol
Therapeutic lifestyle changes to lower LDL cholesterol involves losing excess weight, exercising regularly, and following a diet that is low in saturated fat and cholesterol.
Medications to lower cholesterol
Medications are prescribed when lifestyle changes cannot reduce the LDL cholesterol to desired levels. The most effective and widely used medications to lower LDL cholesterol are called statins. Most of the large controlled trials that demonstrated the heart attack and stroke prevention benefits of lowering LDL cholesterol used one of the statins. Other medications used in lowering LDL cholesterol and in altering cholesterol profiles include, fibrates such as gemfibrozil (Lopid), resins such as cholestyramine (Questran), and ezetimibe, Zetia.
What are "normal" cholesterol blood levels?
There are no established "normal" blood levels for total and LDL cholesterol. In most other blood tests in medicine, normal ranges can be set by taking measurements from large number of healthy subjects. The normal range of LDL cholesterol among "healthy" adults (adults with no known coronary heart disease) in the United States may be too high. The atherosclerosis process may be quietly progressing in many healthy children and adults with average LDL cholesterol blood levels, putting them at risk of developing coronary heart diseases in the future

What are the current NCEP cholesterol treatment guidelines?

Controlling blood cholesterol levels may decrease the risk of heart attack and stroke. The National Institute of Health, the American Heart Association and the American College of Cardiology publish guidelines to help physicians and patients with this risk reduction. The most recent consensus in 2004 recommended the following:

1. Consider more intensive LDL cholesterol-lowering for people at very high, high, and moderately high risk for a heart attack. For example, for patients with a very high risk of heart attacks, the LDL cholesterol treatment goal remains at <100mg/dl, but the report advised doctors to consider the option of lowering the LDL cholesterol (usually using a statin plus lifestyle changes) to <70 mg/dl.
2. Initiate therapeutic lifestyle changes to modify lifestyle-related risk factors (obesity, physical inactivity, metabolic syndrome, high blood triglyceride levels and low HDL cholesterol levels). Lifestyle changes have the potential to reduce heart attack and stroke risks through several mechanisms beyond the lowering of LDL cholesterol.
3. When LDL-lowering medication is used for very high, high or moderately high risk patients, the report advises that the intensity of LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40 percent reduction in LDL cholesterol levels.
4. When a very high or high risk patient also has high blood triglyceride or low HDL cholesterol levels, doctors may consider combining nicotinic acid or a fibrate with a statin. Nicotinic acid and fibrates are more effective than statins in lowering triglycerides and increasing HDL.
5. Age should not be a consideration since older persons also benefit from lowering LDL cholesterol. It is never too late or the patient too old to begin lifestyle changes and medications to lower LDL cholesterol. A word of caution is in order. Elderly patients are more likely to have liver and kidney dysfunction, and are also more likely to be on multiple medications some of which may interfere with the breakdown of cholesterol-lowering drugs such as statins. Thus lower dosing may be necessary to avoid adverse side effects.

The 2004 NCEP treatment goals according to risk categories

Risk category	LDL goal	More intense LDL goal option	Initiate TLC if LDL is:	Consider drugs + TLC if LDL is:
High risk	<100 mg/dl		>100 mg/dl	>100 mg/dl
Very high risk	<100 mg/dl	<70 mg/dl	>100 mg/dl	>100 mg/dl
Moderately high risk (10 yr. risk 10%-20%)	<130 mg/dl	<100 mg/dl	>130 mg/dl	>130mg/dl, consider drug option if LDL is 100-129 mg/dl
Moderate risk (10 yr. risk <10%)	<130 mg/dl		>130 mg/dl	>160 mg/dl
Lower risk	<160 mg/dl		>160 mg/dl	>190 mg/dl, consider drug optional if LDL is 160-189 mg/dl

• High risk patients are those who already have coronary heart disease (such as a prior heart attack), diabetes mellitus, abdominal aortic aneurysm, or those who already have atherosclerosis of the arteries to the brain and extremities (such as patients with strokes, TIA's (mini-strokes), and peripheral vascular diseases). High risk patients also include those with 2 or more risk factors (for example, smoking, hypertension, or a family history of early heart attacks) that places them at a greater than 20 percent chance of having a heart attack within 10 years. (A person's chance of having a heart attack can be calculated by using the Framingham Heart Study Score Sheets, at http://nhlbi.nih.gov/about/framingham/riskabs.htm).
• Very high -risk patients are those who have coronary heart disease in addition to having either multiple risk factors (especially diabetes), or severe and poorly controlled risk factors (such as continued smoking), or metabolic syndrome (a constellation of risk factors associated with obesity, including high triglycerides and low HDL). Patients hospitalized for acute coronary syndromes are also at very high risk.
• Moderately high risk patients are those who have neither coronary heart disease nor diabetes mellitus, but have multiple (2 or more) risk factors for coronary heart disease that put them at a 10 to 20 percent risk of heart attack within 10 years. (Use the Framingham Heart Study Score Sheets, at http://nhlbi.nih.gov/about/framingham/riskabs,htm to calculate the 10 year risk.)
• Moderate risk patients are those who have neither CHD nor diabetes mellitus, but have 2 or more risk factors for coronary heart disease that put them at a <10% risk of heart attack within 10 years.
• Lower risk patients are those with 0 to 1 risk factor for coronary heart disease

• Why is HDL the good cholesterol?

  
  HDL is the good cholesterol because it protects the arteries from the atherosclerosis process. HDL cholesterol extracts cholesterol particles from the artery walls and transports them to the liver to be disposed through the bile. It also interferes with the accumulation of LDL cholesterol particles in the artery walls.
  The risk of atherosclerosis and heart attacks is strongly related to HDL cholesterol levels. Low levels of HDL cholesterol are linked to a higher risk, whereas high HDL cholesterol levels are associated with a lower risk.
  Very low and very high HDL cholesterol levels can run in families. Families with low HDL cholesterol levels have a higher incidence of heart attacks than the general population, while families with high HDL cholesterol levels tend to live longer with a lower frequency of heart attacks.
  Like LDL cholesterol, life style factors and other conditions influence HDL cholesterol levels. HDL cholesterol levels tend to be lower in persons who smoke cigarettes, are overweight and inactive, and in people with type II diabetes mellitus.
  HDL cholesterol is higher in people who are lean, exercise regularly, and do not smoke cigarettes. Estrogen increases a person's HDL cholesterol, which explains why women generally have higher HDL levels than men do.
  For individuals with low HDL cholesterol levels, a high total or LDL cholesterol blood level further increases the incidence of atherosclerosis and heart attacks. Therefore, the combination of high levels of total and LDL cholesterol with low levels of HDL cholesterol is undesirable whereas the combination of low levels of total and LDL cholesterol and high levels of HDL cholesterol is favorable.
  What are LDL/HDL and total/HDL ratios?
  The total cholesterol to HDL cholesterol ratio (total chol/HDL) is a number that is helpful in estimating the risk of developing atherosclerosis. The number is obtained by dividing total cholesterol by HDL cholesterol. (High ratios indicate a higher risk of heart attacks, whereas low ratios indicate a lower risk).
  High total cholesterol and low HDL cholesterol increases the ratio and is undesirable. Conversely, high HDL cholesterol and low total cholesterol lowers the ratio and is desirable. An average ratio would be about 4.5. Ideally, one should strive for ratios of 2 or 3 (less than 4).
  What are the treatment guidelines for low HDL cholesterol?
  In clinical trials involving lowering LDL cholesterol, scientists also studied the effect of HDL cholesterol on atherosclerosis and heart attack rates. They found that even small increases in HDL cholesterol could reduce the frequency of heart attacks. For each 1 mg/dl increase in HDL cholesterol, there is a 2% to 4% reduction in the risk of coronary heart disease. Although there are no formal NCEP (please see discussion above) target treatment levels of HDL cholesterol, an HDL level of <40 mg/dl is considered undesirable and measures should be taken to increase it.
  How can levels of HDL cholesterol be raised?
  The first step in increasing HDL cholesterol levels (and decreasing LDL/HDL ratios) is therapeutic life style changes. When these modifications are insufficient, medications are used. In prescribing medications or medication combinations, doctors have to take into account medication side effects as well as the presence or absence of other abnormalities in cholesterol profiles.
  Regular aerobic exercise, loss of excess weight (fat), and cessation of smoking cigarettes will increase HDL cholesterol levels. Regular alcohol consumption (such as one drink a day) will also raise HDL cholesterol. Because of other adverse health consequences of excessive alcohol consumption, alcohol is not recommended as a standard treatment for low HDL cholesterol.
  Medications that are effective in increasing HDL cholesterol include gemfibrozil (Lopid), estrogen, and to a much lesser extent, the statin drugs (discussed below). A newer medicine, fenofibrate (Tricor) has shown much promise in selectively increasing HDL levels and reducing serum triglycerides
  
  

  What are triglycerides and VLDL?

  
  Triglyceride is a fatty substance that is composed of three fatty acids. Like cholesterol, triglyceride in the blood either comes from the diet or the liver. Also, like cholesterol, triglyceride cannot dissolve and circulate in the blood without combining with a lipoprotein.
  The liver removes triglyceride from the blood, and it synthesizes and packages triglyceride into VLDL (very low-density lipoprotein) particles and releases them back into the blood circulation.
  Do high triglyceride levels cause atherosclerosis?
  Whether elevated triglyceride levels in the blood lead to atherosclerosis and heart attacks is controversial. While abnormally high triglyceride levels may be a risk factor for atherosclerosis, it is difficult to conclusively prove that elevated triglyceride by itself can cause atherosclerosis. Elevated triglyceride levels are often associated with other conditions that increase the risk of atherosclerosis, including obesity, low levels of HDL- cholesterol, insulin resistance and poorly controlled diabetes mellitus, and small, dense LDL cholesterol particles.
  What are the causes of elevated triglyceride levels?
  High triglyceride levels may be genetic or they may be acquired. Examples of inherited hypertriglyceridemia (hyper=high + triglyceride + emia= in blood) disorders include mixed hypertriglyceridemia, familial hypertriglyceridemia, and familial dysbetalipoproteinemia.
  Hypertriglyceridemia can often be caused by non-genetic factors such as obesity, excessive alcohol intake, diabetes mellitus, kidney disease, and estrogen- containing medications such as birth control pills.
  How can elevated blood triglyceride levels be treated?
  Diet is the first step in treating hypertriglyceridemia. A low fat diet, regular aerobic exercise, loss of excess weight, reduction of alcohol consumption, and stopping cigarette smoking may be enough to control triglyceride levels in the blood. In patients with diabetes mellitus, meticulous control of elevated blood glucose is also important.
  When medications are necessary, fibrates (such as Lopid), nicotinic acid, and statin medications can be used. Lopid not only decreases triglyceride levels but also increases HDL cholesterol levels and LDL cholesterol particle size. Nicotinic acid lowers triglyceride levels, increases HDL cholesterol levels and the size of LDL cholesterol particles.
  The statin drugs have been found effective in decreasing triglyceride as well as LDL cholesterol levels and, to a lesser extent, in elevating HDL cholesterol levels.
  
  

  What medications are available to lower cholesterol, lipids, and triglycerides?

  
  Lipid altering medications are used in lowering blood levels of undesirable lipids such as LDL cholesterol and triglycerides and increasing blood levels of desirable lipids such as HDL cholesterol. Several classes of medications are available in the United States, including HMG CoA reductase inhibitors (statins), nicotinic acid, fibric acid derivatives, and medications that decrease intestinal cholesterol absorption (bile acid sequestrants and cholesterol absorption inhibitors). Some of these medications are primarily useful in lowering LDL cholesterol, others in lowering triglycerides, and some in elevating HDL cholesterol. Medications also can be combined to more aggressively lower LDL, as well as in lowering LDL and increasing HDL at the same time.
  Note: Dosing guidelines change. The US Food and Drug Administration (FDA) issued a guideline concerning the potential dangers of taking the 80mg dose of simvastatin (Zocor).
  Lipid altering medications commonly used in the United States
  

  Medication class	Medication examples	Effects on blood lipids
  Statins	pravastatin sodium (Pravachol), lovastatin (Mevacor), atorvastatin calcium (Lipitor), fluvastatin sodium (Lescol), rosuvastatin (Crestor), simvastatin (Zocor)	Most effective in lowering LDL, mildly effective in increasing HDL, mildly effective in lowering triglycerides
  Fibric acid	Lopid, Tricor	Most effective in lowering triglycerides, effective in increasing HDL, minimally effective in lowering LDL
  Bile acid sequestrants	cholestyramine (Questran), colestipol (Colestid), and colesevelam (Welchol)	Mildly to modestly effective in lowering LDL, no effect on HDL and triglycerides
  Cholesterol absorption inhibitors	ezetimibe (Zetia)	Mildly to modestly effective in lowering LDL, no effect on HDL and triglycerides
  Combining nicotinic acid with statin	lovastatin+niaspan (Advicor)	Effective in lowering LDL and triglycerides and increasing HDL

  Historically, niacin has been a one of the medications used to lower cholesterol and decrease the risk of heart attack and stroke. Its usefulness has been called into question by studies conducted in 2011 by the National Institutes of Health. Patients who are taking niacin should not stop using it without discussing treatment options for cholesterol control with their health care provider.
  
  

  Is lowering LDL cholesterol enough?

  
  
  
  LDL cholesterol reduction is only part of the battle against atherosclerosis. Individuals who have normal or only mildly elevated LDL cholesterol levels can still develop atherosclerosis and heart attacks even in the absence of other risk factors such as cigarette smoking, high blood pressure, and diabetes mellitus. It is clear that while lowering LDL cholesterol below NCEP target levels is an important step, there are other factors involved in heart disease that are yet to be discovered.
  
  

  Cholesterol Levels Pictures Slideshow: What They Mean, Diet and Treatment
  Reviewed by Andrew Seibert, MD on Wednesday, November 23, 2011
  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

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  What Is Cholesterol?

  
  We may associate cholesterol with fatty foods, but most of the waxy substance is made by our own bodies. The liver produces 75% of the cholesterol that circulates in our blood. The other 25% comes from food. At normal levels, cholesterol actually plays an important role in helping cells do their jobs. But cholesterol levels are precariously high in more than 100 million Americans.
  

  Symptoms of High Cholesterol

  
  High cholesterol does not cause any symptoms. But it does cause damage deep within the body. Over time, too much cholesterol may lead to a buildup of plaque inside the arteries. Known as atherosclerosis, this condition narrows the space available for blood flow and can trigger heart disease. The good news is high cholesterol is simple to detect, and there are many ways to bring it down.
  

  Cholesterol Testing

  
  People older than 20 should have their cholesterol levels checked at least once every five years. This is done with a simple blood test known as a fasting lipoprotein profile. It measures the different forms of cholesterol that are circulating in your blood after you avoid eating for nine to 12 hours. The results show your levels of "bad" cholesterol, "good" cholesterol, and triglycerides.
  

  'Bad' Cholesterol

  
  Most of the cholesterol in the blood is carried by proteins called low density lipoproteins or LDL. This is known as the bad cholesterol because it combines with other substances to clog the arteries. A diet high in saturated fats and trans fats tends to raise the level of LDL cholesterol. For most people, an LDL score below 100 is healthy, but people with heart disease may need to aim even lower.
  

  'Good' Cholesterol

  
  Up to a third of blood cholesterol is carried by high-density lipoproteins or HDL. This is called good cholesterol because it helps remove bad cholesterol, preventing it from building up inside the arteries. The higher the level of HDL cholesterol, the better. People with too little are more likely to develop heart disease. Eating healthy fats, such as olive oil, may help boost HDL cholesterol.
  

  Triglycerides

  
  The body converts excess calories, sugar, and alcohol into triglycerides, a type of fat that is carried in the blood and stored in fat cells throughout the body. People who are overweight, inactive, smokers, or heavy drinkers tend to have high triglycerides, as do those who eat a very high-carb diet. A triglycerides score of 150 or higher puts you at risk for metabolic syndrome, which is linked to heart disease and diabetes.
  

  Total Cholesterol

  
  Total cholesterol measures the combination of LDL, HDL, and VLDL (very low density lipoprotein) in your bloodstream. VLDL is a precursor of LDL, the bad cholesterol. A total cholesterol score of under 200 is considered healthy in most cases. People who score in the "high" range have an increased risk of developing heart disease compared to those who score below 200.
  

  Cholesterol Ratio

  
  To calculate your cholesterol ratio, divide your total cholesterol by your HDL cholesterol. For example, a total score of 200 divided by an HDL score of 50 equals a cholesterol ratio of 4 to 1. Doctors recommend maintaining a ratio of 4 to 1 or lower. The smaller the ratio, the better. While this figure is useful in estimating heart disease risk, it's not as important in guiding treatment. Doctors look at total cholesterol, HDL cholesterol, and LDL cholesterol to determine treatment.
  

  Cholesterol in Food

  
  Cholesterol-rich foods, like eggs, shrimp, and lobster are no longer completely forbidden. Research shows that the cholesterol we eat has only a small effect on blood cholesterol levels for most people. A few people are "responders," whose blood levels spike up after eating eggs. But for most, saturated fat and trans fats are bigger concerns. Daily cholesterol limits are 300 mg for healthy people and 200 mg for those at higher risk. One egg has 186 mg of cholesterol.
  

  Cholesterol and Family History

  
  Cholesterol comes from two sources -- the body and food -- and either one can contribute to high cholesterol. Some people inherit genes that trigger too much cholesterol production. For others, diet is the main culprit. Saturated fat and cholesterol occur in animal-based foods, including meat, eggs, and dairy products made with milk. In many cases, high cholesterol stems from a combination of diet and genetics.
  

  What Boosts Your Risk?

  
  Several factors can make you more likely to develop high cholesterol:
  

  • A diet high in saturated fats and cholesterol
  • A family history of high cholesterol
  • Being overweight or obese
  • Getting older

  Cholesterol and Gender

  
  Until menopause, women typically have lower total cholesterol levels than men of the same age. They also have higher levels of HDL cholesterol, the good kind. One reason is estrogen: The female sex hormone raises the level of HDL cholesterol. Estrogen production peaks during the childbearing years and drops off during menopause. After age 55, a woman's risk of developing high cholesterol begins to climb.
  

  Cholesterol and Children

  
  There's evidence that cholesterol can begin clogging the arteries during childhood, leading to atherosclerosis and heart disease later in life. The American Heart Association recommends kids and teenagers with high cholesterol take steps to bring it down. Ideally, total cholesterol should be below 170 in people ages 2 to 19.
  

  Why High Cholesterol Matters

  
  High cholesterol is one of the major risk factors for coronary artery disease, heart attacks, and strokes. It also appears to boost the risk of Alzheimer's disease. As we saw earlier, high cholesterol leads to a buildup of plaque that narrows the arteries. This is dangerous because it can restrict blood flow. If the blood supply to a part of the heart or brain is completely cut off, the result is a heart attack or stroke.
  

  Cholesterol Buster: Eat More Fiber

  
  Diet changes offer a powerful way to fight high cholesterol. If you've ever wondered why some cereals claim to be heart-healthy, it's the fiber. The soluble fiber found in many foods helps reduce LDL, the bad cholesterol. Good sources of soluble fiber include whole-grain breads and cereals, oatmeal, fruits, dried fruits, vegetables, and legumes such as kidney beans.
  

  Cholesterol Buster: Know Your Fats

  
  No more than 35% of your daily calories should come from fat. But not all fats are equal. Saturated fats -- from animal products and tropical oils -- raise LDL cholesterol. Trans fats carry a double-whammy, boosting bad cholesterol, while lowering the good kind. These two bad fats are found in many baked goods, fried foods (doughnuts, fries, chips), stick margarine, and cookies. Unsaturated fats may lower LDL when combined with other healthy diet changes. They're found in avocados, olive oil, and peanut oil.
  

  Cholesterol Buster: Smart Protein

  
  Meat and full-fat milk offer plenty of protein, but they are also major sources of cholesterol. You may be able to reduce LDL cholesterol by switching to soy protein, such as tofu, at some meals. Fish is another great choice. It's rich in omega-3 fatty acids, which can improve cholesterol levels. The American Heart Association recommends eating fish at least twice a week.
  

  Cholesterol Buster: Low-Carb Diet

  
  There's growing evidence that low-carb diets may be better than low-fat diets for improving cholesterol levels. In a two-year study funded by the National Institutes of Health, people who followed a low-carb plan had significantly better HDL (good cholesterol) levels than those who followed a low-fat plan.
  

  Cholesterol Buster: Lose Weight

  
  If you're overweight, talk to your doctor about beginning a weight loss program. Losing weight can help you reduce your levels of triglycerides, LDL, and total cholesterol. Shedding even a few pounds can also boost your good cholesterol level -- it tends to go up one point for every 6 pounds you lose.
  

  Cholesterol Buster: Quit Smoking

  
  Giving up tobacco is tough, but here's one more reason to try. When you stop smoking, your good cholesterol is likely to improve by as much as 10%. You may be more successful if you combine several smoking cessation strategies. Talk to your doctor about which options are best for you.
  

  Cholesterol Buster: Exercise

  
  If you're healthy but not very active, starting an aerobic exercise program could increase your good cholesterol by 5% in the first two months. Regular exercise also lowers bad cholesterol. Choose an activity that boosts your heart rate, such as running, swimming, or walking briskly, and aim for at least 30 minutes on most days of the week. It doesn't have to be 30 continuous minutes; two 15-minute walks works just as well.
  

  Treatment: Medications

  
  If high cholesterol runs in your family, diet and exercise may not be enough to get your numbers where you want them. In that case, medication can give your cholesterol levels an extra nudge. Statins are usually the first choice. They block the production of cholesterol in the liver. Other options include cholesterol absorption inhibitors, bile acid resins, and fibrates. Your doctor may recommend a combination of these medications.
  

  Treatment: Supplements

  
  Certain dietary supplements may also improve cholesterol levels. These include flaxseed oil, fish oil, and plant sterols, such as beta-sitosterol. Prescription niacin, a B-complex vitamin, has been found to raise good cholesterol while reducing bad cholesterol. Niacin found in ordinary supplements should not be used to lower cholesterol.
  

  Herbal Remedies

  
  Some studies suggest garlic can knock a few percentage points off total cholesterol. But garlic pills can have side effects and may interact with medications. Other herbs that may reduce cholesterol include:
  

  • Fenugreek seeds
  • Artichoke leaf extract
  • Yarrow
  • Holy basil

  How Low Should You Go?

  
  Many people are able to lower cholesterol levels through a combination of medication and lifestyle changes. But how low is low enough? For people with diabetes or a high risk of developing heart disease, an LDL score of less than 100 is desirable. If you already have heart disease or coronary artery disease, some doctors recommend reducing LDL to 70 or lower.
  

  Can the Damage Be Undone?

  
  It takes years for high cholesterol to clog the arteries with plaque. But there is evidence that atherosclerosis can be reversed, at least to some degree. Dean Ornish, MD, has published several studies showing that a low-fat vegetarian diet, stress management, and moderate exercise can chip away at the build-up inside the coronary arteries. Other research supports the idea that big drops in cholesterol can somewhat help open clogged arteries.
  

  source:medicinenet.com

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